Damian McNamara

The birth rate for U.S. teens aged 15-19 years dropped to its lowest ever recorded levels in 2010, according to a new government report.

A slight decrease in cesarean section delivery rates also was notable as the first drop since 1996. The C-section rate decreased to 32.8% last year, compared with 32.9% in 2009.

The rate of 34 births per 1,000 females aged 15-19 years represents a 9% decline from 2009 and continues the decreasing trend observed in 17 of the past 19 years, according to the National Vital Statistics Report released by the Centers for Disease Control and Prevention.

Similarly, birth rates among all other adolescents dropped to historic lows last year as well, according to the 36-page report entitled "Births: Preliminary Data for 2010" (Nat. Vital Stat. Rep. 2011;60:1-36).

The birth rate for girls aged 10-14 years declined from 0.5 per 1,000 in 2009 to 0.4 in 2010, for example. Just looking at the oldest teenagers, those aged 18-19, the birth rate declined 9% as well, from 64 per 1,000 in 2009 to 58 per 1,000 in 2010.

In terms of absolute numbers, total births among teenagers younger than 20 years were 372,252 in 2010, the fewest since 1946.

These findings come from an analysis by researchers at the CDC’s National Center for Health Statistics, who have access to 100% of birth records collected from all 50 states each year.

Historic lows in birth rates also were discovered for all race or Hispanic-origin groups of teens aged 15-19 years old. For example, compared with 2009, rates decreased 9% among non-Hispanic whites to 24 per 1,000 births and 9% among non-Hispanic black teenagers to 52 per 1,000 last year. Greater decreases, 12% each, were observed among American Indian/Alaska natives (to 39 per 1,000) and Hispanics (to 56 per 1,000) in 2010. The greatest decrease, 13%, was reported among Asian or Pacific Islander teenagers (to 11 per 1,000).

The researchers also assessed the data for characteristics of maternal and infant health at birth. The one-tenth of a percentage point drop in cesarean deliveries last year, for example, was the first decrease seen in more than a decade. Prior to 2010, the proportion of births in the United States delivered via C-section had risen steadily from approximately 21% in 1996 to 32.9% in 2009. The pace of the increase had slowed in recent years, the report authors noted.

Unlike the teenage birth rate findings, decreases in cesarean sections were not uniform according to the race or ethnicity of the mother. Non-Hispanic white women experienced a decrease from 32.8% in 2009 to 32.6% last year, whereas the rate did not significantly change among non-Hispanic black mothers, from 35.5% to 34.4%. At the same time, the rate actually increased among Hispanic mothers, from 31.6% to 31.8%.

Maternal age was not significantly associated with changes in the C-section rate. Between 2009 and 2010, cesarean rates either declined slightly or remained essentially unchanged for U.S. women of all age groups.

Other major findings of the report included:

• The preterm birth rate fell to 11.99% in 2010, the fourth consecutive year this decreased. The decline in the preterm rate for 2010 was primarily among infants delivered late preterm (at 34-36 weeks’ gestation), down 2% from 8.66% to 8.49%.

• The rate of low birth weight births remained essentially the same at 8.15%.

• Preliminary data suggest a 3% decrease in the general fertility rate in the United States, from 66.2 births per 1,000 women aged 15-44 years in 2009 to a rate of 64.1 per 1,000 last year. This is the lowest rate reported since the late 1990s.

• Preliminary data also point to a 4% decrease in the birth rate among unmarried women, from 49.9 per 1,000 in 2009 to 47.7 births per 1,000 in 2010. This is the second year of a decrease in this rate and contrasts the 19% increase recorded between 2002 and 2007.

The birth rate for U.S. teens aged 15-19 years dropped to its lowest ever recorded levels in 2010, according to a new government report.

A slight decrease in cesarean section delivery rates also was notable as the first drop since 1996. The C-section rate decreased to 32.8% last year, compared with 32.9% in 2009.

The rate of 34 births per 1,000 females aged 15-19 years represents a 9% decline from 2009 and continues the decreasing trend observed in 17 of the past 19 years, according to the National Vital Statistics Report released by the Centers for Disease Control and Prevention.

Similarly, birth rates among all other adolescents dropped to historic lows last year as well, according to the 36-page report entitled "Births: Preliminary Data for 2010" (Nat. Vital Stat. Rep. 2011;60:1-36).

The birth rate for girls aged 10-14 years declined from 0.5 per 1,000 in 2009 to 0.4 in 2010, for example. Just looking at the oldest teenagers, those aged 18-19, the birth rate declined 9% as well, from 64 per 1,000 in 2009 to 58 per 1,000 in 2010.

In terms of absolute numbers, total births among teenagers younger than 20 years were 372,252 in 2010, the fewest since 1946.

These findings come from an analysis by researchers at the CDC’s National Center for Health Statistics, who have access to 100% of birth records collected from all 50 states each year.

Historic lows in birth rates also were discovered for all race or Hispanic-origin groups of teens aged 15-19 years old. For example, compared with 2009, rates decreased 9% among non-Hispanic whites to 24 per 1,000 births and 9% among non-Hispanic black teenagers to 52 per 1,000 last year. Greater decreases, 12% each, were observed among American Indian/Alaska natives (to 39 per 1,000) and Hispanics (to 56 per 1,000) in 2010. The greatest decrease, 13%, was reported among Asian or Pacific Islander teenagers (to 11 per 1,000).

The researchers also assessed the data for characteristics of maternal and infant health at birth. The one-tenth of a percentage point drop in cesarean deliveries last year, for example, was the first decrease seen in more than a decade. Prior to 2010, the proportion of births in the United States delivered via C-section had risen steadily from approximately 21% in 1996 to 32.9% in 2009. The pace of the increase had slowed in recent years, the report authors noted.

Unlike the teenage birth rate findings, decreases in cesarean sections were not uniform according to the race or ethnicity of the mother. Non-Hispanic white women experienced a decrease from 32.8% in 2009 to 32.6% last year, whereas the rate did not significantly change among non-Hispanic black mothers, from 35.5% to 34.4%. At the same time, the rate actually increased among Hispanic mothers, from 31.6% to 31.8%.

Maternal age was not significantly associated with changes in the C-section rate. Between 2009 and 2010, cesarean rates either declined slightly or remained essentially unchanged for U.S. women of all age groups.

Other major findings of the report included:

• The preterm birth rate fell to 11.99% in 2010, the fourth consecutive year this decreased. The decline in the preterm rate for 2010 was primarily among infants delivered late preterm (at 34-36 weeks’ gestation), down 2% from 8.66% to 8.49%.

• The rate of low birth weight births remained essentially the same at 8.15%.

• Preliminary data suggest a 3% decrease in the general fertility rate in the United States, from 66.2 births per 1,000 women aged 15-44 years in 2009 to a rate of 64.1 per 1,000 last year. This is the lowest rate reported since the late 1990s.

• Preliminary data also point to a 4% decrease in the birth rate among unmarried women, from 49.9 per 1,000 in 2009 to 47.7 births per 1,000 in 2010. This is the second year of a decrease in this rate and contrasts the 19% increase recorded between 2002 and 2007.

The birth rate for U.S. teens aged 15-19 years dropped to its lowest ever recorded levels in 2010, according to a new government report.

A slight decrease in cesarean section delivery rates also was notable as the first drop since 1996. The C-section rate decreased to 32.8% last year, compared with 32.9% in 2009.

The rate of 34 births per 1,000 females aged 15-19 years represents a 9% decline from 2009 and continues the decreasing trend observed in 17 of the past 19 years, according to the National Vital Statistics Report released by the Centers for Disease Control and Prevention.

Similarly, birth rates among all other adolescents dropped to historic lows last year as well, according to the 36-page report entitled "Births: Preliminary Data for 2010" (Nat. Vital Stat. Rep. 2011;60:1-36).

The birth rate for girls aged 10-14 years declined from 0.5 per 1,000 in 2009 to 0.4 in 2010, for example. Just looking at the oldest teenagers, those aged 18-19, the birth rate declined 9% as well, from 64 per 1,000 in 2009 to 58 per 1,000 in 2010.

In terms of absolute numbers, total births among teenagers younger than 20 years were 372,252 in 2010, the fewest since 1946.

These findings come from an analysis by researchers at the CDC’s National Center for Health Statistics, who have access to 100% of birth records collected from all 50 states each year.

Historic lows in birth rates also were discovered for all race or Hispanic-origin groups of teens aged 15-19 years old. For example, compared with 2009, rates decreased 9% among non-Hispanic whites to 24 per 1,000 births and 9% among non-Hispanic black teenagers to 52 per 1,000 last year. Greater decreases, 12% each, were observed among American Indian/Alaska natives (to 39 per 1,000) and Hispanics (to 56 per 1,000) in 2010. The greatest decrease, 13%, was reported among Asian or Pacific Islander teenagers (to 11 per 1,000).

The researchers also assessed the data for characteristics of maternal and infant health at birth. The one-tenth of a percentage point drop in cesarean deliveries last year, for example, was the first decrease seen in more than a decade. Prior to 2010, the proportion of births in the United States delivered via C-section had risen steadily from approximately 21% in 1996 to 32.9% in 2009. The pace of the increase had slowed in recent years, the report authors noted.

Unlike the teenage birth rate findings, decreases in cesarean sections were not uniform according to the race or ethnicity of the mother. Non-Hispanic white women experienced a decrease from 32.8% in 2009 to 32.6% last year, whereas the rate did not significantly change among non-Hispanic black mothers, from 35.5% to 34.4%. At the same time, the rate actually increased among Hispanic mothers, from 31.6% to 31.8%.

Maternal age was not significantly associated with changes in the C-section rate. Between 2009 and 2010, cesarean rates either declined slightly or remained essentially unchanged for U.S. women of all age groups.

Other major findings of the report included:

• The preterm birth rate fell to 11.99% in 2010, the fourth consecutive year this decreased. The decline in the preterm rate for 2010 was primarily among infants delivered late preterm (at 34-36 weeks’ gestation), down 2% from 8.66% to 8.49%.

• The rate of low birth weight births remained essentially the same at 8.15%.

• Preliminary data suggest a 3% decrease in the general fertility rate in the United States, from 66.2 births per 1,000 women aged 15-44 years in 2009 to a rate of 64.1 per 1,000 last year. This is the lowest rate reported since the late 1990s.

• Preliminary data also point to a 4% decrease in the birth rate among unmarried women, from 49.9 per 1,000 in 2009 to 47.7 births per 1,000 in 2010. This is the second year of a decrease in this rate and contrasts the 19% increase recorded between 2002 and 2007.

ORLANDO – Short cervical length during the first trimester predicts preterm delivery of an in vitro fertilization pregnancy, according to two retrospective studies involving a total of 167 women.

Although they used slightly different parameters, researchers who assessed 113 women at Montreal Fertility Center and others who studied 54 women at Detroit Medical Center reached the same conclusion: a cervical length shorter than approximately 4 cm is associated with greater risk of delivery before 37 weeks’ gestation.

These studies are part of a move to identify women at risk for preterm delivery earlier, when clinicians would have more time to intervene. Some previous researchers report associations between shorter midterm cervical length and preterm delivery (Ultrasound Obstet. Gynecol. 2008;32:640-5), while others point to a need for additional evidence (Cochrane Database Syst. Rev. 2009;CD007235 [doi:10.1002/14651858.CD007235.pub2]).

"Little is known about the predictive value of a first trimester cervical length measurement," Dr. Olivia Vincent-Boulay of the Montreal Fertility Centre said at the annual meeting of the American Society for Reproductive Medicine.

"If we know cervical length in the future correlates to preterm delivery ... we could prevent it."

Dr. Vincent-Boulay and her associates reviewed transvaginal ultrasound findings for 113 women who conceived via in vitro fertilization (IVF) at their center. Cervical length measurements were taken between 6-12 weeks’ gestation. A total 60% delivered full term, at 37 weeks or longer. Another 23% delivered at 34-36 weeks; 10% at 30-33 weeks; and 7% of women delivered before 30 weeks’ gestation. Thus, 40% delivered prior to 37 weeks’ gestation.

As their average first trimester cervical length decreased, so did mean gestational age. For example, women with a cervix of 5 cm or longer delivered at a mean of 37 weeks. This decreased to 35 weeks for those with a cervical length from 4.0 cm-4.9 cm and to 32 weeks for mothers with a cervix shorter than 4.0 cm.

"Our sample size was pretty small, which is why we chose 5 cm and below 4 cm groups," Dr. Vincent-Boulay said. "It would be great to do further studies with a larger sample to do a more stratified analysis."

There were some interesting differences between the 86 singleton and 27 twin pregnancies. Cervical length below 5 cm during the first trimester significantly correlated with preterm delivery in twin pregnancies. In the case of singletons, only a measurement below 4 cm was a significant predictor. The researchers assessed serial ultrasound measurements, and found, for example, that cervical length at 10 weeks predicted a preterm delivery of twins but not singletons.

Of the 113 IVF pregnancies, 86 or (76%) were singletons and 27 (24%) were twins. A greater number of singletons were delivered at full term (58 children), compared with twins (10 sets) in the study.

Put into clinical terms, Dr. Vincent-Boulay said: "Less than 4 cm at any time during pregnancy, whether it is single or twins, may be a cause for alarm. A cervical length less than 5 cm at 10 weeks for twins is also significant risk for preterm delivery."

A second study presented at the ASRM meeting revealed a very similar cervical length cutoff during the first trimester, 38.5 mm (or 3.85 cm) or less. Dr. Zain Al-Safi and his colleagues reviewed the records for 54 women who conceived via IVF at Wayne State University/Detroit Medical Center.

Specifically, they found 17 or 32% of pregnant women with a short cervical length measured at the first ultrasound (between 5-9 weeks’ gestation) delivered before 37 weeks’ gestation. Fifteen women who delivered preterm had an ultrasound measurement of 38.5 mm or less, giving this cutoff a sensitivity of 47% and a specificity of 81%.

This study is important because "premature delivery is a major obstetric complication and a substantial contributor to neonatal morbidity," said Dr. Al-Safi, an ob.gyn. at Wayne State University.

"Little is known about the predictive value of a first trimester cervical length measurement."

A total 21 women (39%) had multiple gestations. A meeting attendee commented that this was a high percentage and asked about IVF embryo transfer protocol. "We did not include that in our results. We looked at twins, but did not go back and look at how many embryos were transferred," Dr. Al-Safi replied.

A follow-up question was asked about the findings without multiples. "We took out multiples and frozen embryos and found similar results," Dr. Al-Safi said.

A lack of follow-up ultrasound assessment in the second trimester, a small sample size, and the retrospective design are potential limitations, Dr. Al-Safi said. The findings should be considered experimental until replicated in larger, prospective studies, he added.

"If we know cervical length in the future correlates to preterm delivery ... we could prevent it," Dr. Al-Safi said.

Future studies also should evaluate the optimal management for patients with a short cervix, Dr. Vincent-Boulay said.

Dr. Vincent-Boulay and Dr. Al-Safi said they did not have any relevant financial disclosures.

ORLANDO – Short cervical length during the first trimester predicts preterm delivery of an in vitro fertilization pregnancy, according to two retrospective studies involving a total of 167 women.

Although they used slightly different parameters, researchers who assessed 113 women at Montreal Fertility Center and others who studied 54 women at Detroit Medical Center reached the same conclusion: a cervical length shorter than approximately 4 cm is associated with greater risk of delivery before 37 weeks’ gestation.

These studies are part of a move to identify women at risk for preterm delivery earlier, when clinicians would have more time to intervene. Some previous researchers report associations between shorter midterm cervical length and preterm delivery (Ultrasound Obstet. Gynecol. 2008;32:640-5), while others point to a need for additional evidence (Cochrane Database Syst. Rev. 2009;CD007235 [doi:10.1002/14651858.CD007235.pub2]).

"Little is known about the predictive value of a first trimester cervical length measurement," Dr. Olivia Vincent-Boulay of the Montreal Fertility Centre said at the annual meeting of the American Society for Reproductive Medicine.

"If we know cervical length in the future correlates to preterm delivery ... we could prevent it."

Dr. Vincent-Boulay and her associates reviewed transvaginal ultrasound findings for 113 women who conceived via in vitro fertilization (IVF) at their center. Cervical length measurements were taken between 6-12 weeks’ gestation. A total 60% delivered full term, at 37 weeks or longer. Another 23% delivered at 34-36 weeks; 10% at 30-33 weeks; and 7% of women delivered before 30 weeks’ gestation. Thus, 40% delivered prior to 37 weeks’ gestation.

As their average first trimester cervical length decreased, so did mean gestational age. For example, women with a cervix of 5 cm or longer delivered at a mean of 37 weeks. This decreased to 35 weeks for those with a cervical length from 4.0 cm-4.9 cm and to 32 weeks for mothers with a cervix shorter than 4.0 cm.

"Our sample size was pretty small, which is why we chose 5 cm and below 4 cm groups," Dr. Vincent-Boulay said. "It would be great to do further studies with a larger sample to do a more stratified analysis."

There were some interesting differences between the 86 singleton and 27 twin pregnancies. Cervical length below 5 cm during the first trimester significantly correlated with preterm delivery in twin pregnancies. In the case of singletons, only a measurement below 4 cm was a significant predictor. The researchers assessed serial ultrasound measurements, and found, for example, that cervical length at 10 weeks predicted a preterm delivery of twins but not singletons.

Of the 113 IVF pregnancies, 86 or (76%) were singletons and 27 (24%) were twins. A greater number of singletons were delivered at full term (58 children), compared with twins (10 sets) in the study.

Put into clinical terms, Dr. Vincent-Boulay said: "Less than 4 cm at any time during pregnancy, whether it is single or twins, may be a cause for alarm. A cervical length less than 5 cm at 10 weeks for twins is also significant risk for preterm delivery."

A second study presented at the ASRM meeting revealed a very similar cervical length cutoff during the first trimester, 38.5 mm (or 3.85 cm) or less. Dr. Zain Al-Safi and his colleagues reviewed the records for 54 women who conceived via IVF at Wayne State University/Detroit Medical Center.

Specifically, they found 17 or 32% of pregnant women with a short cervical length measured at the first ultrasound (between 5-9 weeks’ gestation) delivered before 37 weeks’ gestation. Fifteen women who delivered preterm had an ultrasound measurement of 38.5 mm or less, giving this cutoff a sensitivity of 47% and a specificity of 81%.

This study is important because "premature delivery is a major obstetric complication and a substantial contributor to neonatal morbidity," said Dr. Al-Safi, an ob.gyn. at Wayne State University.

"Little is known about the predictive value of a first trimester cervical length measurement."

A total 21 women (39%) had multiple gestations. A meeting attendee commented that this was a high percentage and asked about IVF embryo transfer protocol. "We did not include that in our results. We looked at twins, but did not go back and look at how many embryos were transferred," Dr. Al-Safi replied.

A follow-up question was asked about the findings without multiples. "We took out multiples and frozen embryos and found similar results," Dr. Al-Safi said.

A lack of follow-up ultrasound assessment in the second trimester, a small sample size, and the retrospective design are potential limitations, Dr. Al-Safi said. The findings should be considered experimental until replicated in larger, prospective studies, he added.

"If we know cervical length in the future correlates to preterm delivery ... we could prevent it," Dr. Al-Safi said.

Future studies also should evaluate the optimal management for patients with a short cervix, Dr. Vincent-Boulay said.

Dr. Vincent-Boulay and Dr. Al-Safi said they did not have any relevant financial disclosures.

ORLANDO – Short cervical length during the first trimester predicts preterm delivery of an in vitro fertilization pregnancy, according to two retrospective studies involving a total of 167 women.

Although they used slightly different parameters, researchers who assessed 113 women at Montreal Fertility Center and others who studied 54 women at Detroit Medical Center reached the same conclusion: a cervical length shorter than approximately 4 cm is associated with greater risk of delivery before 37 weeks’ gestation.

These studies are part of a move to identify women at risk for preterm delivery earlier, when clinicians would have more time to intervene. Some previous researchers report associations between shorter midterm cervical length and preterm delivery (Ultrasound Obstet. Gynecol. 2008;32:640-5), while others point to a need for additional evidence (Cochrane Database Syst. Rev. 2009;CD007235 [doi:10.1002/14651858.CD007235.pub2]).

"Little is known about the predictive value of a first trimester cervical length measurement," Dr. Olivia Vincent-Boulay of the Montreal Fertility Centre said at the annual meeting of the American Society for Reproductive Medicine.

"If we know cervical length in the future correlates to preterm delivery ... we could prevent it."

Dr. Vincent-Boulay and her associates reviewed transvaginal ultrasound findings for 113 women who conceived via in vitro fertilization (IVF) at their center. Cervical length measurements were taken between 6-12 weeks’ gestation. A total 60% delivered full term, at 37 weeks or longer. Another 23% delivered at 34-36 weeks; 10% at 30-33 weeks; and 7% of women delivered before 30 weeks’ gestation. Thus, 40% delivered prior to 37 weeks’ gestation.

As their average first trimester cervical length decreased, so did mean gestational age. For example, women with a cervix of 5 cm or longer delivered at a mean of 37 weeks. This decreased to 35 weeks for those with a cervical length from 4.0 cm-4.9 cm and to 32 weeks for mothers with a cervix shorter than 4.0 cm.

"Our sample size was pretty small, which is why we chose 5 cm and below 4 cm groups," Dr. Vincent-Boulay said. "It would be great to do further studies with a larger sample to do a more stratified analysis."

There were some interesting differences between the 86 singleton and 27 twin pregnancies. Cervical length below 5 cm during the first trimester significantly correlated with preterm delivery in twin pregnancies. In the case of singletons, only a measurement below 4 cm was a significant predictor. The researchers assessed serial ultrasound measurements, and found, for example, that cervical length at 10 weeks predicted a preterm delivery of twins but not singletons.

Of the 113 IVF pregnancies, 86 or (76%) were singletons and 27 (24%) were twins. A greater number of singletons were delivered at full term (58 children), compared with twins (10 sets) in the study.

Put into clinical terms, Dr. Vincent-Boulay said: "Less than 4 cm at any time during pregnancy, whether it is single or twins, may be a cause for alarm. A cervical length less than 5 cm at 10 weeks for twins is also significant risk for preterm delivery."

A second study presented at the ASRM meeting revealed a very similar cervical length cutoff during the first trimester, 38.5 mm (or 3.85 cm) or less. Dr. Zain Al-Safi and his colleagues reviewed the records for 54 women who conceived via IVF at Wayne State University/Detroit Medical Center.

Specifically, they found 17 or 32% of pregnant women with a short cervical length measured at the first ultrasound (between 5-9 weeks’ gestation) delivered before 37 weeks’ gestation. Fifteen women who delivered preterm had an ultrasound measurement of 38.5 mm or less, giving this cutoff a sensitivity of 47% and a specificity of 81%.

This study is important because "premature delivery is a major obstetric complication and a substantial contributor to neonatal morbidity," said Dr. Al-Safi, an ob.gyn. at Wayne State University.

"Little is known about the predictive value of a first trimester cervical length measurement."

A total 21 women (39%) had multiple gestations. A meeting attendee commented that this was a high percentage and asked about IVF embryo transfer protocol. "We did not include that in our results. We looked at twins, but did not go back and look at how many embryos were transferred," Dr. Al-Safi replied.

A follow-up question was asked about the findings without multiples. "We took out multiples and frozen embryos and found similar results," Dr. Al-Safi said.

A lack of follow-up ultrasound assessment in the second trimester, a small sample size, and the retrospective design are potential limitations, Dr. Al-Safi said. The findings should be considered experimental until replicated in larger, prospective studies, he added.

"If we know cervical length in the future correlates to preterm delivery ... we could prevent it," Dr. Al-Safi said.

Future studies also should evaluate the optimal management for patients with a short cervix, Dr. Vincent-Boulay said.

Dr. Vincent-Boulay and Dr. Al-Safi said they did not have any relevant financial disclosures.

ORLANDO – Uterine fibroids are bad for pregnancy and neonatal outcomes, and a new study shows just how bad.

Women diagnosed with fibroids on their first obstetric ultrasound examination, for example, were significantly more likely to experience preterm labor or preterm premature rupture of the membranes (pPROM). Also, significantly more deliver before 37 weeks’ gestation or via cesarean section, compared with a group of women without these noncancerous growths of the uterus.

Dr. Radwan Asaad and his colleagues compared 152 women with fibroids to another 165 matched controls in a retrospective cohort analysis conducted at Wayne State University, Detroit. They also found fibroids weren’t good news for the baby either.

"Uterine fibroids complicate the pregnancy course as evidenced by a considerable impact on the obstetrical and neonatal outcomes," Dr. Asaad said at the annual meeting of the American Society for Reproductive Medicine.

In terms of the significantly different maternal numbers, women with fibroids were more likely to experience preterm labor (16.4% vs. 2.4% of controls), pPROM (15.8% vs. 3.6%), and to deliver preterm (33.3% vs. 10.1%).

Fetal malpresentation also was significantly more likely in the fibroid group (22% vs. 6% in controls). Cesarean delivery occurred in 54.3% of the fibroid group vs. 28.0% of the control group, another significant difference.

Gestational age at delivery was significantly less when the mother had fibroids (mean 35.3 weeks) vs. without (38.6 weeks).

"Uterine fibroids complicate the pregnancy course as evidenced by a considerable impact on the obstetrical and neonatal outcomes."

Children born to women in the fibroid group had a mean birth weight of 2,634 g, compared with 3,181 g for those born to control group women. Apgar scores at 1 minute were a mean 6.7 vs. 7.8 in the control group and at 5 minutes were a mean 7.9 vs. 8.8.

Pregnancy loss was higher in the fibroid group during the first trimester (7.9% vs. 3.6% in controls) and during the second trimester (5.9% vs. 1.2%), but these differences were not statistically significant to the P less than .001 level. A trend toward more arrested dilation in the fibroid group likewise did not reach significance.

"Uterine myomas are the most common pelvic tumor in reproductive-age women," said Dr. Asaad, a laparoscopic and minimally invasive surgeon in the department of obstetrics and gynecology at Hutzel Women’s Hospital and Wayne State University/Detroit Medical Center. Prevalence in published studies varies from 2% to 11%, depending on the trimester in which they are measured and the size threshold chosen by researchers.

A meeting attendee asked for information on the size and anatomic location of the fibroids. Dr. Asaad replied that he was only able to categorize women dichotomously as yes/no for presence of fibroids in this retrospective study.

Dr. Asaad and his associates reviewed all department ultrasounds from 1998 to 2006 at their tertiary care center. Women with complete records in the fibroid group were matched to controls for age, gravidity, parity, and year of delivery.

Demographics were similar between groups, except black women comprised a significantly higher proportion of the fibroid group, 98%, vs. 69% of the control group. Chronic hypertension was the only comorbidity that occurred significantly more often in one group than the other (13.8% of the fibroid group vs. 6.7% of controls). There were no significant differences in prevalence of diabetes, asthma, hypothyroidism and hyperthyroidism, or history of cesarean section delivery.

Dr. Asaad said he had no relevant financial disclosures.

ORLANDO – Uterine fibroids are bad for pregnancy and neonatal outcomes, and a new study shows just how bad.

Women diagnosed with fibroids on their first obstetric ultrasound examination, for example, were significantly more likely to experience preterm labor or preterm premature rupture of the membranes (pPROM). Also, significantly more deliver before 37 weeks’ gestation or via cesarean section, compared with a group of women without these noncancerous growths of the uterus.

Dr. Radwan Asaad and his colleagues compared 152 women with fibroids to another 165 matched controls in a retrospective cohort analysis conducted at Wayne State University, Detroit. They also found fibroids weren’t good news for the baby either.

"Uterine fibroids complicate the pregnancy course as evidenced by a considerable impact on the obstetrical and neonatal outcomes," Dr. Asaad said at the annual meeting of the American Society for Reproductive Medicine.

In terms of the significantly different maternal numbers, women with fibroids were more likely to experience preterm labor (16.4% vs. 2.4% of controls), pPROM (15.8% vs. 3.6%), and to deliver preterm (33.3% vs. 10.1%).

Fetal malpresentation also was significantly more likely in the fibroid group (22% vs. 6% in controls). Cesarean delivery occurred in 54.3% of the fibroid group vs. 28.0% of the control group, another significant difference.

Gestational age at delivery was significantly less when the mother had fibroids (mean 35.3 weeks) vs. without (38.6 weeks).

"Uterine fibroids complicate the pregnancy course as evidenced by a considerable impact on the obstetrical and neonatal outcomes."

Children born to women in the fibroid group had a mean birth weight of 2,634 g, compared with 3,181 g for those born to control group women. Apgar scores at 1 minute were a mean 6.7 vs. 7.8 in the control group and at 5 minutes were a mean 7.9 vs. 8.8.

Pregnancy loss was higher in the fibroid group during the first trimester (7.9% vs. 3.6% in controls) and during the second trimester (5.9% vs. 1.2%), but these differences were not statistically significant to the P less than .001 level. A trend toward more arrested dilation in the fibroid group likewise did not reach significance.

"Uterine myomas are the most common pelvic tumor in reproductive-age women," said Dr. Asaad, a laparoscopic and minimally invasive surgeon in the department of obstetrics and gynecology at Hutzel Women’s Hospital and Wayne State University/Detroit Medical Center. Prevalence in published studies varies from 2% to 11%, depending on the trimester in which they are measured and the size threshold chosen by researchers.

A meeting attendee asked for information on the size and anatomic location of the fibroids. Dr. Asaad replied that he was only able to categorize women dichotomously as yes/no for presence of fibroids in this retrospective study.

Dr. Asaad and his associates reviewed all department ultrasounds from 1998 to 2006 at their tertiary care center. Women with complete records in the fibroid group were matched to controls for age, gravidity, parity, and year of delivery.

Demographics were similar between groups, except black women comprised a significantly higher proportion of the fibroid group, 98%, vs. 69% of the control group. Chronic hypertension was the only comorbidity that occurred significantly more often in one group than the other (13.8% of the fibroid group vs. 6.7% of controls). There were no significant differences in prevalence of diabetes, asthma, hypothyroidism and hyperthyroidism, or history of cesarean section delivery.

Dr. Asaad said he had no relevant financial disclosures.

ORLANDO – Uterine fibroids are bad for pregnancy and neonatal outcomes, and a new study shows just how bad.

Women diagnosed with fibroids on their first obstetric ultrasound examination, for example, were significantly more likely to experience preterm labor or preterm premature rupture of the membranes (pPROM). Also, significantly more deliver before 37 weeks’ gestation or via cesarean section, compared with a group of women without these noncancerous growths of the uterus.

Dr. Radwan Asaad and his colleagues compared 152 women with fibroids to another 165 matched controls in a retrospective cohort analysis conducted at Wayne State University, Detroit. They also found fibroids weren’t good news for the baby either.

"Uterine fibroids complicate the pregnancy course as evidenced by a considerable impact on the obstetrical and neonatal outcomes," Dr. Asaad said at the annual meeting of the American Society for Reproductive Medicine.

In terms of the significantly different maternal numbers, women with fibroids were more likely to experience preterm labor (16.4% vs. 2.4% of controls), pPROM (15.8% vs. 3.6%), and to deliver preterm (33.3% vs. 10.1%).

Fetal malpresentation also was significantly more likely in the fibroid group (22% vs. 6% in controls). Cesarean delivery occurred in 54.3% of the fibroid group vs. 28.0% of the control group, another significant difference.

Gestational age at delivery was significantly less when the mother had fibroids (mean 35.3 weeks) vs. without (38.6 weeks).

"Uterine fibroids complicate the pregnancy course as evidenced by a considerable impact on the obstetrical and neonatal outcomes."

Children born to women in the fibroid group had a mean birth weight of 2,634 g, compared with 3,181 g for those born to control group women. Apgar scores at 1 minute were a mean 6.7 vs. 7.8 in the control group and at 5 minutes were a mean 7.9 vs. 8.8.

Pregnancy loss was higher in the fibroid group during the first trimester (7.9% vs. 3.6% in controls) and during the second trimester (5.9% vs. 1.2%), but these differences were not statistically significant to the P less than .001 level. A trend toward more arrested dilation in the fibroid group likewise did not reach significance.

"Uterine myomas are the most common pelvic tumor in reproductive-age women," said Dr. Asaad, a laparoscopic and minimally invasive surgeon in the department of obstetrics and gynecology at Hutzel Women’s Hospital and Wayne State University/Detroit Medical Center. Prevalence in published studies varies from 2% to 11%, depending on the trimester in which they are measured and the size threshold chosen by researchers.

A meeting attendee asked for information on the size and anatomic location of the fibroids. Dr. Asaad replied that he was only able to categorize women dichotomously as yes/no for presence of fibroids in this retrospective study.

Dr. Asaad and his associates reviewed all department ultrasounds from 1998 to 2006 at their tertiary care center. Women with complete records in the fibroid group were matched to controls for age, gravidity, parity, and year of delivery.

Demographics were similar between groups, except black women comprised a significantly higher proportion of the fibroid group, 98%, vs. 69% of the control group. Chronic hypertension was the only comorbidity that occurred significantly more often in one group than the other (13.8% of the fibroid group vs. 6.7% of controls). There were no significant differences in prevalence of diabetes, asthma, hypothyroidism and hyperthyroidism, or history of cesarean section delivery.

Dr. Asaad said he had no relevant financial disclosures.

Greater global cooperation and collaboration among scleroderma researchers and clinicians would be all that is required to fuel a drive toward important discoveries and optimize outcomes for patients with this chronic, progressive, and often debilitating autoimmune disease. And the organizations are in place to support such collaboration.

"Scleroderma is a multisystem disease, and we as a community, working together, can learn to understand it, treat it, and perhaps cure it," Dr. Daniel Furst said.

Currently, multiple research groups in multiple countries around the world strive in a largely independent way to combat scleroderma through experimental, translational, and clinical studies. These separate silos of researchers – and patients – could benefit from increased interaction and cooperation, Dr. Furst said in an interview.

"If the international community agrees to work together, we can move things forward much more quickly," said Dr. Furst, Carl M. Pearson chair of rheumatology and director of interventional therapeutics at University of California, Los Angeles Medical Center for Health Sciences.

"The scientific complexity and the clinical heterogeneity of scleroderma benefit from multiple collaborators each contributing a piece to the puzzle."

"The timing is right for this," said Dr. Furst, now that there is an organization, the World Scleroderma Foundation (WSF), to facilitate increased collaboration worldwide. He cofounded the foundation in 2009 and currently serves as treasurer.

"The main message is that we need to work together and share our experiences in order to better understand the disease, thus ameliorating our capacity to fight its evolution," said Dr. Marco Matucci-Cerinic, WSF chairman and professor of rheumatology at the University of Florence in Italy.

"Recently, we have worked all together to lift the cultural barrier differentiating the clinical behavior of the American and European physicians," Dr. Matucci-Cerinic said. "The challenge for the future is, therefore, to foster worldwide the awareness of the disease and teach the rheumatologist to have all the same approach to the disease in order to make an early diagnosis, obtain remission and [block] disease progression."

Increased collaboration also is a matter of economics, Dr. Furst said. "There isn’t enough money in any given place to do all the research that is needed."

The Switzerland-based WSF also aims to increase translational research worldwide or find ways to take scientific findings in scleroderma from the bench to the bedside. For this reason, the U.S.-based Scleroderma Research Foundation, with its focus on experimental rather than clinical research, could be an important ally in increasing the amount of translational research studies.

Promotion of greater patient awareness about scleroderma is a second major aim for the WSF. Greater education could foster earlier scleroderma diagnoses and greater participation in care, Dr. Furst said. Ten years ago, it took 1-2 years from the onset of symptoms until patients with scleroderma received the correct diagnosis. "Even today, in the United States, it’s still 6 to 9 months on average for time to diagnosis. So awareness is a major issue."

In terms of physician education, every American College of Rheumatology annual meeting includes a skin scoring session. The intention is for rheumatologists to learn how to recognize and score the skin changes in scleroderma. Dr. Furst said, "We are trying to teach rheumatologists how to recognize and score scleroderma, and we are trying to teach patients how to educate their rheumatologists."

"Not only rheumatologists, but internists as well, through listening to their patients and through accessing things like the WSF or the Scleroderma Foundation in the U.S., can make it easier for patients to understand their disease," Dr. Furst said.

Leading the charge in Europe is the EULAR Scleroderma Trials and Research (EUSTAR) group. This group "has significantly helped to raise the awareness of the disease among physicians and politicians and has pushed ahead the clinical and basic research on the disease," Dr. Matucci-Cerinic said.

"The main message is that we need to work together and share our experiences in order to better understand [scleroderma]."

Scleroderma affects people worldwide, even in regions without a strong research base. There are approximately 100,000 persons with scleroderma in the European Union and the United States, but as many as 2.5 million worldwide, said Dr. James R. Seibold, founder and principal member of Scleroderma Research Consultants in Avon, Conn. "The scientific complexity and the clinical heterogeneity of scleroderma benefit from multiple collaborators each contributing a piece to the puzzle."

There are smaller groups, including PANLAR in South America. There is also a scleroderma group in Australia, and there are national groups in Asia, "but they are not really well organized," Dr. Furst said.

"Large populations where scleroderma is both prevalent and high impact lack the infrastructure and financial resources," Dr. Seibold said. "I would include South Asia, China, and much of South America as currently underserved areas."

Even though findings will come from multiple research groups around the globe, Dr. Furst does not expect any significant hurdles in terms of protected data. "It just so happens that the scleroderma community is very collaborative. While there always will be some proprietary issues, partially because of governmental regulations, the overwhelming urge among scleroderma community researchers is to work together rather than to work apart."

The WSF is holding its second annual World Scleroderma Congress in Florence in February 2012. Dr. Furst said, "We already have over 500 registrants four or five months ahead. It really is very encouraging."

Dr. Furst disclosed that his scleroderma research is supported by the National Institutes of Health, Gilead, and Actelion. Dr. Matucci-Cerinic said the he had no relevant disclosures. Dr. Seibold said he has consultancy relationships with a number of companies considering drug development projects in scleroderma, including Actelion, Bristol Myers Squibb, Celgene, Genentech, Gilead, MedImmune, NexMed, Pfizer, Sanofi-Aventis, Sigma Tau, and United Therapeutics.

Greater global cooperation and collaboration among scleroderma researchers and clinicians would be all that is required to fuel a drive toward important discoveries and optimize outcomes for patients with this chronic, progressive, and often debilitating autoimmune disease. And the organizations are in place to support such collaboration.

"Scleroderma is a multisystem disease, and we as a community, working together, can learn to understand it, treat it, and perhaps cure it," Dr. Daniel Furst said.

Currently, multiple research groups in multiple countries around the world strive in a largely independent way to combat scleroderma through experimental, translational, and clinical studies. These separate silos of researchers – and patients – could benefit from increased interaction and cooperation, Dr. Furst said in an interview.

"If the international community agrees to work together, we can move things forward much more quickly," said Dr. Furst, Carl M. Pearson chair of rheumatology and director of interventional therapeutics at University of California, Los Angeles Medical Center for Health Sciences.

"The scientific complexity and the clinical heterogeneity of scleroderma benefit from multiple collaborators each contributing a piece to the puzzle."

"The timing is right for this," said Dr. Furst, now that there is an organization, the World Scleroderma Foundation (WSF), to facilitate increased collaboration worldwide. He cofounded the foundation in 2009 and currently serves as treasurer.

"The main message is that we need to work together and share our experiences in order to better understand the disease, thus ameliorating our capacity to fight its evolution," said Dr. Marco Matucci-Cerinic, WSF chairman and professor of rheumatology at the University of Florence in Italy.

"Recently, we have worked all together to lift the cultural barrier differentiating the clinical behavior of the American and European physicians," Dr. Matucci-Cerinic said. "The challenge for the future is, therefore, to foster worldwide the awareness of the disease and teach the rheumatologist to have all the same approach to the disease in order to make an early diagnosis, obtain remission and [block] disease progression."

Increased collaboration also is a matter of economics, Dr. Furst said. "There isn’t enough money in any given place to do all the research that is needed."

The Switzerland-based WSF also aims to increase translational research worldwide or find ways to take scientific findings in scleroderma from the bench to the bedside. For this reason, the U.S.-based Scleroderma Research Foundation, with its focus on experimental rather than clinical research, could be an important ally in increasing the amount of translational research studies.

Promotion of greater patient awareness about scleroderma is a second major aim for the WSF. Greater education could foster earlier scleroderma diagnoses and greater participation in care, Dr. Furst said. Ten years ago, it took 1-2 years from the onset of symptoms until patients with scleroderma received the correct diagnosis. "Even today, in the United States, it’s still 6 to 9 months on average for time to diagnosis. So awareness is a major issue."

In terms of physician education, every American College of Rheumatology annual meeting includes a skin scoring session. The intention is for rheumatologists to learn how to recognize and score the skin changes in scleroderma. Dr. Furst said, "We are trying to teach rheumatologists how to recognize and score scleroderma, and we are trying to teach patients how to educate their rheumatologists."

"Not only rheumatologists, but internists as well, through listening to their patients and through accessing things like the WSF or the Scleroderma Foundation in the U.S., can make it easier for patients to understand their disease," Dr. Furst said.

Leading the charge in Europe is the EULAR Scleroderma Trials and Research (EUSTAR) group. This group "has significantly helped to raise the awareness of the disease among physicians and politicians and has pushed ahead the clinical and basic research on the disease," Dr. Matucci-Cerinic said.

"The main message is that we need to work together and share our experiences in order to better understand [scleroderma]."

Scleroderma affects people worldwide, even in regions without a strong research base. There are approximately 100,000 persons with scleroderma in the European Union and the United States, but as many as 2.5 million worldwide, said Dr. James R. Seibold, founder and principal member of Scleroderma Research Consultants in Avon, Conn. "The scientific complexity and the clinical heterogeneity of scleroderma benefit from multiple collaborators each contributing a piece to the puzzle."

There are smaller groups, including PANLAR in South America. There is also a scleroderma group in Australia, and there are national groups in Asia, "but they are not really well organized," Dr. Furst said.

"Large populations where scleroderma is both prevalent and high impact lack the infrastructure and financial resources," Dr. Seibold said. "I would include South Asia, China, and much of South America as currently underserved areas."

Even though findings will come from multiple research groups around the globe, Dr. Furst does not expect any significant hurdles in terms of protected data. "It just so happens that the scleroderma community is very collaborative. While there always will be some proprietary issues, partially because of governmental regulations, the overwhelming urge among scleroderma community researchers is to work together rather than to work apart."

The WSF is holding its second annual World Scleroderma Congress in Florence in February 2012. Dr. Furst said, "We already have over 500 registrants four or five months ahead. It really is very encouraging."

Dr. Furst disclosed that his scleroderma research is supported by the National Institutes of Health, Gilead, and Actelion. Dr. Matucci-Cerinic said the he had no relevant disclosures. Dr. Seibold said he has consultancy relationships with a number of companies considering drug development projects in scleroderma, including Actelion, Bristol Myers Squibb, Celgene, Genentech, Gilead, MedImmune, NexMed, Pfizer, Sanofi-Aventis, Sigma Tau, and United Therapeutics.

Greater global cooperation and collaboration among scleroderma researchers and clinicians would be all that is required to fuel a drive toward important discoveries and optimize outcomes for patients with this chronic, progressive, and often debilitating autoimmune disease. And the organizations are in place to support such collaboration.

"Scleroderma is a multisystem disease, and we as a community, working together, can learn to understand it, treat it, and perhaps cure it," Dr. Daniel Furst said.

Currently, multiple research groups in multiple countries around the world strive in a largely independent way to combat scleroderma through experimental, translational, and clinical studies. These separate silos of researchers – and patients – could benefit from increased interaction and cooperation, Dr. Furst said in an interview.

"If the international community agrees to work together, we can move things forward much more quickly," said Dr. Furst, Carl M. Pearson chair of rheumatology and director of interventional therapeutics at University of California, Los Angeles Medical Center for Health Sciences.

"The scientific complexity and the clinical heterogeneity of scleroderma benefit from multiple collaborators each contributing a piece to the puzzle."

"The timing is right for this," said Dr. Furst, now that there is an organization, the World Scleroderma Foundation (WSF), to facilitate increased collaboration worldwide. He cofounded the foundation in 2009 and currently serves as treasurer.

"The main message is that we need to work together and share our experiences in order to better understand the disease, thus ameliorating our capacity to fight its evolution," said Dr. Marco Matucci-Cerinic, WSF chairman and professor of rheumatology at the University of Florence in Italy.

"Recently, we have worked all together to lift the cultural barrier differentiating the clinical behavior of the American and European physicians," Dr. Matucci-Cerinic said. "The challenge for the future is, therefore, to foster worldwide the awareness of the disease and teach the rheumatologist to have all the same approach to the disease in order to make an early diagnosis, obtain remission and [block] disease progression."

Increased collaboration also is a matter of economics, Dr. Furst said. "There isn’t enough money in any given place to do all the research that is needed."

The Switzerland-based WSF also aims to increase translational research worldwide or find ways to take scientific findings in scleroderma from the bench to the bedside. For this reason, the U.S.-based Scleroderma Research Foundation, with its focus on experimental rather than clinical research, could be an important ally in increasing the amount of translational research studies.

Promotion of greater patient awareness about scleroderma is a second major aim for the WSF. Greater education could foster earlier scleroderma diagnoses and greater participation in care, Dr. Furst said. Ten years ago, it took 1-2 years from the onset of symptoms until patients with scleroderma received the correct diagnosis. "Even today, in the United States, it’s still 6 to 9 months on average for time to diagnosis. So awareness is a major issue."

In terms of physician education, every American College of Rheumatology annual meeting includes a skin scoring session. The intention is for rheumatologists to learn how to recognize and score the skin changes in scleroderma. Dr. Furst said, "We are trying to teach rheumatologists how to recognize and score scleroderma, and we are trying to teach patients how to educate their rheumatologists."

"Not only rheumatologists, but internists as well, through listening to their patients and through accessing things like the WSF or the Scleroderma Foundation in the U.S., can make it easier for patients to understand their disease," Dr. Furst said.

Leading the charge in Europe is the EULAR Scleroderma Trials and Research (EUSTAR) group. This group "has significantly helped to raise the awareness of the disease among physicians and politicians and has pushed ahead the clinical and basic research on the disease," Dr. Matucci-Cerinic said.

"The main message is that we need to work together and share our experiences in order to better understand [scleroderma]."

Scleroderma affects people worldwide, even in regions without a strong research base. There are approximately 100,000 persons with scleroderma in the European Union and the United States, but as many as 2.5 million worldwide, said Dr. James R. Seibold, founder and principal member of Scleroderma Research Consultants in Avon, Conn. "The scientific complexity and the clinical heterogeneity of scleroderma benefit from multiple collaborators each contributing a piece to the puzzle."

There are smaller groups, including PANLAR in South America. There is also a scleroderma group in Australia, and there are national groups in Asia, "but they are not really well organized," Dr. Furst said.

"Large populations where scleroderma is both prevalent and high impact lack the infrastructure and financial resources," Dr. Seibold said. "I would include South Asia, China, and much of South America as currently underserved areas."

Even though findings will come from multiple research groups around the globe, Dr. Furst does not expect any significant hurdles in terms of protected data. "It just so happens that the scleroderma community is very collaborative. While there always will be some proprietary issues, partially because of governmental regulations, the overwhelming urge among scleroderma community researchers is to work together rather than to work apart."

The WSF is holding its second annual World Scleroderma Congress in Florence in February 2012. Dr. Furst said, "We already have over 500 registrants four or five months ahead. It really is very encouraging."

Dr. Furst disclosed that his scleroderma research is supported by the National Institutes of Health, Gilead, and Actelion. Dr. Matucci-Cerinic said the he had no relevant disclosures. Dr. Seibold said he has consultancy relationships with a number of companies considering drug development projects in scleroderma, including Actelion, Bristol Myers Squibb, Celgene, Genentech, Gilead, MedImmune, NexMed, Pfizer, Sanofi-Aventis, Sigma Tau, and United Therapeutics.

Empowering people in low-resource communities to eat better and exercise more and thereby lessen their risk for heart disease, obesity, and diabetes continues to be a challenge for clinicians.

Motivational interviewing, however, can help and be part of an effective strategy to inspire patients at risk for cardiovascular and metabolic problems to change their behavior, Dr. Jeanie Tse said.

Photo Damian McNamara/Elsevier Global Medical News

"As psychiatrists, we learn about physical health care in medical school and training, but we forget a lot when we start our practices," said Dr. Tse, director of integrated health at the Institute for Community Living, a nonprofit behavioral health agency in New York.

Psychiatrists and other health care providers can adopt motivational interviewing techniques to improve patient outcomes, Dr. Tse said. "We feel strongly about collaboration. This is really about reaching out to primary care physicians, endocrinologists, and case managers."

Close collaboration also is important because "sometimes physical problems are misidentified as mental health symptoms." An example would be a person who goes to the emergency room with low blood glucose and ends up assigned to mental health care.

Motivational interviewing helps clinicians learn to phrase guidance in a way that encourages and supports patients. Advice about making healthy choices is provided in a nonjudgmental manner, for example. Empathic counseling delivered with warmth, respect, and understanding can foster self-efficacy and promote change, said Elisa Chow, Ph.D., director of outcomes evaluation at the Institute for Community Living. "It is really a simple tool that we as providers can use with our patients or clients.

Patients ready to make changes choose their own goals. "It is really about what patients want," Dr. Tse said, and it’s important to be realistic. "We may care about their diabetes, but in their world, they care more about housing, having a job, and finding a boyfriend or girlfriend."

Encourage patients to take small, "doable" steps, Dr. Chow recommended. "Your patient may walk away thinking ‘Oh my God, how am I going to lose 45 to 50 pounds?’ We help them step by step, maybe [with] losing a pound per week or just watching their portion sizes. Weight loss may be a goal over a year."

Dr. Jeffrey C. Fetter said in an interview that motivational interviewing is a well-established technique for improving behaviors such as smoking, but is rarely used to systematically improve diet and exercise in patients with severe mental illness. "One of the strengths of motivational interviewing is its respect for the client and his/her choices, a respect that especially resonates with mentally ill clients," said Dr. Fetter, a psychiatrist in private practice in Concord, N.H.

A recently published study showed that perceptions of motivational interviewing were more positive than standard care among patients with type 2 diabetes (Diabetes Res. Clin. Pract. 2011 [doi:10.1016/j.diabres.2011.08.011]). In that study, five themes tied to motivational interviewing emerged: nonjudgmental accountability, being heard and responded to as a person, encouragement and empowerment, collaborative action planning and goal setting, and coaching rather than critiquing.

"A patient might say, ‘I’m going to eat one apple a week. Great. Let’s go with that,’ " said Rosemarie Sultana-Cordero, a licensed mental health counselor and clinical coordinator at Community Living for its Diabetes Project and Healthy Living Project.

Dr. Tse, Dr. Chow, and Ms. Sultana-Cordero shared their expertise during an interactive workshop session at the annual meeting of the American Psychiatric Association in Honolulu.

"We tell case managers that everyone has a goal, and they will be more motivated if the goal is self-imposed," Ms. Sultana-Cordero said. Instead of a lecture about the adverse health consequences of poor eating or physical inactivity, she suggested asking patients: What changes have you thought of making? What might you have to give up to make this change? What might you gain? Will your life be different if you make this change?

If you do not have time to learn all the aspects of motivational interviewing, "Developing Discrepancies" and "Rolling With Resistance" are two essential components, Dr. Chow said. Clinicians can, for example, increase a patient’s awareness about the discrepancy between where they are in terms of cardiometabolic or diabetes risk and where they want to be. A greater awareness of this dichotomy can motivate patients to reach their goals.

Psychiatrists and other health care providers can adopt motivational interviewing techniques to improve patient outcomes.

"We have client we will call ‘Matt,’ who is slightly overweight, and sees Dr. Chow," Dr. Tse said. Matt told her he was going to diet and they agreed on a weight-loss plan. He plans to eat one vegetable every day and stay away from the corner bodega. They plan to follow up in 1 week. "Dr. Chow is then driving around and sees Matt eating fried rice and ribs in the window of a Chinese restaurant. Matt is saying one thing, but his actions say something else," Dr. Tse said. Dr. Chow will bring that up at next meeting and will use motivational interviewing to say something like: "I saw you at Chinese takeout place the other day. This seems to be in contrast with your goal."

Pointing out his discrepancies is "really about making him aware and taking ownership of his lifestyle," Dr. Chow said.

Rolling With Resistance prevents a communication breakdown between parties. The clinician does not argue or directly oppose resistance from the patient. A clinician can offer new perspectives but does not impose them.

Dr. Tse teaches basic reflective listening to case managers as part of this technique. "We line them up. One will say: ‘I don’t want to quit smoking.’ The other says it back: ‘You don’t want to quit smoking. "In our training, the psychiatrists and nurses have the most difficulty with this training. They feel the need to engage the person more and counsel about smoking cessation."

"We find that training very helpful for psychiatrists, medical doctors, social workers, and others," Dr. Chow said.

Regular progress checks are an important component of motivational interviewing and the overall chronic care model of medical care. At Community Living, participants provide feedback via self-management workbooks. These books contain "Action Step" pages. If, for example, a patient decides their goal is to drink a bottle of water instead of a soda once a week, they specify when and where they will make this substitution. They indicate whether they need someone to remind them. Later, they write why they succeeded or did not succeed, as well as how they plan to reward themselves if they followed through.

"There is also an action step review page, which is an opportunity for case manager and client to review how they did," Ms. Sultana-Cordero said.

"Our ‘Caring for Your Mental Health’ workbook is one of our most popular," Dr. Tse said. "It’s a huge realization for many that their mental health can adversely affect their overall health."

The Institute for Community Living offers about 100 programs focused primarily on housing, case management, clinics, and shelters, Dr. Tse said. More than 70% of the clients have schizophrenia or are schizoaffective, she added.

"People with serious mental illness are more than twice as likely to have diabetes. Why? Antipsychotics and other meds increase risk of dyslipidemia, diabetes, and stroke," Dr. Tse said. Also, "changes in appetite, medication side effects, and income make it harder to maintain a healthy diet." In addition, many people with mental illness also feature avolition and low energy, symptoms that can lead to reduced physical activity and contribute to worse outcomes.

"There is a lot of stigma associated with our patients with serious mental illness and intellectual disabilities. This stigma is huge, and it puts our patients at risk," Dr. Tse said. "They are at a disadvantage for getting their diabetes or heart disease looked at." Case managers complete psychiatric forms that include prompts for an annual physical exam report, weight, waist circumference, and blood pressure measurements. "It’s right in the notes. They have to fill it out each time they see a patient."

"We have two full-time psychiatrists for 10,000 people," Dr. Tse said. The workforce primarily comprises 1,400 bachelor- or associate-degree level case managers who receive 4 hours of training in motivational interviewing. "We’ve had to be very creative with very low resources to train these folks in the kind of integrative care work we want them to do."

Patients receive self-management material to reinforce their goals. These include a "Healthy Living Info Card"; a similar mini-card for their wallet or purse; letters to give their psychiatrist and primary care physician; and if they have or are at risk for diabetes, a Diabetes Info Card.

For his part, Dr. Fetter said preliminary data show that motivational interviewing focused on healthy lifestyle choices can move people with high metabolic risk with mental illness forward through stages of change toward making healthy diet, exercise, and tobacco choices. "This area bears further research, and the Community Living model is a great example of how motivational interviewing interventions to address cardiometabolic risk can be successful," he said.

Dr. Tse, Dr. Chow, and Ms. Sultana-Cordero are employees of Community Living Inc. They had no other relevant disclosures.

Empowering people in low-resource communities to eat better and exercise more and thereby lessen their risk for heart disease, obesity, and diabetes continues to be a challenge for clinicians.

Motivational interviewing, however, can help and be part of an effective strategy to inspire patients at risk for cardiovascular and metabolic problems to change their behavior, Dr. Jeanie Tse said.

Photo Damian McNamara/Elsevier Global Medical News

"As psychiatrists, we learn about physical health care in medical school and training, but we forget a lot when we start our practices," said Dr. Tse, director of integrated health at the Institute for Community Living, a nonprofit behavioral health agency in New York.

Psychiatrists and other health care providers can adopt motivational interviewing techniques to improve patient outcomes, Dr. Tse said. "We feel strongly about collaboration. This is really about reaching out to primary care physicians, endocrinologists, and case managers."

Close collaboration also is important because "sometimes physical problems are misidentified as mental health symptoms." An example would be a person who goes to the emergency room with low blood glucose and ends up assigned to mental health care.

Motivational interviewing helps clinicians learn to phrase guidance in a way that encourages and supports patients. Advice about making healthy choices is provided in a nonjudgmental manner, for example. Empathic counseling delivered with warmth, respect, and understanding can foster self-efficacy and promote change, said Elisa Chow, Ph.D., director of outcomes evaluation at the Institute for Community Living. "It is really a simple tool that we as providers can use with our patients or clients.

Patients ready to make changes choose their own goals. "It is really about what patients want," Dr. Tse said, and it’s important to be realistic. "We may care about their diabetes, but in their world, they care more about housing, having a job, and finding a boyfriend or girlfriend."

Encourage patients to take small, "doable" steps, Dr. Chow recommended. "Your patient may walk away thinking ‘Oh my God, how am I going to lose 45 to 50 pounds?’ We help them step by step, maybe [with] losing a pound per week or just watching their portion sizes. Weight loss may be a goal over a year."

Dr. Jeffrey C. Fetter said in an interview that motivational interviewing is a well-established technique for improving behaviors such as smoking, but is rarely used to systematically improve diet and exercise in patients with severe mental illness. "One of the strengths of motivational interviewing is its respect for the client and his/her choices, a respect that especially resonates with mentally ill clients," said Dr. Fetter, a psychiatrist in private practice in Concord, N.H.

A recently published study showed that perceptions of motivational interviewing were more positive than standard care among patients with type 2 diabetes (Diabetes Res. Clin. Pract. 2011 [doi:10.1016/j.diabres.2011.08.011]). In that study, five themes tied to motivational interviewing emerged: nonjudgmental accountability, being heard and responded to as a person, encouragement and empowerment, collaborative action planning and goal setting, and coaching rather than critiquing.

"A patient might say, ‘I’m going to eat one apple a week. Great. Let’s go with that,’ " said Rosemarie Sultana-Cordero, a licensed mental health counselor and clinical coordinator at Community Living for its Diabetes Project and Healthy Living Project.

Dr. Tse, Dr. Chow, and Ms. Sultana-Cordero shared their expertise during an interactive workshop session at the annual meeting of the American Psychiatric Association in Honolulu.

"We tell case managers that everyone has a goal, and they will be more motivated if the goal is self-imposed," Ms. Sultana-Cordero said. Instead of a lecture about the adverse health consequences of poor eating or physical inactivity, she suggested asking patients: What changes have you thought of making? What might you have to give up to make this change? What might you gain? Will your life be different if you make this change?

If you do not have time to learn all the aspects of motivational interviewing, "Developing Discrepancies" and "Rolling With Resistance" are two essential components, Dr. Chow said. Clinicians can, for example, increase a patient’s awareness about the discrepancy between where they are in terms of cardiometabolic or diabetes risk and where they want to be. A greater awareness of this dichotomy can motivate patients to reach their goals.

Psychiatrists and other health care providers can adopt motivational interviewing techniques to improve patient outcomes.

"We have client we will call ‘Matt,’ who is slightly overweight, and sees Dr. Chow," Dr. Tse said. Matt told her he was going to diet and they agreed on a weight-loss plan. He plans to eat one vegetable every day and stay away from the corner bodega. They plan to follow up in 1 week. "Dr. Chow is then driving around and sees Matt eating fried rice and ribs in the window of a Chinese restaurant. Matt is saying one thing, but his actions say something else," Dr. Tse said. Dr. Chow will bring that up at next meeting and will use motivational interviewing to say something like: "I saw you at Chinese takeout place the other day. This seems to be in contrast with your goal."

Pointing out his discrepancies is "really about making him aware and taking ownership of his lifestyle," Dr. Chow said.

Rolling With Resistance prevents a communication breakdown between parties. The clinician does not argue or directly oppose resistance from the patient. A clinician can offer new perspectives but does not impose them.

Dr. Tse teaches basic reflective listening to case managers as part of this technique. "We line them up. One will say: ‘I don’t want to quit smoking.’ The other says it back: ‘You don’t want to quit smoking. "In our training, the psychiatrists and nurses have the most difficulty with this training. They feel the need to engage the person more and counsel about smoking cessation."

"We find that training very helpful for psychiatrists, medical doctors, social workers, and others," Dr. Chow said.

Regular progress checks are an important component of motivational interviewing and the overall chronic care model of medical care. At Community Living, participants provide feedback via self-management workbooks. These books contain "Action Step" pages. If, for example, a patient decides their goal is to drink a bottle of water instead of a soda once a week, they specify when and where they will make this substitution. They indicate whether they need someone to remind them. Later, they write why they succeeded or did not succeed, as well as how they plan to reward themselves if they followed through.

"There is also an action step review page, which is an opportunity for case manager and client to review how they did," Ms. Sultana-Cordero said.

"Our ‘Caring for Your Mental Health’ workbook is one of our most popular," Dr. Tse said. "It’s a huge realization for many that their mental health can adversely affect their overall health."

The Institute for Community Living offers about 100 programs focused primarily on housing, case management, clinics, and shelters, Dr. Tse said. More than 70% of the clients have schizophrenia or are schizoaffective, she added.

"People with serious mental illness are more than twice as likely to have diabetes. Why? Antipsychotics and other meds increase risk of dyslipidemia, diabetes, and stroke," Dr. Tse said. Also, "changes in appetite, medication side effects, and income make it harder to maintain a healthy diet." In addition, many people with mental illness also feature avolition and low energy, symptoms that can lead to reduced physical activity and contribute to worse outcomes.

"There is a lot of stigma associated with our patients with serious mental illness and intellectual disabilities. This stigma is huge, and it puts our patients at risk," Dr. Tse said. "They are at a disadvantage for getting their diabetes or heart disease looked at." Case managers complete psychiatric forms that include prompts for an annual physical exam report, weight, waist circumference, and blood pressure measurements. "It’s right in the notes. They have to fill it out each time they see a patient."

"We have two full-time psychiatrists for 10,000 people," Dr. Tse said. The workforce primarily comprises 1,400 bachelor- or associate-degree level case managers who receive 4 hours of training in motivational interviewing. "We’ve had to be very creative with very low resources to train these folks in the kind of integrative care work we want them to do."

Patients receive self-management material to reinforce their goals. These include a "Healthy Living Info Card"; a similar mini-card for their wallet or purse; letters to give their psychiatrist and primary care physician; and if they have or are at risk for diabetes, a Diabetes Info Card.

For his part, Dr. Fetter said preliminary data show that motivational interviewing focused on healthy lifestyle choices can move people with high metabolic risk with mental illness forward through stages of change toward making healthy diet, exercise, and tobacco choices. "This area bears further research, and the Community Living model is a great example of how motivational interviewing interventions to address cardiometabolic risk can be successful," he said.

Dr. Tse, Dr. Chow, and Ms. Sultana-Cordero are employees of Community Living Inc. They had no other relevant disclosures.

Empowering people in low-resource communities to eat better and exercise more and thereby lessen their risk for heart disease, obesity, and diabetes continues to be a challenge for clinicians.

Motivational interviewing, however, can help and be part of an effective strategy to inspire patients at risk for cardiovascular and metabolic problems to change their behavior, Dr. Jeanie Tse said.

Photo Damian McNamara/Elsevier Global Medical News

"As psychiatrists, we learn about physical health care in medical school and training, but we forget a lot when we start our practices," said Dr. Tse, director of integrated health at the Institute for Community Living, a nonprofit behavioral health agency in New York.

Psychiatrists and other health care providers can adopt motivational interviewing techniques to improve patient outcomes, Dr. Tse said. "We feel strongly about collaboration. This is really about reaching out to primary care physicians, endocrinologists, and case managers."

Close collaboration also is important because "sometimes physical problems are misidentified as mental health symptoms." An example would be a person who goes to the emergency room with low blood glucose and ends up assigned to mental health care.

Motivational interviewing helps clinicians learn to phrase guidance in a way that encourages and supports patients. Advice about making healthy choices is provided in a nonjudgmental manner, for example. Empathic counseling delivered with warmth, respect, and understanding can foster self-efficacy and promote change, said Elisa Chow, Ph.D., director of outcomes evaluation at the Institute for Community Living. "It is really a simple tool that we as providers can use with our patients or clients.

Patients ready to make changes choose their own goals. "It is really about what patients want," Dr. Tse said, and it’s important to be realistic. "We may care about their diabetes, but in their world, they care more about housing, having a job, and finding a boyfriend or girlfriend."

Encourage patients to take small, "doable" steps, Dr. Chow recommended. "Your patient may walk away thinking ‘Oh my God, how am I going to lose 45 to 50 pounds?’ We help them step by step, maybe [with] losing a pound per week or just watching their portion sizes. Weight loss may be a goal over a year."

Dr. Jeffrey C. Fetter said in an interview that motivational interviewing is a well-established technique for improving behaviors such as smoking, but is rarely used to systematically improve diet and exercise in patients with severe mental illness. "One of the strengths of motivational interviewing is its respect for the client and his/her choices, a respect that especially resonates with mentally ill clients," said Dr. Fetter, a psychiatrist in private practice in Concord, N.H.

A recently published study showed that perceptions of motivational interviewing were more positive than standard care among patients with type 2 diabetes (Diabetes Res. Clin. Pract. 2011 [doi:10.1016/j.diabres.2011.08.011]). In that study, five themes tied to motivational interviewing emerged: nonjudgmental accountability, being heard and responded to as a person, encouragement and empowerment, collaborative action planning and goal setting, and coaching rather than critiquing.

"A patient might say, ‘I’m going to eat one apple a week. Great. Let’s go with that,’ " said Rosemarie Sultana-Cordero, a licensed mental health counselor and clinical coordinator at Community Living for its Diabetes Project and Healthy Living Project.

Dr. Tse, Dr. Chow, and Ms. Sultana-Cordero shared their expertise during an interactive workshop session at the annual meeting of the American Psychiatric Association in Honolulu.

"We tell case managers that everyone has a goal, and they will be more motivated if the goal is self-imposed," Ms. Sultana-Cordero said. Instead of a lecture about the adverse health consequences of poor eating or physical inactivity, she suggested asking patients: What changes have you thought of making? What might you have to give up to make this change? What might you gain? Will your life be different if you make this change?

If you do not have time to learn all the aspects of motivational interviewing, "Developing Discrepancies" and "Rolling With Resistance" are two essential components, Dr. Chow said. Clinicians can, for example, increase a patient’s awareness about the discrepancy between where they are in terms of cardiometabolic or diabetes risk and where they want to be. A greater awareness of this dichotomy can motivate patients to reach their goals.

Psychiatrists and other health care providers can adopt motivational interviewing techniques to improve patient outcomes.

"We have client we will call ‘Matt,’ who is slightly overweight, and sees Dr. Chow," Dr. Tse said. Matt told her he was going to diet and they agreed on a weight-loss plan. He plans to eat one vegetable every day and stay away from the corner bodega. They plan to follow up in 1 week. "Dr. Chow is then driving around and sees Matt eating fried rice and ribs in the window of a Chinese restaurant. Matt is saying one thing, but his actions say something else," Dr. Tse said. Dr. Chow will bring that up at next meeting and will use motivational interviewing to say something like: "I saw you at Chinese takeout place the other day. This seems to be in contrast with your goal."

Pointing out his discrepancies is "really about making him aware and taking ownership of his lifestyle," Dr. Chow said.

Rolling With Resistance prevents a communication breakdown between parties. The clinician does not argue or directly oppose resistance from the patient. A clinician can offer new perspectives but does not impose them.

Dr. Tse teaches basic reflective listening to case managers as part of this technique. "We line them up. One will say: ‘I don’t want to quit smoking.’ The other says it back: ‘You don’t want to quit smoking. "In our training, the psychiatrists and nurses have the most difficulty with this training. They feel the need to engage the person more and counsel about smoking cessation."

"We find that training very helpful for psychiatrists, medical doctors, social workers, and others," Dr. Chow said.

Regular progress checks are an important component of motivational interviewing and the overall chronic care model of medical care. At Community Living, participants provide feedback via self-management workbooks. These books contain "Action Step" pages. If, for example, a patient decides their goal is to drink a bottle of water instead of a soda once a week, they specify when and where they will make this substitution. They indicate whether they need someone to remind them. Later, they write why they succeeded or did not succeed, as well as how they plan to reward themselves if they followed through.

"There is also an action step review page, which is an opportunity for case manager and client to review how they did," Ms. Sultana-Cordero said.

"Our ‘Caring for Your Mental Health’ workbook is one of our most popular," Dr. Tse said. "It’s a huge realization for many that their mental health can adversely affect their overall health."

The Institute for Community Living offers about 100 programs focused primarily on housing, case management, clinics, and shelters, Dr. Tse said. More than 70% of the clients have schizophrenia or are schizoaffective, she added.

"People with serious mental illness are more than twice as likely to have diabetes. Why? Antipsychotics and other meds increase risk of dyslipidemia, diabetes, and stroke," Dr. Tse said. Also, "changes in appetite, medication side effects, and income make it harder to maintain a healthy diet." In addition, many people with mental illness also feature avolition and low energy, symptoms that can lead to reduced physical activity and contribute to worse outcomes.

"There is a lot of stigma associated with our patients with serious mental illness and intellectual disabilities. This stigma is huge, and it puts our patients at risk," Dr. Tse said. "They are at a disadvantage for getting their diabetes or heart disease looked at." Case managers complete psychiatric forms that include prompts for an annual physical exam report, weight, waist circumference, and blood pressure measurements. "It’s right in the notes. They have to fill it out each time they see a patient."

"We have two full-time psychiatrists for 10,000 people," Dr. Tse said. The workforce primarily comprises 1,400 bachelor- or associate-degree level case managers who receive 4 hours of training in motivational interviewing. "We’ve had to be very creative with very low resources to train these folks in the kind of integrative care work we want them to do."

Patients receive self-management material to reinforce their goals. These include a "Healthy Living Info Card"; a similar mini-card for their wallet or purse; letters to give their psychiatrist and primary care physician; and if they have or are at risk for diabetes, a Diabetes Info Card.

For his part, Dr. Fetter said preliminary data show that motivational interviewing focused on healthy lifestyle choices can move people with high metabolic risk with mental illness forward through stages of change toward making healthy diet, exercise, and tobacco choices. "This area bears further research, and the Community Living model is a great example of how motivational interviewing interventions to address cardiometabolic risk can be successful," he said.

Dr. Tse, Dr. Chow, and Ms. Sultana-Cordero are employees of Community Living Inc. They had no other relevant disclosures.

Evidence does not conclusively support widespread prostate cancer screening of healthy men for reduction of deaths in the long term, according to a systematic review of the literature.

In a move that could spark as much or more controversy as its recommendation against routine mammography for women in their 40s, the U.S. Preventive Services Task Force is taking this evidence and recommending against routine prostate-specific antigen (PSA) testing for healthy men in draft guidelines to be opened to public comment on Oct. 11.

Dr. Roger Chou and his colleagues conducted the review for the task force. They identified randomized trials of PSA-based screening, randomized trials, and cohort studies that compared prostatectomy or radiation therapy with watchful waiting, and large observational studies of perioperative adverse effects associated with surgical treatment.

"Screening based on PSA identifies additional prostate cancers, but most trials found no statistically significant effect on prostate cancer–specific mortality," the authors wrote. "Recent meta-analyses of randomized trials included in this review found no pooled effects of screening on prostate cancer–specific mortality."

In its 2008 recommendations, the task force previously had determined there was insufficient evidence for improved health outcomes (including reduced prostate cancer–specific and all-cause mortality) associated with prostate cancer screening for men younger than 75 years (Ann. Intern. Med. 2008;149:185-91). At the same time, they recommended against screening men 75 years or older, citing enough conclusive evidence to suggest the harms of screening and treatment would outweigh the potential benefits.

The current task force recommendations say no to PSA screening for all healthy men, regardless of age.

Dr. Chou and his colleagues noted the two largest, highest-quality studies in their review yielded conflicting results. The ERSPC (European Randomized Study of Screening for Prostate Cancer) randomly assessed 182,000 men aged 50-74 years to PSA testing or usual care (N. Engl. J. Med. 2009;360:1320-8). After a median 9 years, they found no statistically significant difference between groups in prostate cancer–specific mortality (relative risk, 0.85). A prespecified subgroup analysis did, however, show a 20% reduction in relative risk (0.80).

Investigators for the U.S. Prostate, Lung, Colorectal and Ovarian (PLCO) screening trial found no significant difference after 10 years in a study of 76,693 men ages 55 to 74 years randomized to PSA screening and digital rectal examinations vs. usual care (relative risk 1.1) (N. Engl. J. Med. 2009;360:1310-9).

"There is a substantial, cultural belief that prostate cancer screening saves lives. That does not reflect what the evidence shows."

"We think the task force reached a reasonable conclusion based on the evidence that they reviewed," said Dr. Len Lichtenfeld, deputy chief medical officer at the American Cancer Society, when asked to comment.

"What I think has to start happening is that doctors and their patients have to have a lot more honest conversations ... that this is not a test that has been shown unequivocally to have value when applied to large numbers of men, as it is being done today," Dr. Lichtenfeld said.

This call for more open and honest communication with patients about the relative risks and benefits of PSA testing is an essential feature of the society’s own 2010 recommendations on prostate cancer screening.

"At that time, we had looked at these same studies and we said we were unable to demonstrate conclusively that prostate cancer screening saves lives," Dr. Lichtenfeld said. "We weren’t advocating for or against [PSA test screening] but thought men needed to know that the evidence that this saves lives was limited and that the potential harms of diagnosis and treatment were real."

Public and physician perceptions, as well as the relative ease of ordering the PSA blood test, are real challenges to overcome, Dr. Lichtenfeld said. "There is a substantial, cultural belief – not only in the community but among health professionals – that prostate cancer screening saves lives. That does not reflect what the evidence shows."

"This is an easy test – it’s a blood test – go ahead and just do it. Why not?" he added. "Well, the ‘why nots’ are the men who are incontinent, the men who are impotent, the men who have radiation cystitis 15 years later [from resultant treatment] and are in so much pain that they can’t function."

The potential harms associated with false-positive tests and subsequent interventions are addressed in the systematic review. For example, about 1 in 200 men who undergo a prostate biopsy as a result of screening experiences a serious infection or urinary retention. The authors also noted that screening is likely to lead to overdiagnosis because the PSA enzyme test can pick up low-risk cancers that, left undetected and untreated, would not have caused death during a man’s lifetime.

Treatment of approximately three men with prostatectomy or seven men with radiation therapy instead of watchful waiting would each result in one additional case of erectile dysfunction, the review revealed. Similarly, treatment of five men with prostatectomy instead of watchful waiting would result in one additional case of urinary incontinence.

"Everybody wants to believe that PSA screening saved their lives. Well, it may work for some men, but the problem is we cannot tell which men it works for," Dr. Lichtenfeld said. "And it clearly does not work well enough for enough men that it justifies a uniform recommendation that requires men to be screened."

"I don’t believe PSA screening is going to go away," he said. "But I do believe doctors and patients are going to have more appropriate discussions about the potential value." For more of Dr. Lichtenfeld’s perspective, see his blog post.

Dr. Lichtenfeld had no relevant financial disclosures. Dr. Chou received a research grant and travel support from the Agency for Healthcare Research and Quality, which funded the systematic review study.

Evidence does not conclusively support widespread prostate cancer screening of healthy men for reduction of deaths in the long term, according to a systematic review of the literature.

In a move that could spark as much or more controversy as its recommendation against routine mammography for women in their 40s, the U.S. Preventive Services Task Force is taking this evidence and recommending against routine prostate-specific antigen (PSA) testing for healthy men in draft guidelines to be opened to public comment on Oct. 11.

Dr. Roger Chou and his colleagues conducted the review for the task force. They identified randomized trials of PSA-based screening, randomized trials, and cohort studies that compared prostatectomy or radiation therapy with watchful waiting, and large observational studies of perioperative adverse effects associated with surgical treatment.

"Screening based on PSA identifies additional prostate cancers, but most trials found no statistically significant effect on prostate cancer–specific mortality," the authors wrote. "Recent meta-analyses of randomized trials included in this review found no pooled effects of screening on prostate cancer–specific mortality."

In its 2008 recommendations, the task force previously had determined there was insufficient evidence for improved health outcomes (including reduced prostate cancer–specific and all-cause mortality) associated with prostate cancer screening for men younger than 75 years (Ann. Intern. Med. 2008;149:185-91). At the same time, they recommended against screening men 75 years or older, citing enough conclusive evidence to suggest the harms of screening and treatment would outweigh the potential benefits.

The current task force recommendations say no to PSA screening for all healthy men, regardless of age.

Dr. Chou and his colleagues noted the two largest, highest-quality studies in their review yielded conflicting results. The ERSPC (European Randomized Study of Screening for Prostate Cancer) randomly assessed 182,000 men aged 50-74 years to PSA testing or usual care (N. Engl. J. Med. 2009;360:1320-8). After a median 9 years, they found no statistically significant difference between groups in prostate cancer–specific mortality (relative risk, 0.85). A prespecified subgroup analysis did, however, show a 20% reduction in relative risk (0.80).

Investigators for the U.S. Prostate, Lung, Colorectal and Ovarian (PLCO) screening trial found no significant difference after 10 years in a study of 76,693 men ages 55 to 74 years randomized to PSA screening and digital rectal examinations vs. usual care (relative risk 1.1) (N. Engl. J. Med. 2009;360:1310-9).

"There is a substantial, cultural belief that prostate cancer screening saves lives. That does not reflect what the evidence shows."

"We think the task force reached a reasonable conclusion based on the evidence that they reviewed," said Dr. Len Lichtenfeld, deputy chief medical officer at the American Cancer Society, when asked to comment.

"What I think has to start happening is that doctors and their patients have to have a lot more honest conversations ... that this is not a test that has been shown unequivocally to have value when applied to large numbers of men, as it is being done today," Dr. Lichtenfeld said.

This call for more open and honest communication with patients about the relative risks and benefits of PSA testing is an essential feature of the society’s own 2010 recommendations on prostate cancer screening.

"At that time, we had looked at these same studies and we said we were unable to demonstrate conclusively that prostate cancer screening saves lives," Dr. Lichtenfeld said. "We weren’t advocating for or against [PSA test screening] but thought men needed to know that the evidence that this saves lives was limited and that the potential harms of diagnosis and treatment were real."

Public and physician perceptions, as well as the relative ease of ordering the PSA blood test, are real challenges to overcome, Dr. Lichtenfeld said. "There is a substantial, cultural belief – not only in the community but among health professionals – that prostate cancer screening saves lives. That does not reflect what the evidence shows."

"This is an easy test – it’s a blood test – go ahead and just do it. Why not?" he added. "Well, the ‘why nots’ are the men who are incontinent, the men who are impotent, the men who have radiation cystitis 15 years later [from resultant treatment] and are in so much pain that they can’t function."

The potential harms associated with false-positive tests and subsequent interventions are addressed in the systematic review. For example, about 1 in 200 men who undergo a prostate biopsy as a result of screening experiences a serious infection or urinary retention. The authors also noted that screening is likely to lead to overdiagnosis because the PSA enzyme test can pick up low-risk cancers that, left undetected and untreated, would not have caused death during a man’s lifetime.

Treatment of approximately three men with prostatectomy or seven men with radiation therapy instead of watchful waiting would each result in one additional case of erectile dysfunction, the review revealed. Similarly, treatment of five men with prostatectomy instead of watchful waiting would result in one additional case of urinary incontinence.

"Everybody wants to believe that PSA screening saved their lives. Well, it may work for some men, but the problem is we cannot tell which men it works for," Dr. Lichtenfeld said. "And it clearly does not work well enough for enough men that it justifies a uniform recommendation that requires men to be screened."

"I don’t believe PSA screening is going to go away," he said. "But I do believe doctors and patients are going to have more appropriate discussions about the potential value." For more of Dr. Lichtenfeld’s perspective, see his blog post.

Dr. Lichtenfeld had no relevant financial disclosures. Dr. Chou received a research grant and travel support from the Agency for Healthcare Research and Quality, which funded the systematic review study.

Evidence does not conclusively support widespread prostate cancer screening of healthy men for reduction of deaths in the long term, according to a systematic review of the literature.

In a move that could spark as much or more controversy as its recommendation against routine mammography for women in their 40s, the U.S. Preventive Services Task Force is taking this evidence and recommending against routine prostate-specific antigen (PSA) testing for healthy men in draft guidelines to be opened to public comment on Oct. 11.

Dr. Roger Chou and his colleagues conducted the review for the task force. They identified randomized trials of PSA-based screening, randomized trials, and cohort studies that compared prostatectomy or radiation therapy with watchful waiting, and large observational studies of perioperative adverse effects associated with surgical treatment.

"Screening based on PSA identifies additional prostate cancers, but most trials found no statistically significant effect on prostate cancer–specific mortality," the authors wrote. "Recent meta-analyses of randomized trials included in this review found no pooled effects of screening on prostate cancer–specific mortality."

In its 2008 recommendations, the task force previously had determined there was insufficient evidence for improved health outcomes (including reduced prostate cancer–specific and all-cause mortality) associated with prostate cancer screening for men younger than 75 years (Ann. Intern. Med. 2008;149:185-91). At the same time, they recommended against screening men 75 years or older, citing enough conclusive evidence to suggest the harms of screening and treatment would outweigh the potential benefits.

The current task force recommendations say no to PSA screening for all healthy men, regardless of age.

Dr. Chou and his colleagues noted the two largest, highest-quality studies in their review yielded conflicting results. The ERSPC (European Randomized Study of Screening for Prostate Cancer) randomly assessed 182,000 men aged 50-74 years to PSA testing or usual care (N. Engl. J. Med. 2009;360:1320-8). After a median 9 years, they found no statistically significant difference between groups in prostate cancer–specific mortality (relative risk, 0.85). A prespecified subgroup analysis did, however, show a 20% reduction in relative risk (0.80).

Investigators for the U.S. Prostate, Lung, Colorectal and Ovarian (PLCO) screening trial found no significant difference after 10 years in a study of 76,693 men ages 55 to 74 years randomized to PSA screening and digital rectal examinations vs. usual care (relative risk 1.1) (N. Engl. J. Med. 2009;360:1310-9).

"There is a substantial, cultural belief that prostate cancer screening saves lives. That does not reflect what the evidence shows."

"We think the task force reached a reasonable conclusion based on the evidence that they reviewed," said Dr. Len Lichtenfeld, deputy chief medical officer at the American Cancer Society, when asked to comment.

"What I think has to start happening is that doctors and their patients have to have a lot more honest conversations ... that this is not a test that has been shown unequivocally to have value when applied to large numbers of men, as it is being done today," Dr. Lichtenfeld said.

This call for more open and honest communication with patients about the relative risks and benefits of PSA testing is an essential feature of the society’s own 2010 recommendations on prostate cancer screening.

"At that time, we had looked at these same studies and we said we were unable to demonstrate conclusively that prostate cancer screening saves lives," Dr. Lichtenfeld said. "We weren’t advocating for or against [PSA test screening] but thought men needed to know that the evidence that this saves lives was limited and that the potential harms of diagnosis and treatment were real."

Public and physician perceptions, as well as the relative ease of ordering the PSA blood test, are real challenges to overcome, Dr. Lichtenfeld said. "There is a substantial, cultural belief – not only in the community but among health professionals – that prostate cancer screening saves lives. That does not reflect what the evidence shows."

"This is an easy test – it’s a blood test – go ahead and just do it. Why not?" he added. "Well, the ‘why nots’ are the men who are incontinent, the men who are impotent, the men who have radiation cystitis 15 years later [from resultant treatment] and are in so much pain that they can’t function."

The potential harms associated with false-positive tests and subsequent interventions are addressed in the systematic review. For example, about 1 in 200 men who undergo a prostate biopsy as a result of screening experiences a serious infection or urinary retention. The authors also noted that screening is likely to lead to overdiagnosis because the PSA enzyme test can pick up low-risk cancers that, left undetected and untreated, would not have caused death during a man’s lifetime.

Treatment of approximately three men with prostatectomy or seven men with radiation therapy instead of watchful waiting would each result in one additional case of erectile dysfunction, the review revealed. Similarly, treatment of five men with prostatectomy instead of watchful waiting would result in one additional case of urinary incontinence.

"Everybody wants to believe that PSA screening saved their lives. Well, it may work for some men, but the problem is we cannot tell which men it works for," Dr. Lichtenfeld said. "And it clearly does not work well enough for enough men that it justifies a uniform recommendation that requires men to be screened."

"I don’t believe PSA screening is going to go away," he said. "But I do believe doctors and patients are going to have more appropriate discussions about the potential value." For more of Dr. Lichtenfeld’s perspective, see his blog post.

Dr. Lichtenfeld had no relevant financial disclosures. Dr. Chou received a research grant and travel support from the Agency for Healthcare Research and Quality, which funded the systematic review study.

The number of children and teenagers presenting at hospital emergency departments for evaluation of nonfatal traumatic brain injury related to sports and recreation activities grew by more than 60% between 2001 and 2009, according to a report from the Centers for Disease Control and Prevention released Oct. 6.

This significant increase of 62% over 8 years – from 153,375 emergency visits in 2001 to 248,418 in 2009 – is likely due to increasing awareness of the severity of traumatic brain injury (TBI) and the importance of prompt medical attention for these children and adolescents, according to CDC officials.

A primary strategy is to educate your patients and their families about prevention of TBIs, including concussions. Skills practice, strength and conditioning exercises, sportsmanship, and proper use of protective equipment are important strategies outlined in the report (MMWR 2011 Oct. 7;60:1337-42). Secondary measures include teaching parents, coaches, and others in your community about the signs and symptoms of TBI and how to respond appropriately to a suspected injury.

©photoaged/FOTOLIA

Physicians also play an essential role in deciding when an injured child or adolescent can return to his or her activity. An experienced health care provider should evaluate the patient and make the appropriate clearance call, according to the report.

"Return to play is a critical decision because children and adolescents are at increased risk for both repeat concussion during sports- and recreation-related activities and for long-term sequelae, delayed recovery, and cumulative consequences of multiple TBIs (e.g., increased severity of future TBIs and increased risk for depression and dementia)," the authors wrote.

Even though symptoms can initially appear mild, significant long-term effects can include impaired memory and learning, as well as changes to behavior and/or emotions. For these reasons, appropriate diagnosis, management, and education are critical.

An online course for health care professionals is the latest addition to the CDC Heads Up initiative, a program to educate specific audiences (such as parents, coaches, school nurses) about concussions and mild TBIs. The "Heads Up to Clinicians: Addressing Concussion in Sports Among Kids and Teens" was developed with support from the CDC Foundation and the National Football League.

Bicycling, football, playground activities, basketball, and soccer were associated with the overall greatest number of emergency department visits related to TBI in the report.

The riskiest activities varied by patient age and gender. For example, playground activities and bicycling led the list for boys and girls 9 years or younger. For children aged 10-19 years, there was a split by gender: football and bicycling were associated with the most TBIs among boys, whereas soccer, basketball, and bicycling were the most common culprits among girls.

Overall, boys accounted for 71% all sports- and recreation-related TBI visits to the ED over the 8 years of the study. Likewise, older children aged 10-19 years accounted for 71% of such ED visits.

The report also revealed activities for which TBI accounted for more than 10% of all associated injury visits to the ED. For example, TBIs accounted for 15% of horseback riding injuries; 11% of ice skating injuries; 11% of golfing injuries; 11% of all-terrain vehicle injuries; and 10% of tobogganing/sledding injuries.

The annual average number of 173,285 TBIs from 2001 to 2009 comprises almost 7% of the estimated 2.6 million sports- and recreation-related injuries treated each year among individuals aged 19 years and younger in the United States.

Researchers from the CDC Division of Unintentional Injury Prevention compiled the report based on data from NEISS-AIP (National Electronic Injury Surveillance System–All Injury Program). The U.S. Consumer Product Safety Commission operates the NEISS-AIP using a nationally representative sample of 66 hospitals.

The NEISS-AIP database tracks only hospital ED–reported injuries and does not include patients treated in other settings. This limitation underestimates the actual TBI rate from sports and recreation among children and adolescents, according to the CDC. In addition, TBIs are included in the data only if they are the principal diagnosis and primary body part injured. The inability to capture secondary TBIs is another limitation of the study.

Visit the CDC concussion pages for additional information and resources regarding TBI.

The authors of the CDC report had no relevant financial disclosures.

The number of children and teenagers presenting at hospital emergency departments for evaluation of nonfatal traumatic brain injury related to sports and recreation activities grew by more than 60% between 2001 and 2009, according to a report from the Centers for Disease Control and Prevention released Oct. 6.

This significant increase of 62% over 8 years – from 153,375 emergency visits in 2001 to 248,418 in 2009 – is likely due to increasing awareness of the severity of traumatic brain injury (TBI) and the importance of prompt medical attention for these children and adolescents, according to CDC officials.

A primary strategy is to educate your patients and their families about prevention of TBIs, including concussions. Skills practice, strength and conditioning exercises, sportsmanship, and proper use of protective equipment are important strategies outlined in the report (MMWR 2011 Oct. 7;60:1337-42). Secondary measures include teaching parents, coaches, and others in your community about the signs and symptoms of TBI and how to respond appropriately to a suspected injury.

©photoaged/FOTOLIA

Physicians also play an essential role in deciding when an injured child or adolescent can return to his or her activity. An experienced health care provider should evaluate the patient and make the appropriate clearance call, according to the report.

"Return to play is a critical decision because children and adolescents are at increased risk for both repeat concussion during sports- and recreation-related activities and for long-term sequelae, delayed recovery, and cumulative consequences of multiple TBIs (e.g., increased severity of future TBIs and increased risk for depression and dementia)," the authors wrote.

Even though symptoms can initially appear mild, significant long-term effects can include impaired memory and learning, as well as changes to behavior and/or emotions. For these reasons, appropriate diagnosis, management, and education are critical.

An online course for health care professionals is the latest addition to the CDC Heads Up initiative, a program to educate specific audiences (such as parents, coaches, school nurses) about concussions and mild TBIs. The "Heads Up to Clinicians: Addressing Concussion in Sports Among Kids and Teens" was developed with support from the CDC Foundation and the National Football League.

Bicycling, football, playground activities, basketball, and soccer were associated with the overall greatest number of emergency department visits related to TBI in the report.

The riskiest activities varied by patient age and gender. For example, playground activities and bicycling led the list for boys and girls 9 years or younger. For children aged 10-19 years, there was a split by gender: football and bicycling were associated with the most TBIs among boys, whereas soccer, basketball, and bicycling were the most common culprits among girls.

Overall, boys accounted for 71% all sports- and recreation-related TBI visits to the ED over the 8 years of the study. Likewise, older children aged 10-19 years accounted for 71% of such ED visits.

The report also revealed activities for which TBI accounted for more than 10% of all associated injury visits to the ED. For example, TBIs accounted for 15% of horseback riding injuries; 11% of ice skating injuries; 11% of golfing injuries; 11% of all-terrain vehicle injuries; and 10% of tobogganing/sledding injuries.

The annual average number of 173,285 TBIs from 2001 to 2009 comprises almost 7% of the estimated 2.6 million sports- and recreation-related injuries treated each year among individuals aged 19 years and younger in the United States.

Researchers from the CDC Division of Unintentional Injury Prevention compiled the report based on data from NEISS-AIP (National Electronic Injury Surveillance System–All Injury Program). The U.S. Consumer Product Safety Commission operates the NEISS-AIP using a nationally representative sample of 66 hospitals.

The NEISS-AIP database tracks only hospital ED–reported injuries and does not include patients treated in other settings. This limitation underestimates the actual TBI rate from sports and recreation among children and adolescents, according to the CDC. In addition, TBIs are included in the data only if they are the principal diagnosis and primary body part injured. The inability to capture secondary TBIs is another limitation of the study.

Visit the CDC concussion pages for additional information and resources regarding TBI.

The authors of the CDC report had no relevant financial disclosures.

The number of children and teenagers presenting at hospital emergency departments for evaluation of nonfatal traumatic brain injury related to sports and recreation activities grew by more than 60% between 2001 and 2009, according to a report from the Centers for Disease Control and Prevention released Oct. 6.

This significant increase of 62% over 8 years – from 153,375 emergency visits in 2001 to 248,418 in 2009 – is likely due to increasing awareness of the severity of traumatic brain injury (TBI) and the importance of prompt medical attention for these children and adolescents, according to CDC officials.

A primary strategy is to educate your patients and their families about prevention of TBIs, including concussions. Skills practice, strength and conditioning exercises, sportsmanship, and proper use of protective equipment are important strategies outlined in the report (MMWR 2011 Oct. 7;60:1337-42). Secondary measures include teaching parents, coaches, and others in your community about the signs and symptoms of TBI and how to respond appropriately to a suspected injury.

©photoaged/FOTOLIA

Physicians also play an essential role in deciding when an injured child or adolescent can return to his or her activity. An experienced health care provider should evaluate the patient and make the appropriate clearance call, according to the report.

"Return to play is a critical decision because children and adolescents are at increased risk for both repeat concussion during sports- and recreation-related activities and for long-term sequelae, delayed recovery, and cumulative consequences of multiple TBIs (e.g., increased severity of future TBIs and increased risk for depression and dementia)," the authors wrote.

Even though symptoms can initially appear mild, significant long-term effects can include impaired memory and learning, as well as changes to behavior and/or emotions. For these reasons, appropriate diagnosis, management, and education are critical.

An online course for health care professionals is the latest addition to the CDC Heads Up initiative, a program to educate specific audiences (such as parents, coaches, school nurses) about concussions and mild TBIs. The "Heads Up to Clinicians: Addressing Concussion in Sports Among Kids and Teens" was developed with support from the CDC Foundation and the National Football League.

Bicycling, football, playground activities, basketball, and soccer were associated with the overall greatest number of emergency department visits related to TBI in the report.

The riskiest activities varied by patient age and gender. For example, playground activities and bicycling led the list for boys and girls 9 years or younger. For children aged 10-19 years, there was a split by gender: football and bicycling were associated with the most TBIs among boys, whereas soccer, basketball, and bicycling were the most common culprits among girls.

Overall, boys accounted for 71% all sports- and recreation-related TBI visits to the ED over the 8 years of the study. Likewise, older children aged 10-19 years accounted for 71% of such ED visits.

The report also revealed activities for which TBI accounted for more than 10% of all associated injury visits to the ED. For example, TBIs accounted for 15% of horseback riding injuries; 11% of ice skating injuries; 11% of golfing injuries; 11% of all-terrain vehicle injuries; and 10% of tobogganing/sledding injuries.

The annual average number of 173,285 TBIs from 2001 to 2009 comprises almost 7% of the estimated 2.6 million sports- and recreation-related injuries treated each year among individuals aged 19 years and younger in the United States.

Researchers from the CDC Division of Unintentional Injury Prevention compiled the report based on data from NEISS-AIP (National Electronic Injury Surveillance System–All Injury Program). The U.S. Consumer Product Safety Commission operates the NEISS-AIP using a nationally representative sample of 66 hospitals.

The NEISS-AIP database tracks only hospital ED–reported injuries and does not include patients treated in other settings. This limitation underestimates the actual TBI rate from sports and recreation among children and adolescents, according to the CDC. In addition, TBIs are included in the data only if they are the principal diagnosis and primary body part injured. The inability to capture secondary TBIs is another limitation of the study.

Visit the CDC concussion pages for additional information and resources regarding TBI.

The authors of the CDC report had no relevant financial disclosures.

Almost one-third of the elderly Medicare fee-for-service beneficiaries who died in 2008 underwent surgery within one year of their death, according to a retrospective study reported Oct. 6 in The Lancet. Many procedures performed on the elderly may be unnecessary or unwanted, and physicians should consider patients’ goals when making decisions about surgical intervention, researchers wrote.

End of life surgical care among those over age 65 varies based on age and U.S. region, according to the study.

Increasing age and likelihood for surgery in the final 12 months of life were inversely related. Older seniors, particularly those over 80 years, were less likely to undergo surgery compared to younger Medicare recipients, Dr. Alvin C. Kwok and his colleagues discovered (Lancet 2011 Oct. 6 [doi:10.1016/S0140-6736(11)61268-3]).

The elderly with Medicare coverage also were more likely to have surgery in the final year of life in regions of the country with a higher number of hospital beds and greater Medicare expenditures. In contrast, the numbers of surgeons in a region did not have a significant effect.

The substantial variations by age and region might suggest that health care provider discretion plays a role in allocation of end of life surgical care, according to Dr. Kwok and his colleagues. Dr. Kwok is a researcher in the Department of Health Policy and Management, Harvard School of Public Health in Boston.

Previous "studies have shown a strong association between Medicare costs and regional characteristics, including number of hospital beds or specialist physicians per head" (Ann. Intern. Med. 2003;138:273-87; Ann. Intern. Med. 2003;138:288-98).

These data suggest that "some hospital admissions could be discretionary or avoidable and some high-intensity treatments could be unnecessary or discordant with patients’ preferences," Dr. Amy S. Kelley, a member of the faculty at Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York City, wrote in an accompanying commentary (Lancet 2011 Oct. 6 [doi:10.1016/S0140-6736(11)61420-7]).

Although multiple studies have assessed end of life medical care, only one previous study specifically examined surgery (Health Serv. Res. 2004;39:363-75), Dr. Kwok and his colleagues noted. So they assessed ICD-9-CM codes for the 1.8 million Medicare beneficiaries ages 65 and older who died in 2008. They found 32% had an inpatient surgery at an acute care hospital or skilled nursing facility during their last year of life, compared with 14% of Medicare recipients who survived that year. They also discovered 25% had a surgical procedure during their final three months of life; 18% during their final month; and 8% during their final week.

Those who had surgery within a year of death were significantly younger, an average 79.8 years of age, compared with an average 82.5 years among decedents who did not undergo surgery. So, despite increasing comorbidities with increasing age, the surgery rate actually dropped as ages climbed.

"These data should prompt careful consideration of patients' goals when assessing the need for surgical intervention at the end of life."

"Health care providers might have a high threshold to undertake surgery for elderly patients or a perception that these patients are more likely to have complications or less likely to benefit from such interventions than might younger patients," the authors wrote. "Some of these age-related differences could also be due to the preferences of patients and their families."

At age 65 years, 38% of patients were likely to undergo surgery in their final year of life. This dropped slightly to 35% by age 80 years, after which it decreased more dramatically to 24% for patients between 80 and 90 years of age.

Regional variations did not significantly differ by patient age, even for those older than 80 years. Because this was one of the first studies of its kind, the investigators devised a measure of end of life surgical intensity (EOLSI) to compare hospital referral regions. EOLSI reflects the rate of receipt of at least one surgical procedure during the last year of life for all those who died, after adjustments for age, gender, race, and income.

The adjusted EOLSI score varied by as much as three times between the lowest intensity region, Honolulu, and the highest, Munster, Ind., again indicating a wide variation in end of life surgical care by region. Dr. Kwok and his colleagues also found high-intensity areas had almost 40% more hospital beds and significantly higher Medicare spending, compared with low intensity areas.

"Our finding that surgical intensity is related to the number of hospital beds (although not the number of surgeons) suggests that wide-ranging practice patterns could exist in intensive regions that affect other aspects of care, such as when and how aggressively to intervene at the end of a patient’s life," the authors wrote. "For clinicians, these data should prompt careful consideration of patients’ goals when assessing the need for surgical intervention at the end of life."

"Kwok and colleagues’ study shows that the provision of appropriate, preference-guided treatment for patients with serious illness is the shared responsibility of all clinicians," Dr. Kelley commented. "Surgeons, like general practitioners, are obliged to work with patients and their families to identify appropriate goals of care and recommend treatment plans that help achieve those goals."

The study did not include the approximately 44% of surgical procedures performed in outpatient settings, a potential limitation. Also, although they adjusted for risk factors for death, Dr. Kwok and his colleagues acknowledged that some comorbidities could have been caused by the surgical intervention itself.

Dr. Kelley addressed another potential limitation: "Certainly, studies relying solely on administrative and census data cannot sufficiently adjust for patients’ risk factors (i.e., health, function, and socioeconomic status), or for patients’ or families’ preferences; and studies of decedents cannot fully account for those who survived despite a high risk of mortality. Nevertheless, the consistent reproducible pattern of findings across many studies cannot be ignored. Treatments are heavily influenced by external factors (i.e., number of hospital beds per head, local practice patterns, physician supply), rather than purely what is medically appropriate for and preferred by patients. Although some might continue to critique such study methods, including those used by Kwok and colleagues, the weight of evidence supports the need for action on many levels."

There was no sponsor for this study. Dr. Kwok and his study coauthors, as well as Dr. Kelley, had no relevant financial disclosures.

Almost one-third of the elderly Medicare fee-for-service beneficiaries who died in 2008 underwent surgery within one year of their death, according to a retrospective study reported Oct. 6 in The Lancet. Many procedures performed on the elderly may be unnecessary or unwanted, and physicians should consider patients’ goals when making decisions about surgical intervention, researchers wrote.

End of life surgical care among those over age 65 varies based on age and U.S. region, according to the study.

Increasing age and likelihood for surgery in the final 12 months of life were inversely related. Older seniors, particularly those over 80 years, were less likely to undergo surgery compared to younger Medicare recipients, Dr. Alvin C. Kwok and his colleagues discovered (Lancet 2011 Oct. 6 [doi:10.1016/S0140-6736(11)61268-3]).

The elderly with Medicare coverage also were more likely to have surgery in the final year of life in regions of the country with a higher number of hospital beds and greater Medicare expenditures. In contrast, the numbers of surgeons in a region did not have a significant effect.

The substantial variations by age and region might suggest that health care provider discretion plays a role in allocation of end of life surgical care, according to Dr. Kwok and his colleagues. Dr. Kwok is a researcher in the Department of Health Policy and Management, Harvard School of Public Health in Boston.

Previous "studies have shown a strong association between Medicare costs and regional characteristics, including number of hospital beds or specialist physicians per head" (Ann. Intern. Med. 2003;138:273-87; Ann. Intern. Med. 2003;138:288-98).

These data suggest that "some hospital admissions could be discretionary or avoidable and some high-intensity treatments could be unnecessary or discordant with patients’ preferences," Dr. Amy S. Kelley, a member of the faculty at Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York City, wrote in an accompanying commentary (Lancet 2011 Oct. 6 [doi:10.1016/S0140-6736(11)61420-7]).

Although multiple studies have assessed end of life medical care, only one previous study specifically examined surgery (Health Serv. Res. 2004;39:363-75), Dr. Kwok and his colleagues noted. So they assessed ICD-9-CM codes for the 1.8 million Medicare beneficiaries ages 65 and older who died in 2008. They found 32% had an inpatient surgery at an acute care hospital or skilled nursing facility during their last year of life, compared with 14% of Medicare recipients who survived that year. They also discovered 25% had a surgical procedure during their final three months of life; 18% during their final month; and 8% during their final week.

Those who had surgery within a year of death were significantly younger, an average 79.8 years of age, compared with an average 82.5 years among decedents who did not undergo surgery. So, despite increasing comorbidities with increasing age, the surgery rate actually dropped as ages climbed.

"These data should prompt careful consideration of patients' goals when assessing the need for surgical intervention at the end of life."

"Health care providers might have a high threshold to undertake surgery for elderly patients or a perception that these patients are more likely to have complications or less likely to benefit from such interventions than might younger patients," the authors wrote. "Some of these age-related differences could also be due to the preferences of patients and their families."

At age 65 years, 38% of patients were likely to undergo surgery in their final year of life. This dropped slightly to 35% by age 80 years, after which it decreased more dramatically to 24% for patients between 80 and 90 years of age.

Regional variations did not significantly differ by patient age, even for those older than 80 years. Because this was one of the first studies of its kind, the investigators devised a measure of end of life surgical intensity (EOLSI) to compare hospital referral regions. EOLSI reflects the rate of receipt of at least one surgical procedure during the last year of life for all those who died, after adjustments for age, gender, race, and income.

The adjusted EOLSI score varied by as much as three times between the lowest intensity region, Honolulu, and the highest, Munster, Ind., again indicating a wide variation in end of life surgical care by region. Dr. Kwok and his colleagues also found high-intensity areas had almost 40% more hospital beds and significantly higher Medicare spending, compared with low intensity areas.

"Our finding that surgical intensity is related to the number of hospital beds (although not the number of surgeons) suggests that wide-ranging practice patterns could exist in intensive regions that affect other aspects of care, such as when and how aggressively to intervene at the end of a patient’s life," the authors wrote. "For clinicians, these data should prompt careful consideration of patients’ goals when assessing the need for surgical intervention at the end of life."

"Kwok and colleagues’ study shows that the provision of appropriate, preference-guided treatment for patients with serious illness is the shared responsibility of all clinicians," Dr. Kelley commented. "Surgeons, like general practitioners, are obliged to work with patients and their families to identify appropriate goals of care and recommend treatment plans that help achieve those goals."

The study did not include the approximately 44% of surgical procedures performed in outpatient settings, a potential limitation. Also, although they adjusted for risk factors for death, Dr. Kwok and his colleagues acknowledged that some comorbidities could have been caused by the surgical intervention itself.

Dr. Kelley addressed another potential limitation: "Certainly, studies relying solely on administrative and census data cannot sufficiently adjust for patients’ risk factors (i.e., health, function, and socioeconomic status), or for patients’ or families’ preferences; and studies of decedents cannot fully account for those who survived despite a high risk of mortality. Nevertheless, the consistent reproducible pattern of findings across many studies cannot be ignored. Treatments are heavily influenced by external factors (i.e., number of hospital beds per head, local practice patterns, physician supply), rather than purely what is medically appropriate for and preferred by patients. Although some might continue to critique such study methods, including those used by Kwok and colleagues, the weight of evidence supports the need for action on many levels."

There was no sponsor for this study. Dr. Kwok and his study coauthors, as well as Dr. Kelley, had no relevant financial disclosures.

Almost one-third of the elderly Medicare fee-for-service beneficiaries who died in 2008 underwent surgery within one year of their death, according to a retrospective study reported Oct. 6 in The Lancet. Many procedures performed on the elderly may be unnecessary or unwanted, and physicians should consider patients’ goals when making decisions about surgical intervention, researchers wrote.

End of life surgical care among those over age 65 varies based on age and U.S. region, according to the study.

Increasing age and likelihood for surgery in the final 12 months of life were inversely related. Older seniors, particularly those over 80 years, were less likely to undergo surgery compared to younger Medicare recipients, Dr. Alvin C. Kwok and his colleagues discovered (Lancet 2011 Oct. 6 [doi:10.1016/S0140-6736(11)61268-3]).

The elderly with Medicare coverage also were more likely to have surgery in the final year of life in regions of the country with a higher number of hospital beds and greater Medicare expenditures. In contrast, the numbers of surgeons in a region did not have a significant effect.

The substantial variations by age and region might suggest that health care provider discretion plays a role in allocation of end of life surgical care, according to Dr. Kwok and his colleagues. Dr. Kwok is a researcher in the Department of Health Policy and Management, Harvard School of Public Health in Boston.

Previous "studies have shown a strong association between Medicare costs and regional characteristics, including number of hospital beds or specialist physicians per head" (Ann. Intern. Med. 2003;138:273-87; Ann. Intern. Med. 2003;138:288-98).

These data suggest that "some hospital admissions could be discretionary or avoidable and some high-intensity treatments could be unnecessary or discordant with patients’ preferences," Dr. Amy S. Kelley, a member of the faculty at Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York City, wrote in an accompanying commentary (Lancet 2011 Oct. 6 [doi:10.1016/S0140-6736(11)61420-7]).

Although multiple studies have assessed end of life medical care, only one previous study specifically examined surgery (Health Serv. Res. 2004;39:363-75), Dr. Kwok and his colleagues noted. So they assessed ICD-9-CM codes for the 1.8 million Medicare beneficiaries ages 65 and older who died in 2008. They found 32% had an inpatient surgery at an acute care hospital or skilled nursing facility during their last year of life, compared with 14% of Medicare recipients who survived that year. They also discovered 25% had a surgical procedure during their final three months of life; 18% during their final month; and 8% during their final week.

Those who had surgery within a year of death were significantly younger, an average 79.8 years of age, compared with an average 82.5 years among decedents who did not undergo surgery. So, despite increasing comorbidities with increasing age, the surgery rate actually dropped as ages climbed.

"These data should prompt careful consideration of patients' goals when assessing the need for surgical intervention at the end of life."

"Health care providers might have a high threshold to undertake surgery for elderly patients or a perception that these patients are more likely to have complications or less likely to benefit from such interventions than might younger patients," the authors wrote. "Some of these age-related differences could also be due to the preferences of patients and their families."

At age 65 years, 38% of patients were likely to undergo surgery in their final year of life. This dropped slightly to 35% by age 80 years, after which it decreased more dramatically to 24% for patients between 80 and 90 years of age.

Regional variations did not significantly differ by patient age, even for those older than 80 years. Because this was one of the first studies of its kind, the investigators devised a measure of end of life surgical intensity (EOLSI) to compare hospital referral regions. EOLSI reflects the rate of receipt of at least one surgical procedure during the last year of life for all those who died, after adjustments for age, gender, race, and income.

The adjusted EOLSI score varied by as much as three times between the lowest intensity region, Honolulu, and the highest, Munster, Ind., again indicating a wide variation in end of life surgical care by region. Dr. Kwok and his colleagues also found high-intensity areas had almost 40% more hospital beds and significantly higher Medicare spending, compared with low intensity areas.

"Our finding that surgical intensity is related to the number of hospital beds (although not the number of surgeons) suggests that wide-ranging practice patterns could exist in intensive regions that affect other aspects of care, such as when and how aggressively to intervene at the end of a patient’s life," the authors wrote. "For clinicians, these data should prompt careful consideration of patients’ goals when assessing the need for surgical intervention at the end of life."

"Kwok and colleagues’ study shows that the provision of appropriate, preference-guided treatment for patients with serious illness is the shared responsibility of all clinicians," Dr. Kelley commented. "Surgeons, like general practitioners, are obliged to work with patients and their families to identify appropriate goals of care and recommend treatment plans that help achieve those goals."

The study did not include the approximately 44% of surgical procedures performed in outpatient settings, a potential limitation. Also, although they adjusted for risk factors for death, Dr. Kwok and his colleagues acknowledged that some comorbidities could have been caused by the surgical intervention itself.

Dr. Kelley addressed another potential limitation: "Certainly, studies relying solely on administrative and census data cannot sufficiently adjust for patients’ risk factors (i.e., health, function, and socioeconomic status), or for patients’ or families’ preferences; and studies of decedents cannot fully account for those who survived despite a high risk of mortality. Nevertheless, the consistent reproducible pattern of findings across many studies cannot be ignored. Treatments are heavily influenced by external factors (i.e., number of hospital beds per head, local practice patterns, physician supply), rather than purely what is medically appropriate for and preferred by patients. Although some might continue to critique such study methods, including those used by Kwok and colleagues, the weight of evidence supports the need for action on many levels."

There was no sponsor for this study. Dr. Kwok and his study coauthors, as well as Dr. Kelley, had no relevant financial disclosures.

The number of alcohol-impaired driving episodes dropped by 30% from a peak of 161 million in 2006 to 112 million last year, according to a report by the Centers for Disease Control and Prevention.

Although prevalence has declined, alcohol-impaired driving continues to kill thousands of Americans every year. Therefore, continued and strengthened efforts to decrease drinking and driving are essential, CDC officials said at a telebriefing announcing the findings of the report (MMWR 2011 Oct. 4;60[early release]:1-6).

PhotoDisk

"Every primary care practitioner can help patients realize that car crashes are the leading cause of death for everyone ages 5-34 and that one in three car crash deaths involves someone who is an alcohol-impaired driver," said Dr. Thomas R. Frieden, director of the CDC.

Routinely screen patients for risky drinking patterns, he suggested. Also, "provide a brief intervention, a 10- to 15-minute motivational counseling session, which can substantially reduce the long-term risk of problem drinking and, therefore, of drinking and driving as well," Dr. Frieden said.

Binge drinking was strongly associated with alcohol-impaired driving, according to the report, with binge drinkers accounting for 85% of all episodes of alcohol-impaired driving. A binge drinker was defined as a man who consumes five or more drinks or a woman who consumes four or more drinks on one occasion.

Young men, people who said they do not always wear a seatbelt, and residents of the Midwest also had disproportionately high rates of alcohol-impaired driving. The data were taken from 451,000 responses to the 2010 Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative telephone survey.

A total of 1.8% of respondents reported at least one episode of alcohol-impaired driving in the past 30 days. Extrapolation of monthly figures means more than 4 million adults would report an estimated 112,116,000 episodes of alcohol-impaired driving in 2010.

"There were more than 100 million episodes of alcohol-impaired driving by self-report last year. Each of those episodes could have resulted in the severe injury or death of a pedestrian or a fellow driver or a kid biking to school," Dr. Frieden said. "This is something that is unacceptable."

Men are much more likely than women to drive after drinking, according to the report. A total of 81% of respondents who reported alcohol-impaired driving episodes were men, and men aged 21-34 years may be at especially high risk. Although these younger men account for 11% of the U.S. adult population, they reported 32% of all episodes.

Dr. Frieden said the gender ratio has remained stable over the past few years.

"There is an outstanding question in the field as to whether more women are drinking and driving, but that question is still being researched and there is not a clear answer," said Gwen Bergen, Ph.D., an author of the report and a behavioral scientist at the CDC Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control.

Consider asking patients about seatbelt use as part of a screen, as well. Survey respondents who reported not always wearing a seatbelt were nearly four times more likely to drink and drive, compared with universal seatbelt users.

Geography also was a factor. People surveyed in the Midwest census region had significantly higher rates of annual alcohol-impaired driving episodes (at 643/1,000 population), compared with those living in other regions of the United States. Excluding the District of Columbia and 12 states with small and potentially unstable numbers of respondents, four of the seven states that exceeded the national average for alcohol-impaired driving were in the Midwest.

Midwest residents also reported a significantly higher rate of binge drinking, at 16.5%, compared with 15.1% in the Northeast, 14.3% in the West, and 12.6% in the South.

Reasons for the overall decrease in alcohol-impaired driving are not well understood. However, one possibility is that fewer people are going out to bars and restaurants as a result of the downturn in the U.S. economy, which would decrease the number of impaired drivers, he said.

"While we’ve made progress, this is still a huge problem that is a threat to everyone who uses the road, with often tragic consequences," Dr. Frieden said.

The CDC offered several recommendations to help further decrease drinking and driving rates. More widespread use of sobriety checkpoints, greater enforcement of laws concerning blood alcohol concentrations and minimum drinking age, and ignition interlock programs for all convicted alcohol-impaired driving offenders are among the effective, evidence-based strategies, Dr. Frieden said. He added that public support for these and other proven strategies is strong.

Drivers younger than 18 years are not included in the BRFSS, a potential limitation of the report. The survey was conducted only via land-line telephones and exclusion of responses via cell phones is another potential limitation. In addition, "significant underreporting" is likely because the alcohol-impaired driving rates are based on self-reports, Dr. Frieden said.

Dr. Frieden and Dr. Bergen said that they had no relevant financial disclosures.

The number of alcohol-impaired driving episodes dropped by 30% from a peak of 161 million in 2006 to 112 million last year, according to a report by the Centers for Disease Control and Prevention.

Although prevalence has declined, alcohol-impaired driving continues to kill thousands of Americans every year. Therefore, continued and strengthened efforts to decrease drinking and driving are essential, CDC officials said at a telebriefing announcing the findings of the report (MMWR 2011 Oct. 4;60[early release]:1-6).

PhotoDisk

"Every primary care practitioner can help patients realize that car crashes are the leading cause of death for everyone ages 5-34 and that one in three car crash deaths involves someone who is an alcohol-impaired driver," said Dr. Thomas R. Frieden, director of the CDC.

Routinely screen patients for risky drinking patterns, he suggested. Also, "provide a brief intervention, a 10- to 15-minute motivational counseling session, which can substantially reduce the long-term risk of problem drinking and, therefore, of drinking and driving as well," Dr. Frieden said.

Binge drinking was strongly associated with alcohol-impaired driving, according to the report, with binge drinkers accounting for 85% of all episodes of alcohol-impaired driving. A binge drinker was defined as a man who consumes five or more drinks or a woman who consumes four or more drinks on one occasion.

Young men, people who said they do not always wear a seatbelt, and residents of the Midwest also had disproportionately high rates of alcohol-impaired driving. The data were taken from 451,000 responses to the 2010 Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative telephone survey.

A total of 1.8% of respondents reported at least one episode of alcohol-impaired driving in the past 30 days. Extrapolation of monthly figures means more than 4 million adults would report an estimated 112,116,000 episodes of alcohol-impaired driving in 2010.

"There were more than 100 million episodes of alcohol-impaired driving by self-report last year. Each of those episodes could have resulted in the severe injury or death of a pedestrian or a fellow driver or a kid biking to school," Dr. Frieden said. "This is something that is unacceptable."

Men are much more likely than women to drive after drinking, according to the report. A total of 81% of respondents who reported alcohol-impaired driving episodes were men, and men aged 21-34 years may be at especially high risk. Although these younger men account for 11% of the U.S. adult population, they reported 32% of all episodes.

Dr. Frieden said the gender ratio has remained stable over the past few years.

"There is an outstanding question in the field as to whether more women are drinking and driving, but that question is still being researched and there is not a clear answer," said Gwen Bergen, Ph.D., an author of the report and a behavioral scientist at the CDC Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control.

Consider asking patients about seatbelt use as part of a screen, as well. Survey respondents who reported not always wearing a seatbelt were nearly four times more likely to drink and drive, compared with universal seatbelt users.

Geography also was a factor. People surveyed in the Midwest census region had significantly higher rates of annual alcohol-impaired driving episodes (at 643/1,000 population), compared with those living in other regions of the United States. Excluding the District of Columbia and 12 states with small and potentially unstable numbers of respondents, four of the seven states that exceeded the national average for alcohol-impaired driving were in the Midwest.

Midwest residents also reported a significantly higher rate of binge drinking, at 16.5%, compared with 15.1% in the Northeast, 14.3% in the West, and 12.6% in the South.

Reasons for the overall decrease in alcohol-impaired driving are not well understood. However, one possibility is that fewer people are going out to bars and restaurants as a result of the downturn in the U.S. economy, which would decrease the number of impaired drivers, he said.

"While we’ve made progress, this is still a huge problem that is a threat to everyone who uses the road, with often tragic consequences," Dr. Frieden said.

The CDC offered several recommendations to help further decrease drinking and driving rates. More widespread use of sobriety checkpoints, greater enforcement of laws concerning blood alcohol concentrations and minimum drinking age, and ignition interlock programs for all convicted alcohol-impaired driving offenders are among the effective, evidence-based strategies, Dr. Frieden said. He added that public support for these and other proven strategies is strong.

Drivers younger than 18 years are not included in the BRFSS, a potential limitation of the report. The survey was conducted only via land-line telephones and exclusion of responses via cell phones is another potential limitation. In addition, "significant underreporting" is likely because the alcohol-impaired driving rates are based on self-reports, Dr. Frieden said.

Dr. Frieden and Dr. Bergen said that they had no relevant financial disclosures.

The number of alcohol-impaired driving episodes dropped by 30% from a peak of 161 million in 2006 to 112 million last year, according to a report by the Centers for Disease Control and Prevention.

Although prevalence has declined, alcohol-impaired driving continues to kill thousands of Americans every year. Therefore, continued and strengthened efforts to decrease drinking and driving are essential, CDC officials said at a telebriefing announcing the findings of the report (MMWR 2011 Oct. 4;60[early release]:1-6).

PhotoDisk

"Every primary care practitioner can help patients realize that car crashes are the leading cause of death for everyone ages 5-34 and that one in three car crash deaths involves someone who is an alcohol-impaired driver," said Dr. Thomas R. Frieden, director of the CDC.

Routinely screen patients for risky drinking patterns, he suggested. Also, "provide a brief intervention, a 10- to 15-minute motivational counseling session, which can substantially reduce the long-term risk of problem drinking and, therefore, of drinking and driving as well," Dr. Frieden said.

Binge drinking was strongly associated with alcohol-impaired driving, according to the report, with binge drinkers accounting for 85% of all episodes of alcohol-impaired driving. A binge drinker was defined as a man who consumes five or more drinks or a woman who consumes four or more drinks on one occasion.

Young men, people who said they do not always wear a seatbelt, and residents of the Midwest also had disproportionately high rates of alcohol-impaired driving. The data were taken from 451,000 responses to the 2010 Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative telephone survey.

A total of 1.8% of respondents reported at least one episode of alcohol-impaired driving in the past 30 days. Extrapolation of monthly figures means more than 4 million adults would report an estimated 112,116,000 episodes of alcohol-impaired driving in 2010.

"There were more than 100 million episodes of alcohol-impaired driving by self-report last year. Each of those episodes could have resulted in the severe injury or death of a pedestrian or a fellow driver or a kid biking to school," Dr. Frieden said. "This is something that is unacceptable."

Men are much more likely than women to drive after drinking, according to the report. A total of 81% of respondents who reported alcohol-impaired driving episodes were men, and men aged 21-34 years may be at especially high risk. Although these younger men account for 11% of the U.S. adult population, they reported 32% of all episodes.

Dr. Frieden said the gender ratio has remained stable over the past few years.

"There is an outstanding question in the field as to whether more women are drinking and driving, but that question is still being researched and there is not a clear answer," said Gwen Bergen, Ph.D., an author of the report and a behavioral scientist at the CDC Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control.

Consider asking patients about seatbelt use as part of a screen, as well. Survey respondents who reported not always wearing a seatbelt were nearly four times more likely to drink and drive, compared with universal seatbelt users.

Geography also was a factor. People surveyed in the Midwest census region had significantly higher rates of annual alcohol-impaired driving episodes (at 643/1,000 population), compared with those living in other regions of the United States. Excluding the District of Columbia and 12 states with small and potentially unstable numbers of respondents, four of the seven states that exceeded the national average for alcohol-impaired driving were in the Midwest.

Midwest residents also reported a significantly higher rate of binge drinking, at 16.5%, compared with 15.1% in the Northeast, 14.3% in the West, and 12.6% in the South.

Reasons for the overall decrease in alcohol-impaired driving are not well understood. However, one possibility is that fewer people are going out to bars and restaurants as a result of the downturn in the U.S. economy, which would decrease the number of impaired drivers, he said.

"While we’ve made progress, this is still a huge problem that is a threat to everyone who uses the road, with often tragic consequences," Dr. Frieden said.

The CDC offered several recommendations to help further decrease drinking and driving rates. More widespread use of sobriety checkpoints, greater enforcement of laws concerning blood alcohol concentrations and minimum drinking age, and ignition interlock programs for all convicted alcohol-impaired driving offenders are among the effective, evidence-based strategies, Dr. Frieden said. He added that public support for these and other proven strategies is strong.

Drivers younger than 18 years are not included in the BRFSS, a potential limitation of the report. The survey was conducted only via land-line telephones and exclusion of responses via cell phones is another potential limitation. In addition, "significant underreporting" is likely because the alcohol-impaired driving rates are based on self-reports, Dr. Frieden said.

Dr. Frieden and Dr. Bergen said that they had no relevant financial disclosures.

BOCA RATON, FLA. – Ovarian suppression to treat endometriosis might cause a woman to experience significantly more migraines, as well as more sleep disturbances, numbness, joint pain, hot flashes, and heart palpitations, a study revealed. Some women also experience more depression.

Migraines affect more than three times as many women as men in the United States. Decreases in hormone levels and sex steroids during the late luteal phase of the menstrual period, during the postpartum period, and during perimenopause, for example, can increase a woman's susceptibility to migraines. Researchers figured that treatments that intentionally lower a woman's estrogen levels to tackle endometriosis might, at the same time, increase her risk for more severe and more frequent migraines and depressive symptoms.

Dr. Julia K. Warnock said that gonadotropin-releasing hormone (GnRH) agonists will decrease estrogen and increase the risk of headaches, including migraines, and increase the risk for depressive symptoms. Some women tend to be more sensitive to mood-related hormonal changes, Dr. Warnock said at the meeting She is professor of psychiatry and director of clinical research at the University of Oklahoma Health Science Center in Tulsa.

“As the patient transitions through the reproductive cycle, a number of [her] associated mood symptoms…are influenced by fluctuations in estrogen,” said study coauthor Dr. J. Clark Bundren, an ob. gyn. in private practice in Tulsa.

“Proper supplementation of low dose estradiol in this population can improve migraine headache, anxiety, and depression,” Dr. Bundren said.

Dr. Warnock and colleagues evaluated baseline hormone levels, depression, and physical symptoms for 56 women with endometriosis. Women completed the MENSI (Menopause Symptom Index) and the HAM-D (Hamilton Rating Scale for Depression).

Participants were then treated with 3.75 mg GnRH agonist via intramuscular injection daily for 28 days. They were reevaluated at 1 month, 2 months, and 5 months.

A significant increase in the frequency of headaches was observed at each follow-up, according to an item level chi square analysis of MENSI scores, compared with baseline. Total MENSI scores likewise significantly increased at 1, 3, and 5 months, according to a t-test of dependent samples.

Similarly, depressive symptoms significantly increased, compared with baseline, at months 1, 3, and 5, as reflected by the percentages of women who scored greater than 10 on the HAM-D.

“Psychiatrists should consider hormonal fluctuations in the treatment of women [with depression],” Dr. Warnock said, because decreases in estrogen levels can predispose some to worsening depression. Combination hormone and antidepressant treatment can have synergistic benefits.

“Together is better.” This dual approach also can mean lower doses of antidepressants and therefore, lower risk of associated adverse events, Dr. Warnock added.

Regarding the well-publicized risks associated with hormone therapy, Dr. Bundren said, “Women on estrogen alone have a decreased risk of breast cancer, but it's not a simple message.”

“It matters which estrogen, which patient, and how it's delivered,” Dr. Warnock said. “In general, transdermal is better than oral. For women who are suffering, it's about their quality of life.”

Potential limitations of the study include patient self-report of headache frequency on the MENSI, and a lack of assessment of progesterone or its metabolites.

The study was unfunded. Dr. Warnock and Dr. Bundren said they had no relevant disclosures.

BOCA RATON, FLA. – Ovarian suppression to treat endometriosis might cause a woman to experience significantly more migraines, as well as more sleep disturbances, numbness, joint pain, hot flashes, and heart palpitations, a study revealed. Some women also experience more depression.

Migraines affect more than three times as many women as men in the United States. Decreases in hormone levels and sex steroids during the late luteal phase of the menstrual period, during the postpartum period, and during perimenopause, for example, can increase a woman's susceptibility to migraines. Researchers figured that treatments that intentionally lower a woman's estrogen levels to tackle endometriosis might, at the same time, increase her risk for more severe and more frequent migraines and depressive symptoms.

Dr. Julia K. Warnock said that gonadotropin-releasing hormone (GnRH) agonists will decrease estrogen and increase the risk of headaches, including migraines, and increase the risk for depressive symptoms. Some women tend to be more sensitive to mood-related hormonal changes, Dr. Warnock said at the meeting She is professor of psychiatry and director of clinical research at the University of Oklahoma Health Science Center in Tulsa.

“As the patient transitions through the reproductive cycle, a number of [her] associated mood symptoms…are influenced by fluctuations in estrogen,” said study coauthor Dr. J. Clark Bundren, an ob. gyn. in private practice in Tulsa.

“Proper supplementation of low dose estradiol in this population can improve migraine headache, anxiety, and depression,” Dr. Bundren said.

Dr. Warnock and colleagues evaluated baseline hormone levels, depression, and physical symptoms for 56 women with endometriosis. Women completed the MENSI (Menopause Symptom Index) and the HAM-D (Hamilton Rating Scale for Depression).

Participants were then treated with 3.75 mg GnRH agonist via intramuscular injection daily for 28 days. They were reevaluated at 1 month, 2 months, and 5 months.

A significant increase in the frequency of headaches was observed at each follow-up, according to an item level chi square analysis of MENSI scores, compared with baseline. Total MENSI scores likewise significantly increased at 1, 3, and 5 months, according to a t-test of dependent samples.

Similarly, depressive symptoms significantly increased, compared with baseline, at months 1, 3, and 5, as reflected by the percentages of women who scored greater than 10 on the HAM-D.

“Psychiatrists should consider hormonal fluctuations in the treatment of women [with depression],” Dr. Warnock said, because decreases in estrogen levels can predispose some to worsening depression. Combination hormone and antidepressant treatment can have synergistic benefits.

“Together is better.” This dual approach also can mean lower doses of antidepressants and therefore, lower risk of associated adverse events, Dr. Warnock added.

Regarding the well-publicized risks associated with hormone therapy, Dr. Bundren said, “Women on estrogen alone have a decreased risk of breast cancer, but it's not a simple message.”

“It matters which estrogen, which patient, and how it's delivered,” Dr. Warnock said. “In general, transdermal is better than oral. For women who are suffering, it's about their quality of life.”

Potential limitations of the study include patient self-report of headache frequency on the MENSI, and a lack of assessment of progesterone or its metabolites.

The study was unfunded. Dr. Warnock and Dr. Bundren said they had no relevant disclosures.

BOCA RATON, FLA. – Ovarian suppression to treat endometriosis might cause a woman to experience significantly more migraines, as well as more sleep disturbances, numbness, joint pain, hot flashes, and heart palpitations, a study revealed. Some women also experience more depression.

Migraines affect more than three times as many women as men in the United States. Decreases in hormone levels and sex steroids during the late luteal phase of the menstrual period, during the postpartum period, and during perimenopause, for example, can increase a woman's susceptibility to migraines. Researchers figured that treatments that intentionally lower a woman's estrogen levels to tackle endometriosis might, at the same time, increase her risk for more severe and more frequent migraines and depressive symptoms.

Dr. Julia K. Warnock said that gonadotropin-releasing hormone (GnRH) agonists will decrease estrogen and increase the risk of headaches, including migraines, and increase the risk for depressive symptoms. Some women tend to be more sensitive to mood-related hormonal changes, Dr. Warnock said at the meeting She is professor of psychiatry and director of clinical research at the University of Oklahoma Health Science Center in Tulsa.

“As the patient transitions through the reproductive cycle, a number of [her] associated mood symptoms…are influenced by fluctuations in estrogen,” said study coauthor Dr. J. Clark Bundren, an ob. gyn. in private practice in Tulsa.

“Proper supplementation of low dose estradiol in this population can improve migraine headache, anxiety, and depression,” Dr. Bundren said.

Dr. Warnock and colleagues evaluated baseline hormone levels, depression, and physical symptoms for 56 women with endometriosis. Women completed the MENSI (Menopause Symptom Index) and the HAM-D (Hamilton Rating Scale for Depression).

Participants were then treated with 3.75 mg GnRH agonist via intramuscular injection daily for 28 days. They were reevaluated at 1 month, 2 months, and 5 months.

A significant increase in the frequency of headaches was observed at each follow-up, according to an item level chi square analysis of MENSI scores, compared with baseline. Total MENSI scores likewise significantly increased at 1, 3, and 5 months, according to a t-test of dependent samples.

Similarly, depressive symptoms significantly increased, compared with baseline, at months 1, 3, and 5, as reflected by the percentages of women who scored greater than 10 on the HAM-D.

“Psychiatrists should consider hormonal fluctuations in the treatment of women [with depression],” Dr. Warnock said, because decreases in estrogen levels can predispose some to worsening depression. Combination hormone and antidepressant treatment can have synergistic benefits.

“Together is better.” This dual approach also can mean lower doses of antidepressants and therefore, lower risk of associated adverse events, Dr. Warnock added.

Regarding the well-publicized risks associated with hormone therapy, Dr. Bundren said, “Women on estrogen alone have a decreased risk of breast cancer, but it's not a simple message.”

“It matters which estrogen, which patient, and how it's delivered,” Dr. Warnock said. “In general, transdermal is better than oral. For women who are suffering, it's about their quality of life.”

Potential limitations of the study include patient self-report of headache frequency on the MENSI, and a lack of assessment of progesterone or its metabolites.

The study was unfunded. Dr. Warnock and Dr. Bundren said they had no relevant disclosures.