Sharon Worcester

NEW ORLEANS – A school-based life skills training program proved feasible and was beneficial for improving anger control in African American adolescents who participated in a randomized, controlled study of the program.

Spielberger State-Trait Anger Scale scores in 52 normotensive African American adolescents who were randomized to participate in the 12-session program, which was conducted during health or physical education classes, improved significantly from a mean preintervention score of 23.0 (out of a possible 40) to a mean postintervention score of 23.9. Scores in 52 African American adolescent controls who did not participate in the program decreased significantly during the same time period from 22.1 to 20.5, Vernon A. Barnes, Ph.D., reported at a meeting sponsored by the International Society on Hypertension in Blacks.

Participants included 104 adolescents, 44% of whom were boys, with a mean age of 15.7 years. Training included 12 50-minute Williams LifeSkills Workshop sessions adapted for adolescents and conducted by teachers specifically trained to facilitate these programs. The sessions focused on stress-related coping skills, including early recognition of negative feelings, thinking before acting, deflection, problem solving, assertion, saying no, speaking clearly, listening, empathy, and building supportive relationships.

“The findings demonstrate the feasibility of conducting the Williams LifeSkills program in the school setting and its potential beneficial impact on anger control levels in African American adolescents,” Dr. Barnes of the Medical College of Georgia, Augusta, wrote in a poster.

Replication and verification of the results in a larger group with a longer follow-up is warranted, he noted.

The findings are important given that there is increasing evidence linking anger expression and trait anger/hostility with subclinical cardiovascular disease in youth and with coronary heart disease in adults, Dr. Barnes noted. Although the benefits of psychosocial-behavioral interventions for reducing coronary heart disease risk have been demonstrated in numerous trials in adults, few have evaluated their impact on youth, he added.

Two of the study's coauthors are the founder and president of Williams LifeSkills Inc. The study was supported in part by the National Heart, Lung, and Blood Institute.

NEW ORLEANS – A school-based life skills training program proved feasible and was beneficial for improving anger control in African American adolescents who participated in a randomized, controlled study of the program.

Spielberger State-Trait Anger Scale scores in 52 normotensive African American adolescents who were randomized to participate in the 12-session program, which was conducted during health or physical education classes, improved significantly from a mean preintervention score of 23.0 (out of a possible 40) to a mean postintervention score of 23.9. Scores in 52 African American adolescent controls who did not participate in the program decreased significantly during the same time period from 22.1 to 20.5, Vernon A. Barnes, Ph.D., reported at a meeting sponsored by the International Society on Hypertension in Blacks.

Participants included 104 adolescents, 44% of whom were boys, with a mean age of 15.7 years. Training included 12 50-minute Williams LifeSkills Workshop sessions adapted for adolescents and conducted by teachers specifically trained to facilitate these programs. The sessions focused on stress-related coping skills, including early recognition of negative feelings, thinking before acting, deflection, problem solving, assertion, saying no, speaking clearly, listening, empathy, and building supportive relationships.

“The findings demonstrate the feasibility of conducting the Williams LifeSkills program in the school setting and its potential beneficial impact on anger control levels in African American adolescents,” Dr. Barnes of the Medical College of Georgia, Augusta, wrote in a poster.

Replication and verification of the results in a larger group with a longer follow-up is warranted, he noted.

The findings are important given that there is increasing evidence linking anger expression and trait anger/hostility with subclinical cardiovascular disease in youth and with coronary heart disease in adults, Dr. Barnes noted. Although the benefits of psychosocial-behavioral interventions for reducing coronary heart disease risk have been demonstrated in numerous trials in adults, few have evaluated their impact on youth, he added.

Two of the study's coauthors are the founder and president of Williams LifeSkills Inc. The study was supported in part by the National Heart, Lung, and Blood Institute.

NEW ORLEANS – A school-based life skills training program proved feasible and was beneficial for improving anger control in African American adolescents who participated in a randomized, controlled study of the program.

Spielberger State-Trait Anger Scale scores in 52 normotensive African American adolescents who were randomized to participate in the 12-session program, which was conducted during health or physical education classes, improved significantly from a mean preintervention score of 23.0 (out of a possible 40) to a mean postintervention score of 23.9. Scores in 52 African American adolescent controls who did not participate in the program decreased significantly during the same time period from 22.1 to 20.5, Vernon A. Barnes, Ph.D., reported at a meeting sponsored by the International Society on Hypertension in Blacks.

Participants included 104 adolescents, 44% of whom were boys, with a mean age of 15.7 years. Training included 12 50-minute Williams LifeSkills Workshop sessions adapted for adolescents and conducted by teachers specifically trained to facilitate these programs. The sessions focused on stress-related coping skills, including early recognition of negative feelings, thinking before acting, deflection, problem solving, assertion, saying no, speaking clearly, listening, empathy, and building supportive relationships.

“The findings demonstrate the feasibility of conducting the Williams LifeSkills program in the school setting and its potential beneficial impact on anger control levels in African American adolescents,” Dr. Barnes of the Medical College of Georgia, Augusta, wrote in a poster.

Replication and verification of the results in a larger group with a longer follow-up is warranted, he noted.

The findings are important given that there is increasing evidence linking anger expression and trait anger/hostility with subclinical cardiovascular disease in youth and with coronary heart disease in adults, Dr. Barnes noted. Although the benefits of psychosocial-behavioral interventions for reducing coronary heart disease risk have been demonstrated in numerous trials in adults, few have evaluated their impact on youth, he added.

Two of the study's coauthors are the founder and president of Williams LifeSkills Inc. The study was supported in part by the National Heart, Lung, and Blood Institute.

NEW YORK — Patient-centered management and early, aggressive treatment of hypertension are necessary in patients with diabetes to address the sevenfold mortality increase in this patient population, according to an updated guidance from the American Society of Hypertension.

Physicians need to take a more integrated, individualized approach to treating hypertension in patients with diabetes by “treating the intricacies of each patient profile, rather than focusing on the disease in isolation,” according to a statement by ASH.

The guidance does not alter the fundamental treatment of blood pressure goals for this patient population, but it does emphasize that early detection of risk factors unique to each patient is needed and that earlier, more-aggressive treatment should be implemented, including the identification and reduction of proteinuria (J. Clin. Hypertens. 2008;10:707).

Once high blood pressure is identified, initiation of ACE inhibitors or angiotensin receptor blocker therapy along with either thiazide-like diuretics or calcium antagonists is needed to maintain a target blood pressure of 130/80 mm Hg. More frequent patient follow-up also is needed, according to the guidance.

Specifically, follow-up visits after each medication adjustment should occur within 2–3 weeks rather than 4–8 weeks as was previously recommended, and immediate referral to a specialist is necessary if repeated attempts to achieve blood pressure goals fail, according to the guidance.

Previous studies show that, compared with conventional treatment, aggressive blood pressure control is associated with far fewer cardiovascular events in diabetic patients, Dr. George Bakris, professor of medicine at the University of Chicago, said during a press briefing sponsored by the society. Yet physicians are not being as aggressive as necessary to get blood pressure under control. Physicians also need to empower patients to take control, and they need to focus on the goal of reducing morbidity.

Patients who make the necessary lifestyle changes and who comply with aggressive therapy will prolong their lives and improve their quality of life by reducing morbidity, he said.

Physicians need to emphasize that the need for treatment is not transient but is lifelong. That said, obese patients who lose weight can successfully reduce their antihypertensive pill burden, he noted.

“These patients require an integrated therapeutic intervention that, in addition to blood pressure control, should include glycemic and lipid control and antiplatelet therapy,” Dr. Bakris noted in an ASH statement. It is imperative that all risk factors be attacked simultaneously to manage the profile of each patient more vigilantly, he added.

The challenges of identifying and treating hypertension are not limited to adults.

Nearly a third of obese teens also have high blood pressure, Dr. Bonita Falkner, a nephrologist at Thomas Jefferson University, Philadelphia, said during the briefing.

Obesity has become such a significant problem among adolescents that the prevalence of premature heart disease in young adults is expected to more than triple from 5% to 16% when currently obese adolescents reach age 35, she added.

Dr. Henry Black, president of ASH, said at the briefing that immediate action is needed to address the problem of childhood obesity and the associated risks.

Overall, about 3.5% of children have hypertension and another 3.5% have prehypertension. It is likely that these children have—or will develop—blood pressure levels that require therapy and that they will become hypertensive young adults, said Dr. Falkner, an author of pediatric hypertension guidelines published in 2004.

Additional clinical research involving adolescents is needed to define the disease pathway, to improve detection and treatment methods, and to determine the most beneficial time point for interventions, she said.

For now, she recommended that:

▸ Blood pressure be measured as part of routine health care beginning at age 3 years.

▸ Blood pressure be measured as part of a medical exam in those younger than 3 years with chronic disease or unexplained symptoms.

▸ An appropriate evaluation be conducted in patients with detected and verified hypertension.

NEW YORK — Patient-centered management and early, aggressive treatment of hypertension are necessary in patients with diabetes to address the sevenfold mortality increase in this patient population, according to an updated guidance from the American Society of Hypertension.

Physicians need to take a more integrated, individualized approach to treating hypertension in patients with diabetes by “treating the intricacies of each patient profile, rather than focusing on the disease in isolation,” according to a statement by ASH.

The guidance does not alter the fundamental treatment of blood pressure goals for this patient population, but it does emphasize that early detection of risk factors unique to each patient is needed and that earlier, more-aggressive treatment should be implemented, including the identification and reduction of proteinuria (J. Clin. Hypertens. 2008;10:707).

Once high blood pressure is identified, initiation of ACE inhibitors or angiotensin receptor blocker therapy along with either thiazide-like diuretics or calcium antagonists is needed to maintain a target blood pressure of 130/80 mm Hg. More frequent patient follow-up also is needed, according to the guidance.

Specifically, follow-up visits after each medication adjustment should occur within 2–3 weeks rather than 4–8 weeks as was previously recommended, and immediate referral to a specialist is necessary if repeated attempts to achieve blood pressure goals fail, according to the guidance.

Previous studies show that, compared with conventional treatment, aggressive blood pressure control is associated with far fewer cardiovascular events in diabetic patients, Dr. George Bakris, professor of medicine at the University of Chicago, said during a press briefing sponsored by the society. Yet physicians are not being as aggressive as necessary to get blood pressure under control. Physicians also need to empower patients to take control, and they need to focus on the goal of reducing morbidity.

Patients who make the necessary lifestyle changes and who comply with aggressive therapy will prolong their lives and improve their quality of life by reducing morbidity, he said.

Physicians need to emphasize that the need for treatment is not transient but is lifelong. That said, obese patients who lose weight can successfully reduce their antihypertensive pill burden, he noted.

“These patients require an integrated therapeutic intervention that, in addition to blood pressure control, should include glycemic and lipid control and antiplatelet therapy,” Dr. Bakris noted in an ASH statement. It is imperative that all risk factors be attacked simultaneously to manage the profile of each patient more vigilantly, he added.

The challenges of identifying and treating hypertension are not limited to adults.

Nearly a third of obese teens also have high blood pressure, Dr. Bonita Falkner, a nephrologist at Thomas Jefferson University, Philadelphia, said during the briefing.

Obesity has become such a significant problem among adolescents that the prevalence of premature heart disease in young adults is expected to more than triple from 5% to 16% when currently obese adolescents reach age 35, she added.

Dr. Henry Black, president of ASH, said at the briefing that immediate action is needed to address the problem of childhood obesity and the associated risks.

Overall, about 3.5% of children have hypertension and another 3.5% have prehypertension. It is likely that these children have—or will develop—blood pressure levels that require therapy and that they will become hypertensive young adults, said Dr. Falkner, an author of pediatric hypertension guidelines published in 2004.

Additional clinical research involving adolescents is needed to define the disease pathway, to improve detection and treatment methods, and to determine the most beneficial time point for interventions, she said.

For now, she recommended that:

▸ Blood pressure be measured as part of routine health care beginning at age 3 years.

▸ Blood pressure be measured as part of a medical exam in those younger than 3 years with chronic disease or unexplained symptoms.

▸ An appropriate evaluation be conducted in patients with detected and verified hypertension.

NEW YORK — Patient-centered management and early, aggressive treatment of hypertension are necessary in patients with diabetes to address the sevenfold mortality increase in this patient population, according to an updated guidance from the American Society of Hypertension.

Physicians need to take a more integrated, individualized approach to treating hypertension in patients with diabetes by “treating the intricacies of each patient profile, rather than focusing on the disease in isolation,” according to a statement by ASH.

The guidance does not alter the fundamental treatment of blood pressure goals for this patient population, but it does emphasize that early detection of risk factors unique to each patient is needed and that earlier, more-aggressive treatment should be implemented, including the identification and reduction of proteinuria (J. Clin. Hypertens. 2008;10:707).

Once high blood pressure is identified, initiation of ACE inhibitors or angiotensin receptor blocker therapy along with either thiazide-like diuretics or calcium antagonists is needed to maintain a target blood pressure of 130/80 mm Hg. More frequent patient follow-up also is needed, according to the guidance.

Specifically, follow-up visits after each medication adjustment should occur within 2–3 weeks rather than 4–8 weeks as was previously recommended, and immediate referral to a specialist is necessary if repeated attempts to achieve blood pressure goals fail, according to the guidance.

Previous studies show that, compared with conventional treatment, aggressive blood pressure control is associated with far fewer cardiovascular events in diabetic patients, Dr. George Bakris, professor of medicine at the University of Chicago, said during a press briefing sponsored by the society. Yet physicians are not being as aggressive as necessary to get blood pressure under control. Physicians also need to empower patients to take control, and they need to focus on the goal of reducing morbidity.

Patients who make the necessary lifestyle changes and who comply with aggressive therapy will prolong their lives and improve their quality of life by reducing morbidity, he said.

Physicians need to emphasize that the need for treatment is not transient but is lifelong. That said, obese patients who lose weight can successfully reduce their antihypertensive pill burden, he noted.

“These patients require an integrated therapeutic intervention that, in addition to blood pressure control, should include glycemic and lipid control and antiplatelet therapy,” Dr. Bakris noted in an ASH statement. It is imperative that all risk factors be attacked simultaneously to manage the profile of each patient more vigilantly, he added.

The challenges of identifying and treating hypertension are not limited to adults.

Nearly a third of obese teens also have high blood pressure, Dr. Bonita Falkner, a nephrologist at Thomas Jefferson University, Philadelphia, said during the briefing.

Obesity has become such a significant problem among adolescents that the prevalence of premature heart disease in young adults is expected to more than triple from 5% to 16% when currently obese adolescents reach age 35, she added.

Dr. Henry Black, president of ASH, said at the briefing that immediate action is needed to address the problem of childhood obesity and the associated risks.

Overall, about 3.5% of children have hypertension and another 3.5% have prehypertension. It is likely that these children have—or will develop—blood pressure levels that require therapy and that they will become hypertensive young adults, said Dr. Falkner, an author of pediatric hypertension guidelines published in 2004.

Additional clinical research involving adolescents is needed to define the disease pathway, to improve detection and treatment methods, and to determine the most beneficial time point for interventions, she said.

For now, she recommended that:

▸ Blood pressure be measured as part of routine health care beginning at age 3 years.

▸ Blood pressure be measured as part of a medical exam in those younger than 3 years with chronic disease or unexplained symptoms.

▸ An appropriate evaluation be conducted in patients with detected and verified hypertension.

Identifying and treating the potentially life-threatening problem of gastrointestinal complications in patients who use the combination of antiplatelet therapy and NSAIDs are the focus of a new scientific statement by the American College of Cardiology Foundation, the American College of Gastroenterology, and the American Heart Association.

Practical clinical guidance for reducing the risk of ulceration and related bleeding—including the use of gastroprotection, either with protein pump inhibitor therapy or treatment of Helicobacter pylori infection—was included in the consensus document.

Ulcerations and gastrointestinal bleeding are recognizable risks in individuals who use antiplatelet agents and NSAIDs, with these patients having up to a fourfold increased risk of such complications, compared with those who are not using the medications, according to Dr. Deepak L. Bhatt, document cochair, and his colleagues on the consensus document writing committee (J. Am. Coll. Cardiol. 2008 Oct. 6 [doi:10.1016/j.jacc.2008.08.002

Since NSAIDs, including aspirin, are the most widely used class of medication in the United States, and more Americans are living with heart disease in addition to conditions that require them to take NSAIDs (such as arthritis, inflammation, and related musculoskeletal pain), the management of GI risk will become an increasingly important part of cardiovascular care, according to an American College of Cardiology (ACC) statement on the consensus document.

“Doctors are uncertain about how best to prevent bleeding complications in patients receiving antiplatelet therapy and NSAIDs, which are both commonly used, and can cause erosions in the stomach lining,” Dr. Bhatt, chief of cardiology at VA Boston Healthcare System, noted in the statement. “These recommendations represent the collective expertise of leading cardiologists and gastroenterologists, as well as an extensive review of the literature, and provide specialists with practical measures to manage competing risks and help improve patient safety.”

In addition, Dr. David Johnson, immediate past president of the American College of Gastroenterology and professor of medicine and chief of gastroenterology at Eastern Virginia Medical School, Norfolk, stressed the importance of “proactive assessment” of individual risk, and of the need for improved communication among cardiologists, gastroenterologists, and primary care physicians to improve patient safety. Likewise, patients must be informed of the importance of disclosing all medication information to ensure that appropriate measures can be taken to reduce risk, he noted.

The organizations made recommendations for these clinical scenarios:

▸ GI complications of aspirin and of combined aspirin and nonaspirin NSAIDs. Gastroprotective therapy should be prescribed for at-risk patients who use low-dose aspirin, and for those using any NSAIDs in conjunction with cardiac-dose aspirin. Because the risk of upper-gastrointestinal events increases with aspirin dose escalation, doses greater than 81 mg should not be routinely prescribed for chronic phase therapy.

▸ GI effects of combined aspirin and anticoagulate therapy. There is a “clinically meaningful and significantly increased risk of major extracranial bleeding events, a large proportion from the upper GI tract” in those on this combination, which has an “established vascular, arrhythmic, or valvular indication.” Concomitant proton pump inhibitor (PPI) therapy is advised.

▸ GI effects of clopidogrel and clopidogrel plus anticoagulant therapy. Clopidogrel should not be substituted for aspirin as a strategy to reduce recurrent ulcer bleeding in high-risk patients because it is inferior to the combination of aspirin plus PPIs. Also, the combination of clopidogrel and warfarin therapy is associated with an increased incidence of major bleeding, compared with monotherapy; this combination should be considered only when the benefits are likely to outweigh the risks. An international normalized ratio of 2.0–2.5 is recommended when warfarin is added to aspirin or to aspirin and clopidogrel.

▸ Treatment and prevention of aspirin and NSAID-related gastroduodenal injury. PPIs should be used for both the prevention and the treatment of NSAID- and aspirin-associated GI injury.

▸ H. pylori testing and eradication. Before initiating chronic antiplatelet therapy in patients with a history of ulcer disease, test for and eradicate H. pylori.

▸ Discontinuation of antiplatelet therapy because of bleeding. The decision to discontinue aspirin therapy in the setting of acute ulcer bleeding should be individualized based on cardiac risk and GI risk assessments to discern potential thrombotic and hemorrhagic complications.

▸ Endoscopy in patients on mono or dual antiplatelet therapy. High-risk cardiovascular patients on dual therapy may benefit from endoscopic therapy. Collaboration between the cardiologist and endoscopist is important to assess the risk of bleeding against the risk of thrombosis in regard to the timing of antiplatelet therapy cessation.

The consensus document is considered to be part of “an ongoing dialogue” and will be updated “as more definitive data are accrued,” according to the ACC statement.

Identifying and treating the potentially life-threatening problem of gastrointestinal complications in patients who use the combination of antiplatelet therapy and NSAIDs are the focus of a new scientific statement by the American College of Cardiology Foundation, the American College of Gastroenterology, and the American Heart Association.

Practical clinical guidance for reducing the risk of ulceration and related bleeding—including the use of gastroprotection, either with protein pump inhibitor therapy or treatment of Helicobacter pylori infection—was included in the consensus document.

Ulcerations and gastrointestinal bleeding are recognizable risks in individuals who use antiplatelet agents and NSAIDs, with these patients having up to a fourfold increased risk of such complications, compared with those who are not using the medications, according to Dr. Deepak L. Bhatt, document cochair, and his colleagues on the consensus document writing committee (J. Am. Coll. Cardiol. 2008 Oct. 6 [doi:10.1016/j.jacc.2008.08.002

Since NSAIDs, including aspirin, are the most widely used class of medication in the United States, and more Americans are living with heart disease in addition to conditions that require them to take NSAIDs (such as arthritis, inflammation, and related musculoskeletal pain), the management of GI risk will become an increasingly important part of cardiovascular care, according to an American College of Cardiology (ACC) statement on the consensus document.

“Doctors are uncertain about how best to prevent bleeding complications in patients receiving antiplatelet therapy and NSAIDs, which are both commonly used, and can cause erosions in the stomach lining,” Dr. Bhatt, chief of cardiology at VA Boston Healthcare System, noted in the statement. “These recommendations represent the collective expertise of leading cardiologists and gastroenterologists, as well as an extensive review of the literature, and provide specialists with practical measures to manage competing risks and help improve patient safety.”

In addition, Dr. David Johnson, immediate past president of the American College of Gastroenterology and professor of medicine and chief of gastroenterology at Eastern Virginia Medical School, Norfolk, stressed the importance of “proactive assessment” of individual risk, and of the need for improved communication among cardiologists, gastroenterologists, and primary care physicians to improve patient safety. Likewise, patients must be informed of the importance of disclosing all medication information to ensure that appropriate measures can be taken to reduce risk, he noted.

The organizations made recommendations for these clinical scenarios:

▸ GI complications of aspirin and of combined aspirin and nonaspirin NSAIDs. Gastroprotective therapy should be prescribed for at-risk patients who use low-dose aspirin, and for those using any NSAIDs in conjunction with cardiac-dose aspirin. Because the risk of upper-gastrointestinal events increases with aspirin dose escalation, doses greater than 81 mg should not be routinely prescribed for chronic phase therapy.

▸ GI effects of combined aspirin and anticoagulate therapy. There is a “clinically meaningful and significantly increased risk of major extracranial bleeding events, a large proportion from the upper GI tract” in those on this combination, which has an “established vascular, arrhythmic, or valvular indication.” Concomitant proton pump inhibitor (PPI) therapy is advised.

▸ GI effects of clopidogrel and clopidogrel plus anticoagulant therapy. Clopidogrel should not be substituted for aspirin as a strategy to reduce recurrent ulcer bleeding in high-risk patients because it is inferior to the combination of aspirin plus PPIs. Also, the combination of clopidogrel and warfarin therapy is associated with an increased incidence of major bleeding, compared with monotherapy; this combination should be considered only when the benefits are likely to outweigh the risks. An international normalized ratio of 2.0–2.5 is recommended when warfarin is added to aspirin or to aspirin and clopidogrel.

▸ Treatment and prevention of aspirin and NSAID-related gastroduodenal injury. PPIs should be used for both the prevention and the treatment of NSAID- and aspirin-associated GI injury.

▸ H. pylori testing and eradication. Before initiating chronic antiplatelet therapy in patients with a history of ulcer disease, test for and eradicate H. pylori.

▸ Discontinuation of antiplatelet therapy because of bleeding. The decision to discontinue aspirin therapy in the setting of acute ulcer bleeding should be individualized based on cardiac risk and GI risk assessments to discern potential thrombotic and hemorrhagic complications.

▸ Endoscopy in patients on mono or dual antiplatelet therapy. High-risk cardiovascular patients on dual therapy may benefit from endoscopic therapy. Collaboration between the cardiologist and endoscopist is important to assess the risk of bleeding against the risk of thrombosis in regard to the timing of antiplatelet therapy cessation.

The consensus document is considered to be part of “an ongoing dialogue” and will be updated “as more definitive data are accrued,” according to the ACC statement.

Identifying and treating the potentially life-threatening problem of gastrointestinal complications in patients who use the combination of antiplatelet therapy and NSAIDs are the focus of a new scientific statement by the American College of Cardiology Foundation, the American College of Gastroenterology, and the American Heart Association.

Practical clinical guidance for reducing the risk of ulceration and related bleeding—including the use of gastroprotection, either with protein pump inhibitor therapy or treatment of Helicobacter pylori infection—was included in the consensus document.

Ulcerations and gastrointestinal bleeding are recognizable risks in individuals who use antiplatelet agents and NSAIDs, with these patients having up to a fourfold increased risk of such complications, compared with those who are not using the medications, according to Dr. Deepak L. Bhatt, document cochair, and his colleagues on the consensus document writing committee (J. Am. Coll. Cardiol. 2008 Oct. 6 [doi:10.1016/j.jacc.2008.08.002

Since NSAIDs, including aspirin, are the most widely used class of medication in the United States, and more Americans are living with heart disease in addition to conditions that require them to take NSAIDs (such as arthritis, inflammation, and related musculoskeletal pain), the management of GI risk will become an increasingly important part of cardiovascular care, according to an American College of Cardiology (ACC) statement on the consensus document.

“Doctors are uncertain about how best to prevent bleeding complications in patients receiving antiplatelet therapy and NSAIDs, which are both commonly used, and can cause erosions in the stomach lining,” Dr. Bhatt, chief of cardiology at VA Boston Healthcare System, noted in the statement. “These recommendations represent the collective expertise of leading cardiologists and gastroenterologists, as well as an extensive review of the literature, and provide specialists with practical measures to manage competing risks and help improve patient safety.”

In addition, Dr. David Johnson, immediate past president of the American College of Gastroenterology and professor of medicine and chief of gastroenterology at Eastern Virginia Medical School, Norfolk, stressed the importance of “proactive assessment” of individual risk, and of the need for improved communication among cardiologists, gastroenterologists, and primary care physicians to improve patient safety. Likewise, patients must be informed of the importance of disclosing all medication information to ensure that appropriate measures can be taken to reduce risk, he noted.

The organizations made recommendations for these clinical scenarios:

▸ GI complications of aspirin and of combined aspirin and nonaspirin NSAIDs. Gastroprotective therapy should be prescribed for at-risk patients who use low-dose aspirin, and for those using any NSAIDs in conjunction with cardiac-dose aspirin. Because the risk of upper-gastrointestinal events increases with aspirin dose escalation, doses greater than 81 mg should not be routinely prescribed for chronic phase therapy.

▸ GI effects of combined aspirin and anticoagulate therapy. There is a “clinically meaningful and significantly increased risk of major extracranial bleeding events, a large proportion from the upper GI tract” in those on this combination, which has an “established vascular, arrhythmic, or valvular indication.” Concomitant proton pump inhibitor (PPI) therapy is advised.

▸ GI effects of clopidogrel and clopidogrel plus anticoagulant therapy. Clopidogrel should not be substituted for aspirin as a strategy to reduce recurrent ulcer bleeding in high-risk patients because it is inferior to the combination of aspirin plus PPIs. Also, the combination of clopidogrel and warfarin therapy is associated with an increased incidence of major bleeding, compared with monotherapy; this combination should be considered only when the benefits are likely to outweigh the risks. An international normalized ratio of 2.0–2.5 is recommended when warfarin is added to aspirin or to aspirin and clopidogrel.

▸ Treatment and prevention of aspirin and NSAID-related gastroduodenal injury. PPIs should be used for both the prevention and the treatment of NSAID- and aspirin-associated GI injury.

▸ H. pylori testing and eradication. Before initiating chronic antiplatelet therapy in patients with a history of ulcer disease, test for and eradicate H. pylori.

▸ Discontinuation of antiplatelet therapy because of bleeding. The decision to discontinue aspirin therapy in the setting of acute ulcer bleeding should be individualized based on cardiac risk and GI risk assessments to discern potential thrombotic and hemorrhagic complications.

▸ Endoscopy in patients on mono or dual antiplatelet therapy. High-risk cardiovascular patients on dual therapy may benefit from endoscopic therapy. Collaboration between the cardiologist and endoscopist is important to assess the risk of bleeding against the risk of thrombosis in regard to the timing of antiplatelet therapy cessation.

The consensus document is considered to be part of “an ongoing dialogue” and will be updated “as more definitive data are accrued,” according to the ACC statement.

Patients with heart disease are at increased risk of depression and should be screened routinely, and referred and treated as necessary for the condition, a new science advisory from the American Heart Association states.

Depression has been shown in numerous studies to have profound adverse effects on prognosis and quality of life in heart disease patients. Findings from more than 60 prospective studies, several major review articles, and more than 100 additional narrative reviews of the literature have demonstrated links between depression and cardiovascular morbidity and mortality, according to the advisory, which was published online last month by the Prevention Committee of the American Heart Association Cardiovascular Nursing Council, Clinical Cardiology Council, Epidemiology and Prevention Council, and Interdisciplinary Council on Quality of Care and Outcome Research.

It has been shown that depression is about three times more common in acute myocardial infarction patients than it is in the general community, and in-hospital assessments indicate that up to 20% of patients with myocardial infarction meet the criteria for major depression. An even greater proportion exhibits depressive symptoms, Judith H.K. Lichtman, Ph.D., cochair of the committee, and her colleagues wrote (Circulation 2008 Sept. 29 [doi:10.1161/circulationaha.108.190769]).

Furthermore, the 12-month prevalence of major depression in patients with cardiac disease was 9.3%, compared with 4.8% in those with no comorbid medical illness, in nearly 40,000 participants in a recent National Health Interview Survey.

“There is general consensus that depression remains associated with at least a doubling in risk of cardiac events over the subsequent 1–2 years after an MI,” the authors wrote. Both biological factors—such as human platelet antigen dysfunction, impaired vascular function, and reduced heart rate variability—and behavioral and/or social mechanisms—such as diet, exercise, medication adherence, tobacco use, social isolation, and chronic life stress—have been suggested as possible links between depression and heart disease.

“Although the specific behavioral and biological processes remain unclear, the alteration of these processes is associated with depressive symptoms, consistently in a direction that increases cardiovascular risk,” wrote the committee, adding that depression is associated with decreased compliance with medications; reduced chances of successful modification of other cardiac risk factors and participation in cardiac rehabilitation; higher health care utilization and cost; and greatly reduced quality of life.

“Thus, whether depression impacts cardiac outcomes directly or indirectly, the need to screen and treat depression is imperative,” they wrote.

The committee advised the following:

▸ Routine screening for depression in heart disease patients in a variety of settings, including the doctor's office, hospital, clinic, and cardiac rehabilitation center. At a minimum, administration of the Patient Health Questionnaire (PHQ-2), a two-item assessment of depression that addresses loss of interest or pleasure in normal activities, and feelings of depression and hopelessness, is advised.

▸ Administration of PHQ-9, an expanded version of the PHQ-2, to those who answer “yes” to one or both of the PHQ-2 items. The PHQ-9 assesses additional symptoms of depression, such as altered sleep patterns, fatigue, changes in appetite, and feelings of failure. In addition to yielding a provisional depression diagnosis, it provides a severity score that can be useful for guiding treatment and for patient monitoring. The tool has been shown to have “reasonable” sensitivity and specificity for those with heart disease, according to the advisory.

▸ Follow-up assessment during a subsequent visit in patients with mild symptoms.

▸ A review of the responses with those patients who had high depression scores.

▸ Referral for more comprehensive evaluation by a qualified professional in those with a PHQ-9 score of 10 or higher (out of a possible 27).

▸ Evaluation for other mental disorders, such as anxiety, in those who meet criteria for a more comprehensive evaluation.

▸ Careful monitoring for adherence to medical care, drug efficacy, and safety (with respect to both cardiovascular disease and mental health).

▸ Coordination of care among health care providers.

“Cardiologists should take depression into account in the management of [heart disease], regardless of whether they treat the depression or refer the patient to a health care provider who is qualified in the assessment and treatment of depression, which often may be the patient's primary care provider,” the committee wrote.

Depression can occur before and continue after an acute cardiac event and should not be ignored based on the premise that it is a “normal” reaction to a stressful life event, the authors wrote.

They explained that although there is no direct evidence that depression screening improves outcomes in heart disease patients, there is plenty of evidence that the presence of depression is linked with increased morbidity and mortality, poorer risk factor modifications, lower rates of rehabilitation, and reduced quality of life.

“Therefore, it is important to assess depression in cardiac patients with the goal of targeting those most in need of treatment and support services,” the committee concluded.

The advisory also includes an overview of treatment options for depression, including antidepressant drugs, cognitive behavioral therapy, lifestyle modifications, and combinations of these options.

Data suggest that treatment with SSRIs soon after acute MI is safe and effective. First-line treatments are sertraline and citalopram; among contraindicated treatments are tricyclic antidepressants and monamine oxidase inhibitors, which have cardiotoxic side effects, the advisory states.

Cognitive behavioral therapy can also be of benefit, and may be an alternative for those who cannot or will not tolerate pharmacologic therapy. In some patients, a combination of pharmacologic and psychotherapy works best. Depending on cardiac status and exercise capacity, patients might also benefit from aerobic exercise and cardiac rehabilitation alone or in combination with other treatments, but individual assessment is necessary for determining the appropriate approach.

In a written statement from the AHA, Dr. Lichtman stressed that “you can't treat the heart in isolation from the patient's mental health.”

Patients with heart disease are at increased risk of depression and should be screened routinely, and referred and treated as necessary for the condition, a new science advisory from the American Heart Association states.

Depression has been shown in numerous studies to have profound adverse effects on prognosis and quality of life in heart disease patients. Findings from more than 60 prospective studies, several major review articles, and more than 100 additional narrative reviews of the literature have demonstrated links between depression and cardiovascular morbidity and mortality, according to the advisory, which was published online last month by the Prevention Committee of the American Heart Association Cardiovascular Nursing Council, Clinical Cardiology Council, Epidemiology and Prevention Council, and Interdisciplinary Council on Quality of Care and Outcome Research.

It has been shown that depression is about three times more common in acute myocardial infarction patients than it is in the general community, and in-hospital assessments indicate that up to 20% of patients with myocardial infarction meet the criteria for major depression. An even greater proportion exhibits depressive symptoms, Judith H.K. Lichtman, Ph.D., cochair of the committee, and her colleagues wrote (Circulation 2008 Sept. 29 [doi:10.1161/circulationaha.108.190769]).

Furthermore, the 12-month prevalence of major depression in patients with cardiac disease was 9.3%, compared with 4.8% in those with no comorbid medical illness, in nearly 40,000 participants in a recent National Health Interview Survey.

“There is general consensus that depression remains associated with at least a doubling in risk of cardiac events over the subsequent 1–2 years after an MI,” the authors wrote. Both biological factors—such as human platelet antigen dysfunction, impaired vascular function, and reduced heart rate variability—and behavioral and/or social mechanisms—such as diet, exercise, medication adherence, tobacco use, social isolation, and chronic life stress—have been suggested as possible links between depression and heart disease.

“Although the specific behavioral and biological processes remain unclear, the alteration of these processes is associated with depressive symptoms, consistently in a direction that increases cardiovascular risk,” wrote the committee, adding that depression is associated with decreased compliance with medications; reduced chances of successful modification of other cardiac risk factors and participation in cardiac rehabilitation; higher health care utilization and cost; and greatly reduced quality of life.

“Thus, whether depression impacts cardiac outcomes directly or indirectly, the need to screen and treat depression is imperative,” they wrote.

The committee advised the following:

▸ Routine screening for depression in heart disease patients in a variety of settings, including the doctor's office, hospital, clinic, and cardiac rehabilitation center. At a minimum, administration of the Patient Health Questionnaire (PHQ-2), a two-item assessment of depression that addresses loss of interest or pleasure in normal activities, and feelings of depression and hopelessness, is advised.

▸ Administration of PHQ-9, an expanded version of the PHQ-2, to those who answer “yes” to one or both of the PHQ-2 items. The PHQ-9 assesses additional symptoms of depression, such as altered sleep patterns, fatigue, changes in appetite, and feelings of failure. In addition to yielding a provisional depression diagnosis, it provides a severity score that can be useful for guiding treatment and for patient monitoring. The tool has been shown to have “reasonable” sensitivity and specificity for those with heart disease, according to the advisory.

▸ Follow-up assessment during a subsequent visit in patients with mild symptoms.

▸ A review of the responses with those patients who had high depression scores.

▸ Referral for more comprehensive evaluation by a qualified professional in those with a PHQ-9 score of 10 or higher (out of a possible 27).

▸ Evaluation for other mental disorders, such as anxiety, in those who meet criteria for a more comprehensive evaluation.

▸ Careful monitoring for adherence to medical care, drug efficacy, and safety (with respect to both cardiovascular disease and mental health).

▸ Coordination of care among health care providers.

“Cardiologists should take depression into account in the management of [heart disease], regardless of whether they treat the depression or refer the patient to a health care provider who is qualified in the assessment and treatment of depression, which often may be the patient's primary care provider,” the committee wrote.

Depression can occur before and continue after an acute cardiac event and should not be ignored based on the premise that it is a “normal” reaction to a stressful life event, the authors wrote.

They explained that although there is no direct evidence that depression screening improves outcomes in heart disease patients, there is plenty of evidence that the presence of depression is linked with increased morbidity and mortality, poorer risk factor modifications, lower rates of rehabilitation, and reduced quality of life.

“Therefore, it is important to assess depression in cardiac patients with the goal of targeting those most in need of treatment and support services,” the committee concluded.

The advisory also includes an overview of treatment options for depression, including antidepressant drugs, cognitive behavioral therapy, lifestyle modifications, and combinations of these options.

Data suggest that treatment with SSRIs soon after acute MI is safe and effective. First-line treatments are sertraline and citalopram; among contraindicated treatments are tricyclic antidepressants and monamine oxidase inhibitors, which have cardiotoxic side effects, the advisory states.

Cognitive behavioral therapy can also be of benefit, and may be an alternative for those who cannot or will not tolerate pharmacologic therapy. In some patients, a combination of pharmacologic and psychotherapy works best. Depending on cardiac status and exercise capacity, patients might also benefit from aerobic exercise and cardiac rehabilitation alone or in combination with other treatments, but individual assessment is necessary for determining the appropriate approach.

In a written statement from the AHA, Dr. Lichtman stressed that “you can't treat the heart in isolation from the patient's mental health.”

Patients with heart disease are at increased risk of depression and should be screened routinely, and referred and treated as necessary for the condition, a new science advisory from the American Heart Association states.

Depression has been shown in numerous studies to have profound adverse effects on prognosis and quality of life in heart disease patients. Findings from more than 60 prospective studies, several major review articles, and more than 100 additional narrative reviews of the literature have demonstrated links between depression and cardiovascular morbidity and mortality, according to the advisory, which was published online last month by the Prevention Committee of the American Heart Association Cardiovascular Nursing Council, Clinical Cardiology Council, Epidemiology and Prevention Council, and Interdisciplinary Council on Quality of Care and Outcome Research.

It has been shown that depression is about three times more common in acute myocardial infarction patients than it is in the general community, and in-hospital assessments indicate that up to 20% of patients with myocardial infarction meet the criteria for major depression. An even greater proportion exhibits depressive symptoms, Judith H.K. Lichtman, Ph.D., cochair of the committee, and her colleagues wrote (Circulation 2008 Sept. 29 [doi:10.1161/circulationaha.108.190769]).

Furthermore, the 12-month prevalence of major depression in patients with cardiac disease was 9.3%, compared with 4.8% in those with no comorbid medical illness, in nearly 40,000 participants in a recent National Health Interview Survey.

“There is general consensus that depression remains associated with at least a doubling in risk of cardiac events over the subsequent 1–2 years after an MI,” the authors wrote. Both biological factors—such as human platelet antigen dysfunction, impaired vascular function, and reduced heart rate variability—and behavioral and/or social mechanisms—such as diet, exercise, medication adherence, tobacco use, social isolation, and chronic life stress—have been suggested as possible links between depression and heart disease.

“Although the specific behavioral and biological processes remain unclear, the alteration of these processes is associated with depressive symptoms, consistently in a direction that increases cardiovascular risk,” wrote the committee, adding that depression is associated with decreased compliance with medications; reduced chances of successful modification of other cardiac risk factors and participation in cardiac rehabilitation; higher health care utilization and cost; and greatly reduced quality of life.

“Thus, whether depression impacts cardiac outcomes directly or indirectly, the need to screen and treat depression is imperative,” they wrote.

The committee advised the following:

▸ Routine screening for depression in heart disease patients in a variety of settings, including the doctor's office, hospital, clinic, and cardiac rehabilitation center. At a minimum, administration of the Patient Health Questionnaire (PHQ-2), a two-item assessment of depression that addresses loss of interest or pleasure in normal activities, and feelings of depression and hopelessness, is advised.

▸ Administration of PHQ-9, an expanded version of the PHQ-2, to those who answer “yes” to one or both of the PHQ-2 items. The PHQ-9 assesses additional symptoms of depression, such as altered sleep patterns, fatigue, changes in appetite, and feelings of failure. In addition to yielding a provisional depression diagnosis, it provides a severity score that can be useful for guiding treatment and for patient monitoring. The tool has been shown to have “reasonable” sensitivity and specificity for those with heart disease, according to the advisory.

▸ Follow-up assessment during a subsequent visit in patients with mild symptoms.

▸ A review of the responses with those patients who had high depression scores.

▸ Referral for more comprehensive evaluation by a qualified professional in those with a PHQ-9 score of 10 or higher (out of a possible 27).

▸ Evaluation for other mental disorders, such as anxiety, in those who meet criteria for a more comprehensive evaluation.

▸ Careful monitoring for adherence to medical care, drug efficacy, and safety (with respect to both cardiovascular disease and mental health).

▸ Coordination of care among health care providers.

“Cardiologists should take depression into account in the management of [heart disease], regardless of whether they treat the depression or refer the patient to a health care provider who is qualified in the assessment and treatment of depression, which often may be the patient's primary care provider,” the committee wrote.

Depression can occur before and continue after an acute cardiac event and should not be ignored based on the premise that it is a “normal” reaction to a stressful life event, the authors wrote.

They explained that although there is no direct evidence that depression screening improves outcomes in heart disease patients, there is plenty of evidence that the presence of depression is linked with increased morbidity and mortality, poorer risk factor modifications, lower rates of rehabilitation, and reduced quality of life.

“Therefore, it is important to assess depression in cardiac patients with the goal of targeting those most in need of treatment and support services,” the committee concluded.

The advisory also includes an overview of treatment options for depression, including antidepressant drugs, cognitive behavioral therapy, lifestyle modifications, and combinations of these options.

Data suggest that treatment with SSRIs soon after acute MI is safe and effective. First-line treatments are sertraline and citalopram; among contraindicated treatments are tricyclic antidepressants and monamine oxidase inhibitors, which have cardiotoxic side effects, the advisory states.

Cognitive behavioral therapy can also be of benefit, and may be an alternative for those who cannot or will not tolerate pharmacologic therapy. In some patients, a combination of pharmacologic and psychotherapy works best. Depending on cardiac status and exercise capacity, patients might also benefit from aerobic exercise and cardiac rehabilitation alone or in combination with other treatments, but individual assessment is necessary for determining the appropriate approach.

In a written statement from the AHA, Dr. Lichtman stressed that “you can't treat the heart in isolation from the patient's mental health.”

Obese women who undergo bariatric surgery before pregnancy have significantly better perinatal outcomes, according to findings from a retrospective study of 808 deliveries.

When 507 deliveries after bariatric surgery were compared with 301 deliveries prior to such surgery, lower rates of diabetes mellitus and hypertensive disorders (11% vs. 17% and 11% vs. 24%, respectively) were seen in those who had prepregnancy surgery, investigators said in the International Journal of Gynecology and Obstetrics (doi:10.1016/j.ijgo.2008.07.008

As for fetal outcomes, macrosomia occurred in 3% of postsurgery deliveries and 8% of presurgery deliveries, Dr. Adi Y. Weintraub of Ben-Gurion University of the Negev in Beer-Sheva, Israel, and associates wrote.

All differences were statistically significant. After controlling for potential confounders, the researchers found bariatric surgery to be independently associated with a reduction in the incidence of each of these outcomes (odds ratios of 0.42 for diabetes mellitus, 0.38 for hypertensive disorders, and 0.45 for fetal macrosomia).

The findings are important given the increasing incidence of obesity—and a concomitant increase in adverse perinatal outcomes and comorbidities—in many nations throughout the world. In the United States and Israel, about a third of women of childbearing age were classified as obese between 1999 and 2002, for example. In the United Kingdom, about 40% of women in one study were classified as moderately or very obese.

“Weight loss before conception is the optimum way to decrease the risk for medical and obstetric complications in obese women of reproductive age,” according to the authors, who note that bariatric surgery has become an increasingly popular alternative to medical therapy and lifestyle changes, which have had limited success for maintaining long-term weight loss.

Previous studies have shown that pregnancies after bariatric surgery are uncomplicated and well tolerated by the mothers, despite the presence of gestational diabetes, and these findings are corroborated by those from the current study.

Women included in the current study delivered at a tertiary medical center from 1988 to 2006, and in those who delivered after bariatric surgery there was a significant reduction in the obesity rate (10% vs. 20%; odds ratio 0.43). Such a reduction indicates the surgical intervention was relatively successful, the researchers wrote.

No significant differences were seen between post- and prebariatric surgery patients in this study in the rates of recurrent abortion (6% vs. 4%), placental abruption (0.8% vs. 0.3%), premature rupture of the membranes (11% vs. 8%), intrauterine growth restriction (4% vs. 2%), or anemia (62% vs. 71%). Cesarean deliveries, however, were significantly more common in those who underwent bariatric surgery (30% vs. 18%).

Women who had bariatric surgery before delivery also had higher rates of previous Cesarean deliveries, and prior Cesarean delivery was the most common indication for Cesarean delivery among postsurgery patients. After controlling for previous Cesarean delivery, the difference in Cesarean rates between the post- and presurgery patients was no longer statistically significant. Fetal macrosomia, however, was the indication for Cesarean delivery in only 4% of postsurgery cases, compared with 15% of presurgery patients.

Limitations of the study include the fact that all forms of bariatric surgery were included and grouped together (including restrictive and malabsorptive procedures and procedures performed using open and laparoscopic techniques). There also was a lack of information regarding body mass index and weight gain during pregnancy.

Based on their findings, the researchers concluded that bariatric surgery reduces maternal complications and fetal macrosomia, and that it is not an independent risk factor for adverse perinatal outcomes.

Obese women who undergo bariatric surgery before pregnancy have significantly better perinatal outcomes, according to findings from a retrospective study of 808 deliveries.

When 507 deliveries after bariatric surgery were compared with 301 deliveries prior to such surgery, lower rates of diabetes mellitus and hypertensive disorders (11% vs. 17% and 11% vs. 24%, respectively) were seen in those who had prepregnancy surgery, investigators said in the International Journal of Gynecology and Obstetrics (doi:10.1016/j.ijgo.2008.07.008

As for fetal outcomes, macrosomia occurred in 3% of postsurgery deliveries and 8% of presurgery deliveries, Dr. Adi Y. Weintraub of Ben-Gurion University of the Negev in Beer-Sheva, Israel, and associates wrote.

All differences were statistically significant. After controlling for potential confounders, the researchers found bariatric surgery to be independently associated with a reduction in the incidence of each of these outcomes (odds ratios of 0.42 for diabetes mellitus, 0.38 for hypertensive disorders, and 0.45 for fetal macrosomia).

The findings are important given the increasing incidence of obesity—and a concomitant increase in adverse perinatal outcomes and comorbidities—in many nations throughout the world. In the United States and Israel, about a third of women of childbearing age were classified as obese between 1999 and 2002, for example. In the United Kingdom, about 40% of women in one study were classified as moderately or very obese.

“Weight loss before conception is the optimum way to decrease the risk for medical and obstetric complications in obese women of reproductive age,” according to the authors, who note that bariatric surgery has become an increasingly popular alternative to medical therapy and lifestyle changes, which have had limited success for maintaining long-term weight loss.

Previous studies have shown that pregnancies after bariatric surgery are uncomplicated and well tolerated by the mothers, despite the presence of gestational diabetes, and these findings are corroborated by those from the current study.

Women included in the current study delivered at a tertiary medical center from 1988 to 2006, and in those who delivered after bariatric surgery there was a significant reduction in the obesity rate (10% vs. 20%; odds ratio 0.43). Such a reduction indicates the surgical intervention was relatively successful, the researchers wrote.

No significant differences were seen between post- and prebariatric surgery patients in this study in the rates of recurrent abortion (6% vs. 4%), placental abruption (0.8% vs. 0.3%), premature rupture of the membranes (11% vs. 8%), intrauterine growth restriction (4% vs. 2%), or anemia (62% vs. 71%). Cesarean deliveries, however, were significantly more common in those who underwent bariatric surgery (30% vs. 18%).

Women who had bariatric surgery before delivery also had higher rates of previous Cesarean deliveries, and prior Cesarean delivery was the most common indication for Cesarean delivery among postsurgery patients. After controlling for previous Cesarean delivery, the difference in Cesarean rates between the post- and presurgery patients was no longer statistically significant. Fetal macrosomia, however, was the indication for Cesarean delivery in only 4% of postsurgery cases, compared with 15% of presurgery patients.

Limitations of the study include the fact that all forms of bariatric surgery were included and grouped together (including restrictive and malabsorptive procedures and procedures performed using open and laparoscopic techniques). There also was a lack of information regarding body mass index and weight gain during pregnancy.

Based on their findings, the researchers concluded that bariatric surgery reduces maternal complications and fetal macrosomia, and that it is not an independent risk factor for adverse perinatal outcomes.

Obese women who undergo bariatric surgery before pregnancy have significantly better perinatal outcomes, according to findings from a retrospective study of 808 deliveries.

When 507 deliveries after bariatric surgery were compared with 301 deliveries prior to such surgery, lower rates of diabetes mellitus and hypertensive disorders (11% vs. 17% and 11% vs. 24%, respectively) were seen in those who had prepregnancy surgery, investigators said in the International Journal of Gynecology and Obstetrics (doi:10.1016/j.ijgo.2008.07.008

As for fetal outcomes, macrosomia occurred in 3% of postsurgery deliveries and 8% of presurgery deliveries, Dr. Adi Y. Weintraub of Ben-Gurion University of the Negev in Beer-Sheva, Israel, and associates wrote.

All differences were statistically significant. After controlling for potential confounders, the researchers found bariatric surgery to be independently associated with a reduction in the incidence of each of these outcomes (odds ratios of 0.42 for diabetes mellitus, 0.38 for hypertensive disorders, and 0.45 for fetal macrosomia).

The findings are important given the increasing incidence of obesity—and a concomitant increase in adverse perinatal outcomes and comorbidities—in many nations throughout the world. In the United States and Israel, about a third of women of childbearing age were classified as obese between 1999 and 2002, for example. In the United Kingdom, about 40% of women in one study were classified as moderately or very obese.

“Weight loss before conception is the optimum way to decrease the risk for medical and obstetric complications in obese women of reproductive age,” according to the authors, who note that bariatric surgery has become an increasingly popular alternative to medical therapy and lifestyle changes, which have had limited success for maintaining long-term weight loss.

Previous studies have shown that pregnancies after bariatric surgery are uncomplicated and well tolerated by the mothers, despite the presence of gestational diabetes, and these findings are corroborated by those from the current study.

Women included in the current study delivered at a tertiary medical center from 1988 to 2006, and in those who delivered after bariatric surgery there was a significant reduction in the obesity rate (10% vs. 20%; odds ratio 0.43). Such a reduction indicates the surgical intervention was relatively successful, the researchers wrote.

No significant differences were seen between post- and prebariatric surgery patients in this study in the rates of recurrent abortion (6% vs. 4%), placental abruption (0.8% vs. 0.3%), premature rupture of the membranes (11% vs. 8%), intrauterine growth restriction (4% vs. 2%), or anemia (62% vs. 71%). Cesarean deliveries, however, were significantly more common in those who underwent bariatric surgery (30% vs. 18%).

Women who had bariatric surgery before delivery also had higher rates of previous Cesarean deliveries, and prior Cesarean delivery was the most common indication for Cesarean delivery among postsurgery patients. After controlling for previous Cesarean delivery, the difference in Cesarean rates between the post- and presurgery patients was no longer statistically significant. Fetal macrosomia, however, was the indication for Cesarean delivery in only 4% of postsurgery cases, compared with 15% of presurgery patients.

Limitations of the study include the fact that all forms of bariatric surgery were included and grouped together (including restrictive and malabsorptive procedures and procedures performed using open and laparoscopic techniques). There also was a lack of information regarding body mass index and weight gain during pregnancy.

Based on their findings, the researchers concluded that bariatric surgery reduces maternal complications and fetal macrosomia, and that it is not an independent risk factor for adverse perinatal outcomes.

DESTIN, FLA. — Since Epstein-Barr virus is known in rare cases to initially present as severe, painful genital ulcerations without other clinical or laboratory evidence of acute disease, this infection should be considered in the differential diagnosis of patients who present with such lesions.

“You won't see it presenting this way very often, but … if you have young patients presenting like this, remember to test for EBV,” Dr. Bari Cunningham said at a meeting sponsored by the Alabama Dermatology Society.

Dr. Cunningham, of the University of California, San Diego, described the case of a 15-year-old girl who presented with extremely painful vaginal lesions.

“Of course, sexually transmitted diseases were first and foremost on everybody's mind,” she said, noting that the patient, who was adamant that she was not sexually active, was traumatized by the constant questioning about her sexual history and by the fact that no one believed her.

When the cultures came back negative, the differential was broadened, and Behçet's syndrome, systemic lupus erythematosus, pyoderma gangrenosum, and inflammatory bowel disease were among the diagnoses considered. The girl's conditioned worsened. She became sicker and stopped eating, and more skin surfaces became involved. She was noted to have a swollen liver. All cultures up to that point were negative and a complete blood count was unremarkable; however, mild elevations on liver function tests, which developed during hospitalization, were noted, and the test for EBV immunoglobulin M came back positive.

Several cases of EBV presenting in this manner have been reported in the literature, she said, noting the lesions are extremely painful and there is typically a lack of evidence of acute EBV at presentation.

DESTIN, FLA. — Since Epstein-Barr virus is known in rare cases to initially present as severe, painful genital ulcerations without other clinical or laboratory evidence of acute disease, this infection should be considered in the differential diagnosis of patients who present with such lesions.

“You won't see it presenting this way very often, but … if you have young patients presenting like this, remember to test for EBV,” Dr. Bari Cunningham said at a meeting sponsored by the Alabama Dermatology Society.

Dr. Cunningham, of the University of California, San Diego, described the case of a 15-year-old girl who presented with extremely painful vaginal lesions.

“Of course, sexually transmitted diseases were first and foremost on everybody's mind,” she said, noting that the patient, who was adamant that she was not sexually active, was traumatized by the constant questioning about her sexual history and by the fact that no one believed her.

When the cultures came back negative, the differential was broadened, and Behçet's syndrome, systemic lupus erythematosus, pyoderma gangrenosum, and inflammatory bowel disease were among the diagnoses considered. The girl's conditioned worsened. She became sicker and stopped eating, and more skin surfaces became involved. She was noted to have a swollen liver. All cultures up to that point were negative and a complete blood count was unremarkable; however, mild elevations on liver function tests, which developed during hospitalization, were noted, and the test for EBV immunoglobulin M came back positive.

Several cases of EBV presenting in this manner have been reported in the literature, she said, noting the lesions are extremely painful and there is typically a lack of evidence of acute EBV at presentation.

DESTIN, FLA. — Since Epstein-Barr virus is known in rare cases to initially present as severe, painful genital ulcerations without other clinical or laboratory evidence of acute disease, this infection should be considered in the differential diagnosis of patients who present with such lesions.

“You won't see it presenting this way very often, but … if you have young patients presenting like this, remember to test for EBV,” Dr. Bari Cunningham said at a meeting sponsored by the Alabama Dermatology Society.

Dr. Cunningham, of the University of California, San Diego, described the case of a 15-year-old girl who presented with extremely painful vaginal lesions.

“Of course, sexually transmitted diseases were first and foremost on everybody's mind,” she said, noting that the patient, who was adamant that she was not sexually active, was traumatized by the constant questioning about her sexual history and by the fact that no one believed her.

When the cultures came back negative, the differential was broadened, and Behçet's syndrome, systemic lupus erythematosus, pyoderma gangrenosum, and inflammatory bowel disease were among the diagnoses considered. The girl's conditioned worsened. She became sicker and stopped eating, and more skin surfaces became involved. She was noted to have a swollen liver. All cultures up to that point were negative and a complete blood count was unremarkable; however, mild elevations on liver function tests, which developed during hospitalization, were noted, and the test for EBV immunoglobulin M came back positive.

Several cases of EBV presenting in this manner have been reported in the literature, she said, noting the lesions are extremely painful and there is typically a lack of evidence of acute EBV at presentation.

DESTIN, FLA. — Ethnicity appears to play an important role in the incidence and clinical manifestations of pediatric systemic lupus erythematosus, data from a recent study suggest.

Findings from the study of 87 white and 154 nonwhite children showed that more than 60% of age-matched controls without pediatric systemic lupus erythematosus (SLE) were white; however, fewer than 40% of the pediatric SLE patients were white. Black, Asian, and South Asian patients are overrepresented in the pediatric SLE population, Dr. Earl Silverman reported at a rheumatology conference sponsored by Virginia Commonwealth University, Richmond.

The study, which has been submitted for publication, found that mucocutaneous manifestations were more common in white children and organ involvement was more common in nonwhite children, said Dr. Silverman, professor of pediatrics and immunology at the University of Toronto.

Malar rash and photosensitivity were the mucocutaneous manifestations seen more often in the white patients, compared with the nonwhite patients (occurring in 86% vs. 66% and 40% vs. 18%, respectively). Renal disease occurred in 45% of the white patients, compared with 62% of the nonwhite patients, he noted. Central nervous system involvement occurred at similar rates in both groups (24% and 25%, respectively).

In regard to autoantibodies, ethnicity also appeared to play a role. Although anti-DNA, anticardiolipin, lupus anticoagulant, and anti-La antibodies were similar in white and nonwhite children, anti-Sm, anti-RNP, and anti-Ro were expressed more in the nonwhite patients (34% vs. 56%; 30% vs. 42%; and 28% vs. 45%, respectively).

The differences in course and incidence of SLE, based on ethnicity, are likely a result of interactions between genes and environment. Although there are no direct implications for physicians based on these findings, it is hoped that the study will help identify groups that are at low and high risk for mild and severe SLE, he said.

In addition to the ethnic differences in pediatric SLE, compared with adult SLE, physicians should also keep in mind that 20% of all SLE cases begin before age 18 years, with an overall prevalence of 10–20/10,000 children in this age group. In addition, girls are four times as likely as boys to develop SLE, Dr. Silverman said.

The diagnosis of pediatric SLE usually occurs during the ages of 11–14 years.

Common features are fever, weight loss, malaise or lethargy, and fatigue. Despite controversy over whether the features of SLE differ in pre- and postpubertal children, a study by Catherine DiSipio and her colleagues at Columbia University, New York, presented in poster form at the 2007 meeting of the American College of Rheumatology showed that the rates of arthritis, serositis, renal disease, central nervous system disease, and hematologic complications did not differ between the groups, nor did median SLE disease activity index.

However, intensive care unit admissions and deaths occurred more often in those younger than age 11 years, compared with those 11 years and older (32% vs. 21% and 11% vs. 0%, respectively).

Neuropsychiatric manifestations also can occur in pediatric SLE. Studies suggest that, among patients with neurologic involvement (about 25% of SLE patients), headache occurs in 68%, psychosis occurs in 36%, cognitive dysfunction occurs in 27%, cardiovascular disease occurs in 24%, seizures occur in 18%, mood disorders occur in 15%, and chorea occurs in 11%.

Visual hallucinations are a hallmark of SLE-related psychosis in pediatric patients. Visual distortions are often seen, as is sensitivity to light and sound. Magnetic resonance imaging is frequently normal in SLE-related psychosis, but a SPECT scan can be helpful for differentiating it from idiopathic schizophrenia, he said.

DESTIN, FLA. — Ethnicity appears to play an important role in the incidence and clinical manifestations of pediatric systemic lupus erythematosus, data from a recent study suggest.

Findings from the study of 87 white and 154 nonwhite children showed that more than 60% of age-matched controls without pediatric systemic lupus erythematosus (SLE) were white; however, fewer than 40% of the pediatric SLE patients were white. Black, Asian, and South Asian patients are overrepresented in the pediatric SLE population, Dr. Earl Silverman reported at a rheumatology conference sponsored by Virginia Commonwealth University, Richmond.

The study, which has been submitted for publication, found that mucocutaneous manifestations were more common in white children and organ involvement was more common in nonwhite children, said Dr. Silverman, professor of pediatrics and immunology at the University of Toronto.

Malar rash and photosensitivity were the mucocutaneous manifestations seen more often in the white patients, compared with the nonwhite patients (occurring in 86% vs. 66% and 40% vs. 18%, respectively). Renal disease occurred in 45% of the white patients, compared with 62% of the nonwhite patients, he noted. Central nervous system involvement occurred at similar rates in both groups (24% and 25%, respectively).

In regard to autoantibodies, ethnicity also appeared to play a role. Although anti-DNA, anticardiolipin, lupus anticoagulant, and anti-La antibodies were similar in white and nonwhite children, anti-Sm, anti-RNP, and anti-Ro were expressed more in the nonwhite patients (34% vs. 56%; 30% vs. 42%; and 28% vs. 45%, respectively).

The differences in course and incidence of SLE, based on ethnicity, are likely a result of interactions between genes and environment. Although there are no direct implications for physicians based on these findings, it is hoped that the study will help identify groups that are at low and high risk for mild and severe SLE, he said.

In addition to the ethnic differences in pediatric SLE, compared with adult SLE, physicians should also keep in mind that 20% of all SLE cases begin before age 18 years, with an overall prevalence of 10–20/10,000 children in this age group. In addition, girls are four times as likely as boys to develop SLE, Dr. Silverman said.

The diagnosis of pediatric SLE usually occurs during the ages of 11–14 years.

Common features are fever, weight loss, malaise or lethargy, and fatigue. Despite controversy over whether the features of SLE differ in pre- and postpubertal children, a study by Catherine DiSipio and her colleagues at Columbia University, New York, presented in poster form at the 2007 meeting of the American College of Rheumatology showed that the rates of arthritis, serositis, renal disease, central nervous system disease, and hematologic complications did not differ between the groups, nor did median SLE disease activity index.

However, intensive care unit admissions and deaths occurred more often in those younger than age 11 years, compared with those 11 years and older (32% vs. 21% and 11% vs. 0%, respectively).

Neuropsychiatric manifestations also can occur in pediatric SLE. Studies suggest that, among patients with neurologic involvement (about 25% of SLE patients), headache occurs in 68%, psychosis occurs in 36%, cognitive dysfunction occurs in 27%, cardiovascular disease occurs in 24%, seizures occur in 18%, mood disorders occur in 15%, and chorea occurs in 11%.

Visual hallucinations are a hallmark of SLE-related psychosis in pediatric patients. Visual distortions are often seen, as is sensitivity to light and sound. Magnetic resonance imaging is frequently normal in SLE-related psychosis, but a SPECT scan can be helpful for differentiating it from idiopathic schizophrenia, he said.

DESTIN, FLA. — Ethnicity appears to play an important role in the incidence and clinical manifestations of pediatric systemic lupus erythematosus, data from a recent study suggest.

Findings from the study of 87 white and 154 nonwhite children showed that more than 60% of age-matched controls without pediatric systemic lupus erythematosus (SLE) were white; however, fewer than 40% of the pediatric SLE patients were white. Black, Asian, and South Asian patients are overrepresented in the pediatric SLE population, Dr. Earl Silverman reported at a rheumatology conference sponsored by Virginia Commonwealth University, Richmond.

The study, which has been submitted for publication, found that mucocutaneous manifestations were more common in white children and organ involvement was more common in nonwhite children, said Dr. Silverman, professor of pediatrics and immunology at the University of Toronto.

Malar rash and photosensitivity were the mucocutaneous manifestations seen more often in the white patients, compared with the nonwhite patients (occurring in 86% vs. 66% and 40% vs. 18%, respectively). Renal disease occurred in 45% of the white patients, compared with 62% of the nonwhite patients, he noted. Central nervous system involvement occurred at similar rates in both groups (24% and 25%, respectively).

In regard to autoantibodies, ethnicity also appeared to play a role. Although anti-DNA, anticardiolipin, lupus anticoagulant, and anti-La antibodies were similar in white and nonwhite children, anti-Sm, anti-RNP, and anti-Ro were expressed more in the nonwhite patients (34% vs. 56%; 30% vs. 42%; and 28% vs. 45%, respectively).

The differences in course and incidence of SLE, based on ethnicity, are likely a result of interactions between genes and environment. Although there are no direct implications for physicians based on these findings, it is hoped that the study will help identify groups that are at low and high risk for mild and severe SLE, he said.

In addition to the ethnic differences in pediatric SLE, compared with adult SLE, physicians should also keep in mind that 20% of all SLE cases begin before age 18 years, with an overall prevalence of 10–20/10,000 children in this age group. In addition, girls are four times as likely as boys to develop SLE, Dr. Silverman said.

The diagnosis of pediatric SLE usually occurs during the ages of 11–14 years.

Common features are fever, weight loss, malaise or lethargy, and fatigue. Despite controversy over whether the features of SLE differ in pre- and postpubertal children, a study by Catherine DiSipio and her colleagues at Columbia University, New York, presented in poster form at the 2007 meeting of the American College of Rheumatology showed that the rates of arthritis, serositis, renal disease, central nervous system disease, and hematologic complications did not differ between the groups, nor did median SLE disease activity index.

However, intensive care unit admissions and deaths occurred more often in those younger than age 11 years, compared with those 11 years and older (32% vs. 21% and 11% vs. 0%, respectively).

Neuropsychiatric manifestations also can occur in pediatric SLE. Studies suggest that, among patients with neurologic involvement (about 25% of SLE patients), headache occurs in 68%, psychosis occurs in 36%, cognitive dysfunction occurs in 27%, cardiovascular disease occurs in 24%, seizures occur in 18%, mood disorders occur in 15%, and chorea occurs in 11%.

Visual hallucinations are a hallmark of SLE-related psychosis in pediatric patients. Visual distortions are often seen, as is sensitivity to light and sound. Magnetic resonance imaging is frequently normal in SLE-related psychosis, but a SPECT scan can be helpful for differentiating it from idiopathic schizophrenia, he said.

NEW ORLEANS — Reduced serum selenium is an independent predictor of hypertension, according to an analysis of data from the third National Health and Nutrition Examination Surveys.

The findings from this and other studies, that serum selenium concentrations are reduced in African Americans, compared with those in with whites, may in part explain the increased incidence of hypertension in African Americans, Dr. Chizobam Ani said in a poster at a meeting sponsored by the International Society on Hypertension in Blacks.

Serum selenium is an essential component in substances shown to mediate the incidence of cardiovascular disease, such as glutathione peroxidase and homocysteine. In 9,881 nonpregnant participants aged 40 years and older, researchers noted significant differences in serum selenium concentrations between African Americans and whites at the highest and lowest quartile concentrations, reported Dr. Ani of Charles Drew University of Medicine and Science, Los Angeles.

On bivariate analysis, there was a significant association between serum selenium concentration and the prevalence of hypertension and other cardiovascular disease, including peripheral vascular disease, myocardial infarction, and congestive heart failure.

An analysis that controlled for known predictors of cardiovascular disease, including family history, diabetes, sociodemographic variables, and renal disease, showed a significant relationship between serum selenium and the prevalence of hypertension (odds ratio 1.30) and a significant interaction effect between ethnicity and serum selenium in individuals with hypertension (OR 1.10).

These findings are important because African Americans have higher rates of hypertension and mortality from heart disease and stroke than do whites and Hispanics in the United States, and because African American men have three times the risk of sudden death as do white men.

Based on the emerging understanding of the role of serum selenium in hypertension and cardiovascular disease, and the differing concentrations in African Americans and whites, Dr. Ani and his colleagues theorized that high serum concentrations of selenium might predict reduced levels of oxidate stress and vascular injury in certain ethnic groups that correlates with the incidence of cardiovascular diseases.

The current findings seem to support this theory of “differential oxidative protection for cardiovascular injury” in African Americans, compared with whites, he said in an interview. The findings are of interest because low serum selenium concentration is a modifiable risk factor, he said.

NEW ORLEANS — Reduced serum selenium is an independent predictor of hypertension, according to an analysis of data from the third National Health and Nutrition Examination Surveys.

The findings from this and other studies, that serum selenium concentrations are reduced in African Americans, compared with those in with whites, may in part explain the increased incidence of hypertension in African Americans, Dr. Chizobam Ani said in a poster at a meeting sponsored by the International Society on Hypertension in Blacks.

Serum selenium is an essential component in substances shown to mediate the incidence of cardiovascular disease, such as glutathione peroxidase and homocysteine. In 9,881 nonpregnant participants aged 40 years and older, researchers noted significant differences in serum selenium concentrations between African Americans and whites at the highest and lowest quartile concentrations, reported Dr. Ani of Charles Drew University of Medicine and Science, Los Angeles.

On bivariate analysis, there was a significant association between serum selenium concentration and the prevalence of hypertension and other cardiovascular disease, including peripheral vascular disease, myocardial infarction, and congestive heart failure.

An analysis that controlled for known predictors of cardiovascular disease, including family history, diabetes, sociodemographic variables, and renal disease, showed a significant relationship between serum selenium and the prevalence of hypertension (odds ratio 1.30) and a significant interaction effect between ethnicity and serum selenium in individuals with hypertension (OR 1.10).

These findings are important because African Americans have higher rates of hypertension and mortality from heart disease and stroke than do whites and Hispanics in the United States, and because African American men have three times the risk of sudden death as do white men.

Based on the emerging understanding of the role of serum selenium in hypertension and cardiovascular disease, and the differing concentrations in African Americans and whites, Dr. Ani and his colleagues theorized that high serum concentrations of selenium might predict reduced levels of oxidate stress and vascular injury in certain ethnic groups that correlates with the incidence of cardiovascular diseases.

The current findings seem to support this theory of “differential oxidative protection for cardiovascular injury” in African Americans, compared with whites, he said in an interview. The findings are of interest because low serum selenium concentration is a modifiable risk factor, he said.

NEW ORLEANS — Reduced serum selenium is an independent predictor of hypertension, according to an analysis of data from the third National Health and Nutrition Examination Surveys.

The findings from this and other studies, that serum selenium concentrations are reduced in African Americans, compared with those in with whites, may in part explain the increased incidence of hypertension in African Americans, Dr. Chizobam Ani said in a poster at a meeting sponsored by the International Society on Hypertension in Blacks.

Serum selenium is an essential component in substances shown to mediate the incidence of cardiovascular disease, such as glutathione peroxidase and homocysteine. In 9,881 nonpregnant participants aged 40 years and older, researchers noted significant differences in serum selenium concentrations between African Americans and whites at the highest and lowest quartile concentrations, reported Dr. Ani of Charles Drew University of Medicine and Science, Los Angeles.

On bivariate analysis, there was a significant association between serum selenium concentration and the prevalence of hypertension and other cardiovascular disease, including peripheral vascular disease, myocardial infarction, and congestive heart failure.

An analysis that controlled for known predictors of cardiovascular disease, including family history, diabetes, sociodemographic variables, and renal disease, showed a significant relationship between serum selenium and the prevalence of hypertension (odds ratio 1.30) and a significant interaction effect between ethnicity and serum selenium in individuals with hypertension (OR 1.10).

These findings are important because African Americans have higher rates of hypertension and mortality from heart disease and stroke than do whites and Hispanics in the United States, and because African American men have three times the risk of sudden death as do white men.

Based on the emerging understanding of the role of serum selenium in hypertension and cardiovascular disease, and the differing concentrations in African Americans and whites, Dr. Ani and his colleagues theorized that high serum concentrations of selenium might predict reduced levels of oxidate stress and vascular injury in certain ethnic groups that correlates with the incidence of cardiovascular diseases.

The current findings seem to support this theory of “differential oxidative protection for cardiovascular injury” in African Americans, compared with whites, he said in an interview. The findings are of interest because low serum selenium concentration is a modifiable risk factor, he said.

Tanning dependence, sometimes called "tanorexia," is common in young adults and can be predicted by certain demographic and behavioral variables, according to a survey of 400 college students.

More than a quarter (27%) of survey respondents were classified as tanning dependent, and ethnicity, skin type, lack of skin protective behaviors, tanning behaviors, smoking, and body mass index each were found to be significant independent predictors of tanning dependence, reported Carolyn J. Heckman, Ph.D., of Fox Chase Cancer Center in Cheltenham, Pa., and her colleagues (Am. J. Health Behav. 2008;32:451–64).

The findings could assist clinicians in identifying individuals who are tanning dependent or who are at risk of becoming dependent, the investigators said.

In the article, which is now in press, the investigators stated that tanning dependence has a number of similarities to substance use, including higher prevalence among youth, an initial perception that the behavior is image enhancing, and high health risks and disregard for warnings about those risks. Although a primary motivation for tanning is appearance enhancement, tanners often report other benefits, such as mood enhancement, and socialization, commonly reported by individuals with other types of dependencies, Dr. Heckman and her associates noted.

Tanning dependence also has similarities to disorders such as obsessive compulsive disorder and eating disorders, thus the nickname "tanorexia," but it is unclear which comparisons are most applicable.

Prior studies have suggested that one possible mechanism for tanning dependence is endogenous opioid release during ultraviolet radiation (UVR) exposure: Blinded study participants demonstrated a preference for UVR vs. non-UVR tanning beds, and UVR exposure was associated with a more relaxed and less tense mood in those studies. Furthermore, in at least one other study, the preference for UVR tanning beds was reduced with increasing doses of the opioid antagonist naltrexone.

In the current study, which was sponsored by the National Cancer Institute, tanning dependence was assessed using measures developed to evaluate more traditional addictive behaviors such as substance use, which were adapted for the purpose of assessing tanning addiction. The scales used were the four-question CAGE alcohol evaluation and the American Psychiatric Association's Diagnostic and Statistics Manual IV-Text Revision substance dependence criteria.

Participants, who had a mean age of 21 years and were mostly women (75%), were asked questions about tanning behaviors such as "Do you think you need to spend more and more time in the sun to maintain your perfect tan?" and "Does your belief that tanning can cause skin cancer keep you from spending time in the sun or going to tanning beds?"

Of the 400 individuals surveyed, 106 (27%) were classified as tanning dependent by one or both of the two scales used, the investigators found.

Race was found to be predictive of tanning dependence, with white participants having 7.6-fold greater odds than African Americans. Also predictive was moderate skin type, compared with fair and dark skin. Those with Fitzpatrick type III and IV skin had the highest risk: Sixteen percent of those with type I, 21% with type II, 39% with type III, 32% with type IV, and 4% with type V skin were tanning dependent.

Several exposure and skin protection factors were found to predict tanning dependence:

▸ Those with highest level of summer sunbathing were more likely to be tanning dependent (odds ratio 7.5) than were those with the lowest level.

▸ Respondents who had the highest number of sunburns were more likely to be tanning dependent (OR 2.85).

▸ Those who used moderate (OR 0.27) or high levels (OR 0.36) of sun protection were less likely than were those who used low levels to be tanning dependent.

▸ Those who tanned indoors during warm weather were more likely to be tanning dependent (OR 2.99) than were those who did not use indoor tanning.

The use of chemical sunless tanners and the overall rates of indoor tanning did not predict tanning dependence in this study.

Health-related behaviors that were linked with tanning dependence included current smoking, with smokers having 1.81 greater odds of tanning dependence, and obesity, with those considered obese having lower likelihood of being dependent (odds ratio 0.34).

The findings may offer new avenues for research as well as skin protection and skin cancer prevention interventions, the investigators concluded, but they also noted that "not all tanning behavior or even frequent behavior should be seen as indicative of tanning dependence."

Nonetheless, they expressed concern regarding the finding that about 40% of respondents had used tanning beds, with a mean age of 17 years at first tanning and a mean number of lifetime uses of 57. This is alarming, considering the mean age of 21 in the respondents, they stated.

Tanning dependence bears similarities both to substance use disorder and to eating disorders, thus the nickname "tanorexia." ©Bora

Tanning dependence, sometimes called "tanorexia," is common in young adults and can be predicted by certain demographic and behavioral variables, according to a survey of 400 college students.

More than a quarter (27%) of survey respondents were classified as tanning dependent, and ethnicity, skin type, lack of skin protective behaviors, tanning behaviors, smoking, and body mass index each were found to be significant independent predictors of tanning dependence, reported Carolyn J. Heckman, Ph.D., of Fox Chase Cancer Center in Cheltenham, Pa., and her colleagues (Am. J. Health Behav. 2008;32:451–64).

The findings could assist clinicians in identifying individuals who are tanning dependent or who are at risk of becoming dependent, the investigators said.

In the article, which is now in press, the investigators stated that tanning dependence has a number of similarities to substance use, including higher prevalence among youth, an initial perception that the behavior is image enhancing, and high health risks and disregard for warnings about those risks. Although a primary motivation for tanning is appearance enhancement, tanners often report other benefits, such as mood enhancement, and socialization, commonly reported by individuals with other types of dependencies, Dr. Heckman and her associates noted.

Tanning dependence also has similarities to disorders such as obsessive compulsive disorder and eating disorders, thus the nickname "tanorexia," but it is unclear which comparisons are most applicable.

Prior studies have suggested that one possible mechanism for tanning dependence is endogenous opioid release during ultraviolet radiation (UVR) exposure: Blinded study participants demonstrated a preference for UVR vs. non-UVR tanning beds, and UVR exposure was associated with a more relaxed and less tense mood in those studies. Furthermore, in at least one other study, the preference for UVR tanning beds was reduced with increasing doses of the opioid antagonist naltrexone.

In the current study, which was sponsored by the National Cancer Institute, tanning dependence was assessed using measures developed to evaluate more traditional addictive behaviors such as substance use, which were adapted for the purpose of assessing tanning addiction. The scales used were the four-question CAGE alcohol evaluation and the American Psychiatric Association's Diagnostic and Statistics Manual IV-Text Revision substance dependence criteria.

Participants, who had a mean age of 21 years and were mostly women (75%), were asked questions about tanning behaviors such as "Do you think you need to spend more and more time in the sun to maintain your perfect tan?" and "Does your belief that tanning can cause skin cancer keep you from spending time in the sun or going to tanning beds?"

Of the 400 individuals surveyed, 106 (27%) were classified as tanning dependent by one or both of the two scales used, the investigators found.

Race was found to be predictive of tanning dependence, with white participants having 7.6-fold greater odds than African Americans. Also predictive was moderate skin type, compared with fair and dark skin. Those with Fitzpatrick type III and IV skin had the highest risk: Sixteen percent of those with type I, 21% with type II, 39% with type III, 32% with type IV, and 4% with type V skin were tanning dependent.

Several exposure and skin protection factors were found to predict tanning dependence:

▸ Those with highest level of summer sunbathing were more likely to be tanning dependent (odds ratio 7.5) than were those with the lowest level.

▸ Respondents who had the highest number of sunburns were more likely to be tanning dependent (OR 2.85).

▸ Those who used moderate (OR 0.27) or high levels (OR 0.36) of sun protection were less likely than were those who used low levels to be tanning dependent.

▸ Those who tanned indoors during warm weather were more likely to be tanning dependent (OR 2.99) than were those who did not use indoor tanning.

The use of chemical sunless tanners and the overall rates of indoor tanning did not predict tanning dependence in this study.

Health-related behaviors that were linked with tanning dependence included current smoking, with smokers having 1.81 greater odds of tanning dependence, and obesity, with those considered obese having lower likelihood of being dependent (odds ratio 0.34).

The findings may offer new avenues for research as well as skin protection and skin cancer prevention interventions, the investigators concluded, but they also noted that "not all tanning behavior or even frequent behavior should be seen as indicative of tanning dependence."

Nonetheless, they expressed concern regarding the finding that about 40% of respondents had used tanning beds, with a mean age of 17 years at first tanning and a mean number of lifetime uses of 57. This is alarming, considering the mean age of 21 in the respondents, they stated.

Tanning dependence bears similarities both to substance use disorder and to eating disorders, thus the nickname "tanorexia." ©Bora

Tanning dependence, sometimes called "tanorexia," is common in young adults and can be predicted by certain demographic and behavioral variables, according to a survey of 400 college students.

More than a quarter (27%) of survey respondents were classified as tanning dependent, and ethnicity, skin type, lack of skin protective behaviors, tanning behaviors, smoking, and body mass index each were found to be significant independent predictors of tanning dependence, reported Carolyn J. Heckman, Ph.D., of Fox Chase Cancer Center in Cheltenham, Pa., and her colleagues (Am. J. Health Behav. 2008;32:451–64).

The findings could assist clinicians in identifying individuals who are tanning dependent or who are at risk of becoming dependent, the investigators said.

In the article, which is now in press, the investigators stated that tanning dependence has a number of similarities to substance use, including higher prevalence among youth, an initial perception that the behavior is image enhancing, and high health risks and disregard for warnings about those risks. Although a primary motivation for tanning is appearance enhancement, tanners often report other benefits, such as mood enhancement, and socialization, commonly reported by individuals with other types of dependencies, Dr. Heckman and her associates noted.

Tanning dependence also has similarities to disorders such as obsessive compulsive disorder and eating disorders, thus the nickname "tanorexia," but it is unclear which comparisons are most applicable.

Prior studies have suggested that one possible mechanism for tanning dependence is endogenous opioid release during ultraviolet radiation (UVR) exposure: Blinded study participants demonstrated a preference for UVR vs. non-UVR tanning beds, and UVR exposure was associated with a more relaxed and less tense mood in those studies. Furthermore, in at least one other study, the preference for UVR tanning beds was reduced with increasing doses of the opioid antagonist naltrexone.

In the current study, which was sponsored by the National Cancer Institute, tanning dependence was assessed using measures developed to evaluate more traditional addictive behaviors such as substance use, which were adapted for the purpose of assessing tanning addiction. The scales used were the four-question CAGE alcohol evaluation and the American Psychiatric Association's Diagnostic and Statistics Manual IV-Text Revision substance dependence criteria.

Participants, who had a mean age of 21 years and were mostly women (75%), were asked questions about tanning behaviors such as "Do you think you need to spend more and more time in the sun to maintain your perfect tan?" and "Does your belief that tanning can cause skin cancer keep you from spending time in the sun or going to tanning beds?"

Of the 400 individuals surveyed, 106 (27%) were classified as tanning dependent by one or both of the two scales used, the investigators found.

Race was found to be predictive of tanning dependence, with white participants having 7.6-fold greater odds than African Americans. Also predictive was moderate skin type, compared with fair and dark skin. Those with Fitzpatrick type III and IV skin had the highest risk: Sixteen percent of those with type I, 21% with type II, 39% with type III, 32% with type IV, and 4% with type V skin were tanning dependent.

Several exposure and skin protection factors were found to predict tanning dependence:

▸ Those with highest level of summer sunbathing were more likely to be tanning dependent (odds ratio 7.5) than were those with the lowest level.

▸ Respondents who had the highest number of sunburns were more likely to be tanning dependent (OR 2.85).

▸ Those who used moderate (OR 0.27) or high levels (OR 0.36) of sun protection were less likely than were those who used low levels to be tanning dependent.

▸ Those who tanned indoors during warm weather were more likely to be tanning dependent (OR 2.99) than were those who did not use indoor tanning.

The use of chemical sunless tanners and the overall rates of indoor tanning did not predict tanning dependence in this study.

Health-related behaviors that were linked with tanning dependence included current smoking, with smokers having 1.81 greater odds of tanning dependence, and obesity, with those considered obese having lower likelihood of being dependent (odds ratio 0.34).

The findings may offer new avenues for research as well as skin protection and skin cancer prevention interventions, the investigators concluded, but they also noted that "not all tanning behavior or even frequent behavior should be seen as indicative of tanning dependence."

Nonetheless, they expressed concern regarding the finding that about 40% of respondents had used tanning beds, with a mean age of 17 years at first tanning and a mean number of lifetime uses of 57. This is alarming, considering the mean age of 21 in the respondents, they stated.

Tanning dependence bears similarities both to substance use disorder and to eating disorders, thus the nickname "tanorexia." ©Bora

NEW ORLEANS — Obesity blunts the normal pattern of nocturnal blood pressure dipping, and this might be one mechanism through which obesity contributes to adverse cardiovascular outcomes, findings from a recent study suggest.

Blood pressure normally drops by 10%-20% at night during sleep, compared with blood pressure during waking hours during the day, and studies have shown that nondipping (defined as less than a 10% decrease in blood pressure at night) is associated with increased cardiovascular morbidity and mortality, Dr. Otelio Randall reported in a poster at a meeting sponsored by the International Society on Hypertension in Blacks.

In the study, hourly blood pressure measurements were taken in 200 obese African American patients who were classified into three groups on the basis of their body mass index, in kg/m2: less than 40, 40-49, and at least 50. The average age of the patients was 47 years, and most (83%) were women.

The researchers found that as BMI increased, so did the rates of nocturnal nondipping. The rates of nondipping were 26%, 41%, and 76% for the three BMI categories, respectively. Additionally, 36% of the patients were “reverse dippers,” meaning that their blood pressure actually increased at night, reported Dr. Randall, professor of medicine and cardiology at Howard University, Washington.

The mean percentage of dipping was 8.6% in those with a BMI of less than 40, 8.4% in those with a BMI of 40-49, and 3.9% in those with a BMI of 50 or greater. Those with a BMI of at least 50 had a significantly smaller decrease in nocturnal blood pressure than the other two BMI groups.

Daytime blood pressure for this study was defined as the average of hourly readings between 8 a.m. and 10 p.m., and nighttime blood pressure was defined as the average of hourly readings from 10 p.m. to 6 a.m.

“Nondipping and reverse dipping are known to be associated with the potential risk for target organ damage. The high rates of nondipping and reverse dipping in this obese population reinforces the need to reduce BMI and improve hemodynamic and lipid profiles through lifestyle changes,” Dr. Randall said.

NEW ORLEANS — Obesity blunts the normal pattern of nocturnal blood pressure dipping, and this might be one mechanism through which obesity contributes to adverse cardiovascular outcomes, findings from a recent study suggest.

Blood pressure normally drops by 10%-20% at night during sleep, compared with blood pressure during waking hours during the day, and studies have shown that nondipping (defined as less than a 10% decrease in blood pressure at night) is associated with increased cardiovascular morbidity and mortality, Dr. Otelio Randall reported in a poster at a meeting sponsored by the International Society on Hypertension in Blacks.

In the study, hourly blood pressure measurements were taken in 200 obese African American patients who were classified into three groups on the basis of their body mass index, in kg/m2: less than 40, 40-49, and at least 50. The average age of the patients was 47 years, and most (83%) were women.

The researchers found that as BMI increased, so did the rates of nocturnal nondipping. The rates of nondipping were 26%, 41%, and 76% for the three BMI categories, respectively. Additionally, 36% of the patients were “reverse dippers,” meaning that their blood pressure actually increased at night, reported Dr. Randall, professor of medicine and cardiology at Howard University, Washington.

The mean percentage of dipping was 8.6% in those with a BMI of less than 40, 8.4% in those with a BMI of 40-49, and 3.9% in those with a BMI of 50 or greater. Those with a BMI of at least 50 had a significantly smaller decrease in nocturnal blood pressure than the other two BMI groups.

Daytime blood pressure for this study was defined as the average of hourly readings between 8 a.m. and 10 p.m., and nighttime blood pressure was defined as the average of hourly readings from 10 p.m. to 6 a.m.

“Nondipping and reverse dipping are known to be associated with the potential risk for target organ damage. The high rates of nondipping and reverse dipping in this obese population reinforces the need to reduce BMI and improve hemodynamic and lipid profiles through lifestyle changes,” Dr. Randall said.

NEW ORLEANS — Obesity blunts the normal pattern of nocturnal blood pressure dipping, and this might be one mechanism through which obesity contributes to adverse cardiovascular outcomes, findings from a recent study suggest.

Blood pressure normally drops by 10%-20% at night during sleep, compared with blood pressure during waking hours during the day, and studies have shown that nondipping (defined as less than a 10% decrease in blood pressure at night) is associated with increased cardiovascular morbidity and mortality, Dr. Otelio Randall reported in a poster at a meeting sponsored by the International Society on Hypertension in Blacks.

In the study, hourly blood pressure measurements were taken in 200 obese African American patients who were classified into three groups on the basis of their body mass index, in kg/m2: less than 40, 40-49, and at least 50. The average age of the patients was 47 years, and most (83%) were women.

The researchers found that as BMI increased, so did the rates of nocturnal nondipping. The rates of nondipping were 26%, 41%, and 76% for the three BMI categories, respectively. Additionally, 36% of the patients were “reverse dippers,” meaning that their blood pressure actually increased at night, reported Dr. Randall, professor of medicine and cardiology at Howard University, Washington.

The mean percentage of dipping was 8.6% in those with a BMI of less than 40, 8.4% in those with a BMI of 40-49, and 3.9% in those with a BMI of 50 or greater. Those with a BMI of at least 50 had a significantly smaller decrease in nocturnal blood pressure than the other two BMI groups.

Daytime blood pressure for this study was defined as the average of hourly readings between 8 a.m. and 10 p.m., and nighttime blood pressure was defined as the average of hourly readings from 10 p.m. to 6 a.m.

“Nondipping and reverse dipping are known to be associated with the potential risk for target organ damage. The high rates of nondipping and reverse dipping in this obese population reinforces the need to reduce BMI and improve hemodynamic and lipid profiles through lifestyle changes,” Dr. Randall said.