Robert Finn

The routine use of 7-valent pneumococcal conjugate vaccine reduced the annual incidence of invasive pneumococcal disease in young children from 62.5 cases per 10,000 patient-years to 15.3 cases per 10,000 patient-years over a 5-year period.

The surveillance study included all children younger than 5 years of age in the Northern California Kaiser Permanente health care system from April 2000 (when routine immunization began) to March 2005. These children were compared with children of the same age in the same health care system from April 1996 to March 2000 (Pediatr. Infect. Dis. J. 2007;26:771-7).

Dr. Steven Black of Stanford (Calif.) University and his colleagues determined that 131 children were diagnosed with invasive pneumococcal disease (IPD) in the period following the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7). A total of 412 children were diagnosed with IPD during the comparison period.

The annual incidence of IPD declined rapidly following the introduction of the vaccine. The overall incidence of IPD was 56.7 cases per 10,000 patient-years in the year before introduction of the vaccine, 27.3 per 10,000 in the first year after the vaccine's introduction, and 10.2 per 10,000 the year after that.

The decline was even more dramatic among the IPD cases caused by one of the seven vaccine serotypes included in PCV7. The overall incidence declined from 50.1 per 10,000 in the 5 years before the introduction of the vaccine to 4.9 per 10,000 in the 5 years after the vaccine's introduction.

Although there were some concerns that the introduction of the vaccine might result in substantial increases in the incidence of IPD with nonvaccine serotypes, the investigators found little evidence of this. The incidence of IPD resulting from nonvaccine serotypes was 5.3 per 10,000 in the 5 years preceding the introduction of the vaccine and 6.2 per 10,000 in the following 5 years. There was a good deal of year-to-year variability in the incidence of nonvaccine serotypes, and the investigators noted no consistent pattern.

Of the 131 cases of IPD that occurred after the vaccine's introduction, 42 involved vaccine serotypes. Of those, only six of the children had received one or more doses of PCV7, and only three were fully vaccinated.

The investigators found evidence of indirect or herd immunity in their population. For example, 50% of children aged 2–3 years and 75% of children aged 3–5 years had not yet received any vaccine during the second year of routine vaccination. Despite that, the incidence of IPD in children aged 2–5 years fell from 24.4 per 10,000 to 7.1 per 10,000 during that year.

The most common IPD diagnoses before introduction of the vaccine—bacteremia and pneumonia—were still the most common IPD diagnoses after the vaccine was in use. Bacteremia fell from 242 of 412 cases in the earlier period to 66 of 131 cases in the study period.

The study was supported by Wyeth Pharmaceuticals, which manufactures PCV7 under the brand name Prevnar.

The routine use of 7-valent pneumococcal conjugate vaccine reduced the annual incidence of invasive pneumococcal disease in young children from 62.5 cases per 10,000 patient-years to 15.3 cases per 10,000 patient-years over a 5-year period.

The surveillance study included all children younger than 5 years of age in the Northern California Kaiser Permanente health care system from April 2000 (when routine immunization began) to March 2005. These children were compared with children of the same age in the same health care system from April 1996 to March 2000 (Pediatr. Infect. Dis. J. 2007;26:771-7).

Dr. Steven Black of Stanford (Calif.) University and his colleagues determined that 131 children were diagnosed with invasive pneumococcal disease (IPD) in the period following the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7). A total of 412 children were diagnosed with IPD during the comparison period.

The annual incidence of IPD declined rapidly following the introduction of the vaccine. The overall incidence of IPD was 56.7 cases per 10,000 patient-years in the year before introduction of the vaccine, 27.3 per 10,000 in the first year after the vaccine's introduction, and 10.2 per 10,000 the year after that.

The decline was even more dramatic among the IPD cases caused by one of the seven vaccine serotypes included in PCV7. The overall incidence declined from 50.1 per 10,000 in the 5 years before the introduction of the vaccine to 4.9 per 10,000 in the 5 years after the vaccine's introduction.

Although there were some concerns that the introduction of the vaccine might result in substantial increases in the incidence of IPD with nonvaccine serotypes, the investigators found little evidence of this. The incidence of IPD resulting from nonvaccine serotypes was 5.3 per 10,000 in the 5 years preceding the introduction of the vaccine and 6.2 per 10,000 in the following 5 years. There was a good deal of year-to-year variability in the incidence of nonvaccine serotypes, and the investigators noted no consistent pattern.

Of the 131 cases of IPD that occurred after the vaccine's introduction, 42 involved vaccine serotypes. Of those, only six of the children had received one or more doses of PCV7, and only three were fully vaccinated.

The investigators found evidence of indirect or herd immunity in their population. For example, 50% of children aged 2–3 years and 75% of children aged 3–5 years had not yet received any vaccine during the second year of routine vaccination. Despite that, the incidence of IPD in children aged 2–5 years fell from 24.4 per 10,000 to 7.1 per 10,000 during that year.

The most common IPD diagnoses before introduction of the vaccine—bacteremia and pneumonia—were still the most common IPD diagnoses after the vaccine was in use. Bacteremia fell from 242 of 412 cases in the earlier period to 66 of 131 cases in the study period.

The study was supported by Wyeth Pharmaceuticals, which manufactures PCV7 under the brand name Prevnar.

The routine use of 7-valent pneumococcal conjugate vaccine reduced the annual incidence of invasive pneumococcal disease in young children from 62.5 cases per 10,000 patient-years to 15.3 cases per 10,000 patient-years over a 5-year period.

The surveillance study included all children younger than 5 years of age in the Northern California Kaiser Permanente health care system from April 2000 (when routine immunization began) to March 2005. These children were compared with children of the same age in the same health care system from April 1996 to March 2000 (Pediatr. Infect. Dis. J. 2007;26:771-7).

Dr. Steven Black of Stanford (Calif.) University and his colleagues determined that 131 children were diagnosed with invasive pneumococcal disease (IPD) in the period following the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7). A total of 412 children were diagnosed with IPD during the comparison period.

The annual incidence of IPD declined rapidly following the introduction of the vaccine. The overall incidence of IPD was 56.7 cases per 10,000 patient-years in the year before introduction of the vaccine, 27.3 per 10,000 in the first year after the vaccine's introduction, and 10.2 per 10,000 the year after that.

The decline was even more dramatic among the IPD cases caused by one of the seven vaccine serotypes included in PCV7. The overall incidence declined from 50.1 per 10,000 in the 5 years before the introduction of the vaccine to 4.9 per 10,000 in the 5 years after the vaccine's introduction.

Although there were some concerns that the introduction of the vaccine might result in substantial increases in the incidence of IPD with nonvaccine serotypes, the investigators found little evidence of this. The incidence of IPD resulting from nonvaccine serotypes was 5.3 per 10,000 in the 5 years preceding the introduction of the vaccine and 6.2 per 10,000 in the following 5 years. There was a good deal of year-to-year variability in the incidence of nonvaccine serotypes, and the investigators noted no consistent pattern.

Of the 131 cases of IPD that occurred after the vaccine's introduction, 42 involved vaccine serotypes. Of those, only six of the children had received one or more doses of PCV7, and only three were fully vaccinated.

The investigators found evidence of indirect or herd immunity in their population. For example, 50% of children aged 2–3 years and 75% of children aged 3–5 years had not yet received any vaccine during the second year of routine vaccination. Despite that, the incidence of IPD in children aged 2–5 years fell from 24.4 per 10,000 to 7.1 per 10,000 during that year.

The most common IPD diagnoses before introduction of the vaccine—bacteremia and pneumonia—were still the most common IPD diagnoses after the vaccine was in use. Bacteremia fell from 242 of 412 cases in the earlier period to 66 of 131 cases in the study period.

The study was supported by Wyeth Pharmaceuticals, which manufactures PCV7 under the brand name Prevnar.

SAN FRANCISCO — A diagnostic algorithm employing nocturnal pulse oximetry before referring children to polysomnography can greatly reduce the costs of diagnosing obstructive sleep apnea syndrome, according to a poster presentation by M. Kirstman, Dr. Robert T. Brouillette, and their colleagues at the International Conference of the American Thoracic Society.

The study involved a consecutive case series of 325 children, aged 1–18 years, who were referred to the sleep lab of the Montreal Children's Hospital/McGill University Health Centre for evaluation of possible obstructive sleep apnea syndrome (OSAS).

After converting all costs to U.S. dollars, the investigators determined it would have cost $220,000 to provide polysomnography for all of the children who were referred. By using nocturnal pulse oximetry as a way of limiting the number of patients who were referred to polysomnography, the actual cost of 325 oximetries and of 32 polysomnoraphies was $49,000, a savings of $171,000 (78%).

Previous studies had shown that nocturnal pulse oximetry has a 97% positive predictive value and a 47% negative predictive value for the diagnosis of OSAS in children (Pediatrics 2000;105:405–12).

On the basis of these findings, Dr. Brouillette and his colleagues developed the McGill OSAS Diagnostic Algorithm. According to this algorithm, oximetry and subsequent polysomnography are used only when the otolaryngologist is unsure whether adenotonsillectomy is required. Nocturnal oximetry is used as the first test, and if the results are positive the patient is referred for adenotonsillectomy without the need for polysomnography.

On the other hand, if the oximetry results are inconclusive the patient undergoes polysomnography unless the referring otolaryngologist intends to operate regardless of the polysomnography results.

According to the cost analysis, an individual nocturnal oximetry study costs $84, with the largest proportion of that, 40%, coming from the physician's consultation fee. An individual polysomnography study costs $678.19, 57% of which comes from personnel costs.

Only 10% of the patients in the McGill case series required polysomnography. The costs of the McGill diagnostic algorithm would have exceeded the costs of providing polysomnography for all only if 90% or more of the patients had required it.

SAN FRANCISCO — A diagnostic algorithm employing nocturnal pulse oximetry before referring children to polysomnography can greatly reduce the costs of diagnosing obstructive sleep apnea syndrome, according to a poster presentation by M. Kirstman, Dr. Robert T. Brouillette, and their colleagues at the International Conference of the American Thoracic Society.

The study involved a consecutive case series of 325 children, aged 1–18 years, who were referred to the sleep lab of the Montreal Children's Hospital/McGill University Health Centre for evaluation of possible obstructive sleep apnea syndrome (OSAS).

After converting all costs to U.S. dollars, the investigators determined it would have cost $220,000 to provide polysomnography for all of the children who were referred. By using nocturnal pulse oximetry as a way of limiting the number of patients who were referred to polysomnography, the actual cost of 325 oximetries and of 32 polysomnoraphies was $49,000, a savings of $171,000 (78%).

Previous studies had shown that nocturnal pulse oximetry has a 97% positive predictive value and a 47% negative predictive value for the diagnosis of OSAS in children (Pediatrics 2000;105:405–12).

On the basis of these findings, Dr. Brouillette and his colleagues developed the McGill OSAS Diagnostic Algorithm. According to this algorithm, oximetry and subsequent polysomnography are used only when the otolaryngologist is unsure whether adenotonsillectomy is required. Nocturnal oximetry is used as the first test, and if the results are positive the patient is referred for adenotonsillectomy without the need for polysomnography.

On the other hand, if the oximetry results are inconclusive the patient undergoes polysomnography unless the referring otolaryngologist intends to operate regardless of the polysomnography results.

According to the cost analysis, an individual nocturnal oximetry study costs $84, with the largest proportion of that, 40%, coming from the physician's consultation fee. An individual polysomnography study costs $678.19, 57% of which comes from personnel costs.

Only 10% of the patients in the McGill case series required polysomnography. The costs of the McGill diagnostic algorithm would have exceeded the costs of providing polysomnography for all only if 90% or more of the patients had required it.

SAN FRANCISCO — A diagnostic algorithm employing nocturnal pulse oximetry before referring children to polysomnography can greatly reduce the costs of diagnosing obstructive sleep apnea syndrome, according to a poster presentation by M. Kirstman, Dr. Robert T. Brouillette, and their colleagues at the International Conference of the American Thoracic Society.

The study involved a consecutive case series of 325 children, aged 1–18 years, who were referred to the sleep lab of the Montreal Children's Hospital/McGill University Health Centre for evaluation of possible obstructive sleep apnea syndrome (OSAS).

After converting all costs to U.S. dollars, the investigators determined it would have cost $220,000 to provide polysomnography for all of the children who were referred. By using nocturnal pulse oximetry as a way of limiting the number of patients who were referred to polysomnography, the actual cost of 325 oximetries and of 32 polysomnoraphies was $49,000, a savings of $171,000 (78%).

Previous studies had shown that nocturnal pulse oximetry has a 97% positive predictive value and a 47% negative predictive value for the diagnosis of OSAS in children (Pediatrics 2000;105:405–12).

On the basis of these findings, Dr. Brouillette and his colleagues developed the McGill OSAS Diagnostic Algorithm. According to this algorithm, oximetry and subsequent polysomnography are used only when the otolaryngologist is unsure whether adenotonsillectomy is required. Nocturnal oximetry is used as the first test, and if the results are positive the patient is referred for adenotonsillectomy without the need for polysomnography.

On the other hand, if the oximetry results are inconclusive the patient undergoes polysomnography unless the referring otolaryngologist intends to operate regardless of the polysomnography results.

According to the cost analysis, an individual nocturnal oximetry study costs $84, with the largest proportion of that, 40%, coming from the physician's consultation fee. An individual polysomnography study costs $678.19, 57% of which comes from personnel costs.

Only 10% of the patients in the McGill case series required polysomnography. The costs of the McGill diagnostic algorithm would have exceeded the costs of providing polysomnography for all only if 90% or more of the patients had required it.

SAN FRANCISCO — Obstructive sleep apnea is tied to a 30% increased risk of myocardial infarction or death even after adjustment for many cofactors, Dr. Neomi A. Shah said at the International Conference of the American Thoracic Society.

Moreover, the greater the severity of obstructive sleep apnea (OSA), the greater the risk of MI or death, said Dr. Shah of Yale University, New Haven, Conn.

The observational cohort study of 1,640 patients referred for polysomnography compared the 844 patients who didn't qualify for an OSA diagnosis with the 796 who did. The patients were followed for 5 years. The mean apnea-hypopnea index (AHI) of those with OSA was 47.8, compared with 5.1 in the controls.

After adjustment for cardiovascular risk factors and other confounders, OSA was associated with a 40% increased risk of myocardial infarction or death. There was also a dose-response relationship between OSA severity as judged by AHI and the adjusted risk of myocardial infarction or death.

Compared with patients in the lowest quartile (AHA 0–4), those in the highest quartile (AHA > 30) had a 90% increased risk of myocardial infarction or death. Those in the second quartile (AHA 5–14) had a 20% greater risk, and those in the third quartile (AHA 15–30), a 50% greater risk, a statistically significant trend.

SAN FRANCISCO — Obstructive sleep apnea is tied to a 30% increased risk of myocardial infarction or death even after adjustment for many cofactors, Dr. Neomi A. Shah said at the International Conference of the American Thoracic Society.

Moreover, the greater the severity of obstructive sleep apnea (OSA), the greater the risk of MI or death, said Dr. Shah of Yale University, New Haven, Conn.

The observational cohort study of 1,640 patients referred for polysomnography compared the 844 patients who didn't qualify for an OSA diagnosis with the 796 who did. The patients were followed for 5 years. The mean apnea-hypopnea index (AHI) of those with OSA was 47.8, compared with 5.1 in the controls.

After adjustment for cardiovascular risk factors and other confounders, OSA was associated with a 40% increased risk of myocardial infarction or death. There was also a dose-response relationship between OSA severity as judged by AHI and the adjusted risk of myocardial infarction or death.

Compared with patients in the lowest quartile (AHA 0–4), those in the highest quartile (AHA > 30) had a 90% increased risk of myocardial infarction or death. Those in the second quartile (AHA 5–14) had a 20% greater risk, and those in the third quartile (AHA 15–30), a 50% greater risk, a statistically significant trend.

SAN FRANCISCO — Obstructive sleep apnea is tied to a 30% increased risk of myocardial infarction or death even after adjustment for many cofactors, Dr. Neomi A. Shah said at the International Conference of the American Thoracic Society.

Moreover, the greater the severity of obstructive sleep apnea (OSA), the greater the risk of MI or death, said Dr. Shah of Yale University, New Haven, Conn.

The observational cohort study of 1,640 patients referred for polysomnography compared the 844 patients who didn't qualify for an OSA diagnosis with the 796 who did. The patients were followed for 5 years. The mean apnea-hypopnea index (AHI) of those with OSA was 47.8, compared with 5.1 in the controls.

After adjustment for cardiovascular risk factors and other confounders, OSA was associated with a 40% increased risk of myocardial infarction or death. There was also a dose-response relationship between OSA severity as judged by AHI and the adjusted risk of myocardial infarction or death.

Compared with patients in the lowest quartile (AHA 0–4), those in the highest quartile (AHA > 30) had a 90% increased risk of myocardial infarction or death. Those in the second quartile (AHA 5–14) had a 20% greater risk, and those in the third quartile (AHA 15–30), a 50% greater risk, a statistically significant trend.

Once-daily oral valacyclovir is as good as twice-daily oral acyclovir for preventing the recurrence of eye disease caused by herpes simplex virus, according to a recent study.

In a randomized, controlled trial, Dr. Elisabetta Miserocchi of the San Raffaele Scientific Institute, Milan, and her colleagues compared 26 patients taking a single 500-mg tablet of valacyclovir daily with 26 patients taking 400-mg tablets of acyclovir twice daily (Am. J. Ophthalmol. 2007 Aug. 9 [Epub doi:10.1016/j.ajo.2007.06.001]).

All patients were immunocompetent and had a history of recurrent ocular herpes simplex virus (HSV) disease. By the end of 12 months of daily therapy, six of the patients in the valacyclovir group and six of the patients in the acyclovir group (23% in both cases) experienced a recurrence of ocular HSV.

Both drugs were well tolerated, and the incidence of adverse events was similar in both groups. Gastrointestinal upset and headache were the most frequent treatment-related side effects. Three patients in the valacyclovir group and four patients in the acyclovir group experienced nausea and vomiting, and five patients in the valacyclovir group and three patients in the acyclovir group experienced headache.

The investigators noted that HSV is the leading cause of corneal opacity and secondary visual loss in the United States and other industrialized countries, affecting some 450,000 people, with 50,000 new and recurrent cases each year. Recurrent episodes are frequent, with about 10% of patients reporting recurrence at 1 year, 23% at 2 years, and 63% at 20 years.

Although acyclovir is effective at preventing HSV recurrence, the drug has relatively poor oral bioavailability, and resistant isolates may develop. Valacyclovir is a prodrug of acyclovir, and is rapidly converted to acyclovir after administration. Plasma concentrations after oral valacyclovir are similar to plasma concentrations after intravenous acyclovir.

The authors acknowledged that valacyclovir treatment is more costly than acyclovir treatment, and that even acyclovir prophylaxis costs about $8,532 per ocular HSV episode averted, according to one study. Because this is not cost effective for all patients, "therapeutic decisions must be made on a case-by-case basis; prophylactic therapy may be appropriate for patients with sight-threatening recurrences, frequent episodes, or other reasons for reduced quality of life caused by ocular herpes," wrote Dr. Miserocchi and her associates.

They posited that the single daily dose of valacyclovir is likely to result in better compliance than is the multiple daily doses required with acyclovir. Therefore, valacyclovir may be particularly beneficial in cases of acyclovir-resistant HSV in which high-dose systemic or intravenous treatment with acyclovir has been necessary, and in which the resistance has been attributed to inadequate drug exposure.

"Because the optimal levels of acyclovir are achieved with a simpler dosing regimen of valacyclovir, compliance may be improved in many patients, thus reducing the incidence of a resistant virus," the investigators wrote. "A compound with improved absorption and bioavailability theoretically would extend the therapeutic usefulness of the drug."

The investigators stated that they had no conflicts of interest related to their study.

Once-daily oral valacyclovir is as good as twice-daily oral acyclovir for preventing the recurrence of eye disease caused by herpes simplex virus, according to a recent study.

In a randomized, controlled trial, Dr. Elisabetta Miserocchi of the San Raffaele Scientific Institute, Milan, and her colleagues compared 26 patients taking a single 500-mg tablet of valacyclovir daily with 26 patients taking 400-mg tablets of acyclovir twice daily (Am. J. Ophthalmol. 2007 Aug. 9 [Epub doi:10.1016/j.ajo.2007.06.001]).

All patients were immunocompetent and had a history of recurrent ocular herpes simplex virus (HSV) disease. By the end of 12 months of daily therapy, six of the patients in the valacyclovir group and six of the patients in the acyclovir group (23% in both cases) experienced a recurrence of ocular HSV.

Both drugs were well tolerated, and the incidence of adverse events was similar in both groups. Gastrointestinal upset and headache were the most frequent treatment-related side effects. Three patients in the valacyclovir group and four patients in the acyclovir group experienced nausea and vomiting, and five patients in the valacyclovir group and three patients in the acyclovir group experienced headache.

The investigators noted that HSV is the leading cause of corneal opacity and secondary visual loss in the United States and other industrialized countries, affecting some 450,000 people, with 50,000 new and recurrent cases each year. Recurrent episodes are frequent, with about 10% of patients reporting recurrence at 1 year, 23% at 2 years, and 63% at 20 years.

Although acyclovir is effective at preventing HSV recurrence, the drug has relatively poor oral bioavailability, and resistant isolates may develop. Valacyclovir is a prodrug of acyclovir, and is rapidly converted to acyclovir after administration. Plasma concentrations after oral valacyclovir are similar to plasma concentrations after intravenous acyclovir.

The authors acknowledged that valacyclovir treatment is more costly than acyclovir treatment, and that even acyclovir prophylaxis costs about $8,532 per ocular HSV episode averted, according to one study. Because this is not cost effective for all patients, "therapeutic decisions must be made on a case-by-case basis; prophylactic therapy may be appropriate for patients with sight-threatening recurrences, frequent episodes, or other reasons for reduced quality of life caused by ocular herpes," wrote Dr. Miserocchi and her associates.

They posited that the single daily dose of valacyclovir is likely to result in better compliance than is the multiple daily doses required with acyclovir. Therefore, valacyclovir may be particularly beneficial in cases of acyclovir-resistant HSV in which high-dose systemic or intravenous treatment with acyclovir has been necessary, and in which the resistance has been attributed to inadequate drug exposure.

"Because the optimal levels of acyclovir are achieved with a simpler dosing regimen of valacyclovir, compliance may be improved in many patients, thus reducing the incidence of a resistant virus," the investigators wrote. "A compound with improved absorption and bioavailability theoretically would extend the therapeutic usefulness of the drug."

The investigators stated that they had no conflicts of interest related to their study.

Once-daily oral valacyclovir is as good as twice-daily oral acyclovir for preventing the recurrence of eye disease caused by herpes simplex virus, according to a recent study.

In a randomized, controlled trial, Dr. Elisabetta Miserocchi of the San Raffaele Scientific Institute, Milan, and her colleagues compared 26 patients taking a single 500-mg tablet of valacyclovir daily with 26 patients taking 400-mg tablets of acyclovir twice daily (Am. J. Ophthalmol. 2007 Aug. 9 [Epub doi:10.1016/j.ajo.2007.06.001]).

All patients were immunocompetent and had a history of recurrent ocular herpes simplex virus (HSV) disease. By the end of 12 months of daily therapy, six of the patients in the valacyclovir group and six of the patients in the acyclovir group (23% in both cases) experienced a recurrence of ocular HSV.

Both drugs were well tolerated, and the incidence of adverse events was similar in both groups. Gastrointestinal upset and headache were the most frequent treatment-related side effects. Three patients in the valacyclovir group and four patients in the acyclovir group experienced nausea and vomiting, and five patients in the valacyclovir group and three patients in the acyclovir group experienced headache.

The investigators noted that HSV is the leading cause of corneal opacity and secondary visual loss in the United States and other industrialized countries, affecting some 450,000 people, with 50,000 new and recurrent cases each year. Recurrent episodes are frequent, with about 10% of patients reporting recurrence at 1 year, 23% at 2 years, and 63% at 20 years.

Although acyclovir is effective at preventing HSV recurrence, the drug has relatively poor oral bioavailability, and resistant isolates may develop. Valacyclovir is a prodrug of acyclovir, and is rapidly converted to acyclovir after administration. Plasma concentrations after oral valacyclovir are similar to plasma concentrations after intravenous acyclovir.

The authors acknowledged that valacyclovir treatment is more costly than acyclovir treatment, and that even acyclovir prophylaxis costs about $8,532 per ocular HSV episode averted, according to one study. Because this is not cost effective for all patients, "therapeutic decisions must be made on a case-by-case basis; prophylactic therapy may be appropriate for patients with sight-threatening recurrences, frequent episodes, or other reasons for reduced quality of life caused by ocular herpes," wrote Dr. Miserocchi and her associates.

They posited that the single daily dose of valacyclovir is likely to result in better compliance than is the multiple daily doses required with acyclovir. Therefore, valacyclovir may be particularly beneficial in cases of acyclovir-resistant HSV in which high-dose systemic or intravenous treatment with acyclovir has been necessary, and in which the resistance has been attributed to inadequate drug exposure.

"Because the optimal levels of acyclovir are achieved with a simpler dosing regimen of valacyclovir, compliance may be improved in many patients, thus reducing the incidence of a resistant virus," the investigators wrote. "A compound with improved absorption and bioavailability theoretically would extend the therapeutic usefulness of the drug."

The investigators stated that they had no conflicts of interest related to their study.

A 6-year-old boy developed unilateral optic neuritis following a varicella infection, but the neuritis improved spontaneously with only symptomatic relief provided, investigators reported.

Some clinicians advocate the early use of steroids for optic neuritis, but others point out that steroids might exacerbate the condition if there is direct viral invasion of the optic nerve, wrote Dr. Panagiotis K. Stergiou and his colleagues from Hippokration General Hospital, Thessaloniki, Greece.

One week following a varicella eruption, the boy presented with severely decreased visual acuity and painful movement of his right eye; he was only able to count fingers for a counting test with that eye.

The child's pupil was dilated and sluggishly reactive to light, and he had no color vision. His left eye was normal, with 20/20 vision (Pediatr. Neurol. 2007;37:138–9).

Fundoscopic examination revealed edema of the right disk with opacification of the nerve fibers, venous engorgement, and a splinter hemorrhage at the margin of the disk. Visual evoked potential measurements revealed abnormal responses in the right eye, while the left eye remained normal.

Clinicians prescribed only symptomatic relief with antipyretics, and the boy returned 4 weeks later with a visual acuity of 20/60 in the right eye. After 3 months there was further improvement to 20/40, but the right optic disk remained pale, the pupil did not react to light, and the boy's color perception remained poor.

The investigators noted that optic neuritis is a rare complication of varicella, and that it often accompanies other complications such as acute transverse myelitis, encephalomyelitis, ataxia, and retinopathy.

The pathogenesis is unknown, and the condition may result from direct viral invasions or from an autoimmune mechanism.

Dr. Stergiou and his colleagues wrote that steroid treatment is usually contraindicated because the disease typically improves both rapidly and spontaneously.

Steroids do appear to be appropriate, however, in cases of bilateral optic neuritis after chickenpox.

A 6-year-old boy developed unilateral optic neuritis following a varicella infection, but the neuritis improved spontaneously with only symptomatic relief provided, investigators reported.

Some clinicians advocate the early use of steroids for optic neuritis, but others point out that steroids might exacerbate the condition if there is direct viral invasion of the optic nerve, wrote Dr. Panagiotis K. Stergiou and his colleagues from Hippokration General Hospital, Thessaloniki, Greece.

One week following a varicella eruption, the boy presented with severely decreased visual acuity and painful movement of his right eye; he was only able to count fingers for a counting test with that eye.

The child's pupil was dilated and sluggishly reactive to light, and he had no color vision. His left eye was normal, with 20/20 vision (Pediatr. Neurol. 2007;37:138–9).

Fundoscopic examination revealed edema of the right disk with opacification of the nerve fibers, venous engorgement, and a splinter hemorrhage at the margin of the disk. Visual evoked potential measurements revealed abnormal responses in the right eye, while the left eye remained normal.

Clinicians prescribed only symptomatic relief with antipyretics, and the boy returned 4 weeks later with a visual acuity of 20/60 in the right eye. After 3 months there was further improvement to 20/40, but the right optic disk remained pale, the pupil did not react to light, and the boy's color perception remained poor.

The investigators noted that optic neuritis is a rare complication of varicella, and that it often accompanies other complications such as acute transverse myelitis, encephalomyelitis, ataxia, and retinopathy.

The pathogenesis is unknown, and the condition may result from direct viral invasions or from an autoimmune mechanism.

Dr. Stergiou and his colleagues wrote that steroid treatment is usually contraindicated because the disease typically improves both rapidly and spontaneously.

Steroids do appear to be appropriate, however, in cases of bilateral optic neuritis after chickenpox.

A 6-year-old boy developed unilateral optic neuritis following a varicella infection, but the neuritis improved spontaneously with only symptomatic relief provided, investigators reported.

Some clinicians advocate the early use of steroids for optic neuritis, but others point out that steroids might exacerbate the condition if there is direct viral invasion of the optic nerve, wrote Dr. Panagiotis K. Stergiou and his colleagues from Hippokration General Hospital, Thessaloniki, Greece.

One week following a varicella eruption, the boy presented with severely decreased visual acuity and painful movement of his right eye; he was only able to count fingers for a counting test with that eye.

The child's pupil was dilated and sluggishly reactive to light, and he had no color vision. His left eye was normal, with 20/20 vision (Pediatr. Neurol. 2007;37:138–9).

Fundoscopic examination revealed edema of the right disk with opacification of the nerve fibers, venous engorgement, and a splinter hemorrhage at the margin of the disk. Visual evoked potential measurements revealed abnormal responses in the right eye, while the left eye remained normal.

Clinicians prescribed only symptomatic relief with antipyretics, and the boy returned 4 weeks later with a visual acuity of 20/60 in the right eye. After 3 months there was further improvement to 20/40, but the right optic disk remained pale, the pupil did not react to light, and the boy's color perception remained poor.

The investigators noted that optic neuritis is a rare complication of varicella, and that it often accompanies other complications such as acute transverse myelitis, encephalomyelitis, ataxia, and retinopathy.

The pathogenesis is unknown, and the condition may result from direct viral invasions or from an autoimmune mechanism.

Dr. Stergiou and his colleagues wrote that steroid treatment is usually contraindicated because the disease typically improves both rapidly and spontaneously.

Steroids do appear to be appropriate, however, in cases of bilateral optic neuritis after chickenpox.

SAN FRANCISCO — Used once daily, a single pressurized metered-dose inhaler containing both budesonide and formoterol provided good asthma control in patients with mild to moderate persistent asthma, according to a series of poster presentations at the International Conference of the American Thoracic Society.

The poster presentations—by Dr. William E. Berger of a group practice specializing in allergy and asthma in Mission Viejo, Calif.; Dr. Eugene R. Bleeker, professor of medicine at Wake Forest University, Winston-Salem, N.C.; and three employees of AstraZeneca Pharmaceuticals L.P.—reported on different aspects of the same five-armed, randomized, controlled trial. This trial compared a once-daily dosage of 320 mcg of budesonide and 9 mcg formoterol, a once-daily dosage of 160 mcg budesonide and 9 mcg formoterol, a twice-daily dosage totaling 320 mcg budesonide and 18 mcg of formoterol, a once-daily dosage of 320 mcg of budesonide alone, and placebo.

The 12-week multicenter trial involved 751 patients, aged 16 years and older. Patients were excluded from the trial if they had severe persistent asthma, had received systemic corticosteroids within 1 month of screening, were current smokers, or had a smoking history greater than 10 pack-years.

The studies were supported by AstraZeneca, which manufactures budesonide and formoterol under the brand name Symbicort.

All the active treatments were significantly more effective than placebo in all measures of lung function, including evening peak expiratory flow (PEF), morning PEF, and morning and evening forced expiratory volume in 1 second (FEV₁).

Both of the once-daily doses of budesonide and formoterol were more effective on these measures than was budesonide alone, even when the combination drug contained only 160 mcg of budesonide.

Twice-daily dosing with budesonide and formoterol was significantly more effective on evening measures of lung function than were the once-daily doses.

Investigators assessed asthma control with an electronic diary provided to all patients. Patients recorded daytime and nighttime asthma symptoms, nighttime awakenings because of asthma, and the use of rescue medication.

For all measures of asthma control, the 320/18 twice-daily dosage of budesonide and formoterol and the 320/9 once-daily dosage were significantly more effective than was either placebo or budesonide alone. The 320/9 once-daily dosage provided about the same amount of nighttime asthma control as did the 320/18 twice-daily dosage, despite having only half the total daily dose of formoterol. On the other hand, twice-daily dosing was more effective than once-daily dosing on daytime asthma control.

SAN FRANCISCO — Used once daily, a single pressurized metered-dose inhaler containing both budesonide and formoterol provided good asthma control in patients with mild to moderate persistent asthma, according to a series of poster presentations at the International Conference of the American Thoracic Society.

The poster presentations—by Dr. William E. Berger of a group practice specializing in allergy and asthma in Mission Viejo, Calif.; Dr. Eugene R. Bleeker, professor of medicine at Wake Forest University, Winston-Salem, N.C.; and three employees of AstraZeneca Pharmaceuticals L.P.—reported on different aspects of the same five-armed, randomized, controlled trial. This trial compared a once-daily dosage of 320 mcg of budesonide and 9 mcg formoterol, a once-daily dosage of 160 mcg budesonide and 9 mcg formoterol, a twice-daily dosage totaling 320 mcg budesonide and 18 mcg of formoterol, a once-daily dosage of 320 mcg of budesonide alone, and placebo.

The 12-week multicenter trial involved 751 patients, aged 16 years and older. Patients were excluded from the trial if they had severe persistent asthma, had received systemic corticosteroids within 1 month of screening, were current smokers, or had a smoking history greater than 10 pack-years.

The studies were supported by AstraZeneca, which manufactures budesonide and formoterol under the brand name Symbicort.

All the active treatments were significantly more effective than placebo in all measures of lung function, including evening peak expiratory flow (PEF), morning PEF, and morning and evening forced expiratory volume in 1 second (FEV₁).

Both of the once-daily doses of budesonide and formoterol were more effective on these measures than was budesonide alone, even when the combination drug contained only 160 mcg of budesonide.

Twice-daily dosing with budesonide and formoterol was significantly more effective on evening measures of lung function than were the once-daily doses.

Investigators assessed asthma control with an electronic diary provided to all patients. Patients recorded daytime and nighttime asthma symptoms, nighttime awakenings because of asthma, and the use of rescue medication.

For all measures of asthma control, the 320/18 twice-daily dosage of budesonide and formoterol and the 320/9 once-daily dosage were significantly more effective than was either placebo or budesonide alone. The 320/9 once-daily dosage provided about the same amount of nighttime asthma control as did the 320/18 twice-daily dosage, despite having only half the total daily dose of formoterol. On the other hand, twice-daily dosing was more effective than once-daily dosing on daytime asthma control.

SAN FRANCISCO — Used once daily, a single pressurized metered-dose inhaler containing both budesonide and formoterol provided good asthma control in patients with mild to moderate persistent asthma, according to a series of poster presentations at the International Conference of the American Thoracic Society.

The poster presentations—by Dr. William E. Berger of a group practice specializing in allergy and asthma in Mission Viejo, Calif.; Dr. Eugene R. Bleeker, professor of medicine at Wake Forest University, Winston-Salem, N.C.; and three employees of AstraZeneca Pharmaceuticals L.P.—reported on different aspects of the same five-armed, randomized, controlled trial. This trial compared a once-daily dosage of 320 mcg of budesonide and 9 mcg formoterol, a once-daily dosage of 160 mcg budesonide and 9 mcg formoterol, a twice-daily dosage totaling 320 mcg budesonide and 18 mcg of formoterol, a once-daily dosage of 320 mcg of budesonide alone, and placebo.

The 12-week multicenter trial involved 751 patients, aged 16 years and older. Patients were excluded from the trial if they had severe persistent asthma, had received systemic corticosteroids within 1 month of screening, were current smokers, or had a smoking history greater than 10 pack-years.

The studies were supported by AstraZeneca, which manufactures budesonide and formoterol under the brand name Symbicort.

All the active treatments were significantly more effective than placebo in all measures of lung function, including evening peak expiratory flow (PEF), morning PEF, and morning and evening forced expiratory volume in 1 second (FEV₁).

Both of the once-daily doses of budesonide and formoterol were more effective on these measures than was budesonide alone, even when the combination drug contained only 160 mcg of budesonide.

Twice-daily dosing with budesonide and formoterol was significantly more effective on evening measures of lung function than were the once-daily doses.

Investigators assessed asthma control with an electronic diary provided to all patients. Patients recorded daytime and nighttime asthma symptoms, nighttime awakenings because of asthma, and the use of rescue medication.

For all measures of asthma control, the 320/18 twice-daily dosage of budesonide and formoterol and the 320/9 once-daily dosage were significantly more effective than was either placebo or budesonide alone. The 320/9 once-daily dosage provided about the same amount of nighttime asthma control as did the 320/18 twice-daily dosage, despite having only half the total daily dose of formoterol. On the other hand, twice-daily dosing was more effective than once-daily dosing on daytime asthma control.

Dietary counseling of parents and their children about diets low in saturated fats reduced cholesterol levels in children up to age 14 without affecting growth, development, or the onset of puberty, in a Finnish study

The Special Turku Coronary Risk Factor Intervention Project (STRIP), a prospective, randomized, controlled study, involved 1,062 children recruited at age 7 months. The researchers, led by Dr. Harri Niinikoski of the University of Turku (Finland), gave intensive counseling on a low-fat, low-cholesterol diet to 540 children and their families. The other 522 received no special dietary advice (Circulation 2007 [doi: 10.1161/CIRCULATIONAHA.107.699447]).

The intervention resulted in small differences in serum lipid and lipoprotein values throughout childhood and up to age 14. In boys, for example, the difference in serum cholesterol values between the intervention and control group was about 5% and was statistically significant. In girls the difference was 2%–4% depending on age, but did not reach statistical significance. Similarly, dietary counseling affected triglyceride levels significantly in boys, but not in girls.

In the group that received dietary counseling, both genders consumed diets significantly lower in fat and saturated fat and significantly higher in protein and carbohydrates than did the children who received no counseling.

The investigators found no significant differences in growth or development between the intervention and control groups. For example, there were no differences in heights and weights, and about 60% of both groups had entered puberty by age 11. In girls the median age of menarche was 13.0 in the intervention group and 12.8 in the control group, a nonsignificant difference.

“I think that the major importance here is providing a reassurance that giving lower fat, lower saturated-fat diets to children from infancy up until adolescence, while having a positive effect on reducing serum lipids, has no negative effect on growth, development, [or] onset of puberty,” said Dr. Alan B. Lewis in an interview. “The information is very reassuring in that regard.

“And notice these are not ultra-low-fat diets,” continued Dr. Lewis a pediatric cardiologist who runs a preventive cardiology program at Childrens Hospital Los Angeles who was not involved in the study. “[The investigators] talked about total fat intake of 30%–35% of total calories. And the American Heart Association's recommendations for a good, healthful, nutritional diet is approximately 30% of calories from fat, with an emphasis being on the reduction of saturated fats and proportionally greater amount of polyunsaturated fats, and that's what they did. This is really a very modest limitation in fats.”

Families in the intervention group had the benefit of individualized diet counseling from a nutritionist every 1–3 months until the child reached age 2, and twice annually thereafter. Starting at age 7 the children were counseled directly.

Investigators saw the control families twice a year until the child reached age 7, and once a year thereafter.

“This diet is not vegetarian or even close to it,” Dr. Niinikoski empahsized in a statement prepared by the American Heart Association. “Our aim was not to reduce intake of cholesterol and total fat in infancy. The children were advised to use meat and fish, etc., but to choose meat and milk products lower in saturated fat.”

Regarding the relatively small differences in lipids and lipoproteins between the two groups, Dr. Niinikoski said, “In the long run, even a minor decrease in serum cholesterol concentrations in a large population can have a major influence on coronary heart disease.”

Families in STRIP were recruited during February 1990-June 1992 at well-baby clinics in Turku. The study was supported by grants from a number of Finnish foundations. The authors stated that they had no conflicts of interest to disclose.

Dietary counseling of parents and their children about diets low in saturated fats reduced cholesterol levels in children up to age 14 without affecting growth, development, or the onset of puberty, in a Finnish study

The Special Turku Coronary Risk Factor Intervention Project (STRIP), a prospective, randomized, controlled study, involved 1,062 children recruited at age 7 months. The researchers, led by Dr. Harri Niinikoski of the University of Turku (Finland), gave intensive counseling on a low-fat, low-cholesterol diet to 540 children and their families. The other 522 received no special dietary advice (Circulation 2007 [doi: 10.1161/CIRCULATIONAHA.107.699447]).

The intervention resulted in small differences in serum lipid and lipoprotein values throughout childhood and up to age 14. In boys, for example, the difference in serum cholesterol values between the intervention and control group was about 5% and was statistically significant. In girls the difference was 2%–4% depending on age, but did not reach statistical significance. Similarly, dietary counseling affected triglyceride levels significantly in boys, but not in girls.

In the group that received dietary counseling, both genders consumed diets significantly lower in fat and saturated fat and significantly higher in protein and carbohydrates than did the children who received no counseling.

The investigators found no significant differences in growth or development between the intervention and control groups. For example, there were no differences in heights and weights, and about 60% of both groups had entered puberty by age 11. In girls the median age of menarche was 13.0 in the intervention group and 12.8 in the control group, a nonsignificant difference.

“I think that the major importance here is providing a reassurance that giving lower fat, lower saturated-fat diets to children from infancy up until adolescence, while having a positive effect on reducing serum lipids, has no negative effect on growth, development, [or] onset of puberty,” said Dr. Alan B. Lewis in an interview. “The information is very reassuring in that regard.

“And notice these are not ultra-low-fat diets,” continued Dr. Lewis a pediatric cardiologist who runs a preventive cardiology program at Childrens Hospital Los Angeles who was not involved in the study. “[The investigators] talked about total fat intake of 30%–35% of total calories. And the American Heart Association's recommendations for a good, healthful, nutritional diet is approximately 30% of calories from fat, with an emphasis being on the reduction of saturated fats and proportionally greater amount of polyunsaturated fats, and that's what they did. This is really a very modest limitation in fats.”

Families in the intervention group had the benefit of individualized diet counseling from a nutritionist every 1–3 months until the child reached age 2, and twice annually thereafter. Starting at age 7 the children were counseled directly.

Investigators saw the control families twice a year until the child reached age 7, and once a year thereafter.

“This diet is not vegetarian or even close to it,” Dr. Niinikoski empahsized in a statement prepared by the American Heart Association. “Our aim was not to reduce intake of cholesterol and total fat in infancy. The children were advised to use meat and fish, etc., but to choose meat and milk products lower in saturated fat.”

Regarding the relatively small differences in lipids and lipoproteins between the two groups, Dr. Niinikoski said, “In the long run, even a minor decrease in serum cholesterol concentrations in a large population can have a major influence on coronary heart disease.”

Families in STRIP were recruited during February 1990-June 1992 at well-baby clinics in Turku. The study was supported by grants from a number of Finnish foundations. The authors stated that they had no conflicts of interest to disclose.

Dietary counseling of parents and their children about diets low in saturated fats reduced cholesterol levels in children up to age 14 without affecting growth, development, or the onset of puberty, in a Finnish study

The Special Turku Coronary Risk Factor Intervention Project (STRIP), a prospective, randomized, controlled study, involved 1,062 children recruited at age 7 months. The researchers, led by Dr. Harri Niinikoski of the University of Turku (Finland), gave intensive counseling on a low-fat, low-cholesterol diet to 540 children and their families. The other 522 received no special dietary advice (Circulation 2007 [doi: 10.1161/CIRCULATIONAHA.107.699447]).

The intervention resulted in small differences in serum lipid and lipoprotein values throughout childhood and up to age 14. In boys, for example, the difference in serum cholesterol values between the intervention and control group was about 5% and was statistically significant. In girls the difference was 2%–4% depending on age, but did not reach statistical significance. Similarly, dietary counseling affected triglyceride levels significantly in boys, but not in girls.

In the group that received dietary counseling, both genders consumed diets significantly lower in fat and saturated fat and significantly higher in protein and carbohydrates than did the children who received no counseling.

The investigators found no significant differences in growth or development between the intervention and control groups. For example, there were no differences in heights and weights, and about 60% of both groups had entered puberty by age 11. In girls the median age of menarche was 13.0 in the intervention group and 12.8 in the control group, a nonsignificant difference.

“I think that the major importance here is providing a reassurance that giving lower fat, lower saturated-fat diets to children from infancy up until adolescence, while having a positive effect on reducing serum lipids, has no negative effect on growth, development, [or] onset of puberty,” said Dr. Alan B. Lewis in an interview. “The information is very reassuring in that regard.

“And notice these are not ultra-low-fat diets,” continued Dr. Lewis a pediatric cardiologist who runs a preventive cardiology program at Childrens Hospital Los Angeles who was not involved in the study. “[The investigators] talked about total fat intake of 30%–35% of total calories. And the American Heart Association's recommendations for a good, healthful, nutritional diet is approximately 30% of calories from fat, with an emphasis being on the reduction of saturated fats and proportionally greater amount of polyunsaturated fats, and that's what they did. This is really a very modest limitation in fats.”

Families in the intervention group had the benefit of individualized diet counseling from a nutritionist every 1–3 months until the child reached age 2, and twice annually thereafter. Starting at age 7 the children were counseled directly.

Investigators saw the control families twice a year until the child reached age 7, and once a year thereafter.

“This diet is not vegetarian or even close to it,” Dr. Niinikoski empahsized in a statement prepared by the American Heart Association. “Our aim was not to reduce intake of cholesterol and total fat in infancy. The children were advised to use meat and fish, etc., but to choose meat and milk products lower in saturated fat.”

Regarding the relatively small differences in lipids and lipoproteins between the two groups, Dr. Niinikoski said, “In the long run, even a minor decrease in serum cholesterol concentrations in a large population can have a major influence on coronary heart disease.”

Families in STRIP were recruited during February 1990-June 1992 at well-baby clinics in Turku. The study was supported by grants from a number of Finnish foundations. The authors stated that they had no conflicts of interest to disclose.

Patients with metabolic syndrome are nearly three times as likely to die following coronary artery bypass graft surgery as are patients without the syndrome, according to a large study.

Patients with both metabolic syndrome and diabetes had a 2.7-fold increase in the risk of mortality, and patients with metabolic syndrome but without diabetes had a 2.4-fold increase in risk. In the multivariate analysis, there proved to be no significant increase in the risk of mortality in patients who had diabetes but not metabolic syndrome, wrote Dr. Najmeddine Echahidi of the Centre de Recherche de l'Hôpital Laval, Quebec, and colleagues (J. Am. Coll. Cardiol. 2007;50:843–51).

The retrospective analysis involved 5,304 consecutive patients who underwent an isolated coronary artery bypass graft (CABG) between 2000 and 2004 at a single institution. An analysis of prospectively collected laboratory and physical data revealed that 46% met criteria for metabolic syndrome as set out by the National Cholesterol Education Program Adult Treatment Panel III.

The study's primary end point was death from any cause, either within 30 days of surgery or after any interval if the patient was not discharged from the hospital. Results were adjusted for gender, peripheral vascular disease, chronic obstructive pulmonary disease, preoperative renal failure, preoperative myocardial infarction, and preoperative stroke.

The overall unadjusted mortality was 1.6%, but was significantly higher (2.4%) among patients with metabolic syndrome, and significantly lower (0.9%) among patients without metabolic syndrome.

In addition to metabolic syndrome, several other factors increased the risk of mortality following CABG. These included age older than 75 years (relative risk 3.4), body mass index (kg/m

Considering the prevalence of metabolic syndrome, the investigators suggested that patients be assessed for metabolic syndrome before surgery, and that metabolic syndrome be incorporated into operative risk algorithms.

Patients with metabolic syndrome are nearly three times as likely to die following coronary artery bypass graft surgery as are patients without the syndrome, according to a large study.

Patients with both metabolic syndrome and diabetes had a 2.7-fold increase in the risk of mortality, and patients with metabolic syndrome but without diabetes had a 2.4-fold increase in risk. In the multivariate analysis, there proved to be no significant increase in the risk of mortality in patients who had diabetes but not metabolic syndrome, wrote Dr. Najmeddine Echahidi of the Centre de Recherche de l'Hôpital Laval, Quebec, and colleagues (J. Am. Coll. Cardiol. 2007;50:843–51).

The retrospective analysis involved 5,304 consecutive patients who underwent an isolated coronary artery bypass graft (CABG) between 2000 and 2004 at a single institution. An analysis of prospectively collected laboratory and physical data revealed that 46% met criteria for metabolic syndrome as set out by the National Cholesterol Education Program Adult Treatment Panel III.

The study's primary end point was death from any cause, either within 30 days of surgery or after any interval if the patient was not discharged from the hospital. Results were adjusted for gender, peripheral vascular disease, chronic obstructive pulmonary disease, preoperative renal failure, preoperative myocardial infarction, and preoperative stroke.

The overall unadjusted mortality was 1.6%, but was significantly higher (2.4%) among patients with metabolic syndrome, and significantly lower (0.9%) among patients without metabolic syndrome.

In addition to metabolic syndrome, several other factors increased the risk of mortality following CABG. These included age older than 75 years (relative risk 3.4), body mass index (kg/m

Considering the prevalence of metabolic syndrome, the investigators suggested that patients be assessed for metabolic syndrome before surgery, and that metabolic syndrome be incorporated into operative risk algorithms.

Patients with metabolic syndrome are nearly three times as likely to die following coronary artery bypass graft surgery as are patients without the syndrome, according to a large study.

Patients with both metabolic syndrome and diabetes had a 2.7-fold increase in the risk of mortality, and patients with metabolic syndrome but without diabetes had a 2.4-fold increase in risk. In the multivariate analysis, there proved to be no significant increase in the risk of mortality in patients who had diabetes but not metabolic syndrome, wrote Dr. Najmeddine Echahidi of the Centre de Recherche de l'Hôpital Laval, Quebec, and colleagues (J. Am. Coll. Cardiol. 2007;50:843–51).

The retrospective analysis involved 5,304 consecutive patients who underwent an isolated coronary artery bypass graft (CABG) between 2000 and 2004 at a single institution. An analysis of prospectively collected laboratory and physical data revealed that 46% met criteria for metabolic syndrome as set out by the National Cholesterol Education Program Adult Treatment Panel III.

The study's primary end point was death from any cause, either within 30 days of surgery or after any interval if the patient was not discharged from the hospital. Results were adjusted for gender, peripheral vascular disease, chronic obstructive pulmonary disease, preoperative renal failure, preoperative myocardial infarction, and preoperative stroke.

The overall unadjusted mortality was 1.6%, but was significantly higher (2.4%) among patients with metabolic syndrome, and significantly lower (0.9%) among patients without metabolic syndrome.

In addition to metabolic syndrome, several other factors increased the risk of mortality following CABG. These included age older than 75 years (relative risk 3.4), body mass index (kg/m

Considering the prevalence of metabolic syndrome, the investigators suggested that patients be assessed for metabolic syndrome before surgery, and that metabolic syndrome be incorporated into operative risk algorithms.

A low adiponectin level is a better predictor of carotid intima-media thickness in obese children than are conventional cardiovascular disease risk factors, according to a report published in the Journal of Clinical Endocrinology and Metabolism.

Increased intima-media thickness (IMT) is considered to be an early marker of atherosclerosis in adults. Adiponectin is one of a class of bioactive substances called adipokines produced by adipose tissue. High levels of adiponectin have antidiabetic properties, but low levels have been shown to predict myocardial infarction in adults. Paradoxically, the more adipose tissue a person has, the less adiponectin the adipose tissue produces.

In this study, Dr. Véronique Beauloye and her colleagues at Université Catholique de Louvain, Brussels, studied 104 obese children and adolescents and compared them with 93 children of normal weight. They used ultrasound to measure IMT in the carotid artery of each child, and the children underwent oral glucose tolerance tests (J. Clin. Endocrinol. Metab. 2007;92:3025–32).

A univariate analysis found a significant inverse correlation between IMT and adiponectin levels, and significant positive correlations between IMT and relative body mass index, systolic hypertension, fasting insulin levels, the homeostatic model assessment R-index, and concentrations of resistin (a molecule called such for “resistance to insulin” that may be the hormone connecting obesity and diabetes). But after adjusting their statistical model for sex, Tanner stage, and relative BMI, the investigators found that only adiponectin concentration remained as an independent predictor of IMT.

The children in the study ranged from 8 to 18 years of age, with an average age of 13. The children in the obese group had BMI z scores averaging 2.8, while the children in the control group averaged -0.2. The obese children differed significantly from the controls in many cardiovascular risk factors, including LDL and HDL cholesterol, glucose tolerance, and measures of subclinical inflammation.

The authors wrote that their study suggests that adiponectin may play an early role in the pathophysiology of atherosclerosis. While earlier studies showed a relationship between adiponectin levels and IMT in severely obese children, this is apparently the first study to show a similar association in less obese children.

A low adiponectin level is a better predictor of carotid intima-media thickness in obese children than are conventional cardiovascular disease risk factors, according to a report published in the Journal of Clinical Endocrinology and Metabolism.

Increased intima-media thickness (IMT) is considered to be an early marker of atherosclerosis in adults. Adiponectin is one of a class of bioactive substances called adipokines produced by adipose tissue. High levels of adiponectin have antidiabetic properties, but low levels have been shown to predict myocardial infarction in adults. Paradoxically, the more adipose tissue a person has, the less adiponectin the adipose tissue produces.

In this study, Dr. Véronique Beauloye and her colleagues at Université Catholique de Louvain, Brussels, studied 104 obese children and adolescents and compared them with 93 children of normal weight. They used ultrasound to measure IMT in the carotid artery of each child, and the children underwent oral glucose tolerance tests (J. Clin. Endocrinol. Metab. 2007;92:3025–32).

A univariate analysis found a significant inverse correlation between IMT and adiponectin levels, and significant positive correlations between IMT and relative body mass index, systolic hypertension, fasting insulin levels, the homeostatic model assessment R-index, and concentrations of resistin (a molecule called such for “resistance to insulin” that may be the hormone connecting obesity and diabetes). But after adjusting their statistical model for sex, Tanner stage, and relative BMI, the investigators found that only adiponectin concentration remained as an independent predictor of IMT.

The children in the study ranged from 8 to 18 years of age, with an average age of 13. The children in the obese group had BMI z scores averaging 2.8, while the children in the control group averaged -0.2. The obese children differed significantly from the controls in many cardiovascular risk factors, including LDL and HDL cholesterol, glucose tolerance, and measures of subclinical inflammation.

The authors wrote that their study suggests that adiponectin may play an early role in the pathophysiology of atherosclerosis. While earlier studies showed a relationship between adiponectin levels and IMT in severely obese children, this is apparently the first study to show a similar association in less obese children.

A low adiponectin level is a better predictor of carotid intima-media thickness in obese children than are conventional cardiovascular disease risk factors, according to a report published in the Journal of Clinical Endocrinology and Metabolism.

Increased intima-media thickness (IMT) is considered to be an early marker of atherosclerosis in adults. Adiponectin is one of a class of bioactive substances called adipokines produced by adipose tissue. High levels of adiponectin have antidiabetic properties, but low levels have been shown to predict myocardial infarction in adults. Paradoxically, the more adipose tissue a person has, the less adiponectin the adipose tissue produces.

In this study, Dr. Véronique Beauloye and her colleagues at Université Catholique de Louvain, Brussels, studied 104 obese children and adolescents and compared them with 93 children of normal weight. They used ultrasound to measure IMT in the carotid artery of each child, and the children underwent oral glucose tolerance tests (J. Clin. Endocrinol. Metab. 2007;92:3025–32).

A univariate analysis found a significant inverse correlation between IMT and adiponectin levels, and significant positive correlations between IMT and relative body mass index, systolic hypertension, fasting insulin levels, the homeostatic model assessment R-index, and concentrations of resistin (a molecule called such for “resistance to insulin” that may be the hormone connecting obesity and diabetes). But after adjusting their statistical model for sex, Tanner stage, and relative BMI, the investigators found that only adiponectin concentration remained as an independent predictor of IMT.

The children in the study ranged from 8 to 18 years of age, with an average age of 13. The children in the obese group had BMI z scores averaging 2.8, while the children in the control group averaged -0.2. The obese children differed significantly from the controls in many cardiovascular risk factors, including LDL and HDL cholesterol, glucose tolerance, and measures of subclinical inflammation.

The authors wrote that their study suggests that adiponectin may play an early role in the pathophysiology of atherosclerosis. While earlier studies showed a relationship between adiponectin levels and IMT in severely obese children, this is apparently the first study to show a similar association in less obese children.

SAN FRANCISCO — Despite the introduction in 2001 of an objective scoring system for liver disease, African Americans and Medicaid recipients remain less likely than other groups to receive the special exemptions that can shorten the wait for a liver transplant, according to a poster presentation at the American Transplant Congress.

Compared with whites, African Americans are 22% less likely to receive a special case exemption (SCE). And compared with patients with private insurance, those receiving Medicaid are 38% less likely to receive an SCE, according to the study by Dr. Curtis K. Argo and colleagues at the University of Virginia, Charlottesville.

“Most worrisome,” wrote the investigators, is the fact that self-payers were 64% more likely than those with private insurance to receive an SCE. “[This] implies that more SCEs are awarded to the wealthiest candidates.” The investigators noted that 37% of self-pay patients are foreign nationals.

The study involved 66,153 liver transplant candidates who were listed on the United Network for Organ Sharing waiting list from the inception of the Model for End-Stage Liver Disease (MELD) scoring system in 2001 through April 2006.

Of those, 28% had received a transplant, 50% remained on the waiting list, and 22% had died or had been removed from the waiting list for other reasons.

Special case exemptions are allowed for certain genetic or physiologic conditions such as hepatopulmonary syndrome or familial amyloidosis, or for certain symptom-based reasons such as refractory ascites, refractory encephalopathy, or refractory pruritus.

In all, 7.9% of the transplant recipients received an SCE.

Other research has determined that receiving an SCE decreases the likelihood that a patient will die on the waiting list by 71%.

After adjustment for MELD score, region, ABO blood group, degree of encephalopathy, degree of ascites, ethnic group, gender, year of listing, age at listing, and primary insurance payer, an African American patient's odds ratio of receiving an SCE was 0.78, compared with that of a white patient, a statistically significant difference.

There were no significant differences between white and Hispanics or members of other ethnic groups.

Compared with patients covered by private insurance, a Medicaid patient's odds ratio of receiving an SCE was 0.62, and self-payers had an odds ratio of 1.64, with both differences being statistically significant.

There were no significant differences between patients with private insurance and those on Medicare or those receiving their insurance from another government agency.

The investigators concluded, “These findings strongly support additional close scrutiny of current SCE award procedures and insinuate that SCE awards criteria require significant revision due to these biases.”

The congress was cosponsored by The American Society of Transplant Surgeons and the American Society of Tranplantation.

SAN FRANCISCO — Despite the introduction in 2001 of an objective scoring system for liver disease, African Americans and Medicaid recipients remain less likely than other groups to receive the special exemptions that can shorten the wait for a liver transplant, according to a poster presentation at the American Transplant Congress.

Compared with whites, African Americans are 22% less likely to receive a special case exemption (SCE). And compared with patients with private insurance, those receiving Medicaid are 38% less likely to receive an SCE, according to the study by Dr. Curtis K. Argo and colleagues at the University of Virginia, Charlottesville.

“Most worrisome,” wrote the investigators, is the fact that self-payers were 64% more likely than those with private insurance to receive an SCE. “[This] implies that more SCEs are awarded to the wealthiest candidates.” The investigators noted that 37% of self-pay patients are foreign nationals.

The study involved 66,153 liver transplant candidates who were listed on the United Network for Organ Sharing waiting list from the inception of the Model for End-Stage Liver Disease (MELD) scoring system in 2001 through April 2006.

Of those, 28% had received a transplant, 50% remained on the waiting list, and 22% had died or had been removed from the waiting list for other reasons.

Special case exemptions are allowed for certain genetic or physiologic conditions such as hepatopulmonary syndrome or familial amyloidosis, or for certain symptom-based reasons such as refractory ascites, refractory encephalopathy, or refractory pruritus.

In all, 7.9% of the transplant recipients received an SCE.

Other research has determined that receiving an SCE decreases the likelihood that a patient will die on the waiting list by 71%.

After adjustment for MELD score, region, ABO blood group, degree of encephalopathy, degree of ascites, ethnic group, gender, year of listing, age at listing, and primary insurance payer, an African American patient's odds ratio of receiving an SCE was 0.78, compared with that of a white patient, a statistically significant difference.

There were no significant differences between white and Hispanics or members of other ethnic groups.

Compared with patients covered by private insurance, a Medicaid patient's odds ratio of receiving an SCE was 0.62, and self-payers had an odds ratio of 1.64, with both differences being statistically significant.

There were no significant differences between patients with private insurance and those on Medicare or those receiving their insurance from another government agency.

The investigators concluded, “These findings strongly support additional close scrutiny of current SCE award procedures and insinuate that SCE awards criteria require significant revision due to these biases.”

The congress was cosponsored by The American Society of Transplant Surgeons and the American Society of Tranplantation.

SAN FRANCISCO — Despite the introduction in 2001 of an objective scoring system for liver disease, African Americans and Medicaid recipients remain less likely than other groups to receive the special exemptions that can shorten the wait for a liver transplant, according to a poster presentation at the American Transplant Congress.

Compared with whites, African Americans are 22% less likely to receive a special case exemption (SCE). And compared with patients with private insurance, those receiving Medicaid are 38% less likely to receive an SCE, according to the study by Dr. Curtis K. Argo and colleagues at the University of Virginia, Charlottesville.

“Most worrisome,” wrote the investigators, is the fact that self-payers were 64% more likely than those with private insurance to receive an SCE. “[This] implies that more SCEs are awarded to the wealthiest candidates.” The investigators noted that 37% of self-pay patients are foreign nationals.

The study involved 66,153 liver transplant candidates who were listed on the United Network for Organ Sharing waiting list from the inception of the Model for End-Stage Liver Disease (MELD) scoring system in 2001 through April 2006.

Of those, 28% had received a transplant, 50% remained on the waiting list, and 22% had died or had been removed from the waiting list for other reasons.

Special case exemptions are allowed for certain genetic or physiologic conditions such as hepatopulmonary syndrome or familial amyloidosis, or for certain symptom-based reasons such as refractory ascites, refractory encephalopathy, or refractory pruritus.

In all, 7.9% of the transplant recipients received an SCE.

Other research has determined that receiving an SCE decreases the likelihood that a patient will die on the waiting list by 71%.

After adjustment for MELD score, region, ABO blood group, degree of encephalopathy, degree of ascites, ethnic group, gender, year of listing, age at listing, and primary insurance payer, an African American patient's odds ratio of receiving an SCE was 0.78, compared with that of a white patient, a statistically significant difference.

There were no significant differences between white and Hispanics or members of other ethnic groups.

Compared with patients covered by private insurance, a Medicaid patient's odds ratio of receiving an SCE was 0.62, and self-payers had an odds ratio of 1.64, with both differences being statistically significant.

There were no significant differences between patients with private insurance and those on Medicare or those receiving their insurance from another government agency.

The investigators concluded, “These findings strongly support additional close scrutiny of current SCE award procedures and insinuate that SCE awards criteria require significant revision due to these biases.”

The congress was cosponsored by The American Society of Transplant Surgeons and the American Society of Tranplantation.