Damian McNamara

SAN ANTONIO — What makes researchers study the male partners of adolescent and adult women infected with a sexually transmitted infection? When their female patients get treated and return reinfected, it makes them think there must be a way to improve and deliver age- and partner-appropriate prevention messages.

“Once you diagnose an STI in an adolescent girl, you know there is at least one more person who has an STI,” Dr. Andrea Thurman said. “I was treating girls who I knew were taking their medication but kept coming back.

“They were getting reinfected by their partners. I don't think these male partners were getting treated,” she said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Dr. Thurman and her colleagues proposed that prevention messages targeted to male sexual partners based on the age of the woman might be more effective. So they looked for demographic and behavioral differences between partners of teenagers and partners of adult women. They compared the male partners of 152 adolescent girls (14- to 19-years-old, mean age 18 years) with the partners of 362 adult women (20 years and older, mean age 24 years).

All women in the study had a lab-verified, nonviral sexually transmitted infection (STI) diagnosis. “STIs are common in teens, and we cannot screen them enough,” Dr. Thurman said. Prevalence might be as high as 25%, based on a study by Forhan et al. presented at the 2008 National STD Prevention Conference in Chicago.

As part of study participation, each woman was required to invite a male sexual partner from the previous 2 months to participate. Approximately half the men tested positive for an STI at intake. However, partners of teenage women were significantly more likely to have such an infection (57% vs. 47%), especially chlamydia (51% vs. 39%). The gonorrhea coinfection rates were not significantly different (13% vs. 11%), and syphilis affected 1% of male partners in both groups.

“It is unclear why these men partnered with teenagers were more infected,” Dr. Thurman said. It was not exposure, she added. “We thought that teens were having more sex, but the mean number of sexual acts in past 3 months was not significantly different between partners of teens, 68, and partners of adults, 62.”

The mean age of partners of teenage women was 21 years versus 26 years for the partners of adults. Partners of teenage women were more likely to have less money and a higher number of partners; they were more likely to report current drug use and fewer had a high school education. In addition, partners of teens were more likely to be unmarried and not live with the index woman.

“These are things that we all assume, but it was interesting to look at [more than] 500 couples and see what is going on in their relationships, and what they are thinking,” Dr. Thurman said.

Mean length of monogamy was 10 months for partners of teenagers versus almost 20 months for partners of adult women. “The guys dating the teenagers are like the girls—they are sampling around,” said Dr. Thurman of the University of Texas Health Sciences Center, San Antonio.

“Men partnered with teens were significantly more likely to report using any drug, including marijuana, within 1 month,” Dr. Thurman said. A total of 95 (63%) partners of teenagers reported recent drug use versus 158 (44%) men dating adult women.

The researchers found a significant difference in reported condom use: A total of 41 (47%) of 88 partners of teenagers said they did not use condoms, compared with 69 (32%) of 215 partners of adult women specifically because “they like the sensation of 'skin on skin,'” Dr. Thurman said. “Keep this in mind when counseling teenage women—they may have different issues than adult women.”

In some cases, when a woman tests positive for an STI, she agrees to notify her partner. Another approach is provider referral. “Someone from the ob.gyn. [office] calls and says an anonymous woman tested positive for chlamydia, and they offer to call in a prescription for him. The more I do this, the more men appreciate this,” she said.

A meeting attendee asked how often Dr. Thurman encounters an infected woman who does not know the partner's last name or address. “Not so much in this study,” she replied. “This was a self-selected group of women who already tested positive for an STI.”

Dr. Thurman had no conflicts of interest.

'I was treating girls who I knew were taking their medication but kept coming back.'

Source DR. THURMAN

SAN ANTONIO — What makes researchers study the male partners of adolescent and adult women infected with a sexually transmitted infection? When their female patients get treated and return reinfected, it makes them think there must be a way to improve and deliver age- and partner-appropriate prevention messages.

“Once you diagnose an STI in an adolescent girl, you know there is at least one more person who has an STI,” Dr. Andrea Thurman said. “I was treating girls who I knew were taking their medication but kept coming back.

“They were getting reinfected by their partners. I don't think these male partners were getting treated,” she said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Dr. Thurman and her colleagues proposed that prevention messages targeted to male sexual partners based on the age of the woman might be more effective. So they looked for demographic and behavioral differences between partners of teenagers and partners of adult women. They compared the male partners of 152 adolescent girls (14- to 19-years-old, mean age 18 years) with the partners of 362 adult women (20 years and older, mean age 24 years).

All women in the study had a lab-verified, nonviral sexually transmitted infection (STI) diagnosis. “STIs are common in teens, and we cannot screen them enough,” Dr. Thurman said. Prevalence might be as high as 25%, based on a study by Forhan et al. presented at the 2008 National STD Prevention Conference in Chicago.

As part of study participation, each woman was required to invite a male sexual partner from the previous 2 months to participate. Approximately half the men tested positive for an STI at intake. However, partners of teenage women were significantly more likely to have such an infection (57% vs. 47%), especially chlamydia (51% vs. 39%). The gonorrhea coinfection rates were not significantly different (13% vs. 11%), and syphilis affected 1% of male partners in both groups.

“It is unclear why these men partnered with teenagers were more infected,” Dr. Thurman said. It was not exposure, she added. “We thought that teens were having more sex, but the mean number of sexual acts in past 3 months was not significantly different between partners of teens, 68, and partners of adults, 62.”

The mean age of partners of teenage women was 21 years versus 26 years for the partners of adults. Partners of teenage women were more likely to have less money and a higher number of partners; they were more likely to report current drug use and fewer had a high school education. In addition, partners of teens were more likely to be unmarried and not live with the index woman.

“These are things that we all assume, but it was interesting to look at [more than] 500 couples and see what is going on in their relationships, and what they are thinking,” Dr. Thurman said.

Mean length of monogamy was 10 months for partners of teenagers versus almost 20 months for partners of adult women. “The guys dating the teenagers are like the girls—they are sampling around,” said Dr. Thurman of the University of Texas Health Sciences Center, San Antonio.

“Men partnered with teens were significantly more likely to report using any drug, including marijuana, within 1 month,” Dr. Thurman said. A total of 95 (63%) partners of teenagers reported recent drug use versus 158 (44%) men dating adult women.

The researchers found a significant difference in reported condom use: A total of 41 (47%) of 88 partners of teenagers said they did not use condoms, compared with 69 (32%) of 215 partners of adult women specifically because “they like the sensation of 'skin on skin,'” Dr. Thurman said. “Keep this in mind when counseling teenage women—they may have different issues than adult women.”

In some cases, when a woman tests positive for an STI, she agrees to notify her partner. Another approach is provider referral. “Someone from the ob.gyn. [office] calls and says an anonymous woman tested positive for chlamydia, and they offer to call in a prescription for him. The more I do this, the more men appreciate this,” she said.

A meeting attendee asked how often Dr. Thurman encounters an infected woman who does not know the partner's last name or address. “Not so much in this study,” she replied. “This was a self-selected group of women who already tested positive for an STI.”

Dr. Thurman had no conflicts of interest.

'I was treating girls who I knew were taking their medication but kept coming back.'

Source DR. THURMAN

SAN ANTONIO — What makes researchers study the male partners of adolescent and adult women infected with a sexually transmitted infection? When their female patients get treated and return reinfected, it makes them think there must be a way to improve and deliver age- and partner-appropriate prevention messages.

“Once you diagnose an STI in an adolescent girl, you know there is at least one more person who has an STI,” Dr. Andrea Thurman said. “I was treating girls who I knew were taking their medication but kept coming back.

“They were getting reinfected by their partners. I don't think these male partners were getting treated,” she said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Dr. Thurman and her colleagues proposed that prevention messages targeted to male sexual partners based on the age of the woman might be more effective. So they looked for demographic and behavioral differences between partners of teenagers and partners of adult women. They compared the male partners of 152 adolescent girls (14- to 19-years-old, mean age 18 years) with the partners of 362 adult women (20 years and older, mean age 24 years).

All women in the study had a lab-verified, nonviral sexually transmitted infection (STI) diagnosis. “STIs are common in teens, and we cannot screen them enough,” Dr. Thurman said. Prevalence might be as high as 25%, based on a study by Forhan et al. presented at the 2008 National STD Prevention Conference in Chicago.

As part of study participation, each woman was required to invite a male sexual partner from the previous 2 months to participate. Approximately half the men tested positive for an STI at intake. However, partners of teenage women were significantly more likely to have such an infection (57% vs. 47%), especially chlamydia (51% vs. 39%). The gonorrhea coinfection rates were not significantly different (13% vs. 11%), and syphilis affected 1% of male partners in both groups.

“It is unclear why these men partnered with teenagers were more infected,” Dr. Thurman said. It was not exposure, she added. “We thought that teens were having more sex, but the mean number of sexual acts in past 3 months was not significantly different between partners of teens, 68, and partners of adults, 62.”

The mean age of partners of teenage women was 21 years versus 26 years for the partners of adults. Partners of teenage women were more likely to have less money and a higher number of partners; they were more likely to report current drug use and fewer had a high school education. In addition, partners of teens were more likely to be unmarried and not live with the index woman.

“These are things that we all assume, but it was interesting to look at [more than] 500 couples and see what is going on in their relationships, and what they are thinking,” Dr. Thurman said.

Mean length of monogamy was 10 months for partners of teenagers versus almost 20 months for partners of adult women. “The guys dating the teenagers are like the girls—they are sampling around,” said Dr. Thurman of the University of Texas Health Sciences Center, San Antonio.

“Men partnered with teens were significantly more likely to report using any drug, including marijuana, within 1 month,” Dr. Thurman said. A total of 95 (63%) partners of teenagers reported recent drug use versus 158 (44%) men dating adult women.

The researchers found a significant difference in reported condom use: A total of 41 (47%) of 88 partners of teenagers said they did not use condoms, compared with 69 (32%) of 215 partners of adult women specifically because “they like the sensation of 'skin on skin,'” Dr. Thurman said. “Keep this in mind when counseling teenage women—they may have different issues than adult women.”

In some cases, when a woman tests positive for an STI, she agrees to notify her partner. Another approach is provider referral. “Someone from the ob.gyn. [office] calls and says an anonymous woman tested positive for chlamydia, and they offer to call in a prescription for him. The more I do this, the more men appreciate this,” she said.

A meeting attendee asked how often Dr. Thurman encounters an infected woman who does not know the partner's last name or address. “Not so much in this study,” she replied. “This was a self-selected group of women who already tested positive for an STI.”

Dr. Thurman had no conflicts of interest.

'I was treating girls who I knew were taking their medication but kept coming back.'

Source DR. THURMAN

HOLLYWOOD, FLA. — A 10-point scale based on three intraoperative hemodynamic factors accurately predicts which patients undergoing colorectal resection are likely to experience complications after discharge, according to a study of nearly 800 patients.

The traditional Apgar score is a convenient 10-point scale to assess the status of a newborn shortly after birth. Scores 3 and below are regarded as critically low, 4–6 are fairly low, and 7–10 are normal.

A “surgical Apgar” score can calculate a patient's condition following general or vascular surgery and grade the chances of major complications or death. Among the advantages of using a surgical Apgar score are immediate feedback, no cost, and little effort, Dr. Scott E. Regenbogen said. A patient's score is computed in the operating room using estimated blood loss, lowest mean arterial pressure, and lowest heart rate. (See box.)

“We are looking for opportunities to improve outcomes,” Dr. Regenbogen said in an interview at his poster during the annual meeting of the American Society of Colon and Rectal Surgeons.

He and his associates assessed outcomes after 795 colorectal resections over 4 years at Massachusetts General Hospital in Boston. The likelihood of complications after discharge quadrupled among patients with an operating room score between 0 and 4 (relative risk, 4.5), compared with a reference group that had scores of 7 or 8. “So information in the OR still gives us valuable information on how they do even after they leave the hospital,” said Dr. Regenbogen, of Massachusetts General Hospital.

The likelihood of complications after discharge also was higher for patients who scored 5 or 6 (RR, 2.6) but lower for those who scored the highest, a 9 or 10 (RR, 0.6).

There were 49 patients in the 0–4 score group, 186 patients in the 5–6 group, 406 patients in the reference 7–8 group, and 154 in the 9–10 group. The complication rates were 24% for the lowest scoring group, 14% for the 5–6 score group, 5% for the reference group, and 3% among those who scored the highest in the operating room.

The researchers used data from the American College of Surgeons National Surgical Quality Improvement Program database at Massachusetts General Hospital and the institution's Anesthesia Information Management System.

Previous studies validated the score's significant associations with complications in the immediate postoperative period and for other procedures, he said.

For example, a study of 4,119 general and vascular procedures at Mass General and Brigham and Women's Hospital, also in Boston, showed that the score significantly predicts in-hospital postoperative complications (Ann. Surg. 2008;248:320–8). A patient who scored a 7 or 8 in the operating room had no significant change, compared with preoperative risk variables (likelihood ratio, 1.05). In contrast, a score of 0–4 nearly tripled the odds of a major complication within 30 days (LR, 2.80). Again, the best outcomes were associated with a score of 9 or 10 (LR, 0.52).

Dr. Regenbogen had no conflicts of interest to declare.

Source ELSEVIER GLOBAL MEDICAL NEWS

HOLLYWOOD, FLA. — A 10-point scale based on three intraoperative hemodynamic factors accurately predicts which patients undergoing colorectal resection are likely to experience complications after discharge, according to a study of nearly 800 patients.

The traditional Apgar score is a convenient 10-point scale to assess the status of a newborn shortly after birth. Scores 3 and below are regarded as critically low, 4–6 are fairly low, and 7–10 are normal.

A “surgical Apgar” score can calculate a patient's condition following general or vascular surgery and grade the chances of major complications or death. Among the advantages of using a surgical Apgar score are immediate feedback, no cost, and little effort, Dr. Scott E. Regenbogen said. A patient's score is computed in the operating room using estimated blood loss, lowest mean arterial pressure, and lowest heart rate. (See box.)

“We are looking for opportunities to improve outcomes,” Dr. Regenbogen said in an interview at his poster during the annual meeting of the American Society of Colon and Rectal Surgeons.

He and his associates assessed outcomes after 795 colorectal resections over 4 years at Massachusetts General Hospital in Boston. The likelihood of complications after discharge quadrupled among patients with an operating room score between 0 and 4 (relative risk, 4.5), compared with a reference group that had scores of 7 or 8. “So information in the OR still gives us valuable information on how they do even after they leave the hospital,” said Dr. Regenbogen, of Massachusetts General Hospital.

The likelihood of complications after discharge also was higher for patients who scored 5 or 6 (RR, 2.6) but lower for those who scored the highest, a 9 or 10 (RR, 0.6).

There were 49 patients in the 0–4 score group, 186 patients in the 5–6 group, 406 patients in the reference 7–8 group, and 154 in the 9–10 group. The complication rates were 24% for the lowest scoring group, 14% for the 5–6 score group, 5% for the reference group, and 3% among those who scored the highest in the operating room.

The researchers used data from the American College of Surgeons National Surgical Quality Improvement Program database at Massachusetts General Hospital and the institution's Anesthesia Information Management System.

Previous studies validated the score's significant associations with complications in the immediate postoperative period and for other procedures, he said.

For example, a study of 4,119 general and vascular procedures at Mass General and Brigham and Women's Hospital, also in Boston, showed that the score significantly predicts in-hospital postoperative complications (Ann. Surg. 2008;248:320–8). A patient who scored a 7 or 8 in the operating room had no significant change, compared with preoperative risk variables (likelihood ratio, 1.05). In contrast, a score of 0–4 nearly tripled the odds of a major complication within 30 days (LR, 2.80). Again, the best outcomes were associated with a score of 9 or 10 (LR, 0.52).

Dr. Regenbogen had no conflicts of interest to declare.

Source ELSEVIER GLOBAL MEDICAL NEWS

HOLLYWOOD, FLA. — A 10-point scale based on three intraoperative hemodynamic factors accurately predicts which patients undergoing colorectal resection are likely to experience complications after discharge, according to a study of nearly 800 patients.

The traditional Apgar score is a convenient 10-point scale to assess the status of a newborn shortly after birth. Scores 3 and below are regarded as critically low, 4–6 are fairly low, and 7–10 are normal.

A “surgical Apgar” score can calculate a patient's condition following general or vascular surgery and grade the chances of major complications or death. Among the advantages of using a surgical Apgar score are immediate feedback, no cost, and little effort, Dr. Scott E. Regenbogen said. A patient's score is computed in the operating room using estimated blood loss, lowest mean arterial pressure, and lowest heart rate. (See box.)

“We are looking for opportunities to improve outcomes,” Dr. Regenbogen said in an interview at his poster during the annual meeting of the American Society of Colon and Rectal Surgeons.

He and his associates assessed outcomes after 795 colorectal resections over 4 years at Massachusetts General Hospital in Boston. The likelihood of complications after discharge quadrupled among patients with an operating room score between 0 and 4 (relative risk, 4.5), compared with a reference group that had scores of 7 or 8. “So information in the OR still gives us valuable information on how they do even after they leave the hospital,” said Dr. Regenbogen, of Massachusetts General Hospital.

The likelihood of complications after discharge also was higher for patients who scored 5 or 6 (RR, 2.6) but lower for those who scored the highest, a 9 or 10 (RR, 0.6).

There were 49 patients in the 0–4 score group, 186 patients in the 5–6 group, 406 patients in the reference 7–8 group, and 154 in the 9–10 group. The complication rates were 24% for the lowest scoring group, 14% for the 5–6 score group, 5% for the reference group, and 3% among those who scored the highest in the operating room.

The researchers used data from the American College of Surgeons National Surgical Quality Improvement Program database at Massachusetts General Hospital and the institution's Anesthesia Information Management System.

Previous studies validated the score's significant associations with complications in the immediate postoperative period and for other procedures, he said.

For example, a study of 4,119 general and vascular procedures at Mass General and Brigham and Women's Hospital, also in Boston, showed that the score significantly predicts in-hospital postoperative complications (Ann. Surg. 2008;248:320–8). A patient who scored a 7 or 8 in the operating room had no significant change, compared with preoperative risk variables (likelihood ratio, 1.05). In contrast, a score of 0–4 nearly tripled the odds of a major complication within 30 days (LR, 2.80). Again, the best outcomes were associated with a score of 9 or 10 (LR, 0.52).

Dr. Regenbogen had no conflicts of interest to declare.

Source ELSEVIER GLOBAL MEDICAL NEWS

MIAMI BEACH — Universal health care coverage for all adults aged 51 years and older would curb future increases in Medicare spending for beneficiaries after they reach age 65 years, a study has found.

Medicare savings of $98 billion would offset about half the estimated $197 billion increase in total spending for all 51- to 64-year-old Americans to have coverage, Dr. J. Michael McWilliams said at the annual meeting of the Society of General Internal Medicine.

Near-universal Medicare coverage is associated with increased use of health care services and improved self-reported health, said Dr. McWilliams, of Brigham and Women's Hospital and Harvard University, Boston. He and his colleagues proposed that previously uninsured Medicare beneficiaries would be costlier than enrollees who had previous, continuous health insurance. Among the factors that might contribute to increased Medicare spending are irreversible complications from conditions that would have been treatable prior to age 65, persistently increased health care needs after age 65, and delays in elective procedures during the period without insurance, he said.

The investigators assessed 4,567 participants in the National Institute on Aging Health and Retirement Study, a national sample of community-dwelling adults older than 50 years followed since 1992 (J. Hum. Resour. 1995;30:S7-56). After linking annual Medicare claims to subsequent utilization and spending 1-10 years after age 65, the researchers compared 2,951 beneficiaries with continuous insurance coverage and 1,616 others previously uninsured (continuously or intermittently) from 1996 to 2005.

Overall annual spending was significantly lower for the previously insured group ($3,589 vs. $4,521). “Averaged over the follow-up, we found just over $1,000 spending difference due to significant differences in inpatient spending, such as for cardiovascular disease,” he said. Annual Medicare spending was $1,398 less among beneficiaries with cardiovascular disease or diabetes if they were previously insured vs. not previously insured.

The spending differences between groups tended to narrow 7 years after Medicare eligibility, suggesting attenuation in the effects of not having insurance prior to Medicare coverage.

Hospitalization for complications related to cardiovascular disease, diabetes, and joint replacement surgery accounted for about 70% of the spending differences between groups, Dr. McWilliams said.

A statistical method called inverse probability weighting was used to factor in the possibility that a decline in health might lead to uninsured status.

MIAMI BEACH — Universal health care coverage for all adults aged 51 years and older would curb future increases in Medicare spending for beneficiaries after they reach age 65 years, a study has found.

Medicare savings of $98 billion would offset about half the estimated $197 billion increase in total spending for all 51- to 64-year-old Americans to have coverage, Dr. J. Michael McWilliams said at the annual meeting of the Society of General Internal Medicine.

Near-universal Medicare coverage is associated with increased use of health care services and improved self-reported health, said Dr. McWilliams, of Brigham and Women's Hospital and Harvard University, Boston. He and his colleagues proposed that previously uninsured Medicare beneficiaries would be costlier than enrollees who had previous, continuous health insurance. Among the factors that might contribute to increased Medicare spending are irreversible complications from conditions that would have been treatable prior to age 65, persistently increased health care needs after age 65, and delays in elective procedures during the period without insurance, he said.

The investigators assessed 4,567 participants in the National Institute on Aging Health and Retirement Study, a national sample of community-dwelling adults older than 50 years followed since 1992 (J. Hum. Resour. 1995;30:S7-56). After linking annual Medicare claims to subsequent utilization and spending 1-10 years after age 65, the researchers compared 2,951 beneficiaries with continuous insurance coverage and 1,616 others previously uninsured (continuously or intermittently) from 1996 to 2005.

Overall annual spending was significantly lower for the previously insured group ($3,589 vs. $4,521). “Averaged over the follow-up, we found just over $1,000 spending difference due to significant differences in inpatient spending, such as for cardiovascular disease,” he said. Annual Medicare spending was $1,398 less among beneficiaries with cardiovascular disease or diabetes if they were previously insured vs. not previously insured.

The spending differences between groups tended to narrow 7 years after Medicare eligibility, suggesting attenuation in the effects of not having insurance prior to Medicare coverage.

Hospitalization for complications related to cardiovascular disease, diabetes, and joint replacement surgery accounted for about 70% of the spending differences between groups, Dr. McWilliams said.

A statistical method called inverse probability weighting was used to factor in the possibility that a decline in health might lead to uninsured status.

MIAMI BEACH — Universal health care coverage for all adults aged 51 years and older would curb future increases in Medicare spending for beneficiaries after they reach age 65 years, a study has found.

Medicare savings of $98 billion would offset about half the estimated $197 billion increase in total spending for all 51- to 64-year-old Americans to have coverage, Dr. J. Michael McWilliams said at the annual meeting of the Society of General Internal Medicine.

Near-universal Medicare coverage is associated with increased use of health care services and improved self-reported health, said Dr. McWilliams, of Brigham and Women's Hospital and Harvard University, Boston. He and his colleagues proposed that previously uninsured Medicare beneficiaries would be costlier than enrollees who had previous, continuous health insurance. Among the factors that might contribute to increased Medicare spending are irreversible complications from conditions that would have been treatable prior to age 65, persistently increased health care needs after age 65, and delays in elective procedures during the period without insurance, he said.

The investigators assessed 4,567 participants in the National Institute on Aging Health and Retirement Study, a national sample of community-dwelling adults older than 50 years followed since 1992 (J. Hum. Resour. 1995;30:S7-56). After linking annual Medicare claims to subsequent utilization and spending 1-10 years after age 65, the researchers compared 2,951 beneficiaries with continuous insurance coverage and 1,616 others previously uninsured (continuously or intermittently) from 1996 to 2005.

Overall annual spending was significantly lower for the previously insured group ($3,589 vs. $4,521). “Averaged over the follow-up, we found just over $1,000 spending difference due to significant differences in inpatient spending, such as for cardiovascular disease,” he said. Annual Medicare spending was $1,398 less among beneficiaries with cardiovascular disease or diabetes if they were previously insured vs. not previously insured.

The spending differences between groups tended to narrow 7 years after Medicare eligibility, suggesting attenuation in the effects of not having insurance prior to Medicare coverage.

Hospitalization for complications related to cardiovascular disease, diabetes, and joint replacement surgery accounted for about 70% of the spending differences between groups, Dr. McWilliams said.

A statistical method called inverse probability weighting was used to factor in the possibility that a decline in health might lead to uninsured status.

MIAMI BEACH — A value-based insurance program with lower copayments significantly increased use of medications for secondary prevention among people with diabetes, compared with traditional insurance coverage, according to a prospective, controlled study.

There was a nearly 5% increase in metformin use, an almost 9% increase in utilization of ACE inhibitors or angiotensin II receptor blockers (ARBs), and a greater than 9% increase in statin use among 1,777 diabetics with value-based insurance, compared with a control group of 3,273 diabetics with conventional insurance.

With value-based insurance design (VBID), copayments are lowered for procedures or medications deemed beneficial according to the evidence-based literature. At the same time, copayments are increased for services or drugs that are not well demonstrated to improve outcomes, Dr. Allison B. Rosen said at the annual meeting of the Society of General Internal Medicine.

VBID also improved the other primary study outcome, medication adherence. For example, there was a significant 7% increase in ACE/ARB adherence and a nonsignificant 4% increase in statin adherence in the intervention group.

Although evidence-based medicine supports use of many secondary prevention agents for people with diabetes, underutilization remains a concern, Dr. Rosen said. High out-of-pocket costs are often cited as a culprit, and VBID might make a difference by linking patient copayments to value.

“There are few rigorous studies to support these positive claims,” said Dr. Rosen of the University of Michigan, Ann Arbor.

So she and her colleagues enrolled active University of Michigan employees and their dependents with diabetes into a VBID program that reduced their copays for antihypertensive, lipid-lowering, and glucose-lowering agents starting in July 2006. The control patients were employees of other institutions or companies and their dependents with diabetes enrolled in the same managed care plan.

All participants had at least one glycemic drug prescription filled in the year before implementation and at least one prescription filled for a secondary preventive medication in the 12 months thereafter.

Medication utilization at baseline ranged from 53% for statins to 65% for metformin. Following implementation of the VBID program, there was a significant increase in use of medications from all drug classes in the intervention group, compared with the control group: Metformin use increased by 4.8%, ACE/ARB use by 8.5%, and statin use by 9.3%.

The study was funded by the National Institutes of Health, the University of Michigan, and the John A. Hartford Foundation.

MIAMI BEACH — A value-based insurance program with lower copayments significantly increased use of medications for secondary prevention among people with diabetes, compared with traditional insurance coverage, according to a prospective, controlled study.

There was a nearly 5% increase in metformin use, an almost 9% increase in utilization of ACE inhibitors or angiotensin II receptor blockers (ARBs), and a greater than 9% increase in statin use among 1,777 diabetics with value-based insurance, compared with a control group of 3,273 diabetics with conventional insurance.

With value-based insurance design (VBID), copayments are lowered for procedures or medications deemed beneficial according to the evidence-based literature. At the same time, copayments are increased for services or drugs that are not well demonstrated to improve outcomes, Dr. Allison B. Rosen said at the annual meeting of the Society of General Internal Medicine.

VBID also improved the other primary study outcome, medication adherence. For example, there was a significant 7% increase in ACE/ARB adherence and a nonsignificant 4% increase in statin adherence in the intervention group.

Although evidence-based medicine supports use of many secondary prevention agents for people with diabetes, underutilization remains a concern, Dr. Rosen said. High out-of-pocket costs are often cited as a culprit, and VBID might make a difference by linking patient copayments to value.

“There are few rigorous studies to support these positive claims,” said Dr. Rosen of the University of Michigan, Ann Arbor.

So she and her colleagues enrolled active University of Michigan employees and their dependents with diabetes into a VBID program that reduced their copays for antihypertensive, lipid-lowering, and glucose-lowering agents starting in July 2006. The control patients were employees of other institutions or companies and their dependents with diabetes enrolled in the same managed care plan.

All participants had at least one glycemic drug prescription filled in the year before implementation and at least one prescription filled for a secondary preventive medication in the 12 months thereafter.

Medication utilization at baseline ranged from 53% for statins to 65% for metformin. Following implementation of the VBID program, there was a significant increase in use of medications from all drug classes in the intervention group, compared with the control group: Metformin use increased by 4.8%, ACE/ARB use by 8.5%, and statin use by 9.3%.

The study was funded by the National Institutes of Health, the University of Michigan, and the John A. Hartford Foundation.

MIAMI BEACH — A value-based insurance program with lower copayments significantly increased use of medications for secondary prevention among people with diabetes, compared with traditional insurance coverage, according to a prospective, controlled study.

There was a nearly 5% increase in metformin use, an almost 9% increase in utilization of ACE inhibitors or angiotensin II receptor blockers (ARBs), and a greater than 9% increase in statin use among 1,777 diabetics with value-based insurance, compared with a control group of 3,273 diabetics with conventional insurance.

With value-based insurance design (VBID), copayments are lowered for procedures or medications deemed beneficial according to the evidence-based literature. At the same time, copayments are increased for services or drugs that are not well demonstrated to improve outcomes, Dr. Allison B. Rosen said at the annual meeting of the Society of General Internal Medicine.

VBID also improved the other primary study outcome, medication adherence. For example, there was a significant 7% increase in ACE/ARB adherence and a nonsignificant 4% increase in statin adherence in the intervention group.

Although evidence-based medicine supports use of many secondary prevention agents for people with diabetes, underutilization remains a concern, Dr. Rosen said. High out-of-pocket costs are often cited as a culprit, and VBID might make a difference by linking patient copayments to value.

“There are few rigorous studies to support these positive claims,” said Dr. Rosen of the University of Michigan, Ann Arbor.

So she and her colleagues enrolled active University of Michigan employees and their dependents with diabetes into a VBID program that reduced their copays for antihypertensive, lipid-lowering, and glucose-lowering agents starting in July 2006. The control patients were employees of other institutions or companies and their dependents with diabetes enrolled in the same managed care plan.

All participants had at least one glycemic drug prescription filled in the year before implementation and at least one prescription filled for a secondary preventive medication in the 12 months thereafter.

Medication utilization at baseline ranged from 53% for statins to 65% for metformin. Following implementation of the VBID program, there was a significant increase in use of medications from all drug classes in the intervention group, compared with the control group: Metformin use increased by 4.8%, ACE/ARB use by 8.5%, and statin use by 9.3%.

The study was funded by the National Institutes of Health, the University of Michigan, and the John A. Hartford Foundation.

ORLANDO — Adjuvant radiotherapy following lymphadenectomy improved lymph node field control for patients with melanoma who were at an increased risk of relapse in an ongoing, multicenter trial.

Dr. Michael A. Henderson and his colleagues did not observe a significant difference in relapse-free or overall survival benefit between 109 patients randomized to adjuvant radiotherapy after surgery and 108 controls assigned to observation only.

The study was positive in terms of the primary end point, however. At a mean follow-up of 39 months, "radiotherapy patients were significantly less likely to develop a lymph node field relapse," Dr. Henderson said at the annual meeting of the American Society of Clinical Oncology. The hazard ratio was 0.56 vs. observation (P = .041).

An intent-to-treat analysis of an initial 248 patients "demonstrates an even larger and more significant advantage in lymph node field control" in the radiotherapy vs. observation patients (HR, 0.47; P = .005), said Dr. Henderson, a surgical oncologist at Peter MacCallum Cancer Centre in Melbourne. He had no disclosures.

In all, relapses in all-local, in-transit, or distant sites occurred in 161 patients during follow-up. This total included 62 patients with a first relapse in a lymph node field. There were 120 deaths (all but 2 due to melanoma), and about 40 patients have active disease.

This intergroup study from ANZMTG (Australia and New Zealand Melanoma Trials Group) and TROG (Trans-Tasman Radiation Oncology Group) included patients from 22 centers. Median age was 58 years in the radiotherapy group and 57 years in the observation arm. Men accounted for about 75% of each arm.

After 31 patients were excluded for "major eligibility infractions," the 217 remaining participants received 48 Gy of adjuvant radiotherapy in 20 fractions over 4 weeks or observation following complete resection of their palpable lymph nodes. Radiotherapy was delivered to axillae, groin, or parotid and neck lymph node fields.

"This is the first multicenter, randomized, controlled trial of adjuvant radiotherapy after resection of node metastases," said study discussant Dr. Antoni Ribas, before outlining several concerns.

"Is local control a reasonable goal in the treatment of stage III melanoma?" he asked rhetorically. "Yes, if it's well tolerated. We know the really important event is systemic metastasis, which is what kills patients, and that will have to be balanced along with possible toxicities."

Quality of life measures and long-term effects of radiation are pending in the trial, and may ultimately guide how patients are counseled about an adjuvant radiotherapy option, said Dr. Ribas of the medicine and surgery faculties at the University of California, Los Angeles. He is a consultant and/or adviser to Pfizer Inc., MannKind Corp., and Sanofi-Pasteur Inc., and receives honoraria from these companies and Amgen Inc., as well as research funding from Pfizer.

The "early radiotherapy toxicity appears acceptable," Dr. Henderson said. At 2 weeks after radiotherapy, grade 3 toxicities included 18 cases of radiation dermatitis and two reports of pain. At 6 weeks post radiotherapy, five cases of radiation dermatitis, two reports of pain, and one case of fatigue were reported. There were no early grade 4 toxicities.

"Similarly, late radiotherapy toxicities were also uncommon," he continued. Grade 3 or 4 late toxicities in the radiotherapy arm included four reports of pain, four cases of skin toxicity, three reports of subcutaneous tissue toxicity, and one report each of bone, joint, and nerve damage toxicity.

The intent-to-treat analysis also showed no difference in relapse-free survival (P = .53) or overall survival (P = .14). Overall survival at 5 years was 38% in the radiotherapy group vs. 44% in the observation group, Dr. Henderson said.

A meeting attendee noted that the radiotherapy group's survival curve was below the observation group's curve and said, "At this immature stage of the trial, I don't think radiotherapy can be recommended." Dr. Henderson had no comment.

ORLANDO — Adjuvant radiotherapy following lymphadenectomy improved lymph node field control for patients with melanoma who were at an increased risk of relapse in an ongoing, multicenter trial.

Dr. Michael A. Henderson and his colleagues did not observe a significant difference in relapse-free or overall survival benefit between 109 patients randomized to adjuvant radiotherapy after surgery and 108 controls assigned to observation only.

The study was positive in terms of the primary end point, however. At a mean follow-up of 39 months, "radiotherapy patients were significantly less likely to develop a lymph node field relapse," Dr. Henderson said at the annual meeting of the American Society of Clinical Oncology. The hazard ratio was 0.56 vs. observation (P = .041).

An intent-to-treat analysis of an initial 248 patients "demonstrates an even larger and more significant advantage in lymph node field control" in the radiotherapy vs. observation patients (HR, 0.47; P = .005), said Dr. Henderson, a surgical oncologist at Peter MacCallum Cancer Centre in Melbourne. He had no disclosures.

In all, relapses in all-local, in-transit, or distant sites occurred in 161 patients during follow-up. This total included 62 patients with a first relapse in a lymph node field. There were 120 deaths (all but 2 due to melanoma), and about 40 patients have active disease.

This intergroup study from ANZMTG (Australia and New Zealand Melanoma Trials Group) and TROG (Trans-Tasman Radiation Oncology Group) included patients from 22 centers. Median age was 58 years in the radiotherapy group and 57 years in the observation arm. Men accounted for about 75% of each arm.

After 31 patients were excluded for "major eligibility infractions," the 217 remaining participants received 48 Gy of adjuvant radiotherapy in 20 fractions over 4 weeks or observation following complete resection of their palpable lymph nodes. Radiotherapy was delivered to axillae, groin, or parotid and neck lymph node fields.

"This is the first multicenter, randomized, controlled trial of adjuvant radiotherapy after resection of node metastases," said study discussant Dr. Antoni Ribas, before outlining several concerns.

"Is local control a reasonable goal in the treatment of stage III melanoma?" he asked rhetorically. "Yes, if it's well tolerated. We know the really important event is systemic metastasis, which is what kills patients, and that will have to be balanced along with possible toxicities."

Quality of life measures and long-term effects of radiation are pending in the trial, and may ultimately guide how patients are counseled about an adjuvant radiotherapy option, said Dr. Ribas of the medicine and surgery faculties at the University of California, Los Angeles. He is a consultant and/or adviser to Pfizer Inc., MannKind Corp., and Sanofi-Pasteur Inc., and receives honoraria from these companies and Amgen Inc., as well as research funding from Pfizer.

The "early radiotherapy toxicity appears acceptable," Dr. Henderson said. At 2 weeks after radiotherapy, grade 3 toxicities included 18 cases of radiation dermatitis and two reports of pain. At 6 weeks post radiotherapy, five cases of radiation dermatitis, two reports of pain, and one case of fatigue were reported. There were no early grade 4 toxicities.

"Similarly, late radiotherapy toxicities were also uncommon," he continued. Grade 3 or 4 late toxicities in the radiotherapy arm included four reports of pain, four cases of skin toxicity, three reports of subcutaneous tissue toxicity, and one report each of bone, joint, and nerve damage toxicity.

The intent-to-treat analysis also showed no difference in relapse-free survival (P = .53) or overall survival (P = .14). Overall survival at 5 years was 38% in the radiotherapy group vs. 44% in the observation group, Dr. Henderson said.

A meeting attendee noted that the radiotherapy group's survival curve was below the observation group's curve and said, "At this immature stage of the trial, I don't think radiotherapy can be recommended." Dr. Henderson had no comment.

ORLANDO — Adjuvant radiotherapy following lymphadenectomy improved lymph node field control for patients with melanoma who were at an increased risk of relapse in an ongoing, multicenter trial.

Dr. Michael A. Henderson and his colleagues did not observe a significant difference in relapse-free or overall survival benefit between 109 patients randomized to adjuvant radiotherapy after surgery and 108 controls assigned to observation only.

The study was positive in terms of the primary end point, however. At a mean follow-up of 39 months, "radiotherapy patients were significantly less likely to develop a lymph node field relapse," Dr. Henderson said at the annual meeting of the American Society of Clinical Oncology. The hazard ratio was 0.56 vs. observation (P = .041).

An intent-to-treat analysis of an initial 248 patients "demonstrates an even larger and more significant advantage in lymph node field control" in the radiotherapy vs. observation patients (HR, 0.47; P = .005), said Dr. Henderson, a surgical oncologist at Peter MacCallum Cancer Centre in Melbourne. He had no disclosures.

In all, relapses in all-local, in-transit, or distant sites occurred in 161 patients during follow-up. This total included 62 patients with a first relapse in a lymph node field. There were 120 deaths (all but 2 due to melanoma), and about 40 patients have active disease.

This intergroup study from ANZMTG (Australia and New Zealand Melanoma Trials Group) and TROG (Trans-Tasman Radiation Oncology Group) included patients from 22 centers. Median age was 58 years in the radiotherapy group and 57 years in the observation arm. Men accounted for about 75% of each arm.

After 31 patients were excluded for "major eligibility infractions," the 217 remaining participants received 48 Gy of adjuvant radiotherapy in 20 fractions over 4 weeks or observation following complete resection of their palpable lymph nodes. Radiotherapy was delivered to axillae, groin, or parotid and neck lymph node fields.

"This is the first multicenter, randomized, controlled trial of adjuvant radiotherapy after resection of node metastases," said study discussant Dr. Antoni Ribas, before outlining several concerns.

"Is local control a reasonable goal in the treatment of stage III melanoma?" he asked rhetorically. "Yes, if it's well tolerated. We know the really important event is systemic metastasis, which is what kills patients, and that will have to be balanced along with possible toxicities."

Quality of life measures and long-term effects of radiation are pending in the trial, and may ultimately guide how patients are counseled about an adjuvant radiotherapy option, said Dr. Ribas of the medicine and surgery faculties at the University of California, Los Angeles. He is a consultant and/or adviser to Pfizer Inc., MannKind Corp., and Sanofi-Pasteur Inc., and receives honoraria from these companies and Amgen Inc., as well as research funding from Pfizer.

The "early radiotherapy toxicity appears acceptable," Dr. Henderson said. At 2 weeks after radiotherapy, grade 3 toxicities included 18 cases of radiation dermatitis and two reports of pain. At 6 weeks post radiotherapy, five cases of radiation dermatitis, two reports of pain, and one case of fatigue were reported. There were no early grade 4 toxicities.

"Similarly, late radiotherapy toxicities were also uncommon," he continued. Grade 3 or 4 late toxicities in the radiotherapy arm included four reports of pain, four cases of skin toxicity, three reports of subcutaneous tissue toxicity, and one report each of bone, joint, and nerve damage toxicity.

The intent-to-treat analysis also showed no difference in relapse-free survival (P = .53) or overall survival (P = .14). Overall survival at 5 years was 38% in the radiotherapy group vs. 44% in the observation group, Dr. Henderson said.

A meeting attendee noted that the radiotherapy group's survival curve was below the observation group's curve and said, "At this immature stage of the trial, I don't think radiotherapy can be recommended." Dr. Henderson had no comment.

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

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. Paul Nathan, an oncologist at the Hospital for Sick Children in Toronto.

High-risk survivors were the least compliant with colonoscopy recommendations: Only 11.5% of 794 survivors who were considered vulnerable for colorectal cancer had a colonoscopy during the 5 years before they were surveyed, Dr. Nathan reported at the annual meeting of the American Society of Clinical Oncology.

Women at high risk for breast cancer were more compliant with recommendations, he added; even so, only 46.3% of 521 in this group had a mammogram performed during the 2 years before they were asked about screening.

Most of the 8,318 survivors surveyed in this phase of the National Cancer Institute-funded study were in the care of family physicians. 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," 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, he said, but they should be made aware of 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]," Dr. Nathan said.

Study discussant Dr. Charles L. Bennett, professor of geriatrics, economics, and oncology at Northwestern University, Chicago, was unsure whether survivorship care was the responsibility of oncologists or primary care providers but suggested 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."

With a 5-year survival rate of 80% for pediatric cancers, 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. In addition, 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 these original participants, 3,305 had been lost to follow-up and 1,541 had died by the time of the 2003 follow-up survey, on which the new study is based. 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 31.2 years. A matched group of 2,661 siblings and 8,318 population controls was also assessed.

The study's primary aim was to determine adherence to the Children's Oncology Group's guidelines for following survivors of childhood cancers. Survivors were considered at high risk for the following:

▸ Skin cancer, if they 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.)

▸ Breast cancer, if they received 20 Gy or more of radiation therapy to the breast during childhood. Mammography is recommended every 1-2 years beginning at age 25 years, or 8 years after the initial cancer diagnosis for these patients.

▸ Colorectal cancer, if they 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.

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.

They found that these survivors were more likely 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).

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), he reported.

Significant predictors of adherence to mammography were older age at interview (RR, 1.09) and care at a cancer center (RR, 1.70).

Older age at the time of the interview was the only significant predictor of colonoscopy adherence (RR, 1.08).

The investigation 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 ask similar questions of a more contemporary cohort.

The new study population also will include more minorities. About 89% of 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 therapy administration will have an impact on these downstream 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.

To view a video interview of Dr. Nathan, go to www.youtube.com/watch?v=aF7c1xCGpAY&feature=channel_page

Just 26.7% of the 4,833 skin cancer survivors at high risk had ever had a complete skin exam.

Source DR. NATHAN

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

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. Paul Nathan, an oncologist at the Hospital for Sick Children in Toronto.

High-risk survivors were the least compliant with colonoscopy recommendations: Only 11.5% of 794 survivors who were considered vulnerable for colorectal cancer had a colonoscopy during the 5 years before they were surveyed, Dr. Nathan reported at the annual meeting of the American Society of Clinical Oncology.

Women at high risk for breast cancer were more compliant with recommendations, he added; even so, only 46.3% of 521 in this group had a mammogram performed during the 2 years before they were asked about screening.

Most of the 8,318 survivors surveyed in this phase of the National Cancer Institute-funded study were in the care of family physicians. 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," 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, he said, but they should be made aware of 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]," Dr. Nathan said.

Study discussant Dr. Charles L. Bennett, professor of geriatrics, economics, and oncology at Northwestern University, Chicago, was unsure whether survivorship care was the responsibility of oncologists or primary care providers but suggested 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."

With a 5-year survival rate of 80% for pediatric cancers, 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. In addition, 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 these original participants, 3,305 had been lost to follow-up and 1,541 had died by the time of the 2003 follow-up survey, on which the new study is based. 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 31.2 years. A matched group of 2,661 siblings and 8,318 population controls was also assessed.

The study's primary aim was to determine adherence to the Children's Oncology Group's guidelines for following survivors of childhood cancers. Survivors were considered at high risk for the following:

▸ Skin cancer, if they 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.)

▸ Breast cancer, if they received 20 Gy or more of radiation therapy to the breast during childhood. Mammography is recommended every 1-2 years beginning at age 25 years, or 8 years after the initial cancer diagnosis for these patients.

▸ Colorectal cancer, if they 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.

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.

They found that these survivors were more likely 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).

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), he reported.

Significant predictors of adherence to mammography were older age at interview (RR, 1.09) and care at a cancer center (RR, 1.70).

Older age at the time of the interview was the only significant predictor of colonoscopy adherence (RR, 1.08).

The investigation 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 ask similar questions of a more contemporary cohort.

The new study population also will include more minorities. About 89% of 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 therapy administration will have an impact on these downstream 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.

To view a video interview of Dr. Nathan, go to www.youtube.com/watch?v=aF7c1xCGpAY&feature=channel_page

Just 26.7% of the 4,833 skin cancer survivors at high risk had ever had a complete skin exam.

Source DR. NATHAN

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

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. Paul Nathan, an oncologist at the Hospital for Sick Children in Toronto.

High-risk survivors were the least compliant with colonoscopy recommendations: Only 11.5% of 794 survivors who were considered vulnerable for colorectal cancer had a colonoscopy during the 5 years before they were surveyed, Dr. Nathan reported at the annual meeting of the American Society of Clinical Oncology.

Women at high risk for breast cancer were more compliant with recommendations, he added; even so, only 46.3% of 521 in this group had a mammogram performed during the 2 years before they were asked about screening.

Most of the 8,318 survivors surveyed in this phase of the National Cancer Institute-funded study were in the care of family physicians. 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," 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, he said, but they should be made aware of 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]," Dr. Nathan said.

Study discussant Dr. Charles L. Bennett, professor of geriatrics, economics, and oncology at Northwestern University, Chicago, was unsure whether survivorship care was the responsibility of oncologists or primary care providers but suggested 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."

With a 5-year survival rate of 80% for pediatric cancers, 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. In addition, 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 these original participants, 3,305 had been lost to follow-up and 1,541 had died by the time of the 2003 follow-up survey, on which the new study is based. 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 31.2 years. A matched group of 2,661 siblings and 8,318 population controls was also assessed.

The study's primary aim was to determine adherence to the Children's Oncology Group's guidelines for following survivors of childhood cancers. Survivors were considered at high risk for the following:

▸ Skin cancer, if they 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.)

▸ Breast cancer, if they received 20 Gy or more of radiation therapy to the breast during childhood. Mammography is recommended every 1-2 years beginning at age 25 years, or 8 years after the initial cancer diagnosis for these patients.

▸ Colorectal cancer, if they 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.

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.

They found that these survivors were more likely 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).

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), he reported.

Significant predictors of adherence to mammography were older age at interview (RR, 1.09) and care at a cancer center (RR, 1.70).

Older age at the time of the interview was the only significant predictor of colonoscopy adherence (RR, 1.08).

The investigation 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 ask similar questions of a more contemporary cohort.

The new study population also will include more minorities. About 89% of 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 therapy administration will have an impact on these downstream 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.

To view a video interview of Dr. Nathan, go to www.youtube.com/watch?v=aF7c1xCGpAY&feature=channel_page

Just 26.7% of the 4,833 skin cancer survivors at high risk had ever had a complete skin exam.

Source DR. NATHAN

SAN ANTONIO — Routine repeat screening for sexually transmitted infections is worthwhile for pregnant adolescents during the third trimester, a Canadian study showed.

“We screen all adolescent pregnancies at baseline and again during the third trimester. This is different from adults, who we only screen at baseline,” said Dr. Anjali Aggarwal of the Hospital for Sick Children in Toronto.

Part of the concern is that teenage women tend to use condoms less often once they become pregnant (Am. J. Public Health 2009 April 16 [doi:10.2105/AJPH.2007.131870

She and her associates at the University of Toronto hospital assessed 89 pregnant adolescents with a median age of 16 years (range, 13-17 years) who were screened both at baseline and during the third trimester. They also screened 77 of the same participants again during the postpartum period.

Overall, 26 patients (29%) were diagnosed with an STI during or after pregnancy. “I was surprised it was that high,” Dr. Aggarwal said in an interview. Specifically, STIs were detected in 17 patients during the first trimester, 7 in the third trimester, and 1 in the postpartum period. An additional patient was diagnosed in the first trimester, treated, and then treated again during the third trimester, based on symptoms later in her pregnancy.

The finding that more than 25% of the patients identified as having an STI were diagnosed in the third trimester justifies routine rescreening, said Dr. Aggarwal.

Only one statistically significant risk factor was associated with an STI in pregnancy: a history of not using contraception, other than a condom. There was no significant association with patient age, previous pregnancy, or previous STI. Women who lived with a partner, lived with the baby's father, or reported only one previous sexual partner versus more than one were at lower risk of an STI during pregnancy. These factors only trended toward statistical significance.

Dr. Aggarwal said she plans to compare computer-based patient interviews with those done by clinicians. The goal would be to determine if pregnant teenagers are more forthright when interfacing with a computer, she said.

SAN ANTONIO — Routine repeat screening for sexually transmitted infections is worthwhile for pregnant adolescents during the third trimester, a Canadian study showed.

“We screen all adolescent pregnancies at baseline and again during the third trimester. This is different from adults, who we only screen at baseline,” said Dr. Anjali Aggarwal of the Hospital for Sick Children in Toronto.

Part of the concern is that teenage women tend to use condoms less often once they become pregnant (Am. J. Public Health 2009 April 16 [doi:10.2105/AJPH.2007.131870

She and her associates at the University of Toronto hospital assessed 89 pregnant adolescents with a median age of 16 years (range, 13-17 years) who were screened both at baseline and during the third trimester. They also screened 77 of the same participants again during the postpartum period.

Overall, 26 patients (29%) were diagnosed with an STI during or after pregnancy. “I was surprised it was that high,” Dr. Aggarwal said in an interview. Specifically, STIs were detected in 17 patients during the first trimester, 7 in the third trimester, and 1 in the postpartum period. An additional patient was diagnosed in the first trimester, treated, and then treated again during the third trimester, based on symptoms later in her pregnancy.

The finding that more than 25% of the patients identified as having an STI were diagnosed in the third trimester justifies routine rescreening, said Dr. Aggarwal.

Only one statistically significant risk factor was associated with an STI in pregnancy: a history of not using contraception, other than a condom. There was no significant association with patient age, previous pregnancy, or previous STI. Women who lived with a partner, lived with the baby's father, or reported only one previous sexual partner versus more than one were at lower risk of an STI during pregnancy. These factors only trended toward statistical significance.

Dr. Aggarwal said she plans to compare computer-based patient interviews with those done by clinicians. The goal would be to determine if pregnant teenagers are more forthright when interfacing with a computer, she said.

SAN ANTONIO — Routine repeat screening for sexually transmitted infections is worthwhile for pregnant adolescents during the third trimester, a Canadian study showed.

“We screen all adolescent pregnancies at baseline and again during the third trimester. This is different from adults, who we only screen at baseline,” said Dr. Anjali Aggarwal of the Hospital for Sick Children in Toronto.

Part of the concern is that teenage women tend to use condoms less often once they become pregnant (Am. J. Public Health 2009 April 16 [doi:10.2105/AJPH.2007.131870

She and her associates at the University of Toronto hospital assessed 89 pregnant adolescents with a median age of 16 years (range, 13-17 years) who were screened both at baseline and during the third trimester. They also screened 77 of the same participants again during the postpartum period.

Overall, 26 patients (29%) were diagnosed with an STI during or after pregnancy. “I was surprised it was that high,” Dr. Aggarwal said in an interview. Specifically, STIs were detected in 17 patients during the first trimester, 7 in the third trimester, and 1 in the postpartum period. An additional patient was diagnosed in the first trimester, treated, and then treated again during the third trimester, based on symptoms later in her pregnancy.

The finding that more than 25% of the patients identified as having an STI were diagnosed in the third trimester justifies routine rescreening, said Dr. Aggarwal.

Only one statistically significant risk factor was associated with an STI in pregnancy: a history of not using contraception, other than a condom. There was no significant association with patient age, previous pregnancy, or previous STI. Women who lived with a partner, lived with the baby's father, or reported only one previous sexual partner versus more than one were at lower risk of an STI during pregnancy. These factors only trended toward statistical significance.

Dr. Aggarwal said she plans to compare computer-based patient interviews with those done by clinicians. The goal would be to determine if pregnant teenagers are more forthright when interfacing with a computer, she said.

SAN ANTONIO — The number of unintended subsequent teenage pregnancies might decrease with enhanced postpartum contraceptive counseling, particularly about side effects of different birth control options, according to a study of 40 young women.

Dr. Suzanne Elizabeth Jose and Dr. Julie Jacobstein explored the effectiveness of postpartum counseling at their institution, Sinai Hospital in Baltimore, through a telephone survey of 40 women (aged 21 years and younger) who were delivered between April and September 2007.

“We see a lot of 15-year-old, 16-year-old girls coming in with their second or third babies,” Dr. Jose said in an interview. “Before they leave the hospital, we counsel them about birth control options.” They are allowed to choose a contraceptive option. The most common choices were the birth control pill (13 patients) and injectable contraception (10 patients).

“But they come back. So we asked ourselves: What are we doing wrong?” Dr. Jose said at her poster during the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

The survey was conducted 7 months to 1 year post partum. The investigators called the patients to determine if they were using contraception, including the type they selected during postpartum counseling. “All of them got some form of counseling, but half had discontinued [contraception],” said Dr. Jose.

“Some had no reason—they just stopped.” Others cited the adverse effects of contraception. “We have to improve our counseling about side effects,” Dr. Jose said. Group contraception counseling for these adolescent women is a possible future strategy.

Talking to adolescents is not the same as talking to 30-year-olds. “You have to be able to talk to them in language they understand,” Dr. Jose said. Determination of the most effective, age-appropriate dialogue is planned for a future study.

The routine 6-week follow-up visit following vaginal deliveries might be a good time to reinforce contraceptive counseling, she added. Of the 40 adolescent mothers, 11 (28%) reported a subsequent pregnancy—all unintended, Dr. Jose said. There were no miscarriages or ectopic pregnancies.

Although it did not occur in this study, some adolescents choose to get pregnant again, she said. Physicians can ask about such plans during contraceptive counseling and consider the duration of different options. For example, an intrauterine device that lasts 5 years may not be a good option for a teenager.

Next, Dr. Jose and her associates plan to study the effectiveness of postpartum contraceptive counseling in a prospective study.

Dr. Jose said she had no relevant financial disclosures.

SAN ANTONIO — The number of unintended subsequent teenage pregnancies might decrease with enhanced postpartum contraceptive counseling, particularly about side effects of different birth control options, according to a study of 40 young women.

Dr. Suzanne Elizabeth Jose and Dr. Julie Jacobstein explored the effectiveness of postpartum counseling at their institution, Sinai Hospital in Baltimore, through a telephone survey of 40 women (aged 21 years and younger) who were delivered between April and September 2007.

“We see a lot of 15-year-old, 16-year-old girls coming in with their second or third babies,” Dr. Jose said in an interview. “Before they leave the hospital, we counsel them about birth control options.” They are allowed to choose a contraceptive option. The most common choices were the birth control pill (13 patients) and injectable contraception (10 patients).

“But they come back. So we asked ourselves: What are we doing wrong?” Dr. Jose said at her poster during the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

The survey was conducted 7 months to 1 year post partum. The investigators called the patients to determine if they were using contraception, including the type they selected during postpartum counseling. “All of them got some form of counseling, but half had discontinued [contraception],” said Dr. Jose.

“Some had no reason—they just stopped.” Others cited the adverse effects of contraception. “We have to improve our counseling about side effects,” Dr. Jose said. Group contraception counseling for these adolescent women is a possible future strategy.

Talking to adolescents is not the same as talking to 30-year-olds. “You have to be able to talk to them in language they understand,” Dr. Jose said. Determination of the most effective, age-appropriate dialogue is planned for a future study.

The routine 6-week follow-up visit following vaginal deliveries might be a good time to reinforce contraceptive counseling, she added. Of the 40 adolescent mothers, 11 (28%) reported a subsequent pregnancy—all unintended, Dr. Jose said. There were no miscarriages or ectopic pregnancies.

Although it did not occur in this study, some adolescents choose to get pregnant again, she said. Physicians can ask about such plans during contraceptive counseling and consider the duration of different options. For example, an intrauterine device that lasts 5 years may not be a good option for a teenager.

Next, Dr. Jose and her associates plan to study the effectiveness of postpartum contraceptive counseling in a prospective study.

Dr. Jose said she had no relevant financial disclosures.

SAN ANTONIO — The number of unintended subsequent teenage pregnancies might decrease with enhanced postpartum contraceptive counseling, particularly about side effects of different birth control options, according to a study of 40 young women.

Dr. Suzanne Elizabeth Jose and Dr. Julie Jacobstein explored the effectiveness of postpartum counseling at their institution, Sinai Hospital in Baltimore, through a telephone survey of 40 women (aged 21 years and younger) who were delivered between April and September 2007.

“We see a lot of 15-year-old, 16-year-old girls coming in with their second or third babies,” Dr. Jose said in an interview. “Before they leave the hospital, we counsel them about birth control options.” They are allowed to choose a contraceptive option. The most common choices were the birth control pill (13 patients) and injectable contraception (10 patients).

“But they come back. So we asked ourselves: What are we doing wrong?” Dr. Jose said at her poster during the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

The survey was conducted 7 months to 1 year post partum. The investigators called the patients to determine if they were using contraception, including the type they selected during postpartum counseling. “All of them got some form of counseling, but half had discontinued [contraception],” said Dr. Jose.

“Some had no reason—they just stopped.” Others cited the adverse effects of contraception. “We have to improve our counseling about side effects,” Dr. Jose said. Group contraception counseling for these adolescent women is a possible future strategy.

Talking to adolescents is not the same as talking to 30-year-olds. “You have to be able to talk to them in language they understand,” Dr. Jose said. Determination of the most effective, age-appropriate dialogue is planned for a future study.

The routine 6-week follow-up visit following vaginal deliveries might be a good time to reinforce contraceptive counseling, she added. Of the 40 adolescent mothers, 11 (28%) reported a subsequent pregnancy—all unintended, Dr. Jose said. There were no miscarriages or ectopic pregnancies.

Although it did not occur in this study, some adolescents choose to get pregnant again, she said. Physicians can ask about such plans during contraceptive counseling and consider the duration of different options. For example, an intrauterine device that lasts 5 years may not be a good option for a teenager.

Next, Dr. Jose and her associates plan to study the effectiveness of postpartum contraceptive counseling in a prospective study.

Dr. Jose said she had no relevant financial disclosures.

MIAMI BEACH — Male physicians who decreased or maintained a low body mass index and/or started or continued to drink an average of one or more alcohol drinks per day experienced small but significant improvements in their HDL cholesterol levels at 14 years' follow-up, according to a study.

“What is exciting is you may not have to take medication to modify your HDL,” Dr. Catherine Rahilly-Tierney said in an interview. “The overall theme is you can change your life and future if you lose weight or initiate moderate intake of alcohol.”

She and her colleagues assessed 4,501 male physicians participating in the Physicians' Health Study who had HDL cholesterol levels measured in 1982 and in 1997. Their aim was to determine how doctors in this longitudinal study achieved a significant decrease in risk of coronary heart disease by increasing their HDL levels, as previously reported (Am. Heart J. 2008;155:869-75).

The investigators studied self-reported changes in body mass index, alcohol intake, physical activity, and smoking status. The objective was to demonstrate that lifestyle changes could have a beneficial impact because, unlike LDL cholesterol, there are few well-tolerated medications to improve HDL cholesterol levels, Dr. Rahilly-Tierney said during a poster session at the annual meeting of the Society of General Internal Medicine.

“We found the biggest drivers of HDL change were BMI and alcohol intake, which we expected based on what we know about the relationship between these and HDL,” said Dr. Rahilly-Tierney, a researcher with Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston Veterans Affairs Healthcare System.

The mean HDL cholesterol change in the entire cohort was an increase of 0.88 mg/dL. However, doctors who maintained an ideal BMI, defined as 25 kg/m2 or less, achieved a statistically significant 3.5 mg/dL increase in HDL cholesterol.

Similarly, participants who lowered a higher baseline BMI to 25 kg/m2 or less experienced a statistically significant increase of 5.1 mg/dL.

“BMI and alcohol intake seemed to be the most important factors, but this is not applicable outside this study yet. We had a limited demographic,” Dr. Rahilly-Tierney cautioned.

Strengths of the study include a 99% follow-up rate and clean, accurate data, she said.

Doctors who reported drinking one or more alcoholic beverages daily at baseline and at follow-up had an HDL cholesterol increase of 2.6 mg/dL. Those who reported drinking less than one alcoholic beverage per day in 1982 but who increased their alcohol intake to one or more drinks per day in 1997 achieved an increase of 2.2 mg/dL. These differences were statistically significant, although moderate, Dr. Rahilly-Tierney said.

In contrast, participants who decreased alcohol intake from one or more daily beverages to less than one per day experienced a mean HDL cholesterol decrease of 2.6 mg/dL.

Other lifestyle factors, including changes in physical activity and smoking status, were not significantly associated with changes in HDL cholesterol levels, but this may have been due to small numbers of smokers and physically inactive participants in this cohort, Dr. Rahilly-Tierney said. The researchers used linear regression to adjust for patient age, hypertension, diabetes mellitus, parental history of myocardial infarction, cholesterol-modifying therapy, and baseline HDL cholesterol.

'We found the biggest drivers of HDL change were BMI and alcohol intake.' DR. RAHILLY-TIERNEY

MIAMI BEACH — Male physicians who decreased or maintained a low body mass index and/or started or continued to drink an average of one or more alcohol drinks per day experienced small but significant improvements in their HDL cholesterol levels at 14 years' follow-up, according to a study.

“What is exciting is you may not have to take medication to modify your HDL,” Dr. Catherine Rahilly-Tierney said in an interview. “The overall theme is you can change your life and future if you lose weight or initiate moderate intake of alcohol.”

She and her colleagues assessed 4,501 male physicians participating in the Physicians' Health Study who had HDL cholesterol levels measured in 1982 and in 1997. Their aim was to determine how doctors in this longitudinal study achieved a significant decrease in risk of coronary heart disease by increasing their HDL levels, as previously reported (Am. Heart J. 2008;155:869-75).

The investigators studied self-reported changes in body mass index, alcohol intake, physical activity, and smoking status. The objective was to demonstrate that lifestyle changes could have a beneficial impact because, unlike LDL cholesterol, there are few well-tolerated medications to improve HDL cholesterol levels, Dr. Rahilly-Tierney said during a poster session at the annual meeting of the Society of General Internal Medicine.

“We found the biggest drivers of HDL change were BMI and alcohol intake, which we expected based on what we know about the relationship between these and HDL,” said Dr. Rahilly-Tierney, a researcher with Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston Veterans Affairs Healthcare System.

The mean HDL cholesterol change in the entire cohort was an increase of 0.88 mg/dL. However, doctors who maintained an ideal BMI, defined as 25 kg/m2 or less, achieved a statistically significant 3.5 mg/dL increase in HDL cholesterol.

Similarly, participants who lowered a higher baseline BMI to 25 kg/m2 or less experienced a statistically significant increase of 5.1 mg/dL.

“BMI and alcohol intake seemed to be the most important factors, but this is not applicable outside this study yet. We had a limited demographic,” Dr. Rahilly-Tierney cautioned.

Strengths of the study include a 99% follow-up rate and clean, accurate data, she said.

Doctors who reported drinking one or more alcoholic beverages daily at baseline and at follow-up had an HDL cholesterol increase of 2.6 mg/dL. Those who reported drinking less than one alcoholic beverage per day in 1982 but who increased their alcohol intake to one or more drinks per day in 1997 achieved an increase of 2.2 mg/dL. These differences were statistically significant, although moderate, Dr. Rahilly-Tierney said.

In contrast, participants who decreased alcohol intake from one or more daily beverages to less than one per day experienced a mean HDL cholesterol decrease of 2.6 mg/dL.

Other lifestyle factors, including changes in physical activity and smoking status, were not significantly associated with changes in HDL cholesterol levels, but this may have been due to small numbers of smokers and physically inactive participants in this cohort, Dr. Rahilly-Tierney said. The researchers used linear regression to adjust for patient age, hypertension, diabetes mellitus, parental history of myocardial infarction, cholesterol-modifying therapy, and baseline HDL cholesterol.

'We found the biggest drivers of HDL change were BMI and alcohol intake.' DR. RAHILLY-TIERNEY

MIAMI BEACH — Male physicians who decreased or maintained a low body mass index and/or started or continued to drink an average of one or more alcohol drinks per day experienced small but significant improvements in their HDL cholesterol levels at 14 years' follow-up, according to a study.

“What is exciting is you may not have to take medication to modify your HDL,” Dr. Catherine Rahilly-Tierney said in an interview. “The overall theme is you can change your life and future if you lose weight or initiate moderate intake of alcohol.”

She and her colleagues assessed 4,501 male physicians participating in the Physicians' Health Study who had HDL cholesterol levels measured in 1982 and in 1997. Their aim was to determine how doctors in this longitudinal study achieved a significant decrease in risk of coronary heart disease by increasing their HDL levels, as previously reported (Am. Heart J. 2008;155:869-75).

The investigators studied self-reported changes in body mass index, alcohol intake, physical activity, and smoking status. The objective was to demonstrate that lifestyle changes could have a beneficial impact because, unlike LDL cholesterol, there are few well-tolerated medications to improve HDL cholesterol levels, Dr. Rahilly-Tierney said during a poster session at the annual meeting of the Society of General Internal Medicine.

“We found the biggest drivers of HDL change were BMI and alcohol intake, which we expected based on what we know about the relationship between these and HDL,” said Dr. Rahilly-Tierney, a researcher with Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston Veterans Affairs Healthcare System.

The mean HDL cholesterol change in the entire cohort was an increase of 0.88 mg/dL. However, doctors who maintained an ideal BMI, defined as 25 kg/m2 or less, achieved a statistically significant 3.5 mg/dL increase in HDL cholesterol.

Similarly, participants who lowered a higher baseline BMI to 25 kg/m2 or less experienced a statistically significant increase of 5.1 mg/dL.

“BMI and alcohol intake seemed to be the most important factors, but this is not applicable outside this study yet. We had a limited demographic,” Dr. Rahilly-Tierney cautioned.

Strengths of the study include a 99% follow-up rate and clean, accurate data, she said.

Doctors who reported drinking one or more alcoholic beverages daily at baseline and at follow-up had an HDL cholesterol increase of 2.6 mg/dL. Those who reported drinking less than one alcoholic beverage per day in 1982 but who increased their alcohol intake to one or more drinks per day in 1997 achieved an increase of 2.2 mg/dL. These differences were statistically significant, although moderate, Dr. Rahilly-Tierney said.

In contrast, participants who decreased alcohol intake from one or more daily beverages to less than one per day experienced a mean HDL cholesterol decrease of 2.6 mg/dL.

Other lifestyle factors, including changes in physical activity and smoking status, were not significantly associated with changes in HDL cholesterol levels, but this may have been due to small numbers of smokers and physically inactive participants in this cohort, Dr. Rahilly-Tierney said. The researchers used linear regression to adjust for patient age, hypertension, diabetes mellitus, parental history of myocardial infarction, cholesterol-modifying therapy, and baseline HDL cholesterol.

'We found the biggest drivers of HDL change were BMI and alcohol intake.' DR. RAHILLY-TIERNEY

SAN ANTONIO — A minority of teens and young women in a study who chose an implantable contraceptive device discontinued because of spotting and irregular bleeding, despite prior counseling about this common side effect.

“We noticed there was increased interest from our adolescent patients for Implanon and realized some were complaining of bleeding,” Dr. Wendy L. Jackson said. Implanon (Organon), a 4-cm rod implanted in the subdermis, contains 68 mg of etonogestrel.

Dr. Jackson and her colleagues conducted a chart review at the University of Kentucky in Lexington. “We know that 52 patients had Implanon placed at our clinic” since February 2008, she said in an interview at her poster at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

“The likelihood of their having some bleeding is relatively high,” she said. “We counsel them to make sure it's an appropriate choice for them.” Still, 6 (12%) of the patients (age range, 13-21 years) returned to have Implanon removed at the University of Kentucky Adolescent Medicine Clinic, where Dr. Jackson is in the department of obstetrics and gynecology.

Because 31% of the patients did not return later for treatment or consultation, the study might have underestimated the discontinuation rate. It's unclear why 16 patients did not return, but it might represent normal adolescent behavior, satisfaction with Implanon, or removal of the device at another clinic, she speculated.

When patients return complaining of bleeding and/or spotting, a trial of oral contraceptives or Premarin (conjugated estrogens, Wyeth) can stop the bleeding so they can keep the device in place. “Implanon is a safe method for the adolescent population. It is more long term, so compliance is not an issue,” Dr. Jackson said. She had no relevant disclosures.

“Implanon is great birth control,” Dr. Nichole Tyson said during a separate presentation at the meeting. “It's good for 3 years, probably longer.”

“The downside is bleeding, and they all bleed,” said Dr. Tyson, director of the Teen Clinic at Kaiser Permanente, Roseville, Calif. She cautioned that the return to fertility is rapid—often within 24 hours—once the implant is removed. Dr. Tyson could not be reached to ascertain whether she had any conflicts of interest.

In terms of future research, Dr. Jackson said, “It would be nice to look back at the charts and see if any of the 31% returned for bleeding.”

The Food and Drug Administration revised instructions for implantation and removal of Implanon in February 2009.

Counseling is important because 'the likelihood of their having some bleeding is relatively high.' DR. JACKSON

SAN ANTONIO — A minority of teens and young women in a study who chose an implantable contraceptive device discontinued because of spotting and irregular bleeding, despite prior counseling about this common side effect.

“We noticed there was increased interest from our adolescent patients for Implanon and realized some were complaining of bleeding,” Dr. Wendy L. Jackson said. Implanon (Organon), a 4-cm rod implanted in the subdermis, contains 68 mg of etonogestrel.

Dr. Jackson and her colleagues conducted a chart review at the University of Kentucky in Lexington. “We know that 52 patients had Implanon placed at our clinic” since February 2008, she said in an interview at her poster at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

“The likelihood of their having some bleeding is relatively high,” she said. “We counsel them to make sure it's an appropriate choice for them.” Still, 6 (12%) of the patients (age range, 13-21 years) returned to have Implanon removed at the University of Kentucky Adolescent Medicine Clinic, where Dr. Jackson is in the department of obstetrics and gynecology.

Because 31% of the patients did not return later for treatment or consultation, the study might have underestimated the discontinuation rate. It's unclear why 16 patients did not return, but it might represent normal adolescent behavior, satisfaction with Implanon, or removal of the device at another clinic, she speculated.

When patients return complaining of bleeding and/or spotting, a trial of oral contraceptives or Premarin (conjugated estrogens, Wyeth) can stop the bleeding so they can keep the device in place. “Implanon is a safe method for the adolescent population. It is more long term, so compliance is not an issue,” Dr. Jackson said. She had no relevant disclosures.

“Implanon is great birth control,” Dr. Nichole Tyson said during a separate presentation at the meeting. “It's good for 3 years, probably longer.”

“The downside is bleeding, and they all bleed,” said Dr. Tyson, director of the Teen Clinic at Kaiser Permanente, Roseville, Calif. She cautioned that the return to fertility is rapid—often within 24 hours—once the implant is removed. Dr. Tyson could not be reached to ascertain whether she had any conflicts of interest.

In terms of future research, Dr. Jackson said, “It would be nice to look back at the charts and see if any of the 31% returned for bleeding.”

The Food and Drug Administration revised instructions for implantation and removal of Implanon in February 2009.

Counseling is important because 'the likelihood of their having some bleeding is relatively high.' DR. JACKSON

SAN ANTONIO — A minority of teens and young women in a study who chose an implantable contraceptive device discontinued because of spotting and irregular bleeding, despite prior counseling about this common side effect.

“We noticed there was increased interest from our adolescent patients for Implanon and realized some were complaining of bleeding,” Dr. Wendy L. Jackson said. Implanon (Organon), a 4-cm rod implanted in the subdermis, contains 68 mg of etonogestrel.

Dr. Jackson and her colleagues conducted a chart review at the University of Kentucky in Lexington. “We know that 52 patients had Implanon placed at our clinic” since February 2008, she said in an interview at her poster at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

“The likelihood of their having some bleeding is relatively high,” she said. “We counsel them to make sure it's an appropriate choice for them.” Still, 6 (12%) of the patients (age range, 13-21 years) returned to have Implanon removed at the University of Kentucky Adolescent Medicine Clinic, where Dr. Jackson is in the department of obstetrics and gynecology.

Because 31% of the patients did not return later for treatment or consultation, the study might have underestimated the discontinuation rate. It's unclear why 16 patients did not return, but it might represent normal adolescent behavior, satisfaction with Implanon, or removal of the device at another clinic, she speculated.

When patients return complaining of bleeding and/or spotting, a trial of oral contraceptives or Premarin (conjugated estrogens, Wyeth) can stop the bleeding so they can keep the device in place. “Implanon is a safe method for the adolescent population. It is more long term, so compliance is not an issue,” Dr. Jackson said. She had no relevant disclosures.

“Implanon is great birth control,” Dr. Nichole Tyson said during a separate presentation at the meeting. “It's good for 3 years, probably longer.”

“The downside is bleeding, and they all bleed,” said Dr. Tyson, director of the Teen Clinic at Kaiser Permanente, Roseville, Calif. She cautioned that the return to fertility is rapid—often within 24 hours—once the implant is removed. Dr. Tyson could not be reached to ascertain whether she had any conflicts of interest.

In terms of future research, Dr. Jackson said, “It would be nice to look back at the charts and see if any of the 31% returned for bleeding.”

The Food and Drug Administration revised instructions for implantation and removal of Implanon in February 2009.

Counseling is important because 'the likelihood of their having some bleeding is relatively high.' DR. JACKSON