Naseem S. Miller

MUNICH – Gender differences in comorbidities affected the medications prescribed to men and women hospitalized with acute heart failure, although their in-hospital mortality rate remained similar, according to a retrospective analysis of nearly 5,000 hospital charts.

The study showed that men who were hospitalized with acute heart failure (AHF) were more likely to receive beta-blockers and aspirin than were women. Meanwhile, women were more likely to be obese, have diabetes, or have atrial fibrillation.

"Perhaps there are differences in the pathophysiology of AHF between women and men, which should be taken into account in order to achieve gender-tailored management," said Dr. John Parissis, who presented the study at the annual congress of the European Society of Cardiology.

The study was a subanalysis of the Acute Heart Failure Global Registry of Standard Treatment (ALARM-HF), a chart audit survey of 4,953 patients hospitalized for AHF in 666 hospitals in nine countries (France, Germany, Spain, Italy, Greece, United Kingdom, Turkey, Australia, and Mexico.)

Women made up 37% of the patients, consistent with ratios in other registries, said Dr. Parissis of Attikon University Hospital, Greece. They presented with AHF at an older age and had higher rates of de novo heart failure. They were also half as likely as were men to present with cardiogenic shock, but more than twice as likely to have right heart failure.

The study showed that women hospitalized with AHF had a higher prevalence of diabetes (47% v. 43%), obesity (30% v. 25%), anemia (17% v. 13%), atrial fibrillation or flutter (49% v. 42%), dementia (6% v. 3%), and depression (11% v. 7%), compared with men.

Meanwhile, men had a higher prevalence of chronic obstructive pulmonary disease (COPD) and asthma (27% v. 21%), and coronary artery disease (CAD) (35% v. 24%) compared with women.

Upon admission, women were less likely than were men to receive aspirin, clopidogrel, and beta-blockers, because of their comorbidities and lower rates of CAD. But compared with men, they were more likely to be on angiotensin receptors blockers and digitalis treatment, because of higher incidence of atrial fibrillation, according to the investigators.

There were no significant differences in use of ACE inhibitors, diuretics, and nitrates between genders, the analysis showed.

Both genders received continuous positive airway pressure (CPAP) and mechanical ventilation. Fewer women, however, were supported by intra-aortic balloon pump (IABP), underwent percutaneous coronary intervention, or had coronary artery bypass graft surgery.

In addition, in-hospital mortality was similar between genders (10.5% for men vs 11.1% for women). "The presence of higher ejection fraction and less CAD in women may positively affect survival in women," said Dr. Parissis.

But, "the existence of other serious comorbidities and underprescription of life saving medications such as beta-blockers may counteract this positive effect on their in-hospital survival," he added. "This point may explain the similar mortality rate between genders."

At discharge, the proportion of patients treated with medications increased. Nevertheless, the differences between genders remained significant, the authors wrote.

The differences in treatment call for "a more intensive implementation of heart failure guidelines to optimize life saving medications, especially in women," said Dr. Parissis.

Dr. Parissis is a member of the ALARM-HF Steering Committee and presented the study on the committee’s behalf. He said he had received research grants from Abbott and Orion Pharma.

MUNICH – Gender differences in comorbidities affected the medications prescribed to men and women hospitalized with acute heart failure, although their in-hospital mortality rate remained similar, according to a retrospective analysis of nearly 5,000 hospital charts.

The study showed that men who were hospitalized with acute heart failure (AHF) were more likely to receive beta-blockers and aspirin than were women. Meanwhile, women were more likely to be obese, have diabetes, or have atrial fibrillation.

"Perhaps there are differences in the pathophysiology of AHF between women and men, which should be taken into account in order to achieve gender-tailored management," said Dr. John Parissis, who presented the study at the annual congress of the European Society of Cardiology.

The study was a subanalysis of the Acute Heart Failure Global Registry of Standard Treatment (ALARM-HF), a chart audit survey of 4,953 patients hospitalized for AHF in 666 hospitals in nine countries (France, Germany, Spain, Italy, Greece, United Kingdom, Turkey, Australia, and Mexico.)

Women made up 37% of the patients, consistent with ratios in other registries, said Dr. Parissis of Attikon University Hospital, Greece. They presented with AHF at an older age and had higher rates of de novo heart failure. They were also half as likely as were men to present with cardiogenic shock, but more than twice as likely to have right heart failure.

The study showed that women hospitalized with AHF had a higher prevalence of diabetes (47% v. 43%), obesity (30% v. 25%), anemia (17% v. 13%), atrial fibrillation or flutter (49% v. 42%), dementia (6% v. 3%), and depression (11% v. 7%), compared with men.

Meanwhile, men had a higher prevalence of chronic obstructive pulmonary disease (COPD) and asthma (27% v. 21%), and coronary artery disease (CAD) (35% v. 24%) compared with women.

Upon admission, women were less likely than were men to receive aspirin, clopidogrel, and beta-blockers, because of their comorbidities and lower rates of CAD. But compared with men, they were more likely to be on angiotensin receptors blockers and digitalis treatment, because of higher incidence of atrial fibrillation, according to the investigators.

There were no significant differences in use of ACE inhibitors, diuretics, and nitrates between genders, the analysis showed.

Both genders received continuous positive airway pressure (CPAP) and mechanical ventilation. Fewer women, however, were supported by intra-aortic balloon pump (IABP), underwent percutaneous coronary intervention, or had coronary artery bypass graft surgery.

In addition, in-hospital mortality was similar between genders (10.5% for men vs 11.1% for women). "The presence of higher ejection fraction and less CAD in women may positively affect survival in women," said Dr. Parissis.

But, "the existence of other serious comorbidities and underprescription of life saving medications such as beta-blockers may counteract this positive effect on their in-hospital survival," he added. "This point may explain the similar mortality rate between genders."

At discharge, the proportion of patients treated with medications increased. Nevertheless, the differences between genders remained significant, the authors wrote.

The differences in treatment call for "a more intensive implementation of heart failure guidelines to optimize life saving medications, especially in women," said Dr. Parissis.

Dr. Parissis is a member of the ALARM-HF Steering Committee and presented the study on the committee’s behalf. He said he had received research grants from Abbott and Orion Pharma.

MUNICH – Gender differences in comorbidities affected the medications prescribed to men and women hospitalized with acute heart failure, although their in-hospital mortality rate remained similar, according to a retrospective analysis of nearly 5,000 hospital charts.

The study showed that men who were hospitalized with acute heart failure (AHF) were more likely to receive beta-blockers and aspirin than were women. Meanwhile, women were more likely to be obese, have diabetes, or have atrial fibrillation.

"Perhaps there are differences in the pathophysiology of AHF between women and men, which should be taken into account in order to achieve gender-tailored management," said Dr. John Parissis, who presented the study at the annual congress of the European Society of Cardiology.

The study was a subanalysis of the Acute Heart Failure Global Registry of Standard Treatment (ALARM-HF), a chart audit survey of 4,953 patients hospitalized for AHF in 666 hospitals in nine countries (France, Germany, Spain, Italy, Greece, United Kingdom, Turkey, Australia, and Mexico.)

Women made up 37% of the patients, consistent with ratios in other registries, said Dr. Parissis of Attikon University Hospital, Greece. They presented with AHF at an older age and had higher rates of de novo heart failure. They were also half as likely as were men to present with cardiogenic shock, but more than twice as likely to have right heart failure.

The study showed that women hospitalized with AHF had a higher prevalence of diabetes (47% v. 43%), obesity (30% v. 25%), anemia (17% v. 13%), atrial fibrillation or flutter (49% v. 42%), dementia (6% v. 3%), and depression (11% v. 7%), compared with men.

Meanwhile, men had a higher prevalence of chronic obstructive pulmonary disease (COPD) and asthma (27% v. 21%), and coronary artery disease (CAD) (35% v. 24%) compared with women.

Upon admission, women were less likely than were men to receive aspirin, clopidogrel, and beta-blockers, because of their comorbidities and lower rates of CAD. But compared with men, they were more likely to be on angiotensin receptors blockers and digitalis treatment, because of higher incidence of atrial fibrillation, according to the investigators.

There were no significant differences in use of ACE inhibitors, diuretics, and nitrates between genders, the analysis showed.

Both genders received continuous positive airway pressure (CPAP) and mechanical ventilation. Fewer women, however, were supported by intra-aortic balloon pump (IABP), underwent percutaneous coronary intervention, or had coronary artery bypass graft surgery.

In addition, in-hospital mortality was similar between genders (10.5% for men vs 11.1% for women). "The presence of higher ejection fraction and less CAD in women may positively affect survival in women," said Dr. Parissis.

But, "the existence of other serious comorbidities and underprescription of life saving medications such as beta-blockers may counteract this positive effect on their in-hospital survival," he added. "This point may explain the similar mortality rate between genders."

At discharge, the proportion of patients treated with medications increased. Nevertheless, the differences between genders remained significant, the authors wrote.

The differences in treatment call for "a more intensive implementation of heart failure guidelines to optimize life saving medications, especially in women," said Dr. Parissis.

Dr. Parissis is a member of the ALARM-HF Steering Committee and presented the study on the committee’s behalf. He said he had received research grants from Abbott and Orion Pharma.

WASHINGTON – Nationwide efforts to curb prescription drug abuse might be paying off, as fewer Americans reported nonmedical use of such drugs – pain relievers in particular – according to a government survey.

The most significant decline was seen among 18- to 25-year-olds, a 14% decline from 2 million users in 2010 to 1.7 million in 2011. The decline is particularly exciting, because this is a cohort where most substances are abused and a lot mental health disorders occur, said Dr. H. Westley Clark, director of the Substance Abuse and Mental Health Services Administration’s Center for Behavioral Health Statistics and Quality, which plans and manages the annual National Survey on Drug Use and Health. There was no significant change in the overall rate of past-month illicit drug use, which was estimated to be around 8.7% in 2011, compared with 8.9% during the previous year.

The government survey, released by SAMHSA and conducted since 1971, is based on statistical estimates from 67,500 face-to-face interviews with Americans aged 12 years or older.

Over the past 30 years, overall drug use among Americans has declined by 30%, said R. Gil Kerlikowske, director of the White House Office of National Drug Control Policy. He added that the Obama administration has spent more than $31 billion in drug education and treatment programs over the last 3 years.

"We have repeatedly affirmed that we’re not waging a war on drugs," Mr. Kerlikowske said. The administration is taking a holistic approach, instead, he said. "We understand that addiction is disease. It’s not a moral failing. It can be treated, and recovery is possible."

The SAMHSA survey showed that in 2011, nearly 9% of Americans older than 12 years of age reported using an illicit drug, including marijuana, cocaine, heroin, hallucinogens, inhalants, or prescription drugs used nonmedically.

Of the four categories of prescription drugs – pain relievers, tranquilizers, stimulants, and sedatives – the past-month use of pain relievers reported by people aged 12 years or older showed the sharpest decline from 2010, dropping from 2.0% to 1.7%. That was followed by a 0.2% decline in tranquilizers, which were the second most commonly used prescription drugs. The misuse rates for stimulants (0.4%) and sedatives (0.1%) did not change.

More than half of Americans reported being current alcohol drinkers, and more than a quarter said they used tobacco products.

Among the tobacco users, the prevalence of smoking among pregnant women is on the rise (17.6%), the survey showed, slowly creeping up to the ranges reported in 2002-2003 (18%), after reaching a low of 15.2% in 2008-2009.

Marijuana remains the most commonly used illicit drug. The number of users increased from 14.5 million in 2007 (5.8% of Americans) to 18.1 million in 2011 (7.0%).

Meanwhile, the rate of illicit drug use among adults between aged 50-59 years has been increasing since 2002, from 2.7% to 6.3% in 2011. The trend is partly because baby boomers are entering this age group and their "lifetime rate of illicit drug use has been higher than those of older cohorts," authors write in the 150-page report.

2012 National Drug Use Survey

The survey did not include data on synthetic drugs such as bath salts and synthetic marijuana, which have become a concern for state and federal officials only in recent years. Dr. Clark said officials are closely monitoring the states and hope that passage of state and federal bans on chemicals used to make the drugs would curb their spread.

Dr. Clark stressed the importance of physician education, whether it’s through mentoring programs or continuing medical education, as he attributed the decline in prescription drug abuse rates partly to the efforts in the physician community.

"Physicians need to be educated about prescription drug abuse; they need to educate their patients; and they should tell their patients what they should do with prescription drugs that they don’t finish," he said.

More than half of those who reported abusing prescription pain medication said that they had received the drugs from a friend or relative for free. Only 4% reported having received the drugs from a dealer or stranger.

WASHINGTON – Nationwide efforts to curb prescription drug abuse might be paying off, as fewer Americans reported nonmedical use of such drugs – pain relievers in particular – according to a government survey.

The most significant decline was seen among 18- to 25-year-olds, a 14% decline from 2 million users in 2010 to 1.7 million in 2011. The decline is particularly exciting, because this is a cohort where most substances are abused and a lot mental health disorders occur, said Dr. H. Westley Clark, director of the Substance Abuse and Mental Health Services Administration’s Center for Behavioral Health Statistics and Quality, which plans and manages the annual National Survey on Drug Use and Health. There was no significant change in the overall rate of past-month illicit drug use, which was estimated to be around 8.7% in 2011, compared with 8.9% during the previous year.

The government survey, released by SAMHSA and conducted since 1971, is based on statistical estimates from 67,500 face-to-face interviews with Americans aged 12 years or older.

Over the past 30 years, overall drug use among Americans has declined by 30%, said R. Gil Kerlikowske, director of the White House Office of National Drug Control Policy. He added that the Obama administration has spent more than $31 billion in drug education and treatment programs over the last 3 years.

"We have repeatedly affirmed that we’re not waging a war on drugs," Mr. Kerlikowske said. The administration is taking a holistic approach, instead, he said. "We understand that addiction is disease. It’s not a moral failing. It can be treated, and recovery is possible."

The SAMHSA survey showed that in 2011, nearly 9% of Americans older than 12 years of age reported using an illicit drug, including marijuana, cocaine, heroin, hallucinogens, inhalants, or prescription drugs used nonmedically.

Of the four categories of prescription drugs – pain relievers, tranquilizers, stimulants, and sedatives – the past-month use of pain relievers reported by people aged 12 years or older showed the sharpest decline from 2010, dropping from 2.0% to 1.7%. That was followed by a 0.2% decline in tranquilizers, which were the second most commonly used prescription drugs. The misuse rates for stimulants (0.4%) and sedatives (0.1%) did not change.

More than half of Americans reported being current alcohol drinkers, and more than a quarter said they used tobacco products.

Among the tobacco users, the prevalence of smoking among pregnant women is on the rise (17.6%), the survey showed, slowly creeping up to the ranges reported in 2002-2003 (18%), after reaching a low of 15.2% in 2008-2009.

Marijuana remains the most commonly used illicit drug. The number of users increased from 14.5 million in 2007 (5.8% of Americans) to 18.1 million in 2011 (7.0%).

Meanwhile, the rate of illicit drug use among adults between aged 50-59 years has been increasing since 2002, from 2.7% to 6.3% in 2011. The trend is partly because baby boomers are entering this age group and their "lifetime rate of illicit drug use has been higher than those of older cohorts," authors write in the 150-page report.

2012 National Drug Use Survey

The survey did not include data on synthetic drugs such as bath salts and synthetic marijuana, which have become a concern for state and federal officials only in recent years. Dr. Clark said officials are closely monitoring the states and hope that passage of state and federal bans on chemicals used to make the drugs would curb their spread.

Dr. Clark stressed the importance of physician education, whether it’s through mentoring programs or continuing medical education, as he attributed the decline in prescription drug abuse rates partly to the efforts in the physician community.

"Physicians need to be educated about prescription drug abuse; they need to educate their patients; and they should tell their patients what they should do with prescription drugs that they don’t finish," he said.

More than half of those who reported abusing prescription pain medication said that they had received the drugs from a friend or relative for free. Only 4% reported having received the drugs from a dealer or stranger.

WASHINGTON – Nationwide efforts to curb prescription drug abuse might be paying off, as fewer Americans reported nonmedical use of such drugs – pain relievers in particular – according to a government survey.

The most significant decline was seen among 18- to 25-year-olds, a 14% decline from 2 million users in 2010 to 1.7 million in 2011. The decline is particularly exciting, because this is a cohort where most substances are abused and a lot mental health disorders occur, said Dr. H. Westley Clark, director of the Substance Abuse and Mental Health Services Administration’s Center for Behavioral Health Statistics and Quality, which plans and manages the annual National Survey on Drug Use and Health. There was no significant change in the overall rate of past-month illicit drug use, which was estimated to be around 8.7% in 2011, compared with 8.9% during the previous year.

The government survey, released by SAMHSA and conducted since 1971, is based on statistical estimates from 67,500 face-to-face interviews with Americans aged 12 years or older.

Over the past 30 years, overall drug use among Americans has declined by 30%, said R. Gil Kerlikowske, director of the White House Office of National Drug Control Policy. He added that the Obama administration has spent more than $31 billion in drug education and treatment programs over the last 3 years.

"We have repeatedly affirmed that we’re not waging a war on drugs," Mr. Kerlikowske said. The administration is taking a holistic approach, instead, he said. "We understand that addiction is disease. It’s not a moral failing. It can be treated, and recovery is possible."

The SAMHSA survey showed that in 2011, nearly 9% of Americans older than 12 years of age reported using an illicit drug, including marijuana, cocaine, heroin, hallucinogens, inhalants, or prescription drugs used nonmedically.

Of the four categories of prescription drugs – pain relievers, tranquilizers, stimulants, and sedatives – the past-month use of pain relievers reported by people aged 12 years or older showed the sharpest decline from 2010, dropping from 2.0% to 1.7%. That was followed by a 0.2% decline in tranquilizers, which were the second most commonly used prescription drugs. The misuse rates for stimulants (0.4%) and sedatives (0.1%) did not change.

More than half of Americans reported being current alcohol drinkers, and more than a quarter said they used tobacco products.

Among the tobacco users, the prevalence of smoking among pregnant women is on the rise (17.6%), the survey showed, slowly creeping up to the ranges reported in 2002-2003 (18%), after reaching a low of 15.2% in 2008-2009.

Marijuana remains the most commonly used illicit drug. The number of users increased from 14.5 million in 2007 (5.8% of Americans) to 18.1 million in 2011 (7.0%).

Meanwhile, the rate of illicit drug use among adults between aged 50-59 years has been increasing since 2002, from 2.7% to 6.3% in 2011. The trend is partly because baby boomers are entering this age group and their "lifetime rate of illicit drug use has been higher than those of older cohorts," authors write in the 150-page report.

2012 National Drug Use Survey

The survey did not include data on synthetic drugs such as bath salts and synthetic marijuana, which have become a concern for state and federal officials only in recent years. Dr. Clark said officials are closely monitoring the states and hope that passage of state and federal bans on chemicals used to make the drugs would curb their spread.

Dr. Clark stressed the importance of physician education, whether it’s through mentoring programs or continuing medical education, as he attributed the decline in prescription drug abuse rates partly to the efforts in the physician community.

"Physicians need to be educated about prescription drug abuse; they need to educate their patients; and they should tell their patients what they should do with prescription drugs that they don’t finish," he said.

More than half of those who reported abusing prescription pain medication said that they had received the drugs from a friend or relative for free. Only 4% reported having received the drugs from a dealer or stranger.

Patient-centered medical homes should be led by physicians, not nurse practitioners, according to a report by the American Academy of Family Physicians.

The report emphasizes the importance of teamwork and collaboration between the two professions, but it raises concerns about the idea of filling the physician shortage gap with nurse practitioners.

"Workforce policies and payment systems must recognize that training more nurse practitioners and physician assistants neither eliminates the need nor substitutes for increasing the number of physicians trained to provide primary care," the authors wrote.

Titled "Primary Care for the 21st Century: Ensuring a Quality, Physician-led Team for Every Patient," the report has been a project of AAFP Board Chair Dr. Roland A. Goertz.

The 2010 Institute of Medicine report "The Future of Nursing" was one of the reasons Dr. Goertz decided to issue a position paper. "I started with every intention to try and find a way to resolve essentially what are two different model proposals going forward," he said in an interview.

The patient-centered medical home (PCMH) model has been around for decades, but it began gaining traction during the past decade, especially with the passage of the Affordable Care Act.

Under the model, every person or family would have a provider who serves as their first point of contact for health care. The goal is to lower costs by reducing fragmentation and improving the quality of patient care. And primary care stands at the center of that model.

But the shortage of primary care physicians has prompted "a significant amount of discussion about expanding the role of nurse practitioners to practice independently and direct medical homes without a physician on staff," Dr. Goertz said during a briefing.

That expansion of nurse practitioners’ roles, however, takes the health care system "in opposite and conflicting directions," he cautioned. "Americans shouldn’t be forced into this two-tiered scenario."

Splintering the PCMH model into too many variations may threaten its success, Dr. Goertz noted. "If you have 10 or 20 versions of patient-centered medical homes, you may never prove that it can do what it was designed to do."

Currently, nurse practitioners can practice independently in 16 states and the District of Columbia. While several states have their own criteria for recognition of PCMHs, none of the main accrediting bodies, including the Joint Commission, requires a PCMH to be run by a physician, according to information from the nonpartisan Patient-Centered Primary Care Collaborative.

The National Committee for Quality Assurance has recognized some nurse-managed clinics as medical homes, according to the collaborative.

The AAFP’s report wasn’t a surprise to the leadership at the American Academy of Nurse Practitioners.

"They’ve been saying this all along, and we’re disappointed that they keep saying this," Jan Towers, Ph.D., director of federal health policy and professional affairs at AANP, said in an interview. "There are so many patients out there, and there will be more," said Dr. Towers, referring to the parts of the Affordable Care Act that will insure millions of Americans by 2014. "We’re not trying to take anything from [physicians]."

AANP also issued a statement in response to the AAFP’s report, calling it "misleading." "As our nation looks to address health care provider workforce challenges, we must embrace the diversity of care models that multiple disciplines sharing overlapping knowledge and skills can offer our county," AANP President Angela K. Golden said in the statement.

The American Academy of Family Physicians’ report highlights the differences between the training and education of physicians and nurse practitioners. Primary care physician complete 11 years of education and clinical training, compared with 5-7 years for nurse practitioners.

That difference in training "brings breadth and depth to the diagnosis and treatment of all health problems, from strep throat to chronic obstructive pulmonary disease, from stress headaches to refractory multiple sclerosis," the AAFP report noted.

But, the AANP’s Dr. Towers countered, "Do you need to go to school for all that time to become a good primary care provider?"

The American Academy of Family Physicians also cites surveys from the American Medical Association, in which more than 90% of patients said that a physician’s years of education and training were vital to patient care, and three out of four said they preferred to be treated by a physician.

The AAFP report acknowledges the nation’s shortage of nurses, physician assistants, and other health care professionals, and it provides several recommendations to address the primary care physician shortage, which will reach 45,000 by 2020, according to the report. The recommendations include training more physicians by increasing funding for primary care physician education, helping medical students with their debt, and improving primary care physician payments to make it a more attractive specialty to medical students.

The report cites research that shows that the best care is achieved when the ratio of nurse practitioners to physicians is about four to one. "At this ratio, we can provide everyone a physician-led team, and fill the primary care shortage," the authors noted.

"Everyone deserves to be under the care of a physician," Dr. Goertz said.

Patient-centered medical homes should be led by physicians, not nurse practitioners, according to a report by the American Academy of Family Physicians.

The report emphasizes the importance of teamwork and collaboration between the two professions, but it raises concerns about the idea of filling the physician shortage gap with nurse practitioners.

"Workforce policies and payment systems must recognize that training more nurse practitioners and physician assistants neither eliminates the need nor substitutes for increasing the number of physicians trained to provide primary care," the authors wrote.

Titled "Primary Care for the 21st Century: Ensuring a Quality, Physician-led Team for Every Patient," the report has been a project of AAFP Board Chair Dr. Roland A. Goertz.

The 2010 Institute of Medicine report "The Future of Nursing" was one of the reasons Dr. Goertz decided to issue a position paper. "I started with every intention to try and find a way to resolve essentially what are two different model proposals going forward," he said in an interview.

The patient-centered medical home (PCMH) model has been around for decades, but it began gaining traction during the past decade, especially with the passage of the Affordable Care Act.

Under the model, every person or family would have a provider who serves as their first point of contact for health care. The goal is to lower costs by reducing fragmentation and improving the quality of patient care. And primary care stands at the center of that model.

But the shortage of primary care physicians has prompted "a significant amount of discussion about expanding the role of nurse practitioners to practice independently and direct medical homes without a physician on staff," Dr. Goertz said during a briefing.

That expansion of nurse practitioners’ roles, however, takes the health care system "in opposite and conflicting directions," he cautioned. "Americans shouldn’t be forced into this two-tiered scenario."

Splintering the PCMH model into too many variations may threaten its success, Dr. Goertz noted. "If you have 10 or 20 versions of patient-centered medical homes, you may never prove that it can do what it was designed to do."

Currently, nurse practitioners can practice independently in 16 states and the District of Columbia. While several states have their own criteria for recognition of PCMHs, none of the main accrediting bodies, including the Joint Commission, requires a PCMH to be run by a physician, according to information from the nonpartisan Patient-Centered Primary Care Collaborative.

The National Committee for Quality Assurance has recognized some nurse-managed clinics as medical homes, according to the collaborative.

The AAFP’s report wasn’t a surprise to the leadership at the American Academy of Nurse Practitioners.

"They’ve been saying this all along, and we’re disappointed that they keep saying this," Jan Towers, Ph.D., director of federal health policy and professional affairs at AANP, said in an interview. "There are so many patients out there, and there will be more," said Dr. Towers, referring to the parts of the Affordable Care Act that will insure millions of Americans by 2014. "We’re not trying to take anything from [physicians]."

AANP also issued a statement in response to the AAFP’s report, calling it "misleading." "As our nation looks to address health care provider workforce challenges, we must embrace the diversity of care models that multiple disciplines sharing overlapping knowledge and skills can offer our county," AANP President Angela K. Golden said in the statement.

The American Academy of Family Physicians’ report highlights the differences between the training and education of physicians and nurse practitioners. Primary care physician complete 11 years of education and clinical training, compared with 5-7 years for nurse practitioners.

That difference in training "brings breadth and depth to the diagnosis and treatment of all health problems, from strep throat to chronic obstructive pulmonary disease, from stress headaches to refractory multiple sclerosis," the AAFP report noted.

But, the AANP’s Dr. Towers countered, "Do you need to go to school for all that time to become a good primary care provider?"

The American Academy of Family Physicians also cites surveys from the American Medical Association, in which more than 90% of patients said that a physician’s years of education and training were vital to patient care, and three out of four said they preferred to be treated by a physician.

The AAFP report acknowledges the nation’s shortage of nurses, physician assistants, and other health care professionals, and it provides several recommendations to address the primary care physician shortage, which will reach 45,000 by 2020, according to the report. The recommendations include training more physicians by increasing funding for primary care physician education, helping medical students with their debt, and improving primary care physician payments to make it a more attractive specialty to medical students.

The report cites research that shows that the best care is achieved when the ratio of nurse practitioners to physicians is about four to one. "At this ratio, we can provide everyone a physician-led team, and fill the primary care shortage," the authors noted.

"Everyone deserves to be under the care of a physician," Dr. Goertz said.

Patient-centered medical homes should be led by physicians, not nurse practitioners, according to a report by the American Academy of Family Physicians.

The report emphasizes the importance of teamwork and collaboration between the two professions, but it raises concerns about the idea of filling the physician shortage gap with nurse practitioners.

"Workforce policies and payment systems must recognize that training more nurse practitioners and physician assistants neither eliminates the need nor substitutes for increasing the number of physicians trained to provide primary care," the authors wrote.

Titled "Primary Care for the 21st Century: Ensuring a Quality, Physician-led Team for Every Patient," the report has been a project of AAFP Board Chair Dr. Roland A. Goertz.

The 2010 Institute of Medicine report "The Future of Nursing" was one of the reasons Dr. Goertz decided to issue a position paper. "I started with every intention to try and find a way to resolve essentially what are two different model proposals going forward," he said in an interview.

The patient-centered medical home (PCMH) model has been around for decades, but it began gaining traction during the past decade, especially with the passage of the Affordable Care Act.

Under the model, every person or family would have a provider who serves as their first point of contact for health care. The goal is to lower costs by reducing fragmentation and improving the quality of patient care. And primary care stands at the center of that model.

But the shortage of primary care physicians has prompted "a significant amount of discussion about expanding the role of nurse practitioners to practice independently and direct medical homes without a physician on staff," Dr. Goertz said during a briefing.

That expansion of nurse practitioners’ roles, however, takes the health care system "in opposite and conflicting directions," he cautioned. "Americans shouldn’t be forced into this two-tiered scenario."

Splintering the PCMH model into too many variations may threaten its success, Dr. Goertz noted. "If you have 10 or 20 versions of patient-centered medical homes, you may never prove that it can do what it was designed to do."

Currently, nurse practitioners can practice independently in 16 states and the District of Columbia. While several states have their own criteria for recognition of PCMHs, none of the main accrediting bodies, including the Joint Commission, requires a PCMH to be run by a physician, according to information from the nonpartisan Patient-Centered Primary Care Collaborative.

The National Committee for Quality Assurance has recognized some nurse-managed clinics as medical homes, according to the collaborative.

The AAFP’s report wasn’t a surprise to the leadership at the American Academy of Nurse Practitioners.

"They’ve been saying this all along, and we’re disappointed that they keep saying this," Jan Towers, Ph.D., director of federal health policy and professional affairs at AANP, said in an interview. "There are so many patients out there, and there will be more," said Dr. Towers, referring to the parts of the Affordable Care Act that will insure millions of Americans by 2014. "We’re not trying to take anything from [physicians]."

AANP also issued a statement in response to the AAFP’s report, calling it "misleading." "As our nation looks to address health care provider workforce challenges, we must embrace the diversity of care models that multiple disciplines sharing overlapping knowledge and skills can offer our county," AANP President Angela K. Golden said in the statement.

The American Academy of Family Physicians’ report highlights the differences between the training and education of physicians and nurse practitioners. Primary care physician complete 11 years of education and clinical training, compared with 5-7 years for nurse practitioners.

That difference in training "brings breadth and depth to the diagnosis and treatment of all health problems, from strep throat to chronic obstructive pulmonary disease, from stress headaches to refractory multiple sclerosis," the AAFP report noted.

But, the AANP’s Dr. Towers countered, "Do you need to go to school for all that time to become a good primary care provider?"

The American Academy of Family Physicians also cites surveys from the American Medical Association, in which more than 90% of patients said that a physician’s years of education and training were vital to patient care, and three out of four said they preferred to be treated by a physician.

The AAFP report acknowledges the nation’s shortage of nurses, physician assistants, and other health care professionals, and it provides several recommendations to address the primary care physician shortage, which will reach 45,000 by 2020, according to the report. The recommendations include training more physicians by increasing funding for primary care physician education, helping medical students with their debt, and improving primary care physician payments to make it a more attractive specialty to medical students.

The report cites research that shows that the best care is achieved when the ratio of nurse practitioners to physicians is about four to one. "At this ratio, we can provide everyone a physician-led team, and fill the primary care shortage," the authors noted.

"Everyone deserves to be under the care of a physician," Dr. Goertz said.

WASHINGTON – The Department of Defense needs to update its guidelines and practices in order to address the rising rates of alcohol and drug misuse and abuse among the active duty personnel, according to a report released Sept. 17 by the Institute of Medicine.

The 350-page report, mandated by Congress, recommends that the military increase its preventive efforts, adopt evidence-based programs, increase access to care, and increase its health care workforce, while providing them with appropriate training.

bowdenimages/istockphoto.com

"I can’t say I was surprised at anything," Dr. Charles P. O’Brien, chair of the committee that wrote the report, said in an interview. "Maybe what was surprising was that some of the guidelines haven’t been changed in 20 years, and I think they need to be updated right away."

In a statement, the Department of Defense (DoD) said, it appreciates the Institute’s work in assessing substance abuse programs and policies in the military health system. "We are in the process of analyzing [the] findings and recommendations, but most importantly, we want to do the right thing for the service member.

"If there are areas in need of improvement, then we will work to improve those areas. The health and well-being of our service members is paramount."

Roughly 20% of active duty personnel reported engaging in heavy drinking in 2008, compared with 15% in 1998. Binge drinking rates increased from 35% in 1998 to 47% in 2008, according to the IOM study. Meanwhile, of prescription drug use rates increased among the military personnel over the past decade, the study points out, mirroring the increase in the civilian population. Only 2% of active duty personnel reported prescription drug misuse in 2002. That rate increased to 11% in 2008.

Meanwhile, military physicians wrote nearly 3.8 million prescriptions for pain medications in 2009, almost four times as many as they prescribed in 2001, according to the IOM report.

Training of military health care professionals is among the recommendations in the report. During a press briefing announcing release of the report, Dr. O’Brien said providing training on how to recognize and deal with addiction should extend to medical schools.

The report also recommends that TRICARE, which provides health insurance to service members and their families, needs to update its substance use disorder (SUD) guidelines. The program, the IOM noted, does not include several evidence-based therapies that are currently considered standard practice, and it does not allow for long-term use of certain medications used for treatment of addiction.

"If the DoD fails to make these needed changes to the TRICARE SUD benefits in a timely manner, the committee recommends that Congress consider taking action to mandate such DoD policy changes," the authors wrote.

The report also identifies several barriers to access, including gaps in insurance coverage, stigma, lack of confidentiality, and fear of negative consequences.

The study not only recommends that branches provide optional confidential treatment, but also offer routine screening for unhealthy alcohol use; and reduce reliance on residential and inpatient care; and add capacity for outpatient care, using a chronic care model.

"Recommendations are clear and they’re doable. There’s nothing that’s impossible," said Dr. O’Brien, director of the Center for Studies of Addiction at the University of Pennsylvania, Philadelphia. "If they would follow these recommendations, we would see a big improvement."

WASHINGTON – The Department of Defense needs to update its guidelines and practices in order to address the rising rates of alcohol and drug misuse and abuse among the active duty personnel, according to a report released Sept. 17 by the Institute of Medicine.

The 350-page report, mandated by Congress, recommends that the military increase its preventive efforts, adopt evidence-based programs, increase access to care, and increase its health care workforce, while providing them with appropriate training.

bowdenimages/istockphoto.com

"I can’t say I was surprised at anything," Dr. Charles P. O’Brien, chair of the committee that wrote the report, said in an interview. "Maybe what was surprising was that some of the guidelines haven’t been changed in 20 years, and I think they need to be updated right away."

In a statement, the Department of Defense (DoD) said, it appreciates the Institute’s work in assessing substance abuse programs and policies in the military health system. "We are in the process of analyzing [the] findings and recommendations, but most importantly, we want to do the right thing for the service member.

"If there are areas in need of improvement, then we will work to improve those areas. The health and well-being of our service members is paramount."

Roughly 20% of active duty personnel reported engaging in heavy drinking in 2008, compared with 15% in 1998. Binge drinking rates increased from 35% in 1998 to 47% in 2008, according to the IOM study. Meanwhile, of prescription drug use rates increased among the military personnel over the past decade, the study points out, mirroring the increase in the civilian population. Only 2% of active duty personnel reported prescription drug misuse in 2002. That rate increased to 11% in 2008.

Meanwhile, military physicians wrote nearly 3.8 million prescriptions for pain medications in 2009, almost four times as many as they prescribed in 2001, according to the IOM report.

Training of military health care professionals is among the recommendations in the report. During a press briefing announcing release of the report, Dr. O’Brien said providing training on how to recognize and deal with addiction should extend to medical schools.

The report also recommends that TRICARE, which provides health insurance to service members and their families, needs to update its substance use disorder (SUD) guidelines. The program, the IOM noted, does not include several evidence-based therapies that are currently considered standard practice, and it does not allow for long-term use of certain medications used for treatment of addiction.

"If the DoD fails to make these needed changes to the TRICARE SUD benefits in a timely manner, the committee recommends that Congress consider taking action to mandate such DoD policy changes," the authors wrote.

The report also identifies several barriers to access, including gaps in insurance coverage, stigma, lack of confidentiality, and fear of negative consequences.

The study not only recommends that branches provide optional confidential treatment, but also offer routine screening for unhealthy alcohol use; and reduce reliance on residential and inpatient care; and add capacity for outpatient care, using a chronic care model.

"Recommendations are clear and they’re doable. There’s nothing that’s impossible," said Dr. O’Brien, director of the Center for Studies of Addiction at the University of Pennsylvania, Philadelphia. "If they would follow these recommendations, we would see a big improvement."

WASHINGTON – The Department of Defense needs to update its guidelines and practices in order to address the rising rates of alcohol and drug misuse and abuse among the active duty personnel, according to a report released Sept. 17 by the Institute of Medicine.

The 350-page report, mandated by Congress, recommends that the military increase its preventive efforts, adopt evidence-based programs, increase access to care, and increase its health care workforce, while providing them with appropriate training.

bowdenimages/istockphoto.com

"I can’t say I was surprised at anything," Dr. Charles P. O’Brien, chair of the committee that wrote the report, said in an interview. "Maybe what was surprising was that some of the guidelines haven’t been changed in 20 years, and I think they need to be updated right away."

In a statement, the Department of Defense (DoD) said, it appreciates the Institute’s work in assessing substance abuse programs and policies in the military health system. "We are in the process of analyzing [the] findings and recommendations, but most importantly, we want to do the right thing for the service member.

"If there are areas in need of improvement, then we will work to improve those areas. The health and well-being of our service members is paramount."

Roughly 20% of active duty personnel reported engaging in heavy drinking in 2008, compared with 15% in 1998. Binge drinking rates increased from 35% in 1998 to 47% in 2008, according to the IOM study. Meanwhile, of prescription drug use rates increased among the military personnel over the past decade, the study points out, mirroring the increase in the civilian population. Only 2% of active duty personnel reported prescription drug misuse in 2002. That rate increased to 11% in 2008.

Meanwhile, military physicians wrote nearly 3.8 million prescriptions for pain medications in 2009, almost four times as many as they prescribed in 2001, according to the IOM report.

Training of military health care professionals is among the recommendations in the report. During a press briefing announcing release of the report, Dr. O’Brien said providing training on how to recognize and deal with addiction should extend to medical schools.

The report also recommends that TRICARE, which provides health insurance to service members and their families, needs to update its substance use disorder (SUD) guidelines. The program, the IOM noted, does not include several evidence-based therapies that are currently considered standard practice, and it does not allow for long-term use of certain medications used for treatment of addiction.

"If the DoD fails to make these needed changes to the TRICARE SUD benefits in a timely manner, the committee recommends that Congress consider taking action to mandate such DoD policy changes," the authors wrote.

The report also identifies several barriers to access, including gaps in insurance coverage, stigma, lack of confidentiality, and fear of negative consequences.

The study not only recommends that branches provide optional confidential treatment, but also offer routine screening for unhealthy alcohol use; and reduce reliance on residential and inpatient care; and add capacity for outpatient care, using a chronic care model.

"Recommendations are clear and they’re doable. There’s nothing that’s impossible," said Dr. O’Brien, director of the Center for Studies of Addiction at the University of Pennsylvania, Philadelphia. "If they would follow these recommendations, we would see a big improvement."

Frailty was associated with a threefold increase in mortality risk 1 year after transcatheter aortic valve replacement, according to a single-center study published online Sept. 16 in JACC: Cardiovascular Interventions.

Researchers also found that there was no significant association between frailty status and the majority of post-TAVR procedural outcomes, suggesting that the current standard for patient selection is adequate, they wrote.

"We hope that the result will convince physicians to measure frailty," Dr. Philip Green, the study’s lead author, said in an interview. "Formally assessed frailty can be extremely useful for prognostic information."

Risk prediction for older adults undergoing cardiac surgery is somewhat tricky, said Dr. Green, because some of the well established measurement tools are based on studies that did not include many adults who were very old or at high risk.

"So the risk-prediction confidence intervals among the highest risk patients tend to get very wide," said Dr. Green, a fellow in cardiovascular medicine at Columbia University Medical Center, New York, where the study was conducted.

Frailty, which is the loss of resiliency and physiological reserve, helps predict the patients’ tolerance for certain procedures, their odds of survival, and their overall prognosis.

For an objective frailty score, Dr. Green said he and colleagues built on findings from previous studies and measured gait speed, grip strength, serum albumin, and activities of daily living to derive a frailty score in 159 very-high-risk patients with severe aortic stenosis who underwent TAVR at the Valve Center at Columbia University Medical Center/New York–Presbyterian Hospital.

They then broke down the patients into two groups based on their median frailty score: those who were frail and those who were not.

Patients’ mean age was 86 years, and half were men. Half of the patients had at least three comorbidities, although the frailty score was not associated with the number of comorbidities.

Overall, 76 patients had a frailty score higher than 5, and 83 had a score of 5 or less (considered not frail).

Patients whose frailty score was higher than 5 had longer hospital stays and were at a higher risk of in-hospital, life-threatening, or major bleeding events compared with the nonfrail group (JACC Cardiovasc. Interv. 2012;5:974-81).

Eight patients died during the first 30 days; however, frailty status was not associated with adverse periprocedural events such as vascular complications, stroke, or procedural mortality.

Meanwhile, 1-year follow-up showed that patients with a frailty score of more than 5 had a threefold increase in mortality after the procedure, compared with the nonfrail group (17 frail vs. 7 nonfrail; hazard ratio, 1.15).

"But it’s really important to distinguish between frailty and futility [of the procedure]," said Dr. Green. "Even the frail group had an 80% survival rate, and that suggests that even the most frail can tolerate and live for a long time after TAVR."

He added that the study did not address the patients’ quality of life, which could be a subject for another study.

The authors pointed out a few methodological issues.

For one, all the patients were carefully selected for TAVR, and hence it is not clear whether the findings can be generalized to unselected or lower-risk patients, or to patients who undergo surgical aortic valve replacement (SAVR).

Also, the components of the frailty score used are somewhat of a departure from the previously validated assessment tools.

"For our study, we had to raise the threshold for who’s frail," said Dr. Green. "We’re really talking about the frailest of the frail. Nevertheless we saw excellent outcome."

But for now, "the bottom line is measure frailty," advised Dr. Green. "Understand the functional status of your patients. Understand their abilities to perform activities and their nutritional status. It can shed light on patients who are thriving despite their heart disease and other comorbidities compared to those who are really limited on the basis of their diseases."

Dr. Green said that he had no relevant financial disclosures.

Frailty was associated with a threefold increase in mortality risk 1 year after transcatheter aortic valve replacement, according to a single-center study published online Sept. 16 in JACC: Cardiovascular Interventions.

Researchers also found that there was no significant association between frailty status and the majority of post-TAVR procedural outcomes, suggesting that the current standard for patient selection is adequate, they wrote.

"We hope that the result will convince physicians to measure frailty," Dr. Philip Green, the study’s lead author, said in an interview. "Formally assessed frailty can be extremely useful for prognostic information."

Risk prediction for older adults undergoing cardiac surgery is somewhat tricky, said Dr. Green, because some of the well established measurement tools are based on studies that did not include many adults who were very old or at high risk.

"So the risk-prediction confidence intervals among the highest risk patients tend to get very wide," said Dr. Green, a fellow in cardiovascular medicine at Columbia University Medical Center, New York, where the study was conducted.

Frailty, which is the loss of resiliency and physiological reserve, helps predict the patients’ tolerance for certain procedures, their odds of survival, and their overall prognosis.

For an objective frailty score, Dr. Green said he and colleagues built on findings from previous studies and measured gait speed, grip strength, serum albumin, and activities of daily living to derive a frailty score in 159 very-high-risk patients with severe aortic stenosis who underwent TAVR at the Valve Center at Columbia University Medical Center/New York–Presbyterian Hospital.

They then broke down the patients into two groups based on their median frailty score: those who were frail and those who were not.

Patients’ mean age was 86 years, and half were men. Half of the patients had at least three comorbidities, although the frailty score was not associated with the number of comorbidities.

Overall, 76 patients had a frailty score higher than 5, and 83 had a score of 5 or less (considered not frail).

Patients whose frailty score was higher than 5 had longer hospital stays and were at a higher risk of in-hospital, life-threatening, or major bleeding events compared with the nonfrail group (JACC Cardiovasc. Interv. 2012;5:974-81).

Eight patients died during the first 30 days; however, frailty status was not associated with adverse periprocedural events such as vascular complications, stroke, or procedural mortality.

Meanwhile, 1-year follow-up showed that patients with a frailty score of more than 5 had a threefold increase in mortality after the procedure, compared with the nonfrail group (17 frail vs. 7 nonfrail; hazard ratio, 1.15).

"But it’s really important to distinguish between frailty and futility [of the procedure]," said Dr. Green. "Even the frail group had an 80% survival rate, and that suggests that even the most frail can tolerate and live for a long time after TAVR."

He added that the study did not address the patients’ quality of life, which could be a subject for another study.

The authors pointed out a few methodological issues.

For one, all the patients were carefully selected for TAVR, and hence it is not clear whether the findings can be generalized to unselected or lower-risk patients, or to patients who undergo surgical aortic valve replacement (SAVR).

Also, the components of the frailty score used are somewhat of a departure from the previously validated assessment tools.

"For our study, we had to raise the threshold for who’s frail," said Dr. Green. "We’re really talking about the frailest of the frail. Nevertheless we saw excellent outcome."

But for now, "the bottom line is measure frailty," advised Dr. Green. "Understand the functional status of your patients. Understand their abilities to perform activities and their nutritional status. It can shed light on patients who are thriving despite their heart disease and other comorbidities compared to those who are really limited on the basis of their diseases."

Dr. Green said that he had no relevant financial disclosures.

Frailty was associated with a threefold increase in mortality risk 1 year after transcatheter aortic valve replacement, according to a single-center study published online Sept. 16 in JACC: Cardiovascular Interventions.

Researchers also found that there was no significant association between frailty status and the majority of post-TAVR procedural outcomes, suggesting that the current standard for patient selection is adequate, they wrote.

"We hope that the result will convince physicians to measure frailty," Dr. Philip Green, the study’s lead author, said in an interview. "Formally assessed frailty can be extremely useful for prognostic information."

Risk prediction for older adults undergoing cardiac surgery is somewhat tricky, said Dr. Green, because some of the well established measurement tools are based on studies that did not include many adults who were very old or at high risk.

"So the risk-prediction confidence intervals among the highest risk patients tend to get very wide," said Dr. Green, a fellow in cardiovascular medicine at Columbia University Medical Center, New York, where the study was conducted.

Frailty, which is the loss of resiliency and physiological reserve, helps predict the patients’ tolerance for certain procedures, their odds of survival, and their overall prognosis.

For an objective frailty score, Dr. Green said he and colleagues built on findings from previous studies and measured gait speed, grip strength, serum albumin, and activities of daily living to derive a frailty score in 159 very-high-risk patients with severe aortic stenosis who underwent TAVR at the Valve Center at Columbia University Medical Center/New York–Presbyterian Hospital.

They then broke down the patients into two groups based on their median frailty score: those who were frail and those who were not.

Patients’ mean age was 86 years, and half were men. Half of the patients had at least three comorbidities, although the frailty score was not associated with the number of comorbidities.

Overall, 76 patients had a frailty score higher than 5, and 83 had a score of 5 or less (considered not frail).

Patients whose frailty score was higher than 5 had longer hospital stays and were at a higher risk of in-hospital, life-threatening, or major bleeding events compared with the nonfrail group (JACC Cardiovasc. Interv. 2012;5:974-81).

Eight patients died during the first 30 days; however, frailty status was not associated with adverse periprocedural events such as vascular complications, stroke, or procedural mortality.

Meanwhile, 1-year follow-up showed that patients with a frailty score of more than 5 had a threefold increase in mortality after the procedure, compared with the nonfrail group (17 frail vs. 7 nonfrail; hazard ratio, 1.15).

"But it’s really important to distinguish between frailty and futility [of the procedure]," said Dr. Green. "Even the frail group had an 80% survival rate, and that suggests that even the most frail can tolerate and live for a long time after TAVR."

He added that the study did not address the patients’ quality of life, which could be a subject for another study.

The authors pointed out a few methodological issues.

For one, all the patients were carefully selected for TAVR, and hence it is not clear whether the findings can be generalized to unselected or lower-risk patients, or to patients who undergo surgical aortic valve replacement (SAVR).

Also, the components of the frailty score used are somewhat of a departure from the previously validated assessment tools.

"For our study, we had to raise the threshold for who’s frail," said Dr. Green. "We’re really talking about the frailest of the frail. Nevertheless we saw excellent outcome."

But for now, "the bottom line is measure frailty," advised Dr. Green. "Understand the functional status of your patients. Understand their abilities to perform activities and their nutritional status. It can shed light on patients who are thriving despite their heart disease and other comorbidities compared to those who are really limited on the basis of their diseases."

Dr. Green said that he had no relevant financial disclosures.

The Food and Drug Administration has approved the production and use of the imaging agent Choline C 11 for the detection of recurrent prostate cancer.

"Choline C 11 injection provides an important imaging method to help detect the location of prostate cancer in patients whose blood tests suggest recurrent cancer when other imaging tests are negative," noted Dr. Charles Ganley, director of the Office of Drug Evaluation IV in the FDA’s Center for Drug Evaluation and Research, in an FDA statement.

Several imaging facilities have been performing PET imaging with Choline C 11 for the past couple of years, but none were approved by the FDA to manufacture the agent. The Mayo Clinic, which manufactures and distributes the agent in its Rochester, Minn., facility, is the first FDA-approved center to produce Choline C 11 injection.

The safety and effectiveness of Choline C 11 were verified after a review of four independent studies of 98 patients. In at least half of the patients in each study, prostate cancer detected by PET imaging was confirmed by tissue sampling of the abnormal areas.

There were also PET scan errors and false positive scans, which "underscore the need for confirmatory tissue sampling of abnormalities detected with Choline C 11 injection PET scans," according to the FDA statement.

No side effects of Choline C 11 were observed, except for mild skin reactions at the injection site.

The Food and Drug Administration has approved the production and use of the imaging agent Choline C 11 for the detection of recurrent prostate cancer.

"Choline C 11 injection provides an important imaging method to help detect the location of prostate cancer in patients whose blood tests suggest recurrent cancer when other imaging tests are negative," noted Dr. Charles Ganley, director of the Office of Drug Evaluation IV in the FDA’s Center for Drug Evaluation and Research, in an FDA statement.

Several imaging facilities have been performing PET imaging with Choline C 11 for the past couple of years, but none were approved by the FDA to manufacture the agent. The Mayo Clinic, which manufactures and distributes the agent in its Rochester, Minn., facility, is the first FDA-approved center to produce Choline C 11 injection.

The safety and effectiveness of Choline C 11 were verified after a review of four independent studies of 98 patients. In at least half of the patients in each study, prostate cancer detected by PET imaging was confirmed by tissue sampling of the abnormal areas.

There were also PET scan errors and false positive scans, which "underscore the need for confirmatory tissue sampling of abnormalities detected with Choline C 11 injection PET scans," according to the FDA statement.

No side effects of Choline C 11 were observed, except for mild skin reactions at the injection site.

The Food and Drug Administration has approved the production and use of the imaging agent Choline C 11 for the detection of recurrent prostate cancer.

"Choline C 11 injection provides an important imaging method to help detect the location of prostate cancer in patients whose blood tests suggest recurrent cancer when other imaging tests are negative," noted Dr. Charles Ganley, director of the Office of Drug Evaluation IV in the FDA’s Center for Drug Evaluation and Research, in an FDA statement.

Several imaging facilities have been performing PET imaging with Choline C 11 for the past couple of years, but none were approved by the FDA to manufacture the agent. The Mayo Clinic, which manufactures and distributes the agent in its Rochester, Minn., facility, is the first FDA-approved center to produce Choline C 11 injection.

The safety and effectiveness of Choline C 11 were verified after a review of four independent studies of 98 patients. In at least half of the patients in each study, prostate cancer detected by PET imaging was confirmed by tissue sampling of the abnormal areas.

There were also PET scan errors and false positive scans, which "underscore the need for confirmatory tissue sampling of abnormalities detected with Choline C 11 injection PET scans," according to the FDA statement.

No side effects of Choline C 11 were observed, except for mild skin reactions at the injection site.

WASHINGTON – After more than a decade, the nation’s suicide prevention strategy has been updated to reflect major advancements in research, practice, and prevention efforts, and for the first time it enlists the social networking site Facebook as part of the nationwide efforts.

"Back in 2001, when the strategy was last offered, if someone asked me for Facebook, I’d start looking for a photo album," said John McHugh, secretary of the Army and cochair of the alliance that helped relaunch the strategy. Friends and family now can report suicidal comments and postings to Facebook.

Despite the advancements, nearly 356,000 Americans have died by their own hands in the last decade, making suicide the 10th leading cause of death in the nation and the third leading cause of death among young people.

The trend has been especially alarming in the armed forces, according to a statement by U.S. Department of Health and Human Services Secretary Kathleen Sebelius at the Sept. 10 press conference announcing the relaunch. In July, the Army lost 38 soldiers to suicide, an all-time one-month high, she said.

The 2012 National Strategy for Suicide Prevention lists 13 goals and 60 objectives aimed at reducing the nation’s suicide rate over the next decade. Among those goals are availability of timely treatment and support services, and enhancement of clinical and community preventive services.

Surgeon General Dr. Regina Benjamin said one focus of the prevention strategy is an increase in training for all physicians and their staff.

The Centers for Disease Control and Prevention recently introduced a screening tool for depression, said Pamela Hyde, administrator for the Substance Abuse and Mental Health Services Administration. "We’re also interested in emergency rooms," where people are brought in after attempting suicide, Ms. Hyde said. The hope is to connect those individuals with follow-up care and help save a life, she explained.

Ms. Sebelius also announced $55.6 million in new grants for national and local suicide prevention programs, partly funded by the Affordable Care Act.

"We want to make sure suicide prevention efforts are part of the broader efforts to improve health care across America," Ms. Sebelius said. Medicare began covering annual screening for depression in 2011, "which is especially important, since older Americans have the highest rate of death by suicide," she said.

Also, the Department of Veterans Affairs has launched a new outreach campaign that includes public service announcements and local efforts to connect veterans and service members to the Veterans Crisis Line (800-273-8255, press 1). Dr. Benjamin has released a public service announcement promoting the National Suicide Prevention Line, which also is 800-273-8255.

VA officials said they were doubling the Crisis Line workforce and hiring 1,600 new mental health professionals.

Suicide rates declined among both males and females from 1991 to 2000; according to the Centers for Disease Control and Prevention. However, those rates have gradually increased since then.

The first National Strategy for Suicide Prevention was launched in 2001 by then–Surgeon General Dr. David Satcher. The 2012 National Strategy was put together by collaboration of the Office of the U.S. Surgeon General and the National Action Alliance for Suicide Prevention, which is made up of about 200 public and private organizations.

"In the past we’ve often treated mental health and substance abuse as personal issues," Ms. Sebelius said. "But by addressing these conditions and recognizing that they’re just as important to our country as addressing any health issue ... we must take action against suicide together, as a community."

WASHINGTON – After more than a decade, the nation’s suicide prevention strategy has been updated to reflect major advancements in research, practice, and prevention efforts, and for the first time it enlists the social networking site Facebook as part of the nationwide efforts.

"Back in 2001, when the strategy was last offered, if someone asked me for Facebook, I’d start looking for a photo album," said John McHugh, secretary of the Army and cochair of the alliance that helped relaunch the strategy. Friends and family now can report suicidal comments and postings to Facebook.

Despite the advancements, nearly 356,000 Americans have died by their own hands in the last decade, making suicide the 10th leading cause of death in the nation and the third leading cause of death among young people.

The trend has been especially alarming in the armed forces, according to a statement by U.S. Department of Health and Human Services Secretary Kathleen Sebelius at the Sept. 10 press conference announcing the relaunch. In July, the Army lost 38 soldiers to suicide, an all-time one-month high, she said.

The 2012 National Strategy for Suicide Prevention lists 13 goals and 60 objectives aimed at reducing the nation’s suicide rate over the next decade. Among those goals are availability of timely treatment and support services, and enhancement of clinical and community preventive services.

Surgeon General Dr. Regina Benjamin said one focus of the prevention strategy is an increase in training for all physicians and their staff.

The Centers for Disease Control and Prevention recently introduced a screening tool for depression, said Pamela Hyde, administrator for the Substance Abuse and Mental Health Services Administration. "We’re also interested in emergency rooms," where people are brought in after attempting suicide, Ms. Hyde said. The hope is to connect those individuals with follow-up care and help save a life, she explained.

Ms. Sebelius also announced $55.6 million in new grants for national and local suicide prevention programs, partly funded by the Affordable Care Act.

"We want to make sure suicide prevention efforts are part of the broader efforts to improve health care across America," Ms. Sebelius said. Medicare began covering annual screening for depression in 2011, "which is especially important, since older Americans have the highest rate of death by suicide," she said.

Also, the Department of Veterans Affairs has launched a new outreach campaign that includes public service announcements and local efforts to connect veterans and service members to the Veterans Crisis Line (800-273-8255, press 1). Dr. Benjamin has released a public service announcement promoting the National Suicide Prevention Line, which also is 800-273-8255.

VA officials said they were doubling the Crisis Line workforce and hiring 1,600 new mental health professionals.

Suicide rates declined among both males and females from 1991 to 2000; according to the Centers for Disease Control and Prevention. However, those rates have gradually increased since then.

The first National Strategy for Suicide Prevention was launched in 2001 by then–Surgeon General Dr. David Satcher. The 2012 National Strategy was put together by collaboration of the Office of the U.S. Surgeon General and the National Action Alliance for Suicide Prevention, which is made up of about 200 public and private organizations.

"In the past we’ve often treated mental health and substance abuse as personal issues," Ms. Sebelius said. "But by addressing these conditions and recognizing that they’re just as important to our country as addressing any health issue ... we must take action against suicide together, as a community."

WASHINGTON – After more than a decade, the nation’s suicide prevention strategy has been updated to reflect major advancements in research, practice, and prevention efforts, and for the first time it enlists the social networking site Facebook as part of the nationwide efforts.

"Back in 2001, when the strategy was last offered, if someone asked me for Facebook, I’d start looking for a photo album," said John McHugh, secretary of the Army and cochair of the alliance that helped relaunch the strategy. Friends and family now can report suicidal comments and postings to Facebook.

Despite the advancements, nearly 356,000 Americans have died by their own hands in the last decade, making suicide the 10th leading cause of death in the nation and the third leading cause of death among young people.

The trend has been especially alarming in the armed forces, according to a statement by U.S. Department of Health and Human Services Secretary Kathleen Sebelius at the Sept. 10 press conference announcing the relaunch. In July, the Army lost 38 soldiers to suicide, an all-time one-month high, she said.

The 2012 National Strategy for Suicide Prevention lists 13 goals and 60 objectives aimed at reducing the nation’s suicide rate over the next decade. Among those goals are availability of timely treatment and support services, and enhancement of clinical and community preventive services.

Surgeon General Dr. Regina Benjamin said one focus of the prevention strategy is an increase in training for all physicians and their staff.

The Centers for Disease Control and Prevention recently introduced a screening tool for depression, said Pamela Hyde, administrator for the Substance Abuse and Mental Health Services Administration. "We’re also interested in emergency rooms," where people are brought in after attempting suicide, Ms. Hyde said. The hope is to connect those individuals with follow-up care and help save a life, she explained.

Ms. Sebelius also announced $55.6 million in new grants for national and local suicide prevention programs, partly funded by the Affordable Care Act.

"We want to make sure suicide prevention efforts are part of the broader efforts to improve health care across America," Ms. Sebelius said. Medicare began covering annual screening for depression in 2011, "which is especially important, since older Americans have the highest rate of death by suicide," she said.

Also, the Department of Veterans Affairs has launched a new outreach campaign that includes public service announcements and local efforts to connect veterans and service members to the Veterans Crisis Line (800-273-8255, press 1). Dr. Benjamin has released a public service announcement promoting the National Suicide Prevention Line, which also is 800-273-8255.

VA officials said they were doubling the Crisis Line workforce and hiring 1,600 new mental health professionals.

Suicide rates declined among both males and females from 1991 to 2000; according to the Centers for Disease Control and Prevention. However, those rates have gradually increased since then.

The first National Strategy for Suicide Prevention was launched in 2001 by then–Surgeon General Dr. David Satcher. The 2012 National Strategy was put together by collaboration of the Office of the U.S. Surgeon General and the National Action Alliance for Suicide Prevention, which is made up of about 200 public and private organizations.

"In the past we’ve often treated mental health and substance abuse as personal issues," Ms. Sebelius said. "But by addressing these conditions and recognizing that they’re just as important to our country as addressing any health issue ... we must take action against suicide together, as a community."

NATIONAL HARBOR, MD. – Measurements of aortic annular geometry, valve calcification, and final device position with two- and three-dimensional echocardiography are predictive of increased risk of leakage after trans-catheter valve implantation, according to a retrospective study.

The study also showed that 3-D transesophageal echocardiography (3-D TEE) does a better job of measuring the aortic annulus, compared with 2-D TEE.

The annular measurement is critical for optimal valve sizing and prevention of paravalvular aortic regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR).

Paravalvular aortic regurgitation (PAR), is a known complication of TAVR, and according to 2-year analysis of the PARTNER trial, PAR after TAVR was associated with increased late mortality ( N. Engl. J. Med. 2012;366:1686-95).

TAVR is in its infancy in the United States, compared with Europe, and experts are studying how and which imaging techniques could yield the best results before, during, and after TAVR (also called TAVI).

"Every center has their preference," said Dr. Praveen Mehrotra, a noninvasive cardiologist and the lead author of the study at Massachusetts General Hospital in Boston. "Some centers use CT and 2-D TEE. At Mass General, we integrate information obtained from 2-D and 3-D TEE."

Meanwhile, the role of 3-D TEE in TAVR hasn’t been adequately explored, added Dr. Mehrotra, who presented his poster at the annual meeting of the American Society of Echocardiography.

Dr. Mehrotra and his colleagues set out to retrospectively identify 2-D and 3-D TEE parameters that could predict significant PAR after TAVR.

They analyzed 2-D and 3-D TEE images from 94 patients undergoing TAVR between June 2008 and December 2011. The images were used to assess three parameters: annulus geometry, aortic valve apparatus calcification, and final device position.

Twenty-one of the patients (22%) showed significant PAR after TAVR, but before postdilation.

In 2-D TEE, the annulus geometry was assessed by measuring the largest anteroposterior annulus dimension at the aortic valve hinge points in mid systole, the authors wrote. Using 3-D TEE, researchers measured or calculated four parameters for the aortic annulus geometry: minor axis, major axis, eccentricity index, and annular area.

The annular dimension measured by 2-D TEE was similar in the PAR (22.8 mm) and No PAR (22.4 mm) groups. But, the 3-D TEE measurements were significantly larger in the PAR group than in the No PAR group, as measured by annular minor axis (23.8 mm vs. 22.7 mm), major axis (27.0 mm vs. 25.3 mm), eccentricity index (0.88 vs. 0.90), and annular area (5.19 cm² vs. 4.52 cm²), the researchers reported.

The annular-prosthesis incongruence (API) index was also significantly higher in patients with PAR (1.07% vs. 0.93%), "indicating valve undersizing in this group," the authors wrote.

Using 3-D TEE, the researchers identified and graded significant areas of calcification in the aortic valve apparatus, which is also very important before TAVR, said Mehrotra.

The final device position was assessed using 2-D TEE images.

The results showed that higher API index, Aortic Valve Apparatus Calcification score, and final position of the device were predictors of significant PAR after TAVR, with odds ratios of 9.4, 3.6, and 1.2, respectively, the authors reported.

"Our study highlights the ability of 2-D and 3-D TEE for accurate annular sizing and optimal valve positioning during TAVR," they wrote.

The takeaway message, said Dr. Mehrotra in an interview, is that "the role of echo is essential before, during, and after TAVR.

He added that 3-D echocardiography has an emerging role in annular sizing. In particular, annular area by 3-D TEE may be more important than the anteroposterior dimension by 2-D TEE for accurate valve sizing, said Dr. Mehrotra. "Technologies like 3-D TEE and cardiac CT can help with preprocedural planning, but they should be used by people who understand how to use them."

While his study focused on 2-D and 3-D TEE, Dr. Mehrotra said he expected more studies begin comparing cardiac CT and 3-D TEE, which is more like, "comparing apples to apples."

In a discussion on TAVR imaging, Dr. Rebecca T. Hahn, director of interventional echocardiography at Columbia University, New York, said that cardiac CT and echocardiography are complementary. However, CT is less user-dependent, compared with 3-D TEE.

Dr. Mehrotra and Dr. Hahn had no relevant financial disclosures.

NATIONAL HARBOR, MD. – Measurements of aortic annular geometry, valve calcification, and final device position with two- and three-dimensional echocardiography are predictive of increased risk of leakage after trans-catheter valve implantation, according to a retrospective study.

The study also showed that 3-D transesophageal echocardiography (3-D TEE) does a better job of measuring the aortic annulus, compared with 2-D TEE.

The annular measurement is critical for optimal valve sizing and prevention of paravalvular aortic regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR).

Paravalvular aortic regurgitation (PAR), is a known complication of TAVR, and according to 2-year analysis of the PARTNER trial, PAR after TAVR was associated with increased late mortality ( N. Engl. J. Med. 2012;366:1686-95).

TAVR is in its infancy in the United States, compared with Europe, and experts are studying how and which imaging techniques could yield the best results before, during, and after TAVR (also called TAVI).

"Every center has their preference," said Dr. Praveen Mehrotra, a noninvasive cardiologist and the lead author of the study at Massachusetts General Hospital in Boston. "Some centers use CT and 2-D TEE. At Mass General, we integrate information obtained from 2-D and 3-D TEE."

Meanwhile, the role of 3-D TEE in TAVR hasn’t been adequately explored, added Dr. Mehrotra, who presented his poster at the annual meeting of the American Society of Echocardiography.

Dr. Mehrotra and his colleagues set out to retrospectively identify 2-D and 3-D TEE parameters that could predict significant PAR after TAVR.

They analyzed 2-D and 3-D TEE images from 94 patients undergoing TAVR between June 2008 and December 2011. The images were used to assess three parameters: annulus geometry, aortic valve apparatus calcification, and final device position.

Twenty-one of the patients (22%) showed significant PAR after TAVR, but before postdilation.

In 2-D TEE, the annulus geometry was assessed by measuring the largest anteroposterior annulus dimension at the aortic valve hinge points in mid systole, the authors wrote. Using 3-D TEE, researchers measured or calculated four parameters for the aortic annulus geometry: minor axis, major axis, eccentricity index, and annular area.

The annular dimension measured by 2-D TEE was similar in the PAR (22.8 mm) and No PAR (22.4 mm) groups. But, the 3-D TEE measurements were significantly larger in the PAR group than in the No PAR group, as measured by annular minor axis (23.8 mm vs. 22.7 mm), major axis (27.0 mm vs. 25.3 mm), eccentricity index (0.88 vs. 0.90), and annular area (5.19 cm² vs. 4.52 cm²), the researchers reported.

The annular-prosthesis incongruence (API) index was also significantly higher in patients with PAR (1.07% vs. 0.93%), "indicating valve undersizing in this group," the authors wrote.

Using 3-D TEE, the researchers identified and graded significant areas of calcification in the aortic valve apparatus, which is also very important before TAVR, said Mehrotra.

The final device position was assessed using 2-D TEE images.

The results showed that higher API index, Aortic Valve Apparatus Calcification score, and final position of the device were predictors of significant PAR after TAVR, with odds ratios of 9.4, 3.6, and 1.2, respectively, the authors reported.

"Our study highlights the ability of 2-D and 3-D TEE for accurate annular sizing and optimal valve positioning during TAVR," they wrote.

The takeaway message, said Dr. Mehrotra in an interview, is that "the role of echo is essential before, during, and after TAVR.

He added that 3-D echocardiography has an emerging role in annular sizing. In particular, annular area by 3-D TEE may be more important than the anteroposterior dimension by 2-D TEE for accurate valve sizing, said Dr. Mehrotra. "Technologies like 3-D TEE and cardiac CT can help with preprocedural planning, but they should be used by people who understand how to use them."

While his study focused on 2-D and 3-D TEE, Dr. Mehrotra said he expected more studies begin comparing cardiac CT and 3-D TEE, which is more like, "comparing apples to apples."

In a discussion on TAVR imaging, Dr. Rebecca T. Hahn, director of interventional echocardiography at Columbia University, New York, said that cardiac CT and echocardiography are complementary. However, CT is less user-dependent, compared with 3-D TEE.

Dr. Mehrotra and Dr. Hahn had no relevant financial disclosures.

NATIONAL HARBOR, MD. – Measurements of aortic annular geometry, valve calcification, and final device position with two- and three-dimensional echocardiography are predictive of increased risk of leakage after trans-catheter valve implantation, according to a retrospective study.

The study also showed that 3-D transesophageal echocardiography (3-D TEE) does a better job of measuring the aortic annulus, compared with 2-D TEE.

The annular measurement is critical for optimal valve sizing and prevention of paravalvular aortic regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR).

Paravalvular aortic regurgitation (PAR), is a known complication of TAVR, and according to 2-year analysis of the PARTNER trial, PAR after TAVR was associated with increased late mortality ( N. Engl. J. Med. 2012;366:1686-95).

TAVR is in its infancy in the United States, compared with Europe, and experts are studying how and which imaging techniques could yield the best results before, during, and after TAVR (also called TAVI).

"Every center has their preference," said Dr. Praveen Mehrotra, a noninvasive cardiologist and the lead author of the study at Massachusetts General Hospital in Boston. "Some centers use CT and 2-D TEE. At Mass General, we integrate information obtained from 2-D and 3-D TEE."

Meanwhile, the role of 3-D TEE in TAVR hasn’t been adequately explored, added Dr. Mehrotra, who presented his poster at the annual meeting of the American Society of Echocardiography.

Dr. Mehrotra and his colleagues set out to retrospectively identify 2-D and 3-D TEE parameters that could predict significant PAR after TAVR.

They analyzed 2-D and 3-D TEE images from 94 patients undergoing TAVR between June 2008 and December 2011. The images were used to assess three parameters: annulus geometry, aortic valve apparatus calcification, and final device position.

Twenty-one of the patients (22%) showed significant PAR after TAVR, but before postdilation.

In 2-D TEE, the annulus geometry was assessed by measuring the largest anteroposterior annulus dimension at the aortic valve hinge points in mid systole, the authors wrote. Using 3-D TEE, researchers measured or calculated four parameters for the aortic annulus geometry: minor axis, major axis, eccentricity index, and annular area.

The annular dimension measured by 2-D TEE was similar in the PAR (22.8 mm) and No PAR (22.4 mm) groups. But, the 3-D TEE measurements were significantly larger in the PAR group than in the No PAR group, as measured by annular minor axis (23.8 mm vs. 22.7 mm), major axis (27.0 mm vs. 25.3 mm), eccentricity index (0.88 vs. 0.90), and annular area (5.19 cm² vs. 4.52 cm²), the researchers reported.

The annular-prosthesis incongruence (API) index was also significantly higher in patients with PAR (1.07% vs. 0.93%), "indicating valve undersizing in this group," the authors wrote.

Using 3-D TEE, the researchers identified and graded significant areas of calcification in the aortic valve apparatus, which is also very important before TAVR, said Mehrotra.

The final device position was assessed using 2-D TEE images.

The results showed that higher API index, Aortic Valve Apparatus Calcification score, and final position of the device were predictors of significant PAR after TAVR, with odds ratios of 9.4, 3.6, and 1.2, respectively, the authors reported.

"Our study highlights the ability of 2-D and 3-D TEE for accurate annular sizing and optimal valve positioning during TAVR," they wrote.

The takeaway message, said Dr. Mehrotra in an interview, is that "the role of echo is essential before, during, and after TAVR.

He added that 3-D echocardiography has an emerging role in annular sizing. In particular, annular area by 3-D TEE may be more important than the anteroposterior dimension by 2-D TEE for accurate valve sizing, said Dr. Mehrotra. "Technologies like 3-D TEE and cardiac CT can help with preprocedural planning, but they should be used by people who understand how to use them."

While his study focused on 2-D and 3-D TEE, Dr. Mehrotra said he expected more studies begin comparing cardiac CT and 3-D TEE, which is more like, "comparing apples to apples."

In a discussion on TAVR imaging, Dr. Rebecca T. Hahn, director of interventional echocardiography at Columbia University, New York, said that cardiac CT and echocardiography are complementary. However, CT is less user-dependent, compared with 3-D TEE.

Dr. Mehrotra and Dr. Hahn had no relevant financial disclosures.

NATIONAL HARBOR, MD. – Measurements of aortic annular geometry, valve calcification, and final device position with two- and three-dimensional echocardiography are predictive of increased risk of leakage after trans-catheter valve implantation, according to a retrospective study.

The study also showed that 3-D transesophageal echocardiography (3-D TEE) does a better job of measuring the aortic annulus, compared with 2-D TEE.

The annular measurement is critical for optimal valve sizing and prevention of paravalvular aortic regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR).

Paravalvular aortic regurgitation (PAR), is a known complication of TAVR, and according to 2-year analysis of the PARTNER trial, PAR after TAVR was associated with increased late mortality ( N. Engl. J. Med. 2012;366:1686-95).

TAVR is in its infancy in the United States, compared with Europe, and experts are studying how and which imaging techniques could yield the best results before, during, and after TAVR (also called TAVI).

"Every center has their preference," said Dr. Praveen Mehrotra, a noninvasive cardiologist and the lead author of the study at Massachusetts General Hospital in Boston. "Some centers use CT and 2-D TEE. At Mass General, we integrate information obtained from 2-D and 3-D TEE."

Meanwhile, the role of 3-D TEE in TAVR hasn’t been adequately explored, added Dr. Mehrotra, who presented his poster at the annual meeting of the American Society of Echocardiography.

Dr. Mehrotra and his colleagues set out to retrospectively identify 2-D and 3-D TEE parameters that could predict significant PAR after TAVR.

They analyzed 2-D and 3-D TEE images from 94 patients undergoing TAVR between June 2008 and December 2011. The images were used to assess three parameters: annulus geometry, aortic valve apparatus calcification, and final device position.

Twenty-one of the patients (22%) showed significant PAR after TAVR, but before postdilation.

In 2-D TEE, the annulus geometry was assessed by measuring the largest anteroposterior annulus dimension at the aortic valve hinge points in mid systole, the authors wrote. Using 3-D TEE, researchers measured or calculated four parameters for the aortic annulus geometry: minor axis, major axis, eccentricity index, and annular area.

The annular dimension measured by 2-D TEE was similar in the PAR (22.8 mm) and No PAR (22.4 mm) groups. But, the 3-D TEE measurements were significantly larger in the PAR group than in the No PAR group, as measured by annular minor axis (23.8 mm vs. 22.7 mm), major axis (27.0 mm vs. 25.3 mm), eccentricity index (0.88 vs. 0.90), and annular area (5.19 cm² vs. 4.52 cm²), the researchers reported.

The annular-prosthesis incongruence (API) index was also significantly higher in patients with PAR (1.07% vs. 0.93%), "indicating valve undersizing in this group," the authors wrote.

Using 3-D TEE, the researchers identified and graded significant areas of calcification in the aortic valve apparatus, which is also very important before TAVR, said Mehrotra.

The final device position was assessed using 2-D TEE images.

The results showed that higher API index, Aortic Valve Apparatus Calcification score, and final position of the device were predictors of significant PAR after TAVR, with odds ratios of 9.4, 3.6, and 1.2, respectively, the authors reported.

"Our study highlights the ability of 2-D and 3-D TEE for accurate annular sizing and optimal valve positioning during TAVR," they wrote.

The takeaway message, said Dr. Mehrotra in an interview, is that "the role of echo is essential before, during, and after TAVR.

He added that 3-D echocardiography has an emerging role in annular sizing. In particular, annular area by 3-D TEE may be more important than the anteroposterior dimension by 2-D TEE for accurate valve sizing, said Dr. Mehrotra. "Technologies like 3-D TEE and cardiac CT can help with preprocedural planning, but they should be used by people who understand how to use them."

While his study focused on 2-D and 3-D TEE, Dr. Mehrotra said he expected more studies begin comparing cardiac CT and 3-D TEE, which is more like, "comparing apples to apples."

In a discussion on TAVR imaging, Dr. Rebecca T. Hahn, director of interventional echocardiography at Columbia University, New York, said that cardiac CT and echocardiography are complementary. However, CT is less user-dependent, compared with 3-D TEE.

Dr. Mehrotra and Dr. Hahn had no relevant financial disclosures.

NATIONAL HARBOR, MD. – Measurements of aortic annular geometry, valve calcification, and final device position with two- and three-dimensional echocardiography are predictive of increased risk of leakage after trans-catheter valve implantation, according to a retrospective study.

The study also showed that 3-D transesophageal echocardiography (3-D TEE) does a better job of measuring the aortic annulus, compared with 2-D TEE.

The annular measurement is critical for optimal valve sizing and prevention of paravalvular aortic regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR).

Paravalvular aortic regurgitation (PAR), is a known complication of TAVR, and according to 2-year analysis of the PARTNER trial, PAR after TAVR was associated with increased late mortality ( N. Engl. J. Med. 2012;366:1686-95).

TAVR is in its infancy in the United States, compared with Europe, and experts are studying how and which imaging techniques could yield the best results before, during, and after TAVR (also called TAVI).

"Every center has their preference," said Dr. Praveen Mehrotra, a noninvasive cardiologist and the lead author of the study at Massachusetts General Hospital in Boston. "Some centers use CT and 2-D TEE. At Mass General, we integrate information obtained from 2-D and 3-D TEE."

Meanwhile, the role of 3-D TEE in TAVR hasn’t been adequately explored, added Dr. Mehrotra, who presented his poster at the annual meeting of the American Society of Echocardiography.

Dr. Mehrotra and his colleagues set out to retrospectively identify 2-D and 3-D TEE parameters that could predict significant PAR after TAVR.

They analyzed 2-D and 3-D TEE images from 94 patients undergoing TAVR between June 2008 and December 2011. The images were used to assess three parameters: annulus geometry, aortic valve apparatus calcification, and final device position.

Twenty-one of the patients (22%) showed significant PAR after TAVR, but before postdilation.

In 2-D TEE, the annulus geometry was assessed by measuring the largest anteroposterior annulus dimension at the aortic valve hinge points in mid systole, the authors wrote. Using 3-D TEE, researchers measured or calculated four parameters for the aortic annulus geometry: minor axis, major axis, eccentricity index, and annular area.

The annular dimension measured by 2-D TEE was similar in the PAR (22.8 mm) and No PAR (22.4 mm) groups. But, the 3-D TEE measurements were significantly larger in the PAR group than in the No PAR group, as measured by annular minor axis (23.8 mm vs. 22.7 mm), major axis (27.0 mm vs. 25.3 mm), eccentricity index (0.88 vs. 0.90), and annular area (5.19 cm² vs. 4.52 cm²), the researchers reported.

The annular-prosthesis incongruence (API) index was also significantly higher in patients with PAR (1.07% vs. 0.93%), "indicating valve undersizing in this group," the authors wrote.

Using 3-D TEE, the researchers identified and graded significant areas of calcification in the aortic valve apparatus, which is also very important before TAVR, said Mehrotra.

The final device position was assessed using 2-D TEE images.

The results showed that higher API index, Aortic Valve Apparatus Calcification score, and final position of the device were predictors of significant PAR after TAVR, with odds ratios of 9.4, 3.6, and 1.2, respectively, the authors reported.

"Our study highlights the ability of 2-D and 3-D TEE for accurate annular sizing and optimal valve positioning during TAVR," they wrote.

The takeaway message, said Dr. Mehrotra in an interview, is that "the role of echo is essential before, during, and after TAVR.

He added that 3-D echocardiography has an emerging role in annular sizing. In particular, annular area by 3-D TEE may be more important than the anteroposterior dimension by 2-D TEE for accurate valve sizing, said Dr. Mehrotra. "Technologies like 3-D TEE and cardiac CT can help with preprocedural planning, but they should be used by people who understand how to use them."

While his study focused on 2-D and 3-D TEE, Dr. Mehrotra said he expected more studies begin comparing cardiac CT and 3-D TEE, which is more like, "comparing apples to apples."

In a discussion on TAVR imaging, Dr. Rebecca T. Hahn, director of interventional echocardiography at Columbia University, New York, said that cardiac CT and echocardiography are complementary. However, CT is less user-dependent, compared with 3-D TEE.

Dr. Mehrotra and Dr. Hahn had no relevant financial disclosures.

NATIONAL HARBOR, MD. – Measurements of aortic annular geometry, valve calcification, and final device position with two- and three-dimensional echocardiography are predictive of increased risk of leakage after trans-catheter valve implantation, according to a retrospective study.

The study also showed that 3-D transesophageal echocardiography (3-D TEE) does a better job of measuring the aortic annulus, compared with 2-D TEE.

The annular measurement is critical for optimal valve sizing and prevention of paravalvular aortic regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR).

Paravalvular aortic regurgitation (PAR), is a known complication of TAVR, and according to 2-year analysis of the PARTNER trial, PAR after TAVR was associated with increased late mortality ( N. Engl. J. Med. 2012;366:1686-95).

TAVR is in its infancy in the United States, compared with Europe, and experts are studying how and which imaging techniques could yield the best results before, during, and after TAVR (also called TAVI).

"Every center has their preference," said Dr. Praveen Mehrotra, a noninvasive cardiologist and the lead author of the study at Massachusetts General Hospital in Boston. "Some centers use CT and 2-D TEE. At Mass General, we integrate information obtained from 2-D and 3-D TEE."

Meanwhile, the role of 3-D TEE in TAVR hasn’t been adequately explored, added Dr. Mehrotra, who presented his poster at the annual meeting of the American Society of Echocardiography.

Dr. Mehrotra and his colleagues set out to retrospectively identify 2-D and 3-D TEE parameters that could predict significant PAR after TAVR.

They analyzed 2-D and 3-D TEE images from 94 patients undergoing TAVR between June 2008 and December 2011. The images were used to assess three parameters: annulus geometry, aortic valve apparatus calcification, and final device position.

Twenty-one of the patients (22%) showed significant PAR after TAVR, but before postdilation.

In 2-D TEE, the annulus geometry was assessed by measuring the largest anteroposterior annulus dimension at the aortic valve hinge points in mid systole, the authors wrote. Using 3-D TEE, researchers measured or calculated four parameters for the aortic annulus geometry: minor axis, major axis, eccentricity index, and annular area.

The annular dimension measured by 2-D TEE was similar in the PAR (22.8 mm) and No PAR (22.4 mm) groups. But, the 3-D TEE measurements were significantly larger in the PAR group than in the No PAR group, as measured by annular minor axis (23.8 mm vs. 22.7 mm), major axis (27.0 mm vs. 25.3 mm), eccentricity index (0.88 vs. 0.90), and annular area (5.19 cm² vs. 4.52 cm²), the researchers reported.

The annular-prosthesis incongruence (API) index was also significantly higher in patients with PAR (1.07% vs. 0.93%), "indicating valve undersizing in this group," the authors wrote.

Using 3-D TEE, the researchers identified and graded significant areas of calcification in the aortic valve apparatus, which is also very important before TAVR, said Mehrotra.

The final device position was assessed using 2-D TEE images.

The results showed that higher API index, Aortic Valve Apparatus Calcification score, and final position of the device were predictors of significant PAR after TAVR, with odds ratios of 9.4, 3.6, and 1.2, respectively, the authors reported.

"Our study highlights the ability of 2-D and 3-D TEE for accurate annular sizing and optimal valve positioning during TAVR," they wrote.

The takeaway message, said Dr. Mehrotra in an interview, is that "the role of echo is essential before, during, and after TAVR.

He added that 3-D echocardiography has an emerging role in annular sizing. In particular, annular area by 3-D TEE may be more important than the anteroposterior dimension by 2-D TEE for accurate valve sizing, said Dr. Mehrotra. "Technologies like 3-D TEE and cardiac CT can help with preprocedural planning, but they should be used by people who understand how to use them."

While his study focused on 2-D and 3-D TEE, Dr. Mehrotra said he expected more studies begin comparing cardiac CT and 3-D TEE, which is more like, "comparing apples to apples."

In a discussion on TAVR imaging, Dr. Rebecca T. Hahn, director of interventional echocardiography at Columbia University, New York, said that cardiac CT and echocardiography are complementary. However, CT is less user-dependent, compared with 3-D TEE.

Dr. Mehrotra and Dr. Hahn had no relevant financial disclosures.

MUNICH – Smoking in young people can induce structural changes to the arterial wall and possibly lead to the development of atherosclerosis before adulthood, according to a Swiss study.

Ultrasound analysis of the common carotid artery of adolescents who actively smoked showed that their intima-media was as much as 0.03 mm thicker than those of youth who didn’t smoke, researchers reported at the annual congress of the European Society of Cardiology.

While the preliminary findings may not dissuade adolescents from smoking, they highlight the need for prevention efforts, such as implementing smoking bans in cities and states, said study investigator Dr. Julia Dratva, a research fellow at the Swiss Tropical and Public Health Institute, Basel.

Studies have established the negative health effects of tobacco exposure in adolescents, but the Swiss study is one of the first to show the impact of smoking on the arterial walls of youths.

"What the study does is make it clear that the vascular wall starts falling into pieces," in youth who smoke, session moderator Dr. Joep Perk said in an interview. "So you are starting on a path that your vascular wall is going to be eventually plugged," added Dr. Perk, professor of health sciences at Linnaeus University, Sweden.

Researchers recruited 279 subjects in the Swiss Study on Air Pollution and Lung and Heart Disease in Adults (SAPALDIA) Youth Study. Study participants were between ages 9 and 20. Their clinical examination included anthropometry, blood pressure measurement, ultrasound assessment of the carotid artery intima-media thickness, and blood tests for cardiovascular biomarkers.

Many of the study participants had cardiovascular disease risk factors that are known to continue into adulthood and are associated with increased atherosclerotic risk, the authors reported. Thirteen percent of the youth were overweight, 3% had elevated cholesterol, 5% had an HbA_1c level higher than 5.7%, and blood pressure was elevated in 7%.

Ten percent of the participants reported weekly smoking (at least one cigarette per week), and 14% reported smoking monthly. Very few reported daily smoking habits, said Dr. Dratva. Mean smoking duration was 2.3 years in ever-smokers. Exposure to passive smoke up to 10 years of age was reported by 31% and current parental smoking by 25%.

Results showed that smoking duration was positively associated with common carotid intima-media thickness (0.014-mm increase/year). The carotid intima-media was significantly thicker in youth who smoked weekly (0.03 mm) compared with those who didn’t smoke. The results remained consistent after adjustment for parental smoking.

Meanwhile, there was not a significant difference in the intima-media thickness among those who reported smoking at least once a month and those who said they didn’t smoke (slightly more than a 0.01-mm difference).

"The thickening of the intima-media is reversible," said Dr. Dratva. "But we don’t know for how long this reversibility will stay," and there’s a need for further investigations, she said.

Dr. Dratva reported no financial conflicts.

MUNICH – Smoking in young people can induce structural changes to the arterial wall and possibly lead to the development of atherosclerosis before adulthood, according to a Swiss study.

Ultrasound analysis of the common carotid artery of adolescents who actively smoked showed that their intima-media was as much as 0.03 mm thicker than those of youth who didn’t smoke, researchers reported at the annual congress of the European Society of Cardiology.

While the preliminary findings may not dissuade adolescents from smoking, they highlight the need for prevention efforts, such as implementing smoking bans in cities and states, said study investigator Dr. Julia Dratva, a research fellow at the Swiss Tropical and Public Health Institute, Basel.

Studies have established the negative health effects of tobacco exposure in adolescents, but the Swiss study is one of the first to show the impact of smoking on the arterial walls of youths.

"What the study does is make it clear that the vascular wall starts falling into pieces," in youth who smoke, session moderator Dr. Joep Perk said in an interview. "So you are starting on a path that your vascular wall is going to be eventually plugged," added Dr. Perk, professor of health sciences at Linnaeus University, Sweden.

Researchers recruited 279 subjects in the Swiss Study on Air Pollution and Lung and Heart Disease in Adults (SAPALDIA) Youth Study. Study participants were between ages 9 and 20. Their clinical examination included anthropometry, blood pressure measurement, ultrasound assessment of the carotid artery intima-media thickness, and blood tests for cardiovascular biomarkers.

Many of the study participants had cardiovascular disease risk factors that are known to continue into adulthood and are associated with increased atherosclerotic risk, the authors reported. Thirteen percent of the youth were overweight, 3% had elevated cholesterol, 5% had an HbA_1c level higher than 5.7%, and blood pressure was elevated in 7%.

Ten percent of the participants reported weekly smoking (at least one cigarette per week), and 14% reported smoking monthly. Very few reported daily smoking habits, said Dr. Dratva. Mean smoking duration was 2.3 years in ever-smokers. Exposure to passive smoke up to 10 years of age was reported by 31% and current parental smoking by 25%.

Results showed that smoking duration was positively associated with common carotid intima-media thickness (0.014-mm increase/year). The carotid intima-media was significantly thicker in youth who smoked weekly (0.03 mm) compared with those who didn’t smoke. The results remained consistent after adjustment for parental smoking.

Meanwhile, there was not a significant difference in the intima-media thickness among those who reported smoking at least once a month and those who said they didn’t smoke (slightly more than a 0.01-mm difference).

"The thickening of the intima-media is reversible," said Dr. Dratva. "But we don’t know for how long this reversibility will stay," and there’s a need for further investigations, she said.

Dr. Dratva reported no financial conflicts.

MUNICH – Smoking in young people can induce structural changes to the arterial wall and possibly lead to the development of atherosclerosis before adulthood, according to a Swiss study.

Ultrasound analysis of the common carotid artery of adolescents who actively smoked showed that their intima-media was as much as 0.03 mm thicker than those of youth who didn’t smoke, researchers reported at the annual congress of the European Society of Cardiology.

While the preliminary findings may not dissuade adolescents from smoking, they highlight the need for prevention efforts, such as implementing smoking bans in cities and states, said study investigator Dr. Julia Dratva, a research fellow at the Swiss Tropical and Public Health Institute, Basel.

Studies have established the negative health effects of tobacco exposure in adolescents, but the Swiss study is one of the first to show the impact of smoking on the arterial walls of youths.

"What the study does is make it clear that the vascular wall starts falling into pieces," in youth who smoke, session moderator Dr. Joep Perk said in an interview. "So you are starting on a path that your vascular wall is going to be eventually plugged," added Dr. Perk, professor of health sciences at Linnaeus University, Sweden.

Researchers recruited 279 subjects in the Swiss Study on Air Pollution and Lung and Heart Disease in Adults (SAPALDIA) Youth Study. Study participants were between ages 9 and 20. Their clinical examination included anthropometry, blood pressure measurement, ultrasound assessment of the carotid artery intima-media thickness, and blood tests for cardiovascular biomarkers.

Many of the study participants had cardiovascular disease risk factors that are known to continue into adulthood and are associated with increased atherosclerotic risk, the authors reported. Thirteen percent of the youth were overweight, 3% had elevated cholesterol, 5% had an HbA_1c level higher than 5.7%, and blood pressure was elevated in 7%.

Ten percent of the participants reported weekly smoking (at least one cigarette per week), and 14% reported smoking monthly. Very few reported daily smoking habits, said Dr. Dratva. Mean smoking duration was 2.3 years in ever-smokers. Exposure to passive smoke up to 10 years of age was reported by 31% and current parental smoking by 25%.

Results showed that smoking duration was positively associated with common carotid intima-media thickness (0.014-mm increase/year). The carotid intima-media was significantly thicker in youth who smoked weekly (0.03 mm) compared with those who didn’t smoke. The results remained consistent after adjustment for parental smoking.

Meanwhile, there was not a significant difference in the intima-media thickness among those who reported smoking at least once a month and those who said they didn’t smoke (slightly more than a 0.01-mm difference).

"The thickening of the intima-media is reversible," said Dr. Dratva. "But we don’t know for how long this reversibility will stay," and there’s a need for further investigations, she said.

Dr. Dratva reported no financial conflicts.