Sherry Boschert

SAN DIEGO – Neuropathic pain can be acute instead of chronic, and treatments for the two differ, Scott M. Fishman, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

“There seems to be a prevalent belief that neuropathic pain is only a disorder of chronic illness,” said Dr. Fishman, chief of the pain medicine division and professor of anesthesiology and pain medicine at the University of California, Davis.

Few physicians appear to know that the proper treatment for acute neuropathic pain is corticosteroids, not the anticonvulsants, antiarrhythmics, or antidepressants used conventionally for chronic neuropathic pain, he added.

For a patient who comes out of the operating room with a positional neuropathy or patients with acute-onset neuropathy due to trauma or a cut nerve, treat with corticosteroids. “That acute neuropathic pain actually is a neuritis,” and steroids will cure the pain in most cases.

Dexamethasone dosing for acute neuropathic pain ranges from 4–8 mg orally b.i.d. or t.i.d. to 10–20 mg by IV every 6 hours. Methylprednisolone dosing for acute neuropathic pain usually ranges from 16–32 mg orally b.i.d. or t.i.d. to 40–80 mg by IV every 6 hours, he said.

These regimens also have been used to treat metastatic bone pain or cancerous soft tissue infiltration. Cancer patients frequently develop neuropathic pain due to a tumor's compressing or infiltrating nerves or resulting from paraneoplastic syndromes. The neuropathic pain may be a side effect from surgery, chemotherapy, or radiotherapy. Immunocompromise from cancer also can cause neuropathic pain, as can malignancy-related infection, bleeding, or fracture.

“I've seen oncologists becoming much better at treating pain,” Dr. Fishman said, adding that he's less likely today to see patients with cancer whose neuropathic pain was undertreated by oncologists, compared with a few years ago.

Neuropathic Pain Points Test

Think you know about neuropathic pain? Test yourself with this quiz provided by Dr. Fishman.

Neuropathic pain is distinguished from somatic pain by the fact that:

It's never acute.

It always represents a dysfunction within the nervous system.

It always has a component of “burning.”

It's not responsive to opioids.

Pain associated with nonpainful stimuli is termed:

Hyperalgesia.

Causalgia.

Hyperpathia.

Allodynia.

Most conventionally used medications for neuropathic pain are:

Anticonvulsants.

Antidepressants.

Benzodiazepines.

Antiarrhythmics.

All of the above.

First-line treatment for acute-onset neuropathic pain (within the first week of onset) is usually:

Lidocaine.

Neurontin.

Ibuprofen.

Corticosteroids.

Amitriptyline.

Answers: 1. b; 2. d; 3. e; 4. d.

SAN DIEGO – Neuropathic pain can be acute instead of chronic, and treatments for the two differ, Scott M. Fishman, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

“There seems to be a prevalent belief that neuropathic pain is only a disorder of chronic illness,” said Dr. Fishman, chief of the pain medicine division and professor of anesthesiology and pain medicine at the University of California, Davis.

Few physicians appear to know that the proper treatment for acute neuropathic pain is corticosteroids, not the anticonvulsants, antiarrhythmics, or antidepressants used conventionally for chronic neuropathic pain, he added.

For a patient who comes out of the operating room with a positional neuropathy or patients with acute-onset neuropathy due to trauma or a cut nerve, treat with corticosteroids. “That acute neuropathic pain actually is a neuritis,” and steroids will cure the pain in most cases.

Dexamethasone dosing for acute neuropathic pain ranges from 4–8 mg orally b.i.d. or t.i.d. to 10–20 mg by IV every 6 hours. Methylprednisolone dosing for acute neuropathic pain usually ranges from 16–32 mg orally b.i.d. or t.i.d. to 40–80 mg by IV every 6 hours, he said.

These regimens also have been used to treat metastatic bone pain or cancerous soft tissue infiltration. Cancer patients frequently develop neuropathic pain due to a tumor's compressing or infiltrating nerves or resulting from paraneoplastic syndromes. The neuropathic pain may be a side effect from surgery, chemotherapy, or radiotherapy. Immunocompromise from cancer also can cause neuropathic pain, as can malignancy-related infection, bleeding, or fracture.

“I've seen oncologists becoming much better at treating pain,” Dr. Fishman said, adding that he's less likely today to see patients with cancer whose neuropathic pain was undertreated by oncologists, compared with a few years ago.

Neuropathic Pain Points Test

Think you know about neuropathic pain? Test yourself with this quiz provided by Dr. Fishman.

Neuropathic pain is distinguished from somatic pain by the fact that:

It's never acute.

It always represents a dysfunction within the nervous system.

It always has a component of “burning.”

It's not responsive to opioids.

Pain associated with nonpainful stimuli is termed:

Hyperalgesia.

Causalgia.

Hyperpathia.

Allodynia.

Most conventionally used medications for neuropathic pain are:

Anticonvulsants.

Antidepressants.

Benzodiazepines.

Antiarrhythmics.

All of the above.

First-line treatment for acute-onset neuropathic pain (within the first week of onset) is usually:

Lidocaine.

Neurontin.

Ibuprofen.

Corticosteroids.

Amitriptyline.

Answers: 1. b; 2. d; 3. e; 4. d.

SAN DIEGO – Neuropathic pain can be acute instead of chronic, and treatments for the two differ, Scott M. Fishman, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

“There seems to be a prevalent belief that neuropathic pain is only a disorder of chronic illness,” said Dr. Fishman, chief of the pain medicine division and professor of anesthesiology and pain medicine at the University of California, Davis.

Few physicians appear to know that the proper treatment for acute neuropathic pain is corticosteroids, not the anticonvulsants, antiarrhythmics, or antidepressants used conventionally for chronic neuropathic pain, he added.

For a patient who comes out of the operating room with a positional neuropathy or patients with acute-onset neuropathy due to trauma or a cut nerve, treat with corticosteroids. “That acute neuropathic pain actually is a neuritis,” and steroids will cure the pain in most cases.

Dexamethasone dosing for acute neuropathic pain ranges from 4–8 mg orally b.i.d. or t.i.d. to 10–20 mg by IV every 6 hours. Methylprednisolone dosing for acute neuropathic pain usually ranges from 16–32 mg orally b.i.d. or t.i.d. to 40–80 mg by IV every 6 hours, he said.

These regimens also have been used to treat metastatic bone pain or cancerous soft tissue infiltration. Cancer patients frequently develop neuropathic pain due to a tumor's compressing or infiltrating nerves or resulting from paraneoplastic syndromes. The neuropathic pain may be a side effect from surgery, chemotherapy, or radiotherapy. Immunocompromise from cancer also can cause neuropathic pain, as can malignancy-related infection, bleeding, or fracture.

“I've seen oncologists becoming much better at treating pain,” Dr. Fishman said, adding that he's less likely today to see patients with cancer whose neuropathic pain was undertreated by oncologists, compared with a few years ago.

Neuropathic Pain Points Test

Think you know about neuropathic pain? Test yourself with this quiz provided by Dr. Fishman.

Neuropathic pain is distinguished from somatic pain by the fact that:

It's never acute.

It always represents a dysfunction within the nervous system.

It always has a component of “burning.”

It's not responsive to opioids.

Pain associated with nonpainful stimuli is termed:

Hyperalgesia.

Causalgia.

Hyperpathia.

Allodynia.

Most conventionally used medications for neuropathic pain are:

Anticonvulsants.

Antidepressants.

Benzodiazepines.

Antiarrhythmics.

All of the above.

First-line treatment for acute-onset neuropathic pain (within the first week of onset) is usually:

Lidocaine.

Neurontin.

Ibuprofen.

Corticosteroids.

Amitriptyline.

Answers: 1. b; 2. d; 3. e; 4. d.

KOHALA COAST, HAWAII — Nail salons that offer pedicures may be peddling infections along with pretty toes.

If a female patient complains of recurrent folliculitis of the lower legs, ask if she's had a pedicure lately and if she shaves her legs before going to the nail salon. The shaved skin can be a portal of entry for mycobacteria that exist in tap water and that grow in the filter systems of whirlpool footbaths used in nail salons, said Timothy G. Berger, M.D.

“You can scrub the inside of the salon tub all you want, but it's in the filter and irrigation system, and you can't clean that,” he said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communication Inc.

Pedicures are popular in the San Francisco Bay area. “We've had outbreaks affecting hundreds of patients with this,” said Dr. Berger, professor of clinical dermatology at the University of California, San Francisco.

He described a typical patient: a 37-year-old woman referred to him by her primary care physician for chronic folliculitis of the lower legs who failed sequential treatment with ciprofloxacin, cephalexin, and amoxicillin combined with clavulanate potassium (Augmentin). She had multiple, firm, focally ulcerated and eroded lesions 0.5–1.5 cm in size below the knees. The dermal and subcutaneous nodules had left multiple scars.

A biopsy suggested she might have mycobacterial infection, and a culture of the tissue biopsy grew one of the rapidly growing types of mycobacteria, such as Mycobacterium fortuitum and M. chelonae, which can be seen in cultures in 7–10 days.

Some patients may be followed with observation, but they usually require a prolonged course of antibiotic treatment for 6 months. “If you're lucky enough to grow the bug, then you can get sensitivities” to help pick the antibiotic, he said.

If you don't know the bug's antibiotic sensitivity, treat with monotherapy using doxycycline, clarithromycin, azithromycin, or ciprofloxacin, he suggested. Sulfonamides and trimethoprim is another option. Depending on how the patient responds, combination therapy may be needed.

These rapidly growing mycobacteria do not respond to antimicrobials used to treat tuberculosis, such as isoniazid or ethambutol.

Dr. Berger distinguished between the rapid growers such as M. chelonae and M. fortuitum and the two types of mycobacteria that dermatologists most commonly see. One, M. marinum, causes papules or plaques on the hands after exposure to water in fish tanks.

The other, M. tuberculosis, can cause tender calf nodules and erythema induratum, “which is not a rare disease,” Dr. Berger noted.

Sometimes biopsies from patients with erythema induratum will show polyarteritis nodosa (PAN). If cutaneous TB is the cause, putting those patients on steroids will make them worse, Dr. Berger cautioned. When he sees a biopsy with PAN, he always does a TB screen. “About half of those patients are positive, and they clear when we treat their TB,” he said.

If you see a patient who has risk factors for TB infection (such as Asian ethnicity or foreign birth) and PAN, think about cutaneous TB, Dr. Berger said. “It's still around. We've collected 20 cases over the last 10 years who came to our clinic with cutaneous TB.”

KOHALA COAST, HAWAII — Nail salons that offer pedicures may be peddling infections along with pretty toes.

If a female patient complains of recurrent folliculitis of the lower legs, ask if she's had a pedicure lately and if she shaves her legs before going to the nail salon. The shaved skin can be a portal of entry for mycobacteria that exist in tap water and that grow in the filter systems of whirlpool footbaths used in nail salons, said Timothy G. Berger, M.D.

“You can scrub the inside of the salon tub all you want, but it's in the filter and irrigation system, and you can't clean that,” he said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communication Inc.

Pedicures are popular in the San Francisco Bay area. “We've had outbreaks affecting hundreds of patients with this,” said Dr. Berger, professor of clinical dermatology at the University of California, San Francisco.

He described a typical patient: a 37-year-old woman referred to him by her primary care physician for chronic folliculitis of the lower legs who failed sequential treatment with ciprofloxacin, cephalexin, and amoxicillin combined with clavulanate potassium (Augmentin). She had multiple, firm, focally ulcerated and eroded lesions 0.5–1.5 cm in size below the knees. The dermal and subcutaneous nodules had left multiple scars.

A biopsy suggested she might have mycobacterial infection, and a culture of the tissue biopsy grew one of the rapidly growing types of mycobacteria, such as Mycobacterium fortuitum and M. chelonae, which can be seen in cultures in 7–10 days.

Some patients may be followed with observation, but they usually require a prolonged course of antibiotic treatment for 6 months. “If you're lucky enough to grow the bug, then you can get sensitivities” to help pick the antibiotic, he said.

If you don't know the bug's antibiotic sensitivity, treat with monotherapy using doxycycline, clarithromycin, azithromycin, or ciprofloxacin, he suggested. Sulfonamides and trimethoprim is another option. Depending on how the patient responds, combination therapy may be needed.

These rapidly growing mycobacteria do not respond to antimicrobials used to treat tuberculosis, such as isoniazid or ethambutol.

Dr. Berger distinguished between the rapid growers such as M. chelonae and M. fortuitum and the two types of mycobacteria that dermatologists most commonly see. One, M. marinum, causes papules or plaques on the hands after exposure to water in fish tanks.

The other, M. tuberculosis, can cause tender calf nodules and erythema induratum, “which is not a rare disease,” Dr. Berger noted.

Sometimes biopsies from patients with erythema induratum will show polyarteritis nodosa (PAN). If cutaneous TB is the cause, putting those patients on steroids will make them worse, Dr. Berger cautioned. When he sees a biopsy with PAN, he always does a TB screen. “About half of those patients are positive, and they clear when we treat their TB,” he said.

If you see a patient who has risk factors for TB infection (such as Asian ethnicity or foreign birth) and PAN, think about cutaneous TB, Dr. Berger said. “It's still around. We've collected 20 cases over the last 10 years who came to our clinic with cutaneous TB.”

KOHALA COAST, HAWAII — Nail salons that offer pedicures may be peddling infections along with pretty toes.

If a female patient complains of recurrent folliculitis of the lower legs, ask if she's had a pedicure lately and if she shaves her legs before going to the nail salon. The shaved skin can be a portal of entry for mycobacteria that exist in tap water and that grow in the filter systems of whirlpool footbaths used in nail salons, said Timothy G. Berger, M.D.

“You can scrub the inside of the salon tub all you want, but it's in the filter and irrigation system, and you can't clean that,” he said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communication Inc.

Pedicures are popular in the San Francisco Bay area. “We've had outbreaks affecting hundreds of patients with this,” said Dr. Berger, professor of clinical dermatology at the University of California, San Francisco.

He described a typical patient: a 37-year-old woman referred to him by her primary care physician for chronic folliculitis of the lower legs who failed sequential treatment with ciprofloxacin, cephalexin, and amoxicillin combined with clavulanate potassium (Augmentin). She had multiple, firm, focally ulcerated and eroded lesions 0.5–1.5 cm in size below the knees. The dermal and subcutaneous nodules had left multiple scars.

A biopsy suggested she might have mycobacterial infection, and a culture of the tissue biopsy grew one of the rapidly growing types of mycobacteria, such as Mycobacterium fortuitum and M. chelonae, which can be seen in cultures in 7–10 days.

Some patients may be followed with observation, but they usually require a prolonged course of antibiotic treatment for 6 months. “If you're lucky enough to grow the bug, then you can get sensitivities” to help pick the antibiotic, he said.

If you don't know the bug's antibiotic sensitivity, treat with monotherapy using doxycycline, clarithromycin, azithromycin, or ciprofloxacin, he suggested. Sulfonamides and trimethoprim is another option. Depending on how the patient responds, combination therapy may be needed.

These rapidly growing mycobacteria do not respond to antimicrobials used to treat tuberculosis, such as isoniazid or ethambutol.

Dr. Berger distinguished between the rapid growers such as M. chelonae and M. fortuitum and the two types of mycobacteria that dermatologists most commonly see. One, M. marinum, causes papules or plaques on the hands after exposure to water in fish tanks.

The other, M. tuberculosis, can cause tender calf nodules and erythema induratum, “which is not a rare disease,” Dr. Berger noted.

Sometimes biopsies from patients with erythema induratum will show polyarteritis nodosa (PAN). If cutaneous TB is the cause, putting those patients on steroids will make them worse, Dr. Berger cautioned. When he sees a biopsy with PAN, he always does a TB screen. “About half of those patients are positive, and they clear when we treat their TB,” he said.

If you see a patient who has risk factors for TB infection (such as Asian ethnicity or foreign birth) and PAN, think about cutaneous TB, Dr. Berger said. “It's still around. We've collected 20 cases over the last 10 years who came to our clinic with cutaneous TB.”

SAN FRANCISCO — Most physicians believe in urging hypertensive patients to alter their lifestyle in beneficial ways, even though this seldom comes to pass, Norman Kaplan, M.D., said at the annual meeting of the American Society of Hypertension.

“I'm not sure that we're going to be depending as much on lifestyle modifications as we have in the past” because of the recognition that high blood pressures need to be lowered quickly, said Dr. Kaplan, professor of medicine at the University of Texas, Dallas.

He described lifestyle modifications that do and don't work in treating hypertension:

▸ Smoking cessation. Usually found at the bottom of lists of lifestyle modifications for treating hypertension, smoking cessation deserves first mention because it is the major reversible cardiovascular risk factor in hypertensive smokers. Until recently, physicians didn't recognize the pressor effects of nicotine because patients weren't allowed to smoke during blood pressure measurements. Ambulatory monitoring consistently shows higher BPs while smoking.

Advise patients repeatedly to stop smoking, and explain or show to them the pressor effect of smoking, Dr. Kaplan said. Nicotine replacement products such as patches should not have persistent pressor effects, but advise patients to check their BP on these products anyway because some people may be particularly sensitive.

▸ Weight loss. Significant weight loss reduces blood pressure, but most dieters put the pounds back on in a short amount of time. Studies comparing weight loss diets suggest that the cheapest and “probably the most logical” method—Weight Watchers—may be the best diet strategy, he said.

For morbidly obese people (body mass index greater than 40 kg/m

Gastric banding surgeries have been less successful in morbidly obese patients. It appears that enough food is forced past the banded stomach over time that the patient regains the weight initially lost after surgery.

▸ Physical activity. Unhealthy diets and physical inactivity share the blame equally for Americans' march toward morbid obesity.

Duration is more important than intensity of physical activity for lowering BP, studies have shown. Thirty minutes on a treadmill exercising at 50%–75% of maximal heart rate significantly reduced BP and the effects persisted over 24 hours, one study found.

A metaanalysis of studies on diabetic patients found that walking as little as 2 hours each week reduced mortality by about 40%, compared with less active patients, Dr. Kaplan said.

▸ Sodium reduction. Patients who reduce their sodium intake typically return to old habits over time. The result is that no difference is seen after 5 years, according to an analysis of about 30 studies.

People are surrounded by high-sodium foods in U.S. culture: Some fast food items pack 1,000–3,000 mg sodium each. “Most people have no perception of what they're eating when they eat this kind of food,” he said.

▸ Moderation of alcohol. Drinking modest amounts of alcohol while eating food does not increase the risk of hypertension and may even provide some cardiovascular benefits, he said. Consuming alcohol without food or having more than three drinks per day increases the risk for hypertension and other health problems.

▸ Increasing potassium. Hypertensive patients can reduce their BP by taking 40–80 mmol/day of supplemental potassium, but it's better to recommend that patients eat more fruits and vegetables to boost their potassium intake. One reason the Dietary Approaches to Stop Hypertension diet works is that it triples the typical potassium intake, Dr. Kaplan noted.

▸ Reducing caffeine. The first cup of the day causes a pressor effect in many people. Advise patients monitoring their BP to check before and after drinking coffee or tea containing caffeine, Dr. Kaplan said.

SAN FRANCISCO — Most physicians believe in urging hypertensive patients to alter their lifestyle in beneficial ways, even though this seldom comes to pass, Norman Kaplan, M.D., said at the annual meeting of the American Society of Hypertension.

“I'm not sure that we're going to be depending as much on lifestyle modifications as we have in the past” because of the recognition that high blood pressures need to be lowered quickly, said Dr. Kaplan, professor of medicine at the University of Texas, Dallas.

He described lifestyle modifications that do and don't work in treating hypertension:

▸ Smoking cessation. Usually found at the bottom of lists of lifestyle modifications for treating hypertension, smoking cessation deserves first mention because it is the major reversible cardiovascular risk factor in hypertensive smokers. Until recently, physicians didn't recognize the pressor effects of nicotine because patients weren't allowed to smoke during blood pressure measurements. Ambulatory monitoring consistently shows higher BPs while smoking.

Advise patients repeatedly to stop smoking, and explain or show to them the pressor effect of smoking, Dr. Kaplan said. Nicotine replacement products such as patches should not have persistent pressor effects, but advise patients to check their BP on these products anyway because some people may be particularly sensitive.

▸ Weight loss. Significant weight loss reduces blood pressure, but most dieters put the pounds back on in a short amount of time. Studies comparing weight loss diets suggest that the cheapest and “probably the most logical” method—Weight Watchers—may be the best diet strategy, he said.

For morbidly obese people (body mass index greater than 40 kg/m

Gastric banding surgeries have been less successful in morbidly obese patients. It appears that enough food is forced past the banded stomach over time that the patient regains the weight initially lost after surgery.

▸ Physical activity. Unhealthy diets and physical inactivity share the blame equally for Americans' march toward morbid obesity.

Duration is more important than intensity of physical activity for lowering BP, studies have shown. Thirty minutes on a treadmill exercising at 50%–75% of maximal heart rate significantly reduced BP and the effects persisted over 24 hours, one study found.

A metaanalysis of studies on diabetic patients found that walking as little as 2 hours each week reduced mortality by about 40%, compared with less active patients, Dr. Kaplan said.

▸ Sodium reduction. Patients who reduce their sodium intake typically return to old habits over time. The result is that no difference is seen after 5 years, according to an analysis of about 30 studies.

People are surrounded by high-sodium foods in U.S. culture: Some fast food items pack 1,000–3,000 mg sodium each. “Most people have no perception of what they're eating when they eat this kind of food,” he said.

▸ Moderation of alcohol. Drinking modest amounts of alcohol while eating food does not increase the risk of hypertension and may even provide some cardiovascular benefits, he said. Consuming alcohol without food or having more than three drinks per day increases the risk for hypertension and other health problems.

▸ Increasing potassium. Hypertensive patients can reduce their BP by taking 40–80 mmol/day of supplemental potassium, but it's better to recommend that patients eat more fruits and vegetables to boost their potassium intake. One reason the Dietary Approaches to Stop Hypertension diet works is that it triples the typical potassium intake, Dr. Kaplan noted.

▸ Reducing caffeine. The first cup of the day causes a pressor effect in many people. Advise patients monitoring their BP to check before and after drinking coffee or tea containing caffeine, Dr. Kaplan said.

SAN FRANCISCO — Most physicians believe in urging hypertensive patients to alter their lifestyle in beneficial ways, even though this seldom comes to pass, Norman Kaplan, M.D., said at the annual meeting of the American Society of Hypertension.

“I'm not sure that we're going to be depending as much on lifestyle modifications as we have in the past” because of the recognition that high blood pressures need to be lowered quickly, said Dr. Kaplan, professor of medicine at the University of Texas, Dallas.

He described lifestyle modifications that do and don't work in treating hypertension:

▸ Smoking cessation. Usually found at the bottom of lists of lifestyle modifications for treating hypertension, smoking cessation deserves first mention because it is the major reversible cardiovascular risk factor in hypertensive smokers. Until recently, physicians didn't recognize the pressor effects of nicotine because patients weren't allowed to smoke during blood pressure measurements. Ambulatory monitoring consistently shows higher BPs while smoking.

Advise patients repeatedly to stop smoking, and explain or show to them the pressor effect of smoking, Dr. Kaplan said. Nicotine replacement products such as patches should not have persistent pressor effects, but advise patients to check their BP on these products anyway because some people may be particularly sensitive.

▸ Weight loss. Significant weight loss reduces blood pressure, but most dieters put the pounds back on in a short amount of time. Studies comparing weight loss diets suggest that the cheapest and “probably the most logical” method—Weight Watchers—may be the best diet strategy, he said.

For morbidly obese people (body mass index greater than 40 kg/m

Gastric banding surgeries have been less successful in morbidly obese patients. It appears that enough food is forced past the banded stomach over time that the patient regains the weight initially lost after surgery.

▸ Physical activity. Unhealthy diets and physical inactivity share the blame equally for Americans' march toward morbid obesity.

Duration is more important than intensity of physical activity for lowering BP, studies have shown. Thirty minutes on a treadmill exercising at 50%–75% of maximal heart rate significantly reduced BP and the effects persisted over 24 hours, one study found.

A metaanalysis of studies on diabetic patients found that walking as little as 2 hours each week reduced mortality by about 40%, compared with less active patients, Dr. Kaplan said.

▸ Sodium reduction. Patients who reduce their sodium intake typically return to old habits over time. The result is that no difference is seen after 5 years, according to an analysis of about 30 studies.

People are surrounded by high-sodium foods in U.S. culture: Some fast food items pack 1,000–3,000 mg sodium each. “Most people have no perception of what they're eating when they eat this kind of food,” he said.

▸ Moderation of alcohol. Drinking modest amounts of alcohol while eating food does not increase the risk of hypertension and may even provide some cardiovascular benefits, he said. Consuming alcohol without food or having more than three drinks per day increases the risk for hypertension and other health problems.

▸ Increasing potassium. Hypertensive patients can reduce their BP by taking 40–80 mmol/day of supplemental potassium, but it's better to recommend that patients eat more fruits and vegetables to boost their potassium intake. One reason the Dietary Approaches to Stop Hypertension diet works is that it triples the typical potassium intake, Dr. Kaplan noted.

▸ Reducing caffeine. The first cup of the day causes a pressor effect in many people. Advise patients monitoring their BP to check before and after drinking coffee or tea containing caffeine, Dr. Kaplan said.

SAN FRANCISCO — First-trimester screening for aneuploidy may soon become the standard of care, Robert H. Ball, M.D., predicted at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

There is sufficient evidence to support the incorporation of first-trimester testing into prenatal practice in the United States, and the focus now should be on the most effective way to implement this, according to a consensus statement produced at a workshop sponsored by the National Institute of Child Health and Human Development in December 2004.

At least seven studies now have shown that detection of aneuploidy can be improved by analyzing a combination of risk factors in the first trimester: maternal age, nuchal translucency measured on ultrasound, and serum testing for β-HCG and PAPP-A.

Women at risk may be offered more definitive testing earlier in pregnancy with this approach, or results of negative first-trimester screens can be integrated with second-trimester serum screening for improved aneuploidy detection in the second trimester.

“This is a big deal, no doubt about it,” said Dr. Ball, a perinatologist at UCSF Children's Hospital. Most nuchal translucency screens will be done in prenatal diagnostic centers, not in every ob.gyn.'s office, he said.

Dr. Ball presented data at the meeting from the First and Second Trimester Evaluation of Risk for Aneuploidy (FASTER) trial, in which he was an investigator. The results have been accepted for publication in the New England Journal of Medicine.

The study obtained follow-up information for 37,002 births, from an impressive 97% of the women who enrolled and underwent first- and second-trimester screening. Aneuploidy detection rates improved when first-trimester serum screening was added to nuchal translucency measurement, compared with using nuchal translucency alone to assess risk.

Detection improved further when these first-trimester results were integrated with second-trimester serum screening.

The study's size provided the power to analyze subgroups, including results based on the gestational week of screening. The best time for first-trimester screening was week 11: When screening was performed at that time, detection rates were 73% with nuchal translucency alone and 93% with the combined nuchal translucency/serum screen. After integrating the combined first-trimester screen with second-trimester screening, the detection rate was 98%.

First trimester screening may pose scheduling problems, he predicted. “That's sort of a logistical nightmare, if you think about it,” because physicians will be scrambling to get patients into prenatal diagnostic centers before the 11-week window passes, he said during the meeting.

“I can imagine people suing because they didn't get in for their nuchal translucency screening and they have a Down syndrome kid” that might have been detected earlier, Dr. Ball added.

In hopes that the integrated first- and second-trimester screening strategies might obviate the need for genetic sonograms, investigators analyzed the FASTER data with and without genetic sonogram results. They found that the likelihood of aneuploidy greatly increased with identification of at least one genetic marker on ultrasound. Genetic ultrasound results improved the overall 84% detection rate for aneuploidy using first-trimester screening alone and decreased the false-positive rate.

“Much to my chagrin, having a genetic sonogram after you've had a bucket load of other tests is actually going to be useful,” Dr. Ball said.

SAN FRANCISCO — First-trimester screening for aneuploidy may soon become the standard of care, Robert H. Ball, M.D., predicted at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

There is sufficient evidence to support the incorporation of first-trimester testing into prenatal practice in the United States, and the focus now should be on the most effective way to implement this, according to a consensus statement produced at a workshop sponsored by the National Institute of Child Health and Human Development in December 2004.

At least seven studies now have shown that detection of aneuploidy can be improved by analyzing a combination of risk factors in the first trimester: maternal age, nuchal translucency measured on ultrasound, and serum testing for β-HCG and PAPP-A.

Women at risk may be offered more definitive testing earlier in pregnancy with this approach, or results of negative first-trimester screens can be integrated with second-trimester serum screening for improved aneuploidy detection in the second trimester.

“This is a big deal, no doubt about it,” said Dr. Ball, a perinatologist at UCSF Children's Hospital. Most nuchal translucency screens will be done in prenatal diagnostic centers, not in every ob.gyn.'s office, he said.

Dr. Ball presented data at the meeting from the First and Second Trimester Evaluation of Risk for Aneuploidy (FASTER) trial, in which he was an investigator. The results have been accepted for publication in the New England Journal of Medicine.

The study obtained follow-up information for 37,002 births, from an impressive 97% of the women who enrolled and underwent first- and second-trimester screening. Aneuploidy detection rates improved when first-trimester serum screening was added to nuchal translucency measurement, compared with using nuchal translucency alone to assess risk.

Detection improved further when these first-trimester results were integrated with second-trimester serum screening.

The study's size provided the power to analyze subgroups, including results based on the gestational week of screening. The best time for first-trimester screening was week 11: When screening was performed at that time, detection rates were 73% with nuchal translucency alone and 93% with the combined nuchal translucency/serum screen. After integrating the combined first-trimester screen with second-trimester screening, the detection rate was 98%.

First trimester screening may pose scheduling problems, he predicted. “That's sort of a logistical nightmare, if you think about it,” because physicians will be scrambling to get patients into prenatal diagnostic centers before the 11-week window passes, he said during the meeting.

“I can imagine people suing because they didn't get in for their nuchal translucency screening and they have a Down syndrome kid” that might have been detected earlier, Dr. Ball added.

In hopes that the integrated first- and second-trimester screening strategies might obviate the need for genetic sonograms, investigators analyzed the FASTER data with and without genetic sonogram results. They found that the likelihood of aneuploidy greatly increased with identification of at least one genetic marker on ultrasound. Genetic ultrasound results improved the overall 84% detection rate for aneuploidy using first-trimester screening alone and decreased the false-positive rate.

“Much to my chagrin, having a genetic sonogram after you've had a bucket load of other tests is actually going to be useful,” Dr. Ball said.

SAN FRANCISCO — First-trimester screening for aneuploidy may soon become the standard of care, Robert H. Ball, M.D., predicted at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

There is sufficient evidence to support the incorporation of first-trimester testing into prenatal practice in the United States, and the focus now should be on the most effective way to implement this, according to a consensus statement produced at a workshop sponsored by the National Institute of Child Health and Human Development in December 2004.

At least seven studies now have shown that detection of aneuploidy can be improved by analyzing a combination of risk factors in the first trimester: maternal age, nuchal translucency measured on ultrasound, and serum testing for β-HCG and PAPP-A.

Women at risk may be offered more definitive testing earlier in pregnancy with this approach, or results of negative first-trimester screens can be integrated with second-trimester serum screening for improved aneuploidy detection in the second trimester.

“This is a big deal, no doubt about it,” said Dr. Ball, a perinatologist at UCSF Children's Hospital. Most nuchal translucency screens will be done in prenatal diagnostic centers, not in every ob.gyn.'s office, he said.

Dr. Ball presented data at the meeting from the First and Second Trimester Evaluation of Risk for Aneuploidy (FASTER) trial, in which he was an investigator. The results have been accepted for publication in the New England Journal of Medicine.

The study obtained follow-up information for 37,002 births, from an impressive 97% of the women who enrolled and underwent first- and second-trimester screening. Aneuploidy detection rates improved when first-trimester serum screening was added to nuchal translucency measurement, compared with using nuchal translucency alone to assess risk.

Detection improved further when these first-trimester results were integrated with second-trimester serum screening.

The study's size provided the power to analyze subgroups, including results based on the gestational week of screening. The best time for first-trimester screening was week 11: When screening was performed at that time, detection rates were 73% with nuchal translucency alone and 93% with the combined nuchal translucency/serum screen. After integrating the combined first-trimester screen with second-trimester screening, the detection rate was 98%.

First trimester screening may pose scheduling problems, he predicted. “That's sort of a logistical nightmare, if you think about it,” because physicians will be scrambling to get patients into prenatal diagnostic centers before the 11-week window passes, he said during the meeting.

“I can imagine people suing because they didn't get in for their nuchal translucency screening and they have a Down syndrome kid” that might have been detected earlier, Dr. Ball added.

In hopes that the integrated first- and second-trimester screening strategies might obviate the need for genetic sonograms, investigators analyzed the FASTER data with and without genetic sonogram results. They found that the likelihood of aneuploidy greatly increased with identification of at least one genetic marker on ultrasound. Genetic ultrasound results improved the overall 84% detection rate for aneuploidy using first-trimester screening alone and decreased the false-positive rate.

“Much to my chagrin, having a genetic sonogram after you've had a bucket load of other tests is actually going to be useful,” Dr. Ball said.

SAN FRANCISCO — Recent studies provide some guidance in applying recommendations from the American College of Obstetricians and Gynecologists on the use of progesterone to prevent preterm birth, Steve Caritis, M.D., said at a meeting on antepartum and intrapartum management, sponsored by the University of California, San Francisco.

Only intramuscular injections of 17-hydroxyprogesterone caproate (17-OHPC) have been shown convincingly to prevent recurrent preterm birth, he said.

The American College of Obstetricians and Gynecologists in 2003 recommended that progesterone may be used to help prevent preterm birth but should be restricted to pregnant women with a documented history of spontaneous preterm birth before 37 weeks' gestation. The statement noted that “the ideal progesterone formulation remains unknown until further research is done.”

A 1990 metaanalysis of studies using 17-OHPC found that this agent dramatically lowered the risks for preterm labor and preterm birth.

Although some individual studies had shown a benefit, most were too small to detect significant changes in benefit. When combined in the metaanalysis, they provided the power to show a dramatic impact of 17-OHPC, which reduced the overall odds of preterm labor by 43%, and the odds of preterm birth in women at high risk for preterm birth by 50%, he said.

A separate study conducted for the National Institutes of Child Health and Human Development Maternal-Fetal Medicine Units Network randomized 459 pregnant women who had at least one previous preterm birth to receive weekly injections of 17-OHPC or placebo starting between gestational weeks 16 and 20. The study was stopped early when it became evident that 17-OHPC decreased the risk for preterm birth before 37 weeks by 34%.

Critics of that study noted that the control group had a very high rate of preterm birth and that castor oil (in which 17-OHPC is dissolved) is a uterine stimulant., said Dr. Caritis, who is professor and chief of maternal-fetal medicine at the University of Pittsburgh.

Both the treatment and control groups received castor oil, so it is hard to argue that this created a methodologic problem, he added. The preterm birth rate among controls was similar, however, to rates seen in two other studies and was not unexpected, he said.

Critics also noted a higher rate of spontaneous abortions at less than 20 weeks in the 17-OHPC group. The five spontaneous abortions in that group were counted as preterm births, so there would have been a more significant benefit in the 17-OHPC group, compared with placebo, if these losses had been excluded, he countered.

“I think this is still the best study we have” on preventing preterm birth with progesterones, Dr. Caritis said.

A third study randomized 142 women with singleton gestations and a history of preterm birth to vaginal suppositories of 100 mg of progesterone or placebo starting at 24–34 weeks' gestation, later than the 16–20 weeks' initiation in the 17-OHPC trial.

Results showed a 50% reduction in preterm birth before 37 weeks of gestation with the progesterone suppositories and an 85% reduction in preterm births before 34 weeks' gestation. The latter result “makes me a little suspicious,” he said.

The vaginal suppository trial excluded patients with preterm premature rupture of the membranes (PPROM). “We don't think that's appropriate. It's hard to differentiate preterm labor with or without PPROM,” Dr. Caritis said. His institution offers only 17-OHPC to women with previous spontaneous preterm birth. For now, they do not give this treatment to women who have a short cervix, threatened preterm labor, or multifetal gestation.

Studies are underway in the maternal-fetal medicine units network evaluating 17-OHPC treatment for those indications.

SAN FRANCISCO — Recent studies provide some guidance in applying recommendations from the American College of Obstetricians and Gynecologists on the use of progesterone to prevent preterm birth, Steve Caritis, M.D., said at a meeting on antepartum and intrapartum management, sponsored by the University of California, San Francisco.

Only intramuscular injections of 17-hydroxyprogesterone caproate (17-OHPC) have been shown convincingly to prevent recurrent preterm birth, he said.

The American College of Obstetricians and Gynecologists in 2003 recommended that progesterone may be used to help prevent preterm birth but should be restricted to pregnant women with a documented history of spontaneous preterm birth before 37 weeks' gestation. The statement noted that “the ideal progesterone formulation remains unknown until further research is done.”

A 1990 metaanalysis of studies using 17-OHPC found that this agent dramatically lowered the risks for preterm labor and preterm birth.

Although some individual studies had shown a benefit, most were too small to detect significant changes in benefit. When combined in the metaanalysis, they provided the power to show a dramatic impact of 17-OHPC, which reduced the overall odds of preterm labor by 43%, and the odds of preterm birth in women at high risk for preterm birth by 50%, he said.

A separate study conducted for the National Institutes of Child Health and Human Development Maternal-Fetal Medicine Units Network randomized 459 pregnant women who had at least one previous preterm birth to receive weekly injections of 17-OHPC or placebo starting between gestational weeks 16 and 20. The study was stopped early when it became evident that 17-OHPC decreased the risk for preterm birth before 37 weeks by 34%.

Critics of that study noted that the control group had a very high rate of preterm birth and that castor oil (in which 17-OHPC is dissolved) is a uterine stimulant., said Dr. Caritis, who is professor and chief of maternal-fetal medicine at the University of Pittsburgh.

Both the treatment and control groups received castor oil, so it is hard to argue that this created a methodologic problem, he added. The preterm birth rate among controls was similar, however, to rates seen in two other studies and was not unexpected, he said.

Critics also noted a higher rate of spontaneous abortions at less than 20 weeks in the 17-OHPC group. The five spontaneous abortions in that group were counted as preterm births, so there would have been a more significant benefit in the 17-OHPC group, compared with placebo, if these losses had been excluded, he countered.

“I think this is still the best study we have” on preventing preterm birth with progesterones, Dr. Caritis said.

A third study randomized 142 women with singleton gestations and a history of preterm birth to vaginal suppositories of 100 mg of progesterone or placebo starting at 24–34 weeks' gestation, later than the 16–20 weeks' initiation in the 17-OHPC trial.

Results showed a 50% reduction in preterm birth before 37 weeks of gestation with the progesterone suppositories and an 85% reduction in preterm births before 34 weeks' gestation. The latter result “makes me a little suspicious,” he said.

The vaginal suppository trial excluded patients with preterm premature rupture of the membranes (PPROM). “We don't think that's appropriate. It's hard to differentiate preterm labor with or without PPROM,” Dr. Caritis said. His institution offers only 17-OHPC to women with previous spontaneous preterm birth. For now, they do not give this treatment to women who have a short cervix, threatened preterm labor, or multifetal gestation.

Studies are underway in the maternal-fetal medicine units network evaluating 17-OHPC treatment for those indications.

SAN FRANCISCO — Recent studies provide some guidance in applying recommendations from the American College of Obstetricians and Gynecologists on the use of progesterone to prevent preterm birth, Steve Caritis, M.D., said at a meeting on antepartum and intrapartum management, sponsored by the University of California, San Francisco.

Only intramuscular injections of 17-hydroxyprogesterone caproate (17-OHPC) have been shown convincingly to prevent recurrent preterm birth, he said.

The American College of Obstetricians and Gynecologists in 2003 recommended that progesterone may be used to help prevent preterm birth but should be restricted to pregnant women with a documented history of spontaneous preterm birth before 37 weeks' gestation. The statement noted that “the ideal progesterone formulation remains unknown until further research is done.”

A 1990 metaanalysis of studies using 17-OHPC found that this agent dramatically lowered the risks for preterm labor and preterm birth.

Although some individual studies had shown a benefit, most were too small to detect significant changes in benefit. When combined in the metaanalysis, they provided the power to show a dramatic impact of 17-OHPC, which reduced the overall odds of preterm labor by 43%, and the odds of preterm birth in women at high risk for preterm birth by 50%, he said.

A separate study conducted for the National Institutes of Child Health and Human Development Maternal-Fetal Medicine Units Network randomized 459 pregnant women who had at least one previous preterm birth to receive weekly injections of 17-OHPC or placebo starting between gestational weeks 16 and 20. The study was stopped early when it became evident that 17-OHPC decreased the risk for preterm birth before 37 weeks by 34%.

Critics of that study noted that the control group had a very high rate of preterm birth and that castor oil (in which 17-OHPC is dissolved) is a uterine stimulant., said Dr. Caritis, who is professor and chief of maternal-fetal medicine at the University of Pittsburgh.

Both the treatment and control groups received castor oil, so it is hard to argue that this created a methodologic problem, he added. The preterm birth rate among controls was similar, however, to rates seen in two other studies and was not unexpected, he said.

Critics also noted a higher rate of spontaneous abortions at less than 20 weeks in the 17-OHPC group. The five spontaneous abortions in that group were counted as preterm births, so there would have been a more significant benefit in the 17-OHPC group, compared with placebo, if these losses had been excluded, he countered.

“I think this is still the best study we have” on preventing preterm birth with progesterones, Dr. Caritis said.

A third study randomized 142 women with singleton gestations and a history of preterm birth to vaginal suppositories of 100 mg of progesterone or placebo starting at 24–34 weeks' gestation, later than the 16–20 weeks' initiation in the 17-OHPC trial.

Results showed a 50% reduction in preterm birth before 37 weeks of gestation with the progesterone suppositories and an 85% reduction in preterm births before 34 weeks' gestation. The latter result “makes me a little suspicious,” he said.

The vaginal suppository trial excluded patients with preterm premature rupture of the membranes (PPROM). “We don't think that's appropriate. It's hard to differentiate preterm labor with or without PPROM,” Dr. Caritis said. His institution offers only 17-OHPC to women with previous spontaneous preterm birth. For now, they do not give this treatment to women who have a short cervix, threatened preterm labor, or multifetal gestation.

Studies are underway in the maternal-fetal medicine units network evaluating 17-OHPC treatment for those indications.

RANCHO MIRAGE, CALIF. — The prevalence of fecal incontinence ranged from 3% of women in their 30s and 40s to nearly 15% of women in their 80s and 90s in the first large epidemiologic study of fecal incontinence among women living in a U.S. community.

Overall, more than 7% of the 3,536 women who returned mailed surveys reported fecal incontinence, defined as accidental loss of stool at least monthly. Of those with fecal incontinence, 47% said they used pads for sanitary protection, and 53% said the problem caused them to alter their lifestyle, Jennifer Melville, M.D., and her associates reported in a poster presentation at the annual meeting of the Society of Gynecologic Surgeons.

“Fecal incontinence is very prevalent and causes significant quality-of-life impacts,” said Dr. Melville of the University Washington, Seattle, during an oral presentation in which she discussed the findings at the meeting. Physicians can assist women by helping to manage the problem, she added.

The responses made up 64% of 6,000 surveys mailed to women aged 30–90 years who were enrolled in a nonprofit HMO in Washington state, GroupHealth Cooperative. The surveys asked specifically about fecal incontinence, not anal incontinence, which includes flatus. Of the women with fecal incontinence, 37% said they had daily or weekly episodes of incontinence. They were incontinent of liquid stool in 47% of cases, solid stool in 23% of cases, and both liquid and solid in 30% of cases.

An analysis of the HMO's automated data on the respondents showed that the women with fecal incontinence were twice as likely to have moderate medical illness and nearly three times as likely to have high-level comorbidity when compared with continent women.

Moreover, women with fecal incontinence were twice as likely to have urinary incontinence and three times as likely to have major depressive disorder as were continent women.

A history of operative vaginal delivery raised the risk for fecal incontinence 58%.

Women with fecal incontinence were more likely to report significant functional impairments, measured in the survey using the World Health Organization Disability Assessment Schedule II. The mean scores on this measure were 24 for women with fecal incontinence and 11 for continent women. The scores for incontinent women are comparable to scores for people with disabling medical conditions like chronic back pain or ankylosing spondylitis, Dr. Melville said.

RANCHO MIRAGE, CALIF. — The prevalence of fecal incontinence ranged from 3% of women in their 30s and 40s to nearly 15% of women in their 80s and 90s in the first large epidemiologic study of fecal incontinence among women living in a U.S. community.

Overall, more than 7% of the 3,536 women who returned mailed surveys reported fecal incontinence, defined as accidental loss of stool at least monthly. Of those with fecal incontinence, 47% said they used pads for sanitary protection, and 53% said the problem caused them to alter their lifestyle, Jennifer Melville, M.D., and her associates reported in a poster presentation at the annual meeting of the Society of Gynecologic Surgeons.

“Fecal incontinence is very prevalent and causes significant quality-of-life impacts,” said Dr. Melville of the University Washington, Seattle, during an oral presentation in which she discussed the findings at the meeting. Physicians can assist women by helping to manage the problem, she added.

The responses made up 64% of 6,000 surveys mailed to women aged 30–90 years who were enrolled in a nonprofit HMO in Washington state, GroupHealth Cooperative. The surveys asked specifically about fecal incontinence, not anal incontinence, which includes flatus. Of the women with fecal incontinence, 37% said they had daily or weekly episodes of incontinence. They were incontinent of liquid stool in 47% of cases, solid stool in 23% of cases, and both liquid and solid in 30% of cases.

An analysis of the HMO's automated data on the respondents showed that the women with fecal incontinence were twice as likely to have moderate medical illness and nearly three times as likely to have high-level comorbidity when compared with continent women.

Moreover, women with fecal incontinence were twice as likely to have urinary incontinence and three times as likely to have major depressive disorder as were continent women.

A history of operative vaginal delivery raised the risk for fecal incontinence 58%.

Women with fecal incontinence were more likely to report significant functional impairments, measured in the survey using the World Health Organization Disability Assessment Schedule II. The mean scores on this measure were 24 for women with fecal incontinence and 11 for continent women. The scores for incontinent women are comparable to scores for people with disabling medical conditions like chronic back pain or ankylosing spondylitis, Dr. Melville said.

RANCHO MIRAGE, CALIF. — The prevalence of fecal incontinence ranged from 3% of women in their 30s and 40s to nearly 15% of women in their 80s and 90s in the first large epidemiologic study of fecal incontinence among women living in a U.S. community.

Overall, more than 7% of the 3,536 women who returned mailed surveys reported fecal incontinence, defined as accidental loss of stool at least monthly. Of those with fecal incontinence, 47% said they used pads for sanitary protection, and 53% said the problem caused them to alter their lifestyle, Jennifer Melville, M.D., and her associates reported in a poster presentation at the annual meeting of the Society of Gynecologic Surgeons.

“Fecal incontinence is very prevalent and causes significant quality-of-life impacts,” said Dr. Melville of the University Washington, Seattle, during an oral presentation in which she discussed the findings at the meeting. Physicians can assist women by helping to manage the problem, she added.

The responses made up 64% of 6,000 surveys mailed to women aged 30–90 years who were enrolled in a nonprofit HMO in Washington state, GroupHealth Cooperative. The surveys asked specifically about fecal incontinence, not anal incontinence, which includes flatus. Of the women with fecal incontinence, 37% said they had daily or weekly episodes of incontinence. They were incontinent of liquid stool in 47% of cases, solid stool in 23% of cases, and both liquid and solid in 30% of cases.

An analysis of the HMO's automated data on the respondents showed that the women with fecal incontinence were twice as likely to have moderate medical illness and nearly three times as likely to have high-level comorbidity when compared with continent women.

Moreover, women with fecal incontinence were twice as likely to have urinary incontinence and three times as likely to have major depressive disorder as were continent women.

A history of operative vaginal delivery raised the risk for fecal incontinence 58%.

Women with fecal incontinence were more likely to report significant functional impairments, measured in the survey using the World Health Organization Disability Assessment Schedule II. The mean scores on this measure were 24 for women with fecal incontinence and 11 for continent women. The scores for incontinent women are comparable to scores for people with disabling medical conditions like chronic back pain or ankylosing spondylitis, Dr. Melville said.

SAN FRANCISCO — Three randomized, controlled trials now show evidence of beneficial effects from a limited number of repeat courses of prenatal corticosteroids for fetuses at risk of preterm delivery, according to Julian T. Parer, M.D.

Those aren't necessarily the official conclusions of the studies, however, he acknowledged at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Two of the three studies found no overall benefit from repeat prenatal steroids but reported significantly less respiratory distress and morbidity in babies born at younger gestational ages if they got more than one course of betamethasone prenatally.

The third study showed a benefit from repeat prenatal steroids, but the investigators will not draw conclusions about the results until after a 2-year follow-up period, said Dr. Parer, who is professor of ob.gyn. at the university.

Dr. Parer said he has no financial relationships with companies that make corticosteroids.

A consensus statement issued in 2000 by the National Institutes of Health says that repeat courses of corticosteroids should not be used routinely due to insufficient data from randomized clinical trials.

Data from these three more recent studies, however, support the administration of more than one course of prenatal corticosteroids for women who are at at high risk of delivering before 28 weeks, Dr. Parer said.

“It is possible to justify repeating at least a single course in those patients, particularly if given at a 2-week interval,” he said.

Dr. Parer relayed results of the third, and most recent, study that he heard presented at a conference in Australia earlier this year. That study included 982 pregnant women at risk for preterm delivery who had received one course of prenatal corticosteroids.

The women were randomized to weekly corticosteroids or placebo; treatment continued until 32 weeks' gestation only if the risk for preterm delivery continued.

The study included singletons, twins, and triplets for a total of 1,100 fetuses that were a mean of 28 weeks' gestation at enrollment. The risk factors for preterm birth were similar between groups.

Results showed significantly lower rates of respiratory distress syndrome (RDS) and severe RDS in the weekly corticosteroid group. With weekly corticosteroids, 33% developed RDS, and 12% had severe RDS, compared with 41% and 20%, respectively, in the placebo group.

The need for oxygen or mechanical ventilation fell less dramatically in the weekly corticosteroids group, compared with placebo, but it was not clear whether these differences were significant.

There were no significant differences between groups in the need for intensive care, duration of intensive care, rates of chronic lung disease or severe intraventricular hemorrhage, or maternal outcomes.

Although birth weights were somewhat lower in the steroid group, the weight differences between groups resolved by the time of hospital discharge, he said. Average neonatal length and head circumference did not differ between groups.

No harmful effects of repeat corticosteroids were noted. Of those women who received repeat courses, 24% received at least four courses. The investigators declined to present a conclusion until they've completed 2 years of neurodevelopmental follow-up, he said at the meeting.

A separate study, which was reported at the Society of Maternal and Fetal Medicine meeting in 2004, randomized 495 women after an initial course of prenatal corticosteroids to weekly courses or placebo.

The study was stopped prematurely at 23% of its expected enrollment due to concerns about birth weights, and no signs of a substantial reduction in overall morbidity in the steroid group.

The investigators concluded that there was no benefit to repeated courses of corticosteroids, but Dr. Parer highlighted the “much more impressive” results in infants delivered at less than 32 weeks. These babies had significantly less bronchopulmonary dysplasia and less need for mechanical ventilation or continuous positive airway pressure if they had received repeat corticosteroids, he noted. Birth weights were lower only in infants who had been exposed to more than four courses of corticosteroids.

A third study that randomized 502 women to a single course or weekly courses of corticosteroids also was stopped early and reported no benefit from weekly prenatal steroids (JAMA 2001;286:1581–7).

That study also reported a significantly lower incidence of RDS in babies born before 28 weeks whose mothers received repeated courses of corticosteroids, Dr. Parer noted.

Critics contend that both of these studies were too small and too short to detect significant differences in their primary end point of composite morbidity.

SAN FRANCISCO — Three randomized, controlled trials now show evidence of beneficial effects from a limited number of repeat courses of prenatal corticosteroids for fetuses at risk of preterm delivery, according to Julian T. Parer, M.D.

Those aren't necessarily the official conclusions of the studies, however, he acknowledged at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Two of the three studies found no overall benefit from repeat prenatal steroids but reported significantly less respiratory distress and morbidity in babies born at younger gestational ages if they got more than one course of betamethasone prenatally.

The third study showed a benefit from repeat prenatal steroids, but the investigators will not draw conclusions about the results until after a 2-year follow-up period, said Dr. Parer, who is professor of ob.gyn. at the university.

Dr. Parer said he has no financial relationships with companies that make corticosteroids.

A consensus statement issued in 2000 by the National Institutes of Health says that repeat courses of corticosteroids should not be used routinely due to insufficient data from randomized clinical trials.

Data from these three more recent studies, however, support the administration of more than one course of prenatal corticosteroids for women who are at at high risk of delivering before 28 weeks, Dr. Parer said.

“It is possible to justify repeating at least a single course in those patients, particularly if given at a 2-week interval,” he said.

Dr. Parer relayed results of the third, and most recent, study that he heard presented at a conference in Australia earlier this year. That study included 982 pregnant women at risk for preterm delivery who had received one course of prenatal corticosteroids.

The women were randomized to weekly corticosteroids or placebo; treatment continued until 32 weeks' gestation only if the risk for preterm delivery continued.

The study included singletons, twins, and triplets for a total of 1,100 fetuses that were a mean of 28 weeks' gestation at enrollment. The risk factors for preterm birth were similar between groups.

Results showed significantly lower rates of respiratory distress syndrome (RDS) and severe RDS in the weekly corticosteroid group. With weekly corticosteroids, 33% developed RDS, and 12% had severe RDS, compared with 41% and 20%, respectively, in the placebo group.

The need for oxygen or mechanical ventilation fell less dramatically in the weekly corticosteroids group, compared with placebo, but it was not clear whether these differences were significant.

There were no significant differences between groups in the need for intensive care, duration of intensive care, rates of chronic lung disease or severe intraventricular hemorrhage, or maternal outcomes.

Although birth weights were somewhat lower in the steroid group, the weight differences between groups resolved by the time of hospital discharge, he said. Average neonatal length and head circumference did not differ between groups.

No harmful effects of repeat corticosteroids were noted. Of those women who received repeat courses, 24% received at least four courses. The investigators declined to present a conclusion until they've completed 2 years of neurodevelopmental follow-up, he said at the meeting.

A separate study, which was reported at the Society of Maternal and Fetal Medicine meeting in 2004, randomized 495 women after an initial course of prenatal corticosteroids to weekly courses or placebo.

The study was stopped prematurely at 23% of its expected enrollment due to concerns about birth weights, and no signs of a substantial reduction in overall morbidity in the steroid group.

The investigators concluded that there was no benefit to repeated courses of corticosteroids, but Dr. Parer highlighted the “much more impressive” results in infants delivered at less than 32 weeks. These babies had significantly less bronchopulmonary dysplasia and less need for mechanical ventilation or continuous positive airway pressure if they had received repeat corticosteroids, he noted. Birth weights were lower only in infants who had been exposed to more than four courses of corticosteroids.

A third study that randomized 502 women to a single course or weekly courses of corticosteroids also was stopped early and reported no benefit from weekly prenatal steroids (JAMA 2001;286:1581–7).

That study also reported a significantly lower incidence of RDS in babies born before 28 weeks whose mothers received repeated courses of corticosteroids, Dr. Parer noted.

Critics contend that both of these studies were too small and too short to detect significant differences in their primary end point of composite morbidity.

SAN FRANCISCO — Three randomized, controlled trials now show evidence of beneficial effects from a limited number of repeat courses of prenatal corticosteroids for fetuses at risk of preterm delivery, according to Julian T. Parer, M.D.

Those aren't necessarily the official conclusions of the studies, however, he acknowledged at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Two of the three studies found no overall benefit from repeat prenatal steroids but reported significantly less respiratory distress and morbidity in babies born at younger gestational ages if they got more than one course of betamethasone prenatally.

The third study showed a benefit from repeat prenatal steroids, but the investigators will not draw conclusions about the results until after a 2-year follow-up period, said Dr. Parer, who is professor of ob.gyn. at the university.

Dr. Parer said he has no financial relationships with companies that make corticosteroids.

A consensus statement issued in 2000 by the National Institutes of Health says that repeat courses of corticosteroids should not be used routinely due to insufficient data from randomized clinical trials.

Data from these three more recent studies, however, support the administration of more than one course of prenatal corticosteroids for women who are at at high risk of delivering before 28 weeks, Dr. Parer said.

“It is possible to justify repeating at least a single course in those patients, particularly if given at a 2-week interval,” he said.

Dr. Parer relayed results of the third, and most recent, study that he heard presented at a conference in Australia earlier this year. That study included 982 pregnant women at risk for preterm delivery who had received one course of prenatal corticosteroids.

The women were randomized to weekly corticosteroids or placebo; treatment continued until 32 weeks' gestation only if the risk for preterm delivery continued.

The study included singletons, twins, and triplets for a total of 1,100 fetuses that were a mean of 28 weeks' gestation at enrollment. The risk factors for preterm birth were similar between groups.

Results showed significantly lower rates of respiratory distress syndrome (RDS) and severe RDS in the weekly corticosteroid group. With weekly corticosteroids, 33% developed RDS, and 12% had severe RDS, compared with 41% and 20%, respectively, in the placebo group.

The need for oxygen or mechanical ventilation fell less dramatically in the weekly corticosteroids group, compared with placebo, but it was not clear whether these differences were significant.

There were no significant differences between groups in the need for intensive care, duration of intensive care, rates of chronic lung disease or severe intraventricular hemorrhage, or maternal outcomes.

Although birth weights were somewhat lower in the steroid group, the weight differences between groups resolved by the time of hospital discharge, he said. Average neonatal length and head circumference did not differ between groups.

No harmful effects of repeat corticosteroids were noted. Of those women who received repeat courses, 24% received at least four courses. The investigators declined to present a conclusion until they've completed 2 years of neurodevelopmental follow-up, he said at the meeting.

A separate study, which was reported at the Society of Maternal and Fetal Medicine meeting in 2004, randomized 495 women after an initial course of prenatal corticosteroids to weekly courses or placebo.

The study was stopped prematurely at 23% of its expected enrollment due to concerns about birth weights, and no signs of a substantial reduction in overall morbidity in the steroid group.

The investigators concluded that there was no benefit to repeated courses of corticosteroids, but Dr. Parer highlighted the “much more impressive” results in infants delivered at less than 32 weeks. These babies had significantly less bronchopulmonary dysplasia and less need for mechanical ventilation or continuous positive airway pressure if they had received repeat corticosteroids, he noted. Birth weights were lower only in infants who had been exposed to more than four courses of corticosteroids.

A third study that randomized 502 women to a single course or weekly courses of corticosteroids also was stopped early and reported no benefit from weekly prenatal steroids (JAMA 2001;286:1581–7).

That study also reported a significantly lower incidence of RDS in babies born before 28 weeks whose mothers received repeated courses of corticosteroids, Dr. Parer noted.

Critics contend that both of these studies were too small and too short to detect significant differences in their primary end point of composite morbidity.

VANCOUVER, B.C. — Incorporating testing for human papillomavirus into cervical screening practices for women older than 30 years may take more effort than one would think, Walter Kinney, M.D., said at the 22nd International Papillomavirus Conference.

He described the first 123,909 HPV tests performed within the Kaiser Permanente system on women over age 30 who also had satisfactory results from cytology performed at the same time. Kaiser announced its “cotesting” policy of Pap smears plus HPV tests for women over age 30 in 2002.

“We told the lab to anticipate a tidal wave of specimens. That didn't happen,” said Dr. Kinney of the Permanente Medical Group, Sacramento. “You can't just buy the reagent, announce the guidelines, turn on the machine, and expect this to happen.”

Kaiser officials set about figuring out what to do to get clinicians and patients to accept HPV testing.

“This was a humbling process that went on for a couple of years” but led to excellent acceptance rates by physicians and patients, he said at the meeting, sponsored by the University of California, San Francisco.

Between May 2003 and August 2004, 85%–93% of appropriate patients underwent cotesting at Kaiser facilities, with the exception of one facility that posted a 70% cotesting rate.

This compares with results of a 2005 survey of 185 ob.gyns. randomly selected from the American Medical Association database in which only 33% said they would offer cotesting, despite recommendations for its use by the American College of Obstetricians and Gynecologists and the American Cancer Society (Am. J. Obstet. Gynecol. 2005;192:414–21).

Kaiser gained wider acceptance of cotesting by addressing issues related to staff, patients, and physicians. For staff, training on how and why to do HPV testing is critical. “They have to think it's something they would choose for themselves,” and they need to know how to talk with patients about it, Dr. Kinney said. “Sometimes the patients believe the staff a lot more than they believe you.”

Kaiser created a specimen handling policy and flow charts for cotesting, posted summary sheets, obtained new color-coded order forms and color-coded specimen bins, and redesigned its “Pap books” to track results and patient responses.

Patients should be informed about cotesting before the physician arrives in the exam room, he said.

One way to do this is to have a medical assistant give the patient written materials after taking her blood pressure. Have information sheets as well as brochures handy. For patients with abnormal test results, have available brochures explaining their condition.

What the physician says to the patient about cotesting is important too. A poll of 350 Kaiser patients and 37 physicians asking why the patient did or did not have cotesting found that physicians believed both their words and printed materials were important. Patients, on the other hand, felt that what mattered most was whether physicians said cotesting is a good idea and that they would choose testing themselves.

Give physicians the education and tools they need to know what to say to patients about cotesting, and how to say it. Steps include conferences and guidelines, sample messages or scripts, and handouts on frequently asked questions.

In the Kaiser study, only 5.3% of the first 123,909 cotests were HPV positive. Of these, 3.7% had negative Pap tests.

The rate of HPV positivity dropped by half after age 39, from 9% in 30- to 39-year-olds to 5% of 40- to 49-year-olds. HPV positivity rates decreased with age to a low of 3% in women in their 60s, then crept up a bit over time, he said.

The lead investigator in studying the HPV data was Barbara Fetterman, Ph.D., of the Permanente Medical Group, Oakland, Calif.

VANCOUVER, B.C. — Incorporating testing for human papillomavirus into cervical screening practices for women older than 30 years may take more effort than one would think, Walter Kinney, M.D., said at the 22nd International Papillomavirus Conference.

He described the first 123,909 HPV tests performed within the Kaiser Permanente system on women over age 30 who also had satisfactory results from cytology performed at the same time. Kaiser announced its “cotesting” policy of Pap smears plus HPV tests for women over age 30 in 2002.

“We told the lab to anticipate a tidal wave of specimens. That didn't happen,” said Dr. Kinney of the Permanente Medical Group, Sacramento. “You can't just buy the reagent, announce the guidelines, turn on the machine, and expect this to happen.”

Kaiser officials set about figuring out what to do to get clinicians and patients to accept HPV testing.

“This was a humbling process that went on for a couple of years” but led to excellent acceptance rates by physicians and patients, he said at the meeting, sponsored by the University of California, San Francisco.

Between May 2003 and August 2004, 85%–93% of appropriate patients underwent cotesting at Kaiser facilities, with the exception of one facility that posted a 70% cotesting rate.

This compares with results of a 2005 survey of 185 ob.gyns. randomly selected from the American Medical Association database in which only 33% said they would offer cotesting, despite recommendations for its use by the American College of Obstetricians and Gynecologists and the American Cancer Society (Am. J. Obstet. Gynecol. 2005;192:414–21).

Kaiser gained wider acceptance of cotesting by addressing issues related to staff, patients, and physicians. For staff, training on how and why to do HPV testing is critical. “They have to think it's something they would choose for themselves,” and they need to know how to talk with patients about it, Dr. Kinney said. “Sometimes the patients believe the staff a lot more than they believe you.”

Kaiser created a specimen handling policy and flow charts for cotesting, posted summary sheets, obtained new color-coded order forms and color-coded specimen bins, and redesigned its “Pap books” to track results and patient responses.

Patients should be informed about cotesting before the physician arrives in the exam room, he said.

One way to do this is to have a medical assistant give the patient written materials after taking her blood pressure. Have information sheets as well as brochures handy. For patients with abnormal test results, have available brochures explaining their condition.

What the physician says to the patient about cotesting is important too. A poll of 350 Kaiser patients and 37 physicians asking why the patient did or did not have cotesting found that physicians believed both their words and printed materials were important. Patients, on the other hand, felt that what mattered most was whether physicians said cotesting is a good idea and that they would choose testing themselves.

Give physicians the education and tools they need to know what to say to patients about cotesting, and how to say it. Steps include conferences and guidelines, sample messages or scripts, and handouts on frequently asked questions.

In the Kaiser study, only 5.3% of the first 123,909 cotests were HPV positive. Of these, 3.7% had negative Pap tests.

The rate of HPV positivity dropped by half after age 39, from 9% in 30- to 39-year-olds to 5% of 40- to 49-year-olds. HPV positivity rates decreased with age to a low of 3% in women in their 60s, then crept up a bit over time, he said.

The lead investigator in studying the HPV data was Barbara Fetterman, Ph.D., of the Permanente Medical Group, Oakland, Calif.

VANCOUVER, B.C. — Incorporating testing for human papillomavirus into cervical screening practices for women older than 30 years may take more effort than one would think, Walter Kinney, M.D., said at the 22nd International Papillomavirus Conference.

He described the first 123,909 HPV tests performed within the Kaiser Permanente system on women over age 30 who also had satisfactory results from cytology performed at the same time. Kaiser announced its “cotesting” policy of Pap smears plus HPV tests for women over age 30 in 2002.

“We told the lab to anticipate a tidal wave of specimens. That didn't happen,” said Dr. Kinney of the Permanente Medical Group, Sacramento. “You can't just buy the reagent, announce the guidelines, turn on the machine, and expect this to happen.”

Kaiser officials set about figuring out what to do to get clinicians and patients to accept HPV testing.

“This was a humbling process that went on for a couple of years” but led to excellent acceptance rates by physicians and patients, he said at the meeting, sponsored by the University of California, San Francisco.

Between May 2003 and August 2004, 85%–93% of appropriate patients underwent cotesting at Kaiser facilities, with the exception of one facility that posted a 70% cotesting rate.

This compares with results of a 2005 survey of 185 ob.gyns. randomly selected from the American Medical Association database in which only 33% said they would offer cotesting, despite recommendations for its use by the American College of Obstetricians and Gynecologists and the American Cancer Society (Am. J. Obstet. Gynecol. 2005;192:414–21).

Kaiser gained wider acceptance of cotesting by addressing issues related to staff, patients, and physicians. For staff, training on how and why to do HPV testing is critical. “They have to think it's something they would choose for themselves,” and they need to know how to talk with patients about it, Dr. Kinney said. “Sometimes the patients believe the staff a lot more than they believe you.”

Kaiser created a specimen handling policy and flow charts for cotesting, posted summary sheets, obtained new color-coded order forms and color-coded specimen bins, and redesigned its “Pap books” to track results and patient responses.

Patients should be informed about cotesting before the physician arrives in the exam room, he said.

One way to do this is to have a medical assistant give the patient written materials after taking her blood pressure. Have information sheets as well as brochures handy. For patients with abnormal test results, have available brochures explaining their condition.

What the physician says to the patient about cotesting is important too. A poll of 350 Kaiser patients and 37 physicians asking why the patient did or did not have cotesting found that physicians believed both their words and printed materials were important. Patients, on the other hand, felt that what mattered most was whether physicians said cotesting is a good idea and that they would choose testing themselves.

Give physicians the education and tools they need to know what to say to patients about cotesting, and how to say it. Steps include conferences and guidelines, sample messages or scripts, and handouts on frequently asked questions.

In the Kaiser study, only 5.3% of the first 123,909 cotests were HPV positive. Of these, 3.7% had negative Pap tests.

The rate of HPV positivity dropped by half after age 39, from 9% in 30- to 39-year-olds to 5% of 40- to 49-year-olds. HPV positivity rates decreased with age to a low of 3% in women in their 60s, then crept up a bit over time, he said.

The lead investigator in studying the HPV data was Barbara Fetterman, Ph.D., of the Permanente Medical Group, Oakland, Calif.

SAN FRANCISCO — New data for the first time support assumptions that home monitoring improves blood pressure control because of better adherence to antihypertensive therapy, Gbenga Ogedegbe, M.D., said at the annual meeting of the American Society of Hypertension.

Previous reports showed better control in hypertensive patients performing home blood pressure monitoring, compared with patients monitored in physicians' offices; clinicians assumed this was due to better adherence to home monitoring therapy.

The current data—part of a larger and longer study—came from patients with uncontrolled blood pressure on one or more antihypertensive medications who were randomized to home blood pressure monitoring (118 patients) or usual care in offices (60 patients) for 12 weeks. Investigators assessed adherence to therapy using the well-validated Morisky questionnaire, said Dr. Ogedegbe of Columbia University, New York.

At baseline, 47% of patients in the home monitoring group and 65% in the usual care group reported adherence to therapy, a non- statistically significant difference.

In the home monitoring group, patients took their blood pressure three times per week on average, usually at different times of the day, using a “life-link” monitoring system that gave them immediate feedback on their blood pressure and electronically sent a report to their physicians.

At follow-up 12 weeks later, patients were asked four questions that have been shown to predict the likelihood of blood pressure control: In the past 4 weeks, have you been careless about taking your blood pressure medication? In the past 4 weeks, have you forgotten to take your blood pressure medication? Do you stop taking the medication when you feel better? Do you stop taking the medication when you feel worse, from side effects? Patients who answered “yes” to any of the questions were considered nonadherent to therapy.

In the home monitoring group, 31% went from being nonadherent at baseline to adherent with therapy at 12 weeks, compared with 12% of patients in the usual care group, a significant difference.

Patients in the home monitoring group were less likely to move from adherent to nonadherent (12%), compared with the usual care group (18%). The rest of the patients did not change adherence patterns.

SAN FRANCISCO — New data for the first time support assumptions that home monitoring improves blood pressure control because of better adherence to antihypertensive therapy, Gbenga Ogedegbe, M.D., said at the annual meeting of the American Society of Hypertension.

Previous reports showed better control in hypertensive patients performing home blood pressure monitoring, compared with patients monitored in physicians' offices; clinicians assumed this was due to better adherence to home monitoring therapy.

The current data—part of a larger and longer study—came from patients with uncontrolled blood pressure on one or more antihypertensive medications who were randomized to home blood pressure monitoring (118 patients) or usual care in offices (60 patients) for 12 weeks. Investigators assessed adherence to therapy using the well-validated Morisky questionnaire, said Dr. Ogedegbe of Columbia University, New York.

At baseline, 47% of patients in the home monitoring group and 65% in the usual care group reported adherence to therapy, a non- statistically significant difference.

In the home monitoring group, patients took their blood pressure three times per week on average, usually at different times of the day, using a “life-link” monitoring system that gave them immediate feedback on their blood pressure and electronically sent a report to their physicians.

At follow-up 12 weeks later, patients were asked four questions that have been shown to predict the likelihood of blood pressure control: In the past 4 weeks, have you been careless about taking your blood pressure medication? In the past 4 weeks, have you forgotten to take your blood pressure medication? Do you stop taking the medication when you feel better? Do you stop taking the medication when you feel worse, from side effects? Patients who answered “yes” to any of the questions were considered nonadherent to therapy.

In the home monitoring group, 31% went from being nonadherent at baseline to adherent with therapy at 12 weeks, compared with 12% of patients in the usual care group, a significant difference.

Patients in the home monitoring group were less likely to move from adherent to nonadherent (12%), compared with the usual care group (18%). The rest of the patients did not change adherence patterns.

SAN FRANCISCO — New data for the first time support assumptions that home monitoring improves blood pressure control because of better adherence to antihypertensive therapy, Gbenga Ogedegbe, M.D., said at the annual meeting of the American Society of Hypertension.

Previous reports showed better control in hypertensive patients performing home blood pressure monitoring, compared with patients monitored in physicians' offices; clinicians assumed this was due to better adherence to home monitoring therapy.

The current data—part of a larger and longer study—came from patients with uncontrolled blood pressure on one or more antihypertensive medications who were randomized to home blood pressure monitoring (118 patients) or usual care in offices (60 patients) for 12 weeks. Investigators assessed adherence to therapy using the well-validated Morisky questionnaire, said Dr. Ogedegbe of Columbia University, New York.

At baseline, 47% of patients in the home monitoring group and 65% in the usual care group reported adherence to therapy, a non- statistically significant difference.

In the home monitoring group, patients took their blood pressure three times per week on average, usually at different times of the day, using a “life-link” monitoring system that gave them immediate feedback on their blood pressure and electronically sent a report to their physicians.

At follow-up 12 weeks later, patients were asked four questions that have been shown to predict the likelihood of blood pressure control: In the past 4 weeks, have you been careless about taking your blood pressure medication? In the past 4 weeks, have you forgotten to take your blood pressure medication? Do you stop taking the medication when you feel better? Do you stop taking the medication when you feel worse, from side effects? Patients who answered “yes” to any of the questions were considered nonadherent to therapy.

In the home monitoring group, 31% went from being nonadherent at baseline to adherent with therapy at 12 weeks, compared with 12% of patients in the usual care group, a significant difference.

Patients in the home monitoring group were less likely to move from adherent to nonadherent (12%), compared with the usual care group (18%). The rest of the patients did not change adherence patterns.

SAN FRANCISCO — Most physicians believe in urging hypertensive patients to alter their lifestyle in beneficial ways, even though this seldom comes to pass, Norman Kaplan, M.D., said at the annual meeting of the American Society of Hypertension.

“I'm not sure that we're going to be depending as much on lifestyle modifications as we have in the past” because of the recognition that high blood pressures need to be lowered quickly, said Dr. Kaplan, professor of medicine at the University of Texas, Dallas.

He described lifestyle modifications that do and don't work in treating hypertension:

▸ Smoking cessation. Usually found at the bottom of lists of lifestyle modifications for treating hypertension, smoking cessation deserves first mention because it is the major reversible cardiovascular risk factor in hypertensive smokers. Until recently, physicians didn't recognize the pressor effects of nicotine because patients weren't allowed to smoke during blood pressure measurements. Ambulatory monitoring consistently shows higher blood pressures while smoking.

Advise patients repeatedly to stop smoking, and explain or show to them the pressor effect of smoking, Dr. Kaplan said. Nicotine replacement products such as patches should not have persistent pressor effects but advise patients to check their blood pressure on these products anyway because some people may be particularly sensitive.

▸ Weight loss. Significant weight loss reduces blood pressure, but most dieters put the pounds back on in a short amount of time. Studies comparing weight loss diets suggest that the cheapest and “probably the most logical” method—Weight Watchers—may be the best diet strategy, he said.

For morbidly obese people (body mass index greater than 40 kg/m

Gastric banding surgeries have been less successful in morbidly obese patients. It appears that enough food is forced past the banded stomach over time that the patient regains the weight initially lost after surgery.

▸ Physical activity. Unhealthy diets and physical inactivity share equal blame for Americans' march toward morbid obesity.

Duration is more important than intensity of physical activity for lowering blood pressure, studies have shown. Thirty minutes on a treadmill exercising at 50%–75% of maximal heart rate significantly reduced blood pressure and the effects persisted over 24 hours, one study found, he said.

A metaanalysis of studies on diabetic patients found that walking as little as 2 hours or more each week reduced mortality by about 40%, compared with less active patients, Dr. Kaplan said.

▸ Sodium reduction. Patients who reduce their sodium intake typically return to old habits over time. The result is that no difference is seen after 5 years, according to an analysis of about 30 studies.

People are surrounded by high-sodium foods in U.S. culture: Some fast food items pack 1,000–3,000 mg sodium each. “Most people have no perception of what they're eating when they eat this kind of food,” he said.

▸ Moderation of alcohol. Drinking modest amounts of alcohol while eating food does not increase the risk of hypertension and may even provide some cardiovascular benefits, he said. Consuming alcohol without food or having more than three drinks per day increases the risk for hypertension and other health problems.

▸ Increasing potassium. Hypertensive patients can reduce their blood pressure by taking 40–80 mmol/day of supplemental potassium, but it's better to recommend that patients eat more fruits and vegetables to boost their potassium intake. One reason the Dietary Approaches to Stop Hypertension diet works is that it triples the typical potassium intake, Dr. Kaplan noted.

▸ Reducing caffeine. Be aware that the first cup of the day causes a pressor effect in many people. Advise patients monitoring their blood pressure to check before and after drinking coffee or tea containing caffeine, he advised.

▸ Calcium or magnesium. These minerals, in the form of supplements, have no significant effect on hypertension, Dr. Kaplan said.

'Polymeal' Could Beat 'Polypill' for Lowering CV Risk

Including the following foods in one's daily diet could reduce the risk of cardiovascular disease by 76%, according to a recent analysis (BMJ 2004;329:1447–50).

“I think this was done tongue in cheek, but it's a much tastier proposition than the idea of a 'polypill'” to lower cardiovascular risk, Dr. Kaplan said.

Although the regimen does not specifically address hypertension, the proposed “polymeal” is something that physicians and patients may want to note, he added.

Translated into common U.S. measurements, the ingredients include:

▸ Wine, 5 ounces.

▸ Fish (salmon), 4 ounces.

▸ Dark chocolate, 3.5 ounces.

▸ Fruit/vegetables, 400 g (equivalent of 22/3H apples).

▸ Garlic, 1 clove.

▸ Almonds, 2.5 ounces.

Eating these foods daily could be expected to prolong life by 7 years in men and 5 years in women, the study authors estimated.

SAN FRANCISCO — Most physicians believe in urging hypertensive patients to alter their lifestyle in beneficial ways, even though this seldom comes to pass, Norman Kaplan, M.D., said at the annual meeting of the American Society of Hypertension.

“I'm not sure that we're going to be depending as much on lifestyle modifications as we have in the past” because of the recognition that high blood pressures need to be lowered quickly, said Dr. Kaplan, professor of medicine at the University of Texas, Dallas.

He described lifestyle modifications that do and don't work in treating hypertension:

▸ Smoking cessation. Usually found at the bottom of lists of lifestyle modifications for treating hypertension, smoking cessation deserves first mention because it is the major reversible cardiovascular risk factor in hypertensive smokers. Until recently, physicians didn't recognize the pressor effects of nicotine because patients weren't allowed to smoke during blood pressure measurements. Ambulatory monitoring consistently shows higher blood pressures while smoking.

Advise patients repeatedly to stop smoking, and explain or show to them the pressor effect of smoking, Dr. Kaplan said. Nicotine replacement products such as patches should not have persistent pressor effects but advise patients to check their blood pressure on these products anyway because some people may be particularly sensitive.

▸ Weight loss. Significant weight loss reduces blood pressure, but most dieters put the pounds back on in a short amount of time. Studies comparing weight loss diets suggest that the cheapest and “probably the most logical” method—Weight Watchers—may be the best diet strategy, he said.

For morbidly obese people (body mass index greater than 40 kg/m

Gastric banding surgeries have been less successful in morbidly obese patients. It appears that enough food is forced past the banded stomach over time that the patient regains the weight initially lost after surgery.

▸ Physical activity. Unhealthy diets and physical inactivity share equal blame for Americans' march toward morbid obesity.

Duration is more important than intensity of physical activity for lowering blood pressure, studies have shown. Thirty minutes on a treadmill exercising at 50%–75% of maximal heart rate significantly reduced blood pressure and the effects persisted over 24 hours, one study found, he said.

A metaanalysis of studies on diabetic patients found that walking as little as 2 hours or more each week reduced mortality by about 40%, compared with less active patients, Dr. Kaplan said.

▸ Sodium reduction. Patients who reduce their sodium intake typically return to old habits over time. The result is that no difference is seen after 5 years, according to an analysis of about 30 studies.

People are surrounded by high-sodium foods in U.S. culture: Some fast food items pack 1,000–3,000 mg sodium each. “Most people have no perception of what they're eating when they eat this kind of food,” he said.

▸ Moderation of alcohol. Drinking modest amounts of alcohol while eating food does not increase the risk of hypertension and may even provide some cardiovascular benefits, he said. Consuming alcohol without food or having more than three drinks per day increases the risk for hypertension and other health problems.

▸ Increasing potassium. Hypertensive patients can reduce their blood pressure by taking 40–80 mmol/day of supplemental potassium, but it's better to recommend that patients eat more fruits and vegetables to boost their potassium intake. One reason the Dietary Approaches to Stop Hypertension diet works is that it triples the typical potassium intake, Dr. Kaplan noted.

▸ Reducing caffeine. Be aware that the first cup of the day causes a pressor effect in many people. Advise patients monitoring their blood pressure to check before and after drinking coffee or tea containing caffeine, he advised.

▸ Calcium or magnesium. These minerals, in the form of supplements, have no significant effect on hypertension, Dr. Kaplan said.

'Polymeal' Could Beat 'Polypill' for Lowering CV Risk

Including the following foods in one's daily diet could reduce the risk of cardiovascular disease by 76%, according to a recent analysis (BMJ 2004;329:1447–50).

“I think this was done tongue in cheek, but it's a much tastier proposition than the idea of a 'polypill'” to lower cardiovascular risk, Dr. Kaplan said.

Although the regimen does not specifically address hypertension, the proposed “polymeal” is something that physicians and patients may want to note, he added.

Translated into common U.S. measurements, the ingredients include:

▸ Wine, 5 ounces.

▸ Fish (salmon), 4 ounces.

▸ Dark chocolate, 3.5 ounces.

▸ Fruit/vegetables, 400 g (equivalent of 22/3H apples).

▸ Garlic, 1 clove.

▸ Almonds, 2.5 ounces.

Eating these foods daily could be expected to prolong life by 7 years in men and 5 years in women, the study authors estimated.

SAN FRANCISCO — Most physicians believe in urging hypertensive patients to alter their lifestyle in beneficial ways, even though this seldom comes to pass, Norman Kaplan, M.D., said at the annual meeting of the American Society of Hypertension.

“I'm not sure that we're going to be depending as much on lifestyle modifications as we have in the past” because of the recognition that high blood pressures need to be lowered quickly, said Dr. Kaplan, professor of medicine at the University of Texas, Dallas.

He described lifestyle modifications that do and don't work in treating hypertension:

▸ Smoking cessation. Usually found at the bottom of lists of lifestyle modifications for treating hypertension, smoking cessation deserves first mention because it is the major reversible cardiovascular risk factor in hypertensive smokers. Until recently, physicians didn't recognize the pressor effects of nicotine because patients weren't allowed to smoke during blood pressure measurements. Ambulatory monitoring consistently shows higher blood pressures while smoking.

Advise patients repeatedly to stop smoking, and explain or show to them the pressor effect of smoking, Dr. Kaplan said. Nicotine replacement products such as patches should not have persistent pressor effects but advise patients to check their blood pressure on these products anyway because some people may be particularly sensitive.

▸ Weight loss. Significant weight loss reduces blood pressure, but most dieters put the pounds back on in a short amount of time. Studies comparing weight loss diets suggest that the cheapest and “probably the most logical” method—Weight Watchers—may be the best diet strategy, he said.

For morbidly obese people (body mass index greater than 40 kg/m

Gastric banding surgeries have been less successful in morbidly obese patients. It appears that enough food is forced past the banded stomach over time that the patient regains the weight initially lost after surgery.

▸ Physical activity. Unhealthy diets and physical inactivity share equal blame for Americans' march toward morbid obesity.

Duration is more important than intensity of physical activity for lowering blood pressure, studies have shown. Thirty minutes on a treadmill exercising at 50%–75% of maximal heart rate significantly reduced blood pressure and the effects persisted over 24 hours, one study found, he said.

A metaanalysis of studies on diabetic patients found that walking as little as 2 hours or more each week reduced mortality by about 40%, compared with less active patients, Dr. Kaplan said.

▸ Sodium reduction. Patients who reduce their sodium intake typically return to old habits over time. The result is that no difference is seen after 5 years, according to an analysis of about 30 studies.

People are surrounded by high-sodium foods in U.S. culture: Some fast food items pack 1,000–3,000 mg sodium each. “Most people have no perception of what they're eating when they eat this kind of food,” he said.

▸ Moderation of alcohol. Drinking modest amounts of alcohol while eating food does not increase the risk of hypertension and may even provide some cardiovascular benefits, he said. Consuming alcohol without food or having more than three drinks per day increases the risk for hypertension and other health problems.

▸ Increasing potassium. Hypertensive patients can reduce their blood pressure by taking 40–80 mmol/day of supplemental potassium, but it's better to recommend that patients eat more fruits and vegetables to boost their potassium intake. One reason the Dietary Approaches to Stop Hypertension diet works is that it triples the typical potassium intake, Dr. Kaplan noted.

▸ Reducing caffeine. Be aware that the first cup of the day causes a pressor effect in many people. Advise patients monitoring their blood pressure to check before and after drinking coffee or tea containing caffeine, he advised.

▸ Calcium or magnesium. These minerals, in the form of supplements, have no significant effect on hypertension, Dr. Kaplan said.

'Polymeal' Could Beat 'Polypill' for Lowering CV Risk

Including the following foods in one's daily diet could reduce the risk of cardiovascular disease by 76%, according to a recent analysis (BMJ 2004;329:1447–50).

“I think this was done tongue in cheek, but it's a much tastier proposition than the idea of a 'polypill'” to lower cardiovascular risk, Dr. Kaplan said.

Although the regimen does not specifically address hypertension, the proposed “polymeal” is something that physicians and patients may want to note, he added.

Translated into common U.S. measurements, the ingredients include:

▸ Wine, 5 ounces.

▸ Fish (salmon), 4 ounces.

▸ Dark chocolate, 3.5 ounces.

▸ Fruit/vegetables, 400 g (equivalent of 22/3H apples).

▸ Garlic, 1 clove.

▸ Almonds, 2.5 ounces.

Eating these foods daily could be expected to prolong life by 7 years in men and 5 years in women, the study authors estimated.