Doug Brunk

SAN DIEGO – Adolescents with a history of alcohol use report a significant range of risk behaviors for problematic substance use and other problem behaviors, a study of adolescents being treated in the emergency department for an alcohol-related incident shows.

“Alcohol-positive adolescents with a history of problematic alcohol use prior to the emergency department visit should receive greater attention in the discharge planning process, especially with the parents,” lead author Anne M. Fairlie said in an interview after the study was presented during a poster session at the annual scientific conference of the Research Society on Alcoholism.

“Attention should be given to the broader clinical picture [such as a] history of drinking and peer and parental influences, not just presentation as alcohol positive in order to ensure adequate evaluation and disposition planning,” she said.

Ms. Fairlie, a graduate research assistant in the behavioral science Ph.D. program in psychology at the University of Rhode Island, Kingston, and her associates examined three groups of adolescents: 45 who scored at or above the clinical cutoff (16 or above) on the Adolescent Drinking Inventory (ADI); 68 who scored below the clinical cutoff on the ADI while being treated in the pediatric or adult emergency department of a level I regional care center after an alcohol-related incident; and 64 adolescents who were alcohol negative while being treated in the pediatric or adult emergency departments, or in community settings. The mean age of the subjects was 15 years.

Alcohol-positive adolescents were identified as either having consumed alcohol within 6 hours of admission or tested positive for alcohol via blood-drawn test, while alcohol-negative adolescents did not report consuming alcohol within 6 hours of admission, did not have a positive blood test or breathalyzer (if administered), and scored 3 or lower on the Alcohol Use Disorders Identification Test.

Other measures used in the study included the Center for Epidemiologic Studies–Depression scale, the Behavior Assessment System for Children, and the Parental Strictness/Supervision Scale. The researchers performed one-way analyses of covariance while controlling for age.

Adolescents who scored at or above the clinical cutoff on the ADI reported significantly more alcohol use, compared with those who scored below the clinical cutoff on the ADI, followed by adolescents in the alcohol-negative group. For example, the mean number of days per month alcohol was consumed was 5.28 among adolescents who scored at or above the clinical cutoff on the ADI, 0.94 among those who scored below the clinical cutoff on the ADI, and 0.13 among those in the alcohol-negative group. This pattern continued in the number of days drank per month, the number of days per month five or more drinks in a row were consumed, the maximum number of drinks consumed on one occasion, and the number of days marijuana was used in the past month.

According to parental reports, adolescents in the alcohol-negative group had significantly fewer internalizing and externalizing symptoms, compared with adolescents in the other two groups.

Ms. Fairlie and her associates also found that adolescents who scored at or above the clinical cutoff on the ADI reported significantly higher scores on peer substance use and peer tolerance of substance use (mean scores of 1.63 and 2.59, respectively), compared with those who scored below the clinical cutoff on the ADI (0.79 and 2.00), followed by adolescents in the alcohol-negative group (0.46 and 1.57).

In addition, adolescents who scored at or above the clinical cutoff on the ADI reported significantly lower scores on the Parental Strictness/Supervision scale, compared with their peers in the other two groups.

No differences in depressive symptoms among the study participants were observed.

Ms. Fairlie acknowledged certain limitations of the study, including the homogeneity of the study participants. Most were non-Hispanic whites, “which inhibits our ability to generalize the findings to adolescents from various racial and ethnic backgrounds,” she said.

Also, “the data are cross-sectional and, therefore, longitudinal relationships cannot be examined. There are likely reciprocal relationships among substance abuse, teen behavior, and peer and parental influences.” These relationships may differ over time among the groups of adolescents examined in the current study.

Vitals

Major Finding: Adolescents who score at or above the clinical cutoff on the ADI are at risk for problematic substance use and behaviors.

Data Source: Study of 177 adolescents admitted to ED after an alcohol-related incident.

Disclosures: One investigator received a grant from the National Institute on Alcohol Abuse and Alcoholism.

SAN DIEGO – Adolescents with a history of alcohol use report a significant range of risk behaviors for problematic substance use and other problem behaviors, a study of adolescents being treated in the emergency department for an alcohol-related incident shows.

“Alcohol-positive adolescents with a history of problematic alcohol use prior to the emergency department visit should receive greater attention in the discharge planning process, especially with the parents,” lead author Anne M. Fairlie said in an interview after the study was presented during a poster session at the annual scientific conference of the Research Society on Alcoholism.

“Attention should be given to the broader clinical picture [such as a] history of drinking and peer and parental influences, not just presentation as alcohol positive in order to ensure adequate evaluation and disposition planning,” she said.

Ms. Fairlie, a graduate research assistant in the behavioral science Ph.D. program in psychology at the University of Rhode Island, Kingston, and her associates examined three groups of adolescents: 45 who scored at or above the clinical cutoff (16 or above) on the Adolescent Drinking Inventory (ADI); 68 who scored below the clinical cutoff on the ADI while being treated in the pediatric or adult emergency department of a level I regional care center after an alcohol-related incident; and 64 adolescents who were alcohol negative while being treated in the pediatric or adult emergency departments, or in community settings. The mean age of the subjects was 15 years.

Alcohol-positive adolescents were identified as either having consumed alcohol within 6 hours of admission or tested positive for alcohol via blood-drawn test, while alcohol-negative adolescents did not report consuming alcohol within 6 hours of admission, did not have a positive blood test or breathalyzer (if administered), and scored 3 or lower on the Alcohol Use Disorders Identification Test.

Other measures used in the study included the Center for Epidemiologic Studies–Depression scale, the Behavior Assessment System for Children, and the Parental Strictness/Supervision Scale. The researchers performed one-way analyses of covariance while controlling for age.

Adolescents who scored at or above the clinical cutoff on the ADI reported significantly more alcohol use, compared with those who scored below the clinical cutoff on the ADI, followed by adolescents in the alcohol-negative group. For example, the mean number of days per month alcohol was consumed was 5.28 among adolescents who scored at or above the clinical cutoff on the ADI, 0.94 among those who scored below the clinical cutoff on the ADI, and 0.13 among those in the alcohol-negative group. This pattern continued in the number of days drank per month, the number of days per month five or more drinks in a row were consumed, the maximum number of drinks consumed on one occasion, and the number of days marijuana was used in the past month.

According to parental reports, adolescents in the alcohol-negative group had significantly fewer internalizing and externalizing symptoms, compared with adolescents in the other two groups.

Ms. Fairlie and her associates also found that adolescents who scored at or above the clinical cutoff on the ADI reported significantly higher scores on peer substance use and peer tolerance of substance use (mean scores of 1.63 and 2.59, respectively), compared with those who scored below the clinical cutoff on the ADI (0.79 and 2.00), followed by adolescents in the alcohol-negative group (0.46 and 1.57).

In addition, adolescents who scored at or above the clinical cutoff on the ADI reported significantly lower scores on the Parental Strictness/Supervision scale, compared with their peers in the other two groups.

No differences in depressive symptoms among the study participants were observed.

Ms. Fairlie acknowledged certain limitations of the study, including the homogeneity of the study participants. Most were non-Hispanic whites, “which inhibits our ability to generalize the findings to adolescents from various racial and ethnic backgrounds,” she said.

Also, “the data are cross-sectional and, therefore, longitudinal relationships cannot be examined. There are likely reciprocal relationships among substance abuse, teen behavior, and peer and parental influences.” These relationships may differ over time among the groups of adolescents examined in the current study.

Vitals

Major Finding: Adolescents who score at or above the clinical cutoff on the ADI are at risk for problematic substance use and behaviors.

Data Source: Study of 177 adolescents admitted to ED after an alcohol-related incident.

Disclosures: One investigator received a grant from the National Institute on Alcohol Abuse and Alcoholism.

SAN DIEGO – Adolescents with a history of alcohol use report a significant range of risk behaviors for problematic substance use and other problem behaviors, a study of adolescents being treated in the emergency department for an alcohol-related incident shows.

“Alcohol-positive adolescents with a history of problematic alcohol use prior to the emergency department visit should receive greater attention in the discharge planning process, especially with the parents,” lead author Anne M. Fairlie said in an interview after the study was presented during a poster session at the annual scientific conference of the Research Society on Alcoholism.

“Attention should be given to the broader clinical picture [such as a] history of drinking and peer and parental influences, not just presentation as alcohol positive in order to ensure adequate evaluation and disposition planning,” she said.

Ms. Fairlie, a graduate research assistant in the behavioral science Ph.D. program in psychology at the University of Rhode Island, Kingston, and her associates examined three groups of adolescents: 45 who scored at or above the clinical cutoff (16 or above) on the Adolescent Drinking Inventory (ADI); 68 who scored below the clinical cutoff on the ADI while being treated in the pediatric or adult emergency department of a level I regional care center after an alcohol-related incident; and 64 adolescents who were alcohol negative while being treated in the pediatric or adult emergency departments, or in community settings. The mean age of the subjects was 15 years.

Alcohol-positive adolescents were identified as either having consumed alcohol within 6 hours of admission or tested positive for alcohol via blood-drawn test, while alcohol-negative adolescents did not report consuming alcohol within 6 hours of admission, did not have a positive blood test or breathalyzer (if administered), and scored 3 or lower on the Alcohol Use Disorders Identification Test.

Other measures used in the study included the Center for Epidemiologic Studies–Depression scale, the Behavior Assessment System for Children, and the Parental Strictness/Supervision Scale. The researchers performed one-way analyses of covariance while controlling for age.

Adolescents who scored at or above the clinical cutoff on the ADI reported significantly more alcohol use, compared with those who scored below the clinical cutoff on the ADI, followed by adolescents in the alcohol-negative group. For example, the mean number of days per month alcohol was consumed was 5.28 among adolescents who scored at or above the clinical cutoff on the ADI, 0.94 among those who scored below the clinical cutoff on the ADI, and 0.13 among those in the alcohol-negative group. This pattern continued in the number of days drank per month, the number of days per month five or more drinks in a row were consumed, the maximum number of drinks consumed on one occasion, and the number of days marijuana was used in the past month.

According to parental reports, adolescents in the alcohol-negative group had significantly fewer internalizing and externalizing symptoms, compared with adolescents in the other two groups.

Ms. Fairlie and her associates also found that adolescents who scored at or above the clinical cutoff on the ADI reported significantly higher scores on peer substance use and peer tolerance of substance use (mean scores of 1.63 and 2.59, respectively), compared with those who scored below the clinical cutoff on the ADI (0.79 and 2.00), followed by adolescents in the alcohol-negative group (0.46 and 1.57).

In addition, adolescents who scored at or above the clinical cutoff on the ADI reported significantly lower scores on the Parental Strictness/Supervision scale, compared with their peers in the other two groups.

No differences in depressive symptoms among the study participants were observed.

Ms. Fairlie acknowledged certain limitations of the study, including the homogeneity of the study participants. Most were non-Hispanic whites, “which inhibits our ability to generalize the findings to adolescents from various racial and ethnic backgrounds,” she said.

Also, “the data are cross-sectional and, therefore, longitudinal relationships cannot be examined. There are likely reciprocal relationships among substance abuse, teen behavior, and peer and parental influences.” These relationships may differ over time among the groups of adolescents examined in the current study.

Vitals

Major Finding: Adolescents who score at or above the clinical cutoff on the ADI are at risk for problematic substance use and behaviors.

Data Source: Study of 177 adolescents admitted to ED after an alcohol-related incident.

Disclosures: One investigator received a grant from the National Institute on Alcohol Abuse and Alcoholism.

SAN FRANCISCO — Ceftaroline demonstrated a higher clinical cure rate, compared with ceftriaxone in patients hospitalized with community-acquired pneumonia, according to combined results from two phase III studies.

A parenteral, broad-spectrum cephalosporin being developed by Forest Laboratories and AstraZeneca, ceftaroline “has a similar spectrum of activity as ceftriaxone, but it adds additional coverage against resistant gram-positive [organisms] that cause pneumonia in increasing frequency,” Dr. Paul Eckburg said in an interview during a poster session at the annual meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy.

The researchers enrolled 1,228 hospitalized patients with community-acquired pneumonia who required IV therapy; 614 received ceftaroline 600 mg every 12 hours and 614 received ceftriaxone (Rocephin) 1 gram every 24 hours. Each group was treated for 5–7 days. The mean age of patients was 61 years and 63% were male, Dr. Eckburg and his associates reported.

The primary objective of the two clinical trials was to determine noninferiority in the clinical cure rate with ceftaroline, compared with ceftriaxone (Rocephin) at 8–15 days after therapy. Of the 1,228 patients in the two trials, 908 met clinically evaluable criteria; they had clinical cure rates of 84.3% with ceftaroline and 77.7% with ceftriaxone.

“What surprised us was that the clinical cure rates were much higher in the ceftaroline arm than what we expected,” commented Dr. Eckburg, director of anti-infective development at Cerexa Inc., the wholly owned anti-infectives subsidiary of Forest Laboratories Inc. “We expected to see very similar cure rates.”

Among the 1,153 patients in the modified intent-to-treat efficacy group (limited to patients with class III and IV pneumonia), the overall clinical cure rates for ceftaroline and ceftriaxone were 82.6%and 76.6%.

Both drugs were well tolerated in the trials. Diarrhea was the most common adverse event (4.2% in ceftaroline users vs. 2.6% in ceftriaxone users), followed by headache (3.4% vs. 1.5%) and insomnia (3.1% vs. 2.3%).

“The bottom line is that we now have a new drug that shows similar efficacy to an older drug, ceftriaxone, but it offers additional coverage against emerging resistant pathogens,” Dr. Eckburg said.

The study was supported by Forest Laboratories.

SAN FRANCISCO — Ceftaroline demonstrated a higher clinical cure rate, compared with ceftriaxone in patients hospitalized with community-acquired pneumonia, according to combined results from two phase III studies.

A parenteral, broad-spectrum cephalosporin being developed by Forest Laboratories and AstraZeneca, ceftaroline “has a similar spectrum of activity as ceftriaxone, but it adds additional coverage against resistant gram-positive [organisms] that cause pneumonia in increasing frequency,” Dr. Paul Eckburg said in an interview during a poster session at the annual meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy.

The researchers enrolled 1,228 hospitalized patients with community-acquired pneumonia who required IV therapy; 614 received ceftaroline 600 mg every 12 hours and 614 received ceftriaxone (Rocephin) 1 gram every 24 hours. Each group was treated for 5–7 days. The mean age of patients was 61 years and 63% were male, Dr. Eckburg and his associates reported.

The primary objective of the two clinical trials was to determine noninferiority in the clinical cure rate with ceftaroline, compared with ceftriaxone (Rocephin) at 8–15 days after therapy. Of the 1,228 patients in the two trials, 908 met clinically evaluable criteria; they had clinical cure rates of 84.3% with ceftaroline and 77.7% with ceftriaxone.

“What surprised us was that the clinical cure rates were much higher in the ceftaroline arm than what we expected,” commented Dr. Eckburg, director of anti-infective development at Cerexa Inc., the wholly owned anti-infectives subsidiary of Forest Laboratories Inc. “We expected to see very similar cure rates.”

Among the 1,153 patients in the modified intent-to-treat efficacy group (limited to patients with class III and IV pneumonia), the overall clinical cure rates for ceftaroline and ceftriaxone were 82.6%and 76.6%.

Both drugs were well tolerated in the trials. Diarrhea was the most common adverse event (4.2% in ceftaroline users vs. 2.6% in ceftriaxone users), followed by headache (3.4% vs. 1.5%) and insomnia (3.1% vs. 2.3%).

“The bottom line is that we now have a new drug that shows similar efficacy to an older drug, ceftriaxone, but it offers additional coverage against emerging resistant pathogens,” Dr. Eckburg said.

The study was supported by Forest Laboratories.

SAN FRANCISCO — Ceftaroline demonstrated a higher clinical cure rate, compared with ceftriaxone in patients hospitalized with community-acquired pneumonia, according to combined results from two phase III studies.

A parenteral, broad-spectrum cephalosporin being developed by Forest Laboratories and AstraZeneca, ceftaroline “has a similar spectrum of activity as ceftriaxone, but it adds additional coverage against resistant gram-positive [organisms] that cause pneumonia in increasing frequency,” Dr. Paul Eckburg said in an interview during a poster session at the annual meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy.

The researchers enrolled 1,228 hospitalized patients with community-acquired pneumonia who required IV therapy; 614 received ceftaroline 600 mg every 12 hours and 614 received ceftriaxone (Rocephin) 1 gram every 24 hours. Each group was treated for 5–7 days. The mean age of patients was 61 years and 63% were male, Dr. Eckburg and his associates reported.

The primary objective of the two clinical trials was to determine noninferiority in the clinical cure rate with ceftaroline, compared with ceftriaxone (Rocephin) at 8–15 days after therapy. Of the 1,228 patients in the two trials, 908 met clinically evaluable criteria; they had clinical cure rates of 84.3% with ceftaroline and 77.7% with ceftriaxone.

“What surprised us was that the clinical cure rates were much higher in the ceftaroline arm than what we expected,” commented Dr. Eckburg, director of anti-infective development at Cerexa Inc., the wholly owned anti-infectives subsidiary of Forest Laboratories Inc. “We expected to see very similar cure rates.”

Among the 1,153 patients in the modified intent-to-treat efficacy group (limited to patients with class III and IV pneumonia), the overall clinical cure rates for ceftaroline and ceftriaxone were 82.6%and 76.6%.

Both drugs were well tolerated in the trials. Diarrhea was the most common adverse event (4.2% in ceftaroline users vs. 2.6% in ceftriaxone users), followed by headache (3.4% vs. 1.5%) and insomnia (3.1% vs. 2.3%).

“The bottom line is that we now have a new drug that shows similar efficacy to an older drug, ceftriaxone, but it offers additional coverage against emerging resistant pathogens,” Dr. Eckburg said.

The study was supported by Forest Laboratories.

Five years ago, Dr. Eva Briggs became a search and rescue volunteer in Tompkins County, N.Y., a hilly region in the central part of the state marked by gorges, farmland, and a population of more than 101,000.

Dr. Briggs subsequently acquired Boomer, a border collie puppy, to train for search and rescue work. Now almost 3 years old, Boomer has not participated in formal search and rescue operations, but he did earn certification in wilderness air scent from the International Police Working Dog Association in October 2009.

“I've always liked being outdoors, plus I've always liked dogs, so once my kids started getting older, I thought, 'This might be an interesting thing to try,'” said Dr. Briggs, a family physician who lives in Marcellus, N.Y., and has a master's degree in environmental forestry from the State University of New York College of Environmental Science and Forestry in Syracuse.

“In an actual search, the canine team would be assigned a specific area, say 40 acres,” said Dr. Briggs, who works at two urgent care centers operated by Cayuga Medical Center in nearby Ithaca, N.Y. “The dog will find any person whose scent he detects. When the dog finds the subject, he comes back to me and gives his trained indication, which in the case of my dog is a bark, and then he leads me back to the subject.”

Boomer may be relatively new to search and rescue, but Dr. Briggs has long been acquainted. She began her volunteer post armed with the know-how of map reading and compass navigation, thanks to her graduate work in environmental science and forestry and her love of the outdoors.

As one of about 15 volunteers for Tompkins County search and rescue, Dr. Briggs has participated in several searches as a “ground pounder,” a person who combs through terrain searching for people who are lost or injured.

In addition to assisting on the ground, her commitment as a search and rescue volunteer involves attending monthly training sessions and business meetings. She is a member of the committee that plans and carries out the training sessions. “We also do public relations and teaching and interacting with the public, which can be really nice,” she said. “I've even written some book reviews for the National Search Dog Alliance.”

As for working with Boomer, “I probably do something training-wise every day, and something specific to search and rescue 2–3 times a week. It makes me go outdoors no matter what the weather is,” Dr. Briggs said.

Dr. Eva Briggs is training her dog Boomer to help in search and rescue.

Source Courtesy Rob Howard

Five years ago, Dr. Eva Briggs became a search and rescue volunteer in Tompkins County, N.Y., a hilly region in the central part of the state marked by gorges, farmland, and a population of more than 101,000.

Dr. Briggs subsequently acquired Boomer, a border collie puppy, to train for search and rescue work. Now almost 3 years old, Boomer has not participated in formal search and rescue operations, but he did earn certification in wilderness air scent from the International Police Working Dog Association in October 2009.

“I've always liked being outdoors, plus I've always liked dogs, so once my kids started getting older, I thought, 'This might be an interesting thing to try,'” said Dr. Briggs, a family physician who lives in Marcellus, N.Y., and has a master's degree in environmental forestry from the State University of New York College of Environmental Science and Forestry in Syracuse.

“In an actual search, the canine team would be assigned a specific area, say 40 acres,” said Dr. Briggs, who works at two urgent care centers operated by Cayuga Medical Center in nearby Ithaca, N.Y. “The dog will find any person whose scent he detects. When the dog finds the subject, he comes back to me and gives his trained indication, which in the case of my dog is a bark, and then he leads me back to the subject.”

Boomer may be relatively new to search and rescue, but Dr. Briggs has long been acquainted. She began her volunteer post armed with the know-how of map reading and compass navigation, thanks to her graduate work in environmental science and forestry and her love of the outdoors.

As one of about 15 volunteers for Tompkins County search and rescue, Dr. Briggs has participated in several searches as a “ground pounder,” a person who combs through terrain searching for people who are lost or injured.

In addition to assisting on the ground, her commitment as a search and rescue volunteer involves attending monthly training sessions and business meetings. She is a member of the committee that plans and carries out the training sessions. “We also do public relations and teaching and interacting with the public, which can be really nice,” she said. “I've even written some book reviews for the National Search Dog Alliance.”

As for working with Boomer, “I probably do something training-wise every day, and something specific to search and rescue 2–3 times a week. It makes me go outdoors no matter what the weather is,” Dr. Briggs said.

Dr. Eva Briggs is training her dog Boomer to help in search and rescue.

Source Courtesy Rob Howard

Five years ago, Dr. Eva Briggs became a search and rescue volunteer in Tompkins County, N.Y., a hilly region in the central part of the state marked by gorges, farmland, and a population of more than 101,000.

Dr. Briggs subsequently acquired Boomer, a border collie puppy, to train for search and rescue work. Now almost 3 years old, Boomer has not participated in formal search and rescue operations, but he did earn certification in wilderness air scent from the International Police Working Dog Association in October 2009.

“I've always liked being outdoors, plus I've always liked dogs, so once my kids started getting older, I thought, 'This might be an interesting thing to try,'” said Dr. Briggs, a family physician who lives in Marcellus, N.Y., and has a master's degree in environmental forestry from the State University of New York College of Environmental Science and Forestry in Syracuse.

“In an actual search, the canine team would be assigned a specific area, say 40 acres,” said Dr. Briggs, who works at two urgent care centers operated by Cayuga Medical Center in nearby Ithaca, N.Y. “The dog will find any person whose scent he detects. When the dog finds the subject, he comes back to me and gives his trained indication, which in the case of my dog is a bark, and then he leads me back to the subject.”

Boomer may be relatively new to search and rescue, but Dr. Briggs has long been acquainted. She began her volunteer post armed with the know-how of map reading and compass navigation, thanks to her graduate work in environmental science and forestry and her love of the outdoors.

As one of about 15 volunteers for Tompkins County search and rescue, Dr. Briggs has participated in several searches as a “ground pounder,” a person who combs through terrain searching for people who are lost or injured.

In addition to assisting on the ground, her commitment as a search and rescue volunteer involves attending monthly training sessions and business meetings. She is a member of the committee that plans and carries out the training sessions. “We also do public relations and teaching and interacting with the public, which can be really nice,” she said. “I've even written some book reviews for the National Search Dog Alliance.”

As for working with Boomer, “I probably do something training-wise every day, and something specific to search and rescue 2–3 times a week. It makes me go outdoors no matter what the weather is,” Dr. Briggs said.

Dr. Eva Briggs is training her dog Boomer to help in search and rescue.

Source Courtesy Rob Howard

Dr. Charlotte Cowan was practicing at Boston's MassGeneral Hospital for Children in 2000 when she approached the chairman of pediatrics about her aspiration to write stories for sick children in an illustrated picture book format.

On the spot, he offered her a sabbatical to pursue her goal.

“That was a real gift,” recalled Dr. Cowan, a pediatrician who majored in English as an undergraduate at Princeton (N.J.) University.

The next year she left her pediatric practice to write and publish full-color picture books intended for readers aged 2-7 years. Collectively known as the Dr. Hippo series, her first five books address acute infectious illnesses and are written with the mission of entertaining, educating, and comforting both parents and children (www.drhippo.com).

The notion of writing children's books first came during her residency training. One night, several children under 4 years of age came into the emergency department with acute asthmatic exacerbations. “They needed nebulizers and were frightened by the mask,” Dr. Cowan said. “I remember thinking 'there must be a better way to do this.'”

Each book in the Dr. Hippo series has a child-friendly plot, follows an illness from first symptom through resolution, and contains information and reassurance for the sick child.

The first book of the series, “The Little Elephant With the Big Earache” (Concord, Mass.: Hippocratic Press, 2004), recounts the story of Eddie, a young elephant who awakens in the middle of the night with an earache after an afternoon of playing with his cousins who are visiting for his upcoming birthday party. The next morning, Eddie's mom takes him to see Dr. Hippocrates, a friendly hippopotamus drawn from Dr. Cowan's own experience as a pediatrician and mother of three. Dr. Hippo takes a wait and see approach without prescribing antibiotics for Eddie's mild case of otitis media, and Eddie recovers in time to enjoy his birthday party.

Dr. Cowan, who resides in eastern Massachusetts, said that she has not taken formal courses in writing short stories, “but I have read a great many of them. The need to create characters, develop a plot, and convey medical education in 900 words or less was extremely challenging.”

The next book planned for the series is about obesity, the first in a number of titles that will address chronic illnesses.

Ten states have used the “The Little Elephant With the Big Earache” in antibiotic awareness outreach campaigns, and the Centers for Disease Control and Prevention invited the Hippocratic Press to be part of its 2009 “Get Smart About Antibiotics” campaign.

Each book in the series helps reassure sick children by following an illness.

Source Courtesy Dr. Charlotte Cowan

'The need to create characters, develop a plot, and convey' information in 900 words or less was challenging.

Source DR. COWAN

Dr. Charlotte Cowan was practicing at Boston's MassGeneral Hospital for Children in 2000 when she approached the chairman of pediatrics about her aspiration to write stories for sick children in an illustrated picture book format.

On the spot, he offered her a sabbatical to pursue her goal.

“That was a real gift,” recalled Dr. Cowan, a pediatrician who majored in English as an undergraduate at Princeton (N.J.) University.

The next year she left her pediatric practice to write and publish full-color picture books intended for readers aged 2-7 years. Collectively known as the Dr. Hippo series, her first five books address acute infectious illnesses and are written with the mission of entertaining, educating, and comforting both parents and children (www.drhippo.com).

The notion of writing children's books first came during her residency training. One night, several children under 4 years of age came into the emergency department with acute asthmatic exacerbations. “They needed nebulizers and were frightened by the mask,” Dr. Cowan said. “I remember thinking 'there must be a better way to do this.'”

Each book in the Dr. Hippo series has a child-friendly plot, follows an illness from first symptom through resolution, and contains information and reassurance for the sick child.

The first book of the series, “The Little Elephant With the Big Earache” (Concord, Mass.: Hippocratic Press, 2004), recounts the story of Eddie, a young elephant who awakens in the middle of the night with an earache after an afternoon of playing with his cousins who are visiting for his upcoming birthday party. The next morning, Eddie's mom takes him to see Dr. Hippocrates, a friendly hippopotamus drawn from Dr. Cowan's own experience as a pediatrician and mother of three. Dr. Hippo takes a wait and see approach without prescribing antibiotics for Eddie's mild case of otitis media, and Eddie recovers in time to enjoy his birthday party.

Dr. Cowan, who resides in eastern Massachusetts, said that she has not taken formal courses in writing short stories, “but I have read a great many of them. The need to create characters, develop a plot, and convey medical education in 900 words or less was extremely challenging.”

The next book planned for the series is about obesity, the first in a number of titles that will address chronic illnesses.

Ten states have used the “The Little Elephant With the Big Earache” in antibiotic awareness outreach campaigns, and the Centers for Disease Control and Prevention invited the Hippocratic Press to be part of its 2009 “Get Smart About Antibiotics” campaign.

Each book in the series helps reassure sick children by following an illness.

Source Courtesy Dr. Charlotte Cowan

'The need to create characters, develop a plot, and convey' information in 900 words or less was challenging.

Source DR. COWAN

Dr. Charlotte Cowan was practicing at Boston's MassGeneral Hospital for Children in 2000 when she approached the chairman of pediatrics about her aspiration to write stories for sick children in an illustrated picture book format.

On the spot, he offered her a sabbatical to pursue her goal.

“That was a real gift,” recalled Dr. Cowan, a pediatrician who majored in English as an undergraduate at Princeton (N.J.) University.

The next year she left her pediatric practice to write and publish full-color picture books intended for readers aged 2-7 years. Collectively known as the Dr. Hippo series, her first five books address acute infectious illnesses and are written with the mission of entertaining, educating, and comforting both parents and children (www.drhippo.com).

The notion of writing children's books first came during her residency training. One night, several children under 4 years of age came into the emergency department with acute asthmatic exacerbations. “They needed nebulizers and were frightened by the mask,” Dr. Cowan said. “I remember thinking 'there must be a better way to do this.'”

Each book in the Dr. Hippo series has a child-friendly plot, follows an illness from first symptom through resolution, and contains information and reassurance for the sick child.

The first book of the series, “The Little Elephant With the Big Earache” (Concord, Mass.: Hippocratic Press, 2004), recounts the story of Eddie, a young elephant who awakens in the middle of the night with an earache after an afternoon of playing with his cousins who are visiting for his upcoming birthday party. The next morning, Eddie's mom takes him to see Dr. Hippocrates, a friendly hippopotamus drawn from Dr. Cowan's own experience as a pediatrician and mother of three. Dr. Hippo takes a wait and see approach without prescribing antibiotics for Eddie's mild case of otitis media, and Eddie recovers in time to enjoy his birthday party.

Dr. Cowan, who resides in eastern Massachusetts, said that she has not taken formal courses in writing short stories, “but I have read a great many of them. The need to create characters, develop a plot, and convey medical education in 900 words or less was extremely challenging.”

The next book planned for the series is about obesity, the first in a number of titles that will address chronic illnesses.

Ten states have used the “The Little Elephant With the Big Earache” in antibiotic awareness outreach campaigns, and the Centers for Disease Control and Prevention invited the Hippocratic Press to be part of its 2009 “Get Smart About Antibiotics” campaign.

Each book in the series helps reassure sick children by following an illness.

Source Courtesy Dr. Charlotte Cowan

'The need to create characters, develop a plot, and convey' information in 900 words or less was challenging.

Source DR. COWAN

SAN DIEGO — Adult patients with type 2 diabetes and severe vitamin D deficiency face a twofold increased risk of all-cause mortality, independent of urinary albumin excretion rate and conventional cardiovascular risk factors, results from a long-term observational study showed.

”A lot of people have insufficient levels of vitamin D without even knowing it,” Dr. Christel Joergensen, lead author, said in an interview during a poster session at the annual meeting of the American Society of Nephrology.

Dr. Joergensen of the Steno Diabetes Center, Gentofte, Denmark, and her associates followed 290 white patients with type 2 diabetes for a median of 15.5 years.

They defined severe vitamin D deficiency as the lower 10th percentile (below 13.9 nmol/L, corresponding to 34.7 ng/mL).

At baseline, patients' mean age was 54 years, 173 were normoalbuminuric, 73 had microalbuminuria, and 44 had macroalbuminuria. The median vitamin D level was 35.7 nmol/L.

During follow-up, 142 patients (49%) died. Of these, 102 (73%) died from cardiovascular causes. All-cause mortality was significantly increased in patients with severe vitamin D deficiency, an association that persisted after adjustment for urinary albumin excretion rate, glomerular filtration rate, hemoglobin A_1c, and conventional cardiovascular risk factors.

Severe vitamin D deficiency was also significantly associated with cardiovascular mortality.

Dr. Joergensen cited the small number of patients as a study limitation. She had no financial conflicts to disclose.

SAN DIEGO — Adult patients with type 2 diabetes and severe vitamin D deficiency face a twofold increased risk of all-cause mortality, independent of urinary albumin excretion rate and conventional cardiovascular risk factors, results from a long-term observational study showed.

”A lot of people have insufficient levels of vitamin D without even knowing it,” Dr. Christel Joergensen, lead author, said in an interview during a poster session at the annual meeting of the American Society of Nephrology.

Dr. Joergensen of the Steno Diabetes Center, Gentofte, Denmark, and her associates followed 290 white patients with type 2 diabetes for a median of 15.5 years.

They defined severe vitamin D deficiency as the lower 10th percentile (below 13.9 nmol/L, corresponding to 34.7 ng/mL).

At baseline, patients' mean age was 54 years, 173 were normoalbuminuric, 73 had microalbuminuria, and 44 had macroalbuminuria. The median vitamin D level was 35.7 nmol/L.

During follow-up, 142 patients (49%) died. Of these, 102 (73%) died from cardiovascular causes. All-cause mortality was significantly increased in patients with severe vitamin D deficiency, an association that persisted after adjustment for urinary albumin excretion rate, glomerular filtration rate, hemoglobin A_1c, and conventional cardiovascular risk factors.

Severe vitamin D deficiency was also significantly associated with cardiovascular mortality.

Dr. Joergensen cited the small number of patients as a study limitation. She had no financial conflicts to disclose.

SAN DIEGO — Adult patients with type 2 diabetes and severe vitamin D deficiency face a twofold increased risk of all-cause mortality, independent of urinary albumin excretion rate and conventional cardiovascular risk factors, results from a long-term observational study showed.

”A lot of people have insufficient levels of vitamin D without even knowing it,” Dr. Christel Joergensen, lead author, said in an interview during a poster session at the annual meeting of the American Society of Nephrology.

Dr. Joergensen of the Steno Diabetes Center, Gentofte, Denmark, and her associates followed 290 white patients with type 2 diabetes for a median of 15.5 years.

They defined severe vitamin D deficiency as the lower 10th percentile (below 13.9 nmol/L, corresponding to 34.7 ng/mL).

At baseline, patients' mean age was 54 years, 173 were normoalbuminuric, 73 had microalbuminuria, and 44 had macroalbuminuria. The median vitamin D level was 35.7 nmol/L.

During follow-up, 142 patients (49%) died. Of these, 102 (73%) died from cardiovascular causes. All-cause mortality was significantly increased in patients with severe vitamin D deficiency, an association that persisted after adjustment for urinary albumin excretion rate, glomerular filtration rate, hemoglobin A_1c, and conventional cardiovascular risk factors.

Severe vitamin D deficiency was also significantly associated with cardiovascular mortality.

Dr. Joergensen cited the small number of patients as a study limitation. She had no financial conflicts to disclose.

SAN DIEGO — Patients with diabetic nephropathy have a slightly lower mean level of hemoglobin in the year leading up to the start of renal dialysis, compared with patients who have nondiabetic renal disease, results of a large analysis showed.

The difference persisted after adjustment for several other variables including age, gender, ethnicity, and estimated glomerular filtration rate, Dr. Daniel Ford said in an interview during a poster session at the annual meeting of the American Society of Nephrology.

“This reiterates what we know about patients with diabetic nephropathy—that they do have a tendency to have more anemia than patients with nondiabetic renal diseases,” said Dr. Ford, of the United Kingdom Renal Registry, Bristol, England. “I suspect it's because patients with diabetic nephropathy have a higher incidence of concurrent diseases, which would make it more likely that they would suffer with more anemia than patients without diabetic renal diseases.”

In what he said is the largest multicenter study of its kind in the United Kingdom, Dr. Ford and his associates evaluated the electronic medical records of 1,823 patients from the U.K. Renal Registry who underwent renal dialysis at seven centers between 2001 and 2006. They extracted data at time points 0, 1, 2, 3, 4, 5, 6, and 12 months prior to the commencement of dialysis and used a quadratic multilevel model to estimate the average pattern of decline in hemoglobin over that period.

The median age of patients was 66 years. Patients with diabetic nephropathy had slightly lower mean hemoglobin levels prior to undergoing dialysis, compared with those who had nondiabetic renal disease (10.8 vs. 11.0 g/dL, respectively). “It's a small but statistically significant difference,” Dr. Ford said. After adjustment for age, gender, ethnicity, and eGFR, “this significant difference remained.”

He acknowledged certain limitations of the study, including its observational design and the fact that the data came directly from renal information technology systems, “so we have to rely on the accuracy of what's being sent.”

Dr. Ford reported that he had no relevant financial conflicts to disclose.

This reiterates that diabetic nephropathy patients tend to have more anemia than nondiabetic renal patients.

Source DR. FORD

SAN DIEGO — Patients with diabetic nephropathy have a slightly lower mean level of hemoglobin in the year leading up to the start of renal dialysis, compared with patients who have nondiabetic renal disease, results of a large analysis showed.

The difference persisted after adjustment for several other variables including age, gender, ethnicity, and estimated glomerular filtration rate, Dr. Daniel Ford said in an interview during a poster session at the annual meeting of the American Society of Nephrology.

“This reiterates what we know about patients with diabetic nephropathy—that they do have a tendency to have more anemia than patients with nondiabetic renal diseases,” said Dr. Ford, of the United Kingdom Renal Registry, Bristol, England. “I suspect it's because patients with diabetic nephropathy have a higher incidence of concurrent diseases, which would make it more likely that they would suffer with more anemia than patients without diabetic renal diseases.”

In what he said is the largest multicenter study of its kind in the United Kingdom, Dr. Ford and his associates evaluated the electronic medical records of 1,823 patients from the U.K. Renal Registry who underwent renal dialysis at seven centers between 2001 and 2006. They extracted data at time points 0, 1, 2, 3, 4, 5, 6, and 12 months prior to the commencement of dialysis and used a quadratic multilevel model to estimate the average pattern of decline in hemoglobin over that period.

The median age of patients was 66 years. Patients with diabetic nephropathy had slightly lower mean hemoglobin levels prior to undergoing dialysis, compared with those who had nondiabetic renal disease (10.8 vs. 11.0 g/dL, respectively). “It's a small but statistically significant difference,” Dr. Ford said. After adjustment for age, gender, ethnicity, and eGFR, “this significant difference remained.”

He acknowledged certain limitations of the study, including its observational design and the fact that the data came directly from renal information technology systems, “so we have to rely on the accuracy of what's being sent.”

Dr. Ford reported that he had no relevant financial conflicts to disclose.

This reiterates that diabetic nephropathy patients tend to have more anemia than nondiabetic renal patients.

Source DR. FORD

SAN DIEGO — Patients with diabetic nephropathy have a slightly lower mean level of hemoglobin in the year leading up to the start of renal dialysis, compared with patients who have nondiabetic renal disease, results of a large analysis showed.

The difference persisted after adjustment for several other variables including age, gender, ethnicity, and estimated glomerular filtration rate, Dr. Daniel Ford said in an interview during a poster session at the annual meeting of the American Society of Nephrology.

“This reiterates what we know about patients with diabetic nephropathy—that they do have a tendency to have more anemia than patients with nondiabetic renal diseases,” said Dr. Ford, of the United Kingdom Renal Registry, Bristol, England. “I suspect it's because patients with diabetic nephropathy have a higher incidence of concurrent diseases, which would make it more likely that they would suffer with more anemia than patients without diabetic renal diseases.”

In what he said is the largest multicenter study of its kind in the United Kingdom, Dr. Ford and his associates evaluated the electronic medical records of 1,823 patients from the U.K. Renal Registry who underwent renal dialysis at seven centers between 2001 and 2006. They extracted data at time points 0, 1, 2, 3, 4, 5, 6, and 12 months prior to the commencement of dialysis and used a quadratic multilevel model to estimate the average pattern of decline in hemoglobin over that period.

The median age of patients was 66 years. Patients with diabetic nephropathy had slightly lower mean hemoglobin levels prior to undergoing dialysis, compared with those who had nondiabetic renal disease (10.8 vs. 11.0 g/dL, respectively). “It's a small but statistically significant difference,” Dr. Ford said. After adjustment for age, gender, ethnicity, and eGFR, “this significant difference remained.”

He acknowledged certain limitations of the study, including its observational design and the fact that the data came directly from renal information technology systems, “so we have to rely on the accuracy of what's being sent.”

Dr. Ford reported that he had no relevant financial conflicts to disclose.

This reiterates that diabetic nephropathy patients tend to have more anemia than nondiabetic renal patients.

Source DR. FORD

SAN DIEGO — Olmesartan reduced the risk of microalbuminuria by 23% in normoalbuminuric patients with type 2 diabetes and at least one additional cardiovascular disease risk factor, results from a large European trial showed.

The angiotensin receptor blocker (ARB) also yielded unprecedented blood pressure control for this population.

Those are the first key findings from the Randomized Olmesartan and Diabetes Microalbuminuria Prevention (ROADMAP) study, presented at the annual meeting of the American Society of Nephrology.

“Despite all of our efforts, we still have problems effectively treating diabetic nephropathy,” said the study's steering committee chair, Dr. Hermann G. Haller of the department of nephrology at Hannover (Germany) Medical School. “The problem for prevention is that we have to diagnose and treat it early. Microalbuminuria is the first sign of the pathogenesis of diabetic nephropathy. It is also an important marker of early development of cardiovascular disease and can indicate microvascular disease.”

The primary end point of the study was occurrence of microalbuminuria based on two or more positive morning spot urine measurements. Secondary end points were cardiovascular events, renal function, and microvascular morbidity.

With support from Daiichi Sankyo, which markets olmesartan, researchers in 19 countries enrolled 4,449 patients aged 18-75 years with well-controlled type 2 diabetes. All patients were normoalbuminuric (a level of 25 mg/g or less for men, 35 mg/g or less for women) and had at least one additional cardiovascular risk factor such as high triglyceride levels or hypertension. None of the participants had received an ACE inhibitor or an ARB within 6 months of participation.

The patients were randomized to olmesartan 40 mg/day or placebo. The urine albumin creatinine ratio was determined every 6 months. Patients were followed for an average of 3.2 years.

At their discretion, study investigators could add calcium channel blockers, diuretics, or beta-blockers to the regimen to help patients achieve the target blood pressure goal of 130/80 mm Hg.

The patients' mean age was 58 years, mean duration of diabetes was 6 years, mean hemoglobin A_1c level was 7.6%, and mean body mass index was 31 kg/m

Dr. Haller reported that nearly 80% of patients in the olmesartan group reached the target BP of 130/80 mm Hg at 42 months, compared with 75% of patients in the placebo group. “The percentage of patients reaching the blood pressure goal was very high,” he said.

Over the study period, microalbuminuria occurred in 8% of the patients in the olmesartan group and 10% of the patients on placebo, a statistically significant difference. This translated into a risk reduction of 23% for the olmesartan group, compared with the placebo group.

After 1 year, the first incidence of microalbuminuria occurred in 3% of patients in both groups. For the remainder of the study, fewer patients in the olmesartan group experienced microalbuminuria, compared with the placebo group. “The divergence after 1 year indicates that the specific effects of olmesartan are not due to early hemodynamic changes that would have happened in the first couple of months,” Dr. Haller said in an interview. “We think that olmesartan has a specific, perhaps structural effect on the kidney, either in the glomeruli or in the basal membrane, in the microcirculation.”

When the researchers assessed the BP effect in the olmesartan group corrected for diastolic and systolic BP, the risk reductions did not reach statistical significance (18% vs. 17%, respectively).

No adverse events from olmesartan were observed on renal outcomes, and the incidence of cardiovascular morbidity and mortality affected fewer than 1% of the entire study population. “Most likely the event rate is very low because of the excellent blood pressure control,” Dr. Haller said.

Some cardiovascular events such as a higher incidence of nonfatal stroke and sudden cardiac death were seen in the olmesartan group, compared with the placebo group, but due to the small number of cases, “we have to analyze this further,” Dr. Haller emphasized. An observational follow-up study is underway to further understand the long-term benefits of microalbuminuria prevention.

Dr. Haller is a paid consultant for Daiichi Sankyo and several other pharmaceutical companies, and has received honoraria from various drug companies.

Microalbuminuria is an important marker of diabetic nephropathy, which must be diagnosed and treated early.

Source DR. HALLER

SAN DIEGO — Olmesartan reduced the risk of microalbuminuria by 23% in normoalbuminuric patients with type 2 diabetes and at least one additional cardiovascular disease risk factor, results from a large European trial showed.

The angiotensin receptor blocker (ARB) also yielded unprecedented blood pressure control for this population.

Those are the first key findings from the Randomized Olmesartan and Diabetes Microalbuminuria Prevention (ROADMAP) study, presented at the annual meeting of the American Society of Nephrology.

“Despite all of our efforts, we still have problems effectively treating diabetic nephropathy,” said the study's steering committee chair, Dr. Hermann G. Haller of the department of nephrology at Hannover (Germany) Medical School. “The problem for prevention is that we have to diagnose and treat it early. Microalbuminuria is the first sign of the pathogenesis of diabetic nephropathy. It is also an important marker of early development of cardiovascular disease and can indicate microvascular disease.”

The primary end point of the study was occurrence of microalbuminuria based on two or more positive morning spot urine measurements. Secondary end points were cardiovascular events, renal function, and microvascular morbidity.

With support from Daiichi Sankyo, which markets olmesartan, researchers in 19 countries enrolled 4,449 patients aged 18-75 years with well-controlled type 2 diabetes. All patients were normoalbuminuric (a level of 25 mg/g or less for men, 35 mg/g or less for women) and had at least one additional cardiovascular risk factor such as high triglyceride levels or hypertension. None of the participants had received an ACE inhibitor or an ARB within 6 months of participation.

The patients were randomized to olmesartan 40 mg/day or placebo. The urine albumin creatinine ratio was determined every 6 months. Patients were followed for an average of 3.2 years.

At their discretion, study investigators could add calcium channel blockers, diuretics, or beta-blockers to the regimen to help patients achieve the target blood pressure goal of 130/80 mm Hg.

The patients' mean age was 58 years, mean duration of diabetes was 6 years, mean hemoglobin A_1c level was 7.6%, and mean body mass index was 31 kg/m

Dr. Haller reported that nearly 80% of patients in the olmesartan group reached the target BP of 130/80 mm Hg at 42 months, compared with 75% of patients in the placebo group. “The percentage of patients reaching the blood pressure goal was very high,” he said.

Over the study period, microalbuminuria occurred in 8% of the patients in the olmesartan group and 10% of the patients on placebo, a statistically significant difference. This translated into a risk reduction of 23% for the olmesartan group, compared with the placebo group.

After 1 year, the first incidence of microalbuminuria occurred in 3% of patients in both groups. For the remainder of the study, fewer patients in the olmesartan group experienced microalbuminuria, compared with the placebo group. “The divergence after 1 year indicates that the specific effects of olmesartan are not due to early hemodynamic changes that would have happened in the first couple of months,” Dr. Haller said in an interview. “We think that olmesartan has a specific, perhaps structural effect on the kidney, either in the glomeruli or in the basal membrane, in the microcirculation.”

When the researchers assessed the BP effect in the olmesartan group corrected for diastolic and systolic BP, the risk reductions did not reach statistical significance (18% vs. 17%, respectively).

No adverse events from olmesartan were observed on renal outcomes, and the incidence of cardiovascular morbidity and mortality affected fewer than 1% of the entire study population. “Most likely the event rate is very low because of the excellent blood pressure control,” Dr. Haller said.

Some cardiovascular events such as a higher incidence of nonfatal stroke and sudden cardiac death were seen in the olmesartan group, compared with the placebo group, but due to the small number of cases, “we have to analyze this further,” Dr. Haller emphasized. An observational follow-up study is underway to further understand the long-term benefits of microalbuminuria prevention.

Dr. Haller is a paid consultant for Daiichi Sankyo and several other pharmaceutical companies, and has received honoraria from various drug companies.

Microalbuminuria is an important marker of diabetic nephropathy, which must be diagnosed and treated early.

Source DR. HALLER

SAN DIEGO — Olmesartan reduced the risk of microalbuminuria by 23% in normoalbuminuric patients with type 2 diabetes and at least one additional cardiovascular disease risk factor, results from a large European trial showed.

The angiotensin receptor blocker (ARB) also yielded unprecedented blood pressure control for this population.

Those are the first key findings from the Randomized Olmesartan and Diabetes Microalbuminuria Prevention (ROADMAP) study, presented at the annual meeting of the American Society of Nephrology.

“Despite all of our efforts, we still have problems effectively treating diabetic nephropathy,” said the study's steering committee chair, Dr. Hermann G. Haller of the department of nephrology at Hannover (Germany) Medical School. “The problem for prevention is that we have to diagnose and treat it early. Microalbuminuria is the first sign of the pathogenesis of diabetic nephropathy. It is also an important marker of early development of cardiovascular disease and can indicate microvascular disease.”

The primary end point of the study was occurrence of microalbuminuria based on two or more positive morning spot urine measurements. Secondary end points were cardiovascular events, renal function, and microvascular morbidity.

With support from Daiichi Sankyo, which markets olmesartan, researchers in 19 countries enrolled 4,449 patients aged 18-75 years with well-controlled type 2 diabetes. All patients were normoalbuminuric (a level of 25 mg/g or less for men, 35 mg/g or less for women) and had at least one additional cardiovascular risk factor such as high triglyceride levels or hypertension. None of the participants had received an ACE inhibitor or an ARB within 6 months of participation.

The patients were randomized to olmesartan 40 mg/day or placebo. The urine albumin creatinine ratio was determined every 6 months. Patients were followed for an average of 3.2 years.

At their discretion, study investigators could add calcium channel blockers, diuretics, or beta-blockers to the regimen to help patients achieve the target blood pressure goal of 130/80 mm Hg.

The patients' mean age was 58 years, mean duration of diabetes was 6 years, mean hemoglobin A_1c level was 7.6%, and mean body mass index was 31 kg/m

Dr. Haller reported that nearly 80% of patients in the olmesartan group reached the target BP of 130/80 mm Hg at 42 months, compared with 75% of patients in the placebo group. “The percentage of patients reaching the blood pressure goal was very high,” he said.

Over the study period, microalbuminuria occurred in 8% of the patients in the olmesartan group and 10% of the patients on placebo, a statistically significant difference. This translated into a risk reduction of 23% for the olmesartan group, compared with the placebo group.

After 1 year, the first incidence of microalbuminuria occurred in 3% of patients in both groups. For the remainder of the study, fewer patients in the olmesartan group experienced microalbuminuria, compared with the placebo group. “The divergence after 1 year indicates that the specific effects of olmesartan are not due to early hemodynamic changes that would have happened in the first couple of months,” Dr. Haller said in an interview. “We think that olmesartan has a specific, perhaps structural effect on the kidney, either in the glomeruli or in the basal membrane, in the microcirculation.”

When the researchers assessed the BP effect in the olmesartan group corrected for diastolic and systolic BP, the risk reductions did not reach statistical significance (18% vs. 17%, respectively).

No adverse events from olmesartan were observed on renal outcomes, and the incidence of cardiovascular morbidity and mortality affected fewer than 1% of the entire study population. “Most likely the event rate is very low because of the excellent blood pressure control,” Dr. Haller said.

Some cardiovascular events such as a higher incidence of nonfatal stroke and sudden cardiac death were seen in the olmesartan group, compared with the placebo group, but due to the small number of cases, “we have to analyze this further,” Dr. Haller emphasized. An observational follow-up study is underway to further understand the long-term benefits of microalbuminuria prevention.

Dr. Haller is a paid consultant for Daiichi Sankyo and several other pharmaceutical companies, and has received honoraria from various drug companies.

Microalbuminuria is an important marker of diabetic nephropathy, which must be diagnosed and treated early.

Source DR. HALLER

SAN DIEGO — Women who underwent bilateral oophorectomy at the time of hysterectomy reported significantly decreased levels of sexual functioning compared with women who underwent hysterectomy with ovarian conservation, results from a survey of 50 women showed.

The findings underscore the potential impact of prophylactic ovary removal on women's sexual functioning, Elizabeth Plourde, Ph.D., said in an interview during a post esession at the annual meeting of the North American Menopause Society.

“The potential for loss of ability to respond sexually is a very important consideration for women who are being advised to do prophylactic oophorectomy,” said Dr. Plourde, a psychologist in Irvine, Calif., with research interests in the biochemical and structural changes that arise from reproductive organ removal. “They're not really being apprised of the significance.”

Dr. Plourde and her associates asked 25 women who underwent hysterectomy with ovarian conservation and 25 women who underwent bilateral oophorohysterectomy to complete the Changes in Sexual Functioning Questionnaire–Female (CSFQ-F) and the Sexual Response Questionnaire–Hysterectomy (SRQ-H). The latter measure was designed for the study to compare the changes in sexual response before and after surgery. The mean age of the respondents was 49 years.

Only women with functioning ovaries, based on their responses to a survey of menopause symptoms, were retained for the hysterectomy-only group, she said.

Compared with women who underwent a hysterectomy with ovarian conservation, those who underwent bilateral oophorectomy at the time of hysterectomy had significantly lower scores in total sexual functioning and in the subscale aspects of pleasure, desire/frequency and desire/interest; the number who were orgasmic was also lower among those who had bilateral oophorectomy.

Significant interactions favoring the hysterectomy with ovarian conservation group were also detected before and after surgery in total sexual functioning scores and in the subscales of pleasure, desire/frequency, desire/interest, and orgasm/completion.

“I redid all of the calculations to make sure that they were right, because the degree of significance between the two groups surprised me,” Dr. Plourde said.

There were no statistically significant differences between the two groups of women in the rating of the importance of sex before and after surgery.

“The complexity and multifaceted nature of the human sexual response is demonstrated by the fact that not all the women who had their ovaries removed lost their interest in sex or ability to respond sexually, and not all of the women who retained their ovaries maintained their sexual functioning,” the researchers wrote in their poster. “These conflicting results indicate there are other factors that influence sexual functioning and need further research.”

Dr. Plourde acknowledged that the small sample size was a limitation of the study. She disclosed no conflicts of interest.

To see an interview with Dr. Plourde, go to www.youtube.com/user/ObGynNews#p/a/u/2/xnEfceR4lHs

The number of women who were orgasmic was lower among those who had bilateral oophorectomy.

Source DR. PLOURDE

SAN DIEGO — Women who underwent bilateral oophorectomy at the time of hysterectomy reported significantly decreased levels of sexual functioning compared with women who underwent hysterectomy with ovarian conservation, results from a survey of 50 women showed.

The findings underscore the potential impact of prophylactic ovary removal on women's sexual functioning, Elizabeth Plourde, Ph.D., said in an interview during a post esession at the annual meeting of the North American Menopause Society.

“The potential for loss of ability to respond sexually is a very important consideration for women who are being advised to do prophylactic oophorectomy,” said Dr. Plourde, a psychologist in Irvine, Calif., with research interests in the biochemical and structural changes that arise from reproductive organ removal. “They're not really being apprised of the significance.”

Dr. Plourde and her associates asked 25 women who underwent hysterectomy with ovarian conservation and 25 women who underwent bilateral oophorohysterectomy to complete the Changes in Sexual Functioning Questionnaire–Female (CSFQ-F) and the Sexual Response Questionnaire–Hysterectomy (SRQ-H). The latter measure was designed for the study to compare the changes in sexual response before and after surgery. The mean age of the respondents was 49 years.

Only women with functioning ovaries, based on their responses to a survey of menopause symptoms, were retained for the hysterectomy-only group, she said.

Compared with women who underwent a hysterectomy with ovarian conservation, those who underwent bilateral oophorectomy at the time of hysterectomy had significantly lower scores in total sexual functioning and in the subscale aspects of pleasure, desire/frequency and desire/interest; the number who were orgasmic was also lower among those who had bilateral oophorectomy.

Significant interactions favoring the hysterectomy with ovarian conservation group were also detected before and after surgery in total sexual functioning scores and in the subscales of pleasure, desire/frequency, desire/interest, and orgasm/completion.

“I redid all of the calculations to make sure that they were right, because the degree of significance between the two groups surprised me,” Dr. Plourde said.

There were no statistically significant differences between the two groups of women in the rating of the importance of sex before and after surgery.

“The complexity and multifaceted nature of the human sexual response is demonstrated by the fact that not all the women who had their ovaries removed lost their interest in sex or ability to respond sexually, and not all of the women who retained their ovaries maintained their sexual functioning,” the researchers wrote in their poster. “These conflicting results indicate there are other factors that influence sexual functioning and need further research.”

Dr. Plourde acknowledged that the small sample size was a limitation of the study. She disclosed no conflicts of interest.

To see an interview with Dr. Plourde, go to www.youtube.com/user/ObGynNews#p/a/u/2/xnEfceR4lHs

The number of women who were orgasmic was lower among those who had bilateral oophorectomy.

Source DR. PLOURDE

SAN DIEGO — Women who underwent bilateral oophorectomy at the time of hysterectomy reported significantly decreased levels of sexual functioning compared with women who underwent hysterectomy with ovarian conservation, results from a survey of 50 women showed.

The findings underscore the potential impact of prophylactic ovary removal on women's sexual functioning, Elizabeth Plourde, Ph.D., said in an interview during a post esession at the annual meeting of the North American Menopause Society.

“The potential for loss of ability to respond sexually is a very important consideration for women who are being advised to do prophylactic oophorectomy,” said Dr. Plourde, a psychologist in Irvine, Calif., with research interests in the biochemical and structural changes that arise from reproductive organ removal. “They're not really being apprised of the significance.”

Dr. Plourde and her associates asked 25 women who underwent hysterectomy with ovarian conservation and 25 women who underwent bilateral oophorohysterectomy to complete the Changes in Sexual Functioning Questionnaire–Female (CSFQ-F) and the Sexual Response Questionnaire–Hysterectomy (SRQ-H). The latter measure was designed for the study to compare the changes in sexual response before and after surgery. The mean age of the respondents was 49 years.

Only women with functioning ovaries, based on their responses to a survey of menopause symptoms, were retained for the hysterectomy-only group, she said.

Compared with women who underwent a hysterectomy with ovarian conservation, those who underwent bilateral oophorectomy at the time of hysterectomy had significantly lower scores in total sexual functioning and in the subscale aspects of pleasure, desire/frequency and desire/interest; the number who were orgasmic was also lower among those who had bilateral oophorectomy.

Significant interactions favoring the hysterectomy with ovarian conservation group were also detected before and after surgery in total sexual functioning scores and in the subscales of pleasure, desire/frequency, desire/interest, and orgasm/completion.

“I redid all of the calculations to make sure that they were right, because the degree of significance between the two groups surprised me,” Dr. Plourde said.

There were no statistically significant differences between the two groups of women in the rating of the importance of sex before and after surgery.

“The complexity and multifaceted nature of the human sexual response is demonstrated by the fact that not all the women who had their ovaries removed lost their interest in sex or ability to respond sexually, and not all of the women who retained their ovaries maintained their sexual functioning,” the researchers wrote in their poster. “These conflicting results indicate there are other factors that influence sexual functioning and need further research.”

Dr. Plourde acknowledged that the small sample size was a limitation of the study. She disclosed no conflicts of interest.

To see an interview with Dr. Plourde, go to www.youtube.com/user/ObGynNews#p/a/u/2/xnEfceR4lHs

The number of women who were orgasmic was lower among those who had bilateral oophorectomy.

Source DR. PLOURDE

SAN DIEGO — The combination of breastfeeding and delaying pregnancy until a woman has acquired the majority of her bone mass appears to have a protective effect on bones, astudy of more than 600 women found.

“Several studies have shown that people who have had many pregnancies have less bone loss than women with no pregnancies,” lead author Dr. Peter F. Schnatz said in an interview.

“Our study is the first to our knowledge looking at the effect of pregnancy during the time of peak bone mineral acquisition and its eventual and ultimate effect on the development of postmenopausal osteoporosis. Most prior adolescent pregnancy studies, for instance, are limited to the immediate postpartum period,” he said at a poster session at the annual meeting of the North American Menopause Society.

Dr. Schnatz, residency program director in the department of obstetrics and gynecology at Reading (Pa.) Hospital and Medical Center, and his associates analyzed data from 619 women over 49 years old who presented for bone density scanning at one of four radiology groups in the Hartford, Conn., area. They assessed risk factors for osteoporosis, including a previous atraumatic fracture of the hip or spine, pregnancy information, and dual-energy x-ray absorptiometry results. They defined osteoporosis as a T score of −2.5 or lower at the lumbar spine, the femoral neck, or the total femur.

The mean age of the study participants was 62 years, and 50% were either current or past smokers. Slightly more than one-quarter (27%) were using or had used a bisphosphonate, 64% were using or had used hormonal therapy, and 5% had used steroids.

Women with any breastfeeding had a significantly lower prevalence of osteoporosis (8%) than women who did not breastfeed (19%), a finding that surprised the researchers. “It would seem that breastfeeding, which requires acquisition of calcium from the mother to nourish the baby, would cause bone loss,” Dr. Schnatz said. “We wonder if there may be a rebound anabolic phenomenon, hence resulting in overall benefit.”

Within the group of women who breastfed, those who were younger than age 27 years at their first pregnancy had a significantly higher prevalence of osteoporosis, compared with those who were 27 years of age and older at their first pregnancy (11% vs. 5%), he reported.

Of the women who were at least 27 years old at first pregnancy, there was a significantly increased prevalence of osteoporosis in those who did not breastfeed, compared with those who did (25% vs. 5%).

Women who were at least 27 years old at their first pregnancy and who breastfed had a statistically lower prevalence of osteoporosis, compared with their counterparts who had their first pregnancy when they were younger than age 27 and who had no history of breastfeeding (5% vs. 16%).

Among women who did not breastfeed, there was little difference in the risk of postmenopausal osteoporosis if the first pregnancy occurred at or after age 22 or 27 years, Dr. Schnatz wrote.

“Based on the current evidence, along with these results, women should be encouraged to wait until the postadolescent years for childbearing and should be encouraged to breastfeed,” he concluded.

Dr. Schnatz acknowledged certain limitations of the study, including its retrospective design.

The study was supported by an unrestricted grant from the Alliance for Better Bone Health. Dr. Schnatz and his associates had no other financial conflicts to disclose.

Women with any breastfeeding had a lower prevalence of osteoporosis than women who did not breastfeed.

Source DR. SCHNATZ

SAN DIEGO — The combination of breastfeeding and delaying pregnancy until a woman has acquired the majority of her bone mass appears to have a protective effect on bones, astudy of more than 600 women found.

“Several studies have shown that people who have had many pregnancies have less bone loss than women with no pregnancies,” lead author Dr. Peter F. Schnatz said in an interview.

“Our study is the first to our knowledge looking at the effect of pregnancy during the time of peak bone mineral acquisition and its eventual and ultimate effect on the development of postmenopausal osteoporosis. Most prior adolescent pregnancy studies, for instance, are limited to the immediate postpartum period,” he said at a poster session at the annual meeting of the North American Menopause Society.

Dr. Schnatz, residency program director in the department of obstetrics and gynecology at Reading (Pa.) Hospital and Medical Center, and his associates analyzed data from 619 women over 49 years old who presented for bone density scanning at one of four radiology groups in the Hartford, Conn., area. They assessed risk factors for osteoporosis, including a previous atraumatic fracture of the hip or spine, pregnancy information, and dual-energy x-ray absorptiometry results. They defined osteoporosis as a T score of −2.5 or lower at the lumbar spine, the femoral neck, or the total femur.

The mean age of the study participants was 62 years, and 50% were either current or past smokers. Slightly more than one-quarter (27%) were using or had used a bisphosphonate, 64% were using or had used hormonal therapy, and 5% had used steroids.

Women with any breastfeeding had a significantly lower prevalence of osteoporosis (8%) than women who did not breastfeed (19%), a finding that surprised the researchers. “It would seem that breastfeeding, which requires acquisition of calcium from the mother to nourish the baby, would cause bone loss,” Dr. Schnatz said. “We wonder if there may be a rebound anabolic phenomenon, hence resulting in overall benefit.”

Within the group of women who breastfed, those who were younger than age 27 years at their first pregnancy had a significantly higher prevalence of osteoporosis, compared with those who were 27 years of age and older at their first pregnancy (11% vs. 5%), he reported.

Of the women who were at least 27 years old at first pregnancy, there was a significantly increased prevalence of osteoporosis in those who did not breastfeed, compared with those who did (25% vs. 5%).

Women who were at least 27 years old at their first pregnancy and who breastfed had a statistically lower prevalence of osteoporosis, compared with their counterparts who had their first pregnancy when they were younger than age 27 and who had no history of breastfeeding (5% vs. 16%).

Among women who did not breastfeed, there was little difference in the risk of postmenopausal osteoporosis if the first pregnancy occurred at or after age 22 or 27 years, Dr. Schnatz wrote.

“Based on the current evidence, along with these results, women should be encouraged to wait until the postadolescent years for childbearing and should be encouraged to breastfeed,” he concluded.

Dr. Schnatz acknowledged certain limitations of the study, including its retrospective design.

The study was supported by an unrestricted grant from the Alliance for Better Bone Health. Dr. Schnatz and his associates had no other financial conflicts to disclose.

Women with any breastfeeding had a lower prevalence of osteoporosis than women who did not breastfeed.

Source DR. SCHNATZ

SAN DIEGO — The combination of breastfeeding and delaying pregnancy until a woman has acquired the majority of her bone mass appears to have a protective effect on bones, astudy of more than 600 women found.

“Several studies have shown that people who have had many pregnancies have less bone loss than women with no pregnancies,” lead author Dr. Peter F. Schnatz said in an interview.

“Our study is the first to our knowledge looking at the effect of pregnancy during the time of peak bone mineral acquisition and its eventual and ultimate effect on the development of postmenopausal osteoporosis. Most prior adolescent pregnancy studies, for instance, are limited to the immediate postpartum period,” he said at a poster session at the annual meeting of the North American Menopause Society.

Dr. Schnatz, residency program director in the department of obstetrics and gynecology at Reading (Pa.) Hospital and Medical Center, and his associates analyzed data from 619 women over 49 years old who presented for bone density scanning at one of four radiology groups in the Hartford, Conn., area. They assessed risk factors for osteoporosis, including a previous atraumatic fracture of the hip or spine, pregnancy information, and dual-energy x-ray absorptiometry results. They defined osteoporosis as a T score of −2.5 or lower at the lumbar spine, the femoral neck, or the total femur.

The mean age of the study participants was 62 years, and 50% were either current or past smokers. Slightly more than one-quarter (27%) were using or had used a bisphosphonate, 64% were using or had used hormonal therapy, and 5% had used steroids.

Women with any breastfeeding had a significantly lower prevalence of osteoporosis (8%) than women who did not breastfeed (19%), a finding that surprised the researchers. “It would seem that breastfeeding, which requires acquisition of calcium from the mother to nourish the baby, would cause bone loss,” Dr. Schnatz said. “We wonder if there may be a rebound anabolic phenomenon, hence resulting in overall benefit.”

Within the group of women who breastfed, those who were younger than age 27 years at their first pregnancy had a significantly higher prevalence of osteoporosis, compared with those who were 27 years of age and older at their first pregnancy (11% vs. 5%), he reported.

Of the women who were at least 27 years old at first pregnancy, there was a significantly increased prevalence of osteoporosis in those who did not breastfeed, compared with those who did (25% vs. 5%).

Women who were at least 27 years old at their first pregnancy and who breastfed had a statistically lower prevalence of osteoporosis, compared with their counterparts who had their first pregnancy when they were younger than age 27 and who had no history of breastfeeding (5% vs. 16%).

Among women who did not breastfeed, there was little difference in the risk of postmenopausal osteoporosis if the first pregnancy occurred at or after age 22 or 27 years, Dr. Schnatz wrote.

“Based on the current evidence, along with these results, women should be encouraged to wait until the postadolescent years for childbearing and should be encouraged to breastfeed,” he concluded.

Dr. Schnatz acknowledged certain limitations of the study, including its retrospective design.

The study was supported by an unrestricted grant from the Alliance for Better Bone Health. Dr. Schnatz and his associates had no other financial conflicts to disclose.

Women with any breastfeeding had a lower prevalence of osteoporosis than women who did not breastfeed.

Source DR. SCHNATZ

SAN DIEGO — Although an estimated 80% of patients with systemic lupus erythematosus acquire the disease before age 50 years, beware of ruling out the potential for diagnosing new cases in older patients.

“It certainly can happen,” Dr. Bevra H. Hahn said at the annual meeting of the North American Menopause Society. “It's not rare, so it's okay to let it cross your mind.”

The clinical presentation of SLE that develops before the age of 50 differs from that of disease that occurs later in life, said Dr. Hahn, chief of rheumatology at the University of California, Los Angeles. SLE that develops before age 50 is marked by development of nephritis, anti-DNA antibodies, malar rash, and/or discoid lupus. This relatively early-onset form of SLE causes less organ damage in general. Mortality in this patient population “is primarily from active lupus or from infections that relate to being sick and having immunosuppressive therapies,” Dr. Hahn said.

SLE that develops after age 50 is marked by cardiac and pulmonary problems. “I see a lot of patients who present with heart failure or with pericarditis, or arrhythmias, and they have a strongly positive antinuclear antibody, so it's fine to screen for ANA in that situation,” she said.

Compared with their younger counterparts, patients who develop SLE after age 50 are also more likely to have arthritis, Sjögren's syndrome, and a high damage index. “Their mortality is more from coronary artery disease or stroke, some from infection, and less of it from antilupus medications,” said Dr. Hahn. “For this group, preventive care is very important for the coronary artery disease.”

Several clinical studies have demonstrated that the antimalarial drug hydroxychloroquine reduces damage over time. “In general, we think most people should be on [hydroxychloroquine] if there is not a contraindication,” she said. The major problem with the drug is its potential for associated retinal damage, which occurs only rarely, Dr. Hahn added.

Dr. Hahn's approach to treatment involves first determining whether the disease threatens life or organs. If the disease is mild, she will consider agents to lessen pain, fatigue, and rash, including NSAIDs; topical agents, such as steroids or tacrolimus; sunscreen with SPF 50; antimalarials, such as hydroxychloroquine at a dosage of 200-400 mg/day or quinacrine dosed at 100 mg/day; DHEA (dehydroepiandrosterone) dosed at 100-200 mg/day; or low-dose prednisone.

She cautioned that the use of NSAIDs “can bump creatinine levels and cause aseptic meningitis in patients with lupus. It's not common, but it happens.”

For women with severe lupus, she prescribes agents that confer a survival benefit with as few adverse effects as possible. “The three phases of treatment for severe SLE are 'induce improvement, maintain improvement, and prevent damage,'” she said. For these patients, high-dose prednisone “saves lives. It causes cataracts, osteoporosis, and diabetes, but it really is life saving.”

For patients with severe lupus, consider antimalarials and the cytotoxic agents mycophenolate mofetil, azathioprine, and cyclophosphamide. Other agents showing promise include rituximab and belimumab.

Dr. Hahn had no relevant financial disclosures to make.

SAN DIEGO — Although an estimated 80% of patients with systemic lupus erythematosus acquire the disease before age 50 years, beware of ruling out the potential for diagnosing new cases in older patients.

“It certainly can happen,” Dr. Bevra H. Hahn said at the annual meeting of the North American Menopause Society. “It's not rare, so it's okay to let it cross your mind.”

The clinical presentation of SLE that develops before the age of 50 differs from that of disease that occurs later in life, said Dr. Hahn, chief of rheumatology at the University of California, Los Angeles. SLE that develops before age 50 is marked by development of nephritis, anti-DNA antibodies, malar rash, and/or discoid lupus. This relatively early-onset form of SLE causes less organ damage in general. Mortality in this patient population “is primarily from active lupus or from infections that relate to being sick and having immunosuppressive therapies,” Dr. Hahn said.

SLE that develops after age 50 is marked by cardiac and pulmonary problems. “I see a lot of patients who present with heart failure or with pericarditis, or arrhythmias, and they have a strongly positive antinuclear antibody, so it's fine to screen for ANA in that situation,” she said.

Compared with their younger counterparts, patients who develop SLE after age 50 are also more likely to have arthritis, Sjögren's syndrome, and a high damage index. “Their mortality is more from coronary artery disease or stroke, some from infection, and less of it from antilupus medications,” said Dr. Hahn. “For this group, preventive care is very important for the coronary artery disease.”

Several clinical studies have demonstrated that the antimalarial drug hydroxychloroquine reduces damage over time. “In general, we think most people should be on [hydroxychloroquine] if there is not a contraindication,” she said. The major problem with the drug is its potential for associated retinal damage, which occurs only rarely, Dr. Hahn added.

Dr. Hahn's approach to treatment involves first determining whether the disease threatens life or organs. If the disease is mild, she will consider agents to lessen pain, fatigue, and rash, including NSAIDs; topical agents, such as steroids or tacrolimus; sunscreen with SPF 50; antimalarials, such as hydroxychloroquine at a dosage of 200-400 mg/day or quinacrine dosed at 100 mg/day; DHEA (dehydroepiandrosterone) dosed at 100-200 mg/day; or low-dose prednisone.

She cautioned that the use of NSAIDs “can bump creatinine levels and cause aseptic meningitis in patients with lupus. It's not common, but it happens.”

For women with severe lupus, she prescribes agents that confer a survival benefit with as few adverse effects as possible. “The three phases of treatment for severe SLE are 'induce improvement, maintain improvement, and prevent damage,'” she said. For these patients, high-dose prednisone “saves lives. It causes cataracts, osteoporosis, and diabetes, but it really is life saving.”

For patients with severe lupus, consider antimalarials and the cytotoxic agents mycophenolate mofetil, azathioprine, and cyclophosphamide. Other agents showing promise include rituximab and belimumab.

Dr. Hahn had no relevant financial disclosures to make.

SAN DIEGO — Although an estimated 80% of patients with systemic lupus erythematosus acquire the disease before age 50 years, beware of ruling out the potential for diagnosing new cases in older patients.

“It certainly can happen,” Dr. Bevra H. Hahn said at the annual meeting of the North American Menopause Society. “It's not rare, so it's okay to let it cross your mind.”

The clinical presentation of SLE that develops before the age of 50 differs from that of disease that occurs later in life, said Dr. Hahn, chief of rheumatology at the University of California, Los Angeles. SLE that develops before age 50 is marked by development of nephritis, anti-DNA antibodies, malar rash, and/or discoid lupus. This relatively early-onset form of SLE causes less organ damage in general. Mortality in this patient population “is primarily from active lupus or from infections that relate to being sick and having immunosuppressive therapies,” Dr. Hahn said.

SLE that develops after age 50 is marked by cardiac and pulmonary problems. “I see a lot of patients who present with heart failure or with pericarditis, or arrhythmias, and they have a strongly positive antinuclear antibody, so it's fine to screen for ANA in that situation,” she said.

Compared with their younger counterparts, patients who develop SLE after age 50 are also more likely to have arthritis, Sjögren's syndrome, and a high damage index. “Their mortality is more from coronary artery disease or stroke, some from infection, and less of it from antilupus medications,” said Dr. Hahn. “For this group, preventive care is very important for the coronary artery disease.”

Several clinical studies have demonstrated that the antimalarial drug hydroxychloroquine reduces damage over time. “In general, we think most people should be on [hydroxychloroquine] if there is not a contraindication,” she said. The major problem with the drug is its potential for associated retinal damage, which occurs only rarely, Dr. Hahn added.

Dr. Hahn's approach to treatment involves first determining whether the disease threatens life or organs. If the disease is mild, she will consider agents to lessen pain, fatigue, and rash, including NSAIDs; topical agents, such as steroids or tacrolimus; sunscreen with SPF 50; antimalarials, such as hydroxychloroquine at a dosage of 200-400 mg/day or quinacrine dosed at 100 mg/day; DHEA (dehydroepiandrosterone) dosed at 100-200 mg/day; or low-dose prednisone.

She cautioned that the use of NSAIDs “can bump creatinine levels and cause aseptic meningitis in patients with lupus. It's not common, but it happens.”

For women with severe lupus, she prescribes agents that confer a survival benefit with as few adverse effects as possible. “The three phases of treatment for severe SLE are 'induce improvement, maintain improvement, and prevent damage,'” she said. For these patients, high-dose prednisone “saves lives. It causes cataracts, osteoporosis, and diabetes, but it really is life saving.”

For patients with severe lupus, consider antimalarials and the cytotoxic agents mycophenolate mofetil, azathioprine, and cyclophosphamide. Other agents showing promise include rituximab and belimumab.

Dr. Hahn had no relevant financial disclosures to make.