From Staff Reports

Unrecognized MI Tied to Stroke Risk

Men with unrecognized MI are at significantly increased risk for stroke, a large population-based cohort study has shown.

Of 6,439 participants in the Rotterdam Study who were free of stroke and MI at baseline and who had digital echocardiographic data available, 505 had a stroke during 12 years of follow-up. The stroke patients included 213 men and 292 women.

Unrecognized MI—defined as ECG evidence of MI in a patient who did not report a history of MI—occurred in 159 men and 202 women, and was associated with a 75% increase in stroke risk, compared with participants who did not have evidence of MI; the age- and sex-adjusted hazard ratio was 1.76, Dr. Monique Breteler reported at the 31st International Stroke Conference.

The risk remained significantly elevated after adjusting for cardiovascular risk factors such as smoking, diabetes, hypertension, and total and HDL cholesterol levels (hazard ratio 1.80), said Dr. Breteler of Erasmus University Medical Centre in Rotterdam, the Netherlands. However, stratification by gender showed that the risk was significantly elevated only in men (hazard ratio of 2.53 for men vs. 1.27 for women). As for stroke types, of the 505 that occurred in the patient population, 299 were ischemic, 48 were hemorrhagic, and 158 were of unspecified type. The study data are of particular concern given the finding—also from the Rotterdam study—that 43% of MIs are unrecognized, Dr. Breteler said.

She noted that further study is needed to evaluate possible mechanisms for the relationship between unrecognized MI and stroke. Recognized MI occurred in 442 patients (305 men and 137 women); these patients had a borderline association with increased stroke risk.

Depression Hinders Cardiac Rehab

Both social isolation and depression hampered health behaviors in a study of 492 patients who had acute coronary syndrome events, Dr. Manual Paz-Yepes reported in a poster presented at the annual meeting of the American Psychosomatic Society.

Within 7 days after their ACS event, all patients completed the Beck Depression Inventory and the UCLA loneliness scale, a measure of social isolation; they completed the tests again after 3 months, wrote Dr. Paz-Yepes of Mount Sinai School of Medicine, New York.

The 174 patients without life partners were significantly less likely than the 318 patients with partners to participate in cardiac rehabilitation (35% vs. 64%) or exercise (46% vs. 57%), and were more likely to smoke (15% vs. 8%) 3 months after an acute coronary syndrome (ACS) event.

In regression analysis, depression, but not scores on the UCLA loneliness scale or partner status, was significantly associated with reduced participation in cardiac rehabilitation or exercise, and with reduced medication adherence. Higher loneliness scores were significantly associated with decreased medication adherence, lack of exercise, and greater likelihood of smoking.

Both social isolation and depression should be considered when discussing health behaviors with ACS patients, and different treatment strategies may be needed for depressed patients, compared with isolated patients, the investigators noted.

Doppler Helps Define LV Hypertrophy

Doppler myocardial imaging to assess systolic activation delay can help determine if a patient has hypertrophic cardiomyopathy or merely has the cardiac effects of athletic training, Italian researchers reported.

Dr. Antonello D'Andrea of the Second University of Naples (Italy) and colleagues followed 70 patients with hypertrophic cardiomyopathy (HCM) and 85 age- and sex-matched competitive athletes (40 swimmers and 45 weight lifters) with enlarged left ventricles and interventricular septa thicker than 12 mm. In the total sample, average age was 29, and more than 80% of subjects were men (Br. J. Sports Med. 2006;40:244–50).

During the 4-year follow-up period, the study's primary end point was cardiovascular mortality, defined as death resulting from documented significant arrhythmia, cardiac arrest, heart failure, or MI, with no precipitating factors. Eight HCM patients died during follow-up, whereas none of the athletes had a cardiovascular event.

All participants underwent standard pulsed Doppler echocardiography and pulsed Doppler myocardial imaging (DMI), as well as 24-hour Holter monitoring. HCM patients exhibited a “significant global Doppler interventricular delay,” the authors reported. The investigators estimated that a delay cutoff value of more than 45 milliseconds put HCM patients at higher risk of sudden cardiac death.

The researchers concluded that “pulsed DMI may represent an effective noninvasive and easily repeatable technique for assessing the severity of regional delay in activation of LV walls and therefore for the differential diagnosis between patients with either physiological or pathological LV hypertrophy.”

Unrecognized MI Tied to Stroke Risk

Men with unrecognized MI are at significantly increased risk for stroke, a large population-based cohort study has shown.

Of 6,439 participants in the Rotterdam Study who were free of stroke and MI at baseline and who had digital echocardiographic data available, 505 had a stroke during 12 years of follow-up. The stroke patients included 213 men and 292 women.

Unrecognized MI—defined as ECG evidence of MI in a patient who did not report a history of MI—occurred in 159 men and 202 women, and was associated with a 75% increase in stroke risk, compared with participants who did not have evidence of MI; the age- and sex-adjusted hazard ratio was 1.76, Dr. Monique Breteler reported at the 31st International Stroke Conference.

The risk remained significantly elevated after adjusting for cardiovascular risk factors such as smoking, diabetes, hypertension, and total and HDL cholesterol levels (hazard ratio 1.80), said Dr. Breteler of Erasmus University Medical Centre in Rotterdam, the Netherlands. However, stratification by gender showed that the risk was significantly elevated only in men (hazard ratio of 2.53 for men vs. 1.27 for women). As for stroke types, of the 505 that occurred in the patient population, 299 were ischemic, 48 were hemorrhagic, and 158 were of unspecified type. The study data are of particular concern given the finding—also from the Rotterdam study—that 43% of MIs are unrecognized, Dr. Breteler said.

She noted that further study is needed to evaluate possible mechanisms for the relationship between unrecognized MI and stroke. Recognized MI occurred in 442 patients (305 men and 137 women); these patients had a borderline association with increased stroke risk.

Depression Hinders Cardiac Rehab

Both social isolation and depression hampered health behaviors in a study of 492 patients who had acute coronary syndrome events, Dr. Manual Paz-Yepes reported in a poster presented at the annual meeting of the American Psychosomatic Society.

Within 7 days after their ACS event, all patients completed the Beck Depression Inventory and the UCLA loneliness scale, a measure of social isolation; they completed the tests again after 3 months, wrote Dr. Paz-Yepes of Mount Sinai School of Medicine, New York.

The 174 patients without life partners were significantly less likely than the 318 patients with partners to participate in cardiac rehabilitation (35% vs. 64%) or exercise (46% vs. 57%), and were more likely to smoke (15% vs. 8%) 3 months after an acute coronary syndrome (ACS) event.

In regression analysis, depression, but not scores on the UCLA loneliness scale or partner status, was significantly associated with reduced participation in cardiac rehabilitation or exercise, and with reduced medication adherence. Higher loneliness scores were significantly associated with decreased medication adherence, lack of exercise, and greater likelihood of smoking.

Both social isolation and depression should be considered when discussing health behaviors with ACS patients, and different treatment strategies may be needed for depressed patients, compared with isolated patients, the investigators noted.

Doppler Helps Define LV Hypertrophy

Doppler myocardial imaging to assess systolic activation delay can help determine if a patient has hypertrophic cardiomyopathy or merely has the cardiac effects of athletic training, Italian researchers reported.

Dr. Antonello D'Andrea of the Second University of Naples (Italy) and colleagues followed 70 patients with hypertrophic cardiomyopathy (HCM) and 85 age- and sex-matched competitive athletes (40 swimmers and 45 weight lifters) with enlarged left ventricles and interventricular septa thicker than 12 mm. In the total sample, average age was 29, and more than 80% of subjects were men (Br. J. Sports Med. 2006;40:244–50).

During the 4-year follow-up period, the study's primary end point was cardiovascular mortality, defined as death resulting from documented significant arrhythmia, cardiac arrest, heart failure, or MI, with no precipitating factors. Eight HCM patients died during follow-up, whereas none of the athletes had a cardiovascular event.

All participants underwent standard pulsed Doppler echocardiography and pulsed Doppler myocardial imaging (DMI), as well as 24-hour Holter monitoring. HCM patients exhibited a “significant global Doppler interventricular delay,” the authors reported. The investigators estimated that a delay cutoff value of more than 45 milliseconds put HCM patients at higher risk of sudden cardiac death.

The researchers concluded that “pulsed DMI may represent an effective noninvasive and easily repeatable technique for assessing the severity of regional delay in activation of LV walls and therefore for the differential diagnosis between patients with either physiological or pathological LV hypertrophy.”

Unrecognized MI Tied to Stroke Risk

Men with unrecognized MI are at significantly increased risk for stroke, a large population-based cohort study has shown.

Of 6,439 participants in the Rotterdam Study who were free of stroke and MI at baseline and who had digital echocardiographic data available, 505 had a stroke during 12 years of follow-up. The stroke patients included 213 men and 292 women.

Unrecognized MI—defined as ECG evidence of MI in a patient who did not report a history of MI—occurred in 159 men and 202 women, and was associated with a 75% increase in stroke risk, compared with participants who did not have evidence of MI; the age- and sex-adjusted hazard ratio was 1.76, Dr. Monique Breteler reported at the 31st International Stroke Conference.

The risk remained significantly elevated after adjusting for cardiovascular risk factors such as smoking, diabetes, hypertension, and total and HDL cholesterol levels (hazard ratio 1.80), said Dr. Breteler of Erasmus University Medical Centre in Rotterdam, the Netherlands. However, stratification by gender showed that the risk was significantly elevated only in men (hazard ratio of 2.53 for men vs. 1.27 for women). As for stroke types, of the 505 that occurred in the patient population, 299 were ischemic, 48 were hemorrhagic, and 158 were of unspecified type. The study data are of particular concern given the finding—also from the Rotterdam study—that 43% of MIs are unrecognized, Dr. Breteler said.

She noted that further study is needed to evaluate possible mechanisms for the relationship between unrecognized MI and stroke. Recognized MI occurred in 442 patients (305 men and 137 women); these patients had a borderline association with increased stroke risk.

Depression Hinders Cardiac Rehab

Both social isolation and depression hampered health behaviors in a study of 492 patients who had acute coronary syndrome events, Dr. Manual Paz-Yepes reported in a poster presented at the annual meeting of the American Psychosomatic Society.

Within 7 days after their ACS event, all patients completed the Beck Depression Inventory and the UCLA loneliness scale, a measure of social isolation; they completed the tests again after 3 months, wrote Dr. Paz-Yepes of Mount Sinai School of Medicine, New York.

The 174 patients without life partners were significantly less likely than the 318 patients with partners to participate in cardiac rehabilitation (35% vs. 64%) or exercise (46% vs. 57%), and were more likely to smoke (15% vs. 8%) 3 months after an acute coronary syndrome (ACS) event.

In regression analysis, depression, but not scores on the UCLA loneliness scale or partner status, was significantly associated with reduced participation in cardiac rehabilitation or exercise, and with reduced medication adherence. Higher loneliness scores were significantly associated with decreased medication adherence, lack of exercise, and greater likelihood of smoking.

Both social isolation and depression should be considered when discussing health behaviors with ACS patients, and different treatment strategies may be needed for depressed patients, compared with isolated patients, the investigators noted.

Doppler Helps Define LV Hypertrophy

Doppler myocardial imaging to assess systolic activation delay can help determine if a patient has hypertrophic cardiomyopathy or merely has the cardiac effects of athletic training, Italian researchers reported.

Dr. Antonello D'Andrea of the Second University of Naples (Italy) and colleagues followed 70 patients with hypertrophic cardiomyopathy (HCM) and 85 age- and sex-matched competitive athletes (40 swimmers and 45 weight lifters) with enlarged left ventricles and interventricular septa thicker than 12 mm. In the total sample, average age was 29, and more than 80% of subjects were men (Br. J. Sports Med. 2006;40:244–50).

During the 4-year follow-up period, the study's primary end point was cardiovascular mortality, defined as death resulting from documented significant arrhythmia, cardiac arrest, heart failure, or MI, with no precipitating factors. Eight HCM patients died during follow-up, whereas none of the athletes had a cardiovascular event.

All participants underwent standard pulsed Doppler echocardiography and pulsed Doppler myocardial imaging (DMI), as well as 24-hour Holter monitoring. HCM patients exhibited a “significant global Doppler interventricular delay,” the authors reported. The investigators estimated that a delay cutoff value of more than 45 milliseconds put HCM patients at higher risk of sudden cardiac death.

The researchers concluded that “pulsed DMI may represent an effective noninvasive and easily repeatable technique for assessing the severity of regional delay in activation of LV walls and therefore for the differential diagnosis between patients with either physiological or pathological LV hypertrophy.”

Deaths Reported in Donepezil Trial

Eleven of 648 patients died while taking donepezil (Aricept) in a trial of the drug for the treatment of vascular dementia, according to preliminary study results announced by Eisai Co. Ltd., the drug's maker. None of the 326 patients taking placebo during the 24-week trial died.

The multicenter, randomized, double-blind study was conducted in nine countries and enrolled only people with vascular dementia (VaD), who had no prior diagnosis of Alzheimer's disease.

Those patients taking donepezil showed improvement on measures of cognition, compared with those on placebo, but there was no benefit observed on global function, the trial's other primary measure.

An analysis of adverse events data revealed that the mortality rate of 1.7% for the donepezil treatment group in this trial was consistent with that observed in a combined analysis of two previous VaD studies (1.7%) and was lower than that reported in the general population of patients with vascular dementia. However, the mortality rate observed in the placebo group of this study (0%) was lower than that seen in the placebo groups in the combined analysis for the two prior VaD studies (2%), and was lower than the rate for the general VaD population.

Additional analyses of vascular events such as stroke and myocardial infarction for the three VaD trials, alone and combined, showed a statistically significant higher risk of a vascular event in the donepezil group, compared with placebo.

Adverse events in the treatment group occurred at a rate greater than 5%, and twice the rate of placebo, for abdominal pain (5.1% vs. 2.5%), anorexia (5.7% vs. 2.8%), and nausea (9.9% vs. 4.3%).

Another FDA Panel: No ADHD Black Box

The potential for certain cardiovascular and psychiatric adverse events associated with ADHD drugs should be well communicated, but not in the form of a black box warning, a Food and Drug Administration advisory panel agreed last month.

Instead, the FDA's Pediatric Advisory Committee recommended that information about reported psychiatric and cardiovascular events be included in the half-page highlights box that appears at the beginning of the label in the newly designed format for drug labels that was introduced in January.

The panel also supported the use of a medication guide, dispensed with each prescription at the pharmacy. No formal votes on these issues were taken.

In February, another panel—the FDA's Drug Safety and Risk Management Advisory Committee, which reviewed cardiovascular event reports—narrowly recommended adding a black box warning to ADHD drug labels to alert physicians and the public that cases of sudden death and nonfatal cardiovascular events have been reported in children and adults on these drugs.

At a press conference held after the meeting, Dr. Robert Temple, director of the office of medical policy at the FDA, said that the agency would quickly start working on implementing the panel's recommendations. The area of uncertainty pertains to the cardiovascular risks in adults, he added.

Atypicals Show Modest Behavior Effect

Atypical antipsychotics appear to have a modest effect on behavioral symptoms in elderly dementia patients, but the effectiveness of nonpharmacologic treatments is less clear, according to a metaanalysis presented at the annual meeting of the American Association for Geriatric Psychiatry.

Dr. Mark B. Snowden of the department of psychiatry and behavioral sciences at the University of Washington, Seattle, and his colleagues used metaanalysis techniques to compare the efficacy of nonpharmacologic treatments with that of pharmacologic therapies. The researchers identified five randomized, controlled trials of antipsychotic drugs and three randomized, controlled trials for nonpharmacologic interventions. The drug trials included four atypical drugs and one traditional antipsychotic drug.

The calculated effect size for nonpharmacologic interventions was -.088, which was not statistically significant. In comparison, the calculated effect size for pharmacologic interventions was -.23, which “would be considered small to modest at best,” Dr. Snowden said. “In this instance, the finding was consistent enough across studies that it is statistically significant.”

Only the pharmacologic studies provided data on the number of patients whose condition did or didn't improve. Those studies yielded a statistically significant mean odds ratio of 1.87; thus, patients had an 87% chance of improving with treatment. The researchers also calculated the benefit-to-harm ratio for antipsychotic treatment. “For every 14 people who got a drug and improved, you would expect one excess death,” Dr. Snowden said.

The FDA has issued a public health advisory about increased mortality associated with off-label use of atypical antipsychotics among elderly patients.

Deaths Reported in Donepezil Trial

Eleven of 648 patients died while taking donepezil (Aricept) in a trial of the drug for the treatment of vascular dementia, according to preliminary study results announced by Eisai Co. Ltd., the drug's maker. None of the 326 patients taking placebo during the 24-week trial died.

The multicenter, randomized, double-blind study was conducted in nine countries and enrolled only people with vascular dementia (VaD), who had no prior diagnosis of Alzheimer's disease.

Those patients taking donepezil showed improvement on measures of cognition, compared with those on placebo, but there was no benefit observed on global function, the trial's other primary measure.

An analysis of adverse events data revealed that the mortality rate of 1.7% for the donepezil treatment group in this trial was consistent with that observed in a combined analysis of two previous VaD studies (1.7%) and was lower than that reported in the general population of patients with vascular dementia. However, the mortality rate observed in the placebo group of this study (0%) was lower than that seen in the placebo groups in the combined analysis for the two prior VaD studies (2%), and was lower than the rate for the general VaD population.

Additional analyses of vascular events such as stroke and myocardial infarction for the three VaD trials, alone and combined, showed a statistically significant higher risk of a vascular event in the donepezil group, compared with placebo.

Adverse events in the treatment group occurred at a rate greater than 5%, and twice the rate of placebo, for abdominal pain (5.1% vs. 2.5%), anorexia (5.7% vs. 2.8%), and nausea (9.9% vs. 4.3%).

Another FDA Panel: No ADHD Black Box

The potential for certain cardiovascular and psychiatric adverse events associated with ADHD drugs should be well communicated, but not in the form of a black box warning, a Food and Drug Administration advisory panel agreed last month.

Instead, the FDA's Pediatric Advisory Committee recommended that information about reported psychiatric and cardiovascular events be included in the half-page highlights box that appears at the beginning of the label in the newly designed format for drug labels that was introduced in January.

The panel also supported the use of a medication guide, dispensed with each prescription at the pharmacy. No formal votes on these issues were taken.

In February, another panel—the FDA's Drug Safety and Risk Management Advisory Committee, which reviewed cardiovascular event reports—narrowly recommended adding a black box warning to ADHD drug labels to alert physicians and the public that cases of sudden death and nonfatal cardiovascular events have been reported in children and adults on these drugs.

At a press conference held after the meeting, Dr. Robert Temple, director of the office of medical policy at the FDA, said that the agency would quickly start working on implementing the panel's recommendations. The area of uncertainty pertains to the cardiovascular risks in adults, he added.

Atypicals Show Modest Behavior Effect

Atypical antipsychotics appear to have a modest effect on behavioral symptoms in elderly dementia patients, but the effectiveness of nonpharmacologic treatments is less clear, according to a metaanalysis presented at the annual meeting of the American Association for Geriatric Psychiatry.

Dr. Mark B. Snowden of the department of psychiatry and behavioral sciences at the University of Washington, Seattle, and his colleagues used metaanalysis techniques to compare the efficacy of nonpharmacologic treatments with that of pharmacologic therapies. The researchers identified five randomized, controlled trials of antipsychotic drugs and three randomized, controlled trials for nonpharmacologic interventions. The drug trials included four atypical drugs and one traditional antipsychotic drug.

The calculated effect size for nonpharmacologic interventions was -.088, which was not statistically significant. In comparison, the calculated effect size for pharmacologic interventions was -.23, which “would be considered small to modest at best,” Dr. Snowden said. “In this instance, the finding was consistent enough across studies that it is statistically significant.”

Only the pharmacologic studies provided data on the number of patients whose condition did or didn't improve. Those studies yielded a statistically significant mean odds ratio of 1.87; thus, patients had an 87% chance of improving with treatment. The researchers also calculated the benefit-to-harm ratio for antipsychotic treatment. “For every 14 people who got a drug and improved, you would expect one excess death,” Dr. Snowden said.

The FDA has issued a public health advisory about increased mortality associated with off-label use of atypical antipsychotics among elderly patients.

Deaths Reported in Donepezil Trial

Eleven of 648 patients died while taking donepezil (Aricept) in a trial of the drug for the treatment of vascular dementia, according to preliminary study results announced by Eisai Co. Ltd., the drug's maker. None of the 326 patients taking placebo during the 24-week trial died.

The multicenter, randomized, double-blind study was conducted in nine countries and enrolled only people with vascular dementia (VaD), who had no prior diagnosis of Alzheimer's disease.

Those patients taking donepezil showed improvement on measures of cognition, compared with those on placebo, but there was no benefit observed on global function, the trial's other primary measure.

An analysis of adverse events data revealed that the mortality rate of 1.7% for the donepezil treatment group in this trial was consistent with that observed in a combined analysis of two previous VaD studies (1.7%) and was lower than that reported in the general population of patients with vascular dementia. However, the mortality rate observed in the placebo group of this study (0%) was lower than that seen in the placebo groups in the combined analysis for the two prior VaD studies (2%), and was lower than the rate for the general VaD population.

Additional analyses of vascular events such as stroke and myocardial infarction for the three VaD trials, alone and combined, showed a statistically significant higher risk of a vascular event in the donepezil group, compared with placebo.

Adverse events in the treatment group occurred at a rate greater than 5%, and twice the rate of placebo, for abdominal pain (5.1% vs. 2.5%), anorexia (5.7% vs. 2.8%), and nausea (9.9% vs. 4.3%).

Another FDA Panel: No ADHD Black Box

The potential for certain cardiovascular and psychiatric adverse events associated with ADHD drugs should be well communicated, but not in the form of a black box warning, a Food and Drug Administration advisory panel agreed last month.

Instead, the FDA's Pediatric Advisory Committee recommended that information about reported psychiatric and cardiovascular events be included in the half-page highlights box that appears at the beginning of the label in the newly designed format for drug labels that was introduced in January.

The panel also supported the use of a medication guide, dispensed with each prescription at the pharmacy. No formal votes on these issues were taken.

In February, another panel—the FDA's Drug Safety and Risk Management Advisory Committee, which reviewed cardiovascular event reports—narrowly recommended adding a black box warning to ADHD drug labels to alert physicians and the public that cases of sudden death and nonfatal cardiovascular events have been reported in children and adults on these drugs.

At a press conference held after the meeting, Dr. Robert Temple, director of the office of medical policy at the FDA, said that the agency would quickly start working on implementing the panel's recommendations. The area of uncertainty pertains to the cardiovascular risks in adults, he added.

Atypicals Show Modest Behavior Effect

Atypical antipsychotics appear to have a modest effect on behavioral symptoms in elderly dementia patients, but the effectiveness of nonpharmacologic treatments is less clear, according to a metaanalysis presented at the annual meeting of the American Association for Geriatric Psychiatry.

Dr. Mark B. Snowden of the department of psychiatry and behavioral sciences at the University of Washington, Seattle, and his colleagues used metaanalysis techniques to compare the efficacy of nonpharmacologic treatments with that of pharmacologic therapies. The researchers identified five randomized, controlled trials of antipsychotic drugs and three randomized, controlled trials for nonpharmacologic interventions. The drug trials included four atypical drugs and one traditional antipsychotic drug.

The calculated effect size for nonpharmacologic interventions was -.088, which was not statistically significant. In comparison, the calculated effect size for pharmacologic interventions was -.23, which “would be considered small to modest at best,” Dr. Snowden said. “In this instance, the finding was consistent enough across studies that it is statistically significant.”

Only the pharmacologic studies provided data on the number of patients whose condition did or didn't improve. Those studies yielded a statistically significant mean odds ratio of 1.87; thus, patients had an 87% chance of improving with treatment. The researchers also calculated the benefit-to-harm ratio for antipsychotic treatment. “For every 14 people who got a drug and improved, you would expect one excess death,” Dr. Snowden said.

The FDA has issued a public health advisory about increased mortality associated with off-label use of atypical antipsychotics among elderly patients.

Type 1 Diabetic Women Have Low BMD

Women with type 1 diabetes should be targeted for osteoporosis screening and possible fracture prevention as they transition through menopause, said Elsa S. Strotmeyer, Ph.D., and her associates of the University of Pittsburgh.

Reported fracture rates were higher and bone mineral density (BMD) was lower in 67 premenopausal women aged 35–55 with type 1 diabetes than among 237 nondiabetic women, Dr. Strotmeyer and her associates said (Diabetes Care 2006;29:306–11).

Compared with the nondiabetic women, those with type 1 diabetes were younger (43.1 vs. 45.2 years) and weighed less (69.1 vs. 74.5 kg). One-third of the diabetic women reported having had a fracture after age 20 years, compared with less than a quarter of the nondiabetics.

Type 1 diabetes was associated with a 7.5% lower total hip BMD, 6.1% lower BMD in the femoral neck, 2.9% reduced whole-body BMD, and 15.8% lower calcaneal broadband ultrasound attenuation (BUA). All the differences were significant. Adjusting for age, lean mass, and fat mass reduced but did not eliminate any of the differences, they said.

After adjustment for age, neither duration of diabetes nor hemoglobin A_1c levels were significantly associated with BMD or BUA. Blindness (10.6% of the diabetic women vs. 0.4% of the controls) was associated with lower femoral neck and whole-body BMD, and reduced detection of the 10-g monofilament was related to lower femoral neck BMD after adjusting for age and diabetes duration.

The observed differences in BMD at multiple sites approached one standard deviation, which may confer an approximately doubled risk for hip fracture.

The large decrease in calcaneal BUA in the type 1 diabetic women suggests that peripheral bone sites may be even more compromised than other sites, Dr. Strotmeyer and her associates said.

Infections Prolong Elderly Surgery Stay

Elderly patients who developed surgical site infections after undergoing orthopedic surgery had significantly longer hospital stays, Dr. Jeanne Lee wrote in a poster at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Infection was an independent predictor of prolonged stay according to both bivariate and multivariate analyses in the outcomes study, conducted by Dr. Lee and colleagues at Duke University in Durham, N.C.

The study was conducted in eight hospitals between June 1991 and July 2002. The most common procedures were hip arthroplasty in 74 patients (22%), fracture repair in 55 patients (16%), and knee arthroplasty in 40 patients (12%). Staphylococcus aureus was the dominant pathogen, associated with 95 infections (56%), and 55% of these pathogens were methicillin resistant.

The mean length of stay was 13 days among 169 infected patients, compared with 4 days among 171 uninfected controls. The patients' mean age was 75 years, 66% were women, and 83% were Caucasian.

Other predictors of prolonged hospital stay included an inability to bathe independently, undergoing procedures of longer duration, postoperative glucose greater than 200 mg/dL, and having procedures on the same day as hospitalization.

The meeting was sponsored by the American Society for Microbiology.

Many Intercarpal Fusions Fail Early

Many patients who undergo intercarpal fusion later require total wrist arthrodesis, Dr. Samuel Koo and his colleagues reported at the annual meeting of the American Association for Hand Surgery.

The conversion rate was 17% in a retrospective analysis of data available on 72 of 90 consecutive patients who had intercarpal fusion from 1990 and 2002 performed by three surgeons.

The initial diagnosis in 80% of patients was posttraumatic arthrosis. The cohort of 54 men and 18 women had an average age of 35 years. Worker's compensation patients comprised about 75% of the cohort.

Midcarpal fusions were significantly more likely to fail than triscaphe, lunotriquetral, and radiocarpal fusions. Conversion to total wrist arthrodesis occurred in 9 of 32 (28%) midcarpal fusions, 2 of 24 (8%) triscaphe fusions, and 1 of 10 (10%) lunotriquetral fusions. None of the six radiocarpal fusions performed subsequently required total wrist arthrodesis. The average follow-up was 37 months.

More than half the conversions occurred within 11 months, and all but one occurred at less than 2 years. The average time from initial surgery to total wrist fusion was 13 months, said Dr. Koo of Northwestern University in Chicago. Age, gender, and worker's compensation status did not influence conversion rates.

Limitations of the study include its retrospective design, small sample size, and possible bias introduced by excluding patients in the initial study group due to incomplete charts, Dr. Koo said.

Type 1 Diabetic Women Have Low BMD

Women with type 1 diabetes should be targeted for osteoporosis screening and possible fracture prevention as they transition through menopause, said Elsa S. Strotmeyer, Ph.D., and her associates of the University of Pittsburgh.

Reported fracture rates were higher and bone mineral density (BMD) was lower in 67 premenopausal women aged 35–55 with type 1 diabetes than among 237 nondiabetic women, Dr. Strotmeyer and her associates said (Diabetes Care 2006;29:306–11).

Compared with the nondiabetic women, those with type 1 diabetes were younger (43.1 vs. 45.2 years) and weighed less (69.1 vs. 74.5 kg). One-third of the diabetic women reported having had a fracture after age 20 years, compared with less than a quarter of the nondiabetics.

Type 1 diabetes was associated with a 7.5% lower total hip BMD, 6.1% lower BMD in the femoral neck, 2.9% reduced whole-body BMD, and 15.8% lower calcaneal broadband ultrasound attenuation (BUA). All the differences were significant. Adjusting for age, lean mass, and fat mass reduced but did not eliminate any of the differences, they said.

After adjustment for age, neither duration of diabetes nor hemoglobin A_1c levels were significantly associated with BMD or BUA. Blindness (10.6% of the diabetic women vs. 0.4% of the controls) was associated with lower femoral neck and whole-body BMD, and reduced detection of the 10-g monofilament was related to lower femoral neck BMD after adjusting for age and diabetes duration.

The observed differences in BMD at multiple sites approached one standard deviation, which may confer an approximately doubled risk for hip fracture.

The large decrease in calcaneal BUA in the type 1 diabetic women suggests that peripheral bone sites may be even more compromised than other sites, Dr. Strotmeyer and her associates said.

Infections Prolong Elderly Surgery Stay

Elderly patients who developed surgical site infections after undergoing orthopedic surgery had significantly longer hospital stays, Dr. Jeanne Lee wrote in a poster at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Infection was an independent predictor of prolonged stay according to both bivariate and multivariate analyses in the outcomes study, conducted by Dr. Lee and colleagues at Duke University in Durham, N.C.

The study was conducted in eight hospitals between June 1991 and July 2002. The most common procedures were hip arthroplasty in 74 patients (22%), fracture repair in 55 patients (16%), and knee arthroplasty in 40 patients (12%). Staphylococcus aureus was the dominant pathogen, associated with 95 infections (56%), and 55% of these pathogens were methicillin resistant.

The mean length of stay was 13 days among 169 infected patients, compared with 4 days among 171 uninfected controls. The patients' mean age was 75 years, 66% were women, and 83% were Caucasian.

Other predictors of prolonged hospital stay included an inability to bathe independently, undergoing procedures of longer duration, postoperative glucose greater than 200 mg/dL, and having procedures on the same day as hospitalization.

The meeting was sponsored by the American Society for Microbiology.

Many Intercarpal Fusions Fail Early

Many patients who undergo intercarpal fusion later require total wrist arthrodesis, Dr. Samuel Koo and his colleagues reported at the annual meeting of the American Association for Hand Surgery.

The conversion rate was 17% in a retrospective analysis of data available on 72 of 90 consecutive patients who had intercarpal fusion from 1990 and 2002 performed by three surgeons.

The initial diagnosis in 80% of patients was posttraumatic arthrosis. The cohort of 54 men and 18 women had an average age of 35 years. Worker's compensation patients comprised about 75% of the cohort.

Midcarpal fusions were significantly more likely to fail than triscaphe, lunotriquetral, and radiocarpal fusions. Conversion to total wrist arthrodesis occurred in 9 of 32 (28%) midcarpal fusions, 2 of 24 (8%) triscaphe fusions, and 1 of 10 (10%) lunotriquetral fusions. None of the six radiocarpal fusions performed subsequently required total wrist arthrodesis. The average follow-up was 37 months.

More than half the conversions occurred within 11 months, and all but one occurred at less than 2 years. The average time from initial surgery to total wrist fusion was 13 months, said Dr. Koo of Northwestern University in Chicago. Age, gender, and worker's compensation status did not influence conversion rates.

Limitations of the study include its retrospective design, small sample size, and possible bias introduced by excluding patients in the initial study group due to incomplete charts, Dr. Koo said.

Type 1 Diabetic Women Have Low BMD

Women with type 1 diabetes should be targeted for osteoporosis screening and possible fracture prevention as they transition through menopause, said Elsa S. Strotmeyer, Ph.D., and her associates of the University of Pittsburgh.

Reported fracture rates were higher and bone mineral density (BMD) was lower in 67 premenopausal women aged 35–55 with type 1 diabetes than among 237 nondiabetic women, Dr. Strotmeyer and her associates said (Diabetes Care 2006;29:306–11).

Compared with the nondiabetic women, those with type 1 diabetes were younger (43.1 vs. 45.2 years) and weighed less (69.1 vs. 74.5 kg). One-third of the diabetic women reported having had a fracture after age 20 years, compared with less than a quarter of the nondiabetics.

Type 1 diabetes was associated with a 7.5% lower total hip BMD, 6.1% lower BMD in the femoral neck, 2.9% reduced whole-body BMD, and 15.8% lower calcaneal broadband ultrasound attenuation (BUA). All the differences were significant. Adjusting for age, lean mass, and fat mass reduced but did not eliminate any of the differences, they said.

After adjustment for age, neither duration of diabetes nor hemoglobin A_1c levels were significantly associated with BMD or BUA. Blindness (10.6% of the diabetic women vs. 0.4% of the controls) was associated with lower femoral neck and whole-body BMD, and reduced detection of the 10-g monofilament was related to lower femoral neck BMD after adjusting for age and diabetes duration.

The observed differences in BMD at multiple sites approached one standard deviation, which may confer an approximately doubled risk for hip fracture.

The large decrease in calcaneal BUA in the type 1 diabetic women suggests that peripheral bone sites may be even more compromised than other sites, Dr. Strotmeyer and her associates said.

Infections Prolong Elderly Surgery Stay

Elderly patients who developed surgical site infections after undergoing orthopedic surgery had significantly longer hospital stays, Dr. Jeanne Lee wrote in a poster at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Infection was an independent predictor of prolonged stay according to both bivariate and multivariate analyses in the outcomes study, conducted by Dr. Lee and colleagues at Duke University in Durham, N.C.

The study was conducted in eight hospitals between June 1991 and July 2002. The most common procedures were hip arthroplasty in 74 patients (22%), fracture repair in 55 patients (16%), and knee arthroplasty in 40 patients (12%). Staphylococcus aureus was the dominant pathogen, associated with 95 infections (56%), and 55% of these pathogens were methicillin resistant.

The mean length of stay was 13 days among 169 infected patients, compared with 4 days among 171 uninfected controls. The patients' mean age was 75 years, 66% were women, and 83% were Caucasian.

Other predictors of prolonged hospital stay included an inability to bathe independently, undergoing procedures of longer duration, postoperative glucose greater than 200 mg/dL, and having procedures on the same day as hospitalization.

The meeting was sponsored by the American Society for Microbiology.

Many Intercarpal Fusions Fail Early

Many patients who undergo intercarpal fusion later require total wrist arthrodesis, Dr. Samuel Koo and his colleagues reported at the annual meeting of the American Association for Hand Surgery.

The conversion rate was 17% in a retrospective analysis of data available on 72 of 90 consecutive patients who had intercarpal fusion from 1990 and 2002 performed by three surgeons.

The initial diagnosis in 80% of patients was posttraumatic arthrosis. The cohort of 54 men and 18 women had an average age of 35 years. Worker's compensation patients comprised about 75% of the cohort.

Midcarpal fusions were significantly more likely to fail than triscaphe, lunotriquetral, and radiocarpal fusions. Conversion to total wrist arthrodesis occurred in 9 of 32 (28%) midcarpal fusions, 2 of 24 (8%) triscaphe fusions, and 1 of 10 (10%) lunotriquetral fusions. None of the six radiocarpal fusions performed subsequently required total wrist arthrodesis. The average follow-up was 37 months.

More than half the conversions occurred within 11 months, and all but one occurred at less than 2 years. The average time from initial surgery to total wrist fusion was 13 months, said Dr. Koo of Northwestern University in Chicago. Age, gender, and worker's compensation status did not influence conversion rates.

Limitations of the study include its retrospective design, small sample size, and possible bias introduced by excluding patients in the initial study group due to incomplete charts, Dr. Koo said.

Rupture Risk Up With Single Closure

Single-layer closure from a prior cesarean delivery increases risk of symptomatic uterine rupture in a subsequent trial of labor, compared with double-layer closure, Dr. Martine Goyet said at the annual meeting of the Society for Maternal-Fetal Medicine. Dr. Goyet and colleagues conducted a multicenter, case-control study to compare the two closure techniques. They reviewed records from 1993 to 2003 for nine maternity wards. “Single-layer closure was the only significant negative factor associated with uterine rupture in a multivariate analysis [odds ratio 2.31],” said Dr. Goyet of the department of obstetrics and gynecology, Hôpital Sainte-Justine, Montreal. “Prior vaginal delivery was the only positive significant factor [OR 0.49].” They identified 96 cases of symptomatic uterine rupture, including emergency laparotomy, using ICD-9 codes and perinatal databases. They also identified three matched controls for each case. The controls were women who underwent a trial of labor before each uterine rupture case; the control group totaled 288. Maternal age and parity did not significantly differ between groups. Cases had a history of one low-transverse cesarean delivery and uterine rupture with an attempted trial of labor. The researchers excluded women with a history of more than one cesarean delivery, prior myomectomy, or multiple gestations. Women who had uterine rupture were more likely to have had a single-layer closure than controls (37% vs. 20%); induction of labor with an unfavorable cervix (38% vs. 23%); gestational age of 41 weeks or more (26% vs. 17%); birth weight of 4,000 g or greater (23% vs. 13%); and no prior vaginal delivery (87% vs. 73%), according to a univariate analysis. Women who had uterine rupture also tended to have a shorter interval between deliveries (less than 24 months), Dr. Goyet said.

Herpes Hepatitis Diagnosis Lifesaving

The diagnosis of herpes simplex hepatitis in pregnancy is one that can't afford to be missed, Dr. Eileen Hay said at the annual meeting of the American College of Gastroenterology. That's because treatment with acyclovir or vidarabine is lifesaving—and without it, one-half of affected mothers will die of fulminant hepatitis, stressed Dr. Hay, professor of medicine at the Mayo Medical School, Rochester, Minn. Herpes hepatitis is a rare disorder. In pregnancy, it occurs in the third trimester. It is usually but not always preceded by a flulike viral prodrome. The typical mucocutaneous herpetic lesions aren't always present. The characteristic features of this infection are the third-trimester presentation, marked elevation of transaminases (with levels often in the thousands) along with coagulopathy and encephalopathy, and no jaundice. Liver biopsy shows hepatocytes with the classic viral inclusion bodies of herpes simplex virus. It's necessary to consider delivery only in the very rare instance where the patient shows no response to antiviral therapy, Dr. Hay said.

Smoking Boosts Pelvic Prolapse Risk

Tobacco smoking is an independent risk factor for pelvic organ prolapse, data from the Pelvic Organ Support Study suggest. The findings from this multicenter, cross-sectional, observational study—known as POSST—contrast with those from the Women's Health Initiative, which suggested that smoking was protective against pelvic organ prolapse, Dr. Cecilia K. Wieslander reported at the annual meeting of the American Urogynecologic Society. Of 906 women included in the POSST analysis, 773 were nonsmokers (including 173 former smokers) and 133 were current smokers. On multivariate analysis, smoking was an independent, noninteractive risk factor for pelvic organ prolapse of stage II or greater (odds ratio 2.37), said Dr. Wieslander, a fellow in obstetrics and gynecology at the University of Texas Southwestern Medical Center at Dallas. Even among nulliparous smokers, the prevalence of prolapse was significantly greater, compared with the prevalence in nonsmokers (28% vs. 12%, adjusted odds ratio 1.95). In nonsmokers with one vaginal delivery, the prevalence of prolapse increased from 12% to 27%, so the risk associated with smoking in nulliparous women is greater than the risk associated with one vaginal delivery in nonsmokers. The findings, which are consistent with laboratory data showing that smoking-induced activation of vaginal macrophage elastase may contribute to the pathogenesis of organ prolapse, suggest that smoking is a modifiable risk factor for pelvic organ prolapse. However, further study of dose response is needed to evaluate the effects of secondhand smoke exposures, to determine if symptoms associated with smoking—such as chronic cough—are a cause of pelvic organ prolapse, and to determine if other illnesses with effects similar to those of smoking—such as inflammation—can contribute to pelvic organ prolapse, Dr. Wieslander said.

Rupture Risk Up With Single Closure

Single-layer closure from a prior cesarean delivery increases risk of symptomatic uterine rupture in a subsequent trial of labor, compared with double-layer closure, Dr. Martine Goyet said at the annual meeting of the Society for Maternal-Fetal Medicine. Dr. Goyet and colleagues conducted a multicenter, case-control study to compare the two closure techniques. They reviewed records from 1993 to 2003 for nine maternity wards. “Single-layer closure was the only significant negative factor associated with uterine rupture in a multivariate analysis [odds ratio 2.31],” said Dr. Goyet of the department of obstetrics and gynecology, Hôpital Sainte-Justine, Montreal. “Prior vaginal delivery was the only positive significant factor [OR 0.49].” They identified 96 cases of symptomatic uterine rupture, including emergency laparotomy, using ICD-9 codes and perinatal databases. They also identified three matched controls for each case. The controls were women who underwent a trial of labor before each uterine rupture case; the control group totaled 288. Maternal age and parity did not significantly differ between groups. Cases had a history of one low-transverse cesarean delivery and uterine rupture with an attempted trial of labor. The researchers excluded women with a history of more than one cesarean delivery, prior myomectomy, or multiple gestations. Women who had uterine rupture were more likely to have had a single-layer closure than controls (37% vs. 20%); induction of labor with an unfavorable cervix (38% vs. 23%); gestational age of 41 weeks or more (26% vs. 17%); birth weight of 4,000 g or greater (23% vs. 13%); and no prior vaginal delivery (87% vs. 73%), according to a univariate analysis. Women who had uterine rupture also tended to have a shorter interval between deliveries (less than 24 months), Dr. Goyet said.

Herpes Hepatitis Diagnosis Lifesaving

The diagnosis of herpes simplex hepatitis in pregnancy is one that can't afford to be missed, Dr. Eileen Hay said at the annual meeting of the American College of Gastroenterology. That's because treatment with acyclovir or vidarabine is lifesaving—and without it, one-half of affected mothers will die of fulminant hepatitis, stressed Dr. Hay, professor of medicine at the Mayo Medical School, Rochester, Minn. Herpes hepatitis is a rare disorder. In pregnancy, it occurs in the third trimester. It is usually but not always preceded by a flulike viral prodrome. The typical mucocutaneous herpetic lesions aren't always present. The characteristic features of this infection are the third-trimester presentation, marked elevation of transaminases (with levels often in the thousands) along with coagulopathy and encephalopathy, and no jaundice. Liver biopsy shows hepatocytes with the classic viral inclusion bodies of herpes simplex virus. It's necessary to consider delivery only in the very rare instance where the patient shows no response to antiviral therapy, Dr. Hay said.

Smoking Boosts Pelvic Prolapse Risk

Tobacco smoking is an independent risk factor for pelvic organ prolapse, data from the Pelvic Organ Support Study suggest. The findings from this multicenter, cross-sectional, observational study—known as POSST—contrast with those from the Women's Health Initiative, which suggested that smoking was protective against pelvic organ prolapse, Dr. Cecilia K. Wieslander reported at the annual meeting of the American Urogynecologic Society. Of 906 women included in the POSST analysis, 773 were nonsmokers (including 173 former smokers) and 133 were current smokers. On multivariate analysis, smoking was an independent, noninteractive risk factor for pelvic organ prolapse of stage II or greater (odds ratio 2.37), said Dr. Wieslander, a fellow in obstetrics and gynecology at the University of Texas Southwestern Medical Center at Dallas. Even among nulliparous smokers, the prevalence of prolapse was significantly greater, compared with the prevalence in nonsmokers (28% vs. 12%, adjusted odds ratio 1.95). In nonsmokers with one vaginal delivery, the prevalence of prolapse increased from 12% to 27%, so the risk associated with smoking in nulliparous women is greater than the risk associated with one vaginal delivery in nonsmokers. The findings, which are consistent with laboratory data showing that smoking-induced activation of vaginal macrophage elastase may contribute to the pathogenesis of organ prolapse, suggest that smoking is a modifiable risk factor for pelvic organ prolapse. However, further study of dose response is needed to evaluate the effects of secondhand smoke exposures, to determine if symptoms associated with smoking—such as chronic cough—are a cause of pelvic organ prolapse, and to determine if other illnesses with effects similar to those of smoking—such as inflammation—can contribute to pelvic organ prolapse, Dr. Wieslander said.

Rupture Risk Up With Single Closure

Single-layer closure from a prior cesarean delivery increases risk of symptomatic uterine rupture in a subsequent trial of labor, compared with double-layer closure, Dr. Martine Goyet said at the annual meeting of the Society for Maternal-Fetal Medicine. Dr. Goyet and colleagues conducted a multicenter, case-control study to compare the two closure techniques. They reviewed records from 1993 to 2003 for nine maternity wards. “Single-layer closure was the only significant negative factor associated with uterine rupture in a multivariate analysis [odds ratio 2.31],” said Dr. Goyet of the department of obstetrics and gynecology, Hôpital Sainte-Justine, Montreal. “Prior vaginal delivery was the only positive significant factor [OR 0.49].” They identified 96 cases of symptomatic uterine rupture, including emergency laparotomy, using ICD-9 codes and perinatal databases. They also identified three matched controls for each case. The controls were women who underwent a trial of labor before each uterine rupture case; the control group totaled 288. Maternal age and parity did not significantly differ between groups. Cases had a history of one low-transverse cesarean delivery and uterine rupture with an attempted trial of labor. The researchers excluded women with a history of more than one cesarean delivery, prior myomectomy, or multiple gestations. Women who had uterine rupture were more likely to have had a single-layer closure than controls (37% vs. 20%); induction of labor with an unfavorable cervix (38% vs. 23%); gestational age of 41 weeks or more (26% vs. 17%); birth weight of 4,000 g or greater (23% vs. 13%); and no prior vaginal delivery (87% vs. 73%), according to a univariate analysis. Women who had uterine rupture also tended to have a shorter interval between deliveries (less than 24 months), Dr. Goyet said.

Herpes Hepatitis Diagnosis Lifesaving

The diagnosis of herpes simplex hepatitis in pregnancy is one that can't afford to be missed, Dr. Eileen Hay said at the annual meeting of the American College of Gastroenterology. That's because treatment with acyclovir or vidarabine is lifesaving—and without it, one-half of affected mothers will die of fulminant hepatitis, stressed Dr. Hay, professor of medicine at the Mayo Medical School, Rochester, Minn. Herpes hepatitis is a rare disorder. In pregnancy, it occurs in the third trimester. It is usually but not always preceded by a flulike viral prodrome. The typical mucocutaneous herpetic lesions aren't always present. The characteristic features of this infection are the third-trimester presentation, marked elevation of transaminases (with levels often in the thousands) along with coagulopathy and encephalopathy, and no jaundice. Liver biopsy shows hepatocytes with the classic viral inclusion bodies of herpes simplex virus. It's necessary to consider delivery only in the very rare instance where the patient shows no response to antiviral therapy, Dr. Hay said.

Smoking Boosts Pelvic Prolapse Risk

Tobacco smoking is an independent risk factor for pelvic organ prolapse, data from the Pelvic Organ Support Study suggest. The findings from this multicenter, cross-sectional, observational study—known as POSST—contrast with those from the Women's Health Initiative, which suggested that smoking was protective against pelvic organ prolapse, Dr. Cecilia K. Wieslander reported at the annual meeting of the American Urogynecologic Society. Of 906 women included in the POSST analysis, 773 were nonsmokers (including 173 former smokers) and 133 were current smokers. On multivariate analysis, smoking was an independent, noninteractive risk factor for pelvic organ prolapse of stage II or greater (odds ratio 2.37), said Dr. Wieslander, a fellow in obstetrics and gynecology at the University of Texas Southwestern Medical Center at Dallas. Even among nulliparous smokers, the prevalence of prolapse was significantly greater, compared with the prevalence in nonsmokers (28% vs. 12%, adjusted odds ratio 1.95). In nonsmokers with one vaginal delivery, the prevalence of prolapse increased from 12% to 27%, so the risk associated with smoking in nulliparous women is greater than the risk associated with one vaginal delivery in nonsmokers. The findings, which are consistent with laboratory data showing that smoking-induced activation of vaginal macrophage elastase may contribute to the pathogenesis of organ prolapse, suggest that smoking is a modifiable risk factor for pelvic organ prolapse. However, further study of dose response is needed to evaluate the effects of secondhand smoke exposures, to determine if symptoms associated with smoking—such as chronic cough—are a cause of pelvic organ prolapse, and to determine if other illnesses with effects similar to those of smoking—such as inflammation—can contribute to pelvic organ prolapse, Dr. Wieslander said.

OTC Drugs Don't Stop DTaP Reactions

Neither acetaminophen nor ibuprofen had a significant preventive effect against localized reactions to the fifth dose of the diphtheria-tetanus-acellular pertussis vaccine based on data from 372 children aged 4–6 years. Dr. Lisa A. Jackson of the University of Washington, Seattle, and her colleagues conducted a randomized, blinded controlled trial within a larger safety study of the Tripedia DTaP vaccine. Dr. Jackson has served on the speakers' bureau for Sanofi Pasteur, which manufactures the vaccine and provided a research grant for the study (Pediatrics 2006;117:620–5). The children were assigned to receive their first dose of 15 mg/kg of acetaminophen, with a maximum dose of 450 mg; 10 mg/kg of ibuprofen, with a maximum dose of 300 mg; or a placebo 2 hours before their scheduled vaccinations. The second and third doses were given at 6-hour intervals after vaccination, although an interval of up to 12 hours between consecutive doses was allowed. Overall, 90% of parents reported giving their children all three doses, and 70% reported giving all doses on schedule. Local reactions with an area of redness at least 2.5 cm in size occurred in 43% of the children. In addition, 49% reported some pain in the vaccinated limb and 23% reported some itching in the vaccinated limb during the 2 days after vaccination. However, the intent-to-treat analysis showed no significant differences in outcomes in either treatment group, compared with the placebo group. Although acetaminophen was given every 6 hours for study consistency rather than at the minimal recommended dosing interval of 4 hours, the results suggest that more frequent dosing would be unlikely to reduce the risk of local reactions, the investigators noted.

Shunts, MRSA, Chills ID Bacteremia

Three clinical characteristics—shunts or grafts, history of methicillin-resistant Staphylococcus aureus, and the presence of chills—were significantly associated with S. aureus bacteremia in a study of 1,015 patients, Dr. Zeina A. Kanafani reported in a poster presented at the annual meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy. The findings may facilitate earlier detection of infection and encourage the timely initiation of antibiotics in bacteremic patients, noted Dr. Kanafani and her colleagues at Duke University Medical Center in Durham, N.C. Data were collected from hospitalized patients aged 18 years and older with fevers of at least 38° C who underwent blood cultures between December 2003 and December 2004. A total of 235 patients (23%) had positive blood cultures; 76 were excluded from the study due to possible culture contamination. Of the remaining 159 patients (16% of the original patient population), 78 had S. aureus bacteremia; the other 81 patients grew organisms including Candida species, Enterococcus species, and Bacteroides species. Overall, 15 (19%) of patients with S. aureus bacteremia had histories of S. aureus infection, compared with 42 (5%) of the 780 patients whose blood cultures were negative for bacteremia. In addition, 25 (32%) bacteremia patients had an arteriovenous shunt or graft, compared with 74 (10%) of the culture-negative patients, and 34 (44%) of the bacteremia patients suffered from chills, compared with 126 (16%) of the culture-negative patients. In a subgroup of 829 nonhemodialysis patients, 45 (5%) had S. aureus bacteremia, and these patients were significantly more likely to have a tunneled-cuff catheter and a history of methicillin-resistant S. aureus. The meeting was sponsored by the American Society for Microbiology.

Oral Nystatin Cuts Candida Risk

A medical practice intervention reduced the incidence of Candida species from 36% among 45 control neonates admitted between Jan. 1, 1995, and June 30, 1996, to 6% among 69 neonates admitted between July 1, 1996, and December 31, 1998, said Dr. Maliha J. Shareef in a poster presented at the annual meeting of the Midwest Society for Pediatric Research. The intervention included administration of oral nystatin every 6 hours for the first week of life, and as an accompaniment to each antibiotic course during the first 4 weeks, wrote Dr. Shareef of St. Francis Medical Center, Peoria, Ill. Modification of parameters for early extubation, early discontinuation of central lines, and use of parenteral nutrition and antibiotics use also were part of the intervention. The study included neonates weighing 750 g or less at birth, who were admitted to a neonatal ICU within the first week of life. A retrospective analysis revealed that the intervention group had significantly fewer episodes of Candida after the investigators controlled for gestational age, model of delivery, and number of days of central vascular access. However, exposure to a high-humidity environment was significantly associated with an increased risk of Candida sepsis in the intervention group (odds ratio 10.5). Overall infection rates remained 0%–3% during the period 1999–2004.

OTC Drugs Don't Stop DTaP Reactions

Neither acetaminophen nor ibuprofen had a significant preventive effect against localized reactions to the fifth dose of the diphtheria-tetanus-acellular pertussis vaccine based on data from 372 children aged 4–6 years. Dr. Lisa A. Jackson of the University of Washington, Seattle, and her colleagues conducted a randomized, blinded controlled trial within a larger safety study of the Tripedia DTaP vaccine. Dr. Jackson has served on the speakers' bureau for Sanofi Pasteur, which manufactures the vaccine and provided a research grant for the study (Pediatrics 2006;117:620–5). The children were assigned to receive their first dose of 15 mg/kg of acetaminophen, with a maximum dose of 450 mg; 10 mg/kg of ibuprofen, with a maximum dose of 300 mg; or a placebo 2 hours before their scheduled vaccinations. The second and third doses were given at 6-hour intervals after vaccination, although an interval of up to 12 hours between consecutive doses was allowed. Overall, 90% of parents reported giving their children all three doses, and 70% reported giving all doses on schedule. Local reactions with an area of redness at least 2.5 cm in size occurred in 43% of the children. In addition, 49% reported some pain in the vaccinated limb and 23% reported some itching in the vaccinated limb during the 2 days after vaccination. However, the intent-to-treat analysis showed no significant differences in outcomes in either treatment group, compared with the placebo group. Although acetaminophen was given every 6 hours for study consistency rather than at the minimal recommended dosing interval of 4 hours, the results suggest that more frequent dosing would be unlikely to reduce the risk of local reactions, the investigators noted.

Shunts, MRSA, Chills ID Bacteremia

Three clinical characteristics—shunts or grafts, history of methicillin-resistant Staphylococcus aureus, and the presence of chills—were significantly associated with S. aureus bacteremia in a study of 1,015 patients, Dr. Zeina A. Kanafani reported in a poster presented at the annual meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy. The findings may facilitate earlier detection of infection and encourage the timely initiation of antibiotics in bacteremic patients, noted Dr. Kanafani and her colleagues at Duke University Medical Center in Durham, N.C. Data were collected from hospitalized patients aged 18 years and older with fevers of at least 38° C who underwent blood cultures between December 2003 and December 2004. A total of 235 patients (23%) had positive blood cultures; 76 were excluded from the study due to possible culture contamination. Of the remaining 159 patients (16% of the original patient population), 78 had S. aureus bacteremia; the other 81 patients grew organisms including Candida species, Enterococcus species, and Bacteroides species. Overall, 15 (19%) of patients with S. aureus bacteremia had histories of S. aureus infection, compared with 42 (5%) of the 780 patients whose blood cultures were negative for bacteremia. In addition, 25 (32%) bacteremia patients had an arteriovenous shunt or graft, compared with 74 (10%) of the culture-negative patients, and 34 (44%) of the bacteremia patients suffered from chills, compared with 126 (16%) of the culture-negative patients. In a subgroup of 829 nonhemodialysis patients, 45 (5%) had S. aureus bacteremia, and these patients were significantly more likely to have a tunneled-cuff catheter and a history of methicillin-resistant S. aureus. The meeting was sponsored by the American Society for Microbiology.

Oral Nystatin Cuts Candida Risk

A medical practice intervention reduced the incidence of Candida species from 36% among 45 control neonates admitted between Jan. 1, 1995, and June 30, 1996, to 6% among 69 neonates admitted between July 1, 1996, and December 31, 1998, said Dr. Maliha J. Shareef in a poster presented at the annual meeting of the Midwest Society for Pediatric Research. The intervention included administration of oral nystatin every 6 hours for the first week of life, and as an accompaniment to each antibiotic course during the first 4 weeks, wrote Dr. Shareef of St. Francis Medical Center, Peoria, Ill. Modification of parameters for early extubation, early discontinuation of central lines, and use of parenteral nutrition and antibiotics use also were part of the intervention. The study included neonates weighing 750 g or less at birth, who were admitted to a neonatal ICU within the first week of life. A retrospective analysis revealed that the intervention group had significantly fewer episodes of Candida after the investigators controlled for gestational age, model of delivery, and number of days of central vascular access. However, exposure to a high-humidity environment was significantly associated with an increased risk of Candida sepsis in the intervention group (odds ratio 10.5). Overall infection rates remained 0%–3% during the period 1999–2004.

OTC Drugs Don't Stop DTaP Reactions

Neither acetaminophen nor ibuprofen had a significant preventive effect against localized reactions to the fifth dose of the diphtheria-tetanus-acellular pertussis vaccine based on data from 372 children aged 4–6 years. Dr. Lisa A. Jackson of the University of Washington, Seattle, and her colleagues conducted a randomized, blinded controlled trial within a larger safety study of the Tripedia DTaP vaccine. Dr. Jackson has served on the speakers' bureau for Sanofi Pasteur, which manufactures the vaccine and provided a research grant for the study (Pediatrics 2006;117:620–5). The children were assigned to receive their first dose of 15 mg/kg of acetaminophen, with a maximum dose of 450 mg; 10 mg/kg of ibuprofen, with a maximum dose of 300 mg; or a placebo 2 hours before their scheduled vaccinations. The second and third doses were given at 6-hour intervals after vaccination, although an interval of up to 12 hours between consecutive doses was allowed. Overall, 90% of parents reported giving their children all three doses, and 70% reported giving all doses on schedule. Local reactions with an area of redness at least 2.5 cm in size occurred in 43% of the children. In addition, 49% reported some pain in the vaccinated limb and 23% reported some itching in the vaccinated limb during the 2 days after vaccination. However, the intent-to-treat analysis showed no significant differences in outcomes in either treatment group, compared with the placebo group. Although acetaminophen was given every 6 hours for study consistency rather than at the minimal recommended dosing interval of 4 hours, the results suggest that more frequent dosing would be unlikely to reduce the risk of local reactions, the investigators noted.

Shunts, MRSA, Chills ID Bacteremia

Three clinical characteristics—shunts or grafts, history of methicillin-resistant Staphylococcus aureus, and the presence of chills—were significantly associated with S. aureus bacteremia in a study of 1,015 patients, Dr. Zeina A. Kanafani reported in a poster presented at the annual meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy. The findings may facilitate earlier detection of infection and encourage the timely initiation of antibiotics in bacteremic patients, noted Dr. Kanafani and her colleagues at Duke University Medical Center in Durham, N.C. Data were collected from hospitalized patients aged 18 years and older with fevers of at least 38° C who underwent blood cultures between December 2003 and December 2004. A total of 235 patients (23%) had positive blood cultures; 76 were excluded from the study due to possible culture contamination. Of the remaining 159 patients (16% of the original patient population), 78 had S. aureus bacteremia; the other 81 patients grew organisms including Candida species, Enterococcus species, and Bacteroides species. Overall, 15 (19%) of patients with S. aureus bacteremia had histories of S. aureus infection, compared with 42 (5%) of the 780 patients whose blood cultures were negative for bacteremia. In addition, 25 (32%) bacteremia patients had an arteriovenous shunt or graft, compared with 74 (10%) of the culture-negative patients, and 34 (44%) of the bacteremia patients suffered from chills, compared with 126 (16%) of the culture-negative patients. In a subgroup of 829 nonhemodialysis patients, 45 (5%) had S. aureus bacteremia, and these patients were significantly more likely to have a tunneled-cuff catheter and a history of methicillin-resistant S. aureus. The meeting was sponsored by the American Society for Microbiology.

Oral Nystatin Cuts Candida Risk

A medical practice intervention reduced the incidence of Candida species from 36% among 45 control neonates admitted between Jan. 1, 1995, and June 30, 1996, to 6% among 69 neonates admitted between July 1, 1996, and December 31, 1998, said Dr. Maliha J. Shareef in a poster presented at the annual meeting of the Midwest Society for Pediatric Research. The intervention included administration of oral nystatin every 6 hours for the first week of life, and as an accompaniment to each antibiotic course during the first 4 weeks, wrote Dr. Shareef of St. Francis Medical Center, Peoria, Ill. Modification of parameters for early extubation, early discontinuation of central lines, and use of parenteral nutrition and antibiotics use also were part of the intervention. The study included neonates weighing 750 g or less at birth, who were admitted to a neonatal ICU within the first week of life. A retrospective analysis revealed that the intervention group had significantly fewer episodes of Candida after the investigators controlled for gestational age, model of delivery, and number of days of central vascular access. However, exposure to a high-humidity environment was significantly associated with an increased risk of Candida sepsis in the intervention group (odds ratio 10.5). Overall infection rates remained 0%–3% during the period 1999–2004.

Itopride for Functional Dyspepsia

For patients with functional dyspepsia, treatment with itopride for 8 weeks provides a significantly greater reduction in symptoms than does placebo, according to results from a recent randomized trial.

Itopride is a dopamine D2 antagonist that inhibits acetylcholinesterase activity. In Japan, the drug is often prescribed for functional dyspepsia, even though it had not been evaluated in randomized, controlled trials.

In the current study, Dr. Gerald Holtmann of the University of Adelaide (Australia) and his associates randomized 554 patients with functional dyspepsia to receive itopride at 50 mg, 100 mg, or 200 mg three times daily or placebo (N. Engl. J. Med. 2006;354:832–40).

After 8 weeks, the overall response rate, defined by the patient's global assessment of efficacy, was significantly greater with itopride than with placebo (60% vs 41%). This was a dose-dependent effect, with response rates of 57% at 50 mg, 59% at 100 mg, and 64% at 200 mg.

The incidence of adverse events was similar for itopride (38%) and placebo (37%). Although prolactin levels increased significantly in the 100-mg and 200-mg itopride groups, no related clinical signs or symptoms were noted.

COX-2 Inhibitors in IBD Patients

Patients with ulcerative colitis in remission who had a history of nonspecific arthritis, arthralgia, or another condition treatable with NSAID therapy did not have a greater relapse rate with the use of celecoxib for up to 14 days than with placebo, Dr. William J. Sandborn and his colleagues reported.

In a double-blind, pilot trial, 221 patients were randomized to receive oral celecoxib 200 mg or placebo twice daily for 14 days. Ulcerative colitis (UC) exacerbation occurred in 3 of 110 evaluated patients on celecoxib and in 4 of 107 on placebo (Clin. Gastroenterol. Hepatol. 2006;4:203–11). The study was supported by a research grant from Pfizer Inc.

In a second study, Dr. Ken Takeuchi and his colleagues studied patients with quiescent Crohn's disease or UC. First, they randomized 109 patients to 4 weeks of treatment with either acetaminophen or a conventional NSAID (naproxen, diclofenac, or indomethacin). Of patients taking NSAIDs, 17%–28% had a relapse; whereas no patients taking acetaminophen relapsed (Clin. Gastroenterol. Hepatol. 2006;4:196–202).

None of the 100 patients in the second part of the study had an early relapse on acetaminophen, low-dose aspirin (selective COX-1 inhibitor), or nimesulide (selective COX-2 inhibitor not available in the United States). Those on naproxen (topical COX-1 and −2 inhibitor) or nabumetone (COX-1 and −2 inhibitor) had relapses associated with intestinal inflammation. The research was funded in part by grants from Merck Sharp & Dohme and Helsinn Pharmaceuticals, manufacturer of nimesulide.

The studies “indicate that nonselective inhibitors carry a significant risk for exacerbating IBD whereas celecoxib is safe for 2 weeks for patients in remission. Low-dose aspirin use remains in a gray zone of uncertain but probable safety,” said Dr. Joshua R. Korzenik and Dr. Daniel K. Podolsky of Harvard Medical School, Boston, in an editorial (Clin. Gastroenterol. Hepatol. 2006;4:157–9).

Treatment Options for Pancreatitis

Surgical drainage of the pancreatic duct was more effective for relieving pain than endoscopic drainage in a study of 39 patients with chronic pancreatitis.

“Surgery is safe and required fewer therapeutic interventions,” Dr. Djuna L. Cahen said at the 13th United European Gastroenterology Week. Surgery also led to faster pain relief, said Dr. Cahen, a gastroenterologist at the University of Amsterdam Academic Medical Center.

The study involved all patients referred to the Academic Medical Center from January 2000 to October 2004 with symptomatic, chronic pancreatitis and a dominant pancreatic duct obstruction caused by strictures or stones.

Of the 39 patients, 20 were randomized to surgical drainage by pancreaticojejunostomy and 19 underwent endoscopic drainage by stent insertion. Endoscopic treatment was preceded by extracorporeal shock wave lithotripsy in 16 patients who had stones causing the obstruction.

The study's primary end point was the average Izbicki pain score during a median follow-up of 24 months. The average pain score was 25 in the surgery group and 51 in the endoscopy group, a statistically significant difference.

Clinical success—defined as a reduction in the pain score of at least 50% from baseline to the end of follow-up—was achieved in 32% of endoscopy patients and 75% of surgery patients. The two groups did not differ in terms of complications, morbidity, mortality, or hospital length of stay.

Itopride for Functional Dyspepsia

For patients with functional dyspepsia, treatment with itopride for 8 weeks provides a significantly greater reduction in symptoms than does placebo, according to results from a recent randomized trial.

Itopride is a dopamine D2 antagonist that inhibits acetylcholinesterase activity. In Japan, the drug is often prescribed for functional dyspepsia, even though it had not been evaluated in randomized, controlled trials.

In the current study, Dr. Gerald Holtmann of the University of Adelaide (Australia) and his associates randomized 554 patients with functional dyspepsia to receive itopride at 50 mg, 100 mg, or 200 mg three times daily or placebo (N. Engl. J. Med. 2006;354:832–40).

After 8 weeks, the overall response rate, defined by the patient's global assessment of efficacy, was significantly greater with itopride than with placebo (60% vs 41%). This was a dose-dependent effect, with response rates of 57% at 50 mg, 59% at 100 mg, and 64% at 200 mg.

The incidence of adverse events was similar for itopride (38%) and placebo (37%). Although prolactin levels increased significantly in the 100-mg and 200-mg itopride groups, no related clinical signs or symptoms were noted.

COX-2 Inhibitors in IBD Patients

Patients with ulcerative colitis in remission who had a history of nonspecific arthritis, arthralgia, or another condition treatable with NSAID therapy did not have a greater relapse rate with the use of celecoxib for up to 14 days than with placebo, Dr. William J. Sandborn and his colleagues reported.

In a double-blind, pilot trial, 221 patients were randomized to receive oral celecoxib 200 mg or placebo twice daily for 14 days. Ulcerative colitis (UC) exacerbation occurred in 3 of 110 evaluated patients on celecoxib and in 4 of 107 on placebo (Clin. Gastroenterol. Hepatol. 2006;4:203–11). The study was supported by a research grant from Pfizer Inc.

In a second study, Dr. Ken Takeuchi and his colleagues studied patients with quiescent Crohn's disease or UC. First, they randomized 109 patients to 4 weeks of treatment with either acetaminophen or a conventional NSAID (naproxen, diclofenac, or indomethacin). Of patients taking NSAIDs, 17%–28% had a relapse; whereas no patients taking acetaminophen relapsed (Clin. Gastroenterol. Hepatol. 2006;4:196–202).

None of the 100 patients in the second part of the study had an early relapse on acetaminophen, low-dose aspirin (selective COX-1 inhibitor), or nimesulide (selective COX-2 inhibitor not available in the United States). Those on naproxen (topical COX-1 and −2 inhibitor) or nabumetone (COX-1 and −2 inhibitor) had relapses associated with intestinal inflammation. The research was funded in part by grants from Merck Sharp & Dohme and Helsinn Pharmaceuticals, manufacturer of nimesulide.

The studies “indicate that nonselective inhibitors carry a significant risk for exacerbating IBD whereas celecoxib is safe for 2 weeks for patients in remission. Low-dose aspirin use remains in a gray zone of uncertain but probable safety,” said Dr. Joshua R. Korzenik and Dr. Daniel K. Podolsky of Harvard Medical School, Boston, in an editorial (Clin. Gastroenterol. Hepatol. 2006;4:157–9).

Treatment Options for Pancreatitis

Surgical drainage of the pancreatic duct was more effective for relieving pain than endoscopic drainage in a study of 39 patients with chronic pancreatitis.

“Surgery is safe and required fewer therapeutic interventions,” Dr. Djuna L. Cahen said at the 13th United European Gastroenterology Week. Surgery also led to faster pain relief, said Dr. Cahen, a gastroenterologist at the University of Amsterdam Academic Medical Center.

The study involved all patients referred to the Academic Medical Center from January 2000 to October 2004 with symptomatic, chronic pancreatitis and a dominant pancreatic duct obstruction caused by strictures or stones.

Of the 39 patients, 20 were randomized to surgical drainage by pancreaticojejunostomy and 19 underwent endoscopic drainage by stent insertion. Endoscopic treatment was preceded by extracorporeal shock wave lithotripsy in 16 patients who had stones causing the obstruction.

The study's primary end point was the average Izbicki pain score during a median follow-up of 24 months. The average pain score was 25 in the surgery group and 51 in the endoscopy group, a statistically significant difference.

Clinical success—defined as a reduction in the pain score of at least 50% from baseline to the end of follow-up—was achieved in 32% of endoscopy patients and 75% of surgery patients. The two groups did not differ in terms of complications, morbidity, mortality, or hospital length of stay.

Itopride for Functional Dyspepsia

For patients with functional dyspepsia, treatment with itopride for 8 weeks provides a significantly greater reduction in symptoms than does placebo, according to results from a recent randomized trial.

Itopride is a dopamine D2 antagonist that inhibits acetylcholinesterase activity. In Japan, the drug is often prescribed for functional dyspepsia, even though it had not been evaluated in randomized, controlled trials.

In the current study, Dr. Gerald Holtmann of the University of Adelaide (Australia) and his associates randomized 554 patients with functional dyspepsia to receive itopride at 50 mg, 100 mg, or 200 mg three times daily or placebo (N. Engl. J. Med. 2006;354:832–40).

After 8 weeks, the overall response rate, defined by the patient's global assessment of efficacy, was significantly greater with itopride than with placebo (60% vs 41%). This was a dose-dependent effect, with response rates of 57% at 50 mg, 59% at 100 mg, and 64% at 200 mg.

The incidence of adverse events was similar for itopride (38%) and placebo (37%). Although prolactin levels increased significantly in the 100-mg and 200-mg itopride groups, no related clinical signs or symptoms were noted.

COX-2 Inhibitors in IBD Patients

Patients with ulcerative colitis in remission who had a history of nonspecific arthritis, arthralgia, or another condition treatable with NSAID therapy did not have a greater relapse rate with the use of celecoxib for up to 14 days than with placebo, Dr. William J. Sandborn and his colleagues reported.

In a double-blind, pilot trial, 221 patients were randomized to receive oral celecoxib 200 mg or placebo twice daily for 14 days. Ulcerative colitis (UC) exacerbation occurred in 3 of 110 evaluated patients on celecoxib and in 4 of 107 on placebo (Clin. Gastroenterol. Hepatol. 2006;4:203–11). The study was supported by a research grant from Pfizer Inc.

In a second study, Dr. Ken Takeuchi and his colleagues studied patients with quiescent Crohn's disease or UC. First, they randomized 109 patients to 4 weeks of treatment with either acetaminophen or a conventional NSAID (naproxen, diclofenac, or indomethacin). Of patients taking NSAIDs, 17%–28% had a relapse; whereas no patients taking acetaminophen relapsed (Clin. Gastroenterol. Hepatol. 2006;4:196–202).

None of the 100 patients in the second part of the study had an early relapse on acetaminophen, low-dose aspirin (selective COX-1 inhibitor), or nimesulide (selective COX-2 inhibitor not available in the United States). Those on naproxen (topical COX-1 and −2 inhibitor) or nabumetone (COX-1 and −2 inhibitor) had relapses associated with intestinal inflammation. The research was funded in part by grants from Merck Sharp & Dohme and Helsinn Pharmaceuticals, manufacturer of nimesulide.

The studies “indicate that nonselective inhibitors carry a significant risk for exacerbating IBD whereas celecoxib is safe for 2 weeks for patients in remission. Low-dose aspirin use remains in a gray zone of uncertain but probable safety,” said Dr. Joshua R. Korzenik and Dr. Daniel K. Podolsky of Harvard Medical School, Boston, in an editorial (Clin. Gastroenterol. Hepatol. 2006;4:157–9).

Treatment Options for Pancreatitis

Surgical drainage of the pancreatic duct was more effective for relieving pain than endoscopic drainage in a study of 39 patients with chronic pancreatitis.

“Surgery is safe and required fewer therapeutic interventions,” Dr. Djuna L. Cahen said at the 13th United European Gastroenterology Week. Surgery also led to faster pain relief, said Dr. Cahen, a gastroenterologist at the University of Amsterdam Academic Medical Center.

The study involved all patients referred to the Academic Medical Center from January 2000 to October 2004 with symptomatic, chronic pancreatitis and a dominant pancreatic duct obstruction caused by strictures or stones.

Of the 39 patients, 20 were randomized to surgical drainage by pancreaticojejunostomy and 19 underwent endoscopic drainage by stent insertion. Endoscopic treatment was preceded by extracorporeal shock wave lithotripsy in 16 patients who had stones causing the obstruction.

The study's primary end point was the average Izbicki pain score during a median follow-up of 24 months. The average pain score was 25 in the surgery group and 51 in the endoscopy group, a statistically significant difference.

Clinical success—defined as a reduction in the pain score of at least 50% from baseline to the end of follow-up—was achieved in 32% of endoscopy patients and 75% of surgery patients. The two groups did not differ in terms of complications, morbidity, mortality, or hospital length of stay.

Reminders for Teen Immunization

Telephone calls to remind families about needed adolescent immunizations or well-child appointments did little to improve response rates in a large, randomized trial of 3,006 urban adolescents aged 11–14 years, primarily because phone numbers were often inaccurate.

During the first 2 months of the study, the telephone reminder/recall intervention was linked to minor improvements in vaccination rates (18.1%, vs. 11.6% for controls) and well-child visits (40.4%, vs. 34.4% for controls), but these benefits faded throughout the remaining 16 months of the intervention.

“The initial improvements were probably owing to the reminders reaching those families with accurate telephone numbers or those who were going to respond. Continued intervention had no effect,” said Dr. Peter G. Szilagyi of the University of Rochester (N.Y.) and his associates (Arch. Pediatr. Adolesc. Med. 2006;160:157–63).

Adolescents included in the trial received treatment at one of four urban primary care centers in Rochester. An automated telephone reminder system was used to call the households, and the reminder calls were repeated unless recipients requested that the calls be stopped or if five calls were made within a month without an appointment being made.

Calls to study adolescents significantly increased the rate of hepatitis B vaccinations, compared with the rate in control adolescents (62.0% vs. 57.8%), but no significant differences between the groups were found in the rates of tetanus-diphtheria vaccinations (52.0% vs. 49.9%) or well-child visits (53.1% vs. 54.3%). In addition, an analysis suggested that the intervention performed no differently among demographic subgroups.

“Given that our intervention has some initial benefit … health care professionals serving urban populations may consider short-term reminder/recall interventions instead of prolonged and intensive interventions,” the authors wrote.

Low BMI and Mortality in Septic Shock

Body mass index has long been recognized as a prognostic factor for a variety of medical conditions. For at least one condition, it's low—not high—BMI that is linked to greater mortality.

Patients admitted to the ICU for septic shock had a significantly greater risk of death if they had a lower-than-normal BMI, according to a poster presented by Dr. Almothana Shanaah at the annual congress of the Society of Critical Care Medicine. Patients with BMI values in the overweight or obese ranges did not have a significantly increased risk of dying.

Dr. Shanaah of Cooper University Hospital, Camden, N.J., and colleagues used a multicenter database, extracting data on 1,745 patients admitted with septic shock. Patients with BMIs from 18.5 to 24.9 kg/m

The groups did not differ significantly in age or APACHE II (Acute Physiology and Chronic Health Evaluation) severity of disease score. Two other factors were significantly associated with mortality in these patients: ventilator dependency and chronic renal failure.

Herpesviruses and PAH

New findings from German researchers do not support previous findings that linked Kaposi's sarcoma-associated herpesvirus infection to idiopathic pulmonary arterial hypertension.

Using immunohistochemistry and polymerase chain reaction (PCR), Dr. Cornelia Henke-Gendo and colleagues at Hannover (Germany) Medical School analyzed lung tissue from 26 patients with idiopathic pulmonary artery hypertension (PAH) for the presence of Kaposi's sarcoma-associated herpesvirus (KSHV) antigen and genomes.

They found latent nuclear antigen 1 (LANA-1) of KSHV in 16 cases (62%) when they used immunohistochemistry (Am. J. Respir. Crit. Care Med. 2005;172:1581–5). However, three different PCR assays could not confirm the immunohistochemistry results, they said.

“Whether the positive antibody stain is really detecting KSHV LANA-1 in our samples is therefore doubtful,” the investigators wrote. They noted that KSHV infection can occur in patients with idiopathic PAH, “but it is unlikely to play an etiologic role in this condition.”

In an editorial, Harutaka Katano, D.D.S., of the National Institute of Infectious Diseases in Tokyo, and Cory M. Hogaboam, Ph.D., of the University of Michigan, Ann Arbor, said that although it may be unlikely that KSHV is associated with pulmonary hypertension, “it is too soon to rule out the presence of and a putative role for other herpesviruses” in the condition (Am. J. Respir. Crit. Care Med. 2005;172:1485–6).

Reminders for Teen Immunization

Telephone calls to remind families about needed adolescent immunizations or well-child appointments did little to improve response rates in a large, randomized trial of 3,006 urban adolescents aged 11–14 years, primarily because phone numbers were often inaccurate.

During the first 2 months of the study, the telephone reminder/recall intervention was linked to minor improvements in vaccination rates (18.1%, vs. 11.6% for controls) and well-child visits (40.4%, vs. 34.4% for controls), but these benefits faded throughout the remaining 16 months of the intervention.

“The initial improvements were probably owing to the reminders reaching those families with accurate telephone numbers or those who were going to respond. Continued intervention had no effect,” said Dr. Peter G. Szilagyi of the University of Rochester (N.Y.) and his associates (Arch. Pediatr. Adolesc. Med. 2006;160:157–63).

Adolescents included in the trial received treatment at one of four urban primary care centers in Rochester. An automated telephone reminder system was used to call the households, and the reminder calls were repeated unless recipients requested that the calls be stopped or if five calls were made within a month without an appointment being made.

Calls to study adolescents significantly increased the rate of hepatitis B vaccinations, compared with the rate in control adolescents (62.0% vs. 57.8%), but no significant differences between the groups were found in the rates of tetanus-diphtheria vaccinations (52.0% vs. 49.9%) or well-child visits (53.1% vs. 54.3%). In addition, an analysis suggested that the intervention performed no differently among demographic subgroups.

“Given that our intervention has some initial benefit … health care professionals serving urban populations may consider short-term reminder/recall interventions instead of prolonged and intensive interventions,” the authors wrote.

Low BMI and Mortality in Septic Shock

Body mass index has long been recognized as a prognostic factor for a variety of medical conditions. For at least one condition, it's low—not high—BMI that is linked to greater mortality.

Patients admitted to the ICU for septic shock had a significantly greater risk of death if they had a lower-than-normal BMI, according to a poster presented by Dr. Almothana Shanaah at the annual congress of the Society of Critical Care Medicine. Patients with BMI values in the overweight or obese ranges did not have a significantly increased risk of dying.

Dr. Shanaah of Cooper University Hospital, Camden, N.J., and colleagues used a multicenter database, extracting data on 1,745 patients admitted with septic shock. Patients with BMIs from 18.5 to 24.9 kg/m

The groups did not differ significantly in age or APACHE II (Acute Physiology and Chronic Health Evaluation) severity of disease score. Two other factors were significantly associated with mortality in these patients: ventilator dependency and chronic renal failure.

Herpesviruses and PAH

New findings from German researchers do not support previous findings that linked Kaposi's sarcoma-associated herpesvirus infection to idiopathic pulmonary arterial hypertension.

Using immunohistochemistry and polymerase chain reaction (PCR), Dr. Cornelia Henke-Gendo and colleagues at Hannover (Germany) Medical School analyzed lung tissue from 26 patients with idiopathic pulmonary artery hypertension (PAH) for the presence of Kaposi's sarcoma-associated herpesvirus (KSHV) antigen and genomes.

They found latent nuclear antigen 1 (LANA-1) of KSHV in 16 cases (62%) when they used immunohistochemistry (Am. J. Respir. Crit. Care Med. 2005;172:1581–5). However, three different PCR assays could not confirm the immunohistochemistry results, they said.

“Whether the positive antibody stain is really detecting KSHV LANA-1 in our samples is therefore doubtful,” the investigators wrote. They noted that KSHV infection can occur in patients with idiopathic PAH, “but it is unlikely to play an etiologic role in this condition.”

In an editorial, Harutaka Katano, D.D.S., of the National Institute of Infectious Diseases in Tokyo, and Cory M. Hogaboam, Ph.D., of the University of Michigan, Ann Arbor, said that although it may be unlikely that KSHV is associated with pulmonary hypertension, “it is too soon to rule out the presence of and a putative role for other herpesviruses” in the condition (Am. J. Respir. Crit. Care Med. 2005;172:1485–6).

Reminders for Teen Immunization

Telephone calls to remind families about needed adolescent immunizations or well-child appointments did little to improve response rates in a large, randomized trial of 3,006 urban adolescents aged 11–14 years, primarily because phone numbers were often inaccurate.

During the first 2 months of the study, the telephone reminder/recall intervention was linked to minor improvements in vaccination rates (18.1%, vs. 11.6% for controls) and well-child visits (40.4%, vs. 34.4% for controls), but these benefits faded throughout the remaining 16 months of the intervention.

“The initial improvements were probably owing to the reminders reaching those families with accurate telephone numbers or those who were going to respond. Continued intervention had no effect,” said Dr. Peter G. Szilagyi of the University of Rochester (N.Y.) and his associates (Arch. Pediatr. Adolesc. Med. 2006;160:157–63).

Adolescents included in the trial received treatment at one of four urban primary care centers in Rochester. An automated telephone reminder system was used to call the households, and the reminder calls were repeated unless recipients requested that the calls be stopped or if five calls were made within a month without an appointment being made.

Calls to study adolescents significantly increased the rate of hepatitis B vaccinations, compared with the rate in control adolescents (62.0% vs. 57.8%), but no significant differences between the groups were found in the rates of tetanus-diphtheria vaccinations (52.0% vs. 49.9%) or well-child visits (53.1% vs. 54.3%). In addition, an analysis suggested that the intervention performed no differently among demographic subgroups.

“Given that our intervention has some initial benefit … health care professionals serving urban populations may consider short-term reminder/recall interventions instead of prolonged and intensive interventions,” the authors wrote.

Low BMI and Mortality in Septic Shock

Body mass index has long been recognized as a prognostic factor for a variety of medical conditions. For at least one condition, it's low—not high—BMI that is linked to greater mortality.

Patients admitted to the ICU for septic shock had a significantly greater risk of death if they had a lower-than-normal BMI, according to a poster presented by Dr. Almothana Shanaah at the annual congress of the Society of Critical Care Medicine. Patients with BMI values in the overweight or obese ranges did not have a significantly increased risk of dying.

Dr. Shanaah of Cooper University Hospital, Camden, N.J., and colleagues used a multicenter database, extracting data on 1,745 patients admitted with septic shock. Patients with BMIs from 18.5 to 24.9 kg/m

The groups did not differ significantly in age or APACHE II (Acute Physiology and Chronic Health Evaluation) severity of disease score. Two other factors were significantly associated with mortality in these patients: ventilator dependency and chronic renal failure.

Herpesviruses and PAH

New findings from German researchers do not support previous findings that linked Kaposi's sarcoma-associated herpesvirus infection to idiopathic pulmonary arterial hypertension.

Using immunohistochemistry and polymerase chain reaction (PCR), Dr. Cornelia Henke-Gendo and colleagues at Hannover (Germany) Medical School analyzed lung tissue from 26 patients with idiopathic pulmonary artery hypertension (PAH) for the presence of Kaposi's sarcoma-associated herpesvirus (KSHV) antigen and genomes.

They found latent nuclear antigen 1 (LANA-1) of KSHV in 16 cases (62%) when they used immunohistochemistry (Am. J. Respir. Crit. Care Med. 2005;172:1581–5). However, three different PCR assays could not confirm the immunohistochemistry results, they said.

“Whether the positive antibody stain is really detecting KSHV LANA-1 in our samples is therefore doubtful,” the investigators wrote. They noted that KSHV infection can occur in patients with idiopathic PAH, “but it is unlikely to play an etiologic role in this condition.”

In an editorial, Harutaka Katano, D.D.S., of the National Institute of Infectious Diseases in Tokyo, and Cory M. Hogaboam, Ph.D., of the University of Michigan, Ann Arbor, said that although it may be unlikely that KSHV is associated with pulmonary hypertension, “it is too soon to rule out the presence of and a putative role for other herpesviruses” in the condition (Am. J. Respir. Crit. Care Med. 2005;172:1485–6).

Guidelines for ICD Recall Response

Physicians should soon have a better idea of how to handle recalls of their patients' implantable cardioverter defibrillators.

A 14-member task force working on guidelines for responding to ICD recalls is “on track” for getting its report out on May 1, according to a spokeswoman for the Heart Rhythm Society, which has 12 members on the task force. The American College of Cardiology and the American Heart Association each have one member representing their groups.

Members of the committee “recognize that these devices perform to a very high standard, and we recognize the challenge of how to respond to a low incidence of potentially catastrophic failures” Dr. Saxon said. She noted that doctors who choose to replace a recalled device often end up putting in a replacement that has similar odds of a catastrophic event occurring.

One factor that is very important in considering whether to recall a device is what happens over time, Dr. Saxon said. “Suppose there are four deaths out of 30,000 patients. You would want to follow this over time, because something different [from what] you first thought may be going on in 3–6 months.”

The committee is consulting with several outside parties to prepare the guidelines, including device manufacturers, patient advocates, and risk communicators.

Rx for Heart Failure-Related Apnea

A 6-day course of acetazolamide appeared to improve sleep-disordered breathing in a study of 12 men with heart failure-related central sleep apnea.

In central sleep apnea (CSA), respiration temporarily ceases because of a decline in partial pressure of carbon dioxide (PCO₂) below the apneic threshold. However, in a randomized, double-blind study by Dr. Shahrokh Javaheri and his associates, the diuretic and respiratory stimulant acetazolamide seemed to reduce the likelihood of PCO₂ crossing the apneic threshold by inducing a state of metabolic acidosis. Dr. Javaheri of the University of Cincinnati and associates evaluated acetazolamide in 12 men with stable heart failure with left ventricular systolic dysfunction and CSA (Am. J. Respir. Crit. Care Med. 2006;173:234–7).

For 6 nights, patients received either placebo or a single dose (3.5 mg/kg) of acetazolamide and 30 mEq of potassium chloride (to offset the urinary potassium loss caused by acetazolamide). The acetazolamide dosage was increased to 4.0 mg/kg on the third day. After a 2-week washout period, crossover studies were initiated.

The mean baseline frequency of central apnea was 44 episodes/hour. With acetazolamide, CSA frequency was 23 episodes/hour, compared with 49 episodes/hour when patients received placebo. Arterial oxyhemoglobin saturation also improved significantly with acetazolamide, although other sleep-related and pulmonary measurements were similar between study arms.

Patients reported significant improvements in sleep quality, daytime fatigue, and other daytime symptoms with acetazolamide. “In spite of the short duration of the study and modest reduction in period breathing, patient perception improved,” the investigators noted. They hypothesized that long-term improvement in periodic breathing could, in turn, improve cardiac function.

Acupuncture Works for Hypertension

Acupuncture proved effective and safe for the treatment of mild to moderate hypertension in a randomized, single-blind German clinical trial.

This form of therapy may appeal to patients who dislike taking medication. But it's not curative; 3 months after completion of the course of acupuncture, blood pressures were back at baseline levels, Dr. Frank A. Flachskampf reported at the annual scientific sessions of the American Heart Association.

The trial involved 160 patients aged 45–75 years who were randomized to a 6-week course of traditional Chinese acupuncture or sham acupuncture. Seventy-two patients in the acupuncture arm and 69 assigned to sham acupuncture completed the study.

Overall, 78% of study participants were taking antihypertensive medication at baseline, and their dosing remained unchanged during the trial. Mean 24-hour ambulatory blood pressure in the acupuncture group fell from 131/81 mm Hg at baseline to 125/78 at 6 weeks. Blood pressure remained unchanged in the sham-therapy group, said Dr. Flachskampf of the University of Erlangen, Germany.

Follow-up 24-hour ambulatory blood pressure monitoring conducted 3 and 6 months after completing the acupuncture showed blood pressures had returned to pretreatment levels.

Two patients in the acupuncture group dropped out of the study because they said acupuncture was too painful; they were the only subjects who reported any side effects.

Guidelines for ICD Recall Response

Physicians should soon have a better idea of how to handle recalls of their patients' implantable cardioverter defibrillators.

A 14-member task force working on guidelines for responding to ICD recalls is “on track” for getting its report out on May 1, according to a spokeswoman for the Heart Rhythm Society, which has 12 members on the task force. The American College of Cardiology and the American Heart Association each have one member representing their groups.

Members of the committee “recognize that these devices perform to a very high standard, and we recognize the challenge of how to respond to a low incidence of potentially catastrophic failures” Dr. Saxon said. She noted that doctors who choose to replace a recalled device often end up putting in a replacement that has similar odds of a catastrophic event occurring.

One factor that is very important in considering whether to recall a device is what happens over time, Dr. Saxon said. “Suppose there are four deaths out of 30,000 patients. You would want to follow this over time, because something different [from what] you first thought may be going on in 3–6 months.”

The committee is consulting with several outside parties to prepare the guidelines, including device manufacturers, patient advocates, and risk communicators.

Rx for Heart Failure-Related Apnea

A 6-day course of acetazolamide appeared to improve sleep-disordered breathing in a study of 12 men with heart failure-related central sleep apnea.

In central sleep apnea (CSA), respiration temporarily ceases because of a decline in partial pressure of carbon dioxide (PCO₂) below the apneic threshold. However, in a randomized, double-blind study by Dr. Shahrokh Javaheri and his associates, the diuretic and respiratory stimulant acetazolamide seemed to reduce the likelihood of PCO₂ crossing the apneic threshold by inducing a state of metabolic acidosis. Dr. Javaheri of the University of Cincinnati and associates evaluated acetazolamide in 12 men with stable heart failure with left ventricular systolic dysfunction and CSA (Am. J. Respir. Crit. Care Med. 2006;173:234–7).

For 6 nights, patients received either placebo or a single dose (3.5 mg/kg) of acetazolamide and 30 mEq of potassium chloride (to offset the urinary potassium loss caused by acetazolamide). The acetazolamide dosage was increased to 4.0 mg/kg on the third day. After a 2-week washout period, crossover studies were initiated.

The mean baseline frequency of central apnea was 44 episodes/hour. With acetazolamide, CSA frequency was 23 episodes/hour, compared with 49 episodes/hour when patients received placebo. Arterial oxyhemoglobin saturation also improved significantly with acetazolamide, although other sleep-related and pulmonary measurements were similar between study arms.

Patients reported significant improvements in sleep quality, daytime fatigue, and other daytime symptoms with acetazolamide. “In spite of the short duration of the study and modest reduction in period breathing, patient perception improved,” the investigators noted. They hypothesized that long-term improvement in periodic breathing could, in turn, improve cardiac function.

Acupuncture Works for Hypertension

Acupuncture proved effective and safe for the treatment of mild to moderate hypertension in a randomized, single-blind German clinical trial.

This form of therapy may appeal to patients who dislike taking medication. But it's not curative; 3 months after completion of the course of acupuncture, blood pressures were back at baseline levels, Dr. Frank A. Flachskampf reported at the annual scientific sessions of the American Heart Association.

The trial involved 160 patients aged 45–75 years who were randomized to a 6-week course of traditional Chinese acupuncture or sham acupuncture. Seventy-two patients in the acupuncture arm and 69 assigned to sham acupuncture completed the study.

Overall, 78% of study participants were taking antihypertensive medication at baseline, and their dosing remained unchanged during the trial. Mean 24-hour ambulatory blood pressure in the acupuncture group fell from 131/81 mm Hg at baseline to 125/78 at 6 weeks. Blood pressure remained unchanged in the sham-therapy group, said Dr. Flachskampf of the University of Erlangen, Germany.

Follow-up 24-hour ambulatory blood pressure monitoring conducted 3 and 6 months after completing the acupuncture showed blood pressures had returned to pretreatment levels.

Two patients in the acupuncture group dropped out of the study because they said acupuncture was too painful; they were the only subjects who reported any side effects.

Guidelines for ICD Recall Response

Physicians should soon have a better idea of how to handle recalls of their patients' implantable cardioverter defibrillators.

A 14-member task force working on guidelines for responding to ICD recalls is “on track” for getting its report out on May 1, according to a spokeswoman for the Heart Rhythm Society, which has 12 members on the task force. The American College of Cardiology and the American Heart Association each have one member representing their groups.

Members of the committee “recognize that these devices perform to a very high standard, and we recognize the challenge of how to respond to a low incidence of potentially catastrophic failures” Dr. Saxon said. She noted that doctors who choose to replace a recalled device often end up putting in a replacement that has similar odds of a catastrophic event occurring.

One factor that is very important in considering whether to recall a device is what happens over time, Dr. Saxon said. “Suppose there are four deaths out of 30,000 patients. You would want to follow this over time, because something different [from what] you first thought may be going on in 3–6 months.”

The committee is consulting with several outside parties to prepare the guidelines, including device manufacturers, patient advocates, and risk communicators.

Rx for Heart Failure-Related Apnea

A 6-day course of acetazolamide appeared to improve sleep-disordered breathing in a study of 12 men with heart failure-related central sleep apnea.

In central sleep apnea (CSA), respiration temporarily ceases because of a decline in partial pressure of carbon dioxide (PCO₂) below the apneic threshold. However, in a randomized, double-blind study by Dr. Shahrokh Javaheri and his associates, the diuretic and respiratory stimulant acetazolamide seemed to reduce the likelihood of PCO₂ crossing the apneic threshold by inducing a state of metabolic acidosis. Dr. Javaheri of the University of Cincinnati and associates evaluated acetazolamide in 12 men with stable heart failure with left ventricular systolic dysfunction and CSA (Am. J. Respir. Crit. Care Med. 2006;173:234–7).

For 6 nights, patients received either placebo or a single dose (3.5 mg/kg) of acetazolamide and 30 mEq of potassium chloride (to offset the urinary potassium loss caused by acetazolamide). The acetazolamide dosage was increased to 4.0 mg/kg on the third day. After a 2-week washout period, crossover studies were initiated.

The mean baseline frequency of central apnea was 44 episodes/hour. With acetazolamide, CSA frequency was 23 episodes/hour, compared with 49 episodes/hour when patients received placebo. Arterial oxyhemoglobin saturation also improved significantly with acetazolamide, although other sleep-related and pulmonary measurements were similar between study arms.

Patients reported significant improvements in sleep quality, daytime fatigue, and other daytime symptoms with acetazolamide. “In spite of the short duration of the study and modest reduction in period breathing, patient perception improved,” the investigators noted. They hypothesized that long-term improvement in periodic breathing could, in turn, improve cardiac function.

Acupuncture Works for Hypertension

Acupuncture proved effective and safe for the treatment of mild to moderate hypertension in a randomized, single-blind German clinical trial.

This form of therapy may appeal to patients who dislike taking medication. But it's not curative; 3 months after completion of the course of acupuncture, blood pressures were back at baseline levels, Dr. Frank A. Flachskampf reported at the annual scientific sessions of the American Heart Association.

The trial involved 160 patients aged 45–75 years who were randomized to a 6-week course of traditional Chinese acupuncture or sham acupuncture. Seventy-two patients in the acupuncture arm and 69 assigned to sham acupuncture completed the study.

Overall, 78% of study participants were taking antihypertensive medication at baseline, and their dosing remained unchanged during the trial. Mean 24-hour ambulatory blood pressure in the acupuncture group fell from 131/81 mm Hg at baseline to 125/78 at 6 weeks. Blood pressure remained unchanged in the sham-therapy group, said Dr. Flachskampf of the University of Erlangen, Germany.

Follow-up 24-hour ambulatory blood pressure monitoring conducted 3 and 6 months after completing the acupuncture showed blood pressures had returned to pretreatment levels.

Two patients in the acupuncture group dropped out of the study because they said acupuncture was too painful; they were the only subjects who reported any side effects.

Prolapse Hinders Quality of Life

Advanced pelvic organ prolapse negatively affects body image and quality of life, Dr. Erik Jelovsek reported at the annual meeting of the American Urogynecologic Society.

In a case-control study with 47 case patients and 51 controls, a validated body image scale showed that case patients were less likely to feel physically attractive (adjusted odds ratio 11.3), sexually attractive (adjusted OR 4.8), and feminine (adjusted OR 4.0), than controls, said Dr. Jelovsek, of the Cleveland Clinic Foundation.

Although body image has been shown to be important in quality of life and the effect of advanced organ prolapse on body image might seem obvious, no one has specifically assessed this or the relationship between body image and quality of life in these patients, he noted.

These findings indicate that there is indeed a condition-specific decrease in quality of life among women with advanced pelvic organ prolapse and suggest that women seeking treatment for this condition might also be seeking an improvement in body image and quality of life.

Digital Mammography Best for Some

A large, head-to-head comparison of digital and film mammography found no overall difference in diagnostic accuracy, but digital mammography seems to have better diagnostic accuracy in some subgroups.

Digital mammography was significantly more accurate among women under age 50, women with heterogeneously dense or extremely dense breasts, and premenopausal or perimenopausal women, Dr. Etta D. Pisano of the University of North Carolina at Chapel Hill and colleagues reported.

The study included data from 42,760 women for whom the investigators had all relevant information (N. Engl. J. Med. 2005;353:[Epub ahead of print] doi10.1056/nejmoa052911,

www.nejm.org

All women underwent digital and film mammography, independently interpreted by two readers. Readers rated the mammograms on a 7-point malignancy scale and used the classification of the Breast Imaging Reporting and Data System.

Biopsy or aspiration of the suspicious lesion was performed if either reader recommended it. These patients received follow-up mammograms a mean of 455 days following their initial screening. A total of 335 cancers were detected.

Results indicated no advantage in the accuracy of digital mammography for women 50 and older, women with fatty breasts or scattered fibroglandular densities, or postmenopausal women.

But there were other advantages to digital: easier access to images and to computer-assisted diagnosis; improved image transmission, storage, and retrieval; and a lower average dose of radiation without compromised diagnostic accuracy.

Digital mammography costs up to four times more than film imaging.

Deformities Rare in Osteopenia

Moderate to severe vertebral compression deformities are rare in postmenopausal women with osteopenia but no history of fragility fracture, Dr. Angela M. Cheung reported in a poster session at the annual meeting of the International Society for Clinical Densitometry.

In what she said is the first study to describe the prevalence of such deformities in healthy postmenopausal women with osteopenia, Dr. Cheung and her associates conducted a cross-sectional analysis of 439 women in the ongoing 2-year Evaluation of the Clinical Use of Vitamin K Supplementation in Postmenopausal Women with Osteopenia (ECKO) trial.

Of the 48 deformities detected in the study, 45 (94%) were grade 1.

“How does that mild, grade 1 vertebral compression deformity translate to future fracture risk?” Dr. Cheung, osteoporosis program director for University Health Network, Toronto, said. “We'll take a look at that. It's an ongoing study.”

Exclusion criteria included being on an osteoporosis medication, having a clinical fragility fracture, or having a T score of less than −2.0 at the lumbar spine, total hip, or femoral neck. Densitometry was used to measure bone mineral density and to perform a vertebral fracture assessment.

Mean patient age at baseline was 58 years (range 40–82 years), and mean body mass index was 26 kg/m

Dr. Cheung said she and her colleagues were surprised to see vertebral compression deformities in women from all age groups. “While we do see a higher percentage of [older] people [with] vertebral compression deformities, we see it in young people, too,” she said.

Study limitations were a cross-sectional design and a lack of lateral spine x-rays for comparison.

However, vertebral fracture assessment “has been validated by different groups, and the performance of the test is excellent for grades 2–4 deformities.”

Prolapse Hinders Quality of Life

Advanced pelvic organ prolapse negatively affects body image and quality of life, Dr. Erik Jelovsek reported at the annual meeting of the American Urogynecologic Society.

In a case-control study with 47 case patients and 51 controls, a validated body image scale showed that case patients were less likely to feel physically attractive (adjusted odds ratio 11.3), sexually attractive (adjusted OR 4.8), and feminine (adjusted OR 4.0), than controls, said Dr. Jelovsek, of the Cleveland Clinic Foundation.

Although body image has been shown to be important in quality of life and the effect of advanced organ prolapse on body image might seem obvious, no one has specifically assessed this or the relationship between body image and quality of life in these patients, he noted.

These findings indicate that there is indeed a condition-specific decrease in quality of life among women with advanced pelvic organ prolapse and suggest that women seeking treatment for this condition might also be seeking an improvement in body image and quality of life.

Digital Mammography Best for Some

A large, head-to-head comparison of digital and film mammography found no overall difference in diagnostic accuracy, but digital mammography seems to have better diagnostic accuracy in some subgroups.

Digital mammography was significantly more accurate among women under age 50, women with heterogeneously dense or extremely dense breasts, and premenopausal or perimenopausal women, Dr. Etta D. Pisano of the University of North Carolina at Chapel Hill and colleagues reported.

The study included data from 42,760 women for whom the investigators had all relevant information (N. Engl. J. Med. 2005;353:[Epub ahead of print] doi10.1056/nejmoa052911,

www.nejm.org

All women underwent digital and film mammography, independently interpreted by two readers. Readers rated the mammograms on a 7-point malignancy scale and used the classification of the Breast Imaging Reporting and Data System.

Biopsy or aspiration of the suspicious lesion was performed if either reader recommended it. These patients received follow-up mammograms a mean of 455 days following their initial screening. A total of 335 cancers were detected.

Results indicated no advantage in the accuracy of digital mammography for women 50 and older, women with fatty breasts or scattered fibroglandular densities, or postmenopausal women.

But there were other advantages to digital: easier access to images and to computer-assisted diagnosis; improved image transmission, storage, and retrieval; and a lower average dose of radiation without compromised diagnostic accuracy.

Digital mammography costs up to four times more than film imaging.

Deformities Rare in Osteopenia

Moderate to severe vertebral compression deformities are rare in postmenopausal women with osteopenia but no history of fragility fracture, Dr. Angela M. Cheung reported in a poster session at the annual meeting of the International Society for Clinical Densitometry.

In what she said is the first study to describe the prevalence of such deformities in healthy postmenopausal women with osteopenia, Dr. Cheung and her associates conducted a cross-sectional analysis of 439 women in the ongoing 2-year Evaluation of the Clinical Use of Vitamin K Supplementation in Postmenopausal Women with Osteopenia (ECKO) trial.

Of the 48 deformities detected in the study, 45 (94%) were grade 1.

“How does that mild, grade 1 vertebral compression deformity translate to future fracture risk?” Dr. Cheung, osteoporosis program director for University Health Network, Toronto, said. “We'll take a look at that. It's an ongoing study.”

Exclusion criteria included being on an osteoporosis medication, having a clinical fragility fracture, or having a T score of less than −2.0 at the lumbar spine, total hip, or femoral neck. Densitometry was used to measure bone mineral density and to perform a vertebral fracture assessment.

Mean patient age at baseline was 58 years (range 40–82 years), and mean body mass index was 26 kg/m

Dr. Cheung said she and her colleagues were surprised to see vertebral compression deformities in women from all age groups. “While we do see a higher percentage of [older] people [with] vertebral compression deformities, we see it in young people, too,” she said.

Study limitations were a cross-sectional design and a lack of lateral spine x-rays for comparison.

However, vertebral fracture assessment “has been validated by different groups, and the performance of the test is excellent for grades 2–4 deformities.”

Prolapse Hinders Quality of Life

Advanced pelvic organ prolapse negatively affects body image and quality of life, Dr. Erik Jelovsek reported at the annual meeting of the American Urogynecologic Society.

In a case-control study with 47 case patients and 51 controls, a validated body image scale showed that case patients were less likely to feel physically attractive (adjusted odds ratio 11.3), sexually attractive (adjusted OR 4.8), and feminine (adjusted OR 4.0), than controls, said Dr. Jelovsek, of the Cleveland Clinic Foundation.

Although body image has been shown to be important in quality of life and the effect of advanced organ prolapse on body image might seem obvious, no one has specifically assessed this or the relationship between body image and quality of life in these patients, he noted.

These findings indicate that there is indeed a condition-specific decrease in quality of life among women with advanced pelvic organ prolapse and suggest that women seeking treatment for this condition might also be seeking an improvement in body image and quality of life.

Digital Mammography Best for Some

A large, head-to-head comparison of digital and film mammography found no overall difference in diagnostic accuracy, but digital mammography seems to have better diagnostic accuracy in some subgroups.

Digital mammography was significantly more accurate among women under age 50, women with heterogeneously dense or extremely dense breasts, and premenopausal or perimenopausal women, Dr. Etta D. Pisano of the University of North Carolina at Chapel Hill and colleagues reported.

The study included data from 42,760 women for whom the investigators had all relevant information (N. Engl. J. Med. 2005;353:[Epub ahead of print] doi10.1056/nejmoa052911,

www.nejm.org

All women underwent digital and film mammography, independently interpreted by two readers. Readers rated the mammograms on a 7-point malignancy scale and used the classification of the Breast Imaging Reporting and Data System.

Biopsy or aspiration of the suspicious lesion was performed if either reader recommended it. These patients received follow-up mammograms a mean of 455 days following their initial screening. A total of 335 cancers were detected.

Results indicated no advantage in the accuracy of digital mammography for women 50 and older, women with fatty breasts or scattered fibroglandular densities, or postmenopausal women.

But there were other advantages to digital: easier access to images and to computer-assisted diagnosis; improved image transmission, storage, and retrieval; and a lower average dose of radiation without compromised diagnostic accuracy.

Digital mammography costs up to four times more than film imaging.

Deformities Rare in Osteopenia

Moderate to severe vertebral compression deformities are rare in postmenopausal women with osteopenia but no history of fragility fracture, Dr. Angela M. Cheung reported in a poster session at the annual meeting of the International Society for Clinical Densitometry.

In what she said is the first study to describe the prevalence of such deformities in healthy postmenopausal women with osteopenia, Dr. Cheung and her associates conducted a cross-sectional analysis of 439 women in the ongoing 2-year Evaluation of the Clinical Use of Vitamin K Supplementation in Postmenopausal Women with Osteopenia (ECKO) trial.

Of the 48 deformities detected in the study, 45 (94%) were grade 1.

“How does that mild, grade 1 vertebral compression deformity translate to future fracture risk?” Dr. Cheung, osteoporosis program director for University Health Network, Toronto, said. “We'll take a look at that. It's an ongoing study.”

Exclusion criteria included being on an osteoporosis medication, having a clinical fragility fracture, or having a T score of less than −2.0 at the lumbar spine, total hip, or femoral neck. Densitometry was used to measure bone mineral density and to perform a vertebral fracture assessment.

Mean patient age at baseline was 58 years (range 40–82 years), and mean body mass index was 26 kg/m

Dr. Cheung said she and her colleagues were surprised to see vertebral compression deformities in women from all age groups. “While we do see a higher percentage of [older] people [with] vertebral compression deformities, we see it in young people, too,” she said.

Study limitations were a cross-sectional design and a lack of lateral spine x-rays for comparison.

However, vertebral fracture assessment “has been validated by different groups, and the performance of the test is excellent for grades 2–4 deformities.”

Gastric Bypass Alters Gut Hormones

Gastric bypass surgery, unlike gastric banding, alters gut hormones that favor satiety and long-term changes in body weight.

Formerly obese patients who had undergone Roux-en-Y gastric bypass had increased levels of peptide YY (PYY) and glucagon-like peptide 1 (GLP-1) and exaggerated insulin responses immediately following a meal. “None of these effects were observed in patients losing similar amounts of weight through gastric banding, suggesting that the hormonal changes are not secondary to weight loss alone,” said Dr. Carel W. le Roux, of Imperial College London, and colleagues (Ann. Surg. 2006;243:108–14).

Released postprandially from the distal gastrointestinal tract, PYY inhibits the release of a neuropeptide that stimulates food intake. GLP-1 promotes postprandial insulin release and improves pancreatic β-cell function. GLP-1 has also been reported to inhibit food intake in humans.

The researchers compared plasma levels of PYY, GLP-1, and ghrelin after a 420-kcal meal in 15 lean control subjects, 12 obese control subjects, 6 patients who had undergone Roux-en-Y gastric bypass, and 6 patients who had undergone gastric banding. The surgery patients underwent the procedures 6–36 months prior to the measures.

Roux-en-Y bypass patients had an exaggerated GLP-1 response at 30 minutes—230% of the baseline value. In contrast, normal controls, obese controls, and gastric banding patients had GLP-1 responses at 30 minutes of 66%, 22%, and 50% above baseline.

Likewise, Roux-en-Y bypass patients had an exaggerated PYY response at 90 minutes—162% of baseline. Normal controls, obese controls, and gastric banding patients had PYY responses at 90 minutes of 49%, 14%, and 22% above baseline.

“The higher postprandial PYY response after gastric bypass surgery … may contribute to the patients' increased satiety and weight loss.” Increased GLP-1 might contribute to immediate improvements in glycemic control.

Obese subjects had a lower fasting ghrelin level (446 pmol/L), compared with lean subjects (700 pmol/L). There were no differences in the fasting ghrelin levels among the obese and surgically-treated groups. Ghrelin stimulates food intake.

Albuminuria, Central Fat in Diabetes

Microalbuminuria and macroalbuminuria appear to occur more often in men with type 1 diabetes than in women with the disease because men have more visceral fat, according to findings from a cross-sectional follow-up study.

Further studies will be necessary to determine the cause of the association between male gender and increased albumin excretion rate (AER), because central obesity itself may not cause the increased excretion, reported Dr. Shalamar D. Sibley of the University of Minnesota, Minneapolis, and associates (Am. J. Kidney Dis. 2006;47:223–32).

The study involved 1,185 patients with type 1 diabetes who participated in the Epidemiology of Diabetes Interventions and Complications trial. After 4 years of follow-up, 217 patients developed an elevated AER: 163 had microalbuminuria and 54 had macroalbuminuria.

Waist-to-hip ratio was significantly and independently associated with elevated AER in men, but not in women, after adjusting for age, HbA_1c level, smoking status, duration of diabetes, and systolic blood pressure.

Hyperparathyroidism Impairs Respiration

Researchers in Turkey have reported greatly improved respiratory measures after surgical removal of parathyroid adenomas or subtotal parathyroid excision in patients with hyperparathyroidism.

Investigators with the Istanbul Medical Faculty measured forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV₁) before surgery and 6 months after surgery in 15 patients with symptomatic hyperparathyroidism. A group of 10 euthyroid patients with multinodal goiter undergoing near total thyroidectomy served as controls.

Dr. Yasemin Giles and colleagues found that preoperative FVC values were below reference values in 11 of 15 patients (73%) and FEV₁ values were below reference values in 9 of the 15 patients (60%) with hyperparathyroidism (Arch. Surg. 2005;140:1167–71).

Respiratory function was normal before and after surgery in controls. Patients with symptomatic hyperparathyroidism did not have dyspnea before surgery, but all reported fatigue, weakness, and exhaustion with minimal effort.

Improvement in respiratory function was “found to have a linear correlation with preoperative total serum calcium,” the investigators wrote.

Surgery resulted in normalization of serum calcium in all patients. Symptomatic disease is linked to hypercalcemia, they noted.

Gastric Bypass Alters Gut Hormones

Gastric bypass surgery, unlike gastric banding, alters gut hormones that favor satiety and long-term changes in body weight.

Formerly obese patients who had undergone Roux-en-Y gastric bypass had increased levels of peptide YY (PYY) and glucagon-like peptide 1 (GLP-1) and exaggerated insulin responses immediately following a meal. “None of these effects were observed in patients losing similar amounts of weight through gastric banding, suggesting that the hormonal changes are not secondary to weight loss alone,” said Dr. Carel W. le Roux, of Imperial College London, and colleagues (Ann. Surg. 2006;243:108–14).

Released postprandially from the distal gastrointestinal tract, PYY inhibits the release of a neuropeptide that stimulates food intake. GLP-1 promotes postprandial insulin release and improves pancreatic β-cell function. GLP-1 has also been reported to inhibit food intake in humans.

The researchers compared plasma levels of PYY, GLP-1, and ghrelin after a 420-kcal meal in 15 lean control subjects, 12 obese control subjects, 6 patients who had undergone Roux-en-Y gastric bypass, and 6 patients who had undergone gastric banding. The surgery patients underwent the procedures 6–36 months prior to the measures.

Roux-en-Y bypass patients had an exaggerated GLP-1 response at 30 minutes—230% of the baseline value. In contrast, normal controls, obese controls, and gastric banding patients had GLP-1 responses at 30 minutes of 66%, 22%, and 50% above baseline.

Likewise, Roux-en-Y bypass patients had an exaggerated PYY response at 90 minutes—162% of baseline. Normal controls, obese controls, and gastric banding patients had PYY responses at 90 minutes of 49%, 14%, and 22% above baseline.

“The higher postprandial PYY response after gastric bypass surgery … may contribute to the patients' increased satiety and weight loss.” Increased GLP-1 might contribute to immediate improvements in glycemic control.

Obese subjects had a lower fasting ghrelin level (446 pmol/L), compared with lean subjects (700 pmol/L). There were no differences in the fasting ghrelin levels among the obese and surgically-treated groups. Ghrelin stimulates food intake.

Albuminuria, Central Fat in Diabetes

Microalbuminuria and macroalbuminuria appear to occur more often in men with type 1 diabetes than in women with the disease because men have more visceral fat, according to findings from a cross-sectional follow-up study.

Further studies will be necessary to determine the cause of the association between male gender and increased albumin excretion rate (AER), because central obesity itself may not cause the increased excretion, reported Dr. Shalamar D. Sibley of the University of Minnesota, Minneapolis, and associates (Am. J. Kidney Dis. 2006;47:223–32).

The study involved 1,185 patients with type 1 diabetes who participated in the Epidemiology of Diabetes Interventions and Complications trial. After 4 years of follow-up, 217 patients developed an elevated AER: 163 had microalbuminuria and 54 had macroalbuminuria.

Waist-to-hip ratio was significantly and independently associated with elevated AER in men, but not in women, after adjusting for age, HbA_1c level, smoking status, duration of diabetes, and systolic blood pressure.

Hyperparathyroidism Impairs Respiration

Researchers in Turkey have reported greatly improved respiratory measures after surgical removal of parathyroid adenomas or subtotal parathyroid excision in patients with hyperparathyroidism.

Investigators with the Istanbul Medical Faculty measured forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV₁) before surgery and 6 months after surgery in 15 patients with symptomatic hyperparathyroidism. A group of 10 euthyroid patients with multinodal goiter undergoing near total thyroidectomy served as controls.

Dr. Yasemin Giles and colleagues found that preoperative FVC values were below reference values in 11 of 15 patients (73%) and FEV₁ values were below reference values in 9 of the 15 patients (60%) with hyperparathyroidism (Arch. Surg. 2005;140:1167–71).

Respiratory function was normal before and after surgery in controls. Patients with symptomatic hyperparathyroidism did not have dyspnea before surgery, but all reported fatigue, weakness, and exhaustion with minimal effort.

Improvement in respiratory function was “found to have a linear correlation with preoperative total serum calcium,” the investigators wrote.

Surgery resulted in normalization of serum calcium in all patients. Symptomatic disease is linked to hypercalcemia, they noted.

Gastric Bypass Alters Gut Hormones

Gastric bypass surgery, unlike gastric banding, alters gut hormones that favor satiety and long-term changes in body weight.

Formerly obese patients who had undergone Roux-en-Y gastric bypass had increased levels of peptide YY (PYY) and glucagon-like peptide 1 (GLP-1) and exaggerated insulin responses immediately following a meal. “None of these effects were observed in patients losing similar amounts of weight through gastric banding, suggesting that the hormonal changes are not secondary to weight loss alone,” said Dr. Carel W. le Roux, of Imperial College London, and colleagues (Ann. Surg. 2006;243:108–14).

Released postprandially from the distal gastrointestinal tract, PYY inhibits the release of a neuropeptide that stimulates food intake. GLP-1 promotes postprandial insulin release and improves pancreatic β-cell function. GLP-1 has also been reported to inhibit food intake in humans.

The researchers compared plasma levels of PYY, GLP-1, and ghrelin after a 420-kcal meal in 15 lean control subjects, 12 obese control subjects, 6 patients who had undergone Roux-en-Y gastric bypass, and 6 patients who had undergone gastric banding. The surgery patients underwent the procedures 6–36 months prior to the measures.

Roux-en-Y bypass patients had an exaggerated GLP-1 response at 30 minutes—230% of the baseline value. In contrast, normal controls, obese controls, and gastric banding patients had GLP-1 responses at 30 minutes of 66%, 22%, and 50% above baseline.

Likewise, Roux-en-Y bypass patients had an exaggerated PYY response at 90 minutes—162% of baseline. Normal controls, obese controls, and gastric banding patients had PYY responses at 90 minutes of 49%, 14%, and 22% above baseline.

“The higher postprandial PYY response after gastric bypass surgery … may contribute to the patients' increased satiety and weight loss.” Increased GLP-1 might contribute to immediate improvements in glycemic control.

Obese subjects had a lower fasting ghrelin level (446 pmol/L), compared with lean subjects (700 pmol/L). There were no differences in the fasting ghrelin levels among the obese and surgically-treated groups. Ghrelin stimulates food intake.

Albuminuria, Central Fat in Diabetes

Microalbuminuria and macroalbuminuria appear to occur more often in men with type 1 diabetes than in women with the disease because men have more visceral fat, according to findings from a cross-sectional follow-up study.

Further studies will be necessary to determine the cause of the association between male gender and increased albumin excretion rate (AER), because central obesity itself may not cause the increased excretion, reported Dr. Shalamar D. Sibley of the University of Minnesota, Minneapolis, and associates (Am. J. Kidney Dis. 2006;47:223–32).

The study involved 1,185 patients with type 1 diabetes who participated in the Epidemiology of Diabetes Interventions and Complications trial. After 4 years of follow-up, 217 patients developed an elevated AER: 163 had microalbuminuria and 54 had macroalbuminuria.

Waist-to-hip ratio was significantly and independently associated with elevated AER in men, but not in women, after adjusting for age, HbA_1c level, smoking status, duration of diabetes, and systolic blood pressure.

Hyperparathyroidism Impairs Respiration

Researchers in Turkey have reported greatly improved respiratory measures after surgical removal of parathyroid adenomas or subtotal parathyroid excision in patients with hyperparathyroidism.

Investigators with the Istanbul Medical Faculty measured forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV₁) before surgery and 6 months after surgery in 15 patients with symptomatic hyperparathyroidism. A group of 10 euthyroid patients with multinodal goiter undergoing near total thyroidectomy served as controls.

Dr. Yasemin Giles and colleagues found that preoperative FVC values were below reference values in 11 of 15 patients (73%) and FEV₁ values were below reference values in 9 of the 15 patients (60%) with hyperparathyroidism (Arch. Surg. 2005;140:1167–71).

Respiratory function was normal before and after surgery in controls. Patients with symptomatic hyperparathyroidism did not have dyspnea before surgery, but all reported fatigue, weakness, and exhaustion with minimal effort.

Improvement in respiratory function was “found to have a linear correlation with preoperative total serum calcium,” the investigators wrote.

Surgery resulted in normalization of serum calcium in all patients. Symptomatic disease is linked to hypercalcemia, they noted.