Doug Brunk

The proliferation of bariatric surgery procedures performed each year in the United States has led to a burgeoning demand for body contouring, a subspecialty of plastic surgery designed to help patients improve their cosmetic appearance.

Prior to 2000, it was rare for patients who experienced massive weight loss to seek help from plastic surgeons; in fact, this patient population was almost nonexistent, according to Dr. Al Aly, a board-certified plastic surgeon who practices in Iowa City, Iowa.

Today, the demand for procedures such as abdominoplasties, upper arm lifts, and thigh lifts has never been higher. According to the American Society of Plastic Surgeons, between 1992 and 2008 the number of abdominoplasties performed grew by 593%, from 16,810 to 116,512; the number of thigh lifts grew by 731%, from 1,023 to 8,504; and the number of upper arm lifts grew an astounding 2,982%, from 434 to 13,374. Meanwhile, the number of lower body lifts––a procedure that essentially did not exist in 1992—stood at 8,647 in 2008.

Dr. J. Peter Rubin, a board-certified plastic surgeon who directs the multidisciplinary Life After Weight Loss clinical program at the University of Pittsburgh, estimates that 90% of his clinical practice involves body contouring after massive weight loss. “These are fairly complex and technically challenging procedures that are best done by surgeons who have a strong grounding in plastic surgery principles and strong training in plastic surgery,” said Dr. Rubin, coauthor of “Aesthetic Surgery After Massive Weight Loss” (Elsevier Medical Publishing, 2006).

Dr. Aly evaluates potential body-contouring candidates a minimum of 18 months after they have undergone bariatric surgery. “We tend to not want to operate on people who are aiming for specific weight levels,” said Dr. Aly, author of “Body Contouring After Massive Weight Loss” (Quality Medical Publishing, 2005). “We want to operate on people who are in a comfortable lifestyle and are not doing heroic things to reach a particular weight level. If you have access to the bariatric surgeon that the patient was referred from, that's one of your best sources. Ask them if they feel that the patient has stabilized their weight loss.”

Dr. Susan Downey, a board-certified plastic surgeon who practices in Los Angeles, addresses goals and expectations with body-contouring candidates up front. She asks them about their cosmetic priorities, how long they've been at their present weight, and whether they've had plateaus with their weight loss. In her practice, abdominoplasty usually tops the list of procedures requested, followed by breast lift/augmentation; arm lift; thigh lift; and lower body lift (belt lipectomy), a combination procedure that includes abdominoplasty, a thigh lift, and a buttock lift.

“What bothers me [from a cosmetic standpoint] may not be what bothers them,” Dr. Downey noted. “I had one patient who wanted her eyes done first because the bags under her eyes got more pronounced as her face got smaller from the weight loss. You can do two or three procedures if a patient is in good medical condition. We usually limit ourselves to about 6–8 hours of surgery.”

According to published reports, Dr. Downey said, up to 30% of patients with massive weight loss have complications after body contouring. “I would say it's up to 10% for a major complication and up to 30% for a minor complication,” she estimated. “These patients have a higher rate of hematoma formation, a higher rate of seroma, and wound-healing issues. A lot of it has to do with the fact that the skin is so overstretched at the time that you do the surgery.”

Extensive scarring after the procedures is common, “but the improvement in body contour is quite dramatic and well worth the scars,” she added.

Recovery time varies among patients, Dr. Aly said, and tends to be longer after a belt lipectomy (4–6 weeks) than after other common procedures, including an upper body lift (2–3 weeks), an upper arm lift (2–3 weeks), and a thigh lift (2–4 weeks).

Some medical insurance companies cover the panniculectomy portion of the abdominal contour, including anesthesia, but other procedures generally are not covered. “That's one of the issues with this field: The insurance companies are bound to the criteria of medical necessity,” Dr. Rubin said. “It's sometimes hard to justify true medical necessity by the standard of the insurance company for some of these body-contouring operations, despite the overwhelmingly positive impact it will have on the person's quality of life. With these economic times, I'm not sure we're going to see that getting better quickly.”

These procedures produce an immeasurable impact on patient self-perception, Dr. Aly stated, recalling that a patient with massive weight loss once told him, “[Bariatric surgery] gave me back my life. It's part of a life transformation. Plastic surgery allows me to enjoy it.”

ELSEVIER GLOBAL MEDICAL NEWS

Before and after results of an upper body lift in a male bariatric surgery patient are shown.

Source COURTESY DR. AL ALY

The proliferation of bariatric surgery procedures performed each year in the United States has led to a burgeoning demand for body contouring, a subspecialty of plastic surgery designed to help patients improve their cosmetic appearance.

Prior to 2000, it was rare for patients who experienced massive weight loss to seek help from plastic surgeons; in fact, this patient population was almost nonexistent, according to Dr. Al Aly, a board-certified plastic surgeon who practices in Iowa City, Iowa.

Today, the demand for procedures such as abdominoplasties, upper arm lifts, and thigh lifts has never been higher. According to the American Society of Plastic Surgeons, between 1992 and 2008 the number of abdominoplasties performed grew by 593%, from 16,810 to 116,512; the number of thigh lifts grew by 731%, from 1,023 to 8,504; and the number of upper arm lifts grew an astounding 2,982%, from 434 to 13,374. Meanwhile, the number of lower body lifts––a procedure that essentially did not exist in 1992—stood at 8,647 in 2008.

Dr. J. Peter Rubin, a board-certified plastic surgeon who directs the multidisciplinary Life After Weight Loss clinical program at the University of Pittsburgh, estimates that 90% of his clinical practice involves body contouring after massive weight loss. “These are fairly complex and technically challenging procedures that are best done by surgeons who have a strong grounding in plastic surgery principles and strong training in plastic surgery,” said Dr. Rubin, coauthor of “Aesthetic Surgery After Massive Weight Loss” (Elsevier Medical Publishing, 2006).

Dr. Aly evaluates potential body-contouring candidates a minimum of 18 months after they have undergone bariatric surgery. “We tend to not want to operate on people who are aiming for specific weight levels,” said Dr. Aly, author of “Body Contouring After Massive Weight Loss” (Quality Medical Publishing, 2005). “We want to operate on people who are in a comfortable lifestyle and are not doing heroic things to reach a particular weight level. If you have access to the bariatric surgeon that the patient was referred from, that's one of your best sources. Ask them if they feel that the patient has stabilized their weight loss.”

Dr. Susan Downey, a board-certified plastic surgeon who practices in Los Angeles, addresses goals and expectations with body-contouring candidates up front. She asks them about their cosmetic priorities, how long they've been at their present weight, and whether they've had plateaus with their weight loss. In her practice, abdominoplasty usually tops the list of procedures requested, followed by breast lift/augmentation; arm lift; thigh lift; and lower body lift (belt lipectomy), a combination procedure that includes abdominoplasty, a thigh lift, and a buttock lift.

“What bothers me [from a cosmetic standpoint] may not be what bothers them,” Dr. Downey noted. “I had one patient who wanted her eyes done first because the bags under her eyes got more pronounced as her face got smaller from the weight loss. You can do two or three procedures if a patient is in good medical condition. We usually limit ourselves to about 6–8 hours of surgery.”

According to published reports, Dr. Downey said, up to 30% of patients with massive weight loss have complications after body contouring. “I would say it's up to 10% for a major complication and up to 30% for a minor complication,” she estimated. “These patients have a higher rate of hematoma formation, a higher rate of seroma, and wound-healing issues. A lot of it has to do with the fact that the skin is so overstretched at the time that you do the surgery.”

Extensive scarring after the procedures is common, “but the improvement in body contour is quite dramatic and well worth the scars,” she added.

Recovery time varies among patients, Dr. Aly said, and tends to be longer after a belt lipectomy (4–6 weeks) than after other common procedures, including an upper body lift (2–3 weeks), an upper arm lift (2–3 weeks), and a thigh lift (2–4 weeks).

Some medical insurance companies cover the panniculectomy portion of the abdominal contour, including anesthesia, but other procedures generally are not covered. “That's one of the issues with this field: The insurance companies are bound to the criteria of medical necessity,” Dr. Rubin said. “It's sometimes hard to justify true medical necessity by the standard of the insurance company for some of these body-contouring operations, despite the overwhelmingly positive impact it will have on the person's quality of life. With these economic times, I'm not sure we're going to see that getting better quickly.”

These procedures produce an immeasurable impact on patient self-perception, Dr. Aly stated, recalling that a patient with massive weight loss once told him, “[Bariatric surgery] gave me back my life. It's part of a life transformation. Plastic surgery allows me to enjoy it.”

ELSEVIER GLOBAL MEDICAL NEWS

Before and after results of an upper body lift in a male bariatric surgery patient are shown.

Source COURTESY DR. AL ALY

The proliferation of bariatric surgery procedures performed each year in the United States has led to a burgeoning demand for body contouring, a subspecialty of plastic surgery designed to help patients improve their cosmetic appearance.

Prior to 2000, it was rare for patients who experienced massive weight loss to seek help from plastic surgeons; in fact, this patient population was almost nonexistent, according to Dr. Al Aly, a board-certified plastic surgeon who practices in Iowa City, Iowa.

Today, the demand for procedures such as abdominoplasties, upper arm lifts, and thigh lifts has never been higher. According to the American Society of Plastic Surgeons, between 1992 and 2008 the number of abdominoplasties performed grew by 593%, from 16,810 to 116,512; the number of thigh lifts grew by 731%, from 1,023 to 8,504; and the number of upper arm lifts grew an astounding 2,982%, from 434 to 13,374. Meanwhile, the number of lower body lifts––a procedure that essentially did not exist in 1992—stood at 8,647 in 2008.

Dr. J. Peter Rubin, a board-certified plastic surgeon who directs the multidisciplinary Life After Weight Loss clinical program at the University of Pittsburgh, estimates that 90% of his clinical practice involves body contouring after massive weight loss. “These are fairly complex and technically challenging procedures that are best done by surgeons who have a strong grounding in plastic surgery principles and strong training in plastic surgery,” said Dr. Rubin, coauthor of “Aesthetic Surgery After Massive Weight Loss” (Elsevier Medical Publishing, 2006).

Dr. Aly evaluates potential body-contouring candidates a minimum of 18 months after they have undergone bariatric surgery. “We tend to not want to operate on people who are aiming for specific weight levels,” said Dr. Aly, author of “Body Contouring After Massive Weight Loss” (Quality Medical Publishing, 2005). “We want to operate on people who are in a comfortable lifestyle and are not doing heroic things to reach a particular weight level. If you have access to the bariatric surgeon that the patient was referred from, that's one of your best sources. Ask them if they feel that the patient has stabilized their weight loss.”

Dr. Susan Downey, a board-certified plastic surgeon who practices in Los Angeles, addresses goals and expectations with body-contouring candidates up front. She asks them about their cosmetic priorities, how long they've been at their present weight, and whether they've had plateaus with their weight loss. In her practice, abdominoplasty usually tops the list of procedures requested, followed by breast lift/augmentation; arm lift; thigh lift; and lower body lift (belt lipectomy), a combination procedure that includes abdominoplasty, a thigh lift, and a buttock lift.

“What bothers me [from a cosmetic standpoint] may not be what bothers them,” Dr. Downey noted. “I had one patient who wanted her eyes done first because the bags under her eyes got more pronounced as her face got smaller from the weight loss. You can do two or three procedures if a patient is in good medical condition. We usually limit ourselves to about 6–8 hours of surgery.”

According to published reports, Dr. Downey said, up to 30% of patients with massive weight loss have complications after body contouring. “I would say it's up to 10% for a major complication and up to 30% for a minor complication,” she estimated. “These patients have a higher rate of hematoma formation, a higher rate of seroma, and wound-healing issues. A lot of it has to do with the fact that the skin is so overstretched at the time that you do the surgery.”

Extensive scarring after the procedures is common, “but the improvement in body contour is quite dramatic and well worth the scars,” she added.

Recovery time varies among patients, Dr. Aly said, and tends to be longer after a belt lipectomy (4–6 weeks) than after other common procedures, including an upper body lift (2–3 weeks), an upper arm lift (2–3 weeks), and a thigh lift (2–4 weeks).

Some medical insurance companies cover the panniculectomy portion of the abdominal contour, including anesthesia, but other procedures generally are not covered. “That's one of the issues with this field: The insurance companies are bound to the criteria of medical necessity,” Dr. Rubin said. “It's sometimes hard to justify true medical necessity by the standard of the insurance company for some of these body-contouring operations, despite the overwhelmingly positive impact it will have on the person's quality of life. With these economic times, I'm not sure we're going to see that getting better quickly.”

These procedures produce an immeasurable impact on patient self-perception, Dr. Aly stated, recalling that a patient with massive weight loss once told him, “[Bariatric surgery] gave me back my life. It's part of a life transformation. Plastic surgery allows me to enjoy it.”

ELSEVIER GLOBAL MEDICAL NEWS

Before and after results of an upper body lift in a male bariatric surgery patient are shown.

Source COURTESY DR. AL ALY

When a vaccine for the pandemic influenza A(H1N1) virus is cleared for use, expect the distribution process to resemble the Vaccines for Children program.

The vaccine will be allocated to states based on their populations, Dr. Jay C. Butler said during a teleconference of the National Vaccine Advisory Committee (NVAC) last month. McKesson Specialty will receive vaccine from the five manufacturers and ship it to providers under the direction of state health departments.

“Providers may include physician's offices, hospitals, occupational health clinics, pharmacies, anyone the state designates as an appropriate recipient of vaccines to administer,” said Dr. Butler, director of the H1N1 Vaccine Task Force at the Centers for Disease Control and Prevention, Atlanta.

To date, the federal government has purchased 195 million doses of the vaccine. All orders will be filled in increments of 100 doses. For federal employees, Dr. Butler noted, the CDC will play role of “state health department,” receiving and submitting orders from federal agencies.

The overall process “was developed in collaboration with state and local health officials,” he said. “Distribution of vaccine can be achieved without rebuilding infrastructure for in-state distribution, which has mostly been lost within the last couple of years.”

The Countermeasure and Response Administration, a Web-based aggregate reporting by age group, will track the number of doses being given. “This system may underestimate the number of doses that are administered,” Dr. Butler said. “There will be a certain amount of work involved in the data entry, and it's possible that vaccinators may not enter all the data.”

As for coverage assessment, the National Immunization Survey can begin collecting data as early as the week of Oct. 10, and provide weekly coverage estimates, he said. The Behavioral Risk Factor Surveillance System “will provide a more complete picture of vaccine coverage by state and in specific risk groups.”

Dr. Butler emphasized that the current distribution plan is a “dynamic situation. There are a number of things that we don't yet have a good handle on, including the proportion of vaccine that will be delivered in the private sector and the willingness of clinicians to provide H1N1 vaccine.”

While some of the clinical trials of pandemic H1N1 vaccine have been underway since mid-July, Robin Robinson, Ph.D., said that no adverse events have been reported to date. “That is very encouraging,” said Dr. Robinson, director of the Biomedical Advanced Research and Development Authority.

During the 2-hour meeting, NVAC members approved two recommendations that will be passed along to the assistant secretary for health for review. One advises that the Department of Health and Human Services “develop, and where possible test in advance, a strong and organized response to scientific and public concerns about vaccine safety that may emerge during the 2009 H1N1 vaccination campaign. The challenge will be to communicate effectively and to differentiate rapidly between adverse events that may be causally related to the vaccine and those which would be expected by chance alone.”

Such a response, the recommendations continue, could involve “organizing drills or practice scenarios for how the government will respond to concerns about adverse events temporally related to H1N1 vaccination, including identifying data resources and strategies for communications messages.”

When a vaccine for the pandemic influenza A(H1N1) virus is cleared for use, expect the distribution process to resemble the Vaccines for Children program.

The vaccine will be allocated to states based on their populations, Dr. Jay C. Butler said during a teleconference of the National Vaccine Advisory Committee (NVAC) last month. McKesson Specialty will receive vaccine from the five manufacturers and ship it to providers under the direction of state health departments.

“Providers may include physician's offices, hospitals, occupational health clinics, pharmacies, anyone the state designates as an appropriate recipient of vaccines to administer,” said Dr. Butler, director of the H1N1 Vaccine Task Force at the Centers for Disease Control and Prevention, Atlanta.

To date, the federal government has purchased 195 million doses of the vaccine. All orders will be filled in increments of 100 doses. For federal employees, Dr. Butler noted, the CDC will play role of “state health department,” receiving and submitting orders from federal agencies.

The overall process “was developed in collaboration with state and local health officials,” he said. “Distribution of vaccine can be achieved without rebuilding infrastructure for in-state distribution, which has mostly been lost within the last couple of years.”

The Countermeasure and Response Administration, a Web-based aggregate reporting by age group, will track the number of doses being given. “This system may underestimate the number of doses that are administered,” Dr. Butler said. “There will be a certain amount of work involved in the data entry, and it's possible that vaccinators may not enter all the data.”

As for coverage assessment, the National Immunization Survey can begin collecting data as early as the week of Oct. 10, and provide weekly coverage estimates, he said. The Behavioral Risk Factor Surveillance System “will provide a more complete picture of vaccine coverage by state and in specific risk groups.”

Dr. Butler emphasized that the current distribution plan is a “dynamic situation. There are a number of things that we don't yet have a good handle on, including the proportion of vaccine that will be delivered in the private sector and the willingness of clinicians to provide H1N1 vaccine.”

While some of the clinical trials of pandemic H1N1 vaccine have been underway since mid-July, Robin Robinson, Ph.D., said that no adverse events have been reported to date. “That is very encouraging,” said Dr. Robinson, director of the Biomedical Advanced Research and Development Authority.

During the 2-hour meeting, NVAC members approved two recommendations that will be passed along to the assistant secretary for health for review. One advises that the Department of Health and Human Services “develop, and where possible test in advance, a strong and organized response to scientific and public concerns about vaccine safety that may emerge during the 2009 H1N1 vaccination campaign. The challenge will be to communicate effectively and to differentiate rapidly between adverse events that may be causally related to the vaccine and those which would be expected by chance alone.”

Such a response, the recommendations continue, could involve “organizing drills or practice scenarios for how the government will respond to concerns about adverse events temporally related to H1N1 vaccination, including identifying data resources and strategies for communications messages.”

When a vaccine for the pandemic influenza A(H1N1) virus is cleared for use, expect the distribution process to resemble the Vaccines for Children program.

The vaccine will be allocated to states based on their populations, Dr. Jay C. Butler said during a teleconference of the National Vaccine Advisory Committee (NVAC) last month. McKesson Specialty will receive vaccine from the five manufacturers and ship it to providers under the direction of state health departments.

“Providers may include physician's offices, hospitals, occupational health clinics, pharmacies, anyone the state designates as an appropriate recipient of vaccines to administer,” said Dr. Butler, director of the H1N1 Vaccine Task Force at the Centers for Disease Control and Prevention, Atlanta.

To date, the federal government has purchased 195 million doses of the vaccine. All orders will be filled in increments of 100 doses. For federal employees, Dr. Butler noted, the CDC will play role of “state health department,” receiving and submitting orders from federal agencies.

The overall process “was developed in collaboration with state and local health officials,” he said. “Distribution of vaccine can be achieved without rebuilding infrastructure for in-state distribution, which has mostly been lost within the last couple of years.”

The Countermeasure and Response Administration, a Web-based aggregate reporting by age group, will track the number of doses being given. “This system may underestimate the number of doses that are administered,” Dr. Butler said. “There will be a certain amount of work involved in the data entry, and it's possible that vaccinators may not enter all the data.”

As for coverage assessment, the National Immunization Survey can begin collecting data as early as the week of Oct. 10, and provide weekly coverage estimates, he said. The Behavioral Risk Factor Surveillance System “will provide a more complete picture of vaccine coverage by state and in specific risk groups.”

Dr. Butler emphasized that the current distribution plan is a “dynamic situation. There are a number of things that we don't yet have a good handle on, including the proportion of vaccine that will be delivered in the private sector and the willingness of clinicians to provide H1N1 vaccine.”

While some of the clinical trials of pandemic H1N1 vaccine have been underway since mid-July, Robin Robinson, Ph.D., said that no adverse events have been reported to date. “That is very encouraging,” said Dr. Robinson, director of the Biomedical Advanced Research and Development Authority.

During the 2-hour meeting, NVAC members approved two recommendations that will be passed along to the assistant secretary for health for review. One advises that the Department of Health and Human Services “develop, and where possible test in advance, a strong and organized response to scientific and public concerns about vaccine safety that may emerge during the 2009 H1N1 vaccination campaign. The challenge will be to communicate effectively and to differentiate rapidly between adverse events that may be causally related to the vaccine and those which would be expected by chance alone.”

Such a response, the recommendations continue, could involve “organizing drills or practice scenarios for how the government will respond to concerns about adverse events temporally related to H1N1 vaccination, including identifying data resources and strategies for communications messages.”

Dr. James Barron never took physical fitness seriously until age 30, when he served as the physician for a Marine battalion, but he'd always been intrigued by watching Ironman competitions on television—grueling events that consist of a 2.4-mile swim, a 112-mile bike ride, and a 26-mile run.

“In my mind I would think, 'Wouldn't it be great to do that someday?'” said Dr. Barron, a 44-year-old internist practicing in Grand Rapids, Mich.

The motivator for his will to ultimately become an Ironman-level triathlete came from a painful life event: the September 2001 death of his 5-year-old niece, Allie Cibulas, from inoperable brain cancer.

“She had a horrible course,” Dr. Barron recalled. “I remember visiting her, being so frustrated. I had so much pent-up energy and I wanted to do something to try to make a difference in the lives of other people affected by children with any type of illness.”

So in 2003 he registered for an Ironman competition in Madison, Wis., and asked friends, family, and perfect strangers to champion him by donating money to Allie's Angels—a charity serving terminally ill children and research on pediatric brain cancer that was launched in honor of his niece (www.alliesangels.com

“I thought, 'I'm going to push myself to my limit and do what I can to try to help out,'” he said. “When little children go through chemotherapy, they're not prepared for it. I had never done a triathlon in my life, so it was symbolic that I was going to go do something I'd never done before and fight my own personal battle to complete it. It pales in comparison to what Allie went through, but the symbolism is that I was going to fight my hardest battle in honor of her, without having prior experience.”

After nearly a year of training, when race day arrived he completed the event and helped to raise several thousand dollars for Allie's Angels. “It wasn't a lot of money,” he said. “But for me it was more [about] creating awareness and putting my own sweat and tears into it.”

Dr. Barron described feeling like an “imposter” in a crowd of highly trained triathletes during the race. “I remember when I crossed the finish line many hours after the winner, still seeing the winner of the race there to cheer me on and welcome me to the club,” he said. “It's a feeling of acceptance. It was very emotional, thinking about my niece as I went through the race. That kind of kept me going the whole time. It's really an amazing event. The crowds cheer you on from start to finish. Every time I felt like stopping something clicked and told me to keep going.”

With his first Ironman behind him, Dr. Barron went on to improve his completion times in subsequent Ironman competitions in Lake Placid, N.Y., and in Louisville, Ky., keying in on specific charities to support for each event. On Aug. 30, 2009, he plans to return to Louisville to compete in the Ford Ironman Lousiville event and help raise money for the National Alliance on Mental Illness Michigan (www.namimi.orgwww.epilepsymichigan.org

Dr. Barron's ultimate Ironman goal is to compete in Kona, Hawaii, the premier competition in this event.

In addition to his full-time role as a hospitalist for Michigan Medical, P.C. at Spectrum Butterworth in Grand Rapids, Dr. Barron is an essential caretaker of his wife, Dr. Denise Barron-Kraus, and their two teenage sons. Dr. Barron-Kraus left medical practice in 2000 because she suffers from mental health issues and fibromylagia that affects her ability to perform activities of daily living. That leaves Dr. Barron precious little time for training, but he manages.

“My husband's ability to dedicate so much time and energy to exercise, in addition to his demanding work schedule at the hospital and home, is amazing to me,” Dr. Barron-Kraus said. “His choice of hobby is a great one for him as he has a significant family cardiac history. He is in better shape than the 19 year-old I met in college. In addition to the physical benefits of exercise, it serves as his main stress-reliever, improving all areas of his life.”

It's not unusual for Dr. Barron to train in the late evenings until midnight, or to start training at 4:30 a.m., depending on his demands for time. “It's all about prioritizing,” he said.

He noted that participating in Ironman competitions have helped him achieve a “can-do mindset” for whatever challenges come his way.

“Being able to do an Ironman shows that I can accomplish just about anything I put my mind to,” he said. “I believe it positively affects my work attitude and my attitude at home. The biggest thing for me is, as a physician I always want to make a difference in the lives of people.”

By doing Ironman competitions, “I'm able to do that. While I haven't raised a ton of money, I've been able to add meaning to my personal life while raising money and awareness for important causes. There are a lot of people out there who don't get recognized or receive the help that they need. For me, this is one way to give,” he said.

Dr. James Barron registered for his first Ironman in response to his 5-year-old niece's death from brain cancer.

Source Courtesy Kyle Barron-Kraus

Dr. James Barron never took physical fitness seriously until age 30, when he served as the physician for a Marine battalion, but he'd always been intrigued by watching Ironman competitions on television—grueling events that consist of a 2.4-mile swim, a 112-mile bike ride, and a 26-mile run.

“In my mind I would think, 'Wouldn't it be great to do that someday?'” said Dr. Barron, a 44-year-old internist practicing in Grand Rapids, Mich.

The motivator for his will to ultimately become an Ironman-level triathlete came from a painful life event: the September 2001 death of his 5-year-old niece, Allie Cibulas, from inoperable brain cancer.

“She had a horrible course,” Dr. Barron recalled. “I remember visiting her, being so frustrated. I had so much pent-up energy and I wanted to do something to try to make a difference in the lives of other people affected by children with any type of illness.”

So in 2003 he registered for an Ironman competition in Madison, Wis., and asked friends, family, and perfect strangers to champion him by donating money to Allie's Angels—a charity serving terminally ill children and research on pediatric brain cancer that was launched in honor of his niece (www.alliesangels.com

“I thought, 'I'm going to push myself to my limit and do what I can to try to help out,'” he said. “When little children go through chemotherapy, they're not prepared for it. I had never done a triathlon in my life, so it was symbolic that I was going to go do something I'd never done before and fight my own personal battle to complete it. It pales in comparison to what Allie went through, but the symbolism is that I was going to fight my hardest battle in honor of her, without having prior experience.”

After nearly a year of training, when race day arrived he completed the event and helped to raise several thousand dollars for Allie's Angels. “It wasn't a lot of money,” he said. “But for me it was more [about] creating awareness and putting my own sweat and tears into it.”

Dr. Barron described feeling like an “imposter” in a crowd of highly trained triathletes during the race. “I remember when I crossed the finish line many hours after the winner, still seeing the winner of the race there to cheer me on and welcome me to the club,” he said. “It's a feeling of acceptance. It was very emotional, thinking about my niece as I went through the race. That kind of kept me going the whole time. It's really an amazing event. The crowds cheer you on from start to finish. Every time I felt like stopping something clicked and told me to keep going.”

With his first Ironman behind him, Dr. Barron went on to improve his completion times in subsequent Ironman competitions in Lake Placid, N.Y., and in Louisville, Ky., keying in on specific charities to support for each event. On Aug. 30, 2009, he plans to return to Louisville to compete in the Ford Ironman Lousiville event and help raise money for the National Alliance on Mental Illness Michigan (www.namimi.orgwww.epilepsymichigan.org

Dr. Barron's ultimate Ironman goal is to compete in Kona, Hawaii, the premier competition in this event.

In addition to his full-time role as a hospitalist for Michigan Medical, P.C. at Spectrum Butterworth in Grand Rapids, Dr. Barron is an essential caretaker of his wife, Dr. Denise Barron-Kraus, and their two teenage sons. Dr. Barron-Kraus left medical practice in 2000 because she suffers from mental health issues and fibromylagia that affects her ability to perform activities of daily living. That leaves Dr. Barron precious little time for training, but he manages.

“My husband's ability to dedicate so much time and energy to exercise, in addition to his demanding work schedule at the hospital and home, is amazing to me,” Dr. Barron-Kraus said. “His choice of hobby is a great one for him as he has a significant family cardiac history. He is in better shape than the 19 year-old I met in college. In addition to the physical benefits of exercise, it serves as his main stress-reliever, improving all areas of his life.”

It's not unusual for Dr. Barron to train in the late evenings until midnight, or to start training at 4:30 a.m., depending on his demands for time. “It's all about prioritizing,” he said.

He noted that participating in Ironman competitions have helped him achieve a “can-do mindset” for whatever challenges come his way.

“Being able to do an Ironman shows that I can accomplish just about anything I put my mind to,” he said. “I believe it positively affects my work attitude and my attitude at home. The biggest thing for me is, as a physician I always want to make a difference in the lives of people.”

By doing Ironman competitions, “I'm able to do that. While I haven't raised a ton of money, I've been able to add meaning to my personal life while raising money and awareness for important causes. There are a lot of people out there who don't get recognized or receive the help that they need. For me, this is one way to give,” he said.

Dr. James Barron registered for his first Ironman in response to his 5-year-old niece's death from brain cancer.

Source Courtesy Kyle Barron-Kraus

Dr. James Barron never took physical fitness seriously until age 30, when he served as the physician for a Marine battalion, but he'd always been intrigued by watching Ironman competitions on television—grueling events that consist of a 2.4-mile swim, a 112-mile bike ride, and a 26-mile run.

“In my mind I would think, 'Wouldn't it be great to do that someday?'” said Dr. Barron, a 44-year-old internist practicing in Grand Rapids, Mich.

The motivator for his will to ultimately become an Ironman-level triathlete came from a painful life event: the September 2001 death of his 5-year-old niece, Allie Cibulas, from inoperable brain cancer.

“She had a horrible course,” Dr. Barron recalled. “I remember visiting her, being so frustrated. I had so much pent-up energy and I wanted to do something to try to make a difference in the lives of other people affected by children with any type of illness.”

So in 2003 he registered for an Ironman competition in Madison, Wis., and asked friends, family, and perfect strangers to champion him by donating money to Allie's Angels—a charity serving terminally ill children and research on pediatric brain cancer that was launched in honor of his niece (www.alliesangels.com

“I thought, 'I'm going to push myself to my limit and do what I can to try to help out,'” he said. “When little children go through chemotherapy, they're not prepared for it. I had never done a triathlon in my life, so it was symbolic that I was going to go do something I'd never done before and fight my own personal battle to complete it. It pales in comparison to what Allie went through, but the symbolism is that I was going to fight my hardest battle in honor of her, without having prior experience.”

After nearly a year of training, when race day arrived he completed the event and helped to raise several thousand dollars for Allie's Angels. “It wasn't a lot of money,” he said. “But for me it was more [about] creating awareness and putting my own sweat and tears into it.”

Dr. Barron described feeling like an “imposter” in a crowd of highly trained triathletes during the race. “I remember when I crossed the finish line many hours after the winner, still seeing the winner of the race there to cheer me on and welcome me to the club,” he said. “It's a feeling of acceptance. It was very emotional, thinking about my niece as I went through the race. That kind of kept me going the whole time. It's really an amazing event. The crowds cheer you on from start to finish. Every time I felt like stopping something clicked and told me to keep going.”

With his first Ironman behind him, Dr. Barron went on to improve his completion times in subsequent Ironman competitions in Lake Placid, N.Y., and in Louisville, Ky., keying in on specific charities to support for each event. On Aug. 30, 2009, he plans to return to Louisville to compete in the Ford Ironman Lousiville event and help raise money for the National Alliance on Mental Illness Michigan (www.namimi.orgwww.epilepsymichigan.org

Dr. Barron's ultimate Ironman goal is to compete in Kona, Hawaii, the premier competition in this event.

In addition to his full-time role as a hospitalist for Michigan Medical, P.C. at Spectrum Butterworth in Grand Rapids, Dr. Barron is an essential caretaker of his wife, Dr. Denise Barron-Kraus, and their two teenage sons. Dr. Barron-Kraus left medical practice in 2000 because she suffers from mental health issues and fibromylagia that affects her ability to perform activities of daily living. That leaves Dr. Barron precious little time for training, but he manages.

“My husband's ability to dedicate so much time and energy to exercise, in addition to his demanding work schedule at the hospital and home, is amazing to me,” Dr. Barron-Kraus said. “His choice of hobby is a great one for him as he has a significant family cardiac history. He is in better shape than the 19 year-old I met in college. In addition to the physical benefits of exercise, it serves as his main stress-reliever, improving all areas of his life.”

It's not unusual for Dr. Barron to train in the late evenings until midnight, or to start training at 4:30 a.m., depending on his demands for time. “It's all about prioritizing,” he said.

He noted that participating in Ironman competitions have helped him achieve a “can-do mindset” for whatever challenges come his way.

“Being able to do an Ironman shows that I can accomplish just about anything I put my mind to,” he said. “I believe it positively affects my work attitude and my attitude at home. The biggest thing for me is, as a physician I always want to make a difference in the lives of people.”

By doing Ironman competitions, “I'm able to do that. While I haven't raised a ton of money, I've been able to add meaning to my personal life while raising money and awareness for important causes. There are a lot of people out there who don't get recognized or receive the help that they need. For me, this is one way to give,” he said.

Dr. James Barron registered for his first Ironman in response to his 5-year-old niece's death from brain cancer.

Source Courtesy Kyle Barron-Kraus

NEW ORLEANS — The overall U.S. incidence of end-stage renal disease among people with diabetes decreased steadily between 1997 and 2006.

Yet diabetes-related end-stage renal disease (ESRD-DM) continues to disproportionately affect non-Hispanic blacks and Hispanics, compared with non-Hispanic whites.

The findings were presented in a poster at the annual scientific sessions of the American Diabetes Association.

“The declining ESRD-DM incidence in the population with diabetes is likely due in part to a reduction in prevalence of ESRD risk factors, improved treatment and care, and other factors,” said Nilka Ríos Burrows, an epidemiologist with the Division of Diabetes Translation at the Centers for Disease Control and Prevention, Atlanta, and her colleagues. “Continued efforts are needed to sustain and improve these encouraging trends, particularly among older and among minority populations.”

She and her associates analyzed data from the United States Renal Data System to examine racial- and ethnic-specific trends in the incidence of ESRD-DM among patients who began therapy for the disease between 1997 and 2006. They also studied data from the National Health Interview Survey and the Census 2000 to estimate the United States population with diabetes in calculating the incidence of ESRD-DM as well as the age-adjusted incidence.

The number of patients who began treatment for ESRD-DM increased nearly threefold, from 17,727 in 1997 to 48,215 in 2006. During the same period, the overall age-adjusted incidence of ESRD-DM decreased 28%.

The decline in the age-adjusted incidence between 1997 and 2006 was significant (37%) among non-Hispanic whites and among non-Hispanic blacks (18%). Among Hispanics, the decline in the age-adjusted incidence was 17%.

However, in 2006 alone, the incidence of ESRD-DM was 1.8 times higher among Hispanics and 2.3 times higher among non-Hispanic blacks, compared with non-Hispanic whites.

Study limitations include the fact that the data analyzed were for patients receiving treatment as reported to the Centers for Medicare and Medicaid Services, and that changes in factors other than “true” disease incidence could affect trends, the researchers said, adding that they were unable to stratify risk of developing ESRD-DM by duration of diabetes.

Ms. Burrows had no conflicts of interest to disclose.

NEW ORLEANS — The overall U.S. incidence of end-stage renal disease among people with diabetes decreased steadily between 1997 and 2006.

Yet diabetes-related end-stage renal disease (ESRD-DM) continues to disproportionately affect non-Hispanic blacks and Hispanics, compared with non-Hispanic whites.

The findings were presented in a poster at the annual scientific sessions of the American Diabetes Association.

“The declining ESRD-DM incidence in the population with diabetes is likely due in part to a reduction in prevalence of ESRD risk factors, improved treatment and care, and other factors,” said Nilka Ríos Burrows, an epidemiologist with the Division of Diabetes Translation at the Centers for Disease Control and Prevention, Atlanta, and her colleagues. “Continued efforts are needed to sustain and improve these encouraging trends, particularly among older and among minority populations.”

She and her associates analyzed data from the United States Renal Data System to examine racial- and ethnic-specific trends in the incidence of ESRD-DM among patients who began therapy for the disease between 1997 and 2006. They also studied data from the National Health Interview Survey and the Census 2000 to estimate the United States population with diabetes in calculating the incidence of ESRD-DM as well as the age-adjusted incidence.

The number of patients who began treatment for ESRD-DM increased nearly threefold, from 17,727 in 1997 to 48,215 in 2006. During the same period, the overall age-adjusted incidence of ESRD-DM decreased 28%.

The decline in the age-adjusted incidence between 1997 and 2006 was significant (37%) among non-Hispanic whites and among non-Hispanic blacks (18%). Among Hispanics, the decline in the age-adjusted incidence was 17%.

However, in 2006 alone, the incidence of ESRD-DM was 1.8 times higher among Hispanics and 2.3 times higher among non-Hispanic blacks, compared with non-Hispanic whites.

Study limitations include the fact that the data analyzed were for patients receiving treatment as reported to the Centers for Medicare and Medicaid Services, and that changes in factors other than “true” disease incidence could affect trends, the researchers said, adding that they were unable to stratify risk of developing ESRD-DM by duration of diabetes.

Ms. Burrows had no conflicts of interest to disclose.

NEW ORLEANS — The overall U.S. incidence of end-stage renal disease among people with diabetes decreased steadily between 1997 and 2006.

Yet diabetes-related end-stage renal disease (ESRD-DM) continues to disproportionately affect non-Hispanic blacks and Hispanics, compared with non-Hispanic whites.

The findings were presented in a poster at the annual scientific sessions of the American Diabetes Association.

“The declining ESRD-DM incidence in the population with diabetes is likely due in part to a reduction in prevalence of ESRD risk factors, improved treatment and care, and other factors,” said Nilka Ríos Burrows, an epidemiologist with the Division of Diabetes Translation at the Centers for Disease Control and Prevention, Atlanta, and her colleagues. “Continued efforts are needed to sustain and improve these encouraging trends, particularly among older and among minority populations.”

She and her associates analyzed data from the United States Renal Data System to examine racial- and ethnic-specific trends in the incidence of ESRD-DM among patients who began therapy for the disease between 1997 and 2006. They also studied data from the National Health Interview Survey and the Census 2000 to estimate the United States population with diabetes in calculating the incidence of ESRD-DM as well as the age-adjusted incidence.

The number of patients who began treatment for ESRD-DM increased nearly threefold, from 17,727 in 1997 to 48,215 in 2006. During the same period, the overall age-adjusted incidence of ESRD-DM decreased 28%.

The decline in the age-adjusted incidence between 1997 and 2006 was significant (37%) among non-Hispanic whites and among non-Hispanic blacks (18%). Among Hispanics, the decline in the age-adjusted incidence was 17%.

However, in 2006 alone, the incidence of ESRD-DM was 1.8 times higher among Hispanics and 2.3 times higher among non-Hispanic blacks, compared with non-Hispanic whites.

Study limitations include the fact that the data analyzed were for patients receiving treatment as reported to the Centers for Medicare and Medicaid Services, and that changes in factors other than “true” disease incidence could affect trends, the researchers said, adding that they were unable to stratify risk of developing ESRD-DM by duration of diabetes.

Ms. Burrows had no conflicts of interest to disclose.

While clinical results of some 2009 pandemic influenza A(H1N1) vaccine trials won't be known until late September at the earliest, planning a vaccination program for the virus is well underway.

Officials from the National Vaccine Advisory Committee provided a wide-ranging update on activities related to 2009-H1N1 vaccine development and implementation planning during a recent teleconference.

Dr. Anne Schuchat, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, noted that there have been “disruptive clusters and outbreaks” of H1N1 influenza at summer camps in the United States with “remarkable heterogeneity,” with some people disproportionately affected. “We are continuing to see illness here in the U.S. at a lower frequency than in the spring, but a very high frequency compared to a usual summer.”

Robin Robinson, Ph.D., director of BARDA (Biomedical Advanced Research and Development Authority), an agency of the Health and Human Services department, noted that the HHS has contracted with five manufacturers to develop 2009 H1N1 vaccine: Four are producing an inactivated form of the vaccine, which will be available in prefilled syringes and multidose vials, and one is producing a live attenuated form. Clinical vaccine trials will be carried out in adults first, and then proceed to pediatric populations. Dr. Robinson estimated that about 20% of the entire clinical trial population will include children. Results from the first clinical trials—which began in mid-July—are expected by late September or early October.

The CDC's H1N1 Vaccine Task Force recommends that vaccine administration planning should take into account certain at-risk groups, including children and staff in day care centers and in schools serving grades K-12; pregnant women; young children; persons with household contact of children younger than 6 months of age; persons with underlying medical conditions; health care workers; and then—when enough vaccine is available—everyone else. Dr. Jay C. Butler, director of the task force, noted that uncertainties about a vaccine roll-out persist, including the amount of vaccine required and when it will be available; its formulation; specific recommendations for use; and demand for the vaccine.

Dr. Marie McCormick, a member of NVAC who is also a professor of maternal and child health at Harvard School of Public Health, presented draft recommendations of the H1N1 Vaccine Safety Subgroup. It calls for a federal plan to monitor 2009 H1N1 influenza vaccine safety, “both for proper planning purposes and to provide information to the public and stakeholders (including states) about important vaccine activities.”

One key recommendation says that the need “to actively monitor vaccine recipients for vaccine adverse events is critical given that the vaccine candidates will all contain a new antigen and may be combined with adjuvants that are not part of licensed vaccines in the United States.” Another recommendation calls for “transparent and independent review of vaccine safety data as it accumulates.”

The NVAC voted to adopt these recommendations, which will be passed along to National Vaccine Program Director Dr. Bruce G. Gellin for consideration.

Dr. Anne Bailowitz, medical director of environmental health and emergency programs for the National Association of County and City Health Officials, expressed concern about the implementation of a 2009 H1N1 vaccine program in light of financial challenges faced by many local health departments. In 2008, she said, 27% of local health departments had budget cuts and 53% had layoffs. This year, she said, 44% of local departments have had budget cuts and 32% have had layoffs. Establishing local partnerships, such as encouraging large business to immunize their own employees, will be key to successful implementation, she said. Volunteer H1N1 vaccination providers could also include student nurses, medical school students, dental students, veterinarians, EMTs, and pharmacy chain personnel.

While clinical results of some 2009 pandemic influenza A(H1N1) vaccine trials won't be known until late September at the earliest, planning a vaccination program for the virus is well underway.

Officials from the National Vaccine Advisory Committee provided a wide-ranging update on activities related to 2009-H1N1 vaccine development and implementation planning during a recent teleconference.

Dr. Anne Schuchat, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, noted that there have been “disruptive clusters and outbreaks” of H1N1 influenza at summer camps in the United States with “remarkable heterogeneity,” with some people disproportionately affected. “We are continuing to see illness here in the U.S. at a lower frequency than in the spring, but a very high frequency compared to a usual summer.”

Robin Robinson, Ph.D., director of BARDA (Biomedical Advanced Research and Development Authority), an agency of the Health and Human Services department, noted that the HHS has contracted with five manufacturers to develop 2009 H1N1 vaccine: Four are producing an inactivated form of the vaccine, which will be available in prefilled syringes and multidose vials, and one is producing a live attenuated form. Clinical vaccine trials will be carried out in adults first, and then proceed to pediatric populations. Dr. Robinson estimated that about 20% of the entire clinical trial population will include children. Results from the first clinical trials—which began in mid-July—are expected by late September or early October.

The CDC's H1N1 Vaccine Task Force recommends that vaccine administration planning should take into account certain at-risk groups, including children and staff in day care centers and in schools serving grades K-12; pregnant women; young children; persons with household contact of children younger than 6 months of age; persons with underlying medical conditions; health care workers; and then—when enough vaccine is available—everyone else. Dr. Jay C. Butler, director of the task force, noted that uncertainties about a vaccine roll-out persist, including the amount of vaccine required and when it will be available; its formulation; specific recommendations for use; and demand for the vaccine.

Dr. Marie McCormick, a member of NVAC who is also a professor of maternal and child health at Harvard School of Public Health, presented draft recommendations of the H1N1 Vaccine Safety Subgroup. It calls for a federal plan to monitor 2009 H1N1 influenza vaccine safety, “both for proper planning purposes and to provide information to the public and stakeholders (including states) about important vaccine activities.”

One key recommendation says that the need “to actively monitor vaccine recipients for vaccine adverse events is critical given that the vaccine candidates will all contain a new antigen and may be combined with adjuvants that are not part of licensed vaccines in the United States.” Another recommendation calls for “transparent and independent review of vaccine safety data as it accumulates.”

The NVAC voted to adopt these recommendations, which will be passed along to National Vaccine Program Director Dr. Bruce G. Gellin for consideration.

Dr. Anne Bailowitz, medical director of environmental health and emergency programs for the National Association of County and City Health Officials, expressed concern about the implementation of a 2009 H1N1 vaccine program in light of financial challenges faced by many local health departments. In 2008, she said, 27% of local health departments had budget cuts and 53% had layoffs. This year, she said, 44% of local departments have had budget cuts and 32% have had layoffs. Establishing local partnerships, such as encouraging large business to immunize their own employees, will be key to successful implementation, she said. Volunteer H1N1 vaccination providers could also include student nurses, medical school students, dental students, veterinarians, EMTs, and pharmacy chain personnel.

While clinical results of some 2009 pandemic influenza A(H1N1) vaccine trials won't be known until late September at the earliest, planning a vaccination program for the virus is well underway.

Officials from the National Vaccine Advisory Committee provided a wide-ranging update on activities related to 2009-H1N1 vaccine development and implementation planning during a recent teleconference.

Dr. Anne Schuchat, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, noted that there have been “disruptive clusters and outbreaks” of H1N1 influenza at summer camps in the United States with “remarkable heterogeneity,” with some people disproportionately affected. “We are continuing to see illness here in the U.S. at a lower frequency than in the spring, but a very high frequency compared to a usual summer.”

Robin Robinson, Ph.D., director of BARDA (Biomedical Advanced Research and Development Authority), an agency of the Health and Human Services department, noted that the HHS has contracted with five manufacturers to develop 2009 H1N1 vaccine: Four are producing an inactivated form of the vaccine, which will be available in prefilled syringes and multidose vials, and one is producing a live attenuated form. Clinical vaccine trials will be carried out in adults first, and then proceed to pediatric populations. Dr. Robinson estimated that about 20% of the entire clinical trial population will include children. Results from the first clinical trials—which began in mid-July—are expected by late September or early October.

The CDC's H1N1 Vaccine Task Force recommends that vaccine administration planning should take into account certain at-risk groups, including children and staff in day care centers and in schools serving grades K-12; pregnant women; young children; persons with household contact of children younger than 6 months of age; persons with underlying medical conditions; health care workers; and then—when enough vaccine is available—everyone else. Dr. Jay C. Butler, director of the task force, noted that uncertainties about a vaccine roll-out persist, including the amount of vaccine required and when it will be available; its formulation; specific recommendations for use; and demand for the vaccine.

Dr. Marie McCormick, a member of NVAC who is also a professor of maternal and child health at Harvard School of Public Health, presented draft recommendations of the H1N1 Vaccine Safety Subgroup. It calls for a federal plan to monitor 2009 H1N1 influenza vaccine safety, “both for proper planning purposes and to provide information to the public and stakeholders (including states) about important vaccine activities.”

One key recommendation says that the need “to actively monitor vaccine recipients for vaccine adverse events is critical given that the vaccine candidates will all contain a new antigen and may be combined with adjuvants that are not part of licensed vaccines in the United States.” Another recommendation calls for “transparent and independent review of vaccine safety data as it accumulates.”

The NVAC voted to adopt these recommendations, which will be passed along to National Vaccine Program Director Dr. Bruce G. Gellin for consideration.

Dr. Anne Bailowitz, medical director of environmental health and emergency programs for the National Association of County and City Health Officials, expressed concern about the implementation of a 2009 H1N1 vaccine program in light of financial challenges faced by many local health departments. In 2008, she said, 27% of local health departments had budget cuts and 53% had layoffs. This year, she said, 44% of local departments have had budget cuts and 32% have had layoffs. Establishing local partnerships, such as encouraging large business to immunize their own employees, will be key to successful implementation, she said. Volunteer H1N1 vaccination providers could also include student nurses, medical school students, dental students, veterinarians, EMTs, and pharmacy chain personnel.

Diagnosis: Behçet's Disease

PORTLAND, ORE. — The patient's oral lesions began with minor induration and ulceration along the closure line of teeth on the buccal mucosa, according to Dr. Bruce D. Ragsdale, who presented the case at the annual meeting of the Pacific Dermatologic Association.

Fever and chills set in with gingival, oral mucosal, and tongue ulcerations. The patient had multiple erythematous, dome-shaped, pustular lesions on proximal extremities plus a few on the trunk, noted Dr. Ragsdale. “Oral lesions start as painful fever blisters that come to a head and burst.”

The patient lost 15 pounds because tongue pain affected his ability to eat. Family history revealed that his grandfather and cousin had Behçet's disease. His white blood cell count was 23.9 pg/mL, with a morphonuclear neutrophil count of 89, a lymphocyte count of 5, and a mononucleocyte count of 7%, with no eosinophils or basophils. Tests for antinuclear antibody, mononucleosis, and HIV were negative. The initial differential diagnosis was herpes simplex or Behçet's disease. The man was hospitalized and started on 20 mg of prednisone and colchicine 0.6 mg t.i.d.

Dr. Ragsdale, founder and director of a dermatopathology practice in San Luis Obispo, Calif., selected a shoulder lesion, not yet ulcerated, for biopsy. Histopathology revealed that pus filled the partly destroyed chamber of a follicle, and that a few bacteria—but no fungal agents—occupied keratin debris in the follicular abscess. Nearby was a diffuse infiltrate of neutrophils in papillary dermis that resembled the neutrophil array of Sweet's syndrome, associated with some hypereosinophilic collagen. No vasculitis was evident. Based on the biopsy and the clinical context, Dr. Ragsdale determined that the man had familial Behçet's disease.

“Aphthous stomatitis is a major criterion and frequently the first symptom [in 64%-71% of patients], and is almost always present during the course of the disease,” Dr. Ragsdale noted. “It may precede other manifestations by many years. Genital and perianal aphthae tend to be larger [and] deeper, with regular margins, and [are] more painful than oral lesions.”

The International Study Group criteria for the diagnosis of Behçet's disease requires aphthous (idiopathic) oral ulceration that recurs at least three times in a 12-month period, plus any two of the following: recurrent genital ulceration, eye lesions, cutaneous lesions, or a positive pathergy test.

The patient's prednisone dosage was increased to 40 mg daily prior to his hospital discharge. He continues taking prednisone and colchicine, and finds that his oral lesions return when he takes less than 20 mg of prednisone.

Histopathology image (right) shows pus filling the partly destroyed chamber of a follicle.

Source Photos Courtesy Dr. Bruce D. Ragsdale

This shoulder lesion, shown before it ulcerated, yielded the biopsied tissue.

Diagnosis: Behçet's Disease

PORTLAND, ORE. — The patient's oral lesions began with minor induration and ulceration along the closure line of teeth on the buccal mucosa, according to Dr. Bruce D. Ragsdale, who presented the case at the annual meeting of the Pacific Dermatologic Association.

Fever and chills set in with gingival, oral mucosal, and tongue ulcerations. The patient had multiple erythematous, dome-shaped, pustular lesions on proximal extremities plus a few on the trunk, noted Dr. Ragsdale. “Oral lesions start as painful fever blisters that come to a head and burst.”

The patient lost 15 pounds because tongue pain affected his ability to eat. Family history revealed that his grandfather and cousin had Behçet's disease. His white blood cell count was 23.9 pg/mL, with a morphonuclear neutrophil count of 89, a lymphocyte count of 5, and a mononucleocyte count of 7%, with no eosinophils or basophils. Tests for antinuclear antibody, mononucleosis, and HIV were negative. The initial differential diagnosis was herpes simplex or Behçet's disease. The man was hospitalized and started on 20 mg of prednisone and colchicine 0.6 mg t.i.d.

Dr. Ragsdale, founder and director of a dermatopathology practice in San Luis Obispo, Calif., selected a shoulder lesion, not yet ulcerated, for biopsy. Histopathology revealed that pus filled the partly destroyed chamber of a follicle, and that a few bacteria—but no fungal agents—occupied keratin debris in the follicular abscess. Nearby was a diffuse infiltrate of neutrophils in papillary dermis that resembled the neutrophil array of Sweet's syndrome, associated with some hypereosinophilic collagen. No vasculitis was evident. Based on the biopsy and the clinical context, Dr. Ragsdale determined that the man had familial Behçet's disease.

“Aphthous stomatitis is a major criterion and frequently the first symptom [in 64%-71% of patients], and is almost always present during the course of the disease,” Dr. Ragsdale noted. “It may precede other manifestations by many years. Genital and perianal aphthae tend to be larger [and] deeper, with regular margins, and [are] more painful than oral lesions.”

The International Study Group criteria for the diagnosis of Behçet's disease requires aphthous (idiopathic) oral ulceration that recurs at least three times in a 12-month period, plus any two of the following: recurrent genital ulceration, eye lesions, cutaneous lesions, or a positive pathergy test.

The patient's prednisone dosage was increased to 40 mg daily prior to his hospital discharge. He continues taking prednisone and colchicine, and finds that his oral lesions return when he takes less than 20 mg of prednisone.

Histopathology image (right) shows pus filling the partly destroyed chamber of a follicle.

Source Photos Courtesy Dr. Bruce D. Ragsdale

This shoulder lesion, shown before it ulcerated, yielded the biopsied tissue.

Diagnosis: Behçet's Disease

PORTLAND, ORE. — The patient's oral lesions began with minor induration and ulceration along the closure line of teeth on the buccal mucosa, according to Dr. Bruce D. Ragsdale, who presented the case at the annual meeting of the Pacific Dermatologic Association.

Fever and chills set in with gingival, oral mucosal, and tongue ulcerations. The patient had multiple erythematous, dome-shaped, pustular lesions on proximal extremities plus a few on the trunk, noted Dr. Ragsdale. “Oral lesions start as painful fever blisters that come to a head and burst.”

The patient lost 15 pounds because tongue pain affected his ability to eat. Family history revealed that his grandfather and cousin had Behçet's disease. His white blood cell count was 23.9 pg/mL, with a morphonuclear neutrophil count of 89, a lymphocyte count of 5, and a mononucleocyte count of 7%, with no eosinophils or basophils. Tests for antinuclear antibody, mononucleosis, and HIV were negative. The initial differential diagnosis was herpes simplex or Behçet's disease. The man was hospitalized and started on 20 mg of prednisone and colchicine 0.6 mg t.i.d.

Dr. Ragsdale, founder and director of a dermatopathology practice in San Luis Obispo, Calif., selected a shoulder lesion, not yet ulcerated, for biopsy. Histopathology revealed that pus filled the partly destroyed chamber of a follicle, and that a few bacteria—but no fungal agents—occupied keratin debris in the follicular abscess. Nearby was a diffuse infiltrate of neutrophils in papillary dermis that resembled the neutrophil array of Sweet's syndrome, associated with some hypereosinophilic collagen. No vasculitis was evident. Based on the biopsy and the clinical context, Dr. Ragsdale determined that the man had familial Behçet's disease.

“Aphthous stomatitis is a major criterion and frequently the first symptom [in 64%-71% of patients], and is almost always present during the course of the disease,” Dr. Ragsdale noted. “It may precede other manifestations by many years. Genital and perianal aphthae tend to be larger [and] deeper, with regular margins, and [are] more painful than oral lesions.”

The International Study Group criteria for the diagnosis of Behçet's disease requires aphthous (idiopathic) oral ulceration that recurs at least three times in a 12-month period, plus any two of the following: recurrent genital ulceration, eye lesions, cutaneous lesions, or a positive pathergy test.

The patient's prednisone dosage was increased to 40 mg daily prior to his hospital discharge. He continues taking prednisone and colchicine, and finds that his oral lesions return when he takes less than 20 mg of prednisone.

Histopathology image (right) shows pus filling the partly destroyed chamber of a follicle.

Source Photos Courtesy Dr. Bruce D. Ragsdale

This shoulder lesion, shown before it ulcerated, yielded the biopsied tissue.

SAN DIEGO — Combining an electrocardiogram with serum N-terminal pro-B-type natriuretic peptide measurements is a simple, noninvasive way to diagnose pulmonary hypertension, results from an Austrian study suggest.

“Current pulmonary hypertension diagnosis guidelines say that ECG alone is not useful in the diagnosis of pulmonary hypertension. This is true,” Dr. Diana Bonderman said in an interview during a poster session at an international conference of the American Thoracic Society. “But if you combine ECG with NT-proBNP [N-terminal pro-B-type natriuretic peptide], it's going to be useful.”

The finding is important, she said, because the growing awareness of pulmonary hypertension PH, a high prevalence of postcapillary PH, and the inability to discern between pre- and postcapillary PH by transthoracic echocardiography (TTE) “have led to unnecessary right heart catheterizations.”

She and her associates prospectively analyzed data from 121 patients referred to the Medical University of Vienna between April 2007 and October 2008 for clinical and transthoracic echocardiographic suspicion of precapillary pulmonary hypertension (defined as having a systolic pulmonary artery pressure of at least 36 mm Hg). On admission, all patients underwent TTE, serum analysis including NT-proBNP, a 6-minute walk test, and blood gas analysis.

The patients were then assigned to one of two predicted diagnostic groups: precapillary PH (defined as right ventricular strain on ECG and/or serum NT-proBNP of greater than 80 pg/mL) or no precapillary PH (defined as no right ventricular strain on ECG and NT-proBNP of 80 pg/mL or less). Next, all patients underwent invasive hemodynamic measurements by right heart catheterization, and a final diagnosis was established.

The mean age of the patients was 62 years and 59% were female, reported Dr. Bonderman, a cardiologist at the Medical University of Vienna.

By right heart catheterization, 64 (53%) patients were diagnosed with precapillary PH. Precapillary PH was ruled out in 57 (47%) patients. By the diagnostic algorithm, 15 patients (12%) had been correctly allocated to the group without precapillary PH (true negatives). None of the allocations was a false negative.

“In the diagnostic pathway of PH, integration of the proposed algorithm subsequent to TTE may increase specificity from 0% to 19.3%, with a sensitivity of 100%,” the researchers wrote. “The incorporation of ECG and NT-proBNP into the workup of PH provides incremental diagnostic value and may significantly reduce the number of invasive assessments.”

The researchers had no conflicts to disclose.

SAN DIEGO — Combining an electrocardiogram with serum N-terminal pro-B-type natriuretic peptide measurements is a simple, noninvasive way to diagnose pulmonary hypertension, results from an Austrian study suggest.

“Current pulmonary hypertension diagnosis guidelines say that ECG alone is not useful in the diagnosis of pulmonary hypertension. This is true,” Dr. Diana Bonderman said in an interview during a poster session at an international conference of the American Thoracic Society. “But if you combine ECG with NT-proBNP [N-terminal pro-B-type natriuretic peptide], it's going to be useful.”

The finding is important, she said, because the growing awareness of pulmonary hypertension PH, a high prevalence of postcapillary PH, and the inability to discern between pre- and postcapillary PH by transthoracic echocardiography (TTE) “have led to unnecessary right heart catheterizations.”

She and her associates prospectively analyzed data from 121 patients referred to the Medical University of Vienna between April 2007 and October 2008 for clinical and transthoracic echocardiographic suspicion of precapillary pulmonary hypertension (defined as having a systolic pulmonary artery pressure of at least 36 mm Hg). On admission, all patients underwent TTE, serum analysis including NT-proBNP, a 6-minute walk test, and blood gas analysis.

The patients were then assigned to one of two predicted diagnostic groups: precapillary PH (defined as right ventricular strain on ECG and/or serum NT-proBNP of greater than 80 pg/mL) or no precapillary PH (defined as no right ventricular strain on ECG and NT-proBNP of 80 pg/mL or less). Next, all patients underwent invasive hemodynamic measurements by right heart catheterization, and a final diagnosis was established.

The mean age of the patients was 62 years and 59% were female, reported Dr. Bonderman, a cardiologist at the Medical University of Vienna.

By right heart catheterization, 64 (53%) patients were diagnosed with precapillary PH. Precapillary PH was ruled out in 57 (47%) patients. By the diagnostic algorithm, 15 patients (12%) had been correctly allocated to the group without precapillary PH (true negatives). None of the allocations was a false negative.

“In the diagnostic pathway of PH, integration of the proposed algorithm subsequent to TTE may increase specificity from 0% to 19.3%, with a sensitivity of 100%,” the researchers wrote. “The incorporation of ECG and NT-proBNP into the workup of PH provides incremental diagnostic value and may significantly reduce the number of invasive assessments.”

The researchers had no conflicts to disclose.

SAN DIEGO — Combining an electrocardiogram with serum N-terminal pro-B-type natriuretic peptide measurements is a simple, noninvasive way to diagnose pulmonary hypertension, results from an Austrian study suggest.

“Current pulmonary hypertension diagnosis guidelines say that ECG alone is not useful in the diagnosis of pulmonary hypertension. This is true,” Dr. Diana Bonderman said in an interview during a poster session at an international conference of the American Thoracic Society. “But if you combine ECG with NT-proBNP [N-terminal pro-B-type natriuretic peptide], it's going to be useful.”

The finding is important, she said, because the growing awareness of pulmonary hypertension PH, a high prevalence of postcapillary PH, and the inability to discern between pre- and postcapillary PH by transthoracic echocardiography (TTE) “have led to unnecessary right heart catheterizations.”

She and her associates prospectively analyzed data from 121 patients referred to the Medical University of Vienna between April 2007 and October 2008 for clinical and transthoracic echocardiographic suspicion of precapillary pulmonary hypertension (defined as having a systolic pulmonary artery pressure of at least 36 mm Hg). On admission, all patients underwent TTE, serum analysis including NT-proBNP, a 6-minute walk test, and blood gas analysis.

The patients were then assigned to one of two predicted diagnostic groups: precapillary PH (defined as right ventricular strain on ECG and/or serum NT-proBNP of greater than 80 pg/mL) or no precapillary PH (defined as no right ventricular strain on ECG and NT-proBNP of 80 pg/mL or less). Next, all patients underwent invasive hemodynamic measurements by right heart catheterization, and a final diagnosis was established.

The mean age of the patients was 62 years and 59% were female, reported Dr. Bonderman, a cardiologist at the Medical University of Vienna.

By right heart catheterization, 64 (53%) patients were diagnosed with precapillary PH. Precapillary PH was ruled out in 57 (47%) patients. By the diagnostic algorithm, 15 patients (12%) had been correctly allocated to the group without precapillary PH (true negatives). None of the allocations was a false negative.

“In the diagnostic pathway of PH, integration of the proposed algorithm subsequent to TTE may increase specificity from 0% to 19.3%, with a sensitivity of 100%,” the researchers wrote. “The incorporation of ECG and NT-proBNP into the workup of PH provides incremental diagnostic value and may significantly reduce the number of invasive assessments.”

The researchers had no conflicts to disclose.

When a vaccine for the novel influenza A(H1N1) virus is cleared for use, expect the distribution process to resemble the Vaccines for Children program.

The vaccine will be allocated to states based on their populations, Dr. Jay C. Butler said during a teleconference of the National Vaccine Advisory Committee (NVAC).

“Providers may include physicians' offices, hospitals, occupational health clinics, pharmacies, anyone the state designates as an appropriate recipient of vaccines to administer,” said Dr. Butler, director of the H1N1 Vaccine Task Force at the Centers for Disease Control and Prevention.

To date, the federal government has purchased 195 million doses of the vaccine. All orders will be filled in increments of 100 doses.

The overall vaccine distribution process “was developed in collaboration with state and local health officials,” he said. “This approach provides state and local direction with flexibility in keeping with local needs. Distribution of vaccine can be achieved without rebuilding infrastructure for in-state distribution, which has mostly been lost within the last couple of years.”

The Countermeasure and Response Administration, a Web-based aggregate reporting by age group, will be used to track the number of doses being given. “This system may underestimate the number of doses that are administered,” Dr. Butler said. “There will be a certain amount of work involved in the data entry, and it's possible that vaccinators may not enter all the data.”

As for coverage assessment, the National Immunization Survey can begin collecting data as early as the week of Oct. 10, and provide weekly national coverage estimates, he said, while the Behavioral Risk Factor Surveillance System “will provide a more complete picture of vaccine coverage by state and in specific risk groups.” Updated data will be available as frequently as twice per month.

While some of the clinical trials of novel H1N1 vaccine have been underway since mid-July, Robin Robinson, Ph.D., said that no adverse events have been reported to date. “That is very encouraging,” said Dr. Robinson, director of the Biomedical Advanced Research and Development Authority.

During the 2-hour meeting, NVAC members approved two recommendations that will be passed along to the assistant secretary for health for review. One advises that the Department of Health and Human Services “develop, and where possible test in advance, a strong and organized response to scientific and public concerns about vaccine safety that may emerge during the 2009 H1N1 vaccination campaign.”

The other recommendation concerned the need for a “clear federal plan” to coordinate communications regarding the novel H1N1 influenza vaccination campaign.

This includes “delineating the difference between seasonal influenza and pandemic H1N1 influenza” and “reaching out to health care providers who do not usually supply vaccination services,” such as internists, obstetricians, and gynecologists.

When a vaccine for the novel influenza A(H1N1) virus is cleared for use, expect the distribution process to resemble the Vaccines for Children program.

The vaccine will be allocated to states based on their populations, Dr. Jay C. Butler said during a teleconference of the National Vaccine Advisory Committee (NVAC).

“Providers may include physicians' offices, hospitals, occupational health clinics, pharmacies, anyone the state designates as an appropriate recipient of vaccines to administer,” said Dr. Butler, director of the H1N1 Vaccine Task Force at the Centers for Disease Control and Prevention.

To date, the federal government has purchased 195 million doses of the vaccine. All orders will be filled in increments of 100 doses.

The overall vaccine distribution process “was developed in collaboration with state and local health officials,” he said. “This approach provides state and local direction with flexibility in keeping with local needs. Distribution of vaccine can be achieved without rebuilding infrastructure for in-state distribution, which has mostly been lost within the last couple of years.”

The Countermeasure and Response Administration, a Web-based aggregate reporting by age group, will be used to track the number of doses being given. “This system may underestimate the number of doses that are administered,” Dr. Butler said. “There will be a certain amount of work involved in the data entry, and it's possible that vaccinators may not enter all the data.”

As for coverage assessment, the National Immunization Survey can begin collecting data as early as the week of Oct. 10, and provide weekly national coverage estimates, he said, while the Behavioral Risk Factor Surveillance System “will provide a more complete picture of vaccine coverage by state and in specific risk groups.” Updated data will be available as frequently as twice per month.

While some of the clinical trials of novel H1N1 vaccine have been underway since mid-July, Robin Robinson, Ph.D., said that no adverse events have been reported to date. “That is very encouraging,” said Dr. Robinson, director of the Biomedical Advanced Research and Development Authority.

During the 2-hour meeting, NVAC members approved two recommendations that will be passed along to the assistant secretary for health for review. One advises that the Department of Health and Human Services “develop, and where possible test in advance, a strong and organized response to scientific and public concerns about vaccine safety that may emerge during the 2009 H1N1 vaccination campaign.”

The other recommendation concerned the need for a “clear federal plan” to coordinate communications regarding the novel H1N1 influenza vaccination campaign.

This includes “delineating the difference between seasonal influenza and pandemic H1N1 influenza” and “reaching out to health care providers who do not usually supply vaccination services,” such as internists, obstetricians, and gynecologists.

When a vaccine for the novel influenza A(H1N1) virus is cleared for use, expect the distribution process to resemble the Vaccines for Children program.

The vaccine will be allocated to states based on their populations, Dr. Jay C. Butler said during a teleconference of the National Vaccine Advisory Committee (NVAC).

“Providers may include physicians' offices, hospitals, occupational health clinics, pharmacies, anyone the state designates as an appropriate recipient of vaccines to administer,” said Dr. Butler, director of the H1N1 Vaccine Task Force at the Centers for Disease Control and Prevention.

To date, the federal government has purchased 195 million doses of the vaccine. All orders will be filled in increments of 100 doses.

The overall vaccine distribution process “was developed in collaboration with state and local health officials,” he said. “This approach provides state and local direction with flexibility in keeping with local needs. Distribution of vaccine can be achieved without rebuilding infrastructure for in-state distribution, which has mostly been lost within the last couple of years.”

The Countermeasure and Response Administration, a Web-based aggregate reporting by age group, will be used to track the number of doses being given. “This system may underestimate the number of doses that are administered,” Dr. Butler said. “There will be a certain amount of work involved in the data entry, and it's possible that vaccinators may not enter all the data.”

As for coverage assessment, the National Immunization Survey can begin collecting data as early as the week of Oct. 10, and provide weekly national coverage estimates, he said, while the Behavioral Risk Factor Surveillance System “will provide a more complete picture of vaccine coverage by state and in specific risk groups.” Updated data will be available as frequently as twice per month.

While some of the clinical trials of novel H1N1 vaccine have been underway since mid-July, Robin Robinson, Ph.D., said that no adverse events have been reported to date. “That is very encouraging,” said Dr. Robinson, director of the Biomedical Advanced Research and Development Authority.

During the 2-hour meeting, NVAC members approved two recommendations that will be passed along to the assistant secretary for health for review. One advises that the Department of Health and Human Services “develop, and where possible test in advance, a strong and organized response to scientific and public concerns about vaccine safety that may emerge during the 2009 H1N1 vaccination campaign.”

The other recommendation concerned the need for a “clear federal plan” to coordinate communications regarding the novel H1N1 influenza vaccination campaign.

This includes “delineating the difference between seasonal influenza and pandemic H1N1 influenza” and “reaching out to health care providers who do not usually supply vaccination services,” such as internists, obstetricians, and gynecologists.

SAN DIEGO – Alcohol-dependent patients who were older than age 30 and met certain DSM-IV criteria for alcohol dependence–including tolerance and continuing to drink despite its negative impact on important events–had less dramatic reduction in heavy drinking over time.

The findings suggest that alcohol-dependent patients with those characteristics may benefit from more aggressive intervention efforts, according to results from an analysis of data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

“There have been a number of studies that examined the predictors of change in heavy drinking status over time in the general population,” Khaled Sarsour, Ph.D., said in an interview after presenting the findings in a poster at the annual scientific conference of the Research Society on Alcoholism.

“However, to the best of our research team's knowledge, this was the first study that examined the predictors of change in the number of heavy drinking days within a U.S. nationally representative population of alcohol-dependent patients.”

Dr. Sarsour, a research scientist in the epidemiology and health services research group at Eli Lilly & Co., and his associates examined predictors of the change in frequency of heavy drinking among 1,053 alcohol-dependent patients from baseline (NESARC Wave 1, conducted in 2001-2002) to about 3 year later (NESARC Wave 2, conducted in 2004-2005). Frequency of heavy drinking was defined was the number of heavy drinking days (five drinks or more per day for men; four drinks or more per day for women) in the past year.

The researchers used an analysis of covariance model, adjusting for baseline heavy drinking days, to examine factors associated with change in the frequency of heavy drinking. More than half of patients (64%) were younger than age 39 years, 63% were male, 61% were white, and 37% were married.

Overall, the mean number of heavy drinking days among patients with alcohol dependence fell from 114 per year during NESARC Wave 1 to 84 per year during NESARC Wave 2.

Dr. Sarsour and his associates reported that the factors significantly associated with an increase of heavy drinking days between the two time periods were being older than age 30, being a current smoker, and fulfilling three DSM-IV criteria for dependence: tolerance, giving up or cutting back on important activities to drink, and drinking despite having physical and/or psychological problems.

Alcohol-dependent patients diagnosed with comorbid depression and/or dysthymia reported an additional significant mean decrease of 19 heavy drinking days, compared with their counterparts who were not diagnosed with those conditions.

“We were expecting sociodemographic variables such as level of education, marital status, gender, and ethnicity to be associated with change in heavy drinking over time,” Dr. Sarsour said. “However, in this study, none of these variables were significant predictors of change in heavy drinking status over time. This may have been due to the fact that the study population consisted of alcohol-dependent patients. We will do a follow-up analysis to see if these predictors are significant in predicting change in heavy drinking in non–alcohol-dependent patients from the same national data set.”

Dr. Sarsour and four other members of the research team are employees of Eli Lilly. The other member of the research team was Dr. Howard B. Moss of the National Institute on Alcohol Abuse and Alcoholism, which sponsored the study.

SAN DIEGO – Alcohol-dependent patients who were older than age 30 and met certain DSM-IV criteria for alcohol dependence–including tolerance and continuing to drink despite its negative impact on important events–had less dramatic reduction in heavy drinking over time.

The findings suggest that alcohol-dependent patients with those characteristics may benefit from more aggressive intervention efforts, according to results from an analysis of data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

“There have been a number of studies that examined the predictors of change in heavy drinking status over time in the general population,” Khaled Sarsour, Ph.D., said in an interview after presenting the findings in a poster at the annual scientific conference of the Research Society on Alcoholism.

“However, to the best of our research team's knowledge, this was the first study that examined the predictors of change in the number of heavy drinking days within a U.S. nationally representative population of alcohol-dependent patients.”

Dr. Sarsour, a research scientist in the epidemiology and health services research group at Eli Lilly & Co., and his associates examined predictors of the change in frequency of heavy drinking among 1,053 alcohol-dependent patients from baseline (NESARC Wave 1, conducted in 2001-2002) to about 3 year later (NESARC Wave 2, conducted in 2004-2005). Frequency of heavy drinking was defined was the number of heavy drinking days (five drinks or more per day for men; four drinks or more per day for women) in the past year.

The researchers used an analysis of covariance model, adjusting for baseline heavy drinking days, to examine factors associated with change in the frequency of heavy drinking. More than half of patients (64%) were younger than age 39 years, 63% were male, 61% were white, and 37% were married.

Overall, the mean number of heavy drinking days among patients with alcohol dependence fell from 114 per year during NESARC Wave 1 to 84 per year during NESARC Wave 2.

Dr. Sarsour and his associates reported that the factors significantly associated with an increase of heavy drinking days between the two time periods were being older than age 30, being a current smoker, and fulfilling three DSM-IV criteria for dependence: tolerance, giving up or cutting back on important activities to drink, and drinking despite having physical and/or psychological problems.

Alcohol-dependent patients diagnosed with comorbid depression and/or dysthymia reported an additional significant mean decrease of 19 heavy drinking days, compared with their counterparts who were not diagnosed with those conditions.

“We were expecting sociodemographic variables such as level of education, marital status, gender, and ethnicity to be associated with change in heavy drinking over time,” Dr. Sarsour said. “However, in this study, none of these variables were significant predictors of change in heavy drinking status over time. This may have been due to the fact that the study population consisted of alcohol-dependent patients. We will do a follow-up analysis to see if these predictors are significant in predicting change in heavy drinking in non–alcohol-dependent patients from the same national data set.”

Dr. Sarsour and four other members of the research team are employees of Eli Lilly. The other member of the research team was Dr. Howard B. Moss of the National Institute on Alcohol Abuse and Alcoholism, which sponsored the study.

SAN DIEGO – Alcohol-dependent patients who were older than age 30 and met certain DSM-IV criteria for alcohol dependence–including tolerance and continuing to drink despite its negative impact on important events–had less dramatic reduction in heavy drinking over time.

The findings suggest that alcohol-dependent patients with those characteristics may benefit from more aggressive intervention efforts, according to results from an analysis of data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

“There have been a number of studies that examined the predictors of change in heavy drinking status over time in the general population,” Khaled Sarsour, Ph.D., said in an interview after presenting the findings in a poster at the annual scientific conference of the Research Society on Alcoholism.

“However, to the best of our research team's knowledge, this was the first study that examined the predictors of change in the number of heavy drinking days within a U.S. nationally representative population of alcohol-dependent patients.”

Dr. Sarsour, a research scientist in the epidemiology and health services research group at Eli Lilly & Co., and his associates examined predictors of the change in frequency of heavy drinking among 1,053 alcohol-dependent patients from baseline (NESARC Wave 1, conducted in 2001-2002) to about 3 year later (NESARC Wave 2, conducted in 2004-2005). Frequency of heavy drinking was defined was the number of heavy drinking days (five drinks or more per day for men; four drinks or more per day for women) in the past year.

The researchers used an analysis of covariance model, adjusting for baseline heavy drinking days, to examine factors associated with change in the frequency of heavy drinking. More than half of patients (64%) were younger than age 39 years, 63% were male, 61% were white, and 37% were married.

Overall, the mean number of heavy drinking days among patients with alcohol dependence fell from 114 per year during NESARC Wave 1 to 84 per year during NESARC Wave 2.

Dr. Sarsour and his associates reported that the factors significantly associated with an increase of heavy drinking days between the two time periods were being older than age 30, being a current smoker, and fulfilling three DSM-IV criteria for dependence: tolerance, giving up or cutting back on important activities to drink, and drinking despite having physical and/or psychological problems.

Alcohol-dependent patients diagnosed with comorbid depression and/or dysthymia reported an additional significant mean decrease of 19 heavy drinking days, compared with their counterparts who were not diagnosed with those conditions.

“We were expecting sociodemographic variables such as level of education, marital status, gender, and ethnicity to be associated with change in heavy drinking over time,” Dr. Sarsour said. “However, in this study, none of these variables were significant predictors of change in heavy drinking status over time. This may have been due to the fact that the study population consisted of alcohol-dependent patients. We will do a follow-up analysis to see if these predictors are significant in predicting change in heavy drinking in non–alcohol-dependent patients from the same national data set.”

Dr. Sarsour and four other members of the research team are employees of Eli Lilly. The other member of the research team was Dr. Howard B. Moss of the National Institute on Alcohol Abuse and Alcoholism, which sponsored the study.

NEW ORLEANS — A baseline hemoglobin A_1c level that exceeds 8.5%, a prior clinical history of neuropathy, and/or use of aspirin may flag patients with type 2 diabetes who are at higher risk of mortality with intensive glycemia treatment.

Those are key findings from an analysis of patients enrolled in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, which targeted an HbA_1c of less than 6%. The trial was stopped after 3.5 years because of an increase in all-cause mortality in patients who received intensive glycemia treatment, compared with those who received standard treatment.

“Further analysis is obviously warranted,” Dr. Jorge Calles-Escandón said during the annual scientific sessions of the American Diabetes Association.

To determine if baseline clinical features could identify patients less suitable for intensive glycemic control, Dr. Calles-Escandón and his associates conducted an intention-to-treat analysis of the 10,251 patients in the ACCORD trial and all-cause mortality at the time intensive treatment was discontinued.

There were 257 deaths in the intensive-treatment group and 203 in the standard-treatment group. Dr. Calles-Escandón, an endocrinologist at Wake Forest University, Winston-Salem, N.C., reported that three baseline factors were significantly associated with an increased risk of mortality in the intensive-treatment group: an HbA_1c of 8.5% or greater (hazard ratio 1.64), self-reported history of neuropathy (HR 1.95), and aspirin use (HR 1.45).

Dr. Calles-Escandón is on the speakers bureau for Sanofi-Aventis and Merck, and has received grants from Merck.

NEW ORLEANS — A baseline hemoglobin A_1c level that exceeds 8.5%, a prior clinical history of neuropathy, and/or use of aspirin may flag patients with type 2 diabetes who are at higher risk of mortality with intensive glycemia treatment.

Those are key findings from an analysis of patients enrolled in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, which targeted an HbA_1c of less than 6%. The trial was stopped after 3.5 years because of an increase in all-cause mortality in patients who received intensive glycemia treatment, compared with those who received standard treatment.

“Further analysis is obviously warranted,” Dr. Jorge Calles-Escandón said during the annual scientific sessions of the American Diabetes Association.

To determine if baseline clinical features could identify patients less suitable for intensive glycemic control, Dr. Calles-Escandón and his associates conducted an intention-to-treat analysis of the 10,251 patients in the ACCORD trial and all-cause mortality at the time intensive treatment was discontinued.

There were 257 deaths in the intensive-treatment group and 203 in the standard-treatment group. Dr. Calles-Escandón, an endocrinologist at Wake Forest University, Winston-Salem, N.C., reported that three baseline factors were significantly associated with an increased risk of mortality in the intensive-treatment group: an HbA_1c of 8.5% or greater (hazard ratio 1.64), self-reported history of neuropathy (HR 1.95), and aspirin use (HR 1.45).

Dr. Calles-Escandón is on the speakers bureau for Sanofi-Aventis and Merck, and has received grants from Merck.

NEW ORLEANS — A baseline hemoglobin A_1c level that exceeds 8.5%, a prior clinical history of neuropathy, and/or use of aspirin may flag patients with type 2 diabetes who are at higher risk of mortality with intensive glycemia treatment.

Those are key findings from an analysis of patients enrolled in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, which targeted an HbA_1c of less than 6%. The trial was stopped after 3.5 years because of an increase in all-cause mortality in patients who received intensive glycemia treatment, compared with those who received standard treatment.

“Further analysis is obviously warranted,” Dr. Jorge Calles-Escandón said during the annual scientific sessions of the American Diabetes Association.

To determine if baseline clinical features could identify patients less suitable for intensive glycemic control, Dr. Calles-Escandón and his associates conducted an intention-to-treat analysis of the 10,251 patients in the ACCORD trial and all-cause mortality at the time intensive treatment was discontinued.

There were 257 deaths in the intensive-treatment group and 203 in the standard-treatment group. Dr. Calles-Escandón, an endocrinologist at Wake Forest University, Winston-Salem, N.C., reported that three baseline factors were significantly associated with an increased risk of mortality in the intensive-treatment group: an HbA_1c of 8.5% or greater (hazard ratio 1.64), self-reported history of neuropathy (HR 1.95), and aspirin use (HR 1.45).

Dr. Calles-Escandón is on the speakers bureau for Sanofi-Aventis and Merck, and has received grants from Merck.