Sharon Worcester

The finding that relatively young stroke survivors have less access to care and more difficulty affording medications than their older counterparts reflects the more widespread problem of lack of medical insurance in the United States, which has “staggering ramifications,” according to Dr. Steven Levine, professor of neurology and director of the cerebrovascular education program at The Mount Sinai Stroke Center and School of Medicine, New York, speaking in an interview.

“We can no longer assume that younger stroke survivors have better access to care than their older counterparts,” he said, commenting on findings from research by Dr. Deborah A. Levine of the University of Alabama, Birmingham and her colleagues. The Drs. Levine are not related.

Dr. Deborah A. Levine reported that between 1997 and 2004, the number of stroke survivors aged 45–64 years in the United States who were unable to afford prescribed medications increased significantly from 8% to 13% (Stroke 2007;38:1557–64).

The findings, based on the responses of 5,840 individuals who participated in the National Health Interview Survey—an in-person household survey conducted annually by the National Center for Health Statistics—suggest that in 2004, about 76,000 stroke survivors in the United States were unable to afford prescribed medications. Those under age 65—along with blacks, women, and those with high comorbidity or low health status—had the lowest rates being able to afford their medications. A number of barriers to care and medications were identified among those with reduced ability to afford medication, suggesting these are particularly vulnerable populations.

For example, compared with stroke survivors who were able to afford medications, those who could not more often had a lack of transportation (15% vs. 3%), no health insurance (16% vs. 3%), annual income below $20,000 (66% vs. 40%), no usual place of care (6% vs. 2%), and out of pocket medical expenses of $2,000 or more.

These barriers to care likely equate to the barriers to secondary stroke prevention—and thus to an increased risk of subsequent cardiovascular event, according to Dr. Deborah A. Levine and her associates, who noted that medication access is an essential component of secondary stroke prevention.

Ischemic stroke survivors have up to a 14% annual risk of recurrent stroke, and also are at risk for other cardiovascular events that can adversely affect health, quality of life, and finances; younger patients often are in the most productive years of life, and thus may be hit the hardest by these effects. Stroke tops the list of disabling diseases among adults, with only 1 in 5 returning to work, 1 in 11 returning to work full time, and 1 in 30 becoming institutionalized, according to one study that looked at stroke survivors 3 months following the event (Arch. Phys. Med. Rehab. 2000;81:205–9).

Dr. Deborah A. Levine's findings expand on those from an earlier study in which she and her colleagues found that younger age among stroke survivors was associated with no general doctor visit (odds ratio 1.4), no medical specialist visit (odds ratio 1.69), and an inability to afford medications (odds ratio 2.94) in the previous 12 months after adjusting for sex, race, income, neurologic disability, health status, and comorbidity. Lack of health insurance explained the lack of access to medical care—which is particularly problematic when it comes to primary care visits since the majority of secondary prevention measures are prescribed by primary care physicians—but did not explain the lack of ability to afford medications. After adjusting for health insurance, younger age remained independently associated with reduced medication affordability, perhaps because of competing expenses or lack of prescription drug coverage, Dr. Deborah A. Levine said in an interview.

For the earlier study, Dr. Deborah A. Levine and her colleagues used 1998–2002 data from the National Health Interview Survey, including responses from 3,681 stroke survivors, representing about 4 million U.S. stroke survivors, nearly a third of whom are aged 45–64 years. The implications of the findings of these studies are numerous and alarming, according to the investigators (Arch. Neurol. 2007;64:37–42).

For example, reduced medication access, specifically patient self-reduction in prescription use, has been associated with increased serious adverse event rates and emergency department visits, a number of adverse health conditions and outcomes in diabetics, and high rates of angina and nonfatal stroke or myocardial infarction in those with cardiovascular disease.

And given that stroke survivors are discharged from rehabilitation with an average of 11 medications totaling about $750 per month (based on 2004 monthly average wholesale price), according to one study, and given that stroke survival is improving while age-specific stroke incidence is remaining constant and the size of the 65 and older population is increasing—as is the number of uninsured nonelderly in the United States—the the long-term care of stroke survivors will prove costly, Dr. Deborah A. Levine said.

ELSEVIER GLOBAL MEDICAL NEWS

The finding that relatively young stroke survivors have less access to care and more difficulty affording medications than their older counterparts reflects the more widespread problem of lack of medical insurance in the United States, which has “staggering ramifications,” according to Dr. Steven Levine, professor of neurology and director of the cerebrovascular education program at The Mount Sinai Stroke Center and School of Medicine, New York, speaking in an interview.

“We can no longer assume that younger stroke survivors have better access to care than their older counterparts,” he said, commenting on findings from research by Dr. Deborah A. Levine of the University of Alabama, Birmingham and her colleagues. The Drs. Levine are not related.

Dr. Deborah A. Levine reported that between 1997 and 2004, the number of stroke survivors aged 45–64 years in the United States who were unable to afford prescribed medications increased significantly from 8% to 13% (Stroke 2007;38:1557–64).

The findings, based on the responses of 5,840 individuals who participated in the National Health Interview Survey—an in-person household survey conducted annually by the National Center for Health Statistics—suggest that in 2004, about 76,000 stroke survivors in the United States were unable to afford prescribed medications. Those under age 65—along with blacks, women, and those with high comorbidity or low health status—had the lowest rates being able to afford their medications. A number of barriers to care and medications were identified among those with reduced ability to afford medication, suggesting these are particularly vulnerable populations.

For example, compared with stroke survivors who were able to afford medications, those who could not more often had a lack of transportation (15% vs. 3%), no health insurance (16% vs. 3%), annual income below $20,000 (66% vs. 40%), no usual place of care (6% vs. 2%), and out of pocket medical expenses of $2,000 or more.

These barriers to care likely equate to the barriers to secondary stroke prevention—and thus to an increased risk of subsequent cardiovascular event, according to Dr. Deborah A. Levine and her associates, who noted that medication access is an essential component of secondary stroke prevention.

Ischemic stroke survivors have up to a 14% annual risk of recurrent stroke, and also are at risk for other cardiovascular events that can adversely affect health, quality of life, and finances; younger patients often are in the most productive years of life, and thus may be hit the hardest by these effects. Stroke tops the list of disabling diseases among adults, with only 1 in 5 returning to work, 1 in 11 returning to work full time, and 1 in 30 becoming institutionalized, according to one study that looked at stroke survivors 3 months following the event (Arch. Phys. Med. Rehab. 2000;81:205–9).

Dr. Deborah A. Levine's findings expand on those from an earlier study in which she and her colleagues found that younger age among stroke survivors was associated with no general doctor visit (odds ratio 1.4), no medical specialist visit (odds ratio 1.69), and an inability to afford medications (odds ratio 2.94) in the previous 12 months after adjusting for sex, race, income, neurologic disability, health status, and comorbidity. Lack of health insurance explained the lack of access to medical care—which is particularly problematic when it comes to primary care visits since the majority of secondary prevention measures are prescribed by primary care physicians—but did not explain the lack of ability to afford medications. After adjusting for health insurance, younger age remained independently associated with reduced medication affordability, perhaps because of competing expenses or lack of prescription drug coverage, Dr. Deborah A. Levine said in an interview.

For the earlier study, Dr. Deborah A. Levine and her colleagues used 1998–2002 data from the National Health Interview Survey, including responses from 3,681 stroke survivors, representing about 4 million U.S. stroke survivors, nearly a third of whom are aged 45–64 years. The implications of the findings of these studies are numerous and alarming, according to the investigators (Arch. Neurol. 2007;64:37–42).

For example, reduced medication access, specifically patient self-reduction in prescription use, has been associated with increased serious adverse event rates and emergency department visits, a number of adverse health conditions and outcomes in diabetics, and high rates of angina and nonfatal stroke or myocardial infarction in those with cardiovascular disease.

And given that stroke survivors are discharged from rehabilitation with an average of 11 medications totaling about $750 per month (based on 2004 monthly average wholesale price), according to one study, and given that stroke survival is improving while age-specific stroke incidence is remaining constant and the size of the 65 and older population is increasing—as is the number of uninsured nonelderly in the United States—the the long-term care of stroke survivors will prove costly, Dr. Deborah A. Levine said.

ELSEVIER GLOBAL MEDICAL NEWS

The finding that relatively young stroke survivors have less access to care and more difficulty affording medications than their older counterparts reflects the more widespread problem of lack of medical insurance in the United States, which has “staggering ramifications,” according to Dr. Steven Levine, professor of neurology and director of the cerebrovascular education program at The Mount Sinai Stroke Center and School of Medicine, New York, speaking in an interview.

“We can no longer assume that younger stroke survivors have better access to care than their older counterparts,” he said, commenting on findings from research by Dr. Deborah A. Levine of the University of Alabama, Birmingham and her colleagues. The Drs. Levine are not related.

Dr. Deborah A. Levine reported that between 1997 and 2004, the number of stroke survivors aged 45–64 years in the United States who were unable to afford prescribed medications increased significantly from 8% to 13% (Stroke 2007;38:1557–64).

The findings, based on the responses of 5,840 individuals who participated in the National Health Interview Survey—an in-person household survey conducted annually by the National Center for Health Statistics—suggest that in 2004, about 76,000 stroke survivors in the United States were unable to afford prescribed medications. Those under age 65—along with blacks, women, and those with high comorbidity or low health status—had the lowest rates being able to afford their medications. A number of barriers to care and medications were identified among those with reduced ability to afford medication, suggesting these are particularly vulnerable populations.

For example, compared with stroke survivors who were able to afford medications, those who could not more often had a lack of transportation (15% vs. 3%), no health insurance (16% vs. 3%), annual income below $20,000 (66% vs. 40%), no usual place of care (6% vs. 2%), and out of pocket medical expenses of $2,000 or more.

These barriers to care likely equate to the barriers to secondary stroke prevention—and thus to an increased risk of subsequent cardiovascular event, according to Dr. Deborah A. Levine and her associates, who noted that medication access is an essential component of secondary stroke prevention.

Ischemic stroke survivors have up to a 14% annual risk of recurrent stroke, and also are at risk for other cardiovascular events that can adversely affect health, quality of life, and finances; younger patients often are in the most productive years of life, and thus may be hit the hardest by these effects. Stroke tops the list of disabling diseases among adults, with only 1 in 5 returning to work, 1 in 11 returning to work full time, and 1 in 30 becoming institutionalized, according to one study that looked at stroke survivors 3 months following the event (Arch. Phys. Med. Rehab. 2000;81:205–9).

Dr. Deborah A. Levine's findings expand on those from an earlier study in which she and her colleagues found that younger age among stroke survivors was associated with no general doctor visit (odds ratio 1.4), no medical specialist visit (odds ratio 1.69), and an inability to afford medications (odds ratio 2.94) in the previous 12 months after adjusting for sex, race, income, neurologic disability, health status, and comorbidity. Lack of health insurance explained the lack of access to medical care—which is particularly problematic when it comes to primary care visits since the majority of secondary prevention measures are prescribed by primary care physicians—but did not explain the lack of ability to afford medications. After adjusting for health insurance, younger age remained independently associated with reduced medication affordability, perhaps because of competing expenses or lack of prescription drug coverage, Dr. Deborah A. Levine said in an interview.

For the earlier study, Dr. Deborah A. Levine and her colleagues used 1998–2002 data from the National Health Interview Survey, including responses from 3,681 stroke survivors, representing about 4 million U.S. stroke survivors, nearly a third of whom are aged 45–64 years. The implications of the findings of these studies are numerous and alarming, according to the investigators (Arch. Neurol. 2007;64:37–42).

For example, reduced medication access, specifically patient self-reduction in prescription use, has been associated with increased serious adverse event rates and emergency department visits, a number of adverse health conditions and outcomes in diabetics, and high rates of angina and nonfatal stroke or myocardial infarction in those with cardiovascular disease.

And given that stroke survivors are discharged from rehabilitation with an average of 11 medications totaling about $750 per month (based on 2004 monthly average wholesale price), according to one study, and given that stroke survival is improving while age-specific stroke incidence is remaining constant and the size of the 65 and older population is increasing—as is the number of uninsured nonelderly in the United States—the the long-term care of stroke survivors will prove costly, Dr. Deborah A. Levine said.

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS — Lifestyle modifications in postmenopausal women attenuate the adverse effects that discontinuing hormone therapy can have on cardiovascular disease risk factors, findings from a subgroup of participants in the Women on the Move Through Activity and Nutrition (WOMAN) study show.

The study is a 5-year randomized clinical trial designed to evaluate the effects of an aggressive nonpharmacologic lifestyle intervention, including weight loss, dietary modification, and increased physical activity, on measures of subclinical cardiovascular disease. In all, 508 women were randomized to the lifestyle intervention group or to a health education control group for the study, and 240 of these women—the subgroup that was studied in the current analysis—represent those who were taking hormone therapy (HT) at baseline.

Of these 240, 130 discontinued HT within 18 months of study entry, and in these 130 discontinuers, total and LDL cholesterol levels had significantly increased at 18-month follow-up, compared with levels in the 110 participants who remained on HT at 18 months. Stratification by randomized group assignment (the lifestyle modification “intervention” group, or the health education “control” group) in these women—which enabled a comparison between HT continuers and discontinuers in each of the two groups—showed that lifestyle modifications successfully counteract these increases, Kelley K. Pettee, Ph.D., reported in a poster at the annual meeting of the American College of Sports Medicine, and subsequently in the American Journal of Preventive Medicine (Am. J. Prev. Med. 2007;32:483–9).

At 18 months, the 70 HT discontinuers in the intervention group had a mean 4-mg/dL increase in total cholesterol and a mean 7-mg/dL increase in LDL cholesterol, which was not statistically different from the mean 5-mg/dL increase in both total and LDL cholesterol in the 64 HT continuers in the intervention group. However, the 60 HT discontinuers in the control group experienced a mean 22-mg/dL increase in both total and LDL cholesterol, compared with a mean 3-mg/dL increase in total cholesterol and a mean 5-mg/dL increase in LDL cholesterol in the 46 HT continuers in the control group, noted Dr. Pettee, who conducted the research while she was a doctoral candidate at the University of Pittsburgh, but who is currently at Arizona State University, Mesa.

Furthermore, when all 134 women in the intervention group were compared with all 106 in the control group, those in the intervention group experienced significantly greater overall decreases in weight, body mass index, and waist circumference, as well as significantly improved fat intake and increased leisure physical activity, providing further evidence of the benefits of the lifestyle modifications, she reported. (See box.)

WOMAN study participants had a waist circumference of at least 80 cm, and a body mass index (kg/m

The median duration of HT use prior to study entry did not differ between the continuers and discontinuers, but the groups differed in that continuers were slightly younger and had higher total cholesterol and lower insulin levels. The groups did not differ significantly in regard to anthropometric measures, leisure physical activity, fat intake, or cholesterol, triglyceride, and glucose levels, and they were also similar in regard to education, race, and smoking status.

Those randomized to the control group received a core educational series of six health-related lectures offered during the first year and quarterly thereafter, and those in the lifestyle intervention group worked closely with a team of nutritionists, exercise physiologists, and psychologists who developed individualized diet and exercise programs designed to reduce weight and waist circumference. Those in the intervention group participated in at least 150 minutes per week of moderate-intensity physical activity, and had a caloric intake of 1,300–1,500 calories per day of low total fat and low saturated-fat foods.

Previous studies have shown that lifestyle interventions have a beneficial effect on cardiovascular disease risk factors, but did not account for concurrent changes in HT status, which is “an issue that has become relevant in the post-WHI [Women's Health Initiative] era,” Dr. Pettee wrote, referring to the fact that many women discontinued HT following publication of WHI findings that linked HT use with an increased risk of cancer and other health problems.

ELSEVIER GLOBAL MEDICAL NEWS

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS — Lifestyle modifications in postmenopausal women attenuate the adverse effects that discontinuing hormone therapy can have on cardiovascular disease risk factors, findings from a subgroup of participants in the Women on the Move Through Activity and Nutrition (WOMAN) study show.

The study is a 5-year randomized clinical trial designed to evaluate the effects of an aggressive nonpharmacologic lifestyle intervention, including weight loss, dietary modification, and increased physical activity, on measures of subclinical cardiovascular disease. In all, 508 women were randomized to the lifestyle intervention group or to a health education control group for the study, and 240 of these women—the subgroup that was studied in the current analysis—represent those who were taking hormone therapy (HT) at baseline.

Of these 240, 130 discontinued HT within 18 months of study entry, and in these 130 discontinuers, total and LDL cholesterol levels had significantly increased at 18-month follow-up, compared with levels in the 110 participants who remained on HT at 18 months. Stratification by randomized group assignment (the lifestyle modification “intervention” group, or the health education “control” group) in these women—which enabled a comparison between HT continuers and discontinuers in each of the two groups—showed that lifestyle modifications successfully counteract these increases, Kelley K. Pettee, Ph.D., reported in a poster at the annual meeting of the American College of Sports Medicine, and subsequently in the American Journal of Preventive Medicine (Am. J. Prev. Med. 2007;32:483–9).

At 18 months, the 70 HT discontinuers in the intervention group had a mean 4-mg/dL increase in total cholesterol and a mean 7-mg/dL increase in LDL cholesterol, which was not statistically different from the mean 5-mg/dL increase in both total and LDL cholesterol in the 64 HT continuers in the intervention group. However, the 60 HT discontinuers in the control group experienced a mean 22-mg/dL increase in both total and LDL cholesterol, compared with a mean 3-mg/dL increase in total cholesterol and a mean 5-mg/dL increase in LDL cholesterol in the 46 HT continuers in the control group, noted Dr. Pettee, who conducted the research while she was a doctoral candidate at the University of Pittsburgh, but who is currently at Arizona State University, Mesa.

Furthermore, when all 134 women in the intervention group were compared with all 106 in the control group, those in the intervention group experienced significantly greater overall decreases in weight, body mass index, and waist circumference, as well as significantly improved fat intake and increased leisure physical activity, providing further evidence of the benefits of the lifestyle modifications, she reported. (See box.)

WOMAN study participants had a waist circumference of at least 80 cm, and a body mass index (kg/m

The median duration of HT use prior to study entry did not differ between the continuers and discontinuers, but the groups differed in that continuers were slightly younger and had higher total cholesterol and lower insulin levels. The groups did not differ significantly in regard to anthropometric measures, leisure physical activity, fat intake, or cholesterol, triglyceride, and glucose levels, and they were also similar in regard to education, race, and smoking status.

Those randomized to the control group received a core educational series of six health-related lectures offered during the first year and quarterly thereafter, and those in the lifestyle intervention group worked closely with a team of nutritionists, exercise physiologists, and psychologists who developed individualized diet and exercise programs designed to reduce weight and waist circumference. Those in the intervention group participated in at least 150 minutes per week of moderate-intensity physical activity, and had a caloric intake of 1,300–1,500 calories per day of low total fat and low saturated-fat foods.

Previous studies have shown that lifestyle interventions have a beneficial effect on cardiovascular disease risk factors, but did not account for concurrent changes in HT status, which is “an issue that has become relevant in the post-WHI [Women's Health Initiative] era,” Dr. Pettee wrote, referring to the fact that many women discontinued HT following publication of WHI findings that linked HT use with an increased risk of cancer and other health problems.

ELSEVIER GLOBAL MEDICAL NEWS

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS — Lifestyle modifications in postmenopausal women attenuate the adverse effects that discontinuing hormone therapy can have on cardiovascular disease risk factors, findings from a subgroup of participants in the Women on the Move Through Activity and Nutrition (WOMAN) study show.

The study is a 5-year randomized clinical trial designed to evaluate the effects of an aggressive nonpharmacologic lifestyle intervention, including weight loss, dietary modification, and increased physical activity, on measures of subclinical cardiovascular disease. In all, 508 women were randomized to the lifestyle intervention group or to a health education control group for the study, and 240 of these women—the subgroup that was studied in the current analysis—represent those who were taking hormone therapy (HT) at baseline.

Of these 240, 130 discontinued HT within 18 months of study entry, and in these 130 discontinuers, total and LDL cholesterol levels had significantly increased at 18-month follow-up, compared with levels in the 110 participants who remained on HT at 18 months. Stratification by randomized group assignment (the lifestyle modification “intervention” group, or the health education “control” group) in these women—which enabled a comparison between HT continuers and discontinuers in each of the two groups—showed that lifestyle modifications successfully counteract these increases, Kelley K. Pettee, Ph.D., reported in a poster at the annual meeting of the American College of Sports Medicine, and subsequently in the American Journal of Preventive Medicine (Am. J. Prev. Med. 2007;32:483–9).

At 18 months, the 70 HT discontinuers in the intervention group had a mean 4-mg/dL increase in total cholesterol and a mean 7-mg/dL increase in LDL cholesterol, which was not statistically different from the mean 5-mg/dL increase in both total and LDL cholesterol in the 64 HT continuers in the intervention group. However, the 60 HT discontinuers in the control group experienced a mean 22-mg/dL increase in both total and LDL cholesterol, compared with a mean 3-mg/dL increase in total cholesterol and a mean 5-mg/dL increase in LDL cholesterol in the 46 HT continuers in the control group, noted Dr. Pettee, who conducted the research while she was a doctoral candidate at the University of Pittsburgh, but who is currently at Arizona State University, Mesa.

Furthermore, when all 134 women in the intervention group were compared with all 106 in the control group, those in the intervention group experienced significantly greater overall decreases in weight, body mass index, and waist circumference, as well as significantly improved fat intake and increased leisure physical activity, providing further evidence of the benefits of the lifestyle modifications, she reported. (See box.)

WOMAN study participants had a waist circumference of at least 80 cm, and a body mass index (kg/m

The median duration of HT use prior to study entry did not differ between the continuers and discontinuers, but the groups differed in that continuers were slightly younger and had higher total cholesterol and lower insulin levels. The groups did not differ significantly in regard to anthropometric measures, leisure physical activity, fat intake, or cholesterol, triglyceride, and glucose levels, and they were also similar in regard to education, race, and smoking status.

Those randomized to the control group received a core educational series of six health-related lectures offered during the first year and quarterly thereafter, and those in the lifestyle intervention group worked closely with a team of nutritionists, exercise physiologists, and psychologists who developed individualized diet and exercise programs designed to reduce weight and waist circumference. Those in the intervention group participated in at least 150 minutes per week of moderate-intensity physical activity, and had a caloric intake of 1,300–1,500 calories per day of low total fat and low saturated-fat foods.

Previous studies have shown that lifestyle interventions have a beneficial effect on cardiovascular disease risk factors, but did not account for concurrent changes in HT status, which is “an issue that has become relevant in the post-WHI [Women's Health Initiative] era,” Dr. Pettee wrote, referring to the fact that many women discontinued HT following publication of WHI findings that linked HT use with an increased risk of cancer and other health problems.

ELSEVIER GLOBAL MEDICAL NEWS

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS — Fatness has more influence than does fitness on cardiovascular disease risk in children and adolescents, data from the Cardiovascular Health in Children and Youth II and III studies show.

The findings suggest that interventions to reduce cardiovascular disease risk should begin early in youth and should focus on reducing body fat, reported Kristin S. Ondrak in a poster at the annual meeting of the American College of Sports Medicine.

Ms. Ondrak and her colleagues used baseline information from a total of 1,824 participants in the CHIC studies, including 938 girls and 886 boys aged 8–16 years, for the current analysis. They assessed fatness and fitness for each participant, as well as cardiovascular disease risk.

Fatness in this study was assessed using the sum of skin folds at the triceps and subscapular sites, and was calculated using established equations that factor in gender, race, and pubertal status. Fitness (defined as aerobic power, or peak oxygen intake [VO_2max], and here expressed in mL/kg per minute as kgVO_2max) was estimated using a multistage submaximal test on a cycle ergometer, with a workload corresponding to a heart rate range of 150–170 beats per minute used to predict the maximum intake. The kgVO_2max measurement includes fat mass, so the researchers also calculated the aerobic power per kilogram of fat-free mass (ffmVO_2max) to remove the potentially confounding effect of fat mass.

The cardiovascular risk score was based on measurements of HDL cholesterol, total cholesterol, triglycerides, systolic and diastolic blood pressures, and fasting insulin, with each measurement classified into one of three risk categories and assigned a score (0 = no risk, 1 = borderline risk, 2 = at risk); the sum of a participant's scores represented that individual's total cardiovascular risk score.

After adjustment for gender and socioeconomic status, the percentage of body fat was a stronger predictor of cardiovascular disease risk score than was fitness, with fatness accounting for the majority of variance in total risk score in each of three age groups (8–10 years, 11–13 years, and 14–16 years).

This was particularly true for the youngest group (partial R

Although fatness played a greater role in risk in the youngest age group in this study, it was the 11- to 13-year age group that appeared most vulnerable, because this group had significantly higher cardiovascular risk scores than did the other groups, and also had more risk factors that were classified as “borderline risk” and “at risk” than did the other groups.

Although the mean percentage of body fat was high for boys and girls in each age group (18% for boys and 27% for girls in the 8- to 10-year age group; 21% for boys and 29% for girls in the 11- to 13-year age group; and 16% for boys and 32% for girls in the 14- to 16-year age group), and the mean aerobic power was low (kgVO_2max of 40 for boys and 34 for girls in the 8- to 10-year age group; 41 for boys and 34 for girls in the 11- to 13-year age group; and 41 for boys and 31 for girls in 14- to 16-year age group), the percentages of participants with elevated risk scores (scores greater than 6 out of 12 possible points) was low (mean of 1.5 boys and 1.8 girls in the 8- to 10-year age group; 2.5 boys and 2.7 girls in the 11- to 13-year age group; and 1.7 boys and 1.5 girls in the 14- to 16-year age group). (See box.)

Fatness and fitness have been implicated in the increasing prevalence of cardiovascular disease risk factors in children and adolescents, but which variable is more important in determining risk and whether age plays a role have remained controversial questions. Some data suggest that a higher percentage of body fat is associated with increased risk regardless of fitness levels, and other data suggest high fitness levels are associated with a lower percentage of body fat. The current study is the first to examine the influence of age in the roles that fitness and fatness play in cardiovascular risk, Ms. Ondrak noted.

ELSEVIER GLOBAL MEDICAL NEWS

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS — Fatness has more influence than does fitness on cardiovascular disease risk in children and adolescents, data from the Cardiovascular Health in Children and Youth II and III studies show.

The findings suggest that interventions to reduce cardiovascular disease risk should begin early in youth and should focus on reducing body fat, reported Kristin S. Ondrak in a poster at the annual meeting of the American College of Sports Medicine.

Ms. Ondrak and her colleagues used baseline information from a total of 1,824 participants in the CHIC studies, including 938 girls and 886 boys aged 8–16 years, for the current analysis. They assessed fatness and fitness for each participant, as well as cardiovascular disease risk.

Fatness in this study was assessed using the sum of skin folds at the triceps and subscapular sites, and was calculated using established equations that factor in gender, race, and pubertal status. Fitness (defined as aerobic power, or peak oxygen intake [VO_2max], and here expressed in mL/kg per minute as kgVO_2max) was estimated using a multistage submaximal test on a cycle ergometer, with a workload corresponding to a heart rate range of 150–170 beats per minute used to predict the maximum intake. The kgVO_2max measurement includes fat mass, so the researchers also calculated the aerobic power per kilogram of fat-free mass (ffmVO_2max) to remove the potentially confounding effect of fat mass.

The cardiovascular risk score was based on measurements of HDL cholesterol, total cholesterol, triglycerides, systolic and diastolic blood pressures, and fasting insulin, with each measurement classified into one of three risk categories and assigned a score (0 = no risk, 1 = borderline risk, 2 = at risk); the sum of a participant's scores represented that individual's total cardiovascular risk score.

After adjustment for gender and socioeconomic status, the percentage of body fat was a stronger predictor of cardiovascular disease risk score than was fitness, with fatness accounting for the majority of variance in total risk score in each of three age groups (8–10 years, 11–13 years, and 14–16 years).

This was particularly true for the youngest group (partial R

Although fatness played a greater role in risk in the youngest age group in this study, it was the 11- to 13-year age group that appeared most vulnerable, because this group had significantly higher cardiovascular risk scores than did the other groups, and also had more risk factors that were classified as “borderline risk” and “at risk” than did the other groups.

Although the mean percentage of body fat was high for boys and girls in each age group (18% for boys and 27% for girls in the 8- to 10-year age group; 21% for boys and 29% for girls in the 11- to 13-year age group; and 16% for boys and 32% for girls in the 14- to 16-year age group), and the mean aerobic power was low (kgVO_2max of 40 for boys and 34 for girls in the 8- to 10-year age group; 41 for boys and 34 for girls in the 11- to 13-year age group; and 41 for boys and 31 for girls in 14- to 16-year age group), the percentages of participants with elevated risk scores (scores greater than 6 out of 12 possible points) was low (mean of 1.5 boys and 1.8 girls in the 8- to 10-year age group; 2.5 boys and 2.7 girls in the 11- to 13-year age group; and 1.7 boys and 1.5 girls in the 14- to 16-year age group). (See box.)

Fatness and fitness have been implicated in the increasing prevalence of cardiovascular disease risk factors in children and adolescents, but which variable is more important in determining risk and whether age plays a role have remained controversial questions. Some data suggest that a higher percentage of body fat is associated with increased risk regardless of fitness levels, and other data suggest high fitness levels are associated with a lower percentage of body fat. The current study is the first to examine the influence of age in the roles that fitness and fatness play in cardiovascular risk, Ms. Ondrak noted.

ELSEVIER GLOBAL MEDICAL NEWS

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS — Fatness has more influence than does fitness on cardiovascular disease risk in children and adolescents, data from the Cardiovascular Health in Children and Youth II and III studies show.

The findings suggest that interventions to reduce cardiovascular disease risk should begin early in youth and should focus on reducing body fat, reported Kristin S. Ondrak in a poster at the annual meeting of the American College of Sports Medicine.

Ms. Ondrak and her colleagues used baseline information from a total of 1,824 participants in the CHIC studies, including 938 girls and 886 boys aged 8–16 years, for the current analysis. They assessed fatness and fitness for each participant, as well as cardiovascular disease risk.

Fatness in this study was assessed using the sum of skin folds at the triceps and subscapular sites, and was calculated using established equations that factor in gender, race, and pubertal status. Fitness (defined as aerobic power, or peak oxygen intake [VO_2max], and here expressed in mL/kg per minute as kgVO_2max) was estimated using a multistage submaximal test on a cycle ergometer, with a workload corresponding to a heart rate range of 150–170 beats per minute used to predict the maximum intake. The kgVO_2max measurement includes fat mass, so the researchers also calculated the aerobic power per kilogram of fat-free mass (ffmVO_2max) to remove the potentially confounding effect of fat mass.

The cardiovascular risk score was based on measurements of HDL cholesterol, total cholesterol, triglycerides, systolic and diastolic blood pressures, and fasting insulin, with each measurement classified into one of three risk categories and assigned a score (0 = no risk, 1 = borderline risk, 2 = at risk); the sum of a participant's scores represented that individual's total cardiovascular risk score.

After adjustment for gender and socioeconomic status, the percentage of body fat was a stronger predictor of cardiovascular disease risk score than was fitness, with fatness accounting for the majority of variance in total risk score in each of three age groups (8–10 years, 11–13 years, and 14–16 years).

This was particularly true for the youngest group (partial R

Although fatness played a greater role in risk in the youngest age group in this study, it was the 11- to 13-year age group that appeared most vulnerable, because this group had significantly higher cardiovascular risk scores than did the other groups, and also had more risk factors that were classified as “borderline risk” and “at risk” than did the other groups.

Although the mean percentage of body fat was high for boys and girls in each age group (18% for boys and 27% for girls in the 8- to 10-year age group; 21% for boys and 29% for girls in the 11- to 13-year age group; and 16% for boys and 32% for girls in the 14- to 16-year age group), and the mean aerobic power was low (kgVO_2max of 40 for boys and 34 for girls in the 8- to 10-year age group; 41 for boys and 34 for girls in the 11- to 13-year age group; and 41 for boys and 31 for girls in 14- to 16-year age group), the percentages of participants with elevated risk scores (scores greater than 6 out of 12 possible points) was low (mean of 1.5 boys and 1.8 girls in the 8- to 10-year age group; 2.5 boys and 2.7 girls in the 11- to 13-year age group; and 1.7 boys and 1.5 girls in the 14- to 16-year age group). (See box.)

Fatness and fitness have been implicated in the increasing prevalence of cardiovascular disease risk factors in children and adolescents, but which variable is more important in determining risk and whether age plays a role have remained controversial questions. Some data suggest that a higher percentage of body fat is associated with increased risk regardless of fitness levels, and other data suggest high fitness levels are associated with a lower percentage of body fat. The current study is the first to examine the influence of age in the roles that fitness and fatness play in cardiovascular risk, Ms. Ondrak noted.

ELSEVIER GLOBAL MEDICAL NEWS

ELSEVIER GLOBAL MEDICAL NEWS

DESTIN, FLA. – The prevention of recurrence in patients presenting with methicillin-resistant Staphylococcus aureus skin infections may require decolonization of certain skin surfaces, Dr. Dirk M. Elston said at a meeting sponsored by the Alabama Dermatology Society.

In fact, with MRSA outbreaks, the decolonization of carriers–who typically comprise at least a third, if not most, of the affected population–is warranted, he said.

Although most carriers will not become infected, there are no good data to help determine which individuals should or should not be treated. In cases of a neonatal ICU outbreak, for example, all of the babies might be colonized, and perhaps only one will become sick–but that one might die as a result.

Moist skin surfaces are typically the areas of concern. In addition to the nares, which are the most common areas for MRSA carriage, the axilla, groin, and perianal areas also are typical areas of carriage. The hands in patients with eczema or fissures, and areas such as legs that are shaved and develop folliculitis or have nicks also are high-risk areas and should be targeted for decolonization.

Oral and intravenous antibiotic treatments don't reach areas such as axillary and groin surface skin, so topical treatments typically are required to eradicate skin surface carriage in those areas, said Dr. Elston, director of the department of dermatology at Geisinger Medical Center, Danville, Pa.

Evidence-based recommendations on the best decolonization strategies are lacking, but there is evidence to support some approaches. In vitro data suggest that zinc may interfere with bacterial adherence, thus a product such as the ZNP bar–a soap containing 2% pyrithione zinc–may be helpful, but clinical studies of this approach are needed.

“Failing that, bleach baths are still great,” Dr. Elston said. Two tablespoons (about 2 capfuls) in a bathtub filled with water is sufficient. Up to 1/4 cup can be used, but skin peeling or irritation may occur at this dose. The optimal frequency for bleach bathing has not been established, however. Recommendations can range from weekly to daily. Products containing 10% benzoyl peroxide are another inexpensive alternative that can be used on the skin instead of bleach, he added.

Other topical products that may be useful for MRSA decolonization of the non-nares skin surface areas include chlorhexidine topical antiseptic (Hibiclens) and antibacterial products containing triclosan, which is found in a number of common products, Dr. Elston noted.

As for nares decolonization, mupirocin, which has long been used for this purpose, is losing efficacy because of increasing resistance. Published clearance rates are below 30%–not bad, but not great, he said, suggesting that another topical should be used as a replacement for mupirocin or in conjunction with it. Fusidic acid is one option, and among newer agents is retapamulin, which is expensive, but thus far, typical MRSA strains in the United States remain susceptible to this drug.

“This is probably better than mupirocin for the nose,” said Dr. Elston, noting that that MRSA decolonization of the nares is an off-label use for this drug.

Tea tree oil also appears to be an effective option for MRSA decolonization. Soaps and creams containing tea tree oil were shown in at least one study to be as effective as a number of antibiotic drug treatments for decolonization when used in the nares–at far less expense.

Research has shown that towels and bar soaps, which are frequently shared among children in families, and even among athletes in the locker room, are the most common sources of MRSA transmission, and sharing should be discouraged.

DESTIN, FLA. – The prevention of recurrence in patients presenting with methicillin-resistant Staphylococcus aureus skin infections may require decolonization of certain skin surfaces, Dr. Dirk M. Elston said at a meeting sponsored by the Alabama Dermatology Society.

In fact, with MRSA outbreaks, the decolonization of carriers–who typically comprise at least a third, if not most, of the affected population–is warranted, he said.

Although most carriers will not become infected, there are no good data to help determine which individuals should or should not be treated. In cases of a neonatal ICU outbreak, for example, all of the babies might be colonized, and perhaps only one will become sick–but that one might die as a result.

Moist skin surfaces are typically the areas of concern. In addition to the nares, which are the most common areas for MRSA carriage, the axilla, groin, and perianal areas also are typical areas of carriage. The hands in patients with eczema or fissures, and areas such as legs that are shaved and develop folliculitis or have nicks also are high-risk areas and should be targeted for decolonization.

Oral and intravenous antibiotic treatments don't reach areas such as axillary and groin surface skin, so topical treatments typically are required to eradicate skin surface carriage in those areas, said Dr. Elston, director of the department of dermatology at Geisinger Medical Center, Danville, Pa.

Evidence-based recommendations on the best decolonization strategies are lacking, but there is evidence to support some approaches. In vitro data suggest that zinc may interfere with bacterial adherence, thus a product such as the ZNP bar–a soap containing 2% pyrithione zinc–may be helpful, but clinical studies of this approach are needed.

“Failing that, bleach baths are still great,” Dr. Elston said. Two tablespoons (about 2 capfuls) in a bathtub filled with water is sufficient. Up to 1/4 cup can be used, but skin peeling or irritation may occur at this dose. The optimal frequency for bleach bathing has not been established, however. Recommendations can range from weekly to daily. Products containing 10% benzoyl peroxide are another inexpensive alternative that can be used on the skin instead of bleach, he added.

Other topical products that may be useful for MRSA decolonization of the non-nares skin surface areas include chlorhexidine topical antiseptic (Hibiclens) and antibacterial products containing triclosan, which is found in a number of common products, Dr. Elston noted.

As for nares decolonization, mupirocin, which has long been used for this purpose, is losing efficacy because of increasing resistance. Published clearance rates are below 30%–not bad, but not great, he said, suggesting that another topical should be used as a replacement for mupirocin or in conjunction with it. Fusidic acid is one option, and among newer agents is retapamulin, which is expensive, but thus far, typical MRSA strains in the United States remain susceptible to this drug.

“This is probably better than mupirocin for the nose,” said Dr. Elston, noting that that MRSA decolonization of the nares is an off-label use for this drug.

Tea tree oil also appears to be an effective option for MRSA decolonization. Soaps and creams containing tea tree oil were shown in at least one study to be as effective as a number of antibiotic drug treatments for decolonization when used in the nares–at far less expense.

Research has shown that towels and bar soaps, which are frequently shared among children in families, and even among athletes in the locker room, are the most common sources of MRSA transmission, and sharing should be discouraged.

DESTIN, FLA. – The prevention of recurrence in patients presenting with methicillin-resistant Staphylococcus aureus skin infections may require decolonization of certain skin surfaces, Dr. Dirk M. Elston said at a meeting sponsored by the Alabama Dermatology Society.

In fact, with MRSA outbreaks, the decolonization of carriers–who typically comprise at least a third, if not most, of the affected population–is warranted, he said.

Although most carriers will not become infected, there are no good data to help determine which individuals should or should not be treated. In cases of a neonatal ICU outbreak, for example, all of the babies might be colonized, and perhaps only one will become sick–but that one might die as a result.

Moist skin surfaces are typically the areas of concern. In addition to the nares, which are the most common areas for MRSA carriage, the axilla, groin, and perianal areas also are typical areas of carriage. The hands in patients with eczema or fissures, and areas such as legs that are shaved and develop folliculitis or have nicks also are high-risk areas and should be targeted for decolonization.

Oral and intravenous antibiotic treatments don't reach areas such as axillary and groin surface skin, so topical treatments typically are required to eradicate skin surface carriage in those areas, said Dr. Elston, director of the department of dermatology at Geisinger Medical Center, Danville, Pa.

Evidence-based recommendations on the best decolonization strategies are lacking, but there is evidence to support some approaches. In vitro data suggest that zinc may interfere with bacterial adherence, thus a product such as the ZNP bar–a soap containing 2% pyrithione zinc–may be helpful, but clinical studies of this approach are needed.

“Failing that, bleach baths are still great,” Dr. Elston said. Two tablespoons (about 2 capfuls) in a bathtub filled with water is sufficient. Up to 1/4 cup can be used, but skin peeling or irritation may occur at this dose. The optimal frequency for bleach bathing has not been established, however. Recommendations can range from weekly to daily. Products containing 10% benzoyl peroxide are another inexpensive alternative that can be used on the skin instead of bleach, he added.

Other topical products that may be useful for MRSA decolonization of the non-nares skin surface areas include chlorhexidine topical antiseptic (Hibiclens) and antibacterial products containing triclosan, which is found in a number of common products, Dr. Elston noted.

As for nares decolonization, mupirocin, which has long been used for this purpose, is losing efficacy because of increasing resistance. Published clearance rates are below 30%–not bad, but not great, he said, suggesting that another topical should be used as a replacement for mupirocin or in conjunction with it. Fusidic acid is one option, and among newer agents is retapamulin, which is expensive, but thus far, typical MRSA strains in the United States remain susceptible to this drug.

“This is probably better than mupirocin for the nose,” said Dr. Elston, noting that that MRSA decolonization of the nares is an off-label use for this drug.

Tea tree oil also appears to be an effective option for MRSA decolonization. Soaps and creams containing tea tree oil were shown in at least one study to be as effective as a number of antibiotic drug treatments for decolonization when used in the nares–at far less expense.

Research has shown that towels and bar soaps, which are frequently shared among children in families, and even among athletes in the locker room, are the most common sources of MRSA transmission, and sharing should be discouraged.

NEW ORLEANS – Therapeutic lifestyle changes are effective for lowering blood pressure in individuals with prehypertension, but obese individuals may not derive maximum benefit, according to findings from a prospective study of nearly 2,500 patients who had prehypertension at baseline.

Of the 1,113 obese adults (body mass index of greater than 30 kg/m

The blood pressure reductions were statistically significant in all groups, but the greatest reductions were seen in the nonoverweight subjects (average reduction of 10/8 mm Hg vs. 7/6 mm Hg for overweight subjects, and 6/5 mm Hg for obese subjects), Dr. Barry A. Franklin reported in a poster at the annual meeting of the American College of Sports Medicine.

The greatest changes were seen in the nonoverweight group, despite significantly more weight loss in the obese subjects (6 pounds), and the overweight subjects (3 pounds), compared with the nonoverweight subjects (0 pounds), noted Dr. Franklin of William Beaumont Hospital, Royal Oak, Mich.

Overall, the average resting blood pressure of the study population (125/79 mm Hg) decreased by 6/3 mm Hg. Systolic blood pressure decreased by 7 mm Hg in those with a baseline systolic blood pressure of 120-139 mm Hg, and diastolic blood pressure decreased by 6 mm Hg in those with a baseline diastolic blood pressure of 80-89 mm Hg. All of the decreases were statistically significant.

The participants, who were not using any type of drug therapy to control blood pressure, were evaluated at baseline and after an average of 6 months of participation in the program, which involved exercise training, nutrition, weight management, stress management, and smoking cessation interventions.

The findings are important, Dr. Franklin explained, because although guidelines promote therapeutic lifestyle changes as a cornerstone in the management of prehypertension, findings from recent research that has focused largely on pharmacotherapy for prehypertension suggest that TLC is ineffective or inadequate.

These data show that TLC can be effective for managing prehypertension, which is a precursor of hypertension and a predictor of excessive cardiovascular risk, but they also suggest that there may be BMI-related differences in blood pressure responsiveness to TLC, he concluded.

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS – Therapeutic lifestyle changes are effective for lowering blood pressure in individuals with prehypertension, but obese individuals may not derive maximum benefit, according to findings from a prospective study of nearly 2,500 patients who had prehypertension at baseline.

Of the 1,113 obese adults (body mass index of greater than 30 kg/m

The blood pressure reductions were statistically significant in all groups, but the greatest reductions were seen in the nonoverweight subjects (average reduction of 10/8 mm Hg vs. 7/6 mm Hg for overweight subjects, and 6/5 mm Hg for obese subjects), Dr. Barry A. Franklin reported in a poster at the annual meeting of the American College of Sports Medicine.

The greatest changes were seen in the nonoverweight group, despite significantly more weight loss in the obese subjects (6 pounds), and the overweight subjects (3 pounds), compared with the nonoverweight subjects (0 pounds), noted Dr. Franklin of William Beaumont Hospital, Royal Oak, Mich.

Overall, the average resting blood pressure of the study population (125/79 mm Hg) decreased by 6/3 mm Hg. Systolic blood pressure decreased by 7 mm Hg in those with a baseline systolic blood pressure of 120-139 mm Hg, and diastolic blood pressure decreased by 6 mm Hg in those with a baseline diastolic blood pressure of 80-89 mm Hg. All of the decreases were statistically significant.

The participants, who were not using any type of drug therapy to control blood pressure, were evaluated at baseline and after an average of 6 months of participation in the program, which involved exercise training, nutrition, weight management, stress management, and smoking cessation interventions.

The findings are important, Dr. Franklin explained, because although guidelines promote therapeutic lifestyle changes as a cornerstone in the management of prehypertension, findings from recent research that has focused largely on pharmacotherapy for prehypertension suggest that TLC is ineffective or inadequate.

These data show that TLC can be effective for managing prehypertension, which is a precursor of hypertension and a predictor of excessive cardiovascular risk, but they also suggest that there may be BMI-related differences in blood pressure responsiveness to TLC, he concluded.

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS – Therapeutic lifestyle changes are effective for lowering blood pressure in individuals with prehypertension, but obese individuals may not derive maximum benefit, according to findings from a prospective study of nearly 2,500 patients who had prehypertension at baseline.

Of the 1,113 obese adults (body mass index of greater than 30 kg/m

The blood pressure reductions were statistically significant in all groups, but the greatest reductions were seen in the nonoverweight subjects (average reduction of 10/8 mm Hg vs. 7/6 mm Hg for overweight subjects, and 6/5 mm Hg for obese subjects), Dr. Barry A. Franklin reported in a poster at the annual meeting of the American College of Sports Medicine.

The greatest changes were seen in the nonoverweight group, despite significantly more weight loss in the obese subjects (6 pounds), and the overweight subjects (3 pounds), compared with the nonoverweight subjects (0 pounds), noted Dr. Franklin of William Beaumont Hospital, Royal Oak, Mich.

Overall, the average resting blood pressure of the study population (125/79 mm Hg) decreased by 6/3 mm Hg. Systolic blood pressure decreased by 7 mm Hg in those with a baseline systolic blood pressure of 120-139 mm Hg, and diastolic blood pressure decreased by 6 mm Hg in those with a baseline diastolic blood pressure of 80-89 mm Hg. All of the decreases were statistically significant.

The participants, who were not using any type of drug therapy to control blood pressure, were evaluated at baseline and after an average of 6 months of participation in the program, which involved exercise training, nutrition, weight management, stress management, and smoking cessation interventions.

The findings are important, Dr. Franklin explained, because although guidelines promote therapeutic lifestyle changes as a cornerstone in the management of prehypertension, findings from recent research that has focused largely on pharmacotherapy for prehypertension suggest that TLC is ineffective or inadequate.

These data show that TLC can be effective for managing prehypertension, which is a precursor of hypertension and a predictor of excessive cardiovascular risk, but they also suggest that there may be BMI-related differences in blood pressure responsiveness to TLC, he concluded.

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS — Video and arcade games that require physical activity can increase heart and metabolic rates enough to elicit a training response, Andrea Brandt reported at the annual meeting of the American College of Sports Medicine.

A training response requires a minimum heart rate increase to 50%–85% of heart rate reserve, and a minimum caloric expenditure of 150–400 Kcal per day through physical activity, according to guidelines from ACSM.

Ms. Brandt, a student at California State University, San Bernardino, reported her findings in poster at the meeting. In her study of 13 adults with a mean age of 26 years, participants burned an average of 226 gross Kcal per 30-minute game session (for a net expenditure of 184 Kcal) and were able to attain a heart rate well above 60% of calculated heart rate reserve.

The study was conducted at an arcade where participants used games, including 3-Kick, a kick-boxing game in which the player hits or kicks stacked pads on posts as they light up; Jackie Chan Studio Fitness Power Boxing, a game in which the player wears boxing gloves with sensors and is matched against a virtual opponent, and Disney's Cars Piston Cup Race, which involves the use of a stationary bike to propel a car in the video game.

Mean resting VO2 was 3.74 mL/kg per min, and mean resting caloric expenditure was 1.39 Kcal/min, compared with 7.54 Kcal/min during exercise. Mean resting heart rate was 82 beats per minute, compared with 163 beats per minute during game playing, which was equal to an average of about 72% of heart rate reserve.

The findings suggest that such games could be recommended as an alternative form of exercise, and could be incorporated into an overall aerobic exercise program, Ms. Brandt concluded.

NEW ORLEANS — Video and arcade games that require physical activity can increase heart and metabolic rates enough to elicit a training response, Andrea Brandt reported at the annual meeting of the American College of Sports Medicine.

A training response requires a minimum heart rate increase to 50%–85% of heart rate reserve, and a minimum caloric expenditure of 150–400 Kcal per day through physical activity, according to guidelines from ACSM.

Ms. Brandt, a student at California State University, San Bernardino, reported her findings in poster at the meeting. In her study of 13 adults with a mean age of 26 years, participants burned an average of 226 gross Kcal per 30-minute game session (for a net expenditure of 184 Kcal) and were able to attain a heart rate well above 60% of calculated heart rate reserve.

The study was conducted at an arcade where participants used games, including 3-Kick, a kick-boxing game in which the player hits or kicks stacked pads on posts as they light up; Jackie Chan Studio Fitness Power Boxing, a game in which the player wears boxing gloves with sensors and is matched against a virtual opponent, and Disney's Cars Piston Cup Race, which involves the use of a stationary bike to propel a car in the video game.

Mean resting VO2 was 3.74 mL/kg per min, and mean resting caloric expenditure was 1.39 Kcal/min, compared with 7.54 Kcal/min during exercise. Mean resting heart rate was 82 beats per minute, compared with 163 beats per minute during game playing, which was equal to an average of about 72% of heart rate reserve.

The findings suggest that such games could be recommended as an alternative form of exercise, and could be incorporated into an overall aerobic exercise program, Ms. Brandt concluded.

NEW ORLEANS — Video and arcade games that require physical activity can increase heart and metabolic rates enough to elicit a training response, Andrea Brandt reported at the annual meeting of the American College of Sports Medicine.

A training response requires a minimum heart rate increase to 50%–85% of heart rate reserve, and a minimum caloric expenditure of 150–400 Kcal per day through physical activity, according to guidelines from ACSM.

Ms. Brandt, a student at California State University, San Bernardino, reported her findings in poster at the meeting. In her study of 13 adults with a mean age of 26 years, participants burned an average of 226 gross Kcal per 30-minute game session (for a net expenditure of 184 Kcal) and were able to attain a heart rate well above 60% of calculated heart rate reserve.

The study was conducted at an arcade where participants used games, including 3-Kick, a kick-boxing game in which the player hits or kicks stacked pads on posts as they light up; Jackie Chan Studio Fitness Power Boxing, a game in which the player wears boxing gloves with sensors and is matched against a virtual opponent, and Disney's Cars Piston Cup Race, which involves the use of a stationary bike to propel a car in the video game.

Mean resting VO2 was 3.74 mL/kg per min, and mean resting caloric expenditure was 1.39 Kcal/min, compared with 7.54 Kcal/min during exercise. Mean resting heart rate was 82 beats per minute, compared with 163 beats per minute during game playing, which was equal to an average of about 72% of heart rate reserve.

The findings suggest that such games could be recommended as an alternative form of exercise, and could be incorporated into an overall aerobic exercise program, Ms. Brandt concluded.

The androgenicity of the progestin component of hormonal contraceptives used before pregnancy may affect risk for gestational diabetes mellitus, a recent study suggested.

In a nested case-control study of 724 women with a live singleton birth, the use of only low-androgen hormonal contraceptives for at least 6 months in the 5 years before pregnancy was associated with a 16% reduction in gestational diabetes mellitus (GDM) risk, compared with no hormonal contraceptive use.

In addition, the use of a high-androgen hormonal contraceptive for at least 6 months—regardless of whether low-androgen contraceptives were also used—in the 5 years before pregnancy was associated with a 43% increase in GDM risk (adjusted odds ratio 1.43), reported Monique M. Hedderson, Ph.D., of the Kaiser Permanente Medical Care Program of Northern California, Oakland, and her colleagues.

Women who used Loestrin—the highest-androgen oral contraceptive—had the greatest increase in GDM risk (adjusted odds ratio 1.99), the investigators noted (Diabetes Care 2007;30:1062–8).

The findings remained essentially unchanged when the data analyses were repeated after excluding women who used nonoral hormonal contraceptives.

The 356 case patients and 368 controls were part of a multiethnic cohort of more than 14,000 women who delivered between Jan. 1, 1996, and June 30, 1998 and were screened for GDM between 24 and 28 weeks' gestation. Patients were diagnosed with GDM if at least two of four plasma glucose values obtained during a 100-g, 3-hour oral glucose tolerance test were abnormal by National Diabetes Data Group criteria.

For oral contraceptives, high androgenicity was defined as androgenic activity of at least 0.47 mg of methyl testosterone equivalents per 28 days. Among nonoral hormonal contraceptives, Norplant was considered high androgen because it contains levonorgestrel, which has high androgenic activity; depo-medroxyprogesterone acetate contraceptives were considered low androgen because they contain medroxyprogesterone, which has low androgenic activity.

There was some evidence in this study that the duration of contraceptive use also played a role in GDM risk: A greater reduction in GDM risk was seen with longer duration of low-androgen contraceptives. No clear trend emerged in regard to duration of use of high-androgen contraceptives. “However, the statistical precision of our results was not great, and, given no true associations, chance alone plausibly could have been responsible for those we did observe,” the authors noted.

The risk reduction associated with low-androgen contraceptives was greatest when use was discontinued within 6 months before pregnancy, and the risk increase associated with high-androgen contraceptives was greatest when use was discontinued at least 1 year before pregnancy.

The effect of hormonal contraceptives on GDM risk may vary based on the androgenicity of the progestin component of the contraceptives, but the findings of this study should be interpreted with caution pending additional study, the investigators concluded.

ELSEVIER GLOBAL MEDICAL NEWS

The androgenicity of the progestin component of hormonal contraceptives used before pregnancy may affect risk for gestational diabetes mellitus, a recent study suggested.

In a nested case-control study of 724 women with a live singleton birth, the use of only low-androgen hormonal contraceptives for at least 6 months in the 5 years before pregnancy was associated with a 16% reduction in gestational diabetes mellitus (GDM) risk, compared with no hormonal contraceptive use.

In addition, the use of a high-androgen hormonal contraceptive for at least 6 months—regardless of whether low-androgen contraceptives were also used—in the 5 years before pregnancy was associated with a 43% increase in GDM risk (adjusted odds ratio 1.43), reported Monique M. Hedderson, Ph.D., of the Kaiser Permanente Medical Care Program of Northern California, Oakland, and her colleagues.

Women who used Loestrin—the highest-androgen oral contraceptive—had the greatest increase in GDM risk (adjusted odds ratio 1.99), the investigators noted (Diabetes Care 2007;30:1062–8).

The findings remained essentially unchanged when the data analyses were repeated after excluding women who used nonoral hormonal contraceptives.

The 356 case patients and 368 controls were part of a multiethnic cohort of more than 14,000 women who delivered between Jan. 1, 1996, and June 30, 1998 and were screened for GDM between 24 and 28 weeks' gestation. Patients were diagnosed with GDM if at least two of four plasma glucose values obtained during a 100-g, 3-hour oral glucose tolerance test were abnormal by National Diabetes Data Group criteria.

For oral contraceptives, high androgenicity was defined as androgenic activity of at least 0.47 mg of methyl testosterone equivalents per 28 days. Among nonoral hormonal contraceptives, Norplant was considered high androgen because it contains levonorgestrel, which has high androgenic activity; depo-medroxyprogesterone acetate contraceptives were considered low androgen because they contain medroxyprogesterone, which has low androgenic activity.

There was some evidence in this study that the duration of contraceptive use also played a role in GDM risk: A greater reduction in GDM risk was seen with longer duration of low-androgen contraceptives. No clear trend emerged in regard to duration of use of high-androgen contraceptives. “However, the statistical precision of our results was not great, and, given no true associations, chance alone plausibly could have been responsible for those we did observe,” the authors noted.

The risk reduction associated with low-androgen contraceptives was greatest when use was discontinued within 6 months before pregnancy, and the risk increase associated with high-androgen contraceptives was greatest when use was discontinued at least 1 year before pregnancy.

The effect of hormonal contraceptives on GDM risk may vary based on the androgenicity of the progestin component of the contraceptives, but the findings of this study should be interpreted with caution pending additional study, the investigators concluded.

ELSEVIER GLOBAL MEDICAL NEWS

The androgenicity of the progestin component of hormonal contraceptives used before pregnancy may affect risk for gestational diabetes mellitus, a recent study suggested.

In a nested case-control study of 724 women with a live singleton birth, the use of only low-androgen hormonal contraceptives for at least 6 months in the 5 years before pregnancy was associated with a 16% reduction in gestational diabetes mellitus (GDM) risk, compared with no hormonal contraceptive use.

In addition, the use of a high-androgen hormonal contraceptive for at least 6 months—regardless of whether low-androgen contraceptives were also used—in the 5 years before pregnancy was associated with a 43% increase in GDM risk (adjusted odds ratio 1.43), reported Monique M. Hedderson, Ph.D., of the Kaiser Permanente Medical Care Program of Northern California, Oakland, and her colleagues.

Women who used Loestrin—the highest-androgen oral contraceptive—had the greatest increase in GDM risk (adjusted odds ratio 1.99), the investigators noted (Diabetes Care 2007;30:1062–8).

The findings remained essentially unchanged when the data analyses were repeated after excluding women who used nonoral hormonal contraceptives.

The 356 case patients and 368 controls were part of a multiethnic cohort of more than 14,000 women who delivered between Jan. 1, 1996, and June 30, 1998 and were screened for GDM between 24 and 28 weeks' gestation. Patients were diagnosed with GDM if at least two of four plasma glucose values obtained during a 100-g, 3-hour oral glucose tolerance test were abnormal by National Diabetes Data Group criteria.

For oral contraceptives, high androgenicity was defined as androgenic activity of at least 0.47 mg of methyl testosterone equivalents per 28 days. Among nonoral hormonal contraceptives, Norplant was considered high androgen because it contains levonorgestrel, which has high androgenic activity; depo-medroxyprogesterone acetate contraceptives were considered low androgen because they contain medroxyprogesterone, which has low androgenic activity.

There was some evidence in this study that the duration of contraceptive use also played a role in GDM risk: A greater reduction in GDM risk was seen with longer duration of low-androgen contraceptives. No clear trend emerged in regard to duration of use of high-androgen contraceptives. “However, the statistical precision of our results was not great, and, given no true associations, chance alone plausibly could have been responsible for those we did observe,” the authors noted.

The risk reduction associated with low-androgen contraceptives was greatest when use was discontinued within 6 months before pregnancy, and the risk increase associated with high-androgen contraceptives was greatest when use was discontinued at least 1 year before pregnancy.

The effect of hormonal contraceptives on GDM risk may vary based on the androgenicity of the progestin component of the contraceptives, but the findings of this study should be interpreted with caution pending additional study, the investigators concluded.

ELSEVIER GLOBAL MEDICAL NEWS

The androgenicity of the progestin component of hormonal contraceptives used before pregnancy may affect risk for gestational diabetes mellitus, suggests a recent study.

In a nested case-control study of 724 women with a live singleton birth, the use of only low-androgen hormonal contraceptives for at least 6 months in the 5 years before pregnancy was associated with a 16% reduction in gestational diabetes mellitus (GDM) risk (adjusted odds ratio 0.84), compared with no hormonal contraceptive use. In addition, the use of a high-androgen hormonal contraceptive for at least 6 months—regardless of whether low-androgen contraceptives were also used—in the 5 years before pregnancy was associated with a 43% increase in GDM risk (adjusted odds ratio 1.43), reported Monique M. Hedderson, Ph.D., of the Kaiser Permanente Medical Care Program of Northern California, Oakland, and her colleagues.

Women who used Loestrin—the highest-androgen oral contraceptive—had the greatest increase in GDM risk (adjusted odds ratio 1.99), the investigators noted (Diabetes Care 2007;30:1062–8).

The findings remained essentially unchanged when the data analyses were repeated after excluding women who used nonoral hormonal contraceptives.

The 356 case patients and 368 controls were part of a multiethnic cohort of more than 14,000 women who delivered between Jan. 1, 1996, and June 30, 1998, and who were screened for GDM between 24 and 28 weeks' gestation. Patients were diagnosed with GDM if at least two of four plasma glucose values obtained during a 100-g, 3-hour oral glucose tolerance test were abnormal by National Diabetes Data Group criteria.

For oral contraceptives, high androgenicity was defined as androgenic activity of at least 0.47 mg of methyl testosterone equivalents per 28 days. Among nonoral hormonal contraceptives, Norplant was considered high androgen because it contains levonorgestrel, which has high androgenic activity; depo-medroxyprogesterone acetate contraceptives were considered low androgen because they contain medroxyprogesterone, which has low androgenic activity.

There was some evidence in this study that the duration of contraceptive use also played a role in GDM risk: A greater reduction in GDM risk was seen with longer duration of low-androgen contraceptives. No clear trend emerged in regard to duration of use of high-androgen contraceptives. “However, the statistical precision of our results was not great, and, given no true associations, chance alone plausibly could have been responsible for those we did observe,” the authors noted.

The risk reduction associated with low-androgen contraceptives was greatest when use was discontinued within 6 months before pregnancy, and the risk increase associated with high-androgen contraceptives was greatest when use was discontinued at least 1 year before pregnancy.

The effect of hormonal contraceptives on GDM risk may vary based on the androgenicity of the progestin component of the contraceptives, but the findings of this study should be interpreted with caution pending additional study, the investigators concluded.

ELSEVIER GLOBAL MEDICAL NEWS

The androgenicity of the progestin component of hormonal contraceptives used before pregnancy may affect risk for gestational diabetes mellitus, suggests a recent study.

In a nested case-control study of 724 women with a live singleton birth, the use of only low-androgen hormonal contraceptives for at least 6 months in the 5 years before pregnancy was associated with a 16% reduction in gestational diabetes mellitus (GDM) risk (adjusted odds ratio 0.84), compared with no hormonal contraceptive use. In addition, the use of a high-androgen hormonal contraceptive for at least 6 months—regardless of whether low-androgen contraceptives were also used—in the 5 years before pregnancy was associated with a 43% increase in GDM risk (adjusted odds ratio 1.43), reported Monique M. Hedderson, Ph.D., of the Kaiser Permanente Medical Care Program of Northern California, Oakland, and her colleagues.

Women who used Loestrin—the highest-androgen oral contraceptive—had the greatest increase in GDM risk (adjusted odds ratio 1.99), the investigators noted (Diabetes Care 2007;30:1062–8).

The findings remained essentially unchanged when the data analyses were repeated after excluding women who used nonoral hormonal contraceptives.

The 356 case patients and 368 controls were part of a multiethnic cohort of more than 14,000 women who delivered between Jan. 1, 1996, and June 30, 1998, and who were screened for GDM between 24 and 28 weeks' gestation. Patients were diagnosed with GDM if at least two of four plasma glucose values obtained during a 100-g, 3-hour oral glucose tolerance test were abnormal by National Diabetes Data Group criteria.

For oral contraceptives, high androgenicity was defined as androgenic activity of at least 0.47 mg of methyl testosterone equivalents per 28 days. Among nonoral hormonal contraceptives, Norplant was considered high androgen because it contains levonorgestrel, which has high androgenic activity; depo-medroxyprogesterone acetate contraceptives were considered low androgen because they contain medroxyprogesterone, which has low androgenic activity.

There was some evidence in this study that the duration of contraceptive use also played a role in GDM risk: A greater reduction in GDM risk was seen with longer duration of low-androgen contraceptives. No clear trend emerged in regard to duration of use of high-androgen contraceptives. “However, the statistical precision of our results was not great, and, given no true associations, chance alone plausibly could have been responsible for those we did observe,” the authors noted.

The risk reduction associated with low-androgen contraceptives was greatest when use was discontinued within 6 months before pregnancy, and the risk increase associated with high-androgen contraceptives was greatest when use was discontinued at least 1 year before pregnancy.

The effect of hormonal contraceptives on GDM risk may vary based on the androgenicity of the progestin component of the contraceptives, but the findings of this study should be interpreted with caution pending additional study, the investigators concluded.

ELSEVIER GLOBAL MEDICAL NEWS

The androgenicity of the progestin component of hormonal contraceptives used before pregnancy may affect risk for gestational diabetes mellitus, suggests a recent study.

In a nested case-control study of 724 women with a live singleton birth, the use of only low-androgen hormonal contraceptives for at least 6 months in the 5 years before pregnancy was associated with a 16% reduction in gestational diabetes mellitus (GDM) risk (adjusted odds ratio 0.84), compared with no hormonal contraceptive use. In addition, the use of a high-androgen hormonal contraceptive for at least 6 months—regardless of whether low-androgen contraceptives were also used—in the 5 years before pregnancy was associated with a 43% increase in GDM risk (adjusted odds ratio 1.43), reported Monique M. Hedderson, Ph.D., of the Kaiser Permanente Medical Care Program of Northern California, Oakland, and her colleagues.

Women who used Loestrin—the highest-androgen oral contraceptive—had the greatest increase in GDM risk (adjusted odds ratio 1.99), the investigators noted (Diabetes Care 2007;30:1062–8).

The findings remained essentially unchanged when the data analyses were repeated after excluding women who used nonoral hormonal contraceptives.

The 356 case patients and 368 controls were part of a multiethnic cohort of more than 14,000 women who delivered between Jan. 1, 1996, and June 30, 1998, and who were screened for GDM between 24 and 28 weeks' gestation. Patients were diagnosed with GDM if at least two of four plasma glucose values obtained during a 100-g, 3-hour oral glucose tolerance test were abnormal by National Diabetes Data Group criteria.

For oral contraceptives, high androgenicity was defined as androgenic activity of at least 0.47 mg of methyl testosterone equivalents per 28 days. Among nonoral hormonal contraceptives, Norplant was considered high androgen because it contains levonorgestrel, which has high androgenic activity; depo-medroxyprogesterone acetate contraceptives were considered low androgen because they contain medroxyprogesterone, which has low androgenic activity.

There was some evidence in this study that the duration of contraceptive use also played a role in GDM risk: A greater reduction in GDM risk was seen with longer duration of low-androgen contraceptives. No clear trend emerged in regard to duration of use of high-androgen contraceptives. “However, the statistical precision of our results was not great, and, given no true associations, chance alone plausibly could have been responsible for those we did observe,” the authors noted.

The risk reduction associated with low-androgen contraceptives was greatest when use was discontinued within 6 months before pregnancy, and the risk increase associated with high-androgen contraceptives was greatest when use was discontinued at least 1 year before pregnancy.

The effect of hormonal contraceptives on GDM risk may vary based on the androgenicity of the progestin component of the contraceptives, but the findings of this study should be interpreted with caution pending additional study, the investigators concluded.

ELSEVIER GLOBAL MEDICAL NEWS

DESTIN, FLA. — Classic polyarteritis nodosa, or PAN, is curable in the majority of cases, Dr. John H. Stone said at the annual Rheumatology on the Beach.

The belief that this form of vasculitis is incurable is one of many myths about systemic vasculitides, he said, noting “classic PAN” means disease that does not include palpable purpura, glomerulonephritis, lung disease, or antineutrophil cytoplasmic antibody-positive disease.

In a study reported last year at the annual meeting of the American College of Rheumatology, two-thirds of PANpatients were cured, though that figure is likely high because patients other than those with classic PAN were included, noted Dr. Stone, a Boston-based rheumatologist and editor of Rheumatology UpToDate.

In his experience with classic PAN in the past 5 years, 17 of 21 patients were cured. Some were treated with steroids, and some were treated with steroids and cyclophosphamide; all were tapered completely off their drugs. The remaining four patients remained on low-dose steroids to control persistent skin disease, he said.

“As we understand PAN better, we are going to recognize that we can subclassify it phenotypically a bit more precisely,” he said. Forms of the disease are tied to hepatitis B, there is the classic curable type, and there may be other subtypes.

To debunk another myth about systemic vasculitis, Dr. Stone described a patient with Wegener's granulomatosis who was diagnosed with rheumatoid arthritis based on the presence of arthritis and nodules on his elbows. Arthritis plus nodules does not necessarily equal RA, he said. The Churg-Strauss-type granulomas seen in this patient can be associated with Churg-Strauss syndrome, but another myth is that Churg-Strauss syndrome is the most common cause of the nodules. In fact, Wegener's granulomatosis is the most common cause, Dr. Stone explained.

Myths also exist about treatment for vasculitis. Chemotherapy with cyclophosphamide is indicated in patients with mononeuritis multiplex, central nervous system disease, rapidly progressing glomerulonephritis, mesenteric vasculitis, cardiac involvement, or alveolar hemorrhage. Nonhealing cutaneous ulcers or excessive steroid toxicity are also indications.

Data from one study, presented only in abstract form, show that intravenous cyclophosphamide treatment once every 2 weeks is as effective as oral daily cyclophosphamide but safer. However, daily oral treatment is currently the preferred approach for induction of remission. Some studies suggest oral therapy improves the chance of sustained remission. Oral cyclophosphamide can be titrated based on white cell count, another safety feature.

Patients who fail to respond to conventional daily cyclophosphamide should be considered to have an infection. Systemic vasculitis is almost always reliably controlled with conventional therapy, thus it is important to consider aspergillosis and other agents in refractory cases. Induction of neutropenia is not essential for achieving remission. The goal is to maintain white cell count above 3,500 or 4,000/mm

Episcleritis often is an overlooked clue that a patient's vasculitis has flared. Courtesy Dr. John H. Stone

Episcleritis Is Sign Of Vasculitis Flare

A frequent signal of disease flare in patients with systemic vasculitis is episcleritis, Dr. Stone said.

The Wegener's granulomatosis patient who was misdiagnosed with RA presented with this ocular condition—the most common ocular manifestation of systemic vasculitis—signaling renewed disease activity. The patient was having a flare but didn't realize it.

The onset of episcleritis is often overlooked. Recognizing it provides a very important clinical clue to renewed disease activity in many medium-to small-vessel vasculitides, including PAN, Wegener's granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, and rheumatoid vasculitis. The condition can also occur in the large-vessel vaculitis, Cogan's syndrome, which is characterized by a number of ocular manifestations, he noted.

Episcleritis may be striking, with bilateral redness of the eyes as was the case in this patient, or it can be more subtle and fleeting. But nonetheless, it is a harbinger of disease flare, Dr. Stone said.

DESTIN, FLA. — Classic polyarteritis nodosa, or PAN, is curable in the majority of cases, Dr. John H. Stone said at the annual Rheumatology on the Beach.

The belief that this form of vasculitis is incurable is one of many myths about systemic vasculitides, he said, noting “classic PAN” means disease that does not include palpable purpura, glomerulonephritis, lung disease, or antineutrophil cytoplasmic antibody-positive disease.

In a study reported last year at the annual meeting of the American College of Rheumatology, two-thirds of PANpatients were cured, though that figure is likely high because patients other than those with classic PAN were included, noted Dr. Stone, a Boston-based rheumatologist and editor of Rheumatology UpToDate.

In his experience with classic PAN in the past 5 years, 17 of 21 patients were cured. Some were treated with steroids, and some were treated with steroids and cyclophosphamide; all were tapered completely off their drugs. The remaining four patients remained on low-dose steroids to control persistent skin disease, he said.

“As we understand PAN better, we are going to recognize that we can subclassify it phenotypically a bit more precisely,” he said. Forms of the disease are tied to hepatitis B, there is the classic curable type, and there may be other subtypes.

To debunk another myth about systemic vasculitis, Dr. Stone described a patient with Wegener's granulomatosis who was diagnosed with rheumatoid arthritis based on the presence of arthritis and nodules on his elbows. Arthritis plus nodules does not necessarily equal RA, he said. The Churg-Strauss-type granulomas seen in this patient can be associated with Churg-Strauss syndrome, but another myth is that Churg-Strauss syndrome is the most common cause of the nodules. In fact, Wegener's granulomatosis is the most common cause, Dr. Stone explained.

Myths also exist about treatment for vasculitis. Chemotherapy with cyclophosphamide is indicated in patients with mononeuritis multiplex, central nervous system disease, rapidly progressing glomerulonephritis, mesenteric vasculitis, cardiac involvement, or alveolar hemorrhage. Nonhealing cutaneous ulcers or excessive steroid toxicity are also indications.

Data from one study, presented only in abstract form, show that intravenous cyclophosphamide treatment once every 2 weeks is as effective as oral daily cyclophosphamide but safer. However, daily oral treatment is currently the preferred approach for induction of remission. Some studies suggest oral therapy improves the chance of sustained remission. Oral cyclophosphamide can be titrated based on white cell count, another safety feature.

Patients who fail to respond to conventional daily cyclophosphamide should be considered to have an infection. Systemic vasculitis is almost always reliably controlled with conventional therapy, thus it is important to consider aspergillosis and other agents in refractory cases. Induction of neutropenia is not essential for achieving remission. The goal is to maintain white cell count above 3,500 or 4,000/mm

Episcleritis often is an overlooked clue that a patient's vasculitis has flared. Courtesy Dr. John H. Stone

Episcleritis Is Sign Of Vasculitis Flare

A frequent signal of disease flare in patients with systemic vasculitis is episcleritis, Dr. Stone said.

The Wegener's granulomatosis patient who was misdiagnosed with RA presented with this ocular condition—the most common ocular manifestation of systemic vasculitis—signaling renewed disease activity. The patient was having a flare but didn't realize it.

The onset of episcleritis is often overlooked. Recognizing it provides a very important clinical clue to renewed disease activity in many medium-to small-vessel vasculitides, including PAN, Wegener's granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, and rheumatoid vasculitis. The condition can also occur in the large-vessel vaculitis, Cogan's syndrome, which is characterized by a number of ocular manifestations, he noted.

Episcleritis may be striking, with bilateral redness of the eyes as was the case in this patient, or it can be more subtle and fleeting. But nonetheless, it is a harbinger of disease flare, Dr. Stone said.

DESTIN, FLA. — Classic polyarteritis nodosa, or PAN, is curable in the majority of cases, Dr. John H. Stone said at the annual Rheumatology on the Beach.

The belief that this form of vasculitis is incurable is one of many myths about systemic vasculitides, he said, noting “classic PAN” means disease that does not include palpable purpura, glomerulonephritis, lung disease, or antineutrophil cytoplasmic antibody-positive disease.

In a study reported last year at the annual meeting of the American College of Rheumatology, two-thirds of PANpatients were cured, though that figure is likely high because patients other than those with classic PAN were included, noted Dr. Stone, a Boston-based rheumatologist and editor of Rheumatology UpToDate.

In his experience with classic PAN in the past 5 years, 17 of 21 patients were cured. Some were treated with steroids, and some were treated with steroids and cyclophosphamide; all were tapered completely off their drugs. The remaining four patients remained on low-dose steroids to control persistent skin disease, he said.

“As we understand PAN better, we are going to recognize that we can subclassify it phenotypically a bit more precisely,” he said. Forms of the disease are tied to hepatitis B, there is the classic curable type, and there may be other subtypes.

To debunk another myth about systemic vasculitis, Dr. Stone described a patient with Wegener's granulomatosis who was diagnosed with rheumatoid arthritis based on the presence of arthritis and nodules on his elbows. Arthritis plus nodules does not necessarily equal RA, he said. The Churg-Strauss-type granulomas seen in this patient can be associated with Churg-Strauss syndrome, but another myth is that Churg-Strauss syndrome is the most common cause of the nodules. In fact, Wegener's granulomatosis is the most common cause, Dr. Stone explained.

Myths also exist about treatment for vasculitis. Chemotherapy with cyclophosphamide is indicated in patients with mononeuritis multiplex, central nervous system disease, rapidly progressing glomerulonephritis, mesenteric vasculitis, cardiac involvement, or alveolar hemorrhage. Nonhealing cutaneous ulcers or excessive steroid toxicity are also indications.

Data from one study, presented only in abstract form, show that intravenous cyclophosphamide treatment once every 2 weeks is as effective as oral daily cyclophosphamide but safer. However, daily oral treatment is currently the preferred approach for induction of remission. Some studies suggest oral therapy improves the chance of sustained remission. Oral cyclophosphamide can be titrated based on white cell count, another safety feature.

Patients who fail to respond to conventional daily cyclophosphamide should be considered to have an infection. Systemic vasculitis is almost always reliably controlled with conventional therapy, thus it is important to consider aspergillosis and other agents in refractory cases. Induction of neutropenia is not essential for achieving remission. The goal is to maintain white cell count above 3,500 or 4,000/mm

Episcleritis often is an overlooked clue that a patient's vasculitis has flared. Courtesy Dr. John H. Stone

Episcleritis Is Sign Of Vasculitis Flare

A frequent signal of disease flare in patients with systemic vasculitis is episcleritis, Dr. Stone said.

The Wegener's granulomatosis patient who was misdiagnosed with RA presented with this ocular condition—the most common ocular manifestation of systemic vasculitis—signaling renewed disease activity. The patient was having a flare but didn't realize it.

The onset of episcleritis is often overlooked. Recognizing it provides a very important clinical clue to renewed disease activity in many medium-to small-vessel vasculitides, including PAN, Wegener's granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, and rheumatoid vasculitis. The condition can also occur in the large-vessel vaculitis, Cogan's syndrome, which is characterized by a number of ocular manifestations, he noted.

Episcleritis may be striking, with bilateral redness of the eyes as was the case in this patient, or it can be more subtle and fleeting. But nonetheless, it is a harbinger of disease flare, Dr. Stone said.

DESTIN, FLA. — The fact that some patients have antiphospholipid antibodies for years and only develop clinical problems under certain conditions has given rise to the theory that a “second hit” is sometimes required to trigger antiphospholipid syndrome, Dr. Ann Parke said at the annual Rheumatology on the Beach.

Second hit phenomena include pregnancy, exogenous estrogens, flares of systemic lupus erythematosus (SLE), infection and inflammation, surgery, and vascular procedures or trauma. All may promote thrombosis in these patients, said Dr. Park, professor of medicine at the University of Connecticut, Farmington. These conditions and circumstances interfere with normal anticoagulant pathways, in particular the protein C and S pathways known to be associated with antiphospholipid syndrome (APS). Patients with antiphospholipid antibodies should notify physicians if they become pregnant or if they are to undergo surgery or vascular procedures.

Those undergoing surgery must be adequately anticoagulated perioperatively and maintained on low-molecular-weight heparin as necessary. In those with SLE, flares should be controlled and monitored.

It is also important that patients with antiphospholipid antibodies be warned of risks associated with use of exogenous estrogens, Dr. Park said.

Infection is the most worrisome of the second hit factors, because it is the least controllable. Patient education about preventing infection is critical, she said.

DESTIN, FLA. — The fact that some patients have antiphospholipid antibodies for years and only develop clinical problems under certain conditions has given rise to the theory that a “second hit” is sometimes required to trigger antiphospholipid syndrome, Dr. Ann Parke said at the annual Rheumatology on the Beach.

Second hit phenomena include pregnancy, exogenous estrogens, flares of systemic lupus erythematosus (SLE), infection and inflammation, surgery, and vascular procedures or trauma. All may promote thrombosis in these patients, said Dr. Park, professor of medicine at the University of Connecticut, Farmington. These conditions and circumstances interfere with normal anticoagulant pathways, in particular the protein C and S pathways known to be associated with antiphospholipid syndrome (APS). Patients with antiphospholipid antibodies should notify physicians if they become pregnant or if they are to undergo surgery or vascular procedures.

Those undergoing surgery must be adequately anticoagulated perioperatively and maintained on low-molecular-weight heparin as necessary. In those with SLE, flares should be controlled and monitored.

It is also important that patients with antiphospholipid antibodies be warned of risks associated with use of exogenous estrogens, Dr. Park said.

Infection is the most worrisome of the second hit factors, because it is the least controllable. Patient education about preventing infection is critical, she said.

DESTIN, FLA. — The fact that some patients have antiphospholipid antibodies for years and only develop clinical problems under certain conditions has given rise to the theory that a “second hit” is sometimes required to trigger antiphospholipid syndrome, Dr. Ann Parke said at the annual Rheumatology on the Beach.

Second hit phenomena include pregnancy, exogenous estrogens, flares of systemic lupus erythematosus (SLE), infection and inflammation, surgery, and vascular procedures or trauma. All may promote thrombosis in these patients, said Dr. Park, professor of medicine at the University of Connecticut, Farmington. These conditions and circumstances interfere with normal anticoagulant pathways, in particular the protein C and S pathways known to be associated with antiphospholipid syndrome (APS). Patients with antiphospholipid antibodies should notify physicians if they become pregnant or if they are to undergo surgery or vascular procedures.

Those undergoing surgery must be adequately anticoagulated perioperatively and maintained on low-molecular-weight heparin as necessary. In those with SLE, flares should be controlled and monitored.

It is also important that patients with antiphospholipid antibodies be warned of risks associated with use of exogenous estrogens, Dr. Park said.

Infection is the most worrisome of the second hit factors, because it is the least controllable. Patient education about preventing infection is critical, she said.