Kerri Wachter

Physicians can now turn to a free federally-developed program that provides the tools to educate parents and caregivers on how to help their young adolescent daughters make small and specific behavior changes to maintain a healthy weight and prevent obesity.

The program provides welcome information for physicians, who are bombarded with alarming messages about the rising number of children and adolescents who are overweight or obese and the dangerous effects down the road.

“I feel frustrated as a physician. We're hearing from all directions that we need to identify these kids but we don't know what to do after that,” said Dr. Monica Richter, a pediatrician based in Washington State. Then she discovered the BodyWorks program, developed by the Department of Health and Human Services' Office on Women's Health, which aims to provide physicians with tools to educate parents and caregivers so they can help their young teen daughters prevent obesity.

Parents attend 8–10 weekly sessions and receive a free toolkit. Girls are asked to attend two or three of the meetings, although they can participate in all of the meetings if they choose.

Everyone in the program gets a pedometer, to help measure activity. Refrigerator magnets also are given out to remind the family to sit down and plan out meals for a week. There is a recipe book, coupled with nutritional information. There also is a journal for girls to use to keep track of what they're eating, how they feel when they are eating, and what kind of exercise they are doing.

Dr. Richter saw the program advertised on the Internet a few months prior to a train-the-trainer course offered in the Seattle area, where she practices. The aim of these sessions is not only to teach physicians, nutritionists, and others to provide the program to families but also to train other physicians how to provide the program to families.

Dr. Richter approached the medical staff at Valley Medical Center with a proposal to run this program. They funded the program for the first year, and then the hospital matched the funds for the second year. The hospital provides the room and the equipment for free. She was funded to provide two 10-week sessions for families and also to train other trainers.

“We're not telling kids something they don't know already. They know if they're heavy. The thing that we need to do is tell them what they can do to change … in an office visit—we can't give them all of this information. This way I can hand them a flyer and tell them what the program is all about,” said Dr. Richter.

“My limited experience has been that when a physician says to a family, 'Your child has a problem with a high BMI [body mass index] and obesity. … I want you to make some changes and this program is for you.' … That is an extra push for people to get motivated and committed,” said Dr. Richter. Physicians can refer parents to the Web site (http://www.4women.gov/bodyworks/

The program isn't limited to those with a weight problem though. “There are people who are perfectly fine with their weight and are interested in healthy eating and exercise,” said Dr. Richter. “It's basically an education program that is good for anybody.” The nutritional information is based on the federal government's 2005 Dietary Guidelines for Americans.

The program actually started with some work on eating disorders done through the Office on Women's Health. “As that work was evolving, the experts around the table were really sounding the early warning that this same [age] group of girls was actually seeing huge increases in overweight and obesity. If we were going to be addressing eating disorders, we should seriously be thinking about disordered patterns of eating,” said Wanda Jones, D.P.H., the deputy assistant secretary for health in the U.S. Department of Health and Human Services and the director of the Office on Women's Health.

At the time, there were no materials aimed at addressing healthy eating in this age group of girls, so the office started working on a program to address this gap.

The program was initially aimed at young adolescent girls, aged 9–13 years, for whom there can be a fine line between encouraging healthy eating and regular exercise and straying into eating disorder territory. To this end, the program was designed to focus on body image by presenting different images of health and perspectives on body image to help girls understand that they are unique and different. “Some girls are going to grow much more quickly than other girls. They may be naturally heavier than other girls at the same age—and these patterns may change as they get older,” said Dr. Jones.

There is no weigh-in, noted Dr. Richter. Instead, “we talk about health and small changes for a healthy lifestyle. That's the emphasis—not weight but health.”

While the program for families is free, it does require a commitment of 1 night a week (1.5–2 hours) for 10 weeks. “It's a big time commitment,” said Dr. Richter. The program has struggled not only with getting families to sign up but also to complete it.

There is also a big time commitment for physicians who train to be trainers. “We ask that the folks who come in as trainers commit to providing a certain number—at least one—of training opportunities in their community. We've also had many of the trainers train other trainers,” said Dr. Jones. To date, there are almost 800 trainers who have gone through the program.

While the focus has always been on the family, once the program was out in the field, parents started pointing out that they had boys at home with poor eating and exercise habits. In response to this, the office developed a set of materials aimed at boys that is now in the final stages of review, said Dr. Jones.

The Office of Women's Health is currently evaluating the program nationally to determine if it can help parents and caregivers make and maintain behavior changes. The evaluation will specifically assess the impact of the program on the awareness, knowledge, attitudes, and practices of parents and adolescent girls regarding physical activity and healthy eating. The results should be available later this year.

Physicians can now turn to a free federally-developed program that provides the tools to educate parents and caregivers on how to help their young adolescent daughters make small and specific behavior changes to maintain a healthy weight and prevent obesity.

The program provides welcome information for physicians, who are bombarded with alarming messages about the rising number of children and adolescents who are overweight or obese and the dangerous effects down the road.

“I feel frustrated as a physician. We're hearing from all directions that we need to identify these kids but we don't know what to do after that,” said Dr. Monica Richter, a pediatrician based in Washington State. Then she discovered the BodyWorks program, developed by the Department of Health and Human Services' Office on Women's Health, which aims to provide physicians with tools to educate parents and caregivers so they can help their young teen daughters prevent obesity.

Parents attend 8–10 weekly sessions and receive a free toolkit. Girls are asked to attend two or three of the meetings, although they can participate in all of the meetings if they choose.

Everyone in the program gets a pedometer, to help measure activity. Refrigerator magnets also are given out to remind the family to sit down and plan out meals for a week. There is a recipe book, coupled with nutritional information. There also is a journal for girls to use to keep track of what they're eating, how they feel when they are eating, and what kind of exercise they are doing.

Dr. Richter saw the program advertised on the Internet a few months prior to a train-the-trainer course offered in the Seattle area, where she practices. The aim of these sessions is not only to teach physicians, nutritionists, and others to provide the program to families but also to train other physicians how to provide the program to families.

Dr. Richter approached the medical staff at Valley Medical Center with a proposal to run this program. They funded the program for the first year, and then the hospital matched the funds for the second year. The hospital provides the room and the equipment for free. She was funded to provide two 10-week sessions for families and also to train other trainers.

“We're not telling kids something they don't know already. They know if they're heavy. The thing that we need to do is tell them what they can do to change … in an office visit—we can't give them all of this information. This way I can hand them a flyer and tell them what the program is all about,” said Dr. Richter.

“My limited experience has been that when a physician says to a family, 'Your child has a problem with a high BMI [body mass index] and obesity. … I want you to make some changes and this program is for you.' … That is an extra push for people to get motivated and committed,” said Dr. Richter. Physicians can refer parents to the Web site (http://www.4women.gov/bodyworks/

The program isn't limited to those with a weight problem though. “There are people who are perfectly fine with their weight and are interested in healthy eating and exercise,” said Dr. Richter. “It's basically an education program that is good for anybody.” The nutritional information is based on the federal government's 2005 Dietary Guidelines for Americans.

The program actually started with some work on eating disorders done through the Office on Women's Health. “As that work was evolving, the experts around the table were really sounding the early warning that this same [age] group of girls was actually seeing huge increases in overweight and obesity. If we were going to be addressing eating disorders, we should seriously be thinking about disordered patterns of eating,” said Wanda Jones, D.P.H., the deputy assistant secretary for health in the U.S. Department of Health and Human Services and the director of the Office on Women's Health.

At the time, there were no materials aimed at addressing healthy eating in this age group of girls, so the office started working on a program to address this gap.

The program was initially aimed at young adolescent girls, aged 9–13 years, for whom there can be a fine line between encouraging healthy eating and regular exercise and straying into eating disorder territory. To this end, the program was designed to focus on body image by presenting different images of health and perspectives on body image to help girls understand that they are unique and different. “Some girls are going to grow much more quickly than other girls. They may be naturally heavier than other girls at the same age—and these patterns may change as they get older,” said Dr. Jones.

There is no weigh-in, noted Dr. Richter. Instead, “we talk about health and small changes for a healthy lifestyle. That's the emphasis—not weight but health.”

While the program for families is free, it does require a commitment of 1 night a week (1.5–2 hours) for 10 weeks. “It's a big time commitment,” said Dr. Richter. The program has struggled not only with getting families to sign up but also to complete it.

There is also a big time commitment for physicians who train to be trainers. “We ask that the folks who come in as trainers commit to providing a certain number—at least one—of training opportunities in their community. We've also had many of the trainers train other trainers,” said Dr. Jones. To date, there are almost 800 trainers who have gone through the program.

While the focus has always been on the family, once the program was out in the field, parents started pointing out that they had boys at home with poor eating and exercise habits. In response to this, the office developed a set of materials aimed at boys that is now in the final stages of review, said Dr. Jones.

The Office of Women's Health is currently evaluating the program nationally to determine if it can help parents and caregivers make and maintain behavior changes. The evaluation will specifically assess the impact of the program on the awareness, knowledge, attitudes, and practices of parents and adolescent girls regarding physical activity and healthy eating. The results should be available later this year.

Physicians can now turn to a free federally-developed program that provides the tools to educate parents and caregivers on how to help their young adolescent daughters make small and specific behavior changes to maintain a healthy weight and prevent obesity.

The program provides welcome information for physicians, who are bombarded with alarming messages about the rising number of children and adolescents who are overweight or obese and the dangerous effects down the road.

“I feel frustrated as a physician. We're hearing from all directions that we need to identify these kids but we don't know what to do after that,” said Dr. Monica Richter, a pediatrician based in Washington State. Then she discovered the BodyWorks program, developed by the Department of Health and Human Services' Office on Women's Health, which aims to provide physicians with tools to educate parents and caregivers so they can help their young teen daughters prevent obesity.

Parents attend 8–10 weekly sessions and receive a free toolkit. Girls are asked to attend two or three of the meetings, although they can participate in all of the meetings if they choose.

Everyone in the program gets a pedometer, to help measure activity. Refrigerator magnets also are given out to remind the family to sit down and plan out meals for a week. There is a recipe book, coupled with nutritional information. There also is a journal for girls to use to keep track of what they're eating, how they feel when they are eating, and what kind of exercise they are doing.

Dr. Richter saw the program advertised on the Internet a few months prior to a train-the-trainer course offered in the Seattle area, where she practices. The aim of these sessions is not only to teach physicians, nutritionists, and others to provide the program to families but also to train other physicians how to provide the program to families.

Dr. Richter approached the medical staff at Valley Medical Center with a proposal to run this program. They funded the program for the first year, and then the hospital matched the funds for the second year. The hospital provides the room and the equipment for free. She was funded to provide two 10-week sessions for families and also to train other trainers.

“We're not telling kids something they don't know already. They know if they're heavy. The thing that we need to do is tell them what they can do to change … in an office visit—we can't give them all of this information. This way I can hand them a flyer and tell them what the program is all about,” said Dr. Richter.

“My limited experience has been that when a physician says to a family, 'Your child has a problem with a high BMI [body mass index] and obesity. … I want you to make some changes and this program is for you.' … That is an extra push for people to get motivated and committed,” said Dr. Richter. Physicians can refer parents to the Web site (http://www.4women.gov/bodyworks/

The program isn't limited to those with a weight problem though. “There are people who are perfectly fine with their weight and are interested in healthy eating and exercise,” said Dr. Richter. “It's basically an education program that is good for anybody.” The nutritional information is based on the federal government's 2005 Dietary Guidelines for Americans.

The program actually started with some work on eating disorders done through the Office on Women's Health. “As that work was evolving, the experts around the table were really sounding the early warning that this same [age] group of girls was actually seeing huge increases in overweight and obesity. If we were going to be addressing eating disorders, we should seriously be thinking about disordered patterns of eating,” said Wanda Jones, D.P.H., the deputy assistant secretary for health in the U.S. Department of Health and Human Services and the director of the Office on Women's Health.

At the time, there were no materials aimed at addressing healthy eating in this age group of girls, so the office started working on a program to address this gap.

The program was initially aimed at young adolescent girls, aged 9–13 years, for whom there can be a fine line between encouraging healthy eating and regular exercise and straying into eating disorder territory. To this end, the program was designed to focus on body image by presenting different images of health and perspectives on body image to help girls understand that they are unique and different. “Some girls are going to grow much more quickly than other girls. They may be naturally heavier than other girls at the same age—and these patterns may change as they get older,” said Dr. Jones.

There is no weigh-in, noted Dr. Richter. Instead, “we talk about health and small changes for a healthy lifestyle. That's the emphasis—not weight but health.”

While the program for families is free, it does require a commitment of 1 night a week (1.5–2 hours) for 10 weeks. “It's a big time commitment,” said Dr. Richter. The program has struggled not only with getting families to sign up but also to complete it.

There is also a big time commitment for physicians who train to be trainers. “We ask that the folks who come in as trainers commit to providing a certain number—at least one—of training opportunities in their community. We've also had many of the trainers train other trainers,” said Dr. Jones. To date, there are almost 800 trainers who have gone through the program.

While the focus has always been on the family, once the program was out in the field, parents started pointing out that they had boys at home with poor eating and exercise habits. In response to this, the office developed a set of materials aimed at boys that is now in the final stages of review, said Dr. Jones.

The Office of Women's Health is currently evaluating the program nationally to determine if it can help parents and caregivers make and maintain behavior changes. The evaluation will specifically assess the impact of the program on the awareness, knowledge, attitudes, and practices of parents and adolescent girls regarding physical activity and healthy eating. The results should be available later this year.

Treatment with pioglitazone might help lower the risk of cardiovascular events in patients with chronic kidney disease, the results of a large study suggest.

“CKD, as defined by a glomerular filtration rate of less than 60 mL/min per 1.73 m

The study, by Dr. Christian A. Schneider of the University of Cologne (Germany), and his associates, was funded by Takeda Pharmaceutical Co., which makes Actos (pioglitazone). All of the authors had potential conflicts of interest involving several pharmaceutical companies.

They assessed the effect of CKD on cardiovascular outcomes using data from the Prospective Pioglitazone Clinical Trial in Macrovascular Events, which compared the effects of the thiazolidinedione pioglitazone with placebo on cardiovascular outcomes in patients with diabetes and a history of macrovascular disease. A total of 5,238 patients aged 35–75 years with type 2 diabetes and documented evidence of macrovascular disease were enrolled in the trial.

Patients were randomly assigned to receive pioglitazone (2,605) or placebo (2,633), in addition to their existing glucose-lowering and cardiovascular medications. Pioglitazone was administered at 15 mg/day for the first month, 30 mg/day for the second month, and 45 mg/day for the third month. At baseline, serum creatinine was measured. Urinary albumin concentration was measured locally at the beginning and end of the study. Blood samples were collected for creatinine measurement to observe the natural history of renal disease.

The primary end point was time from randomization to the composite end point of all-cause mortality, nonfatal myocardial infarction (including silent MI), stroke, acute coronary syndrome, coronary/carotid arterial intervention, leg revascularization, or amputation above the ankle. The secondary end point was time to the first event of all-cause mortality, MI (excluding silent MI), and stroke (J. Am. Soc. Nephrol. 2008;19[1]:182–7).

Glomerular filtration rate data were available for 5,154 patients. CKD was defined as a GFR less than 60 mL/min per 1.73 m

In patients with CKD, the incidence of the primary end point was 28%, compared with 20% in patients without the disease. The incidence of the secondary end point was 18% in patients with CKD, compared with 12% in those without. More patients with CKD died of any cause (11%) than did those without the disease (6%).

“Multivariate analysis showed the presence of CKD was an independent risk factor for the primary composite end point,” the researchers wrote.

Among patients with CKD, 24% of those on pioglitazone met the primary end point, compared with 31% of the placebo group. Likewise, fewer patients on pioglitazone (15%) met the secondary end point, compared with those on placebo (21%). All-cause mortality rates were 8% for the pioglitazone group, compared with 14% for the placebo group. Overall, in the group with CKD, “there was a nonsignificant 25% risk reduction for pioglitazone relative to placebo for the primary end point and a significant 34% relative risk reduction for the secondary end point,” the investigators wrote.

In comparison, in patients without CKD, 19% on pioglitazone met the primary end point, compared with 20% in the placebo group. Similar results were seen for the secondary end point—11% of those on pioglitazone versus 12% of those on placebo. All-cause mortality was 6.0% for those on pioglitazone, compared with 5.7% for placebo.

In addition, during the mean 3-year treatment period, GFR for patients with CKD declined by 5.4 and 2.7 mL/min per 1.73 m

The authors offered possible mechanisms for the increased risk of cardiovascular events with CKD. First, CKD often coexists with other cardiovascular risk factors. Second, “impaired kidney function is associated with elevated markers of inflammation” and other cardiovascular risk factors. Third, patients with renal disease are less likely to receive efficacious therapies to prevent cardiovascular disease.

But Dr. David M. Nathan, director of the Diabetes Center at Massachusetts General Hospital, in Boston, and professor of medicine at Harvard Medical School, criticized the analysis, noting that the PROactive study on which it was based was controversial. One of the criticisms of that study is that undue emphasis was given to a secondary end point, which contrasted with the results of the prespecified primary end point (BMJ 2005;331:836–8). He said GFR declined by a greater degree in patients on pioglitazone than in those on placebo and that more patients in the pioglitazone group who did not have CKD at baseline went on to develop CKD, compared with their placebo counterparts.

The authors noted study limitations: Data were collected prospectively, but the analysis was done retrospectively; and treatment randomization was not stratified by CKD.

ELSEVIER GLOBAL MEDICAL NEWS

Treatment with pioglitazone might help lower the risk of cardiovascular events in patients with chronic kidney disease, the results of a large study suggest.

“CKD, as defined by a glomerular filtration rate of less than 60 mL/min per 1.73 m

The study, by Dr. Christian A. Schneider of the University of Cologne (Germany), and his associates, was funded by Takeda Pharmaceutical Co., which makes Actos (pioglitazone). All of the authors had potential conflicts of interest involving several pharmaceutical companies.

They assessed the effect of CKD on cardiovascular outcomes using data from the Prospective Pioglitazone Clinical Trial in Macrovascular Events, which compared the effects of the thiazolidinedione pioglitazone with placebo on cardiovascular outcomes in patients with diabetes and a history of macrovascular disease. A total of 5,238 patients aged 35–75 years with type 2 diabetes and documented evidence of macrovascular disease were enrolled in the trial.

Patients were randomly assigned to receive pioglitazone (2,605) or placebo (2,633), in addition to their existing glucose-lowering and cardiovascular medications. Pioglitazone was administered at 15 mg/day for the first month, 30 mg/day for the second month, and 45 mg/day for the third month. At baseline, serum creatinine was measured. Urinary albumin concentration was measured locally at the beginning and end of the study. Blood samples were collected for creatinine measurement to observe the natural history of renal disease.

The primary end point was time from randomization to the composite end point of all-cause mortality, nonfatal myocardial infarction (including silent MI), stroke, acute coronary syndrome, coronary/carotid arterial intervention, leg revascularization, or amputation above the ankle. The secondary end point was time to the first event of all-cause mortality, MI (excluding silent MI), and stroke (J. Am. Soc. Nephrol. 2008;19[1]:182–7).

Glomerular filtration rate data were available for 5,154 patients. CKD was defined as a GFR less than 60 mL/min per 1.73 m

In patients with CKD, the incidence of the primary end point was 28%, compared with 20% in patients without the disease. The incidence of the secondary end point was 18% in patients with CKD, compared with 12% in those without. More patients with CKD died of any cause (11%) than did those without the disease (6%).

“Multivariate analysis showed the presence of CKD was an independent risk factor for the primary composite end point,” the researchers wrote.

Among patients with CKD, 24% of those on pioglitazone met the primary end point, compared with 31% of the placebo group. Likewise, fewer patients on pioglitazone (15%) met the secondary end point, compared with those on placebo (21%). All-cause mortality rates were 8% for the pioglitazone group, compared with 14% for the placebo group. Overall, in the group with CKD, “there was a nonsignificant 25% risk reduction for pioglitazone relative to placebo for the primary end point and a significant 34% relative risk reduction for the secondary end point,” the investigators wrote.

In comparison, in patients without CKD, 19% on pioglitazone met the primary end point, compared with 20% in the placebo group. Similar results were seen for the secondary end point—11% of those on pioglitazone versus 12% of those on placebo. All-cause mortality was 6.0% for those on pioglitazone, compared with 5.7% for placebo.

In addition, during the mean 3-year treatment period, GFR for patients with CKD declined by 5.4 and 2.7 mL/min per 1.73 m

The authors offered possible mechanisms for the increased risk of cardiovascular events with CKD. First, CKD often coexists with other cardiovascular risk factors. Second, “impaired kidney function is associated with elevated markers of inflammation” and other cardiovascular risk factors. Third, patients with renal disease are less likely to receive efficacious therapies to prevent cardiovascular disease.

But Dr. David M. Nathan, director of the Diabetes Center at Massachusetts General Hospital, in Boston, and professor of medicine at Harvard Medical School, criticized the analysis, noting that the PROactive study on which it was based was controversial. One of the criticisms of that study is that undue emphasis was given to a secondary end point, which contrasted with the results of the prespecified primary end point (BMJ 2005;331:836–8). He said GFR declined by a greater degree in patients on pioglitazone than in those on placebo and that more patients in the pioglitazone group who did not have CKD at baseline went on to develop CKD, compared with their placebo counterparts.

The authors noted study limitations: Data were collected prospectively, but the analysis was done retrospectively; and treatment randomization was not stratified by CKD.

ELSEVIER GLOBAL MEDICAL NEWS

Treatment with pioglitazone might help lower the risk of cardiovascular events in patients with chronic kidney disease, the results of a large study suggest.

“CKD, as defined by a glomerular filtration rate of less than 60 mL/min per 1.73 m

The study, by Dr. Christian A. Schneider of the University of Cologne (Germany), and his associates, was funded by Takeda Pharmaceutical Co., which makes Actos (pioglitazone). All of the authors had potential conflicts of interest involving several pharmaceutical companies.

They assessed the effect of CKD on cardiovascular outcomes using data from the Prospective Pioglitazone Clinical Trial in Macrovascular Events, which compared the effects of the thiazolidinedione pioglitazone with placebo on cardiovascular outcomes in patients with diabetes and a history of macrovascular disease. A total of 5,238 patients aged 35–75 years with type 2 diabetes and documented evidence of macrovascular disease were enrolled in the trial.

Patients were randomly assigned to receive pioglitazone (2,605) or placebo (2,633), in addition to their existing glucose-lowering and cardiovascular medications. Pioglitazone was administered at 15 mg/day for the first month, 30 mg/day for the second month, and 45 mg/day for the third month. At baseline, serum creatinine was measured. Urinary albumin concentration was measured locally at the beginning and end of the study. Blood samples were collected for creatinine measurement to observe the natural history of renal disease.

The primary end point was time from randomization to the composite end point of all-cause mortality, nonfatal myocardial infarction (including silent MI), stroke, acute coronary syndrome, coronary/carotid arterial intervention, leg revascularization, or amputation above the ankle. The secondary end point was time to the first event of all-cause mortality, MI (excluding silent MI), and stroke (J. Am. Soc. Nephrol. 2008;19[1]:182–7).

Glomerular filtration rate data were available for 5,154 patients. CKD was defined as a GFR less than 60 mL/min per 1.73 m

In patients with CKD, the incidence of the primary end point was 28%, compared with 20% in patients without the disease. The incidence of the secondary end point was 18% in patients with CKD, compared with 12% in those without. More patients with CKD died of any cause (11%) than did those without the disease (6%).

“Multivariate analysis showed the presence of CKD was an independent risk factor for the primary composite end point,” the researchers wrote.

Among patients with CKD, 24% of those on pioglitazone met the primary end point, compared with 31% of the placebo group. Likewise, fewer patients on pioglitazone (15%) met the secondary end point, compared with those on placebo (21%). All-cause mortality rates were 8% for the pioglitazone group, compared with 14% for the placebo group. Overall, in the group with CKD, “there was a nonsignificant 25% risk reduction for pioglitazone relative to placebo for the primary end point and a significant 34% relative risk reduction for the secondary end point,” the investigators wrote.

In comparison, in patients without CKD, 19% on pioglitazone met the primary end point, compared with 20% in the placebo group. Similar results were seen for the secondary end point—11% of those on pioglitazone versus 12% of those on placebo. All-cause mortality was 6.0% for those on pioglitazone, compared with 5.7% for placebo.

In addition, during the mean 3-year treatment period, GFR for patients with CKD declined by 5.4 and 2.7 mL/min per 1.73 m

The authors offered possible mechanisms for the increased risk of cardiovascular events with CKD. First, CKD often coexists with other cardiovascular risk factors. Second, “impaired kidney function is associated with elevated markers of inflammation” and other cardiovascular risk factors. Third, patients with renal disease are less likely to receive efficacious therapies to prevent cardiovascular disease.

But Dr. David M. Nathan, director of the Diabetes Center at Massachusetts General Hospital, in Boston, and professor of medicine at Harvard Medical School, criticized the analysis, noting that the PROactive study on which it was based was controversial. One of the criticisms of that study is that undue emphasis was given to a secondary end point, which contrasted with the results of the prespecified primary end point (BMJ 2005;331:836–8). He said GFR declined by a greater degree in patients on pioglitazone than in those on placebo and that more patients in the pioglitazone group who did not have CKD at baseline went on to develop CKD, compared with their placebo counterparts.

The authors noted study limitations: Data were collected prospectively, but the analysis was done retrospectively; and treatment randomization was not stratified by CKD.

ELSEVIER GLOBAL MEDICAL NEWS

Palliative care at the end of life should focus on the assessment and alleviation of symptoms of pain, shortness of breath, and depression, according to new guidelines released by the American College of Physicians.

“The ACP's drawing a line in the sand and saying this is mandatory [and] is a very important symbolic and substantive step” in improving palliative care, said Dr. Diane Meier, professor of geriatrics and adult development at Mount Sinai School of Medicine, New York.

“As minimal as these expectations and requirements are, the fact that there are any is a huge step forward,” Dr. Meier said.

The guidelines (“Evidence-Based Interventions to Improve the Palliative Care of Pain, Dyspnea, and Depression at the End of Life: A Clinical Practice Guideline from the American College of Physicians”) include five recommendations aimed at improving the care of patients with serious terminal illnesses (Ann. Intern. Med. 2008;148:141-6):

▸ Recommendation 1. Clinicians should regularly assess patients for pain, dyspnea, and depression.

“Evidence review showed that the three most common symptoms were pain, difficult breathing, and depression, so our guidelines address these,” Dr. Amir Qaseem said in a press statement. Dr. Qaseem, lead author of the guidelines, is senior medical associate in the ACP's clinical programs and quality of care department.

▸ Recommendation 2. Clinicians should use therapies of proven effectiveness to manage pain.

Strong evidence from cancer trials supports the use of nonsteroidal anti-inflammatory drugs, opioids, bisphosphonates, and radiotherapy or radiopharmaceuticals for pain. There was insufficient evidence to assess the usefulness of exercise or acupuncture in pain management.

▸ Recommendation 3. Clinicians should use therapies of proven effectiveness to manage dyspnea.

Evidence from several studies confirms that morphine can be valuable for treating dyspnea in patients with advanced lung disease or terminal cancer. Good quality evidence also supports the benefit of long-acting β-agonists in the treatment of dyspnea in chronic obstructive pulmonary disease. Evidence was mixed when comparing oxygen therapy with room air.

▸ Recommendation 4. Clinicians should use therapies of proven effectiveness to manage depression.

Good evidence supports the effectiveness of long-term use of tricyclic antidepressants or SSRIs. Good evidence also supports the use of psychosocial interventions for treating patients with cancer who have depression. These interventions include education, cognitive and noncognitive behavioral therapy, informational interventions, and individual and group support.

▸ Recommendation 5. Clinicians should ensure that advance care planning, including the completion of advance directives, occurs for all patients with serious illness.

“Research shows that individuals are more likely to use advance directives in the presence of extensive multicomponent interventions than with limited interventions,” the authors wrote. “Various processes, such as consulting caregivers, enhancing clear communication, eliciting values, and addressing the emotional context, are important elements for comprehensive advance care planning. Clinicians should help patients and families plan in advance for likely or important clinical decisions.”

The new recommendations provide much-needed guidance for physicians. “Physicians have been notoriously poorly trained and poorly prepared to address those aspects of human suffering,” Dr. Meier said. Every general physician has a small subset of patients with a serious, terminal illness.

“Internists need support in identifying, treating, and managing [these patients] over time,” she added.

The guidelines are based on a literature search that included studies from MEDLINE and reviews of cancer, heart failure, and dementia from the Cochrane Library's Database of Abstract of Reviews of Effects from January 1990 to November 2005. In addition, citations from nonsystematic literature were taken from the review by the National Consensus Project for Quality Palliative Care.

All of the recommendations are graded as strong, with moderate quality of evidence, with the exception of the recommendation on advance care planning, which was considered to have low quality of evidence.

Palliative care at the end of life should focus on the assessment and alleviation of symptoms of pain, shortness of breath, and depression, according to new guidelines released by the American College of Physicians.

“The ACP's drawing a line in the sand and saying this is mandatory [and] is a very important symbolic and substantive step” in improving palliative care, said Dr. Diane Meier, professor of geriatrics and adult development at Mount Sinai School of Medicine, New York.

“As minimal as these expectations and requirements are, the fact that there are any is a huge step forward,” Dr. Meier said.

The guidelines (“Evidence-Based Interventions to Improve the Palliative Care of Pain, Dyspnea, and Depression at the End of Life: A Clinical Practice Guideline from the American College of Physicians”) include five recommendations aimed at improving the care of patients with serious terminal illnesses (Ann. Intern. Med. 2008;148:141-6):

▸ Recommendation 1. Clinicians should regularly assess patients for pain, dyspnea, and depression.

“Evidence review showed that the three most common symptoms were pain, difficult breathing, and depression, so our guidelines address these,” Dr. Amir Qaseem said in a press statement. Dr. Qaseem, lead author of the guidelines, is senior medical associate in the ACP's clinical programs and quality of care department.

▸ Recommendation 2. Clinicians should use therapies of proven effectiveness to manage pain.

Strong evidence from cancer trials supports the use of nonsteroidal anti-inflammatory drugs, opioids, bisphosphonates, and radiotherapy or radiopharmaceuticals for pain. There was insufficient evidence to assess the usefulness of exercise or acupuncture in pain management.

▸ Recommendation 3. Clinicians should use therapies of proven effectiveness to manage dyspnea.

Evidence from several studies confirms that morphine can be valuable for treating dyspnea in patients with advanced lung disease or terminal cancer. Good quality evidence also supports the benefit of long-acting β-agonists in the treatment of dyspnea in chronic obstructive pulmonary disease. Evidence was mixed when comparing oxygen therapy with room air.

▸ Recommendation 4. Clinicians should use therapies of proven effectiveness to manage depression.

Good evidence supports the effectiveness of long-term use of tricyclic antidepressants or SSRIs. Good evidence also supports the use of psychosocial interventions for treating patients with cancer who have depression. These interventions include education, cognitive and noncognitive behavioral therapy, informational interventions, and individual and group support.

▸ Recommendation 5. Clinicians should ensure that advance care planning, including the completion of advance directives, occurs for all patients with serious illness.

“Research shows that individuals are more likely to use advance directives in the presence of extensive multicomponent interventions than with limited interventions,” the authors wrote. “Various processes, such as consulting caregivers, enhancing clear communication, eliciting values, and addressing the emotional context, are important elements for comprehensive advance care planning. Clinicians should help patients and families plan in advance for likely or important clinical decisions.”

The new recommendations provide much-needed guidance for physicians. “Physicians have been notoriously poorly trained and poorly prepared to address those aspects of human suffering,” Dr. Meier said. Every general physician has a small subset of patients with a serious, terminal illness.

“Internists need support in identifying, treating, and managing [these patients] over time,” she added.

The guidelines are based on a literature search that included studies from MEDLINE and reviews of cancer, heart failure, and dementia from the Cochrane Library's Database of Abstract of Reviews of Effects from January 1990 to November 2005. In addition, citations from nonsystematic literature were taken from the review by the National Consensus Project for Quality Palliative Care.

All of the recommendations are graded as strong, with moderate quality of evidence, with the exception of the recommendation on advance care planning, which was considered to have low quality of evidence.

Palliative care at the end of life should focus on the assessment and alleviation of symptoms of pain, shortness of breath, and depression, according to new guidelines released by the American College of Physicians.

“The ACP's drawing a line in the sand and saying this is mandatory [and] is a very important symbolic and substantive step” in improving palliative care, said Dr. Diane Meier, professor of geriatrics and adult development at Mount Sinai School of Medicine, New York.

“As minimal as these expectations and requirements are, the fact that there are any is a huge step forward,” Dr. Meier said.

The guidelines (“Evidence-Based Interventions to Improve the Palliative Care of Pain, Dyspnea, and Depression at the End of Life: A Clinical Practice Guideline from the American College of Physicians”) include five recommendations aimed at improving the care of patients with serious terminal illnesses (Ann. Intern. Med. 2008;148:141-6):

▸ Recommendation 1. Clinicians should regularly assess patients for pain, dyspnea, and depression.

“Evidence review showed that the three most common symptoms were pain, difficult breathing, and depression, so our guidelines address these,” Dr. Amir Qaseem said in a press statement. Dr. Qaseem, lead author of the guidelines, is senior medical associate in the ACP's clinical programs and quality of care department.

▸ Recommendation 2. Clinicians should use therapies of proven effectiveness to manage pain.

Strong evidence from cancer trials supports the use of nonsteroidal anti-inflammatory drugs, opioids, bisphosphonates, and radiotherapy or radiopharmaceuticals for pain. There was insufficient evidence to assess the usefulness of exercise or acupuncture in pain management.

▸ Recommendation 3. Clinicians should use therapies of proven effectiveness to manage dyspnea.

Evidence from several studies confirms that morphine can be valuable for treating dyspnea in patients with advanced lung disease or terminal cancer. Good quality evidence also supports the benefit of long-acting β-agonists in the treatment of dyspnea in chronic obstructive pulmonary disease. Evidence was mixed when comparing oxygen therapy with room air.

▸ Recommendation 4. Clinicians should use therapies of proven effectiveness to manage depression.

Good evidence supports the effectiveness of long-term use of tricyclic antidepressants or SSRIs. Good evidence also supports the use of psychosocial interventions for treating patients with cancer who have depression. These interventions include education, cognitive and noncognitive behavioral therapy, informational interventions, and individual and group support.

▸ Recommendation 5. Clinicians should ensure that advance care planning, including the completion of advance directives, occurs for all patients with serious illness.

“Research shows that individuals are more likely to use advance directives in the presence of extensive multicomponent interventions than with limited interventions,” the authors wrote. “Various processes, such as consulting caregivers, enhancing clear communication, eliciting values, and addressing the emotional context, are important elements for comprehensive advance care planning. Clinicians should help patients and families plan in advance for likely or important clinical decisions.”

The new recommendations provide much-needed guidance for physicians. “Physicians have been notoriously poorly trained and poorly prepared to address those aspects of human suffering,” Dr. Meier said. Every general physician has a small subset of patients with a serious, terminal illness.

“Internists need support in identifying, treating, and managing [these patients] over time,” she added.

The guidelines are based on a literature search that included studies from MEDLINE and reviews of cancer, heart failure, and dementia from the Cochrane Library's Database of Abstract of Reviews of Effects from January 1990 to November 2005. In addition, citations from nonsystematic literature were taken from the review by the National Consensus Project for Quality Palliative Care.

All of the recommendations are graded as strong, with moderate quality of evidence, with the exception of the recommendation on advance care planning, which was considered to have low quality of evidence.

PHILADELPHIA — E-mail and fax are the preferred tools for pediatric hospitalists to use when communicating with referring physicians, according to the results of a small survey of 77 physicians.

In this survey of referring pediatricians and emergency physicians in the metropolitan Washington area, most preferred follow-up contact from pediatric hospitalists via fax (34%) or e-mail (30%), Dr. Riva Kamat-Nerikar reported at the annual meeting of the Eastern Society for Pediatric Research.

Dr. Kamat-Nerikar, a pediatric hospitalist at Inova Fairfax Hospital for Children in Falls Church, Va., and her colleagues contacted physicians in 38 pediatric practices and 10 emergency departments that referred patients to the pediatric hospitalist service at Inova. The hospitalist team there admits about 2,300 patients per year.

The initial survey contact was Web based. Those who did not respond via the Web were then contacted by fax. Those who did not respond via fax were then contacted by phone.

In all, 77 physicians responded—74% were pediatricians. Slightly more of the respondents were women (56%). Dr. Kamat-Nerikar noted that almost half of the respondents graduated from medical school after 1990.

Most (94%) said that communication from hospitalists was necessary to follow-up care. Ease, accuracy, and directness of the communication from hospitalists were important to the primary care and emergency department physicians.

The most important information in hospitalist communication was the diagnosis, the results of any consults, and laboratory/radiology results.

One member of the audience raised the issue of e-mail security and patient confidentiality. In Dr. Kamat-Nerikar's group, discharge summaries are automatically e-mailed, faxed, or printed and mailed depending on the primary care/emergency physician's preference. She and her colleagues worked closely with the IT team to set up an automated program that ensured security.

PHILADELPHIA — E-mail and fax are the preferred tools for pediatric hospitalists to use when communicating with referring physicians, according to the results of a small survey of 77 physicians.

In this survey of referring pediatricians and emergency physicians in the metropolitan Washington area, most preferred follow-up contact from pediatric hospitalists via fax (34%) or e-mail (30%), Dr. Riva Kamat-Nerikar reported at the annual meeting of the Eastern Society for Pediatric Research.

Dr. Kamat-Nerikar, a pediatric hospitalist at Inova Fairfax Hospital for Children in Falls Church, Va., and her colleagues contacted physicians in 38 pediatric practices and 10 emergency departments that referred patients to the pediatric hospitalist service at Inova. The hospitalist team there admits about 2,300 patients per year.

The initial survey contact was Web based. Those who did not respond via the Web were then contacted by fax. Those who did not respond via fax were then contacted by phone.

In all, 77 physicians responded—74% were pediatricians. Slightly more of the respondents were women (56%). Dr. Kamat-Nerikar noted that almost half of the respondents graduated from medical school after 1990.

Most (94%) said that communication from hospitalists was necessary to follow-up care. Ease, accuracy, and directness of the communication from hospitalists were important to the primary care and emergency department physicians.

The most important information in hospitalist communication was the diagnosis, the results of any consults, and laboratory/radiology results.

One member of the audience raised the issue of e-mail security and patient confidentiality. In Dr. Kamat-Nerikar's group, discharge summaries are automatically e-mailed, faxed, or printed and mailed depending on the primary care/emergency physician's preference. She and her colleagues worked closely with the IT team to set up an automated program that ensured security.

PHILADELPHIA — E-mail and fax are the preferred tools for pediatric hospitalists to use when communicating with referring physicians, according to the results of a small survey of 77 physicians.

In this survey of referring pediatricians and emergency physicians in the metropolitan Washington area, most preferred follow-up contact from pediatric hospitalists via fax (34%) or e-mail (30%), Dr. Riva Kamat-Nerikar reported at the annual meeting of the Eastern Society for Pediatric Research.

Dr. Kamat-Nerikar, a pediatric hospitalist at Inova Fairfax Hospital for Children in Falls Church, Va., and her colleagues contacted physicians in 38 pediatric practices and 10 emergency departments that referred patients to the pediatric hospitalist service at Inova. The hospitalist team there admits about 2,300 patients per year.

The initial survey contact was Web based. Those who did not respond via the Web were then contacted by fax. Those who did not respond via fax were then contacted by phone.

In all, 77 physicians responded—74% were pediatricians. Slightly more of the respondents were women (56%). Dr. Kamat-Nerikar noted that almost half of the respondents graduated from medical school after 1990.

Most (94%) said that communication from hospitalists was necessary to follow-up care. Ease, accuracy, and directness of the communication from hospitalists were important to the primary care and emergency department physicians.

The most important information in hospitalist communication was the diagnosis, the results of any consults, and laboratory/radiology results.

One member of the audience raised the issue of e-mail security and patient confidentiality. In Dr. Kamat-Nerikar's group, discharge summaries are automatically e-mailed, faxed, or printed and mailed depending on the primary care/emergency physician's preference. She and her colleagues worked closely with the IT team to set up an automated program that ensured security.

Diabetes may significantly increase a woman's risk of developing colorectal cancer, based on the findings of a study involving more than 45,000 women across the United States.

“There was about a 50% increased risk of colorectal cancer in women with diabetes,” said Andrew Flood, Ph.D., a professor of epidemiology and community health at the University of Minnesota in Minneapolis.

Dr. Flood presented study findings at a press briefing held in conjunction with the annual international conference of the American Association for Cancer Research. He and his colleagues prospectively analyzed data from the Breast Cancer Detection Demonstration Project follow-up cohort study.

From 1987 to 1989, 45,519 women without a history of colorectal cancer completed a series of questionnaires that assessed dietary and other health and lifestyle risk factors for colorectal cancer. The average age at the time of the interview was 62 years. On average, the time between the baseline and follow-up was 9 years, during which time 489 women developed colorectal cancer. After the researchers controlled for age, physical activity, energy intake, alcohol consumption, hormone therapy, smoking, multivitamin use, education, ethnicity, NSAID use, calcium supplementation, and calcium intake from diet, women with diabetes at baseline had an adjusted hazard ratio (HR) of 1.50 for developing colorectal cancer.

The researchers hypothesized that the elevated levels of insulin typically seen in people with type 2 diabetes may play a central role. Insulin stimulates the growth of normal colonic and carcinoma cells. Insulin also modulates insulin-like growth factor 1 (IGF-1) and its binding proteins, creating a promitotic environment for colonic epithelial cells.

When the researchers conducted a second analysis that included women who were likely prediabetic at baseline, according to self-reports at the 1993–1995 follow-up, the multivariate adjusted HR for developing colorectal cancer was slightly lower (1.36) in this population of women.

Among the prediabetic women, the degree of hyperinsulinemia may not have been of a sufficient magnitude or duration to increase the risk of colorectal cancer, the researchers speculated. Or there may be some factor related to diabetes, independent of hyperinsulinemia, that is driving the observed increase in colorectal cancer risk among the diabetic women.

Diabetes may significantly increase a woman's risk of developing colorectal cancer, based on the findings of a study involving more than 45,000 women across the United States.

“There was about a 50% increased risk of colorectal cancer in women with diabetes,” said Andrew Flood, Ph.D., a professor of epidemiology and community health at the University of Minnesota in Minneapolis.

Dr. Flood presented study findings at a press briefing held in conjunction with the annual international conference of the American Association for Cancer Research. He and his colleagues prospectively analyzed data from the Breast Cancer Detection Demonstration Project follow-up cohort study.

From 1987 to 1989, 45,519 women without a history of colorectal cancer completed a series of questionnaires that assessed dietary and other health and lifestyle risk factors for colorectal cancer. The average age at the time of the interview was 62 years. On average, the time between the baseline and follow-up was 9 years, during which time 489 women developed colorectal cancer. After the researchers controlled for age, physical activity, energy intake, alcohol consumption, hormone therapy, smoking, multivitamin use, education, ethnicity, NSAID use, calcium supplementation, and calcium intake from diet, women with diabetes at baseline had an adjusted hazard ratio (HR) of 1.50 for developing colorectal cancer.

The researchers hypothesized that the elevated levels of insulin typically seen in people with type 2 diabetes may play a central role. Insulin stimulates the growth of normal colonic and carcinoma cells. Insulin also modulates insulin-like growth factor 1 (IGF-1) and its binding proteins, creating a promitotic environment for colonic epithelial cells.

When the researchers conducted a second analysis that included women who were likely prediabetic at baseline, according to self-reports at the 1993–1995 follow-up, the multivariate adjusted HR for developing colorectal cancer was slightly lower (1.36) in this population of women.

Among the prediabetic women, the degree of hyperinsulinemia may not have been of a sufficient magnitude or duration to increase the risk of colorectal cancer, the researchers speculated. Or there may be some factor related to diabetes, independent of hyperinsulinemia, that is driving the observed increase in colorectal cancer risk among the diabetic women.

Diabetes may significantly increase a woman's risk of developing colorectal cancer, based on the findings of a study involving more than 45,000 women across the United States.

“There was about a 50% increased risk of colorectal cancer in women with diabetes,” said Andrew Flood, Ph.D., a professor of epidemiology and community health at the University of Minnesota in Minneapolis.

Dr. Flood presented study findings at a press briefing held in conjunction with the annual international conference of the American Association for Cancer Research. He and his colleagues prospectively analyzed data from the Breast Cancer Detection Demonstration Project follow-up cohort study.

From 1987 to 1989, 45,519 women without a history of colorectal cancer completed a series of questionnaires that assessed dietary and other health and lifestyle risk factors for colorectal cancer. The average age at the time of the interview was 62 years. On average, the time between the baseline and follow-up was 9 years, during which time 489 women developed colorectal cancer. After the researchers controlled for age, physical activity, energy intake, alcohol consumption, hormone therapy, smoking, multivitamin use, education, ethnicity, NSAID use, calcium supplementation, and calcium intake from diet, women with diabetes at baseline had an adjusted hazard ratio (HR) of 1.50 for developing colorectal cancer.

The researchers hypothesized that the elevated levels of insulin typically seen in people with type 2 diabetes may play a central role. Insulin stimulates the growth of normal colonic and carcinoma cells. Insulin also modulates insulin-like growth factor 1 (IGF-1) and its binding proteins, creating a promitotic environment for colonic epithelial cells.

When the researchers conducted a second analysis that included women who were likely prediabetic at baseline, according to self-reports at the 1993–1995 follow-up, the multivariate adjusted HR for developing colorectal cancer was slightly lower (1.36) in this population of women.

Among the prediabetic women, the degree of hyperinsulinemia may not have been of a sufficient magnitude or duration to increase the risk of colorectal cancer, the researchers speculated. Or there may be some factor related to diabetes, independent of hyperinsulinemia, that is driving the observed increase in colorectal cancer risk among the diabetic women.

BALTIMORE — Nail dystrophy and a history of trauma should raise suspicion of subungual epidermoid inclusions, Dr. Beth S. Ruben said at the annual meeting of the American Society of Dermatopathology.

Dr. Ruben and her colleagues have encountered 17 such cases. Common clinical impressions included pachyonychia, hemorrhage, onychomycosis, or carcinoma.

"The fingers and thumb were involved more than the toes," she said. Fingers and thumbs were affected in nine cases, toes were affected in seven cases, and location was not specified in one case. "In some cases [12], there was nail dystrophy either clinically or histologically," said Dr. Ruben of the University of California, San Francisco.

In five cases, there was evidence of trauma. Calcification was noted in four cases.

Histologically, look for small, pale clusters of keratinocytes forming small cysts that resemble the follicular isthmus, or even ductal epithelium, and small, solid aggregates. Sometimes there might be an underlying bony abnormality, and there might be associated hyperkeratosis of the nail bed, she said.

Subungual cysts can be classified using a system developed by Italian investigators (Dermatologica 1989;178:209–12).

Type I inclusions are quite superficial. Nails might appear normal or exhibit clubbing. Less cystic variants can be mistaken for neoplasms.

Type II inclusions are more extensive. The nail bed might be hyperkeratotic. Cysts can be superficial or deep. The nail plate might be thickened. Most of the cases in the series reported by Dr Ruben were of the superficial type (type I).

The differential diagnosis should include subungual keratoacanthoma and ony-cholemmal carcinoma, Dr. Ruben said.

BALTIMORE — Nail dystrophy and a history of trauma should raise suspicion of subungual epidermoid inclusions, Dr. Beth S. Ruben said at the annual meeting of the American Society of Dermatopathology.

Dr. Ruben and her colleagues have encountered 17 such cases. Common clinical impressions included pachyonychia, hemorrhage, onychomycosis, or carcinoma.

"The fingers and thumb were involved more than the toes," she said. Fingers and thumbs were affected in nine cases, toes were affected in seven cases, and location was not specified in one case. "In some cases [12], there was nail dystrophy either clinically or histologically," said Dr. Ruben of the University of California, San Francisco.

In five cases, there was evidence of trauma. Calcification was noted in four cases.

Histologically, look for small, pale clusters of keratinocytes forming small cysts that resemble the follicular isthmus, or even ductal epithelium, and small, solid aggregates. Sometimes there might be an underlying bony abnormality, and there might be associated hyperkeratosis of the nail bed, she said.

Subungual cysts can be classified using a system developed by Italian investigators (Dermatologica 1989;178:209–12).

Type I inclusions are quite superficial. Nails might appear normal or exhibit clubbing. Less cystic variants can be mistaken for neoplasms.

Type II inclusions are more extensive. The nail bed might be hyperkeratotic. Cysts can be superficial or deep. The nail plate might be thickened. Most of the cases in the series reported by Dr Ruben were of the superficial type (type I).

The differential diagnosis should include subungual keratoacanthoma and ony-cholemmal carcinoma, Dr. Ruben said.

BALTIMORE — Nail dystrophy and a history of trauma should raise suspicion of subungual epidermoid inclusions, Dr. Beth S. Ruben said at the annual meeting of the American Society of Dermatopathology.

Dr. Ruben and her colleagues have encountered 17 such cases. Common clinical impressions included pachyonychia, hemorrhage, onychomycosis, or carcinoma.

"The fingers and thumb were involved more than the toes," she said. Fingers and thumbs were affected in nine cases, toes were affected in seven cases, and location was not specified in one case. "In some cases [12], there was nail dystrophy either clinically or histologically," said Dr. Ruben of the University of California, San Francisco.

In five cases, there was evidence of trauma. Calcification was noted in four cases.

Histologically, look for small, pale clusters of keratinocytes forming small cysts that resemble the follicular isthmus, or even ductal epithelium, and small, solid aggregates. Sometimes there might be an underlying bony abnormality, and there might be associated hyperkeratosis of the nail bed, she said.

Subungual cysts can be classified using a system developed by Italian investigators (Dermatologica 1989;178:209–12).

Type I inclusions are quite superficial. Nails might appear normal or exhibit clubbing. Less cystic variants can be mistaken for neoplasms.

Type II inclusions are more extensive. The nail bed might be hyperkeratotic. Cysts can be superficial or deep. The nail plate might be thickened. Most of the cases in the series reported by Dr Ruben were of the superficial type (type I).

The differential diagnosis should include subungual keratoacanthoma and ony-cholemmal carcinoma, Dr. Ruben said.

Weight gain following a diagnosis of breast cancer significantly increases a woman's risk not only of breast cancer mortality but also of all-cause mortality over a 6-year follow-up period, results of a large study suggest.

“We found that a weight gain of 5 kg [11 pounds] increased the risk of death due to breast cancer and other causes by 14%,” study investigator Hazel B. Nichols, an epidemiology doctoral student at Johns Hopkins University in Baltimore, reported at a press briefing. The briefing was held in conjunction with the annual international conference of the American Association for Cancer Research.

The findings suggest that efforts to prevent postdiagnosis weight gain could improve breast cancer survival.

Ms. Nichols and her colleagues analyzed data from a cohort of 4,021 women, who had previously participated in consecutive population-based, case-control studies of incident breast cancer in Wisconsin, Massachusetts, and New Hampshire. In the initial studies, women aged 20–70 years with a definitive diagnosis of invasive breast cancer between 1988 and 2001 were identified through state registries. Women were included in the studies once they had completed a structured telephone interview with information on height and weight, reproductive and menstrual factors, lifestyle characteristics, family and personal history of breast cancer, and demographics.

During 1998–2001, all surviving women from the original case-control studies were mailed a follow-up questionnaire, which addressed postdiagnosis weight, weight gain, physical activity, diet, medication history, alternative therapies, and quality of life. Vital status was obtained by linkage with the National Death Index through 2005. The researchers identified 121 breast cancer deaths and 428 non-breast cancer deaths after an average follow-up of 6 years (see graphic).

The researchers controlled for age, state of enrollment, time from breast cancer diagnosis to completion of the follow-up questionnaire, family history of breast cancer, menopausal status, and stage of disease. Women with metastatic disease at diagnosis were excluded from the analysis to avoid the influence of disease on postdiagnosis body weight.

Obesity, regardless of weight before diagnosis, also increased a woman's risk of breast cancer and all-cause death. Women with a body mass index greater than 30 kg/m

Ms. Nichols cautioned that the women may have had other medical conditions that could have confounded the results, but the researchers did not have access to this information. The researchers plan to look next at the effect of postdiagnosis weight loss.

ELSEVIER GLOBAL MEDICAL NEWS

Weight gain following a diagnosis of breast cancer significantly increases a woman's risk not only of breast cancer mortality but also of all-cause mortality over a 6-year follow-up period, results of a large study suggest.

“We found that a weight gain of 5 kg [11 pounds] increased the risk of death due to breast cancer and other causes by 14%,” study investigator Hazel B. Nichols, an epidemiology doctoral student at Johns Hopkins University in Baltimore, reported at a press briefing. The briefing was held in conjunction with the annual international conference of the American Association for Cancer Research.

The findings suggest that efforts to prevent postdiagnosis weight gain could improve breast cancer survival.

Ms. Nichols and her colleagues analyzed data from a cohort of 4,021 women, who had previously participated in consecutive population-based, case-control studies of incident breast cancer in Wisconsin, Massachusetts, and New Hampshire. In the initial studies, women aged 20–70 years with a definitive diagnosis of invasive breast cancer between 1988 and 2001 were identified through state registries. Women were included in the studies once they had completed a structured telephone interview with information on height and weight, reproductive and menstrual factors, lifestyle characteristics, family and personal history of breast cancer, and demographics.

During 1998–2001, all surviving women from the original case-control studies were mailed a follow-up questionnaire, which addressed postdiagnosis weight, weight gain, physical activity, diet, medication history, alternative therapies, and quality of life. Vital status was obtained by linkage with the National Death Index through 2005. The researchers identified 121 breast cancer deaths and 428 non-breast cancer deaths after an average follow-up of 6 years (see graphic).

The researchers controlled for age, state of enrollment, time from breast cancer diagnosis to completion of the follow-up questionnaire, family history of breast cancer, menopausal status, and stage of disease. Women with metastatic disease at diagnosis were excluded from the analysis to avoid the influence of disease on postdiagnosis body weight.

Obesity, regardless of weight before diagnosis, also increased a woman's risk of breast cancer and all-cause death. Women with a body mass index greater than 30 kg/m

Ms. Nichols cautioned that the women may have had other medical conditions that could have confounded the results, but the researchers did not have access to this information. The researchers plan to look next at the effect of postdiagnosis weight loss.

ELSEVIER GLOBAL MEDICAL NEWS

Weight gain following a diagnosis of breast cancer significantly increases a woman's risk not only of breast cancer mortality but also of all-cause mortality over a 6-year follow-up period, results of a large study suggest.

“We found that a weight gain of 5 kg [11 pounds] increased the risk of death due to breast cancer and other causes by 14%,” study investigator Hazel B. Nichols, an epidemiology doctoral student at Johns Hopkins University in Baltimore, reported at a press briefing. The briefing was held in conjunction with the annual international conference of the American Association for Cancer Research.

The findings suggest that efforts to prevent postdiagnosis weight gain could improve breast cancer survival.

Ms. Nichols and her colleagues analyzed data from a cohort of 4,021 women, who had previously participated in consecutive population-based, case-control studies of incident breast cancer in Wisconsin, Massachusetts, and New Hampshire. In the initial studies, women aged 20–70 years with a definitive diagnosis of invasive breast cancer between 1988 and 2001 were identified through state registries. Women were included in the studies once they had completed a structured telephone interview with information on height and weight, reproductive and menstrual factors, lifestyle characteristics, family and personal history of breast cancer, and demographics.

During 1998–2001, all surviving women from the original case-control studies were mailed a follow-up questionnaire, which addressed postdiagnosis weight, weight gain, physical activity, diet, medication history, alternative therapies, and quality of life. Vital status was obtained by linkage with the National Death Index through 2005. The researchers identified 121 breast cancer deaths and 428 non-breast cancer deaths after an average follow-up of 6 years (see graphic).

The researchers controlled for age, state of enrollment, time from breast cancer diagnosis to completion of the follow-up questionnaire, family history of breast cancer, menopausal status, and stage of disease. Women with metastatic disease at diagnosis were excluded from the analysis to avoid the influence of disease on postdiagnosis body weight.

Obesity, regardless of weight before diagnosis, also increased a woman's risk of breast cancer and all-cause death. Women with a body mass index greater than 30 kg/m

Ms. Nichols cautioned that the women may have had other medical conditions that could have confounded the results, but the researchers did not have access to this information. The researchers plan to look next at the effect of postdiagnosis weight loss.

ELSEVIER GLOBAL MEDICAL NEWS

Diffusion-based magnetic resonance images are sensitive to water motion in the brain. Diffusion tensor imaging (DTI) provides information on microarchitecture of the brain's white matter that reflects changes in axonal myelination processes and, therefore, the integrity of organized tissue microstructures.

“The part that we can pick up is the water motion that is in the sulci next to the gray matter [in the cerebrospinal fluid]. This is very easy to measure,” said Manzar Ashtari, Ph.D., a senior neuroscientist in the radiology department of the Children's Hospital of Philadelphia.

Dr. Ashtari used a DTI measure called the apparent diffusion coefficient (ADC) to measure cerebrospinal fluid (CSF) changes in the sulci as a surrogate for gray matter changes. The ADC is an average measure of the diffusion of water in all directions in a single voxel. ADC is greatest in CSF and least in coherent, healthy white matter. The idea that ADC could be a surrogate marker is based on the observations that cortical brain atrophy is associated with a corresponding increase in sulcal and ventricular CSF, meaning that CSF may be considered a tracer for detecting cortical gray matter reductions.

ADC rises with increasing CSF volume, which may represent gray matter volume loss. “We are basically saying that if you look at the water motion in the cerebrospinal fluid that is in the sulci, whatever changes that happen to the CSF could be a surrogate for the gray matter right next to it,” said Dr. Ashtari.

Dr. Ashtari used the new technique to look for potentially subtle differences in gray matter volume in high-functioning autism or Asperger syndrome patients. The autism imaging literature on white, gray, and whole-brain volumes is very confusing in part because imaging findings vary by age, she said.

The brains of autistic children appear not to go through normal growth processes, as compared with the neuronal development of healthy children. Although autistic children start with larger brain volumes, eventually normal children catch up with and pass their autistic counterparts in terms of gray or white matter volume.

In her study, Dr. Ashtari looked only at preadolescent boys (average age 11 years for both controls and autistic children). Autism most often affects boys, by a 4:1 ratio. She specifically looked at a preadolescent population because previous work of hers showed a big spurt of myelination during adolescence in healthy participants (Neuroimage 2007;35:501–10).

Quite unexpectedly, “We found increased gray matter [decreased ADC values] in several areas of the cortex,” in autistic preadolescents. “I don't want this study to be generalized. I'm not claiming that if you look at [autistic] adults, this is what you'll see,” said Dr. Ashtari.

The areas of abnormality occurred most often in the parietal lobe, which has a strong connection with the prefrontal region. “I concluded that I'm looking at mirror neuron abnormalities in autistic kids,” she said. Mirror neurons are thought to fire both when an animal acts and experiences an emotion or sensation and when the animal observes the same action, emotions, and sensations in others. They mirror the behavior of another animal, as though the observer were acting itself. These neurons have been directly observed in primates and are believed to exist in humans.

Next, Dr. Ashtari looked for possible correlations between increased gray matter and specific autism behaviors. To do this she used the Autism Diagnostic Interview and the Autism Diagnostic Observation Schedule.

They also measured the children's IQs.

She plotted the inverse of the ADC (which represents gray matter changes) against the measures of stereotyped behavior/restricted interest. She found that the greater the gray matter values, the poorer the performance (correlation factor of 0.6; P value of .04). She also plotted gray matter changes against measures of abnormalities in social interactions. Greater gray matter volume trended toward greater abnormalities in social interaction (correlation factor 0.5; P .08). Next, she plotted gray matter volume against IQ for both normal children and those with autism. She found that normal children have increased IQ with increased gray matter but there was no correlation in children with autism and IQ. In fact, the trend was the reverse; with increased gray matter, children with autism showed a decreased IQ.

“The conclusion I made was that this increased gray matter is nonfunctioning gray matter,” said Dr. Ashtari.

“There was one other area of abnormality that we found and that was deep inside, not really on the cortex … basically around the right amygdala area,” said Dr. Ashtari. The amygdala is a center for emotional processing. The researchers found decreased gray matter in the right amygdala of children with autism.

Apparent diffusion coefficient-based morphometry revealed clusters of increased gray matter (highlighted) in the right and left parietal cortex of an autistic boy. Courtesy Manzar Ashtari, Ph.D.

Diffusion-based magnetic resonance images are sensitive to water motion in the brain. Diffusion tensor imaging (DTI) provides information on microarchitecture of the brain's white matter that reflects changes in axonal myelination processes and, therefore, the integrity of organized tissue microstructures.

“The part that we can pick up is the water motion that is in the sulci next to the gray matter [in the cerebrospinal fluid]. This is very easy to measure,” said Manzar Ashtari, Ph.D., a senior neuroscientist in the radiology department of the Children's Hospital of Philadelphia.

Dr. Ashtari used a DTI measure called the apparent diffusion coefficient (ADC) to measure cerebrospinal fluid (CSF) changes in the sulci as a surrogate for gray matter changes. The ADC is an average measure of the diffusion of water in all directions in a single voxel. ADC is greatest in CSF and least in coherent, healthy white matter. The idea that ADC could be a surrogate marker is based on the observations that cortical brain atrophy is associated with a corresponding increase in sulcal and ventricular CSF, meaning that CSF may be considered a tracer for detecting cortical gray matter reductions.

ADC rises with increasing CSF volume, which may represent gray matter volume loss. “We are basically saying that if you look at the water motion in the cerebrospinal fluid that is in the sulci, whatever changes that happen to the CSF could be a surrogate for the gray matter right next to it,” said Dr. Ashtari.

Dr. Ashtari used the new technique to look for potentially subtle differences in gray matter volume in high-functioning autism or Asperger syndrome patients. The autism imaging literature on white, gray, and whole-brain volumes is very confusing in part because imaging findings vary by age, she said.

The brains of autistic children appear not to go through normal growth processes, as compared with the neuronal development of healthy children. Although autistic children start with larger brain volumes, eventually normal children catch up with and pass their autistic counterparts in terms of gray or white matter volume.

In her study, Dr. Ashtari looked only at preadolescent boys (average age 11 years for both controls and autistic children). Autism most often affects boys, by a 4:1 ratio. She specifically looked at a preadolescent population because previous work of hers showed a big spurt of myelination during adolescence in healthy participants (Neuroimage 2007;35:501–10).

Quite unexpectedly, “We found increased gray matter [decreased ADC values] in several areas of the cortex,” in autistic preadolescents. “I don't want this study to be generalized. I'm not claiming that if you look at [autistic] adults, this is what you'll see,” said Dr. Ashtari.

The areas of abnormality occurred most often in the parietal lobe, which has a strong connection with the prefrontal region. “I concluded that I'm looking at mirror neuron abnormalities in autistic kids,” she said. Mirror neurons are thought to fire both when an animal acts and experiences an emotion or sensation and when the animal observes the same action, emotions, and sensations in others. They mirror the behavior of another animal, as though the observer were acting itself. These neurons have been directly observed in primates and are believed to exist in humans.

Next, Dr. Ashtari looked for possible correlations between increased gray matter and specific autism behaviors. To do this she used the Autism Diagnostic Interview and the Autism Diagnostic Observation Schedule.

They also measured the children's IQs.

She plotted the inverse of the ADC (which represents gray matter changes) against the measures of stereotyped behavior/restricted interest. She found that the greater the gray matter values, the poorer the performance (correlation factor of 0.6; P value of .04). She also plotted gray matter changes against measures of abnormalities in social interactions. Greater gray matter volume trended toward greater abnormalities in social interaction (correlation factor 0.5; P .08). Next, she plotted gray matter volume against IQ for both normal children and those with autism. She found that normal children have increased IQ with increased gray matter but there was no correlation in children with autism and IQ. In fact, the trend was the reverse; with increased gray matter, children with autism showed a decreased IQ.

“The conclusion I made was that this increased gray matter is nonfunctioning gray matter,” said Dr. Ashtari.

“There was one other area of abnormality that we found and that was deep inside, not really on the cortex … basically around the right amygdala area,” said Dr. Ashtari. The amygdala is a center for emotional processing. The researchers found decreased gray matter in the right amygdala of children with autism.

Apparent diffusion coefficient-based morphometry revealed clusters of increased gray matter (highlighted) in the right and left parietal cortex of an autistic boy. Courtesy Manzar Ashtari, Ph.D.

Diffusion-based magnetic resonance images are sensitive to water motion in the brain. Diffusion tensor imaging (DTI) provides information on microarchitecture of the brain's white matter that reflects changes in axonal myelination processes and, therefore, the integrity of organized tissue microstructures.

“The part that we can pick up is the water motion that is in the sulci next to the gray matter [in the cerebrospinal fluid]. This is very easy to measure,” said Manzar Ashtari, Ph.D., a senior neuroscientist in the radiology department of the Children's Hospital of Philadelphia.

Dr. Ashtari used a DTI measure called the apparent diffusion coefficient (ADC) to measure cerebrospinal fluid (CSF) changes in the sulci as a surrogate for gray matter changes. The ADC is an average measure of the diffusion of water in all directions in a single voxel. ADC is greatest in CSF and least in coherent, healthy white matter. The idea that ADC could be a surrogate marker is based on the observations that cortical brain atrophy is associated with a corresponding increase in sulcal and ventricular CSF, meaning that CSF may be considered a tracer for detecting cortical gray matter reductions.

ADC rises with increasing CSF volume, which may represent gray matter volume loss. “We are basically saying that if you look at the water motion in the cerebrospinal fluid that is in the sulci, whatever changes that happen to the CSF could be a surrogate for the gray matter right next to it,” said Dr. Ashtari.

Dr. Ashtari used the new technique to look for potentially subtle differences in gray matter volume in high-functioning autism or Asperger syndrome patients. The autism imaging literature on white, gray, and whole-brain volumes is very confusing in part because imaging findings vary by age, she said.

The brains of autistic children appear not to go through normal growth processes, as compared with the neuronal development of healthy children. Although autistic children start with larger brain volumes, eventually normal children catch up with and pass their autistic counterparts in terms of gray or white matter volume.

In her study, Dr. Ashtari looked only at preadolescent boys (average age 11 years for both controls and autistic children). Autism most often affects boys, by a 4:1 ratio. She specifically looked at a preadolescent population because previous work of hers showed a big spurt of myelination during adolescence in healthy participants (Neuroimage 2007;35:501–10).

Quite unexpectedly, “We found increased gray matter [decreased ADC values] in several areas of the cortex,” in autistic preadolescents. “I don't want this study to be generalized. I'm not claiming that if you look at [autistic] adults, this is what you'll see,” said Dr. Ashtari.

The areas of abnormality occurred most often in the parietal lobe, which has a strong connection with the prefrontal region. “I concluded that I'm looking at mirror neuron abnormalities in autistic kids,” she said. Mirror neurons are thought to fire both when an animal acts and experiences an emotion or sensation and when the animal observes the same action, emotions, and sensations in others. They mirror the behavior of another animal, as though the observer were acting itself. These neurons have been directly observed in primates and are believed to exist in humans.

Next, Dr. Ashtari looked for possible correlations between increased gray matter and specific autism behaviors. To do this she used the Autism Diagnostic Interview and the Autism Diagnostic Observation Schedule.

They also measured the children's IQs.

She plotted the inverse of the ADC (which represents gray matter changes) against the measures of stereotyped behavior/restricted interest. She found that the greater the gray matter values, the poorer the performance (correlation factor of 0.6; P value of .04). She also plotted gray matter changes against measures of abnormalities in social interactions. Greater gray matter volume trended toward greater abnormalities in social interaction (correlation factor 0.5; P .08). Next, she plotted gray matter volume against IQ for both normal children and those with autism. She found that normal children have increased IQ with increased gray matter but there was no correlation in children with autism and IQ. In fact, the trend was the reverse; with increased gray matter, children with autism showed a decreased IQ.

“The conclusion I made was that this increased gray matter is nonfunctioning gray matter,” said Dr. Ashtari.

“There was one other area of abnormality that we found and that was deep inside, not really on the cortex … basically around the right amygdala area,” said Dr. Ashtari. The amygdala is a center for emotional processing. The researchers found decreased gray matter in the right amygdala of children with autism.

Apparent diffusion coefficient-based morphometry revealed clusters of increased gray matter (highlighted) in the right and left parietal cortex of an autistic boy. Courtesy Manzar Ashtari, Ph.D.

WASHINGTON — There doesn't appear to be any difference in long-term cognitive function following coronary artery bypass graft or stenting.

This finding comes from an assessment of cognitive function at 6 years in 152 patients whose coronary artery disease (CAD) was treated with coronary artery bypass graft (CABG) and 92 patients whose CAD was treated with stents. Dr. Guy McKhann, professor of neurology and neuroscience at Johns Hopkins University, Baltimore, and his colleagues found that cognitive declines noticed after surgery are related to the presence of vascular disease. “The real attention should be on modifying risk factors,” he said, adding: “We think that how these people do is very much dependent on how their brains are going in [to surgery].”

In terms of cognitive change over 6 years, there was minimal decline, but essentially these two groups were the same, Dr. McKhann reported at the annual meeting of the American Neurological Association. The average Mini-Mental State Examination (MMSE) score was 27.4 for the CABG group and 27.9 for the stent group. The average Center for Epidemiologic Studies-Depression (CES-D) scale score was 9.5 for the CABG group and 9.0 for the stent group. (See table.)

The issue of long-term cognitive decline following coronary artery surgery is an important one, given that there continues to be uncertainty over the best approach to treat coronary artery disease—surgery or stenting. “This issue of late decline has gotten into this debate” and is used as an argument for stenting rather than surgery, he said.

“We don't think there is any selective long-term decline after CABG that cannot be seen in other groups with significant coronary artery disease. We don't think late decline should be an issue in the choice of what procedure you're going to have done,” said Dr. McKhann.

The researchers have been studying the issue of neurologic outcomes following coronary surgery since 1992. “What we set up then was a prospective evaluation of all heart surgery patients within the intensive care unit,” said Dr. McKhann.

Starting in 1997, the work that Dr. McKhann and his colleagues were doing with acute-care patients became a four-arm study involving those undergoing conventional CABG, those with off-pump CABG, cardiac controls who received stents, and heart-healthy controls lacking traditional risk factors for heart disease. The researchers looked at cognition at baseline, 3 months, 1 year, 3 years, and 6 years.

In this CAD intervention population, 3%–5% have strokes, 10%–15% have encephalopathies, and about 25% have short-term cognitive problems. In-hospital mortality is 22% following a stroke, 7.5% following encephalopathy, and 12% following both.

“If you have coronary artery disease … you're going to be lower at baseline than the heart-healthy controls but not in all cognitive domains,” he said.

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — There doesn't appear to be any difference in long-term cognitive function following coronary artery bypass graft or stenting.

This finding comes from an assessment of cognitive function at 6 years in 152 patients whose coronary artery disease (CAD) was treated with coronary artery bypass graft (CABG) and 92 patients whose CAD was treated with stents. Dr. Guy McKhann, professor of neurology and neuroscience at Johns Hopkins University, Baltimore, and his colleagues found that cognitive declines noticed after surgery are related to the presence of vascular disease. “The real attention should be on modifying risk factors,” he said, adding: “We think that how these people do is very much dependent on how their brains are going in [to surgery].”

In terms of cognitive change over 6 years, there was minimal decline, but essentially these two groups were the same, Dr. McKhann reported at the annual meeting of the American Neurological Association. The average Mini-Mental State Examination (MMSE) score was 27.4 for the CABG group and 27.9 for the stent group. The average Center for Epidemiologic Studies-Depression (CES-D) scale score was 9.5 for the CABG group and 9.0 for the stent group. (See table.)

The issue of long-term cognitive decline following coronary artery surgery is an important one, given that there continues to be uncertainty over the best approach to treat coronary artery disease—surgery or stenting. “This issue of late decline has gotten into this debate” and is used as an argument for stenting rather than surgery, he said.

“We don't think there is any selective long-term decline after CABG that cannot be seen in other groups with significant coronary artery disease. We don't think late decline should be an issue in the choice of what procedure you're going to have done,” said Dr. McKhann.

The researchers have been studying the issue of neurologic outcomes following coronary surgery since 1992. “What we set up then was a prospective evaluation of all heart surgery patients within the intensive care unit,” said Dr. McKhann.

Starting in 1997, the work that Dr. McKhann and his colleagues were doing with acute-care patients became a four-arm study involving those undergoing conventional CABG, those with off-pump CABG, cardiac controls who received stents, and heart-healthy controls lacking traditional risk factors for heart disease. The researchers looked at cognition at baseline, 3 months, 1 year, 3 years, and 6 years.

In this CAD intervention population, 3%–5% have strokes, 10%–15% have encephalopathies, and about 25% have short-term cognitive problems. In-hospital mortality is 22% following a stroke, 7.5% following encephalopathy, and 12% following both.

“If you have coronary artery disease … you're going to be lower at baseline than the heart-healthy controls but not in all cognitive domains,” he said.

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — There doesn't appear to be any difference in long-term cognitive function following coronary artery bypass graft or stenting.

This finding comes from an assessment of cognitive function at 6 years in 152 patients whose coronary artery disease (CAD) was treated with coronary artery bypass graft (CABG) and 92 patients whose CAD was treated with stents. Dr. Guy McKhann, professor of neurology and neuroscience at Johns Hopkins University, Baltimore, and his colleagues found that cognitive declines noticed after surgery are related to the presence of vascular disease. “The real attention should be on modifying risk factors,” he said, adding: “We think that how these people do is very much dependent on how their brains are going in [to surgery].”

In terms of cognitive change over 6 years, there was minimal decline, but essentially these two groups were the same, Dr. McKhann reported at the annual meeting of the American Neurological Association. The average Mini-Mental State Examination (MMSE) score was 27.4 for the CABG group and 27.9 for the stent group. The average Center for Epidemiologic Studies-Depression (CES-D) scale score was 9.5 for the CABG group and 9.0 for the stent group. (See table.)

The issue of long-term cognitive decline following coronary artery surgery is an important one, given that there continues to be uncertainty over the best approach to treat coronary artery disease—surgery or stenting. “This issue of late decline has gotten into this debate” and is used as an argument for stenting rather than surgery, he said.

“We don't think there is any selective long-term decline after CABG that cannot be seen in other groups with significant coronary artery disease. We don't think late decline should be an issue in the choice of what procedure you're going to have done,” said Dr. McKhann.

The researchers have been studying the issue of neurologic outcomes following coronary surgery since 1992. “What we set up then was a prospective evaluation of all heart surgery patients within the intensive care unit,” said Dr. McKhann.

Starting in 1997, the work that Dr. McKhann and his colleagues were doing with acute-care patients became a four-arm study involving those undergoing conventional CABG, those with off-pump CABG, cardiac controls who received stents, and heart-healthy controls lacking traditional risk factors for heart disease. The researchers looked at cognition at baseline, 3 months, 1 year, 3 years, and 6 years.

In this CAD intervention population, 3%–5% have strokes, 10%–15% have encephalopathies, and about 25% have short-term cognitive problems. In-hospital mortality is 22% following a stroke, 7.5% following encephalopathy, and 12% following both.

“If you have coronary artery disease … you're going to be lower at baseline than the heart-healthy controls but not in all cognitive domains,” he said.

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — There doesn't appear to be any difference in long-term cognitive function following coronary artery bypass graft or stenting.

This finding comes from an assessment of cognitive function at 6 years in 152 patients whose coronary artery disease (CAD) was treated with coronary artery bypass graft (CABG) and 92 patients whose CAD was treated with stents. Dr. Guy McKhann, professor of neurology and neuroscience at Johns Hopkins University, Baltimore, and his colleagues found that cognitive declines noticed after surgery are related to the presence of vascular disease. “The real attention should be on modifying risk factors.”

In terms of cognitive change over 6 years, there was minimal decline, but essentially these two groups were the same, Dr. McKhann reported at the annual meeting of the American Neurological Association. The average Mini-Mental State Examination (MMSE) score was 27.4 for the CABG group and 27.9 for the stent group. The average Center for Epidemiologic Studies-Depression (CES-D) scale score was 9.5 for the CABG group and 9.0 for the stent group.

The issue of long-term cognitive decline following coronary artery surgery is an important one, given that there continues to be uncertainty over the best approach to treat coronary artery disease. “This issue of late decline has gotten into this debate” and is used as an argument for stenting rather than surgery, he said.

“We don't think there is any selective long-term decline after CABG that cannot be seen in other groups with significant coronary artery disease. We don't think late decline should be an issue in the choice of what procedure you're going to have done,” Dr. McKhann said.

The researchers have been studying the issue of neurologic outcomes following coronary surgery since 1992.

What they have found is that “If you have coronary artery disease … you're going to be lower at baseline than the heart-healthy controls but not in all cognitive domains,” he said. “In our data we think we see a relative preservation of memory and language, and decreased psychomotor and motor speed and decreased executive function,” he said.

WASHINGTON — There doesn't appear to be any difference in long-term cognitive function following coronary artery bypass graft or stenting.

This finding comes from an assessment of cognitive function at 6 years in 152 patients whose coronary artery disease (CAD) was treated with coronary artery bypass graft (CABG) and 92 patients whose CAD was treated with stents. Dr. Guy McKhann, professor of neurology and neuroscience at Johns Hopkins University, Baltimore, and his colleagues found that cognitive declines noticed after surgery are related to the presence of vascular disease. “The real attention should be on modifying risk factors.”

In terms of cognitive change over 6 years, there was minimal decline, but essentially these two groups were the same, Dr. McKhann reported at the annual meeting of the American Neurological Association. The average Mini-Mental State Examination (MMSE) score was 27.4 for the CABG group and 27.9 for the stent group. The average Center for Epidemiologic Studies-Depression (CES-D) scale score was 9.5 for the CABG group and 9.0 for the stent group.

The issue of long-term cognitive decline following coronary artery surgery is an important one, given that there continues to be uncertainty over the best approach to treat coronary artery disease. “This issue of late decline has gotten into this debate” and is used as an argument for stenting rather than surgery, he said.

“We don't think there is any selective long-term decline after CABG that cannot be seen in other groups with significant coronary artery disease. We don't think late decline should be an issue in the choice of what procedure you're going to have done,” Dr. McKhann said.

The researchers have been studying the issue of neurologic outcomes following coronary surgery since 1992.

What they have found is that “If you have coronary artery disease … you're going to be lower at baseline than the heart-healthy controls but not in all cognitive domains,” he said. “In our data we think we see a relative preservation of memory and language, and decreased psychomotor and motor speed and decreased executive function,” he said.

WASHINGTON — There doesn't appear to be any difference in long-term cognitive function following coronary artery bypass graft or stenting.

This finding comes from an assessment of cognitive function at 6 years in 152 patients whose coronary artery disease (CAD) was treated with coronary artery bypass graft (CABG) and 92 patients whose CAD was treated with stents. Dr. Guy McKhann, professor of neurology and neuroscience at Johns Hopkins University, Baltimore, and his colleagues found that cognitive declines noticed after surgery are related to the presence of vascular disease. “The real attention should be on modifying risk factors.”

In terms of cognitive change over 6 years, there was minimal decline, but essentially these two groups were the same, Dr. McKhann reported at the annual meeting of the American Neurological Association. The average Mini-Mental State Examination (MMSE) score was 27.4 for the CABG group and 27.9 for the stent group. The average Center for Epidemiologic Studies-Depression (CES-D) scale score was 9.5 for the CABG group and 9.0 for the stent group.

The issue of long-term cognitive decline following coronary artery surgery is an important one, given that there continues to be uncertainty over the best approach to treat coronary artery disease. “This issue of late decline has gotten into this debate” and is used as an argument for stenting rather than surgery, he said.

“We don't think there is any selective long-term decline after CABG that cannot be seen in other groups with significant coronary artery disease. We don't think late decline should be an issue in the choice of what procedure you're going to have done,” Dr. McKhann said.

The researchers have been studying the issue of neurologic outcomes following coronary surgery since 1992.

What they have found is that “If you have coronary artery disease … you're going to be lower at baseline than the heart-healthy controls but not in all cognitive domains,” he said. “In our data we think we see a relative preservation of memory and language, and decreased psychomotor and motor speed and decreased executive function,” he said.