Kate Johnson

ORLANDO — The use of biofeedback to control heart rate variability could be useful in the treatment of older patients with depression, just as it has been beneficial for patients with asthma, chronic obstructive pulmonary disease, and various cancers.

“Heart rate variability is probably the best marker of health in general, such that if one has good heart rate variability, one is generally healthy. But should someone have any health problems, they can learn to improve their heart rate variability and do better,” said Leon Hyer, Ph.D., in a poster presentation at the annual meeting of the Gerontological Society of America.

In a pilot study of two depressed women aged 55 and 56 years, Dr. Hyer, a professor of psychiatry at the Robert Wood Johnson Medical School, Piscataway, N.J., found that biofeedback training to improve heart rate variability (HRV) resulted in a significant decrease in depressive symptoms. “This has been shown in young, depressed patients but not in older patients,” he said in an interview.

The two subjects had 10 biofeedback sessions in which they were taught, using audio and video feedback from laptop computers, how to regulate their heart rates and breathe at their resonant frequency. They were encouraged to practice often.

At the end of the 10 sessions, both subjects showed a significant decrease in depressive symptoms. Their baseline scores on the Beck Depression Inventory II were 18 and 21, dropping to 0 for one patient by the study's end. The other patient's score dropped from 21 to 3 by the end of the 4th session, but rose to 11 by the study's end. “Since both medical disorders and mood state have a bidirectionality in their effects, there is a significant advantage in applying a treatment that can improve both,” Dr Hyer said.

Pharmacologic therapy for depression typically has a 60% response rate, but the response is not usually sustained long term. By contrast, biofeedback, combined with cognitive-behavioral training, has been shown to produce sustained responses in other health conditions, he said.

ORLANDO — The use of biofeedback to control heart rate variability could be useful in the treatment of older patients with depression, just as it has been beneficial for patients with asthma, chronic obstructive pulmonary disease, and various cancers.

“Heart rate variability is probably the best marker of health in general, such that if one has good heart rate variability, one is generally healthy. But should someone have any health problems, they can learn to improve their heart rate variability and do better,” said Leon Hyer, Ph.D., in a poster presentation at the annual meeting of the Gerontological Society of America.

In a pilot study of two depressed women aged 55 and 56 years, Dr. Hyer, a professor of psychiatry at the Robert Wood Johnson Medical School, Piscataway, N.J., found that biofeedback training to improve heart rate variability (HRV) resulted in a significant decrease in depressive symptoms. “This has been shown in young, depressed patients but not in older patients,” he said in an interview.

The two subjects had 10 biofeedback sessions in which they were taught, using audio and video feedback from laptop computers, how to regulate their heart rates and breathe at their resonant frequency. They were encouraged to practice often.

At the end of the 10 sessions, both subjects showed a significant decrease in depressive symptoms. Their baseline scores on the Beck Depression Inventory II were 18 and 21, dropping to 0 for one patient by the study's end. The other patient's score dropped from 21 to 3 by the end of the 4th session, but rose to 11 by the study's end. “Since both medical disorders and mood state have a bidirectionality in their effects, there is a significant advantage in applying a treatment that can improve both,” Dr Hyer said.

Pharmacologic therapy for depression typically has a 60% response rate, but the response is not usually sustained long term. By contrast, biofeedback, combined with cognitive-behavioral training, has been shown to produce sustained responses in other health conditions, he said.

ORLANDO — The use of biofeedback to control heart rate variability could be useful in the treatment of older patients with depression, just as it has been beneficial for patients with asthma, chronic obstructive pulmonary disease, and various cancers.

“Heart rate variability is probably the best marker of health in general, such that if one has good heart rate variability, one is generally healthy. But should someone have any health problems, they can learn to improve their heart rate variability and do better,” said Leon Hyer, Ph.D., in a poster presentation at the annual meeting of the Gerontological Society of America.

In a pilot study of two depressed women aged 55 and 56 years, Dr. Hyer, a professor of psychiatry at the Robert Wood Johnson Medical School, Piscataway, N.J., found that biofeedback training to improve heart rate variability (HRV) resulted in a significant decrease in depressive symptoms. “This has been shown in young, depressed patients but not in older patients,” he said in an interview.

The two subjects had 10 biofeedback sessions in which they were taught, using audio and video feedback from laptop computers, how to regulate their heart rates and breathe at their resonant frequency. They were encouraged to practice often.

At the end of the 10 sessions, both subjects showed a significant decrease in depressive symptoms. Their baseline scores on the Beck Depression Inventory II were 18 and 21, dropping to 0 for one patient by the study's end. The other patient's score dropped from 21 to 3 by the end of the 4th session, but rose to 11 by the study's end. “Since both medical disorders and mood state have a bidirectionality in their effects, there is a significant advantage in applying a treatment that can improve both,” Dr Hyer said.

Pharmacologic therapy for depression typically has a 60% response rate, but the response is not usually sustained long term. By contrast, biofeedback, combined with cognitive-behavioral training, has been shown to produce sustained responses in other health conditions, he said.

ORLANDO — Depression in elderly patients is easily missed by primary care physicians, according to a new study.

“Sometimes family doctors don't have time to screen for depression, and patients don't put it out on the table,” said Dr. Irene Mangani, who presented her findings in a poster at the annual meeting of the Gerontological Society of America.

“These people can be helped with a lot of interventions for depression, not just pharmacological interventions but also psychotherapy and exercise. And we miss these opportunities by not screening them for depression,” said Dr. Mangani, who is a geriatrician at the University of Florence, Italy.

Her investigation included data from the ICARe Dicomano Study, which enrolled two waves of community-dwelling individuals, aged 65 years and older. The first group was enrolled in 1995, the second in 1999.

A total of 656 participants (mean age 74 years) completed the 30-item Geriatric Depression Scale (GDS), and their scores were compared with evaluations by primary care physicians who assessed the participants for depressive symptoms.

Using a GDS cutoff of 14 or higher to identify depression, the investigators found that the prevalence of depressive symptoms was 24% in the 1995 wave of participants and 31% in the 1999 wave. However, primary care physicians identified only a 14% prevalence in the first wave and 11% in the second wave.

“The GDS is not a diagnosis of depression. It is a screening tool that identifies depressive symptoms. But if someone has a GDS score higher than 14, they should be asked about other symptoms of depression because if they are depressed, this condition can be cured and can be dangerous if not taken care of,” Dr. Mangani said in an interview.

She said that depression in this population has been linked with higher disability and mortality rates. For this reason, screening is worthwhile, even in the primary care setting where there is so little time.

“Just asking a simple question like 'have you lost interest in things you usually like?' is something that doesn't take much time but can be important. If they answer yes, you can ask more questions or even give them the GDS screen,” she said.

ORLANDO — Depression in elderly patients is easily missed by primary care physicians, according to a new study.

“Sometimes family doctors don't have time to screen for depression, and patients don't put it out on the table,” said Dr. Irene Mangani, who presented her findings in a poster at the annual meeting of the Gerontological Society of America.

“These people can be helped with a lot of interventions for depression, not just pharmacological interventions but also psychotherapy and exercise. And we miss these opportunities by not screening them for depression,” said Dr. Mangani, who is a geriatrician at the University of Florence, Italy.

Her investigation included data from the ICARe Dicomano Study, which enrolled two waves of community-dwelling individuals, aged 65 years and older. The first group was enrolled in 1995, the second in 1999.

A total of 656 participants (mean age 74 years) completed the 30-item Geriatric Depression Scale (GDS), and their scores were compared with evaluations by primary care physicians who assessed the participants for depressive symptoms.

Using a GDS cutoff of 14 or higher to identify depression, the investigators found that the prevalence of depressive symptoms was 24% in the 1995 wave of participants and 31% in the 1999 wave. However, primary care physicians identified only a 14% prevalence in the first wave and 11% in the second wave.

“The GDS is not a diagnosis of depression. It is a screening tool that identifies depressive symptoms. But if someone has a GDS score higher than 14, they should be asked about other symptoms of depression because if they are depressed, this condition can be cured and can be dangerous if not taken care of,” Dr. Mangani said in an interview.

She said that depression in this population has been linked with higher disability and mortality rates. For this reason, screening is worthwhile, even in the primary care setting where there is so little time.

“Just asking a simple question like 'have you lost interest in things you usually like?' is something that doesn't take much time but can be important. If they answer yes, you can ask more questions or even give them the GDS screen,” she said.

ORLANDO — Depression in elderly patients is easily missed by primary care physicians, according to a new study.

“Sometimes family doctors don't have time to screen for depression, and patients don't put it out on the table,” said Dr. Irene Mangani, who presented her findings in a poster at the annual meeting of the Gerontological Society of America.

“These people can be helped with a lot of interventions for depression, not just pharmacological interventions but also psychotherapy and exercise. And we miss these opportunities by not screening them for depression,” said Dr. Mangani, who is a geriatrician at the University of Florence, Italy.

Her investigation included data from the ICARe Dicomano Study, which enrolled two waves of community-dwelling individuals, aged 65 years and older. The first group was enrolled in 1995, the second in 1999.

A total of 656 participants (mean age 74 years) completed the 30-item Geriatric Depression Scale (GDS), and their scores were compared with evaluations by primary care physicians who assessed the participants for depressive symptoms.

Using a GDS cutoff of 14 or higher to identify depression, the investigators found that the prevalence of depressive symptoms was 24% in the 1995 wave of participants and 31% in the 1999 wave. However, primary care physicians identified only a 14% prevalence in the first wave and 11% in the second wave.

“The GDS is not a diagnosis of depression. It is a screening tool that identifies depressive symptoms. But if someone has a GDS score higher than 14, they should be asked about other symptoms of depression because if they are depressed, this condition can be cured and can be dangerous if not taken care of,” Dr. Mangani said in an interview.

She said that depression in this population has been linked with higher disability and mortality rates. For this reason, screening is worthwhile, even in the primary care setting where there is so little time.

“Just asking a simple question like 'have you lost interest in things you usually like?' is something that doesn't take much time but can be important. If they answer yes, you can ask more questions or even give them the GDS screen,” she said.

American and Canadian fertility experts have expressed surprise and disappointment about new warnings concerning the aromatase inhibitor letrozole and its off-label use in fertility treatment.

“This is a knee-jerk reaction without a proper review of the data,” said Dr. Kutluk Oktay, referring to the Swiss company Novartis Pharmaceuticals' letter to health care professionals in Canada and the United States warning that the drug may be associated with congenital anomalies. Letters are also planned for all other countries where the drug is available, said a company spokesperson.

Novartis markets letrozole under the name Femara for the treatment of breast cancer. But worldwide the drug is used off label for ovulation induction, and has replaced clomiphene citrate in many intrauterine insemination programs because of its superior pregnancy success rates and ability to decrease gonadotropin requirements. Additionally, it is one of the only safe options for breast cancer patients wishing to undergo in vitro fertilization with ovarian stimulation to freeze embryos prior to their cancer therapy.

Although Femara's label has always stated a contraindication in premenopausal women because of “the potential for maternal and fetal toxicity,” Novartis' renewed concerns about the drug's use in fertility treatment arose after a small, unpublished Canadian study was presented at the recent conjoint annual meeting of the American Society for Reproductive Medicine and the Canadian Fertility and Andrology Society, said company spokesperson Kim Fox.

Dr. Marinko M. Biljan, medical director of the Montreal Fertility Clinic, reported that among his patients, letrozole, used at the 5-mg dose for ovulation induction, was associated with an increased rate of serious fetal anomalies.

“We stopped using it at our center in September and we hope others will stop using it, at least at this dose,” Dr. Biljan said in an interview.

An analysis of 150 babies born at his clinic after letrozole therapy (5 mg daily on days 3–7) found a 4.7% rate of major anomalies compared with a 1.8% rate in a control group of more than 36,000 babies born at a local “low-risk” hospital. As a result of this study, Novartis subsequently reviewed its safety database and found 13 reports of obstetric exposures to letrozole, of which 4 had adverse obstetric outcomes, said Fox.

Health Canada said three of the four adverse obstetric outcomes occurred in women who were exposed to letrozole as a result of infertility treatment, and the fourth exposure was a result of breast cancer treatment in the first and second trimesters of pregnancy. Two of the three infertility patients had spontaneous abortions, while the third gave birth to a baby who was diagnosed at 1 year with bilateral adrenal neuroblastoma, said Christopher Williams, a spokesman for Health Canada. The breast cancer patient who was exposed to letrozole during pregnancy gave birth to a female baby with a genital abnormality.

Novartis has not studied Femara as an infertility therapy and so cannot comment on this, said Fox. But “because there were some adverse events reported it is important that we remind physicians about the appropriate use and warnings about Femara, regarding not only pregnancy and lactation, but also premenopausal status,” she said.

Although the Food and Drug Administration is reviewing the matter, Health Canada has endorsed the Novartis warning. But several fertility experts with extensive experience using letrozole say the matter has been blown way out of proportion.

“There is a growing body of literature supporting the use of aromatase inhibitors in infertility therapy and the peer-reviewed literature is expected to support its continued use,” said Roger Pierson, Ph.D., professor of obstetrics, gynecology, and reproductive sciences at the University of Saskatchewan, Saskatoon.

“The study reported by Dr. Biljan et al. has done more harm than good as the conclusions are not supported by appropriate data,” he said. Dr. Robert Casper, one of the pioneers of letrozole in the treatment of infertility, said the Biljan study is seriously flawed because it has an inappropriate control group. “It compares young fertile with older infertile women,” said Dr. Casper, professor of obstetrics and gynecology at the University of Toronto.

“An infertile control group would be more valid and the Canadian IVF database for last year showed an overall anomaly rate of 2.6% in over 1,600 deliveries. Using this number, Dr. Biljan's relative risk numbers would be quite a bit lower,” he said. In addition, most of the major anomalies detected in the study's control group would have been referred to specialists prenatally and thus would not have shown up as adverse outcomes in the final analysis, he said.

Dr. Casper has reviewed his experience with more than 200 letrozole births and found no major congenital anomalies—which is “much below the expected rate” even in the general population, he said. Nevertheless, his clinic has stopped using letrozole as a result of the Novartis warning.

“Unfortunately this is going to negatively impact physicians and patients,” said Dr. Oktay, of Cornell University, New York. Dr. Biljan believes the discrepancy between his results and those of others could be explained by his use of a higher than normal dose of letrozole (the more common dose is 2.5 mg daily on days 3–7).

Regardless of dose, both Dr. Oktay and Dr. Casper said that the short half-life of letrozole makes it biologically implausible that the drug could cause anomalies, since it is discontinued before conception occurs.

However, according to the FDA, “although the terminal elimination half-life is said to be 2 days, steady state is not reached for 2–6 weeks—and steady-state levels are maintained over extended periods.”

Dr. Oktay said one would expect fetal exposure to letrozole to result in abnormal sexual development. Indeed, Novartis's one record of second trimester exposure did result in a child with genital abnormalities. But the cases resulting from preconceptual exposure (two spontaneous abortions and one bilateral neuroblastoma) are not obviously drug related, and in some cases could be explained by factors related to infertility, he suggested. Similarly, in Dr. Biljan's study, none of the adverse outcomes were related to abnormal sexual development.

The short half-life of letrozole makes it biologically implausible that the drug could cause anomalies. DR. OKTAY

American and Canadian fertility experts have expressed surprise and disappointment about new warnings concerning the aromatase inhibitor letrozole and its off-label use in fertility treatment.

“This is a knee-jerk reaction without a proper review of the data,” said Dr. Kutluk Oktay, referring to the Swiss company Novartis Pharmaceuticals' letter to health care professionals in Canada and the United States warning that the drug may be associated with congenital anomalies. Letters are also planned for all other countries where the drug is available, said a company spokesperson.

Novartis markets letrozole under the name Femara for the treatment of breast cancer. But worldwide the drug is used off label for ovulation induction, and has replaced clomiphene citrate in many intrauterine insemination programs because of its superior pregnancy success rates and ability to decrease gonadotropin requirements. Additionally, it is one of the only safe options for breast cancer patients wishing to undergo in vitro fertilization with ovarian stimulation to freeze embryos prior to their cancer therapy.

Although Femara's label has always stated a contraindication in premenopausal women because of “the potential for maternal and fetal toxicity,” Novartis' renewed concerns about the drug's use in fertility treatment arose after a small, unpublished Canadian study was presented at the recent conjoint annual meeting of the American Society for Reproductive Medicine and the Canadian Fertility and Andrology Society, said company spokesperson Kim Fox.

Dr. Marinko M. Biljan, medical director of the Montreal Fertility Clinic, reported that among his patients, letrozole, used at the 5-mg dose for ovulation induction, was associated with an increased rate of serious fetal anomalies.

“We stopped using it at our center in September and we hope others will stop using it, at least at this dose,” Dr. Biljan said in an interview.

An analysis of 150 babies born at his clinic after letrozole therapy (5 mg daily on days 3–7) found a 4.7% rate of major anomalies compared with a 1.8% rate in a control group of more than 36,000 babies born at a local “low-risk” hospital. As a result of this study, Novartis subsequently reviewed its safety database and found 13 reports of obstetric exposures to letrozole, of which 4 had adverse obstetric outcomes, said Fox.

Health Canada said three of the four adverse obstetric outcomes occurred in women who were exposed to letrozole as a result of infertility treatment, and the fourth exposure was a result of breast cancer treatment in the first and second trimesters of pregnancy. Two of the three infertility patients had spontaneous abortions, while the third gave birth to a baby who was diagnosed at 1 year with bilateral adrenal neuroblastoma, said Christopher Williams, a spokesman for Health Canada. The breast cancer patient who was exposed to letrozole during pregnancy gave birth to a female baby with a genital abnormality.

Novartis has not studied Femara as an infertility therapy and so cannot comment on this, said Fox. But “because there were some adverse events reported it is important that we remind physicians about the appropriate use and warnings about Femara, regarding not only pregnancy and lactation, but also premenopausal status,” she said.

Although the Food and Drug Administration is reviewing the matter, Health Canada has endorsed the Novartis warning. But several fertility experts with extensive experience using letrozole say the matter has been blown way out of proportion.

“There is a growing body of literature supporting the use of aromatase inhibitors in infertility therapy and the peer-reviewed literature is expected to support its continued use,” said Roger Pierson, Ph.D., professor of obstetrics, gynecology, and reproductive sciences at the University of Saskatchewan, Saskatoon.

“The study reported by Dr. Biljan et al. has done more harm than good as the conclusions are not supported by appropriate data,” he said. Dr. Robert Casper, one of the pioneers of letrozole in the treatment of infertility, said the Biljan study is seriously flawed because it has an inappropriate control group. “It compares young fertile with older infertile women,” said Dr. Casper, professor of obstetrics and gynecology at the University of Toronto.

“An infertile control group would be more valid and the Canadian IVF database for last year showed an overall anomaly rate of 2.6% in over 1,600 deliveries. Using this number, Dr. Biljan's relative risk numbers would be quite a bit lower,” he said. In addition, most of the major anomalies detected in the study's control group would have been referred to specialists prenatally and thus would not have shown up as adverse outcomes in the final analysis, he said.

Dr. Casper has reviewed his experience with more than 200 letrozole births and found no major congenital anomalies—which is “much below the expected rate” even in the general population, he said. Nevertheless, his clinic has stopped using letrozole as a result of the Novartis warning.

“Unfortunately this is going to negatively impact physicians and patients,” said Dr. Oktay, of Cornell University, New York. Dr. Biljan believes the discrepancy between his results and those of others could be explained by his use of a higher than normal dose of letrozole (the more common dose is 2.5 mg daily on days 3–7).

Regardless of dose, both Dr. Oktay and Dr. Casper said that the short half-life of letrozole makes it biologically implausible that the drug could cause anomalies, since it is discontinued before conception occurs.

However, according to the FDA, “although the terminal elimination half-life is said to be 2 days, steady state is not reached for 2–6 weeks—and steady-state levels are maintained over extended periods.”

Dr. Oktay said one would expect fetal exposure to letrozole to result in abnormal sexual development. Indeed, Novartis's one record of second trimester exposure did result in a child with genital abnormalities. But the cases resulting from preconceptual exposure (two spontaneous abortions and one bilateral neuroblastoma) are not obviously drug related, and in some cases could be explained by factors related to infertility, he suggested. Similarly, in Dr. Biljan's study, none of the adverse outcomes were related to abnormal sexual development.

The short half-life of letrozole makes it biologically implausible that the drug could cause anomalies. DR. OKTAY

American and Canadian fertility experts have expressed surprise and disappointment about new warnings concerning the aromatase inhibitor letrozole and its off-label use in fertility treatment.

“This is a knee-jerk reaction without a proper review of the data,” said Dr. Kutluk Oktay, referring to the Swiss company Novartis Pharmaceuticals' letter to health care professionals in Canada and the United States warning that the drug may be associated with congenital anomalies. Letters are also planned for all other countries where the drug is available, said a company spokesperson.

Novartis markets letrozole under the name Femara for the treatment of breast cancer. But worldwide the drug is used off label for ovulation induction, and has replaced clomiphene citrate in many intrauterine insemination programs because of its superior pregnancy success rates and ability to decrease gonadotropin requirements. Additionally, it is one of the only safe options for breast cancer patients wishing to undergo in vitro fertilization with ovarian stimulation to freeze embryos prior to their cancer therapy.

Although Femara's label has always stated a contraindication in premenopausal women because of “the potential for maternal and fetal toxicity,” Novartis' renewed concerns about the drug's use in fertility treatment arose after a small, unpublished Canadian study was presented at the recent conjoint annual meeting of the American Society for Reproductive Medicine and the Canadian Fertility and Andrology Society, said company spokesperson Kim Fox.

Dr. Marinko M. Biljan, medical director of the Montreal Fertility Clinic, reported that among his patients, letrozole, used at the 5-mg dose for ovulation induction, was associated with an increased rate of serious fetal anomalies.

“We stopped using it at our center in September and we hope others will stop using it, at least at this dose,” Dr. Biljan said in an interview.

An analysis of 150 babies born at his clinic after letrozole therapy (5 mg daily on days 3–7) found a 4.7% rate of major anomalies compared with a 1.8% rate in a control group of more than 36,000 babies born at a local “low-risk” hospital. As a result of this study, Novartis subsequently reviewed its safety database and found 13 reports of obstetric exposures to letrozole, of which 4 had adverse obstetric outcomes, said Fox.

Health Canada said three of the four adverse obstetric outcomes occurred in women who were exposed to letrozole as a result of infertility treatment, and the fourth exposure was a result of breast cancer treatment in the first and second trimesters of pregnancy. Two of the three infertility patients had spontaneous abortions, while the third gave birth to a baby who was diagnosed at 1 year with bilateral adrenal neuroblastoma, said Christopher Williams, a spokesman for Health Canada. The breast cancer patient who was exposed to letrozole during pregnancy gave birth to a female baby with a genital abnormality.

Novartis has not studied Femara as an infertility therapy and so cannot comment on this, said Fox. But “because there were some adverse events reported it is important that we remind physicians about the appropriate use and warnings about Femara, regarding not only pregnancy and lactation, but also premenopausal status,” she said.

Although the Food and Drug Administration is reviewing the matter, Health Canada has endorsed the Novartis warning. But several fertility experts with extensive experience using letrozole say the matter has been blown way out of proportion.

“There is a growing body of literature supporting the use of aromatase inhibitors in infertility therapy and the peer-reviewed literature is expected to support its continued use,” said Roger Pierson, Ph.D., professor of obstetrics, gynecology, and reproductive sciences at the University of Saskatchewan, Saskatoon.

“The study reported by Dr. Biljan et al. has done more harm than good as the conclusions are not supported by appropriate data,” he said. Dr. Robert Casper, one of the pioneers of letrozole in the treatment of infertility, said the Biljan study is seriously flawed because it has an inappropriate control group. “It compares young fertile with older infertile women,” said Dr. Casper, professor of obstetrics and gynecology at the University of Toronto.

“An infertile control group would be more valid and the Canadian IVF database for last year showed an overall anomaly rate of 2.6% in over 1,600 deliveries. Using this number, Dr. Biljan's relative risk numbers would be quite a bit lower,” he said. In addition, most of the major anomalies detected in the study's control group would have been referred to specialists prenatally and thus would not have shown up as adverse outcomes in the final analysis, he said.

Dr. Casper has reviewed his experience with more than 200 letrozole births and found no major congenital anomalies—which is “much below the expected rate” even in the general population, he said. Nevertheless, his clinic has stopped using letrozole as a result of the Novartis warning.

“Unfortunately this is going to negatively impact physicians and patients,” said Dr. Oktay, of Cornell University, New York. Dr. Biljan believes the discrepancy between his results and those of others could be explained by his use of a higher than normal dose of letrozole (the more common dose is 2.5 mg daily on days 3–7).

Regardless of dose, both Dr. Oktay and Dr. Casper said that the short half-life of letrozole makes it biologically implausible that the drug could cause anomalies, since it is discontinued before conception occurs.

However, according to the FDA, “although the terminal elimination half-life is said to be 2 days, steady state is not reached for 2–6 weeks—and steady-state levels are maintained over extended periods.”

Dr. Oktay said one would expect fetal exposure to letrozole to result in abnormal sexual development. Indeed, Novartis's one record of second trimester exposure did result in a child with genital abnormalities. But the cases resulting from preconceptual exposure (two spontaneous abortions and one bilateral neuroblastoma) are not obviously drug related, and in some cases could be explained by factors related to infertility, he suggested. Similarly, in Dr. Biljan's study, none of the adverse outcomes were related to abnormal sexual development.

The short half-life of letrozole makes it biologically implausible that the drug could cause anomalies. DR. OKTAY

ORLANDO — Older women with a family history of breast cancer place extraordinary faith in mammography over clinical breast exam for reassurance about their breast health, according to Karen Greco, R.N., Ph.D., lead investigator of a small, qualitative study on mammography decision making.

Furthermore, many of these women may not appreciate their potentially increased risk for hereditary cancer syndromes, added Dr. Greco, who presented her study as a poster at the annual meeting of the Gerontological Society of America.

“The women in my study were not aware that if they had a first-degree relative with breast cancer and another one with ovarian cancer, that there was a connection,” she said in an interview. “Although some had been asked about family history they didn't understand what it meant, and they didn't understand the significance.”

Ten of the 16 women in her study had family histories that suggested they could be at risk for a hereditary cancer syndrome, yet they reported they had not received a cancer risk assessment, said Dr. Greco of the Oregon Health & Science University School of Nursing in West Linn.

The study included 16 women over age 65 years (average age 73) who were at increased risk for breast cancer because of family history—at least one first-degree relative diagnosed with breast cancer—and advancing age. The women were interviewed regarding their decisions about screening mammography.

Although 15 of the 16 women had regular visits with their health care provider, and 14 had regular mammograms, less than half (7) said they received regular clinical breast exams, Dr. Greco said.

ORLANDO — Older women with a family history of breast cancer place extraordinary faith in mammography over clinical breast exam for reassurance about their breast health, according to Karen Greco, R.N., Ph.D., lead investigator of a small, qualitative study on mammography decision making.

Furthermore, many of these women may not appreciate their potentially increased risk for hereditary cancer syndromes, added Dr. Greco, who presented her study as a poster at the annual meeting of the Gerontological Society of America.

“The women in my study were not aware that if they had a first-degree relative with breast cancer and another one with ovarian cancer, that there was a connection,” she said in an interview. “Although some had been asked about family history they didn't understand what it meant, and they didn't understand the significance.”

Ten of the 16 women in her study had family histories that suggested they could be at risk for a hereditary cancer syndrome, yet they reported they had not received a cancer risk assessment, said Dr. Greco of the Oregon Health & Science University School of Nursing in West Linn.

The study included 16 women over age 65 years (average age 73) who were at increased risk for breast cancer because of family history—at least one first-degree relative diagnosed with breast cancer—and advancing age. The women were interviewed regarding their decisions about screening mammography.

Although 15 of the 16 women had regular visits with their health care provider, and 14 had regular mammograms, less than half (7) said they received regular clinical breast exams, Dr. Greco said.

ORLANDO — Older women with a family history of breast cancer place extraordinary faith in mammography over clinical breast exam for reassurance about their breast health, according to Karen Greco, R.N., Ph.D., lead investigator of a small, qualitative study on mammography decision making.

Furthermore, many of these women may not appreciate their potentially increased risk for hereditary cancer syndromes, added Dr. Greco, who presented her study as a poster at the annual meeting of the Gerontological Society of America.

“The women in my study were not aware that if they had a first-degree relative with breast cancer and another one with ovarian cancer, that there was a connection,” she said in an interview. “Although some had been asked about family history they didn't understand what it meant, and they didn't understand the significance.”

Ten of the 16 women in her study had family histories that suggested they could be at risk for a hereditary cancer syndrome, yet they reported they had not received a cancer risk assessment, said Dr. Greco of the Oregon Health & Science University School of Nursing in West Linn.

The study included 16 women over age 65 years (average age 73) who were at increased risk for breast cancer because of family history—at least one first-degree relative diagnosed with breast cancer—and advancing age. The women were interviewed regarding their decisions about screening mammography.

Although 15 of the 16 women had regular visits with their health care provider, and 14 had regular mammograms, less than half (7) said they received regular clinical breast exams, Dr. Greco said.

MONTREAL — Genetic testing of patients with Barrett's esophagus to determine their risk for progression to esophageal adenocarcinoma might be a reasonable consideration in the near future, according to Alan G. Casson, M.B., professor of surgery at Dalhousie University in Halifax, N.S.

In a recently published paper presented at the annual meeting of the Canadian Association of Thoracic Surgeons, Dr. Casson showed that the CCND1 G870A polymorphism is found with increasing frequency through the chronic inflammation spectrum from gastroesophageal reflux disease (GERD) through Barrett's esophagus (BE) and on to esophageal adenocarcinoma (EACA).

“The contribution of this polymorphism to susceptibility of defined stages of progression to esophageal adenocarcinoma suggests [that] the incorporation of CCND1 genotype analysis in endoscopic Barrett surveillance programs may allow better stratification of individuals at increased risk for malignant progression,” he wrote (Cancer 2005;104:730–9).

“This now needs to be tested in larger prospective studies, but it looks promising,” he said.

The analysis included 307 patients enrolled in a prospective case-control study designed to evaluate risk factors and molecular alterations in GERD (126 patients), BE (125), and EACA (56).

Compared with healthy, asymptomatic controls (95), all patients had elevated levels of the CCND1 A/A genotype, after adjustment for age and gender, Dr. Casson said. And the prevalence of this abnormality increased from GERD (odds ratio 2.8) through BE (OR 3.7) and EACA (OR 5.9).

In the second part of the study, which was presented as an award-winning poster at the 13th World Congress of Gastroenterology, Dr. Casson's team identified obesity, smoking, and increased alcohol consumption as significant predictors of risk for progression of GERD and BE to EACA.

Obesity was identified as the main lifestyle risk factor for EACA (OR 4.67), followed by smoking (OR 3.86), whereas increased alcohol consumption was a risk factor for GERD (OR 2.69) and BE (OR 3.86).

The study found that a diet high in vitamin C can decrease the risk of GERD (OR 0.4), BE (OR 0.44), and EACA (OR 0.2), and that multivitamin supplementation further reduced the risk of EACA (OR 0.17).

Other work presented by Dr. Casson's team—at both the Canadian Association of Thoracic Surgeons meeting and the World Congress of Gastroenterology—supports the hypothesis that a chronic inflammatory process is behind the progression from GERD to EACA.

The study found a progressive increase in levels of nitrotyrosine, a marker for nitric oxide-induced cellular damage, in esophageal tissue samples from patients with GERD (4%), BE (20%), and EACA (35%).

It also found nitrotyrosine expression present in 43% of EACA patients, compared with 22% and 24% of BE and GERD patients, respectively.

Nitric oxide damage has been implicated as a potential causative factor in p53 mutations, and the studies also found higher levels of these mutations in EACA patients, compared with BE and GERD patients.

MONTREAL — Genetic testing of patients with Barrett's esophagus to determine their risk for progression to esophageal adenocarcinoma might be a reasonable consideration in the near future, according to Alan G. Casson, M.B., professor of surgery at Dalhousie University in Halifax, N.S.

In a recently published paper presented at the annual meeting of the Canadian Association of Thoracic Surgeons, Dr. Casson showed that the CCND1 G870A polymorphism is found with increasing frequency through the chronic inflammation spectrum from gastroesophageal reflux disease (GERD) through Barrett's esophagus (BE) and on to esophageal adenocarcinoma (EACA).

“The contribution of this polymorphism to susceptibility of defined stages of progression to esophageal adenocarcinoma suggests [that] the incorporation of CCND1 genotype analysis in endoscopic Barrett surveillance programs may allow better stratification of individuals at increased risk for malignant progression,” he wrote (Cancer 2005;104:730–9).

“This now needs to be tested in larger prospective studies, but it looks promising,” he said.

The analysis included 307 patients enrolled in a prospective case-control study designed to evaluate risk factors and molecular alterations in GERD (126 patients), BE (125), and EACA (56).

Compared with healthy, asymptomatic controls (95), all patients had elevated levels of the CCND1 A/A genotype, after adjustment for age and gender, Dr. Casson said. And the prevalence of this abnormality increased from GERD (odds ratio 2.8) through BE (OR 3.7) and EACA (OR 5.9).

In the second part of the study, which was presented as an award-winning poster at the 13th World Congress of Gastroenterology, Dr. Casson's team identified obesity, smoking, and increased alcohol consumption as significant predictors of risk for progression of GERD and BE to EACA.

Obesity was identified as the main lifestyle risk factor for EACA (OR 4.67), followed by smoking (OR 3.86), whereas increased alcohol consumption was a risk factor for GERD (OR 2.69) and BE (OR 3.86).

The study found that a diet high in vitamin C can decrease the risk of GERD (OR 0.4), BE (OR 0.44), and EACA (OR 0.2), and that multivitamin supplementation further reduced the risk of EACA (OR 0.17).

Other work presented by Dr. Casson's team—at both the Canadian Association of Thoracic Surgeons meeting and the World Congress of Gastroenterology—supports the hypothesis that a chronic inflammatory process is behind the progression from GERD to EACA.

The study found a progressive increase in levels of nitrotyrosine, a marker for nitric oxide-induced cellular damage, in esophageal tissue samples from patients with GERD (4%), BE (20%), and EACA (35%).

It also found nitrotyrosine expression present in 43% of EACA patients, compared with 22% and 24% of BE and GERD patients, respectively.

Nitric oxide damage has been implicated as a potential causative factor in p53 mutations, and the studies also found higher levels of these mutations in EACA patients, compared with BE and GERD patients.

MONTREAL — Genetic testing of patients with Barrett's esophagus to determine their risk for progression to esophageal adenocarcinoma might be a reasonable consideration in the near future, according to Alan G. Casson, M.B., professor of surgery at Dalhousie University in Halifax, N.S.

In a recently published paper presented at the annual meeting of the Canadian Association of Thoracic Surgeons, Dr. Casson showed that the CCND1 G870A polymorphism is found with increasing frequency through the chronic inflammation spectrum from gastroesophageal reflux disease (GERD) through Barrett's esophagus (BE) and on to esophageal adenocarcinoma (EACA).

“The contribution of this polymorphism to susceptibility of defined stages of progression to esophageal adenocarcinoma suggests [that] the incorporation of CCND1 genotype analysis in endoscopic Barrett surveillance programs may allow better stratification of individuals at increased risk for malignant progression,” he wrote (Cancer 2005;104:730–9).

“This now needs to be tested in larger prospective studies, but it looks promising,” he said.

The analysis included 307 patients enrolled in a prospective case-control study designed to evaluate risk factors and molecular alterations in GERD (126 patients), BE (125), and EACA (56).

Compared with healthy, asymptomatic controls (95), all patients had elevated levels of the CCND1 A/A genotype, after adjustment for age and gender, Dr. Casson said. And the prevalence of this abnormality increased from GERD (odds ratio 2.8) through BE (OR 3.7) and EACA (OR 5.9).

In the second part of the study, which was presented as an award-winning poster at the 13th World Congress of Gastroenterology, Dr. Casson's team identified obesity, smoking, and increased alcohol consumption as significant predictors of risk for progression of GERD and BE to EACA.

Obesity was identified as the main lifestyle risk factor for EACA (OR 4.67), followed by smoking (OR 3.86), whereas increased alcohol consumption was a risk factor for GERD (OR 2.69) and BE (OR 3.86).

The study found that a diet high in vitamin C can decrease the risk of GERD (OR 0.4), BE (OR 0.44), and EACA (OR 0.2), and that multivitamin supplementation further reduced the risk of EACA (OR 0.17).

Other work presented by Dr. Casson's team—at both the Canadian Association of Thoracic Surgeons meeting and the World Congress of Gastroenterology—supports the hypothesis that a chronic inflammatory process is behind the progression from GERD to EACA.

The study found a progressive increase in levels of nitrotyrosine, a marker for nitric oxide-induced cellular damage, in esophageal tissue samples from patients with GERD (4%), BE (20%), and EACA (35%).

It also found nitrotyrosine expression present in 43% of EACA patients, compared with 22% and 24% of BE and GERD patients, respectively.

Nitric oxide damage has been implicated as a potential causative factor in p53 mutations, and the studies also found higher levels of these mutations in EACA patients, compared with BE and GERD patients.

ORLANDO — Contrary to many physicians' fears, disclosing a diagnosis of dementia to patients and their caregivers does not produce negative reactions, and in some cases actually lowers their anxiety and depression levels, according to a survey.

The findings should encourage physicians to be more up front when faced with reporting such a diagnosis, said the study's lead investigator Brian D. Carpenter, Ph.D., of the department of psychology at Washington University, St. Louis.

In a review paper, Dr. Carpenter's team reported that reluctance to disclose a dementia diagnosis is common among physicians (Gerontologist 2004;44:149–58).

“On average, somewhere around 50% of physicians say they don't routinely tell patients and caregivers when there is a diagnosis of dementia because they are worried about an extremely negative, even suicidal, reaction,” he said in an interview. “They just tell them it's normal aging.”

But in his study, which he presented as a poster at the annual meeting of the Gerontological Society of America, Dr. Carpenter found that, among 80 patient-caregiver dyads, initial reactions within 3 days of a diagnosis of dementia were not negative—even among those who did not expect such a diagnosis.

The longitudinal study recruited patients and their caregivers at the time of their initial contact with the Washington University Alzheimer's Disease Research Center. Surveys assessing baseline data on self-reported anxiety and depression were mailed to all subjects as soon as their initial appointment was scheduled. Similar surveys were then obtained by telephone 2–3 days after a diagnosis had been given.

Depression was measured using the Geriatric Depression Scale, and anxiety was measured using the State-Trait Anxiety Inventory. Participants were asked about their diagnostic expectations.

In total, 67% of patients were diagnosed with dementia (21% with mild dementia and 46% with very mild dementia), and the remaining 33% had no dementia.

Regarding diagnostic expectations, caregivers were more accurate than patients when estimating the likelihood of a dementia diagnosis. More than half (52%) were correct when they said they expected a dementia diagnosis, compared with 32% of patients.

Among those who said they did not expect a diagnosis of dementia, 15% of caregivers were incorrect, compared with 34% of patients. Regardless of their diagnostic expectations, patients experienced no change in depression and a decrease in anxiety after receiving their diagnosis, regardless of what the diagnosis was.

The picture was less straightforward for caregivers. Regardless of their expectations, depression levels decreased with a diagnosis of dementia, and remained unchanged when dementia was not diagnosed.

Anxiety levels were influenced by their diagnostic expectations and not by the actual diagnosis. Anxiety decreased when caregivers expected a dementia diagnosis (regardless of the actual diagnosis) and remained unchanged when they did not expect a dementia diagnosis.

“We think many of the patients and caregivers feel better after they receive the news because they anticipate that there's something wrong. They're not really sure what in some cases, and then when they have a diagnosis, a label, sometimes that results in a great sense of relief,” Dr. Carpenter said.

“When they get the news, they are also shuttled toward more services so they get a better sense of what they can do to manage their disease,” he added.

Most of the caregivers in the study were family members: 58% were spouses, 23% were children or in-laws; and 6% were other family. Thirteen percent were friends.

The ongoing investigation will measure if and how the subjects' reactions may change with time. Participants will be assessed 1 month, 6 months, and 1 year after the diagnosis, Dr. Carpenter said.

ORLANDO — Contrary to many physicians' fears, disclosing a diagnosis of dementia to patients and their caregivers does not produce negative reactions, and in some cases actually lowers their anxiety and depression levels, according to a survey.

The findings should encourage physicians to be more up front when faced with reporting such a diagnosis, said the study's lead investigator Brian D. Carpenter, Ph.D., of the department of psychology at Washington University, St. Louis.

In a review paper, Dr. Carpenter's team reported that reluctance to disclose a dementia diagnosis is common among physicians (Gerontologist 2004;44:149–58).

“On average, somewhere around 50% of physicians say they don't routinely tell patients and caregivers when there is a diagnosis of dementia because they are worried about an extremely negative, even suicidal, reaction,” he said in an interview. “They just tell them it's normal aging.”

But in his study, which he presented as a poster at the annual meeting of the Gerontological Society of America, Dr. Carpenter found that, among 80 patient-caregiver dyads, initial reactions within 3 days of a diagnosis of dementia were not negative—even among those who did not expect such a diagnosis.

The longitudinal study recruited patients and their caregivers at the time of their initial contact with the Washington University Alzheimer's Disease Research Center. Surveys assessing baseline data on self-reported anxiety and depression were mailed to all subjects as soon as their initial appointment was scheduled. Similar surveys were then obtained by telephone 2–3 days after a diagnosis had been given.

Depression was measured using the Geriatric Depression Scale, and anxiety was measured using the State-Trait Anxiety Inventory. Participants were asked about their diagnostic expectations.

In total, 67% of patients were diagnosed with dementia (21% with mild dementia and 46% with very mild dementia), and the remaining 33% had no dementia.

Regarding diagnostic expectations, caregivers were more accurate than patients when estimating the likelihood of a dementia diagnosis. More than half (52%) were correct when they said they expected a dementia diagnosis, compared with 32% of patients.

Among those who said they did not expect a diagnosis of dementia, 15% of caregivers were incorrect, compared with 34% of patients. Regardless of their diagnostic expectations, patients experienced no change in depression and a decrease in anxiety after receiving their diagnosis, regardless of what the diagnosis was.

The picture was less straightforward for caregivers. Regardless of their expectations, depression levels decreased with a diagnosis of dementia, and remained unchanged when dementia was not diagnosed.

Anxiety levels were influenced by their diagnostic expectations and not by the actual diagnosis. Anxiety decreased when caregivers expected a dementia diagnosis (regardless of the actual diagnosis) and remained unchanged when they did not expect a dementia diagnosis.

“We think many of the patients and caregivers feel better after they receive the news because they anticipate that there's something wrong. They're not really sure what in some cases, and then when they have a diagnosis, a label, sometimes that results in a great sense of relief,” Dr. Carpenter said.

“When they get the news, they are also shuttled toward more services so they get a better sense of what they can do to manage their disease,” he added.

Most of the caregivers in the study were family members: 58% were spouses, 23% were children or in-laws; and 6% were other family. Thirteen percent were friends.

The ongoing investigation will measure if and how the subjects' reactions may change with time. Participants will be assessed 1 month, 6 months, and 1 year after the diagnosis, Dr. Carpenter said.

ORLANDO — Contrary to many physicians' fears, disclosing a diagnosis of dementia to patients and their caregivers does not produce negative reactions, and in some cases actually lowers their anxiety and depression levels, according to a survey.

The findings should encourage physicians to be more up front when faced with reporting such a diagnosis, said the study's lead investigator Brian D. Carpenter, Ph.D., of the department of psychology at Washington University, St. Louis.

In a review paper, Dr. Carpenter's team reported that reluctance to disclose a dementia diagnosis is common among physicians (Gerontologist 2004;44:149–58).

“On average, somewhere around 50% of physicians say they don't routinely tell patients and caregivers when there is a diagnosis of dementia because they are worried about an extremely negative, even suicidal, reaction,” he said in an interview. “They just tell them it's normal aging.”

But in his study, which he presented as a poster at the annual meeting of the Gerontological Society of America, Dr. Carpenter found that, among 80 patient-caregiver dyads, initial reactions within 3 days of a diagnosis of dementia were not negative—even among those who did not expect such a diagnosis.

The longitudinal study recruited patients and their caregivers at the time of their initial contact with the Washington University Alzheimer's Disease Research Center. Surveys assessing baseline data on self-reported anxiety and depression were mailed to all subjects as soon as their initial appointment was scheduled. Similar surveys were then obtained by telephone 2–3 days after a diagnosis had been given.

Depression was measured using the Geriatric Depression Scale, and anxiety was measured using the State-Trait Anxiety Inventory. Participants were asked about their diagnostic expectations.

In total, 67% of patients were diagnosed with dementia (21% with mild dementia and 46% with very mild dementia), and the remaining 33% had no dementia.

Regarding diagnostic expectations, caregivers were more accurate than patients when estimating the likelihood of a dementia diagnosis. More than half (52%) were correct when they said they expected a dementia diagnosis, compared with 32% of patients.

Among those who said they did not expect a diagnosis of dementia, 15% of caregivers were incorrect, compared with 34% of patients. Regardless of their diagnostic expectations, patients experienced no change in depression and a decrease in anxiety after receiving their diagnosis, regardless of what the diagnosis was.

The picture was less straightforward for caregivers. Regardless of their expectations, depression levels decreased with a diagnosis of dementia, and remained unchanged when dementia was not diagnosed.

Anxiety levels were influenced by their diagnostic expectations and not by the actual diagnosis. Anxiety decreased when caregivers expected a dementia diagnosis (regardless of the actual diagnosis) and remained unchanged when they did not expect a dementia diagnosis.

“We think many of the patients and caregivers feel better after they receive the news because they anticipate that there's something wrong. They're not really sure what in some cases, and then when they have a diagnosis, a label, sometimes that results in a great sense of relief,” Dr. Carpenter said.

“When they get the news, they are also shuttled toward more services so they get a better sense of what they can do to manage their disease,” he added.

Most of the caregivers in the study were family members: 58% were spouses, 23% were children or in-laws; and 6% were other family. Thirteen percent were friends.

The ongoing investigation will measure if and how the subjects' reactions may change with time. Participants will be assessed 1 month, 6 months, and 1 year after the diagnosis, Dr. Carpenter said.

ORLANDO – Denial is a frequently used coping strategy in geriatric patients with fall-related injuries and is likely a risk factor for inadequate treatment, according to study findings presented at the annual meeting of the Gerontological Society of America.

“It is important for doctors to be aware that when they talk to geriatric patients, it is not always cognitive impairment that contributes to them forgetting about their falls; they may also simply repress it because they are so afraid to admit it,” the study's principal investigator, Dr. Klaus Hauer, said in an interview.

“These patients need a person who knows this to approach them in a different way.”

The investigation findings were based on 80 geriatric patients (average age 83 years) admitted to the hospital with serious injuries as a result of a fall.

Interviews using standardized psychological questionnaires revealed that patients frequently rely on “repressive coping,” or denial, as a mechanism to defend against the threat of chronic impairment that is associated with falling.

Previous studies have shown that “when geriatric patients are asked what they fear most, many patients say they would prefer death to the consequences of a serious fall,” said Dr. Hauer, a professor at the University of Heidelberg (Germany).

Patients who were in the highest tertile of repressive coping were significantly more likely to underreport falls, independent of depression, age, cognitive impairment, or education, Dr. Hauer reported.

Moreover, the charts of patients who used repressive coping documented significantly fewer diagnoses and less medication use, a finding that supports the association between denial and inadequate medical treatment, Dr. Hauer noted.

This population is in all likelihood undertreated, Dr. Hauer added, because they tend to downplay their symptoms and the severity of their falls, if they admit to falling at all.

Patients identified as those who rely on denial tended to report less fear of falling, fewer comorbidities, and less medication use and were less likely to regard their fall as a sign of “terminal decline,” compared with less repressive patients, he said.

Although identifying patients who use repressive coping styles is not easily done in physicians' offices or emergency departments, Dr. Hauer said that awareness of the high prevalence of denial among geriatric patients is nevertheless important.

And when denial is identified, it may take extra motivational effort to get such patients to participate in fall prevention programs.

Dr. Hauer also offered strategies that might help these patients. For example, he suggested that it may be more effective to approach them with ideas aimed at improving physical conditioning, rather than strategies focusing on risk prevention, to emphasize a positive self-image, he said.

ORLANDO – Denial is a frequently used coping strategy in geriatric patients with fall-related injuries and is likely a risk factor for inadequate treatment, according to study findings presented at the annual meeting of the Gerontological Society of America.

“It is important for doctors to be aware that when they talk to geriatric patients, it is not always cognitive impairment that contributes to them forgetting about their falls; they may also simply repress it because they are so afraid to admit it,” the study's principal investigator, Dr. Klaus Hauer, said in an interview.

“These patients need a person who knows this to approach them in a different way.”

The investigation findings were based on 80 geriatric patients (average age 83 years) admitted to the hospital with serious injuries as a result of a fall.

Interviews using standardized psychological questionnaires revealed that patients frequently rely on “repressive coping,” or denial, as a mechanism to defend against the threat of chronic impairment that is associated with falling.

Previous studies have shown that “when geriatric patients are asked what they fear most, many patients say they would prefer death to the consequences of a serious fall,” said Dr. Hauer, a professor at the University of Heidelberg (Germany).

Patients who were in the highest tertile of repressive coping were significantly more likely to underreport falls, independent of depression, age, cognitive impairment, or education, Dr. Hauer reported.

Moreover, the charts of patients who used repressive coping documented significantly fewer diagnoses and less medication use, a finding that supports the association between denial and inadequate medical treatment, Dr. Hauer noted.

This population is in all likelihood undertreated, Dr. Hauer added, because they tend to downplay their symptoms and the severity of their falls, if they admit to falling at all.

Patients identified as those who rely on denial tended to report less fear of falling, fewer comorbidities, and less medication use and were less likely to regard their fall as a sign of “terminal decline,” compared with less repressive patients, he said.

Although identifying patients who use repressive coping styles is not easily done in physicians' offices or emergency departments, Dr. Hauer said that awareness of the high prevalence of denial among geriatric patients is nevertheless important.

And when denial is identified, it may take extra motivational effort to get such patients to participate in fall prevention programs.

Dr. Hauer also offered strategies that might help these patients. For example, he suggested that it may be more effective to approach them with ideas aimed at improving physical conditioning, rather than strategies focusing on risk prevention, to emphasize a positive self-image, he said.

ORLANDO – Denial is a frequently used coping strategy in geriatric patients with fall-related injuries and is likely a risk factor for inadequate treatment, according to study findings presented at the annual meeting of the Gerontological Society of America.

“It is important for doctors to be aware that when they talk to geriatric patients, it is not always cognitive impairment that contributes to them forgetting about their falls; they may also simply repress it because they are so afraid to admit it,” the study's principal investigator, Dr. Klaus Hauer, said in an interview.

“These patients need a person who knows this to approach them in a different way.”

The investigation findings were based on 80 geriatric patients (average age 83 years) admitted to the hospital with serious injuries as a result of a fall.

Interviews using standardized psychological questionnaires revealed that patients frequently rely on “repressive coping,” or denial, as a mechanism to defend against the threat of chronic impairment that is associated with falling.

Previous studies have shown that “when geriatric patients are asked what they fear most, many patients say they would prefer death to the consequences of a serious fall,” said Dr. Hauer, a professor at the University of Heidelberg (Germany).

Patients who were in the highest tertile of repressive coping were significantly more likely to underreport falls, independent of depression, age, cognitive impairment, or education, Dr. Hauer reported.

Moreover, the charts of patients who used repressive coping documented significantly fewer diagnoses and less medication use, a finding that supports the association between denial and inadequate medical treatment, Dr. Hauer noted.

This population is in all likelihood undertreated, Dr. Hauer added, because they tend to downplay their symptoms and the severity of their falls, if they admit to falling at all.

Patients identified as those who rely on denial tended to report less fear of falling, fewer comorbidities, and less medication use and were less likely to regard their fall as a sign of “terminal decline,” compared with less repressive patients, he said.

Although identifying patients who use repressive coping styles is not easily done in physicians' offices or emergency departments, Dr. Hauer said that awareness of the high prevalence of denial among geriatric patients is nevertheless important.

And when denial is identified, it may take extra motivational effort to get such patients to participate in fall prevention programs.

Dr. Hauer also offered strategies that might help these patients. For example, he suggested that it may be more effective to approach them with ideas aimed at improving physical conditioning, rather than strategies focusing on risk prevention, to emphasize a positive self-image, he said.

ORLANDO – Elderly persons with hearing loss are more likely to describe themselves as aging unsuccessfully, compared with their peers who hear well, despite the absence of any other chronic conditions, according to a study presented as a poster at the annual meeting of the Gerontological Society of America.

But this impairment to healthy aging is often underappreciated by physicians, said the lead investigator, Margaret Wallhagen, Ph.D., R.N.

“Hearing loss is strongly linked to depression,” she said in an interview. “It makes people feel isolated and left out, and they may feel bad or embarrassed because they can misinterpret things.”

The study used data from the Alameda County (Calif.) Study, a longitudinal study on aging that began in 1965.

A total of 899 subjects aged at least 65 years were identified and asked to evaluate their own aging as successful or unsuccessful. The presence and number of chronic conditions were recorded, and hearing capability was also assessed with questions about hearing difficulties–even with hearing aids–in three settings: normal conversation, over the telephone, and in a noisy room.

Half the subjects described themselves as aging “successfully,” and half deemed their aging “unsuccessful.” But although the number of chronic conditions was a significant predictor of successful aging, one-third of those with no chronic conditions still described themselves as not aging successfully. Conversely, one-third of subjects with two or more chronic conditions described themselves as aging well.

This inconsistency between subjects' physical health and their self-rated successful aging can be partly explained by their hearing, said Dr. Wallhagen, a professor in the department of physiological nursing at the University of California, San Francisco.

Subjects rating themselves as not aging successfully had significantly more hearing loss (a score of 2.26 on the hearing loss scale) than did subjects who said they were aging well (a score of 1.57), even in the absence of any chronic conditions.

And even among those with two or more chronic conditions, subjects who described themselves as aging successfully had less hearing loss (score of 2.13), compared with those who said they were not aging well (score of 3.22).

“Our data support the importance of hearing in the aging experience,” Dr. Wallhagen said. “My wish is that physicians would pay more attention to hearing loss in their patients, and if they find it, they can send them for an evaluation.”

Other research by her group has shown that more than 80% of elderly people never have their hearing impairment addressed by their primary care practitioner–or when it is identified, its importance is discounted.

“[Physicians] have a time limitation, so they focus on things they think are critical. And [hearing loss] not something people die of, so that's why it is often ignored,” she said.

Additionally, another of her studies has found that spousal hearing loss is a significant predictor of unsuccessful aging in the partner.

Dr. Wallhagen said that while it is often assumed the adjustment to hearing aids may be too difficult for many aging adults, most can be coached through the transition period.

He said physicians can help people with their expectations. “In other words, they need to know that they have to work at wearing hearing aids. You can't just put them on like glasses.” he said. “But many people–if they are given the coaching and if they are instructed to understand that their brain has to relearn how to listen–they can get used to them.”

Dr. Wallhagen said in another study she is doing, many subjects with newly acquired hearing aids are surprised at the number of sounds they did not even know they were missing.

ORLANDO – Elderly persons with hearing loss are more likely to describe themselves as aging unsuccessfully, compared with their peers who hear well, despite the absence of any other chronic conditions, according to a study presented as a poster at the annual meeting of the Gerontological Society of America.

But this impairment to healthy aging is often underappreciated by physicians, said the lead investigator, Margaret Wallhagen, Ph.D., R.N.

“Hearing loss is strongly linked to depression,” she said in an interview. “It makes people feel isolated and left out, and they may feel bad or embarrassed because they can misinterpret things.”

The study used data from the Alameda County (Calif.) Study, a longitudinal study on aging that began in 1965.

A total of 899 subjects aged at least 65 years were identified and asked to evaluate their own aging as successful or unsuccessful. The presence and number of chronic conditions were recorded, and hearing capability was also assessed with questions about hearing difficulties–even with hearing aids–in three settings: normal conversation, over the telephone, and in a noisy room.

Half the subjects described themselves as aging “successfully,” and half deemed their aging “unsuccessful.” But although the number of chronic conditions was a significant predictor of successful aging, one-third of those with no chronic conditions still described themselves as not aging successfully. Conversely, one-third of subjects with two or more chronic conditions described themselves as aging well.

This inconsistency between subjects' physical health and their self-rated successful aging can be partly explained by their hearing, said Dr. Wallhagen, a professor in the department of physiological nursing at the University of California, San Francisco.

Subjects rating themselves as not aging successfully had significantly more hearing loss (a score of 2.26 on the hearing loss scale) than did subjects who said they were aging well (a score of 1.57), even in the absence of any chronic conditions.

And even among those with two or more chronic conditions, subjects who described themselves as aging successfully had less hearing loss (score of 2.13), compared with those who said they were not aging well (score of 3.22).

“Our data support the importance of hearing in the aging experience,” Dr. Wallhagen said. “My wish is that physicians would pay more attention to hearing loss in their patients, and if they find it, they can send them for an evaluation.”

Other research by her group has shown that more than 80% of elderly people never have their hearing impairment addressed by their primary care practitioner–or when it is identified, its importance is discounted.

“[Physicians] have a time limitation, so they focus on things they think are critical. And [hearing loss] not something people die of, so that's why it is often ignored,” she said.

Additionally, another of her studies has found that spousal hearing loss is a significant predictor of unsuccessful aging in the partner.

Dr. Wallhagen said that while it is often assumed the adjustment to hearing aids may be too difficult for many aging adults, most can be coached through the transition period.

He said physicians can help people with their expectations. “In other words, they need to know that they have to work at wearing hearing aids. You can't just put them on like glasses.” he said. “But many people–if they are given the coaching and if they are instructed to understand that their brain has to relearn how to listen–they can get used to them.”

Dr. Wallhagen said in another study she is doing, many subjects with newly acquired hearing aids are surprised at the number of sounds they did not even know they were missing.

ORLANDO – Elderly persons with hearing loss are more likely to describe themselves as aging unsuccessfully, compared with their peers who hear well, despite the absence of any other chronic conditions, according to a study presented as a poster at the annual meeting of the Gerontological Society of America.

But this impairment to healthy aging is often underappreciated by physicians, said the lead investigator, Margaret Wallhagen, Ph.D., R.N.

“Hearing loss is strongly linked to depression,” she said in an interview. “It makes people feel isolated and left out, and they may feel bad or embarrassed because they can misinterpret things.”

The study used data from the Alameda County (Calif.) Study, a longitudinal study on aging that began in 1965.

A total of 899 subjects aged at least 65 years were identified and asked to evaluate their own aging as successful or unsuccessful. The presence and number of chronic conditions were recorded, and hearing capability was also assessed with questions about hearing difficulties–even with hearing aids–in three settings: normal conversation, over the telephone, and in a noisy room.

Half the subjects described themselves as aging “successfully,” and half deemed their aging “unsuccessful.” But although the number of chronic conditions was a significant predictor of successful aging, one-third of those with no chronic conditions still described themselves as not aging successfully. Conversely, one-third of subjects with two or more chronic conditions described themselves as aging well.

This inconsistency between subjects' physical health and their self-rated successful aging can be partly explained by their hearing, said Dr. Wallhagen, a professor in the department of physiological nursing at the University of California, San Francisco.

Subjects rating themselves as not aging successfully had significantly more hearing loss (a score of 2.26 on the hearing loss scale) than did subjects who said they were aging well (a score of 1.57), even in the absence of any chronic conditions.

And even among those with two or more chronic conditions, subjects who described themselves as aging successfully had less hearing loss (score of 2.13), compared with those who said they were not aging well (score of 3.22).

“Our data support the importance of hearing in the aging experience,” Dr. Wallhagen said. “My wish is that physicians would pay more attention to hearing loss in their patients, and if they find it, they can send them for an evaluation.”

Other research by her group has shown that more than 80% of elderly people never have their hearing impairment addressed by their primary care practitioner–or when it is identified, its importance is discounted.

“[Physicians] have a time limitation, so they focus on things they think are critical. And [hearing loss] not something people die of, so that's why it is often ignored,” she said.

Additionally, another of her studies has found that spousal hearing loss is a significant predictor of unsuccessful aging in the partner.

Dr. Wallhagen said that while it is often assumed the adjustment to hearing aids may be too difficult for many aging adults, most can be coached through the transition period.

He said physicians can help people with their expectations. “In other words, they need to know that they have to work at wearing hearing aids. You can't just put them on like glasses.” he said. “But many people–if they are given the coaching and if they are instructed to understand that their brain has to relearn how to listen–they can get used to them.”

Dr. Wallhagen said in another study she is doing, many subjects with newly acquired hearing aids are surprised at the number of sounds they did not even know they were missing.

MONTREAL — Contrary to its effect with other progesterone-only contraceptives, mifepristone increases breakthrough bleeding in patients using the levonorgestrel intrauterine system, according to a new study.

“Mifespristone cannot be recommended as a therapy for breakthrough bleeding in new users of the LNG-IUS,” reported Dr. Megan Econimidis of the Keck School of Medicine at the University of Southern California in Los Angeles.

Mifepristone, an antiprogesterone, has been shown to decrease irregular bleeding in users of progesterone-only implants and injectables. But when given to 20 regularly menstruating women who were new starters of the LNG-IUS, mifepristone actually had the opposite of its usual effect, she said at the joint annual meeting of the American Society for Reproductive Medicine and the Canadian Fertility and Andrology Society.

The women in the study, 18–45 years old, were randomized to receive mifepristone 50 mg or placebo every 2 weeks for six cycles. The treatment was started 2 weeks after LNG-IUS insertion.

Over the six cycles, the median number of days of breakthrough bleeding was 57 in the mifepristone group, compared with 26 in the placebo group; this difference was statistically significant. In addition, when all the subjects' cycles were combined, there were 22 (42%) mifepristone cycles with more than 8 days of breakthrough bleeding vs. 16 (27%) placebo cycles. This difference was not statistically significant.

Endometrial biopsies showed a decrease in endometrial estrogen receptors after mifepristone treatment. This is in contrast to other studies of progesterone implants and injectables, which have shown an increase in estrogen receptors with mifepristone treatment, she said.

MONTREAL — Contrary to its effect with other progesterone-only contraceptives, mifepristone increases breakthrough bleeding in patients using the levonorgestrel intrauterine system, according to a new study.

“Mifespristone cannot be recommended as a therapy for breakthrough bleeding in new users of the LNG-IUS,” reported Dr. Megan Econimidis of the Keck School of Medicine at the University of Southern California in Los Angeles.

Mifepristone, an antiprogesterone, has been shown to decrease irregular bleeding in users of progesterone-only implants and injectables. But when given to 20 regularly menstruating women who were new starters of the LNG-IUS, mifepristone actually had the opposite of its usual effect, she said at the joint annual meeting of the American Society for Reproductive Medicine and the Canadian Fertility and Andrology Society.

The women in the study, 18–45 years old, were randomized to receive mifepristone 50 mg or placebo every 2 weeks for six cycles. The treatment was started 2 weeks after LNG-IUS insertion.

Over the six cycles, the median number of days of breakthrough bleeding was 57 in the mifepristone group, compared with 26 in the placebo group; this difference was statistically significant. In addition, when all the subjects' cycles were combined, there were 22 (42%) mifepristone cycles with more than 8 days of breakthrough bleeding vs. 16 (27%) placebo cycles. This difference was not statistically significant.

Endometrial biopsies showed a decrease in endometrial estrogen receptors after mifepristone treatment. This is in contrast to other studies of progesterone implants and injectables, which have shown an increase in estrogen receptors with mifepristone treatment, she said.

MONTREAL — Contrary to its effect with other progesterone-only contraceptives, mifepristone increases breakthrough bleeding in patients using the levonorgestrel intrauterine system, according to a new study.

“Mifespristone cannot be recommended as a therapy for breakthrough bleeding in new users of the LNG-IUS,” reported Dr. Megan Econimidis of the Keck School of Medicine at the University of Southern California in Los Angeles.

Mifepristone, an antiprogesterone, has been shown to decrease irregular bleeding in users of progesterone-only implants and injectables. But when given to 20 regularly menstruating women who were new starters of the LNG-IUS, mifepristone actually had the opposite of its usual effect, she said at the joint annual meeting of the American Society for Reproductive Medicine and the Canadian Fertility and Andrology Society.

The women in the study, 18–45 years old, were randomized to receive mifepristone 50 mg or placebo every 2 weeks for six cycles. The treatment was started 2 weeks after LNG-IUS insertion.

Over the six cycles, the median number of days of breakthrough bleeding was 57 in the mifepristone group, compared with 26 in the placebo group; this difference was statistically significant. In addition, when all the subjects' cycles were combined, there were 22 (42%) mifepristone cycles with more than 8 days of breakthrough bleeding vs. 16 (27%) placebo cycles. This difference was not statistically significant.

Endometrial biopsies showed a decrease in endometrial estrogen receptors after mifepristone treatment. This is in contrast to other studies of progesterone implants and injectables, which have shown an increase in estrogen receptors with mifepristone treatment, she said.

MONTREAL — Laparoscopically assisted transhiatal esophagectomy is safe and technically feasible in most patients, but attempting the operation entirely through the laparoscope can result in higher morbidity rates, according to Dr. Dalilah Fortin.

In a prospective study that she presented at the annual meeting of the Canadian Association of Thoracic Surgeons, Dr. Fortin and her colleagues at the London (Ontario) Health Sciences Center concluded that laparoscopic-assisted transhiatal esophagectomy (LTE)—although not the least invasive approach—is the safest and most feasible of the minimally invasive techniques for esophagectomy.

“If you want the least invasive approach, you have to do a right video-assisted thoracic esophageal mobilization through the chest and then a laparoscopy in the abdomen, and then you need only a small incision to get the specimen out. But this is a complex operation; there is a learning curve, and the morbidity is higher,” she said in an interview.

The study involved 48 patients scheduled for minimally invasive esophagectomy. At exploratory laparoscopy, five of the patients were found to be unresectable and were converted to minilaparotomy with feeding-tube placement. Another five patients were converted to laparotomy and underwent gastrectomy.

Of the remaining 38 patients, 26 underwent LTE, 4 had a right thoracotomy and laparoscopic-assisted esophagectomy (T-LE), and 8 had the least invasive right video-assisted thoracic esophageal mobilization and laparoscopic esophagectomy (V-LE).

A total of nine procedures (23%) were converted to laparotomy—four for local invasion, four for adhesions, and one for spleen injury. The operating time, length of hospital stay, and rate of major complications were all significantly increased in the V-LE group.

Median operating time was 475 minutes in the V-LE group compared with 330 minutes and 270 minutes in the T-LE and LTE groups, respectively. In addition, patients in the V-LE group spent a median of about 40 days in the hospital, compared with about 10 days in the other groups.

Major complications leading to reoperation occurred in two LTE patients (port-site hernia, colon herniation), one T-LE patient (chylothorax), and five V-LE patients (three chylothorax, one empyema, one bronchial injury). There was one postoperative death, and two patients died within 3 months of surgery from metastatic disease.

Initial laparoscopic staging was possible, with up to 29 lymph nodes per resected specimen identified and histologically examined, Dr. Fortin said.

MONTREAL — Laparoscopically assisted transhiatal esophagectomy is safe and technically feasible in most patients, but attempting the operation entirely through the laparoscope can result in higher morbidity rates, according to Dr. Dalilah Fortin.

In a prospective study that she presented at the annual meeting of the Canadian Association of Thoracic Surgeons, Dr. Fortin and her colleagues at the London (Ontario) Health Sciences Center concluded that laparoscopic-assisted transhiatal esophagectomy (LTE)—although not the least invasive approach—is the safest and most feasible of the minimally invasive techniques for esophagectomy.

“If you want the least invasive approach, you have to do a right video-assisted thoracic esophageal mobilization through the chest and then a laparoscopy in the abdomen, and then you need only a small incision to get the specimen out. But this is a complex operation; there is a learning curve, and the morbidity is higher,” she said in an interview.

The study involved 48 patients scheduled for minimally invasive esophagectomy. At exploratory laparoscopy, five of the patients were found to be unresectable and were converted to minilaparotomy with feeding-tube placement. Another five patients were converted to laparotomy and underwent gastrectomy.

Of the remaining 38 patients, 26 underwent LTE, 4 had a right thoracotomy and laparoscopic-assisted esophagectomy (T-LE), and 8 had the least invasive right video-assisted thoracic esophageal mobilization and laparoscopic esophagectomy (V-LE).

A total of nine procedures (23%) were converted to laparotomy—four for local invasion, four for adhesions, and one for spleen injury. The operating time, length of hospital stay, and rate of major complications were all significantly increased in the V-LE group.

Median operating time was 475 minutes in the V-LE group compared with 330 minutes and 270 minutes in the T-LE and LTE groups, respectively. In addition, patients in the V-LE group spent a median of about 40 days in the hospital, compared with about 10 days in the other groups.

Major complications leading to reoperation occurred in two LTE patients (port-site hernia, colon herniation), one T-LE patient (chylothorax), and five V-LE patients (three chylothorax, one empyema, one bronchial injury). There was one postoperative death, and two patients died within 3 months of surgery from metastatic disease.

Initial laparoscopic staging was possible, with up to 29 lymph nodes per resected specimen identified and histologically examined, Dr. Fortin said.

MONTREAL — Laparoscopically assisted transhiatal esophagectomy is safe and technically feasible in most patients, but attempting the operation entirely through the laparoscope can result in higher morbidity rates, according to Dr. Dalilah Fortin.

In a prospective study that she presented at the annual meeting of the Canadian Association of Thoracic Surgeons, Dr. Fortin and her colleagues at the London (Ontario) Health Sciences Center concluded that laparoscopic-assisted transhiatal esophagectomy (LTE)—although not the least invasive approach—is the safest and most feasible of the minimally invasive techniques for esophagectomy.

“If you want the least invasive approach, you have to do a right video-assisted thoracic esophageal mobilization through the chest and then a laparoscopy in the abdomen, and then you need only a small incision to get the specimen out. But this is a complex operation; there is a learning curve, and the morbidity is higher,” she said in an interview.

The study involved 48 patients scheduled for minimally invasive esophagectomy. At exploratory laparoscopy, five of the patients were found to be unresectable and were converted to minilaparotomy with feeding-tube placement. Another five patients were converted to laparotomy and underwent gastrectomy.

Of the remaining 38 patients, 26 underwent LTE, 4 had a right thoracotomy and laparoscopic-assisted esophagectomy (T-LE), and 8 had the least invasive right video-assisted thoracic esophageal mobilization and laparoscopic esophagectomy (V-LE).

A total of nine procedures (23%) were converted to laparotomy—four for local invasion, four for adhesions, and one for spleen injury. The operating time, length of hospital stay, and rate of major complications were all significantly increased in the V-LE group.

Median operating time was 475 minutes in the V-LE group compared with 330 minutes and 270 minutes in the T-LE and LTE groups, respectively. In addition, patients in the V-LE group spent a median of about 40 days in the hospital, compared with about 10 days in the other groups.

Major complications leading to reoperation occurred in two LTE patients (port-site hernia, colon herniation), one T-LE patient (chylothorax), and five V-LE patients (three chylothorax, one empyema, one bronchial injury). There was one postoperative death, and two patients died within 3 months of surgery from metastatic disease.

Initial laparoscopic staging was possible, with up to 29 lymph nodes per resected specimen identified and histologically examined, Dr. Fortin said.