Damian McNamara

PALM BEACH, FLA. — Regional chemotherapy via isolated limb infusion is an acceptable and minimally invasive alternative to hyperthermic isolated limb perfusion to combat in-transit extremity melanoma, according to a review.

"Perfusion is appropriate with lymph node involvement. For all others, infusion should be considered," Dr. Georgia M. Beasley said. She, Dr. Douglas S. Tyler, and their colleagues reviewed response and toxicity for 166 isolated limb infusions in 157 patients with advanced extremity melanoma. At 3 months after the infusion of melphalan, patients' responses were fairly evenly divided among complete response, partial response, and no response. In cases when the melphalan dose was adjusted for ideal body weight (IBW), the rate of grade 3 or higher toxicity fell more than half, with no effect on complete response rate.

Melphalan (Alkeran) was administered at eight centers, representing the majority of institutions performing limb infusions in the United States, Dr. Beasley said at the annual meeting of the Southern Surgical Association.

Patients received melphalan at doses of 7.5 mg/L for advanced melanoma of the lower extremity and 10 mg/L for the upper extremity. Mean ischemic time was 72 minutes. Papaverine was also administered in 60% of procedures. "We currently recommend use of papaverine in conjunction with adjustment of melphalan for ideal body weight to minimize toxicity," Dr. Beasley said.

Among the 122 evaluable patients, 31% experienced a complete response at 3 months according to RECIST (Response Evaluation Criteria in Solid Tumors), modified for cutaneous lesions. Another 33% of patients had a partial response, and 36% did not respond at 3 months. The complete response rate for hyperthermic isolated limb perfusion is generally accepted to be 40%-80%, Dr. Beasley said. Discussant Dr. Kirby I. Bland drew attention to the 36% rate of nonresponders. "You were still unable to control local disease in [almost] 40% of that population," said Dr. Bland, chair of the surgery department at the University of Alabama at Birmingham.

"For extensive in-transit disease in the lower extremity, I would recommend infusion, even though one-third of patients are not expected to have a response," responded Dr. Beasley, a first-year general surgery resident at Duke University Medical Center, Durham, N.C. "This allows reservation of perfusion for those who do not respond. Also, repeat perfusions are more difficult to do."

Dr. Beasley said that 36% of cases were associated with grade 3 or higher clinical toxicity. In 42% of the procedures, melphalan was adjusted for IBW. This modification reduced grade 3 or greater toxicities from 47% to 21%. At the same time, it did not alter the complete response rate. "By the end of the series, we were correcting everyone [at Duke] for ideal body weight," Dr. Beasley said. She cautioned that the dose adjustment did reduce the partial response rate, however.

Limb infusion and perfusion exhibit major differences in the rates of grade 5 toxicity, Dr. Beasley said. Even though one limb infusion patient had an amputation, the rate of grade 5 toxicity "appears to be nearly 10-fold higher with perfusion," based on all the published data for isolated limb infusion. The study did not directly compare rates of grade 3 and 4 toxicity in infusion and perfusion, but the rates appear to be somewhat similar, she said, with dose correction for IBW significantly reducing toxicity.

"How many patients had compartment syndrome, and what are your recommendations for monitoring?" asked Dr. Kelly M. McMasters, a study discussant and chair of surgery at the University of Louisville (Ky.). Nine cases of compartment syndrome were reported, Dr. Beasley replied. She recommended daily creatine phosphokinase measurements and close clinical monitoring.

Only two U.S. studies previously assessed isolated limb infusion, with both reporting single-center experience (Ann. Surg. Oncol. 2008;15:2195–205; Ann. Surg. Oncol. 2006;13:1123–9).

None of the researchers in the current study had any relevant disclosures.

PALM BEACH, FLA. — Regional chemotherapy via isolated limb infusion is an acceptable and minimally invasive alternative to hyperthermic isolated limb perfusion to combat in-transit extremity melanoma, according to a review.

"Perfusion is appropriate with lymph node involvement. For all others, infusion should be considered," Dr. Georgia M. Beasley said. She, Dr. Douglas S. Tyler, and their colleagues reviewed response and toxicity for 166 isolated limb infusions in 157 patients with advanced extremity melanoma. At 3 months after the infusion of melphalan, patients' responses were fairly evenly divided among complete response, partial response, and no response. In cases when the melphalan dose was adjusted for ideal body weight (IBW), the rate of grade 3 or higher toxicity fell more than half, with no effect on complete response rate.

Melphalan (Alkeran) was administered at eight centers, representing the majority of institutions performing limb infusions in the United States, Dr. Beasley said at the annual meeting of the Southern Surgical Association.

Patients received melphalan at doses of 7.5 mg/L for advanced melanoma of the lower extremity and 10 mg/L for the upper extremity. Mean ischemic time was 72 minutes. Papaverine was also administered in 60% of procedures. "We currently recommend use of papaverine in conjunction with adjustment of melphalan for ideal body weight to minimize toxicity," Dr. Beasley said.

Among the 122 evaluable patients, 31% experienced a complete response at 3 months according to RECIST (Response Evaluation Criteria in Solid Tumors), modified for cutaneous lesions. Another 33% of patients had a partial response, and 36% did not respond at 3 months. The complete response rate for hyperthermic isolated limb perfusion is generally accepted to be 40%-80%, Dr. Beasley said. Discussant Dr. Kirby I. Bland drew attention to the 36% rate of nonresponders. "You were still unable to control local disease in [almost] 40% of that population," said Dr. Bland, chair of the surgery department at the University of Alabama at Birmingham.

"For extensive in-transit disease in the lower extremity, I would recommend infusion, even though one-third of patients are not expected to have a response," responded Dr. Beasley, a first-year general surgery resident at Duke University Medical Center, Durham, N.C. "This allows reservation of perfusion for those who do not respond. Also, repeat perfusions are more difficult to do."

Dr. Beasley said that 36% of cases were associated with grade 3 or higher clinical toxicity. In 42% of the procedures, melphalan was adjusted for IBW. This modification reduced grade 3 or greater toxicities from 47% to 21%. At the same time, it did not alter the complete response rate. "By the end of the series, we were correcting everyone [at Duke] for ideal body weight," Dr. Beasley said. She cautioned that the dose adjustment did reduce the partial response rate, however.

Limb infusion and perfusion exhibit major differences in the rates of grade 5 toxicity, Dr. Beasley said. Even though one limb infusion patient had an amputation, the rate of grade 5 toxicity "appears to be nearly 10-fold higher with perfusion," based on all the published data for isolated limb infusion. The study did not directly compare rates of grade 3 and 4 toxicity in infusion and perfusion, but the rates appear to be somewhat similar, she said, with dose correction for IBW significantly reducing toxicity.

"How many patients had compartment syndrome, and what are your recommendations for monitoring?" asked Dr. Kelly M. McMasters, a study discussant and chair of surgery at the University of Louisville (Ky.). Nine cases of compartment syndrome were reported, Dr. Beasley replied. She recommended daily creatine phosphokinase measurements and close clinical monitoring.

Only two U.S. studies previously assessed isolated limb infusion, with both reporting single-center experience (Ann. Surg. Oncol. 2008;15:2195–205; Ann. Surg. Oncol. 2006;13:1123–9).

None of the researchers in the current study had any relevant disclosures.

PALM BEACH, FLA. — Regional chemotherapy via isolated limb infusion is an acceptable and minimally invasive alternative to hyperthermic isolated limb perfusion to combat in-transit extremity melanoma, according to a review.

"Perfusion is appropriate with lymph node involvement. For all others, infusion should be considered," Dr. Georgia M. Beasley said. She, Dr. Douglas S. Tyler, and their colleagues reviewed response and toxicity for 166 isolated limb infusions in 157 patients with advanced extremity melanoma. At 3 months after the infusion of melphalan, patients' responses were fairly evenly divided among complete response, partial response, and no response. In cases when the melphalan dose was adjusted for ideal body weight (IBW), the rate of grade 3 or higher toxicity fell more than half, with no effect on complete response rate.

Melphalan (Alkeran) was administered at eight centers, representing the majority of institutions performing limb infusions in the United States, Dr. Beasley said at the annual meeting of the Southern Surgical Association.

Patients received melphalan at doses of 7.5 mg/L for advanced melanoma of the lower extremity and 10 mg/L for the upper extremity. Mean ischemic time was 72 minutes. Papaverine was also administered in 60% of procedures. "We currently recommend use of papaverine in conjunction with adjustment of melphalan for ideal body weight to minimize toxicity," Dr. Beasley said.

Among the 122 evaluable patients, 31% experienced a complete response at 3 months according to RECIST (Response Evaluation Criteria in Solid Tumors), modified for cutaneous lesions. Another 33% of patients had a partial response, and 36% did not respond at 3 months. The complete response rate for hyperthermic isolated limb perfusion is generally accepted to be 40%-80%, Dr. Beasley said. Discussant Dr. Kirby I. Bland drew attention to the 36% rate of nonresponders. "You were still unable to control local disease in [almost] 40% of that population," said Dr. Bland, chair of the surgery department at the University of Alabama at Birmingham.

"For extensive in-transit disease in the lower extremity, I would recommend infusion, even though one-third of patients are not expected to have a response," responded Dr. Beasley, a first-year general surgery resident at Duke University Medical Center, Durham, N.C. "This allows reservation of perfusion for those who do not respond. Also, repeat perfusions are more difficult to do."

Dr. Beasley said that 36% of cases were associated with grade 3 or higher clinical toxicity. In 42% of the procedures, melphalan was adjusted for IBW. This modification reduced grade 3 or greater toxicities from 47% to 21%. At the same time, it did not alter the complete response rate. "By the end of the series, we were correcting everyone [at Duke] for ideal body weight," Dr. Beasley said. She cautioned that the dose adjustment did reduce the partial response rate, however.

Limb infusion and perfusion exhibit major differences in the rates of grade 5 toxicity, Dr. Beasley said. Even though one limb infusion patient had an amputation, the rate of grade 5 toxicity "appears to be nearly 10-fold higher with perfusion," based on all the published data for isolated limb infusion. The study did not directly compare rates of grade 3 and 4 toxicity in infusion and perfusion, but the rates appear to be somewhat similar, she said, with dose correction for IBW significantly reducing toxicity.

"How many patients had compartment syndrome, and what are your recommendations for monitoring?" asked Dr. Kelly M. McMasters, a study discussant and chair of surgery at the University of Louisville (Ky.). Nine cases of compartment syndrome were reported, Dr. Beasley replied. She recommended daily creatine phosphokinase measurements and close clinical monitoring.

Only two U.S. studies previously assessed isolated limb infusion, with both reporting single-center experience (Ann. Surg. Oncol. 2008;15:2195–205; Ann. Surg. Oncol. 2006;13:1123–9).

None of the researchers in the current study had any relevant disclosures.

PALM BEACH, FLA. — The presence of microscopic or even submicroscopic melanoma in a sentinel lymph node may be clinically relevant, a retrospective study has shown.

"We believe patients with microscopic deposits of metastatic melanoma have biologically relevant, potentially life-threatening disease," Dr. David W. Ollila said at the annual meeting of the Southern Surgical Association.

Although other investigators have proposed that submicroscopic disease (a sentinel node tumor that is less than 0.1 mm) is not associated with a significantly increased risk of recurrence or death (Br. J. Surg. 2007;94:1293–9), Dr. Ollila and his associates hypothesized that any sentinel node evidence of metastatic melanoma, regardless of size or stage, may be a cause for concern.

He and his associates retrospectively studied 586 patients (mean age, 55 years) with invasive melanoma and a sentinel node biopsy from 1998 to 2007 in a prospectively maintained database. They classified the 322 men and 264 women as node negative or as having a tumor burden of less than 0.1 mm, 0.1–1.0 mm, or greater than 1.0 mm.

The investigators found a statistically significant difference in recurrence of any type between node-negative patients and those with a tumor burden less than 0.1 mm. During a mean follow-up of 2.7 years, 57 (11%) of the 496 node-negative patients had a recurrence, compared with 8 (24%) of the 33 patients with a sentinel node tumor less than 0.1 mm.

"We [also] found a significant difference in disease-free survival between sentinel node-negative [patients] and the submicroscopic group. They cannot be considered equivalent," said Dr. Ollila, director of the sentinel node program and codirector of the multidisciplinary melanoma program at the University of North Carolina at Chapel Hill.

In the node-negative group, 51 patients (10%) died, as did 5 (15%) of those with a tumor burden less than 0.1 mm, 6 of 27 patients (22%) in the 0.1- to 1.0-mm group, and 12 of 30 patients (40%) who had tumors larger than 1.0 mm.

Dr. Ollila pointed out that the stepwise decrease in survival with increasing diameter of the metastatic deposit was statistically different among the four groups. "This is an interesting [finding], contrary to Rotterdam criteria. I submit to you that these patients are on a continuum, and this is clinically relevant disease," he said.

An increased sentinel node tumor burden was also associated with a greater risk of metastatic disease in other nodes. A total of 7% of node-negative patients had distant recurrence, as did 15% of those with tumors less than 0.1 mm, 22% of the 0.1- to 1.0-mm group, and 47% of those with tumors larger than 1.0 mm.

Dr. Marshall M. Urist, professor of surgery, University of Alabama at Birmingham, commented that this is an excellent study and asked, "Why did you measure these metastases in a two-dimensional way for a three-dimensional process?"

Dr. Ollila replied: "Point well taken. It's a volume disease. It would be more representative if we could do volumetric measures." The two-dimensional measurement was a limitation of the database used in the study, he said.

PALM BEACH, FLA. — The presence of microscopic or even submicroscopic melanoma in a sentinel lymph node may be clinically relevant, a retrospective study has shown.

"We believe patients with microscopic deposits of metastatic melanoma have biologically relevant, potentially life-threatening disease," Dr. David W. Ollila said at the annual meeting of the Southern Surgical Association.

Although other investigators have proposed that submicroscopic disease (a sentinel node tumor that is less than 0.1 mm) is not associated with a significantly increased risk of recurrence or death (Br. J. Surg. 2007;94:1293–9), Dr. Ollila and his associates hypothesized that any sentinel node evidence of metastatic melanoma, regardless of size or stage, may be a cause for concern.

He and his associates retrospectively studied 586 patients (mean age, 55 years) with invasive melanoma and a sentinel node biopsy from 1998 to 2007 in a prospectively maintained database. They classified the 322 men and 264 women as node negative or as having a tumor burden of less than 0.1 mm, 0.1–1.0 mm, or greater than 1.0 mm.

The investigators found a statistically significant difference in recurrence of any type between node-negative patients and those with a tumor burden less than 0.1 mm. During a mean follow-up of 2.7 years, 57 (11%) of the 496 node-negative patients had a recurrence, compared with 8 (24%) of the 33 patients with a sentinel node tumor less than 0.1 mm.

"We [also] found a significant difference in disease-free survival between sentinel node-negative [patients] and the submicroscopic group. They cannot be considered equivalent," said Dr. Ollila, director of the sentinel node program and codirector of the multidisciplinary melanoma program at the University of North Carolina at Chapel Hill.

In the node-negative group, 51 patients (10%) died, as did 5 (15%) of those with a tumor burden less than 0.1 mm, 6 of 27 patients (22%) in the 0.1- to 1.0-mm group, and 12 of 30 patients (40%) who had tumors larger than 1.0 mm.

Dr. Ollila pointed out that the stepwise decrease in survival with increasing diameter of the metastatic deposit was statistically different among the four groups. "This is an interesting [finding], contrary to Rotterdam criteria. I submit to you that these patients are on a continuum, and this is clinically relevant disease," he said.

An increased sentinel node tumor burden was also associated with a greater risk of metastatic disease in other nodes. A total of 7% of node-negative patients had distant recurrence, as did 15% of those with tumors less than 0.1 mm, 22% of the 0.1- to 1.0-mm group, and 47% of those with tumors larger than 1.0 mm.

Dr. Marshall M. Urist, professor of surgery, University of Alabama at Birmingham, commented that this is an excellent study and asked, "Why did you measure these metastases in a two-dimensional way for a three-dimensional process?"

Dr. Ollila replied: "Point well taken. It's a volume disease. It would be more representative if we could do volumetric measures." The two-dimensional measurement was a limitation of the database used in the study, he said.

PALM BEACH, FLA. — The presence of microscopic or even submicroscopic melanoma in a sentinel lymph node may be clinically relevant, a retrospective study has shown.

"We believe patients with microscopic deposits of metastatic melanoma have biologically relevant, potentially life-threatening disease," Dr. David W. Ollila said at the annual meeting of the Southern Surgical Association.

Although other investigators have proposed that submicroscopic disease (a sentinel node tumor that is less than 0.1 mm) is not associated with a significantly increased risk of recurrence or death (Br. J. Surg. 2007;94:1293–9), Dr. Ollila and his associates hypothesized that any sentinel node evidence of metastatic melanoma, regardless of size or stage, may be a cause for concern.

He and his associates retrospectively studied 586 patients (mean age, 55 years) with invasive melanoma and a sentinel node biopsy from 1998 to 2007 in a prospectively maintained database. They classified the 322 men and 264 women as node negative or as having a tumor burden of less than 0.1 mm, 0.1–1.0 mm, or greater than 1.0 mm.

The investigators found a statistically significant difference in recurrence of any type between node-negative patients and those with a tumor burden less than 0.1 mm. During a mean follow-up of 2.7 years, 57 (11%) of the 496 node-negative patients had a recurrence, compared with 8 (24%) of the 33 patients with a sentinel node tumor less than 0.1 mm.

"We [also] found a significant difference in disease-free survival between sentinel node-negative [patients] and the submicroscopic group. They cannot be considered equivalent," said Dr. Ollila, director of the sentinel node program and codirector of the multidisciplinary melanoma program at the University of North Carolina at Chapel Hill.

In the node-negative group, 51 patients (10%) died, as did 5 (15%) of those with a tumor burden less than 0.1 mm, 6 of 27 patients (22%) in the 0.1- to 1.0-mm group, and 12 of 30 patients (40%) who had tumors larger than 1.0 mm.

Dr. Ollila pointed out that the stepwise decrease in survival with increasing diameter of the metastatic deposit was statistically different among the four groups. "This is an interesting [finding], contrary to Rotterdam criteria. I submit to you that these patients are on a continuum, and this is clinically relevant disease," he said.

An increased sentinel node tumor burden was also associated with a greater risk of metastatic disease in other nodes. A total of 7% of node-negative patients had distant recurrence, as did 15% of those with tumors less than 0.1 mm, 22% of the 0.1- to 1.0-mm group, and 47% of those with tumors larger than 1.0 mm.

Dr. Marshall M. Urist, professor of surgery, University of Alabama at Birmingham, commented that this is an excellent study and asked, "Why did you measure these metastases in a two-dimensional way for a three-dimensional process?"

Dr. Ollila replied: "Point well taken. It's a volume disease. It would be more representative if we could do volumetric measures." The two-dimensional measurement was a limitation of the database used in the study, he said.

PALM BEACH, FLA. — A scoring system improved the accuracy of preoperatively differentiating ruptured and acute appendicitis in a study of 248 children.

Without the scoring system, surgeons preoperatively diagnosed ruptured appendicitis with 96% sensitivity but with only 83% specificity. When patients scored a 9 or greater on the scoring system, however, that specificity was increased to 98%.

Dr. Martin L. Blakely, and his colleagues, who developed the scoring system, reported the results at the annual meeting of the Southern Surgical Association.

The capacity to distinguish acute and ruptured appendicitis may gain importance. Historically, both conditions have warranted an urgent appendectomy, however, some studies indicate a ruptured appendicitis may respond better to a protocol of immediate antibiotics and later interval appendectomy, said Dr. Blakely, of the division of pediatric surgery at the University of Tennessee Health Science Center in Memphis.

With multivariate analysis, the researchers compiled a weighted scoring system based on five independent and statistically significant variables available preoperatively. Generalized tenderness was assigned a score of 4 points; abscess on CT scan was 3 points; symptom duration longer than 48 hours was 3 points; a white blood count greater than 19,400 cells/mm

Dr. Blakely along with lead author Dr. Regan F. Williams and their associates prospectively studied 248 children referred over a 9-month period to the University of Tennessee for suspected appendicitis. Mean patient age was 10 years (range, 3 months to 18 years), and 61% of the study subjects were boys.

The researchers compared the surgeons' preoperative diagnosis with the intraoperative findings, the pathology report findings, and the discharge diagnosis. The cohort included 98 children with acute appendicitis, 53 children with ruptured appendicitis, and 97 children who ultimately had no appendicitis.

Of the 53 with a diagnosis of ruptured appendicitis, 18 patients were treated with initial antibiotics and interval appendectomy. A meeting attendee asked if the researchers later confirmed the diagnosis in those given antibiotics. Of the 17 who returned for follow-up, Dr. Blakely replied, “all had intraoperative evidence … and with the pathology report follow-up, we feel pretty certain they had ruptured appendicitis.”

Another attendee raised concerns about exposing children to CT ionizing radiation and asked if the scoring system would still have high specificity and sensitivity without the use of CT imaging.

Dr. Blakely explained that “the decision to obtain CT often came from the referring pediatrician or emergency physician before the patient reached us.”

“You can get a score of 9 without having a CT scan,” Dr. Williams added. “So [the score] can be utilized without a CT scan, but we had one on a majority of our patients.”

The scoring system “must be prospectively evaluated in other institutions to make it generalizable,” according to study discussant Dr. Kurt D. Newman, a pediatric surgeon at Georgetown University Hospital in Washington. Dr. Blakely agreed that validation is warranted.

“The value of this scoring system, at least from what I can see, depends primarily on your point of view about interval appendectomy,” said Dr. James A. O'Neill Jr., chairman emeritus of the department of surgery at Vanderbilt University, Nashville, Tenn. “If one searches the Cochrane database, there is no evidence that that is the best approach. We should be cautious about application of these data across the nation.”

PALM BEACH, FLA. — A scoring system improved the accuracy of preoperatively differentiating ruptured and acute appendicitis in a study of 248 children.

Without the scoring system, surgeons preoperatively diagnosed ruptured appendicitis with 96% sensitivity but with only 83% specificity. When patients scored a 9 or greater on the scoring system, however, that specificity was increased to 98%.

Dr. Martin L. Blakely, and his colleagues, who developed the scoring system, reported the results at the annual meeting of the Southern Surgical Association.

The capacity to distinguish acute and ruptured appendicitis may gain importance. Historically, both conditions have warranted an urgent appendectomy, however, some studies indicate a ruptured appendicitis may respond better to a protocol of immediate antibiotics and later interval appendectomy, said Dr. Blakely, of the division of pediatric surgery at the University of Tennessee Health Science Center in Memphis.

With multivariate analysis, the researchers compiled a weighted scoring system based on five independent and statistically significant variables available preoperatively. Generalized tenderness was assigned a score of 4 points; abscess on CT scan was 3 points; symptom duration longer than 48 hours was 3 points; a white blood count greater than 19,400 cells/mm

Dr. Blakely along with lead author Dr. Regan F. Williams and their associates prospectively studied 248 children referred over a 9-month period to the University of Tennessee for suspected appendicitis. Mean patient age was 10 years (range, 3 months to 18 years), and 61% of the study subjects were boys.

The researchers compared the surgeons' preoperative diagnosis with the intraoperative findings, the pathology report findings, and the discharge diagnosis. The cohort included 98 children with acute appendicitis, 53 children with ruptured appendicitis, and 97 children who ultimately had no appendicitis.

Of the 53 with a diagnosis of ruptured appendicitis, 18 patients were treated with initial antibiotics and interval appendectomy. A meeting attendee asked if the researchers later confirmed the diagnosis in those given antibiotics. Of the 17 who returned for follow-up, Dr. Blakely replied, “all had intraoperative evidence … and with the pathology report follow-up, we feel pretty certain they had ruptured appendicitis.”

Another attendee raised concerns about exposing children to CT ionizing radiation and asked if the scoring system would still have high specificity and sensitivity without the use of CT imaging.

Dr. Blakely explained that “the decision to obtain CT often came from the referring pediatrician or emergency physician before the patient reached us.”

“You can get a score of 9 without having a CT scan,” Dr. Williams added. “So [the score] can be utilized without a CT scan, but we had one on a majority of our patients.”

The scoring system “must be prospectively evaluated in other institutions to make it generalizable,” according to study discussant Dr. Kurt D. Newman, a pediatric surgeon at Georgetown University Hospital in Washington. Dr. Blakely agreed that validation is warranted.

“The value of this scoring system, at least from what I can see, depends primarily on your point of view about interval appendectomy,” said Dr. James A. O'Neill Jr., chairman emeritus of the department of surgery at Vanderbilt University, Nashville, Tenn. “If one searches the Cochrane database, there is no evidence that that is the best approach. We should be cautious about application of these data across the nation.”

PALM BEACH, FLA. — A scoring system improved the accuracy of preoperatively differentiating ruptured and acute appendicitis in a study of 248 children.

Without the scoring system, surgeons preoperatively diagnosed ruptured appendicitis with 96% sensitivity but with only 83% specificity. When patients scored a 9 or greater on the scoring system, however, that specificity was increased to 98%.

Dr. Martin L. Blakely, and his colleagues, who developed the scoring system, reported the results at the annual meeting of the Southern Surgical Association.

The capacity to distinguish acute and ruptured appendicitis may gain importance. Historically, both conditions have warranted an urgent appendectomy, however, some studies indicate a ruptured appendicitis may respond better to a protocol of immediate antibiotics and later interval appendectomy, said Dr. Blakely, of the division of pediatric surgery at the University of Tennessee Health Science Center in Memphis.

With multivariate analysis, the researchers compiled a weighted scoring system based on five independent and statistically significant variables available preoperatively. Generalized tenderness was assigned a score of 4 points; abscess on CT scan was 3 points; symptom duration longer than 48 hours was 3 points; a white blood count greater than 19,400 cells/mm

Dr. Blakely along with lead author Dr. Regan F. Williams and their associates prospectively studied 248 children referred over a 9-month period to the University of Tennessee for suspected appendicitis. Mean patient age was 10 years (range, 3 months to 18 years), and 61% of the study subjects were boys.

The researchers compared the surgeons' preoperative diagnosis with the intraoperative findings, the pathology report findings, and the discharge diagnosis. The cohort included 98 children with acute appendicitis, 53 children with ruptured appendicitis, and 97 children who ultimately had no appendicitis.

Of the 53 with a diagnosis of ruptured appendicitis, 18 patients were treated with initial antibiotics and interval appendectomy. A meeting attendee asked if the researchers later confirmed the diagnosis in those given antibiotics. Of the 17 who returned for follow-up, Dr. Blakely replied, “all had intraoperative evidence … and with the pathology report follow-up, we feel pretty certain they had ruptured appendicitis.”

Another attendee raised concerns about exposing children to CT ionizing radiation and asked if the scoring system would still have high specificity and sensitivity without the use of CT imaging.

Dr. Blakely explained that “the decision to obtain CT often came from the referring pediatrician or emergency physician before the patient reached us.”

“You can get a score of 9 without having a CT scan,” Dr. Williams added. “So [the score] can be utilized without a CT scan, but we had one on a majority of our patients.”

The scoring system “must be prospectively evaluated in other institutions to make it generalizable,” according to study discussant Dr. Kurt D. Newman, a pediatric surgeon at Georgetown University Hospital in Washington. Dr. Blakely agreed that validation is warranted.

“The value of this scoring system, at least from what I can see, depends primarily on your point of view about interval appendectomy,” said Dr. James A. O'Neill Jr., chairman emeritus of the department of surgery at Vanderbilt University, Nashville, Tenn. “If one searches the Cochrane database, there is no evidence that that is the best approach. We should be cautious about application of these data across the nation.”

ORLANDO — A short survey that assesses compliance with a gluten-free diet among adults with celiac disease has been validated.

Scores on the Celiac Dietary Adherence Test corresponded better with an independent dietician's assessment of adherence than the standard serum test, the IgA tissue transglutaminase titer, according to a comparison among 200 people with biopsy-proven celiac disease.

Celiac disease affects up to 1% of the general population worldwide (Nutr. Clin. Care 2005;8:54–69). Its increasing prevalence is outpacing the number of adequately trained dieticians. This survey may be especially useful in areas where access to such a dietician is limited, said Dr. Daniel Leffler, director of clinical research at the Celiac Center, Beth Israel Deaconess Medical Center, Boston. He presented results at the annual meeting of the American College of Gastroenterology.

An expert panel of gastroenterologists, dieticians, and psychologists, as well as focus panels of people with celiac disease, created an initial 80-item survey. They agreed on factors in five domains: symptoms, perceived adherence, reasons for adherence, self-efficacy, and disease-specific knowledge.

An initial cohort of 150 patients completed the survey and had IgA tissue transglutaminase titers measured. The survey was then pared down to 40 items and administered to a second cohort of 50 others with celiac disease to confirm its validity. This process resulted in a seven-item survey with 89% accuracy in predicting gluten-free diet adherence, Dr. Leffler said.

The Celiac Dietary Adherence Test asks patients to respond to the following questions and statements and uses a table to rate the responses and obtain a total score that reflects the likelihood of adherence to the gluten-free diet:

▸ Have you been bothered by low energy level during past 4 weeks?

▸ Have you been bothered by headaches during the past 4 weeks?

▸ I am able to follow a gluten-free diet when dining outside my home.

▸ Before I do something I carefully consider the consequences.

▸ I do not consider myself a failure.

▸ How important to your health are accidental gluten exposures?

▸ Over the past 4 weeks how many times have you eaten foods containing gluten on purpose?

The score on the tool highly correlated with dietician evaluation at 3 months: 0.771 among the first cohort of patients and 0.764 among the second group (using a Pearson's correlation coefficient area under the curve calculation).

The IgA tissue transglutaminase assay, in contrast, correlated less with the dietician's evaluation, at 0.647. Dr. Leffler commented, “serologic tests are generally good for diagnosis, but unfortunately, few lines of testing suggest they're as good for ongoing monitoring.”

ORLANDO — A short survey that assesses compliance with a gluten-free diet among adults with celiac disease has been validated.

Scores on the Celiac Dietary Adherence Test corresponded better with an independent dietician's assessment of adherence than the standard serum test, the IgA tissue transglutaminase titer, according to a comparison among 200 people with biopsy-proven celiac disease.

Celiac disease affects up to 1% of the general population worldwide (Nutr. Clin. Care 2005;8:54–69). Its increasing prevalence is outpacing the number of adequately trained dieticians. This survey may be especially useful in areas where access to such a dietician is limited, said Dr. Daniel Leffler, director of clinical research at the Celiac Center, Beth Israel Deaconess Medical Center, Boston. He presented results at the annual meeting of the American College of Gastroenterology.

An expert panel of gastroenterologists, dieticians, and psychologists, as well as focus panels of people with celiac disease, created an initial 80-item survey. They agreed on factors in five domains: symptoms, perceived adherence, reasons for adherence, self-efficacy, and disease-specific knowledge.

An initial cohort of 150 patients completed the survey and had IgA tissue transglutaminase titers measured. The survey was then pared down to 40 items and administered to a second cohort of 50 others with celiac disease to confirm its validity. This process resulted in a seven-item survey with 89% accuracy in predicting gluten-free diet adherence, Dr. Leffler said.

The Celiac Dietary Adherence Test asks patients to respond to the following questions and statements and uses a table to rate the responses and obtain a total score that reflects the likelihood of adherence to the gluten-free diet:

▸ Have you been bothered by low energy level during past 4 weeks?

▸ Have you been bothered by headaches during the past 4 weeks?

▸ I am able to follow a gluten-free diet when dining outside my home.

▸ Before I do something I carefully consider the consequences.

▸ I do not consider myself a failure.

▸ How important to your health are accidental gluten exposures?

▸ Over the past 4 weeks how many times have you eaten foods containing gluten on purpose?

The score on the tool highly correlated with dietician evaluation at 3 months: 0.771 among the first cohort of patients and 0.764 among the second group (using a Pearson's correlation coefficient area under the curve calculation).

The IgA tissue transglutaminase assay, in contrast, correlated less with the dietician's evaluation, at 0.647. Dr. Leffler commented, “serologic tests are generally good for diagnosis, but unfortunately, few lines of testing suggest they're as good for ongoing monitoring.”

ORLANDO — A short survey that assesses compliance with a gluten-free diet among adults with celiac disease has been validated.

Scores on the Celiac Dietary Adherence Test corresponded better with an independent dietician's assessment of adherence than the standard serum test, the IgA tissue transglutaminase titer, according to a comparison among 200 people with biopsy-proven celiac disease.

Celiac disease affects up to 1% of the general population worldwide (Nutr. Clin. Care 2005;8:54–69). Its increasing prevalence is outpacing the number of adequately trained dieticians. This survey may be especially useful in areas where access to such a dietician is limited, said Dr. Daniel Leffler, director of clinical research at the Celiac Center, Beth Israel Deaconess Medical Center, Boston. He presented results at the annual meeting of the American College of Gastroenterology.

An expert panel of gastroenterologists, dieticians, and psychologists, as well as focus panels of people with celiac disease, created an initial 80-item survey. They agreed on factors in five domains: symptoms, perceived adherence, reasons for adherence, self-efficacy, and disease-specific knowledge.

An initial cohort of 150 patients completed the survey and had IgA tissue transglutaminase titers measured. The survey was then pared down to 40 items and administered to a second cohort of 50 others with celiac disease to confirm its validity. This process resulted in a seven-item survey with 89% accuracy in predicting gluten-free diet adherence, Dr. Leffler said.

The Celiac Dietary Adherence Test asks patients to respond to the following questions and statements and uses a table to rate the responses and obtain a total score that reflects the likelihood of adherence to the gluten-free diet:

▸ Have you been bothered by low energy level during past 4 weeks?

▸ Have you been bothered by headaches during the past 4 weeks?

▸ I am able to follow a gluten-free diet when dining outside my home.

▸ Before I do something I carefully consider the consequences.

▸ I do not consider myself a failure.

▸ How important to your health are accidental gluten exposures?

▸ Over the past 4 weeks how many times have you eaten foods containing gluten on purpose?

The score on the tool highly correlated with dietician evaluation at 3 months: 0.771 among the first cohort of patients and 0.764 among the second group (using a Pearson's correlation coefficient area under the curve calculation).

The IgA tissue transglutaminase assay, in contrast, correlated less with the dietician's evaluation, at 0.647. Dr. Leffler commented, “serologic tests are generally good for diagnosis, but unfortunately, few lines of testing suggest they're as good for ongoing monitoring.”

SINT MAARTEN, NETHERLANDS ANTILLES — Primary care physicians can use a “2-minute drill” that combines questions and a physical exam to screen psoriasis patients for psoriatic arthritis.

Routinely ask patients with psoriasis about musculoskeletal complaints, and then determine whether their symptoms are inflammatory, Dr. Gary L. Crump recommended at the Caribbean Dermatology Symposium. Examine them for soft tissue joint swelling, joint tenderness, nail pitting, dactylitis, and pain on motion.

The final question is about morning stiffness that lasts longer than 30 minutes, which affects more than 50% of people with psoriatic arthritis (PsA), Dr. Crump said. “It's important how you ask patients,” because some will have chronic back stiffness, for example. He recommended asking: 'How long does it take you to get as loose as you are going to get?'

Patients with PsA also can present with erythroderma, psoriasis, onycholysis, conjunctivitis/iritis, and valvular heart disease. “Psoriatic arthritis is a true systemic inflammatory disease,” Dr. Crump said.

Clinical judgment and physical examination remain superior to laboratory tests, which can vary and are not very predictive. If acute PsA is suspected, erythrocyte sedimentation rate and rheumatoid factor assays are better than a C-reactive protein test, he said.

“If you are not sure, refer and let the rheumatologist figure it out,” said Dr. Crump, a private practice rheumatologist in Louisville, Ky. The ideal approach is multidisciplinary, he added. “A dermatologist should confirm that it is psoriasis, and a rheumatologist should confirm that it is inflammatory arthritis.”

A clinical tip is to examine the patient's feet. “If you see someone with 'sausage toes' or dactylitis, you're done. They have psoriatic arthritis,” Dr. Crump said. Nail dystrophy is also very strongly associated with PsA, even if only one distal joint is affected.

Although not part of the 2-minute screen, Dr. Crump also recommends quality of life assessment for patients with PsA. Many rheumatologists use the validated Classification Criteria for Psoriatic Arthritis (CASPAR) for diagnosis (Arthritis Rheum. 2006;54:2665–73).

After initial confirmation of articular joint disease, the criteria stipulate 3 or more points, using a scoring system. Assign 2 points for current psoriasis, and 1 point for each of the following: dactylitis, nail dystrophy, juxta-articular bone formation, and negative rheumatoid factor assay. Patients without current psoriasis also score 1 point if they have either a personal or family history of psoriasis. “So you cannot diagnose PsA with just psoriasis and arthritis alone—you need something else,” Dr. Crump said.

A differential diagnosis includes exclusion of other forms of inflammatory arthritis. Some patients with psoriasis also have rheumatoid arthritis, gout, or osteoarthritis, for example. Asymmetry of affected joints is one tip that a patient does not have rheumatoid arthritis, Dr. Crump said.

An estimated 40% of patients have a family history in first-degree relatives, Dr. Crump said. Even so, “the epidemiology has been hard to pin down.” Researchers have confirmed genetic polymorphisms related to tumor necrosis factor (TNF)-α promoters in patients with PsA (Pharmacogenomics 2008;9:195–205). Immunologic studies point to T-cell activation in the skin and increases in proinflammatory cytokines, including TNF-α, interleukin-1, IL-6, and IL-8.

Features of the five subtypes of PsA often overlap, further confounding diagnosis, Dr. Crump said. And although the distal pattern of PsA affects less than 20% of patients, “it is pretty diagnostic.” Asymmetric oligoarthritis, symmetric polyarthritis (indistinguishable from rheumatoid arthritis), arthritis mutilans, and spondyloarthropathy (usually with peripheral involvement) are other subtypes.

In terms of treatment, NSAIDs can control PsA symptoms, including pain, but they do not prevent structural damage, Dr. Crump said. There are also gastrointestinal, renal, and cardiovascular risks, he said. Methotrexate 7.5 mg/wk to 20 mg/wk can slow radiographic progression, but it is not effective for axial disease.

TNF inhibitors can slow or halt radiographic progression, including axial disease. “These are our 'go-to' class of drugs now.” This class includes etanercept (Enbrel, Immunex Corp.), adalimumab (Humira, Abbott Laboratories), and infliximab (Remicade, Centocor Inc.) “My impression of these agents is they all work well for the joints,” said Dr. Crump, who is on the speakers bureau for Centocor, Novartis, Bristol-Myers Squibb, Roche, and Abbott.

SINT MAARTEN, NETHERLANDS ANTILLES — Primary care physicians can use a “2-minute drill” that combines questions and a physical exam to screen psoriasis patients for psoriatic arthritis.

Routinely ask patients with psoriasis about musculoskeletal complaints, and then determine whether their symptoms are inflammatory, Dr. Gary L. Crump recommended at the Caribbean Dermatology Symposium. Examine them for soft tissue joint swelling, joint tenderness, nail pitting, dactylitis, and pain on motion.

The final question is about morning stiffness that lasts longer than 30 minutes, which affects more than 50% of people with psoriatic arthritis (PsA), Dr. Crump said. “It's important how you ask patients,” because some will have chronic back stiffness, for example. He recommended asking: 'How long does it take you to get as loose as you are going to get?'

Patients with PsA also can present with erythroderma, psoriasis, onycholysis, conjunctivitis/iritis, and valvular heart disease. “Psoriatic arthritis is a true systemic inflammatory disease,” Dr. Crump said.

Clinical judgment and physical examination remain superior to laboratory tests, which can vary and are not very predictive. If acute PsA is suspected, erythrocyte sedimentation rate and rheumatoid factor assays are better than a C-reactive protein test, he said.

“If you are not sure, refer and let the rheumatologist figure it out,” said Dr. Crump, a private practice rheumatologist in Louisville, Ky. The ideal approach is multidisciplinary, he added. “A dermatologist should confirm that it is psoriasis, and a rheumatologist should confirm that it is inflammatory arthritis.”

A clinical tip is to examine the patient's feet. “If you see someone with 'sausage toes' or dactylitis, you're done. They have psoriatic arthritis,” Dr. Crump said. Nail dystrophy is also very strongly associated with PsA, even if only one distal joint is affected.

Although not part of the 2-minute screen, Dr. Crump also recommends quality of life assessment for patients with PsA. Many rheumatologists use the validated Classification Criteria for Psoriatic Arthritis (CASPAR) for diagnosis (Arthritis Rheum. 2006;54:2665–73).

After initial confirmation of articular joint disease, the criteria stipulate 3 or more points, using a scoring system. Assign 2 points for current psoriasis, and 1 point for each of the following: dactylitis, nail dystrophy, juxta-articular bone formation, and negative rheumatoid factor assay. Patients without current psoriasis also score 1 point if they have either a personal or family history of psoriasis. “So you cannot diagnose PsA with just psoriasis and arthritis alone—you need something else,” Dr. Crump said.

A differential diagnosis includes exclusion of other forms of inflammatory arthritis. Some patients with psoriasis also have rheumatoid arthritis, gout, or osteoarthritis, for example. Asymmetry of affected joints is one tip that a patient does not have rheumatoid arthritis, Dr. Crump said.

An estimated 40% of patients have a family history in first-degree relatives, Dr. Crump said. Even so, “the epidemiology has been hard to pin down.” Researchers have confirmed genetic polymorphisms related to tumor necrosis factor (TNF)-α promoters in patients with PsA (Pharmacogenomics 2008;9:195–205). Immunologic studies point to T-cell activation in the skin and increases in proinflammatory cytokines, including TNF-α, interleukin-1, IL-6, and IL-8.

Features of the five subtypes of PsA often overlap, further confounding diagnosis, Dr. Crump said. And although the distal pattern of PsA affects less than 20% of patients, “it is pretty diagnostic.” Asymmetric oligoarthritis, symmetric polyarthritis (indistinguishable from rheumatoid arthritis), arthritis mutilans, and spondyloarthropathy (usually with peripheral involvement) are other subtypes.

In terms of treatment, NSAIDs can control PsA symptoms, including pain, but they do not prevent structural damage, Dr. Crump said. There are also gastrointestinal, renal, and cardiovascular risks, he said. Methotrexate 7.5 mg/wk to 20 mg/wk can slow radiographic progression, but it is not effective for axial disease.

TNF inhibitors can slow or halt radiographic progression, including axial disease. “These are our 'go-to' class of drugs now.” This class includes etanercept (Enbrel, Immunex Corp.), adalimumab (Humira, Abbott Laboratories), and infliximab (Remicade, Centocor Inc.) “My impression of these agents is they all work well for the joints,” said Dr. Crump, who is on the speakers bureau for Centocor, Novartis, Bristol-Myers Squibb, Roche, and Abbott.

SINT MAARTEN, NETHERLANDS ANTILLES — Primary care physicians can use a “2-minute drill” that combines questions and a physical exam to screen psoriasis patients for psoriatic arthritis.

Routinely ask patients with psoriasis about musculoskeletal complaints, and then determine whether their symptoms are inflammatory, Dr. Gary L. Crump recommended at the Caribbean Dermatology Symposium. Examine them for soft tissue joint swelling, joint tenderness, nail pitting, dactylitis, and pain on motion.

The final question is about morning stiffness that lasts longer than 30 minutes, which affects more than 50% of people with psoriatic arthritis (PsA), Dr. Crump said. “It's important how you ask patients,” because some will have chronic back stiffness, for example. He recommended asking: 'How long does it take you to get as loose as you are going to get?'

Patients with PsA also can present with erythroderma, psoriasis, onycholysis, conjunctivitis/iritis, and valvular heart disease. “Psoriatic arthritis is a true systemic inflammatory disease,” Dr. Crump said.

Clinical judgment and physical examination remain superior to laboratory tests, which can vary and are not very predictive. If acute PsA is suspected, erythrocyte sedimentation rate and rheumatoid factor assays are better than a C-reactive protein test, he said.

“If you are not sure, refer and let the rheumatologist figure it out,” said Dr. Crump, a private practice rheumatologist in Louisville, Ky. The ideal approach is multidisciplinary, he added. “A dermatologist should confirm that it is psoriasis, and a rheumatologist should confirm that it is inflammatory arthritis.”

A clinical tip is to examine the patient's feet. “If you see someone with 'sausage toes' or dactylitis, you're done. They have psoriatic arthritis,” Dr. Crump said. Nail dystrophy is also very strongly associated with PsA, even if only one distal joint is affected.

Although not part of the 2-minute screen, Dr. Crump also recommends quality of life assessment for patients with PsA. Many rheumatologists use the validated Classification Criteria for Psoriatic Arthritis (CASPAR) for diagnosis (Arthritis Rheum. 2006;54:2665–73).

After initial confirmation of articular joint disease, the criteria stipulate 3 or more points, using a scoring system. Assign 2 points for current psoriasis, and 1 point for each of the following: dactylitis, nail dystrophy, juxta-articular bone formation, and negative rheumatoid factor assay. Patients without current psoriasis also score 1 point if they have either a personal or family history of psoriasis. “So you cannot diagnose PsA with just psoriasis and arthritis alone—you need something else,” Dr. Crump said.

A differential diagnosis includes exclusion of other forms of inflammatory arthritis. Some patients with psoriasis also have rheumatoid arthritis, gout, or osteoarthritis, for example. Asymmetry of affected joints is one tip that a patient does not have rheumatoid arthritis, Dr. Crump said.

An estimated 40% of patients have a family history in first-degree relatives, Dr. Crump said. Even so, “the epidemiology has been hard to pin down.” Researchers have confirmed genetic polymorphisms related to tumor necrosis factor (TNF)-α promoters in patients with PsA (Pharmacogenomics 2008;9:195–205). Immunologic studies point to T-cell activation in the skin and increases in proinflammatory cytokines, including TNF-α, interleukin-1, IL-6, and IL-8.

Features of the five subtypes of PsA often overlap, further confounding diagnosis, Dr. Crump said. And although the distal pattern of PsA affects less than 20% of patients, “it is pretty diagnostic.” Asymmetric oligoarthritis, symmetric polyarthritis (indistinguishable from rheumatoid arthritis), arthritis mutilans, and spondyloarthropathy (usually with peripheral involvement) are other subtypes.

In terms of treatment, NSAIDs can control PsA symptoms, including pain, but they do not prevent structural damage, Dr. Crump said. There are also gastrointestinal, renal, and cardiovascular risks, he said. Methotrexate 7.5 mg/wk to 20 mg/wk can slow radiographic progression, but it is not effective for axial disease.

TNF inhibitors can slow or halt radiographic progression, including axial disease. “These are our 'go-to' class of drugs now.” This class includes etanercept (Enbrel, Immunex Corp.), adalimumab (Humira, Abbott Laboratories), and infliximab (Remicade, Centocor Inc.) “My impression of these agents is they all work well for the joints,” said Dr. Crump, who is on the speakers bureau for Centocor, Novartis, Bristol-Myers Squibb, Roche, and Abbott.

Use of oral bisphosphonate drugs is associated with an increased risk of esophageal cancer, according to reports in the United States, Europe, and Japan.

Multiple agents in the class are associated with the esophageal cancer warning, which was raised by an epidemiologist at the Food and Drug Administration in a letter to the New England Journal of Medicine.

Between October 1995, when alendronate (Fosamax) was first approved by the FDA, and May 2008, the agency has received reports of 23 patients taking the drug diagnosed with esophageal cancer. This includes 21 cases where oral alendronate was the suspect drug and 2 where concomitant use of the agent was implicated, Diane K. Wysowski, Ph.D., wrote (N. Engl. J. Med. 2009;360:89–90).

Of the 23 patients, 18 (78%) were women and the median age was 74 years. The median time from alendronate use to diagnosis was 2.1 years (based on 16 patients).

One patient took alendronate despite having Barrett's esophagus, a precursor of esophageal adenocarcinoma, pointed out Dr. Wysowski, of FDA's Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research. She reported no relevant disclosures.

Merck, which manufactures alendronate, said in a statement that “the incidence of esophageal cancer in the general population increases with age and is reported to be more common in the older population. According to U.S. statistics from the National Cancer Institute, the annual incidence of esophageal cancer in the population aged 65 years or older is 22.3 per 100,000.”

The statement also noted that “data from Merck's clinical trials of Fosamax and from postmarketing reports do not suggest any association between alendronate and esophageal cancer. Fosamax has been studied in controlled clinical trials involving more than 17,000 patients, contributing as much as 10 years' data.”

The FDA's adverse event reporting database did not include any reports of esophageal cancer associated with other bisphosphonates. In contrast, reports for 31 patients in Europe and Japan included a diagnosis of this cancer following use of alendronate, risedronate (Actonel, Procter & Gamble), ibandronate (Boniva, Roche), and/or etidronate (Didronel, Procter & Gamble).

Twenty-two patients (71%) were women and the median age was 69 years. The median time from drug exposure to diagnosis was 1.3 years (based on 21 patients). Barrett's esophagus was diagnosed in three patients. The distal esophagus was affected in eight patients (with gastric involvement in four).

An association between esophagitis and oral bisphosphonates is suggested in studies (Radiology 1998;206:389–91; N. Engl. J. Med. 1996;335:1016–21), “usually when the drugs are not taken according to directions,” Dr. Wysowski wrote.

A second published report extends the link between use of bisphosphonates and jaw necrosis to the oral preparation of the agents, which had heretofore been thought to be without this risk. Although researchers previously demonstrated an elevated risk of osteonecrosis of the jaw (ONJ) with intravenous bisphosphonates (J. Oral Maxillofac. Surg. 2004;62:527–34), the current study is the first to show a similar elevated risk with long-term use of an oral agent. Parish P. Sedghizadeh, D.D.S., and his associates at the University of Southern California, Los Angeles, launched the study after evidence suggested the rate of ONJ secondary to alendronate treatment was higher at their institution than that reported by the manufacturer.

In 2006, Merck estimated incidence of this adverse outcome as 0.7 per 100,000 person-years of alendronate exposure, or 170 cases worldwide. An American Dental Association (ADA) expert panel cited this figure when stating that oral bisphosphonate use should not trigger modification of routine dental treatment (J. Am. Dent. Assoc. 2006;137:1144–50; J. Am. Dent. Assoc. 2008;139:1674–7).

Tooth extraction seems to be a significant trigger of jaw necrosis in patients on long-term bisphosphonates.

Dr. Sedghizadeh and his colleagues identified 208 patients with a history of alendronate in their electronic medical record system. This group included nine patients with active ONJ undergoing treatment at the University of Southern California clinics. The nine represented 1 in 23 of the patients taking alendronate, or about 4% of the study population.

“Most of the patients receiving alendronate at USC who developed ONJ did so after routine tooth extraction, suggesting that perhaps these patients should be identified as an at-risk population and preventive measures should be taken,” the authors wrote. The investigators had no relevant disclosures.

Merck released a written statement saying that the study “has material methodological flaws and scientific limitations, making it unreliable as a source for valid scientific conclusions regarding the prevalence of ONJ in patients taking alendronate.” The statement said that “In controlled clinical trials involving more than 17,000 patients … there have been no reports of ONJ.”

Use of oral bisphosphonate drugs is associated with an increased risk of esophageal cancer, according to reports in the United States, Europe, and Japan.

Multiple agents in the class are associated with the esophageal cancer warning, which was raised by an epidemiologist at the Food and Drug Administration in a letter to the New England Journal of Medicine.

Between October 1995, when alendronate (Fosamax) was first approved by the FDA, and May 2008, the agency has received reports of 23 patients taking the drug diagnosed with esophageal cancer. This includes 21 cases where oral alendronate was the suspect drug and 2 where concomitant use of the agent was implicated, Diane K. Wysowski, Ph.D., wrote (N. Engl. J. Med. 2009;360:89–90).

Of the 23 patients, 18 (78%) were women and the median age was 74 years. The median time from alendronate use to diagnosis was 2.1 years (based on 16 patients).

One patient took alendronate despite having Barrett's esophagus, a precursor of esophageal adenocarcinoma, pointed out Dr. Wysowski, of FDA's Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research. She reported no relevant disclosures.

Merck, which manufactures alendronate, said in a statement that “the incidence of esophageal cancer in the general population increases with age and is reported to be more common in the older population. According to U.S. statistics from the National Cancer Institute, the annual incidence of esophageal cancer in the population aged 65 years or older is 22.3 per 100,000.”

The statement also noted that “data from Merck's clinical trials of Fosamax and from postmarketing reports do not suggest any association between alendronate and esophageal cancer. Fosamax has been studied in controlled clinical trials involving more than 17,000 patients, contributing as much as 10 years' data.”

The FDA's adverse event reporting database did not include any reports of esophageal cancer associated with other bisphosphonates. In contrast, reports for 31 patients in Europe and Japan included a diagnosis of this cancer following use of alendronate, risedronate (Actonel, Procter & Gamble), ibandronate (Boniva, Roche), and/or etidronate (Didronel, Procter & Gamble).

Twenty-two patients (71%) were women and the median age was 69 years. The median time from drug exposure to diagnosis was 1.3 years (based on 21 patients). Barrett's esophagus was diagnosed in three patients. The distal esophagus was affected in eight patients (with gastric involvement in four).

An association between esophagitis and oral bisphosphonates is suggested in studies (Radiology 1998;206:389–91; N. Engl. J. Med. 1996;335:1016–21), “usually when the drugs are not taken according to directions,” Dr. Wysowski wrote.

A second published report extends the link between use of bisphosphonates and jaw necrosis to the oral preparation of the agents, which had heretofore been thought to be without this risk. Although researchers previously demonstrated an elevated risk of osteonecrosis of the jaw (ONJ) with intravenous bisphosphonates (J. Oral Maxillofac. Surg. 2004;62:527–34), the current study is the first to show a similar elevated risk with long-term use of an oral agent. Parish P. Sedghizadeh, D.D.S., and his associates at the University of Southern California, Los Angeles, launched the study after evidence suggested the rate of ONJ secondary to alendronate treatment was higher at their institution than that reported by the manufacturer.

In 2006, Merck estimated incidence of this adverse outcome as 0.7 per 100,000 person-years of alendronate exposure, or 170 cases worldwide. An American Dental Association (ADA) expert panel cited this figure when stating that oral bisphosphonate use should not trigger modification of routine dental treatment (J. Am. Dent. Assoc. 2006;137:1144–50; J. Am. Dent. Assoc. 2008;139:1674–7).

Tooth extraction seems to be a significant trigger of jaw necrosis in patients on long-term bisphosphonates.

Dr. Sedghizadeh and his colleagues identified 208 patients with a history of alendronate in their electronic medical record system. This group included nine patients with active ONJ undergoing treatment at the University of Southern California clinics. The nine represented 1 in 23 of the patients taking alendronate, or about 4% of the study population.

“Most of the patients receiving alendronate at USC who developed ONJ did so after routine tooth extraction, suggesting that perhaps these patients should be identified as an at-risk population and preventive measures should be taken,” the authors wrote. The investigators had no relevant disclosures.

Merck released a written statement saying that the study “has material methodological flaws and scientific limitations, making it unreliable as a source for valid scientific conclusions regarding the prevalence of ONJ in patients taking alendronate.” The statement said that “In controlled clinical trials involving more than 17,000 patients … there have been no reports of ONJ.”

Use of oral bisphosphonate drugs is associated with an increased risk of esophageal cancer, according to reports in the United States, Europe, and Japan.

Multiple agents in the class are associated with the esophageal cancer warning, which was raised by an epidemiologist at the Food and Drug Administration in a letter to the New England Journal of Medicine.

Between October 1995, when alendronate (Fosamax) was first approved by the FDA, and May 2008, the agency has received reports of 23 patients taking the drug diagnosed with esophageal cancer. This includes 21 cases where oral alendronate was the suspect drug and 2 where concomitant use of the agent was implicated, Diane K. Wysowski, Ph.D., wrote (N. Engl. J. Med. 2009;360:89–90).

Of the 23 patients, 18 (78%) were women and the median age was 74 years. The median time from alendronate use to diagnosis was 2.1 years (based on 16 patients).

One patient took alendronate despite having Barrett's esophagus, a precursor of esophageal adenocarcinoma, pointed out Dr. Wysowski, of FDA's Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research. She reported no relevant disclosures.

Merck, which manufactures alendronate, said in a statement that “the incidence of esophageal cancer in the general population increases with age and is reported to be more common in the older population. According to U.S. statistics from the National Cancer Institute, the annual incidence of esophageal cancer in the population aged 65 years or older is 22.3 per 100,000.”

The statement also noted that “data from Merck's clinical trials of Fosamax and from postmarketing reports do not suggest any association between alendronate and esophageal cancer. Fosamax has been studied in controlled clinical trials involving more than 17,000 patients, contributing as much as 10 years' data.”

The FDA's adverse event reporting database did not include any reports of esophageal cancer associated with other bisphosphonates. In contrast, reports for 31 patients in Europe and Japan included a diagnosis of this cancer following use of alendronate, risedronate (Actonel, Procter & Gamble), ibandronate (Boniva, Roche), and/or etidronate (Didronel, Procter & Gamble).

Twenty-two patients (71%) were women and the median age was 69 years. The median time from drug exposure to diagnosis was 1.3 years (based on 21 patients). Barrett's esophagus was diagnosed in three patients. The distal esophagus was affected in eight patients (with gastric involvement in four).

An association between esophagitis and oral bisphosphonates is suggested in studies (Radiology 1998;206:389–91; N. Engl. J. Med. 1996;335:1016–21), “usually when the drugs are not taken according to directions,” Dr. Wysowski wrote.

A second published report extends the link between use of bisphosphonates and jaw necrosis to the oral preparation of the agents, which had heretofore been thought to be without this risk. Although researchers previously demonstrated an elevated risk of osteonecrosis of the jaw (ONJ) with intravenous bisphosphonates (J. Oral Maxillofac. Surg. 2004;62:527–34), the current study is the first to show a similar elevated risk with long-term use of an oral agent. Parish P. Sedghizadeh, D.D.S., and his associates at the University of Southern California, Los Angeles, launched the study after evidence suggested the rate of ONJ secondary to alendronate treatment was higher at their institution than that reported by the manufacturer.

In 2006, Merck estimated incidence of this adverse outcome as 0.7 per 100,000 person-years of alendronate exposure, or 170 cases worldwide. An American Dental Association (ADA) expert panel cited this figure when stating that oral bisphosphonate use should not trigger modification of routine dental treatment (J. Am. Dent. Assoc. 2006;137:1144–50; J. Am. Dent. Assoc. 2008;139:1674–7).

Tooth extraction seems to be a significant trigger of jaw necrosis in patients on long-term bisphosphonates.

Dr. Sedghizadeh and his colleagues identified 208 patients with a history of alendronate in their electronic medical record system. This group included nine patients with active ONJ undergoing treatment at the University of Southern California clinics. The nine represented 1 in 23 of the patients taking alendronate, or about 4% of the study population.

“Most of the patients receiving alendronate at USC who developed ONJ did so after routine tooth extraction, suggesting that perhaps these patients should be identified as an at-risk population and preventive measures should be taken,” the authors wrote. The investigators had no relevant disclosures.

Merck released a written statement saying that the study “has material methodological flaws and scientific limitations, making it unreliable as a source for valid scientific conclusions regarding the prevalence of ONJ in patients taking alendronate.” The statement said that “In controlled clinical trials involving more than 17,000 patients … there have been no reports of ONJ.”

Men with type 2 diabetes mellitus and no cardiovascular disease and men who experience a first acute cardiovascular event were found to have similar long-term cardiovascular and total mortality risks in a large, longitudinal study.

In addition, the risk of cardiovascular death was more than three times greater for men in either group, compared with matched controls with neither diabetes nor cardiovascular disease, Dr. Gilles R. Dagenais of the University Laval, Quebec City, and his associates reported in the Canadian Medical Association Journal (2009;180:40–7 [doi:10.1503/cmaj.071027]).

They looked at the issue of whether diabetes alone is associated with a similar long-term increase in cardiovascular mortality risk, compared with a first cardiovascular event. There is no consensus in the literature, with some studies supporting the association (Lancet 2006;368:29–36; Diabetes Care 2005;28:1588–9) and others not (Circulation 2004;109:855–60; BMJ 2002;324:939–42).

The current study differed from previous research, because it looked at incident cases of diabetes and cardiovascular disease instead of prevalence. In addition, the study also excluded men with previous angina or intermittent claudication, conditions known to increase cardiovascular disease risk.

Dr. Dagenais and his colleagues at University Laval and the University of Montreal assessed 4,376 men at baseline in 1973 or 1974 and over time. The men were participants in the longitudinal Quebec Cardiovascular Study and were aged 35–64 years at entry in the current study. Blood pressure, cholesterol levels, family history of coronary artery disease and stroke, self-reported smoking status, and other factors were assessed in person in 1980 and 1985 and via standardized telephone or mail questionnaires in 1990 and in 1997 or 1998.

During the 24 years of follow-up, 137 men had a new diagnosis of type 2 diabetes without any previous cardiovascular disease. Another group of 527 men without diabetes experienced a first nonfatal cardiovascular event. Events included myocardial infarction in 354 patients, unstable angina in 58 men, and stroke in 115. Researchers compared survival with an age-matched group of 627 controls without diabetes or a cardiovascular event.

A total of 18 men experienced both a new diagnosis of diabetes and a cardiovascular event during the study. This group, however, was excluded from survival comparisons because of its small number.

The researchers found that men with cardiovascular disease only had a significantly higher risk of cardiovascular death during the first 5 years, compared with those with diabetes only (age-adjusted relative risk 2.03). Thereafter, researchers found no statistically significant difference in cardiovascular or total mortality between the two groups. “A longer duration of diabetes likely aggravates the atherothrombotic process that is associated with diabetes,” the authors wrote.

The study highlights the high risk of death associated with diabetes and underscores “the importance of optimal management of this disease and its associated cardiovascular conditions, as well as the importance of pursuing research to prevent type 2 diabetes altogether,” the researchers wrote.

A total of 23% of men with diabetes and no cardiovascular disease had a cardiovascular-related death during follow-up, compared with 7% of controls (RR 3.11). In addition, death from any cause occurred in 44% of this group, compared with 22% of controls (RR 1.89).

In the group of men with incident cardiovascular disease and no diabetes, 25% experienced cardiovascular death during follow-up (RR 4.46). In addition, 38% died from any cause (RR 2.19).

The authors noted some caveats and limitations, including “major changes in risk factors” during the study period. For example, between 1974 and 1985, smoking declined from 74% to 30% for the group of men with diabetes. At the same time, blood pressure for these men declined from 146/90 mmHg to 138/81 mmHg. In addition, smoking declined from 76% to 40% among men with cardiovascular disease.

Other limitations of the study included the fact that it consisted of white men only and that diabetes was self-reported by two-thirds of participants. Another limitation was that some men in the nodiabetes group may have had impaired fasting glucose or glucose intolerance, factors known to increase cardiovascular risk. Also, the research was conducted before important pharmacologic interventions to lower cardiovascular disease risk entered clinical practice, the authors noted.

The study was supported in part by the Heart and Stroke Foundation of Canada and an unrestricted grant from Sanofi-Aventis and Merck Frosst Canada Ltd. The authors reported no conflicts of interest.

Men with type 2 diabetes mellitus and no cardiovascular disease and men who experience a first acute cardiovascular event were found to have similar long-term cardiovascular and total mortality risks in a large, longitudinal study.

In addition, the risk of cardiovascular death was more than three times greater for men in either group, compared with matched controls with neither diabetes nor cardiovascular disease, Dr. Gilles R. Dagenais of the University Laval, Quebec City, and his associates reported in the Canadian Medical Association Journal (2009;180:40–7 [doi:10.1503/cmaj.071027]).

They looked at the issue of whether diabetes alone is associated with a similar long-term increase in cardiovascular mortality risk, compared with a first cardiovascular event. There is no consensus in the literature, with some studies supporting the association (Lancet 2006;368:29–36; Diabetes Care 2005;28:1588–9) and others not (Circulation 2004;109:855–60; BMJ 2002;324:939–42).

The current study differed from previous research, because it looked at incident cases of diabetes and cardiovascular disease instead of prevalence. In addition, the study also excluded men with previous angina or intermittent claudication, conditions known to increase cardiovascular disease risk.

Dr. Dagenais and his colleagues at University Laval and the University of Montreal assessed 4,376 men at baseline in 1973 or 1974 and over time. The men were participants in the longitudinal Quebec Cardiovascular Study and were aged 35–64 years at entry in the current study. Blood pressure, cholesterol levels, family history of coronary artery disease and stroke, self-reported smoking status, and other factors were assessed in person in 1980 and 1985 and via standardized telephone or mail questionnaires in 1990 and in 1997 or 1998.

During the 24 years of follow-up, 137 men had a new diagnosis of type 2 diabetes without any previous cardiovascular disease. Another group of 527 men without diabetes experienced a first nonfatal cardiovascular event. Events included myocardial infarction in 354 patients, unstable angina in 58 men, and stroke in 115. Researchers compared survival with an age-matched group of 627 controls without diabetes or a cardiovascular event.

A total of 18 men experienced both a new diagnosis of diabetes and a cardiovascular event during the study. This group, however, was excluded from survival comparisons because of its small number.

The researchers found that men with cardiovascular disease only had a significantly higher risk of cardiovascular death during the first 5 years, compared with those with diabetes only (age-adjusted relative risk 2.03). Thereafter, researchers found no statistically significant difference in cardiovascular or total mortality between the two groups. “A longer duration of diabetes likely aggravates the atherothrombotic process that is associated with diabetes,” the authors wrote.

The study highlights the high risk of death associated with diabetes and underscores “the importance of optimal management of this disease and its associated cardiovascular conditions, as well as the importance of pursuing research to prevent type 2 diabetes altogether,” the researchers wrote.

A total of 23% of men with diabetes and no cardiovascular disease had a cardiovascular-related death during follow-up, compared with 7% of controls (RR 3.11). In addition, death from any cause occurred in 44% of this group, compared with 22% of controls (RR 1.89).

In the group of men with incident cardiovascular disease and no diabetes, 25% experienced cardiovascular death during follow-up (RR 4.46). In addition, 38% died from any cause (RR 2.19).

The authors noted some caveats and limitations, including “major changes in risk factors” during the study period. For example, between 1974 and 1985, smoking declined from 74% to 30% for the group of men with diabetes. At the same time, blood pressure for these men declined from 146/90 mmHg to 138/81 mmHg. In addition, smoking declined from 76% to 40% among men with cardiovascular disease.

Other limitations of the study included the fact that it consisted of white men only and that diabetes was self-reported by two-thirds of participants. Another limitation was that some men in the nodiabetes group may have had impaired fasting glucose or glucose intolerance, factors known to increase cardiovascular risk. Also, the research was conducted before important pharmacologic interventions to lower cardiovascular disease risk entered clinical practice, the authors noted.

The study was supported in part by the Heart and Stroke Foundation of Canada and an unrestricted grant from Sanofi-Aventis and Merck Frosst Canada Ltd. The authors reported no conflicts of interest.

Men with type 2 diabetes mellitus and no cardiovascular disease and men who experience a first acute cardiovascular event were found to have similar long-term cardiovascular and total mortality risks in a large, longitudinal study.

In addition, the risk of cardiovascular death was more than three times greater for men in either group, compared with matched controls with neither diabetes nor cardiovascular disease, Dr. Gilles R. Dagenais of the University Laval, Quebec City, and his associates reported in the Canadian Medical Association Journal (2009;180:40–7 [doi:10.1503/cmaj.071027]).

They looked at the issue of whether diabetes alone is associated with a similar long-term increase in cardiovascular mortality risk, compared with a first cardiovascular event. There is no consensus in the literature, with some studies supporting the association (Lancet 2006;368:29–36; Diabetes Care 2005;28:1588–9) and others not (Circulation 2004;109:855–60; BMJ 2002;324:939–42).

The current study differed from previous research, because it looked at incident cases of diabetes and cardiovascular disease instead of prevalence. In addition, the study also excluded men with previous angina or intermittent claudication, conditions known to increase cardiovascular disease risk.

Dr. Dagenais and his colleagues at University Laval and the University of Montreal assessed 4,376 men at baseline in 1973 or 1974 and over time. The men were participants in the longitudinal Quebec Cardiovascular Study and were aged 35–64 years at entry in the current study. Blood pressure, cholesterol levels, family history of coronary artery disease and stroke, self-reported smoking status, and other factors were assessed in person in 1980 and 1985 and via standardized telephone or mail questionnaires in 1990 and in 1997 or 1998.

During the 24 years of follow-up, 137 men had a new diagnosis of type 2 diabetes without any previous cardiovascular disease. Another group of 527 men without diabetes experienced a first nonfatal cardiovascular event. Events included myocardial infarction in 354 patients, unstable angina in 58 men, and stroke in 115. Researchers compared survival with an age-matched group of 627 controls without diabetes or a cardiovascular event.

A total of 18 men experienced both a new diagnosis of diabetes and a cardiovascular event during the study. This group, however, was excluded from survival comparisons because of its small number.

The researchers found that men with cardiovascular disease only had a significantly higher risk of cardiovascular death during the first 5 years, compared with those with diabetes only (age-adjusted relative risk 2.03). Thereafter, researchers found no statistically significant difference in cardiovascular or total mortality between the two groups. “A longer duration of diabetes likely aggravates the atherothrombotic process that is associated with diabetes,” the authors wrote.

The study highlights the high risk of death associated with diabetes and underscores “the importance of optimal management of this disease and its associated cardiovascular conditions, as well as the importance of pursuing research to prevent type 2 diabetes altogether,” the researchers wrote.

A total of 23% of men with diabetes and no cardiovascular disease had a cardiovascular-related death during follow-up, compared with 7% of controls (RR 3.11). In addition, death from any cause occurred in 44% of this group, compared with 22% of controls (RR 1.89).

In the group of men with incident cardiovascular disease and no diabetes, 25% experienced cardiovascular death during follow-up (RR 4.46). In addition, 38% died from any cause (RR 2.19).

The authors noted some caveats and limitations, including “major changes in risk factors” during the study period. For example, between 1974 and 1985, smoking declined from 74% to 30% for the group of men with diabetes. At the same time, blood pressure for these men declined from 146/90 mmHg to 138/81 mmHg. In addition, smoking declined from 76% to 40% among men with cardiovascular disease.

Other limitations of the study included the fact that it consisted of white men only and that diabetes was self-reported by two-thirds of participants. Another limitation was that some men in the nodiabetes group may have had impaired fasting glucose or glucose intolerance, factors known to increase cardiovascular risk. Also, the research was conducted before important pharmacologic interventions to lower cardiovascular disease risk entered clinical practice, the authors noted.

The study was supported in part by the Heart and Stroke Foundation of Canada and an unrestricted grant from Sanofi-Aventis and Merck Frosst Canada Ltd. The authors reported no conflicts of interest.

PALM BEACH, FLA. — Helical multidetector computed tomography increases the detection of smaller segmental and subsegmental—but not central—pulmonary emboli following cancer surgery, according to the results of a database review.

In the study of almost 300 cancer surgery patients at a single center, MDCT increased the detection of PEs fourfold because of the ability to diagnose subsegmental PEs. MDCT did not increase the detection of central PEs.

“Diagnosis of pulmonary embolism in most major hospitals has changed, mostly because of the MDCT scan,” said Dr. Yuman Fong, chair of the department of surgery at Memorial Sloan-Kettering Cancer Center, New York, where the study was conducted. “There is increased sensitivity and the ability to get these scans much faster—in a single breath hold.”

MDCT has replaced ventilation/perfusion lung scans as the test of choice for detecting PE in most institutions, he noted at the annual meeting of the Southern Surgical Association.

Dr. Fong and his associates reviewed a prospective database of 47,601 patients who had abdominal, pelvic, thoracic, or soft-tissue major surgery at the cancer center. A total of 1,441 patients had a CT angiogram to rule out PE from January 2000 to December 2005. During this time, use of the contrast-enhanced, high-resolution MDCT scans of the chest within 30 days of surgery increased at the center from 5 per 1,000 patients in 2000 to 45 per 1,000 in 2005. The researchers sought to determine if patient outcomes changed as a result, said Dr. Fong, who is also vice chair of the technology department at the center.

They identified 311 patients who had a PE within 30 days of surgery. In all, 17 of the patients had a PE but no malignancy, and were excluded from the analysis; the remaining 294 cancer patients were assessed further.

The overall incidence of PE among cancer surgery patients increased from 2.3 per 1,000 patients in 2000 to 9.3 per 1,000 in 2005, a significant difference. This higher rate resulted from significantly greater diagnosis of subsegmental PEs, which increased from 0.1 per 1,000 patients in 2000 to 3 per 1,000 in 2005. At the same time, MDCT did not increase detection of central PEs, diagnosed in 0.7 per 1,000 patients in 2000 versus 0.6 per 1,000 in 2005.

Increased detection of subsegmental PEs with MDCT “makes sense because it's more sensitive,” Dr. Fong said. “Subsegmentals are harder to find with VQ [ventilation/perfusion] scan or single-detector CT.”

The researchers also looked at mortality. The annual incidence rate of fatal PE did not change during the study, remaining at 0.4 per 1,000. Not surprisingly, the 30-day mortality rate for patients with the more serious central PE was higher, at 44%, compared with 6% for patients with subsegmental PE. Those with central PE “were more likely to go to the ICU, have cardiopulmonary arrest, and die in the hospital,” Dr. Fong said.

More than half of the central PE group was symptomatic, whereas “only a few of the peripheral PEs were severely symptomatic,” Dr. Fong said. Shortness of breath, hypoxia, and an elevated heart rate (more than 100 beats per minute) were more common among central PE patients.

All 294 cancer patients with PE were treated with anticoagulants. Of these, 40 patients (14%) developed complications from the treatment. “Given a 14% complication rate with anticoagulation, are we putting some patients at increased risk?” asked Dr. Robert C.G. Martin, a surgical oncologist at the University of Louisville (Ky.).

“At Memorial Sloan-Kettering, when we discover a PE, whether or not it's central, we anticoagulate them,” Dr. Fong replied. “Surgeons put the patients on [anticoagulants,] and then the oncologists are generally afraid to take folks off anticoagulants, so they remain on semipermanent anticoagulation.” There is a balance to strike between a higher risk of complications and the lower likelihood of metastasizing cancer cells circulating in the blood “being able to stick,” he added.

PALM BEACH, FLA. — Helical multidetector computed tomography increases the detection of smaller segmental and subsegmental—but not central—pulmonary emboli following cancer surgery, according to the results of a database review.

In the study of almost 300 cancer surgery patients at a single center, MDCT increased the detection of PEs fourfold because of the ability to diagnose subsegmental PEs. MDCT did not increase the detection of central PEs.

“Diagnosis of pulmonary embolism in most major hospitals has changed, mostly because of the MDCT scan,” said Dr. Yuman Fong, chair of the department of surgery at Memorial Sloan-Kettering Cancer Center, New York, where the study was conducted. “There is increased sensitivity and the ability to get these scans much faster—in a single breath hold.”

MDCT has replaced ventilation/perfusion lung scans as the test of choice for detecting PE in most institutions, he noted at the annual meeting of the Southern Surgical Association.

Dr. Fong and his associates reviewed a prospective database of 47,601 patients who had abdominal, pelvic, thoracic, or soft-tissue major surgery at the cancer center. A total of 1,441 patients had a CT angiogram to rule out PE from January 2000 to December 2005. During this time, use of the contrast-enhanced, high-resolution MDCT scans of the chest within 30 days of surgery increased at the center from 5 per 1,000 patients in 2000 to 45 per 1,000 in 2005. The researchers sought to determine if patient outcomes changed as a result, said Dr. Fong, who is also vice chair of the technology department at the center.

They identified 311 patients who had a PE within 30 days of surgery. In all, 17 of the patients had a PE but no malignancy, and were excluded from the analysis; the remaining 294 cancer patients were assessed further.

The overall incidence of PE among cancer surgery patients increased from 2.3 per 1,000 patients in 2000 to 9.3 per 1,000 in 2005, a significant difference. This higher rate resulted from significantly greater diagnosis of subsegmental PEs, which increased from 0.1 per 1,000 patients in 2000 to 3 per 1,000 in 2005. At the same time, MDCT did not increase detection of central PEs, diagnosed in 0.7 per 1,000 patients in 2000 versus 0.6 per 1,000 in 2005.

Increased detection of subsegmental PEs with MDCT “makes sense because it's more sensitive,” Dr. Fong said. “Subsegmentals are harder to find with VQ [ventilation/perfusion] scan or single-detector CT.”

The researchers also looked at mortality. The annual incidence rate of fatal PE did not change during the study, remaining at 0.4 per 1,000. Not surprisingly, the 30-day mortality rate for patients with the more serious central PE was higher, at 44%, compared with 6% for patients with subsegmental PE. Those with central PE “were more likely to go to the ICU, have cardiopulmonary arrest, and die in the hospital,” Dr. Fong said.

More than half of the central PE group was symptomatic, whereas “only a few of the peripheral PEs were severely symptomatic,” Dr. Fong said. Shortness of breath, hypoxia, and an elevated heart rate (more than 100 beats per minute) were more common among central PE patients.

All 294 cancer patients with PE were treated with anticoagulants. Of these, 40 patients (14%) developed complications from the treatment. “Given a 14% complication rate with anticoagulation, are we putting some patients at increased risk?” asked Dr. Robert C.G. Martin, a surgical oncologist at the University of Louisville (Ky.).

“At Memorial Sloan-Kettering, when we discover a PE, whether or not it's central, we anticoagulate them,” Dr. Fong replied. “Surgeons put the patients on [anticoagulants,] and then the oncologists are generally afraid to take folks off anticoagulants, so they remain on semipermanent anticoagulation.” There is a balance to strike between a higher risk of complications and the lower likelihood of metastasizing cancer cells circulating in the blood “being able to stick,” he added.

PALM BEACH, FLA. — Helical multidetector computed tomography increases the detection of smaller segmental and subsegmental—but not central—pulmonary emboli following cancer surgery, according to the results of a database review.

In the study of almost 300 cancer surgery patients at a single center, MDCT increased the detection of PEs fourfold because of the ability to diagnose subsegmental PEs. MDCT did not increase the detection of central PEs.

“Diagnosis of pulmonary embolism in most major hospitals has changed, mostly because of the MDCT scan,” said Dr. Yuman Fong, chair of the department of surgery at Memorial Sloan-Kettering Cancer Center, New York, where the study was conducted. “There is increased sensitivity and the ability to get these scans much faster—in a single breath hold.”

MDCT has replaced ventilation/perfusion lung scans as the test of choice for detecting PE in most institutions, he noted at the annual meeting of the Southern Surgical Association.

Dr. Fong and his associates reviewed a prospective database of 47,601 patients who had abdominal, pelvic, thoracic, or soft-tissue major surgery at the cancer center. A total of 1,441 patients had a CT angiogram to rule out PE from January 2000 to December 2005. During this time, use of the contrast-enhanced, high-resolution MDCT scans of the chest within 30 days of surgery increased at the center from 5 per 1,000 patients in 2000 to 45 per 1,000 in 2005. The researchers sought to determine if patient outcomes changed as a result, said Dr. Fong, who is also vice chair of the technology department at the center.

They identified 311 patients who had a PE within 30 days of surgery. In all, 17 of the patients had a PE but no malignancy, and were excluded from the analysis; the remaining 294 cancer patients were assessed further.

The overall incidence of PE among cancer surgery patients increased from 2.3 per 1,000 patients in 2000 to 9.3 per 1,000 in 2005, a significant difference. This higher rate resulted from significantly greater diagnosis of subsegmental PEs, which increased from 0.1 per 1,000 patients in 2000 to 3 per 1,000 in 2005. At the same time, MDCT did not increase detection of central PEs, diagnosed in 0.7 per 1,000 patients in 2000 versus 0.6 per 1,000 in 2005.

Increased detection of subsegmental PEs with MDCT “makes sense because it's more sensitive,” Dr. Fong said. “Subsegmentals are harder to find with VQ [ventilation/perfusion] scan or single-detector CT.”

The researchers also looked at mortality. The annual incidence rate of fatal PE did not change during the study, remaining at 0.4 per 1,000. Not surprisingly, the 30-day mortality rate for patients with the more serious central PE was higher, at 44%, compared with 6% for patients with subsegmental PE. Those with central PE “were more likely to go to the ICU, have cardiopulmonary arrest, and die in the hospital,” Dr. Fong said.

More than half of the central PE group was symptomatic, whereas “only a few of the peripheral PEs were severely symptomatic,” Dr. Fong said. Shortness of breath, hypoxia, and an elevated heart rate (more than 100 beats per minute) were more common among central PE patients.

All 294 cancer patients with PE were treated with anticoagulants. Of these, 40 patients (14%) developed complications from the treatment. “Given a 14% complication rate with anticoagulation, are we putting some patients at increased risk?” asked Dr. Robert C.G. Martin, a surgical oncologist at the University of Louisville (Ky.).

“At Memorial Sloan-Kettering, when we discover a PE, whether or not it's central, we anticoagulate them,” Dr. Fong replied. “Surgeons put the patients on [anticoagulants,] and then the oncologists are generally afraid to take folks off anticoagulants, so they remain on semipermanent anticoagulation.” There is a balance to strike between a higher risk of complications and the lower likelihood of metastasizing cancer cells circulating in the blood “being able to stick,” he added.

ORLANDO — Endoscopic mucosal resection of Barrett's esophagus can provide a safe and effective alternative to esophagectomy, according to a retrospective study of long-term clinical experience at the University of Chicago Medical Center.

The endoscopic technique also allows clinicians to downstage or upstage patients with high-grade dysplasia and/or intramucosal carcinoma, and thereby determine who requires additional treatment, Dr. Jennifer S. Chennat said.

The most common adverse event, symptomatic esophageal stenosis, affected 14 of the 48 patients (29%) in the study. All these patients were treated effectively with endoscopic dilation, Dr. Chennat said at the annual meeting of the American College of Gastroenterology. There were no perforations or uncontrolled bleeding events.

“Esophagectomy has been the standard of care but is associated with high morbidity and mortality,” said Dr. Chennat, an internist at the Center for Endoscopic Research and Therapeutics at the University of Chicago Medical Center. “There is a recent paradigm shift in management of Barrett's esophagus.” That is why she and her colleagues decided to study long-term experience with endoscopic mucosal resection at their institution.

All patients were referred to the University of Chicago for complete endoscopic mucosal resection of their Barrett's endothelium between August 2003 and May 2008. The majority, 33 patients, presented with a diagnosis of high-grade dysplasia, another 8 were diagnosed with intramucosal carcinoma, and 7 had both.

The cohort included 36 men and 12 women with a mean age of 67 years. Mean length of Barrett's esophagus was 3.7 cm (range, 2–14 cm).

All received high-dose proton pump inhibitor therapy. Staging endoscopic ultrasound was used to exclude invasive disease or suspicious lymphadenopathy. All patients also had a baseline examination for visible lesions using high-definition white light endoscopy and narrow-band imaging.

Dr. Chennat and her colleagues changed some of the diagnoses. The endoscopic mucosal resection upstaged baseline pathology in 8 patients and downstaged initial findings for 13 patients, she said.

The investigators determined that 8 patients had Barrett's esophagus with no cancer or dysplasia, 27 had high-grade dysplasia, and 8 had intramucosal carcinoma. Another five patients had advanced pathology: Three had superficial submucosal invasion, and two had intramucosal carcinoma with lymphatic channel invasion.

All five of these patients were referred for esophagectomy; three had the surgery and two declined, opting to continue endoscopic management.

Endoscopy was repeated every 3–6 months to gauge the need for additional mucosal resection and to obtain surveillance biopsies. Patients were followed every 12 months once no residual Barrett's esophagus was detected. A total of 104 endoscopic mucosal resections were performed.

Twenty-three patients completed treatment after an average of two sessions. Surveillance biopsies revealed normal squamous endothelium for 19 of these 23 patients. Three others had nondysplastic Barrett's esophagus and one patient had residual high-grade dysplasia and was treated further. All 23 in this group ultimately achieved remission after a mean of 23 months (range, 3–54 months).

A total of 21 other patients were still undergoing therapy when these results were presented at the ACG meeting. One patient died of unrelated causes.

The role of complete Barrett's esophagus eradication with endoscopic mucosal resection remains to be determined for patients with Barrett's esophagus who present with lymphatic invasion or superficial submucosal invasion, Dr. Chennat said.

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

ORLANDO — Endoscopic mucosal resection of Barrett's esophagus can provide a safe and effective alternative to esophagectomy, according to a retrospective study of long-term clinical experience at the University of Chicago Medical Center.

The endoscopic technique also allows clinicians to downstage or upstage patients with high-grade dysplasia and/or intramucosal carcinoma, and thereby determine who requires additional treatment, Dr. Jennifer S. Chennat said.

The most common adverse event, symptomatic esophageal stenosis, affected 14 of the 48 patients (29%) in the study. All these patients were treated effectively with endoscopic dilation, Dr. Chennat said at the annual meeting of the American College of Gastroenterology. There were no perforations or uncontrolled bleeding events.

“Esophagectomy has been the standard of care but is associated with high morbidity and mortality,” said Dr. Chennat, an internist at the Center for Endoscopic Research and Therapeutics at the University of Chicago Medical Center. “There is a recent paradigm shift in management of Barrett's esophagus.” That is why she and her colleagues decided to study long-term experience with endoscopic mucosal resection at their institution.

All patients were referred to the University of Chicago for complete endoscopic mucosal resection of their Barrett's endothelium between August 2003 and May 2008. The majority, 33 patients, presented with a diagnosis of high-grade dysplasia, another 8 were diagnosed with intramucosal carcinoma, and 7 had both.

The cohort included 36 men and 12 women with a mean age of 67 years. Mean length of Barrett's esophagus was 3.7 cm (range, 2–14 cm).

All received high-dose proton pump inhibitor therapy. Staging endoscopic ultrasound was used to exclude invasive disease or suspicious lymphadenopathy. All patients also had a baseline examination for visible lesions using high-definition white light endoscopy and narrow-band imaging.

Dr. Chennat and her colleagues changed some of the diagnoses. The endoscopic mucosal resection upstaged baseline pathology in 8 patients and downstaged initial findings for 13 patients, she said.

The investigators determined that 8 patients had Barrett's esophagus with no cancer or dysplasia, 27 had high-grade dysplasia, and 8 had intramucosal carcinoma. Another five patients had advanced pathology: Three had superficial submucosal invasion, and two had intramucosal carcinoma with lymphatic channel invasion.

All five of these patients were referred for esophagectomy; three had the surgery and two declined, opting to continue endoscopic management.

Endoscopy was repeated every 3–6 months to gauge the need for additional mucosal resection and to obtain surveillance biopsies. Patients were followed every 12 months once no residual Barrett's esophagus was detected. A total of 104 endoscopic mucosal resections were performed.

Twenty-three patients completed treatment after an average of two sessions. Surveillance biopsies revealed normal squamous endothelium for 19 of these 23 patients. Three others had nondysplastic Barrett's esophagus and one patient had residual high-grade dysplasia and was treated further. All 23 in this group ultimately achieved remission after a mean of 23 months (range, 3–54 months).

A total of 21 other patients were still undergoing therapy when these results were presented at the ACG meeting. One patient died of unrelated causes.

The role of complete Barrett's esophagus eradication with endoscopic mucosal resection remains to be determined for patients with Barrett's esophagus who present with lymphatic invasion or superficial submucosal invasion, Dr. Chennat said.

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

ORLANDO — Endoscopic mucosal resection of Barrett's esophagus can provide a safe and effective alternative to esophagectomy, according to a retrospective study of long-term clinical experience at the University of Chicago Medical Center.

The endoscopic technique also allows clinicians to downstage or upstage patients with high-grade dysplasia and/or intramucosal carcinoma, and thereby determine who requires additional treatment, Dr. Jennifer S. Chennat said.

The most common adverse event, symptomatic esophageal stenosis, affected 14 of the 48 patients (29%) in the study. All these patients were treated effectively with endoscopic dilation, Dr. Chennat said at the annual meeting of the American College of Gastroenterology. There were no perforations or uncontrolled bleeding events.

“Esophagectomy has been the standard of care but is associated with high morbidity and mortality,” said Dr. Chennat, an internist at the Center for Endoscopic Research and Therapeutics at the University of Chicago Medical Center. “There is a recent paradigm shift in management of Barrett's esophagus.” That is why she and her colleagues decided to study long-term experience with endoscopic mucosal resection at their institution.

All patients were referred to the University of Chicago for complete endoscopic mucosal resection of their Barrett's endothelium between August 2003 and May 2008. The majority, 33 patients, presented with a diagnosis of high-grade dysplasia, another 8 were diagnosed with intramucosal carcinoma, and 7 had both.

The cohort included 36 men and 12 women with a mean age of 67 years. Mean length of Barrett's esophagus was 3.7 cm (range, 2–14 cm).

All received high-dose proton pump inhibitor therapy. Staging endoscopic ultrasound was used to exclude invasive disease or suspicious lymphadenopathy. All patients also had a baseline examination for visible lesions using high-definition white light endoscopy and narrow-band imaging.

Dr. Chennat and her colleagues changed some of the diagnoses. The endoscopic mucosal resection upstaged baseline pathology in 8 patients and downstaged initial findings for 13 patients, she said.

The investigators determined that 8 patients had Barrett's esophagus with no cancer or dysplasia, 27 had high-grade dysplasia, and 8 had intramucosal carcinoma. Another five patients had advanced pathology: Three had superficial submucosal invasion, and two had intramucosal carcinoma with lymphatic channel invasion.

All five of these patients were referred for esophagectomy; three had the surgery and two declined, opting to continue endoscopic management.

Endoscopy was repeated every 3–6 months to gauge the need for additional mucosal resection and to obtain surveillance biopsies. Patients were followed every 12 months once no residual Barrett's esophagus was detected. A total of 104 endoscopic mucosal resections were performed.

Twenty-three patients completed treatment after an average of two sessions. Surveillance biopsies revealed normal squamous endothelium for 19 of these 23 patients. Three others had nondysplastic Barrett's esophagus and one patient had residual high-grade dysplasia and was treated further. All 23 in this group ultimately achieved remission after a mean of 23 months (range, 3–54 months).

A total of 21 other patients were still undergoing therapy when these results were presented at the ACG meeting. One patient died of unrelated causes.

The role of complete Barrett's esophagus eradication with endoscopic mucosal resection remains to be determined for patients with Barrett's esophagus who present with lymphatic invasion or superficial submucosal invasion, Dr. Chennat said.

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

LAKE BUENA VISTA, FLA. — Menopause symptoms vary significantly by ethnic group, based on data emerging from a longitudinal study.

The acculturation of women immigrants to the United States, as well as their socioeconomic status, are two factors that might account for these differences, said Dr. Nanette F. Santoro, an endocrinologist who has coauthored multiple studies based on data from the Study of Women's Health Across the Nation (SWAN).

The study included women from seven sites: Boston; Newark, N.J.; Pittsburgh; Detroit; Chicago; Oakland, Calif.; and Los Angeles. Each site recruited white women and women from one ethnic minority group: black, Hispanic, Chinese, or Japanese. More than 10 years later, about 85% of the participants remain in the study.

“We found differences by ethnicity—very intriguing differences,” Dr. Santoro said.

For example, in one study of 11,652 women from SWAN, Dr. Santoro and her colleagues found that 126 participants (1.1%) reported onset of menopause before age 40 years, a condition known as premature ovarian failure (Human Reprod. 2003;18:199–206). This occurred in 1.4% of both black and Hispanic women, 1.0% of white women, 0.5% of Chinese women, and 0.1% of Japanese women. (See bar chart.)

These differences were deemed statistically significant.

Acculturation of immigrants is “a double-edged sword,” Dr. Santoro said at the annual meeting of the North American Menopause Society. It can improve socioeconomic status, access to health care, and attainment of higher education, but at the same time can worsen health through a less-nutritious diet.

In contrast to other minorities, Hispanic women in SWAN and similar studies tend to improve little or even to worsen in terms of health once they are assimilated, she said. Watch for the “Hispanic paradox”: Health outcomes are worse among this population with increased acculturation, despite better socioeconomic status, because of factors such as higher rates of teen pregnancy and cigarette smoking, said Dr. Santoro, director of the division of reproductive endocrinology and infertility at Albert Einstein College of Medicine, New York.

She cautioned, however, that the Hispanic population is heterogeneous and cannot be addressed as a single entity.

The Hispanic SWAN participants came from many different countries and cultures and displayed some internal differences. For example, women from Puerto Rico were more vulnerable to acculturation and reported more menopause-related sleep problems and depressive symptoms than did other Hispanics.

Meanwhile, the acculturation of Japanese women was associated with fewer menopausal symptoms than were seen in Hispanics. Similarly, Chinese participants reported fewer symptoms compared with white, black, and Hispanic women in SWAN. “There are clear-cut differences in symptom reporting by ethnicity,” Dr. Santoro said.

Hispanic and black women were more likely to report depressive symptoms, and Chinese and Japanese women were less likely to do so, the study found.

“This is confounded, possibly, by lower socioeconomic status in the African American and Hispanic groups, and a higher socioeconomic status in Chinese and especially Japanese women,” she said.

Black women in SWAN reported the most hot flashes. Dr. Santoro proposed that increased adiposity among these women might provide more insulation and make them less heat tolerant.

Black women, however, were less bothered by hot flashes than were Hispanic women, who reported more embarrassment with vasomotor symptoms.

SWAN is supported by grants from the Department of Health and Human Services.

ELSEVIER GLOBAL MEDICAL NEWS

LAKE BUENA VISTA, FLA. — Menopause symptoms vary significantly by ethnic group, based on data emerging from a longitudinal study.

The acculturation of women immigrants to the United States, as well as their socioeconomic status, are two factors that might account for these differences, said Dr. Nanette F. Santoro, an endocrinologist who has coauthored multiple studies based on data from the Study of Women's Health Across the Nation (SWAN).

The study included women from seven sites: Boston; Newark, N.J.; Pittsburgh; Detroit; Chicago; Oakland, Calif.; and Los Angeles. Each site recruited white women and women from one ethnic minority group: black, Hispanic, Chinese, or Japanese. More than 10 years later, about 85% of the participants remain in the study.

“We found differences by ethnicity—very intriguing differences,” Dr. Santoro said.

For example, in one study of 11,652 women from SWAN, Dr. Santoro and her colleagues found that 126 participants (1.1%) reported onset of menopause before age 40 years, a condition known as premature ovarian failure (Human Reprod. 2003;18:199–206). This occurred in 1.4% of both black and Hispanic women, 1.0% of white women, 0.5% of Chinese women, and 0.1% of Japanese women. (See bar chart.)

These differences were deemed statistically significant.

Acculturation of immigrants is “a double-edged sword,” Dr. Santoro said at the annual meeting of the North American Menopause Society. It can improve socioeconomic status, access to health care, and attainment of higher education, but at the same time can worsen health through a less-nutritious diet.

In contrast to other minorities, Hispanic women in SWAN and similar studies tend to improve little or even to worsen in terms of health once they are assimilated, she said. Watch for the “Hispanic paradox”: Health outcomes are worse among this population with increased acculturation, despite better socioeconomic status, because of factors such as higher rates of teen pregnancy and cigarette smoking, said Dr. Santoro, director of the division of reproductive endocrinology and infertility at Albert Einstein College of Medicine, New York.

She cautioned, however, that the Hispanic population is heterogeneous and cannot be addressed as a single entity.

The Hispanic SWAN participants came from many different countries and cultures and displayed some internal differences. For example, women from Puerto Rico were more vulnerable to acculturation and reported more menopause-related sleep problems and depressive symptoms than did other Hispanics.

Meanwhile, the acculturation of Japanese women was associated with fewer menopausal symptoms than were seen in Hispanics. Similarly, Chinese participants reported fewer symptoms compared with white, black, and Hispanic women in SWAN. “There are clear-cut differences in symptom reporting by ethnicity,” Dr. Santoro said.

Hispanic and black women were more likely to report depressive symptoms, and Chinese and Japanese women were less likely to do so, the study found.

“This is confounded, possibly, by lower socioeconomic status in the African American and Hispanic groups, and a higher socioeconomic status in Chinese and especially Japanese women,” she said.

Black women in SWAN reported the most hot flashes. Dr. Santoro proposed that increased adiposity among these women might provide more insulation and make them less heat tolerant.

Black women, however, were less bothered by hot flashes than were Hispanic women, who reported more embarrassment with vasomotor symptoms.

SWAN is supported by grants from the Department of Health and Human Services.

ELSEVIER GLOBAL MEDICAL NEWS

LAKE BUENA VISTA, FLA. — Menopause symptoms vary significantly by ethnic group, based on data emerging from a longitudinal study.

The acculturation of women immigrants to the United States, as well as their socioeconomic status, are two factors that might account for these differences, said Dr. Nanette F. Santoro, an endocrinologist who has coauthored multiple studies based on data from the Study of Women's Health Across the Nation (SWAN).

The study included women from seven sites: Boston; Newark, N.J.; Pittsburgh; Detroit; Chicago; Oakland, Calif.; and Los Angeles. Each site recruited white women and women from one ethnic minority group: black, Hispanic, Chinese, or Japanese. More than 10 years later, about 85% of the participants remain in the study.

“We found differences by ethnicity—very intriguing differences,” Dr. Santoro said.

For example, in one study of 11,652 women from SWAN, Dr. Santoro and her colleagues found that 126 participants (1.1%) reported onset of menopause before age 40 years, a condition known as premature ovarian failure (Human Reprod. 2003;18:199–206). This occurred in 1.4% of both black and Hispanic women, 1.0% of white women, 0.5% of Chinese women, and 0.1% of Japanese women. (See bar chart.)

These differences were deemed statistically significant.

Acculturation of immigrants is “a double-edged sword,” Dr. Santoro said at the annual meeting of the North American Menopause Society. It can improve socioeconomic status, access to health care, and attainment of higher education, but at the same time can worsen health through a less-nutritious diet.

In contrast to other minorities, Hispanic women in SWAN and similar studies tend to improve little or even to worsen in terms of health once they are assimilated, she said. Watch for the “Hispanic paradox”: Health outcomes are worse among this population with increased acculturation, despite better socioeconomic status, because of factors such as higher rates of teen pregnancy and cigarette smoking, said Dr. Santoro, director of the division of reproductive endocrinology and infertility at Albert Einstein College of Medicine, New York.

She cautioned, however, that the Hispanic population is heterogeneous and cannot be addressed as a single entity.

The Hispanic SWAN participants came from many different countries and cultures and displayed some internal differences. For example, women from Puerto Rico were more vulnerable to acculturation and reported more menopause-related sleep problems and depressive symptoms than did other Hispanics.

Meanwhile, the acculturation of Japanese women was associated with fewer menopausal symptoms than were seen in Hispanics. Similarly, Chinese participants reported fewer symptoms compared with white, black, and Hispanic women in SWAN. “There are clear-cut differences in symptom reporting by ethnicity,” Dr. Santoro said.

Hispanic and black women were more likely to report depressive symptoms, and Chinese and Japanese women were less likely to do so, the study found.

“This is confounded, possibly, by lower socioeconomic status in the African American and Hispanic groups, and a higher socioeconomic status in Chinese and especially Japanese women,” she said.

Black women in SWAN reported the most hot flashes. Dr. Santoro proposed that increased adiposity among these women might provide more insulation and make them less heat tolerant.

Black women, however, were less bothered by hot flashes than were Hispanic women, who reported more embarrassment with vasomotor symptoms.

SWAN is supported by grants from the Department of Health and Human Services.

ELSEVIER GLOBAL MEDICAL NEWS