Heidi Splete

SAN DIEGO — Older age was the strongest predictor of early mortality in adults with gastrointestinal bleeding after investigators controlled for medications and comorbidities, according to data from more than 1,000 adults treated at a single medical center.

In recent years, more clinicians have turned to low-dose aspirin and antithrombotic agents for the prevention of cardiovascular disease, but the interaction of these products with other risk factors for GI bleeding has not been studied thoroughly.

“We aimed to assess the 30-day mortality after upper gastrointestinal bleeding in association with the use of NSAIDs, low-dose aspirin, and other antithrombotic drugs,” Dr. Ali S. Taha of Crosshouse Hospital and the University of Glasgow, Scotland, and associates wrote in a poster presented at the annual Digestive Disease Week.

The investigators analyzed data from 1,014 adults who presented with a first episode of upper GI bleeding. A total of 45% of the patients were aged 65 years and older, and 8.1% of these patients died within 30 days of bleeding, compared with 1.3% of the younger patients.

After adjustment for multiple variables, patients who were aged 65 years and older had a significantly greater risk of 30-day mortality, compared with their younger counterparts.

In a univariate analysis, cerebrovascular disease, cardiovascular disease, and the use of diuretics, digoxin, and either low-dose aspirin or other antithrombotic drugs were significantly associated with an increased risk of 30-day mortality.

Low-dose aspirin was defined as 75 mg/day, and the antithrombotic drugs included clopidogrel, dipyridamole, and warfarin.

Use of NSAIDs had no significant impact on 30-day mortality, and the specific withdrawal of rofecoxib (Vioxx) had no apparent effect on 30-day mortality rates in this population.

The Blatchford score (an accepted measure of risk in patients with upper GI bleeding) was calculated using both clinical and laboratory data at each patient's presentation.

Patients scoring higher than 10 on this measure had five times the risk of early death, compared with patients who scored 0-2.

Despite the importance of comorbidities and medication use, the results suggest that age is a strong and independent predictor of early mortality in patients with upper GI bleeding. However, more studies are needed to determine the clinical implications for treatment, Dr. Taha said in an interview.

“Ulcer prevention should be considered seriously in elderly patients, particularly in the presence of other comorbid conditions and use of ulcerogenic drugs,” Dr. Taha said. “And once bleeding has taken place, such patients should be targeted for intensive management.”

Dr. Taha stated that he has received grants and research support from Astellas Pharma Inc., AstraZeneca Pharmaceuticals, Merck & Co., and Yamanouchi Pharmaceutical Co.

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — Older age was the strongest predictor of early mortality in adults with gastrointestinal bleeding after investigators controlled for medications and comorbidities, according to data from more than 1,000 adults treated at a single medical center.

In recent years, more clinicians have turned to low-dose aspirin and antithrombotic agents for the prevention of cardiovascular disease, but the interaction of these products with other risk factors for GI bleeding has not been studied thoroughly.

“We aimed to assess the 30-day mortality after upper gastrointestinal bleeding in association with the use of NSAIDs, low-dose aspirin, and other antithrombotic drugs,” Dr. Ali S. Taha of Crosshouse Hospital and the University of Glasgow, Scotland, and associates wrote in a poster presented at the annual Digestive Disease Week.

The investigators analyzed data from 1,014 adults who presented with a first episode of upper GI bleeding. A total of 45% of the patients were aged 65 years and older, and 8.1% of these patients died within 30 days of bleeding, compared with 1.3% of the younger patients.

After adjustment for multiple variables, patients who were aged 65 years and older had a significantly greater risk of 30-day mortality, compared with their younger counterparts.

In a univariate analysis, cerebrovascular disease, cardiovascular disease, and the use of diuretics, digoxin, and either low-dose aspirin or other antithrombotic drugs were significantly associated with an increased risk of 30-day mortality.

Low-dose aspirin was defined as 75 mg/day, and the antithrombotic drugs included clopidogrel, dipyridamole, and warfarin.

Use of NSAIDs had no significant impact on 30-day mortality, and the specific withdrawal of rofecoxib (Vioxx) had no apparent effect on 30-day mortality rates in this population.

The Blatchford score (an accepted measure of risk in patients with upper GI bleeding) was calculated using both clinical and laboratory data at each patient's presentation.

Patients scoring higher than 10 on this measure had five times the risk of early death, compared with patients who scored 0-2.

Despite the importance of comorbidities and medication use, the results suggest that age is a strong and independent predictor of early mortality in patients with upper GI bleeding. However, more studies are needed to determine the clinical implications for treatment, Dr. Taha said in an interview.

“Ulcer prevention should be considered seriously in elderly patients, particularly in the presence of other comorbid conditions and use of ulcerogenic drugs,” Dr. Taha said. “And once bleeding has taken place, such patients should be targeted for intensive management.”

Dr. Taha stated that he has received grants and research support from Astellas Pharma Inc., AstraZeneca Pharmaceuticals, Merck & Co., and Yamanouchi Pharmaceutical Co.

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — Older age was the strongest predictor of early mortality in adults with gastrointestinal bleeding after investigators controlled for medications and comorbidities, according to data from more than 1,000 adults treated at a single medical center.

In recent years, more clinicians have turned to low-dose aspirin and antithrombotic agents for the prevention of cardiovascular disease, but the interaction of these products with other risk factors for GI bleeding has not been studied thoroughly.

“We aimed to assess the 30-day mortality after upper gastrointestinal bleeding in association with the use of NSAIDs, low-dose aspirin, and other antithrombotic drugs,” Dr. Ali S. Taha of Crosshouse Hospital and the University of Glasgow, Scotland, and associates wrote in a poster presented at the annual Digestive Disease Week.

The investigators analyzed data from 1,014 adults who presented with a first episode of upper GI bleeding. A total of 45% of the patients were aged 65 years and older, and 8.1% of these patients died within 30 days of bleeding, compared with 1.3% of the younger patients.

After adjustment for multiple variables, patients who were aged 65 years and older had a significantly greater risk of 30-day mortality, compared with their younger counterparts.

In a univariate analysis, cerebrovascular disease, cardiovascular disease, and the use of diuretics, digoxin, and either low-dose aspirin or other antithrombotic drugs were significantly associated with an increased risk of 30-day mortality.

Low-dose aspirin was defined as 75 mg/day, and the antithrombotic drugs included clopidogrel, dipyridamole, and warfarin.

Use of NSAIDs had no significant impact on 30-day mortality, and the specific withdrawal of rofecoxib (Vioxx) had no apparent effect on 30-day mortality rates in this population.

The Blatchford score (an accepted measure of risk in patients with upper GI bleeding) was calculated using both clinical and laboratory data at each patient's presentation.

Patients scoring higher than 10 on this measure had five times the risk of early death, compared with patients who scored 0-2.

Despite the importance of comorbidities and medication use, the results suggest that age is a strong and independent predictor of early mortality in patients with upper GI bleeding. However, more studies are needed to determine the clinical implications for treatment, Dr. Taha said in an interview.

“Ulcer prevention should be considered seriously in elderly patients, particularly in the presence of other comorbid conditions and use of ulcerogenic drugs,” Dr. Taha said. “And once bleeding has taken place, such patients should be targeted for intensive management.”

Dr. Taha stated that he has received grants and research support from Astellas Pharma Inc., AstraZeneca Pharmaceuticals, Merck & Co., and Yamanouchi Pharmaceutical Co.

ELSEVIER GLOBAL MEDICAL NEWS

Rates of methicillin-resistant Staphylococcus aureus infections were reduced by more than half when all new patients were tested for MRSA, according to results from three hospitals.

With methicillin-resistant S. aureus (MRSA) has become a fixture in many hospitals, and the resulting MRSA infections are causing poor health outcomes and increasing health care costs, reported Dr. Ari Robicsek of Evanston (Ill.) Northwestern Healthcare and his colleagues.

To cut MRSA infection rates, the researchers implemented a universal MRSA surveillance program at a three-hospital organization in Chicago.

Their observational study compared MRSA rates during a baseline year when patients were not universally screened at admission with rates after conducting polymerase chain reaction-based nasal tests for MRSA. The tests were conducted on all patients admitted to the ICU for 1 year and on all patients admitted to the hospital for another year (Ann. Intern. Med. 2008;148:409–18).

During the ICU surveillance year, 3,334 of 4,392 patients (76%) admitted to the ICU were tested for MRSA and 277 (8%) were positive. During the universal screening year, 62,035 of 73,464 patients (84%) admitted to the hospital were tested for MRSA and 3,926 (6%) were positive. Patients who tested positive were isolated. Of the 2,085 patients for whom mupirocin data were available, 1,288 (62%) received at least four doses of mupirocin.

During the year of universal surveillance, the total number of isolation days was 11,454 across the three hospitals. "With no surveillance, clinical cultures alone would have captured 2,036 of those days," the investigators noted. "Thus, 9,418 MRSA patient-days would have been spent without infection control contact precautions to limit MRSA spread."

Overall prevalence density of clinical infections caused by MRSA decreased from 8.9/10,000 patient days during the baseline year to 7.4/10,000 patient days during the ICU screening year, but this difference was not statistically significant. By contrast, prevalence density decreased significantly from baseline to 3.9/10,000 patient days during the universal screening year.

In addition, the prevalence density of four types of MRSA infections—bloodstream, respiratory tract, urinary tract, and surgical site infections—dropped significantly between baseline and the end of the universal screening year.

This improvement following universal screening persisted for up to 30 days after the patients left the hospital but had no apparent effect on infection rates from 31 days to 180 days, the researchers noted.

To control for a possible unrecognized coinfection, the researchers also compared changes in rates of hospital-associated MRSA bacteremia with rates of hospital-associated methicillin-susceptible S. aureus (MSSA) bacteremia. The MRSA bacteremia rates decreased significantly after the surveillance program was implemented, but MSSA bacteremia rates did not.

The study was limited by the lack of an unscreened control group and the inclusion of only one hospital organization, but the findings support results from previous studies in which anything less than universal screening detected fewer than 20% of patients with MRSA infections.

"However, given the intermediate size and community-based nature of our three hospitals, our experience is probably representative of most U.S. hospitals," the investigators wrote.

ELSEVIER GLOBAL MEDICAL NEWS

Rates of methicillin-resistant Staphylococcus aureus infections were reduced by more than half when all new patients were tested for MRSA, according to results from three hospitals.

With methicillin-resistant S. aureus (MRSA) has become a fixture in many hospitals, and the resulting MRSA infections are causing poor health outcomes and increasing health care costs, reported Dr. Ari Robicsek of Evanston (Ill.) Northwestern Healthcare and his colleagues.

To cut MRSA infection rates, the researchers implemented a universal MRSA surveillance program at a three-hospital organization in Chicago.

Their observational study compared MRSA rates during a baseline year when patients were not universally screened at admission with rates after conducting polymerase chain reaction-based nasal tests for MRSA. The tests were conducted on all patients admitted to the ICU for 1 year and on all patients admitted to the hospital for another year (Ann. Intern. Med. 2008;148:409–18).

During the ICU surveillance year, 3,334 of 4,392 patients (76%) admitted to the ICU were tested for MRSA and 277 (8%) were positive. During the universal screening year, 62,035 of 73,464 patients (84%) admitted to the hospital were tested for MRSA and 3,926 (6%) were positive. Patients who tested positive were isolated. Of the 2,085 patients for whom mupirocin data were available, 1,288 (62%) received at least four doses of mupirocin.

During the year of universal surveillance, the total number of isolation days was 11,454 across the three hospitals. "With no surveillance, clinical cultures alone would have captured 2,036 of those days," the investigators noted. "Thus, 9,418 MRSA patient-days would have been spent without infection control contact precautions to limit MRSA spread."

Overall prevalence density of clinical infections caused by MRSA decreased from 8.9/10,000 patient days during the baseline year to 7.4/10,000 patient days during the ICU screening year, but this difference was not statistically significant. By contrast, prevalence density decreased significantly from baseline to 3.9/10,000 patient days during the universal screening year.

In addition, the prevalence density of four types of MRSA infections—bloodstream, respiratory tract, urinary tract, and surgical site infections—dropped significantly between baseline and the end of the universal screening year.

This improvement following universal screening persisted for up to 30 days after the patients left the hospital but had no apparent effect on infection rates from 31 days to 180 days, the researchers noted.

To control for a possible unrecognized coinfection, the researchers also compared changes in rates of hospital-associated MRSA bacteremia with rates of hospital-associated methicillin-susceptible S. aureus (MSSA) bacteremia. The MRSA bacteremia rates decreased significantly after the surveillance program was implemented, but MSSA bacteremia rates did not.

The study was limited by the lack of an unscreened control group and the inclusion of only one hospital organization, but the findings support results from previous studies in which anything less than universal screening detected fewer than 20% of patients with MRSA infections.

"However, given the intermediate size and community-based nature of our three hospitals, our experience is probably representative of most U.S. hospitals," the investigators wrote.

ELSEVIER GLOBAL MEDICAL NEWS

Rates of methicillin-resistant Staphylococcus aureus infections were reduced by more than half when all new patients were tested for MRSA, according to results from three hospitals.

With methicillin-resistant S. aureus (MRSA) has become a fixture in many hospitals, and the resulting MRSA infections are causing poor health outcomes and increasing health care costs, reported Dr. Ari Robicsek of Evanston (Ill.) Northwestern Healthcare and his colleagues.

To cut MRSA infection rates, the researchers implemented a universal MRSA surveillance program at a three-hospital organization in Chicago.

Their observational study compared MRSA rates during a baseline year when patients were not universally screened at admission with rates after conducting polymerase chain reaction-based nasal tests for MRSA. The tests were conducted on all patients admitted to the ICU for 1 year and on all patients admitted to the hospital for another year (Ann. Intern. Med. 2008;148:409–18).

During the ICU surveillance year, 3,334 of 4,392 patients (76%) admitted to the ICU were tested for MRSA and 277 (8%) were positive. During the universal screening year, 62,035 of 73,464 patients (84%) admitted to the hospital were tested for MRSA and 3,926 (6%) were positive. Patients who tested positive were isolated. Of the 2,085 patients for whom mupirocin data were available, 1,288 (62%) received at least four doses of mupirocin.

During the year of universal surveillance, the total number of isolation days was 11,454 across the three hospitals. "With no surveillance, clinical cultures alone would have captured 2,036 of those days," the investigators noted. "Thus, 9,418 MRSA patient-days would have been spent without infection control contact precautions to limit MRSA spread."

Overall prevalence density of clinical infections caused by MRSA decreased from 8.9/10,000 patient days during the baseline year to 7.4/10,000 patient days during the ICU screening year, but this difference was not statistically significant. By contrast, prevalence density decreased significantly from baseline to 3.9/10,000 patient days during the universal screening year.

In addition, the prevalence density of four types of MRSA infections—bloodstream, respiratory tract, urinary tract, and surgical site infections—dropped significantly between baseline and the end of the universal screening year.

This improvement following universal screening persisted for up to 30 days after the patients left the hospital but had no apparent effect on infection rates from 31 days to 180 days, the researchers noted.

To control for a possible unrecognized coinfection, the researchers also compared changes in rates of hospital-associated MRSA bacteremia with rates of hospital-associated methicillin-susceptible S. aureus (MSSA) bacteremia. The MRSA bacteremia rates decreased significantly after the surveillance program was implemented, but MSSA bacteremia rates did not.

The study was limited by the lack of an unscreened control group and the inclusion of only one hospital organization, but the findings support results from previous studies in which anything less than universal screening detected fewer than 20% of patients with MRSA infections.

"However, given the intermediate size and community-based nature of our three hospitals, our experience is probably representative of most U.S. hospitals," the investigators wrote.

ELSEVIER GLOBAL MEDICAL NEWS

Breast-fed babies may be protected against developing type 2 diabetes during childhood, regardless of ethnicity, according to results from an adjunct study to the ongoing SEARCH for Diabetes in Youth study.

The dramatic increase in type 2 diabetes in youth has inspired researchers to identify behaviors that might prevent both obesity and type 2 diabetes, wrote Elizabeth J. Mayer-Davis, Ph.D., of the University of South Carolina, Columbia, and her colleagues.

Their case-control study, conducted at two of the SEARCH for Diabetes in Youth study sites, included 80 participants aged 10–21 years with type 2 diabetes and 167 age-matched controls (Diabetes Care 2008;31:470–5).

Overall, the prevalence of breast-feeding for any length of time was significantly lower among youth with type 2 diabetes, compared with controls (31% vs. 64%).

When the study population was divided into three ethnic groups, the prevalence of breast-feeding was lower among black youth with type 2 diabetes than among controls (20% vs. 27%), although this difference was not statistically significant. But the difference remained significant among Hispanics (50% vs. 84%), and among non-Hispanic whites (39% vs. 78%).

The researchers noted previous evidence that a lower prevalence of breast-feeding among blacks, compared with other ethnicities, might be a confounding variable.

Breast-fed babies may be protected against developing type 2 diabetes during childhood, regardless of ethnicity, according to results from an adjunct study to the ongoing SEARCH for Diabetes in Youth study.

The dramatic increase in type 2 diabetes in youth has inspired researchers to identify behaviors that might prevent both obesity and type 2 diabetes, wrote Elizabeth J. Mayer-Davis, Ph.D., of the University of South Carolina, Columbia, and her colleagues.

Their case-control study, conducted at two of the SEARCH for Diabetes in Youth study sites, included 80 participants aged 10–21 years with type 2 diabetes and 167 age-matched controls (Diabetes Care 2008;31:470–5).

Overall, the prevalence of breast-feeding for any length of time was significantly lower among youth with type 2 diabetes, compared with controls (31% vs. 64%).

When the study population was divided into three ethnic groups, the prevalence of breast-feeding was lower among black youth with type 2 diabetes than among controls (20% vs. 27%), although this difference was not statistically significant. But the difference remained significant among Hispanics (50% vs. 84%), and among non-Hispanic whites (39% vs. 78%).

The researchers noted previous evidence that a lower prevalence of breast-feeding among blacks, compared with other ethnicities, might be a confounding variable.

Breast-fed babies may be protected against developing type 2 diabetes during childhood, regardless of ethnicity, according to results from an adjunct study to the ongoing SEARCH for Diabetes in Youth study.

The dramatic increase in type 2 diabetes in youth has inspired researchers to identify behaviors that might prevent both obesity and type 2 diabetes, wrote Elizabeth J. Mayer-Davis, Ph.D., of the University of South Carolina, Columbia, and her colleagues.

Their case-control study, conducted at two of the SEARCH for Diabetes in Youth study sites, included 80 participants aged 10–21 years with type 2 diabetes and 167 age-matched controls (Diabetes Care 2008;31:470–5).

Overall, the prevalence of breast-feeding for any length of time was significantly lower among youth with type 2 diabetes, compared with controls (31% vs. 64%).

When the study population was divided into three ethnic groups, the prevalence of breast-feeding was lower among black youth with type 2 diabetes than among controls (20% vs. 27%), although this difference was not statistically significant. But the difference remained significant among Hispanics (50% vs. 84%), and among non-Hispanic whites (39% vs. 78%).

The researchers noted previous evidence that a lower prevalence of breast-feeding among blacks, compared with other ethnicities, might be a confounding variable.

Subtle nonpolypoid colorectal neoplasms were more predictive of colorectal cancer than the more obvious polypoid neoplasms, according to findings from a study of 1,819 adult patients.

Polypoid neoplasms are easy to detect during a colonoscopy, and they are routinely removed to prevent colorectal cancer. By contrast, nonpolypoid colorectal neoplasms (NP-CRNs) are flat or slightly depressed in shape and are harder to distinguish from the surrounding normal mucosa. Previous studies have shown that depressed NP-CRNs are more likely to be cancerous, but few studies have examined them as predictors of colorectal cancer.

In this cross-sectional study, Dr. Roy M. Soetikno of the Veterans Affairs Palo Alto (Calif.) Health Care System, and his colleagues reviewed the characteristics of colorectal neoplasms in asymptomatic and symptomatic adults.

The study included 616 asymptomatic patients (the screening patients), 654 asymptomatic patients with a personal or family history of colorectal neoplasms (surveillance patients), and 549 symptomatic patients. They had elective outpatient colonoscopies between July 2003 and June 2004 (JAMA 2008;299:1027–35). Average age was 64 years, 95% were men, and 79% were white. Those undergoing emergency colonoscopies were excluded.

NP-CRNs were found in 170 patients (9.4%). Prevalence in the screening, surveillance, and symptomatic subgroups was 5.8%, 15.4%, and 6.0%, respectively. In the screening group, nonpolypoid lesions were more than twice as likely as polypoid lesions to contain neoplasms, whereas in the surveillance and symptomatic groups, they were more than three times as likely to contain neoplasms.

“Nonpolypoid lesions accounted for 15% of neoplasms, [but] contributed to 54% of superficial carcinomas,” the authors said. NP-CRN lesions were almost 10 times as likely to be associated with in situ or submucosal invasive carcinoma, compared with polypoid lesions, regardless of size.

A total of 227 NP-CRNs were found; 209 were flat and 18 were depressed. Although the number of depressed neoplasms was too small to show statistical significance, 6 (33%) contained carcinoma, compared with 9 of the flat neoplasms (4.3%). The depressed NP-CRNs were also the smallest, averaging 9.77 mm in diameter, compared with an average of 19.2 mm for polypoid lesions and 15.9 mm for NP-CRNs overall. None of the researchers disclosed any conflicts of interest.

Nonpolypoid lesions accounted for 15% of neoplasms, [but] contributed to 54% of superficial carcinomas. DR. SOETIKNO

Subtle nonpolypoid colorectal neoplasms were more predictive of colorectal cancer than the more obvious polypoid neoplasms, according to findings from a study of 1,819 adult patients.

Polypoid neoplasms are easy to detect during a colonoscopy, and they are routinely removed to prevent colorectal cancer. By contrast, nonpolypoid colorectal neoplasms (NP-CRNs) are flat or slightly depressed in shape and are harder to distinguish from the surrounding normal mucosa. Previous studies have shown that depressed NP-CRNs are more likely to be cancerous, but few studies have examined them as predictors of colorectal cancer.

In this cross-sectional study, Dr. Roy M. Soetikno of the Veterans Affairs Palo Alto (Calif.) Health Care System, and his colleagues reviewed the characteristics of colorectal neoplasms in asymptomatic and symptomatic adults.

The study included 616 asymptomatic patients (the screening patients), 654 asymptomatic patients with a personal or family history of colorectal neoplasms (surveillance patients), and 549 symptomatic patients. They had elective outpatient colonoscopies between July 2003 and June 2004 (JAMA 2008;299:1027–35). Average age was 64 years, 95% were men, and 79% were white. Those undergoing emergency colonoscopies were excluded.

NP-CRNs were found in 170 patients (9.4%). Prevalence in the screening, surveillance, and symptomatic subgroups was 5.8%, 15.4%, and 6.0%, respectively. In the screening group, nonpolypoid lesions were more than twice as likely as polypoid lesions to contain neoplasms, whereas in the surveillance and symptomatic groups, they were more than three times as likely to contain neoplasms.

“Nonpolypoid lesions accounted for 15% of neoplasms, [but] contributed to 54% of superficial carcinomas,” the authors said. NP-CRN lesions were almost 10 times as likely to be associated with in situ or submucosal invasive carcinoma, compared with polypoid lesions, regardless of size.

A total of 227 NP-CRNs were found; 209 were flat and 18 were depressed. Although the number of depressed neoplasms was too small to show statistical significance, 6 (33%) contained carcinoma, compared with 9 of the flat neoplasms (4.3%). The depressed NP-CRNs were also the smallest, averaging 9.77 mm in diameter, compared with an average of 19.2 mm for polypoid lesions and 15.9 mm for NP-CRNs overall. None of the researchers disclosed any conflicts of interest.

Nonpolypoid lesions accounted for 15% of neoplasms, [but] contributed to 54% of superficial carcinomas. DR. SOETIKNO

Subtle nonpolypoid colorectal neoplasms were more predictive of colorectal cancer than the more obvious polypoid neoplasms, according to findings from a study of 1,819 adult patients.

Polypoid neoplasms are easy to detect during a colonoscopy, and they are routinely removed to prevent colorectal cancer. By contrast, nonpolypoid colorectal neoplasms (NP-CRNs) are flat or slightly depressed in shape and are harder to distinguish from the surrounding normal mucosa. Previous studies have shown that depressed NP-CRNs are more likely to be cancerous, but few studies have examined them as predictors of colorectal cancer.

In this cross-sectional study, Dr. Roy M. Soetikno of the Veterans Affairs Palo Alto (Calif.) Health Care System, and his colleagues reviewed the characteristics of colorectal neoplasms in asymptomatic and symptomatic adults.

The study included 616 asymptomatic patients (the screening patients), 654 asymptomatic patients with a personal or family history of colorectal neoplasms (surveillance patients), and 549 symptomatic patients. They had elective outpatient colonoscopies between July 2003 and June 2004 (JAMA 2008;299:1027–35). Average age was 64 years, 95% were men, and 79% were white. Those undergoing emergency colonoscopies were excluded.

NP-CRNs were found in 170 patients (9.4%). Prevalence in the screening, surveillance, and symptomatic subgroups was 5.8%, 15.4%, and 6.0%, respectively. In the screening group, nonpolypoid lesions were more than twice as likely as polypoid lesions to contain neoplasms, whereas in the surveillance and symptomatic groups, they were more than three times as likely to contain neoplasms.

“Nonpolypoid lesions accounted for 15% of neoplasms, [but] contributed to 54% of superficial carcinomas,” the authors said. NP-CRN lesions were almost 10 times as likely to be associated with in situ or submucosal invasive carcinoma, compared with polypoid lesions, regardless of size.

A total of 227 NP-CRNs were found; 209 were flat and 18 were depressed. Although the number of depressed neoplasms was too small to show statistical significance, 6 (33%) contained carcinoma, compared with 9 of the flat neoplasms (4.3%). The depressed NP-CRNs were also the smallest, averaging 9.77 mm in diameter, compared with an average of 19.2 mm for polypoid lesions and 15.9 mm for NP-CRNs overall. None of the researchers disclosed any conflicts of interest.

Nonpolypoid lesions accounted for 15% of neoplasms, [but] contributed to 54% of superficial carcinomas. DR. SOETIKNO

Talking frequently with adolescents about sexuality is more effective than having one “big talk” and then ignoring the topic, data from a study of 312 adolescents show.

Given this, it makes sense to advise parents about the value of repeatedly discussing sexual topics with their adolescent children.

Previous studies have shown that parents can play a key role in promoting healthy sexual development in their adolescents, but most parents are uncomfortable talking about sex and prefer to have a single talk about the subject.

But regular, shorter conversations might be more effective at building a stronger bond with adolescents and reinforcing messages, reported Steven C. Martino, Ph.D., of Rand Corp. in Pittsburgh and his colleagues.

This study, the first to examine the role of repeated talks about sex on adolescents, included adolescents (52% girls, 48% boys) aged an average of 13 years and their parents who were randomized to an 8-week intervention to promote better communication.

The average age of the participating parents was 44 years, and 70% were women (Pediatrics 2008;121:3612–8).

The adolescents and parents completed surveys at the start of the study, and again at 1 week, 3 months, and 9 months after the intervention.

The researchers asked which of 22 sex-related topics the adolescents and parents had discussed, including, “How will you make decisions about whether to have sex” and, “What it feels like to have sex.” They also asked the adolescents to answer questions about their relationship with the participating parent on a scale of 1 (terrible) to 7 (excellent).

Parents discussed an average of 7 of the 22 topics at baseline, and an average of 10 topics had been discussed repeatedly by the end of the study.

The parents in the control group completed the surveys but did not participate in the communication intervention.

Overall, repetition of sexual topics was significantly associated with an adolescent's perception of a close relationship with a parent, while the number of topics mentioned in a single talk or the number of talks had no apparent impact on relationship quality, the researchers said.

But that doesn't mean that addressing a range of sexual topics in one talk is negative.

Adolescents whose parents cover many topics during discussions about sex might be better equipped to make safe sexual decisions, compared with those whose parents limit discussions of sex to one or two topics, Dr. Martino and his associates said.

“Our results suggest, however, that parents who take a checklist approach to broadening their sexual discussions with their children are unlikely to have as great an influence on their children as parents who introduce new sexual topics and develop them through repeated discussions,” they wrote.

The study was limited by the use of adolescent reports and the fact that the study subjects were participants in a communication improvement program, the researchers noted.

More research is needed to determine whether the results are applicable to a broader population. In addition, the researchers said that it is important for future studies to “establish the roles of breadth and repetition of parent-adolescent sexual communication in adolescent sexual risk taking.”

Talking frequently with adolescents about sexuality is more effective than having one “big talk” and then ignoring the topic, data from a study of 312 adolescents show.

Given this, it makes sense to advise parents about the value of repeatedly discussing sexual topics with their adolescent children.

Previous studies have shown that parents can play a key role in promoting healthy sexual development in their adolescents, but most parents are uncomfortable talking about sex and prefer to have a single talk about the subject.

But regular, shorter conversations might be more effective at building a stronger bond with adolescents and reinforcing messages, reported Steven C. Martino, Ph.D., of Rand Corp. in Pittsburgh and his colleagues.

This study, the first to examine the role of repeated talks about sex on adolescents, included adolescents (52% girls, 48% boys) aged an average of 13 years and their parents who were randomized to an 8-week intervention to promote better communication.

The average age of the participating parents was 44 years, and 70% were women (Pediatrics 2008;121:3612–8).

The adolescents and parents completed surveys at the start of the study, and again at 1 week, 3 months, and 9 months after the intervention.

The researchers asked which of 22 sex-related topics the adolescents and parents had discussed, including, “How will you make decisions about whether to have sex” and, “What it feels like to have sex.” They also asked the adolescents to answer questions about their relationship with the participating parent on a scale of 1 (terrible) to 7 (excellent).

Parents discussed an average of 7 of the 22 topics at baseline, and an average of 10 topics had been discussed repeatedly by the end of the study.

The parents in the control group completed the surveys but did not participate in the communication intervention.

Overall, repetition of sexual topics was significantly associated with an adolescent's perception of a close relationship with a parent, while the number of topics mentioned in a single talk or the number of talks had no apparent impact on relationship quality, the researchers said.

But that doesn't mean that addressing a range of sexual topics in one talk is negative.

Adolescents whose parents cover many topics during discussions about sex might be better equipped to make safe sexual decisions, compared with those whose parents limit discussions of sex to one or two topics, Dr. Martino and his associates said.

“Our results suggest, however, that parents who take a checklist approach to broadening their sexual discussions with their children are unlikely to have as great an influence on their children as parents who introduce new sexual topics and develop them through repeated discussions,” they wrote.

The study was limited by the use of adolescent reports and the fact that the study subjects were participants in a communication improvement program, the researchers noted.

More research is needed to determine whether the results are applicable to a broader population. In addition, the researchers said that it is important for future studies to “establish the roles of breadth and repetition of parent-adolescent sexual communication in adolescent sexual risk taking.”

Talking frequently with adolescents about sexuality is more effective than having one “big talk” and then ignoring the topic, data from a study of 312 adolescents show.

Given this, it makes sense to advise parents about the value of repeatedly discussing sexual topics with their adolescent children.

Previous studies have shown that parents can play a key role in promoting healthy sexual development in their adolescents, but most parents are uncomfortable talking about sex and prefer to have a single talk about the subject.

But regular, shorter conversations might be more effective at building a stronger bond with adolescents and reinforcing messages, reported Steven C. Martino, Ph.D., of Rand Corp. in Pittsburgh and his colleagues.

This study, the first to examine the role of repeated talks about sex on adolescents, included adolescents (52% girls, 48% boys) aged an average of 13 years and their parents who were randomized to an 8-week intervention to promote better communication.

The average age of the participating parents was 44 years, and 70% were women (Pediatrics 2008;121:3612–8).

The adolescents and parents completed surveys at the start of the study, and again at 1 week, 3 months, and 9 months after the intervention.

The researchers asked which of 22 sex-related topics the adolescents and parents had discussed, including, “How will you make decisions about whether to have sex” and, “What it feels like to have sex.” They also asked the adolescents to answer questions about their relationship with the participating parent on a scale of 1 (terrible) to 7 (excellent).

Parents discussed an average of 7 of the 22 topics at baseline, and an average of 10 topics had been discussed repeatedly by the end of the study.

The parents in the control group completed the surveys but did not participate in the communication intervention.

Overall, repetition of sexual topics was significantly associated with an adolescent's perception of a close relationship with a parent, while the number of topics mentioned in a single talk or the number of talks had no apparent impact on relationship quality, the researchers said.

But that doesn't mean that addressing a range of sexual topics in one talk is negative.

Adolescents whose parents cover many topics during discussions about sex might be better equipped to make safe sexual decisions, compared with those whose parents limit discussions of sex to one or two topics, Dr. Martino and his associates said.

“Our results suggest, however, that parents who take a checklist approach to broadening their sexual discussions with their children are unlikely to have as great an influence on their children as parents who introduce new sexual topics and develop them through repeated discussions,” they wrote.

The study was limited by the use of adolescent reports and the fact that the study subjects were participants in a communication improvement program, the researchers noted.

More research is needed to determine whether the results are applicable to a broader population. In addition, the researchers said that it is important for future studies to “establish the roles of breadth and repetition of parent-adolescent sexual communication in adolescent sexual risk taking.”

Consistent handwashing, staff immunizations, and common sense are the keys to preventing and controlling infections in an office practice, said Dr. Jerome O. Klein, a professor of pediatrics at Boston University.

Physicians in office practice have two obligations: to prevent patients from acquiring infections from sick health care workers and to prevent health care workers from acquiring infections from patients, Dr. Klein said in an interview.

He presented a review of infection prevention pointers at a conference on infectious diseases held in Cambridge, Mass.

Hand hygiene is a mainstay of any effective plan to both prevent and control infections in pediatric ambulatory care settings, Dr. Klein said at the meeting sponsored by the university.

“Handwashing before and after seeing a patient should be automatic, and any of the soap or cleansing products will be satisfactory,” he said. The handwashing technique and the type of cleanser used are less important than the consistency of the handwashing.

Encourage a “no hand jewelry” policy during patient care, although such a policy is difficult to implement. “There is a residue of dirt, germs, and grime underneath a ring that cannot be accessed by the wash,” he said.

In addition, Dr. Klein emphasized the importance of following a standardized policy for the use of gloves and gowns in pediatric ambulatory care settings. The American Academy of Pediatrics recommends that health care workers wear gloves for contact with any body fluids including blood, secretions, excretions, and nonintact skin, and when they perform venipunctures.

Gowns and masks or protective eyewear should be worn for any procedures where there is a chance that blood or other fluids might splash.

The American Academy of Pediatrics' Committee on Infectious Diseases published a policy statement on infection prevention and control in pediatric ambulatory care settings in September 2007 (Pediatrics 2007;120:650–65). The statement includes guidelines for many aspects of infection prevention and control ranging from cough etiquette and proper waste disposal to managing possible exposure to bloodborne pathogens.

In addition, the statement includes guidelines for when to restrict health care workers from patient care and when they should be restricted from the facility. Dr. Klein highlighted five common infections as examples:

▸ Staphylococcal skin infections. Restrict the worker from direct patient care until he or she has been treated for 24 hours with an agent active against the particular isolate.

▸ Conjunctivitis. Restrict the worker from direct patient care until the discharge resolves.

▸ Herpetic whitlow. Restrict the worker from direct patient care until the lesions have crusted.

▸ Streptococcal group A pharyngitis. Restrict the worker from direct patient care until he or she has been treated for 24 hours.

▸ Zoster. Restrict the worker from patient care until lesions have crusted if they can't be covered. If the lesions can be covered, the worker may have contact with patients, excluding newborns and immunocompromised patients.

By contrast, workers with measles should be excluded from the ambulatory facility until 7 days after the onset of the measles rash, workers with rubella should be excluded from the facility until 5 days from the onset of rash, and workers with mumps should be excluded from the facility until 5 days after the onset of parotitis.

“All health care workers should read the AAP statement both to protect themselves as well as the patient,” Dr. Klein said. “Since time away from work for common communicable diseases is often ambiguous, reviewing the statement is most valuable.”

Be sure to maintain vaccination records for all employees. Although immunizations are not mandatory, the AAP statement suggests the following five for health care workers in pediatric settings:

▸ Hepatitis B. The AAP recommends this vaccine for all employees who may come in contact with blood. All employees who may be at risk for bloodborne pathogens must be offered this vaccine to comply with the Occupational Safety and Health Administration, so be sure to keep a record on file if an employee refuses the vaccine.

▸ MMR. The AAP recommends two doses for all adults born after 1956.

▸ Varicella. The AAP recommends immunizing all staff members who have not been vaccinated or whose vaccination status is unknown.

▸ Influenza. The Centers for Disease Control and Prevention (CDC) recommends yearly flu vaccination for all health care workers.

▸ Adolescent-Adult Tdap. The CDC recommends this tetanus, diphtheria, and acellular pertussis vaccine for all health care workers who have direct contact with patients; remember that there should be at least a 2-year gap between administering Tdap and the most recent dose of tetanus-diphtheria vaccine.

Dr. Klein serves on the scientific advisory committees for the Merck & Co. vaccine division and Innovia Medical LLC.

Encourage a 'no hand jewelry' policy during patient care, although it maybe difficult to implement. DR. KLEIN

Consistent handwashing, staff immunizations, and common sense are the keys to preventing and controlling infections in an office practice, said Dr. Jerome O. Klein, a professor of pediatrics at Boston University.

Physicians in office practice have two obligations: to prevent patients from acquiring infections from sick health care workers and to prevent health care workers from acquiring infections from patients, Dr. Klein said in an interview.

He presented a review of infection prevention pointers at a conference on infectious diseases held in Cambridge, Mass.

Hand hygiene is a mainstay of any effective plan to both prevent and control infections in pediatric ambulatory care settings, Dr. Klein said at the meeting sponsored by the university.

“Handwashing before and after seeing a patient should be automatic, and any of the soap or cleansing products will be satisfactory,” he said. The handwashing technique and the type of cleanser used are less important than the consistency of the handwashing.

Encourage a “no hand jewelry” policy during patient care, although such a policy is difficult to implement. “There is a residue of dirt, germs, and grime underneath a ring that cannot be accessed by the wash,” he said.

In addition, Dr. Klein emphasized the importance of following a standardized policy for the use of gloves and gowns in pediatric ambulatory care settings. The American Academy of Pediatrics recommends that health care workers wear gloves for contact with any body fluids including blood, secretions, excretions, and nonintact skin, and when they perform venipunctures.

Gowns and masks or protective eyewear should be worn for any procedures where there is a chance that blood or other fluids might splash.

The American Academy of Pediatrics' Committee on Infectious Diseases published a policy statement on infection prevention and control in pediatric ambulatory care settings in September 2007 (Pediatrics 2007;120:650–65). The statement includes guidelines for many aspects of infection prevention and control ranging from cough etiquette and proper waste disposal to managing possible exposure to bloodborne pathogens.

In addition, the statement includes guidelines for when to restrict health care workers from patient care and when they should be restricted from the facility. Dr. Klein highlighted five common infections as examples:

▸ Staphylococcal skin infections. Restrict the worker from direct patient care until he or she has been treated for 24 hours with an agent active against the particular isolate.

▸ Conjunctivitis. Restrict the worker from direct patient care until the discharge resolves.

▸ Herpetic whitlow. Restrict the worker from direct patient care until the lesions have crusted.

▸ Streptococcal group A pharyngitis. Restrict the worker from direct patient care until he or she has been treated for 24 hours.

▸ Zoster. Restrict the worker from patient care until lesions have crusted if they can't be covered. If the lesions can be covered, the worker may have contact with patients, excluding newborns and immunocompromised patients.

By contrast, workers with measles should be excluded from the ambulatory facility until 7 days after the onset of the measles rash, workers with rubella should be excluded from the facility until 5 days from the onset of rash, and workers with mumps should be excluded from the facility until 5 days after the onset of parotitis.

“All health care workers should read the AAP statement both to protect themselves as well as the patient,” Dr. Klein said. “Since time away from work for common communicable diseases is often ambiguous, reviewing the statement is most valuable.”

Be sure to maintain vaccination records for all employees. Although immunizations are not mandatory, the AAP statement suggests the following five for health care workers in pediatric settings:

▸ Hepatitis B. The AAP recommends this vaccine for all employees who may come in contact with blood. All employees who may be at risk for bloodborne pathogens must be offered this vaccine to comply with the Occupational Safety and Health Administration, so be sure to keep a record on file if an employee refuses the vaccine.

▸ MMR. The AAP recommends two doses for all adults born after 1956.

▸ Varicella. The AAP recommends immunizing all staff members who have not been vaccinated or whose vaccination status is unknown.

▸ Influenza. The Centers for Disease Control and Prevention (CDC) recommends yearly flu vaccination for all health care workers.

▸ Adolescent-Adult Tdap. The CDC recommends this tetanus, diphtheria, and acellular pertussis vaccine for all health care workers who have direct contact with patients; remember that there should be at least a 2-year gap between administering Tdap and the most recent dose of tetanus-diphtheria vaccine.

Dr. Klein serves on the scientific advisory committees for the Merck & Co. vaccine division and Innovia Medical LLC.

Encourage a 'no hand jewelry' policy during patient care, although it maybe difficult to implement. DR. KLEIN

Consistent handwashing, staff immunizations, and common sense are the keys to preventing and controlling infections in an office practice, said Dr. Jerome O. Klein, a professor of pediatrics at Boston University.

Physicians in office practice have two obligations: to prevent patients from acquiring infections from sick health care workers and to prevent health care workers from acquiring infections from patients, Dr. Klein said in an interview.

He presented a review of infection prevention pointers at a conference on infectious diseases held in Cambridge, Mass.

Hand hygiene is a mainstay of any effective plan to both prevent and control infections in pediatric ambulatory care settings, Dr. Klein said at the meeting sponsored by the university.

“Handwashing before and after seeing a patient should be automatic, and any of the soap or cleansing products will be satisfactory,” he said. The handwashing technique and the type of cleanser used are less important than the consistency of the handwashing.

Encourage a “no hand jewelry” policy during patient care, although such a policy is difficult to implement. “There is a residue of dirt, germs, and grime underneath a ring that cannot be accessed by the wash,” he said.

In addition, Dr. Klein emphasized the importance of following a standardized policy for the use of gloves and gowns in pediatric ambulatory care settings. The American Academy of Pediatrics recommends that health care workers wear gloves for contact with any body fluids including blood, secretions, excretions, and nonintact skin, and when they perform venipunctures.

Gowns and masks or protective eyewear should be worn for any procedures where there is a chance that blood or other fluids might splash.

The American Academy of Pediatrics' Committee on Infectious Diseases published a policy statement on infection prevention and control in pediatric ambulatory care settings in September 2007 (Pediatrics 2007;120:650–65). The statement includes guidelines for many aspects of infection prevention and control ranging from cough etiquette and proper waste disposal to managing possible exposure to bloodborne pathogens.

In addition, the statement includes guidelines for when to restrict health care workers from patient care and when they should be restricted from the facility. Dr. Klein highlighted five common infections as examples:

▸ Staphylococcal skin infections. Restrict the worker from direct patient care until he or she has been treated for 24 hours with an agent active against the particular isolate.

▸ Conjunctivitis. Restrict the worker from direct patient care until the discharge resolves.

▸ Herpetic whitlow. Restrict the worker from direct patient care until the lesions have crusted.

▸ Streptococcal group A pharyngitis. Restrict the worker from direct patient care until he or she has been treated for 24 hours.

▸ Zoster. Restrict the worker from patient care until lesions have crusted if they can't be covered. If the lesions can be covered, the worker may have contact with patients, excluding newborns and immunocompromised patients.

By contrast, workers with measles should be excluded from the ambulatory facility until 7 days after the onset of the measles rash, workers with rubella should be excluded from the facility until 5 days from the onset of rash, and workers with mumps should be excluded from the facility until 5 days after the onset of parotitis.

“All health care workers should read the AAP statement both to protect themselves as well as the patient,” Dr. Klein said. “Since time away from work for common communicable diseases is often ambiguous, reviewing the statement is most valuable.”

Be sure to maintain vaccination records for all employees. Although immunizations are not mandatory, the AAP statement suggests the following five for health care workers in pediatric settings:

▸ Hepatitis B. The AAP recommends this vaccine for all employees who may come in contact with blood. All employees who may be at risk for bloodborne pathogens must be offered this vaccine to comply with the Occupational Safety and Health Administration, so be sure to keep a record on file if an employee refuses the vaccine.

▸ MMR. The AAP recommends two doses for all adults born after 1956.

▸ Varicella. The AAP recommends immunizing all staff members who have not been vaccinated or whose vaccination status is unknown.

▸ Influenza. The Centers for Disease Control and Prevention (CDC) recommends yearly flu vaccination for all health care workers.

▸ Adolescent-Adult Tdap. The CDC recommends this tetanus, diphtheria, and acellular pertussis vaccine for all health care workers who have direct contact with patients; remember that there should be at least a 2-year gap between administering Tdap and the most recent dose of tetanus-diphtheria vaccine.

Dr. Klein serves on the scientific advisory committees for the Merck & Co. vaccine division and Innovia Medical LLC.

Encourage a 'no hand jewelry' policy during patient care, although it maybe difficult to implement. DR. KLEIN

MINNEAPOLIS – Metabolic changes and comorbid conditions are just a few of the factors that challenge clinicians when they treat insomnia in older adults.

“The predictability of your giving drug X to patient A and knowing what is going to happen goes way down. That's the bottom line,” said Dr. Daniel Buysse, a professor of psychiatry and the director of the Clinical Neuroscience Research Center at the University of Pittsburgh.

The physiologic changes that occur with aging affect how the body absorbs medication, he said at the annual meeting of the Associated Professional Sleep Societies.

“As we get older, our lean body mass decreases and our adipose tissue increases,” he noted. Because the drugs used to treat insomnia are lipid soluble, older adults who have a greater proportion of adipose tissue will store the drug longer before processing it through the body, Dr. Buysse explained. Consequently, older patients may have more residual sleepiness the next day after taking a sleep medication the previous night, and their dosages may need adjustment.

Hypnotics have shown effectiveness in treating insomnia in adults, but be aware that the measured blood concentrations of drugs are much more variable in an older population, Dr. Buysse said. In addition, some studies have shown that hypnotics are associated with cognitive and psychomotor problems in older patients.

Antidepressants such as trazodone may be helpful for some patients; but be aware of the risks of dizziness, which could lead to falls, and the risk of oversedation because of older adults' slower metabolisms.

Choosing insomnia medications for older adults is tricky, said Dr. Alon Avidan, a neurologist at the University of California, Los Angeles. Drugs have their risks, but untreated insomnia can be just as risky, because it has been linked to an increased risk of falls in older adults. Elderly people who wake up at night are likely to get out of bed, which means that they are at greater risk for falls than older adults who are able to sleep longer.

In fact, hypnotics may be protective in preventing falls in older adults with insomnia, Dr. Avidan said, based on data from his study of more than 34,000 nursing home residents with an average age of 84 years (J. Am. Geriatr. Soc. 2005;53:955–62).

The patients with untreated insomnia were 30% more likely to fall, compared with those who were treated with hypnotics. But treating insomnia had no measurable effect on the patients' risk for hip fractures, Dr. Avidan noted.

Dr. Buysse shared his top clinical considerations when choosing drug therapies for elderly patients with insomnia.

First, keep expectations realistic, he advised. “The fact that older adults have comorbidities may limit how well we can do with our treatments,” he noted.

Second, remind patients that insomnia medication is not a general anesthesia. “Some older adults look at sleep as a behavioral alternative when they run out of things to do,” Dr. Buysse said.

In addition, remember that no evidence-based treatment guidelines exist to direct treatment of insomnia in older adults.

“We have not the least idea how to match a particular treatment to a patient, and we don't really know what constitutes a clinically significant response,” Dr. Buysse said. Findings from a recent meta-analysis suggest that many of the drugs currently available for treating insomnia have not shown consistent effectiveness in improving sleep in older adults (Ann. Clin. Psychiatry 2006;18:49–56).

Dr. Buysse recommended starting with a benzodiazepine receptor agonist, and then switching to a sedating antidepressant if the benzodiazepine doesn't help. “When people still don't improve, you could start moving to other methods such as behavioral therapy,” he said.

More research is needed to understand how to combine drug therapy with behavior therapy to treat insomnia in older adults, he added.

The measured blood concentrations of drugs might be more variable in older populations. DR. BUYSSE

MINNEAPOLIS – Metabolic changes and comorbid conditions are just a few of the factors that challenge clinicians when they treat insomnia in older adults.

“The predictability of your giving drug X to patient A and knowing what is going to happen goes way down. That's the bottom line,” said Dr. Daniel Buysse, a professor of psychiatry and the director of the Clinical Neuroscience Research Center at the University of Pittsburgh.

The physiologic changes that occur with aging affect how the body absorbs medication, he said at the annual meeting of the Associated Professional Sleep Societies.

“As we get older, our lean body mass decreases and our adipose tissue increases,” he noted. Because the drugs used to treat insomnia are lipid soluble, older adults who have a greater proportion of adipose tissue will store the drug longer before processing it through the body, Dr. Buysse explained. Consequently, older patients may have more residual sleepiness the next day after taking a sleep medication the previous night, and their dosages may need adjustment.

Hypnotics have shown effectiveness in treating insomnia in adults, but be aware that the measured blood concentrations of drugs are much more variable in an older population, Dr. Buysse said. In addition, some studies have shown that hypnotics are associated with cognitive and psychomotor problems in older patients.

Antidepressants such as trazodone may be helpful for some patients; but be aware of the risks of dizziness, which could lead to falls, and the risk of oversedation because of older adults' slower metabolisms.

Choosing insomnia medications for older adults is tricky, said Dr. Alon Avidan, a neurologist at the University of California, Los Angeles. Drugs have their risks, but untreated insomnia can be just as risky, because it has been linked to an increased risk of falls in older adults. Elderly people who wake up at night are likely to get out of bed, which means that they are at greater risk for falls than older adults who are able to sleep longer.

In fact, hypnotics may be protective in preventing falls in older adults with insomnia, Dr. Avidan said, based on data from his study of more than 34,000 nursing home residents with an average age of 84 years (J. Am. Geriatr. Soc. 2005;53:955–62).

The patients with untreated insomnia were 30% more likely to fall, compared with those who were treated with hypnotics. But treating insomnia had no measurable effect on the patients' risk for hip fractures, Dr. Avidan noted.

Dr. Buysse shared his top clinical considerations when choosing drug therapies for elderly patients with insomnia.

First, keep expectations realistic, he advised. “The fact that older adults have comorbidities may limit how well we can do with our treatments,” he noted.

Second, remind patients that insomnia medication is not a general anesthesia. “Some older adults look at sleep as a behavioral alternative when they run out of things to do,” Dr. Buysse said.

In addition, remember that no evidence-based treatment guidelines exist to direct treatment of insomnia in older adults.

“We have not the least idea how to match a particular treatment to a patient, and we don't really know what constitutes a clinically significant response,” Dr. Buysse said. Findings from a recent meta-analysis suggest that many of the drugs currently available for treating insomnia have not shown consistent effectiveness in improving sleep in older adults (Ann. Clin. Psychiatry 2006;18:49–56).

Dr. Buysse recommended starting with a benzodiazepine receptor agonist, and then switching to a sedating antidepressant if the benzodiazepine doesn't help. “When people still don't improve, you could start moving to other methods such as behavioral therapy,” he said.

More research is needed to understand how to combine drug therapy with behavior therapy to treat insomnia in older adults, he added.

The measured blood concentrations of drugs might be more variable in older populations. DR. BUYSSE

MINNEAPOLIS – Metabolic changes and comorbid conditions are just a few of the factors that challenge clinicians when they treat insomnia in older adults.

“The predictability of your giving drug X to patient A and knowing what is going to happen goes way down. That's the bottom line,” said Dr. Daniel Buysse, a professor of psychiatry and the director of the Clinical Neuroscience Research Center at the University of Pittsburgh.

The physiologic changes that occur with aging affect how the body absorbs medication, he said at the annual meeting of the Associated Professional Sleep Societies.

“As we get older, our lean body mass decreases and our adipose tissue increases,” he noted. Because the drugs used to treat insomnia are lipid soluble, older adults who have a greater proportion of adipose tissue will store the drug longer before processing it through the body, Dr. Buysse explained. Consequently, older patients may have more residual sleepiness the next day after taking a sleep medication the previous night, and their dosages may need adjustment.

Hypnotics have shown effectiveness in treating insomnia in adults, but be aware that the measured blood concentrations of drugs are much more variable in an older population, Dr. Buysse said. In addition, some studies have shown that hypnotics are associated with cognitive and psychomotor problems in older patients.

Antidepressants such as trazodone may be helpful for some patients; but be aware of the risks of dizziness, which could lead to falls, and the risk of oversedation because of older adults' slower metabolisms.

Choosing insomnia medications for older adults is tricky, said Dr. Alon Avidan, a neurologist at the University of California, Los Angeles. Drugs have their risks, but untreated insomnia can be just as risky, because it has been linked to an increased risk of falls in older adults. Elderly people who wake up at night are likely to get out of bed, which means that they are at greater risk for falls than older adults who are able to sleep longer.

In fact, hypnotics may be protective in preventing falls in older adults with insomnia, Dr. Avidan said, based on data from his study of more than 34,000 nursing home residents with an average age of 84 years (J. Am. Geriatr. Soc. 2005;53:955–62).

The patients with untreated insomnia were 30% more likely to fall, compared with those who were treated with hypnotics. But treating insomnia had no measurable effect on the patients' risk for hip fractures, Dr. Avidan noted.

Dr. Buysse shared his top clinical considerations when choosing drug therapies for elderly patients with insomnia.

First, keep expectations realistic, he advised. “The fact that older adults have comorbidities may limit how well we can do with our treatments,” he noted.

Second, remind patients that insomnia medication is not a general anesthesia. “Some older adults look at sleep as a behavioral alternative when they run out of things to do,” Dr. Buysse said.

In addition, remember that no evidence-based treatment guidelines exist to direct treatment of insomnia in older adults.

“We have not the least idea how to match a particular treatment to a patient, and we don't really know what constitutes a clinically significant response,” Dr. Buysse said. Findings from a recent meta-analysis suggest that many of the drugs currently available for treating insomnia have not shown consistent effectiveness in improving sleep in older adults (Ann. Clin. Psychiatry 2006;18:49–56).

Dr. Buysse recommended starting with a benzodiazepine receptor agonist, and then switching to a sedating antidepressant if the benzodiazepine doesn't help. “When people still don't improve, you could start moving to other methods such as behavioral therapy,” he said.

More research is needed to understand how to combine drug therapy with behavior therapy to treat insomnia in older adults, he added.

The measured blood concentrations of drugs might be more variable in older populations. DR. BUYSSE

BALTIMORE — Obstructive sleep apnea is associated with significant morbidity among hospital inpatients, based on a review of about 60,000 hospitalized patients at a single facility during a 2-year period.

“Our goal was to characterize the frequency with which OSA patients needed acute care,” said Dr. Lisa Wolfe of the division of pulmonary medicine at Northwestern University, Chicago. She presented the results at the annual meeting of the Associated Professional Sleep Societies.

Increased morbidity has been linked with OSA in outpatients, but the impact of OSA on inpatients has not been well studied, Dr. Wolfe said. The Joint Commission has asked the medical community to comment on how to curb postoperative complications in patients with OSA, she noted.

Dr. Wolfe and her colleagues reviewed data on all patients hospitalized at Northwestern Memorial Hospital, Chicago, from September 2005 to May 2007. Acute care management was defined as rapid response team calls, code calls, or unplanned transfers to the intensive care unit. OSA was identified based on medical records.

Overall, 56 of 1,377 patients with OSA required action from a rapid response team, compared with 800 of 59,030 patients without OSA (4.1% vs. 1.4%). Significantly more patients with OSA required code calls, compared with patients without OSA (2.9% vs. 1.7%). On average, one patient with OSA underwent acute care management every 4.5 days.

“We know that OSA is a predictor for other health problems,” Dr. Wolfe said.

The study was limited by its use of medical records and by a lack of data on continuous positive airway pressure (CPAP) therapy, but the findings support results from previous studies and emphasize the need for enhanced monitoring of hospitalized patients with OSA to reduce their use of acute care resources, she noted.

The topic of OSA as a marker of increased mortality in hospitalized patients attracted national attention in the wake of a study conducted at the Mayo Clinic in Rochester, Minn., in 2001, Dr. Wolfe said. In that study, which included patients who had undergone surgeries for hip or knee replacements, patients with OSA were significantly more likely to have complications, compared with control patients without OSA. The complications often were serious and led to longer hospital stays.

Further studies are needed to explore ways to ensure patient safety and to assess the implications of improved monitoring strategies for hospitalized patients with OSA, Dr. Wolfe added. She reported that she had no financial conflicts to disclose.

BALTIMORE — Obstructive sleep apnea is associated with significant morbidity among hospital inpatients, based on a review of about 60,000 hospitalized patients at a single facility during a 2-year period.

“Our goal was to characterize the frequency with which OSA patients needed acute care,” said Dr. Lisa Wolfe of the division of pulmonary medicine at Northwestern University, Chicago. She presented the results at the annual meeting of the Associated Professional Sleep Societies.

Increased morbidity has been linked with OSA in outpatients, but the impact of OSA on inpatients has not been well studied, Dr. Wolfe said. The Joint Commission has asked the medical community to comment on how to curb postoperative complications in patients with OSA, she noted.

Dr. Wolfe and her colleagues reviewed data on all patients hospitalized at Northwestern Memorial Hospital, Chicago, from September 2005 to May 2007. Acute care management was defined as rapid response team calls, code calls, or unplanned transfers to the intensive care unit. OSA was identified based on medical records.

Overall, 56 of 1,377 patients with OSA required action from a rapid response team, compared with 800 of 59,030 patients without OSA (4.1% vs. 1.4%). Significantly more patients with OSA required code calls, compared with patients without OSA (2.9% vs. 1.7%). On average, one patient with OSA underwent acute care management every 4.5 days.

“We know that OSA is a predictor for other health problems,” Dr. Wolfe said.

The study was limited by its use of medical records and by a lack of data on continuous positive airway pressure (CPAP) therapy, but the findings support results from previous studies and emphasize the need for enhanced monitoring of hospitalized patients with OSA to reduce their use of acute care resources, she noted.

The topic of OSA as a marker of increased mortality in hospitalized patients attracted national attention in the wake of a study conducted at the Mayo Clinic in Rochester, Minn., in 2001, Dr. Wolfe said. In that study, which included patients who had undergone surgeries for hip or knee replacements, patients with OSA were significantly more likely to have complications, compared with control patients without OSA. The complications often were serious and led to longer hospital stays.

Further studies are needed to explore ways to ensure patient safety and to assess the implications of improved monitoring strategies for hospitalized patients with OSA, Dr. Wolfe added. She reported that she had no financial conflicts to disclose.

BALTIMORE — Obstructive sleep apnea is associated with significant morbidity among hospital inpatients, based on a review of about 60,000 hospitalized patients at a single facility during a 2-year period.

“Our goal was to characterize the frequency with which OSA patients needed acute care,” said Dr. Lisa Wolfe of the division of pulmonary medicine at Northwestern University, Chicago. She presented the results at the annual meeting of the Associated Professional Sleep Societies.

Increased morbidity has been linked with OSA in outpatients, but the impact of OSA on inpatients has not been well studied, Dr. Wolfe said. The Joint Commission has asked the medical community to comment on how to curb postoperative complications in patients with OSA, she noted.

Dr. Wolfe and her colleagues reviewed data on all patients hospitalized at Northwestern Memorial Hospital, Chicago, from September 2005 to May 2007. Acute care management was defined as rapid response team calls, code calls, or unplanned transfers to the intensive care unit. OSA was identified based on medical records.

Overall, 56 of 1,377 patients with OSA required action from a rapid response team, compared with 800 of 59,030 patients without OSA (4.1% vs. 1.4%). Significantly more patients with OSA required code calls, compared with patients without OSA (2.9% vs. 1.7%). On average, one patient with OSA underwent acute care management every 4.5 days.

“We know that OSA is a predictor for other health problems,” Dr. Wolfe said.

The study was limited by its use of medical records and by a lack of data on continuous positive airway pressure (CPAP) therapy, but the findings support results from previous studies and emphasize the need for enhanced monitoring of hospitalized patients with OSA to reduce their use of acute care resources, she noted.

The topic of OSA as a marker of increased mortality in hospitalized patients attracted national attention in the wake of a study conducted at the Mayo Clinic in Rochester, Minn., in 2001, Dr. Wolfe said. In that study, which included patients who had undergone surgeries for hip or knee replacements, patients with OSA were significantly more likely to have complications, compared with control patients without OSA. The complications often were serious and led to longer hospital stays.

Further studies are needed to explore ways to ensure patient safety and to assess the implications of improved monitoring strategies for hospitalized patients with OSA, Dr. Wolfe added. She reported that she had no financial conflicts to disclose.

During the past year, more than 75% of infection prevention and control professionals have taken extra steps to prevent transmission of methicillin-resistant Staphylococcus aureus in health care facilities, according to results of a survey conducted by the Association for Professionals in Infection Control and Epidemiology.

The nationwide survey was conducted in the wake of a 2007 report that showed a surprisingly high prevalence of MRSA in hospitals—eight times higher than previously estimated, said Janet E. Frain, R.N., president of the Association for Professionals in Infection Control and Epidemiology (APIC) and a certified professional in health care quality.

The poll results included data from 2,041 infection control professionals, representing 17% of the APIC's nearly 12,000 members. The results were presented last month in a teleconference.

Staff education was the most common new action among those who reported taking additional steps to prevent and control MRSA (64%). Other measures included stricter use of gowns and gloves for anyone who tests positive for MRSA (53%); improved compliance with house cleaning, equipment cleaning, and decontamination practices (49%); and targeted patient MRSA screening (49%).

But more than half of the survey respondents (54%) also reported that their institutions were not doing as much as they could or should to prevent and control MRSA.

“We are still seeing some infection control professionals struggling to get the support they need,” said Kathy Warye, CEO of APIC. But the overall trend of the poll is encouraging, she said.

“We are talking about a complete culture change within the organization, where infection prevention and control is everyone's job,” Ms. Frain said.

“I have a CEO who gets it,” said Marcia Patrick, R.N., who serves as the infection control director for the MultiCare Health System in Tacoma, Wash. “In October 2008, Medicare will stop paying for things that shouldn't happen, such as urinary tract infections from Foley catheters. If hospitals aren't working on reducing these things, they are going to be in a world of hurt financially.”

Successful infection control strategies that have been implemented at her facility include improving hand hygiene by installing alcohol gel dispensers in convenient places, adding an infection control professional to the staff, and using data-mining software to review culture reports and identify infections quickly.

For more information about preventing infections, visit the APIC's Web site at www.apic.orgwww.preventinfection.org

ELSEVIER GLOBAL MEDICAL NEWS

During the past year, more than 75% of infection prevention and control professionals have taken extra steps to prevent transmission of methicillin-resistant Staphylococcus aureus in health care facilities, according to results of a survey conducted by the Association for Professionals in Infection Control and Epidemiology.

The nationwide survey was conducted in the wake of a 2007 report that showed a surprisingly high prevalence of MRSA in hospitals—eight times higher than previously estimated, said Janet E. Frain, R.N., president of the Association for Professionals in Infection Control and Epidemiology (APIC) and a certified professional in health care quality.

The poll results included data from 2,041 infection control professionals, representing 17% of the APIC's nearly 12,000 members. The results were presented last month in a teleconference.

Staff education was the most common new action among those who reported taking additional steps to prevent and control MRSA (64%). Other measures included stricter use of gowns and gloves for anyone who tests positive for MRSA (53%); improved compliance with house cleaning, equipment cleaning, and decontamination practices (49%); and targeted patient MRSA screening (49%).

But more than half of the survey respondents (54%) also reported that their institutions were not doing as much as they could or should to prevent and control MRSA.

“We are still seeing some infection control professionals struggling to get the support they need,” said Kathy Warye, CEO of APIC. But the overall trend of the poll is encouraging, she said.

“We are talking about a complete culture change within the organization, where infection prevention and control is everyone's job,” Ms. Frain said.

“I have a CEO who gets it,” said Marcia Patrick, R.N., who serves as the infection control director for the MultiCare Health System in Tacoma, Wash. “In October 2008, Medicare will stop paying for things that shouldn't happen, such as urinary tract infections from Foley catheters. If hospitals aren't working on reducing these things, they are going to be in a world of hurt financially.”

Successful infection control strategies that have been implemented at her facility include improving hand hygiene by installing alcohol gel dispensers in convenient places, adding an infection control professional to the staff, and using data-mining software to review culture reports and identify infections quickly.

For more information about preventing infections, visit the APIC's Web site at www.apic.orgwww.preventinfection.org

ELSEVIER GLOBAL MEDICAL NEWS

During the past year, more than 75% of infection prevention and control professionals have taken extra steps to prevent transmission of methicillin-resistant Staphylococcus aureus in health care facilities, according to results of a survey conducted by the Association for Professionals in Infection Control and Epidemiology.

The nationwide survey was conducted in the wake of a 2007 report that showed a surprisingly high prevalence of MRSA in hospitals—eight times higher than previously estimated, said Janet E. Frain, R.N., president of the Association for Professionals in Infection Control and Epidemiology (APIC) and a certified professional in health care quality.

The poll results included data from 2,041 infection control professionals, representing 17% of the APIC's nearly 12,000 members. The results were presented last month in a teleconference.

Staff education was the most common new action among those who reported taking additional steps to prevent and control MRSA (64%). Other measures included stricter use of gowns and gloves for anyone who tests positive for MRSA (53%); improved compliance with house cleaning, equipment cleaning, and decontamination practices (49%); and targeted patient MRSA screening (49%).

But more than half of the survey respondents (54%) also reported that their institutions were not doing as much as they could or should to prevent and control MRSA.

“We are still seeing some infection control professionals struggling to get the support they need,” said Kathy Warye, CEO of APIC. But the overall trend of the poll is encouraging, she said.

“We are talking about a complete culture change within the organization, where infection prevention and control is everyone's job,” Ms. Frain said.

“I have a CEO who gets it,” said Marcia Patrick, R.N., who serves as the infection control director for the MultiCare Health System in Tacoma, Wash. “In October 2008, Medicare will stop paying for things that shouldn't happen, such as urinary tract infections from Foley catheters. If hospitals aren't working on reducing these things, they are going to be in a world of hurt financially.”

Successful infection control strategies that have been implemented at her facility include improving hand hygiene by installing alcohol gel dispensers in convenient places, adding an infection control professional to the staff, and using data-mining software to review culture reports and identify infections quickly.

For more information about preventing infections, visit the APIC's Web site at www.apic.orgwww.preventinfection.org

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — Complications including gestational diabetes, placenta previa, and hypertension occurred in 41% of assisted reproductive technology pregnancies, based on data from 293 pregnancies.

“Increased fetal and maternal surveillance is warranted in these pregnancies,” wrote Dr. Elena Chinea and colleagues from the Centro de Asistencia a la Reproducción Humana de Canarias S.L., Santa Cruz de Tenerife, Spain, in a poster presented at the annual meeting of the American Society for Reproductive Medicine.

To determine the nature and incidence of adverse events for assisted reproductive technology (ART) pregnancies, as well as the effect of increasing maternal age, the researchers analyzed the rates of preexisting maternal conditions, pregnancy complications, labor and delivery complications, and perinatal outcomes in pregnancies from 1,056 cycles of in vitro fertilization with intracytoplasmic sperm injection.

Preexisting maternal conditions were noted in 15% of the women, and the incidence increased consistently from 10% in women under 31 years to 28% in women over 40 years. Gestational diabetes occurred in 18% overall (16% of singleton and 25% of twin pregnancies). But no age-related increases in rates of gestational diabetes or pregnancy-induced hypertension were seen.

As for labor and delivery complications, the overall incidence of premature labor was 13%, and the rate for twin pregnancies was double the rate for singleton pregnancies (20% vs. 10%). The average overall cesarean section rate was 49%, with an average of 40% in singleton pregnancies and an average of 77% for twin pregnancies.

Low birth weights occurred in 30% of the infants overall (11% of singletons, 51% of twins). Very low birth weights occurred in 4.5% of the infants overall (2% of singletons and 7% of twins).

WASHINGTON — Complications including gestational diabetes, placenta previa, and hypertension occurred in 41% of assisted reproductive technology pregnancies, based on data from 293 pregnancies.

“Increased fetal and maternal surveillance is warranted in these pregnancies,” wrote Dr. Elena Chinea and colleagues from the Centro de Asistencia a la Reproducción Humana de Canarias S.L., Santa Cruz de Tenerife, Spain, in a poster presented at the annual meeting of the American Society for Reproductive Medicine.

To determine the nature and incidence of adverse events for assisted reproductive technology (ART) pregnancies, as well as the effect of increasing maternal age, the researchers analyzed the rates of preexisting maternal conditions, pregnancy complications, labor and delivery complications, and perinatal outcomes in pregnancies from 1,056 cycles of in vitro fertilization with intracytoplasmic sperm injection.

Preexisting maternal conditions were noted in 15% of the women, and the incidence increased consistently from 10% in women under 31 years to 28% in women over 40 years. Gestational diabetes occurred in 18% overall (16% of singleton and 25% of twin pregnancies). But no age-related increases in rates of gestational diabetes or pregnancy-induced hypertension were seen.

As for labor and delivery complications, the overall incidence of premature labor was 13%, and the rate for twin pregnancies was double the rate for singleton pregnancies (20% vs. 10%). The average overall cesarean section rate was 49%, with an average of 40% in singleton pregnancies and an average of 77% for twin pregnancies.

Low birth weights occurred in 30% of the infants overall (11% of singletons, 51% of twins). Very low birth weights occurred in 4.5% of the infants overall (2% of singletons and 7% of twins).

WASHINGTON — Complications including gestational diabetes, placenta previa, and hypertension occurred in 41% of assisted reproductive technology pregnancies, based on data from 293 pregnancies.

“Increased fetal and maternal surveillance is warranted in these pregnancies,” wrote Dr. Elena Chinea and colleagues from the Centro de Asistencia a la Reproducción Humana de Canarias S.L., Santa Cruz de Tenerife, Spain, in a poster presented at the annual meeting of the American Society for Reproductive Medicine.

To determine the nature and incidence of adverse events for assisted reproductive technology (ART) pregnancies, as well as the effect of increasing maternal age, the researchers analyzed the rates of preexisting maternal conditions, pregnancy complications, labor and delivery complications, and perinatal outcomes in pregnancies from 1,056 cycles of in vitro fertilization with intracytoplasmic sperm injection.

Preexisting maternal conditions were noted in 15% of the women, and the incidence increased consistently from 10% in women under 31 years to 28% in women over 40 years. Gestational diabetes occurred in 18% overall (16% of singleton and 25% of twin pregnancies). But no age-related increases in rates of gestational diabetes or pregnancy-induced hypertension were seen.

As for labor and delivery complications, the overall incidence of premature labor was 13%, and the rate for twin pregnancies was double the rate for singleton pregnancies (20% vs. 10%). The average overall cesarean section rate was 49%, with an average of 40% in singleton pregnancies and an average of 77% for twin pregnancies.

Low birth weights occurred in 30% of the infants overall (11% of singletons, 51% of twins). Very low birth weights occurred in 4.5% of the infants overall (2% of singletons and 7% of twins).