Damian McNamara

ATLANTA — Significant others and family members experience posttraumatic stress disorder at rates that exceed those of military service members of current and previous wars, according to a study.

Using the most conservative estimates on the Psychopathology Checklist, 56 of 273 partners, parents, siblings, and other family members studied had PTSD, Brenda Nash, Ph.D., said in an interview at her poster during the annual meeting of the International Society for Traumatic Stress Studies.

This 21% rate is more than three times the reported 6% PTSD prevalence among Afghanistan veterans and well above the 13% rate reported for Iraq War veterans (U.S. Army Med. Dept. J. 2008;July-September:7-17). The prevalence is also more than twice the 9.4% estimate for the general adult population (J. Traum. Stress 2003;16:495-502).

“I'm surprised at the degree of the finding,” Dr. Nash said. “We never expected it would be twice as high.”

A lack of recognition and services to address their mental health symptoms may explain this higher rate of PTSD, compared with military personnel, Dr. Nash said. “My hypothesis is that rates are so much higher because … we prepare our troops before they leave but we don't prepare [their] families.”

Military training facilities and VA and community health centers should screen and treat significant others and family members for PTSD, added Dr. Nash, of Spalding University, Lexington, Ky.

Family members of deployed military personnel “typically don't have support, and they do all the work at home,” Dr. Nash said. Also, they may feel guilty about their symptoms, compared with what their family member might be experiencing, she added.

Lead author Rebecca K. Stahl, Dr. Nash, and their colleagues recruited participants through Yahoo and MSN forums for significant others of military service members. The participants completed a stressor-specific PTSD checklist and provided demographic information through an online survey.

They ranked degree of 17 possible PTSD symptoms on a scale from 1 (not at all) to 5 (extremely). Sleep issues, concentration, isolation, irritability/anger, and feeling upset at being reminded of the military service member's trauma were cited most often. “They see images [of the war] on TV,” Dr. Nash said.

People were diagnosed with PTSD if they had a total checklist score of 50 or more, combined with moderate or higher endorsement of certain DSM-IV TR symptoms: at least one reexperiencing symptom, three avoidance symptoms, and two hyperarousal symptoms. With this dual definition, 55 (20%) of significant others were diagnosed with PTSD.

The study cohort included significant others of service members deployed to Iraq, Afghanistan, Vietnam, Korea, and World War II.

Further investigation of PTSD in significant others is warranted, Dr. Nash said. If the findings are replicated, it would lend credence to inclusion of a vicarious trauma diagnosis in the DSM-5, Dr. Nash said.

ATLANTA — Significant others and family members experience posttraumatic stress disorder at rates that exceed those of military service members of current and previous wars, according to a study.

Using the most conservative estimates on the Psychopathology Checklist, 56 of 273 partners, parents, siblings, and other family members studied had PTSD, Brenda Nash, Ph.D., said in an interview at her poster during the annual meeting of the International Society for Traumatic Stress Studies.

This 21% rate is more than three times the reported 6% PTSD prevalence among Afghanistan veterans and well above the 13% rate reported for Iraq War veterans (U.S. Army Med. Dept. J. 2008;July-September:7-17). The prevalence is also more than twice the 9.4% estimate for the general adult population (J. Traum. Stress 2003;16:495-502).

“I'm surprised at the degree of the finding,” Dr. Nash said. “We never expected it would be twice as high.”

A lack of recognition and services to address their mental health symptoms may explain this higher rate of PTSD, compared with military personnel, Dr. Nash said. “My hypothesis is that rates are so much higher because … we prepare our troops before they leave but we don't prepare [their] families.”

Military training facilities and VA and community health centers should screen and treat significant others and family members for PTSD, added Dr. Nash, of Spalding University, Lexington, Ky.

Family members of deployed military personnel “typically don't have support, and they do all the work at home,” Dr. Nash said. Also, they may feel guilty about their symptoms, compared with what their family member might be experiencing, she added.

Lead author Rebecca K. Stahl, Dr. Nash, and their colleagues recruited participants through Yahoo and MSN forums for significant others of military service members. The participants completed a stressor-specific PTSD checklist and provided demographic information through an online survey.

They ranked degree of 17 possible PTSD symptoms on a scale from 1 (not at all) to 5 (extremely). Sleep issues, concentration, isolation, irritability/anger, and feeling upset at being reminded of the military service member's trauma were cited most often. “They see images [of the war] on TV,” Dr. Nash said.

People were diagnosed with PTSD if they had a total checklist score of 50 or more, combined with moderate or higher endorsement of certain DSM-IV TR symptoms: at least one reexperiencing symptom, three avoidance symptoms, and two hyperarousal symptoms. With this dual definition, 55 (20%) of significant others were diagnosed with PTSD.

The study cohort included significant others of service members deployed to Iraq, Afghanistan, Vietnam, Korea, and World War II.

Further investigation of PTSD in significant others is warranted, Dr. Nash said. If the findings are replicated, it would lend credence to inclusion of a vicarious trauma diagnosis in the DSM-5, Dr. Nash said.

ATLANTA — Significant others and family members experience posttraumatic stress disorder at rates that exceed those of military service members of current and previous wars, according to a study.

Using the most conservative estimates on the Psychopathology Checklist, 56 of 273 partners, parents, siblings, and other family members studied had PTSD, Brenda Nash, Ph.D., said in an interview at her poster during the annual meeting of the International Society for Traumatic Stress Studies.

This 21% rate is more than three times the reported 6% PTSD prevalence among Afghanistan veterans and well above the 13% rate reported for Iraq War veterans (U.S. Army Med. Dept. J. 2008;July-September:7-17). The prevalence is also more than twice the 9.4% estimate for the general adult population (J. Traum. Stress 2003;16:495-502).

“I'm surprised at the degree of the finding,” Dr. Nash said. “We never expected it would be twice as high.”

A lack of recognition and services to address their mental health symptoms may explain this higher rate of PTSD, compared with military personnel, Dr. Nash said. “My hypothesis is that rates are so much higher because … we prepare our troops before they leave but we don't prepare [their] families.”

Military training facilities and VA and community health centers should screen and treat significant others and family members for PTSD, added Dr. Nash, of Spalding University, Lexington, Ky.

Family members of deployed military personnel “typically don't have support, and they do all the work at home,” Dr. Nash said. Also, they may feel guilty about their symptoms, compared with what their family member might be experiencing, she added.

Lead author Rebecca K. Stahl, Dr. Nash, and their colleagues recruited participants through Yahoo and MSN forums for significant others of military service members. The participants completed a stressor-specific PTSD checklist and provided demographic information through an online survey.

They ranked degree of 17 possible PTSD symptoms on a scale from 1 (not at all) to 5 (extremely). Sleep issues, concentration, isolation, irritability/anger, and feeling upset at being reminded of the military service member's trauma were cited most often. “They see images [of the war] on TV,” Dr. Nash said.

People were diagnosed with PTSD if they had a total checklist score of 50 or more, combined with moderate or higher endorsement of certain DSM-IV TR symptoms: at least one reexperiencing symptom, three avoidance symptoms, and two hyperarousal symptoms. With this dual definition, 55 (20%) of significant others were diagnosed with PTSD.

The study cohort included significant others of service members deployed to Iraq, Afghanistan, Vietnam, Korea, and World War II.

Further investigation of PTSD in significant others is warranted, Dr. Nash said. If the findings are replicated, it would lend credence to inclusion of a vicarious trauma diagnosis in the DSM-5, Dr. Nash said.

Major Finding: Risk-adjusted rates of serious complications in bariatric surgery were 4.0% at designated Centers of Excellence, compared with 2.7% at other hospitals.

Data Source: Study of prospective registry of 7,504 bariatric surgeries in Michigan in 2006–2008.

Disclosures: Dr. Dimick had no relevant disclosures.

SAN ANTONIO — The risk-adjusted rate of serious complications associated with bariatric surgery was paradoxically higher at hospitals designated as a Center of Excellence in Michigan, compared with other centers, a study of more than 7,500 procedures indicates.

“I'm going to cause major controversy,” lead investigator Dr. Justin B. Dimick said at the annual Academic Surgical Congress, where he presented prospective data from the Michigan Bariatric Surgery Collaborative (MBSC) population-based clinical registry.

“The use of bariatric surgery has basically skyrocketed. This operation is not easy … and there is some variability,” said Dr. Dimick of the surgery faculty at the University of Michigan, Ann Arbor.

Dr. Dimick, Nancy Birkmeyer, Ph.D., director of the collaborative, and their colleagues studied all 7,504 patients undergoing laparoscopic or open gastric bypass, sleeve gastrectomy, and other bariatric surgery procedures from 2006 to 2008. Excluded from the study were patients who had had Lap-Band procedures.

They found the lowest risk-adjusted rate of serious complications at a high-volume hospital that was not a designated bariatric Center of Excellence. But even when this institution was removed from the analysis, patients at a designated center did not fare significantly better in terms of reoperation, anastomotic leak, or infectious and medical complication rates, compared with other hospitals.

A total of 5,121 patients (68%) had bariatric surgery at a Center of Excellence. They had a 4.0% risk-adjusted rate of serious complications, compared with 2.7% for the 2,383 patients treated at other hospitals. Outcomes included death or disability, complications, and hospitals readmission. “For all three of these, the Centers of Excellence had worse outcomes,” Dr. Dimick said.

There was no significant difference at 1 year in resolution of comorbidities by institution type, he said. One-year weight loss was not significantly different; patients at designated centers lost an average of 106 pounds versus 100 pounds at other hospitals. Also, improvements from baseline in health-related quality of life did not differ significantly; the Bariatric Quality of Life Index improved 12.4 points in patients at a Center of Excellence versus 11.8 among those treated elsewhere.

Dr. Dimick emphasized that he was not suggesting the Center of Excellence designation is bad. Indeed, he praised professional societies such as the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery for creating standards. Blue Cross and Blue Shield, he added, also designates hospitals as Distinction Centers for Bariatric Surgery using their own criteria. Blue Cross Blue Shield of Michigan funds the MBSC via a pay-for-participation system; hospitals are paid to participate, and bariatric surgeons are required to attend quarterly quality improvement meetings to share best practices.

The lack of significant difference in his study between Centers of Excellence and other facilities could be a result of all hospitals striving to improve because the criteria exist, Dr. Dimick suggested. Still, he added, “Patients seeking bariatric care, at least in Michigan, should not rely only on Centers of Excellence designation.”

The findings may not be generalizable to hospitals outside of Michigan because the surgeons in the study participated in a quality improvement collaboration, a meeting attendee said; Dr. Dimick agreed. In a follow-up video interview, he said, “The story here may be more about the success of quality improvement collaboratives statewide, than the lack of success of the Centers of Excellence program.” In the last two quarters, for example, there were no deaths associated with the approximately 3,000 bariatric procedures performed within that state.

Another meeting attendee pointed out that a study by Dr. Edward H. Livingston and his colleagues at the University of Texas Southwestern Medical Center at Dallas found equivalent outcomes at Centers of Excellence versus other hospitals (Arch. Surg. 2009;144:319-25). These researchers used bariatric surgery data from the 2005 National Inpatient Survey and found no significant differences despite a higher volume of procedures at institutions designated as a Center of Excellence.

“I know Dr. Livingston's study is controversial as well … because he used an administrative database, which has a limited ability to ascertain complications. Our study had the limitation of generalizability beyond Michigan.” Dr. Dimick said.

“The next obvious study is to see if Centers of Excellence have better outcomes outside of this unique quality collaborative,” Dr. Dimick said. “The problem with that is we don't really have population-based data sources outside of the State of Michigan.”

To see a video with Dr. Dimick explaining more about the study, including reactions from colleagues, go to www.youtube.com/ClinicalEndoNews

Major Finding: Risk-adjusted rates of serious complications in bariatric surgery were 4.0% at designated Centers of Excellence, compared with 2.7% at other hospitals.

Data Source: Study of prospective registry of 7,504 bariatric surgeries in Michigan in 2006–2008.

Disclosures: Dr. Dimick had no relevant disclosures.

SAN ANTONIO — The risk-adjusted rate of serious complications associated with bariatric surgery was paradoxically higher at hospitals designated as a Center of Excellence in Michigan, compared with other centers, a study of more than 7,500 procedures indicates.

“I'm going to cause major controversy,” lead investigator Dr. Justin B. Dimick said at the annual Academic Surgical Congress, where he presented prospective data from the Michigan Bariatric Surgery Collaborative (MBSC) population-based clinical registry.

“The use of bariatric surgery has basically skyrocketed. This operation is not easy … and there is some variability,” said Dr. Dimick of the surgery faculty at the University of Michigan, Ann Arbor.

Dr. Dimick, Nancy Birkmeyer, Ph.D., director of the collaborative, and their colleagues studied all 7,504 patients undergoing laparoscopic or open gastric bypass, sleeve gastrectomy, and other bariatric surgery procedures from 2006 to 2008. Excluded from the study were patients who had had Lap-Band procedures.

They found the lowest risk-adjusted rate of serious complications at a high-volume hospital that was not a designated bariatric Center of Excellence. But even when this institution was removed from the analysis, patients at a designated center did not fare significantly better in terms of reoperation, anastomotic leak, or infectious and medical complication rates, compared with other hospitals.

A total of 5,121 patients (68%) had bariatric surgery at a Center of Excellence. They had a 4.0% risk-adjusted rate of serious complications, compared with 2.7% for the 2,383 patients treated at other hospitals. Outcomes included death or disability, complications, and hospitals readmission. “For all three of these, the Centers of Excellence had worse outcomes,” Dr. Dimick said.

There was no significant difference at 1 year in resolution of comorbidities by institution type, he said. One-year weight loss was not significantly different; patients at designated centers lost an average of 106 pounds versus 100 pounds at other hospitals. Also, improvements from baseline in health-related quality of life did not differ significantly; the Bariatric Quality of Life Index improved 12.4 points in patients at a Center of Excellence versus 11.8 among those treated elsewhere.

Dr. Dimick emphasized that he was not suggesting the Center of Excellence designation is bad. Indeed, he praised professional societies such as the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery for creating standards. Blue Cross and Blue Shield, he added, also designates hospitals as Distinction Centers for Bariatric Surgery using their own criteria. Blue Cross Blue Shield of Michigan funds the MBSC via a pay-for-participation system; hospitals are paid to participate, and bariatric surgeons are required to attend quarterly quality improvement meetings to share best practices.

The lack of significant difference in his study between Centers of Excellence and other facilities could be a result of all hospitals striving to improve because the criteria exist, Dr. Dimick suggested. Still, he added, “Patients seeking bariatric care, at least in Michigan, should not rely only on Centers of Excellence designation.”

The findings may not be generalizable to hospitals outside of Michigan because the surgeons in the study participated in a quality improvement collaboration, a meeting attendee said; Dr. Dimick agreed. In a follow-up video interview, he said, “The story here may be more about the success of quality improvement collaboratives statewide, than the lack of success of the Centers of Excellence program.” In the last two quarters, for example, there were no deaths associated with the approximately 3,000 bariatric procedures performed within that state.

Another meeting attendee pointed out that a study by Dr. Edward H. Livingston and his colleagues at the University of Texas Southwestern Medical Center at Dallas found equivalent outcomes at Centers of Excellence versus other hospitals (Arch. Surg. 2009;144:319-25). These researchers used bariatric surgery data from the 2005 National Inpatient Survey and found no significant differences despite a higher volume of procedures at institutions designated as a Center of Excellence.

“I know Dr. Livingston's study is controversial as well … because he used an administrative database, which has a limited ability to ascertain complications. Our study had the limitation of generalizability beyond Michigan.” Dr. Dimick said.

“The next obvious study is to see if Centers of Excellence have better outcomes outside of this unique quality collaborative,” Dr. Dimick said. “The problem with that is we don't really have population-based data sources outside of the State of Michigan.”

To see a video with Dr. Dimick explaining more about the study, including reactions from colleagues, go to www.youtube.com/ClinicalEndoNews

Major Finding: Risk-adjusted rates of serious complications in bariatric surgery were 4.0% at designated Centers of Excellence, compared with 2.7% at other hospitals.

Data Source: Study of prospective registry of 7,504 bariatric surgeries in Michigan in 2006–2008.

Disclosures: Dr. Dimick had no relevant disclosures.

SAN ANTONIO — The risk-adjusted rate of serious complications associated with bariatric surgery was paradoxically higher at hospitals designated as a Center of Excellence in Michigan, compared with other centers, a study of more than 7,500 procedures indicates.

“I'm going to cause major controversy,” lead investigator Dr. Justin B. Dimick said at the annual Academic Surgical Congress, where he presented prospective data from the Michigan Bariatric Surgery Collaborative (MBSC) population-based clinical registry.

“The use of bariatric surgery has basically skyrocketed. This operation is not easy … and there is some variability,” said Dr. Dimick of the surgery faculty at the University of Michigan, Ann Arbor.

Dr. Dimick, Nancy Birkmeyer, Ph.D., director of the collaborative, and their colleagues studied all 7,504 patients undergoing laparoscopic or open gastric bypass, sleeve gastrectomy, and other bariatric surgery procedures from 2006 to 2008. Excluded from the study were patients who had had Lap-Band procedures.

They found the lowest risk-adjusted rate of serious complications at a high-volume hospital that was not a designated bariatric Center of Excellence. But even when this institution was removed from the analysis, patients at a designated center did not fare significantly better in terms of reoperation, anastomotic leak, or infectious and medical complication rates, compared with other hospitals.

A total of 5,121 patients (68%) had bariatric surgery at a Center of Excellence. They had a 4.0% risk-adjusted rate of serious complications, compared with 2.7% for the 2,383 patients treated at other hospitals. Outcomes included death or disability, complications, and hospitals readmission. “For all three of these, the Centers of Excellence had worse outcomes,” Dr. Dimick said.

There was no significant difference at 1 year in resolution of comorbidities by institution type, he said. One-year weight loss was not significantly different; patients at designated centers lost an average of 106 pounds versus 100 pounds at other hospitals. Also, improvements from baseline in health-related quality of life did not differ significantly; the Bariatric Quality of Life Index improved 12.4 points in patients at a Center of Excellence versus 11.8 among those treated elsewhere.

Dr. Dimick emphasized that he was not suggesting the Center of Excellence designation is bad. Indeed, he praised professional societies such as the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery for creating standards. Blue Cross and Blue Shield, he added, also designates hospitals as Distinction Centers for Bariatric Surgery using their own criteria. Blue Cross Blue Shield of Michigan funds the MBSC via a pay-for-participation system; hospitals are paid to participate, and bariatric surgeons are required to attend quarterly quality improvement meetings to share best practices.

The lack of significant difference in his study between Centers of Excellence and other facilities could be a result of all hospitals striving to improve because the criteria exist, Dr. Dimick suggested. Still, he added, “Patients seeking bariatric care, at least in Michigan, should not rely only on Centers of Excellence designation.”

The findings may not be generalizable to hospitals outside of Michigan because the surgeons in the study participated in a quality improvement collaboration, a meeting attendee said; Dr. Dimick agreed. In a follow-up video interview, he said, “The story here may be more about the success of quality improvement collaboratives statewide, than the lack of success of the Centers of Excellence program.” In the last two quarters, for example, there were no deaths associated with the approximately 3,000 bariatric procedures performed within that state.

Another meeting attendee pointed out that a study by Dr. Edward H. Livingston and his colleagues at the University of Texas Southwestern Medical Center at Dallas found equivalent outcomes at Centers of Excellence versus other hospitals (Arch. Surg. 2009;144:319-25). These researchers used bariatric surgery data from the 2005 National Inpatient Survey and found no significant differences despite a higher volume of procedures at institutions designated as a Center of Excellence.

“I know Dr. Livingston's study is controversial as well … because he used an administrative database, which has a limited ability to ascertain complications. Our study had the limitation of generalizability beyond Michigan.” Dr. Dimick said.

“The next obvious study is to see if Centers of Excellence have better outcomes outside of this unique quality collaborative,” Dr. Dimick said. “The problem with that is we don't really have population-based data sources outside of the State of Michigan.”

To see a video with Dr. Dimick explaining more about the study, including reactions from colleagues, go to www.youtube.com/ClinicalEndoNews

SAN ANTONIO — Breast conservation therapy resulted in significantly better 5-year overall survival, compared with mastectomy, investigators found in a study of 202 patients with triple receptor–negative breast cancer.

Triple receptor–negative breast tumors lack estrogen-, progesterone-, and Her-2/neu-receptor expression. These aggressive cancers account for 15%–20% of the more than 1 million breast cancers diagnosed each year worldwide.

“Despite the aggressive nature [of these tumors], our hypothesis was that breast conservation therapy [might be a] viable option for some patients,” Dr. Catherine C. Parker said at the annual Academic Surgical Congress.

She and her colleagues at Louisiana State University, Shreveport, studied outcomes of 63 patients (31%) who had breast conservation therapy and 139 who received mastectomy. Cancer recurrence rates and survival were the primary outcomes. Mean tumor size at baseline was significantly greater in the mastectomy group, 3.1 cm, versus 2.5 cm in the breast conservation group. A total of 26% of the mastectomy patients had T3 or T4 tumors, compared with 5% of the breast conservation group, a statistically significant difference.

All patients were offered standard of care treatment and surveillance. The mean follow-up was 53 months. Disease-free survival at 5 years was 56% for the mastectomy group and 69% for the breast conservation therapy group. The difference was not statistically significant, Dr. Parker said.

“Five-year overall survival was significantly better for breast conservation therapy [89% vs. 69%],” said Dr. Parker of the department of surgery at LSU.

Reasons for disparity in overall survival include the larger mean tumor size and more advanced stage of disease in the mastectomy group, Dr. Parker said.

Recurrence rates were 30% for the breast conservation group and 43% for the mastectomy group.

A multivariate analysis indicated that the surgical approach had no effect on disease-free or overall survival.

Dr. Parker had no relevant disclosures.

SAN ANTONIO — Breast conservation therapy resulted in significantly better 5-year overall survival, compared with mastectomy, investigators found in a study of 202 patients with triple receptor–negative breast cancer.

Triple receptor–negative breast tumors lack estrogen-, progesterone-, and Her-2/neu-receptor expression. These aggressive cancers account for 15%–20% of the more than 1 million breast cancers diagnosed each year worldwide.

“Despite the aggressive nature [of these tumors], our hypothesis was that breast conservation therapy [might be a] viable option for some patients,” Dr. Catherine C. Parker said at the annual Academic Surgical Congress.

She and her colleagues at Louisiana State University, Shreveport, studied outcomes of 63 patients (31%) who had breast conservation therapy and 139 who received mastectomy. Cancer recurrence rates and survival were the primary outcomes. Mean tumor size at baseline was significantly greater in the mastectomy group, 3.1 cm, versus 2.5 cm in the breast conservation group. A total of 26% of the mastectomy patients had T3 or T4 tumors, compared with 5% of the breast conservation group, a statistically significant difference.

All patients were offered standard of care treatment and surveillance. The mean follow-up was 53 months. Disease-free survival at 5 years was 56% for the mastectomy group and 69% for the breast conservation therapy group. The difference was not statistically significant, Dr. Parker said.

“Five-year overall survival was significantly better for breast conservation therapy [89% vs. 69%],” said Dr. Parker of the department of surgery at LSU.

Reasons for disparity in overall survival include the larger mean tumor size and more advanced stage of disease in the mastectomy group, Dr. Parker said.

Recurrence rates were 30% for the breast conservation group and 43% for the mastectomy group.

A multivariate analysis indicated that the surgical approach had no effect on disease-free or overall survival.

Dr. Parker had no relevant disclosures.

SAN ANTONIO — Breast conservation therapy resulted in significantly better 5-year overall survival, compared with mastectomy, investigators found in a study of 202 patients with triple receptor–negative breast cancer.

Triple receptor–negative breast tumors lack estrogen-, progesterone-, and Her-2/neu-receptor expression. These aggressive cancers account for 15%–20% of the more than 1 million breast cancers diagnosed each year worldwide.

“Despite the aggressive nature [of these tumors], our hypothesis was that breast conservation therapy [might be a] viable option for some patients,” Dr. Catherine C. Parker said at the annual Academic Surgical Congress.

She and her colleagues at Louisiana State University, Shreveport, studied outcomes of 63 patients (31%) who had breast conservation therapy and 139 who received mastectomy. Cancer recurrence rates and survival were the primary outcomes. Mean tumor size at baseline was significantly greater in the mastectomy group, 3.1 cm, versus 2.5 cm in the breast conservation group. A total of 26% of the mastectomy patients had T3 or T4 tumors, compared with 5% of the breast conservation group, a statistically significant difference.

All patients were offered standard of care treatment and surveillance. The mean follow-up was 53 months. Disease-free survival at 5 years was 56% for the mastectomy group and 69% for the breast conservation therapy group. The difference was not statistically significant, Dr. Parker said.

“Five-year overall survival was significantly better for breast conservation therapy [89% vs. 69%],” said Dr. Parker of the department of surgery at LSU.

Reasons for disparity in overall survival include the larger mean tumor size and more advanced stage of disease in the mastectomy group, Dr. Parker said.

Recurrence rates were 30% for the breast conservation group and 43% for the mastectomy group.

A multivariate analysis indicated that the surgical approach had no effect on disease-free or overall survival.

Dr. Parker had no relevant disclosures.

HOLLYWOOD, FLA. — Obese women planning incontinence surgery have more severe urinary incontinence symptom distress, worse quality of life, and more frequent incontinence episodes than overweight or normal-weight women, even after other obesity-related factors are controlled for, according to a secondary analysis of two large study populations.

There are limited data in the literature, however, to explain why obese women with stress urinary incontinence might experience more distress. One possibility is that increased intra-abdominal pressure in obese patients may cause chronic “stress” to the urinary bladder, leading to incontinence, Dr. Holly E. Richter said.

To find out more, Dr. Richter and her associates performed a secondary analysis of women with stress urinary incontinence seeking surgery. They assessed 655 participants from the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr) (Urology 2005;66:1213-7) and 597 patients from the ongoing Trial of Mid-Urethral Slings (TOMUS)

For the current study, the researchers pooled and grouped the women according to body mass index cutoffs for obesity (30 kg/m

The Urogenital Distress Inventory (UDI) total score, incontinence episode frequency on 3-day diaries, pad weights, and Valsalva leak point pressures were higher among obese women versus overweight and normal-weight women, Dr. Richter said at the annual meeting of the American Urogynecologic Society.

Specifically, the mean UDI total score was 139 in the normal-weight women, 147 in overweight women, and 160 among obese women in SISTEr. In TOMUS, the UDI total scores were 124 in the normal-weight participants, 130 in the overweight participants, and 144 among the obese participants. The differences were statistically significant between groups in both trials.

“Obese women appear to have better urethral function,” Dr. Richter said, based on their higher Valsalva leak point pressures and maximal urethral closure pressures (measured in the TOMUS study). These higher pressures might indicate a compensatory mechanism in obese women.

Other incontinence severity measures, including the UDI urge subscale score and the Incontinence Impact Questionnaire total score also were higher for obese versus other participants, said Dr. Richter, professor of obstetrics and gynecology at the University of Alabama at Birmingham.

Approximately 45% of subjects were obese in both trials. The mean age was about 52 years, the majority of women were white (75%–80%), and there was no significant difference between BMI categories in terms of diabetes incidence, Dr. Richter said.

“Obesity did not [have an] impact in terms of success of surgery, at least in the SISTEr trial,” she said.

Disclosures: The National Institute of Diabetes and Digestive and Kidney Diseases and the National Institute of Child Health and Human Development provided funding. Dr. Richter said she had no relevant disclosures.

HOLLYWOOD, FLA. — Obese women planning incontinence surgery have more severe urinary incontinence symptom distress, worse quality of life, and more frequent incontinence episodes than overweight or normal-weight women, even after other obesity-related factors are controlled for, according to a secondary analysis of two large study populations.

There are limited data in the literature, however, to explain why obese women with stress urinary incontinence might experience more distress. One possibility is that increased intra-abdominal pressure in obese patients may cause chronic “stress” to the urinary bladder, leading to incontinence, Dr. Holly E. Richter said.

To find out more, Dr. Richter and her associates performed a secondary analysis of women with stress urinary incontinence seeking surgery. They assessed 655 participants from the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr) (Urology 2005;66:1213-7) and 597 patients from the ongoing Trial of Mid-Urethral Slings (TOMUS)

For the current study, the researchers pooled and grouped the women according to body mass index cutoffs for obesity (30 kg/m

The Urogenital Distress Inventory (UDI) total score, incontinence episode frequency on 3-day diaries, pad weights, and Valsalva leak point pressures were higher among obese women versus overweight and normal-weight women, Dr. Richter said at the annual meeting of the American Urogynecologic Society.

Specifically, the mean UDI total score was 139 in the normal-weight women, 147 in overweight women, and 160 among obese women in SISTEr. In TOMUS, the UDI total scores were 124 in the normal-weight participants, 130 in the overweight participants, and 144 among the obese participants. The differences were statistically significant between groups in both trials.

“Obese women appear to have better urethral function,” Dr. Richter said, based on their higher Valsalva leak point pressures and maximal urethral closure pressures (measured in the TOMUS study). These higher pressures might indicate a compensatory mechanism in obese women.

Other incontinence severity measures, including the UDI urge subscale score and the Incontinence Impact Questionnaire total score also were higher for obese versus other participants, said Dr. Richter, professor of obstetrics and gynecology at the University of Alabama at Birmingham.

Approximately 45% of subjects were obese in both trials. The mean age was about 52 years, the majority of women were white (75%–80%), and there was no significant difference between BMI categories in terms of diabetes incidence, Dr. Richter said.

“Obesity did not [have an] impact in terms of success of surgery, at least in the SISTEr trial,” she said.

Disclosures: The National Institute of Diabetes and Digestive and Kidney Diseases and the National Institute of Child Health and Human Development provided funding. Dr. Richter said she had no relevant disclosures.

HOLLYWOOD, FLA. — Obese women planning incontinence surgery have more severe urinary incontinence symptom distress, worse quality of life, and more frequent incontinence episodes than overweight or normal-weight women, even after other obesity-related factors are controlled for, according to a secondary analysis of two large study populations.

There are limited data in the literature, however, to explain why obese women with stress urinary incontinence might experience more distress. One possibility is that increased intra-abdominal pressure in obese patients may cause chronic “stress” to the urinary bladder, leading to incontinence, Dr. Holly E. Richter said.

To find out more, Dr. Richter and her associates performed a secondary analysis of women with stress urinary incontinence seeking surgery. They assessed 655 participants from the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr) (Urology 2005;66:1213-7) and 597 patients from the ongoing Trial of Mid-Urethral Slings (TOMUS)

For the current study, the researchers pooled and grouped the women according to body mass index cutoffs for obesity (30 kg/m

The Urogenital Distress Inventory (UDI) total score, incontinence episode frequency on 3-day diaries, pad weights, and Valsalva leak point pressures were higher among obese women versus overweight and normal-weight women, Dr. Richter said at the annual meeting of the American Urogynecologic Society.

Specifically, the mean UDI total score was 139 in the normal-weight women, 147 in overweight women, and 160 among obese women in SISTEr. In TOMUS, the UDI total scores were 124 in the normal-weight participants, 130 in the overweight participants, and 144 among the obese participants. The differences were statistically significant between groups in both trials.

“Obese women appear to have better urethral function,” Dr. Richter said, based on their higher Valsalva leak point pressures and maximal urethral closure pressures (measured in the TOMUS study). These higher pressures might indicate a compensatory mechanism in obese women.

Other incontinence severity measures, including the UDI urge subscale score and the Incontinence Impact Questionnaire total score also were higher for obese versus other participants, said Dr. Richter, professor of obstetrics and gynecology at the University of Alabama at Birmingham.

Approximately 45% of subjects were obese in both trials. The mean age was about 52 years, the majority of women were white (75%–80%), and there was no significant difference between BMI categories in terms of diabetes incidence, Dr. Richter said.

“Obesity did not [have an] impact in terms of success of surgery, at least in the SISTEr trial,” she said.

Disclosures: The National Institute of Diabetes and Digestive and Kidney Diseases and the National Institute of Child Health and Human Development provided funding. Dr. Richter said she had no relevant disclosures.

MIAMI BEACH — Levodopa produces greater symptomatic relief for Parkinson's disease patients compared with a dopamine agonist, consistent results of long-term studies indicate, but more dyskinesia and motor fluctuations are the trade-offs.

Dopamine agonists are still effective treatments for Parkinson's disease, said Dr. Cheryl Waters at World Federation of Neurology World Congress on Parkinson's Disease and Related Disorders. So how do you choose one or the other for initial therapy?

Use patient age as a general guide, she advised. Prescribe levodopa for older and dopamine agonists for younger patients. However, “we shouldn't be firmly stating use of a dopamine agonist or levodopa. We are individualizing therapy.”

“The naysayers are going to say that … the long-term results of recent studies show people will ultimately do poorly,” Dr. Waters said. “But we have a long course of Parkinson's disease. Let's look at that and not just focus on the end stages.”

In the Comparison of the Agonist Pramipexole With Levodopa on Motor Complications of Parkinson's Disease, Dr. Waters, professor of clinical neurology at Columbia University Medical Center in New York City, and her colleagues randomized 151 patients to pramipexole and 150 others to levodopa in 1996 and 1997. The participants were permitted to switch to levodopa during an open-label phase. Six-year results for 222 participants showed that 50% of the initial pramipexole group and 69% of the initial levodopa group experienced motor complications (Arch. Neurol. 2009;66:563-70).

In addition, by the final visit, dyskinesias were more common in the initial levodopa group than in the initial pramipexole group (37% vs. 20%, respectively), she said. “Those in the pramipexole group have substantially remained on pramipexole all these years, even though they are not in the trial anymore,” though the initial levodopa group reported less severe somnolence.

Dr. Waters also referred to the Pergolide versus L-dopa monotherapy and positron emission tomography (PELMOPET) trial in which 148 early Parkinson's disease patients were randomized to pergolide (Permax) and another 146 to levodopa in this 3-year, multicenter, double-blind study (Mov. Disord. 2006;21:343-53)

There was a significant delay in the onset of dyskinesia and lower severity of motor symptoms in the pergolide group, Dr. Waters said. The levodopa group, however, reported significantly greater symptomatic relief on the Unified Parkinson's Disease Rating Scale (UPDRS) sections I, II, and III; Clinical Global Impressions severity and improvement ratings; and the Patient Global Impressions improvement scale.

The authors concluded from these results that both agents are suitable for initial therapy. However, pergolide was withdrawn from the U.S. market in 2007 because of its potential for causing heart valve damage.

Dr. Waters also addressed the 10-year results of a ropinirole (Requip) versus levodopa study (Mov. Disord. 2007;22:2409-17).

This was an extension of a study that compared treatment with ropinirole in 85 patients with levodopa therapy in 45 patients at 5 years (N. Engl. J. Med. 2000;342:1484-91). At that time point, the cumulative incidence of dyskinesia was 20% with ropinirole, compared with 45% with levodopa.

At 10 years, 51 patients remained in the ropinirole cohort and 29 in the levodopa group. “The numbers were small. Not all centers participated,” Dr. Waters said. “Even after the 10 years, there was a substantial difference in those being free of dyskinesia for those initially randomized to ropinirole [52%] versus levodopa [77%].”

“These clinical trials are all quite consistent,” Dr. Waters said. “Dyskinesia is better with dopamine agonists and the [symptomatic] effect of levodopa is greater.”

MIAMI BEACH — Levodopa produces greater symptomatic relief for Parkinson's disease patients compared with a dopamine agonist, consistent results of long-term studies indicate, but more dyskinesia and motor fluctuations are the trade-offs.

Dopamine agonists are still effective treatments for Parkinson's disease, said Dr. Cheryl Waters at World Federation of Neurology World Congress on Parkinson's Disease and Related Disorders. So how do you choose one or the other for initial therapy?

Use patient age as a general guide, she advised. Prescribe levodopa for older and dopamine agonists for younger patients. However, “we shouldn't be firmly stating use of a dopamine agonist or levodopa. We are individualizing therapy.”

“The naysayers are going to say that … the long-term results of recent studies show people will ultimately do poorly,” Dr. Waters said. “But we have a long course of Parkinson's disease. Let's look at that and not just focus on the end stages.”

In the Comparison of the Agonist Pramipexole With Levodopa on Motor Complications of Parkinson's Disease, Dr. Waters, professor of clinical neurology at Columbia University Medical Center in New York City, and her colleagues randomized 151 patients to pramipexole and 150 others to levodopa in 1996 and 1997. The participants were permitted to switch to levodopa during an open-label phase. Six-year results for 222 participants showed that 50% of the initial pramipexole group and 69% of the initial levodopa group experienced motor complications (Arch. Neurol. 2009;66:563-70).

In addition, by the final visit, dyskinesias were more common in the initial levodopa group than in the initial pramipexole group (37% vs. 20%, respectively), she said. “Those in the pramipexole group have substantially remained on pramipexole all these years, even though they are not in the trial anymore,” though the initial levodopa group reported less severe somnolence.

Dr. Waters also referred to the Pergolide versus L-dopa monotherapy and positron emission tomography (PELMOPET) trial in which 148 early Parkinson's disease patients were randomized to pergolide (Permax) and another 146 to levodopa in this 3-year, multicenter, double-blind study (Mov. Disord. 2006;21:343-53)

There was a significant delay in the onset of dyskinesia and lower severity of motor symptoms in the pergolide group, Dr. Waters said. The levodopa group, however, reported significantly greater symptomatic relief on the Unified Parkinson's Disease Rating Scale (UPDRS) sections I, II, and III; Clinical Global Impressions severity and improvement ratings; and the Patient Global Impressions improvement scale.

The authors concluded from these results that both agents are suitable for initial therapy. However, pergolide was withdrawn from the U.S. market in 2007 because of its potential for causing heart valve damage.

Dr. Waters also addressed the 10-year results of a ropinirole (Requip) versus levodopa study (Mov. Disord. 2007;22:2409-17).

This was an extension of a study that compared treatment with ropinirole in 85 patients with levodopa therapy in 45 patients at 5 years (N. Engl. J. Med. 2000;342:1484-91). At that time point, the cumulative incidence of dyskinesia was 20% with ropinirole, compared with 45% with levodopa.

At 10 years, 51 patients remained in the ropinirole cohort and 29 in the levodopa group. “The numbers were small. Not all centers participated,” Dr. Waters said. “Even after the 10 years, there was a substantial difference in those being free of dyskinesia for those initially randomized to ropinirole [52%] versus levodopa [77%].”

“These clinical trials are all quite consistent,” Dr. Waters said. “Dyskinesia is better with dopamine agonists and the [symptomatic] effect of levodopa is greater.”

MIAMI BEACH — Levodopa produces greater symptomatic relief for Parkinson's disease patients compared with a dopamine agonist, consistent results of long-term studies indicate, but more dyskinesia and motor fluctuations are the trade-offs.

Dopamine agonists are still effective treatments for Parkinson's disease, said Dr. Cheryl Waters at World Federation of Neurology World Congress on Parkinson's Disease and Related Disorders. So how do you choose one or the other for initial therapy?

Use patient age as a general guide, she advised. Prescribe levodopa for older and dopamine agonists for younger patients. However, “we shouldn't be firmly stating use of a dopamine agonist or levodopa. We are individualizing therapy.”

“The naysayers are going to say that … the long-term results of recent studies show people will ultimately do poorly,” Dr. Waters said. “But we have a long course of Parkinson's disease. Let's look at that and not just focus on the end stages.”

In the Comparison of the Agonist Pramipexole With Levodopa on Motor Complications of Parkinson's Disease, Dr. Waters, professor of clinical neurology at Columbia University Medical Center in New York City, and her colleagues randomized 151 patients to pramipexole and 150 others to levodopa in 1996 and 1997. The participants were permitted to switch to levodopa during an open-label phase. Six-year results for 222 participants showed that 50% of the initial pramipexole group and 69% of the initial levodopa group experienced motor complications (Arch. Neurol. 2009;66:563-70).

In addition, by the final visit, dyskinesias were more common in the initial levodopa group than in the initial pramipexole group (37% vs. 20%, respectively), she said. “Those in the pramipexole group have substantially remained on pramipexole all these years, even though they are not in the trial anymore,” though the initial levodopa group reported less severe somnolence.

Dr. Waters also referred to the Pergolide versus L-dopa monotherapy and positron emission tomography (PELMOPET) trial in which 148 early Parkinson's disease patients were randomized to pergolide (Permax) and another 146 to levodopa in this 3-year, multicenter, double-blind study (Mov. Disord. 2006;21:343-53)

There was a significant delay in the onset of dyskinesia and lower severity of motor symptoms in the pergolide group, Dr. Waters said. The levodopa group, however, reported significantly greater symptomatic relief on the Unified Parkinson's Disease Rating Scale (UPDRS) sections I, II, and III; Clinical Global Impressions severity and improvement ratings; and the Patient Global Impressions improvement scale.

The authors concluded from these results that both agents are suitable for initial therapy. However, pergolide was withdrawn from the U.S. market in 2007 because of its potential for causing heart valve damage.

Dr. Waters also addressed the 10-year results of a ropinirole (Requip) versus levodopa study (Mov. Disord. 2007;22:2409-17).

This was an extension of a study that compared treatment with ropinirole in 85 patients with levodopa therapy in 45 patients at 5 years (N. Engl. J. Med. 2000;342:1484-91). At that time point, the cumulative incidence of dyskinesia was 20% with ropinirole, compared with 45% with levodopa.

At 10 years, 51 patients remained in the ropinirole cohort and 29 in the levodopa group. “The numbers were small. Not all centers participated,” Dr. Waters said. “Even after the 10 years, there was a substantial difference in those being free of dyskinesia for those initially randomized to ropinirole [52%] versus levodopa [77%].”

“These clinical trials are all quite consistent,” Dr. Waters said. “Dyskinesia is better with dopamine agonists and the [symptomatic] effect of levodopa is greater.”

MIAMI BEACH — Aggregation of proteins within dopaminergic and other neuronal cells may play an important role in the development and progression of Parkinson's disease.

Although the etiology of Parkinson's disease is likely multifactorial, these findings point researchers toward one important group of candidate targets for future therapies, Dr. C. Warren Olanow said at the World Federation of Neurology World Congress on Parkinson's Disease and Related Disorders.

“Although we have not yet found a neuroprotective drug for Parkinson's disease, the future is looking brighter,” he said. “Gene studies are directing us to look at mitochondria and proteins that lead to misfolding and prion-like activity. This may lead to very promising therapies.”

Dr. Olanow is chairman emeritus of the department of neurology at Mount Sinai School of Medicine, New York. He disclosed that he is a consultant for Boehringer Ingelheim GmbH, Ceregene Inc., Merck Serono S.A., Novartis Pharmaceuticals Corp., and Teva Neuroscience Inc., all of which manufacture or are developing medications for Parkinson's disease.

Normally, there is a balance between the number of proteins being formed and the ability to clear them, said Dr. Olanow. “Protein aggregation is much more than what we appreciated. Of the systems for clearing accumulated protein, the ubiquitin-proteasome system is the most important. This is a series of enzymes that signal for protein to be transported to a proteasome, where it is broken down.”

Healthy embryonic cells transferred to the substantia nigra of a person with Parkinson's disease have shown characteristic features of the disease (Nat. Med. 2008;14:504-6). In that study, the transplants showed hallmark signs of Parkinson's disease, including Lewy body pathology; increased levels of the protein alpha-synuclein, a protein of unknown function found abundantly in Lewy bodies; and reduced amounts of dopamine transporter in a post mortem examination 14 years later. The grafted cells had adopted the features of the host dopaminergic neurons, suggesting that ongoing changes occur with Parkinson's disease.

Aggregation and misfolding may occur when excess protein overwhelms the clearance system and/or a neuron with normal levels has an impaired clearance system. Lysosomal or proteasomal degradation of alpha-synuclein is likely the clearance mechanism in healthy individuals. “Overproduction of alpha-synuclein alone is shown to be enough to start the cell death process in Parkinson's disease,” Dr. Olanow noted.

Although alpha-synuclein is a major focus of research, other proteins are likely involved in Parkinson's disease as well, Dr. Olanow said. “With respect to the lysosome system, as you increase protein accumulation, it begins to block the LAMP [lysosome-associated membrane protein] receptors and other proteins can start to accumulate as well.”

Neuron-to-neuron transmission of alpha-synuclein has been demonstrated (Proc. Natl. Acad. Sci. USA 2009;106:13010-15). In that study, a substantial number of transplanted healthy embryonic cells overexpressed alpha-synuclein from host cells in a relatively short time, Dr. Olanow said. “This showed that alpha-synuclein can travel across a neuron and be taken up by a healthy neuron, leading to protein uptake, aggregation, and cell death.” This endocytosis of alpha-synuclein from one neuron to another might play a role in the progressive spread of Lewy pathology in the nervous systems of people with Parkinson's disease.

“With that in mind, we can perhaps revise the hypothesized model [to say] that alpha-synuclein itself can act as a prion to promote protein accumulation,” said Dr. Olanow (Proc. Natl. Acad. Sci. USA 2009;106:12571-2).

“This could perhaps explain the fascinating observations suggested by Braak and his colleagues [Neurobiol. Aging. 2003;24:197-211] where [effects of the disease are] first seen in the olfactory bulb and the brain stem, then spread to other brain regions,” he said. “Could it be a prion-like effect?”

An attendee asked why some brain regions are not included in Braak's hypothesis about connections between different anatomic areas playing a role in progression of Parkinson's disease. “I don't know the answer,” Dr. Olanow said. “[This] is pure speculation, but one type of cell might have a better ability to clear proteins than another.”

The sobering news is that much about the pathogenesis of Parkinson's disease remains unknown. “We are not sure which factor, if any, is the primary driver of cell death. And the primary factor may be different in different individuals,” Dr. Olanow said. In addition, there may be a network of different, interactive pathogenic factors that initiate the disease process, “so blocking any one of them might not halt the process.”

Even so, these recent findings could lead to neuroprotective therapies directed at proteins and/or agents that prevent protein misfolding, promote refolding, and/or facilitate clearance of aggregated proteins, he said.

Gene study data suggest looking at 'mitochondria and proteins that lead to misfolding and prion-like activity.'

Source DR. OLANOW

MIAMI BEACH — Aggregation of proteins within dopaminergic and other neuronal cells may play an important role in the development and progression of Parkinson's disease.

Although the etiology of Parkinson's disease is likely multifactorial, these findings point researchers toward one important group of candidate targets for future therapies, Dr. C. Warren Olanow said at the World Federation of Neurology World Congress on Parkinson's Disease and Related Disorders.

“Although we have not yet found a neuroprotective drug for Parkinson's disease, the future is looking brighter,” he said. “Gene studies are directing us to look at mitochondria and proteins that lead to misfolding and prion-like activity. This may lead to very promising therapies.”

Dr. Olanow is chairman emeritus of the department of neurology at Mount Sinai School of Medicine, New York. He disclosed that he is a consultant for Boehringer Ingelheim GmbH, Ceregene Inc., Merck Serono S.A., Novartis Pharmaceuticals Corp., and Teva Neuroscience Inc., all of which manufacture or are developing medications for Parkinson's disease.

Normally, there is a balance between the number of proteins being formed and the ability to clear them, said Dr. Olanow. “Protein aggregation is much more than what we appreciated. Of the systems for clearing accumulated protein, the ubiquitin-proteasome system is the most important. This is a series of enzymes that signal for protein to be transported to a proteasome, where it is broken down.”

Healthy embryonic cells transferred to the substantia nigra of a person with Parkinson's disease have shown characteristic features of the disease (Nat. Med. 2008;14:504-6). In that study, the transplants showed hallmark signs of Parkinson's disease, including Lewy body pathology; increased levels of the protein alpha-synuclein, a protein of unknown function found abundantly in Lewy bodies; and reduced amounts of dopamine transporter in a post mortem examination 14 years later. The grafted cells had adopted the features of the host dopaminergic neurons, suggesting that ongoing changes occur with Parkinson's disease.

Aggregation and misfolding may occur when excess protein overwhelms the clearance system and/or a neuron with normal levels has an impaired clearance system. Lysosomal or proteasomal degradation of alpha-synuclein is likely the clearance mechanism in healthy individuals. “Overproduction of alpha-synuclein alone is shown to be enough to start the cell death process in Parkinson's disease,” Dr. Olanow noted.

Although alpha-synuclein is a major focus of research, other proteins are likely involved in Parkinson's disease as well, Dr. Olanow said. “With respect to the lysosome system, as you increase protein accumulation, it begins to block the LAMP [lysosome-associated membrane protein] receptors and other proteins can start to accumulate as well.”

Neuron-to-neuron transmission of alpha-synuclein has been demonstrated (Proc. Natl. Acad. Sci. USA 2009;106:13010-15). In that study, a substantial number of transplanted healthy embryonic cells overexpressed alpha-synuclein from host cells in a relatively short time, Dr. Olanow said. “This showed that alpha-synuclein can travel across a neuron and be taken up by a healthy neuron, leading to protein uptake, aggregation, and cell death.” This endocytosis of alpha-synuclein from one neuron to another might play a role in the progressive spread of Lewy pathology in the nervous systems of people with Parkinson's disease.

“With that in mind, we can perhaps revise the hypothesized model [to say] that alpha-synuclein itself can act as a prion to promote protein accumulation,” said Dr. Olanow (Proc. Natl. Acad. Sci. USA 2009;106:12571-2).

“This could perhaps explain the fascinating observations suggested by Braak and his colleagues [Neurobiol. Aging. 2003;24:197-211] where [effects of the disease are] first seen in the olfactory bulb and the brain stem, then spread to other brain regions,” he said. “Could it be a prion-like effect?”

An attendee asked why some brain regions are not included in Braak's hypothesis about connections between different anatomic areas playing a role in progression of Parkinson's disease. “I don't know the answer,” Dr. Olanow said. “[This] is pure speculation, but one type of cell might have a better ability to clear proteins than another.”

The sobering news is that much about the pathogenesis of Parkinson's disease remains unknown. “We are not sure which factor, if any, is the primary driver of cell death. And the primary factor may be different in different individuals,” Dr. Olanow said. In addition, there may be a network of different, interactive pathogenic factors that initiate the disease process, “so blocking any one of them might not halt the process.”

Even so, these recent findings could lead to neuroprotective therapies directed at proteins and/or agents that prevent protein misfolding, promote refolding, and/or facilitate clearance of aggregated proteins, he said.

Gene study data suggest looking at 'mitochondria and proteins that lead to misfolding and prion-like activity.'

Source DR. OLANOW

MIAMI BEACH — Aggregation of proteins within dopaminergic and other neuronal cells may play an important role in the development and progression of Parkinson's disease.

Although the etiology of Parkinson's disease is likely multifactorial, these findings point researchers toward one important group of candidate targets for future therapies, Dr. C. Warren Olanow said at the World Federation of Neurology World Congress on Parkinson's Disease and Related Disorders.

“Although we have not yet found a neuroprotective drug for Parkinson's disease, the future is looking brighter,” he said. “Gene studies are directing us to look at mitochondria and proteins that lead to misfolding and prion-like activity. This may lead to very promising therapies.”

Dr. Olanow is chairman emeritus of the department of neurology at Mount Sinai School of Medicine, New York. He disclosed that he is a consultant for Boehringer Ingelheim GmbH, Ceregene Inc., Merck Serono S.A., Novartis Pharmaceuticals Corp., and Teva Neuroscience Inc., all of which manufacture or are developing medications for Parkinson's disease.

Normally, there is a balance between the number of proteins being formed and the ability to clear them, said Dr. Olanow. “Protein aggregation is much more than what we appreciated. Of the systems for clearing accumulated protein, the ubiquitin-proteasome system is the most important. This is a series of enzymes that signal for protein to be transported to a proteasome, where it is broken down.”

Healthy embryonic cells transferred to the substantia nigra of a person with Parkinson's disease have shown characteristic features of the disease (Nat. Med. 2008;14:504-6). In that study, the transplants showed hallmark signs of Parkinson's disease, including Lewy body pathology; increased levels of the protein alpha-synuclein, a protein of unknown function found abundantly in Lewy bodies; and reduced amounts of dopamine transporter in a post mortem examination 14 years later. The grafted cells had adopted the features of the host dopaminergic neurons, suggesting that ongoing changes occur with Parkinson's disease.

Aggregation and misfolding may occur when excess protein overwhelms the clearance system and/or a neuron with normal levels has an impaired clearance system. Lysosomal or proteasomal degradation of alpha-synuclein is likely the clearance mechanism in healthy individuals. “Overproduction of alpha-synuclein alone is shown to be enough to start the cell death process in Parkinson's disease,” Dr. Olanow noted.

Although alpha-synuclein is a major focus of research, other proteins are likely involved in Parkinson's disease as well, Dr. Olanow said. “With respect to the lysosome system, as you increase protein accumulation, it begins to block the LAMP [lysosome-associated membrane protein] receptors and other proteins can start to accumulate as well.”

Neuron-to-neuron transmission of alpha-synuclein has been demonstrated (Proc. Natl. Acad. Sci. USA 2009;106:13010-15). In that study, a substantial number of transplanted healthy embryonic cells overexpressed alpha-synuclein from host cells in a relatively short time, Dr. Olanow said. “This showed that alpha-synuclein can travel across a neuron and be taken up by a healthy neuron, leading to protein uptake, aggregation, and cell death.” This endocytosis of alpha-synuclein from one neuron to another might play a role in the progressive spread of Lewy pathology in the nervous systems of people with Parkinson's disease.

“With that in mind, we can perhaps revise the hypothesized model [to say] that alpha-synuclein itself can act as a prion to promote protein accumulation,” said Dr. Olanow (Proc. Natl. Acad. Sci. USA 2009;106:12571-2).

“This could perhaps explain the fascinating observations suggested by Braak and his colleagues [Neurobiol. Aging. 2003;24:197-211] where [effects of the disease are] first seen in the olfactory bulb and the brain stem, then spread to other brain regions,” he said. “Could it be a prion-like effect?”

An attendee asked why some brain regions are not included in Braak's hypothesis about connections between different anatomic areas playing a role in progression of Parkinson's disease. “I don't know the answer,” Dr. Olanow said. “[This] is pure speculation, but one type of cell might have a better ability to clear proteins than another.”

The sobering news is that much about the pathogenesis of Parkinson's disease remains unknown. “We are not sure which factor, if any, is the primary driver of cell death. And the primary factor may be different in different individuals,” Dr. Olanow said. In addition, there may be a network of different, interactive pathogenic factors that initiate the disease process, “so blocking any one of them might not halt the process.”

Even so, these recent findings could lead to neuroprotective therapies directed at proteins and/or agents that prevent protein misfolding, promote refolding, and/or facilitate clearance of aggregated proteins, he said.

Gene study data suggest looking at 'mitochondria and proteins that lead to misfolding and prion-like activity.'

Source DR. OLANOW

MIAMI BEACH — Early and aggressive treatment of dementia in people with Parkinson's disease could optimize outcomes and quality of life for patients and their caregivers, growing evidence suggests.

About one-third of people with Parkinson's disease experience dementia. “We know there is such high risk for dementia in this population. We need to be proactive,” Dr. David J. Burn said at the World Federation of Neurology World Congress on Parkinson's Disease and Related Disorders.

Hallucinations are a major concern. These can arise when mild cognitive impairment, common in people with Parkinson's disease, progresses to dementia.

How you deliver a dementia diagnosis to the patient and family members is important, said Dr. Burn, professor of movement disorder neurology at Newcastle University, Newcastle-Upon-Tyne, England. “There is some reluctance to give the diagnosis. You have to be sure [that] the dementia exists. But giving this in a reasonable way might reassure people with hallucinations they are not going mad.”

In addition, a definitive diagnosis can provide a sense of relief to caregivers.

Current patient age is the dominant risk factor for dementia in Parkinson's disease. Cognitive impairments (attention, executive functioning, visuospatial perception, and memory) and behavioral effects (apathy, mood) are clinical features often associated with this classic “dysexecutive visuoperceptual” dementia.

“There is a high psychiatric burden in that dementia, which is important in the management of the disease,” said Dr. Burn.

General and specific diagnostic instruments such as the Mini-Mental State Examination or the Mini-Mental Parkinson test can be helpful in this population. Dr. Burn recommended also using the Neuropsychiatric Inventory–4. “It is fairly quick to administer to the caregiver [together] with the Caregiver Distress Scale. It is a neat, compact way of assessing a lot quite quickly.”

Despite the usefulness of such scales, Dr. Burn advised that clinicians should not feel comfortable even if the resulting score is robust. “Always follow-up with an interview with the patient and the informant—that is essential.”

Fluctuation in symptoms presents one of the diagnostic challenges, Dr. Burn said. “These patients can have good hours or days versus bad hours or days, which can [yield] widely different values on neurologic testing. These fluctuations may be the biggest determinant of [the impact on] activities of daily living in the setting of Parkinson's disease dementia.”

Other confounding factors that can complicate diagnosis include an insidious onset, slow progression, motor effects of Parkinson's disease, and whether the impairment is the result of cognitive dysfunction, Dr. Burn said.

Multiple medications have been studied for efficacy in this comorbid population. These include clozapine (Clozaril); quetiapine (Seroquel); memantine (Namenda); rivastigmine (Exelon); and donepezil (Aricept). Dr. Burn disclosed that he was recently a member of the advisory board for Eisai Inc., the manufacturer of Aricept.

However, the level of evidence to support a particular agent varies in the literature, and many drugs have side effects that need to be considered.

Cholinesterase inhibitors can have effects on the heart, including reports of hospital visits for syncope and bradycardia, for example.

“Most of us, when we diagnose Parkinson's disease dementia, would reach for a cholinesterase inhibitor if patients are symptomatic,” Dr. Burn said. “You need to push the dose to the maximum.”

Keep in mind that patients do not always respond to the first agent, so a switch to a different agent in this class or to a different type of medication may be warranted for some patients, he added.

Evidence-based guidelines in the United Kingdom support the use of clozapine, but sedation and falls are possible, Dr. Burn said.

The choice of agent is unclear in part because randomized, controlled trials of antipsychotics in Parkinson's disease frequently exclude demented cases, he said.

In addition, there is a lack of randomized, controlled trials to support use of quetiapine.

“The jury is out on memantine, but for the moment … studies are favoring [its] use,” Dr. Burn said.

He added that he and his colleagues are planning a study in which they will randomize 500 patients with Parkinson's disease and dementia to either donepezil or placebo. Secondary measures will include caregiver distress, strain, and health economics.

Giving a diagnosis of dementia to patients with hallucinations might reassure them 'they are not going mad.'

Source DR. BURN

MIAMI BEACH — Early and aggressive treatment of dementia in people with Parkinson's disease could optimize outcomes and quality of life for patients and their caregivers, growing evidence suggests.

About one-third of people with Parkinson's disease experience dementia. “We know there is such high risk for dementia in this population. We need to be proactive,” Dr. David J. Burn said at the World Federation of Neurology World Congress on Parkinson's Disease and Related Disorders.

Hallucinations are a major concern. These can arise when mild cognitive impairment, common in people with Parkinson's disease, progresses to dementia.

How you deliver a dementia diagnosis to the patient and family members is important, said Dr. Burn, professor of movement disorder neurology at Newcastle University, Newcastle-Upon-Tyne, England. “There is some reluctance to give the diagnosis. You have to be sure [that] the dementia exists. But giving this in a reasonable way might reassure people with hallucinations they are not going mad.”

In addition, a definitive diagnosis can provide a sense of relief to caregivers.

Current patient age is the dominant risk factor for dementia in Parkinson's disease. Cognitive impairments (attention, executive functioning, visuospatial perception, and memory) and behavioral effects (apathy, mood) are clinical features often associated with this classic “dysexecutive visuoperceptual” dementia.

“There is a high psychiatric burden in that dementia, which is important in the management of the disease,” said Dr. Burn.

General and specific diagnostic instruments such as the Mini-Mental State Examination or the Mini-Mental Parkinson test can be helpful in this population. Dr. Burn recommended also using the Neuropsychiatric Inventory–4. “It is fairly quick to administer to the caregiver [together] with the Caregiver Distress Scale. It is a neat, compact way of assessing a lot quite quickly.”

Despite the usefulness of such scales, Dr. Burn advised that clinicians should not feel comfortable even if the resulting score is robust. “Always follow-up with an interview with the patient and the informant—that is essential.”

Fluctuation in symptoms presents one of the diagnostic challenges, Dr. Burn said. “These patients can have good hours or days versus bad hours or days, which can [yield] widely different values on neurologic testing. These fluctuations may be the biggest determinant of [the impact on] activities of daily living in the setting of Parkinson's disease dementia.”

Other confounding factors that can complicate diagnosis include an insidious onset, slow progression, motor effects of Parkinson's disease, and whether the impairment is the result of cognitive dysfunction, Dr. Burn said.

Multiple medications have been studied for efficacy in this comorbid population. These include clozapine (Clozaril); quetiapine (Seroquel); memantine (Namenda); rivastigmine (Exelon); and donepezil (Aricept). Dr. Burn disclosed that he was recently a member of the advisory board for Eisai Inc., the manufacturer of Aricept.

However, the level of evidence to support a particular agent varies in the literature, and many drugs have side effects that need to be considered.

Cholinesterase inhibitors can have effects on the heart, including reports of hospital visits for syncope and bradycardia, for example.

“Most of us, when we diagnose Parkinson's disease dementia, would reach for a cholinesterase inhibitor if patients are symptomatic,” Dr. Burn said. “You need to push the dose to the maximum.”

Keep in mind that patients do not always respond to the first agent, so a switch to a different agent in this class or to a different type of medication may be warranted for some patients, he added.

Evidence-based guidelines in the United Kingdom support the use of clozapine, but sedation and falls are possible, Dr. Burn said.

The choice of agent is unclear in part because randomized, controlled trials of antipsychotics in Parkinson's disease frequently exclude demented cases, he said.

In addition, there is a lack of randomized, controlled trials to support use of quetiapine.

“The jury is out on memantine, but for the moment … studies are favoring [its] use,” Dr. Burn said.

He added that he and his colleagues are planning a study in which they will randomize 500 patients with Parkinson's disease and dementia to either donepezil or placebo. Secondary measures will include caregiver distress, strain, and health economics.

Giving a diagnosis of dementia to patients with hallucinations might reassure them 'they are not going mad.'

Source DR. BURN

MIAMI BEACH — Early and aggressive treatment of dementia in people with Parkinson's disease could optimize outcomes and quality of life for patients and their caregivers, growing evidence suggests.

About one-third of people with Parkinson's disease experience dementia. “We know there is such high risk for dementia in this population. We need to be proactive,” Dr. David J. Burn said at the World Federation of Neurology World Congress on Parkinson's Disease and Related Disorders.

Hallucinations are a major concern. These can arise when mild cognitive impairment, common in people with Parkinson's disease, progresses to dementia.

How you deliver a dementia diagnosis to the patient and family members is important, said Dr. Burn, professor of movement disorder neurology at Newcastle University, Newcastle-Upon-Tyne, England. “There is some reluctance to give the diagnosis. You have to be sure [that] the dementia exists. But giving this in a reasonable way might reassure people with hallucinations they are not going mad.”

In addition, a definitive diagnosis can provide a sense of relief to caregivers.

Current patient age is the dominant risk factor for dementia in Parkinson's disease. Cognitive impairments (attention, executive functioning, visuospatial perception, and memory) and behavioral effects (apathy, mood) are clinical features often associated with this classic “dysexecutive visuoperceptual” dementia.

“There is a high psychiatric burden in that dementia, which is important in the management of the disease,” said Dr. Burn.

General and specific diagnostic instruments such as the Mini-Mental State Examination or the Mini-Mental Parkinson test can be helpful in this population. Dr. Burn recommended also using the Neuropsychiatric Inventory–4. “It is fairly quick to administer to the caregiver [together] with the Caregiver Distress Scale. It is a neat, compact way of assessing a lot quite quickly.”

Despite the usefulness of such scales, Dr. Burn advised that clinicians should not feel comfortable even if the resulting score is robust. “Always follow-up with an interview with the patient and the informant—that is essential.”

Fluctuation in symptoms presents one of the diagnostic challenges, Dr. Burn said. “These patients can have good hours or days versus bad hours or days, which can [yield] widely different values on neurologic testing. These fluctuations may be the biggest determinant of [the impact on] activities of daily living in the setting of Parkinson's disease dementia.”

Other confounding factors that can complicate diagnosis include an insidious onset, slow progression, motor effects of Parkinson's disease, and whether the impairment is the result of cognitive dysfunction, Dr. Burn said.

Multiple medications have been studied for efficacy in this comorbid population. These include clozapine (Clozaril); quetiapine (Seroquel); memantine (Namenda); rivastigmine (Exelon); and donepezil (Aricept). Dr. Burn disclosed that he was recently a member of the advisory board for Eisai Inc., the manufacturer of Aricept.

However, the level of evidence to support a particular agent varies in the literature, and many drugs have side effects that need to be considered.

Cholinesterase inhibitors can have effects on the heart, including reports of hospital visits for syncope and bradycardia, for example.

“Most of us, when we diagnose Parkinson's disease dementia, would reach for a cholinesterase inhibitor if patients are symptomatic,” Dr. Burn said. “You need to push the dose to the maximum.”

Keep in mind that patients do not always respond to the first agent, so a switch to a different agent in this class or to a different type of medication may be warranted for some patients, he added.

Evidence-based guidelines in the United Kingdom support the use of clozapine, but sedation and falls are possible, Dr. Burn said.

The choice of agent is unclear in part because randomized, controlled trials of antipsychotics in Parkinson's disease frequently exclude demented cases, he said.

In addition, there is a lack of randomized, controlled trials to support use of quetiapine.

“The jury is out on memantine, but for the moment … studies are favoring [its] use,” Dr. Burn said.

He added that he and his colleagues are planning a study in which they will randomize 500 patients with Parkinson's disease and dementia to either donepezil or placebo. Secondary measures will include caregiver distress, strain, and health economics.

Giving a diagnosis of dementia to patients with hallucinations might reassure them 'they are not going mad.'

Source DR. BURN

Major Finding: Risk-adjusted rates of serious complications in bariatric surgery were 4.0% at designated Centers of Excellence, compared with 2.7% at other hospitals.

Data Source: Study of prospective registry of 7,504 bariatric surgeries in Michigan in 2006-2008.

Disclosures: Dr. Dimick had no relevant disclosures.

SAN ANTONIO — The risk-adjusted rate of serious complications associated with bariatric surgery was paradoxically higher at hospitals designated as a Center of Excellence in Michigan, compared with other centers, a study of more than 7,500 procedures indicates.

“I'm going to cause major controversy,” lead investigator Dr. Justin B. Dimick said at the annual Academic Surgical Congress, where he presented prospective data from the Michigan Bariatric Surgery Collaborative (MBSC) population-based clinical registry.

“The use of bariatric surgery has basically skyrocketed. This operation is not easy … and there is some variability,” said Dr. Dimick, who is on the surgery faculty at University of Michigan, Ann Arbor.

Dr. Dimick, Nancy Birkmeyer, Ph.D., director of the collaborative, and their colleagues studied all 7,504 patients who underwent laparoscopic or open gastric bypass, sleeve gastrectomy, and other bariatric surgery procedures from 2006 to 2008. Excluded from the study were patients who had had Lap-Band procedures.

They found the lowest risk-adjusted rate of serious complications at a high-volume hospital that was not a designated bariatric Center of Excellence. But even when this institution was removed from the analysis, patients at a designated center did not fare significantly better in terms of reoperation, anastomotic leak, or infectious and medical complication rates, compared with other hospitals.

A total of 5,121 patients (68%) had bariatric surgery at a Center of Excellence. They had a 4.0% risk-adjusted rate of serious complications, compared with 2.7% for the 2,383 patients treated at other hospitals.

Outcomes included death or disability, complications, and hospitals readmission. “For all three of these, the Centers of Excellence had worse outcomes,” Dr. Dimick said.

There was no significant difference at 1 year in resolution of comorbidities by institution type, he said.

One-year weight loss also was not significantly different; patients at designated centers lost an average of 106 pounds versus 100 pounds at other hospitals.

In addition, improvements from baseline in health-related quality of life did not differ significantly; the Bariatric Quality of Life Index improved 12.4 points in patients treated at a Center of Excellence patients versus 11.8 among those treated elsewhere.

Dr. Dimick emphasized that he was not suggesting the Center of Excellence designation is bad. Indeed, he praised professional societies such as the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery for creating standards. Blue Cross and Blue Shield, he added, also designates hospitals as Distinction Centers for Bariatric Surgery using their own criteria.

The lack of a significant difference in his study between Centers of Excellence and other facilities could be a result of all hospitals striving to improve because the criteria exist, Dr. Dimick suggested.

Still, he added, “Patients seeking bariatric care, at least in Michigan, should not rely only on Centers of Excellence designation.”

The findings may not be generalizable to hospitals outside of Michigan because the surgeons in the study participated in a quality improvement collaboration, a meeting attendee said; Dr. Dimick agreed. In the last two quarters, for example, there were no deaths associated with the approximately 3,000 bariatric procedures performed within that state.

Major Finding: Risk-adjusted rates of serious complications in bariatric surgery were 4.0% at designated Centers of Excellence, compared with 2.7% at other hospitals.

Data Source: Study of prospective registry of 7,504 bariatric surgeries in Michigan in 2006-2008.

Disclosures: Dr. Dimick had no relevant disclosures.

SAN ANTONIO — The risk-adjusted rate of serious complications associated with bariatric surgery was paradoxically higher at hospitals designated as a Center of Excellence in Michigan, compared with other centers, a study of more than 7,500 procedures indicates.

“I'm going to cause major controversy,” lead investigator Dr. Justin B. Dimick said at the annual Academic Surgical Congress, where he presented prospective data from the Michigan Bariatric Surgery Collaborative (MBSC) population-based clinical registry.

“The use of bariatric surgery has basically skyrocketed. This operation is not easy … and there is some variability,” said Dr. Dimick, who is on the surgery faculty at University of Michigan, Ann Arbor.

Dr. Dimick, Nancy Birkmeyer, Ph.D., director of the collaborative, and their colleagues studied all 7,504 patients who underwent laparoscopic or open gastric bypass, sleeve gastrectomy, and other bariatric surgery procedures from 2006 to 2008. Excluded from the study were patients who had had Lap-Band procedures.

They found the lowest risk-adjusted rate of serious complications at a high-volume hospital that was not a designated bariatric Center of Excellence. But even when this institution was removed from the analysis, patients at a designated center did not fare significantly better in terms of reoperation, anastomotic leak, or infectious and medical complication rates, compared with other hospitals.

A total of 5,121 patients (68%) had bariatric surgery at a Center of Excellence. They had a 4.0% risk-adjusted rate of serious complications, compared with 2.7% for the 2,383 patients treated at other hospitals.

Outcomes included death or disability, complications, and hospitals readmission. “For all three of these, the Centers of Excellence had worse outcomes,” Dr. Dimick said.

There was no significant difference at 1 year in resolution of comorbidities by institution type, he said.

One-year weight loss also was not significantly different; patients at designated centers lost an average of 106 pounds versus 100 pounds at other hospitals.

In addition, improvements from baseline in health-related quality of life did not differ significantly; the Bariatric Quality of Life Index improved 12.4 points in patients treated at a Center of Excellence patients versus 11.8 among those treated elsewhere.

Dr. Dimick emphasized that he was not suggesting the Center of Excellence designation is bad. Indeed, he praised professional societies such as the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery for creating standards. Blue Cross and Blue Shield, he added, also designates hospitals as Distinction Centers for Bariatric Surgery using their own criteria.

The lack of a significant difference in his study between Centers of Excellence and other facilities could be a result of all hospitals striving to improve because the criteria exist, Dr. Dimick suggested.

Still, he added, “Patients seeking bariatric care, at least in Michigan, should not rely only on Centers of Excellence designation.”

The findings may not be generalizable to hospitals outside of Michigan because the surgeons in the study participated in a quality improvement collaboration, a meeting attendee said; Dr. Dimick agreed. In the last two quarters, for example, there were no deaths associated with the approximately 3,000 bariatric procedures performed within that state.

Major Finding: Risk-adjusted rates of serious complications in bariatric surgery were 4.0% at designated Centers of Excellence, compared with 2.7% at other hospitals.

Data Source: Study of prospective registry of 7,504 bariatric surgeries in Michigan in 2006-2008.

Disclosures: Dr. Dimick had no relevant disclosures.

SAN ANTONIO — The risk-adjusted rate of serious complications associated with bariatric surgery was paradoxically higher at hospitals designated as a Center of Excellence in Michigan, compared with other centers, a study of more than 7,500 procedures indicates.

“I'm going to cause major controversy,” lead investigator Dr. Justin B. Dimick said at the annual Academic Surgical Congress, where he presented prospective data from the Michigan Bariatric Surgery Collaborative (MBSC) population-based clinical registry.

“The use of bariatric surgery has basically skyrocketed. This operation is not easy … and there is some variability,” said Dr. Dimick, who is on the surgery faculty at University of Michigan, Ann Arbor.

Dr. Dimick, Nancy Birkmeyer, Ph.D., director of the collaborative, and their colleagues studied all 7,504 patients who underwent laparoscopic or open gastric bypass, sleeve gastrectomy, and other bariatric surgery procedures from 2006 to 2008. Excluded from the study were patients who had had Lap-Band procedures.

They found the lowest risk-adjusted rate of serious complications at a high-volume hospital that was not a designated bariatric Center of Excellence. But even when this institution was removed from the analysis, patients at a designated center did not fare significantly better in terms of reoperation, anastomotic leak, or infectious and medical complication rates, compared with other hospitals.

A total of 5,121 patients (68%) had bariatric surgery at a Center of Excellence. They had a 4.0% risk-adjusted rate of serious complications, compared with 2.7% for the 2,383 patients treated at other hospitals.

Outcomes included death or disability, complications, and hospitals readmission. “For all three of these, the Centers of Excellence had worse outcomes,” Dr. Dimick said.

There was no significant difference at 1 year in resolution of comorbidities by institution type, he said.

One-year weight loss also was not significantly different; patients at designated centers lost an average of 106 pounds versus 100 pounds at other hospitals.

In addition, improvements from baseline in health-related quality of life did not differ significantly; the Bariatric Quality of Life Index improved 12.4 points in patients treated at a Center of Excellence patients versus 11.8 among those treated elsewhere.

Dr. Dimick emphasized that he was not suggesting the Center of Excellence designation is bad. Indeed, he praised professional societies such as the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery for creating standards. Blue Cross and Blue Shield, he added, also designates hospitals as Distinction Centers for Bariatric Surgery using their own criteria.

The lack of a significant difference in his study between Centers of Excellence and other facilities could be a result of all hospitals striving to improve because the criteria exist, Dr. Dimick suggested.

Still, he added, “Patients seeking bariatric care, at least in Michigan, should not rely only on Centers of Excellence designation.”

The findings may not be generalizable to hospitals outside of Michigan because the surgeons in the study participated in a quality improvement collaboration, a meeting attendee said; Dr. Dimick agreed. In the last two quarters, for example, there were no deaths associated with the approximately 3,000 bariatric procedures performed within that state.

MIAMI BEACH — Patients who take omega-3 fatty acid fish oil supplements before cardiac surgery might be more likely to need platelet transfusions than would those who do not, a retrospective study indicates.

“At this point, it's advisable to stop fish oil before surgery to reduce the risk of bleeding,” Marc Reichert, Pharm.D., said during a poster rounds session at the annual congress of the Society of Critical Care Medicine.

Dr. Reichert and colleagues at Wake Forest University Baptist Medical Center in Winston-Salem, N.C., compared platelet transfusion requirements between 75 patients who took a fish oil supplement 24 hours or less before surgery and 75 controls who did not. Whether or not a patient otherwise took the supplements (for example, chronically) was not assessed.

They found that 29% of the fish oil group vs. 17% of the controls received at least one transfusion with platelets intraoperatively or within 24 hours postoperatively. This difference was significant. The fish oil group was transfused with a larger mean volume of platelets perioperatively (205 mL, compared with 30 mL in the control group), a difference that also was significant.

All patients underwent cardiac surgery between July 2006 and July 2008. Mean dose of fish oil was 1,848 mg (range, 500-6,000 mg). Controls were propensity matched with the treatment patients; there were no significant differences in baseline demographic or intraoperative or postoperative clinical variables. Mean patient age was 64 years. Men accounted for 80% of the fish oil group and 72% of the control group.

MIAMI BEACH — Patients who take omega-3 fatty acid fish oil supplements before cardiac surgery might be more likely to need platelet transfusions than would those who do not, a retrospective study indicates.

“At this point, it's advisable to stop fish oil before surgery to reduce the risk of bleeding,” Marc Reichert, Pharm.D., said during a poster rounds session at the annual congress of the Society of Critical Care Medicine.

Dr. Reichert and colleagues at Wake Forest University Baptist Medical Center in Winston-Salem, N.C., compared platelet transfusion requirements between 75 patients who took a fish oil supplement 24 hours or less before surgery and 75 controls who did not. Whether or not a patient otherwise took the supplements (for example, chronically) was not assessed.

They found that 29% of the fish oil group vs. 17% of the controls received at least one transfusion with platelets intraoperatively or within 24 hours postoperatively. This difference was significant. The fish oil group was transfused with a larger mean volume of platelets perioperatively (205 mL, compared with 30 mL in the control group), a difference that also was significant.

All patients underwent cardiac surgery between July 2006 and July 2008. Mean dose of fish oil was 1,848 mg (range, 500-6,000 mg). Controls were propensity matched with the treatment patients; there were no significant differences in baseline demographic or intraoperative or postoperative clinical variables. Mean patient age was 64 years. Men accounted for 80% of the fish oil group and 72% of the control group.

MIAMI BEACH — Patients who take omega-3 fatty acid fish oil supplements before cardiac surgery might be more likely to need platelet transfusions than would those who do not, a retrospective study indicates.

“At this point, it's advisable to stop fish oil before surgery to reduce the risk of bleeding,” Marc Reichert, Pharm.D., said during a poster rounds session at the annual congress of the Society of Critical Care Medicine.

Dr. Reichert and colleagues at Wake Forest University Baptist Medical Center in Winston-Salem, N.C., compared platelet transfusion requirements between 75 patients who took a fish oil supplement 24 hours or less before surgery and 75 controls who did not. Whether or not a patient otherwise took the supplements (for example, chronically) was not assessed.

They found that 29% of the fish oil group vs. 17% of the controls received at least one transfusion with platelets intraoperatively or within 24 hours postoperatively. This difference was significant. The fish oil group was transfused with a larger mean volume of platelets perioperatively (205 mL, compared with 30 mL in the control group), a difference that also was significant.

All patients underwent cardiac surgery between July 2006 and July 2008. Mean dose of fish oil was 1,848 mg (range, 500-6,000 mg). Controls were propensity matched with the treatment patients; there were no significant differences in baseline demographic or intraoperative or postoperative clinical variables. Mean patient age was 64 years. Men accounted for 80% of the fish oil group and 72% of the control group.

ATLANTA – Personal injury from a rocket attack, sleep difficulties, alcohol use, and nontraumatic major events in the past year significantly predicted functional impairment associated with symptoms of posttraumatic stress disorder in a large study of Israeli civilians exposed to pervasive war and terrorism.

Researchers surveyed 1,001 Israeli residents via telephone during the summer of 2008. A total of 500 respondents who lived close to the town of Sderot near the Gaza Strip and along the northern border of Gaza, an area subjected to frequent rocket attacks over several years, composed a higher-exposure group. Their reports of posttraumatic stress disorder (PTSD) symptoms and impairment were compared with those of 501 respondents who lived in lower-exposure regions of the country.

PTSD severity was similar between groups, but the level of symptom-related impairment was higher in those living in areas struck by rocket attacks.

A large proportion of people interviewed were distressed but did not necessarily meet the full criteria for PTSD, Katie J. Horsey, said in an interview at her poster during the annual meeting of the International Society for Trauma Stress Studies. “Only about 5.5% met full DSM-IV criteria for PTSD, but 29% reported impairment by those symptoms,” she said, adding that this subclinical impairment after exposure to pervasive trauma suggests reliance on a full PTSD diagnosis may be insufficient to identify those most in need of intervention.

The findings in the current study support previous findings that even people with subthreshold symptoms might significantly suffer from PTSD (Behav. Ther. 2009;40:39-49; J. Nerv. Ment. Dis. 2007;195:48-53). Psychosocial resource loss–defined as a loss of hope, of closeness to family, of a sense that one is of value to others, and of feelings of control over one's life–was “very significantly” associated with impairment, according to logistic regression analysis. People who reported a slight degree of loss were more than twice as likely to be impaired (odds ratio, 2.53), for example, and risk increased with a higher degree of loss (OR, 4.59), compared with those with no such loss.

“It may be that people who have more resources are better able to cope with their PTSD,” Ms. Horsey said.

In addition, poor or fair health quality and sleep difficulty each significantly predicted greater risk for functional impairment (OR, 1.71 and 1.73, respectively). “When you are not sleeping well, you cannot cope as well,” said Ms. Horsey, a doctoral student in the Clinical Psychology Program at Kent State University in Akron, Ohio.

Respondents who reported injury to themselves or a close other were at higher risk for impairment (OR, 2.8), compared with those who reported no such injuries (OR, 1.0).

It might be worthwhile to assess PTSD-related impairment–and not just symptoms–even in populations with a low level of symptoms, Ms. Horsey said. Some respondents reporting a high level of symptoms, including some who met all three DSM-IV clusters, did not report impairment. In contrast, some could not function well at a low level of symptoms.

All of the telephone interviews were conducted in Hebrew. The interviewers used the PTSD Symptom Scale–Self-Report Version, a measure previously validated in Hebrew-speaking populations. Impairment was based on a single question about whether posttraumatic symptoms interfered with functioning.

The researchers may explore more specifics, including which symptoms of PTSD are most associated with functional impairment and which areas of life are most impaired by exposure to trauma.

Ms. Horsey had no relevant disclosures. The study was supported by a National Institutes of Health grant.

Only about 5.5% of respondents met full DSM-IV criteria for PTSD, but 29% reported impairment by those symptoms.

Source MS. HORSEY

ATLANTA – Personal injury from a rocket attack, sleep difficulties, alcohol use, and nontraumatic major events in the past year significantly predicted functional impairment associated with symptoms of posttraumatic stress disorder in a large study of Israeli civilians exposed to pervasive war and terrorism.

Researchers surveyed 1,001 Israeli residents via telephone during the summer of 2008. A total of 500 respondents who lived close to the town of Sderot near the Gaza Strip and along the northern border of Gaza, an area subjected to frequent rocket attacks over several years, composed a higher-exposure group. Their reports of posttraumatic stress disorder (PTSD) symptoms and impairment were compared with those of 501 respondents who lived in lower-exposure regions of the country.

PTSD severity was similar between groups, but the level of symptom-related impairment was higher in those living in areas struck by rocket attacks.

A large proportion of people interviewed were distressed but did not necessarily meet the full criteria for PTSD, Katie J. Horsey, said in an interview at her poster during the annual meeting of the International Society for Trauma Stress Studies. “Only about 5.5% met full DSM-IV criteria for PTSD, but 29% reported impairment by those symptoms,” she said, adding that this subclinical impairment after exposure to pervasive trauma suggests reliance on a full PTSD diagnosis may be insufficient to identify those most in need of intervention.

The findings in the current study support previous findings that even people with subthreshold symptoms might significantly suffer from PTSD (Behav. Ther. 2009;40:39-49; J. Nerv. Ment. Dis. 2007;195:48-53). Psychosocial resource loss–defined as a loss of hope, of closeness to family, of a sense that one is of value to others, and of feelings of control over one's life–was “very significantly” associated with impairment, according to logistic regression analysis. People who reported a slight degree of loss were more than twice as likely to be impaired (odds ratio, 2.53), for example, and risk increased with a higher degree of loss (OR, 4.59), compared with those with no such loss.

“It may be that people who have more resources are better able to cope with their PTSD,” Ms. Horsey said.

In addition, poor or fair health quality and sleep difficulty each significantly predicted greater risk for functional impairment (OR, 1.71 and 1.73, respectively). “When you are not sleeping well, you cannot cope as well,” said Ms. Horsey, a doctoral student in the Clinical Psychology Program at Kent State University in Akron, Ohio.

Respondents who reported injury to themselves or a close other were at higher risk for impairment (OR, 2.8), compared with those who reported no such injuries (OR, 1.0).

It might be worthwhile to assess PTSD-related impairment–and not just symptoms–even in populations with a low level of symptoms, Ms. Horsey said. Some respondents reporting a high level of symptoms, including some who met all three DSM-IV clusters, did not report impairment. In contrast, some could not function well at a low level of symptoms.

All of the telephone interviews were conducted in Hebrew. The interviewers used the PTSD Symptom Scale–Self-Report Version, a measure previously validated in Hebrew-speaking populations. Impairment was based on a single question about whether posttraumatic symptoms interfered with functioning.

The researchers may explore more specifics, including which symptoms of PTSD are most associated with functional impairment and which areas of life are most impaired by exposure to trauma.

Ms. Horsey had no relevant disclosures. The study was supported by a National Institutes of Health grant.

Only about 5.5% of respondents met full DSM-IV criteria for PTSD, but 29% reported impairment by those symptoms.

Source MS. HORSEY

ATLANTA – Personal injury from a rocket attack, sleep difficulties, alcohol use, and nontraumatic major events in the past year significantly predicted functional impairment associated with symptoms of posttraumatic stress disorder in a large study of Israeli civilians exposed to pervasive war and terrorism.

Researchers surveyed 1,001 Israeli residents via telephone during the summer of 2008. A total of 500 respondents who lived close to the town of Sderot near the Gaza Strip and along the northern border of Gaza, an area subjected to frequent rocket attacks over several years, composed a higher-exposure group. Their reports of posttraumatic stress disorder (PTSD) symptoms and impairment were compared with those of 501 respondents who lived in lower-exposure regions of the country.

PTSD severity was similar between groups, but the level of symptom-related impairment was higher in those living in areas struck by rocket attacks.

A large proportion of people interviewed were distressed but did not necessarily meet the full criteria for PTSD, Katie J. Horsey, said in an interview at her poster during the annual meeting of the International Society for Trauma Stress Studies. “Only about 5.5% met full DSM-IV criteria for PTSD, but 29% reported impairment by those symptoms,” she said, adding that this subclinical impairment after exposure to pervasive trauma suggests reliance on a full PTSD diagnosis may be insufficient to identify those most in need of intervention.

The findings in the current study support previous findings that even people with subthreshold symptoms might significantly suffer from PTSD (Behav. Ther. 2009;40:39-49; J. Nerv. Ment. Dis. 2007;195:48-53). Psychosocial resource loss–defined as a loss of hope, of closeness to family, of a sense that one is of value to others, and of feelings of control over one's life–was “very significantly” associated with impairment, according to logistic regression analysis. People who reported a slight degree of loss were more than twice as likely to be impaired (odds ratio, 2.53), for example, and risk increased with a higher degree of loss (OR, 4.59), compared with those with no such loss.

“It may be that people who have more resources are better able to cope with their PTSD,” Ms. Horsey said.

In addition, poor or fair health quality and sleep difficulty each significantly predicted greater risk for functional impairment (OR, 1.71 and 1.73, respectively). “When you are not sleeping well, you cannot cope as well,” said Ms. Horsey, a doctoral student in the Clinical Psychology Program at Kent State University in Akron, Ohio.

Respondents who reported injury to themselves or a close other were at higher risk for impairment (OR, 2.8), compared with those who reported no such injuries (OR, 1.0).

It might be worthwhile to assess PTSD-related impairment–and not just symptoms–even in populations with a low level of symptoms, Ms. Horsey said. Some respondents reporting a high level of symptoms, including some who met all three DSM-IV clusters, did not report impairment. In contrast, some could not function well at a low level of symptoms.

All of the telephone interviews were conducted in Hebrew. The interviewers used the PTSD Symptom Scale–Self-Report Version, a measure previously validated in Hebrew-speaking populations. Impairment was based on a single question about whether posttraumatic symptoms interfered with functioning.

The researchers may explore more specifics, including which symptoms of PTSD are most associated with functional impairment and which areas of life are most impaired by exposure to trauma.

Ms. Horsey had no relevant disclosures. The study was supported by a National Institutes of Health grant.

Only about 5.5% of respondents met full DSM-IV criteria for PTSD, but 29% reported impairment by those symptoms.

Source MS. HORSEY