Doug Brunk

Afully sustained, disease-modifying-antirheumatic-drug-free remission occurred in 15% of patients using conventional, nonbiologic therapy, according to results from a large 10-year study.

“We were surprised by the high number of patients who achieved remission,” Dr. Diane van der Woude of Leiden University Medical Centre (Netherlands), and the study's lead author, said in an interview. The data was reported at the annual European Congress of Rheumatology. “The patients we studied were enrolled between 1993 and 2003, a time when there were no biological agents available and disease activity was not strictly monitored. That 15% of patients treated with conventional therapy achieved remission is a useful number to keep in mind as a reference when reading reports of remission percentages after treatment with novel agents.”

She looked at 454 RA patients. Patients were treated with a delayed or early treatment strategy with chloroquine, sulfasalazine, or methotrexate. They defined DMARD-free remission as absence of synovitis without concomitant use of disease-modifying antirheumatic drugs (DMARDs) for more than 1 year. Average follow-up was 8 years. Of the 454 RA patients, 69 (15%) achieved DMARD-free remission.

Univariate analysis revealed that the following were significantly associated with achieving DMARD-free remission: negative family history (hazard ratio of 1.8), short duration of complaints before presentation (HR 1.08 per month), nonsmoking (HR 1.8), low C-reactive protein at baseline (HR 1.01 per mg/L), absence of IgM rheumatoid factor and anti-CCP antibodies (HR 5.9 and 11.6, respectively), and absence of HLA shared epitope alleles (HR 2.1).

Multivariate analysis revealed that low C-reactive protein at baseline and absence of anti-CCP antibodies were significant independent predictors for DMARD-free remission.

“We are currently working on replication of these data in another large [non-Dutch] early arthritis cohort, also consisting of patients treated with conventional antirheumatic therapy,” Dr. van der Woude said in an interview. “It will be interesting to see if we and our collaborators will find a similar prevalence of DMARD-free remission and similar predictive characteristics,” she added.

Afully sustained, disease-modifying-antirheumatic-drug-free remission occurred in 15% of patients using conventional, nonbiologic therapy, according to results from a large 10-year study.

“We were surprised by the high number of patients who achieved remission,” Dr. Diane van der Woude of Leiden University Medical Centre (Netherlands), and the study's lead author, said in an interview. The data was reported at the annual European Congress of Rheumatology. “The patients we studied were enrolled between 1993 and 2003, a time when there were no biological agents available and disease activity was not strictly monitored. That 15% of patients treated with conventional therapy achieved remission is a useful number to keep in mind as a reference when reading reports of remission percentages after treatment with novel agents.”

She looked at 454 RA patients. Patients were treated with a delayed or early treatment strategy with chloroquine, sulfasalazine, or methotrexate. They defined DMARD-free remission as absence of synovitis without concomitant use of disease-modifying antirheumatic drugs (DMARDs) for more than 1 year. Average follow-up was 8 years. Of the 454 RA patients, 69 (15%) achieved DMARD-free remission.

Univariate analysis revealed that the following were significantly associated with achieving DMARD-free remission: negative family history (hazard ratio of 1.8), short duration of complaints before presentation (HR 1.08 per month), nonsmoking (HR 1.8), low C-reactive protein at baseline (HR 1.01 per mg/L), absence of IgM rheumatoid factor and anti-CCP antibodies (HR 5.9 and 11.6, respectively), and absence of HLA shared epitope alleles (HR 2.1).

Multivariate analysis revealed that low C-reactive protein at baseline and absence of anti-CCP antibodies were significant independent predictors for DMARD-free remission.

“We are currently working on replication of these data in another large [non-Dutch] early arthritis cohort, also consisting of patients treated with conventional antirheumatic therapy,” Dr. van der Woude said in an interview. “It will be interesting to see if we and our collaborators will find a similar prevalence of DMARD-free remission and similar predictive characteristics,” she added.

Afully sustained, disease-modifying-antirheumatic-drug-free remission occurred in 15% of patients using conventional, nonbiologic therapy, according to results from a large 10-year study.

“We were surprised by the high number of patients who achieved remission,” Dr. Diane van der Woude of Leiden University Medical Centre (Netherlands), and the study's lead author, said in an interview. The data was reported at the annual European Congress of Rheumatology. “The patients we studied were enrolled between 1993 and 2003, a time when there were no biological agents available and disease activity was not strictly monitored. That 15% of patients treated with conventional therapy achieved remission is a useful number to keep in mind as a reference when reading reports of remission percentages after treatment with novel agents.”

She looked at 454 RA patients. Patients were treated with a delayed or early treatment strategy with chloroquine, sulfasalazine, or methotrexate. They defined DMARD-free remission as absence of synovitis without concomitant use of disease-modifying antirheumatic drugs (DMARDs) for more than 1 year. Average follow-up was 8 years. Of the 454 RA patients, 69 (15%) achieved DMARD-free remission.

Univariate analysis revealed that the following were significantly associated with achieving DMARD-free remission: negative family history (hazard ratio of 1.8), short duration of complaints before presentation (HR 1.08 per month), nonsmoking (HR 1.8), low C-reactive protein at baseline (HR 1.01 per mg/L), absence of IgM rheumatoid factor and anti-CCP antibodies (HR 5.9 and 11.6, respectively), and absence of HLA shared epitope alleles (HR 2.1).

Multivariate analysis revealed that low C-reactive protein at baseline and absence of anti-CCP antibodies were significant independent predictors for DMARD-free remission.

“We are currently working on replication of these data in another large [non-Dutch] early arthritis cohort, also consisting of patients treated with conventional antirheumatic therapy,” Dr. van der Woude said in an interview. “It will be interesting to see if we and our collaborators will find a similar prevalence of DMARD-free remission and similar predictive characteristics,” she added.

SAN DIEGO — Patients with ST segment elevation MI who underwent off-pump coronary artery bypass grafting had significantly lower morbidity and mortality compared with patients who underwent on-pump CABG, results from a randomized, single-center Italian study showed.

Between February 2002 and October 2007, 127 patients underwent CABG at the University of Palermo, Italy, within 48 hours from onset of symptoms. Patients were included in the study if they had evolving myocardial ischemia refractory to medical therapy; presence of left main stenosis and/or three-vessel disease; ongoing ischemia despite successful or failed percutaneous coronary intervention (PCI); or complicated PCI; or if they were in cardiogenic shock and had complex coronary anatomy.

Of the 127 patients, 65 were assigned to receive on-pump therapy while 62 received off-pump therapy, Dr. Khalil Fattouch reported at the annual meeting of the American Association for Thoracic Surgery.

The mean age of patients was 62 years and 22% were older than age 70. The only statistically significant preoperative differences between the two groups were related to gender (77% in the on-pump group were men vs. 61% in the off-pump group), and history of a previous myocardial infarction (19% in the on-pump group vs. 39% in the off-pump group), said Dr. Fattouch of the department of cardiac surgery at the university.

The mean number of grafts used per patient was 2.8 in the on-pump group vs. 2.6 in the off-pump group, a difference that was not statistically significant. The mean follow-up was 22 months.

Dr. Fattouch reported that the overall in-hospital mortality was 4.7%. In-hospital mortality was significantly higher for the on-pump group compared with the off-pump group (7.7% vs. 1.6%, respectively). More on-pump group patients in cardiac shock died in the hospital compared with their off-pump counterparts (27% vs. 7.5%) as did on-pump patients who underwent CABG in less than 6 hours from onset of symptoms (23% vs. 7.5%).

Intraoperatively, the use of catecholamines, time of inotrope support, time of intra-aortic balloon pump use, and length of mechanical ventilation were significantly greater in the on-pump group compared with the off-pump group.

Postoperatively, the incidence of low cardiac output syndrome, reoperations for bleeding, and lengths of ICU and hospital stays were significantly greater in the on-pump group compared with the off-pump group.

In addition, the serum levels of troponin I and creatine kinase MB were higher during the first 48 hours after surgery in the on-pump group compared with the off-pump group, said Dr. Fattouch, who disclosed that he had no conflicts of interest.

SAN DIEGO — Patients with ST segment elevation MI who underwent off-pump coronary artery bypass grafting had significantly lower morbidity and mortality compared with patients who underwent on-pump CABG, results from a randomized, single-center Italian study showed.

Between February 2002 and October 2007, 127 patients underwent CABG at the University of Palermo, Italy, within 48 hours from onset of symptoms. Patients were included in the study if they had evolving myocardial ischemia refractory to medical therapy; presence of left main stenosis and/or three-vessel disease; ongoing ischemia despite successful or failed percutaneous coronary intervention (PCI); or complicated PCI; or if they were in cardiogenic shock and had complex coronary anatomy.

Of the 127 patients, 65 were assigned to receive on-pump therapy while 62 received off-pump therapy, Dr. Khalil Fattouch reported at the annual meeting of the American Association for Thoracic Surgery.

The mean age of patients was 62 years and 22% were older than age 70. The only statistically significant preoperative differences between the two groups were related to gender (77% in the on-pump group were men vs. 61% in the off-pump group), and history of a previous myocardial infarction (19% in the on-pump group vs. 39% in the off-pump group), said Dr. Fattouch of the department of cardiac surgery at the university.

The mean number of grafts used per patient was 2.8 in the on-pump group vs. 2.6 in the off-pump group, a difference that was not statistically significant. The mean follow-up was 22 months.

Dr. Fattouch reported that the overall in-hospital mortality was 4.7%. In-hospital mortality was significantly higher for the on-pump group compared with the off-pump group (7.7% vs. 1.6%, respectively). More on-pump group patients in cardiac shock died in the hospital compared with their off-pump counterparts (27% vs. 7.5%) as did on-pump patients who underwent CABG in less than 6 hours from onset of symptoms (23% vs. 7.5%).

Intraoperatively, the use of catecholamines, time of inotrope support, time of intra-aortic balloon pump use, and length of mechanical ventilation were significantly greater in the on-pump group compared with the off-pump group.

Postoperatively, the incidence of low cardiac output syndrome, reoperations for bleeding, and lengths of ICU and hospital stays were significantly greater in the on-pump group compared with the off-pump group.

In addition, the serum levels of troponin I and creatine kinase MB were higher during the first 48 hours after surgery in the on-pump group compared with the off-pump group, said Dr. Fattouch, who disclosed that he had no conflicts of interest.

SAN DIEGO — Patients with ST segment elevation MI who underwent off-pump coronary artery bypass grafting had significantly lower morbidity and mortality compared with patients who underwent on-pump CABG, results from a randomized, single-center Italian study showed.

Between February 2002 and October 2007, 127 patients underwent CABG at the University of Palermo, Italy, within 48 hours from onset of symptoms. Patients were included in the study if they had evolving myocardial ischemia refractory to medical therapy; presence of left main stenosis and/or three-vessel disease; ongoing ischemia despite successful or failed percutaneous coronary intervention (PCI); or complicated PCI; or if they were in cardiogenic shock and had complex coronary anatomy.

Of the 127 patients, 65 were assigned to receive on-pump therapy while 62 received off-pump therapy, Dr. Khalil Fattouch reported at the annual meeting of the American Association for Thoracic Surgery.

The mean age of patients was 62 years and 22% were older than age 70. The only statistically significant preoperative differences between the two groups were related to gender (77% in the on-pump group were men vs. 61% in the off-pump group), and history of a previous myocardial infarction (19% in the on-pump group vs. 39% in the off-pump group), said Dr. Fattouch of the department of cardiac surgery at the university.

The mean number of grafts used per patient was 2.8 in the on-pump group vs. 2.6 in the off-pump group, a difference that was not statistically significant. The mean follow-up was 22 months.

Dr. Fattouch reported that the overall in-hospital mortality was 4.7%. In-hospital mortality was significantly higher for the on-pump group compared with the off-pump group (7.7% vs. 1.6%, respectively). More on-pump group patients in cardiac shock died in the hospital compared with their off-pump counterparts (27% vs. 7.5%) as did on-pump patients who underwent CABG in less than 6 hours from onset of symptoms (23% vs. 7.5%).

Intraoperatively, the use of catecholamines, time of inotrope support, time of intra-aortic balloon pump use, and length of mechanical ventilation were significantly greater in the on-pump group compared with the off-pump group.

Postoperatively, the incidence of low cardiac output syndrome, reoperations for bleeding, and lengths of ICU and hospital stays were significantly greater in the on-pump group compared with the off-pump group.

In addition, the serum levels of troponin I and creatine kinase MB were higher during the first 48 hours after surgery in the on-pump group compared with the off-pump group, said Dr. Fattouch, who disclosed that he had no conflicts of interest.

SAN DIEGO — Brain development at birth is significantly delayed in full-term neonates with complex congenital heart defects, both on magnetic resonance imaging and by mean head circumference, results from a single-center study suggest.

These observations “should stimulate discussion on the optimal timing of labor induction for those infants with prenatally diagnosed heart defects,” Dr. Daniel J. Licht said at the annual meeting of the American Association for Thoracic Surgery.

“Historically, the timing of delivery for neonates with prenatally diagnosed congenital heart disease was determined by lung maturity and surgical logistics. The current study suggests that neonates with complex CHD should be delivered as close to term as possible.”

Dr. Licht, a child neurologist at Children's Hospital of Philadelphia, noted that previous studies have shown that at birth, term infants with complex congenital heart defects have smaller head circumferences and, on MRI, have been shown to have structural simplicity of the brain as seen by open operculum. Dr. Licht and his associates hypothesized that term infants with complex forms of congenital heart defects have structurally delayed brain development as measured by smaller head circumferences and a lower total maturation score (TMS), a validated MRI metric for assessing full brain maturity.

A 3-Tesla MRI was used to evaluate 29 full-term infants with hypoplastic left heart syndrome (HLHS) and 13 with transposition of the great arteries (TGA) just prior to heart surgery. Infants with evidence of perinatal distress, shock, or intrauterine growth retardation were excluded from the study “as these were felt to be independent risks for brain injury,” said Dr. Licht, who had no conflicts of interest to disclose.

Clinical studies were reviewed by a single neuroradiologist who was blinded to the clinical data and TMS were rated by two MRI readers who also were blinded to the data. The findings were compared with published normative data of similar gestational age.

The mean gestational age of the 42 infants studied was 39 weeks and 64% were boys. Their average birth weight was 3.4 kg.

The average head circumference for infants in the study was 34.5 cm, which is a full standard deviation below the expected normal of 35.5 cm. In addition, open operculum was seen on MRI in 36 of the infants (86%), and would be expected in less than 5%-10% of normal full-term infants.

The average TMS for infants in the study was just over 10, which is significantly lower than reported normative TMS of 11.1 in noncardiac infants with a gestational age of 36–37 weeks.

“This average TMS … places our term infants with congenital heart defects at 35 weeks of gestational age, a time where white matter remains vulnerable and myelination is just beginning,” Dr. Licht said. “This group of otherwise healthy term babies with congenital heart defects has immature brains as evidenced by the high prevalence of small head circumferences and open opercula and corroborated with the finding of reduced TMS scores, suggesting a delay in brain maturity of a full month.”

The study was funded by the National Institute of Neurological Disorders and Stroke and by the Dana Foundation.

Open operculum, indicating structural simplicity of the brain, was seen in 86% of neonates with congenital heart defects. Courtesy Dr. Daniel J. Licht

SAN DIEGO — Brain development at birth is significantly delayed in full-term neonates with complex congenital heart defects, both on magnetic resonance imaging and by mean head circumference, results from a single-center study suggest.

These observations “should stimulate discussion on the optimal timing of labor induction for those infants with prenatally diagnosed heart defects,” Dr. Daniel J. Licht said at the annual meeting of the American Association for Thoracic Surgery.

“Historically, the timing of delivery for neonates with prenatally diagnosed congenital heart disease was determined by lung maturity and surgical logistics. The current study suggests that neonates with complex CHD should be delivered as close to term as possible.”

Dr. Licht, a child neurologist at Children's Hospital of Philadelphia, noted that previous studies have shown that at birth, term infants with complex congenital heart defects have smaller head circumferences and, on MRI, have been shown to have structural simplicity of the brain as seen by open operculum. Dr. Licht and his associates hypothesized that term infants with complex forms of congenital heart defects have structurally delayed brain development as measured by smaller head circumferences and a lower total maturation score (TMS), a validated MRI metric for assessing full brain maturity.

A 3-Tesla MRI was used to evaluate 29 full-term infants with hypoplastic left heart syndrome (HLHS) and 13 with transposition of the great arteries (TGA) just prior to heart surgery. Infants with evidence of perinatal distress, shock, or intrauterine growth retardation were excluded from the study “as these were felt to be independent risks for brain injury,” said Dr. Licht, who had no conflicts of interest to disclose.

Clinical studies were reviewed by a single neuroradiologist who was blinded to the clinical data and TMS were rated by two MRI readers who also were blinded to the data. The findings were compared with published normative data of similar gestational age.

The mean gestational age of the 42 infants studied was 39 weeks and 64% were boys. Their average birth weight was 3.4 kg.

The average head circumference for infants in the study was 34.5 cm, which is a full standard deviation below the expected normal of 35.5 cm. In addition, open operculum was seen on MRI in 36 of the infants (86%), and would be expected in less than 5%-10% of normal full-term infants.

The average TMS for infants in the study was just over 10, which is significantly lower than reported normative TMS of 11.1 in noncardiac infants with a gestational age of 36–37 weeks.

“This average TMS … places our term infants with congenital heart defects at 35 weeks of gestational age, a time where white matter remains vulnerable and myelination is just beginning,” Dr. Licht said. “This group of otherwise healthy term babies with congenital heart defects has immature brains as evidenced by the high prevalence of small head circumferences and open opercula and corroborated with the finding of reduced TMS scores, suggesting a delay in brain maturity of a full month.”

The study was funded by the National Institute of Neurological Disorders and Stroke and by the Dana Foundation.

Open operculum, indicating structural simplicity of the brain, was seen in 86% of neonates with congenital heart defects. Courtesy Dr. Daniel J. Licht

SAN DIEGO — Brain development at birth is significantly delayed in full-term neonates with complex congenital heart defects, both on magnetic resonance imaging and by mean head circumference, results from a single-center study suggest.

These observations “should stimulate discussion on the optimal timing of labor induction for those infants with prenatally diagnosed heart defects,” Dr. Daniel J. Licht said at the annual meeting of the American Association for Thoracic Surgery.

“Historically, the timing of delivery for neonates with prenatally diagnosed congenital heart disease was determined by lung maturity and surgical logistics. The current study suggests that neonates with complex CHD should be delivered as close to term as possible.”

Dr. Licht, a child neurologist at Children's Hospital of Philadelphia, noted that previous studies have shown that at birth, term infants with complex congenital heart defects have smaller head circumferences and, on MRI, have been shown to have structural simplicity of the brain as seen by open operculum. Dr. Licht and his associates hypothesized that term infants with complex forms of congenital heart defects have structurally delayed brain development as measured by smaller head circumferences and a lower total maturation score (TMS), a validated MRI metric for assessing full brain maturity.

A 3-Tesla MRI was used to evaluate 29 full-term infants with hypoplastic left heart syndrome (HLHS) and 13 with transposition of the great arteries (TGA) just prior to heart surgery. Infants with evidence of perinatal distress, shock, or intrauterine growth retardation were excluded from the study “as these were felt to be independent risks for brain injury,” said Dr. Licht, who had no conflicts of interest to disclose.

Clinical studies were reviewed by a single neuroradiologist who was blinded to the clinical data and TMS were rated by two MRI readers who also were blinded to the data. The findings were compared with published normative data of similar gestational age.

The mean gestational age of the 42 infants studied was 39 weeks and 64% were boys. Their average birth weight was 3.4 kg.

The average head circumference for infants in the study was 34.5 cm, which is a full standard deviation below the expected normal of 35.5 cm. In addition, open operculum was seen on MRI in 36 of the infants (86%), and would be expected in less than 5%-10% of normal full-term infants.

The average TMS for infants in the study was just over 10, which is significantly lower than reported normative TMS of 11.1 in noncardiac infants with a gestational age of 36–37 weeks.

“This average TMS … places our term infants with congenital heart defects at 35 weeks of gestational age, a time where white matter remains vulnerable and myelination is just beginning,” Dr. Licht said. “This group of otherwise healthy term babies with congenital heart defects has immature brains as evidenced by the high prevalence of small head circumferences and open opercula and corroborated with the finding of reduced TMS scores, suggesting a delay in brain maturity of a full month.”

The study was funded by the National Institute of Neurological Disorders and Stroke and by the Dana Foundation.

Open operculum, indicating structural simplicity of the brain, was seen in 86% of neonates with congenital heart defects. Courtesy Dr. Daniel J. Licht

Children with attention-deficit/hyperactivity disorder who wore Daytrana methylphenidate transdermal patches for stretches of 4 or 6 hours experienced improvements in their ADHD symptoms, results from a multicenter controlled trial of 117 young patients showed.

The findings “suggest that the duration of effect for ADHD is related to the length of time that the patch is worn, thereby offering flexibility in the duration of effect on ADHD up to the recommended 9-hour wear time,” Dr. Timothy E. Wilens and his associates reported.

A previous study showed improvements in ADHD symptoms from 2 to 12 hours with a 9-hour wear time; but prior to the current trial, the researchers explained, no data were “available on the duration of action of shorter wear times of the patch or the length of time after patch removal that symptoms of ADHD return appreciably.”

For the multicenter, placebo-controlled, randomized, double-blind, crossover study, 117 children with ADHD aged 6–12 years underwent optimal methylphenidate dosing over a 5-week period using 10-, 15-, 20-, or 30- mg patches worn for 9 hours. The efficacy of 4- and 6-hour wear times was then assessed in analog classroom sessions during weeks 6–8. Follow-ups were conducted at week 12 (J. Am. Acad. Child Adolesc. Psych. 2008;47:700–8).

The main efficacy measures were the Swanson, Kotkin, Agler, M-Flynn, and Pelham Rating Scale (SKAMP) deportment scale and the Permanent Product Measure of Performance (PERMP) math test. Secondary efficacy measures included the Attention-Deficit/Hyperactivity Scale IV, the Clinical Global Impressions-Improvement, the Parent Global Assessment, and the Conners' Parent Rating Scale.

Dr. Wilens of Harvard Medical School and the pediatric pharmacology unit at Massachusetts General Hospital, both in Boston, and his associates reported that all efficacy measures indicated that the 4- and 6-hour wear times improved ADHD symptoms, and that medication effects as measured by the SKAMP deportment scale and the PERMP math problems assessment decreased 2–4 hours after patch removal.

Adverse effects were mild or moderate and limited to those most commonly seen with traditional methylphenidate treatment: decreased appetite and headache.

The study was funded by Shire Development Inc., which manufactures the Daytrana patches. Dr. Wilens and his associates disclosed that they receive or have received research support from, acted as a consultant to, and/or served on the speakers bureaus of many pharmaceutical companies, including Shire.

The researchers said further studies are needed “evaluating the impact of variable wear times on specific short- and longer-term adverse effects.”

Children with attention-deficit/hyperactivity disorder who wore Daytrana methylphenidate transdermal patches for stretches of 4 or 6 hours experienced improvements in their ADHD symptoms, results from a multicenter controlled trial of 117 young patients showed.

The findings “suggest that the duration of effect for ADHD is related to the length of time that the patch is worn, thereby offering flexibility in the duration of effect on ADHD up to the recommended 9-hour wear time,” Dr. Timothy E. Wilens and his associates reported.

A previous study showed improvements in ADHD symptoms from 2 to 12 hours with a 9-hour wear time; but prior to the current trial, the researchers explained, no data were “available on the duration of action of shorter wear times of the patch or the length of time after patch removal that symptoms of ADHD return appreciably.”

For the multicenter, placebo-controlled, randomized, double-blind, crossover study, 117 children with ADHD aged 6–12 years underwent optimal methylphenidate dosing over a 5-week period using 10-, 15-, 20-, or 30- mg patches worn for 9 hours. The efficacy of 4- and 6-hour wear times was then assessed in analog classroom sessions during weeks 6–8. Follow-ups were conducted at week 12 (J. Am. Acad. Child Adolesc. Psych. 2008;47:700–8).

The main efficacy measures were the Swanson, Kotkin, Agler, M-Flynn, and Pelham Rating Scale (SKAMP) deportment scale and the Permanent Product Measure of Performance (PERMP) math test. Secondary efficacy measures included the Attention-Deficit/Hyperactivity Scale IV, the Clinical Global Impressions-Improvement, the Parent Global Assessment, and the Conners' Parent Rating Scale.

Dr. Wilens of Harvard Medical School and the pediatric pharmacology unit at Massachusetts General Hospital, both in Boston, and his associates reported that all efficacy measures indicated that the 4- and 6-hour wear times improved ADHD symptoms, and that medication effects as measured by the SKAMP deportment scale and the PERMP math problems assessment decreased 2–4 hours after patch removal.

Adverse effects were mild or moderate and limited to those most commonly seen with traditional methylphenidate treatment: decreased appetite and headache.

The study was funded by Shire Development Inc., which manufactures the Daytrana patches. Dr. Wilens and his associates disclosed that they receive or have received research support from, acted as a consultant to, and/or served on the speakers bureaus of many pharmaceutical companies, including Shire.

The researchers said further studies are needed “evaluating the impact of variable wear times on specific short- and longer-term adverse effects.”

Children with attention-deficit/hyperactivity disorder who wore Daytrana methylphenidate transdermal patches for stretches of 4 or 6 hours experienced improvements in their ADHD symptoms, results from a multicenter controlled trial of 117 young patients showed.

The findings “suggest that the duration of effect for ADHD is related to the length of time that the patch is worn, thereby offering flexibility in the duration of effect on ADHD up to the recommended 9-hour wear time,” Dr. Timothy E. Wilens and his associates reported.

A previous study showed improvements in ADHD symptoms from 2 to 12 hours with a 9-hour wear time; but prior to the current trial, the researchers explained, no data were “available on the duration of action of shorter wear times of the patch or the length of time after patch removal that symptoms of ADHD return appreciably.”

For the multicenter, placebo-controlled, randomized, double-blind, crossover study, 117 children with ADHD aged 6–12 years underwent optimal methylphenidate dosing over a 5-week period using 10-, 15-, 20-, or 30- mg patches worn for 9 hours. The efficacy of 4- and 6-hour wear times was then assessed in analog classroom sessions during weeks 6–8. Follow-ups were conducted at week 12 (J. Am. Acad. Child Adolesc. Psych. 2008;47:700–8).

The main efficacy measures were the Swanson, Kotkin, Agler, M-Flynn, and Pelham Rating Scale (SKAMP) deportment scale and the Permanent Product Measure of Performance (PERMP) math test. Secondary efficacy measures included the Attention-Deficit/Hyperactivity Scale IV, the Clinical Global Impressions-Improvement, the Parent Global Assessment, and the Conners' Parent Rating Scale.

Dr. Wilens of Harvard Medical School and the pediatric pharmacology unit at Massachusetts General Hospital, both in Boston, and his associates reported that all efficacy measures indicated that the 4- and 6-hour wear times improved ADHD symptoms, and that medication effects as measured by the SKAMP deportment scale and the PERMP math problems assessment decreased 2–4 hours after patch removal.

Adverse effects were mild or moderate and limited to those most commonly seen with traditional methylphenidate treatment: decreased appetite and headache.

The study was funded by Shire Development Inc., which manufactures the Daytrana patches. Dr. Wilens and his associates disclosed that they receive or have received research support from, acted as a consultant to, and/or served on the speakers bureaus of many pharmaceutical companies, including Shire.

The researchers said further studies are needed “evaluating the impact of variable wear times on specific short- and longer-term adverse effects.”

SAN DIEGO — Underweight patients have poorer overall outcomes in vascular surgery, yet morbidly obese patients have increased morbidity, primarily due to wound infections, renal complications, and thromboembolic complications, results from a multicenter analysis showed.

“There are no large studies on the effect of obesity on vascular surgery,” Dr. Eleftherios S. Xenos said at the Vascular Annual Meeting. “There is some agreement that wound infection tends to be higher in obese patients, but in terms of mortality there has not been a definite answer.”

Dr. Xenos and his associates queried the Patient Safety in Surgery Study Database for a sample of major vascular procedures performed at 14 academic medical centers in the United States between 2002 and 2004. They obtained data on 7,543 vascular surgery patients that included the National Surgical Quality Improvement Program (NSQIP) clinical definitions of patient risk factors and 30-day outcomes.

Of the 7,543 patients, 4.6% were underweight (body mass index [BMI] of less than 18.5 kg/m

Vascular procedures performed included lower extremity revascularization (24.5%), aneurysm repair (17.4%), cerebrovascular procedures (17.3%), amputations (9.4%), and “other” (31.4%). Within 30 days after surgery, 1,659 patients (22%) developed complications and 295 (3.9%) died.

As expected, risk factors for hypertension and diabetes increased with increasing BMI. However, rates of smoking, stroke, and recent weight loss—defined as more than 10% of body weight—decreased as BMI increased.

The top three NSQIP predictors of vascular surgery mortality were presence of preoperative sepsis, American Society of Anesthesiologists' physical status classification, and functional dependence. “For these three risk factors, the overweight and obese I patients had the least amount of risk, with the highest risk in the underweight category,” Dr. Xenos said.

“The overweight and obese I category patients had a significantly higher albumin level, as compared with normal class patients,” Dr. Xenos reported.

The distribution of major complications among patients was U-shaped, with a higher incidence of complications among underweight patients and the lowest among the normal weight, overweight, and obese I category patients.

Obese II and obese III category patients had a significantly higher incidence of wound infections and renal and urinary tract infection complications, while morbidly obese patients had a significantly higher incidence of thromboembolic complications.

After the researchers adjusted for age, gender, and type of operation, the 30-day mortality risk was lowest among the obese I patients (OR 0.53) and highest among the underweight patients (OR 1.48).

“Mild obesity may have an independent protective effect on nutrition, metabolic status, and improved cardiac performance,” said Dr. Xenos, who had no conflicts to disclose.

'Mild obesity may have an independent protective effect.' DR. XENOS

SAN DIEGO — Underweight patients have poorer overall outcomes in vascular surgery, yet morbidly obese patients have increased morbidity, primarily due to wound infections, renal complications, and thromboembolic complications, results from a multicenter analysis showed.

“There are no large studies on the effect of obesity on vascular surgery,” Dr. Eleftherios S. Xenos said at the Vascular Annual Meeting. “There is some agreement that wound infection tends to be higher in obese patients, but in terms of mortality there has not been a definite answer.”

Dr. Xenos and his associates queried the Patient Safety in Surgery Study Database for a sample of major vascular procedures performed at 14 academic medical centers in the United States between 2002 and 2004. They obtained data on 7,543 vascular surgery patients that included the National Surgical Quality Improvement Program (NSQIP) clinical definitions of patient risk factors and 30-day outcomes.

Of the 7,543 patients, 4.6% were underweight (body mass index [BMI] of less than 18.5 kg/m

Vascular procedures performed included lower extremity revascularization (24.5%), aneurysm repair (17.4%), cerebrovascular procedures (17.3%), amputations (9.4%), and “other” (31.4%). Within 30 days after surgery, 1,659 patients (22%) developed complications and 295 (3.9%) died.

As expected, risk factors for hypertension and diabetes increased with increasing BMI. However, rates of smoking, stroke, and recent weight loss—defined as more than 10% of body weight—decreased as BMI increased.

The top three NSQIP predictors of vascular surgery mortality were presence of preoperative sepsis, American Society of Anesthesiologists' physical status classification, and functional dependence. “For these three risk factors, the overweight and obese I patients had the least amount of risk, with the highest risk in the underweight category,” Dr. Xenos said.

“The overweight and obese I category patients had a significantly higher albumin level, as compared with normal class patients,” Dr. Xenos reported.

The distribution of major complications among patients was U-shaped, with a higher incidence of complications among underweight patients and the lowest among the normal weight, overweight, and obese I category patients.

Obese II and obese III category patients had a significantly higher incidence of wound infections and renal and urinary tract infection complications, while morbidly obese patients had a significantly higher incidence of thromboembolic complications.

After the researchers adjusted for age, gender, and type of operation, the 30-day mortality risk was lowest among the obese I patients (OR 0.53) and highest among the underweight patients (OR 1.48).

“Mild obesity may have an independent protective effect on nutrition, metabolic status, and improved cardiac performance,” said Dr. Xenos, who had no conflicts to disclose.

'Mild obesity may have an independent protective effect.' DR. XENOS

SAN DIEGO — Underweight patients have poorer overall outcomes in vascular surgery, yet morbidly obese patients have increased morbidity, primarily due to wound infections, renal complications, and thromboembolic complications, results from a multicenter analysis showed.

“There are no large studies on the effect of obesity on vascular surgery,” Dr. Eleftherios S. Xenos said at the Vascular Annual Meeting. “There is some agreement that wound infection tends to be higher in obese patients, but in terms of mortality there has not been a definite answer.”

Dr. Xenos and his associates queried the Patient Safety in Surgery Study Database for a sample of major vascular procedures performed at 14 academic medical centers in the United States between 2002 and 2004. They obtained data on 7,543 vascular surgery patients that included the National Surgical Quality Improvement Program (NSQIP) clinical definitions of patient risk factors and 30-day outcomes.

Of the 7,543 patients, 4.6% were underweight (body mass index [BMI] of less than 18.5 kg/m

Vascular procedures performed included lower extremity revascularization (24.5%), aneurysm repair (17.4%), cerebrovascular procedures (17.3%), amputations (9.4%), and “other” (31.4%). Within 30 days after surgery, 1,659 patients (22%) developed complications and 295 (3.9%) died.

As expected, risk factors for hypertension and diabetes increased with increasing BMI. However, rates of smoking, stroke, and recent weight loss—defined as more than 10% of body weight—decreased as BMI increased.

The top three NSQIP predictors of vascular surgery mortality were presence of preoperative sepsis, American Society of Anesthesiologists' physical status classification, and functional dependence. “For these three risk factors, the overweight and obese I patients had the least amount of risk, with the highest risk in the underweight category,” Dr. Xenos said.

“The overweight and obese I category patients had a significantly higher albumin level, as compared with normal class patients,” Dr. Xenos reported.

The distribution of major complications among patients was U-shaped, with a higher incidence of complications among underweight patients and the lowest among the normal weight, overweight, and obese I category patients.

Obese II and obese III category patients had a significantly higher incidence of wound infections and renal and urinary tract infection complications, while morbidly obese patients had a significantly higher incidence of thromboembolic complications.

After the researchers adjusted for age, gender, and type of operation, the 30-day mortality risk was lowest among the obese I patients (OR 0.53) and highest among the underweight patients (OR 1.48).

“Mild obesity may have an independent protective effect on nutrition, metabolic status, and improved cardiac performance,” said Dr. Xenos, who had no conflicts to disclose.

'Mild obesity may have an independent protective effect.' DR. XENOS

Dr. Marc F. Stern says he feels safer as an internist working in correctional settings than he did in his previous career working for the Veterans Affairs health system.

In that setting, he said, one patient pulled a machete on him in the emergency department. Another tried to open the emergency department door with a chain saw.

“I've never had any of those experiences in prison,” said Dr. Stern, an internist who is health services director of the Washington State Department of Corrections. “Health care professionals in prison are very safe … possibly because patients view the health care folks as there to help them.”

Working in correctional settings is the best-kept secret for physicians with an interest in public health, he said, because the pathology of inmates is wide ranging and the ability to impact their health and well-being is significant.

“We have an opportunity to affect their health, their health care behaviors, and … their social behaviors. This is a population that has a high prevalence of diseases like HIV and hepatitis C. So we have an opportunity to control the disease and teach them low-risk behavior, so when they come back into our communities, they are less likely to spread disease.”

He acknowledged challenges to practicing in correctional settings, including a reliance on tight government budgets and a certain level of animosity from the general public for providing health care to prisoners when so many civilians in the United States lack adequate access to health care.

“What they don't understand is that prisoners have a constitutional right to access to basic health care. That's something the citizens of the United States have said they want through the constitution,” he said.

Dr. John May finds the field of correctional medicine so rewarding that he founded the Florida-based Health Through Walls, a not-for-profit group of volunteers providing sustainable health care in jails and prisoners located in underserved countries.

“Being conscientious in correctional medicine is one of the most important components of delivering good care,” said Dr. May, whose program assists inmates in Haiti, the Dominican Republic, Jamaica, Tanzania, and other counties. “Following through and trying to understand the issues a patient presents with are more important than the medicine you prescribe or the work-up you order.”

Dr. May started working in correctional medicine during his internal medicine residency at Cook County Hospital in Chicago, where he accepted an opportunity to moonlight at the Cook County Jail. “I saw [dedicated] people who had the same values and satisfaction out of medicine that I was seeking.”

Those values include the chance to practice effective preventive medicine such as violence prevention counseling and viewing the provision of health care in correctional settings as a community responsibility.

“If we can provide good quality care while they're incarcerated, it can have a positive impact on the whole community health system,” said Dr. May, an internist who is chief medical officer of Miami-based Armor Correctional Health Services Inc., a physician-owned company that provides health care in jails and prisons in the United States. “If we fail in the jails, they're going to be worse in the community or use more episodic care. It's more costly that way. There's a lot of preventive health you can do in jails and prisons, such as vaccination programs, counseling, and education.”

He remembers an inmate whose complaint was nasal congestion so bad that he had no sense of smell. “He said, 'I couldn't even smell a dead body if it was in front of me.' That statement represented his hopelessness. So I said, 'Why couldn't you say I couldn't smell a beautiful flower?' He said, 'I guess this place is getting to me.' I encouraged him to consider more positive ways of living. There's a lot of hopelessness and resignation in jails and prisons. Once they're incarcerated, they've lost their job, maybe their home. It's very difficult to get back on their feet.

Dr. John May, pictured at Haiti's National Penitentiary in Port-au-Prince, founded a not-for-profit group that provides health care to prisoners in underserved countries. Courtesy Dr. John May

Dr. Marc F. Stern says he feels safer as an internist working in correctional settings than he did in his previous career working for the Veterans Affairs health system.

In that setting, he said, one patient pulled a machete on him in the emergency department. Another tried to open the emergency department door with a chain saw.

“I've never had any of those experiences in prison,” said Dr. Stern, an internist who is health services director of the Washington State Department of Corrections. “Health care professionals in prison are very safe … possibly because patients view the health care folks as there to help them.”

Working in correctional settings is the best-kept secret for physicians with an interest in public health, he said, because the pathology of inmates is wide ranging and the ability to impact their health and well-being is significant.

“We have an opportunity to affect their health, their health care behaviors, and … their social behaviors. This is a population that has a high prevalence of diseases like HIV and hepatitis C. So we have an opportunity to control the disease and teach them low-risk behavior, so when they come back into our communities, they are less likely to spread disease.”

He acknowledged challenges to practicing in correctional settings, including a reliance on tight government budgets and a certain level of animosity from the general public for providing health care to prisoners when so many civilians in the United States lack adequate access to health care.

“What they don't understand is that prisoners have a constitutional right to access to basic health care. That's something the citizens of the United States have said they want through the constitution,” he said.

Dr. John May finds the field of correctional medicine so rewarding that he founded the Florida-based Health Through Walls, a not-for-profit group of volunteers providing sustainable health care in jails and prisoners located in underserved countries.

“Being conscientious in correctional medicine is one of the most important components of delivering good care,” said Dr. May, whose program assists inmates in Haiti, the Dominican Republic, Jamaica, Tanzania, and other counties. “Following through and trying to understand the issues a patient presents with are more important than the medicine you prescribe or the work-up you order.”

Dr. May started working in correctional medicine during his internal medicine residency at Cook County Hospital in Chicago, where he accepted an opportunity to moonlight at the Cook County Jail. “I saw [dedicated] people who had the same values and satisfaction out of medicine that I was seeking.”

Those values include the chance to practice effective preventive medicine such as violence prevention counseling and viewing the provision of health care in correctional settings as a community responsibility.

“If we can provide good quality care while they're incarcerated, it can have a positive impact on the whole community health system,” said Dr. May, an internist who is chief medical officer of Miami-based Armor Correctional Health Services Inc., a physician-owned company that provides health care in jails and prisons in the United States. “If we fail in the jails, they're going to be worse in the community or use more episodic care. It's more costly that way. There's a lot of preventive health you can do in jails and prisons, such as vaccination programs, counseling, and education.”

He remembers an inmate whose complaint was nasal congestion so bad that he had no sense of smell. “He said, 'I couldn't even smell a dead body if it was in front of me.' That statement represented his hopelessness. So I said, 'Why couldn't you say I couldn't smell a beautiful flower?' He said, 'I guess this place is getting to me.' I encouraged him to consider more positive ways of living. There's a lot of hopelessness and resignation in jails and prisons. Once they're incarcerated, they've lost their job, maybe their home. It's very difficult to get back on their feet.

Dr. John May, pictured at Haiti's National Penitentiary in Port-au-Prince, founded a not-for-profit group that provides health care to prisoners in underserved countries. Courtesy Dr. John May

Dr. Marc F. Stern says he feels safer as an internist working in correctional settings than he did in his previous career working for the Veterans Affairs health system.

In that setting, he said, one patient pulled a machete on him in the emergency department. Another tried to open the emergency department door with a chain saw.

“I've never had any of those experiences in prison,” said Dr. Stern, an internist who is health services director of the Washington State Department of Corrections. “Health care professionals in prison are very safe … possibly because patients view the health care folks as there to help them.”

Working in correctional settings is the best-kept secret for physicians with an interest in public health, he said, because the pathology of inmates is wide ranging and the ability to impact their health and well-being is significant.

“We have an opportunity to affect their health, their health care behaviors, and … their social behaviors. This is a population that has a high prevalence of diseases like HIV and hepatitis C. So we have an opportunity to control the disease and teach them low-risk behavior, so when they come back into our communities, they are less likely to spread disease.”

He acknowledged challenges to practicing in correctional settings, including a reliance on tight government budgets and a certain level of animosity from the general public for providing health care to prisoners when so many civilians in the United States lack adequate access to health care.

“What they don't understand is that prisoners have a constitutional right to access to basic health care. That's something the citizens of the United States have said they want through the constitution,” he said.

Dr. John May finds the field of correctional medicine so rewarding that he founded the Florida-based Health Through Walls, a not-for-profit group of volunteers providing sustainable health care in jails and prisoners located in underserved countries.

“Being conscientious in correctional medicine is one of the most important components of delivering good care,” said Dr. May, whose program assists inmates in Haiti, the Dominican Republic, Jamaica, Tanzania, and other counties. “Following through and trying to understand the issues a patient presents with are more important than the medicine you prescribe or the work-up you order.”

Dr. May started working in correctional medicine during his internal medicine residency at Cook County Hospital in Chicago, where he accepted an opportunity to moonlight at the Cook County Jail. “I saw [dedicated] people who had the same values and satisfaction out of medicine that I was seeking.”

Those values include the chance to practice effective preventive medicine such as violence prevention counseling and viewing the provision of health care in correctional settings as a community responsibility.

“If we can provide good quality care while they're incarcerated, it can have a positive impact on the whole community health system,” said Dr. May, an internist who is chief medical officer of Miami-based Armor Correctional Health Services Inc., a physician-owned company that provides health care in jails and prisons in the United States. “If we fail in the jails, they're going to be worse in the community or use more episodic care. It's more costly that way. There's a lot of preventive health you can do in jails and prisons, such as vaccination programs, counseling, and education.”

He remembers an inmate whose complaint was nasal congestion so bad that he had no sense of smell. “He said, 'I couldn't even smell a dead body if it was in front of me.' That statement represented his hopelessness. So I said, 'Why couldn't you say I couldn't smell a beautiful flower?' He said, 'I guess this place is getting to me.' I encouraged him to consider more positive ways of living. There's a lot of hopelessness and resignation in jails and prisons. Once they're incarcerated, they've lost their job, maybe their home. It's very difficult to get back on their feet.

Dr. John May, pictured at Haiti's National Penitentiary in Port-au-Prince, founded a not-for-profit group that provides health care to prisoners in underserved countries. Courtesy Dr. John May

Of 999 people who underwent free biometric screening for diabetes at Wal-Mart stores in five small towns between late September 2007 and early March 2008, many were found to be at high risk for the disease.

In fact, 78% of the participants had high blood pressure (greater than 140/90 mm/Hg), 56% had high cholesterol (greater than 240 mg/dL), and 41% had elevated blood glucose (greater than 101 mg/dL). In addition, 71% of participants were obese (26%-34% body fat measurement in men, 32%-39% in women) or morbidly obese (35% or more body fat for men, 40% or more for women).

“There were cases where a person's blood pressure was so high that we had to say, 'You probably should go to an emergency room today,' which was a reminder of how serious some of the health issues were,” Joe Quinn, senior director of state health care policy for Wal-Mart Stores Inc., based in Bentonville, Ark., said in an interview.

The screenings were one component of a diabetes awareness program that targets communities in the Delta Regional Authority, a federal-state partnership that serves 240 counties and parishes in parts of Alabama, Arkansas, Illinois, Kentucky, Louisiana, Mississippi, Missouri, and Tennessee. The events included free biometric screenings, free blood pressure screenings, and other health information.

The program illustrates several important points, said Dr. Donald A. Bergman, past president of the American Association of Clinical Endocrinologists (AACE) and a creator of AACE's Power of Prevention program. “First, people are ready for a change in the way they view health care,” he said. “Those attending this screening wanted to see if they had a medical problem before they were symptomatic; this means that people are ready to spend the time preserving health rather than restoring health. Second, this project shows that many people are very unhealthy and are not being identified before they become ill. And third, this project demonstrates that when business professionals and health care professionals join together, large numbers of people can be helped by early intervention.”

The program got started in 2007, when the Wal-Mart Foundation provided a gift of $500,000 to the Delta Regional Authority in support of its Healthy Delta diabetes initiative (http://www.healthydelta.com

The partnership kicked off in late September 2007 with a series of radio and television ads that ran in the eight-state region. The ads urged people with clinically confirmed diabetes—as well as people who thought they might have diabetes—to call a toll-free number for more information about management of the disease.

People who called the toll-free number spoke to a bilingual diabetes expert who asked the caller to answer questions from the American Diabetes Association Risk Test. The caller was then offered a free diabetes kit with a brochure called “Taking Control of Your Diabetes,” which included advice about how to talk to a physician or pharmacist about diabetes, as well as a list of affordable medications.

The diabetes experts followed up with the callers by phone at 60 and 120 days to check on their health status, asking questions such as: Are you getting some exercise? Have you changed how you're eating based on our previous conversation? Have you seen a physician? This same follow-up was offered to people who attended the health fairs.

Mr. Quinn likened the program to smoking cessation models in the United States. “What the person with diabetes really needs is someone to talk to on a regular basis—someone to remind them that there are behavior or diet changes that can play a large role,” he explained. “We're all aware that a busy physician in a small town has incredible demands on his time. So if there are other venues that are reminding people about healthy behavior, that certainly is a place where we can help.”

As of early March, 2,598 people—47% of them African American—have enrolled in the program, including 1,593 callers previously diagnosed with diabetes. In addition, 671 callers have received a free blood glucose monitoring kit.

Results of the biometric screening tests on 999 people who attended the first five health fairs were “somewhat worse” than what Mr. Quinn and his associates expected in terms of the high incidence of high blood pressure, elevated cholesterol rates, obesity, and high BMI.

“The Saturday morning health screenings in a Wal-Mart parking lot reinforce what most of us in America know right now: that wellness has to become part of the national health care discussion,” Mr. Quinn said. “The results we saw when we screened people backed that up and underlined the value of projects like this.”

Although the long-term future of the diabetes awareness program is unclear, Mr. Quinn said that he's pleased that it has helped foster education and a dialogue about diabetes in communities where access to health care has been problematic. “[Members of] the Delta Regional Authority are firm believers that it's education plus quality of health in a small town that equals economic development,” he said. “That is certainly an equation that Wal-Mart understands and agrees with. Hopefully we'll be able to find common ground and move ahead.”

A technician administers a fingerstick blood test during a Wal-Mart Hometown Health Fair in Eufaula, Ala., held as part of the regional Healthy Delta initiative. Delta Regional Authority

Of 999 people who underwent free biometric screening for diabetes at Wal-Mart stores in five small towns between late September 2007 and early March 2008, many were found to be at high risk for the disease.

In fact, 78% of the participants had high blood pressure (greater than 140/90 mm/Hg), 56% had high cholesterol (greater than 240 mg/dL), and 41% had elevated blood glucose (greater than 101 mg/dL). In addition, 71% of participants were obese (26%-34% body fat measurement in men, 32%-39% in women) or morbidly obese (35% or more body fat for men, 40% or more for women).

“There were cases where a person's blood pressure was so high that we had to say, 'You probably should go to an emergency room today,' which was a reminder of how serious some of the health issues were,” Joe Quinn, senior director of state health care policy for Wal-Mart Stores Inc., based in Bentonville, Ark., said in an interview.

The screenings were one component of a diabetes awareness program that targets communities in the Delta Regional Authority, a federal-state partnership that serves 240 counties and parishes in parts of Alabama, Arkansas, Illinois, Kentucky, Louisiana, Mississippi, Missouri, and Tennessee. The events included free biometric screenings, free blood pressure screenings, and other health information.

The program illustrates several important points, said Dr. Donald A. Bergman, past president of the American Association of Clinical Endocrinologists (AACE) and a creator of AACE's Power of Prevention program. “First, people are ready for a change in the way they view health care,” he said. “Those attending this screening wanted to see if they had a medical problem before they were symptomatic; this means that people are ready to spend the time preserving health rather than restoring health. Second, this project shows that many people are very unhealthy and are not being identified before they become ill. And third, this project demonstrates that when business professionals and health care professionals join together, large numbers of people can be helped by early intervention.”

The program got started in 2007, when the Wal-Mart Foundation provided a gift of $500,000 to the Delta Regional Authority in support of its Healthy Delta diabetes initiative (http://www.healthydelta.com

The partnership kicked off in late September 2007 with a series of radio and television ads that ran in the eight-state region. The ads urged people with clinically confirmed diabetes—as well as people who thought they might have diabetes—to call a toll-free number for more information about management of the disease.

People who called the toll-free number spoke to a bilingual diabetes expert who asked the caller to answer questions from the American Diabetes Association Risk Test. The caller was then offered a free diabetes kit with a brochure called “Taking Control of Your Diabetes,” which included advice about how to talk to a physician or pharmacist about diabetes, as well as a list of affordable medications.

The diabetes experts followed up with the callers by phone at 60 and 120 days to check on their health status, asking questions such as: Are you getting some exercise? Have you changed how you're eating based on our previous conversation? Have you seen a physician? This same follow-up was offered to people who attended the health fairs.

Mr. Quinn likened the program to smoking cessation models in the United States. “What the person with diabetes really needs is someone to talk to on a regular basis—someone to remind them that there are behavior or diet changes that can play a large role,” he explained. “We're all aware that a busy physician in a small town has incredible demands on his time. So if there are other venues that are reminding people about healthy behavior, that certainly is a place where we can help.”

As of early March, 2,598 people—47% of them African American—have enrolled in the program, including 1,593 callers previously diagnosed with diabetes. In addition, 671 callers have received a free blood glucose monitoring kit.

Results of the biometric screening tests on 999 people who attended the first five health fairs were “somewhat worse” than what Mr. Quinn and his associates expected in terms of the high incidence of high blood pressure, elevated cholesterol rates, obesity, and high BMI.

“The Saturday morning health screenings in a Wal-Mart parking lot reinforce what most of us in America know right now: that wellness has to become part of the national health care discussion,” Mr. Quinn said. “The results we saw when we screened people backed that up and underlined the value of projects like this.”

Although the long-term future of the diabetes awareness program is unclear, Mr. Quinn said that he's pleased that it has helped foster education and a dialogue about diabetes in communities where access to health care has been problematic. “[Members of] the Delta Regional Authority are firm believers that it's education plus quality of health in a small town that equals economic development,” he said. “That is certainly an equation that Wal-Mart understands and agrees with. Hopefully we'll be able to find common ground and move ahead.”

A technician administers a fingerstick blood test during a Wal-Mart Hometown Health Fair in Eufaula, Ala., held as part of the regional Healthy Delta initiative. Delta Regional Authority

Of 999 people who underwent free biometric screening for diabetes at Wal-Mart stores in five small towns between late September 2007 and early March 2008, many were found to be at high risk for the disease.

In fact, 78% of the participants had high blood pressure (greater than 140/90 mm/Hg), 56% had high cholesterol (greater than 240 mg/dL), and 41% had elevated blood glucose (greater than 101 mg/dL). In addition, 71% of participants were obese (26%-34% body fat measurement in men, 32%-39% in women) or morbidly obese (35% or more body fat for men, 40% or more for women).

“There were cases where a person's blood pressure was so high that we had to say, 'You probably should go to an emergency room today,' which was a reminder of how serious some of the health issues were,” Joe Quinn, senior director of state health care policy for Wal-Mart Stores Inc., based in Bentonville, Ark., said in an interview.

The screenings were one component of a diabetes awareness program that targets communities in the Delta Regional Authority, a federal-state partnership that serves 240 counties and parishes in parts of Alabama, Arkansas, Illinois, Kentucky, Louisiana, Mississippi, Missouri, and Tennessee. The events included free biometric screenings, free blood pressure screenings, and other health information.

The program illustrates several important points, said Dr. Donald A. Bergman, past president of the American Association of Clinical Endocrinologists (AACE) and a creator of AACE's Power of Prevention program. “First, people are ready for a change in the way they view health care,” he said. “Those attending this screening wanted to see if they had a medical problem before they were symptomatic; this means that people are ready to spend the time preserving health rather than restoring health. Second, this project shows that many people are very unhealthy and are not being identified before they become ill. And third, this project demonstrates that when business professionals and health care professionals join together, large numbers of people can be helped by early intervention.”

The program got started in 2007, when the Wal-Mart Foundation provided a gift of $500,000 to the Delta Regional Authority in support of its Healthy Delta diabetes initiative (http://www.healthydelta.com

The partnership kicked off in late September 2007 with a series of radio and television ads that ran in the eight-state region. The ads urged people with clinically confirmed diabetes—as well as people who thought they might have diabetes—to call a toll-free number for more information about management of the disease.

People who called the toll-free number spoke to a bilingual diabetes expert who asked the caller to answer questions from the American Diabetes Association Risk Test. The caller was then offered a free diabetes kit with a brochure called “Taking Control of Your Diabetes,” which included advice about how to talk to a physician or pharmacist about diabetes, as well as a list of affordable medications.

The diabetes experts followed up with the callers by phone at 60 and 120 days to check on their health status, asking questions such as: Are you getting some exercise? Have you changed how you're eating based on our previous conversation? Have you seen a physician? This same follow-up was offered to people who attended the health fairs.

Mr. Quinn likened the program to smoking cessation models in the United States. “What the person with diabetes really needs is someone to talk to on a regular basis—someone to remind them that there are behavior or diet changes that can play a large role,” he explained. “We're all aware that a busy physician in a small town has incredible demands on his time. So if there are other venues that are reminding people about healthy behavior, that certainly is a place where we can help.”

As of early March, 2,598 people—47% of them African American—have enrolled in the program, including 1,593 callers previously diagnosed with diabetes. In addition, 671 callers have received a free blood glucose monitoring kit.

Results of the biometric screening tests on 999 people who attended the first five health fairs were “somewhat worse” than what Mr. Quinn and his associates expected in terms of the high incidence of high blood pressure, elevated cholesterol rates, obesity, and high BMI.

“The Saturday morning health screenings in a Wal-Mart parking lot reinforce what most of us in America know right now: that wellness has to become part of the national health care discussion,” Mr. Quinn said. “The results we saw when we screened people backed that up and underlined the value of projects like this.”

Although the long-term future of the diabetes awareness program is unclear, Mr. Quinn said that he's pleased that it has helped foster education and a dialogue about diabetes in communities where access to health care has been problematic. “[Members of] the Delta Regional Authority are firm believers that it's education plus quality of health in a small town that equals economic development,” he said. “That is certainly an equation that Wal-Mart understands and agrees with. Hopefully we'll be able to find common ground and move ahead.”

A technician administers a fingerstick blood test during a Wal-Mart Hometown Health Fair in Eufaula, Ala., held as part of the regional Healthy Delta initiative. Delta Regional Authority

LA JOLLA, CALIF. — Parrots, baby chicks, and turtles may be endearing to young children, but exposure to such exotic and nontraditional pets in the home and in public settings puts children at risk for serious infectious diseases.

“When a child visits your office and has [Escherichia] coli 0157 or campylobacter or salmonella, a thorough history should be performed to determine whether or not he or she has been exposed to an animal in a public setting or whether [there are] some of these pets at home,” Dr. Larry K. Pickering said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics.

In 2007, about 63% of households in the United States contained one or more pets. Of these, 3% contained exotic or nontraditional pets.

“In 2005, approximately 88,000 mammals were imported legally into the United States, including 29 species of rodents,” added Dr. Pickering, executive secretary of the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention, Atlanta. “The illegal importation of animals into the United States and worldwide is huge. It's second only to drug and arms trafficking.”

Exposure to parrots, parakeets, and cockatiels can lead to Chlamydia psittaci, an intracellular bacterial pathogen that causes acute febrile respiratory tract illness. In the United States, there were 12–19 cases per year reported annually from 2002 to 2006, “but the number of cases is probably higher,” Dr. Pickering said. If you see a child or an adult with atypical pneumonia, ask if there is a bird in the home. “All birds can spread this infection. Diagnosis is difficult, confirmed only by serology.” Treatment involves tetracycline or macrolides.

Contact with baby poultry such as chicks, duckling, goslings, and turkeys increases the risk of developing salmonellosis. Children, the elderly, and immunocompromised people are especially vulnerable (MMWR 2007;56:273–6).

Salmonella can be found in chicken feces, feathers, or their environment. Each year, 1.4 million salmonella infections are reported “but we don't know what percent is due to contact with baby poultry,” Dr. Pickering said. “Fewer than 20 hatcheries in the United States provide the majority of baby poultry sold in agricultural feed stores. This is good and bad. It's good because surveillance can be set up easily. The bad part is, if you get salmonella in a flock, an outbreak can be fairly widespread.”

He pointed out that that many parents who purchase baby poultry for their children “remain unaware that the bird puts them in contact with salmonellosis and that these little critters will eventually grow to be adults and not be desirable pets.”

Certain salmonella serotypes are isolated from specific animals, so if a child presents with salmonellosis, the organism should be serotyped to determine if it is an unusual species. Salmonellosis from turtles, lizards, and other reptiles represents 6% of all salmonella infections in the United States and 11% of infections in people less than 21 years of age (Clin. Infect. Dis. 2004;38:5353–61). Reptiles excrete salmonella in feces while asymptomatic. Dr. Pickering said that reptile-associated salmonellosis “is more likely to be associated with invasive disease, to involve infants, and to lead to hospitalization.”

He warned that ferrets, which belong to the weasel family, are unsuitable pets for children younger than 5 years of age. A report from the late 1980s described severe facial injuries to infants from unprovoked attacks by pet ferrets (JAMA 1988;259:2005–6). “Ferrets can be aggressive animals,” he said.

The chances of a child acquiring salmonella, E. coli 0157 or some other infectious disease at a public zoo are “very low, because most zoos are well maintained,” Dr. Pickering said. “Petting zoos can be a problem, as can animal swap meets where children can handle animals and there are no hand-washing facilities on site.”

Diseases that have been reported associated with pet store animals include salmonella in hamsters, mice, and rats; rabies in kittens; tularemia and lymphocytic choriomeningitis in hamsters; and monkeypox in prairie dogs.

The American Academy of Pediatrics is developing guidelines for nontraditional pets in the home, Dr. Pickering said.

The CDC advises washing hands after contact with animals, animal products, or their environment, and supervising children younger than age 5 years while interacting with animals. For more information, see MMWR 2005;54[RR04]:1–12 and www.cdc.gov/healthypets

Salmonellosis from turtles, lizards, and other reptiles represents 11% of such infections in people under age 21 years. ©Djordje Korovljevic/

LA JOLLA, CALIF. — Parrots, baby chicks, and turtles may be endearing to young children, but exposure to such exotic and nontraditional pets in the home and in public settings puts children at risk for serious infectious diseases.

“When a child visits your office and has [Escherichia] coli 0157 or campylobacter or salmonella, a thorough history should be performed to determine whether or not he or she has been exposed to an animal in a public setting or whether [there are] some of these pets at home,” Dr. Larry K. Pickering said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics.

In 2007, about 63% of households in the United States contained one or more pets. Of these, 3% contained exotic or nontraditional pets.

“In 2005, approximately 88,000 mammals were imported legally into the United States, including 29 species of rodents,” added Dr. Pickering, executive secretary of the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention, Atlanta. “The illegal importation of animals into the United States and worldwide is huge. It's second only to drug and arms trafficking.”

Exposure to parrots, parakeets, and cockatiels can lead to Chlamydia psittaci, an intracellular bacterial pathogen that causes acute febrile respiratory tract illness. In the United States, there were 12–19 cases per year reported annually from 2002 to 2006, “but the number of cases is probably higher,” Dr. Pickering said. If you see a child or an adult with atypical pneumonia, ask if there is a bird in the home. “All birds can spread this infection. Diagnosis is difficult, confirmed only by serology.” Treatment involves tetracycline or macrolides.

Contact with baby poultry such as chicks, duckling, goslings, and turkeys increases the risk of developing salmonellosis. Children, the elderly, and immunocompromised people are especially vulnerable (MMWR 2007;56:273–6).

Salmonella can be found in chicken feces, feathers, or their environment. Each year, 1.4 million salmonella infections are reported “but we don't know what percent is due to contact with baby poultry,” Dr. Pickering said. “Fewer than 20 hatcheries in the United States provide the majority of baby poultry sold in agricultural feed stores. This is good and bad. It's good because surveillance can be set up easily. The bad part is, if you get salmonella in a flock, an outbreak can be fairly widespread.”

He pointed out that that many parents who purchase baby poultry for their children “remain unaware that the bird puts them in contact with salmonellosis and that these little critters will eventually grow to be adults and not be desirable pets.”

Certain salmonella serotypes are isolated from specific animals, so if a child presents with salmonellosis, the organism should be serotyped to determine if it is an unusual species. Salmonellosis from turtles, lizards, and other reptiles represents 6% of all salmonella infections in the United States and 11% of infections in people less than 21 years of age (Clin. Infect. Dis. 2004;38:5353–61). Reptiles excrete salmonella in feces while asymptomatic. Dr. Pickering said that reptile-associated salmonellosis “is more likely to be associated with invasive disease, to involve infants, and to lead to hospitalization.”

He warned that ferrets, which belong to the weasel family, are unsuitable pets for children younger than 5 years of age. A report from the late 1980s described severe facial injuries to infants from unprovoked attacks by pet ferrets (JAMA 1988;259:2005–6). “Ferrets can be aggressive animals,” he said.

The chances of a child acquiring salmonella, E. coli 0157 or some other infectious disease at a public zoo are “very low, because most zoos are well maintained,” Dr. Pickering said. “Petting zoos can be a problem, as can animal swap meets where children can handle animals and there are no hand-washing facilities on site.”

Diseases that have been reported associated with pet store animals include salmonella in hamsters, mice, and rats; rabies in kittens; tularemia and lymphocytic choriomeningitis in hamsters; and monkeypox in prairie dogs.

The American Academy of Pediatrics is developing guidelines for nontraditional pets in the home, Dr. Pickering said.

The CDC advises washing hands after contact with animals, animal products, or their environment, and supervising children younger than age 5 years while interacting with animals. For more information, see MMWR 2005;54[RR04]:1–12 and www.cdc.gov/healthypets

Salmonellosis from turtles, lizards, and other reptiles represents 11% of such infections in people under age 21 years. ©Djordje Korovljevic/

LA JOLLA, CALIF. — Parrots, baby chicks, and turtles may be endearing to young children, but exposure to such exotic and nontraditional pets in the home and in public settings puts children at risk for serious infectious diseases.

“When a child visits your office and has [Escherichia] coli 0157 or campylobacter or salmonella, a thorough history should be performed to determine whether or not he or she has been exposed to an animal in a public setting or whether [there are] some of these pets at home,” Dr. Larry K. Pickering said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics.

In 2007, about 63% of households in the United States contained one or more pets. Of these, 3% contained exotic or nontraditional pets.

“In 2005, approximately 88,000 mammals were imported legally into the United States, including 29 species of rodents,” added Dr. Pickering, executive secretary of the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention, Atlanta. “The illegal importation of animals into the United States and worldwide is huge. It's second only to drug and arms trafficking.”

Exposure to parrots, parakeets, and cockatiels can lead to Chlamydia psittaci, an intracellular bacterial pathogen that causes acute febrile respiratory tract illness. In the United States, there were 12–19 cases per year reported annually from 2002 to 2006, “but the number of cases is probably higher,” Dr. Pickering said. If you see a child or an adult with atypical pneumonia, ask if there is a bird in the home. “All birds can spread this infection. Diagnosis is difficult, confirmed only by serology.” Treatment involves tetracycline or macrolides.

Contact with baby poultry such as chicks, duckling, goslings, and turkeys increases the risk of developing salmonellosis. Children, the elderly, and immunocompromised people are especially vulnerable (MMWR 2007;56:273–6).

Salmonella can be found in chicken feces, feathers, or their environment. Each year, 1.4 million salmonella infections are reported “but we don't know what percent is due to contact with baby poultry,” Dr. Pickering said. “Fewer than 20 hatcheries in the United States provide the majority of baby poultry sold in agricultural feed stores. This is good and bad. It's good because surveillance can be set up easily. The bad part is, if you get salmonella in a flock, an outbreak can be fairly widespread.”

He pointed out that that many parents who purchase baby poultry for their children “remain unaware that the bird puts them in contact with salmonellosis and that these little critters will eventually grow to be adults and not be desirable pets.”

Certain salmonella serotypes are isolated from specific animals, so if a child presents with salmonellosis, the organism should be serotyped to determine if it is an unusual species. Salmonellosis from turtles, lizards, and other reptiles represents 6% of all salmonella infections in the United States and 11% of infections in people less than 21 years of age (Clin. Infect. Dis. 2004;38:5353–61). Reptiles excrete salmonella in feces while asymptomatic. Dr. Pickering said that reptile-associated salmonellosis “is more likely to be associated with invasive disease, to involve infants, and to lead to hospitalization.”

He warned that ferrets, which belong to the weasel family, are unsuitable pets for children younger than 5 years of age. A report from the late 1980s described severe facial injuries to infants from unprovoked attacks by pet ferrets (JAMA 1988;259:2005–6). “Ferrets can be aggressive animals,” he said.

The chances of a child acquiring salmonella, E. coli 0157 or some other infectious disease at a public zoo are “very low, because most zoos are well maintained,” Dr. Pickering said. “Petting zoos can be a problem, as can animal swap meets where children can handle animals and there are no hand-washing facilities on site.”

Diseases that have been reported associated with pet store animals include salmonella in hamsters, mice, and rats; rabies in kittens; tularemia and lymphocytic choriomeningitis in hamsters; and monkeypox in prairie dogs.

The American Academy of Pediatrics is developing guidelines for nontraditional pets in the home, Dr. Pickering said.

The CDC advises washing hands after contact with animals, animal products, or their environment, and supervising children younger than age 5 years while interacting with animals. For more information, see MMWR 2005;54[RR04]:1–12 and www.cdc.gov/healthypets

Salmonellosis from turtles, lizards, and other reptiles represents 11% of such infections in people under age 21 years. ©Djordje Korovljevic/

SALT LAKE CITY — Diagnosing frailty in a nursing home resident is often easier said than done.

At the annual symposium of the American Medical Directors Association, Dr. John E. Morley called a generally accepted definition of frailty useful but not practical for most nursing homes because they don't have the time or the staff to test for the criteria that constitute that definition. “Unless someone's reimbursing you, you probably don't have the time to do this in your practice,” said Dr. Morley, professor of gerontology at St. Louis University.

He was referring to the criteria set forth by Dr. Linda P. Fried of the Johns Hopkins Medical Institutions and her associates in 2001. They characterized frailty in older adults as a clinical syndrome occurring when three or more of the following criteria are present: unintentional loss of at least 10 pounds in the past year, self-report of exhaustion, extremely weak grip strength, slow walking speed over 15 feet, and low physical activity as measured by calories expended per week (J. Gerontol. A Biol. Sci. Med. Sci. 2001;56:M146–57).

Instead, Dr. Morley suggested a frailty screening tool developed by the International Academy of Nutrition and Aging, based on simpler answers to questions suggested by the mnemonic FRAIL. F stands for fatigue (Is the person fatigued?); R for resistance (Can the person walk up at least one flight of stairs?); A for aerobic (Can the person walk at least one block?); I for illness (Does the person have more than five illnesses?); and L for loss of weight (Has the person lost more than 5% of his or her weight in the past year?) (J. Am. Med. Dir. Assoc. 2008;9:71–2).

“If you want to measure for frailty quickly in the nursing home setting, this is a nice way to do it,” said Dr. Morley, who is editor in chief of the Journal of the American Medical Directors Association. He noted that validation studies of the screening tool are currently underway. He said it's already clear that the tool “is far more useful than an echocardiogram” in revealing frailty.

Measuring frailty is important because of its direct link to poor nutrition, said Dr. Morley. Recent studies have demonstrated that frail older people consume fewer than 21 kcal/day and have lower than normal intake of protein, vitamin D, vitamin E, vitamin C, and folate.

“We should be pushing for a balanced diet,” rather than just administering multivitamins, he said. “Much of the literature that's coming out suggests that balanced diet is what matters.”

Eating right is hard to do for anyone, let alone a frail elderly person, he added. “If you look at what the average American eats, we often don't come close to five servings of fruits and vegetables a day.”

Weight loss in nursing home residents is a matter of major concern. A study of underweight nursing home residents found that 30% of residents who continued to lose weight died over the next 6 months, while the 6-month mortality rate was 20% among those whose weight stabilized, and 10% among people whose weight loss was reversed (J. Nutr. Health Aging 2002;6:275–81).

The causes of weight loss include anorexia, cachexia, rheumatoid cachexia, sarcopenia, malabsorption, hypermetabolism, and dehydration. “It is now well recognized that not only is weight loss bad for nursing home residents, but anorexia independently predicts mortality at a slightly higher hazard ratio than weight loss,” Dr. Morley said.

He recommends the Simplified Nutritional Appetite Questionnaire as a “simple, easy” way to screen for anorexia. Developed by the Council for Nutritional Strategies in Long-Term Care, this tool is a four-item, single-domain questionnaire. Responses are scored by using a 5-point, verbally labeled Likert-type scale, low scores indicating deterioration in appetite (Am. J. Clin. Nutr. 2005;82:1074–81).

The questionnaire “has very good sensitivity and specificity for weight loss, and it can predict weight loss 6 months down the line,” commented Dr. Morley.

Measuring frailty in elderly patients is important because of its direct link topoor nutrition. DR. MORLEY

SALT LAKE CITY — Diagnosing frailty in a nursing home resident is often easier said than done.

At the annual symposium of the American Medical Directors Association, Dr. John E. Morley called a generally accepted definition of frailty useful but not practical for most nursing homes because they don't have the time or the staff to test for the criteria that constitute that definition. “Unless someone's reimbursing you, you probably don't have the time to do this in your practice,” said Dr. Morley, professor of gerontology at St. Louis University.

He was referring to the criteria set forth by Dr. Linda P. Fried of the Johns Hopkins Medical Institutions and her associates in 2001. They characterized frailty in older adults as a clinical syndrome occurring when three or more of the following criteria are present: unintentional loss of at least 10 pounds in the past year, self-report of exhaustion, extremely weak grip strength, slow walking speed over 15 feet, and low physical activity as measured by calories expended per week (J. Gerontol. A Biol. Sci. Med. Sci. 2001;56:M146–57).

Instead, Dr. Morley suggested a frailty screening tool developed by the International Academy of Nutrition and Aging, based on simpler answers to questions suggested by the mnemonic FRAIL. F stands for fatigue (Is the person fatigued?); R for resistance (Can the person walk up at least one flight of stairs?); A for aerobic (Can the person walk at least one block?); I for illness (Does the person have more than five illnesses?); and L for loss of weight (Has the person lost more than 5% of his or her weight in the past year?) (J. Am. Med. Dir. Assoc. 2008;9:71–2).

“If you want to measure for frailty quickly in the nursing home setting, this is a nice way to do it,” said Dr. Morley, who is editor in chief of the Journal of the American Medical Directors Association. He noted that validation studies of the screening tool are currently underway. He said it's already clear that the tool “is far more useful than an echocardiogram” in revealing frailty.

Measuring frailty is important because of its direct link to poor nutrition, said Dr. Morley. Recent studies have demonstrated that frail older people consume fewer than 21 kcal/day and have lower than normal intake of protein, vitamin D, vitamin E, vitamin C, and folate.

“We should be pushing for a balanced diet,” rather than just administering multivitamins, he said. “Much of the literature that's coming out suggests that balanced diet is what matters.”

Eating right is hard to do for anyone, let alone a frail elderly person, he added. “If you look at what the average American eats, we often don't come close to five servings of fruits and vegetables a day.”

Weight loss in nursing home residents is a matter of major concern. A study of underweight nursing home residents found that 30% of residents who continued to lose weight died over the next 6 months, while the 6-month mortality rate was 20% among those whose weight stabilized, and 10% among people whose weight loss was reversed (J. Nutr. Health Aging 2002;6:275–81).

The causes of weight loss include anorexia, cachexia, rheumatoid cachexia, sarcopenia, malabsorption, hypermetabolism, and dehydration. “It is now well recognized that not only is weight loss bad for nursing home residents, but anorexia independently predicts mortality at a slightly higher hazard ratio than weight loss,” Dr. Morley said.

He recommends the Simplified Nutritional Appetite Questionnaire as a “simple, easy” way to screen for anorexia. Developed by the Council for Nutritional Strategies in Long-Term Care, this tool is a four-item, single-domain questionnaire. Responses are scored by using a 5-point, verbally labeled Likert-type scale, low scores indicating deterioration in appetite (Am. J. Clin. Nutr. 2005;82:1074–81).

The questionnaire “has very good sensitivity and specificity for weight loss, and it can predict weight loss 6 months down the line,” commented Dr. Morley.

Measuring frailty in elderly patients is important because of its direct link topoor nutrition. DR. MORLEY

SALT LAKE CITY — Diagnosing frailty in a nursing home resident is often easier said than done.

At the annual symposium of the American Medical Directors Association, Dr. John E. Morley called a generally accepted definition of frailty useful but not practical for most nursing homes because they don't have the time or the staff to test for the criteria that constitute that definition. “Unless someone's reimbursing you, you probably don't have the time to do this in your practice,” said Dr. Morley, professor of gerontology at St. Louis University.

He was referring to the criteria set forth by Dr. Linda P. Fried of the Johns Hopkins Medical Institutions and her associates in 2001. They characterized frailty in older adults as a clinical syndrome occurring when three or more of the following criteria are present: unintentional loss of at least 10 pounds in the past year, self-report of exhaustion, extremely weak grip strength, slow walking speed over 15 feet, and low physical activity as measured by calories expended per week (J. Gerontol. A Biol. Sci. Med. Sci. 2001;56:M146–57).

Instead, Dr. Morley suggested a frailty screening tool developed by the International Academy of Nutrition and Aging, based on simpler answers to questions suggested by the mnemonic FRAIL. F stands for fatigue (Is the person fatigued?); R for resistance (Can the person walk up at least one flight of stairs?); A for aerobic (Can the person walk at least one block?); I for illness (Does the person have more than five illnesses?); and L for loss of weight (Has the person lost more than 5% of his or her weight in the past year?) (J. Am. Med. Dir. Assoc. 2008;9:71–2).

“If you want to measure for frailty quickly in the nursing home setting, this is a nice way to do it,” said Dr. Morley, who is editor in chief of the Journal of the American Medical Directors Association. He noted that validation studies of the screening tool are currently underway. He said it's already clear that the tool “is far more useful than an echocardiogram” in revealing frailty.

Measuring frailty is important because of its direct link to poor nutrition, said Dr. Morley. Recent studies have demonstrated that frail older people consume fewer than 21 kcal/day and have lower than normal intake of protein, vitamin D, vitamin E, vitamin C, and folate.

“We should be pushing for a balanced diet,” rather than just administering multivitamins, he said. “Much of the literature that's coming out suggests that balanced diet is what matters.”

Eating right is hard to do for anyone, let alone a frail elderly person, he added. “If you look at what the average American eats, we often don't come close to five servings of fruits and vegetables a day.”

Weight loss in nursing home residents is a matter of major concern. A study of underweight nursing home residents found that 30% of residents who continued to lose weight died over the next 6 months, while the 6-month mortality rate was 20% among those whose weight stabilized, and 10% among people whose weight loss was reversed (J. Nutr. Health Aging 2002;6:275–81).

The causes of weight loss include anorexia, cachexia, rheumatoid cachexia, sarcopenia, malabsorption, hypermetabolism, and dehydration. “It is now well recognized that not only is weight loss bad for nursing home residents, but anorexia independently predicts mortality at a slightly higher hazard ratio than weight loss,” Dr. Morley said.

He recommends the Simplified Nutritional Appetite Questionnaire as a “simple, easy” way to screen for anorexia. Developed by the Council for Nutritional Strategies in Long-Term Care, this tool is a four-item, single-domain questionnaire. Responses are scored by using a 5-point, verbally labeled Likert-type scale, low scores indicating deterioration in appetite (Am. J. Clin. Nutr. 2005;82:1074–81).

The questionnaire “has very good sensitivity and specificity for weight loss, and it can predict weight loss 6 months down the line,” commented Dr. Morley.

Measuring frailty in elderly patients is important because of its direct link topoor nutrition. DR. MORLEY

SAN DIEGO — Use of Biobrane wound dressing in pediatric burn patients resulted in a short hospital stay and follow-up as an outpatient with few complications, results from a single-center study demonstrated.

Researchers reviewed the medical charts of 116 pediatric burn patients aged 0–18 years who received Biobrane wound dressing at the University Hospital trauma center in San Antonio, Tex., between 2002 and 2007.

Biobrane (Bertek Pharmaceuticals) is a synthetic nylon mesh bonded to silicone and coated with collagen peptides. It functions as an analogue to the dermis and its pores allow exudate to be drained, Dr. Cristiane M. Ueno told the annual meeting of the Wound Healing Society.

The dressing “usually can be trimmed away after 1 week as the wound heals, decreasing the healing time when compared with some other dressings,” Dr. Ueno of the University of Texas Health Science Center at San Antonio, said in an interview.

The mean patient age was 5 years, males outnumbered females 2:1, and 68% were Hispanic. Of the cases, 52% were scald injuries, and 70% of the patients had second-degree burns.

Of the 116 patients who received Biobrane dressing, 58 had burns to the upper extremity. More than two-thirds were admitted to the hospital for 1–2 days for dressing care and instruction on care. Seven complications occurred from the use of Biobrane, including one case of bacteremia, two cases each of local infection, cellulitis, and fever, Dr. Ueno said at the meeting, held in conjunction with a symposium on advanced wound care.

Most of the patients needed only oral pain medications or mild conscious sedation, not general anesthesia, for debridement, Biobrane application, and dressing changes. This and the low risk of complications suggest the dressing could reduce costs and hospital stays in this population, said Dr. Ueno, who had no conflicts todisclose.

A pediatric burn patient's wound is shown (left) after cleaning and debridement. The hand is then covered with the Biobrane glove, which can be trimmed away as the wound heals. Photos courtesy Dr. Cristiane M. Ueno

The low risk of complications and need for only oral pain medications could help cut costs and reduce hospital stays. DR. UENO

SAN DIEGO — Use of Biobrane wound dressing in pediatric burn patients resulted in a short hospital stay and follow-up as an outpatient with few complications, results from a single-center study demonstrated.

Researchers reviewed the medical charts of 116 pediatric burn patients aged 0–18 years who received Biobrane wound dressing at the University Hospital trauma center in San Antonio, Tex., between 2002 and 2007.

Biobrane (Bertek Pharmaceuticals) is a synthetic nylon mesh bonded to silicone and coated with collagen peptides. It functions as an analogue to the dermis and its pores allow exudate to be drained, Dr. Cristiane M. Ueno told the annual meeting of the Wound Healing Society.

The dressing “usually can be trimmed away after 1 week as the wound heals, decreasing the healing time when compared with some other dressings,” Dr. Ueno of the University of Texas Health Science Center at San Antonio, said in an interview.

The mean patient age was 5 years, males outnumbered females 2:1, and 68% were Hispanic. Of the cases, 52% were scald injuries, and 70% of the patients had second-degree burns.

Of the 116 patients who received Biobrane dressing, 58 had burns to the upper extremity. More than two-thirds were admitted to the hospital for 1–2 days for dressing care and instruction on care. Seven complications occurred from the use of Biobrane, including one case of bacteremia, two cases each of local infection, cellulitis, and fever, Dr. Ueno said at the meeting, held in conjunction with a symposium on advanced wound care.

Most of the patients needed only oral pain medications or mild conscious sedation, not general anesthesia, for debridement, Biobrane application, and dressing changes. This and the low risk of complications suggest the dressing could reduce costs and hospital stays in this population, said Dr. Ueno, who had no conflicts todisclose.

A pediatric burn patient's wound is shown (left) after cleaning and debridement. The hand is then covered with the Biobrane glove, which can be trimmed away as the wound heals. Photos courtesy Dr. Cristiane M. Ueno

The low risk of complications and need for only oral pain medications could help cut costs and reduce hospital stays. DR. UENO

SAN DIEGO — Use of Biobrane wound dressing in pediatric burn patients resulted in a short hospital stay and follow-up as an outpatient with few complications, results from a single-center study demonstrated.

Researchers reviewed the medical charts of 116 pediatric burn patients aged 0–18 years who received Biobrane wound dressing at the University Hospital trauma center in San Antonio, Tex., between 2002 and 2007.

Biobrane (Bertek Pharmaceuticals) is a synthetic nylon mesh bonded to silicone and coated with collagen peptides. It functions as an analogue to the dermis and its pores allow exudate to be drained, Dr. Cristiane M. Ueno told the annual meeting of the Wound Healing Society.

The dressing “usually can be trimmed away after 1 week as the wound heals, decreasing the healing time when compared with some other dressings,” Dr. Ueno of the University of Texas Health Science Center at San Antonio, said in an interview.

The mean patient age was 5 years, males outnumbered females 2:1, and 68% were Hispanic. Of the cases, 52% were scald injuries, and 70% of the patients had second-degree burns.

Of the 116 patients who received Biobrane dressing, 58 had burns to the upper extremity. More than two-thirds were admitted to the hospital for 1–2 days for dressing care and instruction on care. Seven complications occurred from the use of Biobrane, including one case of bacteremia, two cases each of local infection, cellulitis, and fever, Dr. Ueno said at the meeting, held in conjunction with a symposium on advanced wound care.

Most of the patients needed only oral pain medications or mild conscious sedation, not general anesthesia, for debridement, Biobrane application, and dressing changes. This and the low risk of complications suggest the dressing could reduce costs and hospital stays in this population, said Dr. Ueno, who had no conflicts todisclose.

A pediatric burn patient's wound is shown (left) after cleaning and debridement. The hand is then covered with the Biobrane glove, which can be trimmed away as the wound heals. Photos courtesy Dr. Cristiane M. Ueno

The low risk of complications and need for only oral pain medications could help cut costs and reduce hospital stays. DR. UENO