Miriam E. Tucker

BALTIMORE — For as many as a third of adolescents who report riding in a car with a drinking driver, that driver is actually a parent rather than a peer.

That startling finding, from an observational study based on a cross-sectional questionnaire of 2,100 adolescents, highlights “a profoundly underrecognized and undertreated public health problem,” Dr. Celeste R. Wilson said in a poster presentation at the annual meeting of the Pediatric Academic Societies.

“Primary care providers need effective counseling strategies for adolescents exposed to parents who drive while intoxicated and more training in how to deal with parents who are placing their children at risk by engaging in this behavior,” said Dr. Wilson, who is with the Center for Adolescent Substance Abuse Research at Children's Hospital, Boston.

The study sample was recruited from among 12- to 18-year-olds who arrived for routine care visits at one of nine primary care practices in Massachusetts, Vermont, and New Hampshire during 2005-2008.

The total 2,100 adolescents who completed the 20-item survey had a mean age of 16 years, and two-thirds were female. Half had at least one parent with a college degree, and 69% lived with both parents.

Of the 2,100 total respondents, 22% reported having ridden in a car in the previous 90 days with a driver who had been drinking. Of those 459 respondents, 41% identified that driver as someone living in their home. And of those 189 respondents, 91% (172) said that the drinking driver living in their home was an adult who was over 21 years of age.

Because of Institutional Review Board concerns about study subject protection, the survey did not directly inquire whether the drinking driver was a parent or guardian. Instead, the descriptions “an adult over 21 years of age” and “living in your home” were used as proxies, Dr. Wilson explained.

Adolescents who reported riding with a drinking driver who was an adult living in their home were more likely to be female, to be white, and to have a parent with no college degree. Younger adolescents were more likely than older ones to report riding with a drinking “parent,” she said.

Although the exact nature of the relationship between the adult drinking driver and the adolescent could not be confirmed, other questionnaire data supported the supposition that a majority of these were indeed parents.

The risk for having ridden with a drinking driver who was older than 21 and living in the teenager's home was more than three times greater for those who agreed with the survey items, “I have a parent whose use of alcohol or other drugs worries me,” “I have a parent who gets drunk or high,” and/or “I have a parent who needs treatment for alcohol or other drug problems.” The risk was more than double for those who said, “I have a parent who uses alcohol or drugs soon after getting up in the morning.”

Still, Dr. Wilson acknowledged that at least in some cases, the drinking driver might be an older sibling or a parent's romantic partner who is not the teen's parent. Nonetheless, “I think the key issue is that an adult who is well known to the adolescent is engaging in behavior that's potentially putting the adolescent at risk.”

This study was funded by grants from the National Institutes of Health and several private foundations. Dr. Wilson stated that she had no financial disclosures.

Providers need strategies for teens exposed to parents who drink and drive. ©Dmitriy Melnikov/

BALTIMORE — For as many as a third of adolescents who report riding in a car with a drinking driver, that driver is actually a parent rather than a peer.

That startling finding, from an observational study based on a cross-sectional questionnaire of 2,100 adolescents, highlights “a profoundly underrecognized and undertreated public health problem,” Dr. Celeste R. Wilson said in a poster presentation at the annual meeting of the Pediatric Academic Societies.

“Primary care providers need effective counseling strategies for adolescents exposed to parents who drive while intoxicated and more training in how to deal with parents who are placing their children at risk by engaging in this behavior,” said Dr. Wilson, who is with the Center for Adolescent Substance Abuse Research at Children's Hospital, Boston.

The study sample was recruited from among 12- to 18-year-olds who arrived for routine care visits at one of nine primary care practices in Massachusetts, Vermont, and New Hampshire during 2005-2008.

The total 2,100 adolescents who completed the 20-item survey had a mean age of 16 years, and two-thirds were female. Half had at least one parent with a college degree, and 69% lived with both parents.

Of the 2,100 total respondents, 22% reported having ridden in a car in the previous 90 days with a driver who had been drinking. Of those 459 respondents, 41% identified that driver as someone living in their home. And of those 189 respondents, 91% (172) said that the drinking driver living in their home was an adult who was over 21 years of age.

Because of Institutional Review Board concerns about study subject protection, the survey did not directly inquire whether the drinking driver was a parent or guardian. Instead, the descriptions “an adult over 21 years of age” and “living in your home” were used as proxies, Dr. Wilson explained.

Adolescents who reported riding with a drinking driver who was an adult living in their home were more likely to be female, to be white, and to have a parent with no college degree. Younger adolescents were more likely than older ones to report riding with a drinking “parent,” she said.

Although the exact nature of the relationship between the adult drinking driver and the adolescent could not be confirmed, other questionnaire data supported the supposition that a majority of these were indeed parents.

The risk for having ridden with a drinking driver who was older than 21 and living in the teenager's home was more than three times greater for those who agreed with the survey items, “I have a parent whose use of alcohol or other drugs worries me,” “I have a parent who gets drunk or high,” and/or “I have a parent who needs treatment for alcohol or other drug problems.” The risk was more than double for those who said, “I have a parent who uses alcohol or drugs soon after getting up in the morning.”

Still, Dr. Wilson acknowledged that at least in some cases, the drinking driver might be an older sibling or a parent's romantic partner who is not the teen's parent. Nonetheless, “I think the key issue is that an adult who is well known to the adolescent is engaging in behavior that's potentially putting the adolescent at risk.”

This study was funded by grants from the National Institutes of Health and several private foundations. Dr. Wilson stated that she had no financial disclosures.

Providers need strategies for teens exposed to parents who drink and drive. ©Dmitriy Melnikov/

BALTIMORE — For as many as a third of adolescents who report riding in a car with a drinking driver, that driver is actually a parent rather than a peer.

That startling finding, from an observational study based on a cross-sectional questionnaire of 2,100 adolescents, highlights “a profoundly underrecognized and undertreated public health problem,” Dr. Celeste R. Wilson said in a poster presentation at the annual meeting of the Pediatric Academic Societies.

“Primary care providers need effective counseling strategies for adolescents exposed to parents who drive while intoxicated and more training in how to deal with parents who are placing their children at risk by engaging in this behavior,” said Dr. Wilson, who is with the Center for Adolescent Substance Abuse Research at Children's Hospital, Boston.

The study sample was recruited from among 12- to 18-year-olds who arrived for routine care visits at one of nine primary care practices in Massachusetts, Vermont, and New Hampshire during 2005-2008.

The total 2,100 adolescents who completed the 20-item survey had a mean age of 16 years, and two-thirds were female. Half had at least one parent with a college degree, and 69% lived with both parents.

Of the 2,100 total respondents, 22% reported having ridden in a car in the previous 90 days with a driver who had been drinking. Of those 459 respondents, 41% identified that driver as someone living in their home. And of those 189 respondents, 91% (172) said that the drinking driver living in their home was an adult who was over 21 years of age.

Because of Institutional Review Board concerns about study subject protection, the survey did not directly inquire whether the drinking driver was a parent or guardian. Instead, the descriptions “an adult over 21 years of age” and “living in your home” were used as proxies, Dr. Wilson explained.

Adolescents who reported riding with a drinking driver who was an adult living in their home were more likely to be female, to be white, and to have a parent with no college degree. Younger adolescents were more likely than older ones to report riding with a drinking “parent,” she said.

Although the exact nature of the relationship between the adult drinking driver and the adolescent could not be confirmed, other questionnaire data supported the supposition that a majority of these were indeed parents.

The risk for having ridden with a drinking driver who was older than 21 and living in the teenager's home was more than three times greater for those who agreed with the survey items, “I have a parent whose use of alcohol or other drugs worries me,” “I have a parent who gets drunk or high,” and/or “I have a parent who needs treatment for alcohol or other drug problems.” The risk was more than double for those who said, “I have a parent who uses alcohol or drugs soon after getting up in the morning.”

Still, Dr. Wilson acknowledged that at least in some cases, the drinking driver might be an older sibling or a parent's romantic partner who is not the teen's parent. Nonetheless, “I think the key issue is that an adult who is well known to the adolescent is engaging in behavior that's potentially putting the adolescent at risk.”

This study was funded by grants from the National Institutes of Health and several private foundations. Dr. Wilson stated that she had no financial disclosures.

Providers need strategies for teens exposed to parents who drink and drive. ©Dmitriy Melnikov/

BALTIMORE — In 139 children who had primary hypertension, the risk for left ventricular hypertrophy was even greater for African Americans than for non-African Americans in a cross-sectional review.

The children, aged 3-21 years, after being evaluated for hypertension at one of three tertiary medical centers between 1997 and 2005, were ultimately diagnosed with primary hypertension and underwent echocardiography. The overall prevalence of left ventricular hypertrophy (LVH) was 42% in the entire group. Of the 35 African American children, 21 (60%) had LVH, compared with 38 (37%) of the 104 non-African American children. The difference was statistically significant, Dr. Cozumel S. Pruette said at the annual meeting of the Pediatric Academic Societies.

“African American children with primary hypertension may need more aggressive screening for additional cardiovascular risk factors. However, regardless of race, all children with primary hypertension are deserving of close follow-up due to the high prevalence of LVH that we noted in our study,” said Dr. Pruette, a fellow in pediatric nephrology at Johns Hopkins University, Baltimore.

There were no differences within each racial group in mean age, sex, height percentile, or family history of hypertension. Levels of systolic and diastolic blood pressure—assessed by both blood pressure index and 24-hour ambulatory blood pressure monitoring—were not associated with the presence of LVH in African American or non-African American children.

The body mass index z score was significantly higher in both the African American and non-African American groups with LVH (2.0 and 1.8, respectively) than in those two groups without LVH (1.3 and 1.4), but did not differ by race.

Total cholesterol was significantly higher in the African American children with LVH (195 mg/dL) than in those without LVH (151 mg/dL). This difference was not present in non-African American children (163 mg/dL with LVH vs. 166 mg/dL without). However, mean total cholesterol was significantly higher in African American children with LVH than in non-African American children with LVH (195 vs. 163 mg/dL).

“Given our findings, in children referred for primary hypertension, African American children may be at increased cardiovascular risk, due to their increased prevalence of LVH, higher total cholesterol levels and high BMI z scores at the time of initial referral,” she concluded.

Asked about the duration of hypertension in the children by session moderator Dr. Douglas M. Silverstein of Louisiana State University in New Orleans, given that “LVH can happen relatively quickly and can also recede very quickly over a period of months to years,” Dr. Pruette said, “We don't have any information on how long these children were hypertensive, and some may be further into their disease state than others. That's something we hope to capture in future studies.”

Dr. Pruette stated that she had no relevant financial disclosures.

Dr. Cozumel S. Pruette (left) discusses the findings ofher studywith session comoderators Dr. Andrew L. Schwaderer (center) and Dr. Douglas M. Silverstein (right). Miriam E. Tucker/Elsevier Global Medical News

BALTIMORE — In 139 children who had primary hypertension, the risk for left ventricular hypertrophy was even greater for African Americans than for non-African Americans in a cross-sectional review.

The children, aged 3-21 years, after being evaluated for hypertension at one of three tertiary medical centers between 1997 and 2005, were ultimately diagnosed with primary hypertension and underwent echocardiography. The overall prevalence of left ventricular hypertrophy (LVH) was 42% in the entire group. Of the 35 African American children, 21 (60%) had LVH, compared with 38 (37%) of the 104 non-African American children. The difference was statistically significant, Dr. Cozumel S. Pruette said at the annual meeting of the Pediatric Academic Societies.

“African American children with primary hypertension may need more aggressive screening for additional cardiovascular risk factors. However, regardless of race, all children with primary hypertension are deserving of close follow-up due to the high prevalence of LVH that we noted in our study,” said Dr. Pruette, a fellow in pediatric nephrology at Johns Hopkins University, Baltimore.

There were no differences within each racial group in mean age, sex, height percentile, or family history of hypertension. Levels of systolic and diastolic blood pressure—assessed by both blood pressure index and 24-hour ambulatory blood pressure monitoring—were not associated with the presence of LVH in African American or non-African American children.

The body mass index z score was significantly higher in both the African American and non-African American groups with LVH (2.0 and 1.8, respectively) than in those two groups without LVH (1.3 and 1.4), but did not differ by race.

Total cholesterol was significantly higher in the African American children with LVH (195 mg/dL) than in those without LVH (151 mg/dL). This difference was not present in non-African American children (163 mg/dL with LVH vs. 166 mg/dL without). However, mean total cholesterol was significantly higher in African American children with LVH than in non-African American children with LVH (195 vs. 163 mg/dL).

“Given our findings, in children referred for primary hypertension, African American children may be at increased cardiovascular risk, due to their increased prevalence of LVH, higher total cholesterol levels and high BMI z scores at the time of initial referral,” she concluded.

Asked about the duration of hypertension in the children by session moderator Dr. Douglas M. Silverstein of Louisiana State University in New Orleans, given that “LVH can happen relatively quickly and can also recede very quickly over a period of months to years,” Dr. Pruette said, “We don't have any information on how long these children were hypertensive, and some may be further into their disease state than others. That's something we hope to capture in future studies.”

Dr. Pruette stated that she had no relevant financial disclosures.

Dr. Cozumel S. Pruette (left) discusses the findings ofher studywith session comoderators Dr. Andrew L. Schwaderer (center) and Dr. Douglas M. Silverstein (right). Miriam E. Tucker/Elsevier Global Medical News

BALTIMORE — In 139 children who had primary hypertension, the risk for left ventricular hypertrophy was even greater for African Americans than for non-African Americans in a cross-sectional review.

The children, aged 3-21 years, after being evaluated for hypertension at one of three tertiary medical centers between 1997 and 2005, were ultimately diagnosed with primary hypertension and underwent echocardiography. The overall prevalence of left ventricular hypertrophy (LVH) was 42% in the entire group. Of the 35 African American children, 21 (60%) had LVH, compared with 38 (37%) of the 104 non-African American children. The difference was statistically significant, Dr. Cozumel S. Pruette said at the annual meeting of the Pediatric Academic Societies.

“African American children with primary hypertension may need more aggressive screening for additional cardiovascular risk factors. However, regardless of race, all children with primary hypertension are deserving of close follow-up due to the high prevalence of LVH that we noted in our study,” said Dr. Pruette, a fellow in pediatric nephrology at Johns Hopkins University, Baltimore.

There were no differences within each racial group in mean age, sex, height percentile, or family history of hypertension. Levels of systolic and diastolic blood pressure—assessed by both blood pressure index and 24-hour ambulatory blood pressure monitoring—were not associated with the presence of LVH in African American or non-African American children.

The body mass index z score was significantly higher in both the African American and non-African American groups with LVH (2.0 and 1.8, respectively) than in those two groups without LVH (1.3 and 1.4), but did not differ by race.

Total cholesterol was significantly higher in the African American children with LVH (195 mg/dL) than in those without LVH (151 mg/dL). This difference was not present in non-African American children (163 mg/dL with LVH vs. 166 mg/dL without). However, mean total cholesterol was significantly higher in African American children with LVH than in non-African American children with LVH (195 vs. 163 mg/dL).

“Given our findings, in children referred for primary hypertension, African American children may be at increased cardiovascular risk, due to their increased prevalence of LVH, higher total cholesterol levels and high BMI z scores at the time of initial referral,” she concluded.

Asked about the duration of hypertension in the children by session moderator Dr. Douglas M. Silverstein of Louisiana State University in New Orleans, given that “LVH can happen relatively quickly and can also recede very quickly over a period of months to years,” Dr. Pruette said, “We don't have any information on how long these children were hypertensive, and some may be further into their disease state than others. That's something we hope to capture in future studies.”

Dr. Pruette stated that she had no relevant financial disclosures.

Dr. Cozumel S. Pruette (left) discusses the findings ofher studywith session comoderators Dr. Andrew L. Schwaderer (center) and Dr. Douglas M. Silverstein (right). Miriam E. Tucker/Elsevier Global Medical News

WASHINGTON — A history of severe hypoglycemic episodes was associated with an increased risk for dementia in a longitudinal cohort study involving 16,667 older patients with type 2 diabetes.

“Severe hypoglycemic episodes might be associated with a neurological consequence in a population that is already at greater risk for dementia. …This study also adds to the evidence base that balance of glycemic control is a critical issue, particularly for the elderly,” Rachel A. Whitmer, Ph.D., said at a press briefing. The briefing was timed to coincide with publication of the April 15th special diabetes edition of the Journal of the American Medical Association.

The study, which retrospectively analyzed data from the Kaiser Permanente Northern California Diabetes Registry, identified a 2.39% increase in absolute risk of dementia per year of follow-up for patients with a history of hypoglycemia that resulted in hospitalization or an emergency department visit, compared with type 2 diabetic patients without such a history.

“Trying to aim for a very low glycemic target might not be beneficial and might even be harmful. We know that high blood sugar isn't good, but I think the message here is also that very low levels aren't good,” added Dr. Whitmer of Kaiser Permanente's division of research.

Because the data analyses included two methods by which the hypoglycemia events were separated in time from the onset of dementia, the study supports the direction of causality that the hypoglycemia preceded the dementia, rather than the other way around. Moreover, “Our findings were independent of glycemic control as assessed by levels of [hemoglobin A_1c], type of diabetes treatment, and diabetes comorbidities,” wrote Dr. Whitmer and her associates in the published report (JAMA 2009;301:1565–72).

The patients were all aged 55 or older on Jan. 1, 2003, with no signs of dementia at that time. A total of 11% (1,822) patients were diagnosed with dementia during a mean follow-up of 3.8 years and a median follow-up of 4.8 years, and a total of 8.8% (1,465) had at least one episode of severe hypoglycemia during 1980–2002. Of those 1,465, 68.5% had one such episode, 1% had two, and 13.5% had three or more.

Age-adjusted incidence of dementia by frequency of severe hypoglycemic episodes was significantly higher among those with at least one episode, compared with those with no such episodes (566.8 vs. 327.6 per 10,000 person-years), with an attributable risk of 2.4% per year.

After adjustment for age, body mass index, race/ethnicity, education, sex, and diabetes duration, the hazard ratios for dementia compared with patients who had no severe hypoglycemic episodes were 1.7 for those with at least one episode, 2.2 for two or more, and 2.6 for three or more episodes. Further adjustment for diabetes-related comorbidity, HbA_1c level, diabetes treatment, and years of insulin use modestly attenuated the effect but it remained “statistically significant and clinically relevant” with hazard ratios of 1.3, 1.8, and 1.9, respectively, Dr. Whitmer and her associates said.

Trends were similar when only the incident dementia cases diagnosed between Jan. 1, 2005, and Jan. 15, 2007, were considered after adjustment for all the above-mentioned factors, with hazard ratios of 1.2 for at least one severe hypoglycemia episode, 1.7 for two or more episodes, and 2.1 for three or more episodes, compared with patients who had no such episodes.

Possible mechanisms by which hypoglycemia might increase the risk of subsequent dementia in older individuals include neuronal death and/or increased platelet aggregation/fibrinogen formation. Cerebrovascular disease is another possibility, even though another analysis adjusting for acute stroke and transient cerebral ischemia in this study population did not fully account for the effect of hypoglycemia, the investigators noted.

This study was funded by the National Institutes of Health. None of the investigators disclosed any conflicts of interest.

WASHINGTON — A history of severe hypoglycemic episodes was associated with an increased risk for dementia in a longitudinal cohort study involving 16,667 older patients with type 2 diabetes.

“Severe hypoglycemic episodes might be associated with a neurological consequence in a population that is already at greater risk for dementia. …This study also adds to the evidence base that balance of glycemic control is a critical issue, particularly for the elderly,” Rachel A. Whitmer, Ph.D., said at a press briefing. The briefing was timed to coincide with publication of the April 15th special diabetes edition of the Journal of the American Medical Association.

The study, which retrospectively analyzed data from the Kaiser Permanente Northern California Diabetes Registry, identified a 2.39% increase in absolute risk of dementia per year of follow-up for patients with a history of hypoglycemia that resulted in hospitalization or an emergency department visit, compared with type 2 diabetic patients without such a history.

“Trying to aim for a very low glycemic target might not be beneficial and might even be harmful. We know that high blood sugar isn't good, but I think the message here is also that very low levels aren't good,” added Dr. Whitmer of Kaiser Permanente's division of research.

Because the data analyses included two methods by which the hypoglycemia events were separated in time from the onset of dementia, the study supports the direction of causality that the hypoglycemia preceded the dementia, rather than the other way around. Moreover, “Our findings were independent of glycemic control as assessed by levels of [hemoglobin A_1c], type of diabetes treatment, and diabetes comorbidities,” wrote Dr. Whitmer and her associates in the published report (JAMA 2009;301:1565–72).

The patients were all aged 55 or older on Jan. 1, 2003, with no signs of dementia at that time. A total of 11% (1,822) patients were diagnosed with dementia during a mean follow-up of 3.8 years and a median follow-up of 4.8 years, and a total of 8.8% (1,465) had at least one episode of severe hypoglycemia during 1980–2002. Of those 1,465, 68.5% had one such episode, 1% had two, and 13.5% had three or more.

Age-adjusted incidence of dementia by frequency of severe hypoglycemic episodes was significantly higher among those with at least one episode, compared with those with no such episodes (566.8 vs. 327.6 per 10,000 person-years), with an attributable risk of 2.4% per year.

After adjustment for age, body mass index, race/ethnicity, education, sex, and diabetes duration, the hazard ratios for dementia compared with patients who had no severe hypoglycemic episodes were 1.7 for those with at least one episode, 2.2 for two or more, and 2.6 for three or more episodes. Further adjustment for diabetes-related comorbidity, HbA_1c level, diabetes treatment, and years of insulin use modestly attenuated the effect but it remained “statistically significant and clinically relevant” with hazard ratios of 1.3, 1.8, and 1.9, respectively, Dr. Whitmer and her associates said.

Trends were similar when only the incident dementia cases diagnosed between Jan. 1, 2005, and Jan. 15, 2007, were considered after adjustment for all the above-mentioned factors, with hazard ratios of 1.2 for at least one severe hypoglycemia episode, 1.7 for two or more episodes, and 2.1 for three or more episodes, compared with patients who had no such episodes.

Possible mechanisms by which hypoglycemia might increase the risk of subsequent dementia in older individuals include neuronal death and/or increased platelet aggregation/fibrinogen formation. Cerebrovascular disease is another possibility, even though another analysis adjusting for acute stroke and transient cerebral ischemia in this study population did not fully account for the effect of hypoglycemia, the investigators noted.

This study was funded by the National Institutes of Health. None of the investigators disclosed any conflicts of interest.

WASHINGTON — A history of severe hypoglycemic episodes was associated with an increased risk for dementia in a longitudinal cohort study involving 16,667 older patients with type 2 diabetes.

“Severe hypoglycemic episodes might be associated with a neurological consequence in a population that is already at greater risk for dementia. …This study also adds to the evidence base that balance of glycemic control is a critical issue, particularly for the elderly,” Rachel A. Whitmer, Ph.D., said at a press briefing. The briefing was timed to coincide with publication of the April 15th special diabetes edition of the Journal of the American Medical Association.

The study, which retrospectively analyzed data from the Kaiser Permanente Northern California Diabetes Registry, identified a 2.39% increase in absolute risk of dementia per year of follow-up for patients with a history of hypoglycemia that resulted in hospitalization or an emergency department visit, compared with type 2 diabetic patients without such a history.

“Trying to aim for a very low glycemic target might not be beneficial and might even be harmful. We know that high blood sugar isn't good, but I think the message here is also that very low levels aren't good,” added Dr. Whitmer of Kaiser Permanente's division of research.

Because the data analyses included two methods by which the hypoglycemia events were separated in time from the onset of dementia, the study supports the direction of causality that the hypoglycemia preceded the dementia, rather than the other way around. Moreover, “Our findings were independent of glycemic control as assessed by levels of [hemoglobin A_1c], type of diabetes treatment, and diabetes comorbidities,” wrote Dr. Whitmer and her associates in the published report (JAMA 2009;301:1565–72).

The patients were all aged 55 or older on Jan. 1, 2003, with no signs of dementia at that time. A total of 11% (1,822) patients were diagnosed with dementia during a mean follow-up of 3.8 years and a median follow-up of 4.8 years, and a total of 8.8% (1,465) had at least one episode of severe hypoglycemia during 1980–2002. Of those 1,465, 68.5% had one such episode, 1% had two, and 13.5% had three or more.

Age-adjusted incidence of dementia by frequency of severe hypoglycemic episodes was significantly higher among those with at least one episode, compared with those with no such episodes (566.8 vs. 327.6 per 10,000 person-years), with an attributable risk of 2.4% per year.

After adjustment for age, body mass index, race/ethnicity, education, sex, and diabetes duration, the hazard ratios for dementia compared with patients who had no severe hypoglycemic episodes were 1.7 for those with at least one episode, 2.2 for two or more, and 2.6 for three or more episodes. Further adjustment for diabetes-related comorbidity, HbA_1c level, diabetes treatment, and years of insulin use modestly attenuated the effect but it remained “statistically significant and clinically relevant” with hazard ratios of 1.3, 1.8, and 1.9, respectively, Dr. Whitmer and her associates said.

Trends were similar when only the incident dementia cases diagnosed between Jan. 1, 2005, and Jan. 15, 2007, were considered after adjustment for all the above-mentioned factors, with hazard ratios of 1.2 for at least one severe hypoglycemia episode, 1.7 for two or more episodes, and 2.1 for three or more episodes, compared with patients who had no such episodes.

Possible mechanisms by which hypoglycemia might increase the risk of subsequent dementia in older individuals include neuronal death and/or increased platelet aggregation/fibrinogen formation. Cerebrovascular disease is another possibility, even though another analysis adjusting for acute stroke and transient cerebral ischemia in this study population did not fully account for the effect of hypoglycemia, the investigators noted.

This study was funded by the National Institutes of Health. None of the investigators disclosed any conflicts of interest.

Naltrexone reduced heavy drinking in a 4-week exploratory study of 78 nicotine-dependent, nonalcoholic adults who were participating in a smoking cessation program.

In the study, naltrexone had only a limited overall effect on alcohol consumption and did not significantly affect smoking quit rates for the group as a whole. However, the opioid antagonist did appear to have a significant impact on drinking–and to a lesser degree, smoking–among the 36 patients classified as “heavy drinkers,” said Andrea King, Ph.D., of the department of psychiatry at the University of Chicago, and her associates.

Naltrexone is indicated for the treatment of alcohol dependence and for the blockade of the effects of exogenously administered opioids.

“A historically treatment-resistant group, i.e., social heavy/binge drinker-smokers, may selectively respond to naltrexone to improve both smoking cessation and alcohol drinking outcomes, but further research is warranted,” Dr. King and her associates wrote in the article slated to be published in the June issue of Alcoholism: Clinical & Experimental Research (doi:10.1111/j.1530-0277.2009.00925.x).

The 78 participants were selected from a pool of 110 individuals enrolled in a double-blind clinical trial investigating the efficacy of naltrexone in a smoking cessation program that also included six 45-minute counseling sessions over 4 weeks, along with nicotine patch treatment.

All 78 individuals were current drinkers–having consumed at least one alcoholic drink during the 2-week baseline period prior to study enrollment–but did not meet criteria for current or past alcohol dependence. A total of 44 were randomized to receive placebo and the other 34 to naltrexone, at dosages of 25 mg/day beginning 3 days prior to the smoking quit date, then at 50 mg/day for 8 weeks.

The weekly number of alcoholic drinks consumed overall was lower among those receiving naltrexone, but not significantly so. The largest difference occurred during the second week after the smoking quit date, with an average of 3.6 drinks consumed in the naltrexone group, compared with 6.3 drinks in the placebo group. There was no difference by the third and fourth weeks, however.

Among the 36 “heavy” drinkers (defined as consuming five or more drinks for men or four drinks for women on one occasion during the 2-week pre-enrollment period), heavy drinking at week 2 occurred in 10% of the 15 receiving naltrexone, compared with 40% of the 21 on placebo.

Among the heavier drinkers only, naltrexone significantly attenuated weekly heavy drinking throughout the 4-week interval, compared with placebo (odds ratio 0.24). The overall number of drinks per day was also significantly reduced from baseline among heavy drinkers taking naltrexone, from an average of 4.5 drinks/day to 3.2/day during the treatment period, compared with 4.0 to 3.6 drinks/day in the placebo group.

Smoking quit rates were not significantly different between the naltrexone and placebo groups overall, at 71% and 66%, respectively. However, among the heavy drinkers only there was a tendency toward higher smoking quit rates, compared with placebo (80% vs. 52%). At the end of the first month, those who quit smoking were less likely to drink heavily whether or not they received naltrexone, Dr. King and her associates noted.

Regimen adherence was similar between the naltrexone and placebo groups. However, the better the naltrexone group adhered, the less likely they were to drink heavily by the end of the first month.

This association was not seen in the placebo group.

Generally side effects were reported more often in the naltrexone group than in the placebo group, but not among the heavy drinkers.

The one exception was that nausea was reported more often among the naltrexone patients in the heavy-drinking group.

It is possible that naltrexone-related nausea may be involved in the reduction in heavy drinking, but the current study design did not allow for distinguishing between nonspecific nausea and nausea related to drinking alcohol, the investigators commented.

Levels of the liver enzymes aspartate aminotransferase (AST) and alanine transaminase (ALT) did not differ between the naltrexone and placebo group at baseline or at 1 month of treatment, nor did the percentage of individuals with levels out of the normal range: 3.6% of the naltrexone group and 2.7% of the placebo group were outside the normal range for AST at week 2, as were 10.7% and 18.9%, respectively, for ALT. “These findings support the hepatic safety of naltrexone in people with nicotine dependence and may be reassuring to treatment providers concerned about potential liver toxicity with naltrexone,” Dr. King and her associates said.

This study was funded by the National Institute on Alcohol Abuse and Alcoholism and the University of Chicago's Cancer Research Center and General Clinical Research Center.

The authors reported having no conflicts of interest.

Naltrexone reduced heavy drinking in a 4-week exploratory study of 78 nicotine-dependent, nonalcoholic adults who were participating in a smoking cessation program.

In the study, naltrexone had only a limited overall effect on alcohol consumption and did not significantly affect smoking quit rates for the group as a whole. However, the opioid antagonist did appear to have a significant impact on drinking–and to a lesser degree, smoking–among the 36 patients classified as “heavy drinkers,” said Andrea King, Ph.D., of the department of psychiatry at the University of Chicago, and her associates.

Naltrexone is indicated for the treatment of alcohol dependence and for the blockade of the effects of exogenously administered opioids.

“A historically treatment-resistant group, i.e., social heavy/binge drinker-smokers, may selectively respond to naltrexone to improve both smoking cessation and alcohol drinking outcomes, but further research is warranted,” Dr. King and her associates wrote in the article slated to be published in the June issue of Alcoholism: Clinical & Experimental Research (doi:10.1111/j.1530-0277.2009.00925.x).

The 78 participants were selected from a pool of 110 individuals enrolled in a double-blind clinical trial investigating the efficacy of naltrexone in a smoking cessation program that also included six 45-minute counseling sessions over 4 weeks, along with nicotine patch treatment.

All 78 individuals were current drinkers–having consumed at least one alcoholic drink during the 2-week baseline period prior to study enrollment–but did not meet criteria for current or past alcohol dependence. A total of 44 were randomized to receive placebo and the other 34 to naltrexone, at dosages of 25 mg/day beginning 3 days prior to the smoking quit date, then at 50 mg/day for 8 weeks.

The weekly number of alcoholic drinks consumed overall was lower among those receiving naltrexone, but not significantly so. The largest difference occurred during the second week after the smoking quit date, with an average of 3.6 drinks consumed in the naltrexone group, compared with 6.3 drinks in the placebo group. There was no difference by the third and fourth weeks, however.

Among the 36 “heavy” drinkers (defined as consuming five or more drinks for men or four drinks for women on one occasion during the 2-week pre-enrollment period), heavy drinking at week 2 occurred in 10% of the 15 receiving naltrexone, compared with 40% of the 21 on placebo.

Among the heavier drinkers only, naltrexone significantly attenuated weekly heavy drinking throughout the 4-week interval, compared with placebo (odds ratio 0.24). The overall number of drinks per day was also significantly reduced from baseline among heavy drinkers taking naltrexone, from an average of 4.5 drinks/day to 3.2/day during the treatment period, compared with 4.0 to 3.6 drinks/day in the placebo group.

Smoking quit rates were not significantly different between the naltrexone and placebo groups overall, at 71% and 66%, respectively. However, among the heavy drinkers only there was a tendency toward higher smoking quit rates, compared with placebo (80% vs. 52%). At the end of the first month, those who quit smoking were less likely to drink heavily whether or not they received naltrexone, Dr. King and her associates noted.

Regimen adherence was similar between the naltrexone and placebo groups. However, the better the naltrexone group adhered, the less likely they were to drink heavily by the end of the first month.

This association was not seen in the placebo group.

Generally side effects were reported more often in the naltrexone group than in the placebo group, but not among the heavy drinkers.

The one exception was that nausea was reported more often among the naltrexone patients in the heavy-drinking group.

It is possible that naltrexone-related nausea may be involved in the reduction in heavy drinking, but the current study design did not allow for distinguishing between nonspecific nausea and nausea related to drinking alcohol, the investigators commented.

Levels of the liver enzymes aspartate aminotransferase (AST) and alanine transaminase (ALT) did not differ between the naltrexone and placebo group at baseline or at 1 month of treatment, nor did the percentage of individuals with levels out of the normal range: 3.6% of the naltrexone group and 2.7% of the placebo group were outside the normal range for AST at week 2, as were 10.7% and 18.9%, respectively, for ALT. “These findings support the hepatic safety of naltrexone in people with nicotine dependence and may be reassuring to treatment providers concerned about potential liver toxicity with naltrexone,” Dr. King and her associates said.

This study was funded by the National Institute on Alcohol Abuse and Alcoholism and the University of Chicago's Cancer Research Center and General Clinical Research Center.

The authors reported having no conflicts of interest.

Naltrexone reduced heavy drinking in a 4-week exploratory study of 78 nicotine-dependent, nonalcoholic adults who were participating in a smoking cessation program.

In the study, naltrexone had only a limited overall effect on alcohol consumption and did not significantly affect smoking quit rates for the group as a whole. However, the opioid antagonist did appear to have a significant impact on drinking–and to a lesser degree, smoking–among the 36 patients classified as “heavy drinkers,” said Andrea King, Ph.D., of the department of psychiatry at the University of Chicago, and her associates.

Naltrexone is indicated for the treatment of alcohol dependence and for the blockade of the effects of exogenously administered opioids.

“A historically treatment-resistant group, i.e., social heavy/binge drinker-smokers, may selectively respond to naltrexone to improve both smoking cessation and alcohol drinking outcomes, but further research is warranted,” Dr. King and her associates wrote in the article slated to be published in the June issue of Alcoholism: Clinical & Experimental Research (doi:10.1111/j.1530-0277.2009.00925.x).

The 78 participants were selected from a pool of 110 individuals enrolled in a double-blind clinical trial investigating the efficacy of naltrexone in a smoking cessation program that also included six 45-minute counseling sessions over 4 weeks, along with nicotine patch treatment.

All 78 individuals were current drinkers–having consumed at least one alcoholic drink during the 2-week baseline period prior to study enrollment–but did not meet criteria for current or past alcohol dependence. A total of 44 were randomized to receive placebo and the other 34 to naltrexone, at dosages of 25 mg/day beginning 3 days prior to the smoking quit date, then at 50 mg/day for 8 weeks.

The weekly number of alcoholic drinks consumed overall was lower among those receiving naltrexone, but not significantly so. The largest difference occurred during the second week after the smoking quit date, with an average of 3.6 drinks consumed in the naltrexone group, compared with 6.3 drinks in the placebo group. There was no difference by the third and fourth weeks, however.

Among the 36 “heavy” drinkers (defined as consuming five or more drinks for men or four drinks for women on one occasion during the 2-week pre-enrollment period), heavy drinking at week 2 occurred in 10% of the 15 receiving naltrexone, compared with 40% of the 21 on placebo.

Among the heavier drinkers only, naltrexone significantly attenuated weekly heavy drinking throughout the 4-week interval, compared with placebo (odds ratio 0.24). The overall number of drinks per day was also significantly reduced from baseline among heavy drinkers taking naltrexone, from an average of 4.5 drinks/day to 3.2/day during the treatment period, compared with 4.0 to 3.6 drinks/day in the placebo group.

Smoking quit rates were not significantly different between the naltrexone and placebo groups overall, at 71% and 66%, respectively. However, among the heavy drinkers only there was a tendency toward higher smoking quit rates, compared with placebo (80% vs. 52%). At the end of the first month, those who quit smoking were less likely to drink heavily whether or not they received naltrexone, Dr. King and her associates noted.

Regimen adherence was similar between the naltrexone and placebo groups. However, the better the naltrexone group adhered, the less likely they were to drink heavily by the end of the first month.

This association was not seen in the placebo group.

Generally side effects were reported more often in the naltrexone group than in the placebo group, but not among the heavy drinkers.

The one exception was that nausea was reported more often among the naltrexone patients in the heavy-drinking group.

It is possible that naltrexone-related nausea may be involved in the reduction in heavy drinking, but the current study design did not allow for distinguishing between nonspecific nausea and nausea related to drinking alcohol, the investigators commented.

Levels of the liver enzymes aspartate aminotransferase (AST) and alanine transaminase (ALT) did not differ between the naltrexone and placebo group at baseline or at 1 month of treatment, nor did the percentage of individuals with levels out of the normal range: 3.6% of the naltrexone group and 2.7% of the placebo group were outside the normal range for AST at week 2, as were 10.7% and 18.9%, respectively, for ALT. “These findings support the hepatic safety of naltrexone in people with nicotine dependence and may be reassuring to treatment providers concerned about potential liver toxicity with naltrexone,” Dr. King and her associates said.

This study was funded by the National Institute on Alcohol Abuse and Alcoholism and the University of Chicago's Cancer Research Center and General Clinical Research Center.

The authors reported having no conflicts of interest.

NATIONAL HARBOR, MD. – Long-term care residents aged 85 and older are less likely than younger residents to have a serious mental illness, more likely to have dementia, and equally likely to have depression or anxiety.

Up to 80% of long-term care (LTC) residents have diagnosable neuropsychiatric disorders, including dementia, according to an analysis of data from the 2004 National Nursing Home Survey.

The new findings are among the first detailing the rates of these disorders among the “oldest old” population now making up the fastest-growing segment of the over-65 age group and disproportionately represented in nursing homes.

“As a rapidly growing subpopulation, the oldest old in LTC have what appear to be distinct characteristics relative to other age groups, and these no doubt affect their care,” Catherine A. Yeager, Ph.D., and her associates said in a poster presented at the annual meeting of the Gerontological Society of America.

The 2004 National Nursing Home Survey, conducted between August and December 2004, is one in a series of nationally representative sample surveys of U.S. nursing homes conducted by the Centers for Disease Control and Prevention. A total of 1,174 nursing home facilities participated, producing data for 1,317,300 residents.

The population included 674,500 persons aged 85 and older. The survey data show “a few notable exceptions” to expected patterns of frailty and disability with age, said Dr. Yeager, of Robert Wood Johnson Medical School, Piscataway, N.J., and her associates.

The 85-plus group was more female (82%), more white (90%), and more likely to be widowed (72%) than were either the aged 75-84 or 65-74 groups.

Of the 674,500 oldest old population, 17,300 had lived 100 years or more.

Only small proportions of all residents had neuropsychiatric diagnoses at the time they were admitted to LTC: 10% with dementia, 2% with schizophrenia spectrum, 0.3% with bipolar disorder, 0.2% with depressive disorder, and 0.2% with anxiety.

However, neuropsychiatric diagnoses increased in all groups. At the time of the survey, depressive disorders were present in 35% of the oldest old, not significantly different from the 36% among the 75- to 84-year-old group and 32% of the 65- to 74-year-old individuals.

Neither did rates of anxiety disorders differ by age, occurring in 12% of both the 85-plus and aged 75-84 groups, and 11% of the aged 65-74-group, according to the survey.

However, the oldest old were less likely than the two younger groups to have been diagnosed with a serious mental illness, including schizophrenia spectrum disorder (8.5% in 85-plus group, 13% in 75-84 group, and 17% in 65-74 group) and bipolar spectrum (1.2%, 2.3%, and 3.2%, respectively).

Conversely, both the 85-plus and 75-84 groups were more likely than the 65- to 74-year-olds to have dementia (22% in the older groups vs. 13% in the youngest group).

In all three age groups–and especially among the oldest old–the survey found more clinical indicators of dementia and depression than formal diagnoses had indicated.

The researchers reported moderate to severe impairment in decision making, an indicator of dementia, in 55% of the oldest old, 34% of the 75- to 84-year-olds, and 11% of the youngest group. Likewise, the proportions with “low mood not easily altered,” a proxy for depressive disorder, were 49%, 37.5%, and 14%, respectively.

Once in the LTC, all groups show an increased prevalence of formal neuropsychiatric conditions,” reported the group led by Dr. Yeager, who also works in the Essex County Hospital Medical Center, Cedar Grove, N.J.

NATIONAL HARBOR, MD. – Long-term care residents aged 85 and older are less likely than younger residents to have a serious mental illness, more likely to have dementia, and equally likely to have depression or anxiety.

Up to 80% of long-term care (LTC) residents have diagnosable neuropsychiatric disorders, including dementia, according to an analysis of data from the 2004 National Nursing Home Survey.

The new findings are among the first detailing the rates of these disorders among the “oldest old” population now making up the fastest-growing segment of the over-65 age group and disproportionately represented in nursing homes.

“As a rapidly growing subpopulation, the oldest old in LTC have what appear to be distinct characteristics relative to other age groups, and these no doubt affect their care,” Catherine A. Yeager, Ph.D., and her associates said in a poster presented at the annual meeting of the Gerontological Society of America.

The 2004 National Nursing Home Survey, conducted between August and December 2004, is one in a series of nationally representative sample surveys of U.S. nursing homes conducted by the Centers for Disease Control and Prevention. A total of 1,174 nursing home facilities participated, producing data for 1,317,300 residents.

The population included 674,500 persons aged 85 and older. The survey data show “a few notable exceptions” to expected patterns of frailty and disability with age, said Dr. Yeager, of Robert Wood Johnson Medical School, Piscataway, N.J., and her associates.

The 85-plus group was more female (82%), more white (90%), and more likely to be widowed (72%) than were either the aged 75-84 or 65-74 groups.

Of the 674,500 oldest old population, 17,300 had lived 100 years or more.

Only small proportions of all residents had neuropsychiatric diagnoses at the time they were admitted to LTC: 10% with dementia, 2% with schizophrenia spectrum, 0.3% with bipolar disorder, 0.2% with depressive disorder, and 0.2% with anxiety.

However, neuropsychiatric diagnoses increased in all groups. At the time of the survey, depressive disorders were present in 35% of the oldest old, not significantly different from the 36% among the 75- to 84-year-old group and 32% of the 65- to 74-year-old individuals.

Neither did rates of anxiety disorders differ by age, occurring in 12% of both the 85-plus and aged 75-84 groups, and 11% of the aged 65-74-group, according to the survey.

However, the oldest old were less likely than the two younger groups to have been diagnosed with a serious mental illness, including schizophrenia spectrum disorder (8.5% in 85-plus group, 13% in 75-84 group, and 17% in 65-74 group) and bipolar spectrum (1.2%, 2.3%, and 3.2%, respectively).

Conversely, both the 85-plus and 75-84 groups were more likely than the 65- to 74-year-olds to have dementia (22% in the older groups vs. 13% in the youngest group).

In all three age groups–and especially among the oldest old–the survey found more clinical indicators of dementia and depression than formal diagnoses had indicated.

The researchers reported moderate to severe impairment in decision making, an indicator of dementia, in 55% of the oldest old, 34% of the 75- to 84-year-olds, and 11% of the youngest group. Likewise, the proportions with “low mood not easily altered,” a proxy for depressive disorder, were 49%, 37.5%, and 14%, respectively.

Once in the LTC, all groups show an increased prevalence of formal neuropsychiatric conditions,” reported the group led by Dr. Yeager, who also works in the Essex County Hospital Medical Center, Cedar Grove, N.J.

NATIONAL HARBOR, MD. – Long-term care residents aged 85 and older are less likely than younger residents to have a serious mental illness, more likely to have dementia, and equally likely to have depression or anxiety.

Up to 80% of long-term care (LTC) residents have diagnosable neuropsychiatric disorders, including dementia, according to an analysis of data from the 2004 National Nursing Home Survey.

The new findings are among the first detailing the rates of these disorders among the “oldest old” population now making up the fastest-growing segment of the over-65 age group and disproportionately represented in nursing homes.

“As a rapidly growing subpopulation, the oldest old in LTC have what appear to be distinct characteristics relative to other age groups, and these no doubt affect their care,” Catherine A. Yeager, Ph.D., and her associates said in a poster presented at the annual meeting of the Gerontological Society of America.

The 2004 National Nursing Home Survey, conducted between August and December 2004, is one in a series of nationally representative sample surveys of U.S. nursing homes conducted by the Centers for Disease Control and Prevention. A total of 1,174 nursing home facilities participated, producing data for 1,317,300 residents.

The population included 674,500 persons aged 85 and older. The survey data show “a few notable exceptions” to expected patterns of frailty and disability with age, said Dr. Yeager, of Robert Wood Johnson Medical School, Piscataway, N.J., and her associates.

The 85-plus group was more female (82%), more white (90%), and more likely to be widowed (72%) than were either the aged 75-84 or 65-74 groups.

Of the 674,500 oldest old population, 17,300 had lived 100 years or more.

Only small proportions of all residents had neuropsychiatric diagnoses at the time they were admitted to LTC: 10% with dementia, 2% with schizophrenia spectrum, 0.3% with bipolar disorder, 0.2% with depressive disorder, and 0.2% with anxiety.

However, neuropsychiatric diagnoses increased in all groups. At the time of the survey, depressive disorders were present in 35% of the oldest old, not significantly different from the 36% among the 75- to 84-year-old group and 32% of the 65- to 74-year-old individuals.

Neither did rates of anxiety disorders differ by age, occurring in 12% of both the 85-plus and aged 75-84 groups, and 11% of the aged 65-74-group, according to the survey.

However, the oldest old were less likely than the two younger groups to have been diagnosed with a serious mental illness, including schizophrenia spectrum disorder (8.5% in 85-plus group, 13% in 75-84 group, and 17% in 65-74 group) and bipolar spectrum (1.2%, 2.3%, and 3.2%, respectively).

Conversely, both the 85-plus and 75-84 groups were more likely than the 65- to 74-year-olds to have dementia (22% in the older groups vs. 13% in the youngest group).

In all three age groups–and especially among the oldest old–the survey found more clinical indicators of dementia and depression than formal diagnoses had indicated.

The researchers reported moderate to severe impairment in decision making, an indicator of dementia, in 55% of the oldest old, 34% of the 75- to 84-year-olds, and 11% of the youngest group. Likewise, the proportions with “low mood not easily altered,” a proxy for depressive disorder, were 49%, 37.5%, and 14%, respectively.

Once in the LTC, all groups show an increased prevalence of formal neuropsychiatric conditions,” reported the group led by Dr. Yeager, who also works in the Essex County Hospital Medical Center, Cedar Grove, N.J.

The tuberculosis rate in the United States continues to decline, but the pace of the decline has slowed since 2000—and the rate of infection among racial/ethnic minorities and foreign-born individuals continues to be disproportionately high.

Those were among the findings of a report on 2008 U.S. trends in tuberculosis published by the Centers for Disease Control and Prevention.

In 2008, a total of 12,898 incident TB cases were reported in the United States, representing a decline of 3.8% from 2007 and a rate of 4.2 per 100,000 population.

The 2008 rate was the lowest recorded since TB reporting began in 1953.

Progress has slowed in recent years, however, with the average annual percentage decline in the TB rate decreasing from 7.3% per year during 1993–2000 to 3.8% during 2000–2008.

Among the 50 states and the District of Columbia, TB rates ranged from a low of 0.5/100,000 in North Dakota to a high of 9.6/100,000 in Hawaii.

California, Florida, New York, and Texas reported more than 500 cases each and together accounted for 49% of all TB cases in 2008.

TB rates among Hispanics and blacks were nearly 8 times higher than among non-Hispanic whites (8.1 and 8.7 per 100,000, respectively, versus 1.1 per 100,000), while the rate among Asians was nearly 23 times higher than among non-Hispanic whites (25.1 per 100,000).

The report classified persons identified as white, black, Asian, American Indian/Alaska Native, native Hawaiian or other Pacific Islander, or of multiple races, as non-Hispanic. “Persons identified as Hispanic might be of any race,” the report explained.

The 2008 TB rate in foreign-born persons living in the United States was 20.2 per 100,000, 10 times higher than for U.S.-born individuals. People born in Mexico, the Philippines, India, and Vietnam accounted for half of the 7,541 tuberculosis cases in foreign-born persons that year.

However, the rate of TB cases continued to decline both among foreign-born individuals (down 2.6% since 2007), as well as those born in the United States (down 4.7%).

Based on the data, the CDC recommended that TB prevention and control capacity be intensified to improve case management and contact investigations. The agency also called for intensified outreach, testing, and treatment of high-risk populations; enhanced treatment and diagnostic tools; increased scientific research to better understand TB transmission; and continued collaboration with other nations to reduce TB globally (MMWR 2009;58:249–53).

ELSEVIER GLOBAL MEDICAL NEWS

The tuberculosis rate in the United States continues to decline, but the pace of the decline has slowed since 2000—and the rate of infection among racial/ethnic minorities and foreign-born individuals continues to be disproportionately high.

Those were among the findings of a report on 2008 U.S. trends in tuberculosis published by the Centers for Disease Control and Prevention.

In 2008, a total of 12,898 incident TB cases were reported in the United States, representing a decline of 3.8% from 2007 and a rate of 4.2 per 100,000 population.

The 2008 rate was the lowest recorded since TB reporting began in 1953.

Progress has slowed in recent years, however, with the average annual percentage decline in the TB rate decreasing from 7.3% per year during 1993–2000 to 3.8% during 2000–2008.

Among the 50 states and the District of Columbia, TB rates ranged from a low of 0.5/100,000 in North Dakota to a high of 9.6/100,000 in Hawaii.

California, Florida, New York, and Texas reported more than 500 cases each and together accounted for 49% of all TB cases in 2008.

TB rates among Hispanics and blacks were nearly 8 times higher than among non-Hispanic whites (8.1 and 8.7 per 100,000, respectively, versus 1.1 per 100,000), while the rate among Asians was nearly 23 times higher than among non-Hispanic whites (25.1 per 100,000).

The report classified persons identified as white, black, Asian, American Indian/Alaska Native, native Hawaiian or other Pacific Islander, or of multiple races, as non-Hispanic. “Persons identified as Hispanic might be of any race,” the report explained.

The 2008 TB rate in foreign-born persons living in the United States was 20.2 per 100,000, 10 times higher than for U.S.-born individuals. People born in Mexico, the Philippines, India, and Vietnam accounted for half of the 7,541 tuberculosis cases in foreign-born persons that year.

However, the rate of TB cases continued to decline both among foreign-born individuals (down 2.6% since 2007), as well as those born in the United States (down 4.7%).

Based on the data, the CDC recommended that TB prevention and control capacity be intensified to improve case management and contact investigations. The agency also called for intensified outreach, testing, and treatment of high-risk populations; enhanced treatment and diagnostic tools; increased scientific research to better understand TB transmission; and continued collaboration with other nations to reduce TB globally (MMWR 2009;58:249–53).

ELSEVIER GLOBAL MEDICAL NEWS

The tuberculosis rate in the United States continues to decline, but the pace of the decline has slowed since 2000—and the rate of infection among racial/ethnic minorities and foreign-born individuals continues to be disproportionately high.

Those were among the findings of a report on 2008 U.S. trends in tuberculosis published by the Centers for Disease Control and Prevention.

In 2008, a total of 12,898 incident TB cases were reported in the United States, representing a decline of 3.8% from 2007 and a rate of 4.2 per 100,000 population.

The 2008 rate was the lowest recorded since TB reporting began in 1953.

Progress has slowed in recent years, however, with the average annual percentage decline in the TB rate decreasing from 7.3% per year during 1993–2000 to 3.8% during 2000–2008.

Among the 50 states and the District of Columbia, TB rates ranged from a low of 0.5/100,000 in North Dakota to a high of 9.6/100,000 in Hawaii.

California, Florida, New York, and Texas reported more than 500 cases each and together accounted for 49% of all TB cases in 2008.

TB rates among Hispanics and blacks were nearly 8 times higher than among non-Hispanic whites (8.1 and 8.7 per 100,000, respectively, versus 1.1 per 100,000), while the rate among Asians was nearly 23 times higher than among non-Hispanic whites (25.1 per 100,000).

The report classified persons identified as white, black, Asian, American Indian/Alaska Native, native Hawaiian or other Pacific Islander, or of multiple races, as non-Hispanic. “Persons identified as Hispanic might be of any race,” the report explained.

The 2008 TB rate in foreign-born persons living in the United States was 20.2 per 100,000, 10 times higher than for U.S.-born individuals. People born in Mexico, the Philippines, India, and Vietnam accounted for half of the 7,541 tuberculosis cases in foreign-born persons that year.

However, the rate of TB cases continued to decline both among foreign-born individuals (down 2.6% since 2007), as well as those born in the United States (down 4.7%).

Based on the data, the CDC recommended that TB prevention and control capacity be intensified to improve case management and contact investigations. The agency also called for intensified outreach, testing, and treatment of high-risk populations; enhanced treatment and diagnostic tools; increased scientific research to better understand TB transmission; and continued collaboration with other nations to reduce TB globally (MMWR 2009;58:249–53).

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA — Wyeth Pharmaceuticals is in the process of planning the transition from routine childhood immunization with the 7-valent Prevnar to use of a 13-valent pneumococcal conjugate vaccine that is still under investigation.

The Food and Drug Administration has granted fast-track status for PCV13 for the pediatric indication, based on “an unmet medical need.” The company planned to complete the data submission process for PCV13 by the end of March, at which point the agency would decide about priority review, Peter Paradiso, Ph.D., vice president of new business and scientific affairs at Wyeth, Collegeville, Pa., said at the winter meeting of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

The 13-valent version contains the same amounts of the same seven serotypes that Prevnar has (4, 6B, 9V, 14, 18C, 19F, and 23F) along with six new strains (1, 3, 5, 6A, 7F, and 19A). Each of these polysaccharides in both vaccines is conjugated to the same carrier protein, CRM197, he noted.

Since the introduction of Prevnar in 2000, the proportion of cases of invasive pneumococcal disease (IPD) caused by the seven vaccine strains has declined dramatically, while the proportion caused by other strains—19A in particular—has risen.

Dr. Paradiso summarized previously reported data from a pivotal trial done in Germany in which 603 infants received either PCV7 or PCV13 at 2, 3, and 4 months of age. The 13-valent version was noninferior against each serotype, while provoking a high antibody response rate to each of the six new serotypes.

Wyeth's transition scheme—which would be subject to approval by both the FDA and the ACIP after PCV13 is licensed—would involve the substitution of PCV13 for PCV7 at any point in the immunization schedule.

Since data show that a single dose of PCV13 will induce an immune response to the six new serotypes in more than 90% of children aged 12 months and older, any child who received the primary 3-dose series with PCV7 could simply receive PCV13 as a booster after the age of 12 months. For children 12 months and older who already received the complete series with PCV7 including the booster, one additional dose of PCV13 would be needed. Infants aged 6 months or younger who received one or two doses of PCV7 would complete the primary series and the booster using PCV13.

The company will first seek an indication for the use of PCV13 in children under 5 years old. It then hopes to bring it to adults over age 50, and ultimately to the entire population, Dr. Paradiso said.

ATLANTA — Wyeth Pharmaceuticals is in the process of planning the transition from routine childhood immunization with the 7-valent Prevnar to use of a 13-valent pneumococcal conjugate vaccine that is still under investigation.

The Food and Drug Administration has granted fast-track status for PCV13 for the pediatric indication, based on “an unmet medical need.” The company planned to complete the data submission process for PCV13 by the end of March, at which point the agency would decide about priority review, Peter Paradiso, Ph.D., vice president of new business and scientific affairs at Wyeth, Collegeville, Pa., said at the winter meeting of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

The 13-valent version contains the same amounts of the same seven serotypes that Prevnar has (4, 6B, 9V, 14, 18C, 19F, and 23F) along with six new strains (1, 3, 5, 6A, 7F, and 19A). Each of these polysaccharides in both vaccines is conjugated to the same carrier protein, CRM197, he noted.

Since the introduction of Prevnar in 2000, the proportion of cases of invasive pneumococcal disease (IPD) caused by the seven vaccine strains has declined dramatically, while the proportion caused by other strains—19A in particular—has risen.

Dr. Paradiso summarized previously reported data from a pivotal trial done in Germany in which 603 infants received either PCV7 or PCV13 at 2, 3, and 4 months of age. The 13-valent version was noninferior against each serotype, while provoking a high antibody response rate to each of the six new serotypes.

Wyeth's transition scheme—which would be subject to approval by both the FDA and the ACIP after PCV13 is licensed—would involve the substitution of PCV13 for PCV7 at any point in the immunization schedule.

Since data show that a single dose of PCV13 will induce an immune response to the six new serotypes in more than 90% of children aged 12 months and older, any child who received the primary 3-dose series with PCV7 could simply receive PCV13 as a booster after the age of 12 months. For children 12 months and older who already received the complete series with PCV7 including the booster, one additional dose of PCV13 would be needed. Infants aged 6 months or younger who received one or two doses of PCV7 would complete the primary series and the booster using PCV13.

The company will first seek an indication for the use of PCV13 in children under 5 years old. It then hopes to bring it to adults over age 50, and ultimately to the entire population, Dr. Paradiso said.

ATLANTA — Wyeth Pharmaceuticals is in the process of planning the transition from routine childhood immunization with the 7-valent Prevnar to use of a 13-valent pneumococcal conjugate vaccine that is still under investigation.

The Food and Drug Administration has granted fast-track status for PCV13 for the pediatric indication, based on “an unmet medical need.” The company planned to complete the data submission process for PCV13 by the end of March, at which point the agency would decide about priority review, Peter Paradiso, Ph.D., vice president of new business and scientific affairs at Wyeth, Collegeville, Pa., said at the winter meeting of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

The 13-valent version contains the same amounts of the same seven serotypes that Prevnar has (4, 6B, 9V, 14, 18C, 19F, and 23F) along with six new strains (1, 3, 5, 6A, 7F, and 19A). Each of these polysaccharides in both vaccines is conjugated to the same carrier protein, CRM197, he noted.

Since the introduction of Prevnar in 2000, the proportion of cases of invasive pneumococcal disease (IPD) caused by the seven vaccine strains has declined dramatically, while the proportion caused by other strains—19A in particular—has risen.

Dr. Paradiso summarized previously reported data from a pivotal trial done in Germany in which 603 infants received either PCV7 or PCV13 at 2, 3, and 4 months of age. The 13-valent version was noninferior against each serotype, while provoking a high antibody response rate to each of the six new serotypes.

Wyeth's transition scheme—which would be subject to approval by both the FDA and the ACIP after PCV13 is licensed—would involve the substitution of PCV13 for PCV7 at any point in the immunization schedule.

Since data show that a single dose of PCV13 will induce an immune response to the six new serotypes in more than 90% of children aged 12 months and older, any child who received the primary 3-dose series with PCV7 could simply receive PCV13 as a booster after the age of 12 months. For children 12 months and older who already received the complete series with PCV7 including the booster, one additional dose of PCV13 would be needed. Infants aged 6 months or younger who received one or two doses of PCV7 would complete the primary series and the booster using PCV13.

The company will first seek an indication for the use of PCV13 in children under 5 years old. It then hopes to bring it to adults over age 50, and ultimately to the entire population, Dr. Paradiso said.

Diabetic patients with atrial fibrillation obtained greater absolute benefits from blood pressure-lowering treatment than did those without in a study of more than 11,000 patients with type 2 diabetes.

The study findings suggest that an estimated 5 years of active blood pressure-lowering treatment would prevent one cardiovascular death among every 42 patients with atrial fibrillation (AF) at baseline, compared with one death among 120 patients without AF. “These findings … indicate that detection of AF in a patient with diabetes should prompt more aggressive treatment of all cardiovascular risk factors,” said Dr. Xin Du of the University of Sydney, and associates (Eur. Heart J. 2009 March 12 [doi:10.1093/eurheartj/ehp055

Atrial fibrillation (AF) was present at baseline in 847 (7.6%) of the 11,140 patients with type 2 diabetes who participated in the Action in Diabetes and Vascular Disease: preterAx and diamicroN-MR Controlled Evaluation (ADVANCE) study, which was jointly funded by the National Health and Medical Research Council of Australia and Servier, France.

The patients with AF were older and heavier, had higher blood pressure levels and urinary albumin-creatinine ratios, and had lower estimated glomerular filtration rates than patients without AF.

Over a mean follow-up of 4.3 years, 879 patients died. Of those deaths, 468 (53%) were due to cardiovascular causes and 15% of the total deaths occurred in patients with AF. Patients with AF at baseline had significantly higher rates of both all-cause and cardiovascular mortality, at 3.9% and 2.4%, respectively, than did those who did not have AF, whose all-cause and cardiovascular mortality rates were 1.7% and 0.9%, respectively. After adjustment for covariates, those hazard ratios were 1.61 and 1.77, respectively.

Among patients who were on oral anticoagulants at baseline, the adjusted hazard ratios associated with AF were 2.16 for all-cause mortality and 2.32 for cardiovascular death. The association between AF and cardiovascular death was significantly stronger in women compared with men, the investigators said.

During follow-up, active treatment with a fixed combination of perindopril and indapamide reduced blood pressure by 5.3/2.3 mm Hg more than did placebo in those with AF and by 5.9/2.3 mm Hg more than placebo in patients without AF, the researchers said.

This study “highlights the importance of actively evaluating diabetic patients for the presence of AF to identify those at particularly high risk of cardiovascular events,” said the authors, several of whom other than Dr. Du have received lecture fees or grant support from, or served on an advisory board for, Servier.

Diabetic patients with atrial fibrillation obtained greater absolute benefits from blood pressure-lowering treatment than did those without in a study of more than 11,000 patients with type 2 diabetes.

The study findings suggest that an estimated 5 years of active blood pressure-lowering treatment would prevent one cardiovascular death among every 42 patients with atrial fibrillation (AF) at baseline, compared with one death among 120 patients without AF. “These findings … indicate that detection of AF in a patient with diabetes should prompt more aggressive treatment of all cardiovascular risk factors,” said Dr. Xin Du of the University of Sydney, and associates (Eur. Heart J. 2009 March 12 [doi:10.1093/eurheartj/ehp055

Atrial fibrillation (AF) was present at baseline in 847 (7.6%) of the 11,140 patients with type 2 diabetes who participated in the Action in Diabetes and Vascular Disease: preterAx and diamicroN-MR Controlled Evaluation (ADVANCE) study, which was jointly funded by the National Health and Medical Research Council of Australia and Servier, France.

The patients with AF were older and heavier, had higher blood pressure levels and urinary albumin-creatinine ratios, and had lower estimated glomerular filtration rates than patients without AF.

Over a mean follow-up of 4.3 years, 879 patients died. Of those deaths, 468 (53%) were due to cardiovascular causes and 15% of the total deaths occurred in patients with AF. Patients with AF at baseline had significantly higher rates of both all-cause and cardiovascular mortality, at 3.9% and 2.4%, respectively, than did those who did not have AF, whose all-cause and cardiovascular mortality rates were 1.7% and 0.9%, respectively. After adjustment for covariates, those hazard ratios were 1.61 and 1.77, respectively.

Among patients who were on oral anticoagulants at baseline, the adjusted hazard ratios associated with AF were 2.16 for all-cause mortality and 2.32 for cardiovascular death. The association between AF and cardiovascular death was significantly stronger in women compared with men, the investigators said.

During follow-up, active treatment with a fixed combination of perindopril and indapamide reduced blood pressure by 5.3/2.3 mm Hg more than did placebo in those with AF and by 5.9/2.3 mm Hg more than placebo in patients without AF, the researchers said.

This study “highlights the importance of actively evaluating diabetic patients for the presence of AF to identify those at particularly high risk of cardiovascular events,” said the authors, several of whom other than Dr. Du have received lecture fees or grant support from, or served on an advisory board for, Servier.

Diabetic patients with atrial fibrillation obtained greater absolute benefits from blood pressure-lowering treatment than did those without in a study of more than 11,000 patients with type 2 diabetes.

The study findings suggest that an estimated 5 years of active blood pressure-lowering treatment would prevent one cardiovascular death among every 42 patients with atrial fibrillation (AF) at baseline, compared with one death among 120 patients without AF. “These findings … indicate that detection of AF in a patient with diabetes should prompt more aggressive treatment of all cardiovascular risk factors,” said Dr. Xin Du of the University of Sydney, and associates (Eur. Heart J. 2009 March 12 [doi:10.1093/eurheartj/ehp055

Atrial fibrillation (AF) was present at baseline in 847 (7.6%) of the 11,140 patients with type 2 diabetes who participated in the Action in Diabetes and Vascular Disease: preterAx and diamicroN-MR Controlled Evaluation (ADVANCE) study, which was jointly funded by the National Health and Medical Research Council of Australia and Servier, France.

The patients with AF were older and heavier, had higher blood pressure levels and urinary albumin-creatinine ratios, and had lower estimated glomerular filtration rates than patients without AF.

Over a mean follow-up of 4.3 years, 879 patients died. Of those deaths, 468 (53%) were due to cardiovascular causes and 15% of the total deaths occurred in patients with AF. Patients with AF at baseline had significantly higher rates of both all-cause and cardiovascular mortality, at 3.9% and 2.4%, respectively, than did those who did not have AF, whose all-cause and cardiovascular mortality rates were 1.7% and 0.9%, respectively. After adjustment for covariates, those hazard ratios were 1.61 and 1.77, respectively.

Among patients who were on oral anticoagulants at baseline, the adjusted hazard ratios associated with AF were 2.16 for all-cause mortality and 2.32 for cardiovascular death. The association between AF and cardiovascular death was significantly stronger in women compared with men, the investigators said.

During follow-up, active treatment with a fixed combination of perindopril and indapamide reduced blood pressure by 5.3/2.3 mm Hg more than did placebo in those with AF and by 5.9/2.3 mm Hg more than placebo in patients without AF, the researchers said.

This study “highlights the importance of actively evaluating diabetic patients for the presence of AF to identify those at particularly high risk of cardiovascular events,” said the authors, several of whom other than Dr. Du have received lecture fees or grant support from, or served on an advisory board for, Servier.

Diabetic patients with atrial fibrillation obtained greater absolute benefits from blood pres-sure-lowering treatment than did those without in a study of more than 11,000 patients with type 2 diabetes.

The findings suggest that an estimated 5 years of active blood pressure-lowering treatment would prevent one cardiovascular death among every 42 patients with atrial fibrillation (AF) at baseline, compared with one death among 120 patients without AF. “These findings are of direct relevance for the routine clinical management of diabetic patients and indicate that detection of AF in a patient with diabetes should prompt more aggressive treatment of all cardiovascular risk factors,” said Dr. Xin Du of the University of Sydney, and associates (Eur. Heart J. 2009 March 12 [doi:10.1093/eurheartj/ehp055]).

AF was present at baseline in 847 (7.6%) of the 11,140 patients with type 2 diabetes in the Action in Diabetes and Vascular Disease: preterAx and diamicroN-MR Controlled Evaluation (ADVANCE) study, jointly funded by the National Health and Medical Research Council of Australia and Servier, France. Measured outcomes were all-cause mortality cardiovascular death, myocardial infarction, stroke, and heart failure.

Patients with AF were older and heavier, had higher blood pressure levels and urinary albumin-creatinine ratios, and had lower estimated glomerular filtration rates than did the patients without AF. They also were more likely to be taking antiplatelet therapy and were less likely to be current smokers.

Over a mean follow-up of 4.3 years (range less than 1 month to 5.6 years), 879 patients died. Of those deaths, 468 (53%) were due to cardiovascular causes and 15% of the total deaths occurred in patients with AF. Patients with AF at baseline had significantly higher rates of all-cause and cardiovascular mortality, at 3.9% and 2.4%, respectively, than did those without AF, whose all cause and cardiovascular mortality rates were 1.7% and 0.9%, respectively. After adjustment for covariates, those hazard ratios were 1.61 and 1.77, respectively. Patients with AF had higher risk of major cerebrovascular events, with a hazard ratio of 1.68 that was similar for ischemic and hemorrhagic subtypes.

Among patients who were on oral anticoagulants at baseline, the adjusted hazard ratios associated with AF were 2.16 for all-cause mortality and 2.32 for cardiovascular death. The association between AF and cardiovascular death was significantly stronger in women compared with men, while the associations between AF and total mortality, coronary events, and cerebrovascular events were also stronger for women but not significantly so, the investigators said.

During follow-up, active treatment with a fixed combination of perindopril and indapamide reduced blood pressure by 5.3/2.3 mm Hg more than did placebo in those with AF and by 5.9/2.3 mm Hg more in patients without AF. The active treatment produced similar relative reductions in all-cause mortality and cardiovascular mortality in patients with and without AF, but the absolute benefit was greater for those with AF because their baseline risk was higher, the researchers said.

New-onset AF was identified in 3.3% of patients randomized to active treatment and in 3.6% of those who received placebo, but there was limited power to evaluate the effects of the combined treatment on new-onset AF during follow-up.

The study highlights the importance of actively evaluating diabetic patients for AF, said the authors, several of whom other than Dr. Du have received lecture fees or grant support from, or served on an advisory board for, Servier.

Diabetic patients with atrial fibrillation obtained greater absolute benefits from blood pres-sure-lowering treatment than did those without in a study of more than 11,000 patients with type 2 diabetes.

The findings suggest that an estimated 5 years of active blood pressure-lowering treatment would prevent one cardiovascular death among every 42 patients with atrial fibrillation (AF) at baseline, compared with one death among 120 patients without AF. “These findings are of direct relevance for the routine clinical management of diabetic patients and indicate that detection of AF in a patient with diabetes should prompt more aggressive treatment of all cardiovascular risk factors,” said Dr. Xin Du of the University of Sydney, and associates (Eur. Heart J. 2009 March 12 [doi:10.1093/eurheartj/ehp055]).

AF was present at baseline in 847 (7.6%) of the 11,140 patients with type 2 diabetes in the Action in Diabetes and Vascular Disease: preterAx and diamicroN-MR Controlled Evaluation (ADVANCE) study, jointly funded by the National Health and Medical Research Council of Australia and Servier, France. Measured outcomes were all-cause mortality cardiovascular death, myocardial infarction, stroke, and heart failure.

Patients with AF were older and heavier, had higher blood pressure levels and urinary albumin-creatinine ratios, and had lower estimated glomerular filtration rates than did the patients without AF. They also were more likely to be taking antiplatelet therapy and were less likely to be current smokers.

Over a mean follow-up of 4.3 years (range less than 1 month to 5.6 years), 879 patients died. Of those deaths, 468 (53%) were due to cardiovascular causes and 15% of the total deaths occurred in patients with AF. Patients with AF at baseline had significantly higher rates of all-cause and cardiovascular mortality, at 3.9% and 2.4%, respectively, than did those without AF, whose all cause and cardiovascular mortality rates were 1.7% and 0.9%, respectively. After adjustment for covariates, those hazard ratios were 1.61 and 1.77, respectively. Patients with AF had higher risk of major cerebrovascular events, with a hazard ratio of 1.68 that was similar for ischemic and hemorrhagic subtypes.

Among patients who were on oral anticoagulants at baseline, the adjusted hazard ratios associated with AF were 2.16 for all-cause mortality and 2.32 for cardiovascular death. The association between AF and cardiovascular death was significantly stronger in women compared with men, while the associations between AF and total mortality, coronary events, and cerebrovascular events were also stronger for women but not significantly so, the investigators said.

During follow-up, active treatment with a fixed combination of perindopril and indapamide reduced blood pressure by 5.3/2.3 mm Hg more than did placebo in those with AF and by 5.9/2.3 mm Hg more in patients without AF. The active treatment produced similar relative reductions in all-cause mortality and cardiovascular mortality in patients with and without AF, but the absolute benefit was greater for those with AF because their baseline risk was higher, the researchers said.

New-onset AF was identified in 3.3% of patients randomized to active treatment and in 3.6% of those who received placebo, but there was limited power to evaluate the effects of the combined treatment on new-onset AF during follow-up.

The study highlights the importance of actively evaluating diabetic patients for AF, said the authors, several of whom other than Dr. Du have received lecture fees or grant support from, or served on an advisory board for, Servier.

Diabetic patients with atrial fibrillation obtained greater absolute benefits from blood pres-sure-lowering treatment than did those without in a study of more than 11,000 patients with type 2 diabetes.

The findings suggest that an estimated 5 years of active blood pressure-lowering treatment would prevent one cardiovascular death among every 42 patients with atrial fibrillation (AF) at baseline, compared with one death among 120 patients without AF. “These findings are of direct relevance for the routine clinical management of diabetic patients and indicate that detection of AF in a patient with diabetes should prompt more aggressive treatment of all cardiovascular risk factors,” said Dr. Xin Du of the University of Sydney, and associates (Eur. Heart J. 2009 March 12 [doi:10.1093/eurheartj/ehp055]).

AF was present at baseline in 847 (7.6%) of the 11,140 patients with type 2 diabetes in the Action in Diabetes and Vascular Disease: preterAx and diamicroN-MR Controlled Evaluation (ADVANCE) study, jointly funded by the National Health and Medical Research Council of Australia and Servier, France. Measured outcomes were all-cause mortality cardiovascular death, myocardial infarction, stroke, and heart failure.

Patients with AF were older and heavier, had higher blood pressure levels and urinary albumin-creatinine ratios, and had lower estimated glomerular filtration rates than did the patients without AF. They also were more likely to be taking antiplatelet therapy and were less likely to be current smokers.

Over a mean follow-up of 4.3 years (range less than 1 month to 5.6 years), 879 patients died. Of those deaths, 468 (53%) were due to cardiovascular causes and 15% of the total deaths occurred in patients with AF. Patients with AF at baseline had significantly higher rates of all-cause and cardiovascular mortality, at 3.9% and 2.4%, respectively, than did those without AF, whose all cause and cardiovascular mortality rates were 1.7% and 0.9%, respectively. After adjustment for covariates, those hazard ratios were 1.61 and 1.77, respectively. Patients with AF had higher risk of major cerebrovascular events, with a hazard ratio of 1.68 that was similar for ischemic and hemorrhagic subtypes.

Among patients who were on oral anticoagulants at baseline, the adjusted hazard ratios associated with AF were 2.16 for all-cause mortality and 2.32 for cardiovascular death. The association between AF and cardiovascular death was significantly stronger in women compared with men, while the associations between AF and total mortality, coronary events, and cerebrovascular events were also stronger for women but not significantly so, the investigators said.

During follow-up, active treatment with a fixed combination of perindopril and indapamide reduced blood pressure by 5.3/2.3 mm Hg more than did placebo in those with AF and by 5.9/2.3 mm Hg more in patients without AF. The active treatment produced similar relative reductions in all-cause mortality and cardiovascular mortality in patients with and without AF, but the absolute benefit was greater for those with AF because their baseline risk was higher, the researchers said.

New-onset AF was identified in 3.3% of patients randomized to active treatment and in 3.6% of those who received placebo, but there was limited power to evaluate the effects of the combined treatment on new-onset AF during follow-up.

The study highlights the importance of actively evaluating diabetic patients for AF, said the authors, several of whom other than Dr. Du have received lecture fees or grant support from, or served on an advisory board for, Servier.

The cost of digestive diseases in the United States now totals more than $141 billion a year, according to a the National Institutes of Health.

In 2004, the number of digestive disease-related ambulatory care visits totaled 35 for every 100 U.S. residents, an increase of one-third since 1992. Also contributing to the $141.8 billion total was an age-adjusted 35% increase in hospitalizations for digestive disorders between 1998 and 2004.

Those findings are among the data included a 192-page report by the NIH, The Burden of Digestive Diseases in the United States, a comprehensive compilation of statistics related to diseases that include GI cancers, infections, and functional disorders, as well as liver, biliary, and pancreatic disorders.

A series of three consecutive articles in the journal Gastroenterology summarizes certain aspects of the report, including the current state of medical care for GI disorders and the costs of that care. “Digestive, liver, and pancreatic diseases have a far-reaching medical, economic, social, and political impact on society in the United States and worldwide. said Dr. Anil K. Rustgi and Dr. Hashem B. El-Serag, respectively, editor and associate editor for Gastroenterology (2009;136:376–86).

In 2004, there were an estimated 72 million ambulatory care visits with a first-listed diagnosis of a digestive disease, and more than 104 million total listing a digestive disease. Digestive diseases were also common hospital discharge diagnoses, with approximately 4.6 million discharges of patients with a first-listed digestive disease diagnosis. A total of 4,608 of overnight hospital stays per 100,000 U.S. population had a digestive disease diagnosis in 2004, for a rate of nearly 5 per 100.

The recent 35% increase in overnight hospital stays with a diagnosis of digestive disease contrasts with a more modest 13% increase in hospital discharges for all diseases. In 1998, 25% of all hospital discharges had diagnoses of digestive diseases, compared with 30% in 2004. “Thus, rates of hospitalizations with digestive disease diagnoses increased both absolutely and as a proportion of all hospitalizations,” noted the report's editor, Dr. James E. Everhart of the National Institute of Diabetes and Digestive and Kidney Diseases.

In 2004, there were more than 236,000 deaths in the United States with a digestive disease as the underlying cause, representing 10% of all deaths. A gradual decline occurred in digestive disease mortality between 1979 and 2004, both as underlying cause (18%) and as underlying or other cause (20%). The greatest contributor to this decline was the decrease in digestive disease cancer mortality by 20% as an underlying cause and 24% as underlying or other cause.

The leading digestive disease diagnoses among ambulatory visits included gastroesophageal reflux disease (GERD), chronic constipation, abdominal wall hernia, hemorrhoids, diverticular disease, and irritable bowel syndrome, while the most common digestive disease-related diagnoses listed on hospital discharge records were GERD, diverticular disease, liver disease, constipation, gallstones, and peptic ulcer disease. The diagnosis of GERD has increased severalfold in both ambulatory care visits and recorded hospital discharges since the early 1990s, Dr. Everhart noted.

The 10 most common prescription drugs from retail pharmacies for digestive diseases in 2004 included five proton pump inhibitors, accounting for 51% of all prescriptions and 77% of the total cost. Other costly medications included mesalamine, ranitidine, tegaserod, and ribavirin/peginterferon alfa-2a. A major deficiency in these data, derived from the Verispan database of retail pharmacy sales, is that they do not include nonprescription or alternative/complimentary medications, infusions, mail-order drugs, or drugs given in the hospital, the authors said.

Direct costs for digestive diseases in 2004 totaled $97.8 billion, of which hospital facility costs were the largest component, at $40.6 billion. Diseases costing more than $1 billion in facility charges included gallstones ($4.3), abdominal wall hernia ($3.5), and diverticular disease ($2.2). Total physician charges associated with hospital services for digestive diseases were $14.7 billion, of which only $8.5 billion could be attributed to individual digestive diseases. The most expensive of these were GERD ($0.77 billion), gallstones ($0.75 billion), and abdominal wall hernia ($0.54 billion).

Total ambulatory care costs, including physician fees for office visits and in-office procedures, totaled $16 billion. Expenditures for prescription drugs written by physicians during office visits were estimated to be $12.3 billion, of which more than half was associated with drugs prescribed for GERD and peptic ulcer disease.

Of the $85.7 billion in direct costs that could be attributed to individual digestive diseases, the six largest contributors were GERD ($12.1 billion), gallstones ($5.8 billion), abdominal wall hernia ($5.7 billion), colorectal cancer ($4.0 billion), diverticular disease ($3.6 billion), and peptic ulcer disease ($2.6 billion). As a group, cancers accounted for $8.4 billion or 10% of the direct costs assigned to individual diseases.

The most costly diseases overall were liver disease ($13.1 billion), GERD ($12.6 billion) and colorectal cancer ($9.5 billion).

The authors disclosed no conflicts of interest.

The cost of digestive diseases in the United States now totals more than $141 billion a year, according to a the National Institutes of Health.

In 2004, the number of digestive disease-related ambulatory care visits totaled 35 for every 100 U.S. residents, an increase of one-third since 1992. Also contributing to the $141.8 billion total was an age-adjusted 35% increase in hospitalizations for digestive disorders between 1998 and 2004.

Those findings are among the data included a 192-page report by the NIH, The Burden of Digestive Diseases in the United States, a comprehensive compilation of statistics related to diseases that include GI cancers, infections, and functional disorders, as well as liver, biliary, and pancreatic disorders.

A series of three consecutive articles in the journal Gastroenterology summarizes certain aspects of the report, including the current state of medical care for GI disorders and the costs of that care. “Digestive, liver, and pancreatic diseases have a far-reaching medical, economic, social, and political impact on society in the United States and worldwide. said Dr. Anil K. Rustgi and Dr. Hashem B. El-Serag, respectively, editor and associate editor for Gastroenterology (2009;136:376–86).

In 2004, there were an estimated 72 million ambulatory care visits with a first-listed diagnosis of a digestive disease, and more than 104 million total listing a digestive disease. Digestive diseases were also common hospital discharge diagnoses, with approximately 4.6 million discharges of patients with a first-listed digestive disease diagnosis. A total of 4,608 of overnight hospital stays per 100,000 U.S. population had a digestive disease diagnosis in 2004, for a rate of nearly 5 per 100.

The recent 35% increase in overnight hospital stays with a diagnosis of digestive disease contrasts with a more modest 13% increase in hospital discharges for all diseases. In 1998, 25% of all hospital discharges had diagnoses of digestive diseases, compared with 30% in 2004. “Thus, rates of hospitalizations with digestive disease diagnoses increased both absolutely and as a proportion of all hospitalizations,” noted the report's editor, Dr. James E. Everhart of the National Institute of Diabetes and Digestive and Kidney Diseases.

In 2004, there were more than 236,000 deaths in the United States with a digestive disease as the underlying cause, representing 10% of all deaths. A gradual decline occurred in digestive disease mortality between 1979 and 2004, both as underlying cause (18%) and as underlying or other cause (20%). The greatest contributor to this decline was the decrease in digestive disease cancer mortality by 20% as an underlying cause and 24% as underlying or other cause.

The leading digestive disease diagnoses among ambulatory visits included gastroesophageal reflux disease (GERD), chronic constipation, abdominal wall hernia, hemorrhoids, diverticular disease, and irritable bowel syndrome, while the most common digestive disease-related diagnoses listed on hospital discharge records were GERD, diverticular disease, liver disease, constipation, gallstones, and peptic ulcer disease. The diagnosis of GERD has increased severalfold in both ambulatory care visits and recorded hospital discharges since the early 1990s, Dr. Everhart noted.

The 10 most common prescription drugs from retail pharmacies for digestive diseases in 2004 included five proton pump inhibitors, accounting for 51% of all prescriptions and 77% of the total cost. Other costly medications included mesalamine, ranitidine, tegaserod, and ribavirin/peginterferon alfa-2a. A major deficiency in these data, derived from the Verispan database of retail pharmacy sales, is that they do not include nonprescription or alternative/complimentary medications, infusions, mail-order drugs, or drugs given in the hospital, the authors said.

Direct costs for digestive diseases in 2004 totaled $97.8 billion, of which hospital facility costs were the largest component, at $40.6 billion. Diseases costing more than $1 billion in facility charges included gallstones ($4.3), abdominal wall hernia ($3.5), and diverticular disease ($2.2). Total physician charges associated with hospital services for digestive diseases were $14.7 billion, of which only $8.5 billion could be attributed to individual digestive diseases. The most expensive of these were GERD ($0.77 billion), gallstones ($0.75 billion), and abdominal wall hernia ($0.54 billion).

Total ambulatory care costs, including physician fees for office visits and in-office procedures, totaled $16 billion. Expenditures for prescription drugs written by physicians during office visits were estimated to be $12.3 billion, of which more than half was associated with drugs prescribed for GERD and peptic ulcer disease.

Of the $85.7 billion in direct costs that could be attributed to individual digestive diseases, the six largest contributors were GERD ($12.1 billion), gallstones ($5.8 billion), abdominal wall hernia ($5.7 billion), colorectal cancer ($4.0 billion), diverticular disease ($3.6 billion), and peptic ulcer disease ($2.6 billion). As a group, cancers accounted for $8.4 billion or 10% of the direct costs assigned to individual diseases.

The most costly diseases overall were liver disease ($13.1 billion), GERD ($12.6 billion) and colorectal cancer ($9.5 billion).

The authors disclosed no conflicts of interest.

The cost of digestive diseases in the United States now totals more than $141 billion a year, according to a the National Institutes of Health.

In 2004, the number of digestive disease-related ambulatory care visits totaled 35 for every 100 U.S. residents, an increase of one-third since 1992. Also contributing to the $141.8 billion total was an age-adjusted 35% increase in hospitalizations for digestive disorders between 1998 and 2004.

Those findings are among the data included a 192-page report by the NIH, The Burden of Digestive Diseases in the United States, a comprehensive compilation of statistics related to diseases that include GI cancers, infections, and functional disorders, as well as liver, biliary, and pancreatic disorders.

A series of three consecutive articles in the journal Gastroenterology summarizes certain aspects of the report, including the current state of medical care for GI disorders and the costs of that care. “Digestive, liver, and pancreatic diseases have a far-reaching medical, economic, social, and political impact on society in the United States and worldwide. said Dr. Anil K. Rustgi and Dr. Hashem B. El-Serag, respectively, editor and associate editor for Gastroenterology (2009;136:376–86).

In 2004, there were an estimated 72 million ambulatory care visits with a first-listed diagnosis of a digestive disease, and more than 104 million total listing a digestive disease. Digestive diseases were also common hospital discharge diagnoses, with approximately 4.6 million discharges of patients with a first-listed digestive disease diagnosis. A total of 4,608 of overnight hospital stays per 100,000 U.S. population had a digestive disease diagnosis in 2004, for a rate of nearly 5 per 100.

The recent 35% increase in overnight hospital stays with a diagnosis of digestive disease contrasts with a more modest 13% increase in hospital discharges for all diseases. In 1998, 25% of all hospital discharges had diagnoses of digestive diseases, compared with 30% in 2004. “Thus, rates of hospitalizations with digestive disease diagnoses increased both absolutely and as a proportion of all hospitalizations,” noted the report's editor, Dr. James E. Everhart of the National Institute of Diabetes and Digestive and Kidney Diseases.

In 2004, there were more than 236,000 deaths in the United States with a digestive disease as the underlying cause, representing 10% of all deaths. A gradual decline occurred in digestive disease mortality between 1979 and 2004, both as underlying cause (18%) and as underlying or other cause (20%). The greatest contributor to this decline was the decrease in digestive disease cancer mortality by 20% as an underlying cause and 24% as underlying or other cause.

The leading digestive disease diagnoses among ambulatory visits included gastroesophageal reflux disease (GERD), chronic constipation, abdominal wall hernia, hemorrhoids, diverticular disease, and irritable bowel syndrome, while the most common digestive disease-related diagnoses listed on hospital discharge records were GERD, diverticular disease, liver disease, constipation, gallstones, and peptic ulcer disease. The diagnosis of GERD has increased severalfold in both ambulatory care visits and recorded hospital discharges since the early 1990s, Dr. Everhart noted.

The 10 most common prescription drugs from retail pharmacies for digestive diseases in 2004 included five proton pump inhibitors, accounting for 51% of all prescriptions and 77% of the total cost. Other costly medications included mesalamine, ranitidine, tegaserod, and ribavirin/peginterferon alfa-2a. A major deficiency in these data, derived from the Verispan database of retail pharmacy sales, is that they do not include nonprescription or alternative/complimentary medications, infusions, mail-order drugs, or drugs given in the hospital, the authors said.

Direct costs for digestive diseases in 2004 totaled $97.8 billion, of which hospital facility costs were the largest component, at $40.6 billion. Diseases costing more than $1 billion in facility charges included gallstones ($4.3), abdominal wall hernia ($3.5), and diverticular disease ($2.2). Total physician charges associated with hospital services for digestive diseases were $14.7 billion, of which only $8.5 billion could be attributed to individual digestive diseases. The most expensive of these were GERD ($0.77 billion), gallstones ($0.75 billion), and abdominal wall hernia ($0.54 billion).

Total ambulatory care costs, including physician fees for office visits and in-office procedures, totaled $16 billion. Expenditures for prescription drugs written by physicians during office visits were estimated to be $12.3 billion, of which more than half was associated with drugs prescribed for GERD and peptic ulcer disease.

Of the $85.7 billion in direct costs that could be attributed to individual digestive diseases, the six largest contributors were GERD ($12.1 billion), gallstones ($5.8 billion), abdominal wall hernia ($5.7 billion), colorectal cancer ($4.0 billion), diverticular disease ($3.6 billion), and peptic ulcer disease ($2.6 billion). As a group, cancers accounted for $8.4 billion or 10% of the direct costs assigned to individual diseases.

The most costly diseases overall were liver disease ($13.1 billion), GERD ($12.6 billion) and colorectal cancer ($9.5 billion).

The authors disclosed no conflicts of interest.