Sharon Worcester

FAJARDO, P.R. — Patients undergoing arthroplasty of the proximal interphalangeal joint should opt for the cement, Bruce Johnstone, M.D., advised at the annual meeting of the American Association for Hand Surgery.

In 2000, the Avanta surface replacement proximal interphalangeal (PIP) joint was modified to incorporate a titanium stemmed distal component that allows for press fit cementless fixation, Dr. Johnstone noted.

But ever since the product's modification, observational evidence suggests that loosening and subsiding occurs more frequently when cement is not used with this second-generation device, Dr. Johnstone explained.

In a study involving 49 joint replacements using the cement-optional device, 1 of 27 cemented implants with at least 1 year of follow-up loosened and subsided, and 18 of the 27 have had no loosening or subsiding in up to 6 years of follow-up.

Of 22 cementless implants, 10 have loosened or subsided in up to 3 years of follow-up, reported Dr. Johnstone of Royal Children's Hospital, Melbourne, Australia.

When loosening and subsiding has occurred, it is often with angulation that leads to the stems of the device penetrating the cortical bone.

At first the subsidence is typically asymptomatic. However, as it progresses, pain and stiffness tend to develop, he said.

As a precaution, it is best to use methylmethacrylate bone cement to fix the stems of the cement-optional Avanta PIP surface replacement arthroplasty, he recommended at the meeting.

Those with cemented implants experienced a significant decrease in their pain, with scores on the visual analog scale improving by 5 points or more, Dr. Johnstone said.

FAJARDO, P.R. — Patients undergoing arthroplasty of the proximal interphalangeal joint should opt for the cement, Bruce Johnstone, M.D., advised at the annual meeting of the American Association for Hand Surgery.

In 2000, the Avanta surface replacement proximal interphalangeal (PIP) joint was modified to incorporate a titanium stemmed distal component that allows for press fit cementless fixation, Dr. Johnstone noted.

But ever since the product's modification, observational evidence suggests that loosening and subsiding occurs more frequently when cement is not used with this second-generation device, Dr. Johnstone explained.

In a study involving 49 joint replacements using the cement-optional device, 1 of 27 cemented implants with at least 1 year of follow-up loosened and subsided, and 18 of the 27 have had no loosening or subsiding in up to 6 years of follow-up.

Of 22 cementless implants, 10 have loosened or subsided in up to 3 years of follow-up, reported Dr. Johnstone of Royal Children's Hospital, Melbourne, Australia.

When loosening and subsiding has occurred, it is often with angulation that leads to the stems of the device penetrating the cortical bone.

At first the subsidence is typically asymptomatic. However, as it progresses, pain and stiffness tend to develop, he said.

As a precaution, it is best to use methylmethacrylate bone cement to fix the stems of the cement-optional Avanta PIP surface replacement arthroplasty, he recommended at the meeting.

Those with cemented implants experienced a significant decrease in their pain, with scores on the visual analog scale improving by 5 points or more, Dr. Johnstone said.

FAJARDO, P.R. — Patients undergoing arthroplasty of the proximal interphalangeal joint should opt for the cement, Bruce Johnstone, M.D., advised at the annual meeting of the American Association for Hand Surgery.

In 2000, the Avanta surface replacement proximal interphalangeal (PIP) joint was modified to incorporate a titanium stemmed distal component that allows for press fit cementless fixation, Dr. Johnstone noted.

But ever since the product's modification, observational evidence suggests that loosening and subsiding occurs more frequently when cement is not used with this second-generation device, Dr. Johnstone explained.

In a study involving 49 joint replacements using the cement-optional device, 1 of 27 cemented implants with at least 1 year of follow-up loosened and subsided, and 18 of the 27 have had no loosening or subsiding in up to 6 years of follow-up.

Of 22 cementless implants, 10 have loosened or subsided in up to 3 years of follow-up, reported Dr. Johnstone of Royal Children's Hospital, Melbourne, Australia.

When loosening and subsiding has occurred, it is often with angulation that leads to the stems of the device penetrating the cortical bone.

At first the subsidence is typically asymptomatic. However, as it progresses, pain and stiffness tend to develop, he said.

As a precaution, it is best to use methylmethacrylate bone cement to fix the stems of the cement-optional Avanta PIP surface replacement arthroplasty, he recommended at the meeting.

Those with cemented implants experienced a significant decrease in their pain, with scores on the visual analog scale improving by 5 points or more, Dr. Johnstone said.

ORLANDO, FLA. — Corticosteroid use may increase the risk of complications leading to colectomy and death in patients with Clostridium difficile colitis, Sherri L. Burgess, M.D., said at the annual meeting of the American College of Gastroenterology.

In a case-control chart review of 181 adult patients with confirmed C. difficile colitis, 55 patients were treated with corticosteroids for the treatment of other medical problems, and 126 patients did not receive corticosteroids. Mortality was significantly higher in the corticosteroid group (40% vs. 15%), as was the colectomy rate (16% vs. 3%), reported Dr. Burgess of St. Vincent Charity Hospital, Cleveland.

Furthermore, six of nine patients (67%) who underwent colectomy in the corticosteroid group died, compared with one of four (25%) in the control group, she said.

“In our study, we could not explain [the differences] by other patient characteristics or comorbidity,” she said.

Patients who developed severe outcomes were generally older, but this was true in both groups, and although serum albumin levels were lower in patients who required a colectomy or who died, there was no significant difference in the levels between those who did and those who did not receive corticosteroids.

Also, the greater proportions of women, patients with chronic obstructive pulmonary disease, and patients with heart failure in the corticosteroid group did not appear to affect severe outcome, Dr. Burgess said.

The findings suggest that a host immune response to corticosteroids may be a detrimental factor in patients with severe C. difficile. Additional studies are warranted, she concluded.

ORLANDO, FLA. — Corticosteroid use may increase the risk of complications leading to colectomy and death in patients with Clostridium difficile colitis, Sherri L. Burgess, M.D., said at the annual meeting of the American College of Gastroenterology.

In a case-control chart review of 181 adult patients with confirmed C. difficile colitis, 55 patients were treated with corticosteroids for the treatment of other medical problems, and 126 patients did not receive corticosteroids. Mortality was significantly higher in the corticosteroid group (40% vs. 15%), as was the colectomy rate (16% vs. 3%), reported Dr. Burgess of St. Vincent Charity Hospital, Cleveland.

Furthermore, six of nine patients (67%) who underwent colectomy in the corticosteroid group died, compared with one of four (25%) in the control group, she said.

“In our study, we could not explain [the differences] by other patient characteristics or comorbidity,” she said.

Patients who developed severe outcomes were generally older, but this was true in both groups, and although serum albumin levels were lower in patients who required a colectomy or who died, there was no significant difference in the levels between those who did and those who did not receive corticosteroids.

Also, the greater proportions of women, patients with chronic obstructive pulmonary disease, and patients with heart failure in the corticosteroid group did not appear to affect severe outcome, Dr. Burgess said.

The findings suggest that a host immune response to corticosteroids may be a detrimental factor in patients with severe C. difficile. Additional studies are warranted, she concluded.

ORLANDO, FLA. — Corticosteroid use may increase the risk of complications leading to colectomy and death in patients with Clostridium difficile colitis, Sherri L. Burgess, M.D., said at the annual meeting of the American College of Gastroenterology.

In a case-control chart review of 181 adult patients with confirmed C. difficile colitis, 55 patients were treated with corticosteroids for the treatment of other medical problems, and 126 patients did not receive corticosteroids. Mortality was significantly higher in the corticosteroid group (40% vs. 15%), as was the colectomy rate (16% vs. 3%), reported Dr. Burgess of St. Vincent Charity Hospital, Cleveland.

Furthermore, six of nine patients (67%) who underwent colectomy in the corticosteroid group died, compared with one of four (25%) in the control group, she said.

“In our study, we could not explain [the differences] by other patient characteristics or comorbidity,” she said.

Patients who developed severe outcomes were generally older, but this was true in both groups, and although serum albumin levels were lower in patients who required a colectomy or who died, there was no significant difference in the levels between those who did and those who did not receive corticosteroids.

Also, the greater proportions of women, patients with chronic obstructive pulmonary disease, and patients with heart failure in the corticosteroid group did not appear to affect severe outcome, Dr. Burgess said.

The findings suggest that a host immune response to corticosteroids may be a detrimental factor in patients with severe C. difficile. Additional studies are warranted, she concluded.

ORLANDO, FLA. — Many primary care physicians do not prescribe aspirin appropriately for cardioprotection, a national survey suggests.

Many of the 1,000 primary care physicians who responded are unaware of—or disregard—data about the use of aspirin for cardioprotection and recommend to their patients doses that are too high, William D. Chey, M.D., said at the annual meeting of the American College of Gastroenterology.

The lowest cardioprotective dose of aspirin is 81 mg/day in healthy patients and in those at risk for gastrointestinal complications. Those with gastrointestinal risk should receive gastroprotection, such as a proton pump inhibitor, Dr. Chey said.

About half of those responding to the Internet survey were internists, and half were family physicians or general practitioners. Respondents, generally between 35 and 54 years old and evenly distributed geographically across the United States, had previously agreed to participate in survey research.

Overall, 95% said they recommend aspirin for cardioprotection in patients over age 60 years, with 62% always recommending aspirin therapy and 33% usually recommending aspirin therapy, said Dr. Chey of the University of Michigan, Ann Arbor.

Nearly 70% said they recommend 81 mg daily, but 30% said they recommend 325 mg daily. “This is relevant because there may be a dose-response relationship between aspirin and the likelihood of developing ulcer disease and, consequently, gastrointestinal bleeding,” Dr. Chey said.

Another troubling finding was that 62% of respondents said they would recommend enteric-coated aspirin for a patient at high risk for gastrointestinal bleeding due to a previous ulcer bleed despite a lack of data showing any benefit of coated aspirin over regular aspirin. Also only 28% recommended concurrent gastroprotective therapy, such as with a proton pump inhibitor or misoprostol. Most said they would put the patient on aspirin alone, he said.

“I guess the good news is that [gastroenterologists] are going to stay in business if this is truly representative of primary care physicians,” he said, noting that a study last year showed that the likelihood of such a high-risk patient developing recurrent gastrointestinal bleeding when put on aspirin therapy alone is about 15%.

Aspirin cardioprotection in those who require treatment with an NSAID is more controversial, Dr. Chey said. In one study of patients with a history of ulcer bleeding, the use of a PPI and an NSAID and the use of a cyclooxygenase-2 (COX-2) inhibitor alone were both associated with a recurrent bleeding rate of about 5% at 6 months.

The withdrawal of Vioxx from the market has highlighted concerns about COX-2 inhibitor and myocardial infarction risk. For now, avoid using COX-2 inhibitor in those with known coronary artery disease, Dr. Chey advised. In those without coronary artery disease who are at high risk for gastrointestinal complications, the use of a COX-2 inhibitor and PPI is warranted, but there is little or no incremental gastrointestinal safety benefit from aspirin and a COX-2 inhibitor vs. a traditional NSAID alone.

When physicians in the survey were asked about their knowledge of the effects of aspirin in patients using a COX-2 inhibitor, 69% of respondents said they were aware of the data showing that aspirin decreases or eliminates the gastrointestinal safety benefits of the COX-2 inhibitor (31% were unaware or thought that aspirin improved the effects of COX-2 inhibitor). Yet when asked how they would manage a patient with no history of peptic ulcer disease, but with a need for nonsteroidal antiinflammatory drug treatment for arthritis, 45% said they would recommend aspirin and a COX-2 inhibitor.

“Even more interesting, in a high-risk patient with a history of ulcer bleeding, 60% said they would recommend a proton pump inhibitor with a coxib and aspirin—even though there are no published data to support this strategy, and 24%, disturbingly, would choose a coxib and aspirin without gastroprotection,” Dr. Chey said.

There is no logic to this combination, he said, adding that further educational efforts are necessary to correct these “important knowledge deficits.”

ORLANDO, FLA. — Many primary care physicians do not prescribe aspirin appropriately for cardioprotection, a national survey suggests.

Many of the 1,000 primary care physicians who responded are unaware of—or disregard—data about the use of aspirin for cardioprotection and recommend to their patients doses that are too high, William D. Chey, M.D., said at the annual meeting of the American College of Gastroenterology.

The lowest cardioprotective dose of aspirin is 81 mg/day in healthy patients and in those at risk for gastrointestinal complications. Those with gastrointestinal risk should receive gastroprotection, such as a proton pump inhibitor, Dr. Chey said.

About half of those responding to the Internet survey were internists, and half were family physicians or general practitioners. Respondents, generally between 35 and 54 years old and evenly distributed geographically across the United States, had previously agreed to participate in survey research.

Overall, 95% said they recommend aspirin for cardioprotection in patients over age 60 years, with 62% always recommending aspirin therapy and 33% usually recommending aspirin therapy, said Dr. Chey of the University of Michigan, Ann Arbor.

Nearly 70% said they recommend 81 mg daily, but 30% said they recommend 325 mg daily. “This is relevant because there may be a dose-response relationship between aspirin and the likelihood of developing ulcer disease and, consequently, gastrointestinal bleeding,” Dr. Chey said.

Another troubling finding was that 62% of respondents said they would recommend enteric-coated aspirin for a patient at high risk for gastrointestinal bleeding due to a previous ulcer bleed despite a lack of data showing any benefit of coated aspirin over regular aspirin. Also only 28% recommended concurrent gastroprotective therapy, such as with a proton pump inhibitor or misoprostol. Most said they would put the patient on aspirin alone, he said.

“I guess the good news is that [gastroenterologists] are going to stay in business if this is truly representative of primary care physicians,” he said, noting that a study last year showed that the likelihood of such a high-risk patient developing recurrent gastrointestinal bleeding when put on aspirin therapy alone is about 15%.

Aspirin cardioprotection in those who require treatment with an NSAID is more controversial, Dr. Chey said. In one study of patients with a history of ulcer bleeding, the use of a PPI and an NSAID and the use of a cyclooxygenase-2 (COX-2) inhibitor alone were both associated with a recurrent bleeding rate of about 5% at 6 months.

The withdrawal of Vioxx from the market has highlighted concerns about COX-2 inhibitor and myocardial infarction risk. For now, avoid using COX-2 inhibitor in those with known coronary artery disease, Dr. Chey advised. In those without coronary artery disease who are at high risk for gastrointestinal complications, the use of a COX-2 inhibitor and PPI is warranted, but there is little or no incremental gastrointestinal safety benefit from aspirin and a COX-2 inhibitor vs. a traditional NSAID alone.

When physicians in the survey were asked about their knowledge of the effects of aspirin in patients using a COX-2 inhibitor, 69% of respondents said they were aware of the data showing that aspirin decreases or eliminates the gastrointestinal safety benefits of the COX-2 inhibitor (31% were unaware or thought that aspirin improved the effects of COX-2 inhibitor). Yet when asked how they would manage a patient with no history of peptic ulcer disease, but with a need for nonsteroidal antiinflammatory drug treatment for arthritis, 45% said they would recommend aspirin and a COX-2 inhibitor.

“Even more interesting, in a high-risk patient with a history of ulcer bleeding, 60% said they would recommend a proton pump inhibitor with a coxib and aspirin—even though there are no published data to support this strategy, and 24%, disturbingly, would choose a coxib and aspirin without gastroprotection,” Dr. Chey said.

There is no logic to this combination, he said, adding that further educational efforts are necessary to correct these “important knowledge deficits.”

ORLANDO, FLA. — Many primary care physicians do not prescribe aspirin appropriately for cardioprotection, a national survey suggests.

Many of the 1,000 primary care physicians who responded are unaware of—or disregard—data about the use of aspirin for cardioprotection and recommend to their patients doses that are too high, William D. Chey, M.D., said at the annual meeting of the American College of Gastroenterology.

The lowest cardioprotective dose of aspirin is 81 mg/day in healthy patients and in those at risk for gastrointestinal complications. Those with gastrointestinal risk should receive gastroprotection, such as a proton pump inhibitor, Dr. Chey said.

About half of those responding to the Internet survey were internists, and half were family physicians or general practitioners. Respondents, generally between 35 and 54 years old and evenly distributed geographically across the United States, had previously agreed to participate in survey research.

Overall, 95% said they recommend aspirin for cardioprotection in patients over age 60 years, with 62% always recommending aspirin therapy and 33% usually recommending aspirin therapy, said Dr. Chey of the University of Michigan, Ann Arbor.

Nearly 70% said they recommend 81 mg daily, but 30% said they recommend 325 mg daily. “This is relevant because there may be a dose-response relationship between aspirin and the likelihood of developing ulcer disease and, consequently, gastrointestinal bleeding,” Dr. Chey said.

Another troubling finding was that 62% of respondents said they would recommend enteric-coated aspirin for a patient at high risk for gastrointestinal bleeding due to a previous ulcer bleed despite a lack of data showing any benefit of coated aspirin over regular aspirin. Also only 28% recommended concurrent gastroprotective therapy, such as with a proton pump inhibitor or misoprostol. Most said they would put the patient on aspirin alone, he said.

“I guess the good news is that [gastroenterologists] are going to stay in business if this is truly representative of primary care physicians,” he said, noting that a study last year showed that the likelihood of such a high-risk patient developing recurrent gastrointestinal bleeding when put on aspirin therapy alone is about 15%.

Aspirin cardioprotection in those who require treatment with an NSAID is more controversial, Dr. Chey said. In one study of patients with a history of ulcer bleeding, the use of a PPI and an NSAID and the use of a cyclooxygenase-2 (COX-2) inhibitor alone were both associated with a recurrent bleeding rate of about 5% at 6 months.

The withdrawal of Vioxx from the market has highlighted concerns about COX-2 inhibitor and myocardial infarction risk. For now, avoid using COX-2 inhibitor in those with known coronary artery disease, Dr. Chey advised. In those without coronary artery disease who are at high risk for gastrointestinal complications, the use of a COX-2 inhibitor and PPI is warranted, but there is little or no incremental gastrointestinal safety benefit from aspirin and a COX-2 inhibitor vs. a traditional NSAID alone.

When physicians in the survey were asked about their knowledge of the effects of aspirin in patients using a COX-2 inhibitor, 69% of respondents said they were aware of the data showing that aspirin decreases or eliminates the gastrointestinal safety benefits of the COX-2 inhibitor (31% were unaware or thought that aspirin improved the effects of COX-2 inhibitor). Yet when asked how they would manage a patient with no history of peptic ulcer disease, but with a need for nonsteroidal antiinflammatory drug treatment for arthritis, 45% said they would recommend aspirin and a COX-2 inhibitor.

“Even more interesting, in a high-risk patient with a history of ulcer bleeding, 60% said they would recommend a proton pump inhibitor with a coxib and aspirin—even though there are no published data to support this strategy, and 24%, disturbingly, would choose a coxib and aspirin without gastroprotection,” Dr. Chey said.

There is no logic to this combination, he said, adding that further educational efforts are necessary to correct these “important knowledge deficits.”

Acute eosinophilic pneumonia is considered a rare disease, but it occurred at an increased rate among a population of soldiers serving in or near Iraq between March 2003 and March 2004, and may be associated with new-onset smoking and/or dust inhalation, an epidemiologic study shows.

Of 183,000 military personnel deployed in or near Iraq during the study period, 18 developed acute eosinophilic pneumonia (AEP), for an incidence of 9.1/100,000 patient- years.

Two patients died and the remaining soldiers responded to treatment.

No known causes of pulmonary eosinophilia, common sources of exposure, clustering, or person-to-person transmissions were identified, reported Andrew F. Shorr, M.D., of Walter Reed Army Medical Center, Washington, and his colleagues (JAMA 2004;292:2997–3005).

All the patients were smokers, and 78% had recently started smoking. Compared with 48 controls, new-onset smokers had a significantly increased risk of AEP (odds ratio 122).

Prior studies have also suggested a link between new-onset smoking and AEP. All but one patient reported significant exposure to fine airborne sand or dust.

AEP should be considered, and bronchoscopy performed, in military personnel with unexplained respiratory failure, the investigators concluded.

Most patients survive when treated promptly with corticosteroids, they said.

Acute eosinophilic pneumonia is considered a rare disease, but it occurred at an increased rate among a population of soldiers serving in or near Iraq between March 2003 and March 2004, and may be associated with new-onset smoking and/or dust inhalation, an epidemiologic study shows.

Of 183,000 military personnel deployed in or near Iraq during the study period, 18 developed acute eosinophilic pneumonia (AEP), for an incidence of 9.1/100,000 patient- years.

Two patients died and the remaining soldiers responded to treatment.

No known causes of pulmonary eosinophilia, common sources of exposure, clustering, or person-to-person transmissions were identified, reported Andrew F. Shorr, M.D., of Walter Reed Army Medical Center, Washington, and his colleagues (JAMA 2004;292:2997–3005).

All the patients were smokers, and 78% had recently started smoking. Compared with 48 controls, new-onset smokers had a significantly increased risk of AEP (odds ratio 122).

Prior studies have also suggested a link between new-onset smoking and AEP. All but one patient reported significant exposure to fine airborne sand or dust.

AEP should be considered, and bronchoscopy performed, in military personnel with unexplained respiratory failure, the investigators concluded.

Most patients survive when treated promptly with corticosteroids, they said.

Acute eosinophilic pneumonia is considered a rare disease, but it occurred at an increased rate among a population of soldiers serving in or near Iraq between March 2003 and March 2004, and may be associated with new-onset smoking and/or dust inhalation, an epidemiologic study shows.

Of 183,000 military personnel deployed in or near Iraq during the study period, 18 developed acute eosinophilic pneumonia (AEP), for an incidence of 9.1/100,000 patient- years.

Two patients died and the remaining soldiers responded to treatment.

No known causes of pulmonary eosinophilia, common sources of exposure, clustering, or person-to-person transmissions were identified, reported Andrew F. Shorr, M.D., of Walter Reed Army Medical Center, Washington, and his colleagues (JAMA 2004;292:2997–3005).

All the patients were smokers, and 78% had recently started smoking. Compared with 48 controls, new-onset smokers had a significantly increased risk of AEP (odds ratio 122).

Prior studies have also suggested a link between new-onset smoking and AEP. All but one patient reported significant exposure to fine airborne sand or dust.

AEP should be considered, and bronchoscopy performed, in military personnel with unexplained respiratory failure, the investigators concluded.

Most patients survive when treated promptly with corticosteroids, they said.

ORLANDO, FLA. – Family-based therapy and cognitive-behavioral therapy with guided self-help both show promise for the treatment of adolescents with bulimia nervosa, according to data presented at an international conference sponsored by the Academy for Eating Disorders.

Family-based therapy (FBT) has proven benefit for the treatment of anorexia nervosa in adolescents, but it was unclear whether this treatment would also be useful for patients with bulimia. Now, 3-year data from an ongoing 5-year randomized controlled trial suggest it can be adapted successfully for this population, reported Daniel le Grange, Ph.D., of the University of Chicago.

In 18 patients who underwent FBT and were eligible for 6-month follow-up, bingeing, purging, and laxative abuse were significantly reduced.

“This is a very good start,” Dr. le Grange said at the meeting, which was cosponsored by the University of New Mexico.

The National Institutes of Health-sponsored study actually is comparing outcomes among adolescents treated with either manualized FBT or manualized individual supportive psychotherapy; only data from the FBT arm were available at the time of Dr. le Grange's presentation. The FBT was adapted from the therapy used for anorexia nervosa patients to meet the specific needs of bulimia patients, he explained.

Treatment consisted of 20 sessions over 6 months and also addressed comorbidities. In the first of three phases (first 10 sessions), the focus was on resolving the eating disorder and helping parents to help the adolescent reestablish healthy eating habits.

During the second phase (four to five sessions), patients were generally on the way toward healthy weight, and parents withdrew some of their vigilance in overseeing the patient's eating. The therapist began to address developmental issues that were postponed while focusing on the eating disorder.

In the final phase (four to five sessions), developmental issues continued to be addressed, but the focus was on patient independence in regard to control over eating.

Among the treatment challenges encountered in the study and in adapting the treatment for bulimic patients were the difficulty with overcoming the shame and resulting secrecy inherent in bulimia nervosa, as compared with anorexia nervosa, and the substantially greater risk for comorbid conditions among bulimia patients, Dr. le Grange noted.

Comorbidity issues can make it difficult for parents to maintain a focus on the eating disorder, he said.

Nonetheless, in this trial, 52% of patients had a good response (abstinent from bingeing and purging) at 6 months, 25% had an intermediate response (bingeing and purging frequency was reduced at least 50% from baseline), and 25% had a poor response (bingeing and purging frequency was reduced by less than 50% from baseline).

Overall, 81% of the patients were binge free, he said, adding that another success was high treatment retention: 86% of patients completed at least 17 sessions.

Cognitive-behavioral therapy (CBT) with guided self-help also appears useful for the treatment of bulimia, and may be of particular use in older patients who tend to prefer to leave their families out of the treatment equation, Ulrike Schmidt, M.D., reported.

Early data from a multicenter study looking at CBT with guided self-help show that about 45% of patients were abstinent from purging at 12-month follow-up and 32% were abstinent from bingeing and purging, said Dr. Schmidt of the Institute of Psychiatry, London.

Patients completed an average of 15 sessions, including 10 weekly individual sessions and 2 sessions with family members. Treatment was based on a manual, which Dr. Schmidt helped to develop, that includes a patient manual and workbook and clinical guide. In her study, 30% of initial patients refused to participate because they did not want their families involved in the treatment.

Family therapy increasingly appears to have a place in the care of bulimic patients, but these findings support the need for offering at least some individual-based work in the course of treatment, she said.

ORLANDO, FLA. – Family-based therapy and cognitive-behavioral therapy with guided self-help both show promise for the treatment of adolescents with bulimia nervosa, according to data presented at an international conference sponsored by the Academy for Eating Disorders.

Family-based therapy (FBT) has proven benefit for the treatment of anorexia nervosa in adolescents, but it was unclear whether this treatment would also be useful for patients with bulimia. Now, 3-year data from an ongoing 5-year randomized controlled trial suggest it can be adapted successfully for this population, reported Daniel le Grange, Ph.D., of the University of Chicago.

In 18 patients who underwent FBT and were eligible for 6-month follow-up, bingeing, purging, and laxative abuse were significantly reduced.

“This is a very good start,” Dr. le Grange said at the meeting, which was cosponsored by the University of New Mexico.

The National Institutes of Health-sponsored study actually is comparing outcomes among adolescents treated with either manualized FBT or manualized individual supportive psychotherapy; only data from the FBT arm were available at the time of Dr. le Grange's presentation. The FBT was adapted from the therapy used for anorexia nervosa patients to meet the specific needs of bulimia patients, he explained.

Treatment consisted of 20 sessions over 6 months and also addressed comorbidities. In the first of three phases (first 10 sessions), the focus was on resolving the eating disorder and helping parents to help the adolescent reestablish healthy eating habits.

During the second phase (four to five sessions), patients were generally on the way toward healthy weight, and parents withdrew some of their vigilance in overseeing the patient's eating. The therapist began to address developmental issues that were postponed while focusing on the eating disorder.

In the final phase (four to five sessions), developmental issues continued to be addressed, but the focus was on patient independence in regard to control over eating.

Among the treatment challenges encountered in the study and in adapting the treatment for bulimic patients were the difficulty with overcoming the shame and resulting secrecy inherent in bulimia nervosa, as compared with anorexia nervosa, and the substantially greater risk for comorbid conditions among bulimia patients, Dr. le Grange noted.

Comorbidity issues can make it difficult for parents to maintain a focus on the eating disorder, he said.

Nonetheless, in this trial, 52% of patients had a good response (abstinent from bingeing and purging) at 6 months, 25% had an intermediate response (bingeing and purging frequency was reduced at least 50% from baseline), and 25% had a poor response (bingeing and purging frequency was reduced by less than 50% from baseline).

Overall, 81% of the patients were binge free, he said, adding that another success was high treatment retention: 86% of patients completed at least 17 sessions.

Cognitive-behavioral therapy (CBT) with guided self-help also appears useful for the treatment of bulimia, and may be of particular use in older patients who tend to prefer to leave their families out of the treatment equation, Ulrike Schmidt, M.D., reported.

Early data from a multicenter study looking at CBT with guided self-help show that about 45% of patients were abstinent from purging at 12-month follow-up and 32% were abstinent from bingeing and purging, said Dr. Schmidt of the Institute of Psychiatry, London.

Patients completed an average of 15 sessions, including 10 weekly individual sessions and 2 sessions with family members. Treatment was based on a manual, which Dr. Schmidt helped to develop, that includes a patient manual and workbook and clinical guide. In her study, 30% of initial patients refused to participate because they did not want their families involved in the treatment.

Family therapy increasingly appears to have a place in the care of bulimic patients, but these findings support the need for offering at least some individual-based work in the course of treatment, she said.

ORLANDO, FLA. – Family-based therapy and cognitive-behavioral therapy with guided self-help both show promise for the treatment of adolescents with bulimia nervosa, according to data presented at an international conference sponsored by the Academy for Eating Disorders.

Family-based therapy (FBT) has proven benefit for the treatment of anorexia nervosa in adolescents, but it was unclear whether this treatment would also be useful for patients with bulimia. Now, 3-year data from an ongoing 5-year randomized controlled trial suggest it can be adapted successfully for this population, reported Daniel le Grange, Ph.D., of the University of Chicago.

In 18 patients who underwent FBT and were eligible for 6-month follow-up, bingeing, purging, and laxative abuse were significantly reduced.

“This is a very good start,” Dr. le Grange said at the meeting, which was cosponsored by the University of New Mexico.

The National Institutes of Health-sponsored study actually is comparing outcomes among adolescents treated with either manualized FBT or manualized individual supportive psychotherapy; only data from the FBT arm were available at the time of Dr. le Grange's presentation. The FBT was adapted from the therapy used for anorexia nervosa patients to meet the specific needs of bulimia patients, he explained.

Treatment consisted of 20 sessions over 6 months and also addressed comorbidities. In the first of three phases (first 10 sessions), the focus was on resolving the eating disorder and helping parents to help the adolescent reestablish healthy eating habits.

During the second phase (four to five sessions), patients were generally on the way toward healthy weight, and parents withdrew some of their vigilance in overseeing the patient's eating. The therapist began to address developmental issues that were postponed while focusing on the eating disorder.

In the final phase (four to five sessions), developmental issues continued to be addressed, but the focus was on patient independence in regard to control over eating.

Among the treatment challenges encountered in the study and in adapting the treatment for bulimic patients were the difficulty with overcoming the shame and resulting secrecy inherent in bulimia nervosa, as compared with anorexia nervosa, and the substantially greater risk for comorbid conditions among bulimia patients, Dr. le Grange noted.

Comorbidity issues can make it difficult for parents to maintain a focus on the eating disorder, he said.

Nonetheless, in this trial, 52% of patients had a good response (abstinent from bingeing and purging) at 6 months, 25% had an intermediate response (bingeing and purging frequency was reduced at least 50% from baseline), and 25% had a poor response (bingeing and purging frequency was reduced by less than 50% from baseline).

Overall, 81% of the patients were binge free, he said, adding that another success was high treatment retention: 86% of patients completed at least 17 sessions.

Cognitive-behavioral therapy (CBT) with guided self-help also appears useful for the treatment of bulimia, and may be of particular use in older patients who tend to prefer to leave their families out of the treatment equation, Ulrike Schmidt, M.D., reported.

Early data from a multicenter study looking at CBT with guided self-help show that about 45% of patients were abstinent from purging at 12-month follow-up and 32% were abstinent from bingeing and purging, said Dr. Schmidt of the Institute of Psychiatry, London.

Patients completed an average of 15 sessions, including 10 weekly individual sessions and 2 sessions with family members. Treatment was based on a manual, which Dr. Schmidt helped to develop, that includes a patient manual and workbook and clinical guide. In her study, 30% of initial patients refused to participate because they did not want their families involved in the treatment.

Family therapy increasingly appears to have a place in the care of bulimic patients, but these findings support the need for offering at least some individual-based work in the course of treatment, she said.

ORLANDO, FLA. — Don't take this personally, but … “Patients really don't want to see you,” John Bachman, M.D., said at the annual meeting of the American Academy of Family Physicians.

That's one reason why e-mail communication between physicians and patients can be successfully incorporated into a medical practice, he said.

The standard process for an office visit is expensive, inefficient, and inconvenient, but e-mail can change all that, said Dr. Bachman, professor of primary care at the Mayo Clinic, Rochester, Minn.

In a recent survey, 50% of patients said they would like to communicate with their doctor online, and half said they would make the availability of e-mail communication a factor in choosing a doctor. About 25% of doctors said they had communicated with patients via e-mail, and about two-thirds said they would use e-mail if they were paid for the service.

E-mail provides an opportunity to improve patient satisfaction—and it is reimbursable in some instances. Furthermore, most patients are willing to pay out of pocket for the convenience, Dr. Bachman said.

At one major practice, about 16,000 patients pay $60 per year for electronic access to their physician via MyChart (Epic Systems Corp.). More than 90% of the 150 physicians in the practice say they are satisfied with the system, he added.

Additionally, major insurers such as Aetna, BlueCross BlueShield, and UnitedHealthcare provide reimbursement or are testing reimbursement for e-mail communications by doctors. Reimbursement is generally in the $20–$25 range, and in some cases patients have a $5 copay for the service, he said, adding that the ICD-9 code for e-mail consultations is 0074T.

E-mail communication works best with established patients with whom you already have a good relationship; those who start practicing medicine via e-mail with patients they don't know could be setting themselves up for malpractice suits, he said.

But in the right setting, e-mail can enhance patient care.

For example, it is excellent for managing chronic disease such as hypertension. Patients could come in every 2 weeks for blood pressure checks—or they could learn to monitor their own blood pressure at home and e-mail readings to the physician.

It could also be used prior to patient visits for history taking and for appointment reminders, or after a visit for reporting lab results. Immunization records could easily be supplied to patients enrolling in school. The approach reduces phone calls and workload for staff.

A physician could easily process 12 e-mails in an hour, Dr. Bachman said, noting that in his experience, 85% of e-mails can be handled by staff, and e-mail communication reduces follow-up office visits by 50%, and all visits by 20%.

Establishing effective physician-patient e-mail communications requires a secure server. A platform with a Web site that allows patients to provide medical information, download medical information, schedule visits, and pay bills is ideal.

A good place to start is with Medfusion—an AAFP-endorsed company that provides such communications applications. Its Web site can be found at www.medfusion.net

ORLANDO, FLA. — Don't take this personally, but … “Patients really don't want to see you,” John Bachman, M.D., said at the annual meeting of the American Academy of Family Physicians.

That's one reason why e-mail communication between physicians and patients can be successfully incorporated into a medical practice, he said.

The standard process for an office visit is expensive, inefficient, and inconvenient, but e-mail can change all that, said Dr. Bachman, professor of primary care at the Mayo Clinic, Rochester, Minn.

In a recent survey, 50% of patients said they would like to communicate with their doctor online, and half said they would make the availability of e-mail communication a factor in choosing a doctor. About 25% of doctors said they had communicated with patients via e-mail, and about two-thirds said they would use e-mail if they were paid for the service.

E-mail provides an opportunity to improve patient satisfaction—and it is reimbursable in some instances. Furthermore, most patients are willing to pay out of pocket for the convenience, Dr. Bachman said.

At one major practice, about 16,000 patients pay $60 per year for electronic access to their physician via MyChart (Epic Systems Corp.). More than 90% of the 150 physicians in the practice say they are satisfied with the system, he added.

Additionally, major insurers such as Aetna, BlueCross BlueShield, and UnitedHealthcare provide reimbursement or are testing reimbursement for e-mail communications by doctors. Reimbursement is generally in the $20–$25 range, and in some cases patients have a $5 copay for the service, he said, adding that the ICD-9 code for e-mail consultations is 0074T.

E-mail communication works best with established patients with whom you already have a good relationship; those who start practicing medicine via e-mail with patients they don't know could be setting themselves up for malpractice suits, he said.

But in the right setting, e-mail can enhance patient care.

For example, it is excellent for managing chronic disease such as hypertension. Patients could come in every 2 weeks for blood pressure checks—or they could learn to monitor their own blood pressure at home and e-mail readings to the physician.

It could also be used prior to patient visits for history taking and for appointment reminders, or after a visit for reporting lab results. Immunization records could easily be supplied to patients enrolling in school. The approach reduces phone calls and workload for staff.

A physician could easily process 12 e-mails in an hour, Dr. Bachman said, noting that in his experience, 85% of e-mails can be handled by staff, and e-mail communication reduces follow-up office visits by 50%, and all visits by 20%.

Establishing effective physician-patient e-mail communications requires a secure server. A platform with a Web site that allows patients to provide medical information, download medical information, schedule visits, and pay bills is ideal.

A good place to start is with Medfusion—an AAFP-endorsed company that provides such communications applications. Its Web site can be found at www.medfusion.net

ORLANDO, FLA. — Don't take this personally, but … “Patients really don't want to see you,” John Bachman, M.D., said at the annual meeting of the American Academy of Family Physicians.

That's one reason why e-mail communication between physicians and patients can be successfully incorporated into a medical practice, he said.

The standard process for an office visit is expensive, inefficient, and inconvenient, but e-mail can change all that, said Dr. Bachman, professor of primary care at the Mayo Clinic, Rochester, Minn.

In a recent survey, 50% of patients said they would like to communicate with their doctor online, and half said they would make the availability of e-mail communication a factor in choosing a doctor. About 25% of doctors said they had communicated with patients via e-mail, and about two-thirds said they would use e-mail if they were paid for the service.

E-mail provides an opportunity to improve patient satisfaction—and it is reimbursable in some instances. Furthermore, most patients are willing to pay out of pocket for the convenience, Dr. Bachman said.

At one major practice, about 16,000 patients pay $60 per year for electronic access to their physician via MyChart (Epic Systems Corp.). More than 90% of the 150 physicians in the practice say they are satisfied with the system, he added.

Additionally, major insurers such as Aetna, BlueCross BlueShield, and UnitedHealthcare provide reimbursement or are testing reimbursement for e-mail communications by doctors. Reimbursement is generally in the $20–$25 range, and in some cases patients have a $5 copay for the service, he said, adding that the ICD-9 code for e-mail consultations is 0074T.

E-mail communication works best with established patients with whom you already have a good relationship; those who start practicing medicine via e-mail with patients they don't know could be setting themselves up for malpractice suits, he said.

But in the right setting, e-mail can enhance patient care.

For example, it is excellent for managing chronic disease such as hypertension. Patients could come in every 2 weeks for blood pressure checks—or they could learn to monitor their own blood pressure at home and e-mail readings to the physician.

It could also be used prior to patient visits for history taking and for appointment reminders, or after a visit for reporting lab results. Immunization records could easily be supplied to patients enrolling in school. The approach reduces phone calls and workload for staff.

A physician could easily process 12 e-mails in an hour, Dr. Bachman said, noting that in his experience, 85% of e-mails can be handled by staff, and e-mail communication reduces follow-up office visits by 50%, and all visits by 20%.

Establishing effective physician-patient e-mail communications requires a secure server. A platform with a Web site that allows patients to provide medical information, download medical information, schedule visits, and pay bills is ideal.

A good place to start is with Medfusion—an AAFP-endorsed company that provides such communications applications. Its Web site can be found at www.medfusion.net

ORLANDO, FLA. — Many primary care physicians do not prescribe aspirin appropriately for cardioprotection, a national survey suggests.

Many of the 1,000 primary care physicians who responded are unaware of—or disregard—data about the use of aspirin for cardioprotection and recommend to their patients doses that are too high, William D. Chey, M.D., said at the annual meeting of the American College of Gastroenterology.

The lowest cardioprotective dose of aspirin is 81 mg/day in healthy patients and in those at risk for gastrointestinal complications. Those with gastrointestinal risk should receive gastroprotection, such as a proton pump inhibitor (PPI), Dr. Chey said.

About half of those responding to the Internet survey were internists, and half were family physicians or general practitioners. Respondents, generally between 35 and 54 years old and evenly distributed geographically across the United States, had previously agreed to participate in survey research.

Overall, 95% said they recommend aspirin for cardioprotection in patients over age 60 years, with 62% always recommending aspirin therapy and 33% usually recommending aspirin therapy, said Dr. Chey of the University of Michigan, Ann Arbor. Nearly 70% said they recommend 81 mg daily, but 30% said they recommend 325 mg daily. “This is relevant because there may be a dose-response relationship between aspirin and the likelihood of developing ulcer disease and, consequently, gastrointestinal bleeding,” Dr. Chey said.

Another troubling finding was that 62% of respondents said they would recommend enteric-coated aspirin for a patient at high risk for gastrointestinal bleeding due to a previous ulcer bleed despite a lack of data showing any benefit of coated aspirin over regular aspirin. Also only 28% recommended concurrent gastroprotective therapy, such as with a proton pump inhibitor or misoprostol. Most said they would put the patient on aspirin alone, he said.

“I guess the good news is that [gastroenterologists] are going to stay in business if this is truly representative of primary care physicians,” he said, noting that a study last year showed that the likelihood of such a high-risk patient developing recurrent gastrointestinal bleeding when put on aspirin therapy alone is about 15%.

Aspirin cardioprotection in those who require treatment with an NSAID is more controversial, Dr. Chey said. In one study of patients with a history of ulcer bleeding, the use of a PPI and NSAID and the use of a cyclooxygenase-2 (COX-2) selector alone were both associated with a recurrent bleeding rate of about 5% at 6 months.

The withdrawal of Vioxx from the market has highlighted concerns about COX-2 inhibitors and myocardial infarction risk. For now, avoid using COX-2 inhibitors in those with known coronary artery disease, Dr. Chey advised. In those without coronary artery disease who are at high risk for gastrointestinal complications, the use of a COX-2 inhibitor and PPI is warranted, but there is little or no incremental gastrointestinal safety benefit from aspirin and a COX-2 inhibitor vs. a traditional NSAID alone.

When physicians in the survey were asked about their knowledge of the effects of aspirin in patients using a COX-2 inhibitor, 69% of respondents said they were aware of the data showing that aspirin decreases or eliminates the gastrointestinal safety benefits of the COX-2 inhibitors (31% were unaware, or thought that aspirin improved the effects of COX-2 inhibitors).

Yet when asked how they would manage a patient with no history of peptic ulcer disease, but with a need for nonsteroidal antiinflammatory drug treatment for arthritis, 45% said they would recommend aspirin and a COX-2 inhibitor.

“Even more interesting, in a high-risk patient with a history of ulcer bleeding, 60% said they would recommend a proton pump inhibitor with a coxib and aspirin—even though there are no published data to support this strategy, and 24%, disturbingly, would choose a coxib and aspirin without gastroprotection,” Dr. Chey said.

There is no logic to this combination, he said, adding that further educational efforts are necessary to correct these “important knowledge deficits.”

ORLANDO, FLA. — Many primary care physicians do not prescribe aspirin appropriately for cardioprotection, a national survey suggests.

Many of the 1,000 primary care physicians who responded are unaware of—or disregard—data about the use of aspirin for cardioprotection and recommend to their patients doses that are too high, William D. Chey, M.D., said at the annual meeting of the American College of Gastroenterology.

The lowest cardioprotective dose of aspirin is 81 mg/day in healthy patients and in those at risk for gastrointestinal complications. Those with gastrointestinal risk should receive gastroprotection, such as a proton pump inhibitor (PPI), Dr. Chey said.

About half of those responding to the Internet survey were internists, and half were family physicians or general practitioners. Respondents, generally between 35 and 54 years old and evenly distributed geographically across the United States, had previously agreed to participate in survey research.

Overall, 95% said they recommend aspirin for cardioprotection in patients over age 60 years, with 62% always recommending aspirin therapy and 33% usually recommending aspirin therapy, said Dr. Chey of the University of Michigan, Ann Arbor. Nearly 70% said they recommend 81 mg daily, but 30% said they recommend 325 mg daily. “This is relevant because there may be a dose-response relationship between aspirin and the likelihood of developing ulcer disease and, consequently, gastrointestinal bleeding,” Dr. Chey said.

Another troubling finding was that 62% of respondents said they would recommend enteric-coated aspirin for a patient at high risk for gastrointestinal bleeding due to a previous ulcer bleed despite a lack of data showing any benefit of coated aspirin over regular aspirin. Also only 28% recommended concurrent gastroprotective therapy, such as with a proton pump inhibitor or misoprostol. Most said they would put the patient on aspirin alone, he said.

“I guess the good news is that [gastroenterologists] are going to stay in business if this is truly representative of primary care physicians,” he said, noting that a study last year showed that the likelihood of such a high-risk patient developing recurrent gastrointestinal bleeding when put on aspirin therapy alone is about 15%.

Aspirin cardioprotection in those who require treatment with an NSAID is more controversial, Dr. Chey said. In one study of patients with a history of ulcer bleeding, the use of a PPI and NSAID and the use of a cyclooxygenase-2 (COX-2) selector alone were both associated with a recurrent bleeding rate of about 5% at 6 months.

The withdrawal of Vioxx from the market has highlighted concerns about COX-2 inhibitors and myocardial infarction risk. For now, avoid using COX-2 inhibitors in those with known coronary artery disease, Dr. Chey advised. In those without coronary artery disease who are at high risk for gastrointestinal complications, the use of a COX-2 inhibitor and PPI is warranted, but there is little or no incremental gastrointestinal safety benefit from aspirin and a COX-2 inhibitor vs. a traditional NSAID alone.

When physicians in the survey were asked about their knowledge of the effects of aspirin in patients using a COX-2 inhibitor, 69% of respondents said they were aware of the data showing that aspirin decreases or eliminates the gastrointestinal safety benefits of the COX-2 inhibitors (31% were unaware, or thought that aspirin improved the effects of COX-2 inhibitors).

Yet when asked how they would manage a patient with no history of peptic ulcer disease, but with a need for nonsteroidal antiinflammatory drug treatment for arthritis, 45% said they would recommend aspirin and a COX-2 inhibitor.

“Even more interesting, in a high-risk patient with a history of ulcer bleeding, 60% said they would recommend a proton pump inhibitor with a coxib and aspirin—even though there are no published data to support this strategy, and 24%, disturbingly, would choose a coxib and aspirin without gastroprotection,” Dr. Chey said.

There is no logic to this combination, he said, adding that further educational efforts are necessary to correct these “important knowledge deficits.”

ORLANDO, FLA. — Many primary care physicians do not prescribe aspirin appropriately for cardioprotection, a national survey suggests.

Many of the 1,000 primary care physicians who responded are unaware of—or disregard—data about the use of aspirin for cardioprotection and recommend to their patients doses that are too high, William D. Chey, M.D., said at the annual meeting of the American College of Gastroenterology.

The lowest cardioprotective dose of aspirin is 81 mg/day in healthy patients and in those at risk for gastrointestinal complications. Those with gastrointestinal risk should receive gastroprotection, such as a proton pump inhibitor (PPI), Dr. Chey said.

About half of those responding to the Internet survey were internists, and half were family physicians or general practitioners. Respondents, generally between 35 and 54 years old and evenly distributed geographically across the United States, had previously agreed to participate in survey research.

Overall, 95% said they recommend aspirin for cardioprotection in patients over age 60 years, with 62% always recommending aspirin therapy and 33% usually recommending aspirin therapy, said Dr. Chey of the University of Michigan, Ann Arbor. Nearly 70% said they recommend 81 mg daily, but 30% said they recommend 325 mg daily. “This is relevant because there may be a dose-response relationship between aspirin and the likelihood of developing ulcer disease and, consequently, gastrointestinal bleeding,” Dr. Chey said.

Another troubling finding was that 62% of respondents said they would recommend enteric-coated aspirin for a patient at high risk for gastrointestinal bleeding due to a previous ulcer bleed despite a lack of data showing any benefit of coated aspirin over regular aspirin. Also only 28% recommended concurrent gastroprotective therapy, such as with a proton pump inhibitor or misoprostol. Most said they would put the patient on aspirin alone, he said.

“I guess the good news is that [gastroenterologists] are going to stay in business if this is truly representative of primary care physicians,” he said, noting that a study last year showed that the likelihood of such a high-risk patient developing recurrent gastrointestinal bleeding when put on aspirin therapy alone is about 15%.

Aspirin cardioprotection in those who require treatment with an NSAID is more controversial, Dr. Chey said. In one study of patients with a history of ulcer bleeding, the use of a PPI and NSAID and the use of a cyclooxygenase-2 (COX-2) selector alone were both associated with a recurrent bleeding rate of about 5% at 6 months.

The withdrawal of Vioxx from the market has highlighted concerns about COX-2 inhibitors and myocardial infarction risk. For now, avoid using COX-2 inhibitors in those with known coronary artery disease, Dr. Chey advised. In those without coronary artery disease who are at high risk for gastrointestinal complications, the use of a COX-2 inhibitor and PPI is warranted, but there is little or no incremental gastrointestinal safety benefit from aspirin and a COX-2 inhibitor vs. a traditional NSAID alone.

When physicians in the survey were asked about their knowledge of the effects of aspirin in patients using a COX-2 inhibitor, 69% of respondents said they were aware of the data showing that aspirin decreases or eliminates the gastrointestinal safety benefits of the COX-2 inhibitors (31% were unaware, or thought that aspirin improved the effects of COX-2 inhibitors).

Yet when asked how they would manage a patient with no history of peptic ulcer disease, but with a need for nonsteroidal antiinflammatory drug treatment for arthritis, 45% said they would recommend aspirin and a COX-2 inhibitor.

“Even more interesting, in a high-risk patient with a history of ulcer bleeding, 60% said they would recommend a proton pump inhibitor with a coxib and aspirin—even though there are no published data to support this strategy, and 24%, disturbingly, would choose a coxib and aspirin without gastroprotection,” Dr. Chey said.

There is no logic to this combination, he said, adding that further educational efforts are necessary to correct these “important knowledge deficits.”

TB Drug Monitoring

Therapeutic drug monitoring may be of benefit in patients with multidrug-resistant tuberculosis, but it is often underutilized or used inappropriately, according to Jiehui Li, M.B., of the Bureau of Tuberculosis Control, New York, and associates.

In a study of patients in 10 different clinics in which therapeutic drug monitoring is recommended for all patients with multidrug-resistant TB, only 45% of 109 eligible patients received such monitoring, the investigators found (Chest 2004;126:1770–6).

The timing of therapeutic drug-monitoring collections was problematic; 86% of initial collections were timed properly, but subsequent collections were highly variable with only 63%–88% timed properly.

Inappropriate timing of collections can adversely affect a clinician's ability to accurately interpret test results, the investigators said.

Therapeutic drug monitoring in patients with TB should be used if there is clinical suspicion of toxicity from high doses, or of treatment failure from low doses, and when results would be used to guide dosing to achieve recommended concentrations. Therapeutic drug monitoring collections should be taken 2 hours after treatment for most medications, and all results, interpretations of results, and actions taken should be clearly documented, they concluded.

Once-a-Day HIV Pill

A once-daily all-in-one pill for the treatment of HIV may soon be a reality.

Bristol-Myers Squibb Co. and Gilead Sciences Inc. announced a joint venture to test and market such a pill, which combines three common highly active antiretroviral medications from two classes of AIDS drugs, including Bristol-Myers Squibb's drug Sustiva (efavirenz), and Gilead's drug Truvada, which combines Emtriva (emtricitabine) and Viread (tenofovir disoproxil fumarate).

The three-drug combination is one of the preferred nonnucleoside reverse transcriptase inhibitor-based treatments for use in treatment-naive HIV patients, according to guidelines issued by the U.S. Department of Health and Human Services.

Work on the new combination pill has been ongoing for nearly a year, and will continue in 2005, the companies said in a statement.

AEP in Soldiers

Acute eosinophilic pneumonia (AEP) is considered a rare disease, but it occurred at an increased rate among a population of soldiers serving in or near Iraq between March 2003 and March 2004, and may be associated with new-onset smoking and/or dust inhalation, an epidemiologic study shows.

Of 183,000 military personnel deployed in or near Iraq during the study period, 18 developed AEP, for an incidence of 9.1/100,000 patient-years. Two patients died and the remaining soldiers responded to treatment. No known causes of pulmonary eosinophilia, common sources of exposure, clustering, or person-to-person transmissions were identified, reported Andrew F. Shorr, M.D., of Walter Reed Army Medical Center, Washington, and his colleagues (JAMA 2004;292:2997–3005).

All the patients were smokers, and 78% had recently started smoking. Compared with 48 controls, new-onset smokers had a significantly increased risk of AEP (odds ratio 122). Prior studies have also suggested a link between new-onset smoking and AEP. All but one patient reported significant exposure to fine airborne sand or dust.

AEP should be considered, and bronchoscopy performed, in military personnel with unexplained respiratory failure, the investigators concluded. Most patients survive when treated promptly with corticosteroids, they said.

RSV Season Underway

Recent data indicate the onset of the respiratory syncytial virus season, according to a Centers for Disease Control and Prevention report.

RSV is a cause of severe disease among older adults and those with compromised health, as well as a major cause of respiratory infections in children. The virus can exacerbate cardiac and pulmonary conditions.

Preliminary data from July 3 to Dec. 4, based on reports from 84 laboratories in 42 states, suggested that the annual outbreak of the virus had gotten underway in two U.S. regions—the South and the Northeast. Fifty of the laboratories had reported RSV detections since Nov. 6 (MMWR 2004;53:1159–60).

In 2003–2004, widespread disease activity also began in early November and continued for 22 weeks until early April 2004. Health care providers should consider RSV as a cause of acute respiratory disease in all age groups, and implement appropriate isolation precautions, according to the CDC.

TB Drug Monitoring

Therapeutic drug monitoring may be of benefit in patients with multidrug-resistant tuberculosis, but it is often underutilized or used inappropriately, according to Jiehui Li, M.B., of the Bureau of Tuberculosis Control, New York, and associates.

In a study of patients in 10 different clinics in which therapeutic drug monitoring is recommended for all patients with multidrug-resistant TB, only 45% of 109 eligible patients received such monitoring, the investigators found (Chest 2004;126:1770–6).

The timing of therapeutic drug-monitoring collections was problematic; 86% of initial collections were timed properly, but subsequent collections were highly variable with only 63%–88% timed properly.

Inappropriate timing of collections can adversely affect a clinician's ability to accurately interpret test results, the investigators said.

Therapeutic drug monitoring in patients with TB should be used if there is clinical suspicion of toxicity from high doses, or of treatment failure from low doses, and when results would be used to guide dosing to achieve recommended concentrations. Therapeutic drug monitoring collections should be taken 2 hours after treatment for most medications, and all results, interpretations of results, and actions taken should be clearly documented, they concluded.

Once-a-Day HIV Pill

A once-daily all-in-one pill for the treatment of HIV may soon be a reality.

Bristol-Myers Squibb Co. and Gilead Sciences Inc. announced a joint venture to test and market such a pill, which combines three common highly active antiretroviral medications from two classes of AIDS drugs, including Bristol-Myers Squibb's drug Sustiva (efavirenz), and Gilead's drug Truvada, which combines Emtriva (emtricitabine) and Viread (tenofovir disoproxil fumarate).

The three-drug combination is one of the preferred nonnucleoside reverse transcriptase inhibitor-based treatments for use in treatment-naive HIV patients, according to guidelines issued by the U.S. Department of Health and Human Services.

Work on the new combination pill has been ongoing for nearly a year, and will continue in 2005, the companies said in a statement.

AEP in Soldiers

Acute eosinophilic pneumonia (AEP) is considered a rare disease, but it occurred at an increased rate among a population of soldiers serving in or near Iraq between March 2003 and March 2004, and may be associated with new-onset smoking and/or dust inhalation, an epidemiologic study shows.

Of 183,000 military personnel deployed in or near Iraq during the study period, 18 developed AEP, for an incidence of 9.1/100,000 patient-years. Two patients died and the remaining soldiers responded to treatment. No known causes of pulmonary eosinophilia, common sources of exposure, clustering, or person-to-person transmissions were identified, reported Andrew F. Shorr, M.D., of Walter Reed Army Medical Center, Washington, and his colleagues (JAMA 2004;292:2997–3005).

All the patients were smokers, and 78% had recently started smoking. Compared with 48 controls, new-onset smokers had a significantly increased risk of AEP (odds ratio 122). Prior studies have also suggested a link between new-onset smoking and AEP. All but one patient reported significant exposure to fine airborne sand or dust.

AEP should be considered, and bronchoscopy performed, in military personnel with unexplained respiratory failure, the investigators concluded. Most patients survive when treated promptly with corticosteroids, they said.

RSV Season Underway

Recent data indicate the onset of the respiratory syncytial virus season, according to a Centers for Disease Control and Prevention report.

RSV is a cause of severe disease among older adults and those with compromised health, as well as a major cause of respiratory infections in children. The virus can exacerbate cardiac and pulmonary conditions.

Preliminary data from July 3 to Dec. 4, based on reports from 84 laboratories in 42 states, suggested that the annual outbreak of the virus had gotten underway in two U.S. regions—the South and the Northeast. Fifty of the laboratories had reported RSV detections since Nov. 6 (MMWR 2004;53:1159–60).

In 2003–2004, widespread disease activity also began in early November and continued for 22 weeks until early April 2004. Health care providers should consider RSV as a cause of acute respiratory disease in all age groups, and implement appropriate isolation precautions, according to the CDC.

TB Drug Monitoring

Therapeutic drug monitoring may be of benefit in patients with multidrug-resistant tuberculosis, but it is often underutilized or used inappropriately, according to Jiehui Li, M.B., of the Bureau of Tuberculosis Control, New York, and associates.

In a study of patients in 10 different clinics in which therapeutic drug monitoring is recommended for all patients with multidrug-resistant TB, only 45% of 109 eligible patients received such monitoring, the investigators found (Chest 2004;126:1770–6).

The timing of therapeutic drug-monitoring collections was problematic; 86% of initial collections were timed properly, but subsequent collections were highly variable with only 63%–88% timed properly.

Inappropriate timing of collections can adversely affect a clinician's ability to accurately interpret test results, the investigators said.

Therapeutic drug monitoring in patients with TB should be used if there is clinical suspicion of toxicity from high doses, or of treatment failure from low doses, and when results would be used to guide dosing to achieve recommended concentrations. Therapeutic drug monitoring collections should be taken 2 hours after treatment for most medications, and all results, interpretations of results, and actions taken should be clearly documented, they concluded.

Once-a-Day HIV Pill

A once-daily all-in-one pill for the treatment of HIV may soon be a reality.

Bristol-Myers Squibb Co. and Gilead Sciences Inc. announced a joint venture to test and market such a pill, which combines three common highly active antiretroviral medications from two classes of AIDS drugs, including Bristol-Myers Squibb's drug Sustiva (efavirenz), and Gilead's drug Truvada, which combines Emtriva (emtricitabine) and Viread (tenofovir disoproxil fumarate).

The three-drug combination is one of the preferred nonnucleoside reverse transcriptase inhibitor-based treatments for use in treatment-naive HIV patients, according to guidelines issued by the U.S. Department of Health and Human Services.

Work on the new combination pill has been ongoing for nearly a year, and will continue in 2005, the companies said in a statement.

AEP in Soldiers

Acute eosinophilic pneumonia (AEP) is considered a rare disease, but it occurred at an increased rate among a population of soldiers serving in or near Iraq between March 2003 and March 2004, and may be associated with new-onset smoking and/or dust inhalation, an epidemiologic study shows.

Of 183,000 military personnel deployed in or near Iraq during the study period, 18 developed AEP, for an incidence of 9.1/100,000 patient-years. Two patients died and the remaining soldiers responded to treatment. No known causes of pulmonary eosinophilia, common sources of exposure, clustering, or person-to-person transmissions were identified, reported Andrew F. Shorr, M.D., of Walter Reed Army Medical Center, Washington, and his colleagues (JAMA 2004;292:2997–3005).

All the patients were smokers, and 78% had recently started smoking. Compared with 48 controls, new-onset smokers had a significantly increased risk of AEP (odds ratio 122). Prior studies have also suggested a link between new-onset smoking and AEP. All but one patient reported significant exposure to fine airborne sand or dust.

AEP should be considered, and bronchoscopy performed, in military personnel with unexplained respiratory failure, the investigators concluded. Most patients survive when treated promptly with corticosteroids, they said.

RSV Season Underway

Recent data indicate the onset of the respiratory syncytial virus season, according to a Centers for Disease Control and Prevention report.

RSV is a cause of severe disease among older adults and those with compromised health, as well as a major cause of respiratory infections in children. The virus can exacerbate cardiac and pulmonary conditions.

Preliminary data from July 3 to Dec. 4, based on reports from 84 laboratories in 42 states, suggested that the annual outbreak of the virus had gotten underway in two U.S. regions—the South and the Northeast. Fifty of the laboratories had reported RSV detections since Nov. 6 (MMWR 2004;53:1159–60).

In 2003–2004, widespread disease activity also began in early November and continued for 22 weeks until early April 2004. Health care providers should consider RSV as a cause of acute respiratory disease in all age groups, and implement appropriate isolation precautions, according to the CDC.

ATLANTA — Better cardiac disease awareness and prevention programs that target younger women are needed, according to at least two studies presented at a prevention conference on heart disease and stroke sponsored by the Centers for Disease Control and Prevention.

In one study, risk factors for cardiac disease were common among women aged 34–64 years presenting with myocardial infarction. Of 50 such women, with a mean age of 54 years, 18% had 1–3 risk factors, 42% had 4–6 risk factors, and 40% had 7–10 risk factors, Lucia Kamm-Steigelman, Ph.D., and colleagues at Emory University, Atlanta, reported in a poster.

Risk factors included menopause (78% of patients), family history of coronary artery disease (80% of patients), previous diagnosis of coronary artery disease (38% of patients), diabetes (44% of patients), hypertension (64% of patients), hyperlipidemia (56% of patients), moderate depression (36% of patients), lack of exercise (76% of patients), body mass index over 24 kg/m

Public health and clinical prevention programs are clearly needed in this population, the investigators concluded.

Aparna Sunderam, D.O., and colleagues from the CDC analyzed data from the Behavioral Risk Factor Surveillance System and arrived at a similar conclusion.

Of 28,271 women under age 65 years who took part in the state-based telephone survey, 739 white women and 118 black women reported having heart disease.

Among those with reported heart disease, 44% of white women and 56% of black women had two or more risk factors for coronary heart disease, including hypertension (present in 86% of black women and 57% of white women), overweight status (recorded in 63% of black women and 33% of white women), sedentary lifestyle (reported by 50% of black women and 40% of white women), and high cholesterol (found in 53% of black women and 56% of white women).

Comprehensive risk reduction is necessary for all women, but aggressive intervention programs that target women by ethnicity and age, based on selected risk factor profiles, are also needed, according to the investigators.

ATLANTA — Better cardiac disease awareness and prevention programs that target younger women are needed, according to at least two studies presented at a prevention conference on heart disease and stroke sponsored by the Centers for Disease Control and Prevention.

In one study, risk factors for cardiac disease were common among women aged 34–64 years presenting with myocardial infarction. Of 50 such women, with a mean age of 54 years, 18% had 1–3 risk factors, 42% had 4–6 risk factors, and 40% had 7–10 risk factors, Lucia Kamm-Steigelman, Ph.D., and colleagues at Emory University, Atlanta, reported in a poster.

Risk factors included menopause (78% of patients), family history of coronary artery disease (80% of patients), previous diagnosis of coronary artery disease (38% of patients), diabetes (44% of patients), hypertension (64% of patients), hyperlipidemia (56% of patients), moderate depression (36% of patients), lack of exercise (76% of patients), body mass index over 24 kg/m

Public health and clinical prevention programs are clearly needed in this population, the investigators concluded.

Aparna Sunderam, D.O., and colleagues from the CDC analyzed data from the Behavioral Risk Factor Surveillance System and arrived at a similar conclusion.

Of 28,271 women under age 65 years who took part in the state-based telephone survey, 739 white women and 118 black women reported having heart disease.

Among those with reported heart disease, 44% of white women and 56% of black women had two or more risk factors for coronary heart disease, including hypertension (present in 86% of black women and 57% of white women), overweight status (recorded in 63% of black women and 33% of white women), sedentary lifestyle (reported by 50% of black women and 40% of white women), and high cholesterol (found in 53% of black women and 56% of white women).

Comprehensive risk reduction is necessary for all women, but aggressive intervention programs that target women by ethnicity and age, based on selected risk factor profiles, are also needed, according to the investigators.

ATLANTA — Better cardiac disease awareness and prevention programs that target younger women are needed, according to at least two studies presented at a prevention conference on heart disease and stroke sponsored by the Centers for Disease Control and Prevention.

In one study, risk factors for cardiac disease were common among women aged 34–64 years presenting with myocardial infarction. Of 50 such women, with a mean age of 54 years, 18% had 1–3 risk factors, 42% had 4–6 risk factors, and 40% had 7–10 risk factors, Lucia Kamm-Steigelman, Ph.D., and colleagues at Emory University, Atlanta, reported in a poster.

Risk factors included menopause (78% of patients), family history of coronary artery disease (80% of patients), previous diagnosis of coronary artery disease (38% of patients), diabetes (44% of patients), hypertension (64% of patients), hyperlipidemia (56% of patients), moderate depression (36% of patients), lack of exercise (76% of patients), body mass index over 24 kg/m

Public health and clinical prevention programs are clearly needed in this population, the investigators concluded.

Aparna Sunderam, D.O., and colleagues from the CDC analyzed data from the Behavioral Risk Factor Surveillance System and arrived at a similar conclusion.

Of 28,271 women under age 65 years who took part in the state-based telephone survey, 739 white women and 118 black women reported having heart disease.

Among those with reported heart disease, 44% of white women and 56% of black women had two or more risk factors for coronary heart disease, including hypertension (present in 86% of black women and 57% of white women), overweight status (recorded in 63% of black women and 33% of white women), sedentary lifestyle (reported by 50% of black women and 40% of white women), and high cholesterol (found in 53% of black women and 56% of white women).

Comprehensive risk reduction is necessary for all women, but aggressive intervention programs that target women by ethnicity and age, based on selected risk factor profiles, are also needed, according to the investigators.

FORT MYERS, FLA. — The majority of postpartum headaches are primary headaches, and many go untreated, a large study suggests.

About 39% of 985 postpartum women in the prospective cohort study developed a postpartum headache. Primary headaches, such as tension or migraine headaches, were nearly 20 times more frequent than secondary headaches, such as postdural puncture headaches, Eric Goldszmidt, M.D., reported in a poster presentation at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

In fact, migraine and tension headaches accounted for about 73% of all headaches in the study, and musculoskeletal and cervicogenic headaches accounted for about 15%. Postdural puncture headaches accounted for only 4.5%, and the remaining headaches were of an undetermined type, said Dr. Goldszmidt, staff anesthetist at Mount Sinai Hospital, Ontario, and a lecturer at the University of Toronto.

Development of postpartum headache and/or neck and shoulder pain was evaluated via interview and chart review at 3 days and 1 week post partum, and patients were instructed to call if headache developed after that time.

Headache diagnosis was confirmed using an algorithm based on International Headache Society criteria, and risk factors for postpartum headache were identified. Women with known inadvertent dural puncture were at extremely high risk of postpartum headache (adjusted odds ratio 6.4), as were those with a history of headaches (adjusted odds ratio of 1.6 in those with 1–12 headaches per year, and 2.3 in those with more than 12 headaches per year), Dr. Goldszmidt said.

Age slightly increased headache risk with each year. Multiparity also was a significant risk factor for postpartum headache.

Most headaches in this study developed about 3 days after discharge, suggesting that many postpartum headaches might go unreported, untreated, and that the incidence of postpartum headaches is underestimated, he said in an interview.

“Postpartum headaches may be responsible for some discomfort and anxiety that is treatable,” he said.

Of note, postdural puncture headaches accounted for only 21% of all headaches with postdural symptoms—particularly pain relief when supine, which has been considered diagnostic for postdural puncture headaches.

The high incidence of primary headaches with postdural symptoms may confound the diagnosis of postdural puncture headaches, he said.

FORT MYERS, FLA. — The majority of postpartum headaches are primary headaches, and many go untreated, a large study suggests.

About 39% of 985 postpartum women in the prospective cohort study developed a postpartum headache. Primary headaches, such as tension or migraine headaches, were nearly 20 times more frequent than secondary headaches, such as postdural puncture headaches, Eric Goldszmidt, M.D., reported in a poster presentation at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

In fact, migraine and tension headaches accounted for about 73% of all headaches in the study, and musculoskeletal and cervicogenic headaches accounted for about 15%. Postdural puncture headaches accounted for only 4.5%, and the remaining headaches were of an undetermined type, said Dr. Goldszmidt, staff anesthetist at Mount Sinai Hospital, Ontario, and a lecturer at the University of Toronto.

Development of postpartum headache and/or neck and shoulder pain was evaluated via interview and chart review at 3 days and 1 week post partum, and patients were instructed to call if headache developed after that time.

Headache diagnosis was confirmed using an algorithm based on International Headache Society criteria, and risk factors for postpartum headache were identified. Women with known inadvertent dural puncture were at extremely high risk of postpartum headache (adjusted odds ratio 6.4), as were those with a history of headaches (adjusted odds ratio of 1.6 in those with 1–12 headaches per year, and 2.3 in those with more than 12 headaches per year), Dr. Goldszmidt said.

Age slightly increased headache risk with each year. Multiparity also was a significant risk factor for postpartum headache.

Most headaches in this study developed about 3 days after discharge, suggesting that many postpartum headaches might go unreported, untreated, and that the incidence of postpartum headaches is underestimated, he said in an interview.

“Postpartum headaches may be responsible for some discomfort and anxiety that is treatable,” he said.

Of note, postdural puncture headaches accounted for only 21% of all headaches with postdural symptoms—particularly pain relief when supine, which has been considered diagnostic for postdural puncture headaches.

The high incidence of primary headaches with postdural symptoms may confound the diagnosis of postdural puncture headaches, he said.

FORT MYERS, FLA. — The majority of postpartum headaches are primary headaches, and many go untreated, a large study suggests.

About 39% of 985 postpartum women in the prospective cohort study developed a postpartum headache. Primary headaches, such as tension or migraine headaches, were nearly 20 times more frequent than secondary headaches, such as postdural puncture headaches, Eric Goldszmidt, M.D., reported in a poster presentation at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

In fact, migraine and tension headaches accounted for about 73% of all headaches in the study, and musculoskeletal and cervicogenic headaches accounted for about 15%. Postdural puncture headaches accounted for only 4.5%, and the remaining headaches were of an undetermined type, said Dr. Goldszmidt, staff anesthetist at Mount Sinai Hospital, Ontario, and a lecturer at the University of Toronto.

Development of postpartum headache and/or neck and shoulder pain was evaluated via interview and chart review at 3 days and 1 week post partum, and patients were instructed to call if headache developed after that time.

Headache diagnosis was confirmed using an algorithm based on International Headache Society criteria, and risk factors for postpartum headache were identified. Women with known inadvertent dural puncture were at extremely high risk of postpartum headache (adjusted odds ratio 6.4), as were those with a history of headaches (adjusted odds ratio of 1.6 in those with 1–12 headaches per year, and 2.3 in those with more than 12 headaches per year), Dr. Goldszmidt said.

Age slightly increased headache risk with each year. Multiparity also was a significant risk factor for postpartum headache.

Most headaches in this study developed about 3 days after discharge, suggesting that many postpartum headaches might go unreported, untreated, and that the incidence of postpartum headaches is underestimated, he said in an interview.

“Postpartum headaches may be responsible for some discomfort and anxiety that is treatable,” he said.

Of note, postdural puncture headaches accounted for only 21% of all headaches with postdural symptoms—particularly pain relief when supine, which has been considered diagnostic for postdural puncture headaches.

The high incidence of primary headaches with postdural symptoms may confound the diagnosis of postdural puncture headaches, he said.