Diana Mahoney

CAMBRIDGE, MASS. — Women with vulvar vestibulitis have more pain-related complaints and lower thresholds for nongenital tactile pain and pressure than women without the condition, a study has shown.

Typically associated with localized vulvar vestibulum pain, vulvar vestibulitis syndrome (VVS) is characterized by entry dyspareunia, discomfort at the opening of the vagina, and severe point tenderness on vestibular touch. The results of this study, however, suggest that it may be inaccurate to define VVS as a highly localized problem with a specific vulvar etiology.

In fact, the condition—which is estimated to affect up to 12% of premenopausal women in the general population—may be indicative of a more generalized sensory abnormality, Caroline F. Pukall, Ph.D., reported at the annual meeting of the Society for Sex Therapy and Research.

This research finding could have therapeutic implications for women with VVS who have been referred for psychologic intervention, Dr. Pukall said at the meeting, which was also sponsored by the American College of Obstetricians and Gynecologists.

Using a standardized pain sensitivity measure developed for the diagnosis of fibromyalgia, Dr. Pukall and her colleagues in the department of psychology at Queen's University, Kingston, Ont., evaluated the sensitivity to pressure in nongenital areas experienced by women with and without VVS.

Sixteen women with the condition and 16 control participants underwent a physical tender-point examination by an experienced, blinded rheumatologist.

The examination included the manual palpation of nine nongenital bilateral body locations, including left and right gluteal, low cervical, and supraspinatus regions. The rheumatologist noted the number of painful tender points and rated pain intensity and unpleasantness on a 0–10 scale.

Because the intensity and unpleasantness ratings did not differ significantly for the right and left sides of any of the areas, the investigators averaged measures from both sides for each site, Dr. Pukall noted.

Variance analyses on the data showed that women with VVS had significantly more painful areas and significantly higher pain intensity and unpleasantness in response to palpation at each area examined, compared with women in the control group, she said.

A separate comparison of six pairs of VVS and control women who were matched for age and OC use showed similar results, she noted.

While none of the women in the VVS group had histories of chronic and widespread pain consistent with fibromyalgia, the results of their tender-point examinations suggest that “generalized systemic hypersensitivity” may be a contributing factor to VVS in some women, Dr. Pukall said.

These findings and other recent evidence implicating central and peripheral nervous system processes in the development and maintenance of VVS lend credence to the contention that VVS, which is thought to be the major cause of dyspareunia in premenopausal women, should be considered a pain disorder that interferes with sexuality rather than as a sexual disorder characterized by pain, Dr. Pukall said.

She added that by using the proposed definition, clinicians are more apt to focus on efforts to mitigate the patient's experience of pain, she noted.

While there is no “cure” for VVS, therapeutic approaches may include topical medication to suppress pain and/or inflammation, cognitive-behavioral therapy focusing on pain management and coping strategies, and pelvic floor physical therapy to relieve muscle tension, increase muscle strength and voluntary control, and desensitize fears to vulvovaginal touch and penetration, Dr. Pukall said.

CAMBRIDGE, MASS. — Women with vulvar vestibulitis have more pain-related complaints and lower thresholds for nongenital tactile pain and pressure than women without the condition, a study has shown.

Typically associated with localized vulvar vestibulum pain, vulvar vestibulitis syndrome (VVS) is characterized by entry dyspareunia, discomfort at the opening of the vagina, and severe point tenderness on vestibular touch. The results of this study, however, suggest that it may be inaccurate to define VVS as a highly localized problem with a specific vulvar etiology.

In fact, the condition—which is estimated to affect up to 12% of premenopausal women in the general population—may be indicative of a more generalized sensory abnormality, Caroline F. Pukall, Ph.D., reported at the annual meeting of the Society for Sex Therapy and Research.

This research finding could have therapeutic implications for women with VVS who have been referred for psychologic intervention, Dr. Pukall said at the meeting, which was also sponsored by the American College of Obstetricians and Gynecologists.

Using a standardized pain sensitivity measure developed for the diagnosis of fibromyalgia, Dr. Pukall and her colleagues in the department of psychology at Queen's University, Kingston, Ont., evaluated the sensitivity to pressure in nongenital areas experienced by women with and without VVS.

Sixteen women with the condition and 16 control participants underwent a physical tender-point examination by an experienced, blinded rheumatologist.

The examination included the manual palpation of nine nongenital bilateral body locations, including left and right gluteal, low cervical, and supraspinatus regions. The rheumatologist noted the number of painful tender points and rated pain intensity and unpleasantness on a 0–10 scale.

Because the intensity and unpleasantness ratings did not differ significantly for the right and left sides of any of the areas, the investigators averaged measures from both sides for each site, Dr. Pukall noted.

Variance analyses on the data showed that women with VVS had significantly more painful areas and significantly higher pain intensity and unpleasantness in response to palpation at each area examined, compared with women in the control group, she said.

A separate comparison of six pairs of VVS and control women who were matched for age and OC use showed similar results, she noted.

While none of the women in the VVS group had histories of chronic and widespread pain consistent with fibromyalgia, the results of their tender-point examinations suggest that “generalized systemic hypersensitivity” may be a contributing factor to VVS in some women, Dr. Pukall said.

These findings and other recent evidence implicating central and peripheral nervous system processes in the development and maintenance of VVS lend credence to the contention that VVS, which is thought to be the major cause of dyspareunia in premenopausal women, should be considered a pain disorder that interferes with sexuality rather than as a sexual disorder characterized by pain, Dr. Pukall said.

She added that by using the proposed definition, clinicians are more apt to focus on efforts to mitigate the patient's experience of pain, she noted.

While there is no “cure” for VVS, therapeutic approaches may include topical medication to suppress pain and/or inflammation, cognitive-behavioral therapy focusing on pain management and coping strategies, and pelvic floor physical therapy to relieve muscle tension, increase muscle strength and voluntary control, and desensitize fears to vulvovaginal touch and penetration, Dr. Pukall said.

CAMBRIDGE, MASS. — Women with vulvar vestibulitis have more pain-related complaints and lower thresholds for nongenital tactile pain and pressure than women without the condition, a study has shown.

Typically associated with localized vulvar vestibulum pain, vulvar vestibulitis syndrome (VVS) is characterized by entry dyspareunia, discomfort at the opening of the vagina, and severe point tenderness on vestibular touch. The results of this study, however, suggest that it may be inaccurate to define VVS as a highly localized problem with a specific vulvar etiology.

In fact, the condition—which is estimated to affect up to 12% of premenopausal women in the general population—may be indicative of a more generalized sensory abnormality, Caroline F. Pukall, Ph.D., reported at the annual meeting of the Society for Sex Therapy and Research.

This research finding could have therapeutic implications for women with VVS who have been referred for psychologic intervention, Dr. Pukall said at the meeting, which was also sponsored by the American College of Obstetricians and Gynecologists.

Using a standardized pain sensitivity measure developed for the diagnosis of fibromyalgia, Dr. Pukall and her colleagues in the department of psychology at Queen's University, Kingston, Ont., evaluated the sensitivity to pressure in nongenital areas experienced by women with and without VVS.

Sixteen women with the condition and 16 control participants underwent a physical tender-point examination by an experienced, blinded rheumatologist.

The examination included the manual palpation of nine nongenital bilateral body locations, including left and right gluteal, low cervical, and supraspinatus regions. The rheumatologist noted the number of painful tender points and rated pain intensity and unpleasantness on a 0–10 scale.

Because the intensity and unpleasantness ratings did not differ significantly for the right and left sides of any of the areas, the investigators averaged measures from both sides for each site, Dr. Pukall noted.

Variance analyses on the data showed that women with VVS had significantly more painful areas and significantly higher pain intensity and unpleasantness in response to palpation at each area examined, compared with women in the control group, she said.

A separate comparison of six pairs of VVS and control women who were matched for age and OC use showed similar results, she noted.

While none of the women in the VVS group had histories of chronic and widespread pain consistent with fibromyalgia, the results of their tender-point examinations suggest that “generalized systemic hypersensitivity” may be a contributing factor to VVS in some women, Dr. Pukall said.

These findings and other recent evidence implicating central and peripheral nervous system processes in the development and maintenance of VVS lend credence to the contention that VVS, which is thought to be the major cause of dyspareunia in premenopausal women, should be considered a pain disorder that interferes with sexuality rather than as a sexual disorder characterized by pain, Dr. Pukall said.

She added that by using the proposed definition, clinicians are more apt to focus on efforts to mitigate the patient's experience of pain, she noted.

While there is no “cure” for VVS, therapeutic approaches may include topical medication to suppress pain and/or inflammation, cognitive-behavioral therapy focusing on pain management and coping strategies, and pelvic floor physical therapy to relieve muscle tension, increase muscle strength and voluntary control, and desensitize fears to vulvovaginal touch and penetration, Dr. Pukall said.

HARROGATE, ENGLAND — A mother's vitamin D status in late pregnancy is predictive of her child's lumbar spine volumetric bone density at age 9, a prospective study has shown.

The findings add to the growing body of evidence confirming that a woman's diet while pregnant can influence her child's later bone mass, said Nicholas W. Harvey, B.Chir.

The results of the population-based investigation also point to the potential efficacy of preventive measures to protect children's bone health, Dr. Harvey said in a presentation at the annual conference of the National Osteoporosis Society. “Vitamin D supplementation in pregnant women who are deficient may optimize peak accrual of bone mineral in their offspring,” he stated.

The investigation included 210 children of mothers enrolled in a larger cohort study of maternal nutrition and fetal development conducted by Dr. Harvey and his colleagues at the MRC environmental epidemiology unit of the University of Southampton (England). The mothers completed a questionnaire regarding their diet and lifestyle beginning from early pregnancy.

Anthropometric measures were recorded, including mid-upper arm circumference, which is a potential indicator of maternal nutritional status. The mothers gave venous blood samples in late pregnancy for the measurement of 25-hydroxyvitamin D levels and other nutrients. Concentrated umbilical cord blood was collected at birth to measure calcium, albumin, and phosphate.

The investigators recorded the child's size and weight at birth. When the children reached age 9 years, they underwent dual-energy x-ray absorptiometry (DXA) for bone mass measurement. Because bone mineral density measured by DXA represents the areal density (grams per square centimeter) rather than the volumetric density (grams per cubic centimeter) of bone, the investigators generated mathematical estimates of volumetric bone density from the DXA measurements of bone mineral content and bone area.

“When studying bone mineral density during growth, the differences [between volumetric and areal BMD] have to be taken into consideration,” Dr. Harvey explained. As bones grow, the volume increases at a faster rate than the area, so the areal bone density will increase even if the volumetric density remains stable.

At 9 years, the boys in the study group (112) were significantly taller than the girls, and had higher age-adjusted lumbar spine bone mineral content and bone area but lower volumetric bone mineral density. After adjustment for child age and gender, maternal vitamin D was positively correlated with childhood volumetric BMD. “There was a threshold in the relationship, such that mothers in the lowest fifth of the [vitamin D] distribution had children with significantly lower volumetric bone mineral density at age 9 than those in the remaining four-fifths,” Dr. Harvey said.

Maternal mid-upper arm circumference and vitamin D supplementation in late pregnancy both had significant positive associations with volumetric BMD, while social class, maternal smoking, and umbilical cord phosphate, calcium, and albumin levels did not. Calcium from the cord blood was predictive of increased bone mass, but not volumetric BMD, Dr. Harvey noted.

In a multivariate model, both maternal mid-upper arm circumference and low serum vitamin D remained significant predictors of childhood volumetric BMD status, he said.

The findings are especially timely, given that vitamin D deficiency is re-emerging as a significant problem among pregnant women and their infants, particularly among groups with dark skin or low skin exposure to sunlight, Dr. Harvey said. Checking a mother's vitamin D status and recommending sufficient supplementation for women who are deficient are simple steps “that could potentially reduce fractures in future generations,” he said.

HARROGATE, ENGLAND — A mother's vitamin D status in late pregnancy is predictive of her child's lumbar spine volumetric bone density at age 9, a prospective study has shown.

The findings add to the growing body of evidence confirming that a woman's diet while pregnant can influence her child's later bone mass, said Nicholas W. Harvey, B.Chir.

The results of the population-based investigation also point to the potential efficacy of preventive measures to protect children's bone health, Dr. Harvey said in a presentation at the annual conference of the National Osteoporosis Society. “Vitamin D supplementation in pregnant women who are deficient may optimize peak accrual of bone mineral in their offspring,” he stated.

The investigation included 210 children of mothers enrolled in a larger cohort study of maternal nutrition and fetal development conducted by Dr. Harvey and his colleagues at the MRC environmental epidemiology unit of the University of Southampton (England). The mothers completed a questionnaire regarding their diet and lifestyle beginning from early pregnancy.

Anthropometric measures were recorded, including mid-upper arm circumference, which is a potential indicator of maternal nutritional status. The mothers gave venous blood samples in late pregnancy for the measurement of 25-hydroxyvitamin D levels and other nutrients. Concentrated umbilical cord blood was collected at birth to measure calcium, albumin, and phosphate.

The investigators recorded the child's size and weight at birth. When the children reached age 9 years, they underwent dual-energy x-ray absorptiometry (DXA) for bone mass measurement. Because bone mineral density measured by DXA represents the areal density (grams per square centimeter) rather than the volumetric density (grams per cubic centimeter) of bone, the investigators generated mathematical estimates of volumetric bone density from the DXA measurements of bone mineral content and bone area.

“When studying bone mineral density during growth, the differences [between volumetric and areal BMD] have to be taken into consideration,” Dr. Harvey explained. As bones grow, the volume increases at a faster rate than the area, so the areal bone density will increase even if the volumetric density remains stable.

At 9 years, the boys in the study group (112) were significantly taller than the girls, and had higher age-adjusted lumbar spine bone mineral content and bone area but lower volumetric bone mineral density. After adjustment for child age and gender, maternal vitamin D was positively correlated with childhood volumetric BMD. “There was a threshold in the relationship, such that mothers in the lowest fifth of the [vitamin D] distribution had children with significantly lower volumetric bone mineral density at age 9 than those in the remaining four-fifths,” Dr. Harvey said.

Maternal mid-upper arm circumference and vitamin D supplementation in late pregnancy both had significant positive associations with volumetric BMD, while social class, maternal smoking, and umbilical cord phosphate, calcium, and albumin levels did not. Calcium from the cord blood was predictive of increased bone mass, but not volumetric BMD, Dr. Harvey noted.

In a multivariate model, both maternal mid-upper arm circumference and low serum vitamin D remained significant predictors of childhood volumetric BMD status, he said.

The findings are especially timely, given that vitamin D deficiency is re-emerging as a significant problem among pregnant women and their infants, particularly among groups with dark skin or low skin exposure to sunlight, Dr. Harvey said. Checking a mother's vitamin D status and recommending sufficient supplementation for women who are deficient are simple steps “that could potentially reduce fractures in future generations,” he said.

HARROGATE, ENGLAND — A mother's vitamin D status in late pregnancy is predictive of her child's lumbar spine volumetric bone density at age 9, a prospective study has shown.

The findings add to the growing body of evidence confirming that a woman's diet while pregnant can influence her child's later bone mass, said Nicholas W. Harvey, B.Chir.

The results of the population-based investigation also point to the potential efficacy of preventive measures to protect children's bone health, Dr. Harvey said in a presentation at the annual conference of the National Osteoporosis Society. “Vitamin D supplementation in pregnant women who are deficient may optimize peak accrual of bone mineral in their offspring,” he stated.

The investigation included 210 children of mothers enrolled in a larger cohort study of maternal nutrition and fetal development conducted by Dr. Harvey and his colleagues at the MRC environmental epidemiology unit of the University of Southampton (England). The mothers completed a questionnaire regarding their diet and lifestyle beginning from early pregnancy.

Anthropometric measures were recorded, including mid-upper arm circumference, which is a potential indicator of maternal nutritional status. The mothers gave venous blood samples in late pregnancy for the measurement of 25-hydroxyvitamin D levels and other nutrients. Concentrated umbilical cord blood was collected at birth to measure calcium, albumin, and phosphate.

The investigators recorded the child's size and weight at birth. When the children reached age 9 years, they underwent dual-energy x-ray absorptiometry (DXA) for bone mass measurement. Because bone mineral density measured by DXA represents the areal density (grams per square centimeter) rather than the volumetric density (grams per cubic centimeter) of bone, the investigators generated mathematical estimates of volumetric bone density from the DXA measurements of bone mineral content and bone area.

“When studying bone mineral density during growth, the differences [between volumetric and areal BMD] have to be taken into consideration,” Dr. Harvey explained. As bones grow, the volume increases at a faster rate than the area, so the areal bone density will increase even if the volumetric density remains stable.

At 9 years, the boys in the study group (112) were significantly taller than the girls, and had higher age-adjusted lumbar spine bone mineral content and bone area but lower volumetric bone mineral density. After adjustment for child age and gender, maternal vitamin D was positively correlated with childhood volumetric BMD. “There was a threshold in the relationship, such that mothers in the lowest fifth of the [vitamin D] distribution had children with significantly lower volumetric bone mineral density at age 9 than those in the remaining four-fifths,” Dr. Harvey said.

Maternal mid-upper arm circumference and vitamin D supplementation in late pregnancy both had significant positive associations with volumetric BMD, while social class, maternal smoking, and umbilical cord phosphate, calcium, and albumin levels did not. Calcium from the cord blood was predictive of increased bone mass, but not volumetric BMD, Dr. Harvey noted.

In a multivariate model, both maternal mid-upper arm circumference and low serum vitamin D remained significant predictors of childhood volumetric BMD status, he said.

The findings are especially timely, given that vitamin D deficiency is re-emerging as a significant problem among pregnant women and their infants, particularly among groups with dark skin or low skin exposure to sunlight, Dr. Harvey said. Checking a mother's vitamin D status and recommending sufficient supplementation for women who are deficient are simple steps “that could potentially reduce fractures in future generations,” he said.

HOLLYWOOD, FLA. — An aromatase inhibitor, either alone or after tamoxifen therapy, is better than tamoxifen alone for the long-term prevention of breast cancer in postmenopausal women with invasive breast cancer, according to updated treatment guidelines from the National Comprehensive Cancer Network.

Several recent clinical trials have shown that adjuvant endocrine therapy with the aromatase inhibitors anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin) can significantly improve disease-free survival in postmenopausal women, compared with tamoxifen as a single agent.

Consequently, “tamoxifen alone [in this patient population] has fallen off the radar screen,” said Robert Carlson, M.D., chair of the NCCN panel that revised the guidelines, which were last updated in 2004. The network's 19 member institutions are designated as comprehensive cancer centers by the National Cancer Institute.

The updated guidelines recommend that women who are postmenopausal when they begin adjuvant therapy receive one of the following treatment regimens:

▸ Anastrozole for 5 years.

▸ Tamoxifen for 2–3 years, followed by exemestane or anastrozole to complete 5 years of therapy.

▸ Tamoxifen for 4.5–6 years, followed by letrozole for 5 years.

▸ Tamoxifen for 5 years for women with contraindications for, or who decline, aromatase inhibitors.

The new recommendations are based primarily on findings from three large randomized controlled studies of aromatase inhibitors in postmenopausal women, he said at the annual conference of the NCCN.

The Arimidex, Tamoxifen, Alone or in Combination (ATAC) trial compared anastrozole, alone or used with tamoxifen, with tamoxifen alone as 5-year adjuvant treatment for women with early breast cancer following primary treatment with surgery, radiotherapy, and/or chemotherapy. The combination arm was stopped following initial analysis showing it to have similar efficacy to the tamoxifen alone arm.

The ATAC cohort included approximately 9,300 breast cancer patients from 381 medical centers worldwide who had good prognoses: 61% had lymph node-negative disease and 64% had tumors smaller than 2 cm in diameter. The most recent outcome analysis of the ATAC data, representing a median 68 months of follow-up, showed highly significant improvements in disease-free survival, recurrence-free survival, and distant disease-free survival in patients receiving anastrozole.

“In essence, the data showed that anastrozole prevents one in four of the relapses experienced by patients on tamoxifen,” said Dr. Carlson of Stanford (Calif.) University.

Another study, the MA-17 trial coordinated by the National Cancer Institute of Canada Clinical Trials Group at Queen's University, Kingston, Ont., compared the outcomes of nearly 5,200 women whose adjuvant therapy included 5 years of tamoxifen followed by 5 years of letrozole or placebo. At the median 2.5-year follow-up, patients in the letrozole group had a 40% overall reduction in their risk of metastases, compared with those in the tamoxifen/placebo group.

In the Intergroup Exemestane Study (IES) of more than 4,700 women with estrogen-receptor-positive breast cancer, patients who switched to exemestane after 2 or 3 years of taking tamoxifen for the remainder of 5 years total treatment experienced a 32% reduction in the risk of recurrence of the disease at 3 years, compared with those continuing tamoxifen for 5 years.

Because the three selective aromatase inhibitors appear to have similar antitumor efficacy and toxicity profiles, the revised guidelines do not recommend one regimen over another. When making treatment decisions, physicians should try to gauge how well the patient fits the criteria of the clinical trials on which the recommendations are based and use the regimen that most closely approximates the clinical situation, he advised.

The guidelines for adjuvant hormonal therapy in premenopausal women have been updated as well, Dr. Carlson reported. Women who are premenopausal when adjuvant hormonal therapy is initiated should receive 2–3 years of treatment with tamoxifen with or without ovarian supplementation or ablation, according to the guidelines.

“If, after the first round of adjuvant therapy with tamoxifen, a woman becomes postmenopausal, she should complete the 5 years of tamoxifen, followed by 5 years of letrozole because of the success of this regimen in postmenopausal women,” Dr. Carlson said.

Because the ovarian function of some women who appear to become postmenopausal while on tamoxifen resumes when the drug is discontinued and treatment with an aromatase inhibitor begins, serial monitoring of plasma estradiol and FSH levels should be ongoing.

ISO a Standard Definition of Menopause

Critical to the appropriate clinical application of the updated NCCN breast cancer treatment recommendations is a standardized definition of menopause.

“Just about all studies that have been done in postmenopausal women define [menopause] differently,” Dr. Carlson said.

Menopause is generally the permanent cessation of menses. “As the term is used in breast cancer management, it includes a profound and permanent decrease in ovarian estrogen synthesis,” the revised guidelines state. Reasonable criteria for determining menopause include any of the following:

▸ Prior bilateral oophorectomy.

▸ Age 60 years or older.

▸ Age younger than 60 years and amenorrheic for at least 12 months in the absence of chemotherapy, tamoxifen, toremifene, or ovarian suppression, and FSH and estradiol in the postmenopausal range.

▸ Age younger than 60 years and FSH and plasma estradiol level in postmenopausal range in women taking tamoxifen or toremifene.

It is not possible to assign menopausal status to women receiving an LHRH agonist or antagonist, the guidelines state. Amenorrhea is not a reliable indicator of menopausal status in women who are premenopausal at the outset of adjuvant chemotherapy.

“Women who undergo chemotherapy treatments that permanently stop menses may still produce estradiol at levels that are premenopausal,” said Dr. Carlson, stressing that premenopausal estrogen levels can influence treatment with aromatase inhibitors.

HOLLYWOOD, FLA. — An aromatase inhibitor, either alone or after tamoxifen therapy, is better than tamoxifen alone for the long-term prevention of breast cancer in postmenopausal women with invasive breast cancer, according to updated treatment guidelines from the National Comprehensive Cancer Network.

Several recent clinical trials have shown that adjuvant endocrine therapy with the aromatase inhibitors anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin) can significantly improve disease-free survival in postmenopausal women, compared with tamoxifen as a single agent.

Consequently, “tamoxifen alone [in this patient population] has fallen off the radar screen,” said Robert Carlson, M.D., chair of the NCCN panel that revised the guidelines, which were last updated in 2004. The network's 19 member institutions are designated as comprehensive cancer centers by the National Cancer Institute.

The updated guidelines recommend that women who are postmenopausal when they begin adjuvant therapy receive one of the following treatment regimens:

▸ Anastrozole for 5 years.

▸ Tamoxifen for 2–3 years, followed by exemestane or anastrozole to complete 5 years of therapy.

▸ Tamoxifen for 4.5–6 years, followed by letrozole for 5 years.

▸ Tamoxifen for 5 years for women with contraindications for, or who decline, aromatase inhibitors.

The new recommendations are based primarily on findings from three large randomized controlled studies of aromatase inhibitors in postmenopausal women, he said at the annual conference of the NCCN.

The Arimidex, Tamoxifen, Alone or in Combination (ATAC) trial compared anastrozole, alone or used with tamoxifen, with tamoxifen alone as 5-year adjuvant treatment for women with early breast cancer following primary treatment with surgery, radiotherapy, and/or chemotherapy. The combination arm was stopped following initial analysis showing it to have similar efficacy to the tamoxifen alone arm.

The ATAC cohort included approximately 9,300 breast cancer patients from 381 medical centers worldwide who had good prognoses: 61% had lymph node-negative disease and 64% had tumors smaller than 2 cm in diameter. The most recent outcome analysis of the ATAC data, representing a median 68 months of follow-up, showed highly significant improvements in disease-free survival, recurrence-free survival, and distant disease-free survival in patients receiving anastrozole.

“In essence, the data showed that anastrozole prevents one in four of the relapses experienced by patients on tamoxifen,” said Dr. Carlson of Stanford (Calif.) University.

Another study, the MA-17 trial coordinated by the National Cancer Institute of Canada Clinical Trials Group at Queen's University, Kingston, Ont., compared the outcomes of nearly 5,200 women whose adjuvant therapy included 5 years of tamoxifen followed by 5 years of letrozole or placebo. At the median 2.5-year follow-up, patients in the letrozole group had a 40% overall reduction in their risk of metastases, compared with those in the tamoxifen/placebo group.

In the Intergroup Exemestane Study (IES) of more than 4,700 women with estrogen-receptor-positive breast cancer, patients who switched to exemestane after 2 or 3 years of taking tamoxifen for the remainder of 5 years total treatment experienced a 32% reduction in the risk of recurrence of the disease at 3 years, compared with those continuing tamoxifen for 5 years.

Because the three selective aromatase inhibitors appear to have similar antitumor efficacy and toxicity profiles, the revised guidelines do not recommend one regimen over another. When making treatment decisions, physicians should try to gauge how well the patient fits the criteria of the clinical trials on which the recommendations are based and use the regimen that most closely approximates the clinical situation, he advised.

The guidelines for adjuvant hormonal therapy in premenopausal women have been updated as well, Dr. Carlson reported. Women who are premenopausal when adjuvant hormonal therapy is initiated should receive 2–3 years of treatment with tamoxifen with or without ovarian supplementation or ablation, according to the guidelines.

“If, after the first round of adjuvant therapy with tamoxifen, a woman becomes postmenopausal, she should complete the 5 years of tamoxifen, followed by 5 years of letrozole because of the success of this regimen in postmenopausal women,” Dr. Carlson said.

Because the ovarian function of some women who appear to become postmenopausal while on tamoxifen resumes when the drug is discontinued and treatment with an aromatase inhibitor begins, serial monitoring of plasma estradiol and FSH levels should be ongoing.

ISO a Standard Definition of Menopause

Critical to the appropriate clinical application of the updated NCCN breast cancer treatment recommendations is a standardized definition of menopause.

“Just about all studies that have been done in postmenopausal women define [menopause] differently,” Dr. Carlson said.

Menopause is generally the permanent cessation of menses. “As the term is used in breast cancer management, it includes a profound and permanent decrease in ovarian estrogen synthesis,” the revised guidelines state. Reasonable criteria for determining menopause include any of the following:

▸ Prior bilateral oophorectomy.

▸ Age 60 years or older.

▸ Age younger than 60 years and amenorrheic for at least 12 months in the absence of chemotherapy, tamoxifen, toremifene, or ovarian suppression, and FSH and estradiol in the postmenopausal range.

▸ Age younger than 60 years and FSH and plasma estradiol level in postmenopausal range in women taking tamoxifen or toremifene.

It is not possible to assign menopausal status to women receiving an LHRH agonist or antagonist, the guidelines state. Amenorrhea is not a reliable indicator of menopausal status in women who are premenopausal at the outset of adjuvant chemotherapy.

“Women who undergo chemotherapy treatments that permanently stop menses may still produce estradiol at levels that are premenopausal,” said Dr. Carlson, stressing that premenopausal estrogen levels can influence treatment with aromatase inhibitors.

HOLLYWOOD, FLA. — An aromatase inhibitor, either alone or after tamoxifen therapy, is better than tamoxifen alone for the long-term prevention of breast cancer in postmenopausal women with invasive breast cancer, according to updated treatment guidelines from the National Comprehensive Cancer Network.

Several recent clinical trials have shown that adjuvant endocrine therapy with the aromatase inhibitors anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin) can significantly improve disease-free survival in postmenopausal women, compared with tamoxifen as a single agent.

Consequently, “tamoxifen alone [in this patient population] has fallen off the radar screen,” said Robert Carlson, M.D., chair of the NCCN panel that revised the guidelines, which were last updated in 2004. The network's 19 member institutions are designated as comprehensive cancer centers by the National Cancer Institute.

The updated guidelines recommend that women who are postmenopausal when they begin adjuvant therapy receive one of the following treatment regimens:

▸ Anastrozole for 5 years.

▸ Tamoxifen for 2–3 years, followed by exemestane or anastrozole to complete 5 years of therapy.

▸ Tamoxifen for 4.5–6 years, followed by letrozole for 5 years.

▸ Tamoxifen for 5 years for women with contraindications for, or who decline, aromatase inhibitors.

The new recommendations are based primarily on findings from three large randomized controlled studies of aromatase inhibitors in postmenopausal women, he said at the annual conference of the NCCN.

The Arimidex, Tamoxifen, Alone or in Combination (ATAC) trial compared anastrozole, alone or used with tamoxifen, with tamoxifen alone as 5-year adjuvant treatment for women with early breast cancer following primary treatment with surgery, radiotherapy, and/or chemotherapy. The combination arm was stopped following initial analysis showing it to have similar efficacy to the tamoxifen alone arm.

The ATAC cohort included approximately 9,300 breast cancer patients from 381 medical centers worldwide who had good prognoses: 61% had lymph node-negative disease and 64% had tumors smaller than 2 cm in diameter. The most recent outcome analysis of the ATAC data, representing a median 68 months of follow-up, showed highly significant improvements in disease-free survival, recurrence-free survival, and distant disease-free survival in patients receiving anastrozole.

“In essence, the data showed that anastrozole prevents one in four of the relapses experienced by patients on tamoxifen,” said Dr. Carlson of Stanford (Calif.) University.

Another study, the MA-17 trial coordinated by the National Cancer Institute of Canada Clinical Trials Group at Queen's University, Kingston, Ont., compared the outcomes of nearly 5,200 women whose adjuvant therapy included 5 years of tamoxifen followed by 5 years of letrozole or placebo. At the median 2.5-year follow-up, patients in the letrozole group had a 40% overall reduction in their risk of metastases, compared with those in the tamoxifen/placebo group.

In the Intergroup Exemestane Study (IES) of more than 4,700 women with estrogen-receptor-positive breast cancer, patients who switched to exemestane after 2 or 3 years of taking tamoxifen for the remainder of 5 years total treatment experienced a 32% reduction in the risk of recurrence of the disease at 3 years, compared with those continuing tamoxifen for 5 years.

Because the three selective aromatase inhibitors appear to have similar antitumor efficacy and toxicity profiles, the revised guidelines do not recommend one regimen over another. When making treatment decisions, physicians should try to gauge how well the patient fits the criteria of the clinical trials on which the recommendations are based and use the regimen that most closely approximates the clinical situation, he advised.

The guidelines for adjuvant hormonal therapy in premenopausal women have been updated as well, Dr. Carlson reported. Women who are premenopausal when adjuvant hormonal therapy is initiated should receive 2–3 years of treatment with tamoxifen with or without ovarian supplementation or ablation, according to the guidelines.

“If, after the first round of adjuvant therapy with tamoxifen, a woman becomes postmenopausal, she should complete the 5 years of tamoxifen, followed by 5 years of letrozole because of the success of this regimen in postmenopausal women,” Dr. Carlson said.

Because the ovarian function of some women who appear to become postmenopausal while on tamoxifen resumes when the drug is discontinued and treatment with an aromatase inhibitor begins, serial monitoring of plasma estradiol and FSH levels should be ongoing.

ISO a Standard Definition of Menopause

Critical to the appropriate clinical application of the updated NCCN breast cancer treatment recommendations is a standardized definition of menopause.

“Just about all studies that have been done in postmenopausal women define [menopause] differently,” Dr. Carlson said.

Menopause is generally the permanent cessation of menses. “As the term is used in breast cancer management, it includes a profound and permanent decrease in ovarian estrogen synthesis,” the revised guidelines state. Reasonable criteria for determining menopause include any of the following:

▸ Prior bilateral oophorectomy.

▸ Age 60 years or older.

▸ Age younger than 60 years and amenorrheic for at least 12 months in the absence of chemotherapy, tamoxifen, toremifene, or ovarian suppression, and FSH and estradiol in the postmenopausal range.

▸ Age younger than 60 years and FSH and plasma estradiol level in postmenopausal range in women taking tamoxifen or toremifene.

It is not possible to assign menopausal status to women receiving an LHRH agonist or antagonist, the guidelines state. Amenorrhea is not a reliable indicator of menopausal status in women who are premenopausal at the outset of adjuvant chemotherapy.

“Women who undergo chemotherapy treatments that permanently stop menses may still produce estradiol at levels that are premenopausal,” said Dr. Carlson, stressing that premenopausal estrogen levels can influence treatment with aromatase inhibitors.

HARROGATE, ENGLAND — A single bone mineral density measurement early in menopause is a strong predictor of future bone status in women not considered at risk for osteoporosis, a study has shown.

Despite various rates of bone mineral loss among individuals and measurement sites, baseline bone mineral density (BMD) in 766 women in the Danish Osteoporosis Prevention Study predicted 75% of the variation in lumbar spine BMD and 74% of femoral neck BMD variation over 10 years, Bo Abrahamsen, M.D., reported at the annual conference of the National Osteoporosis Society.

None of the women were taking hormone therapy or antiresorptive drugs. The baseline scans were acquired within 2 years of menopause.

Baseline lumbar spine T scores greater than −1.2 were associated with a 90% negative predictive value for developing osteoporosis over 10 years, whereas scores greater than 0.5 had a negative predictive value of 100%. A baseline femoral neck T score greater than -1.7 had a 90% negative predictive value for femoral neck osteoporosis. “No women developed femoral neck osteoporosis in the absence of baseline femoral neck osteopenia,” said Dr. Abrahamsen of Odense (Denmark) University Hospital.

At baseline, a lumbar spine T score greater than −1.0 or a femoral neck T score greater than −0.5 was associated with a 90% negative predictive value for osteoporosis of the lumbar spine and/or the femoral neck. “Women with lumbar spine osteopenia at baseline had a 46% risk for developing osteoporosis of the femoral neck or lumbar spine,” Dr. Abrahamsen explained.

At the same time, fewer than 10% of women whose spine or femoral neck T scores dipped below −2.5 within 10 years had spinal osteopenia at their initial visit, Dr. Abrahamsen said.

The findings support the role of BMD measurements in the first years after menopause, he said. “There is an increasing demand for [bone density measurement] with the onset of menopause due to concerns about the safety of hormone replacement therapy and a possible need for considering other treatment,” he said. “These results tell us that much of the variation in future bone mineral density can be predicted by baseline BMD.”

As such, baseline measures should be considered for long-term treatment planning, he concluded.

HARROGATE, ENGLAND — A single bone mineral density measurement early in menopause is a strong predictor of future bone status in women not considered at risk for osteoporosis, a study has shown.

Despite various rates of bone mineral loss among individuals and measurement sites, baseline bone mineral density (BMD) in 766 women in the Danish Osteoporosis Prevention Study predicted 75% of the variation in lumbar spine BMD and 74% of femoral neck BMD variation over 10 years, Bo Abrahamsen, M.D., reported at the annual conference of the National Osteoporosis Society.

None of the women were taking hormone therapy or antiresorptive drugs. The baseline scans were acquired within 2 years of menopause.

Baseline lumbar spine T scores greater than −1.2 were associated with a 90% negative predictive value for developing osteoporosis over 10 years, whereas scores greater than 0.5 had a negative predictive value of 100%. A baseline femoral neck T score greater than -1.7 had a 90% negative predictive value for femoral neck osteoporosis. “No women developed femoral neck osteoporosis in the absence of baseline femoral neck osteopenia,” said Dr. Abrahamsen of Odense (Denmark) University Hospital.

At baseline, a lumbar spine T score greater than −1.0 or a femoral neck T score greater than −0.5 was associated with a 90% negative predictive value for osteoporosis of the lumbar spine and/or the femoral neck. “Women with lumbar spine osteopenia at baseline had a 46% risk for developing osteoporosis of the femoral neck or lumbar spine,” Dr. Abrahamsen explained.

At the same time, fewer than 10% of women whose spine or femoral neck T scores dipped below −2.5 within 10 years had spinal osteopenia at their initial visit, Dr. Abrahamsen said.

The findings support the role of BMD measurements in the first years after menopause, he said. “There is an increasing demand for [bone density measurement] with the onset of menopause due to concerns about the safety of hormone replacement therapy and a possible need for considering other treatment,” he said. “These results tell us that much of the variation in future bone mineral density can be predicted by baseline BMD.”

As such, baseline measures should be considered for long-term treatment planning, he concluded.

HARROGATE, ENGLAND — A single bone mineral density measurement early in menopause is a strong predictor of future bone status in women not considered at risk for osteoporosis, a study has shown.

Despite various rates of bone mineral loss among individuals and measurement sites, baseline bone mineral density (BMD) in 766 women in the Danish Osteoporosis Prevention Study predicted 75% of the variation in lumbar spine BMD and 74% of femoral neck BMD variation over 10 years, Bo Abrahamsen, M.D., reported at the annual conference of the National Osteoporosis Society.

None of the women were taking hormone therapy or antiresorptive drugs. The baseline scans were acquired within 2 years of menopause.

Baseline lumbar spine T scores greater than −1.2 were associated with a 90% negative predictive value for developing osteoporosis over 10 years, whereas scores greater than 0.5 had a negative predictive value of 100%. A baseline femoral neck T score greater than -1.7 had a 90% negative predictive value for femoral neck osteoporosis. “No women developed femoral neck osteoporosis in the absence of baseline femoral neck osteopenia,” said Dr. Abrahamsen of Odense (Denmark) University Hospital.

At baseline, a lumbar spine T score greater than −1.0 or a femoral neck T score greater than −0.5 was associated with a 90% negative predictive value for osteoporosis of the lumbar spine and/or the femoral neck. “Women with lumbar spine osteopenia at baseline had a 46% risk for developing osteoporosis of the femoral neck or lumbar spine,” Dr. Abrahamsen explained.

At the same time, fewer than 10% of women whose spine or femoral neck T scores dipped below −2.5 within 10 years had spinal osteopenia at their initial visit, Dr. Abrahamsen said.

The findings support the role of BMD measurements in the first years after menopause, he said. “There is an increasing demand for [bone density measurement] with the onset of menopause due to concerns about the safety of hormone replacement therapy and a possible need for considering other treatment,” he said. “These results tell us that much of the variation in future bone mineral density can be predicted by baseline BMD.”

As such, baseline measures should be considered for long-term treatment planning, he concluded.

BOSTON — A program of regular, low-impact exercise can improve mood and executive functioning in older adults with osteoporosis, according to research in a poster presentation at the annual meeting of the Society of Behavioral Medicine.

Of 16 elderly residents with osteoporosis living independently in a multilevel health care facility, the 8 individuals randomized to an osteoporosis exercise intervention two to three times per week for 3 weeks experienced improvements in working memory and self-reported quality of life measures, compared with the 8 individuals assigned to the wait-list control condition, reported Dana B. Kazmerski and her colleagues.

The median age of participants in the study was 84. All of the participants underwent baseline and postintervention screening for cognitive function using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) measure, and for depression and mood swings using the Beck Depression Inventory (BDI), the Geriatric Depression Scale (GDS), and the Wisconsin Quality of Life Index (W-QLI). There were no significant differences between the groups in the preintervention measures.

Postintervention, the exercise group showed significant improvements on the RBANS coding subtest, which measures information-processing speed, and on the quality of life depression and mood swing measures. Repeated ANOVA measures showed no significant impact on the results of potential covariates, including age, gender, and level of education.

The results of the study are consistent with those of investigations linking exercise to increased executive functioning and extend such findings to the current aging population with osteoporosis, noted Ms. Kazmerski who authored the study with Cay Anderson-Hanley, Ph.D., both of Union College in Schenectady, New York.

“Exercise has repeatedly been shown to be beneficial in improving the quality of living of individuals who suffer from late-onset diseases, such as Alzheimer's disease and dementia, but the potential cognitive benefits of exercise for people with osteoporosis—a leading health care concern—has received virtually no attention,” said Ms. Kazmerski. “The improvements [we] found in mood and executive functioning suggest that an osteoporosis exercise program may not only provide protection against brittle, thin bones, but perhaps can also help improve quality of life in terms of less depression, greater stability of mood, and improved working memory.”

The study is limited by its small size and possible self-selection participation bias, as well as its focus specifically on a low-impact osteoporosis exercise program, which may not be generalizable to other exercise regimens, Ms. Kazmerski noted.

In the future, the investigators hope to replicate the findings with a larger sample to examine long-term changes in exercise habits and to evaluate whether the observed cognitive and mood benefits are long lasting, Ms. Kazmerski concluded.

BOSTON — A program of regular, low-impact exercise can improve mood and executive functioning in older adults with osteoporosis, according to research in a poster presentation at the annual meeting of the Society of Behavioral Medicine.

Of 16 elderly residents with osteoporosis living independently in a multilevel health care facility, the 8 individuals randomized to an osteoporosis exercise intervention two to three times per week for 3 weeks experienced improvements in working memory and self-reported quality of life measures, compared with the 8 individuals assigned to the wait-list control condition, reported Dana B. Kazmerski and her colleagues.

The median age of participants in the study was 84. All of the participants underwent baseline and postintervention screening for cognitive function using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) measure, and for depression and mood swings using the Beck Depression Inventory (BDI), the Geriatric Depression Scale (GDS), and the Wisconsin Quality of Life Index (W-QLI). There were no significant differences between the groups in the preintervention measures.

Postintervention, the exercise group showed significant improvements on the RBANS coding subtest, which measures information-processing speed, and on the quality of life depression and mood swing measures. Repeated ANOVA measures showed no significant impact on the results of potential covariates, including age, gender, and level of education.

The results of the study are consistent with those of investigations linking exercise to increased executive functioning and extend such findings to the current aging population with osteoporosis, noted Ms. Kazmerski who authored the study with Cay Anderson-Hanley, Ph.D., both of Union College in Schenectady, New York.

“Exercise has repeatedly been shown to be beneficial in improving the quality of living of individuals who suffer from late-onset diseases, such as Alzheimer's disease and dementia, but the potential cognitive benefits of exercise for people with osteoporosis—a leading health care concern—has received virtually no attention,” said Ms. Kazmerski. “The improvements [we] found in mood and executive functioning suggest that an osteoporosis exercise program may not only provide protection against brittle, thin bones, but perhaps can also help improve quality of life in terms of less depression, greater stability of mood, and improved working memory.”

The study is limited by its small size and possible self-selection participation bias, as well as its focus specifically on a low-impact osteoporosis exercise program, which may not be generalizable to other exercise regimens, Ms. Kazmerski noted.

In the future, the investigators hope to replicate the findings with a larger sample to examine long-term changes in exercise habits and to evaluate whether the observed cognitive and mood benefits are long lasting, Ms. Kazmerski concluded.

BOSTON — A program of regular, low-impact exercise can improve mood and executive functioning in older adults with osteoporosis, according to research in a poster presentation at the annual meeting of the Society of Behavioral Medicine.

Of 16 elderly residents with osteoporosis living independently in a multilevel health care facility, the 8 individuals randomized to an osteoporosis exercise intervention two to three times per week for 3 weeks experienced improvements in working memory and self-reported quality of life measures, compared with the 8 individuals assigned to the wait-list control condition, reported Dana B. Kazmerski and her colleagues.

The median age of participants in the study was 84. All of the participants underwent baseline and postintervention screening for cognitive function using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) measure, and for depression and mood swings using the Beck Depression Inventory (BDI), the Geriatric Depression Scale (GDS), and the Wisconsin Quality of Life Index (W-QLI). There were no significant differences between the groups in the preintervention measures.

Postintervention, the exercise group showed significant improvements on the RBANS coding subtest, which measures information-processing speed, and on the quality of life depression and mood swing measures. Repeated ANOVA measures showed no significant impact on the results of potential covariates, including age, gender, and level of education.

The results of the study are consistent with those of investigations linking exercise to increased executive functioning and extend such findings to the current aging population with osteoporosis, noted Ms. Kazmerski who authored the study with Cay Anderson-Hanley, Ph.D., both of Union College in Schenectady, New York.

“Exercise has repeatedly been shown to be beneficial in improving the quality of living of individuals who suffer from late-onset diseases, such as Alzheimer's disease and dementia, but the potential cognitive benefits of exercise for people with osteoporosis—a leading health care concern—has received virtually no attention,” said Ms. Kazmerski. “The improvements [we] found in mood and executive functioning suggest that an osteoporosis exercise program may not only provide protection against brittle, thin bones, but perhaps can also help improve quality of life in terms of less depression, greater stability of mood, and improved working memory.”

The study is limited by its small size and possible self-selection participation bias, as well as its focus specifically on a low-impact osteoporosis exercise program, which may not be generalizable to other exercise regimens, Ms. Kazmerski noted.

In the future, the investigators hope to replicate the findings with a larger sample to examine long-term changes in exercise habits and to evaluate whether the observed cognitive and mood benefits are long lasting, Ms. Kazmerski concluded.

BOSTON — The use of simple screening instruments in the emergency department setting could aid in the recognition of mental health disorders, a study has shown.

And subsequent referral to mental health services of patients who screen positive would likely have a significant public health impact, as many of them might otherwise go undiagnosed and untreated, Edwin Boudreaux, Ph.D., said in a presentation at the annual meeting of the Society for Behavioral Medicine.

In a prospective, multicenter trial, 28% of consecutive adult patients presenting to an urban emergency department during a 3-week period screened positive for depression, and 7% screened positive for bipolar disorder using brief mood disorder screening instruments, reported Dr. Boudreaux of Cooper Hospital and the Robert Wood Johnson Medical School in Camden (N.J.). The results of the brief screens were then measured against those of validated screening tools to assess the utility of the screens.

The cross-sectional study of patients 18 years or older excluded those who were severely ill or who had altered mental status upon presentation to the emergency department. The initial interview of patients meeting study criteria included the Mood Disorder Questionnaire (MDQ) to screen for bipolar disorder and a depression screener comprising the two questions recommended by the U.S. Preventive Health Services Task Force: Over the past few weeks, have you felt down, depressed, or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things?

To test the validity of the results of the initial screen, investigators contacted all of the patients 3–5 days postvisit and rescreened them using the self-report Center for Epidemiologic Studies Depression (CES-D) scale and the Bipolar Spectrum Diagnostic Scale (BSDS).

Of the 243 patients enrolled, 69 screened positive for depression and 18 screened positive for bipolar disorder based on emergency department interviews.

“The depression screener possessed very strong test characteristics,” said Dr. Boudreaux, noting that the sensitivity and specificity were 91% and 67%, respectively, and the positive and negative predictive values were 91% and 67%, respectively, when measured against the results from the validated tools.

The MDQ standard scoring yielded many false negatives, with a sensitivity of only 21%. Specificity and positive predictive value were both 100%, and negative predictive value was 78%. However, Dr. Boudreaux noted, “alternate scoring helped address this problem” by increasing the sensitivity of the MDQ results to 50%, while reducing the specificity only slightly to 97%.

The results justify the expansion of research efforts on screening, assessment, and emergency department-based brief interventions for affective disorders, said Dr. Boudreaux.

“The MDQ is unlikely to be adopted into routine clinical care in the ED because of its length [three multi-item questions], but the rapid depression screener only consists of two questions,” he said. “I could see such a [tool] being promoted for routine screening, similar to the CAGE alcohol screen.”

The four-question CAGE screening instrument “is already routinely used in practice and has gained widespread acceptance across most fields of medicine,” Dr. Boudreaux said. “It seems as though a similar trend could occur with the depression screening, especially when one considers that depression is more common than alcoholism.”

Dr. Boudreaux and colleagues plan to extend their research by validating the screening instruments against structured clinical interviews.

BOSTON — The use of simple screening instruments in the emergency department setting could aid in the recognition of mental health disorders, a study has shown.

And subsequent referral to mental health services of patients who screen positive would likely have a significant public health impact, as many of them might otherwise go undiagnosed and untreated, Edwin Boudreaux, Ph.D., said in a presentation at the annual meeting of the Society for Behavioral Medicine.

In a prospective, multicenter trial, 28% of consecutive adult patients presenting to an urban emergency department during a 3-week period screened positive for depression, and 7% screened positive for bipolar disorder using brief mood disorder screening instruments, reported Dr. Boudreaux of Cooper Hospital and the Robert Wood Johnson Medical School in Camden (N.J.). The results of the brief screens were then measured against those of validated screening tools to assess the utility of the screens.

The cross-sectional study of patients 18 years or older excluded those who were severely ill or who had altered mental status upon presentation to the emergency department. The initial interview of patients meeting study criteria included the Mood Disorder Questionnaire (MDQ) to screen for bipolar disorder and a depression screener comprising the two questions recommended by the U.S. Preventive Health Services Task Force: Over the past few weeks, have you felt down, depressed, or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things?

To test the validity of the results of the initial screen, investigators contacted all of the patients 3–5 days postvisit and rescreened them using the self-report Center for Epidemiologic Studies Depression (CES-D) scale and the Bipolar Spectrum Diagnostic Scale (BSDS).

Of the 243 patients enrolled, 69 screened positive for depression and 18 screened positive for bipolar disorder based on emergency department interviews.

“The depression screener possessed very strong test characteristics,” said Dr. Boudreaux, noting that the sensitivity and specificity were 91% and 67%, respectively, and the positive and negative predictive values were 91% and 67%, respectively, when measured against the results from the validated tools.

The MDQ standard scoring yielded many false negatives, with a sensitivity of only 21%. Specificity and positive predictive value were both 100%, and negative predictive value was 78%. However, Dr. Boudreaux noted, “alternate scoring helped address this problem” by increasing the sensitivity of the MDQ results to 50%, while reducing the specificity only slightly to 97%.

The results justify the expansion of research efforts on screening, assessment, and emergency department-based brief interventions for affective disorders, said Dr. Boudreaux.

“The MDQ is unlikely to be adopted into routine clinical care in the ED because of its length [three multi-item questions], but the rapid depression screener only consists of two questions,” he said. “I could see such a [tool] being promoted for routine screening, similar to the CAGE alcohol screen.”

The four-question CAGE screening instrument “is already routinely used in practice and has gained widespread acceptance across most fields of medicine,” Dr. Boudreaux said. “It seems as though a similar trend could occur with the depression screening, especially when one considers that depression is more common than alcoholism.”

Dr. Boudreaux and colleagues plan to extend their research by validating the screening instruments against structured clinical interviews.

BOSTON — The use of simple screening instruments in the emergency department setting could aid in the recognition of mental health disorders, a study has shown.

And subsequent referral to mental health services of patients who screen positive would likely have a significant public health impact, as many of them might otherwise go undiagnosed and untreated, Edwin Boudreaux, Ph.D., said in a presentation at the annual meeting of the Society for Behavioral Medicine.

In a prospective, multicenter trial, 28% of consecutive adult patients presenting to an urban emergency department during a 3-week period screened positive for depression, and 7% screened positive for bipolar disorder using brief mood disorder screening instruments, reported Dr. Boudreaux of Cooper Hospital and the Robert Wood Johnson Medical School in Camden (N.J.). The results of the brief screens were then measured against those of validated screening tools to assess the utility of the screens.

The cross-sectional study of patients 18 years or older excluded those who were severely ill or who had altered mental status upon presentation to the emergency department. The initial interview of patients meeting study criteria included the Mood Disorder Questionnaire (MDQ) to screen for bipolar disorder and a depression screener comprising the two questions recommended by the U.S. Preventive Health Services Task Force: Over the past few weeks, have you felt down, depressed, or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things?

To test the validity of the results of the initial screen, investigators contacted all of the patients 3–5 days postvisit and rescreened them using the self-report Center for Epidemiologic Studies Depression (CES-D) scale and the Bipolar Spectrum Diagnostic Scale (BSDS).

Of the 243 patients enrolled, 69 screened positive for depression and 18 screened positive for bipolar disorder based on emergency department interviews.

“The depression screener possessed very strong test characteristics,” said Dr. Boudreaux, noting that the sensitivity and specificity were 91% and 67%, respectively, and the positive and negative predictive values were 91% and 67%, respectively, when measured against the results from the validated tools.

The MDQ standard scoring yielded many false negatives, with a sensitivity of only 21%. Specificity and positive predictive value were both 100%, and negative predictive value was 78%. However, Dr. Boudreaux noted, “alternate scoring helped address this problem” by increasing the sensitivity of the MDQ results to 50%, while reducing the specificity only slightly to 97%.

The results justify the expansion of research efforts on screening, assessment, and emergency department-based brief interventions for affective disorders, said Dr. Boudreaux.

“The MDQ is unlikely to be adopted into routine clinical care in the ED because of its length [three multi-item questions], but the rapid depression screener only consists of two questions,” he said. “I could see such a [tool] being promoted for routine screening, similar to the CAGE alcohol screen.”

The four-question CAGE screening instrument “is already routinely used in practice and has gained widespread acceptance across most fields of medicine,” Dr. Boudreaux said. “It seems as though a similar trend could occur with the depression screening, especially when one considers that depression is more common than alcoholism.”

Dr. Boudreaux and colleagues plan to extend their research by validating the screening instruments against structured clinical interviews.

BOSTON – A program of regular, low-impact exercise can improve mood and executive functioning in older adults with osteoporosis, according to research in a poster presentation at the annual meeting of the Society of Behavioral Medicine.

Of 16 elderly residents with osteoporosis living independently in a multilevel health care facility, the 8 individuals randomized to an osteoporosis exercise intervention two to three times per week for 3 weeks experienced improvements in working memory and self-reported quality of life measures, compared with the 8 individuals assigned to the wait-list control condition, reported Dana B. Kazmerski and her colleagues.

The median age of participants in the study was 84. All of the participants underwent baseline and postintervention screening for cognitive function using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) measure, and for depression and mood swings using the Beck Depression Inventory (BDI), the Geriatric Depression Scale (GDS), and the Wisconsin Quality of Life Index (W-QLI). There were no significant differences between the groups in the preintervention measures.

Postintervention, the exercise group showed significant improvements on the RBANS coding subtest, which measures information-processing speed, and on the quality of life depression and mood swing measures. Repeated ANOVA measures showed no significant impact on the results of potential covariates.

The results of the study are consistent with those of investigations linking exercise to increased executive functioning and extend such findings to the current aging population with osteoporosis, noted Ms. Kazmerski who authored the study with Cay Anderson-Hanley, Ph.D., both of Union College in Schenectady, New York.

“The improvements [we] found in mood and executive functioning suggest that an osteoporosis exercise program may not only provide protection against brittle, thin bones, but perhaps can also help improve quality of life in terms of less depression and improved working memory,” Ms. Kazmerski said.

BOSTON – A program of regular, low-impact exercise can improve mood and executive functioning in older adults with osteoporosis, according to research in a poster presentation at the annual meeting of the Society of Behavioral Medicine.

Of 16 elderly residents with osteoporosis living independently in a multilevel health care facility, the 8 individuals randomized to an osteoporosis exercise intervention two to three times per week for 3 weeks experienced improvements in working memory and self-reported quality of life measures, compared with the 8 individuals assigned to the wait-list control condition, reported Dana B. Kazmerski and her colleagues.

The median age of participants in the study was 84. All of the participants underwent baseline and postintervention screening for cognitive function using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) measure, and for depression and mood swings using the Beck Depression Inventory (BDI), the Geriatric Depression Scale (GDS), and the Wisconsin Quality of Life Index (W-QLI). There were no significant differences between the groups in the preintervention measures.

Postintervention, the exercise group showed significant improvements on the RBANS coding subtest, which measures information-processing speed, and on the quality of life depression and mood swing measures. Repeated ANOVA measures showed no significant impact on the results of potential covariates.

The results of the study are consistent with those of investigations linking exercise to increased executive functioning and extend such findings to the current aging population with osteoporosis, noted Ms. Kazmerski who authored the study with Cay Anderson-Hanley, Ph.D., both of Union College in Schenectady, New York.

“The improvements [we] found in mood and executive functioning suggest that an osteoporosis exercise program may not only provide protection against brittle, thin bones, but perhaps can also help improve quality of life in terms of less depression and improved working memory,” Ms. Kazmerski said.

BOSTON – A program of regular, low-impact exercise can improve mood and executive functioning in older adults with osteoporosis, according to research in a poster presentation at the annual meeting of the Society of Behavioral Medicine.

Of 16 elderly residents with osteoporosis living independently in a multilevel health care facility, the 8 individuals randomized to an osteoporosis exercise intervention two to three times per week for 3 weeks experienced improvements in working memory and self-reported quality of life measures, compared with the 8 individuals assigned to the wait-list control condition, reported Dana B. Kazmerski and her colleagues.

The median age of participants in the study was 84. All of the participants underwent baseline and postintervention screening for cognitive function using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) measure, and for depression and mood swings using the Beck Depression Inventory (BDI), the Geriatric Depression Scale (GDS), and the Wisconsin Quality of Life Index (W-QLI). There were no significant differences between the groups in the preintervention measures.

Postintervention, the exercise group showed significant improvements on the RBANS coding subtest, which measures information-processing speed, and on the quality of life depression and mood swing measures. Repeated ANOVA measures showed no significant impact on the results of potential covariates.

The results of the study are consistent with those of investigations linking exercise to increased executive functioning and extend such findings to the current aging population with osteoporosis, noted Ms. Kazmerski who authored the study with Cay Anderson-Hanley, Ph.D., both of Union College in Schenectady, New York.

“The improvements [we] found in mood and executive functioning suggest that an osteoporosis exercise program may not only provide protection against brittle, thin bones, but perhaps can also help improve quality of life in terms of less depression and improved working memory,” Ms. Kazmerski said.

HARROGATE, ENGLAND — Women whose Pap smears reveal atrophic cell patterns may be at greater risk for osteopenia and osteoporosis than women whose smears show mature cell patterns, a study has shown.

The findings suggest that routine Pap testing could be a useful and inexpensive screening tool for identifying women at risk for the degenerative bone disorders, Alenka Repse-Fokter, M.D., reported in a poster presentation at the annual conference of the National Osteoporosis Society.

Given limited medical resources, the ability to use an already existing and widely performed screening protocol to help identify women with osteoporosis “would be highly appreciated,” she said.

Dr. Repse-Fokter and colleagues at Celje (Slovenia) General Hospital assessed the Pap smear results and dual-energy x-ray absorptiometry (DXA) bone density measurements of 66 women aged 46–67 years. The women had received the Pap smears for routine cervical cancer screening and were invited to undergo bone mineral density measurement as part of the investigation. None of the women used hormonal contraception or hormone therapy.

The investigators grouped the smears into atrophic and mature cell patterns, which can be easily recognized during the screening for cervical dysplasia or cancer, Dr. Repse-Fokter said. “In routine light microscopy, atrophic cells appear much smaller than cells in mature smear patterns,” she noted. The smear patterns were then compared with the patients' T values measured by DXA on the femoral neck and lumbar spine.

Overall, the T scores were significantly lower in the atrophic smear group. Of the 33 women with atrophic smears, 13 had osteopenia and 15 had osteoporosis. Among the 33 women whose smears showed mature cell patterns, 9 had osteopenia and 24 had normal bone density. The sensitivity, specificity, and positive predictive value of the findings were, respectively, 76%, 83%, and 85%.

The findings of a correlation between smear patterns and degenerative bone disease support the investigators' findings from a previous study that revealed a highly significant association between atrophic smear patterns and low bone mineral density.

“This means that a significant number of women with low bone mineral density who are at high risk [for osteoporotic disease] could be identified in parallel with routine Pap testing for cervical cancer screening without added costs,” Dr. Repse-Fokter said.

Although further studies on larger populations are needed, “we strongly suggest that women with atrophic Pap smear patterns be closely followed as recommended by the American National Osteoporosis Foundation,” according to Dr. Repse-Fokter and her colleagues.

HARROGATE, ENGLAND — Women whose Pap smears reveal atrophic cell patterns may be at greater risk for osteopenia and osteoporosis than women whose smears show mature cell patterns, a study has shown.

The findings suggest that routine Pap testing could be a useful and inexpensive screening tool for identifying women at risk for the degenerative bone disorders, Alenka Repse-Fokter, M.D., reported in a poster presentation at the annual conference of the National Osteoporosis Society.

Given limited medical resources, the ability to use an already existing and widely performed screening protocol to help identify women with osteoporosis “would be highly appreciated,” she said.

Dr. Repse-Fokter and colleagues at Celje (Slovenia) General Hospital assessed the Pap smear results and dual-energy x-ray absorptiometry (DXA) bone density measurements of 66 women aged 46–67 years. The women had received the Pap smears for routine cervical cancer screening and were invited to undergo bone mineral density measurement as part of the investigation. None of the women used hormonal contraception or hormone therapy.

The investigators grouped the smears into atrophic and mature cell patterns, which can be easily recognized during the screening for cervical dysplasia or cancer, Dr. Repse-Fokter said. “In routine light microscopy, atrophic cells appear much smaller than cells in mature smear patterns,” she noted. The smear patterns were then compared with the patients' T values measured by DXA on the femoral neck and lumbar spine.

Overall, the T scores were significantly lower in the atrophic smear group. Of the 33 women with atrophic smears, 13 had osteopenia and 15 had osteoporosis. Among the 33 women whose smears showed mature cell patterns, 9 had osteopenia and 24 had normal bone density. The sensitivity, specificity, and positive predictive value of the findings were, respectively, 76%, 83%, and 85%.

The findings of a correlation between smear patterns and degenerative bone disease support the investigators' findings from a previous study that revealed a highly significant association between atrophic smear patterns and low bone mineral density.

“This means that a significant number of women with low bone mineral density who are at high risk [for osteoporotic disease] could be identified in parallel with routine Pap testing for cervical cancer screening without added costs,” Dr. Repse-Fokter said.

Although further studies on larger populations are needed, “we strongly suggest that women with atrophic Pap smear patterns be closely followed as recommended by the American National Osteoporosis Foundation,” according to Dr. Repse-Fokter and her colleagues.

HARROGATE, ENGLAND — Women whose Pap smears reveal atrophic cell patterns may be at greater risk for osteopenia and osteoporosis than women whose smears show mature cell patterns, a study has shown.

The findings suggest that routine Pap testing could be a useful and inexpensive screening tool for identifying women at risk for the degenerative bone disorders, Alenka Repse-Fokter, M.D., reported in a poster presentation at the annual conference of the National Osteoporosis Society.

Given limited medical resources, the ability to use an already existing and widely performed screening protocol to help identify women with osteoporosis “would be highly appreciated,” she said.

Dr. Repse-Fokter and colleagues at Celje (Slovenia) General Hospital assessed the Pap smear results and dual-energy x-ray absorptiometry (DXA) bone density measurements of 66 women aged 46–67 years. The women had received the Pap smears for routine cervical cancer screening and were invited to undergo bone mineral density measurement as part of the investigation. None of the women used hormonal contraception or hormone therapy.

The investigators grouped the smears into atrophic and mature cell patterns, which can be easily recognized during the screening for cervical dysplasia or cancer, Dr. Repse-Fokter said. “In routine light microscopy, atrophic cells appear much smaller than cells in mature smear patterns,” she noted. The smear patterns were then compared with the patients' T values measured by DXA on the femoral neck and lumbar spine.

Overall, the T scores were significantly lower in the atrophic smear group. Of the 33 women with atrophic smears, 13 had osteopenia and 15 had osteoporosis. Among the 33 women whose smears showed mature cell patterns, 9 had osteopenia and 24 had normal bone density. The sensitivity, specificity, and positive predictive value of the findings were, respectively, 76%, 83%, and 85%.

The findings of a correlation between smear patterns and degenerative bone disease support the investigators' findings from a previous study that revealed a highly significant association between atrophic smear patterns and low bone mineral density.

“This means that a significant number of women with low bone mineral density who are at high risk [for osteoporotic disease] could be identified in parallel with routine Pap testing for cervical cancer screening without added costs,” Dr. Repse-Fokter said.

Although further studies on larger populations are needed, “we strongly suggest that women with atrophic Pap smear patterns be closely followed as recommended by the American National Osteoporosis Foundation,” according to Dr. Repse-Fokter and her colleagues.

BERLIN — The most common second-generation antipsychotics prescribed to young people with various psychotic, mood, and behavioral disorders adversely affect all components of body composition and lead to dyslipidemia in this patient population, a study has shown.

Youths who have never taken antipsychotics and those cotreated with olanzapine (Zyprexa) and divalproex (Depakote) who experience significant early weight gain are at highest risk for the metabolic changes, Christoph U. Correll, M.D., said in a presentation at the 16th World Congress of the International Association for Child and Adolescent Psychiatry and Allied Professions.

“Second-generation antipsychotics are widely used in young patients, but limited comparative data exist on their effects on body composition and lipid metabolism,” said Dr. Correll of Zucker Hillside Hospital in Glen Oaks, N.Y. He, along with his colleagues, prospectively evaluated the relative effects on these factors of olanzapine, risperidone (Risperdal), or quetiapine (Seroquel)—the three most widely prescribed drugs in this particular class.

The open-label study included youths between the ages of 5 and 18 years with a DSM-IV diagnosis of psychotic, mood, and/or disruptive behavior disorders who had begun or switched to treatment with one of the three medications within 7 days of the start of the investigation. Exclusion criteria included a history of any eating disorder, active thyroid or severe medical disorder, and pregnancy.

All subjects were assessed at baseline and monthly for height, weight, body mass index, total fat mass and percentage fat (via bioimpedance measurement), and waist circumference. In addition, fasting blood leptin, prolactin, and antipsychotic serum levels were measured at baseline, week 4, and week 12.

After 12 weeks of treatment, the weight, body mass index (BMI), fat mass and percentage fat, and waist circumference of all of the 174 youth in the study—including 57 on olanzapine, 70 on risperidone, and 47 on quetiapine—increased significantly, Dr. Correll said. The greatest increase in all measures was seen in those youths taking olanzapine, followed by risperidone, then quetiapine, he said. Additionally, nearly 81% of the subjects taking olanzapine experienced extreme weight gain—described as an increase in weight from baseline of 7% or more—compared with 57% and 43% of risperidone and quetiapine subjects, respectively.

All of the study participants experienced significant increases in total cholesterol, LDL cholesterol, and triglycerides. A separate analysis comparing pretreated and antipsychotic-naive patients showed that only the olanzapine-induced cholesterol and triglyceride increases remained significant. “Nevertheless, 19.9% of the youths experienced new-onset dyslipidemia, with similar rates for all three drugs,” Dr. Correll reported.

Multiple regression analysis identified the following correlates of weight gain: weight increase at 4 weeks, baseline-to-end increases in leptin, antipsychotic naive status, olanzapine treatment, and divalproex cotreatment.

With respect to lipids, predictors for both cholesterol increase and for triglyceride increase were a low baseline cholesterol level, antidepressant cotreatment, and a 12-week BMI change. Male gender was a predictor for cholesterol increase only.

“Clearly what we're seeing is that these drugs have an impact on all aspects of body composition, and they lead to dyslipidemia, which further increases the cardiovascular risk profile. We're not suggesting they shouldn't be used because obviously these drugs have an important role, but they should be used carefully, and these side effects should be monitored regularly.

“Pretreatment dietary and lifestyle counseling, particularly among those at highest risk, cannot be overlooked,” Dr. Correll concluded.

BERLIN — The most common second-generation antipsychotics prescribed to young people with various psychotic, mood, and behavioral disorders adversely affect all components of body composition and lead to dyslipidemia in this patient population, a study has shown.

Youths who have never taken antipsychotics and those cotreated with olanzapine (Zyprexa) and divalproex (Depakote) who experience significant early weight gain are at highest risk for the metabolic changes, Christoph U. Correll, M.D., said in a presentation at the 16th World Congress of the International Association for Child and Adolescent Psychiatry and Allied Professions.

“Second-generation antipsychotics are widely used in young patients, but limited comparative data exist on their effects on body composition and lipid metabolism,” said Dr. Correll of Zucker Hillside Hospital in Glen Oaks, N.Y. He, along with his colleagues, prospectively evaluated the relative effects on these factors of olanzapine, risperidone (Risperdal), or quetiapine (Seroquel)—the three most widely prescribed drugs in this particular class.

The open-label study included youths between the ages of 5 and 18 years with a DSM-IV diagnosis of psychotic, mood, and/or disruptive behavior disorders who had begun or switched to treatment with one of the three medications within 7 days of the start of the investigation. Exclusion criteria included a history of any eating disorder, active thyroid or severe medical disorder, and pregnancy.

All subjects were assessed at baseline and monthly for height, weight, body mass index, total fat mass and percentage fat (via bioimpedance measurement), and waist circumference. In addition, fasting blood leptin, prolactin, and antipsychotic serum levels were measured at baseline, week 4, and week 12.

After 12 weeks of treatment, the weight, body mass index (BMI), fat mass and percentage fat, and waist circumference of all of the 174 youth in the study—including 57 on olanzapine, 70 on risperidone, and 47 on quetiapine—increased significantly, Dr. Correll said. The greatest increase in all measures was seen in those youths taking olanzapine, followed by risperidone, then quetiapine, he said. Additionally, nearly 81% of the subjects taking olanzapine experienced extreme weight gain—described as an increase in weight from baseline of 7% or more—compared with 57% and 43% of risperidone and quetiapine subjects, respectively.

All of the study participants experienced significant increases in total cholesterol, LDL cholesterol, and triglycerides. A separate analysis comparing pretreated and antipsychotic-naive patients showed that only the olanzapine-induced cholesterol and triglyceride increases remained significant. “Nevertheless, 19.9% of the youths experienced new-onset dyslipidemia, with similar rates for all three drugs,” Dr. Correll reported.

Multiple regression analysis identified the following correlates of weight gain: weight increase at 4 weeks, baseline-to-end increases in leptin, antipsychotic naive status, olanzapine treatment, and divalproex cotreatment.

With respect to lipids, predictors for both cholesterol increase and for triglyceride increase were a low baseline cholesterol level, antidepressant cotreatment, and a 12-week BMI change. Male gender was a predictor for cholesterol increase only.

“Clearly what we're seeing is that these drugs have an impact on all aspects of body composition, and they lead to dyslipidemia, which further increases the cardiovascular risk profile. We're not suggesting they shouldn't be used because obviously these drugs have an important role, but they should be used carefully, and these side effects should be monitored regularly.

“Pretreatment dietary and lifestyle counseling, particularly among those at highest risk, cannot be overlooked,” Dr. Correll concluded.

BERLIN — The most common second-generation antipsychotics prescribed to young people with various psychotic, mood, and behavioral disorders adversely affect all components of body composition and lead to dyslipidemia in this patient population, a study has shown.

Youths who have never taken antipsychotics and those cotreated with olanzapine (Zyprexa) and divalproex (Depakote) who experience significant early weight gain are at highest risk for the metabolic changes, Christoph U. Correll, M.D., said in a presentation at the 16th World Congress of the International Association for Child and Adolescent Psychiatry and Allied Professions.

“Second-generation antipsychotics are widely used in young patients, but limited comparative data exist on their effects on body composition and lipid metabolism,” said Dr. Correll of Zucker Hillside Hospital in Glen Oaks, N.Y. He, along with his colleagues, prospectively evaluated the relative effects on these factors of olanzapine, risperidone (Risperdal), or quetiapine (Seroquel)—the three most widely prescribed drugs in this particular class.

The open-label study included youths between the ages of 5 and 18 years with a DSM-IV diagnosis of psychotic, mood, and/or disruptive behavior disorders who had begun or switched to treatment with one of the three medications within 7 days of the start of the investigation. Exclusion criteria included a history of any eating disorder, active thyroid or severe medical disorder, and pregnancy.

All subjects were assessed at baseline and monthly for height, weight, body mass index, total fat mass and percentage fat (via bioimpedance measurement), and waist circumference. In addition, fasting blood leptin, prolactin, and antipsychotic serum levels were measured at baseline, week 4, and week 12.

After 12 weeks of treatment, the weight, body mass index (BMI), fat mass and percentage fat, and waist circumference of all of the 174 youth in the study—including 57 on olanzapine, 70 on risperidone, and 47 on quetiapine—increased significantly, Dr. Correll said. The greatest increase in all measures was seen in those youths taking olanzapine, followed by risperidone, then quetiapine, he said. Additionally, nearly 81% of the subjects taking olanzapine experienced extreme weight gain—described as an increase in weight from baseline of 7% or more—compared with 57% and 43% of risperidone and quetiapine subjects, respectively.

All of the study participants experienced significant increases in total cholesterol, LDL cholesterol, and triglycerides. A separate analysis comparing pretreated and antipsychotic-naive patients showed that only the olanzapine-induced cholesterol and triglyceride increases remained significant. “Nevertheless, 19.9% of the youths experienced new-onset dyslipidemia, with similar rates for all three drugs,” Dr. Correll reported.

Multiple regression analysis identified the following correlates of weight gain: weight increase at 4 weeks, baseline-to-end increases in leptin, antipsychotic naive status, olanzapine treatment, and divalproex cotreatment.

With respect to lipids, predictors for both cholesterol increase and for triglyceride increase were a low baseline cholesterol level, antidepressant cotreatment, and a 12-week BMI change. Male gender was a predictor for cholesterol increase only.

“Clearly what we're seeing is that these drugs have an impact on all aspects of body composition, and they lead to dyslipidemia, which further increases the cardiovascular risk profile. We're not suggesting they shouldn't be used because obviously these drugs have an important role, but they should be used carefully, and these side effects should be monitored regularly.

“Pretreatment dietary and lifestyle counseling, particularly among those at highest risk, cannot be overlooked,” Dr. Correll concluded.

BOSTON — The concurrent presence of metabolic syndrome and subclinical atherosclerosis in HIV infection may help identify individuals at increased risk for cardiovascular disease, a study has shown.

The findings could be used to guide therapy designed to prevent cardiovascular events in people with AIDS or HIV, reported Alexandra Mangili, M.D., in a poster presentation at a conference on retroviruses and opportunistic infections.

In a longitudinal study examining nutritional and metabolic parameters in HIV infection, Dr. Mangili and colleagues at Tufts University in Boston measured common carotid and internal carotid intima-medial thickness (IMT) by B-mode ultrasonography in 327 HIV-infected patients. Coronary calcium score was also measured by high-resolution ECG-synchronized computed tomography.

The investigators compared these parameters in patients with and without signs of metabolic syndrome, defined as the presence of at least three of the following: abdominal obesity, hypertriglyceridemia, low HDL cholesterol, hypertension, and elevated fasting glucose.

After adjustment for sex, age, race, and smoking, individuals with metabolic syndrome had significantly higher common carotid IMT values than did patients without metabolic syndrome. The metabolic syndrome patients were also more likely to have abnormal coronary calcium scores, but not internal carotid IMT values, Dr. Mangili said at the conference, sponsored by the Foundation for Retrovirology and Human Health.

CD4 cell counts, viral load values, and use of highly active antiretroviral regimens, protease inhibitors, and nonnucleoside reverse transcriptase inhibitors were similar between patients with and without metabolic syndrome, she noted.

Subclinical carotid and coronary atherosclerosis are independent predictors of adverse cardiac events, and there is increasing evidence that metabolic syndrome is predictive of cardiovascular disease. The association seen in this study population between metabolic syndrome and subclinical atherosclerosis as determined by elevated IMT and coronary calcium adds to the growing body of knowledge linking HIV infection and/or treatment to an increased risk of cardiovascular events, Dr. Mangali said.

BOSTON — The concurrent presence of metabolic syndrome and subclinical atherosclerosis in HIV infection may help identify individuals at increased risk for cardiovascular disease, a study has shown.

The findings could be used to guide therapy designed to prevent cardiovascular events in people with AIDS or HIV, reported Alexandra Mangili, M.D., in a poster presentation at a conference on retroviruses and opportunistic infections.

In a longitudinal study examining nutritional and metabolic parameters in HIV infection, Dr. Mangili and colleagues at Tufts University in Boston measured common carotid and internal carotid intima-medial thickness (IMT) by B-mode ultrasonography in 327 HIV-infected patients. Coronary calcium score was also measured by high-resolution ECG-synchronized computed tomography.

The investigators compared these parameters in patients with and without signs of metabolic syndrome, defined as the presence of at least three of the following: abdominal obesity, hypertriglyceridemia, low HDL cholesterol, hypertension, and elevated fasting glucose.

After adjustment for sex, age, race, and smoking, individuals with metabolic syndrome had significantly higher common carotid IMT values than did patients without metabolic syndrome. The metabolic syndrome patients were also more likely to have abnormal coronary calcium scores, but not internal carotid IMT values, Dr. Mangili said at the conference, sponsored by the Foundation for Retrovirology and Human Health.

CD4 cell counts, viral load values, and use of highly active antiretroviral regimens, protease inhibitors, and nonnucleoside reverse transcriptase inhibitors were similar between patients with and without metabolic syndrome, she noted.

Subclinical carotid and coronary atherosclerosis are independent predictors of adverse cardiac events, and there is increasing evidence that metabolic syndrome is predictive of cardiovascular disease. The association seen in this study population between metabolic syndrome and subclinical atherosclerosis as determined by elevated IMT and coronary calcium adds to the growing body of knowledge linking HIV infection and/or treatment to an increased risk of cardiovascular events, Dr. Mangali said.

BOSTON — The concurrent presence of metabolic syndrome and subclinical atherosclerosis in HIV infection may help identify individuals at increased risk for cardiovascular disease, a study has shown.

The findings could be used to guide therapy designed to prevent cardiovascular events in people with AIDS or HIV, reported Alexandra Mangili, M.D., in a poster presentation at a conference on retroviruses and opportunistic infections.

In a longitudinal study examining nutritional and metabolic parameters in HIV infection, Dr. Mangili and colleagues at Tufts University in Boston measured common carotid and internal carotid intima-medial thickness (IMT) by B-mode ultrasonography in 327 HIV-infected patients. Coronary calcium score was also measured by high-resolution ECG-synchronized computed tomography.

The investigators compared these parameters in patients with and without signs of metabolic syndrome, defined as the presence of at least three of the following: abdominal obesity, hypertriglyceridemia, low HDL cholesterol, hypertension, and elevated fasting glucose.

After adjustment for sex, age, race, and smoking, individuals with metabolic syndrome had significantly higher common carotid IMT values than did patients without metabolic syndrome. The metabolic syndrome patients were also more likely to have abnormal coronary calcium scores, but not internal carotid IMT values, Dr. Mangili said at the conference, sponsored by the Foundation for Retrovirology and Human Health.

CD4 cell counts, viral load values, and use of highly active antiretroviral regimens, protease inhibitors, and nonnucleoside reverse transcriptase inhibitors were similar between patients with and without metabolic syndrome, she noted.

Subclinical carotid and coronary atherosclerosis are independent predictors of adverse cardiac events, and there is increasing evidence that metabolic syndrome is predictive of cardiovascular disease. The association seen in this study population between metabolic syndrome and subclinical atherosclerosis as determined by elevated IMT and coronary calcium adds to the growing body of knowledge linking HIV infection and/or treatment to an increased risk of cardiovascular events, Dr. Mangali said.