Damian McNamara

ATLANTA – Increased vigilance for alcohol and substance misuse might be warranted for people with posttraumatic stress disorder, according to a study of 379 recent U.S. veterans.

Significantly higher hazardous or harmful drinking was reported among those with posttraumatic stress disorder (PTSD), compared with those without the diagnosis, for example. Current alcohol dependence and current substance use were each higher in those affected with the disorder, said Angela Meade Eggleston, Ph.D.

“The combination is particularly bad,” Dr. Eggleston said, noting that in a study of pregnant women, those with a substance use disorder and PTSD “are more likely to report suicidality, aggression, and psychosocial impairment, compared with patients with a substance use disorder and another psychiatric disorder, or a substance use disorder only” (Compr. Psychiatry 2009;50:415–23).

In the current study, some of the veterans reported abstinence when asked only about the previous month, “so it is important not to take just a snapshot,” Dr. Eggleston said at the annual meeting of the International Society for Trauma Stress Studies. Thirty percent of veterans with PTSD and 19% without reported symptoms of alcohol use disorders within the past year.

Recent veterans of Operation Enduring Freedom or Operation Iraqi Freedom were recruited from the Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC), located on the Durham VA campus in North Carolina. The subjects had participated in Operation Enduring Freedom or Operation Iraqi Freedom and had experienced combat deployments, active duty, National Guard, and/or Reserve service since October 2001. Data were collected by questionnaire and an interview at least 28 days apart.

For this study, heavy drinking was defined as five or more drinks daily for men and four or more for women, as recommended by the National Institute of Alcohol Abuse and Alcoholism. Regular heavy drinking was one or more times per month. Substance use disorder was defined as regular use causing symptoms and/or dysfunction, Dr. Eggleston said.

The researchers found that a greater percentage of veterans with PTSD scored an 8 or higher on the Alcohol Use Disorder Identification Test (AUDIT), the cutoff for hazardous or harmful drinking, than did those without PTSD–35%, compared with 17%, respectively.

Of those with PTSD, 8% reported current alcohol dependence, compared with 2% without, and 12% reported a current substance use disorder, compared with 9% of the group without PTSD.

Generally, 22% to 75% of individuals with PTSD also meet criteria for a substance use disorder, Dr. Eggleston said. “Marijuana and other substance use increase following trauma exposure. For example, there was a huge increase in marijuana use in New York City after the 911 attacks. That kind of finding is seen across studies,” said Dr. Eggleston, a psychology fellow at the Durham (N.C.) VA Medical Center. She had no financial disclosures.

PTSD, but not trauma alone, increases risk for onset of drug abuse or dependence, according to findings from a previous study (Arch. Gen. Psychiatry 2003;60:289–94). They found 2.2% of trauma-only patients began abusing drugs, compared to 10% of those with PTSD.

The high rate of PTSD and alcohol misuse in the current study “really raises that red flag for us–what we need to tend to that as they go through their readjustments,” said Jean Beckham, Ph.D., a professor of medical psychology, department of psychiatry and behavioral sciences, Duke University Medical Center, Durham, N.C.

ATLANTA – Increased vigilance for alcohol and substance misuse might be warranted for people with posttraumatic stress disorder, according to a study of 379 recent U.S. veterans.

Significantly higher hazardous or harmful drinking was reported among those with posttraumatic stress disorder (PTSD), compared with those without the diagnosis, for example. Current alcohol dependence and current substance use were each higher in those affected with the disorder, said Angela Meade Eggleston, Ph.D.

“The combination is particularly bad,” Dr. Eggleston said, noting that in a study of pregnant women, those with a substance use disorder and PTSD “are more likely to report suicidality, aggression, and psychosocial impairment, compared with patients with a substance use disorder and another psychiatric disorder, or a substance use disorder only” (Compr. Psychiatry 2009;50:415–23).

In the current study, some of the veterans reported abstinence when asked only about the previous month, “so it is important not to take just a snapshot,” Dr. Eggleston said at the annual meeting of the International Society for Trauma Stress Studies. Thirty percent of veterans with PTSD and 19% without reported symptoms of alcohol use disorders within the past year.

Recent veterans of Operation Enduring Freedom or Operation Iraqi Freedom were recruited from the Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC), located on the Durham VA campus in North Carolina. The subjects had participated in Operation Enduring Freedom or Operation Iraqi Freedom and had experienced combat deployments, active duty, National Guard, and/or Reserve service since October 2001. Data were collected by questionnaire and an interview at least 28 days apart.

For this study, heavy drinking was defined as five or more drinks daily for men and four or more for women, as recommended by the National Institute of Alcohol Abuse and Alcoholism. Regular heavy drinking was one or more times per month. Substance use disorder was defined as regular use causing symptoms and/or dysfunction, Dr. Eggleston said.

The researchers found that a greater percentage of veterans with PTSD scored an 8 or higher on the Alcohol Use Disorder Identification Test (AUDIT), the cutoff for hazardous or harmful drinking, than did those without PTSD–35%, compared with 17%, respectively.

Of those with PTSD, 8% reported current alcohol dependence, compared with 2% without, and 12% reported a current substance use disorder, compared with 9% of the group without PTSD.

Generally, 22% to 75% of individuals with PTSD also meet criteria for a substance use disorder, Dr. Eggleston said. “Marijuana and other substance use increase following trauma exposure. For example, there was a huge increase in marijuana use in New York City after the 911 attacks. That kind of finding is seen across studies,” said Dr. Eggleston, a psychology fellow at the Durham (N.C.) VA Medical Center. She had no financial disclosures.

PTSD, but not trauma alone, increases risk for onset of drug abuse or dependence, according to findings from a previous study (Arch. Gen. Psychiatry 2003;60:289–94). They found 2.2% of trauma-only patients began abusing drugs, compared to 10% of those with PTSD.

The high rate of PTSD and alcohol misuse in the current study “really raises that red flag for us–what we need to tend to that as they go through their readjustments,” said Jean Beckham, Ph.D., a professor of medical psychology, department of psychiatry and behavioral sciences, Duke University Medical Center, Durham, N.C.

ATLANTA – Increased vigilance for alcohol and substance misuse might be warranted for people with posttraumatic stress disorder, according to a study of 379 recent U.S. veterans.

Significantly higher hazardous or harmful drinking was reported among those with posttraumatic stress disorder (PTSD), compared with those without the diagnosis, for example. Current alcohol dependence and current substance use were each higher in those affected with the disorder, said Angela Meade Eggleston, Ph.D.

“The combination is particularly bad,” Dr. Eggleston said, noting that in a study of pregnant women, those with a substance use disorder and PTSD “are more likely to report suicidality, aggression, and psychosocial impairment, compared with patients with a substance use disorder and another psychiatric disorder, or a substance use disorder only” (Compr. Psychiatry 2009;50:415–23).

In the current study, some of the veterans reported abstinence when asked only about the previous month, “so it is important not to take just a snapshot,” Dr. Eggleston said at the annual meeting of the International Society for Trauma Stress Studies. Thirty percent of veterans with PTSD and 19% without reported symptoms of alcohol use disorders within the past year.

Recent veterans of Operation Enduring Freedom or Operation Iraqi Freedom were recruited from the Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC), located on the Durham VA campus in North Carolina. The subjects had participated in Operation Enduring Freedom or Operation Iraqi Freedom and had experienced combat deployments, active duty, National Guard, and/or Reserve service since October 2001. Data were collected by questionnaire and an interview at least 28 days apart.

For this study, heavy drinking was defined as five or more drinks daily for men and four or more for women, as recommended by the National Institute of Alcohol Abuse and Alcoholism. Regular heavy drinking was one or more times per month. Substance use disorder was defined as regular use causing symptoms and/or dysfunction, Dr. Eggleston said.

The researchers found that a greater percentage of veterans with PTSD scored an 8 or higher on the Alcohol Use Disorder Identification Test (AUDIT), the cutoff for hazardous or harmful drinking, than did those without PTSD–35%, compared with 17%, respectively.

Of those with PTSD, 8% reported current alcohol dependence, compared with 2% without, and 12% reported a current substance use disorder, compared with 9% of the group without PTSD.

Generally, 22% to 75% of individuals with PTSD also meet criteria for a substance use disorder, Dr. Eggleston said. “Marijuana and other substance use increase following trauma exposure. For example, there was a huge increase in marijuana use in New York City after the 911 attacks. That kind of finding is seen across studies,” said Dr. Eggleston, a psychology fellow at the Durham (N.C.) VA Medical Center. She had no financial disclosures.

PTSD, but not trauma alone, increases risk for onset of drug abuse or dependence, according to findings from a previous study (Arch. Gen. Psychiatry 2003;60:289–94). They found 2.2% of trauma-only patients began abusing drugs, compared to 10% of those with PTSD.

The high rate of PTSD and alcohol misuse in the current study “really raises that red flag for us–what we need to tend to that as they go through their readjustments,” said Jean Beckham, Ph.D., a professor of medical psychology, department of psychiatry and behavioral sciences, Duke University Medical Center, Durham, N.C.

Major Finding: Transfusion of red blood cells stored 14 days or longer increases risk of multiple organ failure in critically ill children nearly twofold, compared with fresher RBCs.

Data Source: Secondary analysis of prospective, multicenter study of 296 patients.

Disclosures: Fonds de la Recherche en Santé du Québec sponsored this secondary analysis, planned a priori, of an initial, prospective, observational study funded by Johnson & Johnson. Dr. Karam disclosed that he has no financial conflict of interest.

MIAMI BEACH — A significantly higher rate of multiple organ failure after transfusion with red blood cells stored 14 days or longer, compared with fresher cells, has been shown for the first time in pediatric critical care patients.

“We were surprised to find such a difference—twice as many patients develop a bad outcome—which is very important for something so frequently used,” Dr. Oliver Karam said in an interview at his poster during the annual congress of the Society of Critical Care Medicine. The poster was selected as a Research Citation Finalist at the meeting.

Transfusions are probably one of the most common treatments in the severely ill pediatric population, he said. About one in every two children admitted to a postoperative intensive care unit (PICU) receives at least one transfusion.

Previous studies in adults and animals yielded conflicting results regarding the safety of older versus newer stored red blood cells, Dr. Karam said. Although a retrospective study of 67 transfused children found no difference in outcomes related to the shelf life of RBCs (Intensive Care Med. 2009;35:179–80), “this has not been answered [prospectively] yet in pediatrics. We are the only ones, to my knowledge, to look at pediatric data.”

Dr. Karam and his colleagues screened 930 consecutive patients younger than 18 years admitted to a PICU for 48 hours or longer at 1 of 29 centers in North America. Of the 447 children who received at least one transfusion, information on storage time was available for 296 patients. The median length of storage was 14 days, so this became the cutoff to define “older” versus “fresher” blood.

The maximum permitted length of storage in both the United States and Canada is 42 days, said Dr. Karam, chief medical fellow at CHU Sainte-Justine in Montreal.

Among patients who received blood stored 14 days or longer, the increased incidence of new or progressive multiple organ failure was almost double (adjusted odds ratio, 1.87), based on a multiple logistic regression that adjusted for gender, weight, number of organ failures at admission, total transfusion number, and total transfusion dose. Clinical severity at admission was associated with more RBC transfusions but not with use of older versus fresher blood, Dr. Karam said.

Although not significant, there was a trend for the older blood group to develop new or progressive multiple organ failure faster than the other patients (hazard ratio, 1.43).

Mortality over 28 days and PICU length of stay were secondary outcomes. There was no significant difference in this mortality rate between groups.

“The good news is pediatric patients do not die as much” as transfused adults in a critical care setting, Dr. Karam said. They generally have a greater resiliency and more functional reserve, which “may be why we did not see a difference in deaths.”

However, patients who received older blood stayed significantly longer in critical care—an adjusted median difference of 3.7 more days than did the fresher blood group. “We were surprised length of stay was so different—almost 4 days, which is huge and costs a lot,” he said.

“There are lots of hypotheses in the literature” about the effects of older stored RBCs, Dr. Karam said, such as activity by cytokines, active biolipids, or thrombotic factors. “It is probably a mix of things, but the clinical effect is there.”

Dr. Karam is planning a study to confirm these findings and look for possible mechanisms. “We are starting a pilot randomized, controlled study called ABC, or Age of Blood in Children.”

“We were surprised to find such a difference” in outcomes related to blood storage, Dr. Oliver Karam said.

Source DAMIAN McNAMARA/ELSEVIER GLOBAL MEDICAL NEWS

My Take

Transfusion Strategies for Children Merit More Study

These study findings are useful to hospitalists and all pediatricians who care for inpatients. A growing body of literature highlights the inherent risks of blood product transfusion. The majority of the work has been done in adult patients, and it is therefore crucial to closely examine the safety and effectiveness of transfusion strategies in children.

If the study findings are reproducible, they may have a significant impact on patients and blood banks, but the topic needs to be studied further before changes are made in current clinical practice.

In a recent study of adult cardiac surgery patients, patients who received transfusions of packed red blood cells more than 7 days old had higher rates of many complications than did those who received fresher cells (N. Engl. J. Med. 2008;358:1229–39).

At our center, we have adopted a strategy of less-frequent transfusions for our pediatric cardiac surgery patients, although we have not specified the age of the packed red blood cells.

Major Finding: Transfusion of red blood cells stored 14 days or longer increases risk of multiple organ failure in critically ill children nearly twofold, compared with fresher RBCs.

Data Source: Secondary analysis of prospective, multicenter study of 296 patients.

Disclosures: Fonds de la Recherche en Santé du Québec sponsored this secondary analysis, planned a priori, of an initial, prospective, observational study funded by Johnson & Johnson. Dr. Karam disclosed that he has no financial conflict of interest.

MIAMI BEACH — A significantly higher rate of multiple organ failure after transfusion with red blood cells stored 14 days or longer, compared with fresher cells, has been shown for the first time in pediatric critical care patients.

“We were surprised to find such a difference—twice as many patients develop a bad outcome—which is very important for something so frequently used,” Dr. Oliver Karam said in an interview at his poster during the annual congress of the Society of Critical Care Medicine. The poster was selected as a Research Citation Finalist at the meeting.

Transfusions are probably one of the most common treatments in the severely ill pediatric population, he said. About one in every two children admitted to a postoperative intensive care unit (PICU) receives at least one transfusion.

Previous studies in adults and animals yielded conflicting results regarding the safety of older versus newer stored red blood cells, Dr. Karam said. Although a retrospective study of 67 transfused children found no difference in outcomes related to the shelf life of RBCs (Intensive Care Med. 2009;35:179–80), “this has not been answered [prospectively] yet in pediatrics. We are the only ones, to my knowledge, to look at pediatric data.”

Dr. Karam and his colleagues screened 930 consecutive patients younger than 18 years admitted to a PICU for 48 hours or longer at 1 of 29 centers in North America. Of the 447 children who received at least one transfusion, information on storage time was available for 296 patients. The median length of storage was 14 days, so this became the cutoff to define “older” versus “fresher” blood.

The maximum permitted length of storage in both the United States and Canada is 42 days, said Dr. Karam, chief medical fellow at CHU Sainte-Justine in Montreal.

Among patients who received blood stored 14 days or longer, the increased incidence of new or progressive multiple organ failure was almost double (adjusted odds ratio, 1.87), based on a multiple logistic regression that adjusted for gender, weight, number of organ failures at admission, total transfusion number, and total transfusion dose. Clinical severity at admission was associated with more RBC transfusions but not with use of older versus fresher blood, Dr. Karam said.

Although not significant, there was a trend for the older blood group to develop new or progressive multiple organ failure faster than the other patients (hazard ratio, 1.43).

Mortality over 28 days and PICU length of stay were secondary outcomes. There was no significant difference in this mortality rate between groups.

“The good news is pediatric patients do not die as much” as transfused adults in a critical care setting, Dr. Karam said. They generally have a greater resiliency and more functional reserve, which “may be why we did not see a difference in deaths.”

However, patients who received older blood stayed significantly longer in critical care—an adjusted median difference of 3.7 more days than did the fresher blood group. “We were surprised length of stay was so different—almost 4 days, which is huge and costs a lot,” he said.

“There are lots of hypotheses in the literature” about the effects of older stored RBCs, Dr. Karam said, such as activity by cytokines, active biolipids, or thrombotic factors. “It is probably a mix of things, but the clinical effect is there.”

Dr. Karam is planning a study to confirm these findings and look for possible mechanisms. “We are starting a pilot randomized, controlled study called ABC, or Age of Blood in Children.”

“We were surprised to find such a difference” in outcomes related to blood storage, Dr. Oliver Karam said.

Source DAMIAN McNAMARA/ELSEVIER GLOBAL MEDICAL NEWS

My Take

Transfusion Strategies for Children Merit More Study

These study findings are useful to hospitalists and all pediatricians who care for inpatients. A growing body of literature highlights the inherent risks of blood product transfusion. The majority of the work has been done in adult patients, and it is therefore crucial to closely examine the safety and effectiveness of transfusion strategies in children.

If the study findings are reproducible, they may have a significant impact on patients and blood banks, but the topic needs to be studied further before changes are made in current clinical practice.

In a recent study of adult cardiac surgery patients, patients who received transfusions of packed red blood cells more than 7 days old had higher rates of many complications than did those who received fresher cells (N. Engl. J. Med. 2008;358:1229–39).

At our center, we have adopted a strategy of less-frequent transfusions for our pediatric cardiac surgery patients, although we have not specified the age of the packed red blood cells.

Major Finding: Transfusion of red blood cells stored 14 days or longer increases risk of multiple organ failure in critically ill children nearly twofold, compared with fresher RBCs.

Data Source: Secondary analysis of prospective, multicenter study of 296 patients.

Disclosures: Fonds de la Recherche en Santé du Québec sponsored this secondary analysis, planned a priori, of an initial, prospective, observational study funded by Johnson & Johnson. Dr. Karam disclosed that he has no financial conflict of interest.

MIAMI BEACH — A significantly higher rate of multiple organ failure after transfusion with red blood cells stored 14 days or longer, compared with fresher cells, has been shown for the first time in pediatric critical care patients.

“We were surprised to find such a difference—twice as many patients develop a bad outcome—which is very important for something so frequently used,” Dr. Oliver Karam said in an interview at his poster during the annual congress of the Society of Critical Care Medicine. The poster was selected as a Research Citation Finalist at the meeting.

Transfusions are probably one of the most common treatments in the severely ill pediatric population, he said. About one in every two children admitted to a postoperative intensive care unit (PICU) receives at least one transfusion.

Previous studies in adults and animals yielded conflicting results regarding the safety of older versus newer stored red blood cells, Dr. Karam said. Although a retrospective study of 67 transfused children found no difference in outcomes related to the shelf life of RBCs (Intensive Care Med. 2009;35:179–80), “this has not been answered [prospectively] yet in pediatrics. We are the only ones, to my knowledge, to look at pediatric data.”

Dr. Karam and his colleagues screened 930 consecutive patients younger than 18 years admitted to a PICU for 48 hours or longer at 1 of 29 centers in North America. Of the 447 children who received at least one transfusion, information on storage time was available for 296 patients. The median length of storage was 14 days, so this became the cutoff to define “older” versus “fresher” blood.

The maximum permitted length of storage in both the United States and Canada is 42 days, said Dr. Karam, chief medical fellow at CHU Sainte-Justine in Montreal.

Among patients who received blood stored 14 days or longer, the increased incidence of new or progressive multiple organ failure was almost double (adjusted odds ratio, 1.87), based on a multiple logistic regression that adjusted for gender, weight, number of organ failures at admission, total transfusion number, and total transfusion dose. Clinical severity at admission was associated with more RBC transfusions but not with use of older versus fresher blood, Dr. Karam said.

Although not significant, there was a trend for the older blood group to develop new or progressive multiple organ failure faster than the other patients (hazard ratio, 1.43).

Mortality over 28 days and PICU length of stay were secondary outcomes. There was no significant difference in this mortality rate between groups.

“The good news is pediatric patients do not die as much” as transfused adults in a critical care setting, Dr. Karam said. They generally have a greater resiliency and more functional reserve, which “may be why we did not see a difference in deaths.”

However, patients who received older blood stayed significantly longer in critical care—an adjusted median difference of 3.7 more days than did the fresher blood group. “We were surprised length of stay was so different—almost 4 days, which is huge and costs a lot,” he said.

“There are lots of hypotheses in the literature” about the effects of older stored RBCs, Dr. Karam said, such as activity by cytokines, active biolipids, or thrombotic factors. “It is probably a mix of things, but the clinical effect is there.”

Dr. Karam is planning a study to confirm these findings and look for possible mechanisms. “We are starting a pilot randomized, controlled study called ABC, or Age of Blood in Children.”

“We were surprised to find such a difference” in outcomes related to blood storage, Dr. Oliver Karam said.

Source DAMIAN McNAMARA/ELSEVIER GLOBAL MEDICAL NEWS

My Take

Transfusion Strategies for Children Merit More Study

These study findings are useful to hospitalists and all pediatricians who care for inpatients. A growing body of literature highlights the inherent risks of blood product transfusion. The majority of the work has been done in adult patients, and it is therefore crucial to closely examine the safety and effectiveness of transfusion strategies in children.

If the study findings are reproducible, they may have a significant impact on patients and blood banks, but the topic needs to be studied further before changes are made in current clinical practice.

In a recent study of adult cardiac surgery patients, patients who received transfusions of packed red blood cells more than 7 days old had higher rates of many complications than did those who received fresher cells (N. Engl. J. Med. 2008;358:1229–39).

At our center, we have adopted a strategy of less-frequent transfusions for our pediatric cardiac surgery patients, although we have not specified the age of the packed red blood cells.

HOLLYWOOD, FLA. — Follow-up data from a study of prolapse repair, which originally found a significant advantage of synthetic mesh over cadaver fascia at 1 year, revealed no significant difference at 5 years based on a new definition of surgical success that included patient-reported symptoms.

“Although fascia did not seem to work as well as mesh using the original definition, the difference did not reach statistical significance with a new definition using a combination of subjective and objective measures of prolapse,” Dr. Susan B. Tate said at the annual meeting of the American Urogynecologic Society.

In the initial study, researchers randomized 100 women with pelvic organ prolapse to receive either mesh or cadaver fascia for abdominal sacral colpopexy (Obstet. Gynecol. 2005;106:29-37). Among the 89 patients assessed at 1-year follow-up, the success rate was significantly higher with mesh (91%) than with fascia (68%), based solely on anatomic changes as assessed using the pelvic organ prolapse quantification (POP-Q) examination.

Dr. Tate and her colleagues attempted to contact all 100 patients for the follow-up study. She presented 5-year findings for 29 women who received mesh repair and 29 who received fascia repair, all of whom underwent assessment of anatomic changes and completed a questionnaire about subjective outcomes. For example, patients were asked about symptoms using questions such as “I feel as though there is a ball between my legs or that I am sitting on a ball,” said Dr. Tate, of the department of obstetrics, gynecology, and women's health, University of Louisville (Ky.).

At 5 years, 100% of the mesh patients and 83% of the fascia patients had achieved success based on a combination of anatomic assessment and patient-reported symptoms. Although all of the failures were in the fascia group, “there was only a trend toward a significant difference,” Dr. Tate said.

During the 5 years, there was one mesh erosion and one fascia erosion. Both were removed without complications, Dr. Tate said.

Dr. Tate noted that the new findings can be viewed in the context of a 2007 American College of Obstetricians and Gynecologists Practice Bulletin that cautions against use of cadaver fascia because of a higher risk of relapse, compared with synthetic mesh (Obstet. Gynecol. 2007;110:717-29).

Strengths of the study include its randomized design and long-term follow-up, Dr. Tate said. A lack of validated questionnaire use at the time of the original study and attrition are potential weaknesses, she added

Disclosures: Dr. Tate, who is a consultant and paid instructor for C.R. Bard, had no relevant disclosures.

HOLLYWOOD, FLA. — Follow-up data from a study of prolapse repair, which originally found a significant advantage of synthetic mesh over cadaver fascia at 1 year, revealed no significant difference at 5 years based on a new definition of surgical success that included patient-reported symptoms.

“Although fascia did not seem to work as well as mesh using the original definition, the difference did not reach statistical significance with a new definition using a combination of subjective and objective measures of prolapse,” Dr. Susan B. Tate said at the annual meeting of the American Urogynecologic Society.

In the initial study, researchers randomized 100 women with pelvic organ prolapse to receive either mesh or cadaver fascia for abdominal sacral colpopexy (Obstet. Gynecol. 2005;106:29-37). Among the 89 patients assessed at 1-year follow-up, the success rate was significantly higher with mesh (91%) than with fascia (68%), based solely on anatomic changes as assessed using the pelvic organ prolapse quantification (POP-Q) examination.

Dr. Tate and her colleagues attempted to contact all 100 patients for the follow-up study. She presented 5-year findings for 29 women who received mesh repair and 29 who received fascia repair, all of whom underwent assessment of anatomic changes and completed a questionnaire about subjective outcomes. For example, patients were asked about symptoms using questions such as “I feel as though there is a ball between my legs or that I am sitting on a ball,” said Dr. Tate, of the department of obstetrics, gynecology, and women's health, University of Louisville (Ky.).

At 5 years, 100% of the mesh patients and 83% of the fascia patients had achieved success based on a combination of anatomic assessment and patient-reported symptoms. Although all of the failures were in the fascia group, “there was only a trend toward a significant difference,” Dr. Tate said.

During the 5 years, there was one mesh erosion and one fascia erosion. Both were removed without complications, Dr. Tate said.

Dr. Tate noted that the new findings can be viewed in the context of a 2007 American College of Obstetricians and Gynecologists Practice Bulletin that cautions against use of cadaver fascia because of a higher risk of relapse, compared with synthetic mesh (Obstet. Gynecol. 2007;110:717-29).

Strengths of the study include its randomized design and long-term follow-up, Dr. Tate said. A lack of validated questionnaire use at the time of the original study and attrition are potential weaknesses, she added

Disclosures: Dr. Tate, who is a consultant and paid instructor for C.R. Bard, had no relevant disclosures.

HOLLYWOOD, FLA. — Follow-up data from a study of prolapse repair, which originally found a significant advantage of synthetic mesh over cadaver fascia at 1 year, revealed no significant difference at 5 years based on a new definition of surgical success that included patient-reported symptoms.

“Although fascia did not seem to work as well as mesh using the original definition, the difference did not reach statistical significance with a new definition using a combination of subjective and objective measures of prolapse,” Dr. Susan B. Tate said at the annual meeting of the American Urogynecologic Society.

In the initial study, researchers randomized 100 women with pelvic organ prolapse to receive either mesh or cadaver fascia for abdominal sacral colpopexy (Obstet. Gynecol. 2005;106:29-37). Among the 89 patients assessed at 1-year follow-up, the success rate was significantly higher with mesh (91%) than with fascia (68%), based solely on anatomic changes as assessed using the pelvic organ prolapse quantification (POP-Q) examination.

Dr. Tate and her colleagues attempted to contact all 100 patients for the follow-up study. She presented 5-year findings for 29 women who received mesh repair and 29 who received fascia repair, all of whom underwent assessment of anatomic changes and completed a questionnaire about subjective outcomes. For example, patients were asked about symptoms using questions such as “I feel as though there is a ball between my legs or that I am sitting on a ball,” said Dr. Tate, of the department of obstetrics, gynecology, and women's health, University of Louisville (Ky.).

At 5 years, 100% of the mesh patients and 83% of the fascia patients had achieved success based on a combination of anatomic assessment and patient-reported symptoms. Although all of the failures were in the fascia group, “there was only a trend toward a significant difference,” Dr. Tate said.

During the 5 years, there was one mesh erosion and one fascia erosion. Both were removed without complications, Dr. Tate said.

Dr. Tate noted that the new findings can be viewed in the context of a 2007 American College of Obstetricians and Gynecologists Practice Bulletin that cautions against use of cadaver fascia because of a higher risk of relapse, compared with synthetic mesh (Obstet. Gynecol. 2007;110:717-29).

Strengths of the study include its randomized design and long-term follow-up, Dr. Tate said. A lack of validated questionnaire use at the time of the original study and attrition are potential weaknesses, she added

Disclosures: Dr. Tate, who is a consultant and paid instructor for C.R. Bard, had no relevant disclosures.

Major Finding: Fewer pelvic organ prolapse procedures are being performed in women under age 52 years.

Data Source: A study of the National Hospital Discharge Survey database.

Disclosures: The National Institutes of Health funded the study. Dr. Jones said she had no relevant disclosures.

HOLLYWOOD, FLA. — The overall number of inpatient surgeries for pelvic organ prolapse decreased over the past few decades, with some interesting trends according to patient age, based on a 1979-2006 study of the National Hospital Discharge Survey database.

“The decrease in overall numbers likely reflects a large decline in procedures in women younger than 52 years,” Dr. Keisha Jones said. “Rates were stable or slightly increased for women 52 and older.”

Epidemiologic data for pelvic organ prolapse are lacking, she said at the annual meeting of the American Urogynecologic Society. So she and her associates evaluated more than 5.6 million prolapse procedures performed from 1979 to 2006. There were approximately 228,000 procedures in 1979 and 186,000 in the final year of the study period, according to ICD-9-CM codes in the database.

The researchers stratified women into two groups—those younger than 52 and those 52 years and older. They chose this cutoff point because 52 is the average age of onset of menopause in the United States.

During the study, mean patient age increased by a decade from 47 years in 1979 to 57 years in 2006, said Dr. Jones, who was an ob.gyn. fellow in the division of female pelvic medicine and reconstructive surgery at Magee-Women's Hospital in Pittsburgh at the time of the study. Dr. Jones is currently a urogynecologist at Baystate Medical Center in Springfield, Mass.

Dr. Jones and her associates also looked at age-adjusted surgery rates based on 1990 U.S. census data. The overall rates of prolapse surgery decreased from 2.93/1,000 women in 1979 to 1.56 in 2006. Among younger women, the rate decreased from 3.03 in 1979 to 0.84 in 2006. Among women 52 and older, the rates actually increased slightly, from 2.73 in 1979 to 2.86 in 2006.

The investigators proposed that a dramatic decrease in overall hysterectomies performed for benign indications among women younger than 52 is directly related to the significant decrease in inpatient prolapse procedures in this population.

The overall age-adjusted rates of hysterectomy for benign indications declined from 7.24/1,000 women in 1979 to 4.50 in 2006, most dramatically in women under age 52 (from 9.4/1,000 women to 5.1), Dr. Jones said. In contrast, no significant change was observed for hysterectomies in women aged 52 years and older (from 3.1 in 1979 to 3.3 in 2006).

A total of 29% of the women had surgical complications, most often uterine or vaginal inflammation and anemia.

Major Finding: Fewer pelvic organ prolapse procedures are being performed in women under age 52 years.

Data Source: A study of the National Hospital Discharge Survey database.

Disclosures: The National Institutes of Health funded the study. Dr. Jones said she had no relevant disclosures.

HOLLYWOOD, FLA. — The overall number of inpatient surgeries for pelvic organ prolapse decreased over the past few decades, with some interesting trends according to patient age, based on a 1979-2006 study of the National Hospital Discharge Survey database.

“The decrease in overall numbers likely reflects a large decline in procedures in women younger than 52 years,” Dr. Keisha Jones said. “Rates were stable or slightly increased for women 52 and older.”

Epidemiologic data for pelvic organ prolapse are lacking, she said at the annual meeting of the American Urogynecologic Society. So she and her associates evaluated more than 5.6 million prolapse procedures performed from 1979 to 2006. There were approximately 228,000 procedures in 1979 and 186,000 in the final year of the study period, according to ICD-9-CM codes in the database.

The researchers stratified women into two groups—those younger than 52 and those 52 years and older. They chose this cutoff point because 52 is the average age of onset of menopause in the United States.

During the study, mean patient age increased by a decade from 47 years in 1979 to 57 years in 2006, said Dr. Jones, who was an ob.gyn. fellow in the division of female pelvic medicine and reconstructive surgery at Magee-Women's Hospital in Pittsburgh at the time of the study. Dr. Jones is currently a urogynecologist at Baystate Medical Center in Springfield, Mass.

Dr. Jones and her associates also looked at age-adjusted surgery rates based on 1990 U.S. census data. The overall rates of prolapse surgery decreased from 2.93/1,000 women in 1979 to 1.56 in 2006. Among younger women, the rate decreased from 3.03 in 1979 to 0.84 in 2006. Among women 52 and older, the rates actually increased slightly, from 2.73 in 1979 to 2.86 in 2006.

The investigators proposed that a dramatic decrease in overall hysterectomies performed for benign indications among women younger than 52 is directly related to the significant decrease in inpatient prolapse procedures in this population.

The overall age-adjusted rates of hysterectomy for benign indications declined from 7.24/1,000 women in 1979 to 4.50 in 2006, most dramatically in women under age 52 (from 9.4/1,000 women to 5.1), Dr. Jones said. In contrast, no significant change was observed for hysterectomies in women aged 52 years and older (from 3.1 in 1979 to 3.3 in 2006).

A total of 29% of the women had surgical complications, most often uterine or vaginal inflammation and anemia.

Major Finding: Fewer pelvic organ prolapse procedures are being performed in women under age 52 years.

Data Source: A study of the National Hospital Discharge Survey database.

Disclosures: The National Institutes of Health funded the study. Dr. Jones said she had no relevant disclosures.

HOLLYWOOD, FLA. — The overall number of inpatient surgeries for pelvic organ prolapse decreased over the past few decades, with some interesting trends according to patient age, based on a 1979-2006 study of the National Hospital Discharge Survey database.

“The decrease in overall numbers likely reflects a large decline in procedures in women younger than 52 years,” Dr. Keisha Jones said. “Rates were stable or slightly increased for women 52 and older.”

Epidemiologic data for pelvic organ prolapse are lacking, she said at the annual meeting of the American Urogynecologic Society. So she and her associates evaluated more than 5.6 million prolapse procedures performed from 1979 to 2006. There were approximately 228,000 procedures in 1979 and 186,000 in the final year of the study period, according to ICD-9-CM codes in the database.

The researchers stratified women into two groups—those younger than 52 and those 52 years and older. They chose this cutoff point because 52 is the average age of onset of menopause in the United States.

During the study, mean patient age increased by a decade from 47 years in 1979 to 57 years in 2006, said Dr. Jones, who was an ob.gyn. fellow in the division of female pelvic medicine and reconstructive surgery at Magee-Women's Hospital in Pittsburgh at the time of the study. Dr. Jones is currently a urogynecologist at Baystate Medical Center in Springfield, Mass.

Dr. Jones and her associates also looked at age-adjusted surgery rates based on 1990 U.S. census data. The overall rates of prolapse surgery decreased from 2.93/1,000 women in 1979 to 1.56 in 2006. Among younger women, the rate decreased from 3.03 in 1979 to 0.84 in 2006. Among women 52 and older, the rates actually increased slightly, from 2.73 in 1979 to 2.86 in 2006.

The investigators proposed that a dramatic decrease in overall hysterectomies performed for benign indications among women younger than 52 is directly related to the significant decrease in inpatient prolapse procedures in this population.

The overall age-adjusted rates of hysterectomy for benign indications declined from 7.24/1,000 women in 1979 to 4.50 in 2006, most dramatically in women under age 52 (from 9.4/1,000 women to 5.1), Dr. Jones said. In contrast, no significant change was observed for hysterectomies in women aged 52 years and older (from 3.1 in 1979 to 3.3 in 2006).

A total of 29% of the women had surgical complications, most often uterine or vaginal inflammation and anemia.

Major Finding: Paravaginal repair of anterior prolapse with synthetic mesh had a higher anatomic success rate than xenograft repair; both beat standard colporrhaphy at 1 year after surgery.

Data Source: Interim results of a double-blind, randomized, controlled study in 78 women with symptomatic prolapse.

Disclosures: The study was supported by an unrestricted grant from Boston Scientific Corp. Dr. Dyer and her coauthors said they had no relevant disclosures.

HOLLYWOOD, FLA. — Paravaginal repair of anterior prolapse with synthetic mesh is associated with a higher anatomic success rate than is xenograft repair; both of these interventions were more successful than standard colporrhaphy, based on interim results of a double-blind, randomized, controlled study.

There were no significant differences in symptomatic prolapse recurrence, operative time, or sexual function outcomes, Dr. Keisha Dyer said.

Recurrence rates of up to 40%-50% are commonly reported after anterior vaginal wall prolapse repair, with about 30% of these women requiring a reoperation, she said.

Although paravaginal repairs and graft augmentation can decrease the number of failures, more data are needed about the optimal material, said Dr. Dyer of the division of female pelvic medicine and reconstructive surgery at the University of California, San Diego.

Dr. Dyer and her associates assessed 99 women with symptomatic prolapse. In the operating room on the day of surgery, 32 were randomized to anterior colporrhaphy; 31, to porcine dermal graft; and the remaining 36, to polypropylene mesh.

At baseline, patients enrolled in this Optimal Anterior Repair Study (OARS) had a mean of stage III anterior prolapse and a mean age of 63 years. They were enrolled from January 2006 to September 2008. The researchers tracked patients' outcomes at 6 weeks and at 6, 12, and 24 months.

Dr. Dyer presented interim results for 78 women followed for at least 1 year (mean, 20 months) at the annual meeting of the American Urogynecologic Society.

Anatomic success was achieved by 14 of 26 women (54%) in the colporrhaphy group, 15 of 24 women (63%) in the porcine graft group, and 25 of 28 (89%) women in the synthetic mesh group. The difference in this primary outcome between the colporrhaphy and synthetic mesh groups was statistically significant, Dr. Dyer said. Anatomic success was defined as prolapse stage I or 0 on the pelvic organ prolapse quantification (POP-Q) examination.

There was no significant difference between groups in symptomatic recurrence, a secondary aim of the study. A total of 12% of the colporrhaphy group, 13% of the porcine graft group, and 4% of the mesh group had a return of prolapse symptoms, such as complaint of “bulge.” Two patients in the porcine graft group had reoperations, Dr. Dyer said.

The erosion rate was higher in the synthetic mesh group. This outcome was experienced by four patients in this group (14%), compared with one patient (4%) who received the porcine graft repair.

There were no significant differences in terms of operative time. However, there was a trend toward approximately 50 mL more blood loss with augmentation, Dr. Dyer said. Estimated blood loss was 171 mL in the colporrhaphy cohort, 229 mL in the porcine graft group, and 225 mL in the synthetic mesh patients.

In terms of subjective outcomes, women in all three groups reported a reduction in prolapse and urinary symptoms at follow-up on subscales of the pelvic floor impact questionnaire (PFIQ) and the pelvic floor distress inventory (PFDI). There were no statistical differences between groups.

In addition, postoperative sexual function scores on the pelvic organ prolapse/urinary incontinence sexual questionnaire (PISQ) were not significantly different between groups, Dr. Dyer said.

The randomized, double-blind, multicenter design was a strength of the study, she said. “A major limitation is that a majority of our subjects underwent concomitant procedures,” which were permitted at the discretion of the surgeon.

“We look forward to sharing our 2-year data in the future,” Dr. Dyer said. Time to failure and any differences in reports of pain are planned to be released with the 24-month data.

Major Finding: Paravaginal repair of anterior prolapse with synthetic mesh had a higher anatomic success rate than xenograft repair; both beat standard colporrhaphy at 1 year after surgery.

Data Source: Interim results of a double-blind, randomized, controlled study in 78 women with symptomatic prolapse.

Disclosures: The study was supported by an unrestricted grant from Boston Scientific Corp. Dr. Dyer and her coauthors said they had no relevant disclosures.

HOLLYWOOD, FLA. — Paravaginal repair of anterior prolapse with synthetic mesh is associated with a higher anatomic success rate than is xenograft repair; both of these interventions were more successful than standard colporrhaphy, based on interim results of a double-blind, randomized, controlled study.

There were no significant differences in symptomatic prolapse recurrence, operative time, or sexual function outcomes, Dr. Keisha Dyer said.

Recurrence rates of up to 40%-50% are commonly reported after anterior vaginal wall prolapse repair, with about 30% of these women requiring a reoperation, she said.

Although paravaginal repairs and graft augmentation can decrease the number of failures, more data are needed about the optimal material, said Dr. Dyer of the division of female pelvic medicine and reconstructive surgery at the University of California, San Diego.

Dr. Dyer and her associates assessed 99 women with symptomatic prolapse. In the operating room on the day of surgery, 32 were randomized to anterior colporrhaphy; 31, to porcine dermal graft; and the remaining 36, to polypropylene mesh.

At baseline, patients enrolled in this Optimal Anterior Repair Study (OARS) had a mean of stage III anterior prolapse and a mean age of 63 years. They were enrolled from January 2006 to September 2008. The researchers tracked patients' outcomes at 6 weeks and at 6, 12, and 24 months.

Dr. Dyer presented interim results for 78 women followed for at least 1 year (mean, 20 months) at the annual meeting of the American Urogynecologic Society.

Anatomic success was achieved by 14 of 26 women (54%) in the colporrhaphy group, 15 of 24 women (63%) in the porcine graft group, and 25 of 28 (89%) women in the synthetic mesh group. The difference in this primary outcome between the colporrhaphy and synthetic mesh groups was statistically significant, Dr. Dyer said. Anatomic success was defined as prolapse stage I or 0 on the pelvic organ prolapse quantification (POP-Q) examination.

There was no significant difference between groups in symptomatic recurrence, a secondary aim of the study. A total of 12% of the colporrhaphy group, 13% of the porcine graft group, and 4% of the mesh group had a return of prolapse symptoms, such as complaint of “bulge.” Two patients in the porcine graft group had reoperations, Dr. Dyer said.

The erosion rate was higher in the synthetic mesh group. This outcome was experienced by four patients in this group (14%), compared with one patient (4%) who received the porcine graft repair.

There were no significant differences in terms of operative time. However, there was a trend toward approximately 50 mL more blood loss with augmentation, Dr. Dyer said. Estimated blood loss was 171 mL in the colporrhaphy cohort, 229 mL in the porcine graft group, and 225 mL in the synthetic mesh patients.

In terms of subjective outcomes, women in all three groups reported a reduction in prolapse and urinary symptoms at follow-up on subscales of the pelvic floor impact questionnaire (PFIQ) and the pelvic floor distress inventory (PFDI). There were no statistical differences between groups.

In addition, postoperative sexual function scores on the pelvic organ prolapse/urinary incontinence sexual questionnaire (PISQ) were not significantly different between groups, Dr. Dyer said.

The randomized, double-blind, multicenter design was a strength of the study, she said. “A major limitation is that a majority of our subjects underwent concomitant procedures,” which were permitted at the discretion of the surgeon.

“We look forward to sharing our 2-year data in the future,” Dr. Dyer said. Time to failure and any differences in reports of pain are planned to be released with the 24-month data.

Major Finding: Paravaginal repair of anterior prolapse with synthetic mesh had a higher anatomic success rate than xenograft repair; both beat standard colporrhaphy at 1 year after surgery.

Data Source: Interim results of a double-blind, randomized, controlled study in 78 women with symptomatic prolapse.

Disclosures: The study was supported by an unrestricted grant from Boston Scientific Corp. Dr. Dyer and her coauthors said they had no relevant disclosures.

HOLLYWOOD, FLA. — Paravaginal repair of anterior prolapse with synthetic mesh is associated with a higher anatomic success rate than is xenograft repair; both of these interventions were more successful than standard colporrhaphy, based on interim results of a double-blind, randomized, controlled study.

There were no significant differences in symptomatic prolapse recurrence, operative time, or sexual function outcomes, Dr. Keisha Dyer said.

Recurrence rates of up to 40%-50% are commonly reported after anterior vaginal wall prolapse repair, with about 30% of these women requiring a reoperation, she said.

Although paravaginal repairs and graft augmentation can decrease the number of failures, more data are needed about the optimal material, said Dr. Dyer of the division of female pelvic medicine and reconstructive surgery at the University of California, San Diego.

Dr. Dyer and her associates assessed 99 women with symptomatic prolapse. In the operating room on the day of surgery, 32 were randomized to anterior colporrhaphy; 31, to porcine dermal graft; and the remaining 36, to polypropylene mesh.

At baseline, patients enrolled in this Optimal Anterior Repair Study (OARS) had a mean of stage III anterior prolapse and a mean age of 63 years. They were enrolled from January 2006 to September 2008. The researchers tracked patients' outcomes at 6 weeks and at 6, 12, and 24 months.

Dr. Dyer presented interim results for 78 women followed for at least 1 year (mean, 20 months) at the annual meeting of the American Urogynecologic Society.

Anatomic success was achieved by 14 of 26 women (54%) in the colporrhaphy group, 15 of 24 women (63%) in the porcine graft group, and 25 of 28 (89%) women in the synthetic mesh group. The difference in this primary outcome between the colporrhaphy and synthetic mesh groups was statistically significant, Dr. Dyer said. Anatomic success was defined as prolapse stage I or 0 on the pelvic organ prolapse quantification (POP-Q) examination.

There was no significant difference between groups in symptomatic recurrence, a secondary aim of the study. A total of 12% of the colporrhaphy group, 13% of the porcine graft group, and 4% of the mesh group had a return of prolapse symptoms, such as complaint of “bulge.” Two patients in the porcine graft group had reoperations, Dr. Dyer said.

The erosion rate was higher in the synthetic mesh group. This outcome was experienced by four patients in this group (14%), compared with one patient (4%) who received the porcine graft repair.

There were no significant differences in terms of operative time. However, there was a trend toward approximately 50 mL more blood loss with augmentation, Dr. Dyer said. Estimated blood loss was 171 mL in the colporrhaphy cohort, 229 mL in the porcine graft group, and 225 mL in the synthetic mesh patients.

In terms of subjective outcomes, women in all three groups reported a reduction in prolapse and urinary symptoms at follow-up on subscales of the pelvic floor impact questionnaire (PFIQ) and the pelvic floor distress inventory (PFDI). There were no statistical differences between groups.

In addition, postoperative sexual function scores on the pelvic organ prolapse/urinary incontinence sexual questionnaire (PISQ) were not significantly different between groups, Dr. Dyer said.

The randomized, double-blind, multicenter design was a strength of the study, she said. “A major limitation is that a majority of our subjects underwent concomitant procedures,” which were permitted at the discretion of the surgeon.

“We look forward to sharing our 2-year data in the future,” Dr. Dyer said. Time to failure and any differences in reports of pain are planned to be released with the 24-month data.

PHOENIX — Dermatologists may be under the clinical impression that botulinum toxin is better suited for the upper face, while fillers are the treatment of choice for the lower face.

However, as demonstrated in a previous upper-face study, the combined use of toxin and filler gave not only a superior aesthetic result but virtually doubled the duration of aesthetic response (Dermatol. Surg. 2003;29:802-9).

To elucidate these findings, Dr. Jean Carruthers and her husband Dr. Alastair Carruthers designed a lower-face study at three clinical sites. Along with Dr. Gary D. Monheit, they recruited 30 women from each site, for a total of 90, for the parallel group study.

They randomized 30 patients to receive onabotulinumtoxinA (Botox, Allergan), 30 to Juvéderm Ultra and/or Juvéderm Ultra Plus (hyaluronic acid, Allergen), and the remaining 30 patients to a combination of both treatments.

They first assessed the 35- to 55-year-old patients at baseline. Each patient was treated once and allowed one touch-up session of filler, but as many treatments with lower-face botulinum toxin as they felt they needed. A blinded rater and a principal investigator followed clinical outcomes over 6 months.

Lip fullness was rated superior in the combination group, Dr. Monheit said at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery. Juvéderm alone was found more effective than botulinum toxin alone at increasing ratings on the lip-fullness scale. Photographic analysis confirmed the investigator evaluation.

In terms of oral commissure improvements, the combination outperformed both of the single treatments, although the “filler almost matched it in most aspects,” said Dr. Monheit of the departments of dermatology and ophthalmology at the University of Alabama at Birmingham.

Dr. Jean Carruthers is clinical professor of ophthalmology at the University of British Columbia, Vancouver. Dr. Alastair Carruthers is clinical professor in the department of dermatology at the same university. Investigators asked participants to purse their lips at each assessment. “We took smooch-pose photos to look at perioral lines,” Dr. Monheit said. “We also took grimace photos to show the power of the [depressor anguli oris] muscle.” At maximal contraction, the combination yielded better results again.

The investigators and patients also completed satisfaction questionnaires. They rated multiple areas. “Botox alone pretty well lagged behind [on the] investigator's lip satisfaction questionnaire,” the investigators noted. “The patient questionnaire had pretty much the same results: The combination and filler did best, and the toxin lagged behind.”

At the conclusion of the study, the combination treatment group fared better than the filler or the toxin groups alone on most outcome measures, including lip fullness, oral commissure severity, and perioral line improvement. In addition, subjective patient satisfaction and objective investigator satisfaction rankings were highest in the combined group. Overall, the results in the combined group were better, and the longevity of response was longer. “This is a confirmation of what we do on an everyday basis,” Dr. Monheit said.

Swelling, bruising, asymmetry, and lumps were adverse events recorded in patient diaries and reported by investigators, but these “minor adverse events were rarely noted in subjects with combination treatment,” Dr. Monheit said.

Disclosures: This investigator-initiated study was funded by Allergan. The company had no input on study design or outcome, according to the investigators. Dr. Jean and Alastair Carruthers are both consultants and researchers for Allergan, Merz Pharmaceuticals, and BioForm Medical. Dr. Monheit is a researcher and consultant for Allergan, Genzyme, and Johnson & Johnson, as well as a researcher for Dermik Laboratories, Inamed Aesthetics, and ColBar LifeScience.

PHOENIX — Dermatologists may be under the clinical impression that botulinum toxin is better suited for the upper face, while fillers are the treatment of choice for the lower face.

However, as demonstrated in a previous upper-face study, the combined use of toxin and filler gave not only a superior aesthetic result but virtually doubled the duration of aesthetic response (Dermatol. Surg. 2003;29:802-9).

To elucidate these findings, Dr. Jean Carruthers and her husband Dr. Alastair Carruthers designed a lower-face study at three clinical sites. Along with Dr. Gary D. Monheit, they recruited 30 women from each site, for a total of 90, for the parallel group study.

They randomized 30 patients to receive onabotulinumtoxinA (Botox, Allergan), 30 to Juvéderm Ultra and/or Juvéderm Ultra Plus (hyaluronic acid, Allergen), and the remaining 30 patients to a combination of both treatments.

They first assessed the 35- to 55-year-old patients at baseline. Each patient was treated once and allowed one touch-up session of filler, but as many treatments with lower-face botulinum toxin as they felt they needed. A blinded rater and a principal investigator followed clinical outcomes over 6 months.

Lip fullness was rated superior in the combination group, Dr. Monheit said at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery. Juvéderm alone was found more effective than botulinum toxin alone at increasing ratings on the lip-fullness scale. Photographic analysis confirmed the investigator evaluation.

In terms of oral commissure improvements, the combination outperformed both of the single treatments, although the “filler almost matched it in most aspects,” said Dr. Monheit of the departments of dermatology and ophthalmology at the University of Alabama at Birmingham.

Dr. Jean Carruthers is clinical professor of ophthalmology at the University of British Columbia, Vancouver. Dr. Alastair Carruthers is clinical professor in the department of dermatology at the same university. Investigators asked participants to purse their lips at each assessment. “We took smooch-pose photos to look at perioral lines,” Dr. Monheit said. “We also took grimace photos to show the power of the [depressor anguli oris] muscle.” At maximal contraction, the combination yielded better results again.

The investigators and patients also completed satisfaction questionnaires. They rated multiple areas. “Botox alone pretty well lagged behind [on the] investigator's lip satisfaction questionnaire,” the investigators noted. “The patient questionnaire had pretty much the same results: The combination and filler did best, and the toxin lagged behind.”

At the conclusion of the study, the combination treatment group fared better than the filler or the toxin groups alone on most outcome measures, including lip fullness, oral commissure severity, and perioral line improvement. In addition, subjective patient satisfaction and objective investigator satisfaction rankings were highest in the combined group. Overall, the results in the combined group were better, and the longevity of response was longer. “This is a confirmation of what we do on an everyday basis,” Dr. Monheit said.

Swelling, bruising, asymmetry, and lumps were adverse events recorded in patient diaries and reported by investigators, but these “minor adverse events were rarely noted in subjects with combination treatment,” Dr. Monheit said.

Disclosures: This investigator-initiated study was funded by Allergan. The company had no input on study design or outcome, according to the investigators. Dr. Jean and Alastair Carruthers are both consultants and researchers for Allergan, Merz Pharmaceuticals, and BioForm Medical. Dr. Monheit is a researcher and consultant for Allergan, Genzyme, and Johnson & Johnson, as well as a researcher for Dermik Laboratories, Inamed Aesthetics, and ColBar LifeScience.

PHOENIX — Dermatologists may be under the clinical impression that botulinum toxin is better suited for the upper face, while fillers are the treatment of choice for the lower face.

However, as demonstrated in a previous upper-face study, the combined use of toxin and filler gave not only a superior aesthetic result but virtually doubled the duration of aesthetic response (Dermatol. Surg. 2003;29:802-9).

To elucidate these findings, Dr. Jean Carruthers and her husband Dr. Alastair Carruthers designed a lower-face study at three clinical sites. Along with Dr. Gary D. Monheit, they recruited 30 women from each site, for a total of 90, for the parallel group study.

They randomized 30 patients to receive onabotulinumtoxinA (Botox, Allergan), 30 to Juvéderm Ultra and/or Juvéderm Ultra Plus (hyaluronic acid, Allergen), and the remaining 30 patients to a combination of both treatments.

They first assessed the 35- to 55-year-old patients at baseline. Each patient was treated once and allowed one touch-up session of filler, but as many treatments with lower-face botulinum toxin as they felt they needed. A blinded rater and a principal investigator followed clinical outcomes over 6 months.

Lip fullness was rated superior in the combination group, Dr. Monheit said at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery. Juvéderm alone was found more effective than botulinum toxin alone at increasing ratings on the lip-fullness scale. Photographic analysis confirmed the investigator evaluation.

In terms of oral commissure improvements, the combination outperformed both of the single treatments, although the “filler almost matched it in most aspects,” said Dr. Monheit of the departments of dermatology and ophthalmology at the University of Alabama at Birmingham.

Dr. Jean Carruthers is clinical professor of ophthalmology at the University of British Columbia, Vancouver. Dr. Alastair Carruthers is clinical professor in the department of dermatology at the same university. Investigators asked participants to purse their lips at each assessment. “We took smooch-pose photos to look at perioral lines,” Dr. Monheit said. “We also took grimace photos to show the power of the [depressor anguli oris] muscle.” At maximal contraction, the combination yielded better results again.

The investigators and patients also completed satisfaction questionnaires. They rated multiple areas. “Botox alone pretty well lagged behind [on the] investigator's lip satisfaction questionnaire,” the investigators noted. “The patient questionnaire had pretty much the same results: The combination and filler did best, and the toxin lagged behind.”

At the conclusion of the study, the combination treatment group fared better than the filler or the toxin groups alone on most outcome measures, including lip fullness, oral commissure severity, and perioral line improvement. In addition, subjective patient satisfaction and objective investigator satisfaction rankings were highest in the combined group. Overall, the results in the combined group were better, and the longevity of response was longer. “This is a confirmation of what we do on an everyday basis,” Dr. Monheit said.

Swelling, bruising, asymmetry, and lumps were adverse events recorded in patient diaries and reported by investigators, but these “minor adverse events were rarely noted in subjects with combination treatment,” Dr. Monheit said.

Disclosures: This investigator-initiated study was funded by Allergan. The company had no input on study design or outcome, according to the investigators. Dr. Jean and Alastair Carruthers are both consultants and researchers for Allergan, Merz Pharmaceuticals, and BioForm Medical. Dr. Monheit is a researcher and consultant for Allergan, Genzyme, and Johnson & Johnson, as well as a researcher for Dermik Laboratories, Inamed Aesthetics, and ColBar LifeScience.

PHOENIX — Some devices commonly touted for skin tightening are supported by evidence-based medicine, although few have data at the randomized, controlled-trial level, according to Dr. E. Victor Ross.

“We have a lot of skin-tightening devices … and I applaud those companies who have spent money trying to do good, controlled studies,” Dr. Ross said at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Thermage (Solta Medical Inc., Hayward, Calif.) leads in the literature in terms of strong evidence to support its use for skin tightening, Dr. Ross said. For example, 8 of 60 published studies are “good randomized, controlled trials,” meaning they provide level 1 evidence of clinical benefit. Level 2 evidence is a nonrandomized study, whereas level 3 evidence is anecdotal or case reports showing benefit of a device.

Thermage is included in the greatest number of published studies because it has been marketed the longest, said Dr. Ross, director of the Scripps Clinic Laser and Cosmetic Dermatology Center in Carmel Valley, Calif.

Other skin-tightening devices are supported by less evidence. For example, there are no published, peer-reviewed studies about the ultrasound-focusing Ulthera system (Ulthera, Mesa, Ariz.). “But at least … you can see changes on routine histology,” he said. The Food and Drug Administration cleared marketing of the Ulthera system in September for noninvasive eyebrow lifts.

Although many manufacturers promote the “real-time temperature rise” of their devices, this may not be a fair basis for comparison because different devices heat to different levels of the skin, he said.

Another option in the skin-tightening market is the UltraShape device (UltraShape, San Ramon, Calif.). “UltraShape does have some good papers—at least two of nine are level 1, prospective randomized studies,” Dr. Ross said.

In contrast, none of the six published studies on the Accent laser system (Alma Lasers, Buffalo Grove, Ill.) are designed to provide level 1 evidence. “My interpretation of the six studies so far … is they are level 2 or 3. Also, clinical photos were not blinded as to which ones were 'before' and 'after,'” Dr. Ross said.

A promising device not yet available in the United States is the high-intensity, focused, ultrasound LipoSonix system (Medicis Technologies, Bothell, Wash.), he said. It is approved for use in Europe and Canada. Foamy macrophages—suggesting lipid uptake—are seen on histology after use of the LipoSonix device, suggesting a true clinical effect.

Disclosures: Dr. Ross is a researcher and/or consultant for Palomar Medical Technologies Inc., Lumenis Ltd., Cutera Inc., Candela Corp., Alma Lasers Ltd., Iridex Corp., Laserscope, Ulthera Inc., and Sciton Inc.

PHOENIX — Some devices commonly touted for skin tightening are supported by evidence-based medicine, although few have data at the randomized, controlled-trial level, according to Dr. E. Victor Ross.

“We have a lot of skin-tightening devices … and I applaud those companies who have spent money trying to do good, controlled studies,” Dr. Ross said at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Thermage (Solta Medical Inc., Hayward, Calif.) leads in the literature in terms of strong evidence to support its use for skin tightening, Dr. Ross said. For example, 8 of 60 published studies are “good randomized, controlled trials,” meaning they provide level 1 evidence of clinical benefit. Level 2 evidence is a nonrandomized study, whereas level 3 evidence is anecdotal or case reports showing benefit of a device.

Thermage is included in the greatest number of published studies because it has been marketed the longest, said Dr. Ross, director of the Scripps Clinic Laser and Cosmetic Dermatology Center in Carmel Valley, Calif.

Other skin-tightening devices are supported by less evidence. For example, there are no published, peer-reviewed studies about the ultrasound-focusing Ulthera system (Ulthera, Mesa, Ariz.). “But at least … you can see changes on routine histology,” he said. The Food and Drug Administration cleared marketing of the Ulthera system in September for noninvasive eyebrow lifts.

Although many manufacturers promote the “real-time temperature rise” of their devices, this may not be a fair basis for comparison because different devices heat to different levels of the skin, he said.

Another option in the skin-tightening market is the UltraShape device (UltraShape, San Ramon, Calif.). “UltraShape does have some good papers—at least two of nine are level 1, prospective randomized studies,” Dr. Ross said.

In contrast, none of the six published studies on the Accent laser system (Alma Lasers, Buffalo Grove, Ill.) are designed to provide level 1 evidence. “My interpretation of the six studies so far … is they are level 2 or 3. Also, clinical photos were not blinded as to which ones were 'before' and 'after,'” Dr. Ross said.

A promising device not yet available in the United States is the high-intensity, focused, ultrasound LipoSonix system (Medicis Technologies, Bothell, Wash.), he said. It is approved for use in Europe and Canada. Foamy macrophages—suggesting lipid uptake—are seen on histology after use of the LipoSonix device, suggesting a true clinical effect.

Disclosures: Dr. Ross is a researcher and/or consultant for Palomar Medical Technologies Inc., Lumenis Ltd., Cutera Inc., Candela Corp., Alma Lasers Ltd., Iridex Corp., Laserscope, Ulthera Inc., and Sciton Inc.

PHOENIX — Some devices commonly touted for skin tightening are supported by evidence-based medicine, although few have data at the randomized, controlled-trial level, according to Dr. E. Victor Ross.

“We have a lot of skin-tightening devices … and I applaud those companies who have spent money trying to do good, controlled studies,” Dr. Ross said at the joint annual meeting of the American Society for Dermatologic Surgery and the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Thermage (Solta Medical Inc., Hayward, Calif.) leads in the literature in terms of strong evidence to support its use for skin tightening, Dr. Ross said. For example, 8 of 60 published studies are “good randomized, controlled trials,” meaning they provide level 1 evidence of clinical benefit. Level 2 evidence is a nonrandomized study, whereas level 3 evidence is anecdotal or case reports showing benefit of a device.

Thermage is included in the greatest number of published studies because it has been marketed the longest, said Dr. Ross, director of the Scripps Clinic Laser and Cosmetic Dermatology Center in Carmel Valley, Calif.

Other skin-tightening devices are supported by less evidence. For example, there are no published, peer-reviewed studies about the ultrasound-focusing Ulthera system (Ulthera, Mesa, Ariz.). “But at least … you can see changes on routine histology,” he said. The Food and Drug Administration cleared marketing of the Ulthera system in September for noninvasive eyebrow lifts.

Although many manufacturers promote the “real-time temperature rise” of their devices, this may not be a fair basis for comparison because different devices heat to different levels of the skin, he said.

Another option in the skin-tightening market is the UltraShape device (UltraShape, San Ramon, Calif.). “UltraShape does have some good papers—at least two of nine are level 1, prospective randomized studies,” Dr. Ross said.

In contrast, none of the six published studies on the Accent laser system (Alma Lasers, Buffalo Grove, Ill.) are designed to provide level 1 evidence. “My interpretation of the six studies so far … is they are level 2 or 3. Also, clinical photos were not blinded as to which ones were 'before' and 'after,'” Dr. Ross said.

A promising device not yet available in the United States is the high-intensity, focused, ultrasound LipoSonix system (Medicis Technologies, Bothell, Wash.), he said. It is approved for use in Europe and Canada. Foamy macrophages—suggesting lipid uptake—are seen on histology after use of the LipoSonix device, suggesting a true clinical effect.

Disclosures: Dr. Ross is a researcher and/or consultant for Palomar Medical Technologies Inc., Lumenis Ltd., Cutera Inc., Candela Corp., Alma Lasers Ltd., Iridex Corp., Laserscope, Ulthera Inc., and Sciton Inc.

Disclosures: Dr. Lowenstein had no conflicts of interest to report.

HOLLYWOOD, FLA. — A better body image perception following pelvic organ prolapse treatment correlated with improved sexual function in a multicenter, prospective cohort study of 239 women.

Sexual function improved 4-6 months after treatment compared with baseline, regardless of whether patients had surgery or pessary placement. Sexual function improvements also correlated with decreased bother from pelvic organ prolapse.

“Sexual dysfunction is highly prevalent in women attending urogynecology services,” Dr. Lior Lowenstein said at the annual meeting of the American Urogynecologic Society. He estimated this condition affects as many as 60% of sexually active patients.

Other researchers previously demonstrated that women seeking treatment for advanced pelvic organ prolapse report a worse perception of body image and decreased quality of life, compared with controls who did not have pelvic organ prolapse (Am. J. Obstet. Gynecol. 2006;194:1455-61). The current study was designed to see if treatment improves body image and/or sexual function, and if there is any relationship between these two factors and prolapse symptoms.

Dr. Lowenstein and his colleagues enrolled 384 consecutive women presenting for urogynecologic care at one of eight U.S. academic medical centers.

At baseline, the mean prolapse stage was III, and the mean age was 62 years. At 4-6 months' follow-up, 145 women were lost to follow-up, but there were no significant demographic differences between that group and the 239 women who remained, said Dr. Lowenstein, who was a urogynecology fellow at Loyola University Medical Center in Chicago at the time of the study. He is now an instructor at Rambam Medical Center in Haifa, Israel.

The majority of patients (86%) chose surgery—most commonly sacrocolpopexy. The remainder opted for more conservative treatment with a pessary. A total of 126 women (61%) in the surgery cohort and 22 (67%) in the pessary group said they were sexually active—a not significant difference.

A meeting attendee asked if women treated with pessaries needed to remove them prior to sexual intercourse. “That was not part of the questionnaire we gave them, but it is an important issue that needs to be explored,” Dr. Lowenstein said.

The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire–12 (PISQ-12) was used to assess sexual function. Poorer sexual function, defined by lower scores on the PSIQ-12, significantly correlated with worse body image perception. Worse body image perception was reflected by higher scores on the Modified Body Image Perception Scale (MBIS).

Lower PISQ-12 numbers also correlated with significantly more bothersome prolapse—defined by higher scores on the prolapse subscale of the Pelvic Floor Distress Inventory (PFDI). Interestingly, Dr. Lowenstein said, the anatomic site of prolapse did not make a significant difference. The PISQ-12 scores were not significantly related to prolapse stage or affected compartment (anterior, apical, or posterior).

In addition to the three validated questionnaires, the investigators took a patient history, conducted a routine pelvic examination, and determined prolapse stage using the Pelvic Organ Prolapse Quantification (POP-Q) exam at baseline and follow-up. Dr. Lowenstein presented these results on behalf of the Fellows' Pelvic Research Network. The complete study findings have been published in the Journal of Sexual Medicine (2009;6:2286-91).

“Body image perception has an important role in sexual function in women with pelvic organ prolapse,” Dr. Lowenstein said. He added that the results suggest sexual function may be related more to a woman's perception of her body image than to actual topographic changes from pelvic organ prolapse.

Disclosures: Dr. Lowenstein had no conflicts of interest to report.

HOLLYWOOD, FLA. — A better body image perception following pelvic organ prolapse treatment correlated with improved sexual function in a multicenter, prospective cohort study of 239 women.

Sexual function improved 4-6 months after treatment compared with baseline, regardless of whether patients had surgery or pessary placement. Sexual function improvements also correlated with decreased bother from pelvic organ prolapse.

“Sexual dysfunction is highly prevalent in women attending urogynecology services,” Dr. Lior Lowenstein said at the annual meeting of the American Urogynecologic Society. He estimated this condition affects as many as 60% of sexually active patients.

Other researchers previously demonstrated that women seeking treatment for advanced pelvic organ prolapse report a worse perception of body image and decreased quality of life, compared with controls who did not have pelvic organ prolapse (Am. J. Obstet. Gynecol. 2006;194:1455-61). The current study was designed to see if treatment improves body image and/or sexual function, and if there is any relationship between these two factors and prolapse symptoms.

Dr. Lowenstein and his colleagues enrolled 384 consecutive women presenting for urogynecologic care at one of eight U.S. academic medical centers.

At baseline, the mean prolapse stage was III, and the mean age was 62 years. At 4-6 months' follow-up, 145 women were lost to follow-up, but there were no significant demographic differences between that group and the 239 women who remained, said Dr. Lowenstein, who was a urogynecology fellow at Loyola University Medical Center in Chicago at the time of the study. He is now an instructor at Rambam Medical Center in Haifa, Israel.

The majority of patients (86%) chose surgery—most commonly sacrocolpopexy. The remainder opted for more conservative treatment with a pessary. A total of 126 women (61%) in the surgery cohort and 22 (67%) in the pessary group said they were sexually active—a not significant difference.

A meeting attendee asked if women treated with pessaries needed to remove them prior to sexual intercourse. “That was not part of the questionnaire we gave them, but it is an important issue that needs to be explored,” Dr. Lowenstein said.

The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire–12 (PISQ-12) was used to assess sexual function. Poorer sexual function, defined by lower scores on the PSIQ-12, significantly correlated with worse body image perception. Worse body image perception was reflected by higher scores on the Modified Body Image Perception Scale (MBIS).

Lower PISQ-12 numbers also correlated with significantly more bothersome prolapse—defined by higher scores on the prolapse subscale of the Pelvic Floor Distress Inventory (PFDI). Interestingly, Dr. Lowenstein said, the anatomic site of prolapse did not make a significant difference. The PISQ-12 scores were not significantly related to prolapse stage or affected compartment (anterior, apical, or posterior).

In addition to the three validated questionnaires, the investigators took a patient history, conducted a routine pelvic examination, and determined prolapse stage using the Pelvic Organ Prolapse Quantification (POP-Q) exam at baseline and follow-up. Dr. Lowenstein presented these results on behalf of the Fellows' Pelvic Research Network. The complete study findings have been published in the Journal of Sexual Medicine (2009;6:2286-91).

“Body image perception has an important role in sexual function in women with pelvic organ prolapse,” Dr. Lowenstein said. He added that the results suggest sexual function may be related more to a woman's perception of her body image than to actual topographic changes from pelvic organ prolapse.

Disclosures: Dr. Lowenstein had no conflicts of interest to report.

HOLLYWOOD, FLA. — A better body image perception following pelvic organ prolapse treatment correlated with improved sexual function in a multicenter, prospective cohort study of 239 women.

Sexual function improved 4-6 months after treatment compared with baseline, regardless of whether patients had surgery or pessary placement. Sexual function improvements also correlated with decreased bother from pelvic organ prolapse.

“Sexual dysfunction is highly prevalent in women attending urogynecology services,” Dr. Lior Lowenstein said at the annual meeting of the American Urogynecologic Society. He estimated this condition affects as many as 60% of sexually active patients.

Other researchers previously demonstrated that women seeking treatment for advanced pelvic organ prolapse report a worse perception of body image and decreased quality of life, compared with controls who did not have pelvic organ prolapse (Am. J. Obstet. Gynecol. 2006;194:1455-61). The current study was designed to see if treatment improves body image and/or sexual function, and if there is any relationship between these two factors and prolapse symptoms.

Dr. Lowenstein and his colleagues enrolled 384 consecutive women presenting for urogynecologic care at one of eight U.S. academic medical centers.

At baseline, the mean prolapse stage was III, and the mean age was 62 years. At 4-6 months' follow-up, 145 women were lost to follow-up, but there were no significant demographic differences between that group and the 239 women who remained, said Dr. Lowenstein, who was a urogynecology fellow at Loyola University Medical Center in Chicago at the time of the study. He is now an instructor at Rambam Medical Center in Haifa, Israel.

The majority of patients (86%) chose surgery—most commonly sacrocolpopexy. The remainder opted for more conservative treatment with a pessary. A total of 126 women (61%) in the surgery cohort and 22 (67%) in the pessary group said they were sexually active—a not significant difference.

A meeting attendee asked if women treated with pessaries needed to remove them prior to sexual intercourse. “That was not part of the questionnaire we gave them, but it is an important issue that needs to be explored,” Dr. Lowenstein said.

The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire–12 (PISQ-12) was used to assess sexual function. Poorer sexual function, defined by lower scores on the PSIQ-12, significantly correlated with worse body image perception. Worse body image perception was reflected by higher scores on the Modified Body Image Perception Scale (MBIS).

Lower PISQ-12 numbers also correlated with significantly more bothersome prolapse—defined by higher scores on the prolapse subscale of the Pelvic Floor Distress Inventory (PFDI). Interestingly, Dr. Lowenstein said, the anatomic site of prolapse did not make a significant difference. The PISQ-12 scores were not significantly related to prolapse stage or affected compartment (anterior, apical, or posterior).

In addition to the three validated questionnaires, the investigators took a patient history, conducted a routine pelvic examination, and determined prolapse stage using the Pelvic Organ Prolapse Quantification (POP-Q) exam at baseline and follow-up. Dr. Lowenstein presented these results on behalf of the Fellows' Pelvic Research Network. The complete study findings have been published in the Journal of Sexual Medicine (2009;6:2286-91).

“Body image perception has an important role in sexual function in women with pelvic organ prolapse,” Dr. Lowenstein said. He added that the results suggest sexual function may be related more to a woman's perception of her body image than to actual topographic changes from pelvic organ prolapse.

CHICAGO — One in four elderly patients discharged to an institution after undergoing elective surgery died within 6 months, investigators found in a study designed to identify the incidence of and risk factors for postoperative admission to a skilled nursing center, rehabilitation center, or nursing home.

Although 30-day postoperative mortality for the 167 patients was similar (2% of the transferred patients vs. 3% of those discharged to home), the 24% 6-month mortality rate among institutionalized patients was significantly greater than the 5% rate for those discharged, Dr. Arek J. Wiktor said at the annual clinical congress of the American College of Surgeons.

He and his associate, Dr. Thomas N. Robinson, both with the University of Colorado at Denver, studied surgical patients aged 50 years and older (mean age, 63). Most (96%) were men.

Of the 167 patients, 29 (17%) required postoperative institutionalization, and there was a significant difference in institutionalization rates between those aged 70 years or older and younger patients, said Dr. Wiktor.

Operative time and blood loss did not differ significantly between the two groups. Mean operative times were 298 minutes in the facility group vs. 276 minutes in the discharge group; mean blood loss was 561 mL vs. 603 mL, respectively.

Identification of risk factors for institutionalization was a secondary aim of the study. Patients admitted to a facility after surgery were older (mean age of 70 years vs. 64 years), had a longer ICU stay (11 days vs. 6 days), and had a longer overall hospital stay (20 days vs. 9 days) than those discharged to home.

“Preoperative markers of frailty strongly correlated with institutionalization,” Dr. Wiktor said.

Preoperative cognitive function was assessed on the basis of the Mini-Cognitive Examination. Admitted patients had a mean score of 2.6 vs. 4.0 in those ultimately discharged to home, a significant difference. Similarly, the mean preoperative function score was 88.5 in admitted patients vs. 97.4 in those discharged to home, as measured on the Barthel Index scale.

My Take

Stratify Patients' Risks

Modifiable risk factors for poor surgical outcome would be nice to have, but there would also be tremendous value in just being able to risk-stratify elderly patients preoperatively for a higher-quality informed consent discussion.

It has already been established that patients with dementia who undergo surgery do not fare as well postoperatively as patients without dementia. In this study, cognitive dysfunction is also linked to poor outcomes.

The more precise we can stratify risk, the better we will be able to identify target groups for interventional studies that may be able to improve outcomes.

FRANK MICHOTA, M.D., is director of academic affairs in the department of hospital medicine at the Cleveland Clinic. He reports no relevant conflicts of interest.

DR. MICHOTA

CHICAGO — One in four elderly patients discharged to an institution after undergoing elective surgery died within 6 months, investigators found in a study designed to identify the incidence of and risk factors for postoperative admission to a skilled nursing center, rehabilitation center, or nursing home.

Although 30-day postoperative mortality for the 167 patients was similar (2% of the transferred patients vs. 3% of those discharged to home), the 24% 6-month mortality rate among institutionalized patients was significantly greater than the 5% rate for those discharged, Dr. Arek J. Wiktor said at the annual clinical congress of the American College of Surgeons.

He and his associate, Dr. Thomas N. Robinson, both with the University of Colorado at Denver, studied surgical patients aged 50 years and older (mean age, 63). Most (96%) were men.

Of the 167 patients, 29 (17%) required postoperative institutionalization, and there was a significant difference in institutionalization rates between those aged 70 years or older and younger patients, said Dr. Wiktor.

Operative time and blood loss did not differ significantly between the two groups. Mean operative times were 298 minutes in the facility group vs. 276 minutes in the discharge group; mean blood loss was 561 mL vs. 603 mL, respectively.

Identification of risk factors for institutionalization was a secondary aim of the study. Patients admitted to a facility after surgery were older (mean age of 70 years vs. 64 years), had a longer ICU stay (11 days vs. 6 days), and had a longer overall hospital stay (20 days vs. 9 days) than those discharged to home.

“Preoperative markers of frailty strongly correlated with institutionalization,” Dr. Wiktor said.

Preoperative cognitive function was assessed on the basis of the Mini-Cognitive Examination. Admitted patients had a mean score of 2.6 vs. 4.0 in those ultimately discharged to home, a significant difference. Similarly, the mean preoperative function score was 88.5 in admitted patients vs. 97.4 in those discharged to home, as measured on the Barthel Index scale.

My Take

Stratify Patients' Risks

Modifiable risk factors for poor surgical outcome would be nice to have, but there would also be tremendous value in just being able to risk-stratify elderly patients preoperatively for a higher-quality informed consent discussion.

It has already been established that patients with dementia who undergo surgery do not fare as well postoperatively as patients without dementia. In this study, cognitive dysfunction is also linked to poor outcomes.

The more precise we can stratify risk, the better we will be able to identify target groups for interventional studies that may be able to improve outcomes.

FRANK MICHOTA, M.D., is director of academic affairs in the department of hospital medicine at the Cleveland Clinic. He reports no relevant conflicts of interest.

DR. MICHOTA

CHICAGO — One in four elderly patients discharged to an institution after undergoing elective surgery died within 6 months, investigators found in a study designed to identify the incidence of and risk factors for postoperative admission to a skilled nursing center, rehabilitation center, or nursing home.

Although 30-day postoperative mortality for the 167 patients was similar (2% of the transferred patients vs. 3% of those discharged to home), the 24% 6-month mortality rate among institutionalized patients was significantly greater than the 5% rate for those discharged, Dr. Arek J. Wiktor said at the annual clinical congress of the American College of Surgeons.

He and his associate, Dr. Thomas N. Robinson, both with the University of Colorado at Denver, studied surgical patients aged 50 years and older (mean age, 63). Most (96%) were men.

Of the 167 patients, 29 (17%) required postoperative institutionalization, and there was a significant difference in institutionalization rates between those aged 70 years or older and younger patients, said Dr. Wiktor.

Operative time and blood loss did not differ significantly between the two groups. Mean operative times were 298 minutes in the facility group vs. 276 minutes in the discharge group; mean blood loss was 561 mL vs. 603 mL, respectively.

Identification of risk factors for institutionalization was a secondary aim of the study. Patients admitted to a facility after surgery were older (mean age of 70 years vs. 64 years), had a longer ICU stay (11 days vs. 6 days), and had a longer overall hospital stay (20 days vs. 9 days) than those discharged to home.

“Preoperative markers of frailty strongly correlated with institutionalization,” Dr. Wiktor said.

Preoperative cognitive function was assessed on the basis of the Mini-Cognitive Examination. Admitted patients had a mean score of 2.6 vs. 4.0 in those ultimately discharged to home, a significant difference. Similarly, the mean preoperative function score was 88.5 in admitted patients vs. 97.4 in those discharged to home, as measured on the Barthel Index scale.

My Take

Stratify Patients' Risks

Modifiable risk factors for poor surgical outcome would be nice to have, but there would also be tremendous value in just being able to risk-stratify elderly patients preoperatively for a higher-quality informed consent discussion.

It has already been established that patients with dementia who undergo surgery do not fare as well postoperatively as patients without dementia. In this study, cognitive dysfunction is also linked to poor outcomes.

The more precise we can stratify risk, the better we will be able to identify target groups for interventional studies that may be able to improve outcomes.

FRANK MICHOTA, M.D., is director of academic affairs in the department of hospital medicine at the Cleveland Clinic. He reports no relevant conflicts of interest.

DR. MICHOTA

ATLANTA — A single, traumatic injury is associated with more psychiatric diagnoses and more psychotropic medication prescriptions among adolescents than among those uninjured, according to a large, prospective, cohort study.

Researchers studied 20,507 patients aged 10–19 years who were treated at Group Health, a large health maintenance organization based in Seattle. Dr. Doug Zatzick and his associate studied the 6,116 teenagers (30%) who experienced a single traumatic injury in the index year of 2001 and looked for mental health diagnoses and psychotropic prescriptions in these patients for 2002, 2003, or 2004. They compared these factors with the group of 14,391 teens (70%) who were not injured.

“Yes, a single event in 2001 was associated with increased risk for broad range of psychopathology,” Dr. Zatzick said at the annual meeting of the International Society for Trauma Stress Studies.

Injury during the index year was significantly and independently associated with an increased likelihood of any psychiatric diagnosis (odds ratio, 1.23) in this population-based study, said Dr. Zatzick, of the psychiatry and behavioral science departments at the University of Washington, Seattle.

Specifically, injured teenagers were more likely to have an anxiety diagnosis (OR, 1.19) or an acute stress disorder (OR, 1.21), compared with the non injured adolescents, according to adjusted regression analyses. As an example, a significantly higher percentage of injured children had an anxiety diagnosis in 2002, 6.5%, compared with 4.8% of the noninjured group.

A total 6.2% of the injured adolescents were subsequently diagnosed with a disruptive behavior disorder, compared with 4.6% of their noninjured peers, Dr. Zatzick said.

A secondary aim of the study was to look at prevalence of traumatic brain injury (TBI). Of the 30% of the kids who were injured, “only 1% had a traumatic-brain related injury, so it's not that common,” Dr. Zatzick said.

A greater percentage of the injured group (15%) received a prescription for a psychotropic medication, compared with the noninjured group (9%). There was an increased odds ratio of 1.35 for psychotropic drug use by the injured teenagers.

“We randomly approach injured adolescents on our trauma ward. About 40% have four or more lifetime trauma [events] when they present, and so do about 50% of their parents—a common story at level 1 trauma centers,” said Dr. Zatzick said, a self-described “front-line, trauma center clinician” at Harborview Injury Prevention and Research Center in Seattle. He is director of Attending Consult Services at Harborview.

Misclassification bias of psychiatric diagnosis is a potential limitation of the study, Dr. Zatzick said.

“Injury surveillance would be good way to pick up these kids in general practice,” Dr. Zatzick said. “There could be screening on pediatrician charts for one injury, two injuries, etc.”

Dr. Zatzick had no conflicts of interest.

ATLANTA — A single, traumatic injury is associated with more psychiatric diagnoses and more psychotropic medication prescriptions among adolescents than among those uninjured, according to a large, prospective, cohort study.

Researchers studied 20,507 patients aged 10–19 years who were treated at Group Health, a large health maintenance organization based in Seattle. Dr. Doug Zatzick and his associate studied the 6,116 teenagers (30%) who experienced a single traumatic injury in the index year of 2001 and looked for mental health diagnoses and psychotropic prescriptions in these patients for 2002, 2003, or 2004. They compared these factors with the group of 14,391 teens (70%) who were not injured.

“Yes, a single event in 2001 was associated with increased risk for broad range of psychopathology,” Dr. Zatzick said at the annual meeting of the International Society for Trauma Stress Studies.

Injury during the index year was significantly and independently associated with an increased likelihood of any psychiatric diagnosis (odds ratio, 1.23) in this population-based study, said Dr. Zatzick, of the psychiatry and behavioral science departments at the University of Washington, Seattle.

Specifically, injured teenagers were more likely to have an anxiety diagnosis (OR, 1.19) or an acute stress disorder (OR, 1.21), compared with the non injured adolescents, according to adjusted regression analyses. As an example, a significantly higher percentage of injured children had an anxiety diagnosis in 2002, 6.5%, compared with 4.8% of the noninjured group.

A total 6.2% of the injured adolescents were subsequently diagnosed with a disruptive behavior disorder, compared with 4.6% of their noninjured peers, Dr. Zatzick said.

A secondary aim of the study was to look at prevalence of traumatic brain injury (TBI). Of the 30% of the kids who were injured, “only 1% had a traumatic-brain related injury, so it's not that common,” Dr. Zatzick said.

A greater percentage of the injured group (15%) received a prescription for a psychotropic medication, compared with the noninjured group (9%). There was an increased odds ratio of 1.35 for psychotropic drug use by the injured teenagers.

“We randomly approach injured adolescents on our trauma ward. About 40% have four or more lifetime trauma [events] when they present, and so do about 50% of their parents—a common story at level 1 trauma centers,” said Dr. Zatzick said, a self-described “front-line, trauma center clinician” at Harborview Injury Prevention and Research Center in Seattle. He is director of Attending Consult Services at Harborview.

Misclassification bias of psychiatric diagnosis is a potential limitation of the study, Dr. Zatzick said.

“Injury surveillance would be good way to pick up these kids in general practice,” Dr. Zatzick said. “There could be screening on pediatrician charts for one injury, two injuries, etc.”

Dr. Zatzick had no conflicts of interest.

ATLANTA — A single, traumatic injury is associated with more psychiatric diagnoses and more psychotropic medication prescriptions among adolescents than among those uninjured, according to a large, prospective, cohort study.

Researchers studied 20,507 patients aged 10–19 years who were treated at Group Health, a large health maintenance organization based in Seattle. Dr. Doug Zatzick and his associate studied the 6,116 teenagers (30%) who experienced a single traumatic injury in the index year of 2001 and looked for mental health diagnoses and psychotropic prescriptions in these patients for 2002, 2003, or 2004. They compared these factors with the group of 14,391 teens (70%) who were not injured.

“Yes, a single event in 2001 was associated with increased risk for broad range of psychopathology,” Dr. Zatzick said at the annual meeting of the International Society for Trauma Stress Studies.

Injury during the index year was significantly and independently associated with an increased likelihood of any psychiatric diagnosis (odds ratio, 1.23) in this population-based study, said Dr. Zatzick, of the psychiatry and behavioral science departments at the University of Washington, Seattle.

Specifically, injured teenagers were more likely to have an anxiety diagnosis (OR, 1.19) or an acute stress disorder (OR, 1.21), compared with the non injured adolescents, according to adjusted regression analyses. As an example, a significantly higher percentage of injured children had an anxiety diagnosis in 2002, 6.5%, compared with 4.8% of the noninjured group.

A total 6.2% of the injured adolescents were subsequently diagnosed with a disruptive behavior disorder, compared with 4.6% of their noninjured peers, Dr. Zatzick said.

A secondary aim of the study was to look at prevalence of traumatic brain injury (TBI). Of the 30% of the kids who were injured, “only 1% had a traumatic-brain related injury, so it's not that common,” Dr. Zatzick said.

A greater percentage of the injured group (15%) received a prescription for a psychotropic medication, compared with the noninjured group (9%). There was an increased odds ratio of 1.35 for psychotropic drug use by the injured teenagers.

“We randomly approach injured adolescents on our trauma ward. About 40% have four or more lifetime trauma [events] when they present, and so do about 50% of their parents—a common story at level 1 trauma centers,” said Dr. Zatzick said, a self-described “front-line, trauma center clinician” at Harborview Injury Prevention and Research Center in Seattle. He is director of Attending Consult Services at Harborview.

Misclassification bias of psychiatric diagnosis is a potential limitation of the study, Dr. Zatzick said.

“Injury surveillance would be good way to pick up these kids in general practice,” Dr. Zatzick said. “There could be screening on pediatrician charts for one injury, two injuries, etc.”

Dr. Zatzick had no conflicts of interest.