Doug Brunk

SAN DIEGO — Seizures in elderly patients may present as subtle changes or unexplained fluctuations in cognitive abilities, results from a small study demonstrated.

The finding suggests that physicians “need to consider subtle or subclinical seizures in the differential diagnosis of cognitive deficits in the elderly,” researchers led by Dr. Eliot A. Licht wrote in a poster presented at the annual meeting of the American Neuropyschiatric Association. “Epilepsy is a potentially reversible cause of dementia.”

In an interview, Dr. Licht of the department of neurology at the Veterans Affairs (VA) Greater Los Angeles Healthcare System said the finding “introduces another possible treatment intervention for patients who might otherwise be receiving standard cholinesterase inhibitor therapy. We're trying to expand the window of investigation to identify alternative treatments that might help to improve their cognitive functions.”

Over a period of 6 months, he and his associates identified six patients aged 64–83 years who presented to the VA's memory disorders program for an evaluation of dementia. All patients underwent clinical examinations for seizure activity and received standard awake and drowsy electroencephalograms (EEGs). One of the six was known to have epilepsy.

EEGs showed recurrent epileptiform activity in all six patients. “This is not to say that in every case the epileptiform activity was causing all of their cognitive deficits, but it's possible that it was contributing to it,” Dr. Licht said.

'This is a source of information that would not have been available had we not done EEG,” he added.

Risk factors for seizures included stroke or ischemic changes, history of tumor, and history of electroconvulsive therapy.

SAN DIEGO — Seizures in elderly patients may present as subtle changes or unexplained fluctuations in cognitive abilities, results from a small study demonstrated.

The finding suggests that physicians “need to consider subtle or subclinical seizures in the differential diagnosis of cognitive deficits in the elderly,” researchers led by Dr. Eliot A. Licht wrote in a poster presented at the annual meeting of the American Neuropyschiatric Association. “Epilepsy is a potentially reversible cause of dementia.”

In an interview, Dr. Licht of the department of neurology at the Veterans Affairs (VA) Greater Los Angeles Healthcare System said the finding “introduces another possible treatment intervention for patients who might otherwise be receiving standard cholinesterase inhibitor therapy. We're trying to expand the window of investigation to identify alternative treatments that might help to improve their cognitive functions.”

Over a period of 6 months, he and his associates identified six patients aged 64–83 years who presented to the VA's memory disorders program for an evaluation of dementia. All patients underwent clinical examinations for seizure activity and received standard awake and drowsy electroencephalograms (EEGs). One of the six was known to have epilepsy.

EEGs showed recurrent epileptiform activity in all six patients. “This is not to say that in every case the epileptiform activity was causing all of their cognitive deficits, but it's possible that it was contributing to it,” Dr. Licht said.

'This is a source of information that would not have been available had we not done EEG,” he added.

Risk factors for seizures included stroke or ischemic changes, history of tumor, and history of electroconvulsive therapy.

SAN DIEGO — Seizures in elderly patients may present as subtle changes or unexplained fluctuations in cognitive abilities, results from a small study demonstrated.

The finding suggests that physicians “need to consider subtle or subclinical seizures in the differential diagnosis of cognitive deficits in the elderly,” researchers led by Dr. Eliot A. Licht wrote in a poster presented at the annual meeting of the American Neuropyschiatric Association. “Epilepsy is a potentially reversible cause of dementia.”

In an interview, Dr. Licht of the department of neurology at the Veterans Affairs (VA) Greater Los Angeles Healthcare System said the finding “introduces another possible treatment intervention for patients who might otherwise be receiving standard cholinesterase inhibitor therapy. We're trying to expand the window of investigation to identify alternative treatments that might help to improve their cognitive functions.”

Over a period of 6 months, he and his associates identified six patients aged 64–83 years who presented to the VA's memory disorders program for an evaluation of dementia. All patients underwent clinical examinations for seizure activity and received standard awake and drowsy electroencephalograms (EEGs). One of the six was known to have epilepsy.

EEGs showed recurrent epileptiform activity in all six patients. “This is not to say that in every case the epileptiform activity was causing all of their cognitive deficits, but it's possible that it was contributing to it,” Dr. Licht said.

'This is a source of information that would not have been available had we not done EEG,” he added.

Risk factors for seizures included stroke or ischemic changes, history of tumor, and history of electroconvulsive therapy.

Celecoxib is just as effective as naproxen and diclofenac for treating osteoarthritis, but it causes significantly fewer serious upper gastrointestinal events, compared with the other agents, according to data from a large international study.

The finding “shows conclusively that celecoxib does reduce the risk of upper GI complications, compared to conventional NSAIDs,” the study's lead author, Dr. Gurkirpal Singh, said. “Up until now managed care has been saying there is no evidence in a randomized, clinical trial that celecoxib is better than NSAIDs in reducing GI bleeding. But here it is; these are level 1 data that conclusively prove that.”

However, Dr. Brennan M.R. Spiegel noted that while the difference favoring celecoxib reached statistical significance in the study, the actual difference was a matter of 1 patient per 100 patient-years, which “is a tiny difference that to me is not enough to warrant spending as much money as we do on COX-2 inhibitors,” said Dr. Spiegel, of the division of digestive diseases at the University of California, Los Angeles.

He added that the study is “notable because it's very large, [but] I believed it before that GI events are less common with coxibs than with NSAIDs. I didn't need another study to demonstrate that.”

In a trial called the Successive Celecoxib Efficacy and Safety Study-1 (SUCCESS-1), Dr. Gurkirpal and his associates randomly assigned 13,194 osteoarthritis patients from 39 countries to double-blinded treatment with celecoxib 100 mg b.i.d., celecoxib 200 mg b.i.d., or nonselective NSAID therapy for 12 weeks. The NSAID therapy consisted of diclofenac 50 mg b.i.d. or naproxen 500 mg b.i.d. (Am. J. Med. 2006; 119:255–66).

Patients with a history of two or more episodes of active peptic ulceration were excluded from the study, as were those with gastrointestinal bleeding or recurrent gastric or duodenal ulcers and those with an esophageal, gastric, or duodenal ulcer within a month prior to randomization. Patients with active gastrointestinal disease or any condition that required NSAID therapy were also excluded from the study.

The mean age of study participants was 62 years, 76% were women, and 80% were white, reported Dr. Singh, of the division of gastroenterology and hepatology in the department of medicine at Stanford (Calif.) University. The mean duration of osteoarthritis was 8 years.

Instruments used to measure efficacy included the Patient's Assessment of Arthritis Pain-Visual Analog Scale, Patients' Global Assessment of Arthritis, and the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index. Serious GI events were evaluated by two independent committees that were blinded to patient randomization.

The researchers reported that the primary efficacy measures for both doses of celecoxib were equally effective as the NSAIDs in treating osteoarthritis.

There were 37 confirmed upper GI events: 19 in the patients who took the NSAIDs and 18 in the patients who took celecoxib. That translated into a rate of 2.1 per 100 patient-years for patients who took the NSAIDs vs. a rate of 1.0 per 100 patient-years for those who took celecoxib. The difference was statistically significant with a P value of .023.

A key limitation of the study, Dr. Singh said, is the fact that it was not powered to detect differences in terms of cardiovascular adverse events. “So we can't make any conclusion about that,” he said. “We did not see any statistically significant differences [between treatment groups], but at the time the study was designed, [concerns about COX-2 inhibitors and risk of] myocardial infarction were not an issue, so that's not something we followed.”

To tease that information out, he added, “you'd need a larger study over a longer period of time, perhaps in a high-risk population that has had myocardial infarction. I'd probably want to do it for at least 2 years.”

Dr. Spiegel said that the current standard of care for older patients with osteoarthritis has “overtaken” the overall impact of the SUCCESS-1 study findings.

“The reality is that people are moving to adding a proton pump inhibitor to an NSAID when [osteoarthritis] patients exceed the age of 65 or if they're put on aspirin,” he said. “They're not moving to COX-2 inhibitor, and this study doesn't give me any more reason to put someone on a COX-2 inhibitor as opposed to just adding a PPI to an NSAID, which is overall a cheaper thing to do. [That approach] is more relevant because it's cheaper, it's cost effective, and there's no risk of MI as there is with COX-2 inhibitors. In fact, there's less overall dyspepsia in patients who are on an NSAID plus a PPI, compared to [those on] a COX-2 inhibitor.”

Dr. Singh disclosed that he received research support from Searle Pharmaceuticals, Pharmacia, Pfizer, Merck & Co., Boehringer Ingelheim, TAP Pharmaceuticals, Wyeth, Altana Pharma, GlaxoSmithKline, Novartis Pharmaceuticals Corp., and Centocor Inc.

The finding 'shows conclusively that celecoxib does reduce the risk of upper GI complications.' DR. SINGH

Celecoxib is just as effective as naproxen and diclofenac for treating osteoarthritis, but it causes significantly fewer serious upper gastrointestinal events, compared with the other agents, according to data from a large international study.

The finding “shows conclusively that celecoxib does reduce the risk of upper GI complications, compared to conventional NSAIDs,” the study's lead author, Dr. Gurkirpal Singh, said. “Up until now managed care has been saying there is no evidence in a randomized, clinical trial that celecoxib is better than NSAIDs in reducing GI bleeding. But here it is; these are level 1 data that conclusively prove that.”

However, Dr. Brennan M.R. Spiegel noted that while the difference favoring celecoxib reached statistical significance in the study, the actual difference was a matter of 1 patient per 100 patient-years, which “is a tiny difference that to me is not enough to warrant spending as much money as we do on COX-2 inhibitors,” said Dr. Spiegel, of the division of digestive diseases at the University of California, Los Angeles.

He added that the study is “notable because it's very large, [but] I believed it before that GI events are less common with coxibs than with NSAIDs. I didn't need another study to demonstrate that.”

In a trial called the Successive Celecoxib Efficacy and Safety Study-1 (SUCCESS-1), Dr. Gurkirpal and his associates randomly assigned 13,194 osteoarthritis patients from 39 countries to double-blinded treatment with celecoxib 100 mg b.i.d., celecoxib 200 mg b.i.d., or nonselective NSAID therapy for 12 weeks. The NSAID therapy consisted of diclofenac 50 mg b.i.d. or naproxen 500 mg b.i.d. (Am. J. Med. 2006; 119:255–66).

Patients with a history of two or more episodes of active peptic ulceration were excluded from the study, as were those with gastrointestinal bleeding or recurrent gastric or duodenal ulcers and those with an esophageal, gastric, or duodenal ulcer within a month prior to randomization. Patients with active gastrointestinal disease or any condition that required NSAID therapy were also excluded from the study.

The mean age of study participants was 62 years, 76% were women, and 80% were white, reported Dr. Singh, of the division of gastroenterology and hepatology in the department of medicine at Stanford (Calif.) University. The mean duration of osteoarthritis was 8 years.

Instruments used to measure efficacy included the Patient's Assessment of Arthritis Pain-Visual Analog Scale, Patients' Global Assessment of Arthritis, and the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index. Serious GI events were evaluated by two independent committees that were blinded to patient randomization.

The researchers reported that the primary efficacy measures for both doses of celecoxib were equally effective as the NSAIDs in treating osteoarthritis.

There were 37 confirmed upper GI events: 19 in the patients who took the NSAIDs and 18 in the patients who took celecoxib. That translated into a rate of 2.1 per 100 patient-years for patients who took the NSAIDs vs. a rate of 1.0 per 100 patient-years for those who took celecoxib. The difference was statistically significant with a P value of .023.

A key limitation of the study, Dr. Singh said, is the fact that it was not powered to detect differences in terms of cardiovascular adverse events. “So we can't make any conclusion about that,” he said. “We did not see any statistically significant differences [between treatment groups], but at the time the study was designed, [concerns about COX-2 inhibitors and risk of] myocardial infarction were not an issue, so that's not something we followed.”

To tease that information out, he added, “you'd need a larger study over a longer period of time, perhaps in a high-risk population that has had myocardial infarction. I'd probably want to do it for at least 2 years.”

Dr. Spiegel said that the current standard of care for older patients with osteoarthritis has “overtaken” the overall impact of the SUCCESS-1 study findings.

“The reality is that people are moving to adding a proton pump inhibitor to an NSAID when [osteoarthritis] patients exceed the age of 65 or if they're put on aspirin,” he said. “They're not moving to COX-2 inhibitor, and this study doesn't give me any more reason to put someone on a COX-2 inhibitor as opposed to just adding a PPI to an NSAID, which is overall a cheaper thing to do. [That approach] is more relevant because it's cheaper, it's cost effective, and there's no risk of MI as there is with COX-2 inhibitors. In fact, there's less overall dyspepsia in patients who are on an NSAID plus a PPI, compared to [those on] a COX-2 inhibitor.”

Dr. Singh disclosed that he received research support from Searle Pharmaceuticals, Pharmacia, Pfizer, Merck & Co., Boehringer Ingelheim, TAP Pharmaceuticals, Wyeth, Altana Pharma, GlaxoSmithKline, Novartis Pharmaceuticals Corp., and Centocor Inc.

The finding 'shows conclusively that celecoxib does reduce the risk of upper GI complications.' DR. SINGH

Celecoxib is just as effective as naproxen and diclofenac for treating osteoarthritis, but it causes significantly fewer serious upper gastrointestinal events, compared with the other agents, according to data from a large international study.

The finding “shows conclusively that celecoxib does reduce the risk of upper GI complications, compared to conventional NSAIDs,” the study's lead author, Dr. Gurkirpal Singh, said. “Up until now managed care has been saying there is no evidence in a randomized, clinical trial that celecoxib is better than NSAIDs in reducing GI bleeding. But here it is; these are level 1 data that conclusively prove that.”

However, Dr. Brennan M.R. Spiegel noted that while the difference favoring celecoxib reached statistical significance in the study, the actual difference was a matter of 1 patient per 100 patient-years, which “is a tiny difference that to me is not enough to warrant spending as much money as we do on COX-2 inhibitors,” said Dr. Spiegel, of the division of digestive diseases at the University of California, Los Angeles.

He added that the study is “notable because it's very large, [but] I believed it before that GI events are less common with coxibs than with NSAIDs. I didn't need another study to demonstrate that.”

In a trial called the Successive Celecoxib Efficacy and Safety Study-1 (SUCCESS-1), Dr. Gurkirpal and his associates randomly assigned 13,194 osteoarthritis patients from 39 countries to double-blinded treatment with celecoxib 100 mg b.i.d., celecoxib 200 mg b.i.d., or nonselective NSAID therapy for 12 weeks. The NSAID therapy consisted of diclofenac 50 mg b.i.d. or naproxen 500 mg b.i.d. (Am. J. Med. 2006; 119:255–66).

Patients with a history of two or more episodes of active peptic ulceration were excluded from the study, as were those with gastrointestinal bleeding or recurrent gastric or duodenal ulcers and those with an esophageal, gastric, or duodenal ulcer within a month prior to randomization. Patients with active gastrointestinal disease or any condition that required NSAID therapy were also excluded from the study.

The mean age of study participants was 62 years, 76% were women, and 80% were white, reported Dr. Singh, of the division of gastroenterology and hepatology in the department of medicine at Stanford (Calif.) University. The mean duration of osteoarthritis was 8 years.

Instruments used to measure efficacy included the Patient's Assessment of Arthritis Pain-Visual Analog Scale, Patients' Global Assessment of Arthritis, and the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index. Serious GI events were evaluated by two independent committees that were blinded to patient randomization.

The researchers reported that the primary efficacy measures for both doses of celecoxib were equally effective as the NSAIDs in treating osteoarthritis.

There were 37 confirmed upper GI events: 19 in the patients who took the NSAIDs and 18 in the patients who took celecoxib. That translated into a rate of 2.1 per 100 patient-years for patients who took the NSAIDs vs. a rate of 1.0 per 100 patient-years for those who took celecoxib. The difference was statistically significant with a P value of .023.

A key limitation of the study, Dr. Singh said, is the fact that it was not powered to detect differences in terms of cardiovascular adverse events. “So we can't make any conclusion about that,” he said. “We did not see any statistically significant differences [between treatment groups], but at the time the study was designed, [concerns about COX-2 inhibitors and risk of] myocardial infarction were not an issue, so that's not something we followed.”

To tease that information out, he added, “you'd need a larger study over a longer period of time, perhaps in a high-risk population that has had myocardial infarction. I'd probably want to do it for at least 2 years.”

Dr. Spiegel said that the current standard of care for older patients with osteoarthritis has “overtaken” the overall impact of the SUCCESS-1 study findings.

“The reality is that people are moving to adding a proton pump inhibitor to an NSAID when [osteoarthritis] patients exceed the age of 65 or if they're put on aspirin,” he said. “They're not moving to COX-2 inhibitor, and this study doesn't give me any more reason to put someone on a COX-2 inhibitor as opposed to just adding a PPI to an NSAID, which is overall a cheaper thing to do. [That approach] is more relevant because it's cheaper, it's cost effective, and there's no risk of MI as there is with COX-2 inhibitors. In fact, there's less overall dyspepsia in patients who are on an NSAID plus a PPI, compared to [those on] a COX-2 inhibitor.”

Dr. Singh disclosed that he received research support from Searle Pharmaceuticals, Pharmacia, Pfizer, Merck & Co., Boehringer Ingelheim, TAP Pharmaceuticals, Wyeth, Altana Pharma, GlaxoSmithKline, Novartis Pharmaceuticals Corp., and Centocor Inc.

The finding 'shows conclusively that celecoxib does reduce the risk of upper GI complications.' DR. SINGH

SAN DIEGO — Heel ultrasound is a promising way to initially identify low bone mass in developmentally disabled patients, Dr. Kelly D. Krohn said during a poster session at the annual meeting of the International Society for Clinical Densitometry.

The finding is important because low bone density “is a common, complicated problem in people who have physical disabilities,” Dr. Krohn, director of clinical research, department of medicine, at Mercy Hospital in Pittsburgh, Pa., said in an interview. “A big part of it is that they're not able to bear weight. They're sitting in a wheelchair for 25–30 years and they have really fragile bones. But they're also challenging to bring to the office and do standard DXA [dual-energy x-ray absorptiometry] bone density testing on.”

He and his associates used a portable heel ultrasound densitometer to screen 135 mentally and physically challenged men and women who were living in intermediate care facilities in Allegheny County, Pa. Screenings took place either in their residence or at the hospital's on-site medical clinic.

The researchers, who were led by Dr. Vinee Varma, also of Mercy Hospital, collected data on age, gender, race, and weight-bearing status.

They defined low bone mass as having a T score of −1.0 or lower.

If heel scans were positive, the researchers forwarded the results to the physician.

When indicated, patients were referred for a central DXA of the hip and spine.

The average age of the 135 patients was 50; about half (68) were men; and most (90%) were white.

Of the patients, 55% had full weight-bearing capabilities, 42% were unable to bear weight, and 3% were able to partially bear weight.

Dr. Krohn and his associates found that 80% of the women and 72% of the men had evidence of low bone density on heel ultrasound. In addition, 91% of patients who were unable to bear weight had low bone mass, compared with 70% of patients who had full weight-bearing capabilities.

Subsequent central DXA scans performed in 91 patients confirmed the overall results of the positive heel ultrasounds. When the researchers used a heel ultrasound T score of −1.0 or lower, 70% had low bone mineral density (BMD) on central DXA. When they used a heel ultrasound score of −2.0 or lower, 81% had low BMD on central DXA.

In another component of the study, five patients with a normal heel ultrasound had central DXA performed. Low BMD was found in two of the five.

“Any screening test has failures,” Dr. Krohn noted.

“You miss some and you overcall some. For us, heel ultrasound has been a nice way to get a good handle on [the BMD in] several hundred disabled residents. A large number of them have a real risk for fractures. This is an easy way to identify them,” he said.

'Heel ultrasound has been a nice way to get a good handle on [BMD in] several hundred disabled residents.' DR. KROHN

SAN DIEGO — Heel ultrasound is a promising way to initially identify low bone mass in developmentally disabled patients, Dr. Kelly D. Krohn said during a poster session at the annual meeting of the International Society for Clinical Densitometry.

The finding is important because low bone density “is a common, complicated problem in people who have physical disabilities,” Dr. Krohn, director of clinical research, department of medicine, at Mercy Hospital in Pittsburgh, Pa., said in an interview. “A big part of it is that they're not able to bear weight. They're sitting in a wheelchair for 25–30 years and they have really fragile bones. But they're also challenging to bring to the office and do standard DXA [dual-energy x-ray absorptiometry] bone density testing on.”

He and his associates used a portable heel ultrasound densitometer to screen 135 mentally and physically challenged men and women who were living in intermediate care facilities in Allegheny County, Pa. Screenings took place either in their residence or at the hospital's on-site medical clinic.

The researchers, who were led by Dr. Vinee Varma, also of Mercy Hospital, collected data on age, gender, race, and weight-bearing status.

They defined low bone mass as having a T score of −1.0 or lower.

If heel scans were positive, the researchers forwarded the results to the physician.

When indicated, patients were referred for a central DXA of the hip and spine.

The average age of the 135 patients was 50; about half (68) were men; and most (90%) were white.

Of the patients, 55% had full weight-bearing capabilities, 42% were unable to bear weight, and 3% were able to partially bear weight.

Dr. Krohn and his associates found that 80% of the women and 72% of the men had evidence of low bone density on heel ultrasound. In addition, 91% of patients who were unable to bear weight had low bone mass, compared with 70% of patients who had full weight-bearing capabilities.

Subsequent central DXA scans performed in 91 patients confirmed the overall results of the positive heel ultrasounds. When the researchers used a heel ultrasound T score of −1.0 or lower, 70% had low bone mineral density (BMD) on central DXA. When they used a heel ultrasound score of −2.0 or lower, 81% had low BMD on central DXA.

In another component of the study, five patients with a normal heel ultrasound had central DXA performed. Low BMD was found in two of the five.

“Any screening test has failures,” Dr. Krohn noted.

“You miss some and you overcall some. For us, heel ultrasound has been a nice way to get a good handle on [the BMD in] several hundred disabled residents. A large number of them have a real risk for fractures. This is an easy way to identify them,” he said.

'Heel ultrasound has been a nice way to get a good handle on [BMD in] several hundred disabled residents.' DR. KROHN

SAN DIEGO — Heel ultrasound is a promising way to initially identify low bone mass in developmentally disabled patients, Dr. Kelly D. Krohn said during a poster session at the annual meeting of the International Society for Clinical Densitometry.

The finding is important because low bone density “is a common, complicated problem in people who have physical disabilities,” Dr. Krohn, director of clinical research, department of medicine, at Mercy Hospital in Pittsburgh, Pa., said in an interview. “A big part of it is that they're not able to bear weight. They're sitting in a wheelchair for 25–30 years and they have really fragile bones. But they're also challenging to bring to the office and do standard DXA [dual-energy x-ray absorptiometry] bone density testing on.”

He and his associates used a portable heel ultrasound densitometer to screen 135 mentally and physically challenged men and women who were living in intermediate care facilities in Allegheny County, Pa. Screenings took place either in their residence or at the hospital's on-site medical clinic.

The researchers, who were led by Dr. Vinee Varma, also of Mercy Hospital, collected data on age, gender, race, and weight-bearing status.

They defined low bone mass as having a T score of −1.0 or lower.

If heel scans were positive, the researchers forwarded the results to the physician.

When indicated, patients were referred for a central DXA of the hip and spine.

The average age of the 135 patients was 50; about half (68) were men; and most (90%) were white.

Of the patients, 55% had full weight-bearing capabilities, 42% were unable to bear weight, and 3% were able to partially bear weight.

Dr. Krohn and his associates found that 80% of the women and 72% of the men had evidence of low bone density on heel ultrasound. In addition, 91% of patients who were unable to bear weight had low bone mass, compared with 70% of patients who had full weight-bearing capabilities.

Subsequent central DXA scans performed in 91 patients confirmed the overall results of the positive heel ultrasounds. When the researchers used a heel ultrasound T score of −1.0 or lower, 70% had low bone mineral density (BMD) on central DXA. When they used a heel ultrasound score of −2.0 or lower, 81% had low BMD on central DXA.

In another component of the study, five patients with a normal heel ultrasound had central DXA performed. Low BMD was found in two of the five.

“Any screening test has failures,” Dr. Krohn noted.

“You miss some and you overcall some. For us, heel ultrasound has been a nice way to get a good handle on [the BMD in] several hundred disabled residents. A large number of them have a real risk for fractures. This is an easy way to identify them,” he said.

'Heel ultrasound has been a nice way to get a good handle on [BMD in] several hundred disabled residents.' DR. KROHN

SAN DIEGO — About half of postmenopausal women who take bisphosphonates for osteoporosis take at least three concomitant medications and 15% take six or more, researchers led by Dr. Sydney Lou Bonnick reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“Patients receiving bisphosphonate therapy for postmenopausal osteoporosis have a substantial pill burden,” the researchers wrote in their poster. “Adherence to therapy may be improved if physicians consider prescribing more convenient, less frequently dosed medications.”

Dr. Bonnick, medical director of the Clinical Research Center of North Texas in Denton, and her associates obtained patient prescription information from November 1999 to June 2004 from NDCHealth, a database that contains records from 14,000 retail pharmacies in the United States.

They identified women aged 50 years and older who were receiving alendronate or risedronate, which were the bisphosphonates approved for osteoporosis treatment during the study period.

Concomitant medications were defined as a minimum of a 2-week supply of medications that are prescribed in the same month as are a minimum of a 2-week supply of bisphosphonates.

Between November 1999 and June 2004 the number of women in the database using bisphosphonates rose from 78,909 to 250,286. Of the women prescribed concomitant medications, 74% were on two or more additional medications, 52% were on three or more, and 15% were on six or more.

The percentage of women taking six or more concomitant medications increased from 12% to 19% during the study period.

The most common concomitant drugs taken were cholesterol reducers, synthetic thyroid hormones, calcium channel blockers, β-blockers, ACE inhibitors, and systemic antiarthritis medications.

Dr. Bonnick and her associates observed that by the end of the study, women on daily bisphosphonate therapy were on a higher mean number of concomitant medications, compared with those on weekly bisphosphonate therapy (4.16 vs. 3.77, respectively). In addition, women aged 75 years and older were on a higher mean number of concomitant medications, compared with those aged 50–64 years (3.97 vs. 3.09, respectively).

GlaxoSmithKline supported the study.

SAN DIEGO — About half of postmenopausal women who take bisphosphonates for osteoporosis take at least three concomitant medications and 15% take six or more, researchers led by Dr. Sydney Lou Bonnick reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“Patients receiving bisphosphonate therapy for postmenopausal osteoporosis have a substantial pill burden,” the researchers wrote in their poster. “Adherence to therapy may be improved if physicians consider prescribing more convenient, less frequently dosed medications.”

Dr. Bonnick, medical director of the Clinical Research Center of North Texas in Denton, and her associates obtained patient prescription information from November 1999 to June 2004 from NDCHealth, a database that contains records from 14,000 retail pharmacies in the United States.

They identified women aged 50 years and older who were receiving alendronate or risedronate, which were the bisphosphonates approved for osteoporosis treatment during the study period.

Concomitant medications were defined as a minimum of a 2-week supply of medications that are prescribed in the same month as are a minimum of a 2-week supply of bisphosphonates.

Between November 1999 and June 2004 the number of women in the database using bisphosphonates rose from 78,909 to 250,286. Of the women prescribed concomitant medications, 74% were on two or more additional medications, 52% were on three or more, and 15% were on six or more.

The percentage of women taking six or more concomitant medications increased from 12% to 19% during the study period.

The most common concomitant drugs taken were cholesterol reducers, synthetic thyroid hormones, calcium channel blockers, β-blockers, ACE inhibitors, and systemic antiarthritis medications.

Dr. Bonnick and her associates observed that by the end of the study, women on daily bisphosphonate therapy were on a higher mean number of concomitant medications, compared with those on weekly bisphosphonate therapy (4.16 vs. 3.77, respectively). In addition, women aged 75 years and older were on a higher mean number of concomitant medications, compared with those aged 50–64 years (3.97 vs. 3.09, respectively).

GlaxoSmithKline supported the study.

SAN DIEGO — About half of postmenopausal women who take bisphosphonates for osteoporosis take at least three concomitant medications and 15% take six or more, researchers led by Dr. Sydney Lou Bonnick reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“Patients receiving bisphosphonate therapy for postmenopausal osteoporosis have a substantial pill burden,” the researchers wrote in their poster. “Adherence to therapy may be improved if physicians consider prescribing more convenient, less frequently dosed medications.”

Dr. Bonnick, medical director of the Clinical Research Center of North Texas in Denton, and her associates obtained patient prescription information from November 1999 to June 2004 from NDCHealth, a database that contains records from 14,000 retail pharmacies in the United States.

They identified women aged 50 years and older who were receiving alendronate or risedronate, which were the bisphosphonates approved for osteoporosis treatment during the study period.

Concomitant medications were defined as a minimum of a 2-week supply of medications that are prescribed in the same month as are a minimum of a 2-week supply of bisphosphonates.

Between November 1999 and June 2004 the number of women in the database using bisphosphonates rose from 78,909 to 250,286. Of the women prescribed concomitant medications, 74% were on two or more additional medications, 52% were on three or more, and 15% were on six or more.

The percentage of women taking six or more concomitant medications increased from 12% to 19% during the study period.

The most common concomitant drugs taken were cholesterol reducers, synthetic thyroid hormones, calcium channel blockers, β-blockers, ACE inhibitors, and systemic antiarthritis medications.

Dr. Bonnick and her associates observed that by the end of the study, women on daily bisphosphonate therapy were on a higher mean number of concomitant medications, compared with those on weekly bisphosphonate therapy (4.16 vs. 3.77, respectively). In addition, women aged 75 years and older were on a higher mean number of concomitant medications, compared with those aged 50–64 years (3.97 vs. 3.09, respectively).

GlaxoSmithKline supported the study.

SAN DIEGO — Increased levels of C-reactive protein and other markers of perioperative inflammatory response are associated with neurocognitive decline following cardiac surgery, Dr. Basel Ramlawi said at a congress sponsored by the Association for Academic Surgery and the Society of University Surgeons.

Dr. Ramlawi and his associates prospectively evaluated 41 patients who underwent coronary artery bypass graft and/or valve procedures that used cardiopulmonary bypass. The patients' mean age was 67 years. All patients had neurocognitive testing preoperatively, postoperatively at day 4, and at 3 months. The validated tests took 45 minutes to administer and covered memory, executive function, naming, attention, fluency, and premorbid intelligence, said Dr. Ramlawi of the division of cardiothoracic surgery at Harvard Medical School, Boston. Neurocognitive decline was defined as performing one standard deviation from baseline on at least 25% of tasks.

Study participants also underwent serum testing preoperatively, postoperatively at 6 hours, and at 4 days. Levels of C-reactive protein (CRP) and of interleukin 1β, IL-6, and IL-10 were assessed, and an increase of serum tau protein after surgery was used as a marker of axonal central nervous system damage.

Of the 41 patients, 7 (17%) developed neurocognitive decline. Baseline characteristics and predictors of neurocognitive decline such as age, education level, and perioperative temperature did not differ significantly between patients with and without postoperative neurocognitive decline.

However, patients who experienced postoperative neurocognitive decline had significantly greater increases of CRP, IL-1β, and IL-10 than those who had no decline.

In addition, the level of tau protein was increased 78% in patients with neurocognitive decline, compared with 29% in their counterparts who did not show a decline.

“There exists a significant association [between] the magnitude and persistence of the perioperative inflammatory response and neurocognitive decline in this cohort,” Dr. Ramlawi said. “This association is likely mediated by axonal damage.”

According to the medical literature, the incidence of neurocognitive decline is 20%–60% in the first 2 weeks after cardiac surgery. “It can range from 5% to 40% for periods up to 5 years after surgery,” he said, adding that the etiology of this complication is not known.

“It is likely a multifactorial problem,” Dr. Ramlawi said. “Several theories have been assessed. The most obvious one is ischemia. Any microemboli might cause this.”

Other possible factors include anesthesia, perioperative hypothermia, and low level of education.

“While there have been certain markers of brain injury following cardiopulmonary bypass, very few have been associated with clinical outcomes and neurocognitive decline,” he said. “Tau protein, on the other hand, assesses axonal damage and has not been [studied] in cardiac surgery before.”

SAN DIEGO — Increased levels of C-reactive protein and other markers of perioperative inflammatory response are associated with neurocognitive decline following cardiac surgery, Dr. Basel Ramlawi said at a congress sponsored by the Association for Academic Surgery and the Society of University Surgeons.

Dr. Ramlawi and his associates prospectively evaluated 41 patients who underwent coronary artery bypass graft and/or valve procedures that used cardiopulmonary bypass. The patients' mean age was 67 years. All patients had neurocognitive testing preoperatively, postoperatively at day 4, and at 3 months. The validated tests took 45 minutes to administer and covered memory, executive function, naming, attention, fluency, and premorbid intelligence, said Dr. Ramlawi of the division of cardiothoracic surgery at Harvard Medical School, Boston. Neurocognitive decline was defined as performing one standard deviation from baseline on at least 25% of tasks.

Study participants also underwent serum testing preoperatively, postoperatively at 6 hours, and at 4 days. Levels of C-reactive protein (CRP) and of interleukin 1β, IL-6, and IL-10 were assessed, and an increase of serum tau protein after surgery was used as a marker of axonal central nervous system damage.

Of the 41 patients, 7 (17%) developed neurocognitive decline. Baseline characteristics and predictors of neurocognitive decline such as age, education level, and perioperative temperature did not differ significantly between patients with and without postoperative neurocognitive decline.

However, patients who experienced postoperative neurocognitive decline had significantly greater increases of CRP, IL-1β, and IL-10 than those who had no decline.

In addition, the level of tau protein was increased 78% in patients with neurocognitive decline, compared with 29% in their counterparts who did not show a decline.

“There exists a significant association [between] the magnitude and persistence of the perioperative inflammatory response and neurocognitive decline in this cohort,” Dr. Ramlawi said. “This association is likely mediated by axonal damage.”

According to the medical literature, the incidence of neurocognitive decline is 20%–60% in the first 2 weeks after cardiac surgery. “It can range from 5% to 40% for periods up to 5 years after surgery,” he said, adding that the etiology of this complication is not known.

“It is likely a multifactorial problem,” Dr. Ramlawi said. “Several theories have been assessed. The most obvious one is ischemia. Any microemboli might cause this.”

Other possible factors include anesthesia, perioperative hypothermia, and low level of education.

“While there have been certain markers of brain injury following cardiopulmonary bypass, very few have been associated with clinical outcomes and neurocognitive decline,” he said. “Tau protein, on the other hand, assesses axonal damage and has not been [studied] in cardiac surgery before.”

SAN DIEGO — Increased levels of C-reactive protein and other markers of perioperative inflammatory response are associated with neurocognitive decline following cardiac surgery, Dr. Basel Ramlawi said at a congress sponsored by the Association for Academic Surgery and the Society of University Surgeons.

Dr. Ramlawi and his associates prospectively evaluated 41 patients who underwent coronary artery bypass graft and/or valve procedures that used cardiopulmonary bypass. The patients' mean age was 67 years. All patients had neurocognitive testing preoperatively, postoperatively at day 4, and at 3 months. The validated tests took 45 minutes to administer and covered memory, executive function, naming, attention, fluency, and premorbid intelligence, said Dr. Ramlawi of the division of cardiothoracic surgery at Harvard Medical School, Boston. Neurocognitive decline was defined as performing one standard deviation from baseline on at least 25% of tasks.

Study participants also underwent serum testing preoperatively, postoperatively at 6 hours, and at 4 days. Levels of C-reactive protein (CRP) and of interleukin 1β, IL-6, and IL-10 were assessed, and an increase of serum tau protein after surgery was used as a marker of axonal central nervous system damage.

Of the 41 patients, 7 (17%) developed neurocognitive decline. Baseline characteristics and predictors of neurocognitive decline such as age, education level, and perioperative temperature did not differ significantly between patients with and without postoperative neurocognitive decline.

However, patients who experienced postoperative neurocognitive decline had significantly greater increases of CRP, IL-1β, and IL-10 than those who had no decline.

In addition, the level of tau protein was increased 78% in patients with neurocognitive decline, compared with 29% in their counterparts who did not show a decline.

“There exists a significant association [between] the magnitude and persistence of the perioperative inflammatory response and neurocognitive decline in this cohort,” Dr. Ramlawi said. “This association is likely mediated by axonal damage.”

According to the medical literature, the incidence of neurocognitive decline is 20%–60% in the first 2 weeks after cardiac surgery. “It can range from 5% to 40% for periods up to 5 years after surgery,” he said, adding that the etiology of this complication is not known.

“It is likely a multifactorial problem,” Dr. Ramlawi said. “Several theories have been assessed. The most obvious one is ischemia. Any microemboli might cause this.”

Other possible factors include anesthesia, perioperative hypothermia, and low level of education.

“While there have been certain markers of brain injury following cardiopulmonary bypass, very few have been associated with clinical outcomes and neurocognitive decline,” he said. “Tau protein, on the other hand, assesses axonal damage and has not been [studied] in cardiac surgery before.”

LAS VEGAS — Most cases of disseminated and CNS neonatal herpes don't present with skin lesions, Dr. M. Jeffrey Maisels said at a meeting sponsored by the American Academy of Pediatrics and its California Chapters 1, 2, 3, and 4.

“You can't rely on seeing a herpetic-looking vesicle on a baby's skin to tip you off that the baby might have systemic herpes or CNS neonatal herpes,” said Dr. Maisels, who chairs the department of pediatrics at William Beaumont Hospital, Royal Oak, Mich. The chief complaint in cases of disseminated neonatal herpes is often decreased activity—the so-called “quiet baby”—in the first 2 weeks of life, as well as decreased oral intake and some respiratory distress.

Physical exam may reveal hypothermia, lethargy, and/or hypoperfusion. Tachypnea and seizures also may occur.

“When you do the lab tests, these babies commonly have metabolic acidosis,” said Dr. Maisels, also of Wayne State University, Detroit. They commonly come in with severe thrombocytopenia and severe coagulopathy. They have liver involvement, renal involvement, and hypoglycemia.

Treatment involves acyclovir 60 mg/kg per day as well as intensive care and management of the coagulopathy, which usually consists of multiple transfusions with fresh frozen plasma, cryoprecipitate, packed red blood cells, and platelets.

“This condition has a high mortality: 56%–90%, and it is close to 100% if they come in with severe shock or coma,” Dr. Maisels said.

In cases of CNS neonatal herpes, which typically occurs between birth and 6 weeks of life, the chief complaints are decreased feeding and slowly progressive lethargy. Physical exam usually reveals hypothermia, depressed neurologic exam, and apnea. Seizures also may occur.

CBC and other lab tests will usually be normal or nonspecific. Cerebrospinal fluid (CSF) findings vary depending on the presence of meningoencephalitis, encephalitis, or meningitis.

In a case of herpetic meningoencephalitis, “the most striking finding is significantly elevated CSF protein,” Dr. Maisels said. “So if you have a baby who shows up and looks a little sick and has what looks like aseptic meningitis but has a CSF protein of 250 [ng/L], then you have to think about CNS neonatal herpes,” he said. “The [blood] glucose can be normal. It can be low as well.”

In the case of herpes meningitis or pure encephalitis, the CSF protein may not be elevated.

Mortality of CNS neonatal herpes is about 15%.

LAS VEGAS — Most cases of disseminated and CNS neonatal herpes don't present with skin lesions, Dr. M. Jeffrey Maisels said at a meeting sponsored by the American Academy of Pediatrics and its California Chapters 1, 2, 3, and 4.

“You can't rely on seeing a herpetic-looking vesicle on a baby's skin to tip you off that the baby might have systemic herpes or CNS neonatal herpes,” said Dr. Maisels, who chairs the department of pediatrics at William Beaumont Hospital, Royal Oak, Mich. The chief complaint in cases of disseminated neonatal herpes is often decreased activity—the so-called “quiet baby”—in the first 2 weeks of life, as well as decreased oral intake and some respiratory distress.

Physical exam may reveal hypothermia, lethargy, and/or hypoperfusion. Tachypnea and seizures also may occur.

“When you do the lab tests, these babies commonly have metabolic acidosis,” said Dr. Maisels, also of Wayne State University, Detroit. They commonly come in with severe thrombocytopenia and severe coagulopathy. They have liver involvement, renal involvement, and hypoglycemia.

Treatment involves acyclovir 60 mg/kg per day as well as intensive care and management of the coagulopathy, which usually consists of multiple transfusions with fresh frozen plasma, cryoprecipitate, packed red blood cells, and platelets.

“This condition has a high mortality: 56%–90%, and it is close to 100% if they come in with severe shock or coma,” Dr. Maisels said.

In cases of CNS neonatal herpes, which typically occurs between birth and 6 weeks of life, the chief complaints are decreased feeding and slowly progressive lethargy. Physical exam usually reveals hypothermia, depressed neurologic exam, and apnea. Seizures also may occur.

CBC and other lab tests will usually be normal or nonspecific. Cerebrospinal fluid (CSF) findings vary depending on the presence of meningoencephalitis, encephalitis, or meningitis.

In a case of herpetic meningoencephalitis, “the most striking finding is significantly elevated CSF protein,” Dr. Maisels said. “So if you have a baby who shows up and looks a little sick and has what looks like aseptic meningitis but has a CSF protein of 250 [ng/L], then you have to think about CNS neonatal herpes,” he said. “The [blood] glucose can be normal. It can be low as well.”

In the case of herpes meningitis or pure encephalitis, the CSF protein may not be elevated.

Mortality of CNS neonatal herpes is about 15%.

LAS VEGAS — Most cases of disseminated and CNS neonatal herpes don't present with skin lesions, Dr. M. Jeffrey Maisels said at a meeting sponsored by the American Academy of Pediatrics and its California Chapters 1, 2, 3, and 4.

“You can't rely on seeing a herpetic-looking vesicle on a baby's skin to tip you off that the baby might have systemic herpes or CNS neonatal herpes,” said Dr. Maisels, who chairs the department of pediatrics at William Beaumont Hospital, Royal Oak, Mich. The chief complaint in cases of disseminated neonatal herpes is often decreased activity—the so-called “quiet baby”—in the first 2 weeks of life, as well as decreased oral intake and some respiratory distress.

Physical exam may reveal hypothermia, lethargy, and/or hypoperfusion. Tachypnea and seizures also may occur.

“When you do the lab tests, these babies commonly have metabolic acidosis,” said Dr. Maisels, also of Wayne State University, Detroit. They commonly come in with severe thrombocytopenia and severe coagulopathy. They have liver involvement, renal involvement, and hypoglycemia.

Treatment involves acyclovir 60 mg/kg per day as well as intensive care and management of the coagulopathy, which usually consists of multiple transfusions with fresh frozen plasma, cryoprecipitate, packed red blood cells, and platelets.

“This condition has a high mortality: 56%–90%, and it is close to 100% if they come in with severe shock or coma,” Dr. Maisels said.

In cases of CNS neonatal herpes, which typically occurs between birth and 6 weeks of life, the chief complaints are decreased feeding and slowly progressive lethargy. Physical exam usually reveals hypothermia, depressed neurologic exam, and apnea. Seizures also may occur.

CBC and other lab tests will usually be normal or nonspecific. Cerebrospinal fluid (CSF) findings vary depending on the presence of meningoencephalitis, encephalitis, or meningitis.

In a case of herpetic meningoencephalitis, “the most striking finding is significantly elevated CSF protein,” Dr. Maisels said. “So if you have a baby who shows up and looks a little sick and has what looks like aseptic meningitis but has a CSF protein of 250 [ng/L], then you have to think about CNS neonatal herpes,” he said. “The [blood] glucose can be normal. It can be low as well.”

In the case of herpes meningitis or pure encephalitis, the CSF protein may not be elevated.

Mortality of CNS neonatal herpes is about 15%.

SAN DIEGO — Seizures in elderly patients may present as subtle changes or unexplained fluctuations in cognitive abilities, results from a small study demonstrated.

The finding suggests that physicians “need to consider subtle or subclinical seizures in the differential diagnosis of cognitive deficits in the elderly,” researchers led by Dr. Eliot A. Licht wrote in a poster presented at the annual meeting of the American Neuropyschiatric Association. “Epilepsy is a potentially reversible cause of dementia.”

In an interview, Dr. Licht, of the department of neurology at the Veterans Affairs (VA) Greater Los Angeles Healthcare System, said the finding “introduces another possible treatment intervention for patients who might otherwise be receiving standard cholinesterase inhibitor therapy.”

Over a period of 6 months, he and his associates identified six patients aged 64–83 years who presented to the VA's memory disorders program for an evaluation of dementia. All patients underwent clinical examinations for seizure activity and received standard awake and drowsy electroencephalograms (EEGs). One of the six was known to have epilepsy.

EEGs showed recurrent epileptiform activity in all six patients. “This is not to say that in every case the epileptiform activity was causing all of their cognitive deficits, but it's possible that it was contributing to it,” Dr. Licht said.

Risk factors for seizures included stroke or ischemic changes, history of tumor, and history of electroconvulsive therapy.

In their poster, the researchers discussed the case of one patient who was admitted for dementia with aggressive behavior, but who did not show clinical seizures at that time. “Following add-on therapy with valproic acid, his epileptiform activity ended and his [Mini Mental State Examination] score of 20/30 improved to 30/30,” they wrote.

“Sometimes you may need to do more than one study to get an idea of what's going on in terms of the fluctuations,” Dr. Licht said. “That is, on day 1 someone may come in and have a small amount of activity that's not too common. But on day 10 [the activity] may be much more common.”

SAN DIEGO — Seizures in elderly patients may present as subtle changes or unexplained fluctuations in cognitive abilities, results from a small study demonstrated.

The finding suggests that physicians “need to consider subtle or subclinical seizures in the differential diagnosis of cognitive deficits in the elderly,” researchers led by Dr. Eliot A. Licht wrote in a poster presented at the annual meeting of the American Neuropyschiatric Association. “Epilepsy is a potentially reversible cause of dementia.”

In an interview, Dr. Licht, of the department of neurology at the Veterans Affairs (VA) Greater Los Angeles Healthcare System, said the finding “introduces another possible treatment intervention for patients who might otherwise be receiving standard cholinesterase inhibitor therapy.”

Over a period of 6 months, he and his associates identified six patients aged 64–83 years who presented to the VA's memory disorders program for an evaluation of dementia. All patients underwent clinical examinations for seizure activity and received standard awake and drowsy electroencephalograms (EEGs). One of the six was known to have epilepsy.

EEGs showed recurrent epileptiform activity in all six patients. “This is not to say that in every case the epileptiform activity was causing all of their cognitive deficits, but it's possible that it was contributing to it,” Dr. Licht said.

Risk factors for seizures included stroke or ischemic changes, history of tumor, and history of electroconvulsive therapy.

In their poster, the researchers discussed the case of one patient who was admitted for dementia with aggressive behavior, but who did not show clinical seizures at that time. “Following add-on therapy with valproic acid, his epileptiform activity ended and his [Mini Mental State Examination] score of 20/30 improved to 30/30,” they wrote.

“Sometimes you may need to do more than one study to get an idea of what's going on in terms of the fluctuations,” Dr. Licht said. “That is, on day 1 someone may come in and have a small amount of activity that's not too common. But on day 10 [the activity] may be much more common.”

SAN DIEGO — Seizures in elderly patients may present as subtle changes or unexplained fluctuations in cognitive abilities, results from a small study demonstrated.

The finding suggests that physicians “need to consider subtle or subclinical seizures in the differential diagnosis of cognitive deficits in the elderly,” researchers led by Dr. Eliot A. Licht wrote in a poster presented at the annual meeting of the American Neuropyschiatric Association. “Epilepsy is a potentially reversible cause of dementia.”

In an interview, Dr. Licht, of the department of neurology at the Veterans Affairs (VA) Greater Los Angeles Healthcare System, said the finding “introduces another possible treatment intervention for patients who might otherwise be receiving standard cholinesterase inhibitor therapy.”

Over a period of 6 months, he and his associates identified six patients aged 64–83 years who presented to the VA's memory disorders program for an evaluation of dementia. All patients underwent clinical examinations for seizure activity and received standard awake and drowsy electroencephalograms (EEGs). One of the six was known to have epilepsy.

EEGs showed recurrent epileptiform activity in all six patients. “This is not to say that in every case the epileptiform activity was causing all of their cognitive deficits, but it's possible that it was contributing to it,” Dr. Licht said.

Risk factors for seizures included stroke or ischemic changes, history of tumor, and history of electroconvulsive therapy.

In their poster, the researchers discussed the case of one patient who was admitted for dementia with aggressive behavior, but who did not show clinical seizures at that time. “Following add-on therapy with valproic acid, his epileptiform activity ended and his [Mini Mental State Examination] score of 20/30 improved to 30/30,” they wrote.

“Sometimes you may need to do more than one study to get an idea of what's going on in terms of the fluctuations,” Dr. Licht said. “That is, on day 1 someone may come in and have a small amount of activity that's not too common. But on day 10 [the activity] may be much more common.”

SAN DIEGO — Perimenopausal women who took eszopiclone for 1 month experienced significant improvements in sleep problems brought on by hot flashes, results from a randomized trial have found.

The drug had no effect on the number or severity of daytime and nighttime hot flashes, however, Rob Mariani, Ph.D., reported in a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

“I think this is another example of how you can improve the quality of your life in great part by improving how well you can sleep at night, especially in perimenopausal women who complain of sleep difficulties,” said Dr. Mariani, senior medical liaison for Sepracor Inc., which markets eszopiclone under the brand Lunesta. The nonbenzodiazepine drug was approved by the Food and Drug Administration in 2004 for the treatment of insomnia.

Dr. Mariani noted that most of the published studies in the area of menopause and sleep “indicate that there are really not any significant sleep architecture changes in patients at menopause or perimenopausal age. Yet at the same time, women who are perimenopausal and postmenopausal complain about a significant number of sleep problems, especially those who have vasomotor symptoms.”

In a study funded by Sepracor Inc., Dr. Mariani and his associates enrolled 410 perimenopausal women aged 40–60 years who met the Stages of Reproductive Aging Workshop criteria for early menopausal transition, late menopausal transition, and early postmenopause, and who reported sleep latency of 30 minutes or more and total sleep time of 6 hours or less per night at least three times a week for 1 month.

Investigators randomized 201 women to receive 3 mg eszopiclone and 209 to receive placebo nightly for 4 weeks. Study end points included sleep latency, wake time after sleep onset, total sleep time, awakenings due to hot flashes, daytime hot flashes, and physician global evaluations.

Compared with the women in the placebo group, those who took eszopiclone had significant changes in median sleep latency (reduction from baseline of 18.6 minutes vs. 8.1 minutes) and in median wake time after sleep onset (reduction of 30.6 minutes vs. 16 minutes). The increase in median total sleep time was greater among women who took eszopiclone (48.9 minutes per day vs. 29.7 minutes).

SAN DIEGO — Perimenopausal women who took eszopiclone for 1 month experienced significant improvements in sleep problems brought on by hot flashes, results from a randomized trial have found.

The drug had no effect on the number or severity of daytime and nighttime hot flashes, however, Rob Mariani, Ph.D., reported in a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

“I think this is another example of how you can improve the quality of your life in great part by improving how well you can sleep at night, especially in perimenopausal women who complain of sleep difficulties,” said Dr. Mariani, senior medical liaison for Sepracor Inc., which markets eszopiclone under the brand Lunesta. The nonbenzodiazepine drug was approved by the Food and Drug Administration in 2004 for the treatment of insomnia.

Dr. Mariani noted that most of the published studies in the area of menopause and sleep “indicate that there are really not any significant sleep architecture changes in patients at menopause or perimenopausal age. Yet at the same time, women who are perimenopausal and postmenopausal complain about a significant number of sleep problems, especially those who have vasomotor symptoms.”

In a study funded by Sepracor Inc., Dr. Mariani and his associates enrolled 410 perimenopausal women aged 40–60 years who met the Stages of Reproductive Aging Workshop criteria for early menopausal transition, late menopausal transition, and early postmenopause, and who reported sleep latency of 30 minutes or more and total sleep time of 6 hours or less per night at least three times a week for 1 month.

Investigators randomized 201 women to receive 3 mg eszopiclone and 209 to receive placebo nightly for 4 weeks. Study end points included sleep latency, wake time after sleep onset, total sleep time, awakenings due to hot flashes, daytime hot flashes, and physician global evaluations.

Compared with the women in the placebo group, those who took eszopiclone had significant changes in median sleep latency (reduction from baseline of 18.6 minutes vs. 8.1 minutes) and in median wake time after sleep onset (reduction of 30.6 minutes vs. 16 minutes). The increase in median total sleep time was greater among women who took eszopiclone (48.9 minutes per day vs. 29.7 minutes).

SAN DIEGO — Perimenopausal women who took eszopiclone for 1 month experienced significant improvements in sleep problems brought on by hot flashes, results from a randomized trial have found.

The drug had no effect on the number or severity of daytime and nighttime hot flashes, however, Rob Mariani, Ph.D., reported in a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

“I think this is another example of how you can improve the quality of your life in great part by improving how well you can sleep at night, especially in perimenopausal women who complain of sleep difficulties,” said Dr. Mariani, senior medical liaison for Sepracor Inc., which markets eszopiclone under the brand Lunesta. The nonbenzodiazepine drug was approved by the Food and Drug Administration in 2004 for the treatment of insomnia.

Dr. Mariani noted that most of the published studies in the area of menopause and sleep “indicate that there are really not any significant sleep architecture changes in patients at menopause or perimenopausal age. Yet at the same time, women who are perimenopausal and postmenopausal complain about a significant number of sleep problems, especially those who have vasomotor symptoms.”

In a study funded by Sepracor Inc., Dr. Mariani and his associates enrolled 410 perimenopausal women aged 40–60 years who met the Stages of Reproductive Aging Workshop criteria for early menopausal transition, late menopausal transition, and early postmenopause, and who reported sleep latency of 30 minutes or more and total sleep time of 6 hours or less per night at least three times a week for 1 month.

Investigators randomized 201 women to receive 3 mg eszopiclone and 209 to receive placebo nightly for 4 weeks. Study end points included sleep latency, wake time after sleep onset, total sleep time, awakenings due to hot flashes, daytime hot flashes, and physician global evaluations.

Compared with the women in the placebo group, those who took eszopiclone had significant changes in median sleep latency (reduction from baseline of 18.6 minutes vs. 8.1 minutes) and in median wake time after sleep onset (reduction of 30.6 minutes vs. 16 minutes). The increase in median total sleep time was greater among women who took eszopiclone (48.9 minutes per day vs. 29.7 minutes).

SAN DIEGO — So-called zero-mortality hospitals subsequently experience mortality rates that are similar to or higher than those of other hospitals, Dr. Justin B. Dimick reported at a congress sponsored by the Association for Academic Surgery and the Society of University Surgeons.

To determine whether zero-mortality hospitals actually achieved better results than did other hospitals “or were just lucky,” Dr. Dimick and his associates obtained national Medicare data for 1997–1999 on five procedures that are widely included in quality improvement measures: coronary artery bypass grafting; abdominal aortic aneurysm repair; and resections for colon, lung, and pancreatic cancers.

For each procedure, the researchers defined zero-mortality hospitals as those with no inpatient or 30-day deaths over the 3-year period.

The investigators then compared the mortality rates of the zero-mortality hospitals for the subsequent year (2000) with the mortality rates at other hospitals for that year.

No significant difference in mortality was observed between zero-mortality hospitals and the other hospitals for the following four procedures: coronary artery bypass surgery (4.0% zero-mortality hospitals vs. 5.0% other hospitals), abdominal aortic aneurysm repair (6.3% vs. 5.8%, respectively), colon cancer resection (6.0% vs. 6.6%, respectively), and lobectomy for lung cancer (5.1% vs. 5.3%, respectively).

In pancreatic cancer resection, however, the mortality rate was significantly worse for zero-mortality hospitals than it was for other hospitals (11.2% vs. 8.7%, respectively).

The researchers also observed that zero-mortality hospitals had fewer cases of all five operations than the other hospitals had.

“More attention should be paid to sample size in quality measurement,” said Dr. Dimick of the University of Michigan, Ann Arbor. He also called for hospital quality measures that “are more reliable and precise.”

The findings suggest that in deciding where to have surgery, patients “cannot consider a reported mortality of zero as a reliable indicator of future performance,” said Dr. Dimick.

Mortality rates are publicly reported and are commonly used to measure quality, he said. “For instance, cardiac surgery report cards are published in many states, including New York, Pennsylvania, California, and New Jersey. But what's even more troubling is the extension of this approach to many other operations. Right now the Agency for Healthcare Research and Quality is using operative mortality rates as quality measures. These are being published on Web sites, despite data showing [such measures] may not be useful,” he said.

Patients 'cannot consider a reported mortality of zero as a reliable indicator of future performance.' DR. DIMICK

SAN DIEGO — So-called zero-mortality hospitals subsequently experience mortality rates that are similar to or higher than those of other hospitals, Dr. Justin B. Dimick reported at a congress sponsored by the Association for Academic Surgery and the Society of University Surgeons.

To determine whether zero-mortality hospitals actually achieved better results than did other hospitals “or were just lucky,” Dr. Dimick and his associates obtained national Medicare data for 1997–1999 on five procedures that are widely included in quality improvement measures: coronary artery bypass grafting; abdominal aortic aneurysm repair; and resections for colon, lung, and pancreatic cancers.

For each procedure, the researchers defined zero-mortality hospitals as those with no inpatient or 30-day deaths over the 3-year period.

The investigators then compared the mortality rates of the zero-mortality hospitals for the subsequent year (2000) with the mortality rates at other hospitals for that year.

No significant difference in mortality was observed between zero-mortality hospitals and the other hospitals for the following four procedures: coronary artery bypass surgery (4.0% zero-mortality hospitals vs. 5.0% other hospitals), abdominal aortic aneurysm repair (6.3% vs. 5.8%, respectively), colon cancer resection (6.0% vs. 6.6%, respectively), and lobectomy for lung cancer (5.1% vs. 5.3%, respectively).

In pancreatic cancer resection, however, the mortality rate was significantly worse for zero-mortality hospitals than it was for other hospitals (11.2% vs. 8.7%, respectively).

The researchers also observed that zero-mortality hospitals had fewer cases of all five operations than the other hospitals had.

“More attention should be paid to sample size in quality measurement,” said Dr. Dimick of the University of Michigan, Ann Arbor. He also called for hospital quality measures that “are more reliable and precise.”

The findings suggest that in deciding where to have surgery, patients “cannot consider a reported mortality of zero as a reliable indicator of future performance,” said Dr. Dimick.

Mortality rates are publicly reported and are commonly used to measure quality, he said. “For instance, cardiac surgery report cards are published in many states, including New York, Pennsylvania, California, and New Jersey. But what's even more troubling is the extension of this approach to many other operations. Right now the Agency for Healthcare Research and Quality is using operative mortality rates as quality measures. These are being published on Web sites, despite data showing [such measures] may not be useful,” he said.

Patients 'cannot consider a reported mortality of zero as a reliable indicator of future performance.' DR. DIMICK

SAN DIEGO — So-called zero-mortality hospitals subsequently experience mortality rates that are similar to or higher than those of other hospitals, Dr. Justin B. Dimick reported at a congress sponsored by the Association for Academic Surgery and the Society of University Surgeons.

To determine whether zero-mortality hospitals actually achieved better results than did other hospitals “or were just lucky,” Dr. Dimick and his associates obtained national Medicare data for 1997–1999 on five procedures that are widely included in quality improvement measures: coronary artery bypass grafting; abdominal aortic aneurysm repair; and resections for colon, lung, and pancreatic cancers.

For each procedure, the researchers defined zero-mortality hospitals as those with no inpatient or 30-day deaths over the 3-year period.

The investigators then compared the mortality rates of the zero-mortality hospitals for the subsequent year (2000) with the mortality rates at other hospitals for that year.

No significant difference in mortality was observed between zero-mortality hospitals and the other hospitals for the following four procedures: coronary artery bypass surgery (4.0% zero-mortality hospitals vs. 5.0% other hospitals), abdominal aortic aneurysm repair (6.3% vs. 5.8%, respectively), colon cancer resection (6.0% vs. 6.6%, respectively), and lobectomy for lung cancer (5.1% vs. 5.3%, respectively).

In pancreatic cancer resection, however, the mortality rate was significantly worse for zero-mortality hospitals than it was for other hospitals (11.2% vs. 8.7%, respectively).

The researchers also observed that zero-mortality hospitals had fewer cases of all five operations than the other hospitals had.

“More attention should be paid to sample size in quality measurement,” said Dr. Dimick of the University of Michigan, Ann Arbor. He also called for hospital quality measures that “are more reliable and precise.”

The findings suggest that in deciding where to have surgery, patients “cannot consider a reported mortality of zero as a reliable indicator of future performance,” said Dr. Dimick.

Mortality rates are publicly reported and are commonly used to measure quality, he said. “For instance, cardiac surgery report cards are published in many states, including New York, Pennsylvania, California, and New Jersey. But what's even more troubling is the extension of this approach to many other operations. Right now the Agency for Healthcare Research and Quality is using operative mortality rates as quality measures. These are being published on Web sites, despite data showing [such measures] may not be useful,” he said.

Patients 'cannot consider a reported mortality of zero as a reliable indicator of future performance.' DR. DIMICK

LA JOLLA, CALIF. — The link between environmental toxins and cancer and other diseases is so suggestive that health care professionals must do all they can to diminish the risks to public health, Dr. Mitchell L. Gaynor said at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

Such an effort, he said, should be based on what Lancet editor Richard Horton termed “the precautionary principle.” This notion holds that “we must act on facts and on the most accurate interpretation of them, using the best scientific information,” Dr. Horton wrote (Lancet 1998;352:251–2). “That does not mean we must sit back until we have 100% evidence about everything. Where the … health of the people is at stake … we should be prepared to take action to diminish those risks, even when the scientific knowledge is not conclusive.”

“We should demand that this principle become part of public policy” in the treatment and prevention of environmental causes of disease, said Dr. Gaynor, of the Weill Medical College of Cornell University, New York.

“I gave a lecture at the United Nations in 2003 on water pollution as it related to all the countries on earth and the fact that very soon, clean drinking water is going to become a scarce commodity,” he said. “It's important that we become advocates for our own health.”

While evidence on the adverse health effects of chemical exposure continues to mount, steps toward more environmentally friendly policies are under way at many health care organizations around the globe. For example, Health Care Without Harm is an organization of almost 450 member groups in 52 countries that are working to reduce pollution in the health care industry (www.noharm.org

“Hospitals are huge releasers of a lot of pollutants, but this is starting to change,” Dr. Gaynor said at the meeting, which was cosponsored by the University of California, San Diego.

For example, more than 1,400 health care facilities in the United States have pledged to become mercury free. In addition, 91% of chain pharmacies and the top 10 largest pharmacy chains have stopped selling mercury fever thermometers.

Consorta Inc., the large national health care group purchasing organization, supports greener and safer product innovation.

The decline of medical waste incinerators in the United States is an additional sign of a lean toward green. In 1998, there were 6,200 medical waste incinerators nationwide. By 2003, that number had dropped to 115. “Hopefully, there will be less need for even those,” said Dr. Gaynor, who is also the author of “Nurture Nature, Nurture Health: Your Health and the Environment” (New York: Nurture Nature Press, 2005).

An effort is also underway to phase out polyvinyl chloride IV tubing; when PVC products are produced or burned, they emit dioxins, which are associated with cancer and damage to the immune system.

In 1998, there were 6,200 medical waste incinerators nationwide. By 2003, that number dropped to 115. DR. GAYNOR

LA JOLLA, CALIF. — The link between environmental toxins and cancer and other diseases is so suggestive that health care professionals must do all they can to diminish the risks to public health, Dr. Mitchell L. Gaynor said at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

Such an effort, he said, should be based on what Lancet editor Richard Horton termed “the precautionary principle.” This notion holds that “we must act on facts and on the most accurate interpretation of them, using the best scientific information,” Dr. Horton wrote (Lancet 1998;352:251–2). “That does not mean we must sit back until we have 100% evidence about everything. Where the … health of the people is at stake … we should be prepared to take action to diminish those risks, even when the scientific knowledge is not conclusive.”

“We should demand that this principle become part of public policy” in the treatment and prevention of environmental causes of disease, said Dr. Gaynor, of the Weill Medical College of Cornell University, New York.

“I gave a lecture at the United Nations in 2003 on water pollution as it related to all the countries on earth and the fact that very soon, clean drinking water is going to become a scarce commodity,” he said. “It's important that we become advocates for our own health.”

While evidence on the adverse health effects of chemical exposure continues to mount, steps toward more environmentally friendly policies are under way at many health care organizations around the globe. For example, Health Care Without Harm is an organization of almost 450 member groups in 52 countries that are working to reduce pollution in the health care industry (www.noharm.org

“Hospitals are huge releasers of a lot of pollutants, but this is starting to change,” Dr. Gaynor said at the meeting, which was cosponsored by the University of California, San Diego.

For example, more than 1,400 health care facilities in the United States have pledged to become mercury free. In addition, 91% of chain pharmacies and the top 10 largest pharmacy chains have stopped selling mercury fever thermometers.

Consorta Inc., the large national health care group purchasing organization, supports greener and safer product innovation.

The decline of medical waste incinerators in the United States is an additional sign of a lean toward green. In 1998, there were 6,200 medical waste incinerators nationwide. By 2003, that number had dropped to 115. “Hopefully, there will be less need for even those,” said Dr. Gaynor, who is also the author of “Nurture Nature, Nurture Health: Your Health and the Environment” (New York: Nurture Nature Press, 2005).

An effort is also underway to phase out polyvinyl chloride IV tubing; when PVC products are produced or burned, they emit dioxins, which are associated with cancer and damage to the immune system.

In 1998, there were 6,200 medical waste incinerators nationwide. By 2003, that number dropped to 115. DR. GAYNOR

LA JOLLA, CALIF. — The link between environmental toxins and cancer and other diseases is so suggestive that health care professionals must do all they can to diminish the risks to public health, Dr. Mitchell L. Gaynor said at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

Such an effort, he said, should be based on what Lancet editor Richard Horton termed “the precautionary principle.” This notion holds that “we must act on facts and on the most accurate interpretation of them, using the best scientific information,” Dr. Horton wrote (Lancet 1998;352:251–2). “That does not mean we must sit back until we have 100% evidence about everything. Where the … health of the people is at stake … we should be prepared to take action to diminish those risks, even when the scientific knowledge is not conclusive.”

“We should demand that this principle become part of public policy” in the treatment and prevention of environmental causes of disease, said Dr. Gaynor, of the Weill Medical College of Cornell University, New York.

“I gave a lecture at the United Nations in 2003 on water pollution as it related to all the countries on earth and the fact that very soon, clean drinking water is going to become a scarce commodity,” he said. “It's important that we become advocates for our own health.”

While evidence on the adverse health effects of chemical exposure continues to mount, steps toward more environmentally friendly policies are under way at many health care organizations around the globe. For example, Health Care Without Harm is an organization of almost 450 member groups in 52 countries that are working to reduce pollution in the health care industry (www.noharm.org

“Hospitals are huge releasers of a lot of pollutants, but this is starting to change,” Dr. Gaynor said at the meeting, which was cosponsored by the University of California, San Diego.

For example, more than 1,400 health care facilities in the United States have pledged to become mercury free. In addition, 91% of chain pharmacies and the top 10 largest pharmacy chains have stopped selling mercury fever thermometers.

Consorta Inc., the large national health care group purchasing organization, supports greener and safer product innovation.

The decline of medical waste incinerators in the United States is an additional sign of a lean toward green. In 1998, there were 6,200 medical waste incinerators nationwide. By 2003, that number had dropped to 115. “Hopefully, there will be less need for even those,” said Dr. Gaynor, who is also the author of “Nurture Nature, Nurture Health: Your Health and the Environment” (New York: Nurture Nature Press, 2005).

An effort is also underway to phase out polyvinyl chloride IV tubing; when PVC products are produced or burned, they emit dioxins, which are associated with cancer and damage to the immune system.

In 1998, there were 6,200 medical waste incinerators nationwide. By 2003, that number dropped to 115. DR. GAYNOR