Sharon Worcester

FORT LAUDERDALE, FLA. — Anal manometry is a useful tool for the evaluation of patients with abnormal anorectal physiology, including those presenting with constipation, fecal incontinence, proctalgia, or rectal prolapse, according to Dana R. Sands, M.D.

Manometry provides information about the functional status of the anal sphincter and distal rectum, and often is used with other tests such as anal ultrasound, anal sphincter EMG, pudendal nerve terminal motor latency assessment, and defecography, said Dr. Sands of the Cleveland Clinic Florida, Weston.

In patients with fecal incontinence, for example, anal ultrasound is the cornerstone of treatment, but anal manometry, EMG, and pudendal nerve assessment “round out the evaluation,” she said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

Anal manometry, however, is not well standardized, Dr. Sands said, noting that different facilities have different protocols and normal values.

Some manometry devices include a microtransducer, some use air-filled balloon systems, and still others use continuously perfused probes. The Cleveland Clinic uses a balloon-tip catheter system that is perfused with water. The device measures rectal sensation, resting and squeezing pressures at different levels in the anal canal, and rectal compliance, all of which can play a role in fecal incontinence.

Although some surgeons say their index finger is the best device for identifying anal sphincter pathology, manometry provides a higher level of information than that achieved via digital rectal exam, she said.

In one study of 64 patients, digital rectal exam performed by an experienced colorectal surgeon yielded 63% sensitivity and 57% specificity for internal anal sphincter pathology, and 84% sensitivity and 57% specificity for external anal sphincter pathology.

“I think we can be a little more sophisticated than that with the manometry machine,” she said, adding that manometry also provides insight into the etiology of conditions such as fecal incontinence and can aid in discussions with patients about expected outcomes and prognosis.

FORT LAUDERDALE, FLA. — Anal manometry is a useful tool for the evaluation of patients with abnormal anorectal physiology, including those presenting with constipation, fecal incontinence, proctalgia, or rectal prolapse, according to Dana R. Sands, M.D.

Manometry provides information about the functional status of the anal sphincter and distal rectum, and often is used with other tests such as anal ultrasound, anal sphincter EMG, pudendal nerve terminal motor latency assessment, and defecography, said Dr. Sands of the Cleveland Clinic Florida, Weston.

In patients with fecal incontinence, for example, anal ultrasound is the cornerstone of treatment, but anal manometry, EMG, and pudendal nerve assessment “round out the evaluation,” she said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

Anal manometry, however, is not well standardized, Dr. Sands said, noting that different facilities have different protocols and normal values.

Some manometry devices include a microtransducer, some use air-filled balloon systems, and still others use continuously perfused probes. The Cleveland Clinic uses a balloon-tip catheter system that is perfused with water. The device measures rectal sensation, resting and squeezing pressures at different levels in the anal canal, and rectal compliance, all of which can play a role in fecal incontinence.

Although some surgeons say their index finger is the best device for identifying anal sphincter pathology, manometry provides a higher level of information than that achieved via digital rectal exam, she said.

In one study of 64 patients, digital rectal exam performed by an experienced colorectal surgeon yielded 63% sensitivity and 57% specificity for internal anal sphincter pathology, and 84% sensitivity and 57% specificity for external anal sphincter pathology.

“I think we can be a little more sophisticated than that with the manometry machine,” she said, adding that manometry also provides insight into the etiology of conditions such as fecal incontinence and can aid in discussions with patients about expected outcomes and prognosis.

FORT LAUDERDALE, FLA. — Anal manometry is a useful tool for the evaluation of patients with abnormal anorectal physiology, including those presenting with constipation, fecal incontinence, proctalgia, or rectal prolapse, according to Dana R. Sands, M.D.

Manometry provides information about the functional status of the anal sphincter and distal rectum, and often is used with other tests such as anal ultrasound, anal sphincter EMG, pudendal nerve terminal motor latency assessment, and defecography, said Dr. Sands of the Cleveland Clinic Florida, Weston.

In patients with fecal incontinence, for example, anal ultrasound is the cornerstone of treatment, but anal manometry, EMG, and pudendal nerve assessment “round out the evaluation,” she said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

Anal manometry, however, is not well standardized, Dr. Sands said, noting that different facilities have different protocols and normal values.

Some manometry devices include a microtransducer, some use air-filled balloon systems, and still others use continuously perfused probes. The Cleveland Clinic uses a balloon-tip catheter system that is perfused with water. The device measures rectal sensation, resting and squeezing pressures at different levels in the anal canal, and rectal compliance, all of which can play a role in fecal incontinence.

Although some surgeons say their index finger is the best device for identifying anal sphincter pathology, manometry provides a higher level of information than that achieved via digital rectal exam, she said.

In one study of 64 patients, digital rectal exam performed by an experienced colorectal surgeon yielded 63% sensitivity and 57% specificity for internal anal sphincter pathology, and 84% sensitivity and 57% specificity for external anal sphincter pathology.

“I think we can be a little more sophisticated than that with the manometry machine,” she said, adding that manometry also provides insight into the etiology of conditions such as fecal incontinence and can aid in discussions with patients about expected outcomes and prognosis.

BAL HARBOUR, FLA. — Fluoroquinolones must be used judiciously in children, Sarah S. Long, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

These drugs are increasingly available, and they are being widely prescribed to children.

More than 520,000 prescriptions for fluoroquinolones were written for this population in 2002—with more than 16,000 written for those under age 6 years and nearly 3,000 written for those under age 2 years, said Dr. Long, professor of pediatrics at Drexel University, Philadelphia.

And that was before ciprofloxacin received Food and Drug Administration approval for use in those under age 18 years with complicated urinary tract infections, pyelonephritis, and inhalation anthrax exposure, Dr. Long commented.

The FDA granted this approval last year, but there is little guidance beyond that for the use of fluoroquinolones in the pediatric population.

The advantages of fluoroquinolones include oral administration, excellent oral bioavailability, and a gram-negative spectrum, but these drugs are associated with adverse musculoskeletal events. The potential for spontaneous Achilles tendon rupture is of particular concern, Dr. Long said.

Tendon rupture is a rare event, but it is definitely “above the radar,” she said.

“These drugs do have some effect on cartilage—there is no question,” she added.

In addition, there is some concern about whether fluoroquinolones are associated with long-term arthropathy, Dr. Long noted.

Central nervous system, hepatic, and metabolic effects are also possible, and some patients experience photosensitivity and rashes after taking fluoroquinolones.

Therefore, the use of these drugs in children should be limited mainly to serious gram-negative rod infections for which there are no other treatment alternatives, Dr. Long emphasized.

Conditions for which fluoroquinolones may be appropriate in children—other than the approved uses—include chronic otitis, chronic or acute Pseudomonas aeruginosa osteomyelitis, cystic fibrosis exacerbations, certain mycobacterium infections, and multidrug-resistant shigella, salmonella, or vibrio infections.

Topical treatment is acceptable for conjunctivitis and otitis externa that are refractory or resistant to other treatments, but fluoroquinolones should not be used for plain conjunctivitis or otitis media or for community-acquired bronchitis and pneumonia, Dr. Long said.

BAL HARBOUR, FLA. — Fluoroquinolones must be used judiciously in children, Sarah S. Long, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

These drugs are increasingly available, and they are being widely prescribed to children.

More than 520,000 prescriptions for fluoroquinolones were written for this population in 2002—with more than 16,000 written for those under age 6 years and nearly 3,000 written for those under age 2 years, said Dr. Long, professor of pediatrics at Drexel University, Philadelphia.

And that was before ciprofloxacin received Food and Drug Administration approval for use in those under age 18 years with complicated urinary tract infections, pyelonephritis, and inhalation anthrax exposure, Dr. Long commented.

The FDA granted this approval last year, but there is little guidance beyond that for the use of fluoroquinolones in the pediatric population.

The advantages of fluoroquinolones include oral administration, excellent oral bioavailability, and a gram-negative spectrum, but these drugs are associated with adverse musculoskeletal events. The potential for spontaneous Achilles tendon rupture is of particular concern, Dr. Long said.

Tendon rupture is a rare event, but it is definitely “above the radar,” she said.

“These drugs do have some effect on cartilage—there is no question,” she added.

In addition, there is some concern about whether fluoroquinolones are associated with long-term arthropathy, Dr. Long noted.

Central nervous system, hepatic, and metabolic effects are also possible, and some patients experience photosensitivity and rashes after taking fluoroquinolones.

Therefore, the use of these drugs in children should be limited mainly to serious gram-negative rod infections for which there are no other treatment alternatives, Dr. Long emphasized.

Conditions for which fluoroquinolones may be appropriate in children—other than the approved uses—include chronic otitis, chronic or acute Pseudomonas aeruginosa osteomyelitis, cystic fibrosis exacerbations, certain mycobacterium infections, and multidrug-resistant shigella, salmonella, or vibrio infections.

Topical treatment is acceptable for conjunctivitis and otitis externa that are refractory or resistant to other treatments, but fluoroquinolones should not be used for plain conjunctivitis or otitis media or for community-acquired bronchitis and pneumonia, Dr. Long said.

BAL HARBOUR, FLA. — Fluoroquinolones must be used judiciously in children, Sarah S. Long, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

These drugs are increasingly available, and they are being widely prescribed to children.

More than 520,000 prescriptions for fluoroquinolones were written for this population in 2002—with more than 16,000 written for those under age 6 years and nearly 3,000 written for those under age 2 years, said Dr. Long, professor of pediatrics at Drexel University, Philadelphia.

And that was before ciprofloxacin received Food and Drug Administration approval for use in those under age 18 years with complicated urinary tract infections, pyelonephritis, and inhalation anthrax exposure, Dr. Long commented.

The FDA granted this approval last year, but there is little guidance beyond that for the use of fluoroquinolones in the pediatric population.

The advantages of fluoroquinolones include oral administration, excellent oral bioavailability, and a gram-negative spectrum, but these drugs are associated with adverse musculoskeletal events. The potential for spontaneous Achilles tendon rupture is of particular concern, Dr. Long said.

Tendon rupture is a rare event, but it is definitely “above the radar,” she said.

“These drugs do have some effect on cartilage—there is no question,” she added.

In addition, there is some concern about whether fluoroquinolones are associated with long-term arthropathy, Dr. Long noted.

Central nervous system, hepatic, and metabolic effects are also possible, and some patients experience photosensitivity and rashes after taking fluoroquinolones.

Therefore, the use of these drugs in children should be limited mainly to serious gram-negative rod infections for which there are no other treatment alternatives, Dr. Long emphasized.

Conditions for which fluoroquinolones may be appropriate in children—other than the approved uses—include chronic otitis, chronic or acute Pseudomonas aeruginosa osteomyelitis, cystic fibrosis exacerbations, certain mycobacterium infections, and multidrug-resistant shigella, salmonella, or vibrio infections.

Topical treatment is acceptable for conjunctivitis and otitis externa that are refractory or resistant to other treatments, but fluoroquinolones should not be used for plain conjunctivitis or otitis media or for community-acquired bronchitis and pneumonia, Dr. Long said.

BAL HARBOUR, FLA. — Aggression is an increasing and troubling problem among young children, but there are things physicians can do to help parents address the matter, Barbara J. Howard, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Teachers and day care workers report that up to 40% of boys and 28% of girls aged 2-5 years exhibit moderate to high levels of aggression. The problem is of concern—particularly before age 3, when aggression peaks in children—because early aggression was associated with later behavior disorders (correlation coefficient 0.68), including conduct disorder, said Dr. Howard, of Johns Hopkins University, Baltimore, Md.

About 40% of severe aggression in adults—the kind associated with criminal behaviors—begins before age 8, she noted.

A number of factors can contribute to aggression, but a particularly important point is that aggression can be stimulated by the thwarting of any major developmental need, she said.

Dr. Howard addressed key developmental needs, including:

▸ State regulation. State regulation requires consistency in routines (such as eating and sleeping) and parental responsiveness. Routines stabilize mood and reduce resistance among children and are especially important for temperamentally irregular, unadaptable children, she said.

Try to educate parents about the impact of environment on emotional state. Encourage routines, including regular snacks and meals, and suggest parents talk softly to their children, decrease television time, and increase sleep time.

Make parents aware of the association between aggression and sexual exposures, bullying (by siblings or peers), and inadequate child care (see box), and advise them to watch for these things. For some parents, keeping a diary of stresses and their effects can be helpful in identifying problems.

▸ Mastery. Experiences of mastery involve balance between respecting the child's need for autonomy and providing the protection the child needs to avoid being overwhelmed by that autonomy. Teach parents to give the autonomy but not beyond what the child can handle.

Mastery also involves avoiding overprotection and over-strictness and providing adequate limits. Inadequate limits can evoke aggression, Dr. Howard said.

Parents with a hyperaggressive child should be counseled about proper discipline—such as instructions about small consequences and the use of time-outs.

For children with gaps in skills such as fine-motor and expressive language skills, placement with younger children should be considered, as should treatment for the deficits to help in the management of problems with mastery that lead to aggression.

▸ Positive emotional tone. Positive tone and stable attachment reduce suspiciousness and enhance resilience under stress that might otherwise evoke aggression in children. Hostility in the family environment increases tension in the child and provides a model for aggression.

Parents should be advised to address their hostility problems, and nonphysical discipline measures should be encouraged.

Eliciting information about parental history of discipline can be helpful for prompting such discussions.

Consider referring families with a lack of positive emotional tone for family therapy, Dr. Howard said.

▸ Assistance in regulating negative affect. Parents can help in the regulation of a child's negative affect through “jollying,” distraction, modeling, acknowledgment, verbalization, and compromise. Lack of a tolerance for negative feelings can lead to excessive negative affect, and this can be a source of aggression, she noted.

Encourage parents to help the aggressive child express negative emotions by echoing their feelings or allowing the child to use alternative outlets for the emotions—such as a punching bag.

Consider referring those families trapped in a “coercive cycle” in which the aggression leads to the parents' backing down; such cycles are highly associated with poor outcomes with regard to childhood aggression, she said.

▸ Learning pro-social behavior and empathy. Children must learn such behaviors, including trading, taking turns, waiting, asking for things, using good manners (such as saying “thank you”), considering other points of view, considering the effects of one's actions, and recognizing the feelings of others. Methods for teaching such behaviors include modeling within the family and providing selective attention to and rewards for positive behaviors.

Providing more individual attention (not linked with aggressive behavior) to an aggressive child also can be helpful, as can providing sympathy to the victims of the aggression, Dr. Howard said

Signs of Problematic Child Care Settings

An important question when a young child is aggressive is “Who is taking care of the child?” Dr. Howard said.

Aggressive children who spend a great deal of time in day care could be exhibiting behaviors associated with problems there. She advised encouraging parents of aggressive children to look for the following warning signs of problematic child care settings:

▸ Large child/caregiver ratios. Smaller class sizes are better.

▸ Lack of attention to positive behaviors. Children should be rewarded for positive behaviors.

▸ Lack of anticipation of problematic behaviors. Teachers should watch for signs of arising problem behaviors and redirect the child.

▸ Lack of a good curriculum. Children should be adequately stimulated.

▸ Limited space for toys and small-group play. Adequate space for appropriate playing is important for limiting aggressive behaviors.

▸ The use of physical discipline. Physical discipline is problematic in any setting but is unacceptable in the child care setting, Dr. Howard said.

BAL HARBOUR, FLA. — Aggression is an increasing and troubling problem among young children, but there are things physicians can do to help parents address the matter, Barbara J. Howard, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Teachers and day care workers report that up to 40% of boys and 28% of girls aged 2-5 years exhibit moderate to high levels of aggression. The problem is of concern—particularly before age 3, when aggression peaks in children—because early aggression was associated with later behavior disorders (correlation coefficient 0.68), including conduct disorder, said Dr. Howard, of Johns Hopkins University, Baltimore, Md.

About 40% of severe aggression in adults—the kind associated with criminal behaviors—begins before age 8, she noted.

A number of factors can contribute to aggression, but a particularly important point is that aggression can be stimulated by the thwarting of any major developmental need, she said.

Dr. Howard addressed key developmental needs, including:

▸ State regulation. State regulation requires consistency in routines (such as eating and sleeping) and parental responsiveness. Routines stabilize mood and reduce resistance among children and are especially important for temperamentally irregular, unadaptable children, she said.

Try to educate parents about the impact of environment on emotional state. Encourage routines, including regular snacks and meals, and suggest parents talk softly to their children, decrease television time, and increase sleep time.

Make parents aware of the association between aggression and sexual exposures, bullying (by siblings or peers), and inadequate child care (see box), and advise them to watch for these things. For some parents, keeping a diary of stresses and their effects can be helpful in identifying problems.

▸ Mastery. Experiences of mastery involve balance between respecting the child's need for autonomy and providing the protection the child needs to avoid being overwhelmed by that autonomy. Teach parents to give the autonomy but not beyond what the child can handle.

Mastery also involves avoiding overprotection and over-strictness and providing adequate limits. Inadequate limits can evoke aggression, Dr. Howard said.

Parents with a hyperaggressive child should be counseled about proper discipline—such as instructions about small consequences and the use of time-outs.

For children with gaps in skills such as fine-motor and expressive language skills, placement with younger children should be considered, as should treatment for the deficits to help in the management of problems with mastery that lead to aggression.

▸ Positive emotional tone. Positive tone and stable attachment reduce suspiciousness and enhance resilience under stress that might otherwise evoke aggression in children. Hostility in the family environment increases tension in the child and provides a model for aggression.

Parents should be advised to address their hostility problems, and nonphysical discipline measures should be encouraged.

Eliciting information about parental history of discipline can be helpful for prompting such discussions.

Consider referring families with a lack of positive emotional tone for family therapy, Dr. Howard said.

▸ Assistance in regulating negative affect. Parents can help in the regulation of a child's negative affect through “jollying,” distraction, modeling, acknowledgment, verbalization, and compromise. Lack of a tolerance for negative feelings can lead to excessive negative affect, and this can be a source of aggression, she noted.

Encourage parents to help the aggressive child express negative emotions by echoing their feelings or allowing the child to use alternative outlets for the emotions—such as a punching bag.

Consider referring those families trapped in a “coercive cycle” in which the aggression leads to the parents' backing down; such cycles are highly associated with poor outcomes with regard to childhood aggression, she said.

▸ Learning pro-social behavior and empathy. Children must learn such behaviors, including trading, taking turns, waiting, asking for things, using good manners (such as saying “thank you”), considering other points of view, considering the effects of one's actions, and recognizing the feelings of others. Methods for teaching such behaviors include modeling within the family and providing selective attention to and rewards for positive behaviors.

Providing more individual attention (not linked with aggressive behavior) to an aggressive child also can be helpful, as can providing sympathy to the victims of the aggression, Dr. Howard said

Signs of Problematic Child Care Settings

An important question when a young child is aggressive is “Who is taking care of the child?” Dr. Howard said.

Aggressive children who spend a great deal of time in day care could be exhibiting behaviors associated with problems there. She advised encouraging parents of aggressive children to look for the following warning signs of problematic child care settings:

▸ Large child/caregiver ratios. Smaller class sizes are better.

▸ Lack of attention to positive behaviors. Children should be rewarded for positive behaviors.

▸ Lack of anticipation of problematic behaviors. Teachers should watch for signs of arising problem behaviors and redirect the child.

▸ Lack of a good curriculum. Children should be adequately stimulated.

▸ Limited space for toys and small-group play. Adequate space for appropriate playing is important for limiting aggressive behaviors.

▸ The use of physical discipline. Physical discipline is problematic in any setting but is unacceptable in the child care setting, Dr. Howard said.

BAL HARBOUR, FLA. — Aggression is an increasing and troubling problem among young children, but there are things physicians can do to help parents address the matter, Barbara J. Howard, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Teachers and day care workers report that up to 40% of boys and 28% of girls aged 2-5 years exhibit moderate to high levels of aggression. The problem is of concern—particularly before age 3, when aggression peaks in children—because early aggression was associated with later behavior disorders (correlation coefficient 0.68), including conduct disorder, said Dr. Howard, of Johns Hopkins University, Baltimore, Md.

About 40% of severe aggression in adults—the kind associated with criminal behaviors—begins before age 8, she noted.

A number of factors can contribute to aggression, but a particularly important point is that aggression can be stimulated by the thwarting of any major developmental need, she said.

Dr. Howard addressed key developmental needs, including:

▸ State regulation. State regulation requires consistency in routines (such as eating and sleeping) and parental responsiveness. Routines stabilize mood and reduce resistance among children and are especially important for temperamentally irregular, unadaptable children, she said.

Try to educate parents about the impact of environment on emotional state. Encourage routines, including regular snacks and meals, and suggest parents talk softly to their children, decrease television time, and increase sleep time.

Make parents aware of the association between aggression and sexual exposures, bullying (by siblings or peers), and inadequate child care (see box), and advise them to watch for these things. For some parents, keeping a diary of stresses and their effects can be helpful in identifying problems.

▸ Mastery. Experiences of mastery involve balance between respecting the child's need for autonomy and providing the protection the child needs to avoid being overwhelmed by that autonomy. Teach parents to give the autonomy but not beyond what the child can handle.

Mastery also involves avoiding overprotection and over-strictness and providing adequate limits. Inadequate limits can evoke aggression, Dr. Howard said.

Parents with a hyperaggressive child should be counseled about proper discipline—such as instructions about small consequences and the use of time-outs.

For children with gaps in skills such as fine-motor and expressive language skills, placement with younger children should be considered, as should treatment for the deficits to help in the management of problems with mastery that lead to aggression.

▸ Positive emotional tone. Positive tone and stable attachment reduce suspiciousness and enhance resilience under stress that might otherwise evoke aggression in children. Hostility in the family environment increases tension in the child and provides a model for aggression.

Parents should be advised to address their hostility problems, and nonphysical discipline measures should be encouraged.

Eliciting information about parental history of discipline can be helpful for prompting such discussions.

Consider referring families with a lack of positive emotional tone for family therapy, Dr. Howard said.

▸ Assistance in regulating negative affect. Parents can help in the regulation of a child's negative affect through “jollying,” distraction, modeling, acknowledgment, verbalization, and compromise. Lack of a tolerance for negative feelings can lead to excessive negative affect, and this can be a source of aggression, she noted.

Encourage parents to help the aggressive child express negative emotions by echoing their feelings or allowing the child to use alternative outlets for the emotions—such as a punching bag.

Consider referring those families trapped in a “coercive cycle” in which the aggression leads to the parents' backing down; such cycles are highly associated with poor outcomes with regard to childhood aggression, she said.

▸ Learning pro-social behavior and empathy. Children must learn such behaviors, including trading, taking turns, waiting, asking for things, using good manners (such as saying “thank you”), considering other points of view, considering the effects of one's actions, and recognizing the feelings of others. Methods for teaching such behaviors include modeling within the family and providing selective attention to and rewards for positive behaviors.

Providing more individual attention (not linked with aggressive behavior) to an aggressive child also can be helpful, as can providing sympathy to the victims of the aggression, Dr. Howard said

Signs of Problematic Child Care Settings

An important question when a young child is aggressive is “Who is taking care of the child?” Dr. Howard said.

Aggressive children who spend a great deal of time in day care could be exhibiting behaviors associated with problems there. She advised encouraging parents of aggressive children to look for the following warning signs of problematic child care settings:

▸ Large child/caregiver ratios. Smaller class sizes are better.

▸ Lack of attention to positive behaviors. Children should be rewarded for positive behaviors.

▸ Lack of anticipation of problematic behaviors. Teachers should watch for signs of arising problem behaviors and redirect the child.

▸ Lack of a good curriculum. Children should be adequately stimulated.

▸ Limited space for toys and small-group play. Adequate space for appropriate playing is important for limiting aggressive behaviors.

▸ The use of physical discipline. Physical discipline is problematic in any setting but is unacceptable in the child care setting, Dr. Howard said.

ORLANDO, FLA. — Middle-aged women should routinely be assessed for metabolic syndrome, Ana M. Schaper, Ph.D., said at an international conference on women, heart disease, and stroke.

In a retrospective study of the charts of 147 women under 65 years who were treated for MI in a rural midwestern community, Dr. Schaper found that 113 (77%) had no history of coronary disease, but many had risk factors: 70% had a history of smoking, 63% had high blood pressure, 52% had a family history of coronary artery disease, and 70% were overweight or obese.

Sufficient data were available for 80 of the women with no history of coronary disease to allow risk stratification based on National Cholesterol Education Program guidelines. Of these, only 10% would have qualified for medical management under the guidelines, and only 18% would have qualified for therapeutic lifestyle changes, but 49% had metabolic syndrome, Dr. Schaper of Gundersen Lutheran Medical Foundation, La Crosse, Wis., said during a news conference at the meeting.

Of the 135 patients who survived their initial hospitalization, 54 were readmitted within a year for chest pain, myocardial infarction, or a revascularization procedure. All women who were discharged on an ACE inhibitor or angiotensin receptor blocker, and lipid therapy, and 90% of those discharged on a β-blocker, remained on their medications at 1-year follow-up.

At that time, total- and LDL-cholesterol levels were lower, and HDL-cholesterol levels were higher. Triglyceride levels were unchanged, Dr. Schaper said.

The findings suggest that all components of metabolic syndrome in women should be identified and treated aggressively, she said.

ORLANDO, FLA. — Middle-aged women should routinely be assessed for metabolic syndrome, Ana M. Schaper, Ph.D., said at an international conference on women, heart disease, and stroke.

In a retrospective study of the charts of 147 women under 65 years who were treated for MI in a rural midwestern community, Dr. Schaper found that 113 (77%) had no history of coronary disease, but many had risk factors: 70% had a history of smoking, 63% had high blood pressure, 52% had a family history of coronary artery disease, and 70% were overweight or obese.

Sufficient data were available for 80 of the women with no history of coronary disease to allow risk stratification based on National Cholesterol Education Program guidelines. Of these, only 10% would have qualified for medical management under the guidelines, and only 18% would have qualified for therapeutic lifestyle changes, but 49% had metabolic syndrome, Dr. Schaper of Gundersen Lutheran Medical Foundation, La Crosse, Wis., said during a news conference at the meeting.

Of the 135 patients who survived their initial hospitalization, 54 were readmitted within a year for chest pain, myocardial infarction, or a revascularization procedure. All women who were discharged on an ACE inhibitor or angiotensin receptor blocker, and lipid therapy, and 90% of those discharged on a β-blocker, remained on their medications at 1-year follow-up.

At that time, total- and LDL-cholesterol levels were lower, and HDL-cholesterol levels were higher. Triglyceride levels were unchanged, Dr. Schaper said.

The findings suggest that all components of metabolic syndrome in women should be identified and treated aggressively, she said.

ORLANDO, FLA. — Middle-aged women should routinely be assessed for metabolic syndrome, Ana M. Schaper, Ph.D., said at an international conference on women, heart disease, and stroke.

In a retrospective study of the charts of 147 women under 65 years who were treated for MI in a rural midwestern community, Dr. Schaper found that 113 (77%) had no history of coronary disease, but many had risk factors: 70% had a history of smoking, 63% had high blood pressure, 52% had a family history of coronary artery disease, and 70% were overweight or obese.

Sufficient data were available for 80 of the women with no history of coronary disease to allow risk stratification based on National Cholesterol Education Program guidelines. Of these, only 10% would have qualified for medical management under the guidelines, and only 18% would have qualified for therapeutic lifestyle changes, but 49% had metabolic syndrome, Dr. Schaper of Gundersen Lutheran Medical Foundation, La Crosse, Wis., said during a news conference at the meeting.

Of the 135 patients who survived their initial hospitalization, 54 were readmitted within a year for chest pain, myocardial infarction, or a revascularization procedure. All women who were discharged on an ACE inhibitor or angiotensin receptor blocker, and lipid therapy, and 90% of those discharged on a β-blocker, remained on their medications at 1-year follow-up.

At that time, total- and LDL-cholesterol levels were lower, and HDL-cholesterol levels were higher. Triglyceride levels were unchanged, Dr. Schaper said.

The findings suggest that all components of metabolic syndrome in women should be identified and treated aggressively, she said.

ORLANDO, FLA. — Men with heart failure and/or bundle branch block appear to be preferentially treated more aggressively with implantable devices than are women with similar health status, a review of nearly 11,000 cases suggests.

The 10,931 patients, of whom 4,138 (38%) were women, were listed in an administrative database and represented consecutive admissions to any of numerous hospitals owned by Hospital Corporation of America. All had a diagnosis of heart failure and/or bundle branch block and underwent a primary procedure of pacemaker, cardiac resynchronization therapy pacemaker (CRT-P), implantable cardioverter defibrillator (ICD), or cardiac resynchronization therapy defibrillator (CRT-D) implantation, Robert Fishel, M.D., reported at an international conference on women, heart disease, and stroke.

Women received 52% of the pacemakers, 33% of the CRT-Ps, 22% of the ICDs, and 21% of the CRT-Ds implanted, said Dr. Fishel of the J.F.K. Medical Center, Atlantis, Fla. Logistic regression analysis showed that men were significantly less likely than women to receive a pacemaker (odds ratio 0.35) and more likely to receive an ICD (odds ratio 1.34) or CRT-D (odds ratio 1.48). There was no significant difference in device utilization of CRP-Ps between sexes.

Further research is needed to determine if the differences in device use among men and women have any long-term effects on outcomes in women, he said.

ORLANDO, FLA. — Men with heart failure and/or bundle branch block appear to be preferentially treated more aggressively with implantable devices than are women with similar health status, a review of nearly 11,000 cases suggests.

The 10,931 patients, of whom 4,138 (38%) were women, were listed in an administrative database and represented consecutive admissions to any of numerous hospitals owned by Hospital Corporation of America. All had a diagnosis of heart failure and/or bundle branch block and underwent a primary procedure of pacemaker, cardiac resynchronization therapy pacemaker (CRT-P), implantable cardioverter defibrillator (ICD), or cardiac resynchronization therapy defibrillator (CRT-D) implantation, Robert Fishel, M.D., reported at an international conference on women, heart disease, and stroke.

Women received 52% of the pacemakers, 33% of the CRT-Ps, 22% of the ICDs, and 21% of the CRT-Ds implanted, said Dr. Fishel of the J.F.K. Medical Center, Atlantis, Fla. Logistic regression analysis showed that men were significantly less likely than women to receive a pacemaker (odds ratio 0.35) and more likely to receive an ICD (odds ratio 1.34) or CRT-D (odds ratio 1.48). There was no significant difference in device utilization of CRP-Ps between sexes.

Further research is needed to determine if the differences in device use among men and women have any long-term effects on outcomes in women, he said.

ORLANDO, FLA. — Men with heart failure and/or bundle branch block appear to be preferentially treated more aggressively with implantable devices than are women with similar health status, a review of nearly 11,000 cases suggests.

The 10,931 patients, of whom 4,138 (38%) were women, were listed in an administrative database and represented consecutive admissions to any of numerous hospitals owned by Hospital Corporation of America. All had a diagnosis of heart failure and/or bundle branch block and underwent a primary procedure of pacemaker, cardiac resynchronization therapy pacemaker (CRT-P), implantable cardioverter defibrillator (ICD), or cardiac resynchronization therapy defibrillator (CRT-D) implantation, Robert Fishel, M.D., reported at an international conference on women, heart disease, and stroke.

Women received 52% of the pacemakers, 33% of the CRT-Ps, 22% of the ICDs, and 21% of the CRT-Ds implanted, said Dr. Fishel of the J.F.K. Medical Center, Atlantis, Fla. Logistic regression analysis showed that men were significantly less likely than women to receive a pacemaker (odds ratio 0.35) and more likely to receive an ICD (odds ratio 1.34) or CRT-D (odds ratio 1.48). There was no significant difference in device utilization of CRP-Ps between sexes.

Further research is needed to determine if the differences in device use among men and women have any long-term effects on outcomes in women, he said.

Certain prenatal and maternal factors may be associated with attempted or completed suicide in offspring, according to Ellenor Mittendorfer-Rutz and her colleagues at the Karolinska Institute, Stockholm.

In a large cohort study involving more than 713,000 young adults born in Sweden between 1973 and 1980 and followed through 1999, a total of 563 committed suicide, and 6,676 attempted suicide. A significantly increased risk for attempted suicide was found in those with gestational age-adjusted short birth length, defined as length between 39 and 47 cm (hazard ratio 1.29), as well as in those born fourth or later in birth order (hazard ratio 1.79).

They also found this increased risk in those born to mothers with a low educational level, defined as fewer than 9 years of education (hazard ratio 1.36), and in those born to a teenage mother (hazard ratio 2.09).

Significant predictors of completed suicide included gestational age-adjusted low birth weight, defined as birth weight below 2,500 g (hazard ratio 2.23) and being born to a teenage mother (hazard ratio 2.30), the investigators found (Lancet 2004;364:1135-40).

They acknowledged that the study is limited by the fact that some patient registers exclude those who were not admitted after a suicide attempt, and by the upper patient age of 26 in this study, which suggests the findings may not apply to older individuals. But they also noted that their findings are in accord with those from earlier studies suggesting a link between low birth weight and various mental disorders, as well as between maternal education level and attempted suicide; teenage motherhood and attempted and completed suicide; and multiparity of at least four and major suicide risk factors.

The findings open a new line of inquiry regarding the relationship between intrauterine and perinatal conditions and other contributors, which might lead to clarification of the determinants of the heritability of suicidal behavior, Maria Oquendo, M.D., and Enrique Baca-Garcia, M.D., said in an accompanying editorial (Lancet 2004;364:1102-3).

The effects of the risk factors identified in the study are mild, and less than the risks conferred by family history of suicidal behavior, but the findings do aid in the construction of a model for understanding–and thus possibly preventing–suicidal behavior, they said.

Certain prenatal and maternal factors may be associated with attempted or completed suicide in offspring, according to Ellenor Mittendorfer-Rutz and her colleagues at the Karolinska Institute, Stockholm.

In a large cohort study involving more than 713,000 young adults born in Sweden between 1973 and 1980 and followed through 1999, a total of 563 committed suicide, and 6,676 attempted suicide. A significantly increased risk for attempted suicide was found in those with gestational age-adjusted short birth length, defined as length between 39 and 47 cm (hazard ratio 1.29), as well as in those born fourth or later in birth order (hazard ratio 1.79).

They also found this increased risk in those born to mothers with a low educational level, defined as fewer than 9 years of education (hazard ratio 1.36), and in those born to a teenage mother (hazard ratio 2.09).

Significant predictors of completed suicide included gestational age-adjusted low birth weight, defined as birth weight below 2,500 g (hazard ratio 2.23) and being born to a teenage mother (hazard ratio 2.30), the investigators found (Lancet 2004;364:1135-40).

They acknowledged that the study is limited by the fact that some patient registers exclude those who were not admitted after a suicide attempt, and by the upper patient age of 26 in this study, which suggests the findings may not apply to older individuals. But they also noted that their findings are in accord with those from earlier studies suggesting a link between low birth weight and various mental disorders, as well as between maternal education level and attempted suicide; teenage motherhood and attempted and completed suicide; and multiparity of at least four and major suicide risk factors.

The findings open a new line of inquiry regarding the relationship between intrauterine and perinatal conditions and other contributors, which might lead to clarification of the determinants of the heritability of suicidal behavior, Maria Oquendo, M.D., and Enrique Baca-Garcia, M.D., said in an accompanying editorial (Lancet 2004;364:1102-3).

The effects of the risk factors identified in the study are mild, and less than the risks conferred by family history of suicidal behavior, but the findings do aid in the construction of a model for understanding–and thus possibly preventing–suicidal behavior, they said.

Certain prenatal and maternal factors may be associated with attempted or completed suicide in offspring, according to Ellenor Mittendorfer-Rutz and her colleagues at the Karolinska Institute, Stockholm.

In a large cohort study involving more than 713,000 young adults born in Sweden between 1973 and 1980 and followed through 1999, a total of 563 committed suicide, and 6,676 attempted suicide. A significantly increased risk for attempted suicide was found in those with gestational age-adjusted short birth length, defined as length between 39 and 47 cm (hazard ratio 1.29), as well as in those born fourth or later in birth order (hazard ratio 1.79).

They also found this increased risk in those born to mothers with a low educational level, defined as fewer than 9 years of education (hazard ratio 1.36), and in those born to a teenage mother (hazard ratio 2.09).

Significant predictors of completed suicide included gestational age-adjusted low birth weight, defined as birth weight below 2,500 g (hazard ratio 2.23) and being born to a teenage mother (hazard ratio 2.30), the investigators found (Lancet 2004;364:1135-40).

They acknowledged that the study is limited by the fact that some patient registers exclude those who were not admitted after a suicide attempt, and by the upper patient age of 26 in this study, which suggests the findings may not apply to older individuals. But they also noted that their findings are in accord with those from earlier studies suggesting a link between low birth weight and various mental disorders, as well as between maternal education level and attempted suicide; teenage motherhood and attempted and completed suicide; and multiparity of at least four and major suicide risk factors.

The findings open a new line of inquiry regarding the relationship between intrauterine and perinatal conditions and other contributors, which might lead to clarification of the determinants of the heritability of suicidal behavior, Maria Oquendo, M.D., and Enrique Baca-Garcia, M.D., said in an accompanying editorial (Lancet 2004;364:1102-3).

The effects of the risk factors identified in the study are mild, and less than the risks conferred by family history of suicidal behavior, but the findings do aid in the construction of a model for understanding–and thus possibly preventing–suicidal behavior, they said.

FORT LAUDERDALE, FLA. — Patients presenting with anal pain pose a diagnostic challenge, but a careful, detailed history will lead to the correct diagnosis in 90% of cases, Dana R. Sands, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

Ask patients about the quality of their pain, as well as the location, the presence of radiating pain, and the duration of pain, advised Dr. Sands, associate staff surgeon at the Cleveland Clinic Florida, Weston.

Also, associated symptoms—such as changes in bowel habits and bleeding, a history of similar pain, medication use, and information about sexual practices— can help in nailing down a diagnosis.

Among the differential diagnoses are:

▸ Hemorrhoids. Most patients presenting with anal pain have been referred for, or believe they have, hemorrhoids. In some cases hemorrhoids are the cause of the pain, but it is important to keep in mind that only external thrombosing hemorrhoids or prolapsed internal hemorrhoids will cause pain. The pain may be described as acute in onset, short-term, and associated with occasional bright red bleeding and the sensation of a lump around the anal canal, Dr. Sands said.

If the pain is severe, excision can usually be accomplished in the office setting, but prolapsed, irreducible internal hemorrhoids can become gangrenous and pose a surgical emergency.

▸ Anal abscesses. Pain associated with anal abscesses is insidious in onset and isusually associated with fever, swelling, and drainage. Patients may have a history of a previous abscess. Evaluation and treatment is entirely dependent on the location of the abscess, as various spaces around the anal canal can harbor abscesses.

The most common type is a perianal abscess, which can usually be drained easily. Unexplained anal pain is often attributed to internal hemorrhoids or fissures, but may be due to an internal abscess. Such pain warrants examination of the patient under anesthesia, Dr. Sands stressed.

▸ Fissures. Patients with anal fissures describe severe pain, bright red blood from the rectum, and pain for 3-4 hours following a bowel movement. There is no associated fever and usually no drainage. Patients may describe being afraid to move their bowels, and the history may include an episode of diarrhea or constipation. Many patients have had long-term anal pain, indicating chronic fissures.

Patients with fissures are in agony—and are “terribly afraid and extremely anxious” about undergoing an anal examination, Dr. Sands said.

In most cases, the diagnosis can be made by visual inspection of the anal verge with the patient in the prone jackknife position. The digital examination usually cannot be tolerated and can be reserved for after the patient has been treated and the pain is improved or resolved.

▸ Tumors. Pain associated with anal cancer is insidious in onset. Patients do not complain of fever or prolapse, but may describe a recent change in bowel habits. A lesion may be noted on the anal margin, or digital examination may reveal a palpable mass.

Low-lying rectal cancers can also cause anal pain, and may be associated with fecal urgency, bloody stool, swelling, weight loss, and a change in the caliber of the stool. The tumor may be palpable on digital examination; pay careful attention to the posterior midline, which is the location where rectal cancer is most often missed, Dr. Sands noted.

Patients with unexplained anal pain and no obvious benign condition who cannot tolerate an office examination should be examined under anesthesia, she said.

▸ Stenosis. This painful condition has a slow onset and can result from overly aggressive anal surgery, such as hemorrhoidectomy. Radiation injury to the anal canal and Crohn's disease also can cause stenosis. The patient complains of painful bowel movements and a change in the stool, but not of fever or prolapse.

▸ Infection. Sexually transmitted diseases are a common cause of anal pain. Ulcerations around the anal canal may signal an STD. Ask about potential exposures during the history, examine external genitalia for additional clues to the diagnosis, and follow up with appropriate cultures and biopsies, Dr. Sands advised.

▸ Proctalgia. This is a diagnosis of exclusion in patients presenting with rectal pain and pressure. They describe increased pain after bowel movement, but not of bleeding or fever. They may describe long-term pain.

“I find this is reproducible on palpation of the levator muscles,” said Dr. Sands, noting that patients may also have associated anal hypertonia.

A good endoscopic evaluation is important in these patients, and once organic pathology is ruled out, a diagnosis of proctalgia is appropriate, she said.

FORT LAUDERDALE, FLA. — Patients presenting with anal pain pose a diagnostic challenge, but a careful, detailed history will lead to the correct diagnosis in 90% of cases, Dana R. Sands, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

Ask patients about the quality of their pain, as well as the location, the presence of radiating pain, and the duration of pain, advised Dr. Sands, associate staff surgeon at the Cleveland Clinic Florida, Weston.

Also, associated symptoms—such as changes in bowel habits and bleeding, a history of similar pain, medication use, and information about sexual practices— can help in nailing down a diagnosis.

Among the differential diagnoses are:

▸ Hemorrhoids. Most patients presenting with anal pain have been referred for, or believe they have, hemorrhoids. In some cases hemorrhoids are the cause of the pain, but it is important to keep in mind that only external thrombosing hemorrhoids or prolapsed internal hemorrhoids will cause pain. The pain may be described as acute in onset, short-term, and associated with occasional bright red bleeding and the sensation of a lump around the anal canal, Dr. Sands said.

If the pain is severe, excision can usually be accomplished in the office setting, but prolapsed, irreducible internal hemorrhoids can become gangrenous and pose a surgical emergency.

▸ Anal abscesses. Pain associated with anal abscesses is insidious in onset and isusually associated with fever, swelling, and drainage. Patients may have a history of a previous abscess. Evaluation and treatment is entirely dependent on the location of the abscess, as various spaces around the anal canal can harbor abscesses.

The most common type is a perianal abscess, which can usually be drained easily. Unexplained anal pain is often attributed to internal hemorrhoids or fissures, but may be due to an internal abscess. Such pain warrants examination of the patient under anesthesia, Dr. Sands stressed.

▸ Fissures. Patients with anal fissures describe severe pain, bright red blood from the rectum, and pain for 3-4 hours following a bowel movement. There is no associated fever and usually no drainage. Patients may describe being afraid to move their bowels, and the history may include an episode of diarrhea or constipation. Many patients have had long-term anal pain, indicating chronic fissures.

Patients with fissures are in agony—and are “terribly afraid and extremely anxious” about undergoing an anal examination, Dr. Sands said.

In most cases, the diagnosis can be made by visual inspection of the anal verge with the patient in the prone jackknife position. The digital examination usually cannot be tolerated and can be reserved for after the patient has been treated and the pain is improved or resolved.

▸ Tumors. Pain associated with anal cancer is insidious in onset. Patients do not complain of fever or prolapse, but may describe a recent change in bowel habits. A lesion may be noted on the anal margin, or digital examination may reveal a palpable mass.

Low-lying rectal cancers can also cause anal pain, and may be associated with fecal urgency, bloody stool, swelling, weight loss, and a change in the caliber of the stool. The tumor may be palpable on digital examination; pay careful attention to the posterior midline, which is the location where rectal cancer is most often missed, Dr. Sands noted.

Patients with unexplained anal pain and no obvious benign condition who cannot tolerate an office examination should be examined under anesthesia, she said.

▸ Stenosis. This painful condition has a slow onset and can result from overly aggressive anal surgery, such as hemorrhoidectomy. Radiation injury to the anal canal and Crohn's disease also can cause stenosis. The patient complains of painful bowel movements and a change in the stool, but not of fever or prolapse.

▸ Infection. Sexually transmitted diseases are a common cause of anal pain. Ulcerations around the anal canal may signal an STD. Ask about potential exposures during the history, examine external genitalia for additional clues to the diagnosis, and follow up with appropriate cultures and biopsies, Dr. Sands advised.

▸ Proctalgia. This is a diagnosis of exclusion in patients presenting with rectal pain and pressure. They describe increased pain after bowel movement, but not of bleeding or fever. They may describe long-term pain.

“I find this is reproducible on palpation of the levator muscles,” said Dr. Sands, noting that patients may also have associated anal hypertonia.

A good endoscopic evaluation is important in these patients, and once organic pathology is ruled out, a diagnosis of proctalgia is appropriate, she said.

FORT LAUDERDALE, FLA. — Patients presenting with anal pain pose a diagnostic challenge, but a careful, detailed history will lead to the correct diagnosis in 90% of cases, Dana R. Sands, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

Ask patients about the quality of their pain, as well as the location, the presence of radiating pain, and the duration of pain, advised Dr. Sands, associate staff surgeon at the Cleveland Clinic Florida, Weston.

Also, associated symptoms—such as changes in bowel habits and bleeding, a history of similar pain, medication use, and information about sexual practices— can help in nailing down a diagnosis.

Among the differential diagnoses are:

▸ Hemorrhoids. Most patients presenting with anal pain have been referred for, or believe they have, hemorrhoids. In some cases hemorrhoids are the cause of the pain, but it is important to keep in mind that only external thrombosing hemorrhoids or prolapsed internal hemorrhoids will cause pain. The pain may be described as acute in onset, short-term, and associated with occasional bright red bleeding and the sensation of a lump around the anal canal, Dr. Sands said.

If the pain is severe, excision can usually be accomplished in the office setting, but prolapsed, irreducible internal hemorrhoids can become gangrenous and pose a surgical emergency.

▸ Anal abscesses. Pain associated with anal abscesses is insidious in onset and isusually associated with fever, swelling, and drainage. Patients may have a history of a previous abscess. Evaluation and treatment is entirely dependent on the location of the abscess, as various spaces around the anal canal can harbor abscesses.

The most common type is a perianal abscess, which can usually be drained easily. Unexplained anal pain is often attributed to internal hemorrhoids or fissures, but may be due to an internal abscess. Such pain warrants examination of the patient under anesthesia, Dr. Sands stressed.

▸ Fissures. Patients with anal fissures describe severe pain, bright red blood from the rectum, and pain for 3-4 hours following a bowel movement. There is no associated fever and usually no drainage. Patients may describe being afraid to move their bowels, and the history may include an episode of diarrhea or constipation. Many patients have had long-term anal pain, indicating chronic fissures.

Patients with fissures are in agony—and are “terribly afraid and extremely anxious” about undergoing an anal examination, Dr. Sands said.

In most cases, the diagnosis can be made by visual inspection of the anal verge with the patient in the prone jackknife position. The digital examination usually cannot be tolerated and can be reserved for after the patient has been treated and the pain is improved or resolved.

▸ Tumors. Pain associated with anal cancer is insidious in onset. Patients do not complain of fever or prolapse, but may describe a recent change in bowel habits. A lesion may be noted on the anal margin, or digital examination may reveal a palpable mass.

Low-lying rectal cancers can also cause anal pain, and may be associated with fecal urgency, bloody stool, swelling, weight loss, and a change in the caliber of the stool. The tumor may be palpable on digital examination; pay careful attention to the posterior midline, which is the location where rectal cancer is most often missed, Dr. Sands noted.

Patients with unexplained anal pain and no obvious benign condition who cannot tolerate an office examination should be examined under anesthesia, she said.

▸ Stenosis. This painful condition has a slow onset and can result from overly aggressive anal surgery, such as hemorrhoidectomy. Radiation injury to the anal canal and Crohn's disease also can cause stenosis. The patient complains of painful bowel movements and a change in the stool, but not of fever or prolapse.

▸ Infection. Sexually transmitted diseases are a common cause of anal pain. Ulcerations around the anal canal may signal an STD. Ask about potential exposures during the history, examine external genitalia for additional clues to the diagnosis, and follow up with appropriate cultures and biopsies, Dr. Sands advised.

▸ Proctalgia. This is a diagnosis of exclusion in patients presenting with rectal pain and pressure. They describe increased pain after bowel movement, but not of bleeding or fever. They may describe long-term pain.

“I find this is reproducible on palpation of the levator muscles,” said Dr. Sands, noting that patients may also have associated anal hypertonia.

A good endoscopic evaluation is important in these patients, and once organic pathology is ruled out, a diagnosis of proctalgia is appropriate, she said.

FORT LAUDERDALE, FLA. — The key to successful treatment of true rectal prolapse is an individualized approach, and in many cases that means a multidisciplinary approach, Eric G. Weiss, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

That's because the majority of women with rectal prolapse have concomitant genital prolapse and/or urinary incontinence. In addition, expanding knowledge of pelvic floor function—and the evolution of the concept of the pelvic floor as a single functioning unit with anterior and posterior components—has led to a greater effort to treat these conditions simultaneously.

At the Cleveland Clinic Florida, about 65% of women with rectal prolapse also have urinary incontinence, and about 34% have genital prolapse, said Dr. Weiss, a colorectal surgeon and director of surgical endoscopy there.

The evaluation of women presenting with rectal prolapse, then, should include a complete vaginal pelvic examination by a urogynecologist, he said.

The evaluation should also differentiate between hemorrhoids and rectal prolapse, which are often confused. Many women are referred for hemorrhoids when they actually have true rectal prolapse—or full thickness prolapse of the rectum through the anal sphincters. The reverse is also true, with some women with hemorrhoids being misdiagnosed with prolapse.

Rectal prolapse will often have a target-like appearance with circular folds of tissue circumferentially protruding from the anus—often up to 10-15 cm. Hemorrhoids, which can include mucosal prolapse, have radial folds that rarely protrude more than 5 cm.

The anorectal evaluation of patients with suspected rectal prolapse is often performed in the prone jack-knife position, in which the prolapse may be immediately evident. But in some patients it may also be necessary to perform the examination with the patient in a squatting position, with the patient pushing down to demonstrate the prolapse.

Anal sphincter tone at rest and squeezing should be evaluated to assess damage from chronic prolapse, and a digital examination is necessary to check for palpable masses.

Conditions such as fecal incontinence and constipation—the presence of which should be elicited during a thorough history—are secondary to the prolapse. These will resolve following correction of the prolapse unless they are due to another condition, such as pudendal neuropathy.

To rule out colonic pathology, a complete endoscopic evaluation should be performed, and colonoscopy should be considered in older patients.

When the prolapse is not demonstrable during the evaluation, defecography is useful for identifying rectoceles and other pathology that might be affecting evacuation.

If surgery is being considered, a cardiovascular assessment is important to determine if the patient is a good candidate. The type of surgery selected depends largely on patient age and health, Dr. Weiss said.

Abdominal approaches typically are more effective, but are associated with greater morbidity. Therefore, they are typically reserved for younger patients with a good surgical risk profile. Perineal procedures are associated with more recurrences, but usually are a safer option for the elderly and other higher risk patients.

The abdominal approaches use posterior mobilization of the rectum with fixation to the sacrum. Rectopexy is most common, and other approaches include anterior resection, and combined sigmoid resection and rectopexy. Complication rates range from 15% to 29%, and mortality ranges from 0% to 2%. Recurrence rates are low, ranging from 2% to 12%.

A common complication with rectopexy is constipation, but some data suggest this may be overcome by using the combined rectopexy/sigmoid resection procedure, Dr. Weiss noted.

The perineal approach usually involves rectosigmoidectomy. Studies suggest that perineal rectosigmoidectomy outcomes are improved when levatorplasty is also performed.

In one Cleveland Clinic Florida series of 84 patients with severe fecal incontinence and rectal prolapse treated over a 7-year period, those who were treated with both had significantly lower recurrence rates and decreased incontinence scores, compared with those who underwent only perineal rectosigmoidectomy, Dr. Weiss noted.

The recurrence rate there for all perineal procedures is about 13%, compared with 5% for perineal rectosigmoidectomy with levatorplasty, and the recurrence-free interval was longer in this group of patients, he added.

Another perineal option is the Delorme procedure. This approach involves circumferential incision of the mucosa of the prolapsed rectal wall just above the dentate line, and circumferential dissection in the submucosal layer of the prolapsed bowel as far up as possible. This is followed by plication of the muscular layer of the prolapsed muscle and coloanal anastomosis.

FORT LAUDERDALE, FLA. — The key to successful treatment of true rectal prolapse is an individualized approach, and in many cases that means a multidisciplinary approach, Eric G. Weiss, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

That's because the majority of women with rectal prolapse have concomitant genital prolapse and/or urinary incontinence. In addition, expanding knowledge of pelvic floor function—and the evolution of the concept of the pelvic floor as a single functioning unit with anterior and posterior components—has led to a greater effort to treat these conditions simultaneously.

At the Cleveland Clinic Florida, about 65% of women with rectal prolapse also have urinary incontinence, and about 34% have genital prolapse, said Dr. Weiss, a colorectal surgeon and director of surgical endoscopy there.

The evaluation of women presenting with rectal prolapse, then, should include a complete vaginal pelvic examination by a urogynecologist, he said.

The evaluation should also differentiate between hemorrhoids and rectal prolapse, which are often confused. Many women are referred for hemorrhoids when they actually have true rectal prolapse—or full thickness prolapse of the rectum through the anal sphincters. The reverse is also true, with some women with hemorrhoids being misdiagnosed with prolapse.

Rectal prolapse will often have a target-like appearance with circular folds of tissue circumferentially protruding from the anus—often up to 10-15 cm. Hemorrhoids, which can include mucosal prolapse, have radial folds that rarely protrude more than 5 cm.

The anorectal evaluation of patients with suspected rectal prolapse is often performed in the prone jack-knife position, in which the prolapse may be immediately evident. But in some patients it may also be necessary to perform the examination with the patient in a squatting position, with the patient pushing down to demonstrate the prolapse.

Anal sphincter tone at rest and squeezing should be evaluated to assess damage from chronic prolapse, and a digital examination is necessary to check for palpable masses.

Conditions such as fecal incontinence and constipation—the presence of which should be elicited during a thorough history—are secondary to the prolapse. These will resolve following correction of the prolapse unless they are due to another condition, such as pudendal neuropathy.

To rule out colonic pathology, a complete endoscopic evaluation should be performed, and colonoscopy should be considered in older patients.

When the prolapse is not demonstrable during the evaluation, defecography is useful for identifying rectoceles and other pathology that might be affecting evacuation.

If surgery is being considered, a cardiovascular assessment is important to determine if the patient is a good candidate. The type of surgery selected depends largely on patient age and health, Dr. Weiss said.

Abdominal approaches typically are more effective, but are associated with greater morbidity. Therefore, they are typically reserved for younger patients with a good surgical risk profile. Perineal procedures are associated with more recurrences, but usually are a safer option for the elderly and other higher risk patients.

The abdominal approaches use posterior mobilization of the rectum with fixation to the sacrum. Rectopexy is most common, and other approaches include anterior resection, and combined sigmoid resection and rectopexy. Complication rates range from 15% to 29%, and mortality ranges from 0% to 2%. Recurrence rates are low, ranging from 2% to 12%.

A common complication with rectopexy is constipation, but some data suggest this may be overcome by using the combined rectopexy/sigmoid resection procedure, Dr. Weiss noted.

The perineal approach usually involves rectosigmoidectomy. Studies suggest that perineal rectosigmoidectomy outcomes are improved when levatorplasty is also performed.

In one Cleveland Clinic Florida series of 84 patients with severe fecal incontinence and rectal prolapse treated over a 7-year period, those who were treated with both had significantly lower recurrence rates and decreased incontinence scores, compared with those who underwent only perineal rectosigmoidectomy, Dr. Weiss noted.

The recurrence rate there for all perineal procedures is about 13%, compared with 5% for perineal rectosigmoidectomy with levatorplasty, and the recurrence-free interval was longer in this group of patients, he added.

Another perineal option is the Delorme procedure. This approach involves circumferential incision of the mucosa of the prolapsed rectal wall just above the dentate line, and circumferential dissection in the submucosal layer of the prolapsed bowel as far up as possible. This is followed by plication of the muscular layer of the prolapsed muscle and coloanal anastomosis.

FORT LAUDERDALE, FLA. — The key to successful treatment of true rectal prolapse is an individualized approach, and in many cases that means a multidisciplinary approach, Eric G. Weiss, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

That's because the majority of women with rectal prolapse have concomitant genital prolapse and/or urinary incontinence. In addition, expanding knowledge of pelvic floor function—and the evolution of the concept of the pelvic floor as a single functioning unit with anterior and posterior components—has led to a greater effort to treat these conditions simultaneously.

At the Cleveland Clinic Florida, about 65% of women with rectal prolapse also have urinary incontinence, and about 34% have genital prolapse, said Dr. Weiss, a colorectal surgeon and director of surgical endoscopy there.

The evaluation of women presenting with rectal prolapse, then, should include a complete vaginal pelvic examination by a urogynecologist, he said.

The evaluation should also differentiate between hemorrhoids and rectal prolapse, which are often confused. Many women are referred for hemorrhoids when they actually have true rectal prolapse—or full thickness prolapse of the rectum through the anal sphincters. The reverse is also true, with some women with hemorrhoids being misdiagnosed with prolapse.

Rectal prolapse will often have a target-like appearance with circular folds of tissue circumferentially protruding from the anus—often up to 10-15 cm. Hemorrhoids, which can include mucosal prolapse, have radial folds that rarely protrude more than 5 cm.

The anorectal evaluation of patients with suspected rectal prolapse is often performed in the prone jack-knife position, in which the prolapse may be immediately evident. But in some patients it may also be necessary to perform the examination with the patient in a squatting position, with the patient pushing down to demonstrate the prolapse.

Anal sphincter tone at rest and squeezing should be evaluated to assess damage from chronic prolapse, and a digital examination is necessary to check for palpable masses.

Conditions such as fecal incontinence and constipation—the presence of which should be elicited during a thorough history—are secondary to the prolapse. These will resolve following correction of the prolapse unless they are due to another condition, such as pudendal neuropathy.

To rule out colonic pathology, a complete endoscopic evaluation should be performed, and colonoscopy should be considered in older patients.

When the prolapse is not demonstrable during the evaluation, defecography is useful for identifying rectoceles and other pathology that might be affecting evacuation.

If surgery is being considered, a cardiovascular assessment is important to determine if the patient is a good candidate. The type of surgery selected depends largely on patient age and health, Dr. Weiss said.

Abdominal approaches typically are more effective, but are associated with greater morbidity. Therefore, they are typically reserved for younger patients with a good surgical risk profile. Perineal procedures are associated with more recurrences, but usually are a safer option for the elderly and other higher risk patients.

The abdominal approaches use posterior mobilization of the rectum with fixation to the sacrum. Rectopexy is most common, and other approaches include anterior resection, and combined sigmoid resection and rectopexy. Complication rates range from 15% to 29%, and mortality ranges from 0% to 2%. Recurrence rates are low, ranging from 2% to 12%.

A common complication with rectopexy is constipation, but some data suggest this may be overcome by using the combined rectopexy/sigmoid resection procedure, Dr. Weiss noted.

The perineal approach usually involves rectosigmoidectomy. Studies suggest that perineal rectosigmoidectomy outcomes are improved when levatorplasty is also performed.

In one Cleveland Clinic Florida series of 84 patients with severe fecal incontinence and rectal prolapse treated over a 7-year period, those who were treated with both had significantly lower recurrence rates and decreased incontinence scores, compared with those who underwent only perineal rectosigmoidectomy, Dr. Weiss noted.

The recurrence rate there for all perineal procedures is about 13%, compared with 5% for perineal rectosigmoidectomy with levatorplasty, and the recurrence-free interval was longer in this group of patients, he added.

Another perineal option is the Delorme procedure. This approach involves circumferential incision of the mucosa of the prolapsed rectal wall just above the dentate line, and circumferential dissection in the submucosal layer of the prolapsed bowel as far up as possible. This is followed by plication of the muscular layer of the prolapsed muscle and coloanal anastomosis.

Soft Cheese Risks

Soft white cheeses made with raw milk present a health risk, the U.S. Food and Drug Administration has warned. Such cheeses can cause listeriosis, brucellosis, salmonellosis, and tuberculosis, and they pose a particular risk to pregnant women, newborns, older adults, and those with weakened immune systems.

Consumption of queso fresco-style cheeses that were imported from or eaten in Mexico were linked with recent cases of tuberculosis in New York City and found to be contaminated with Mycobacterium bovis, according to the FDA. The cheeses of greatest concern are those originating in Mexico and Central American countries and include queso panela, asadero, blanco, and ranchero. The FDA has warned against consumption of any unripened raw-milk soft cheeses, including those obtained at flea markets or from door-to-door sellers or vendors selling out of their trucks.

TB Trends

The tuberculosis case rate in the United States is declining, but the rate of decline from 2003 to 2004 was the lowest in a decade, and racial disparities remain a concern, according to the Centers for Disease Control and Prevention.

More than 14,500 cases of TB were reported in the United States in 2004, for a case rate of 4.9 per 100,000. This is the lowest rate ever recorded, but the 3.3% decline from 2003 was smaller than the 6.8% average annual decline between 1993 and 2002. In 2004, minority populations had significantly higher TB rates than the overall U.S. average: The case rate was 26.9/100,000 in Asians, 11.1/100,000 in blacks, 10.1/100,000 in Hispanics, and 1.3/100,000 in whites.

Furthermore, foreign-born individuals have a case rate of 22.5/100,000, compared with 2.6/100,000 for U.S.-born persons, and the decline in the TB rate over the last 12 years among foreign-born individuals has been only 34%, compared with 65% among U.S.-born persons.

TB remains a health threat that must be taken seriously, according to the CDC, which is stepping up disease elimination efforts, in part by strengthening global partnerships to address TB among the hardest-hit populations.

HCV and Iron Stores

Hepatitis C virus infection is significantly associated with increased serum levels of ferritin and iron, the third National Health and Nutrition Examination Survey shows.

Among more than 14,400 U.S. residents who participated in NHANES III, nearly 1% had HCV infection. Mean serum levels of ferritin and iron were significantly higher in those with HCV infection, compared with individuals with no liver disease (100 ng/mL vs. 83 ng/mL for ferritin; 229 mcg/dL vs. 101 mcg/dL for iron), reported Ying Shan, M.D., and colleagues at the University of Connecticut, Farmington.

Furthermore, serum levels of ferritin and iron were directly correlated with serum concentrations of ALT, AST, and γ-glutamyl-transpeptidase (Clin. Infect. Dis. 2005;40:834-41).

It remains unclear whether higher iron levels—which have been shown in other studies to be associated with increased risk for persistent viral infection and decreased response to treatment—raise the risk for chronic HCV, or if liver damage increases iron levels, the investigators said. Regardless, it is likely that excess iron contributes to hepatic injury and fibrosis, they concluded, noting that improved understanding of the link between iron levels and liver disease is important for devising strategies to prevent associated morbidity.

Pseudomonas Infections

Health care providers who identify cases of infection with Pseudomonas species in patients with central venous catheters should determine if the patient received a heparin/saline flush recalled earlier this year, and should report cases by calling 800-332-1088 or going to

www.fda.gov/medwatch/report.htm

The flush, preloaded in syringes by IV Flush and distributed by Pinnacle Medical Supply, was initially linked with four cases of P. fluorescens bloodstream infections. The FDA issued an alert, and the company recalled the products.

The syringes had been distributed to locations in as many as 17 states, and in an ongoing investigation, 36 associated cases have been identified.

Infections have occurred up to 1 month after receipt of the product; catheters used infrequently can become colonized, and symptoms may not develop until the catheter is used.

Because susceptibility patterns of isolates from affected patients have varied—with some showing resistance to third-generation cephalosporins and carbapenem antibiotics—treatment of potential patients should include targeted antimicrobial therapy. Catheter removal should be considered as well.

Soft Cheese Risks

Soft white cheeses made with raw milk present a health risk, the U.S. Food and Drug Administration has warned. Such cheeses can cause listeriosis, brucellosis, salmonellosis, and tuberculosis, and they pose a particular risk to pregnant women, newborns, older adults, and those with weakened immune systems.

Consumption of queso fresco-style cheeses that were imported from or eaten in Mexico were linked with recent cases of tuberculosis in New York City and found to be contaminated with Mycobacterium bovis, according to the FDA. The cheeses of greatest concern are those originating in Mexico and Central American countries and include queso panela, asadero, blanco, and ranchero. The FDA has warned against consumption of any unripened raw-milk soft cheeses, including those obtained at flea markets or from door-to-door sellers or vendors selling out of their trucks.

TB Trends

The tuberculosis case rate in the United States is declining, but the rate of decline from 2003 to 2004 was the lowest in a decade, and racial disparities remain a concern, according to the Centers for Disease Control and Prevention.

More than 14,500 cases of TB were reported in the United States in 2004, for a case rate of 4.9 per 100,000. This is the lowest rate ever recorded, but the 3.3% decline from 2003 was smaller than the 6.8% average annual decline between 1993 and 2002. In 2004, minority populations had significantly higher TB rates than the overall U.S. average: The case rate was 26.9/100,000 in Asians, 11.1/100,000 in blacks, 10.1/100,000 in Hispanics, and 1.3/100,000 in whites.

Furthermore, foreign-born individuals have a case rate of 22.5/100,000, compared with 2.6/100,000 for U.S.-born persons, and the decline in the TB rate over the last 12 years among foreign-born individuals has been only 34%, compared with 65% among U.S.-born persons.

TB remains a health threat that must be taken seriously, according to the CDC, which is stepping up disease elimination efforts, in part by strengthening global partnerships to address TB among the hardest-hit populations.

HCV and Iron Stores

Hepatitis C virus infection is significantly associated with increased serum levels of ferritin and iron, the third National Health and Nutrition Examination Survey shows.

Among more than 14,400 U.S. residents who participated in NHANES III, nearly 1% had HCV infection. Mean serum levels of ferritin and iron were significantly higher in those with HCV infection, compared with individuals with no liver disease (100 ng/mL vs. 83 ng/mL for ferritin; 229 mcg/dL vs. 101 mcg/dL for iron), reported Ying Shan, M.D., and colleagues at the University of Connecticut, Farmington.

Furthermore, serum levels of ferritin and iron were directly correlated with serum concentrations of ALT, AST, and γ-glutamyl-transpeptidase (Clin. Infect. Dis. 2005;40:834-41).

It remains unclear whether higher iron levels—which have been shown in other studies to be associated with increased risk for persistent viral infection and decreased response to treatment—raise the risk for chronic HCV, or if liver damage increases iron levels, the investigators said. Regardless, it is likely that excess iron contributes to hepatic injury and fibrosis, they concluded, noting that improved understanding of the link between iron levels and liver disease is important for devising strategies to prevent associated morbidity.

Pseudomonas Infections

Health care providers who identify cases of infection with Pseudomonas species in patients with central venous catheters should determine if the patient received a heparin/saline flush recalled earlier this year, and should report cases by calling 800-332-1088 or going to

www.fda.gov/medwatch/report.htm

The flush, preloaded in syringes by IV Flush and distributed by Pinnacle Medical Supply, was initially linked with four cases of P. fluorescens bloodstream infections. The FDA issued an alert, and the company recalled the products.

The syringes had been distributed to locations in as many as 17 states, and in an ongoing investigation, 36 associated cases have been identified.

Infections have occurred up to 1 month after receipt of the product; catheters used infrequently can become colonized, and symptoms may not develop until the catheter is used.

Because susceptibility patterns of isolates from affected patients have varied—with some showing resistance to third-generation cephalosporins and carbapenem antibiotics—treatment of potential patients should include targeted antimicrobial therapy. Catheter removal should be considered as well.

Soft Cheese Risks

Soft white cheeses made with raw milk present a health risk, the U.S. Food and Drug Administration has warned. Such cheeses can cause listeriosis, brucellosis, salmonellosis, and tuberculosis, and they pose a particular risk to pregnant women, newborns, older adults, and those with weakened immune systems.

Consumption of queso fresco-style cheeses that were imported from or eaten in Mexico were linked with recent cases of tuberculosis in New York City and found to be contaminated with Mycobacterium bovis, according to the FDA. The cheeses of greatest concern are those originating in Mexico and Central American countries and include queso panela, asadero, blanco, and ranchero. The FDA has warned against consumption of any unripened raw-milk soft cheeses, including those obtained at flea markets or from door-to-door sellers or vendors selling out of their trucks.

TB Trends

The tuberculosis case rate in the United States is declining, but the rate of decline from 2003 to 2004 was the lowest in a decade, and racial disparities remain a concern, according to the Centers for Disease Control and Prevention.

More than 14,500 cases of TB were reported in the United States in 2004, for a case rate of 4.9 per 100,000. This is the lowest rate ever recorded, but the 3.3% decline from 2003 was smaller than the 6.8% average annual decline between 1993 and 2002. In 2004, minority populations had significantly higher TB rates than the overall U.S. average: The case rate was 26.9/100,000 in Asians, 11.1/100,000 in blacks, 10.1/100,000 in Hispanics, and 1.3/100,000 in whites.

Furthermore, foreign-born individuals have a case rate of 22.5/100,000, compared with 2.6/100,000 for U.S.-born persons, and the decline in the TB rate over the last 12 years among foreign-born individuals has been only 34%, compared with 65% among U.S.-born persons.

TB remains a health threat that must be taken seriously, according to the CDC, which is stepping up disease elimination efforts, in part by strengthening global partnerships to address TB among the hardest-hit populations.

HCV and Iron Stores

Hepatitis C virus infection is significantly associated with increased serum levels of ferritin and iron, the third National Health and Nutrition Examination Survey shows.

Among more than 14,400 U.S. residents who participated in NHANES III, nearly 1% had HCV infection. Mean serum levels of ferritin and iron were significantly higher in those with HCV infection, compared with individuals with no liver disease (100 ng/mL vs. 83 ng/mL for ferritin; 229 mcg/dL vs. 101 mcg/dL for iron), reported Ying Shan, M.D., and colleagues at the University of Connecticut, Farmington.

Furthermore, serum levels of ferritin and iron were directly correlated with serum concentrations of ALT, AST, and γ-glutamyl-transpeptidase (Clin. Infect. Dis. 2005;40:834-41).

It remains unclear whether higher iron levels—which have been shown in other studies to be associated with increased risk for persistent viral infection and decreased response to treatment—raise the risk for chronic HCV, or if liver damage increases iron levels, the investigators said. Regardless, it is likely that excess iron contributes to hepatic injury and fibrosis, they concluded, noting that improved understanding of the link between iron levels and liver disease is important for devising strategies to prevent associated morbidity.

Pseudomonas Infections

Health care providers who identify cases of infection with Pseudomonas species in patients with central venous catheters should determine if the patient received a heparin/saline flush recalled earlier this year, and should report cases by calling 800-332-1088 or going to

www.fda.gov/medwatch/report.htm

The flush, preloaded in syringes by IV Flush and distributed by Pinnacle Medical Supply, was initially linked with four cases of P. fluorescens bloodstream infections. The FDA issued an alert, and the company recalled the products.

The syringes had been distributed to locations in as many as 17 states, and in an ongoing investigation, 36 associated cases have been identified.

Infections have occurred up to 1 month after receipt of the product; catheters used infrequently can become colonized, and symptoms may not develop until the catheter is used.

Because susceptibility patterns of isolates from affected patients have varied—with some showing resistance to third-generation cephalosporins and carbapenem antibiotics—treatment of potential patients should include targeted antimicrobial therapy. Catheter removal should be considered as well.

ORLANDO, FLA. — Early angiography is associated with improved survival in women presenting with acute coronary syndrome, Rasha N. Bazari, M.D., reported at an international conference on women, heart disease, and stroke.

Women who underwent coronary angiography within 2 days of presenting with ACS had significantly lower 3-year mortality rates than did those who had later procedures (7% vs. 20%), said Dr. Bazari of the Henry Ford Heart and Vascular Institute, Detroit.

Angiography beyond 48 hours after presentation was the most significant predictor of mortality, after adjustment for confounding variables (odds ratio 3.7). Marginal predictors of mortality included older age and lower diastolic blood pressure, she said.

Dr. Bazari and associates reviewed the records of 836 patients (350 women and 486 men) admitted to the hospital during 1997-2000 who had angiography during their stay. The study also showed that fewer women than men admitted during the study period underwent early coronary angiography (63% vs. 74%), she noted.

“Gender should not be a reason to delay early angiography” she said.

ORLANDO, FLA. — Early angiography is associated with improved survival in women presenting with acute coronary syndrome, Rasha N. Bazari, M.D., reported at an international conference on women, heart disease, and stroke.

Women who underwent coronary angiography within 2 days of presenting with ACS had significantly lower 3-year mortality rates than did those who had later procedures (7% vs. 20%), said Dr. Bazari of the Henry Ford Heart and Vascular Institute, Detroit.

Angiography beyond 48 hours after presentation was the most significant predictor of mortality, after adjustment for confounding variables (odds ratio 3.7). Marginal predictors of mortality included older age and lower diastolic blood pressure, she said.

Dr. Bazari and associates reviewed the records of 836 patients (350 women and 486 men) admitted to the hospital during 1997-2000 who had angiography during their stay. The study also showed that fewer women than men admitted during the study period underwent early coronary angiography (63% vs. 74%), she noted.

“Gender should not be a reason to delay early angiography” she said.

ORLANDO, FLA. — Early angiography is associated with improved survival in women presenting with acute coronary syndrome, Rasha N. Bazari, M.D., reported at an international conference on women, heart disease, and stroke.

Women who underwent coronary angiography within 2 days of presenting with ACS had significantly lower 3-year mortality rates than did those who had later procedures (7% vs. 20%), said Dr. Bazari of the Henry Ford Heart and Vascular Institute, Detroit.

Angiography beyond 48 hours after presentation was the most significant predictor of mortality, after adjustment for confounding variables (odds ratio 3.7). Marginal predictors of mortality included older age and lower diastolic blood pressure, she said.

Dr. Bazari and associates reviewed the records of 836 patients (350 women and 486 men) admitted to the hospital during 1997-2000 who had angiography during their stay. The study also showed that fewer women than men admitted during the study period underwent early coronary angiography (63% vs. 74%), she noted.

“Gender should not be a reason to delay early angiography” she said.