Damian McNamara

ORLANDO — Fewer than half of childhood cancer survivors who are deemed to be at high risk of secondary breast, colon, and skin malignancies receive recommended cancer screening and surveillance as adults, according to a new analysis of the large, longitudinal Childhood Cancer Survivors Study.

The deficiency was most notable for colonoscopy: Only 11.5% of 794 survivors who were considered vulnerable to colorectal cancer had a colonoscopy during the 5 years before they were surveyed, Dr. Paul Nathan reported at the annual meeting of the American Society of Clinical Oncology.

Skin cancer is the most common radiation-associated second malignancy in survivors, but just 26.7% of 4,833 survivors at high risk had ever had a complete skin exam, said Dr. Nathan, an oncologist at the Hospital for Sick Children in Toronto.

Women at high risk for breast cancer were more likely to undergo recommended screening, he added, yet only 46.3% of 521 women in this group had a mammogram performed during the 2 years before being asked about screening.

Of the 8,318 survivors surveyed in this phase of the National Cancer Institute–funded study, about 12.5% had been seen at a cancer center or within a long-term follow-up program in the previous 2 years. Another 12% reported no medical care during this time. The remaining patients were “predominantly seen by their primary care physician in their community.” Most of the survivors were in the care of family physicians, he said.

Cancer survivors and their primary care physicians need to be more vigilant, Dr. Nathan said. Individual primary care physicians may have only a few childhood cancer survivors in their practice, but they should consider these patients' special requirements. “There is broad consensus that survivors of childhood cancer need regular surveillance and screening in the hope that if we pick up these cancers early, we can change the mortality [and morbidity],” he said.

The study discussant, Dr. Charles L. Bennett, professor of geriatrics, economics, and oncology at Northwestern University in Chicago, said he was unsure whether survivorship care was the responsibility of the oncologist or the primary care provider, but suggested that it is most likely a shared responsibility.

This study is important because “surveillance is essential, yet empirical data are lacking,” Dr. Bennett said, adding that “these are real issues. These are lifelong concerns.”

The 5-year survival rate is 80% for pediatric cancers, and most patients survive long term (J. Clin. Oncol. 2009;27:2308-18). Dr. Nathan estimated that about 9% of 325,000 survivors of childhood cancer who are alive in the United States will develop a new malignancy within 30 years of their original diagnosis. Secondary malignancies are the leading cause of death among survivors who live at least 20 years beyond initial diagnosis.

The Childhood Cancer Survivors Study enrolled 20,602 people who were initially diagnosed with cancer in 1970-1986 and had survived at least 5 years. Of the original participants, 3,305 had been lost to follow-up and 1,541 had died by the time of the 2003 follow-up survey that was used for the new study. Another 3,197 declined to participate in the survey and 990 were excluded from the analysis (among them, 960 survivors who had already developed a secondary malignancy). The average age of survivors interviewed was 31 years. A matched group of 2,661 siblings and 8,318 population controls also was assessed.

The study's primary aim was to determine adherence to the Children's Oncology Group's guidelines for following survivors of childhood cancers (www.survivorshipguidelines.org

▸ Breast cancer. For those who received 20 Gy or more of radiation therapy to the breast during childhood, mammography is recommended every 1-2 years starting at age 25 years, or 8 years after the initial cancer diagnosis.

▸ Colorectal cancer. For those who received 30 Gy or more of radiation to the abdomen, pelvis, or spine, screening colonoscopy is recommended every 5 years starting at age 35 years.

▸ Skin cancer. For those who were exposed to any radiation during childhood, an annual skin examination of treated areas is recommended. “We know the rate of nonmelanoma skin cancers in irradiated areas is approaching 7% for survivors over 30 years,” Dr. Nathan noted.

In a secondary analysis, the researchers compared survivors who were not at high risk of secondary cancers with matched controls from the National Health Interview Survey of the general population to determine adherence to U.S. Preventive Services Task Force cancer screening guidelines for breast, colon, and cervical cancer.

This analysis showed that these survivors were more likely than controls to undergo recommended mammography (67%, vs. 58% of controls), were more compliant with Pap smear recommendations (82% vs. 70%), and had a comparable—albeit low—rate of recommended colonoscopy (24% in both groups). However, the number of survivors who reached the minimum age for the colonoscopy recommendation (50 years) was small, Dr. Nathan noted.

Significant predictors of adherence to mammography were older age at interview (relative risk 1.09) and care at a cancer center (RR 1.70). Older age at time of interview was the only significant predictor of colonoscopy adherence (RR 1.08). Predictors of adherence to the skin examination were care at a cancer center (RR 1.55) and the survivor's having a treatment summary (RR 1.30). Being a nonwhite patient was associated with a lower likelihood of adherence to the skin examination guideline (RR 0.63), Dr. Nathan reported.

The study was limited by the fact that the cancer diagnoses occurred from 1970 to 1986, “and clearly, therapy has changed,” Dr. Nathan said. Investigators are recruiting another 20,000 adult survivors who were treated as children between 1987 and 1999 to explore similar issues among a more contemporary cohort. The new study population also will include more minorities. About 89% of the survivors in the current study are white non-Hispanics.

As survivors of childhood cancer live longer, increasing attention is being paid to the long-term effects of therapy. A key question is whether changes at the time of the initial therapy will have an impact on these subsequent adverse effects. A consortium of institutions is planning intervention studies to address such questions and to see whether using innovative methods to educate patients about their follow-up needs will make a difference, Dr. Nathan added.

Dr. Nathan reported having no relevant conflicts of interests to disclose.

A related video is at www.youtube.com/InternalMedicineNews

Fewer than half of childhood cancer survivors at high risk for another malignancy get screened, Dr. Paul Nathan said.

Source Elsevier Global Medical News

ORLANDO — Fewer than half of childhood cancer survivors who are deemed to be at high risk of secondary breast, colon, and skin malignancies receive recommended cancer screening and surveillance as adults, according to a new analysis of the large, longitudinal Childhood Cancer Survivors Study.

The deficiency was most notable for colonoscopy: Only 11.5% of 794 survivors who were considered vulnerable to colorectal cancer had a colonoscopy during the 5 years before they were surveyed, Dr. Paul Nathan reported at the annual meeting of the American Society of Clinical Oncology.

Skin cancer is the most common radiation-associated second malignancy in survivors, but just 26.7% of 4,833 survivors at high risk had ever had a complete skin exam, said Dr. Nathan, an oncologist at the Hospital for Sick Children in Toronto.

Women at high risk for breast cancer were more likely to undergo recommended screening, he added, yet only 46.3% of 521 women in this group had a mammogram performed during the 2 years before being asked about screening.

Of the 8,318 survivors surveyed in this phase of the National Cancer Institute–funded study, about 12.5% had been seen at a cancer center or within a long-term follow-up program in the previous 2 years. Another 12% reported no medical care during this time. The remaining patients were “predominantly seen by their primary care physician in their community.” Most of the survivors were in the care of family physicians, he said.

Cancer survivors and their primary care physicians need to be more vigilant, Dr. Nathan said. Individual primary care physicians may have only a few childhood cancer survivors in their practice, but they should consider these patients' special requirements. “There is broad consensus that survivors of childhood cancer need regular surveillance and screening in the hope that if we pick up these cancers early, we can change the mortality [and morbidity],” he said.

The study discussant, Dr. Charles L. Bennett, professor of geriatrics, economics, and oncology at Northwestern University in Chicago, said he was unsure whether survivorship care was the responsibility of the oncologist or the primary care provider, but suggested that it is most likely a shared responsibility.

This study is important because “surveillance is essential, yet empirical data are lacking,” Dr. Bennett said, adding that “these are real issues. These are lifelong concerns.”

The 5-year survival rate is 80% for pediatric cancers, and most patients survive long term (J. Clin. Oncol. 2009;27:2308-18). Dr. Nathan estimated that about 9% of 325,000 survivors of childhood cancer who are alive in the United States will develop a new malignancy within 30 years of their original diagnosis. Secondary malignancies are the leading cause of death among survivors who live at least 20 years beyond initial diagnosis.

The Childhood Cancer Survivors Study enrolled 20,602 people who were initially diagnosed with cancer in 1970-1986 and had survived at least 5 years. Of the original participants, 3,305 had been lost to follow-up and 1,541 had died by the time of the 2003 follow-up survey that was used for the new study. Another 3,197 declined to participate in the survey and 990 were excluded from the analysis (among them, 960 survivors who had already developed a secondary malignancy). The average age of survivors interviewed was 31 years. A matched group of 2,661 siblings and 8,318 population controls also was assessed.

The study's primary aim was to determine adherence to the Children's Oncology Group's guidelines for following survivors of childhood cancers (www.survivorshipguidelines.org

▸ Breast cancer. For those who received 20 Gy or more of radiation therapy to the breast during childhood, mammography is recommended every 1-2 years starting at age 25 years, or 8 years after the initial cancer diagnosis.

▸ Colorectal cancer. For those who received 30 Gy or more of radiation to the abdomen, pelvis, or spine, screening colonoscopy is recommended every 5 years starting at age 35 years.

▸ Skin cancer. For those who were exposed to any radiation during childhood, an annual skin examination of treated areas is recommended. “We know the rate of nonmelanoma skin cancers in irradiated areas is approaching 7% for survivors over 30 years,” Dr. Nathan noted.

In a secondary analysis, the researchers compared survivors who were not at high risk of secondary cancers with matched controls from the National Health Interview Survey of the general population to determine adherence to U.S. Preventive Services Task Force cancer screening guidelines for breast, colon, and cervical cancer.

This analysis showed that these survivors were more likely than controls to undergo recommended mammography (67%, vs. 58% of controls), were more compliant with Pap smear recommendations (82% vs. 70%), and had a comparable—albeit low—rate of recommended colonoscopy (24% in both groups). However, the number of survivors who reached the minimum age for the colonoscopy recommendation (50 years) was small, Dr. Nathan noted.

Significant predictors of adherence to mammography were older age at interview (relative risk 1.09) and care at a cancer center (RR 1.70). Older age at time of interview was the only significant predictor of colonoscopy adherence (RR 1.08). Predictors of adherence to the skin examination were care at a cancer center (RR 1.55) and the survivor's having a treatment summary (RR 1.30). Being a nonwhite patient was associated with a lower likelihood of adherence to the skin examination guideline (RR 0.63), Dr. Nathan reported.

The study was limited by the fact that the cancer diagnoses occurred from 1970 to 1986, “and clearly, therapy has changed,” Dr. Nathan said. Investigators are recruiting another 20,000 adult survivors who were treated as children between 1987 and 1999 to explore similar issues among a more contemporary cohort. The new study population also will include more minorities. About 89% of the survivors in the current study are white non-Hispanics.

As survivors of childhood cancer live longer, increasing attention is being paid to the long-term effects of therapy. A key question is whether changes at the time of the initial therapy will have an impact on these subsequent adverse effects. A consortium of institutions is planning intervention studies to address such questions and to see whether using innovative methods to educate patients about their follow-up needs will make a difference, Dr. Nathan added.

Dr. Nathan reported having no relevant conflicts of interests to disclose.

A related video is at www.youtube.com/InternalMedicineNews

Fewer than half of childhood cancer survivors at high risk for another malignancy get screened, Dr. Paul Nathan said.

Source Elsevier Global Medical News

ORLANDO — Fewer than half of childhood cancer survivors who are deemed to be at high risk of secondary breast, colon, and skin malignancies receive recommended cancer screening and surveillance as adults, according to a new analysis of the large, longitudinal Childhood Cancer Survivors Study.

The deficiency was most notable for colonoscopy: Only 11.5% of 794 survivors who were considered vulnerable to colorectal cancer had a colonoscopy during the 5 years before they were surveyed, Dr. Paul Nathan reported at the annual meeting of the American Society of Clinical Oncology.

Skin cancer is the most common radiation-associated second malignancy in survivors, but just 26.7% of 4,833 survivors at high risk had ever had a complete skin exam, said Dr. Nathan, an oncologist at the Hospital for Sick Children in Toronto.

Women at high risk for breast cancer were more likely to undergo recommended screening, he added, yet only 46.3% of 521 women in this group had a mammogram performed during the 2 years before being asked about screening.

Of the 8,318 survivors surveyed in this phase of the National Cancer Institute–funded study, about 12.5% had been seen at a cancer center or within a long-term follow-up program in the previous 2 years. Another 12% reported no medical care during this time. The remaining patients were “predominantly seen by their primary care physician in their community.” Most of the survivors were in the care of family physicians, he said.

Cancer survivors and their primary care physicians need to be more vigilant, Dr. Nathan said. Individual primary care physicians may have only a few childhood cancer survivors in their practice, but they should consider these patients' special requirements. “There is broad consensus that survivors of childhood cancer need regular surveillance and screening in the hope that if we pick up these cancers early, we can change the mortality [and morbidity],” he said.

The study discussant, Dr. Charles L. Bennett, professor of geriatrics, economics, and oncology at Northwestern University in Chicago, said he was unsure whether survivorship care was the responsibility of the oncologist or the primary care provider, but suggested that it is most likely a shared responsibility.

This study is important because “surveillance is essential, yet empirical data are lacking,” Dr. Bennett said, adding that “these are real issues. These are lifelong concerns.”

The 5-year survival rate is 80% for pediatric cancers, and most patients survive long term (J. Clin. Oncol. 2009;27:2308-18). Dr. Nathan estimated that about 9% of 325,000 survivors of childhood cancer who are alive in the United States will develop a new malignancy within 30 years of their original diagnosis. Secondary malignancies are the leading cause of death among survivors who live at least 20 years beyond initial diagnosis.

The Childhood Cancer Survivors Study enrolled 20,602 people who were initially diagnosed with cancer in 1970-1986 and had survived at least 5 years. Of the original participants, 3,305 had been lost to follow-up and 1,541 had died by the time of the 2003 follow-up survey that was used for the new study. Another 3,197 declined to participate in the survey and 990 were excluded from the analysis (among them, 960 survivors who had already developed a secondary malignancy). The average age of survivors interviewed was 31 years. A matched group of 2,661 siblings and 8,318 population controls also was assessed.

The study's primary aim was to determine adherence to the Children's Oncology Group's guidelines for following survivors of childhood cancers (www.survivorshipguidelines.org

▸ Breast cancer. For those who received 20 Gy or more of radiation therapy to the breast during childhood, mammography is recommended every 1-2 years starting at age 25 years, or 8 years after the initial cancer diagnosis.

▸ Colorectal cancer. For those who received 30 Gy or more of radiation to the abdomen, pelvis, or spine, screening colonoscopy is recommended every 5 years starting at age 35 years.

▸ Skin cancer. For those who were exposed to any radiation during childhood, an annual skin examination of treated areas is recommended. “We know the rate of nonmelanoma skin cancers in irradiated areas is approaching 7% for survivors over 30 years,” Dr. Nathan noted.

In a secondary analysis, the researchers compared survivors who were not at high risk of secondary cancers with matched controls from the National Health Interview Survey of the general population to determine adherence to U.S. Preventive Services Task Force cancer screening guidelines for breast, colon, and cervical cancer.

This analysis showed that these survivors were more likely than controls to undergo recommended mammography (67%, vs. 58% of controls), were more compliant with Pap smear recommendations (82% vs. 70%), and had a comparable—albeit low—rate of recommended colonoscopy (24% in both groups). However, the number of survivors who reached the minimum age for the colonoscopy recommendation (50 years) was small, Dr. Nathan noted.

Significant predictors of adherence to mammography were older age at interview (relative risk 1.09) and care at a cancer center (RR 1.70). Older age at time of interview was the only significant predictor of colonoscopy adherence (RR 1.08). Predictors of adherence to the skin examination were care at a cancer center (RR 1.55) and the survivor's having a treatment summary (RR 1.30). Being a nonwhite patient was associated with a lower likelihood of adherence to the skin examination guideline (RR 0.63), Dr. Nathan reported.

The study was limited by the fact that the cancer diagnoses occurred from 1970 to 1986, “and clearly, therapy has changed,” Dr. Nathan said. Investigators are recruiting another 20,000 adult survivors who were treated as children between 1987 and 1999 to explore similar issues among a more contemporary cohort. The new study population also will include more minorities. About 89% of the survivors in the current study are white non-Hispanics.

As survivors of childhood cancer live longer, increasing attention is being paid to the long-term effects of therapy. A key question is whether changes at the time of the initial therapy will have an impact on these subsequent adverse effects. A consortium of institutions is planning intervention studies to address such questions and to see whether using innovative methods to educate patients about their follow-up needs will make a difference, Dr. Nathan added.

Dr. Nathan reported having no relevant conflicts of interests to disclose.

A related video is at www.youtube.com/InternalMedicineNews

Fewer than half of childhood cancer survivors at high risk for another malignancy get screened, Dr. Paul Nathan said.

Source Elsevier Global Medical News

SAN ANTONIO — Make the diagnosis, inform the parents first, and consider full hormone replacement therapy when an adolescent girl presents with irregular menses suggestive of primary ovarian insufficiency, Dr. Lawrence M. Nelson advised.

“The No. 1 thing I am going to ask you to do regarding primary ovarian insufficiency is to make a diagnosis,” he said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Take amenorrhea seriously, Dr. Nelson said. Although the commonly held view is “that anything goes with the menstrual cycle when you are a teenager,” irregularities can signal a serious condition. “When someone comes in with hypothyroidism, they get [thyroid-stimulating hormone] measured. When the menstrual cycle is abnormal, people will just say it's stress,” said Dr. Nelson, head of the integrative reproductive medicine unit at the National Institute of Child Health and Human Development.

Any adolescent girl who has not had menses for 90 days or longer should be evaluated further. Any girl without signs of pubertal development or onset of menses by age 13 also may have primary ovarian insufficiency (POI).

Target your evaluation based on history and physical examination and check hormone levels, including follicle-stimulating hormone, Dr. Nelson said.

A disturbance in the menstrual cycle was the leading initial symptom reported by 48 women surveyed after diagnosis with spontaneous premature ovarian failure (Obstet. Gynecol. 2002;99[pt. 1]:720–5). More than half of the respondents consulted three or more clinicians before a laboratory diagnosis was made. The median delay in diagnosis was 2 years, and for 25% it took longer than 5 years.

Once you make the diagnosis, use a family systems approach to counseling, Dr. Nelson said. “It is important to inform the parents first and then the patient. It is not a good idea, in our experience, to explain it to the parents and child at the same time.” This approach gives parents an opportunity to absorb the news and, in many cases, to grieve their loss of future grandchildren. Also, provide parents with tools that facilitate an ongoing conversation with the child.

Inform both parents and the patient with sensitivity, Dr. Nelson said. Use accurate terminology, provide information, and make appropriate psychosocial referrals. “Placing too much emphasis on the fertility effects early on may do more harm—that is one of my concerns.”

Offer the adolescent advice on how to minimize or avoid stigma and to develop positive self-esteem and body image. Physician counseling can make a difference in self-esteem, anxiety, and depression associated with POI, based on a study by Dr. Nelson and his colleagues (Fertil. Steril. 2009 [doi:10.1016/j.fertnstert.2008.12.122

After diagnosis and counseling, treatment considerations are next. “Unlike postmenopausal women, it's full hormone replacement for these [girls],” he said.

There are multiple treatments and regimens available, and he recommended a review article that outlines how to induce puberty for adolescent patients (Ann. N.Y. Acad. Sci. 2008;1135:204–11). This publication discusses the benefits and risks of hormone replacement therapy—including special concerns about bone health and eating disorders—in this population.

Although common, follicular depletion associated with POI cannot be proven definitively. “It is now clear the ovarian failure is not permanent in all women,” Dr. Nelson said. Rarely, “some women get pregnant with this diagnosis.”

'Placing too much emphasis on the fertility effects early on may do more harm—that is one of my concerns.'

Source DR. NELSON

SAN ANTONIO — Make the diagnosis, inform the parents first, and consider full hormone replacement therapy when an adolescent girl presents with irregular menses suggestive of primary ovarian insufficiency, Dr. Lawrence M. Nelson advised.

“The No. 1 thing I am going to ask you to do regarding primary ovarian insufficiency is to make a diagnosis,” he said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Take amenorrhea seriously, Dr. Nelson said. Although the commonly held view is “that anything goes with the menstrual cycle when you are a teenager,” irregularities can signal a serious condition. “When someone comes in with hypothyroidism, they get [thyroid-stimulating hormone] measured. When the menstrual cycle is abnormal, people will just say it's stress,” said Dr. Nelson, head of the integrative reproductive medicine unit at the National Institute of Child Health and Human Development.

Any adolescent girl who has not had menses for 90 days or longer should be evaluated further. Any girl without signs of pubertal development or onset of menses by age 13 also may have primary ovarian insufficiency (POI).

Target your evaluation based on history and physical examination and check hormone levels, including follicle-stimulating hormone, Dr. Nelson said.

A disturbance in the menstrual cycle was the leading initial symptom reported by 48 women surveyed after diagnosis with spontaneous premature ovarian failure (Obstet. Gynecol. 2002;99[pt. 1]:720–5). More than half of the respondents consulted three or more clinicians before a laboratory diagnosis was made. The median delay in diagnosis was 2 years, and for 25% it took longer than 5 years.

Once you make the diagnosis, use a family systems approach to counseling, Dr. Nelson said. “It is important to inform the parents first and then the patient. It is not a good idea, in our experience, to explain it to the parents and child at the same time.” This approach gives parents an opportunity to absorb the news and, in many cases, to grieve their loss of future grandchildren. Also, provide parents with tools that facilitate an ongoing conversation with the child.

Inform both parents and the patient with sensitivity, Dr. Nelson said. Use accurate terminology, provide information, and make appropriate psychosocial referrals. “Placing too much emphasis on the fertility effects early on may do more harm—that is one of my concerns.”

Offer the adolescent advice on how to minimize or avoid stigma and to develop positive self-esteem and body image. Physician counseling can make a difference in self-esteem, anxiety, and depression associated with POI, based on a study by Dr. Nelson and his colleagues (Fertil. Steril. 2009 [doi:10.1016/j.fertnstert.2008.12.122

After diagnosis and counseling, treatment considerations are next. “Unlike postmenopausal women, it's full hormone replacement for these [girls],” he said.

There are multiple treatments and regimens available, and he recommended a review article that outlines how to induce puberty for adolescent patients (Ann. N.Y. Acad. Sci. 2008;1135:204–11). This publication discusses the benefits and risks of hormone replacement therapy—including special concerns about bone health and eating disorders—in this population.

Although common, follicular depletion associated with POI cannot be proven definitively. “It is now clear the ovarian failure is not permanent in all women,” Dr. Nelson said. Rarely, “some women get pregnant with this diagnosis.”

'Placing too much emphasis on the fertility effects early on may do more harm—that is one of my concerns.'

Source DR. NELSON

SAN ANTONIO — Make the diagnosis, inform the parents first, and consider full hormone replacement therapy when an adolescent girl presents with irregular menses suggestive of primary ovarian insufficiency, Dr. Lawrence M. Nelson advised.

“The No. 1 thing I am going to ask you to do regarding primary ovarian insufficiency is to make a diagnosis,” he said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Take amenorrhea seriously, Dr. Nelson said. Although the commonly held view is “that anything goes with the menstrual cycle when you are a teenager,” irregularities can signal a serious condition. “When someone comes in with hypothyroidism, they get [thyroid-stimulating hormone] measured. When the menstrual cycle is abnormal, people will just say it's stress,” said Dr. Nelson, head of the integrative reproductive medicine unit at the National Institute of Child Health and Human Development.

Any adolescent girl who has not had menses for 90 days or longer should be evaluated further. Any girl without signs of pubertal development or onset of menses by age 13 also may have primary ovarian insufficiency (POI).

Target your evaluation based on history and physical examination and check hormone levels, including follicle-stimulating hormone, Dr. Nelson said.

A disturbance in the menstrual cycle was the leading initial symptom reported by 48 women surveyed after diagnosis with spontaneous premature ovarian failure (Obstet. Gynecol. 2002;99[pt. 1]:720–5). More than half of the respondents consulted three or more clinicians before a laboratory diagnosis was made. The median delay in diagnosis was 2 years, and for 25% it took longer than 5 years.

Once you make the diagnosis, use a family systems approach to counseling, Dr. Nelson said. “It is important to inform the parents first and then the patient. It is not a good idea, in our experience, to explain it to the parents and child at the same time.” This approach gives parents an opportunity to absorb the news and, in many cases, to grieve their loss of future grandchildren. Also, provide parents with tools that facilitate an ongoing conversation with the child.

Inform both parents and the patient with sensitivity, Dr. Nelson said. Use accurate terminology, provide information, and make appropriate psychosocial referrals. “Placing too much emphasis on the fertility effects early on may do more harm—that is one of my concerns.”

Offer the adolescent advice on how to minimize or avoid stigma and to develop positive self-esteem and body image. Physician counseling can make a difference in self-esteem, anxiety, and depression associated with POI, based on a study by Dr. Nelson and his colleagues (Fertil. Steril. 2009 [doi:10.1016/j.fertnstert.2008.12.122

After diagnosis and counseling, treatment considerations are next. “Unlike postmenopausal women, it's full hormone replacement for these [girls],” he said.

There are multiple treatments and regimens available, and he recommended a review article that outlines how to induce puberty for adolescent patients (Ann. N.Y. Acad. Sci. 2008;1135:204–11). This publication discusses the benefits and risks of hormone replacement therapy—including special concerns about bone health and eating disorders—in this population.

Although common, follicular depletion associated with POI cannot be proven definitively. “It is now clear the ovarian failure is not permanent in all women,” Dr. Nelson said. Rarely, “some women get pregnant with this diagnosis.”

'Placing too much emphasis on the fertility effects early on may do more harm—that is one of my concerns.'

Source DR. NELSON

The newly formed American Board of Addiction Medicine has certified more than 1,600 physicians as specialists in addiction medicine so far this year, including more than 200 internists. Physicians from multiple disciplines who meet expertise criteria are taking advantage of the opportunity to be “grandfathered in” to the nascent specialty by taking a special 6-hour certifying examination.

Dr. Kevin B. Kunz, president of the American Board of Addiction Medicine (ABAM), said in an interview that the 15 physicians on the ABAM board of directors will create a new examination to certify physicians after the grandfathering option ends in December. Previously, only psychiatrists could claim addiction-related board certification.

Official recognition of addiction expertise is being expanded to include internists, family physicians, emergency physicians, ob.gyns., surgeons, pediatricians, preventive medicine physicians, and neurologists.

“There are already folks out there toiling in relative obscurity in addiction medicine,” internist Peter D. Friedmann said in an interview. “Creation of the ABAM was driven by the need for better recognition within medicine.” The American Society of Addiction Medicine provided a certification exam for years, “but it was not accorded the same respect and gravitas as fields that have their own subspecialty boards.” Dr. Friedmann of Brown University in Providence, R.I., is one of the internists who took advantage of the grandfathering option.

Criteria for certification grandfathering include at least 1,950 hours over the past decade providing addiction-related care, research, and/or education; 50 hours of CME related to addiction medicine in the past 2 years; letters of recommendation supporting proficiency in this area; and successful completion of the examination.

Primary care physicians will continue to play a large role in addiction care because “there will never be enough ABAM-certified specialists to treat everyone,” Dr. Friedmann said. “It would be like expecting everyone with hypertension to be treated by a cardiologist.”

“So many of the more than 120 million emergency department visits each year are due to substance abuse,” said Dr. Gail D'Onofrio of the ABAM board of directors and section chief of emergency medicine at Yale University in New Haven, Conn. Dr. D'Onofrio cited a statewide survey of seven Tennessee EDs showing that 31% of screened patients tested positive for substance abuse and 27% were assessed as needing substance abuse treatment.

Unfortunately, emergency physicians identified only 1% as having a diagnosis or problem related to substance abuse (Ann. Emerg. Med. 2003;41:802-13). ABAM plans to establish addiction medicine residency programs and get them recognized by the Accreditation Council for Graduate Medical Education (ACGME). “We expect these programs to be in place by 2011, after which time we will add a residency requirement to ABAM certification, as well as a maintenance-of-certification program,” Dr. Kunz said.

There is a core content shared among all specialties treating addiction, and therefore one examination, but individual specialties could add their own content to fellowship programs, Dr. D'Onofrio noted.

Once these requirements are in place, ABAM will seek recognition from the American Board of Medical Specialties (ABMS), which may take another 4-6 years. “We want addiction prevention, screening, intervention, and treatment to become routine aspects of medical care, available virtually any place health care is provided,” noted Dr. Jeffrey H. Samet, ABAM president-elect and professor of medicine at Boston University.

Reimbursement for addiction-related services remains a challenge. “These are difficult patients who take time and for whom there has been little reimbursement,” Dr. Kunz said. Although reimbursement codes for addiction screening and brief intervention in addiction are recognized by Medicare, some states, and some private insurers, “reimbursement for doing this work is still quite low,” Dr. Friedmann said. Better financial incentives are needed to encourage physicians to get into this field and make it a career, he added.

The codes for screening and intervention “are very important. You can't get doctors to do something they won't get paid to do,” Dr. Sokol said.

The next ABAM examination is scheduled for Dec. 11, 2010. Application deadlines are Oct. 31, 2009; Jan. 31, 2010; and April 30, 2010. More information is available at www.asam.org/ABAM.html

The newly formed American Board of Addiction Medicine has certified more than 1,600 physicians as specialists in addiction medicine so far this year, including more than 200 internists. Physicians from multiple disciplines who meet expertise criteria are taking advantage of the opportunity to be “grandfathered in” to the nascent specialty by taking a special 6-hour certifying examination.

Dr. Kevin B. Kunz, president of the American Board of Addiction Medicine (ABAM), said in an interview that the 15 physicians on the ABAM board of directors will create a new examination to certify physicians after the grandfathering option ends in December. Previously, only psychiatrists could claim addiction-related board certification.

Official recognition of addiction expertise is being expanded to include internists, family physicians, emergency physicians, ob.gyns., surgeons, pediatricians, preventive medicine physicians, and neurologists.

“There are already folks out there toiling in relative obscurity in addiction medicine,” internist Peter D. Friedmann said in an interview. “Creation of the ABAM was driven by the need for better recognition within medicine.” The American Society of Addiction Medicine provided a certification exam for years, “but it was not accorded the same respect and gravitas as fields that have their own subspecialty boards.” Dr. Friedmann of Brown University in Providence, R.I., is one of the internists who took advantage of the grandfathering option.

Criteria for certification grandfathering include at least 1,950 hours over the past decade providing addiction-related care, research, and/or education; 50 hours of CME related to addiction medicine in the past 2 years; letters of recommendation supporting proficiency in this area; and successful completion of the examination.

Primary care physicians will continue to play a large role in addiction care because “there will never be enough ABAM-certified specialists to treat everyone,” Dr. Friedmann said. “It would be like expecting everyone with hypertension to be treated by a cardiologist.”

“So many of the more than 120 million emergency department visits each year are due to substance abuse,” said Dr. Gail D'Onofrio of the ABAM board of directors and section chief of emergency medicine at Yale University in New Haven, Conn. Dr. D'Onofrio cited a statewide survey of seven Tennessee EDs showing that 31% of screened patients tested positive for substance abuse and 27% were assessed as needing substance abuse treatment.

Unfortunately, emergency physicians identified only 1% as having a diagnosis or problem related to substance abuse (Ann. Emerg. Med. 2003;41:802-13). ABAM plans to establish addiction medicine residency programs and get them recognized by the Accreditation Council for Graduate Medical Education (ACGME). “We expect these programs to be in place by 2011, after which time we will add a residency requirement to ABAM certification, as well as a maintenance-of-certification program,” Dr. Kunz said.

There is a core content shared among all specialties treating addiction, and therefore one examination, but individual specialties could add their own content to fellowship programs, Dr. D'Onofrio noted.

Once these requirements are in place, ABAM will seek recognition from the American Board of Medical Specialties (ABMS), which may take another 4-6 years. “We want addiction prevention, screening, intervention, and treatment to become routine aspects of medical care, available virtually any place health care is provided,” noted Dr. Jeffrey H. Samet, ABAM president-elect and professor of medicine at Boston University.

Reimbursement for addiction-related services remains a challenge. “These are difficult patients who take time and for whom there has been little reimbursement,” Dr. Kunz said. Although reimbursement codes for addiction screening and brief intervention in addiction are recognized by Medicare, some states, and some private insurers, “reimbursement for doing this work is still quite low,” Dr. Friedmann said. Better financial incentives are needed to encourage physicians to get into this field and make it a career, he added.

The codes for screening and intervention “are very important. You can't get doctors to do something they won't get paid to do,” Dr. Sokol said.

The next ABAM examination is scheduled for Dec. 11, 2010. Application deadlines are Oct. 31, 2009; Jan. 31, 2010; and April 30, 2010. More information is available at www.asam.org/ABAM.html

The newly formed American Board of Addiction Medicine has certified more than 1,600 physicians as specialists in addiction medicine so far this year, including more than 200 internists. Physicians from multiple disciplines who meet expertise criteria are taking advantage of the opportunity to be “grandfathered in” to the nascent specialty by taking a special 6-hour certifying examination.

Dr. Kevin B. Kunz, president of the American Board of Addiction Medicine (ABAM), said in an interview that the 15 physicians on the ABAM board of directors will create a new examination to certify physicians after the grandfathering option ends in December. Previously, only psychiatrists could claim addiction-related board certification.

Official recognition of addiction expertise is being expanded to include internists, family physicians, emergency physicians, ob.gyns., surgeons, pediatricians, preventive medicine physicians, and neurologists.

“There are already folks out there toiling in relative obscurity in addiction medicine,” internist Peter D. Friedmann said in an interview. “Creation of the ABAM was driven by the need for better recognition within medicine.” The American Society of Addiction Medicine provided a certification exam for years, “but it was not accorded the same respect and gravitas as fields that have their own subspecialty boards.” Dr. Friedmann of Brown University in Providence, R.I., is one of the internists who took advantage of the grandfathering option.

Criteria for certification grandfathering include at least 1,950 hours over the past decade providing addiction-related care, research, and/or education; 50 hours of CME related to addiction medicine in the past 2 years; letters of recommendation supporting proficiency in this area; and successful completion of the examination.

Primary care physicians will continue to play a large role in addiction care because “there will never be enough ABAM-certified specialists to treat everyone,” Dr. Friedmann said. “It would be like expecting everyone with hypertension to be treated by a cardiologist.”

“So many of the more than 120 million emergency department visits each year are due to substance abuse,” said Dr. Gail D'Onofrio of the ABAM board of directors and section chief of emergency medicine at Yale University in New Haven, Conn. Dr. D'Onofrio cited a statewide survey of seven Tennessee EDs showing that 31% of screened patients tested positive for substance abuse and 27% were assessed as needing substance abuse treatment.

Unfortunately, emergency physicians identified only 1% as having a diagnosis or problem related to substance abuse (Ann. Emerg. Med. 2003;41:802-13). ABAM plans to establish addiction medicine residency programs and get them recognized by the Accreditation Council for Graduate Medical Education (ACGME). “We expect these programs to be in place by 2011, after which time we will add a residency requirement to ABAM certification, as well as a maintenance-of-certification program,” Dr. Kunz said.

There is a core content shared among all specialties treating addiction, and therefore one examination, but individual specialties could add their own content to fellowship programs, Dr. D'Onofrio noted.

Once these requirements are in place, ABAM will seek recognition from the American Board of Medical Specialties (ABMS), which may take another 4-6 years. “We want addiction prevention, screening, intervention, and treatment to become routine aspects of medical care, available virtually any place health care is provided,” noted Dr. Jeffrey H. Samet, ABAM president-elect and professor of medicine at Boston University.

Reimbursement for addiction-related services remains a challenge. “These are difficult patients who take time and for whom there has been little reimbursement,” Dr. Kunz said. Although reimbursement codes for addiction screening and brief intervention in addiction are recognized by Medicare, some states, and some private insurers, “reimbursement for doing this work is still quite low,” Dr. Friedmann said. Better financial incentives are needed to encourage physicians to get into this field and make it a career, he added.

The codes for screening and intervention “are very important. You can't get doctors to do something they won't get paid to do,” Dr. Sokol said.

The next ABAM examination is scheduled for Dec. 11, 2010. Application deadlines are Oct. 31, 2009; Jan. 31, 2010; and April 30, 2010. More information is available at www.asam.org/ABAM.html

ORLANDO — Consultation by a geriatric clinical pharmacist prompted medication changes for 50% of older cancer patients in a pilot study of a new clinical geriatric program set to launch at Memorial Sloan-Kettering Cancer Center, New York.

Importantly, 17% of older cancer patients were prescribed a potentially inappropriate medication, according to a second, retrospective review of charts at the same institution.

Results of both studies point to a polypharmacy problem in this population, Dr. Stuart M. Lichtman, the lead author, said at the annual meeting of the American Society of Clinical Oncology.

“Polypharmacy is a complex issue that can lead to nonadherence, adverse drug reactions, drug-drug interactions, and increased emergency room visits, hospitalizations, and nursing home admissions,” warned Dr. Lichtman, chair of the 65+ Clinical Geriatric Group, a part of the Cancer and Aging Program at Memorial-Sloan Kettering.

“This incidence of potentially inappropriate mediations is too high,” commented Dr. Jerome Yates of the American Cancer Society, Atlanta, who was invited to discuss the study. “We certainly need to have better approaches” to address adverse drug reactions, drug-drug interactions, and noncompliance issues, he said.

The prospective study assessed 154 patient consultations from April 2007 to December 2008 in an ambulatory oncology care clinic. In collaboration with the patient's oncologist, the geriatric clinical pharmacist took these actions:

▸ Recommended additional medication (42% of patients).

▸ Identified medication adherence problems (37% of patients).

▸ Discontinued an agent (35% of patients).

▸ Suggested an alternative agent (20% of patients).

▸ Adjusted or recommended pain management (18% of patients).

▸ Identified cost as a barrier to treatment (12% of patients).

▸ Changed medication dose (11% of patients).

▸ Identified drug-drug interactions (10% of patients).

Some patients had more than one intervention. The median age was 74 years (range 65-91 years); 59% were women, and 47% reported that this was their first consultation with a pharmacist. Part of the new 65+ Clinical Geriatrics Program includes patient education about optimal drug use and safety.

The five leading reasons for consultations were pain management, osteoporosis management, dementia screening, gastrointestinal toxicity (constipation or diarrhea), and anticoagulation management. “Overall, the clinical pharmacist plays a very active role in providing disease and supportive care management,” Dr. Lichtman said. Also, the drug-specific interventions improved medication management, he added.

Dr. Lichtman and his colleague Manpreet K. Boparai, Pharm.D., also reviewed the charts of 100 consecutive cancer patients older than 65 years seen from July 2007 to November 2007 at a regional site for Memorial Sloan-Kettering in Commack, N.Y. The patients were equally distributed by gender and were prescribed a median of 8 medications (range 0-23). The patients were most likely to be prescribed or to report taking antihypertensive medications (52%), vitamins/herbals (46%), proton-pump inhibitors (32%), and lipid-lowering agents (29%).

Diphenhydramine (when taken as a sleep aid), meprobamate, high-dose benzodiazepines, cyclobenzaprine, meperidine, propoxyphene, metaxalone (Skelaxin), and dipyridamole were the potentially inappropriate medications identified using Beer's criteria (Arch. Intern. Med. 2003;163:2716-24).

A meeting attendee prompted a discussion by asking Dr. Lichtman how hospital administrators could be convinced to hire an additional pharmacist when the resulting savings would go to Medicare and insurance companies, rather than the hospital.

“You're absolutely right,” Dr. Lichtman replied. “Part of this is to justify [the pharmacist's] work, and it's another aspect of high-quality cancer care.”

Dr. Yates noted that “geriatric clinical pharmacists are a luxury that the present system does not support in most environments.” These programs must be shown to save money as well as improve care. “That is really all administrators understand. The outcome is dollars.”

Dr. Harvey Jay Cohen, session moderator, added that “administrators are very sensitive now to rates of rehospitalizations, rates of overutilization, and length of stay.”

“If we can demonstrate we can modify those outcomes, hospital administrators will be jumping up and down to hire people to do it,” said Dr. Cohen, director of the Center for Study of Aging and Human Health at Duke University Medical Center in Durham, N.C.

Dr. Lichtman and Dr. Yates had no relevant disclosures.

ORLANDO — Consultation by a geriatric clinical pharmacist prompted medication changes for 50% of older cancer patients in a pilot study of a new clinical geriatric program set to launch at Memorial Sloan-Kettering Cancer Center, New York.

Importantly, 17% of older cancer patients were prescribed a potentially inappropriate medication, according to a second, retrospective review of charts at the same institution.

Results of both studies point to a polypharmacy problem in this population, Dr. Stuart M. Lichtman, the lead author, said at the annual meeting of the American Society of Clinical Oncology.

“Polypharmacy is a complex issue that can lead to nonadherence, adverse drug reactions, drug-drug interactions, and increased emergency room visits, hospitalizations, and nursing home admissions,” warned Dr. Lichtman, chair of the 65+ Clinical Geriatric Group, a part of the Cancer and Aging Program at Memorial-Sloan Kettering.

“This incidence of potentially inappropriate mediations is too high,” commented Dr. Jerome Yates of the American Cancer Society, Atlanta, who was invited to discuss the study. “We certainly need to have better approaches” to address adverse drug reactions, drug-drug interactions, and noncompliance issues, he said.

The prospective study assessed 154 patient consultations from April 2007 to December 2008 in an ambulatory oncology care clinic. In collaboration with the patient's oncologist, the geriatric clinical pharmacist took these actions:

▸ Recommended additional medication (42% of patients).

▸ Identified medication adherence problems (37% of patients).

▸ Discontinued an agent (35% of patients).

▸ Suggested an alternative agent (20% of patients).

▸ Adjusted or recommended pain management (18% of patients).

▸ Identified cost as a barrier to treatment (12% of patients).

▸ Changed medication dose (11% of patients).

▸ Identified drug-drug interactions (10% of patients).

Some patients had more than one intervention. The median age was 74 years (range 65-91 years); 59% were women, and 47% reported that this was their first consultation with a pharmacist. Part of the new 65+ Clinical Geriatrics Program includes patient education about optimal drug use and safety.

The five leading reasons for consultations were pain management, osteoporosis management, dementia screening, gastrointestinal toxicity (constipation or diarrhea), and anticoagulation management. “Overall, the clinical pharmacist plays a very active role in providing disease and supportive care management,” Dr. Lichtman said. Also, the drug-specific interventions improved medication management, he added.

Dr. Lichtman and his colleague Manpreet K. Boparai, Pharm.D., also reviewed the charts of 100 consecutive cancer patients older than 65 years seen from July 2007 to November 2007 at a regional site for Memorial Sloan-Kettering in Commack, N.Y. The patients were equally distributed by gender and were prescribed a median of 8 medications (range 0-23). The patients were most likely to be prescribed or to report taking antihypertensive medications (52%), vitamins/herbals (46%), proton-pump inhibitors (32%), and lipid-lowering agents (29%).

Diphenhydramine (when taken as a sleep aid), meprobamate, high-dose benzodiazepines, cyclobenzaprine, meperidine, propoxyphene, metaxalone (Skelaxin), and dipyridamole were the potentially inappropriate medications identified using Beer's criteria (Arch. Intern. Med. 2003;163:2716-24).

A meeting attendee prompted a discussion by asking Dr. Lichtman how hospital administrators could be convinced to hire an additional pharmacist when the resulting savings would go to Medicare and insurance companies, rather than the hospital.

“You're absolutely right,” Dr. Lichtman replied. “Part of this is to justify [the pharmacist's] work, and it's another aspect of high-quality cancer care.”

Dr. Yates noted that “geriatric clinical pharmacists are a luxury that the present system does not support in most environments.” These programs must be shown to save money as well as improve care. “That is really all administrators understand. The outcome is dollars.”

Dr. Harvey Jay Cohen, session moderator, added that “administrators are very sensitive now to rates of rehospitalizations, rates of overutilization, and length of stay.”

“If we can demonstrate we can modify those outcomes, hospital administrators will be jumping up and down to hire people to do it,” said Dr. Cohen, director of the Center for Study of Aging and Human Health at Duke University Medical Center in Durham, N.C.

Dr. Lichtman and Dr. Yates had no relevant disclosures.

ORLANDO — Consultation by a geriatric clinical pharmacist prompted medication changes for 50% of older cancer patients in a pilot study of a new clinical geriatric program set to launch at Memorial Sloan-Kettering Cancer Center, New York.

Importantly, 17% of older cancer patients were prescribed a potentially inappropriate medication, according to a second, retrospective review of charts at the same institution.

Results of both studies point to a polypharmacy problem in this population, Dr. Stuart M. Lichtman, the lead author, said at the annual meeting of the American Society of Clinical Oncology.

“Polypharmacy is a complex issue that can lead to nonadherence, adverse drug reactions, drug-drug interactions, and increased emergency room visits, hospitalizations, and nursing home admissions,” warned Dr. Lichtman, chair of the 65+ Clinical Geriatric Group, a part of the Cancer and Aging Program at Memorial-Sloan Kettering.

“This incidence of potentially inappropriate mediations is too high,” commented Dr. Jerome Yates of the American Cancer Society, Atlanta, who was invited to discuss the study. “We certainly need to have better approaches” to address adverse drug reactions, drug-drug interactions, and noncompliance issues, he said.

The prospective study assessed 154 patient consultations from April 2007 to December 2008 in an ambulatory oncology care clinic. In collaboration with the patient's oncologist, the geriatric clinical pharmacist took these actions:

▸ Recommended additional medication (42% of patients).

▸ Identified medication adherence problems (37% of patients).

▸ Discontinued an agent (35% of patients).

▸ Suggested an alternative agent (20% of patients).

▸ Adjusted or recommended pain management (18% of patients).

▸ Identified cost as a barrier to treatment (12% of patients).

▸ Changed medication dose (11% of patients).

▸ Identified drug-drug interactions (10% of patients).

Some patients had more than one intervention. The median age was 74 years (range 65-91 years); 59% were women, and 47% reported that this was their first consultation with a pharmacist. Part of the new 65+ Clinical Geriatrics Program includes patient education about optimal drug use and safety.

The five leading reasons for consultations were pain management, osteoporosis management, dementia screening, gastrointestinal toxicity (constipation or diarrhea), and anticoagulation management. “Overall, the clinical pharmacist plays a very active role in providing disease and supportive care management,” Dr. Lichtman said. Also, the drug-specific interventions improved medication management, he added.

Dr. Lichtman and his colleague Manpreet K. Boparai, Pharm.D., also reviewed the charts of 100 consecutive cancer patients older than 65 years seen from July 2007 to November 2007 at a regional site for Memorial Sloan-Kettering in Commack, N.Y. The patients were equally distributed by gender and were prescribed a median of 8 medications (range 0-23). The patients were most likely to be prescribed or to report taking antihypertensive medications (52%), vitamins/herbals (46%), proton-pump inhibitors (32%), and lipid-lowering agents (29%).

Diphenhydramine (when taken as a sleep aid), meprobamate, high-dose benzodiazepines, cyclobenzaprine, meperidine, propoxyphene, metaxalone (Skelaxin), and dipyridamole were the potentially inappropriate medications identified using Beer's criteria (Arch. Intern. Med. 2003;163:2716-24).

A meeting attendee prompted a discussion by asking Dr. Lichtman how hospital administrators could be convinced to hire an additional pharmacist when the resulting savings would go to Medicare and insurance companies, rather than the hospital.

“You're absolutely right,” Dr. Lichtman replied. “Part of this is to justify [the pharmacist's] work, and it's another aspect of high-quality cancer care.”

Dr. Yates noted that “geriatric clinical pharmacists are a luxury that the present system does not support in most environments.” These programs must be shown to save money as well as improve care. “That is really all administrators understand. The outcome is dollars.”

Dr. Harvey Jay Cohen, session moderator, added that “administrators are very sensitive now to rates of rehospitalizations, rates of overutilization, and length of stay.”

“If we can demonstrate we can modify those outcomes, hospital administrators will be jumping up and down to hire people to do it,” said Dr. Cohen, director of the Center for Study of Aging and Human Health at Duke University Medical Center in Durham, N.C.

Dr. Lichtman and Dr. Yates had no relevant disclosures.

HOLLYWOOD, FLA. — Postoperative costs for patients who develop an ileus after colectomy are almost double those for patients without this complication, a retrospective study indicates.

“It's already established that a postoperative ileus increases length of stay, but the economic impact has been hard to quantify,” Dr. Theodor Asgeirsson said at the annual meeting of the American Society of Colon and Rectal Surgeons.

In a review of 191 colectomies performed at the Ferguson Clinic in Grand Rapids, Mich., starting in July 2007, Dr. Asgeirsson and his colleagues found that postoperative ileus incidence was 26%, including 41 primary cases and 10 secondary cases. A primary postoperative ileus was defined as three episodes of emesis in 24 hours and/or insertion of a nasogastric tube during the index admission. A secondary ileus was associated with intra-abdominal complications. Nineteen patients in the primary ileus group and one in the secondary group required a nasogastric tube.

Development of an ileus affected slightly more than one-quarter of patients, and was associated with 39% of total care costs in the study, said Dr. Asgeirsson, a researcher at the clinic.

During index admissions, the total cost for patients with a postoperative ileus was $31,629 vs. $17,626 for those without this complication, a statistically significant difference. “Surprisingly, this was not significantly different for secondary postoperative ileus,” Dr. Asgeirsson said.

The total readmission cost for postoperative ileus patients was $8,742 vs. $12,946 for non-ileus patients. Readmission for gastrointestinal failure, including nausea, vomiting, and/or poor oral intake, was also considered ileus, unless small bowel obstruction was identified. In contrast, non-ileus patients were readmitted for more serious adverse events, he said.

When asked whether total costs were higher only because patients with a postoperative ileus had longer stays, Dr. Asgeirsson said no. “When these patients get readmitted for a delayed postop ileus, the team usually wants to rule out the worst, such as anastomosis,” he said. “We are doing a lot of diagnostic tests that increase costs.”

HOLLYWOOD, FLA. — Postoperative costs for patients who develop an ileus after colectomy are almost double those for patients without this complication, a retrospective study indicates.

“It's already established that a postoperative ileus increases length of stay, but the economic impact has been hard to quantify,” Dr. Theodor Asgeirsson said at the annual meeting of the American Society of Colon and Rectal Surgeons.

In a review of 191 colectomies performed at the Ferguson Clinic in Grand Rapids, Mich., starting in July 2007, Dr. Asgeirsson and his colleagues found that postoperative ileus incidence was 26%, including 41 primary cases and 10 secondary cases. A primary postoperative ileus was defined as three episodes of emesis in 24 hours and/or insertion of a nasogastric tube during the index admission. A secondary ileus was associated with intra-abdominal complications. Nineteen patients in the primary ileus group and one in the secondary group required a nasogastric tube.

Development of an ileus affected slightly more than one-quarter of patients, and was associated with 39% of total care costs in the study, said Dr. Asgeirsson, a researcher at the clinic.

During index admissions, the total cost for patients with a postoperative ileus was $31,629 vs. $17,626 for those without this complication, a statistically significant difference. “Surprisingly, this was not significantly different for secondary postoperative ileus,” Dr. Asgeirsson said.

The total readmission cost for postoperative ileus patients was $8,742 vs. $12,946 for non-ileus patients. Readmission for gastrointestinal failure, including nausea, vomiting, and/or poor oral intake, was also considered ileus, unless small bowel obstruction was identified. In contrast, non-ileus patients were readmitted for more serious adverse events, he said.

When asked whether total costs were higher only because patients with a postoperative ileus had longer stays, Dr. Asgeirsson said no. “When these patients get readmitted for a delayed postop ileus, the team usually wants to rule out the worst, such as anastomosis,” he said. “We are doing a lot of diagnostic tests that increase costs.”

HOLLYWOOD, FLA. — Postoperative costs for patients who develop an ileus after colectomy are almost double those for patients without this complication, a retrospective study indicates.

“It's already established that a postoperative ileus increases length of stay, but the economic impact has been hard to quantify,” Dr. Theodor Asgeirsson said at the annual meeting of the American Society of Colon and Rectal Surgeons.

In a review of 191 colectomies performed at the Ferguson Clinic in Grand Rapids, Mich., starting in July 2007, Dr. Asgeirsson and his colleagues found that postoperative ileus incidence was 26%, including 41 primary cases and 10 secondary cases. A primary postoperative ileus was defined as three episodes of emesis in 24 hours and/or insertion of a nasogastric tube during the index admission. A secondary ileus was associated with intra-abdominal complications. Nineteen patients in the primary ileus group and one in the secondary group required a nasogastric tube.

Development of an ileus affected slightly more than one-quarter of patients, and was associated with 39% of total care costs in the study, said Dr. Asgeirsson, a researcher at the clinic.

During index admissions, the total cost for patients with a postoperative ileus was $31,629 vs. $17,626 for those without this complication, a statistically significant difference. “Surprisingly, this was not significantly different for secondary postoperative ileus,” Dr. Asgeirsson said.

The total readmission cost for postoperative ileus patients was $8,742 vs. $12,946 for non-ileus patients. Readmission for gastrointestinal failure, including nausea, vomiting, and/or poor oral intake, was also considered ileus, unless small bowel obstruction was identified. In contrast, non-ileus patients were readmitted for more serious adverse events, he said.

When asked whether total costs were higher only because patients with a postoperative ileus had longer stays, Dr. Asgeirsson said no. “When these patients get readmitted for a delayed postop ileus, the team usually wants to rule out the worst, such as anastomosis,” he said. “We are doing a lot of diagnostic tests that increase costs.”

ORLANDO — Hearing difficulties, depression, incontinence, osteoporosis, and falls are reported significantly more often by Medicare beneficiaries with a cancer history than by those who were never diagnosed with cancer, according to a survey of a nationally representative sample of beneficiaries.

Researchers compared reports of geriatric syndromes among 2,349 people with a cancer diagnosis history in the 2003 Medicare Current Beneficiary Survey with those among 10,128 people who did not have a cancer history. The overall difference was “highly statistically significant,” with 63% of the cancer history group reporting one or more geriatric syndromes vs. 57% of the controls, Dr. Supriya Gupta Mohile reported at the annual meeting of the American Society of Clinical Oncology.

History of cancer was independently associated with increased prevalence of self-reported falls (adjusted odds ratio 1.18), depression (OR 1.19), osteoporosis (OR 1.20), trouble hearing (OR 1.31), and incontinence (OR 1.35). It was not significantly associated with dementia/memory loss (adjusted OR 1.04), trouble seeing (OR 1.07), or trouble eating (OR 1.11).

“Clinicians should ask older cancer patients about geriatric syndromes in addition to comorbidity in order to fully evaluate their health status,” said Dr. Mohile, a geriatric oncologist at the University of Rochester (N.Y.).

The 12,477 Medicare beneficiaries studied were community-dwelling adults aged 65 years and older. The 18% who reported a relevant history had a diagnosis of nonskin malignancy. Also, to be considered a true geriatric syndrome, participants had to report symptoms severe or frequent enough to interfere with activities of daily living.

“Geriatric syndromes are highly prevalent in the elderly, especially in those who are frail,” Dr. Mohile said. The syndromes also are highly prevalent in newly diagnosed colon (45%), prostate (51%), and breast (35%) cancer patients (J. Clin. Oncol. 2006; 24:2304-10).

Compared with the controls in the current study, the cancer history group was older (mean age, 77.4 years vs. 76.5 years), more often white (89.7% vs. 86.2%), and more likely to have some college education (34.7% vs. 31.7%). A higher percentage of the cancer history group reported two or more comorbidities (34% vs. 30%).

“We also looked at impact of cancer subtype on numbers and specific types of geriatric syndromes,” Dr. Mohile said. Patients who reported the highest mean number of geriatric syndromes were those with a history of cervical/uterine (1.46) and lung (1.39) cancer. The mean number was smaller for those who reported breast (1.23), colon (1.13), and prostate (0.85) cancer.

A meeting attendee commented that Dr. Mohile could point to associations only between cancer history and geriatric syndromes. “We do have significant limitations,” Dr. Mohile said, noting that the study was cross-sectional, so causality could not be demonstrated.

“These aren't well coupled in causal relationships because of the methodology that was employed. We need better precision in the categorization of cancer treatment and sequelae in order to reach conclusions,” said study discussant Dr. Jerome Yates of the American Cancer Society.

A very heterogeneous participant sample and a small number of patients with some of the cancer subtypes were other limitations, Dr. Mohile said. Timing also is important, she added: “Our study was a self-report of cancer, and cancer could have occurred 10 years or more” before the 2003 survey.

It would interesting to perform a prospective study, said Dr. Harvey Jay Cohen of Duke University Medical Center, Durham, N.C., who moderated the session.

Dr. Yates also noted that the data might have been distorted because beneficiaries with higher comorbidity might have been followed more regularly by their clinicians, and because the cross-sectional design would be less likely to include participants who died sooner rather than later following their cancer diagnosis.

“This is a good start, using the Medicare database,” Dr. Yates added. “You are certainly on the right track, raising the right questions, and so that is very helpful.”

Future research is needed to assess whether cancer and/or treatment causes geriatric syndromes in older cancer patients, Dr. Mohile said.

Dr. Mohile and Dr. Yates had no relevant financial disclosures.

ORLANDO — Hearing difficulties, depression, incontinence, osteoporosis, and falls are reported significantly more often by Medicare beneficiaries with a cancer history than by those who were never diagnosed with cancer, according to a survey of a nationally representative sample of beneficiaries.

Researchers compared reports of geriatric syndromes among 2,349 people with a cancer diagnosis history in the 2003 Medicare Current Beneficiary Survey with those among 10,128 people who did not have a cancer history. The overall difference was “highly statistically significant,” with 63% of the cancer history group reporting one or more geriatric syndromes vs. 57% of the controls, Dr. Supriya Gupta Mohile reported at the annual meeting of the American Society of Clinical Oncology.

History of cancer was independently associated with increased prevalence of self-reported falls (adjusted odds ratio 1.18), depression (OR 1.19), osteoporosis (OR 1.20), trouble hearing (OR 1.31), and incontinence (OR 1.35). It was not significantly associated with dementia/memory loss (adjusted OR 1.04), trouble seeing (OR 1.07), or trouble eating (OR 1.11).

“Clinicians should ask older cancer patients about geriatric syndromes in addition to comorbidity in order to fully evaluate their health status,” said Dr. Mohile, a geriatric oncologist at the University of Rochester (N.Y.).

The 12,477 Medicare beneficiaries studied were community-dwelling adults aged 65 years and older. The 18% who reported a relevant history had a diagnosis of nonskin malignancy. Also, to be considered a true geriatric syndrome, participants had to report symptoms severe or frequent enough to interfere with activities of daily living.

“Geriatric syndromes are highly prevalent in the elderly, especially in those who are frail,” Dr. Mohile said. The syndromes also are highly prevalent in newly diagnosed colon (45%), prostate (51%), and breast (35%) cancer patients (J. Clin. Oncol. 2006; 24:2304-10).

Compared with the controls in the current study, the cancer history group was older (mean age, 77.4 years vs. 76.5 years), more often white (89.7% vs. 86.2%), and more likely to have some college education (34.7% vs. 31.7%). A higher percentage of the cancer history group reported two or more comorbidities (34% vs. 30%).

“We also looked at impact of cancer subtype on numbers and specific types of geriatric syndromes,” Dr. Mohile said. Patients who reported the highest mean number of geriatric syndromes were those with a history of cervical/uterine (1.46) and lung (1.39) cancer. The mean number was smaller for those who reported breast (1.23), colon (1.13), and prostate (0.85) cancer.

A meeting attendee commented that Dr. Mohile could point to associations only between cancer history and geriatric syndromes. “We do have significant limitations,” Dr. Mohile said, noting that the study was cross-sectional, so causality could not be demonstrated.

“These aren't well coupled in causal relationships because of the methodology that was employed. We need better precision in the categorization of cancer treatment and sequelae in order to reach conclusions,” said study discussant Dr. Jerome Yates of the American Cancer Society.

A very heterogeneous participant sample and a small number of patients with some of the cancer subtypes were other limitations, Dr. Mohile said. Timing also is important, she added: “Our study was a self-report of cancer, and cancer could have occurred 10 years or more” before the 2003 survey.

It would interesting to perform a prospective study, said Dr. Harvey Jay Cohen of Duke University Medical Center, Durham, N.C., who moderated the session.

Dr. Yates also noted that the data might have been distorted because beneficiaries with higher comorbidity might have been followed more regularly by their clinicians, and because the cross-sectional design would be less likely to include participants who died sooner rather than later following their cancer diagnosis.

“This is a good start, using the Medicare database,” Dr. Yates added. “You are certainly on the right track, raising the right questions, and so that is very helpful.”

Future research is needed to assess whether cancer and/or treatment causes geriatric syndromes in older cancer patients, Dr. Mohile said.

Dr. Mohile and Dr. Yates had no relevant financial disclosures.

ORLANDO — Hearing difficulties, depression, incontinence, osteoporosis, and falls are reported significantly more often by Medicare beneficiaries with a cancer history than by those who were never diagnosed with cancer, according to a survey of a nationally representative sample of beneficiaries.

Researchers compared reports of geriatric syndromes among 2,349 people with a cancer diagnosis history in the 2003 Medicare Current Beneficiary Survey with those among 10,128 people who did not have a cancer history. The overall difference was “highly statistically significant,” with 63% of the cancer history group reporting one or more geriatric syndromes vs. 57% of the controls, Dr. Supriya Gupta Mohile reported at the annual meeting of the American Society of Clinical Oncology.

History of cancer was independently associated with increased prevalence of self-reported falls (adjusted odds ratio 1.18), depression (OR 1.19), osteoporosis (OR 1.20), trouble hearing (OR 1.31), and incontinence (OR 1.35). It was not significantly associated with dementia/memory loss (adjusted OR 1.04), trouble seeing (OR 1.07), or trouble eating (OR 1.11).

“Clinicians should ask older cancer patients about geriatric syndromes in addition to comorbidity in order to fully evaluate their health status,” said Dr. Mohile, a geriatric oncologist at the University of Rochester (N.Y.).

The 12,477 Medicare beneficiaries studied were community-dwelling adults aged 65 years and older. The 18% who reported a relevant history had a diagnosis of nonskin malignancy. Also, to be considered a true geriatric syndrome, participants had to report symptoms severe or frequent enough to interfere with activities of daily living.

“Geriatric syndromes are highly prevalent in the elderly, especially in those who are frail,” Dr. Mohile said. The syndromes also are highly prevalent in newly diagnosed colon (45%), prostate (51%), and breast (35%) cancer patients (J. Clin. Oncol. 2006; 24:2304-10).

Compared with the controls in the current study, the cancer history group was older (mean age, 77.4 years vs. 76.5 years), more often white (89.7% vs. 86.2%), and more likely to have some college education (34.7% vs. 31.7%). A higher percentage of the cancer history group reported two or more comorbidities (34% vs. 30%).

“We also looked at impact of cancer subtype on numbers and specific types of geriatric syndromes,” Dr. Mohile said. Patients who reported the highest mean number of geriatric syndromes were those with a history of cervical/uterine (1.46) and lung (1.39) cancer. The mean number was smaller for those who reported breast (1.23), colon (1.13), and prostate (0.85) cancer.

A meeting attendee commented that Dr. Mohile could point to associations only between cancer history and geriatric syndromes. “We do have significant limitations,” Dr. Mohile said, noting that the study was cross-sectional, so causality could not be demonstrated.

“These aren't well coupled in causal relationships because of the methodology that was employed. We need better precision in the categorization of cancer treatment and sequelae in order to reach conclusions,” said study discussant Dr. Jerome Yates of the American Cancer Society.

A very heterogeneous participant sample and a small number of patients with some of the cancer subtypes were other limitations, Dr. Mohile said. Timing also is important, she added: “Our study was a self-report of cancer, and cancer could have occurred 10 years or more” before the 2003 survey.

It would interesting to perform a prospective study, said Dr. Harvey Jay Cohen of Duke University Medical Center, Durham, N.C., who moderated the session.

Dr. Yates also noted that the data might have been distorted because beneficiaries with higher comorbidity might have been followed more regularly by their clinicians, and because the cross-sectional design would be less likely to include participants who died sooner rather than later following their cancer diagnosis.

“This is a good start, using the Medicare database,” Dr. Yates added. “You are certainly on the right track, raising the right questions, and so that is very helpful.”

Future research is needed to assess whether cancer and/or treatment causes geriatric syndromes in older cancer patients, Dr. Mohile said.

Dr. Mohile and Dr. Yates had no relevant financial disclosures.

SAN ANTONIO — Despite the controversy surrounding bariatric surgery for very obese adolescents, appropriate candidates often experience better psychosocial quality of life and improve or even reverse obesity-related comorbidities, according to preliminary results of a study at Texas Children's Hospital in Houston.

“This has been one of the most profoundly gratifying things in my career,” said Dr. Mary L. Brandt, director of the hospital's adolescent bariatric surgery program. “They get their lives back.”

Dr. Brandt reported results for 44 severely obese adolescents participating in an ongoing surgery study. Excess weight loss was 58% at 1 year and 60% at 2 years, she said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

The average age of the 32 girls and 12 boys is 16 years, and average body mass index is 60 kg/m

Surgery improved many of the preoperative comorbidities. For example, 70% of the 44 teenagers had preoperative insulin resistance, and 82% of these experienced resolution of the condition; 91% had sleep apnea, which resolved after surgery in 45%.

In preliminary results from the National Institutes of Health-funded Teen LABS study, Dr. Brandt and her associates found that type 2 diabetes resolved after surgery in 10 of 11 severely obese adolescents (Pediatrics 2009;123:214-22). Surgery was associated with a 34% decrease in BMI, a 41% decrease in fasting blood glucose levels, and an 81% decrease in fasting insulin concentrations.

In the Texas Children's Hospital series, 12 (27%) of the 44 patients experienced complications. Two patients experienced anastomotic bleeding, two had thiamine deficiency, and two had a marginal ulcer. Complications that occurred in one patient each included a retained nasogastric tube, coagulopathy, pulmonary embolism, anastomotic leak, urethral injury, and a Peterson hernia. All the complications resolved and there have been no deaths, said Dr. Brandt, professor and vice chair of surgery at Baylor College of Medicine in Houston.

“We are also participating in a second study called TeenView to look at the psychological component—eating disorders and depression especially,” Dr. Brandt said. Changes in body shape satisfaction, social support, and peer victimization/teasing will be assessed.

Other researchers have demonstrated that greater depressive symptoms, decreasing competence and self-esteem, and greater poverty are associated with adolescent obesity (Pediatrics 2000;105:e15; N. Engl. J. Med. 1993;329:1036-7).

Dr. Brandt said quality of life for obese adolescents is similar to levels reported by people with cancer during chemotherapy (JAMA 2003;289:1813-9).

She emphasized that bariatric surgery should be considered only for morbidly obese adolescents who meet specific criteria (Pediatrics 2004;114:217-23). These procedures should be performed only in centers that can provide multidisciplinary evaluation and treatment, Dr. Brandt said. And because the long-term risks are not completely known, all adolescents who have bariatric surgery should be enrolled in a prospective outcomes study.

SAN ANTONIO — Despite the controversy surrounding bariatric surgery for very obese adolescents, appropriate candidates often experience better psychosocial quality of life and improve or even reverse obesity-related comorbidities, according to preliminary results of a study at Texas Children's Hospital in Houston.

“This has been one of the most profoundly gratifying things in my career,” said Dr. Mary L. Brandt, director of the hospital's adolescent bariatric surgery program. “They get their lives back.”

Dr. Brandt reported results for 44 severely obese adolescents participating in an ongoing surgery study. Excess weight loss was 58% at 1 year and 60% at 2 years, she said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

The average age of the 32 girls and 12 boys is 16 years, and average body mass index is 60 kg/m

Surgery improved many of the preoperative comorbidities. For example, 70% of the 44 teenagers had preoperative insulin resistance, and 82% of these experienced resolution of the condition; 91% had sleep apnea, which resolved after surgery in 45%.

In preliminary results from the National Institutes of Health-funded Teen LABS study, Dr. Brandt and her associates found that type 2 diabetes resolved after surgery in 10 of 11 severely obese adolescents (Pediatrics 2009;123:214-22). Surgery was associated with a 34% decrease in BMI, a 41% decrease in fasting blood glucose levels, and an 81% decrease in fasting insulin concentrations.

In the Texas Children's Hospital series, 12 (27%) of the 44 patients experienced complications. Two patients experienced anastomotic bleeding, two had thiamine deficiency, and two had a marginal ulcer. Complications that occurred in one patient each included a retained nasogastric tube, coagulopathy, pulmonary embolism, anastomotic leak, urethral injury, and a Peterson hernia. All the complications resolved and there have been no deaths, said Dr. Brandt, professor and vice chair of surgery at Baylor College of Medicine in Houston.

“We are also participating in a second study called TeenView to look at the psychological component—eating disorders and depression especially,” Dr. Brandt said. Changes in body shape satisfaction, social support, and peer victimization/teasing will be assessed.

Other researchers have demonstrated that greater depressive symptoms, decreasing competence and self-esteem, and greater poverty are associated with adolescent obesity (Pediatrics 2000;105:e15; N. Engl. J. Med. 1993;329:1036-7).

Dr. Brandt said quality of life for obese adolescents is similar to levels reported by people with cancer during chemotherapy (JAMA 2003;289:1813-9).

She emphasized that bariatric surgery should be considered only for morbidly obese adolescents who meet specific criteria (Pediatrics 2004;114:217-23). These procedures should be performed only in centers that can provide multidisciplinary evaluation and treatment, Dr. Brandt said. And because the long-term risks are not completely known, all adolescents who have bariatric surgery should be enrolled in a prospective outcomes study.

SAN ANTONIO — Despite the controversy surrounding bariatric surgery for very obese adolescents, appropriate candidates often experience better psychosocial quality of life and improve or even reverse obesity-related comorbidities, according to preliminary results of a study at Texas Children's Hospital in Houston.

“This has been one of the most profoundly gratifying things in my career,” said Dr. Mary L. Brandt, director of the hospital's adolescent bariatric surgery program. “They get their lives back.”

Dr. Brandt reported results for 44 severely obese adolescents participating in an ongoing surgery study. Excess weight loss was 58% at 1 year and 60% at 2 years, she said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

The average age of the 32 girls and 12 boys is 16 years, and average body mass index is 60 kg/m

Surgery improved many of the preoperative comorbidities. For example, 70% of the 44 teenagers had preoperative insulin resistance, and 82% of these experienced resolution of the condition; 91% had sleep apnea, which resolved after surgery in 45%.

In preliminary results from the National Institutes of Health-funded Teen LABS study, Dr. Brandt and her associates found that type 2 diabetes resolved after surgery in 10 of 11 severely obese adolescents (Pediatrics 2009;123:214-22). Surgery was associated with a 34% decrease in BMI, a 41% decrease in fasting blood glucose levels, and an 81% decrease in fasting insulin concentrations.

In the Texas Children's Hospital series, 12 (27%) of the 44 patients experienced complications. Two patients experienced anastomotic bleeding, two had thiamine deficiency, and two had a marginal ulcer. Complications that occurred in one patient each included a retained nasogastric tube, coagulopathy, pulmonary embolism, anastomotic leak, urethral injury, and a Peterson hernia. All the complications resolved and there have been no deaths, said Dr. Brandt, professor and vice chair of surgery at Baylor College of Medicine in Houston.

“We are also participating in a second study called TeenView to look at the psychological component—eating disorders and depression especially,” Dr. Brandt said. Changes in body shape satisfaction, social support, and peer victimization/teasing will be assessed.

Other researchers have demonstrated that greater depressive symptoms, decreasing competence and self-esteem, and greater poverty are associated with adolescent obesity (Pediatrics 2000;105:e15; N. Engl. J. Med. 1993;329:1036-7).

Dr. Brandt said quality of life for obese adolescents is similar to levels reported by people with cancer during chemotherapy (JAMA 2003;289:1813-9).

She emphasized that bariatric surgery should be considered only for morbidly obese adolescents who meet specific criteria (Pediatrics 2004;114:217-23). These procedures should be performed only in centers that can provide multidisciplinary evaluation and treatment, Dr. Brandt said. And because the long-term risks are not completely known, all adolescents who have bariatric surgery should be enrolled in a prospective outcomes study.

SAN ANTONIO — Recommend only one or two changes at a time in diet and physical activity to help severely obese adolescents improve their health and quality of life, Dr. Mary L. Brandt advised.

Incremental increases in physical activity and small but consistent changes in diet, including smarter fast-food choices, are good starting points, she said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

In assessing the teen's degree of obesity, BMI is important. “I strongly feel all physicians should know the BMI of every patient in their practice. BMI is a way to understand the degree of obesity. The concept is that 200 pounds is okay if you are 6 feet 6 inches, but not if you are 5-feet tall,” Dr. Brandt said.

The adverse health effects of obesity can be considerable. For example, approximately 50% of overweight adolescents have at least one risk factor for cardiovascular disease, and about 20% have two risk factors (Circulation 2009;119:628-47; Am. Fam. Physician 2008;78:1052-8). These patients are at higher risk for insulin resistance, hyperlipidemia, hypertension, and sleep apnea, said Dr. Brandt, professor of surgery at Baylor College of Medicine in Houston.

The unfavorable health effects of obesity can also shorten life expectancy (JAMA 2003;289:187-93). If an individual is morbidly obese (a BMI of 45 kg/m

Obese adolescent patients are heartened to learn that their ancestors are partly to blame. It helps alleviate some of their guilt and shame. “I tell all my obese patients that what they are doing is what human beings are supposed to do. We are genetically programmed to store fat,” she said. About 40%-70% of BMI can be attributed to genetics.

Sex differences also play a role in obesity. The health risk at any level of obesity is higher for boys than for girls. “This has to do with where the fat is, not how much [there is],” Dr. Brandt said. The sex difference in fat distribution starts before puberty.

Another way to deal with obese adolescent patients is to address the 30%-60% of BMI that is caused by factors other than genetics, she said.

Start with the “low-hanging fruit” when counseling teen patients and families about diet and physical activity. For example, begin with what the patient drinks every day. “If you tell a kid they cannot have something, it will not work. If they drink four Cokes a day, see if they will commit to drinking only two or three instead,” she said.

Ask about the patient's diet in a nonjudgmental way, she recommended. Talk to a child or adolescent who eats a lot of fast food about smart choices. For example, the difference between a Double Whopper with cheese (1,010 calories) and a hamburger (290 calories) at Burger King is 720 calories, according to the company's Web site.

Also, “the traffic light diet” works well with kids. Tell them there are “foods that are good [green light], things you need to watch [yellow light], and things you should never have [red light]. I have them pick one change for each of the three categories that they will commit to,” Dr. Brandt said. This diet plan is feasible and significantly decreased BMI in pediatric patients compared with treatment as usual in one study, she added (J. Pediatr. Psychol. 2007;32:106-10).

Decreased teenage physical activity also plays a major role in obesity, with the effect more pronounced in girls than boys, Dr. Brandt said. “We see more overweight girls than boys. What they are eating is about the same, but what they are burning is different.”

“We have to figure out ways to encourage girls to play sports, including safe venues outside the home,” said Dr. Brandt, who is also director of the Texas Children's Hospital adolescent bariatric surgery program in Houston.

'If they drink four Cokes a day, see if they will commit to drinking only two or three instead.'

Source DR. BRANDT

SAN ANTONIO — Recommend only one or two changes at a time in diet and physical activity to help severely obese adolescents improve their health and quality of life, Dr. Mary L. Brandt advised.

Incremental increases in physical activity and small but consistent changes in diet, including smarter fast-food choices, are good starting points, she said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

In assessing the teen's degree of obesity, BMI is important. “I strongly feel all physicians should know the BMI of every patient in their practice. BMI is a way to understand the degree of obesity. The concept is that 200 pounds is okay if you are 6 feet 6 inches, but not if you are 5-feet tall,” Dr. Brandt said.

The adverse health effects of obesity can be considerable. For example, approximately 50% of overweight adolescents have at least one risk factor for cardiovascular disease, and about 20% have two risk factors (Circulation 2009;119:628-47; Am. Fam. Physician 2008;78:1052-8). These patients are at higher risk for insulin resistance, hyperlipidemia, hypertension, and sleep apnea, said Dr. Brandt, professor of surgery at Baylor College of Medicine in Houston.

The unfavorable health effects of obesity can also shorten life expectancy (JAMA 2003;289:187-93). If an individual is morbidly obese (a BMI of 45 kg/m

Obese adolescent patients are heartened to learn that their ancestors are partly to blame. It helps alleviate some of their guilt and shame. “I tell all my obese patients that what they are doing is what human beings are supposed to do. We are genetically programmed to store fat,” she said. About 40%-70% of BMI can be attributed to genetics.

Sex differences also play a role in obesity. The health risk at any level of obesity is higher for boys than for girls. “This has to do with where the fat is, not how much [there is],” Dr. Brandt said. The sex difference in fat distribution starts before puberty.

Another way to deal with obese adolescent patients is to address the 30%-60% of BMI that is caused by factors other than genetics, she said.

Start with the “low-hanging fruit” when counseling teen patients and families about diet and physical activity. For example, begin with what the patient drinks every day. “If you tell a kid they cannot have something, it will not work. If they drink four Cokes a day, see if they will commit to drinking only two or three instead,” she said.

Ask about the patient's diet in a nonjudgmental way, she recommended. Talk to a child or adolescent who eats a lot of fast food about smart choices. For example, the difference between a Double Whopper with cheese (1,010 calories) and a hamburger (290 calories) at Burger King is 720 calories, according to the company's Web site.

Also, “the traffic light diet” works well with kids. Tell them there are “foods that are good [green light], things you need to watch [yellow light], and things you should never have [red light]. I have them pick one change for each of the three categories that they will commit to,” Dr. Brandt said. This diet plan is feasible and significantly decreased BMI in pediatric patients compared with treatment as usual in one study, she added (J. Pediatr. Psychol. 2007;32:106-10).

Decreased teenage physical activity also plays a major role in obesity, with the effect more pronounced in girls than boys, Dr. Brandt said. “We see more overweight girls than boys. What they are eating is about the same, but what they are burning is different.”

“We have to figure out ways to encourage girls to play sports, including safe venues outside the home,” said Dr. Brandt, who is also director of the Texas Children's Hospital adolescent bariatric surgery program in Houston.

'If they drink four Cokes a day, see if they will commit to drinking only two or three instead.'

Source DR. BRANDT

SAN ANTONIO — Recommend only one or two changes at a time in diet and physical activity to help severely obese adolescents improve their health and quality of life, Dr. Mary L. Brandt advised.

Incremental increases in physical activity and small but consistent changes in diet, including smarter fast-food choices, are good starting points, she said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

In assessing the teen's degree of obesity, BMI is important. “I strongly feel all physicians should know the BMI of every patient in their practice. BMI is a way to understand the degree of obesity. The concept is that 200 pounds is okay if you are 6 feet 6 inches, but not if you are 5-feet tall,” Dr. Brandt said.

The adverse health effects of obesity can be considerable. For example, approximately 50% of overweight adolescents have at least one risk factor for cardiovascular disease, and about 20% have two risk factors (Circulation 2009;119:628-47; Am. Fam. Physician 2008;78:1052-8). These patients are at higher risk for insulin resistance, hyperlipidemia, hypertension, and sleep apnea, said Dr. Brandt, professor of surgery at Baylor College of Medicine in Houston.

The unfavorable health effects of obesity can also shorten life expectancy (JAMA 2003;289:187-93). If an individual is morbidly obese (a BMI of 45 kg/m

Obese adolescent patients are heartened to learn that their ancestors are partly to blame. It helps alleviate some of their guilt and shame. “I tell all my obese patients that what they are doing is what human beings are supposed to do. We are genetically programmed to store fat,” she said. About 40%-70% of BMI can be attributed to genetics.

Sex differences also play a role in obesity. The health risk at any level of obesity is higher for boys than for girls. “This has to do with where the fat is, not how much [there is],” Dr. Brandt said. The sex difference in fat distribution starts before puberty.

Another way to deal with obese adolescent patients is to address the 30%-60% of BMI that is caused by factors other than genetics, she said.

Start with the “low-hanging fruit” when counseling teen patients and families about diet and physical activity. For example, begin with what the patient drinks every day. “If you tell a kid they cannot have something, it will not work. If they drink four Cokes a day, see if they will commit to drinking only two or three instead,” she said.

Ask about the patient's diet in a nonjudgmental way, she recommended. Talk to a child or adolescent who eats a lot of fast food about smart choices. For example, the difference between a Double Whopper with cheese (1,010 calories) and a hamburger (290 calories) at Burger King is 720 calories, according to the company's Web site.

Also, “the traffic light diet” works well with kids. Tell them there are “foods that are good [green light], things you need to watch [yellow light], and things you should never have [red light]. I have them pick one change for each of the three categories that they will commit to,” Dr. Brandt said. This diet plan is feasible and significantly decreased BMI in pediatric patients compared with treatment as usual in one study, she added (J. Pediatr. Psychol. 2007;32:106-10).

Decreased teenage physical activity also plays a major role in obesity, with the effect more pronounced in girls than boys, Dr. Brandt said. “We see more overweight girls than boys. What they are eating is about the same, but what they are burning is different.”

“We have to figure out ways to encourage girls to play sports, including safe venues outside the home,” said Dr. Brandt, who is also director of the Texas Children's Hospital adolescent bariatric surgery program in Houston.

'If they drink four Cokes a day, see if they will commit to drinking only two or three instead.'

Source DR. BRANDT

HOLLYWOOD, FLA. — Bipolar disorder is an independent risk factor for lipid disorders among patients without other known risk factors, according to a large, retrospective, managed care claims database study.

Dr. Quinton E. Moss and his associates also found the association between bipolar disorder and elevated risk remained after they controlled for current use of antipsychotic and lipid-lowering medications. This finding was important because treatments for bipolar disorder, particularly some atypical antipsychotics, can increase lipid abnormalities, he said in an interview at his poster at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Age also played a role, with the risk for lipid disorders being greatest among bipolar patients in their 20s and 30s. This means the increased risk for dyslipidemia, hypercholesterolemia, or hypertriglyceridemia was independent of lipid changes typically associated with aging, said Dr. Moss, of i3 Research in Basking Ridge, N.J.

It is widely accepted that there is a greater risk of metabolic syndrome and cardiovascular disease among people with bipolar disorder, Dr. Moss said (Ann. Clin. Psychiatry 2008;20:131-7).

He and his colleagues studied de-identified claims from a large U.S. health insurer. They compared 33,019 enrollees who had bipolar disorder and a diagnosis of a lipid disorder, thyroid disorder, or diabetes with an additional 1 million controls with no Axis I mood or psychosis diagnoses.

Patients were aged 20-55 years (mean age, 39 years in both groups). Men comprised 35% of the bipolar disorder cohort and 52% of controls.

Patients with bipolar disorder and no comorbid thyroid disease or diabetes had a significantly increased likelihood of having lipid disorders (odds ratios ranged from 1.85 to 3.07). But the bipolar disorder and lipid disorder association was no longer significant if either comorbidity was present (OR range, 0.51-1.27).

Because some medication use can alter lipid levels (Neuropsychobiology 2006;53:108-12), Dr. Moss and his associates performed a subanalysis that excluded 31% of the bipolar sample taking an antipsychotic agent and the 13% taking a lipid-lowering drug.

“Looking at those who have not been treated with an atypical antipsychotic or those who have not received a lipid-lowering agent—we still saw a relationship”

Bipolar patients not taking these medications but who had concomitant thyroid disorder or diabetes were not significantly more likely to have a lipid disorder, with the exception of men aged 30-34 years or 40-55 years and women aged 45-55 years.

“Folks who have bipolar disorder are being screened for lipid disorders before [being prescribed] an atypical antipsychotic, supposedly,” Dr. Moss said. “But there is a group with bipolar disorder not about to be treated who have an increased risk. For example, two-thirds in this study were not being treated, and their risk needs to be evaluated.”

These findings support screening all patients with bipolar disorder for lipid abnormalities, Dr. Moss said.

Regardless of sex, the odds ratio was higher if patients were aged 20-39 years versus the older age groups. Again, this applied only to patients without one of the comorbidities. There was no significant increased risk by age if one of the comorbidities was present, except among men aged 30-34 years and 50-55 years.

The retrospective study design was a limitation, Dr. Moss said. Also, he did not assess data based on ethnicity or complete medical history, two factors he hopes to address in future research.

These findings support screening all patients with bipolar disorder for lipid abnormalities.

Source DR. MOSS

HOLLYWOOD, FLA. — Bipolar disorder is an independent risk factor for lipid disorders among patients without other known risk factors, according to a large, retrospective, managed care claims database study.

Dr. Quinton E. Moss and his associates also found the association between bipolar disorder and elevated risk remained after they controlled for current use of antipsychotic and lipid-lowering medications. This finding was important because treatments for bipolar disorder, particularly some atypical antipsychotics, can increase lipid abnormalities, he said in an interview at his poster at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Age also played a role, with the risk for lipid disorders being greatest among bipolar patients in their 20s and 30s. This means the increased risk for dyslipidemia, hypercholesterolemia, or hypertriglyceridemia was independent of lipid changes typically associated with aging, said Dr. Moss, of i3 Research in Basking Ridge, N.J.

It is widely accepted that there is a greater risk of metabolic syndrome and cardiovascular disease among people with bipolar disorder, Dr. Moss said (Ann. Clin. Psychiatry 2008;20:131-7).

He and his colleagues studied de-identified claims from a large U.S. health insurer. They compared 33,019 enrollees who had bipolar disorder and a diagnosis of a lipid disorder, thyroid disorder, or diabetes with an additional 1 million controls with no Axis I mood or psychosis diagnoses.

Patients were aged 20-55 years (mean age, 39 years in both groups). Men comprised 35% of the bipolar disorder cohort and 52% of controls.

Patients with bipolar disorder and no comorbid thyroid disease or diabetes had a significantly increased likelihood of having lipid disorders (odds ratios ranged from 1.85 to 3.07). But the bipolar disorder and lipid disorder association was no longer significant if either comorbidity was present (OR range, 0.51-1.27).

Because some medication use can alter lipid levels (Neuropsychobiology 2006;53:108-12), Dr. Moss and his associates performed a subanalysis that excluded 31% of the bipolar sample taking an antipsychotic agent and the 13% taking a lipid-lowering drug.

“Looking at those who have not been treated with an atypical antipsychotic or those who have not received a lipid-lowering agent—we still saw a relationship”

Bipolar patients not taking these medications but who had concomitant thyroid disorder or diabetes were not significantly more likely to have a lipid disorder, with the exception of men aged 30-34 years or 40-55 years and women aged 45-55 years.

“Folks who have bipolar disorder are being screened for lipid disorders before [being prescribed] an atypical antipsychotic, supposedly,” Dr. Moss said. “But there is a group with bipolar disorder not about to be treated who have an increased risk. For example, two-thirds in this study were not being treated, and their risk needs to be evaluated.”

These findings support screening all patients with bipolar disorder for lipid abnormalities, Dr. Moss said.

Regardless of sex, the odds ratio was higher if patients were aged 20-39 years versus the older age groups. Again, this applied only to patients without one of the comorbidities. There was no significant increased risk by age if one of the comorbidities was present, except among men aged 30-34 years and 50-55 years.

The retrospective study design was a limitation, Dr. Moss said. Also, he did not assess data based on ethnicity or complete medical history, two factors he hopes to address in future research.

These findings support screening all patients with bipolar disorder for lipid abnormalities.

Source DR. MOSS

HOLLYWOOD, FLA. — Bipolar disorder is an independent risk factor for lipid disorders among patients without other known risk factors, according to a large, retrospective, managed care claims database study.

Dr. Quinton E. Moss and his associates also found the association between bipolar disorder and elevated risk remained after they controlled for current use of antipsychotic and lipid-lowering medications. This finding was important because treatments for bipolar disorder, particularly some atypical antipsychotics, can increase lipid abnormalities, he said in an interview at his poster at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Age also played a role, with the risk for lipid disorders being greatest among bipolar patients in their 20s and 30s. This means the increased risk for dyslipidemia, hypercholesterolemia, or hypertriglyceridemia was independent of lipid changes typically associated with aging, said Dr. Moss, of i3 Research in Basking Ridge, N.J.

It is widely accepted that there is a greater risk of metabolic syndrome and cardiovascular disease among people with bipolar disorder, Dr. Moss said (Ann. Clin. Psychiatry 2008;20:131-7).

He and his colleagues studied de-identified claims from a large U.S. health insurer. They compared 33,019 enrollees who had bipolar disorder and a diagnosis of a lipid disorder, thyroid disorder, or diabetes with an additional 1 million controls with no Axis I mood or psychosis diagnoses.

Patients were aged 20-55 years (mean age, 39 years in both groups). Men comprised 35% of the bipolar disorder cohort and 52% of controls.

Patients with bipolar disorder and no comorbid thyroid disease or diabetes had a significantly increased likelihood of having lipid disorders (odds ratios ranged from 1.85 to 3.07). But the bipolar disorder and lipid disorder association was no longer significant if either comorbidity was present (OR range, 0.51-1.27).

Because some medication use can alter lipid levels (Neuropsychobiology 2006;53:108-12), Dr. Moss and his associates performed a subanalysis that excluded 31% of the bipolar sample taking an antipsychotic agent and the 13% taking a lipid-lowering drug.

“Looking at those who have not been treated with an atypical antipsychotic or those who have not received a lipid-lowering agent—we still saw a relationship”

Bipolar patients not taking these medications but who had concomitant thyroid disorder or diabetes were not significantly more likely to have a lipid disorder, with the exception of men aged 30-34 years or 40-55 years and women aged 45-55 years.

“Folks who have bipolar disorder are being screened for lipid disorders before [being prescribed] an atypical antipsychotic, supposedly,” Dr. Moss said. “But there is a group with bipolar disorder not about to be treated who have an increased risk. For example, two-thirds in this study were not being treated, and their risk needs to be evaluated.”

These findings support screening all patients with bipolar disorder for lipid abnormalities, Dr. Moss said.

Regardless of sex, the odds ratio was higher if patients were aged 20-39 years versus the older age groups. Again, this applied only to patients without one of the comorbidities. There was no significant increased risk by age if one of the comorbidities was present, except among men aged 30-34 years and 50-55 years.

The retrospective study design was a limitation, Dr. Moss said. Also, he did not assess data based on ethnicity or complete medical history, two factors he hopes to address in future research.

These findings support screening all patients with bipolar disorder for lipid abnormalities.

Source DR. MOSS

MIAMI BEACH — Group medical visits that combine education and individualized medication adjustment significantly improved hypertension among primary care patients with poorly controlled diabetes, compared with usual care, according to a randomized, controlled trial. This intervention, however, did not significantly improve glycemic control.

Although group medical clinics are widely used, this is the first study to assess the effectiveness of group medical clinics at simultaneously controlling blood pressure and glycemia, Dr. David Edelman said.

He and his colleagues randomized 239 patients with poorly controlled diabetes receiving primary care at the Durham Veterans Affairs Medical Center or the Richmond VA Medical Center, both in North Carolina. At baseline, all participants had a hemoglobin A_1c level of 7.5% or more and hypertension, defined as blood pressure above 140 mm Hg systolic or 90 mm Hg diastolic. Mean age of the patients was 62 years, 59% were African American, and 96% were men.

A total of 133 patients received the group intervention and 106 got usual care. Mean systolic blood pressure at baseline was 152 mm Hg in the intervention cohort and 154 mm Hg in the usual care group; mean HbA_1c was 9.2% in both groups. The intervention was in addition to usual care, Dr. Edelman said at the annual meeting of the Society of General Internal Medicine.

In the intervention arm, a nurse or certified diabetes educator facilitated a group educational session every 2 months for 1 year.

During these sessions, a primary care doctor and a pharmacist met in a separate room to review blood pressure and HbA_1c measurements and to make individual medication adjustments. Following the group discussion, each patient met individually with either the primary care doctor or pharmacist. Qualitative data indicated that patients “really liked the additional access to a health care provider,” said Dr. Edelman, an investigator at the Center for Health Services Research in Primary Care at the Durham VA Medical Center. He is also on the general internal medicine faculty at Duke University.

A total of 89% of patients completed follow-up. Intervention patients had significantly greater improvements in systolic blood pressure, compared with controls. At 6 months, the intervention patients had a mean 14.5 mm Hg decrease in systolic blood pressure, compared with 7.2 mm Hg for usual care patients. At 12 months, mean decreases were 14.1 mm Hg in the intervention patients and 6.2 mm Hg in the usual care group.

After adjustments, there was a statistically significant overall decrease of 7.2 mm Hg between groups, favoring the group medical clinic participants. Most of the difference was seen in the first 6 months, Dr. Edelman said.

The HbA_1c findings were “not as promising.” There was an average 0.9% improvement in the intervention group, “which we would have patted ourselves on the back for, had we not had a control group, which saw 0.6% improvement,” Dr. Edelman said. It might be easier to treat and change blood pressure than to treat and change HbA_1c, especially in patients with poorly controlled diabetes, he said. “It could be these refractory patients are a special challenge.”

“We are working on the possibility of co-intervention” to explain the disparity in results, Dr. Edelman said. Because the primary care physicians were not blinded to group assignment, “it's possible that when they found a patient randomized to control [and] wildly out of control … they may have prescribed something else. It's reasonable and possible [that] there was more co-intervention on HbA_1c than [on] blood pressure.”

The study was funded by the Department of Veterans Affairs, and Dr. Edelman did not disclose any conflicts of interest.

To watch a video interview of Dr. Edelman, go to www.youtube.com/user/ClinicalEndoNews

Group intervention improved blood pressure, but not glycemic control, Dr. David Edelman said in a video interview.

Source Damian McNamara/Elsevier Global Medical News

MIAMI BEACH — Group medical visits that combine education and individualized medication adjustment significantly improved hypertension among primary care patients with poorly controlled diabetes, compared with usual care, according to a randomized, controlled trial. This intervention, however, did not significantly improve glycemic control.

Although group medical clinics are widely used, this is the first study to assess the effectiveness of group medical clinics at simultaneously controlling blood pressure and glycemia, Dr. David Edelman said.

He and his colleagues randomized 239 patients with poorly controlled diabetes receiving primary care at the Durham Veterans Affairs Medical Center or the Richmond VA Medical Center, both in North Carolina. At baseline, all participants had a hemoglobin A_1c level of 7.5% or more and hypertension, defined as blood pressure above 140 mm Hg systolic or 90 mm Hg diastolic. Mean age of the patients was 62 years, 59% were African American, and 96% were men.

A total of 133 patients received the group intervention and 106 got usual care. Mean systolic blood pressure at baseline was 152 mm Hg in the intervention cohort and 154 mm Hg in the usual care group; mean HbA_1c was 9.2% in both groups. The intervention was in addition to usual care, Dr. Edelman said at the annual meeting of the Society of General Internal Medicine.

In the intervention arm, a nurse or certified diabetes educator facilitated a group educational session every 2 months for 1 year.

During these sessions, a primary care doctor and a pharmacist met in a separate room to review blood pressure and HbA_1c measurements and to make individual medication adjustments. Following the group discussion, each patient met individually with either the primary care doctor or pharmacist. Qualitative data indicated that patients “really liked the additional access to a health care provider,” said Dr. Edelman, an investigator at the Center for Health Services Research in Primary Care at the Durham VA Medical Center. He is also on the general internal medicine faculty at Duke University.

A total of 89% of patients completed follow-up. Intervention patients had significantly greater improvements in systolic blood pressure, compared with controls. At 6 months, the intervention patients had a mean 14.5 mm Hg decrease in systolic blood pressure, compared with 7.2 mm Hg for usual care patients. At 12 months, mean decreases were 14.1 mm Hg in the intervention patients and 6.2 mm Hg in the usual care group.

After adjustments, there was a statistically significant overall decrease of 7.2 mm Hg between groups, favoring the group medical clinic participants. Most of the difference was seen in the first 6 months, Dr. Edelman said.

The HbA_1c findings were “not as promising.” There was an average 0.9% improvement in the intervention group, “which we would have patted ourselves on the back for, had we not had a control group, which saw 0.6% improvement,” Dr. Edelman said. It might be easier to treat and change blood pressure than to treat and change HbA_1c, especially in patients with poorly controlled diabetes, he said. “It could be these refractory patients are a special challenge.”

“We are working on the possibility of co-intervention” to explain the disparity in results, Dr. Edelman said. Because the primary care physicians were not blinded to group assignment, “it's possible that when they found a patient randomized to control [and] wildly out of control … they may have prescribed something else. It's reasonable and possible [that] there was more co-intervention on HbA_1c than [on] blood pressure.”

The study was funded by the Department of Veterans Affairs, and Dr. Edelman did not disclose any conflicts of interest.

To watch a video interview of Dr. Edelman, go to www.youtube.com/user/ClinicalEndoNews

Group intervention improved blood pressure, but not glycemic control, Dr. David Edelman said in a video interview.

Source Damian McNamara/Elsevier Global Medical News

MIAMI BEACH — Group medical visits that combine education and individualized medication adjustment significantly improved hypertension among primary care patients with poorly controlled diabetes, compared with usual care, according to a randomized, controlled trial. This intervention, however, did not significantly improve glycemic control.

Although group medical clinics are widely used, this is the first study to assess the effectiveness of group medical clinics at simultaneously controlling blood pressure and glycemia, Dr. David Edelman said.

He and his colleagues randomized 239 patients with poorly controlled diabetes receiving primary care at the Durham Veterans Affairs Medical Center or the Richmond VA Medical Center, both in North Carolina. At baseline, all participants had a hemoglobin A_1c level of 7.5% or more and hypertension, defined as blood pressure above 140 mm Hg systolic or 90 mm Hg diastolic. Mean age of the patients was 62 years, 59% were African American, and 96% were men.

A total of 133 patients received the group intervention and 106 got usual care. Mean systolic blood pressure at baseline was 152 mm Hg in the intervention cohort and 154 mm Hg in the usual care group; mean HbA_1c was 9.2% in both groups. The intervention was in addition to usual care, Dr. Edelman said at the annual meeting of the Society of General Internal Medicine.

In the intervention arm, a nurse or certified diabetes educator facilitated a group educational session every 2 months for 1 year.

During these sessions, a primary care doctor and a pharmacist met in a separate room to review blood pressure and HbA_1c measurements and to make individual medication adjustments. Following the group discussion, each patient met individually with either the primary care doctor or pharmacist. Qualitative data indicated that patients “really liked the additional access to a health care provider,” said Dr. Edelman, an investigator at the Center for Health Services Research in Primary Care at the Durham VA Medical Center. He is also on the general internal medicine faculty at Duke University.

A total of 89% of patients completed follow-up. Intervention patients had significantly greater improvements in systolic blood pressure, compared with controls. At 6 months, the intervention patients had a mean 14.5 mm Hg decrease in systolic blood pressure, compared with 7.2 mm Hg for usual care patients. At 12 months, mean decreases were 14.1 mm Hg in the intervention patients and 6.2 mm Hg in the usual care group.

After adjustments, there was a statistically significant overall decrease of 7.2 mm Hg between groups, favoring the group medical clinic participants. Most of the difference was seen in the first 6 months, Dr. Edelman said.

The HbA_1c findings were “not as promising.” There was an average 0.9% improvement in the intervention group, “which we would have patted ourselves on the back for, had we not had a control group, which saw 0.6% improvement,” Dr. Edelman said. It might be easier to treat and change blood pressure than to treat and change HbA_1c, especially in patients with poorly controlled diabetes, he said. “It could be these refractory patients are a special challenge.”

“We are working on the possibility of co-intervention” to explain the disparity in results, Dr. Edelman said. Because the primary care physicians were not blinded to group assignment, “it's possible that when they found a patient randomized to control [and] wildly out of control … they may have prescribed something else. It's reasonable and possible [that] there was more co-intervention on HbA_1c than [on] blood pressure.”

The study was funded by the Department of Veterans Affairs, and Dr. Edelman did not disclose any conflicts of interest.

To watch a video interview of Dr. Edelman, go to www.youtube.com/user/ClinicalEndoNews

Group intervention improved blood pressure, but not glycemic control, Dr. David Edelman said in a video interview.

Source Damian McNamara/Elsevier Global Medical News