Chronic lymphocytic leukemia

Researchers believe they’ve discovered how the Bcl-2 protein helps leukemia and lymphoma cells survive anticancer treatment.

The team found that Bcl-2 alters the level of calcium ions in cancer cells, and this promotes the cells’ survival.

The group thinks these findings, published in PNAS, could help spur the development of drugs that effectively inhibit Bcl-2 and produce better outcomes for cancer patients.

“Since 1993, our team has been conducting research on key mechanisms by which the protein Bcl-2 keeps cancer cells alive,” said study author Clark W. Distelhorst, MD, of Case Western Reserve School of Medicine in Cleveland, Ohio.

“Now, for the first time, we have evidence of how Bcl-2 is promoting abnormally long survival of the cancer cells by regulating calcium levels within cells, and [we] will use the discovery and data to deliver therapies designed to attack the Bcl-2 protein and inhibit its impact.”

More than a decade ago, researchers in Dr Distelhorst’s lab discovered that Bcl-2 binds to the inositol 1,4,5-trisphosphate receptor (InsP3R) channel and regulates the release of calcium ions.

In the current study, the team found that when Bcl-2 binds to the InsP3R channel, it initiates a complex feedback mechanism that blocks the release of calcium ions intended to induce cell death. Instead of dying, the cancer cells continue to proliferate.

Specifically, the researchers discovered that Bcl-2 interacts with the Ca2+-activated protein phosphatase calcineurin (CaN) and dopamine- and cAMP-regulated phosphoprotein of 32 kDa (DARPP-32), a CaN-regulated inhibitor of protein phosphatase 1.

Bcl-2 docks DARPP-32 and CaN on the InsP3R, creating a negative feedback loop that responds to InsP3R-mediated Ca2+ release by inhibiting InsP3R phosphorylation at Ser1755. And this prevents the excessive Ca2+ elevation that induces cell death.

The team theorized that cancer cells overexpressing Bcl-2 may exploit this mechanism to prevent apoptosis. And experiments in chronic lymphocytic leukemia cells appeared to confirm this theory.

The researchers treated the cells with the peptide TAT-IDPDD/AA, which inhibits Bcl-2–InsP3R interaction. This increased P-Ser1755 InsP3R-1 levels and elevated Ca2+, which induced apoptosis.

“We have recognized for decades that cancer cells grow and forget to die,” said Stanton Gerson, MD, director of the Case Comprehensive Cancer Center, who was not involved in this study.

“[N]ow, we understand why. I predict that this work will focus the discovery of new drugs against the Bcl-2-calcium-flow system.”

Chronic lymphocytic leukemia

Researchers believe they’ve discovered how the Bcl-2 protein helps leukemia and lymphoma cells survive anticancer treatment.

The team found that Bcl-2 alters the level of calcium ions in cancer cells, and this promotes the cells’ survival.

The group thinks these findings, published in PNAS, could help spur the development of drugs that effectively inhibit Bcl-2 and produce better outcomes for cancer patients.

“Since 1993, our team has been conducting research on key mechanisms by which the protein Bcl-2 keeps cancer cells alive,” said study author Clark W. Distelhorst, MD, of Case Western Reserve School of Medicine in Cleveland, Ohio.

“Now, for the first time, we have evidence of how Bcl-2 is promoting abnormally long survival of the cancer cells by regulating calcium levels within cells, and [we] will use the discovery and data to deliver therapies designed to attack the Bcl-2 protein and inhibit its impact.”

More than a decade ago, researchers in Dr Distelhorst’s lab discovered that Bcl-2 binds to the inositol 1,4,5-trisphosphate receptor (InsP3R) channel and regulates the release of calcium ions.

In the current study, the team found that when Bcl-2 binds to the InsP3R channel, it initiates a complex feedback mechanism that blocks the release of calcium ions intended to induce cell death. Instead of dying, the cancer cells continue to proliferate.

Specifically, the researchers discovered that Bcl-2 interacts with the Ca2+-activated protein phosphatase calcineurin (CaN) and dopamine- and cAMP-regulated phosphoprotein of 32 kDa (DARPP-32), a CaN-regulated inhibitor of protein phosphatase 1.

Bcl-2 docks DARPP-32 and CaN on the InsP3R, creating a negative feedback loop that responds to InsP3R-mediated Ca2+ release by inhibiting InsP3R phosphorylation at Ser1755. And this prevents the excessive Ca2+ elevation that induces cell death.

The team theorized that cancer cells overexpressing Bcl-2 may exploit this mechanism to prevent apoptosis. And experiments in chronic lymphocytic leukemia cells appeared to confirm this theory.

The researchers treated the cells with the peptide TAT-IDPDD/AA, which inhibits Bcl-2–InsP3R interaction. This increased P-Ser1755 InsP3R-1 levels and elevated Ca2+, which induced apoptosis.

“We have recognized for decades that cancer cells grow and forget to die,” said Stanton Gerson, MD, director of the Case Comprehensive Cancer Center, who was not involved in this study.

“[N]ow, we understand why. I predict that this work will focus the discovery of new drugs against the Bcl-2-calcium-flow system.”

Chronic lymphocytic leukemia

Researchers believe they’ve discovered how the Bcl-2 protein helps leukemia and lymphoma cells survive anticancer treatment.

The team found that Bcl-2 alters the level of calcium ions in cancer cells, and this promotes the cells’ survival.

The group thinks these findings, published in PNAS, could help spur the development of drugs that effectively inhibit Bcl-2 and produce better outcomes for cancer patients.

“Since 1993, our team has been conducting research on key mechanisms by which the protein Bcl-2 keeps cancer cells alive,” said study author Clark W. Distelhorst, MD, of Case Western Reserve School of Medicine in Cleveland, Ohio.

“Now, for the first time, we have evidence of how Bcl-2 is promoting abnormally long survival of the cancer cells by regulating calcium levels within cells, and [we] will use the discovery and data to deliver therapies designed to attack the Bcl-2 protein and inhibit its impact.”

More than a decade ago, researchers in Dr Distelhorst’s lab discovered that Bcl-2 binds to the inositol 1,4,5-trisphosphate receptor (InsP3R) channel and regulates the release of calcium ions.

In the current study, the team found that when Bcl-2 binds to the InsP3R channel, it initiates a complex feedback mechanism that blocks the release of calcium ions intended to induce cell death. Instead of dying, the cancer cells continue to proliferate.

Specifically, the researchers discovered that Bcl-2 interacts with the Ca2+-activated protein phosphatase calcineurin (CaN) and dopamine- and cAMP-regulated phosphoprotein of 32 kDa (DARPP-32), a CaN-regulated inhibitor of protein phosphatase 1.

Bcl-2 docks DARPP-32 and CaN on the InsP3R, creating a negative feedback loop that responds to InsP3R-mediated Ca2+ release by inhibiting InsP3R phosphorylation at Ser1755. And this prevents the excessive Ca2+ elevation that induces cell death.

The team theorized that cancer cells overexpressing Bcl-2 may exploit this mechanism to prevent apoptosis. And experiments in chronic lymphocytic leukemia cells appeared to confirm this theory.

The researchers treated the cells with the peptide TAT-IDPDD/AA, which inhibits Bcl-2–InsP3R interaction. This increased P-Ser1755 InsP3R-1 levels and elevated Ca2+, which induced apoptosis.

“We have recognized for decades that cancer cells grow and forget to die,” said Stanton Gerson, MD, director of the Case Comprehensive Cancer Center, who was not involved in this study.

“[N]ow, we understand why. I predict that this work will focus the discovery of new drugs against the Bcl-2-calcium-flow system.”

WAIKOLOA, HAWAII – Our editor, Heidi Splete, catches up with attendees at the Hawaii Dermatology Seminar to find out what they learned at the meeting that they will take back to their practices.

During a coffee break video interview, doctors said they enjoyed presentations on tips to treat fine lines around the eyes and mouth, the link between psoriasis and increased cardiovascular risks, and the "two Cs" of potential leather allergies.

[email protected]

WAIKOLOA, HAWAII – Our editor, Heidi Splete, catches up with attendees at the Hawaii Dermatology Seminar to find out what they learned at the meeting that they will take back to their practices.

During a coffee break video interview, doctors said they enjoyed presentations on tips to treat fine lines around the eyes and mouth, the link between psoriasis and increased cardiovascular risks, and the "two Cs" of potential leather allergies.

[email protected]

WAIKOLOA, HAWAII – Our editor, Heidi Splete, catches up with attendees at the Hawaii Dermatology Seminar to find out what they learned at the meeting that they will take back to their practices.

During a coffee break video interview, doctors said they enjoyed presentations on tips to treat fine lines around the eyes and mouth, the link between psoriasis and increased cardiovascular risks, and the "two Cs" of potential leather allergies.

[email protected]

The incidence of thyroid cancer has nearly tripled in the United States since the 1970s. However, this is mainly an epidemic of diagnosis, researchers reported.

Small papillary cancers are not likely to cause death or disease, and women are four times more likely to receive a diagnosis than men, even though autopsy findings show that these cancers occur more frequently in men.

For the research, published online Feb. 20 in JAMA Otolaryngology–Head & Neck Surgery, Dr. Louise Davies and Dr. H. Gilbert Welch reviewed diagnostic trends from the population-based Surveillance, Epidemiology, and End Results (SEER) 9 program, which covers four large U.S. metropolitan areas along with five states. They also reviewed mortality records from the National Vital Statistics System between 1975 and 2009 for the same areas, reported Dr. Davies of the Veterans Affairs Medical Center in White River Junction, Vt., and Dr. Welch of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H.

©Sebastian Kaulitzki/Fotolia.com

The researchers found that thyroid cancer incidence nearly tripled, from 4.9 to 14.3 per 100,000 individuals, in that time period (relative rate, 2.9) and that nearly all of the increase was attributable to diagnoses of small papillary cancers, the least aggressive form of thyroid cancer. The mortality rate from thyroid cancer remained stable – at 0.5 deaths per 100,000 – during the same time, Dr. Davies and Dr. Welch reported (JAMA Otolaryngol. Head Neck Surg. 2014 Feb. 20 [doi: 10.1001/jamaoto.2014.1]).

The investigators saw a much greater absolute increase in thyroid cancer in women, at 3.3-fold (from 6.5 to 21.4 cases per 100,000), than in men, at 2.2-fold (from 3.1 to 6.9), during the study period, which suggests that the burden of overdiagnosis fell heavily on women, they wrote.

Moreover, most thyroid cancers are treated "as though they are destined to cause real problems for the people who have them," Dr. Davies and Dr. Welch wrote, usually with total thyroidectomy, radiation, or both, putting patients at risk for complications and secondary cancers.

Patients – particularly women – might be better served with a less intensive diagnostic and treatment approach to these cancers, and even by relabeling them using a term other than cancer. Clinicians should take care to advise patients of the uncertainty surrounding the small papillary cancers and encourage them to consider the risks of treatment compared with active surveillance, the researchers said.

Dr. Davies and Dr. Welch received support from their institutions for their research; neither declared conflicts of interest.

The incidence of thyroid cancer has nearly tripled in the United States since the 1970s. However, this is mainly an epidemic of diagnosis, researchers reported.

Small papillary cancers are not likely to cause death or disease, and women are four times more likely to receive a diagnosis than men, even though autopsy findings show that these cancers occur more frequently in men.

For the research, published online Feb. 20 in JAMA Otolaryngology–Head & Neck Surgery, Dr. Louise Davies and Dr. H. Gilbert Welch reviewed diagnostic trends from the population-based Surveillance, Epidemiology, and End Results (SEER) 9 program, which covers four large U.S. metropolitan areas along with five states. They also reviewed mortality records from the National Vital Statistics System between 1975 and 2009 for the same areas, reported Dr. Davies of the Veterans Affairs Medical Center in White River Junction, Vt., and Dr. Welch of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H.

©Sebastian Kaulitzki/Fotolia.com

The researchers found that thyroid cancer incidence nearly tripled, from 4.9 to 14.3 per 100,000 individuals, in that time period (relative rate, 2.9) and that nearly all of the increase was attributable to diagnoses of small papillary cancers, the least aggressive form of thyroid cancer. The mortality rate from thyroid cancer remained stable – at 0.5 deaths per 100,000 – during the same time, Dr. Davies and Dr. Welch reported (JAMA Otolaryngol. Head Neck Surg. 2014 Feb. 20 [doi: 10.1001/jamaoto.2014.1]).

The investigators saw a much greater absolute increase in thyroid cancer in women, at 3.3-fold (from 6.5 to 21.4 cases per 100,000), than in men, at 2.2-fold (from 3.1 to 6.9), during the study period, which suggests that the burden of overdiagnosis fell heavily on women, they wrote.

Moreover, most thyroid cancers are treated "as though they are destined to cause real problems for the people who have them," Dr. Davies and Dr. Welch wrote, usually with total thyroidectomy, radiation, or both, putting patients at risk for complications and secondary cancers.

Patients – particularly women – might be better served with a less intensive diagnostic and treatment approach to these cancers, and even by relabeling them using a term other than cancer. Clinicians should take care to advise patients of the uncertainty surrounding the small papillary cancers and encourage them to consider the risks of treatment compared with active surveillance, the researchers said.

Dr. Davies and Dr. Welch received support from their institutions for their research; neither declared conflicts of interest.

The incidence of thyroid cancer has nearly tripled in the United States since the 1970s. However, this is mainly an epidemic of diagnosis, researchers reported.

Small papillary cancers are not likely to cause death or disease, and women are four times more likely to receive a diagnosis than men, even though autopsy findings show that these cancers occur more frequently in men.

For the research, published online Feb. 20 in JAMA Otolaryngology–Head & Neck Surgery, Dr. Louise Davies and Dr. H. Gilbert Welch reviewed diagnostic trends from the population-based Surveillance, Epidemiology, and End Results (SEER) 9 program, which covers four large U.S. metropolitan areas along with five states. They also reviewed mortality records from the National Vital Statistics System between 1975 and 2009 for the same areas, reported Dr. Davies of the Veterans Affairs Medical Center in White River Junction, Vt., and Dr. Welch of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H.

©Sebastian Kaulitzki/Fotolia.com

The researchers found that thyroid cancer incidence nearly tripled, from 4.9 to 14.3 per 100,000 individuals, in that time period (relative rate, 2.9) and that nearly all of the increase was attributable to diagnoses of small papillary cancers, the least aggressive form of thyroid cancer. The mortality rate from thyroid cancer remained stable – at 0.5 deaths per 100,000 – during the same time, Dr. Davies and Dr. Welch reported (JAMA Otolaryngol. Head Neck Surg. 2014 Feb. 20 [doi: 10.1001/jamaoto.2014.1]).

The investigators saw a much greater absolute increase in thyroid cancer in women, at 3.3-fold (from 6.5 to 21.4 cases per 100,000), than in men, at 2.2-fold (from 3.1 to 6.9), during the study period, which suggests that the burden of overdiagnosis fell heavily on women, they wrote.

Moreover, most thyroid cancers are treated "as though they are destined to cause real problems for the people who have them," Dr. Davies and Dr. Welch wrote, usually with total thyroidectomy, radiation, or both, putting patients at risk for complications and secondary cancers.

Patients – particularly women – might be better served with a less intensive diagnostic and treatment approach to these cancers, and even by relabeling them using a term other than cancer. Clinicians should take care to advise patients of the uncertainty surrounding the small papillary cancers and encourage them to consider the risks of treatment compared with active surveillance, the researchers said.

Dr. Davies and Dr. Welch received support from their institutions for their research; neither declared conflicts of interest.

Background There is often a lack of collaboration between hematological malignancy–bone marrow transplantation (HM-BMT) units and palliative care (PC) services. In this paper, we describe a quality improvement project that sought to close this gap at a tertiary care hospital in Pittsburgh, Pennsylvania, from August 2006 to May 2010.
 

Design and methods Through a needs assessment, didactic lectures, clinical consultation, and the informal presence of PC clinicians, the team created a palliative care service in HM-BMT unit of the Western Pennsylvania Hospital in Pittsburgh. The following data were collected for each consult: referral reason, daily pain assessments, whether or not a “goals of care” conversation took place, and hospice enrollment. Lastly, satisfaction surveys were administered.
 

Results During the program, 392 PC consultations were provided to 256 unique patients. Of these 256 patients, the PC clinicians documented the first goals of care conversations in 67% of patients (n = 172). Of the 278 consults referred for pain, 70% (n = 194) involved reports of unacceptable or very unacceptable pain at baseline. Sixty-six percent (n = 129) of these 194 consults involved reports of pain that was acceptable or very acceptable within 48 hours of consultation. In addition, the hospice referral rate grew from a pre-implementation rate of 5% to 41% (n = 67) of 165 patients who died during the period of program implementation. Lastly, hematological oncologists reported high levels of satisfaction with the program.
 

Limitations The main limitation of this project is that it was a single institution study.
 

Conclusion The successful integration of a PC team into a hematological malignancy unit suggests great potential for positive interdisciplinary collaboration between these two fields.
 

Click on the PDF icon at the top of this introduction to read the full article.

Background There is often a lack of collaboration between hematological malignancy–bone marrow transplantation (HM-BMT) units and palliative care (PC) services. In this paper, we describe a quality improvement project that sought to close this gap at a tertiary care hospital in Pittsburgh, Pennsylvania, from August 2006 to May 2010.
 

Design and methods Through a needs assessment, didactic lectures, clinical consultation, and the informal presence of PC clinicians, the team created a palliative care service in HM-BMT unit of the Western Pennsylvania Hospital in Pittsburgh. The following data were collected for each consult: referral reason, daily pain assessments, whether or not a “goals of care” conversation took place, and hospice enrollment. Lastly, satisfaction surveys were administered.
 

Results During the program, 392 PC consultations were provided to 256 unique patients. Of these 256 patients, the PC clinicians documented the first goals of care conversations in 67% of patients (n = 172). Of the 278 consults referred for pain, 70% (n = 194) involved reports of unacceptable or very unacceptable pain at baseline. Sixty-six percent (n = 129) of these 194 consults involved reports of pain that was acceptable or very acceptable within 48 hours of consultation. In addition, the hospice referral rate grew from a pre-implementation rate of 5% to 41% (n = 67) of 165 patients who died during the period of program implementation. Lastly, hematological oncologists reported high levels of satisfaction with the program.
 

Limitations The main limitation of this project is that it was a single institution study.
 

Conclusion The successful integration of a PC team into a hematological malignancy unit suggests great potential for positive interdisciplinary collaboration between these two fields.
 

Click on the PDF icon at the top of this introduction to read the full article.

Background There is often a lack of collaboration between hematological malignancy–bone marrow transplantation (HM-BMT) units and palliative care (PC) services. In this paper, we describe a quality improvement project that sought to close this gap at a tertiary care hospital in Pittsburgh, Pennsylvania, from August 2006 to May 2010.
 

Design and methods Through a needs assessment, didactic lectures, clinical consultation, and the informal presence of PC clinicians, the team created a palliative care service in HM-BMT unit of the Western Pennsylvania Hospital in Pittsburgh. The following data were collected for each consult: referral reason, daily pain assessments, whether or not a “goals of care” conversation took place, and hospice enrollment. Lastly, satisfaction surveys were administered.
 

Results During the program, 392 PC consultations were provided to 256 unique patients. Of these 256 patients, the PC clinicians documented the first goals of care conversations in 67% of patients (n = 172). Of the 278 consults referred for pain, 70% (n = 194) involved reports of unacceptable or very unacceptable pain at baseline. Sixty-six percent (n = 129) of these 194 consults involved reports of pain that was acceptable or very acceptable within 48 hours of consultation. In addition, the hospice referral rate grew from a pre-implementation rate of 5% to 41% (n = 67) of 165 patients who died during the period of program implementation. Lastly, hematological oncologists reported high levels of satisfaction with the program.
 

Limitations The main limitation of this project is that it was a single institution study.
 

Conclusion The successful integration of a PC team into a hematological malignancy unit suggests great potential for positive interdisciplinary collaboration between these two fields.
 

Click on the PDF icon at the top of this introduction to read the full article.

Allergic transfusion reactions (ATRs) are a common complication of blood transfusions. Advances in transfusion medicine have significantly decreased the incidence of ATRs; however, ATRs continue to be burdensome for patients and problematic for providers who regularly order packed red blood cells and platelet transfusions. To further decrease the frequency of ATRs, routine premedication with diphenhydramine is common practice and is part of “transfusion culture” in a majority of institutions. In this article, we review the history, practice, and literature of transfusion premedication, specifically antihistamines given the adverse-effect profile. We discuss the rationale and original academic studies, which have supported the use of premedication for transfusions for decades.

Click on the PDF icon at the top of this introduction to read the full article.

Allergic transfusion reactions (ATRs) are a common complication of blood transfusions. Advances in transfusion medicine have significantly decreased the incidence of ATRs; however, ATRs continue to be burdensome for patients and problematic for providers who regularly order packed red blood cells and platelet transfusions. To further decrease the frequency of ATRs, routine premedication with diphenhydramine is common practice and is part of “transfusion culture” in a majority of institutions. In this article, we review the history, practice, and literature of transfusion premedication, specifically antihistamines given the adverse-effect profile. We discuss the rationale and original academic studies, which have supported the use of premedication for transfusions for decades.

Click on the PDF icon at the top of this introduction to read the full article.

Allergic transfusion reactions (ATRs) are a common complication of blood transfusions. Advances in transfusion medicine have significantly decreased the incidence of ATRs; however, ATRs continue to be burdensome for patients and problematic for providers who regularly order packed red blood cells and platelet transfusions. To further decrease the frequency of ATRs, routine premedication with diphenhydramine is common practice and is part of “transfusion culture” in a majority of institutions. In this article, we review the history, practice, and literature of transfusion premedication, specifically antihistamines given the adverse-effect profile. We discuss the rationale and original academic studies, which have supported the use of premedication for transfusions for decades.

Click on the PDF icon at the top of this introduction to read the full article.

In the wake of the actor Philip Seymour Hoffman’s death, I’ve been thinking a lot about the movie Doubt. In it, Hoffman plays Father Brendan Flynn, a Catholic priest newly assigned to a parish in the Bronx. The school attached to the parish is run by the strict Sister Aloysius Beauvier, played by Meryl Streep. She is suspicious of the priest’s motives behind his befriending a boy, who happens to be the school’s only black student. The boy’s mother welcomes the friendship, as it provides shelter from his abusive father, and begs Sister Beauvier to leave things alone. But the nun doggedly pursues the issue, and in the end she succeeds in getting the priest removed from the parish.

Being relatively new to private practice, I constantly reflect on my methods. I have gotten the diagnosis wrong sometimes, and while I understand that this happens to even the most seasoned among us, when it happens to me, I cannot help but feel like an impostor, unqualified and incompetent. When I risk doing harm to a patient by giving them medications that may not work, I feel like curling up under the covers and not ever coming out. Steroids and chronic immunosuppression don’t exactly inspire confidence. It does not help that rheumatology isn’t the most exact of specialties and the diseases that we diagnose and treat are nebulous by nature.

Therefore, I would venture to say that rheumatologists are probably more comfortable with ambiguity than most other specialists. That’s not easy for a scientist to say; the object of science, after all, is to find answers. Certitude is comforting. Patients expect that from us, and we do our best to provide it. But it is not always possible through no fault of our own, but as a limitation of the field itself. In such situations, it can be very humbling to acknowledge that there are gaps in our knowledge.

I am learning to be comfortable with saying, "I don’t know. I need help. I cannot figure this out on my own." If I do not allow myself to question my judgment, I run the risk of harming this person who trusts me implicitly. Humility and certitude are, in our imperfect science, two sides of the same patient care coin that can spell the difference in a patient’s outcome.

After all, questioning is integral to the pursuit of knowledge. Great science is not possible without curiosity. The philosopher Simon Critchley says that "knowledge is precise, but that precision is confined within a certain toleration of uncertainty." Therefore, just as there is comfort in certitude, there is also some comfort in doubt.

At the end of the movie, we are left wondering if Father Flynn is guilty of abusing the young boy. But we’re not meant to know. In fact, the cast, except for Hoffman, did not know either. Not knowing is the point. We are meant to examine our attitudes toward conviction, toward truth, to the extent that it is limited by what is knowable. As Father Flynn in the movie says: "Doubt can be a bond as powerful and sustaining as certainty. When you are lost, you are not alone."

Dr. Chan practices rheumatology in Pawtucket, R.I.

In the wake of the actor Philip Seymour Hoffman’s death, I’ve been thinking a lot about the movie Doubt. In it, Hoffman plays Father Brendan Flynn, a Catholic priest newly assigned to a parish in the Bronx. The school attached to the parish is run by the strict Sister Aloysius Beauvier, played by Meryl Streep. She is suspicious of the priest’s motives behind his befriending a boy, who happens to be the school’s only black student. The boy’s mother welcomes the friendship, as it provides shelter from his abusive father, and begs Sister Beauvier to leave things alone. But the nun doggedly pursues the issue, and in the end she succeeds in getting the priest removed from the parish.

Being relatively new to private practice, I constantly reflect on my methods. I have gotten the diagnosis wrong sometimes, and while I understand that this happens to even the most seasoned among us, when it happens to me, I cannot help but feel like an impostor, unqualified and incompetent. When I risk doing harm to a patient by giving them medications that may not work, I feel like curling up under the covers and not ever coming out. Steroids and chronic immunosuppression don’t exactly inspire confidence. It does not help that rheumatology isn’t the most exact of specialties and the diseases that we diagnose and treat are nebulous by nature.

Therefore, I would venture to say that rheumatologists are probably more comfortable with ambiguity than most other specialists. That’s not easy for a scientist to say; the object of science, after all, is to find answers. Certitude is comforting. Patients expect that from us, and we do our best to provide it. But it is not always possible through no fault of our own, but as a limitation of the field itself. In such situations, it can be very humbling to acknowledge that there are gaps in our knowledge.

I am learning to be comfortable with saying, "I don’t know. I need help. I cannot figure this out on my own." If I do not allow myself to question my judgment, I run the risk of harming this person who trusts me implicitly. Humility and certitude are, in our imperfect science, two sides of the same patient care coin that can spell the difference in a patient’s outcome.

After all, questioning is integral to the pursuit of knowledge. Great science is not possible without curiosity. The philosopher Simon Critchley says that "knowledge is precise, but that precision is confined within a certain toleration of uncertainty." Therefore, just as there is comfort in certitude, there is also some comfort in doubt.

At the end of the movie, we are left wondering if Father Flynn is guilty of abusing the young boy. But we’re not meant to know. In fact, the cast, except for Hoffman, did not know either. Not knowing is the point. We are meant to examine our attitudes toward conviction, toward truth, to the extent that it is limited by what is knowable. As Father Flynn in the movie says: "Doubt can be a bond as powerful and sustaining as certainty. When you are lost, you are not alone."

Dr. Chan practices rheumatology in Pawtucket, R.I.

In the wake of the actor Philip Seymour Hoffman’s death, I’ve been thinking a lot about the movie Doubt. In it, Hoffman plays Father Brendan Flynn, a Catholic priest newly assigned to a parish in the Bronx. The school attached to the parish is run by the strict Sister Aloysius Beauvier, played by Meryl Streep. She is suspicious of the priest’s motives behind his befriending a boy, who happens to be the school’s only black student. The boy’s mother welcomes the friendship, as it provides shelter from his abusive father, and begs Sister Beauvier to leave things alone. But the nun doggedly pursues the issue, and in the end she succeeds in getting the priest removed from the parish.

Being relatively new to private practice, I constantly reflect on my methods. I have gotten the diagnosis wrong sometimes, and while I understand that this happens to even the most seasoned among us, when it happens to me, I cannot help but feel like an impostor, unqualified and incompetent. When I risk doing harm to a patient by giving them medications that may not work, I feel like curling up under the covers and not ever coming out. Steroids and chronic immunosuppression don’t exactly inspire confidence. It does not help that rheumatology isn’t the most exact of specialties and the diseases that we diagnose and treat are nebulous by nature.

Therefore, I would venture to say that rheumatologists are probably more comfortable with ambiguity than most other specialists. That’s not easy for a scientist to say; the object of science, after all, is to find answers. Certitude is comforting. Patients expect that from us, and we do our best to provide it. But it is not always possible through no fault of our own, but as a limitation of the field itself. In such situations, it can be very humbling to acknowledge that there are gaps in our knowledge.

I am learning to be comfortable with saying, "I don’t know. I need help. I cannot figure this out on my own." If I do not allow myself to question my judgment, I run the risk of harming this person who trusts me implicitly. Humility and certitude are, in our imperfect science, two sides of the same patient care coin that can spell the difference in a patient’s outcome.

After all, questioning is integral to the pursuit of knowledge. Great science is not possible without curiosity. The philosopher Simon Critchley says that "knowledge is precise, but that precision is confined within a certain toleration of uncertainty." Therefore, just as there is comfort in certitude, there is also some comfort in doubt.

At the end of the movie, we are left wondering if Father Flynn is guilty of abusing the young boy. But we’re not meant to know. In fact, the cast, except for Hoffman, did not know either. Not knowing is the point. We are meant to examine our attitudes toward conviction, toward truth, to the extent that it is limited by what is knowable. As Father Flynn in the movie says: "Doubt can be a bond as powerful and sustaining as certainty. When you are lost, you are not alone."

Dr. Chan practices rheumatology in Pawtucket, R.I.

1. Which of the following suture properties is most responsible for accommodation of edema postoperatively?

a. memory
b. plasticity
c. pliability
d. size
e. stretching

2. Which of the following has the highest memory?

a. coated polyester (Ethibond Excel)
b. poliglecaprone 25 (Monocryl)
c. polyglactin 910 (Vicryl)
d. silk
e. stainless steel

3. The most worrisome consequence of capillarity is:

a. increased potential of translocation of bacterium in a wound
b. increased reactivity
c. increased spitting of suture
d. increased wound edema
e. decreased tensile strength

4. Which of the following would be an excellent choice for closing the mucosal surface on an Abbe flap repair?

a. 2-octyl cyanoacrylate (Dermabond Advanced)
b. 5-0 chromic gut
c. 5-0 coated polyester (Ethibond Excel)
d. 5-0 polybutester (Novafil)
e. polypropylene (Prolene)

5. Knot security is thought to be most directly related to which property of suture:

a. coefficient of friction
b. configuration
c. memory
d. size
e. tensile strength

1. Which of the following suture properties is most responsible for accommodation of edema postoperatively?

a. memory
b. plasticity
c. pliability
d. size
e. stretching

2. Which of the following has the highest memory?

a. coated polyester (Ethibond Excel)
b. poliglecaprone 25 (Monocryl)
c. polyglactin 910 (Vicryl)
d. silk
e. stainless steel

3. The most worrisome consequence of capillarity is:

a. increased potential of translocation of bacterium in a wound
b. increased reactivity
c. increased spitting of suture
d. increased wound edema
e. decreased tensile strength

4. Which of the following would be an excellent choice for closing the mucosal surface on an Abbe flap repair?

a. 2-octyl cyanoacrylate (Dermabond Advanced)
b. 5-0 chromic gut
c. 5-0 coated polyester (Ethibond Excel)
d. 5-0 polybutester (Novafil)
e. polypropylene (Prolene)

5. Knot security is thought to be most directly related to which property of suture:

a. coefficient of friction
b. configuration
c. memory
d. size
e. tensile strength

1. Which of the following suture properties is most responsible for accommodation of edema postoperatively?

a. memory
b. plasticity
c. pliability
d. size
e. stretching

2. Which of the following has the highest memory?

a. coated polyester (Ethibond Excel)
b. poliglecaprone 25 (Monocryl)
c. polyglactin 910 (Vicryl)
d. silk
e. stainless steel

3. The most worrisome consequence of capillarity is:

a. increased potential of translocation of bacterium in a wound
b. increased reactivity
c. increased spitting of suture
d. increased wound edema
e. decreased tensile strength

4. Which of the following would be an excellent choice for closing the mucosal surface on an Abbe flap repair?

a. 2-octyl cyanoacrylate (Dermabond Advanced)
b. 5-0 chromic gut
c. 5-0 coated polyester (Ethibond Excel)
d. 5-0 polybutester (Novafil)
e. polypropylene (Prolene)

5. Knot security is thought to be most directly related to which property of suture:

a. coefficient of friction
b. configuration
c. memory
d. size
e. tensile strength

The risk of amputation and death appears to increase as the number of revascularization procedures increases, according to findings from a retrospective analysis of data.

The amputation risk was present among patients who underwent percutaneous transluminal angioplasty (PTA) only, as well as among subsets of patients who underwent lower extremity bypass (LEB) only, reported Dr. Alexander T. Hawkins of the Center for Surgery and Public Health, Boston, and his colleagues.

Among 11,190 patients with critical limb ischemia who underwent one, two, three, four, or five or more revascularization procedures, the 1-year estimated amputation rates were 23.3%, 27.1%, 30.3%, 26.7%, and 28.6%, and the 1-year estimated mortality rates were 18.7%, 21.1%, 26.3%, 23.6%, and 32.1%, respectively, the investigators reported. The findings were published in the January issue of Annals of Vascular Surgery.

The risk of amputation increased significantly for those with two vs. one revascularization procedure (hazard ratio, 1.22) and for those with three vs. two procedures (HR, 1.33). The risk for death at one year also increased significantly among those with two vs. one procedure (HR, 1.18) (Ann. Vasc. Surg. 2014;28:35-47).

Similar trends for amputation were seen in the PTA-only (1: 24.5%; 2: 26.1%; 3: 27.9%; 4: 31.3%; 5+: 26.8%), and LEB-only (1: 26.0%; 2: 32.5%; 3+: 45.5%) groups. "The increases did not appear to be exponential," they noted.

No changes were seen in the PTA-only and LEB-only groups with respect to 1-year estimates of in-hospital death.

A subgroup analysis further showed that timing between procedures was significantly associated with 1-year amputation risk; the risk was 27.2% for a 1-7 day interval, 36.4% for 8 days to 1 month, 19.4% for 1-6 months; and 22.2% for 6 months or more.

"There was also a difference in 1-year amputation rates between bypass patients who underwent bypass first and who underwent PTA followed by bypass" (21.8% vs. 30.7%), the researchers wrote.

Study subjects were adult patients with a mean age of 71 years who underwent revascularization between July 2007 and December 2009. The patients, including 6,225 men (55.9%), were identified from the California State Inpatient Database and had a high burden of comorbidities; 55.2% abused tobacco, 64.9% had coronary artery disease, 51.3% had hypertension, and 68% had diabetes.

Though limited by factors inherent in the use of an administrative database (such as potential inconsistencies in coding accuracy) and in a nonrandomized study (subject to confounding), the findings nonetheless provide "novel and useful information on the increasing risk of amputation and death in patients undergoing multiple revascularization procedures," the investigators said.

They stressed that they are "by no means making the claim that secondary revascularization is inappropriate," but rather, that they are presenting the risks associated with further procedures in an effort to inform the decision-making process.

Critical limb ischemia confers a high risk of limb loss without treatment, they said, noting that 16%-50% of revascularized patients require secondary revascularization. A "major proportion" of these patients will require further procedures, they noted.

"We emphasize continued communication between clinicians and patients on the true risks and benefits of these procedures," they concluded.

Dr. Hawkins and his coauthor, Dr. Stuart Lipsitz, are supported by a grant from the Brigham and Women's Center for Surgery and Public Health Arthur Tracy Cabot Fellowship. Dr. Hawkins is also supported by the NIH NHLBI T32 Harvard/Longwood Vascular Surgery Training Program. Another author, Dr. Maria J. Schaumeier, is supported by a grant from the Freiwillige Akademische Gesellschaft, Basel, Switzerland.

The risk of amputation and death appears to increase as the number of revascularization procedures increases, according to findings from a retrospective analysis of data.

The amputation risk was present among patients who underwent percutaneous transluminal angioplasty (PTA) only, as well as among subsets of patients who underwent lower extremity bypass (LEB) only, reported Dr. Alexander T. Hawkins of the Center for Surgery and Public Health, Boston, and his colleagues.

Among 11,190 patients with critical limb ischemia who underwent one, two, three, four, or five or more revascularization procedures, the 1-year estimated amputation rates were 23.3%, 27.1%, 30.3%, 26.7%, and 28.6%, and the 1-year estimated mortality rates were 18.7%, 21.1%, 26.3%, 23.6%, and 32.1%, respectively, the investigators reported. The findings were published in the January issue of Annals of Vascular Surgery.

The risk of amputation increased significantly for those with two vs. one revascularization procedure (hazard ratio, 1.22) and for those with three vs. two procedures (HR, 1.33). The risk for death at one year also increased significantly among those with two vs. one procedure (HR, 1.18) (Ann. Vasc. Surg. 2014;28:35-47).

Similar trends for amputation were seen in the PTA-only (1: 24.5%; 2: 26.1%; 3: 27.9%; 4: 31.3%; 5+: 26.8%), and LEB-only (1: 26.0%; 2: 32.5%; 3+: 45.5%) groups. "The increases did not appear to be exponential," they noted.

No changes were seen in the PTA-only and LEB-only groups with respect to 1-year estimates of in-hospital death.

A subgroup analysis further showed that timing between procedures was significantly associated with 1-year amputation risk; the risk was 27.2% for a 1-7 day interval, 36.4% for 8 days to 1 month, 19.4% for 1-6 months; and 22.2% for 6 months or more.

"There was also a difference in 1-year amputation rates between bypass patients who underwent bypass first and who underwent PTA followed by bypass" (21.8% vs. 30.7%), the researchers wrote.

Study subjects were adult patients with a mean age of 71 years who underwent revascularization between July 2007 and December 2009. The patients, including 6,225 men (55.9%), were identified from the California State Inpatient Database and had a high burden of comorbidities; 55.2% abused tobacco, 64.9% had coronary artery disease, 51.3% had hypertension, and 68% had diabetes.

Though limited by factors inherent in the use of an administrative database (such as potential inconsistencies in coding accuracy) and in a nonrandomized study (subject to confounding), the findings nonetheless provide "novel and useful information on the increasing risk of amputation and death in patients undergoing multiple revascularization procedures," the investigators said.

They stressed that they are "by no means making the claim that secondary revascularization is inappropriate," but rather, that they are presenting the risks associated with further procedures in an effort to inform the decision-making process.

Critical limb ischemia confers a high risk of limb loss without treatment, they said, noting that 16%-50% of revascularized patients require secondary revascularization. A "major proportion" of these patients will require further procedures, they noted.

"We emphasize continued communication between clinicians and patients on the true risks and benefits of these procedures," they concluded.

Dr. Hawkins and his coauthor, Dr. Stuart Lipsitz, are supported by a grant from the Brigham and Women's Center for Surgery and Public Health Arthur Tracy Cabot Fellowship. Dr. Hawkins is also supported by the NIH NHLBI T32 Harvard/Longwood Vascular Surgery Training Program. Another author, Dr. Maria J. Schaumeier, is supported by a grant from the Freiwillige Akademische Gesellschaft, Basel, Switzerland.

The risk of amputation and death appears to increase as the number of revascularization procedures increases, according to findings from a retrospective analysis of data.

The amputation risk was present among patients who underwent percutaneous transluminal angioplasty (PTA) only, as well as among subsets of patients who underwent lower extremity bypass (LEB) only, reported Dr. Alexander T. Hawkins of the Center for Surgery and Public Health, Boston, and his colleagues.

Among 11,190 patients with critical limb ischemia who underwent one, two, three, four, or five or more revascularization procedures, the 1-year estimated amputation rates were 23.3%, 27.1%, 30.3%, 26.7%, and 28.6%, and the 1-year estimated mortality rates were 18.7%, 21.1%, 26.3%, 23.6%, and 32.1%, respectively, the investigators reported. The findings were published in the January issue of Annals of Vascular Surgery.

The risk of amputation increased significantly for those with two vs. one revascularization procedure (hazard ratio, 1.22) and for those with three vs. two procedures (HR, 1.33). The risk for death at one year also increased significantly among those with two vs. one procedure (HR, 1.18) (Ann. Vasc. Surg. 2014;28:35-47).

Similar trends for amputation were seen in the PTA-only (1: 24.5%; 2: 26.1%; 3: 27.9%; 4: 31.3%; 5+: 26.8%), and LEB-only (1: 26.0%; 2: 32.5%; 3+: 45.5%) groups. "The increases did not appear to be exponential," they noted.

No changes were seen in the PTA-only and LEB-only groups with respect to 1-year estimates of in-hospital death.

A subgroup analysis further showed that timing between procedures was significantly associated with 1-year amputation risk; the risk was 27.2% for a 1-7 day interval, 36.4% for 8 days to 1 month, 19.4% for 1-6 months; and 22.2% for 6 months or more.

"There was also a difference in 1-year amputation rates between bypass patients who underwent bypass first and who underwent PTA followed by bypass" (21.8% vs. 30.7%), the researchers wrote.

Study subjects were adult patients with a mean age of 71 years who underwent revascularization between July 2007 and December 2009. The patients, including 6,225 men (55.9%), were identified from the California State Inpatient Database and had a high burden of comorbidities; 55.2% abused tobacco, 64.9% had coronary artery disease, 51.3% had hypertension, and 68% had diabetes.

Though limited by factors inherent in the use of an administrative database (such as potential inconsistencies in coding accuracy) and in a nonrandomized study (subject to confounding), the findings nonetheless provide "novel and useful information on the increasing risk of amputation and death in patients undergoing multiple revascularization procedures," the investigators said.

They stressed that they are "by no means making the claim that secondary revascularization is inappropriate," but rather, that they are presenting the risks associated with further procedures in an effort to inform the decision-making process.

Critical limb ischemia confers a high risk of limb loss without treatment, they said, noting that 16%-50% of revascularized patients require secondary revascularization. A "major proportion" of these patients will require further procedures, they noted.

"We emphasize continued communication between clinicians and patients on the true risks and benefits of these procedures," they concluded.

Dr. Hawkins and his coauthor, Dr. Stuart Lipsitz, are supported by a grant from the Brigham and Women's Center for Surgery and Public Health Arthur Tracy Cabot Fellowship. Dr. Hawkins is also supported by the NIH NHLBI T32 Harvard/Longwood Vascular Surgery Training Program. Another author, Dr. Maria J. Schaumeier, is supported by a grant from the Freiwillige Akademische Gesellschaft, Basel, Switzerland.

PALM BEACH, FLA. – The ankle-brachial index value is directly associated with the prevalence of carotid artery stenosis and with a history of coronary artery disease and cerebrovascular disease, according to analysis of more than 3.6 million records obtained from the private health screening company, Life Line Screening.

But what makes the study interesting is the database itself, and not so much the findings, which have been previously shown, commented Dr. Spence M. Taylor, president of the Greenville (S.C.) Health System Clinical University.

Life Line Screening has mobile units, which travel to various locations and for a fee of more than $100, screen individuals, collecting nearly 300 data points per person. Meanwhile, the ankle-brachial index (ABI) costs less than $30 approximately. Yet, the test hasn’t become widely used, despite the evidence. Not much has changed since the 2001 PARTNERS study, which showed that the primary care physicians’ awareness of PAD diagnosis was "relatively low" (JAMA 2001;286:1317-24).

Results using the Life Line Screening’s large database may show the federal government that ABI can be cost effective, and getting them on board would popularize the screening tool, said Dr. Mark A. Adelman of the New York University Langone Medical Center, who presented his study at the Southern Association for Vascular Surgery annual meeting.

"Life Line is a huge paradox," said Dr. Taylor, senior associate dean of academic affairs at University of South Carolina, Greenville. It’s an operation that "we love to hate and hate to love," he added.

Dr. Adelman, the Frank J. Veith, M.D. Professor of Vascular and Endovascular Surgery and chief of vascular surgery at NYU Langone, and his colleagues analyzed data obtained from Life Line Screening, and found that individuals with an ABI between 0.41 and 0.60 had a 26.4% incidence of carotid artery stenosis (CAS), compared with individuals who had a normal ABI. The incidence increased to 35% for patients with ABI of 0.4 or less.

The majority of the abnormal ABI cases were between 0.81 and 0.90.

The analysis by Dr. Adelman and his colleagues also showed that individuals with PAD were more likely to be aged 70 years or older, male, and have modifiable risk factors, such as a history of smoking, hypertension, diabetes, and hypercholesterolemia, compared with non–PAD persons (P less than .001). (A comparison of Life Line’s database to one from the general population showed that the risk factors such as hypertension, hyperlipidemia, diabetes, and smoking were comparable.)

PAD subjects were also more likely to have CAS, prior stroke, prior transient ischemic attack, prior MI, and prior coronary revascularization, compared with those who didn’t have PAD (P less than .001). There was a significant correlation between decreasing ABI value and an increase in the prevalence of CAS, CAD, and cardiovascular disease (P less than .001).

In a separate study analyzing the same database, Dr. Adelman and his colleagues found that modifiable risk factors, such as hypertension and smoking, are associated with increased prevalence of peripheral vascular disease (J. Vasc. Surg. 2013;58:673-81).

Dr. Adelman said that screening for ABI could trigger other screening and lead to modification of risk factors that could affect better patient outcomes, changes in lifestyle, or changes in pharmacological management.

Dr. Adelman and Dr. Taylor had no disclosures.

[email protected]

On Twitter @naseemsmiller

PALM BEACH, FLA. – The ankle-brachial index value is directly associated with the prevalence of carotid artery stenosis and with a history of coronary artery disease and cerebrovascular disease, according to analysis of more than 3.6 million records obtained from the private health screening company, Life Line Screening.

But what makes the study interesting is the database itself, and not so much the findings, which have been previously shown, commented Dr. Spence M. Taylor, president of the Greenville (S.C.) Health System Clinical University.

Life Line Screening has mobile units, which travel to various locations and for a fee of more than $100, screen individuals, collecting nearly 300 data points per person. Meanwhile, the ankle-brachial index (ABI) costs less than $30 approximately. Yet, the test hasn’t become widely used, despite the evidence. Not much has changed since the 2001 PARTNERS study, which showed that the primary care physicians’ awareness of PAD diagnosis was "relatively low" (JAMA 2001;286:1317-24).

Results using the Life Line Screening’s large database may show the federal government that ABI can be cost effective, and getting them on board would popularize the screening tool, said Dr. Mark A. Adelman of the New York University Langone Medical Center, who presented his study at the Southern Association for Vascular Surgery annual meeting.

"Life Line is a huge paradox," said Dr. Taylor, senior associate dean of academic affairs at University of South Carolina, Greenville. It’s an operation that "we love to hate and hate to love," he added.

Dr. Adelman, the Frank J. Veith, M.D. Professor of Vascular and Endovascular Surgery and chief of vascular surgery at NYU Langone, and his colleagues analyzed data obtained from Life Line Screening, and found that individuals with an ABI between 0.41 and 0.60 had a 26.4% incidence of carotid artery stenosis (CAS), compared with individuals who had a normal ABI. The incidence increased to 35% for patients with ABI of 0.4 or less.

The majority of the abnormal ABI cases were between 0.81 and 0.90.

The analysis by Dr. Adelman and his colleagues also showed that individuals with PAD were more likely to be aged 70 years or older, male, and have modifiable risk factors, such as a history of smoking, hypertension, diabetes, and hypercholesterolemia, compared with non–PAD persons (P less than .001). (A comparison of Life Line’s database to one from the general population showed that the risk factors such as hypertension, hyperlipidemia, diabetes, and smoking were comparable.)

PAD subjects were also more likely to have CAS, prior stroke, prior transient ischemic attack, prior MI, and prior coronary revascularization, compared with those who didn’t have PAD (P less than .001). There was a significant correlation between decreasing ABI value and an increase in the prevalence of CAS, CAD, and cardiovascular disease (P less than .001).

In a separate study analyzing the same database, Dr. Adelman and his colleagues found that modifiable risk factors, such as hypertension and smoking, are associated with increased prevalence of peripheral vascular disease (J. Vasc. Surg. 2013;58:673-81).

Dr. Adelman said that screening for ABI could trigger other screening and lead to modification of risk factors that could affect better patient outcomes, changes in lifestyle, or changes in pharmacological management.

Dr. Adelman and Dr. Taylor had no disclosures.

[email protected]

On Twitter @naseemsmiller

PALM BEACH, FLA. – The ankle-brachial index value is directly associated with the prevalence of carotid artery stenosis and with a history of coronary artery disease and cerebrovascular disease, according to analysis of more than 3.6 million records obtained from the private health screening company, Life Line Screening.

But what makes the study interesting is the database itself, and not so much the findings, which have been previously shown, commented Dr. Spence M. Taylor, president of the Greenville (S.C.) Health System Clinical University.

Life Line Screening has mobile units, which travel to various locations and for a fee of more than $100, screen individuals, collecting nearly 300 data points per person. Meanwhile, the ankle-brachial index (ABI) costs less than $30 approximately. Yet, the test hasn’t become widely used, despite the evidence. Not much has changed since the 2001 PARTNERS study, which showed that the primary care physicians’ awareness of PAD diagnosis was "relatively low" (JAMA 2001;286:1317-24).

Results using the Life Line Screening’s large database may show the federal government that ABI can be cost effective, and getting them on board would popularize the screening tool, said Dr. Mark A. Adelman of the New York University Langone Medical Center, who presented his study at the Southern Association for Vascular Surgery annual meeting.

"Life Line is a huge paradox," said Dr. Taylor, senior associate dean of academic affairs at University of South Carolina, Greenville. It’s an operation that "we love to hate and hate to love," he added.

Dr. Adelman, the Frank J. Veith, M.D. Professor of Vascular and Endovascular Surgery and chief of vascular surgery at NYU Langone, and his colleagues analyzed data obtained from Life Line Screening, and found that individuals with an ABI between 0.41 and 0.60 had a 26.4% incidence of carotid artery stenosis (CAS), compared with individuals who had a normal ABI. The incidence increased to 35% for patients with ABI of 0.4 or less.

The majority of the abnormal ABI cases were between 0.81 and 0.90.

The analysis by Dr. Adelman and his colleagues also showed that individuals with PAD were more likely to be aged 70 years or older, male, and have modifiable risk factors, such as a history of smoking, hypertension, diabetes, and hypercholesterolemia, compared with non–PAD persons (P less than .001). (A comparison of Life Line’s database to one from the general population showed that the risk factors such as hypertension, hyperlipidemia, diabetes, and smoking were comparable.)

PAD subjects were also more likely to have CAS, prior stroke, prior transient ischemic attack, prior MI, and prior coronary revascularization, compared with those who didn’t have PAD (P less than .001). There was a significant correlation between decreasing ABI value and an increase in the prevalence of CAS, CAD, and cardiovascular disease (P less than .001).

In a separate study analyzing the same database, Dr. Adelman and his colleagues found that modifiable risk factors, such as hypertension and smoking, are associated with increased prevalence of peripheral vascular disease (J. Vasc. Surg. 2013;58:673-81).

Dr. Adelman said that screening for ABI could trigger other screening and lead to modification of risk factors that could affect better patient outcomes, changes in lifestyle, or changes in pharmacological management.

Dr. Adelman and Dr. Taylor had no disclosures.

[email protected]

On Twitter @naseemsmiller