Doug Brunk

SAN DIEGO — Moderate exercise equivalent to a brisk 1-hour walk 4 days a week improved insulin sensitivity in a group of women with polycystic ovary syndrome, even in the absence of weight loss, results from a small trial demonstrated.

The finding is important because obese women with polycystic ovary syndrome (PCOS) “have often been told to lose weight,” Ann J. Brown, M.D., told this newspaper during a poster session at the annual meeting of the Androgen Excess Society. “They know that they need to lose weight, but it's very difficult [for them]. This is a hopeful message that even just picking up the pace of activity will improve your metabolic profile.”

For the 5-month study, she and her associates randomized 19 sedentary women aged 22–41 years with PCOS to one of two groups. One group of 11 women continued their sedentary lifestyle, while another group of 8 women participated in a monitored exercise program that equaled about 230 min/wk at 60% maximal oxygen uptake (VO₂ max), “the equivalent of a brisk walk,” said Dr. Brown of the division of endocrinology, metabolism, and nutrition in the department of medicine at Duke University Medical Center, Durham, N.C.

Study participants completed a 75-g oral glucose tolerance test and a frequently sampled intravenous glucose tolerance test before and after the intervention. The investigators calculated insulin sensitivity and area under the curve (AUC) for glucose and insulin.

At baseline, the women in both groups were similar in age, aerobic fitness level, body mass index, blood pressure, fasting insulin, AUC insulin, and insulin sensitivity.

At the end of 5 months, aerobic fitness among women in the sedentary group worsened by 2.3%, compared with a 4.3% improvement in the exercise group, a statistically significant difference. BMI and waist circumference did not change in either group.

Fasting insulin decreased significantly in the exercise group, compared with the sedentary group (−4.6% vs. +8.9%), as did AUC insulin (−26.0% vs. +1.4%).

“What surprised me is how hard it was for people to do the protocol, which was to come to [a gym] 4 days a week and exercise,” said Dr. Brown, who also directs the Duke Academic Program in Women's Health. “A lot of people were enthusiastic about doing it, but early on they dropped out because they did not have a lot of flexibility in their schedule.”

SAN DIEGO — Moderate exercise equivalent to a brisk 1-hour walk 4 days a week improved insulin sensitivity in a group of women with polycystic ovary syndrome, even in the absence of weight loss, results from a small trial demonstrated.

The finding is important because obese women with polycystic ovary syndrome (PCOS) “have often been told to lose weight,” Ann J. Brown, M.D., told this newspaper during a poster session at the annual meeting of the Androgen Excess Society. “They know that they need to lose weight, but it's very difficult [for them]. This is a hopeful message that even just picking up the pace of activity will improve your metabolic profile.”

For the 5-month study, she and her associates randomized 19 sedentary women aged 22–41 years with PCOS to one of two groups. One group of 11 women continued their sedentary lifestyle, while another group of 8 women participated in a monitored exercise program that equaled about 230 min/wk at 60% maximal oxygen uptake (VO₂ max), “the equivalent of a brisk walk,” said Dr. Brown of the division of endocrinology, metabolism, and nutrition in the department of medicine at Duke University Medical Center, Durham, N.C.

Study participants completed a 75-g oral glucose tolerance test and a frequently sampled intravenous glucose tolerance test before and after the intervention. The investigators calculated insulin sensitivity and area under the curve (AUC) for glucose and insulin.

At baseline, the women in both groups were similar in age, aerobic fitness level, body mass index, blood pressure, fasting insulin, AUC insulin, and insulin sensitivity.

At the end of 5 months, aerobic fitness among women in the sedentary group worsened by 2.3%, compared with a 4.3% improvement in the exercise group, a statistically significant difference. BMI and waist circumference did not change in either group.

Fasting insulin decreased significantly in the exercise group, compared with the sedentary group (−4.6% vs. +8.9%), as did AUC insulin (−26.0% vs. +1.4%).

“What surprised me is how hard it was for people to do the protocol, which was to come to [a gym] 4 days a week and exercise,” said Dr. Brown, who also directs the Duke Academic Program in Women's Health. “A lot of people were enthusiastic about doing it, but early on they dropped out because they did not have a lot of flexibility in their schedule.”

SAN DIEGO — Moderate exercise equivalent to a brisk 1-hour walk 4 days a week improved insulin sensitivity in a group of women with polycystic ovary syndrome, even in the absence of weight loss, results from a small trial demonstrated.

The finding is important because obese women with polycystic ovary syndrome (PCOS) “have often been told to lose weight,” Ann J. Brown, M.D., told this newspaper during a poster session at the annual meeting of the Androgen Excess Society. “They know that they need to lose weight, but it's very difficult [for them]. This is a hopeful message that even just picking up the pace of activity will improve your metabolic profile.”

For the 5-month study, she and her associates randomized 19 sedentary women aged 22–41 years with PCOS to one of two groups. One group of 11 women continued their sedentary lifestyle, while another group of 8 women participated in a monitored exercise program that equaled about 230 min/wk at 60% maximal oxygen uptake (VO₂ max), “the equivalent of a brisk walk,” said Dr. Brown of the division of endocrinology, metabolism, and nutrition in the department of medicine at Duke University Medical Center, Durham, N.C.

Study participants completed a 75-g oral glucose tolerance test and a frequently sampled intravenous glucose tolerance test before and after the intervention. The investigators calculated insulin sensitivity and area under the curve (AUC) for glucose and insulin.

At baseline, the women in both groups were similar in age, aerobic fitness level, body mass index, blood pressure, fasting insulin, AUC insulin, and insulin sensitivity.

At the end of 5 months, aerobic fitness among women in the sedentary group worsened by 2.3%, compared with a 4.3% improvement in the exercise group, a statistically significant difference. BMI and waist circumference did not change in either group.

Fasting insulin decreased significantly in the exercise group, compared with the sedentary group (−4.6% vs. +8.9%), as did AUC insulin (−26.0% vs. +1.4%).

“What surprised me is how hard it was for people to do the protocol, which was to come to [a gym] 4 days a week and exercise,” said Dr. Brown, who also directs the Duke Academic Program in Women's Health. “A lot of people were enthusiastic about doing it, but early on they dropped out because they did not have a lot of flexibility in their schedule.”

LOS ANGELES — Despite growing interest in the use of androgens among postmenopausal women, there are few clinical data about their efficacy for this population of patients, Carol Havens, M.D., said at the annual meeting of the California Academy of Family Physicians.

“My patients are coming into me all the time with stuff off the Internet or out of magazines such as Ladies' Home Journal and People, promoting the use of androgens for impotence in women, mostly for libido,” said Dr. Havens, a family physician who is director of clinical education for Kaiser Permanente's Northern California region. “There is lots of information out there in the lay press but very little in the medical press. Very few trials have actually been done. There's very little we actually know.”

The theory behind androgen replacement is that androgen deficiency causes clinical symptoms such as dysphoria, fatigue, and low sex drive. However, androgen levels in women are highly variable, and they're not clearly linked to such symptoms, she said.

“Contrary to popular belief, androgen levels don't suddenly go down at the time of menopause like estrogen levels do. They actually decrease gradually,” explained Dr. Havens, who also chairs the California Medical Association's Committee on CME. “The androgen level of a woman at the age of 50 is about half that of a woman at the age of 25.”

Estratest is the only androgen-replacement preparation approved for women in the United States. It contains 0.625/1.25-mg esterified estrogen plus 1.25/2.5-mg methyltestosterone.

Transdermal androgen patches are not appropriately dosed for women. In fact, it's difficult to accurately measure testosterone in women because most of the assays were developed to test men.

“The available assays lack the sensitivity to be able to accurately measure the lower testosterone levels that are found in women,” Dr. Havens said. “The other problem is that testosterone is highly bound to sex hormone-binding globulin and albumin. In women, 1% or less of total testosterone is actually available as free testosterone, which is the biologically active one. The free testosterone index is the test that's been widely advertised as being the most reliable, but your lab may not be able to give you an accurate level of free testosterone.”

Key indications for androgen replacement in postmenopausal women with clinical symptoms of androgen deficiency include adequate estrogen status and having free testosterone levels at or below the lowest quartile for reproductive age. “The objective of replacement is to restore their testosterone levels to that of the mid-range for that of healthy young women,” she said.

The effect of androgens on coronary heart disease is unknown, but oral androgens decrease HDL cholesterol (by up to 20%), LDL cholesterol, and triglycerides. “So they could have a significant effect on lipids,” she noted.

Transdermal androgens, on the other hand, do not appear to affect lipid levels.

Estrogenic effects of androgens may include vaginal bleeding, endometrial hyperplasia, and the stimulation of breast epithelium, but there are no reports of direct links to breast or endometrial cancer.

Androgens appear to increase bone mineral density, but they have an unclear effect on fracture rate, muscle performance, and physical function. They also do not decrease visceral fat. “This is the opposite of what happens in men,” Dr. Havens said. “Androgens in women may actually increase visceral fat.”

As for the effect on sexuality, testosterone levels are not well correlated with libido in women, “although women who take testosterone do report an increase in libido and sexual activity,” she noted. “The increase in sexual activity is pretty limited.”

Other effects may include increases in erythropoiesis, hostility, hirsutism, and acne. (The transdermal form does not seem to affect hirsutism or acne.)

Pregnant and lactating women should not take androgens, nor should those with breast or endometrial cancer or polycythemia. Relative contraindications include moderate to severe acne, moderate to severe hirsutism, androgenic alopecia, and severe insulin resistance.

If you start postmenopausal women on androgens, ask them about their symptoms, and do follow-up lipid tests, liver function tests, and hemoglobin tests, Dr. Havens said.

LOS ANGELES — Despite growing interest in the use of androgens among postmenopausal women, there are few clinical data about their efficacy for this population of patients, Carol Havens, M.D., said at the annual meeting of the California Academy of Family Physicians.

“My patients are coming into me all the time with stuff off the Internet or out of magazines such as Ladies' Home Journal and People, promoting the use of androgens for impotence in women, mostly for libido,” said Dr. Havens, a family physician who is director of clinical education for Kaiser Permanente's Northern California region. “There is lots of information out there in the lay press but very little in the medical press. Very few trials have actually been done. There's very little we actually know.”

The theory behind androgen replacement is that androgen deficiency causes clinical symptoms such as dysphoria, fatigue, and low sex drive. However, androgen levels in women are highly variable, and they're not clearly linked to such symptoms, she said.

“Contrary to popular belief, androgen levels don't suddenly go down at the time of menopause like estrogen levels do. They actually decrease gradually,” explained Dr. Havens, who also chairs the California Medical Association's Committee on CME. “The androgen level of a woman at the age of 50 is about half that of a woman at the age of 25.”

Estratest is the only androgen-replacement preparation approved for women in the United States. It contains 0.625/1.25-mg esterified estrogen plus 1.25/2.5-mg methyltestosterone.

Transdermal androgen patches are not appropriately dosed for women. In fact, it's difficult to accurately measure testosterone in women because most of the assays were developed to test men.

“The available assays lack the sensitivity to be able to accurately measure the lower testosterone levels that are found in women,” Dr. Havens said. “The other problem is that testosterone is highly bound to sex hormone-binding globulin and albumin. In women, 1% or less of total testosterone is actually available as free testosterone, which is the biologically active one. The free testosterone index is the test that's been widely advertised as being the most reliable, but your lab may not be able to give you an accurate level of free testosterone.”

Key indications for androgen replacement in postmenopausal women with clinical symptoms of androgen deficiency include adequate estrogen status and having free testosterone levels at or below the lowest quartile for reproductive age. “The objective of replacement is to restore their testosterone levels to that of the mid-range for that of healthy young women,” she said.

The effect of androgens on coronary heart disease is unknown, but oral androgens decrease HDL cholesterol (by up to 20%), LDL cholesterol, and triglycerides. “So they could have a significant effect on lipids,” she noted.

Transdermal androgens, on the other hand, do not appear to affect lipid levels.

Estrogenic effects of androgens may include vaginal bleeding, endometrial hyperplasia, and the stimulation of breast epithelium, but there are no reports of direct links to breast or endometrial cancer.

Androgens appear to increase bone mineral density, but they have an unclear effect on fracture rate, muscle performance, and physical function. They also do not decrease visceral fat. “This is the opposite of what happens in men,” Dr. Havens said. “Androgens in women may actually increase visceral fat.”

As for the effect on sexuality, testosterone levels are not well correlated with libido in women, “although women who take testosterone do report an increase in libido and sexual activity,” she noted. “The increase in sexual activity is pretty limited.”

Other effects may include increases in erythropoiesis, hostility, hirsutism, and acne. (The transdermal form does not seem to affect hirsutism or acne.)

Pregnant and lactating women should not take androgens, nor should those with breast or endometrial cancer or polycythemia. Relative contraindications include moderate to severe acne, moderate to severe hirsutism, androgenic alopecia, and severe insulin resistance.

If you start postmenopausal women on androgens, ask them about their symptoms, and do follow-up lipid tests, liver function tests, and hemoglobin tests, Dr. Havens said.

LOS ANGELES — Despite growing interest in the use of androgens among postmenopausal women, there are few clinical data about their efficacy for this population of patients, Carol Havens, M.D., said at the annual meeting of the California Academy of Family Physicians.

“My patients are coming into me all the time with stuff off the Internet or out of magazines such as Ladies' Home Journal and People, promoting the use of androgens for impotence in women, mostly for libido,” said Dr. Havens, a family physician who is director of clinical education for Kaiser Permanente's Northern California region. “There is lots of information out there in the lay press but very little in the medical press. Very few trials have actually been done. There's very little we actually know.”

The theory behind androgen replacement is that androgen deficiency causes clinical symptoms such as dysphoria, fatigue, and low sex drive. However, androgen levels in women are highly variable, and they're not clearly linked to such symptoms, she said.

“Contrary to popular belief, androgen levels don't suddenly go down at the time of menopause like estrogen levels do. They actually decrease gradually,” explained Dr. Havens, who also chairs the California Medical Association's Committee on CME. “The androgen level of a woman at the age of 50 is about half that of a woman at the age of 25.”

Estratest is the only androgen-replacement preparation approved for women in the United States. It contains 0.625/1.25-mg esterified estrogen plus 1.25/2.5-mg methyltestosterone.

Transdermal androgen patches are not appropriately dosed for women. In fact, it's difficult to accurately measure testosterone in women because most of the assays were developed to test men.

“The available assays lack the sensitivity to be able to accurately measure the lower testosterone levels that are found in women,” Dr. Havens said. “The other problem is that testosterone is highly bound to sex hormone-binding globulin and albumin. In women, 1% or less of total testosterone is actually available as free testosterone, which is the biologically active one. The free testosterone index is the test that's been widely advertised as being the most reliable, but your lab may not be able to give you an accurate level of free testosterone.”

Key indications for androgen replacement in postmenopausal women with clinical symptoms of androgen deficiency include adequate estrogen status and having free testosterone levels at or below the lowest quartile for reproductive age. “The objective of replacement is to restore their testosterone levels to that of the mid-range for that of healthy young women,” she said.

The effect of androgens on coronary heart disease is unknown, but oral androgens decrease HDL cholesterol (by up to 20%), LDL cholesterol, and triglycerides. “So they could have a significant effect on lipids,” she noted.

Transdermal androgens, on the other hand, do not appear to affect lipid levels.

Estrogenic effects of androgens may include vaginal bleeding, endometrial hyperplasia, and the stimulation of breast epithelium, but there are no reports of direct links to breast or endometrial cancer.

Androgens appear to increase bone mineral density, but they have an unclear effect on fracture rate, muscle performance, and physical function. They also do not decrease visceral fat. “This is the opposite of what happens in men,” Dr. Havens said. “Androgens in women may actually increase visceral fat.”

As for the effect on sexuality, testosterone levels are not well correlated with libido in women, “although women who take testosterone do report an increase in libido and sexual activity,” she noted. “The increase in sexual activity is pretty limited.”

Other effects may include increases in erythropoiesis, hostility, hirsutism, and acne. (The transdermal form does not seem to affect hirsutism or acne.)

Pregnant and lactating women should not take androgens, nor should those with breast or endometrial cancer or polycythemia. Relative contraindications include moderate to severe acne, moderate to severe hirsutism, androgenic alopecia, and severe insulin resistance.

If you start postmenopausal women on androgens, ask them about their symptoms, and do follow-up lipid tests, liver function tests, and hemoglobin tests, Dr. Havens said.

LA JOLLA, CALIF. – The recall of Vioxx and safety warnings about Celebrex and Bextra created “a very insecure time for pain management,” Robert Bonakdar, M.D., said at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

But well before concern surfaced about the safety of those drugs, patients with inflammatory disease increasingly began to seek care from providers of complementary and alternative medicine (CAM) because they were dissatisfied with traditional care results.

“They thank their doctor for the NSAIDs, for the advice, for [the referral to] physical therapy, but they still have pain,” said Dr. Bonakdar, director of pain management at the Scripps Center for Integrative Medicine, La Jolla, Calif. “Also, people with higher pain intensity and duration, and those with a greater degree of self-care, are going to end up in more CAM offices.”

He discussed the following natural supplements, which have been found useful in treating pain associated with inflammatory disease:

▸ Willow bark (Salix spp.). This agent contains multiple constituents including phenolic glycosides, tannins, and flavanoids. In a double-blind, placebo-controlled trial of 21 patients who took 240 mg of salicin over a 2-week period, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores were reduced 40%, compared with a 16% reduction among those on placebo. At 2 weeks, the analgesic effect from willow bark was assessed to be about 40% of that from high-dose NSAIDs.

“There is a dose-response relationship,” Dr. Bonakdar said at the meeting, cosponsored by the University of California, San Diego. A randomized, double-blind placebo-controlled trial of 210 patients with low back pain who took 120 mg or 240 mg salicin demonstrated complete relief from pain in 21% and 39% of patients, respectively (Am. J. Med. 2000;109:9–14).

Only 6% of patients in the placebo group reported complete relief from pain.

The dosage used in trials varies, but it is typically standardized to 240 g salicin/day.

▸ Phytodolor. Available since 1963, this patented supplement is from Germany. It contains 1 mg salicin/mL, Populus tremula, Fraxinus excelsior, and Solidago virgaurea. Of the nine randomized, controlled trials involving phytodolor, those with a placebo arm demonstrated superiority of phytodolor; six trials with a comparison group showed no benefit of phytodolor over NSAIDs.

One trial found a dose response to double-strength phytodolor vs. regular dosing at 2 weeks.

The typical dose in trials is 30 drops of standardized extract t.i.d.

▸ Devil's claw (Harpagophytum procumbens). This South African plant is used for arthritis, myalgia, and as an external ointment for burns or sores. Its active ingredients are harpagoside and β-sitosterol.

There have been four double-blind, placebo-controlled trials involving 50–197 patients with osteoarthritis and low back pain. Patients were treated for 3–8 weeks with 50–100 mg harpagosides/iridoid content of 1.5%–3% (the typical dose in trials).

The treatments significantly improved the pain level and joint mobility in study participants. Side effects have included mild and infrequent GI symptoms (BMC Complement. Altern. Med. 2004;4:13).

▸ SAMe (S-adenosylmethionine). This is an endogenous methyl donor that is a naturally occurring product of the reaction between methionine and adenosine triphosphate (ATP). It is postulated to have anti-inflammatory effects through inhibition of tumor necrosis factor-α and upregulation of proteoglycan synthesis and secretion into chondrocytes. SAMe also appears to have a serotonergic effect that may support its pain-modulating abilities.

In a metaanalysis of 11 osteoarthritis trials, SAMe appeared to be as effective as NSAIDs in reducing pain and improving functionality with fewer adverse effects than NSAIDS (J. Fam. Pract. 2002;51:425–30). SAMe is typically initiated in the 200- to 400-mg range and titrated to between 600 and 1,200 mg with caution regarding its serotonergic effects.

Other natural supplements such as ginger (Zingiber officinale), boswellia (Boswellia serrata), turmeric (Curcuma longa), and essential fatty acids have also demonstrated anti-inflammatory activity in preliminary basic research or human trials. While these and other natural supplements have been documented for the treatment of pain, Dr. Bonakdar emphasized that “further well-done trials are required to advance understanding.”

LA JOLLA, CALIF. – The recall of Vioxx and safety warnings about Celebrex and Bextra created “a very insecure time for pain management,” Robert Bonakdar, M.D., said at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

But well before concern surfaced about the safety of those drugs, patients with inflammatory disease increasingly began to seek care from providers of complementary and alternative medicine (CAM) because they were dissatisfied with traditional care results.

“They thank their doctor for the NSAIDs, for the advice, for [the referral to] physical therapy, but they still have pain,” said Dr. Bonakdar, director of pain management at the Scripps Center for Integrative Medicine, La Jolla, Calif. “Also, people with higher pain intensity and duration, and those with a greater degree of self-care, are going to end up in more CAM offices.”

He discussed the following natural supplements, which have been found useful in treating pain associated with inflammatory disease:

▸ Willow bark (Salix spp.). This agent contains multiple constituents including phenolic glycosides, tannins, and flavanoids. In a double-blind, placebo-controlled trial of 21 patients who took 240 mg of salicin over a 2-week period, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores were reduced 40%, compared with a 16% reduction among those on placebo. At 2 weeks, the analgesic effect from willow bark was assessed to be about 40% of that from high-dose NSAIDs.

“There is a dose-response relationship,” Dr. Bonakdar said at the meeting, cosponsored by the University of California, San Diego. A randomized, double-blind placebo-controlled trial of 210 patients with low back pain who took 120 mg or 240 mg salicin demonstrated complete relief from pain in 21% and 39% of patients, respectively (Am. J. Med. 2000;109:9–14).

Only 6% of patients in the placebo group reported complete relief from pain.

The dosage used in trials varies, but it is typically standardized to 240 g salicin/day.

▸ Phytodolor. Available since 1963, this patented supplement is from Germany. It contains 1 mg salicin/mL, Populus tremula, Fraxinus excelsior, and Solidago virgaurea. Of the nine randomized, controlled trials involving phytodolor, those with a placebo arm demonstrated superiority of phytodolor; six trials with a comparison group showed no benefit of phytodolor over NSAIDs.

One trial found a dose response to double-strength phytodolor vs. regular dosing at 2 weeks.

The typical dose in trials is 30 drops of standardized extract t.i.d.

▸ Devil's claw (Harpagophytum procumbens). This South African plant is used for arthritis, myalgia, and as an external ointment for burns or sores. Its active ingredients are harpagoside and β-sitosterol.

There have been four double-blind, placebo-controlled trials involving 50–197 patients with osteoarthritis and low back pain. Patients were treated for 3–8 weeks with 50–100 mg harpagosides/iridoid content of 1.5%–3% (the typical dose in trials).

The treatments significantly improved the pain level and joint mobility in study participants. Side effects have included mild and infrequent GI symptoms (BMC Complement. Altern. Med. 2004;4:13).

▸ SAMe (S-adenosylmethionine). This is an endogenous methyl donor that is a naturally occurring product of the reaction between methionine and adenosine triphosphate (ATP). It is postulated to have anti-inflammatory effects through inhibition of tumor necrosis factor-α and upregulation of proteoglycan synthesis and secretion into chondrocytes. SAMe also appears to have a serotonergic effect that may support its pain-modulating abilities.

In a metaanalysis of 11 osteoarthritis trials, SAMe appeared to be as effective as NSAIDs in reducing pain and improving functionality with fewer adverse effects than NSAIDS (J. Fam. Pract. 2002;51:425–30). SAMe is typically initiated in the 200- to 400-mg range and titrated to between 600 and 1,200 mg with caution regarding its serotonergic effects.

Other natural supplements such as ginger (Zingiber officinale), boswellia (Boswellia serrata), turmeric (Curcuma longa), and essential fatty acids have also demonstrated anti-inflammatory activity in preliminary basic research or human trials. While these and other natural supplements have been documented for the treatment of pain, Dr. Bonakdar emphasized that “further well-done trials are required to advance understanding.”

LA JOLLA, CALIF. – The recall of Vioxx and safety warnings about Celebrex and Bextra created “a very insecure time for pain management,” Robert Bonakdar, M.D., said at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

But well before concern surfaced about the safety of those drugs, patients with inflammatory disease increasingly began to seek care from providers of complementary and alternative medicine (CAM) because they were dissatisfied with traditional care results.

“They thank their doctor for the NSAIDs, for the advice, for [the referral to] physical therapy, but they still have pain,” said Dr. Bonakdar, director of pain management at the Scripps Center for Integrative Medicine, La Jolla, Calif. “Also, people with higher pain intensity and duration, and those with a greater degree of self-care, are going to end up in more CAM offices.”

He discussed the following natural supplements, which have been found useful in treating pain associated with inflammatory disease:

▸ Willow bark (Salix spp.). This agent contains multiple constituents including phenolic glycosides, tannins, and flavanoids. In a double-blind, placebo-controlled trial of 21 patients who took 240 mg of salicin over a 2-week period, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores were reduced 40%, compared with a 16% reduction among those on placebo. At 2 weeks, the analgesic effect from willow bark was assessed to be about 40% of that from high-dose NSAIDs.

“There is a dose-response relationship,” Dr. Bonakdar said at the meeting, cosponsored by the University of California, San Diego. A randomized, double-blind placebo-controlled trial of 210 patients with low back pain who took 120 mg or 240 mg salicin demonstrated complete relief from pain in 21% and 39% of patients, respectively (Am. J. Med. 2000;109:9–14).

Only 6% of patients in the placebo group reported complete relief from pain.

The dosage used in trials varies, but it is typically standardized to 240 g salicin/day.

▸ Phytodolor. Available since 1963, this patented supplement is from Germany. It contains 1 mg salicin/mL, Populus tremula, Fraxinus excelsior, and Solidago virgaurea. Of the nine randomized, controlled trials involving phytodolor, those with a placebo arm demonstrated superiority of phytodolor; six trials with a comparison group showed no benefit of phytodolor over NSAIDs.

One trial found a dose response to double-strength phytodolor vs. regular dosing at 2 weeks.

The typical dose in trials is 30 drops of standardized extract t.i.d.

▸ Devil's claw (Harpagophytum procumbens). This South African plant is used for arthritis, myalgia, and as an external ointment for burns or sores. Its active ingredients are harpagoside and β-sitosterol.

There have been four double-blind, placebo-controlled trials involving 50–197 patients with osteoarthritis and low back pain. Patients were treated for 3–8 weeks with 50–100 mg harpagosides/iridoid content of 1.5%–3% (the typical dose in trials).

The treatments significantly improved the pain level and joint mobility in study participants. Side effects have included mild and infrequent GI symptoms (BMC Complement. Altern. Med. 2004;4:13).

▸ SAMe (S-adenosylmethionine). This is an endogenous methyl donor that is a naturally occurring product of the reaction between methionine and adenosine triphosphate (ATP). It is postulated to have anti-inflammatory effects through inhibition of tumor necrosis factor-α and upregulation of proteoglycan synthesis and secretion into chondrocytes. SAMe also appears to have a serotonergic effect that may support its pain-modulating abilities.

In a metaanalysis of 11 osteoarthritis trials, SAMe appeared to be as effective as NSAIDs in reducing pain and improving functionality with fewer adverse effects than NSAIDS (J. Fam. Pract. 2002;51:425–30). SAMe is typically initiated in the 200- to 400-mg range and titrated to between 600 and 1,200 mg with caution regarding its serotonergic effects.

Other natural supplements such as ginger (Zingiber officinale), boswellia (Boswellia serrata), turmeric (Curcuma longa), and essential fatty acids have also demonstrated anti-inflammatory activity in preliminary basic research or human trials. While these and other natural supplements have been documented for the treatment of pain, Dr. Bonakdar emphasized that “further well-done trials are required to advance understanding.”

SAN DIEGO – Spouses of men and women who have mild cognitive impairment are assuming the role of caregiver and as a result, are experiencing the caregiver burden associated with that role, Linda Garand, Ph.D., said at the annual meeting of the American Association for Geriatric Psychiatry.

In a pilot study, nursing tasks such as administration of medication were significantly associated with symptoms of depression in the caregiver, while lifestyle constraints were significantly associated with symptoms of anxiety, Dr. Garand reported.

The finding suggests that spouses of people with mild cognitive impairment (MCI) “may be ideal targets for preventive interventions, to prevent the later development of psychiatric morbidity in the event that they do progress to become a dementia caregiver,” said Dr. Garand of the University of Pittsburgh.

Although the negative mental health effects of dementia caregiving are firmly established in the medical literature, Dr. Garand added, very little is known “about what it's like to give care to a person with milder levels of [cognitive impairment].”

In a 7-month study funded by the National Institute of Mental Health, Dr. Garand and her associates conducted a cross-sectional study of 23 women and 4 men whose spouses met Alzheimer's Disease Research Center criteria for MCI. Spouses lived with the patients at home and understood English.

Self-reported cross-sectional data were collected in the home.

Dr. Garand and her colleagues used a variety of measures, including the Caregiver Burden Inventory, the Memory and Behavior Problem Checklist, the Center for Epidemiologic Studies-Depression scale, and the state portion of the State-Trait Anxiety Inventory.

Most of the spousal caregivers were white, married for almost 5 decades, and lived alone with their spouse. They ranged in age from 54 to 82 years, with an average age of 70 years.

About three-quarters had at least a bachelor's degree.

Spouses performed an average of four household management tasks per day and 0–1 nursing tasks per day.

Dr. Garand said she and the other investigators found that the amount of time to self received the highest caregiver burden rating, while the amount of privacy and the amount of vacation time received the lowest caregiver burden rating.

The most common MCI-related behaviors spouses reported of their loved ones were asking the same question over and over again, having trouble remembering recent events, and losing or misplacing things.

Spouses who performed nursing tasks such as administration of medication were significantly more likely to have depressive symptoms, while those with perceived lifestyle constraints were significantly more likely to have anxiety symptoms.

“The caregiving responsibilities in this sample were very diverse,” Dr. Garand commented.

“The fact that many of these responsibilities were introduced since the person had been diagnosed with MCI suggests that the burden and psychiatric morbidity are directly associated with the MCI in their spouse.”

She noted that all of the spouses who reported responsibility for transportation, running the errands, and managing business affairs also acknowledged that these were new responsibilities since their spouse developed MCI.

Nearly one-half of the spouses reported being responsible for administering medications for their loved one, and a large proportion of that subsample said that it was a new responsibility since the onset of MCI.

Dr. Garand proposes an in-home intervention with spouses of men and women with MCI that will be built into another study. Such an intervention would include 1 month of in-home education followed by 2 months of support via telephone. The intervention “is going to be based on problem-solving therapy,” Dr. Garand explained.

“I'm hoping that if I can equip these spouses with some real problem-solving tools early in their caregiving trajectory, I may be able to help them down the road as they become dementia caregivers, so they don't become so depressed or anxious,” Dr. Garand said.

SAN DIEGO – Spouses of men and women who have mild cognitive impairment are assuming the role of caregiver and as a result, are experiencing the caregiver burden associated with that role, Linda Garand, Ph.D., said at the annual meeting of the American Association for Geriatric Psychiatry.

In a pilot study, nursing tasks such as administration of medication were significantly associated with symptoms of depression in the caregiver, while lifestyle constraints were significantly associated with symptoms of anxiety, Dr. Garand reported.

The finding suggests that spouses of people with mild cognitive impairment (MCI) “may be ideal targets for preventive interventions, to prevent the later development of psychiatric morbidity in the event that they do progress to become a dementia caregiver,” said Dr. Garand of the University of Pittsburgh.

Although the negative mental health effects of dementia caregiving are firmly established in the medical literature, Dr. Garand added, very little is known “about what it's like to give care to a person with milder levels of [cognitive impairment].”

In a 7-month study funded by the National Institute of Mental Health, Dr. Garand and her associates conducted a cross-sectional study of 23 women and 4 men whose spouses met Alzheimer's Disease Research Center criteria for MCI. Spouses lived with the patients at home and understood English.

Self-reported cross-sectional data were collected in the home.

Dr. Garand and her colleagues used a variety of measures, including the Caregiver Burden Inventory, the Memory and Behavior Problem Checklist, the Center for Epidemiologic Studies-Depression scale, and the state portion of the State-Trait Anxiety Inventory.

Most of the spousal caregivers were white, married for almost 5 decades, and lived alone with their spouse. They ranged in age from 54 to 82 years, with an average age of 70 years.

About three-quarters had at least a bachelor's degree.

Spouses performed an average of four household management tasks per day and 0–1 nursing tasks per day.

Dr. Garand said she and the other investigators found that the amount of time to self received the highest caregiver burden rating, while the amount of privacy and the amount of vacation time received the lowest caregiver burden rating.

The most common MCI-related behaviors spouses reported of their loved ones were asking the same question over and over again, having trouble remembering recent events, and losing or misplacing things.

Spouses who performed nursing tasks such as administration of medication were significantly more likely to have depressive symptoms, while those with perceived lifestyle constraints were significantly more likely to have anxiety symptoms.

“The caregiving responsibilities in this sample were very diverse,” Dr. Garand commented.

“The fact that many of these responsibilities were introduced since the person had been diagnosed with MCI suggests that the burden and psychiatric morbidity are directly associated with the MCI in their spouse.”

She noted that all of the spouses who reported responsibility for transportation, running the errands, and managing business affairs also acknowledged that these were new responsibilities since their spouse developed MCI.

Nearly one-half of the spouses reported being responsible for administering medications for their loved one, and a large proportion of that subsample said that it was a new responsibility since the onset of MCI.

Dr. Garand proposes an in-home intervention with spouses of men and women with MCI that will be built into another study. Such an intervention would include 1 month of in-home education followed by 2 months of support via telephone. The intervention “is going to be based on problem-solving therapy,” Dr. Garand explained.

“I'm hoping that if I can equip these spouses with some real problem-solving tools early in their caregiving trajectory, I may be able to help them down the road as they become dementia caregivers, so they don't become so depressed or anxious,” Dr. Garand said.

SAN DIEGO – Spouses of men and women who have mild cognitive impairment are assuming the role of caregiver and as a result, are experiencing the caregiver burden associated with that role, Linda Garand, Ph.D., said at the annual meeting of the American Association for Geriatric Psychiatry.

In a pilot study, nursing tasks such as administration of medication were significantly associated with symptoms of depression in the caregiver, while lifestyle constraints were significantly associated with symptoms of anxiety, Dr. Garand reported.

The finding suggests that spouses of people with mild cognitive impairment (MCI) “may be ideal targets for preventive interventions, to prevent the later development of psychiatric morbidity in the event that they do progress to become a dementia caregiver,” said Dr. Garand of the University of Pittsburgh.

Although the negative mental health effects of dementia caregiving are firmly established in the medical literature, Dr. Garand added, very little is known “about what it's like to give care to a person with milder levels of [cognitive impairment].”

In a 7-month study funded by the National Institute of Mental Health, Dr. Garand and her associates conducted a cross-sectional study of 23 women and 4 men whose spouses met Alzheimer's Disease Research Center criteria for MCI. Spouses lived with the patients at home and understood English.

Self-reported cross-sectional data were collected in the home.

Dr. Garand and her colleagues used a variety of measures, including the Caregiver Burden Inventory, the Memory and Behavior Problem Checklist, the Center for Epidemiologic Studies-Depression scale, and the state portion of the State-Trait Anxiety Inventory.

Most of the spousal caregivers were white, married for almost 5 decades, and lived alone with their spouse. They ranged in age from 54 to 82 years, with an average age of 70 years.

About three-quarters had at least a bachelor's degree.

Spouses performed an average of four household management tasks per day and 0–1 nursing tasks per day.

Dr. Garand said she and the other investigators found that the amount of time to self received the highest caregiver burden rating, while the amount of privacy and the amount of vacation time received the lowest caregiver burden rating.

The most common MCI-related behaviors spouses reported of their loved ones were asking the same question over and over again, having trouble remembering recent events, and losing or misplacing things.

Spouses who performed nursing tasks such as administration of medication were significantly more likely to have depressive symptoms, while those with perceived lifestyle constraints were significantly more likely to have anxiety symptoms.

“The caregiving responsibilities in this sample were very diverse,” Dr. Garand commented.

“The fact that many of these responsibilities were introduced since the person had been diagnosed with MCI suggests that the burden and psychiatric morbidity are directly associated with the MCI in their spouse.”

She noted that all of the spouses who reported responsibility for transportation, running the errands, and managing business affairs also acknowledged that these were new responsibilities since their spouse developed MCI.

Nearly one-half of the spouses reported being responsible for administering medications for their loved one, and a large proportion of that subsample said that it was a new responsibility since the onset of MCI.

Dr. Garand proposes an in-home intervention with spouses of men and women with MCI that will be built into another study. Such an intervention would include 1 month of in-home education followed by 2 months of support via telephone. The intervention “is going to be based on problem-solving therapy,” Dr. Garand explained.

“I'm hoping that if I can equip these spouses with some real problem-solving tools early in their caregiving trajectory, I may be able to help them down the road as they become dementia caregivers, so they don't become so depressed or anxious,” Dr. Garand said.

LA JOLLA, CALIF. — Several natural supplements are useful for lowering blood lipids, Erminia M. Guarneri, M.D., said at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic. They include:

▸ Soluble fiber. Ingesting 2–10 g/day of soluble fiber has been found to lower total cholesterol levels by 15%-18% (Am. J. Clin. Nutr. 1999;69:30–42). Common sources include oats, psyllium, pectin, and guar gum. GI complaints from ingesting soluble fiber are frequent.

▸ Phytosterols. Produced by plants, these substances impair intestinal absorption of cholesterol. Studies have found that 2–3 g/day of phytosterols can reduce LDL-cholesterol levels by 10%-15%. In one study of 167 patients on stable statin therapy, the 83 patients who received three servings per day of a plant stanol-ester spread showed reduction in LDL cholesterol of more than 16% at 8 weeks, compared with a nearly 7% reduction in the 84 placebo patients. The stanol spread provided the equivalent of 2–3 g/day of phytosterols (Am. J. Cardiol. 2000;86:46–52).

In an unpublished study of 14 Scripps patients who were “maxed out on nutrition and cholesterol-lowering medicines,” adding 2 g/day of phytosterols led to a 14% reduction in total cholesterol, a 16% reduction in LDL cholesterol, an 11% reduction in triglycerides, and a 2% increase in HDL cholesterol.

Although some margarines contain phytosterols, those foods should be avoided, especially if they contain partially hydrogenated oils, said Dr. Guarneri, a cardiologist who is founder and medical director of the Scripps Center for Integrative Medicine in La Jolla, Calif. She recommends getting phytosterols from two products: CholestePure (Emerson Ecologics) and UltraMeal Plus (Metagenics).

▸ B vitamins. Deficiencies of vitamin B6, vitamin B12, and folic acid have been linked to elevated plasma homocysteine levels, which are a strong predictor of mortality in coronary artery disease patients.

In fact, one study of 587 coronary artery disease patients found that the risk of mortality was 3.8% for those with a plasma homocysteine level of less than 9.0 ?mol/L and 24.7% for 15 ?mol/L or greater.

Dr. Guarneri recommends Cardio B (Ortho Molecular Products), a mix of folic acid and vitamins B6 and B12, “in one pill, instead of popping a bunch of pills,” she said at the meeting, which was cosponsored by the University of California, San Diego.

▸ Niacin. Regular use of this supplement has been found to lower LDL cholesterol by 5%-25%, lower triglycerides by 20%-50%, and raise HDL cholesterol by 15%-35%.

“The first treatment [for low HDL] is to get the weight off the midline,” Dr. Guarneri said. “But if I have to reach for a supplement to fix this, I fix it with niacin,” he added. “People often see me and say, 'I'm drinking all this wine to raise my HDL.' A lot of times all that wine gives you more weight on the midline, so that's not necessarily the solution. The niacin is.”

Side effects may include flushing, hyperglycemia, hyperuricemia, upper GI distress, and hepatotoxicity.

Niacin is contraindicated in patients with liver disease and severe gout, and in those with peptic ulcer.

“I like short-acting niacin so people can take it with each meal if they need to, as opposed to the long-acting prescription niacin, which you're really only supposed to take once a day,” she added. “When I use short-acting niacins, I can also use them at higher doses. Start low and go up slowly, [but] you do have to monitor liver function.”

For patients with arrhythmia, Dr. Guarneri called magnesium one of her favorite supplements to use. Magnesium is a front-line treatment for torsades de pointes, and some studies have found it beneficial for mitral valve prolapse patients who have low magnesium levels.

“At least one study demonstrated a decrease in blood pressure with a 1,000-mg dose [of magnesium],” she said. “If someone has normal renal function, and they have arrhythmia or skipped heartbeats, and I get them off caffeine and sugar, I will use chelated magnesium and titrate it and warn them about the potential for soft stool.”

The cardiac benefits of the following supplements are less clear, she noted, and called for more research on them: L-arginine, coenzyme Q 10, hawthorn, ginkgo biloba, red yeast rice, policosanol, and horse chestnut.

Dr. Guarneri said that she has no financial interest in any of the products she recommended.

LA JOLLA, CALIF. — Several natural supplements are useful for lowering blood lipids, Erminia M. Guarneri, M.D., said at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic. They include:

▸ Soluble fiber. Ingesting 2–10 g/day of soluble fiber has been found to lower total cholesterol levels by 15%-18% (Am. J. Clin. Nutr. 1999;69:30–42). Common sources include oats, psyllium, pectin, and guar gum. GI complaints from ingesting soluble fiber are frequent.

▸ Phytosterols. Produced by plants, these substances impair intestinal absorption of cholesterol. Studies have found that 2–3 g/day of phytosterols can reduce LDL-cholesterol levels by 10%-15%. In one study of 167 patients on stable statin therapy, the 83 patients who received three servings per day of a plant stanol-ester spread showed reduction in LDL cholesterol of more than 16% at 8 weeks, compared with a nearly 7% reduction in the 84 placebo patients. The stanol spread provided the equivalent of 2–3 g/day of phytosterols (Am. J. Cardiol. 2000;86:46–52).

In an unpublished study of 14 Scripps patients who were “maxed out on nutrition and cholesterol-lowering medicines,” adding 2 g/day of phytosterols led to a 14% reduction in total cholesterol, a 16% reduction in LDL cholesterol, an 11% reduction in triglycerides, and a 2% increase in HDL cholesterol.

Although some margarines contain phytosterols, those foods should be avoided, especially if they contain partially hydrogenated oils, said Dr. Guarneri, a cardiologist who is founder and medical director of the Scripps Center for Integrative Medicine in La Jolla, Calif. She recommends getting phytosterols from two products: CholestePure (Emerson Ecologics) and UltraMeal Plus (Metagenics).

▸ B vitamins. Deficiencies of vitamin B6, vitamin B12, and folic acid have been linked to elevated plasma homocysteine levels, which are a strong predictor of mortality in coronary artery disease patients.

In fact, one study of 587 coronary artery disease patients found that the risk of mortality was 3.8% for those with a plasma homocysteine level of less than 9.0 ?mol/L and 24.7% for 15 ?mol/L or greater.

Dr. Guarneri recommends Cardio B (Ortho Molecular Products), a mix of folic acid and vitamins B6 and B12, “in one pill, instead of popping a bunch of pills,” she said at the meeting, which was cosponsored by the University of California, San Diego.

▸ Niacin. Regular use of this supplement has been found to lower LDL cholesterol by 5%-25%, lower triglycerides by 20%-50%, and raise HDL cholesterol by 15%-35%.

“The first treatment [for low HDL] is to get the weight off the midline,” Dr. Guarneri said. “But if I have to reach for a supplement to fix this, I fix it with niacin,” he added. “People often see me and say, 'I'm drinking all this wine to raise my HDL.' A lot of times all that wine gives you more weight on the midline, so that's not necessarily the solution. The niacin is.”

Side effects may include flushing, hyperglycemia, hyperuricemia, upper GI distress, and hepatotoxicity.

Niacin is contraindicated in patients with liver disease and severe gout, and in those with peptic ulcer.

“I like short-acting niacin so people can take it with each meal if they need to, as opposed to the long-acting prescription niacin, which you're really only supposed to take once a day,” she added. “When I use short-acting niacins, I can also use them at higher doses. Start low and go up slowly, [but] you do have to monitor liver function.”

For patients with arrhythmia, Dr. Guarneri called magnesium one of her favorite supplements to use. Magnesium is a front-line treatment for torsades de pointes, and some studies have found it beneficial for mitral valve prolapse patients who have low magnesium levels.

“At least one study demonstrated a decrease in blood pressure with a 1,000-mg dose [of magnesium],” she said. “If someone has normal renal function, and they have arrhythmia or skipped heartbeats, and I get them off caffeine and sugar, I will use chelated magnesium and titrate it and warn them about the potential for soft stool.”

The cardiac benefits of the following supplements are less clear, she noted, and called for more research on them: L-arginine, coenzyme Q 10, hawthorn, ginkgo biloba, red yeast rice, policosanol, and horse chestnut.

Dr. Guarneri said that she has no financial interest in any of the products she recommended.

LA JOLLA, CALIF. — Several natural supplements are useful for lowering blood lipids, Erminia M. Guarneri, M.D., said at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic. They include:

▸ Soluble fiber. Ingesting 2–10 g/day of soluble fiber has been found to lower total cholesterol levels by 15%-18% (Am. J. Clin. Nutr. 1999;69:30–42). Common sources include oats, psyllium, pectin, and guar gum. GI complaints from ingesting soluble fiber are frequent.

▸ Phytosterols. Produced by plants, these substances impair intestinal absorption of cholesterol. Studies have found that 2–3 g/day of phytosterols can reduce LDL-cholesterol levels by 10%-15%. In one study of 167 patients on stable statin therapy, the 83 patients who received three servings per day of a plant stanol-ester spread showed reduction in LDL cholesterol of more than 16% at 8 weeks, compared with a nearly 7% reduction in the 84 placebo patients. The stanol spread provided the equivalent of 2–3 g/day of phytosterols (Am. J. Cardiol. 2000;86:46–52).

In an unpublished study of 14 Scripps patients who were “maxed out on nutrition and cholesterol-lowering medicines,” adding 2 g/day of phytosterols led to a 14% reduction in total cholesterol, a 16% reduction in LDL cholesterol, an 11% reduction in triglycerides, and a 2% increase in HDL cholesterol.

Although some margarines contain phytosterols, those foods should be avoided, especially if they contain partially hydrogenated oils, said Dr. Guarneri, a cardiologist who is founder and medical director of the Scripps Center for Integrative Medicine in La Jolla, Calif. She recommends getting phytosterols from two products: CholestePure (Emerson Ecologics) and UltraMeal Plus (Metagenics).

▸ B vitamins. Deficiencies of vitamin B6, vitamin B12, and folic acid have been linked to elevated plasma homocysteine levels, which are a strong predictor of mortality in coronary artery disease patients.

In fact, one study of 587 coronary artery disease patients found that the risk of mortality was 3.8% for those with a plasma homocysteine level of less than 9.0 ?mol/L and 24.7% for 15 ?mol/L or greater.

Dr. Guarneri recommends Cardio B (Ortho Molecular Products), a mix of folic acid and vitamins B6 and B12, “in one pill, instead of popping a bunch of pills,” she said at the meeting, which was cosponsored by the University of California, San Diego.

▸ Niacin. Regular use of this supplement has been found to lower LDL cholesterol by 5%-25%, lower triglycerides by 20%-50%, and raise HDL cholesterol by 15%-35%.

“The first treatment [for low HDL] is to get the weight off the midline,” Dr. Guarneri said. “But if I have to reach for a supplement to fix this, I fix it with niacin,” he added. “People often see me and say, 'I'm drinking all this wine to raise my HDL.' A lot of times all that wine gives you more weight on the midline, so that's not necessarily the solution. The niacin is.”

Side effects may include flushing, hyperglycemia, hyperuricemia, upper GI distress, and hepatotoxicity.

Niacin is contraindicated in patients with liver disease and severe gout, and in those with peptic ulcer.

“I like short-acting niacin so people can take it with each meal if they need to, as opposed to the long-acting prescription niacin, which you're really only supposed to take once a day,” she added. “When I use short-acting niacins, I can also use them at higher doses. Start low and go up slowly, [but] you do have to monitor liver function.”

For patients with arrhythmia, Dr. Guarneri called magnesium one of her favorite supplements to use. Magnesium is a front-line treatment for torsades de pointes, and some studies have found it beneficial for mitral valve prolapse patients who have low magnesium levels.

“At least one study demonstrated a decrease in blood pressure with a 1,000-mg dose [of magnesium],” she said. “If someone has normal renal function, and they have arrhythmia or skipped heartbeats, and I get them off caffeine and sugar, I will use chelated magnesium and titrate it and warn them about the potential for soft stool.”

The cardiac benefits of the following supplements are less clear, she noted, and called for more research on them: L-arginine, coenzyme Q 10, hawthorn, ginkgo biloba, red yeast rice, policosanol, and horse chestnut.

Dr. Guarneri said that she has no financial interest in any of the products she recommended.

SAN DIEGO — If you recommend Mohs surgery for a melanoma patient, remember that you are one point along a spectrum of medical and emotional care for that person, Duane C. Whitaker, M.D., advised at a melanoma update sponsored by the Scripps Clinic.

Consider yourself part of a multiphysician treatment team that may include a pathologist, oncologist, surgical oncologist, and a primary care physician.

More important than proficiency in the technical details of Mohs surgery "is the ability to properly evaluate, prognosticate, follow the patient, educate the patient, and have consultations," said Dr. Whitaker, professor of surgical dermatology at the University of Iowa, Iowa City. "Working with high-risk melanoma as part of a team is key."

He said dermatologists can consider Mohs surgery for melanoma when:

▸ The adequate surgical margin of a tumor is unknown.

▸ The tumor can be evaluated properly by microscopy and frozen section.

▸ The tumor is accessible to a staged surgical approach.

▸ Local tumor growth is thought to be contiguous.

The benefits of Mohs surgery include tissue sparing, precise margin determination, immediate reconstruction, minimal wound and repair, and the opportunity to initiate other therapies immediately.

"There is no evidence that patients who have undergone Mohs surgery are at higher risk for metastasis or have increased local recurrence, but it is evident that less surgical morbidity is a benefit in certain cases," Dr. Whitaker said.

A prospective study of 553 primary melanomas treated with Mohs found local or distant recurrence equivalent to or better than historical controls (J. Am. Acad. Dermatol. 1997;37:236–45). Clear margins were achieved in 85% of patients with a 6-mm margin.

In another study, investigators who used Mohs for treating both lentigo maligna melanoma and lentigo maligna found that no predetermined excisional margin could be established (Arch. Dermatol. 2004; 140:1087–92). They employed frozen section margin control and found 2% recurrence at a mean follow-up of 38 months.

A more recent study found that melanomas of the head and neck commonly have subclinical extension (J. Am. Acad. Dermatol. 2005;52:92–100). Mohs surgery achieved 5-year disease-free rates equivalent to or better than historical data.

Physicians should consider these factors before recommending Mohs surgery:

▸ Surgical experience. "I do not advocate Mohs surgery for melanoma across the board," Dr. Whitaker said. "I think the physician's knowledge of the disease, experience with Mohs surgery, and comfort with reading frozen sections are key."

▸ Facial or critical anatomy where the benefit of tissue conservation is substantial. Examples include melanomas of the foot, hand, or genital areas.

▸ Patient and consultant comprehension. "The patient needs to understand what you're doing," he noted. "There is not a huge body of literature to support the idea of Mohs surgery for melanoma. You may be criticized for performing it, but if it's looked at in the whole of the treatment plan, I think there is a rationale for it."

▸ Review of alternatives and adjunctive therapy. Any time you make a diagnosis as serious as melanoma, "it's part of your obligation to tell the patient what every option is in terms of evaluation, treatment, and what the known benefits are," he said. "If the patient has an in situ melanoma or a thin melanoma, Mohs surgery with good assessment and evaluation may be the only treatment that needs to be done."

Mohs surgery "will continue to be employed in the management of melanoma when the managing physician identifies benefits for the patients and has something to offer that would be hard to equal in any other way," he concluded.

SAN DIEGO — If you recommend Mohs surgery for a melanoma patient, remember that you are one point along a spectrum of medical and emotional care for that person, Duane C. Whitaker, M.D., advised at a melanoma update sponsored by the Scripps Clinic.

Consider yourself part of a multiphysician treatment team that may include a pathologist, oncologist, surgical oncologist, and a primary care physician.

More important than proficiency in the technical details of Mohs surgery "is the ability to properly evaluate, prognosticate, follow the patient, educate the patient, and have consultations," said Dr. Whitaker, professor of surgical dermatology at the University of Iowa, Iowa City. "Working with high-risk melanoma as part of a team is key."

He said dermatologists can consider Mohs surgery for melanoma when:

▸ The adequate surgical margin of a tumor is unknown.

▸ The tumor can be evaluated properly by microscopy and frozen section.

▸ The tumor is accessible to a staged surgical approach.

▸ Local tumor growth is thought to be contiguous.

The benefits of Mohs surgery include tissue sparing, precise margin determination, immediate reconstruction, minimal wound and repair, and the opportunity to initiate other therapies immediately.

"There is no evidence that patients who have undergone Mohs surgery are at higher risk for metastasis or have increased local recurrence, but it is evident that less surgical morbidity is a benefit in certain cases," Dr. Whitaker said.

A prospective study of 553 primary melanomas treated with Mohs found local or distant recurrence equivalent to or better than historical controls (J. Am. Acad. Dermatol. 1997;37:236–45). Clear margins were achieved in 85% of patients with a 6-mm margin.

In another study, investigators who used Mohs for treating both lentigo maligna melanoma and lentigo maligna found that no predetermined excisional margin could be established (Arch. Dermatol. 2004; 140:1087–92). They employed frozen section margin control and found 2% recurrence at a mean follow-up of 38 months.

A more recent study found that melanomas of the head and neck commonly have subclinical extension (J. Am. Acad. Dermatol. 2005;52:92–100). Mohs surgery achieved 5-year disease-free rates equivalent to or better than historical data.

Physicians should consider these factors before recommending Mohs surgery:

▸ Surgical experience. "I do not advocate Mohs surgery for melanoma across the board," Dr. Whitaker said. "I think the physician's knowledge of the disease, experience with Mohs surgery, and comfort with reading frozen sections are key."

▸ Facial or critical anatomy where the benefit of tissue conservation is substantial. Examples include melanomas of the foot, hand, or genital areas.

▸ Patient and consultant comprehension. "The patient needs to understand what you're doing," he noted. "There is not a huge body of literature to support the idea of Mohs surgery for melanoma. You may be criticized for performing it, but if it's looked at in the whole of the treatment plan, I think there is a rationale for it."

▸ Review of alternatives and adjunctive therapy. Any time you make a diagnosis as serious as melanoma, "it's part of your obligation to tell the patient what every option is in terms of evaluation, treatment, and what the known benefits are," he said. "If the patient has an in situ melanoma or a thin melanoma, Mohs surgery with good assessment and evaluation may be the only treatment that needs to be done."

Mohs surgery "will continue to be employed in the management of melanoma when the managing physician identifies benefits for the patients and has something to offer that would be hard to equal in any other way," he concluded.

SAN DIEGO — If you recommend Mohs surgery for a melanoma patient, remember that you are one point along a spectrum of medical and emotional care for that person, Duane C. Whitaker, M.D., advised at a melanoma update sponsored by the Scripps Clinic.

Consider yourself part of a multiphysician treatment team that may include a pathologist, oncologist, surgical oncologist, and a primary care physician.

More important than proficiency in the technical details of Mohs surgery "is the ability to properly evaluate, prognosticate, follow the patient, educate the patient, and have consultations," said Dr. Whitaker, professor of surgical dermatology at the University of Iowa, Iowa City. "Working with high-risk melanoma as part of a team is key."

He said dermatologists can consider Mohs surgery for melanoma when:

▸ The adequate surgical margin of a tumor is unknown.

▸ The tumor can be evaluated properly by microscopy and frozen section.

▸ The tumor is accessible to a staged surgical approach.

▸ Local tumor growth is thought to be contiguous.

The benefits of Mohs surgery include tissue sparing, precise margin determination, immediate reconstruction, minimal wound and repair, and the opportunity to initiate other therapies immediately.

"There is no evidence that patients who have undergone Mohs surgery are at higher risk for metastasis or have increased local recurrence, but it is evident that less surgical morbidity is a benefit in certain cases," Dr. Whitaker said.

A prospective study of 553 primary melanomas treated with Mohs found local or distant recurrence equivalent to or better than historical controls (J. Am. Acad. Dermatol. 1997;37:236–45). Clear margins were achieved in 85% of patients with a 6-mm margin.

In another study, investigators who used Mohs for treating both lentigo maligna melanoma and lentigo maligna found that no predetermined excisional margin could be established (Arch. Dermatol. 2004; 140:1087–92). They employed frozen section margin control and found 2% recurrence at a mean follow-up of 38 months.

A more recent study found that melanomas of the head and neck commonly have subclinical extension (J. Am. Acad. Dermatol. 2005;52:92–100). Mohs surgery achieved 5-year disease-free rates equivalent to or better than historical data.

Physicians should consider these factors before recommending Mohs surgery:

▸ Surgical experience. "I do not advocate Mohs surgery for melanoma across the board," Dr. Whitaker said. "I think the physician's knowledge of the disease, experience with Mohs surgery, and comfort with reading frozen sections are key."

▸ Facial or critical anatomy where the benefit of tissue conservation is substantial. Examples include melanomas of the foot, hand, or genital areas.

▸ Patient and consultant comprehension. "The patient needs to understand what you're doing," he noted. "There is not a huge body of literature to support the idea of Mohs surgery for melanoma. You may be criticized for performing it, but if it's looked at in the whole of the treatment plan, I think there is a rationale for it."

▸ Review of alternatives and adjunctive therapy. Any time you make a diagnosis as serious as melanoma, "it's part of your obligation to tell the patient what every option is in terms of evaluation, treatment, and what the known benefits are," he said. "If the patient has an in situ melanoma or a thin melanoma, Mohs surgery with good assessment and evaluation may be the only treatment that needs to be done."

Mohs surgery "will continue to be employed in the management of melanoma when the managing physician identifies benefits for the patients and has something to offer that would be hard to equal in any other way," he concluded.

SAN DIEGO — Dermoscopy can help you reliably diagnose melanomas as small as 3 mm, James W. Steger, M.D., said at a melanoma update sponsored by the Scripps Clinic.

"The best method of diagnosis is not your naked eye by itself or dermoscopy by itself, but using your clinical judgment and both of those things," said Dr. Steger, who chairs the department of dermatology at Naval Medical Center San Diego.

Dermoscopy is a technique of subsurface imaging of color and structures using magnification and either an optical clearing medium such as oil, alcohol, or water, or polarized light. The technique is widely used in Italy, Germany, and Austria, but only about 20% of dermatologists in the United States use it.

In a prospective study of 349 patients with 375 pigmented lesions that required biopsy for diagnosis, 161 of the lesions ranged in size from 1 to 6 mm. Of these, 13 (8%) were melanomas (Eur. J. Dermatol. 2002;12:573–6).

Clinical diagnosis alone detected 10 of 13 melanomas correctly, for a sensitivity of 77% and specificity of 74%. Dermoscopy alone also detected 10 of 13 melanomas correctly, for a sensitivity of 77% and a specificity of 72%.

Another challenging area for dermatologists is diagnosing early-stage nodular melanomas. Dr. Steger explained that nodular melanomas grow relatively fast and differ clinically from superficial spreading malignant melanomas. Small nodular melanomas are usually symmetrical and of a single color.

"They tend to be elevated and dome shaped. And they tend to be firm because of all the cellularity in those tumors," he explained. "When they get mature, they start to weep, encrust, and ulcerate."

Consequently, he added, the ABCD rule for the diagnosis of superficial spreading malignant melanomas does not apply to nodular melanomas. Instead, consider the EFG rule, where E means the lesion is elevated, F means the lesion is firm, and G means it's been growing progressively for 1 month. The G "is of primary importance" according to the new rule's originator, John W. Kelly, M.D., Director, Victorian Melanoma Service, Alfred Hospital, Melbourne (The Melanoma Letter 2004;22:2).

Dr. Steger added that on dermoscopy, "some clinically amelanotic lesions may show areas of light or medium brown pigmentation. Atypical vascular patterns may also be seen."

If you plan to learn dermoscopy, the easiest screening algorithms to use include the three-color test and the three-criteria checklist, Dr. Steger said.

In a study of the three-color test, the presence of three or more colors seen in the lesion on dermoscopy yielded sensitivity for melanoma that ranged from 92% to 97% (Br. J. Dermatol. 2002;146:481–4). However, melanoma was wrongly diagnosed about 50% of the time.

"So you'll be biopsying more benign lesions [with the three-color test], but that's OK," Dr. Steger added.

The three-criteria checklist includes asymmetry of color of dermoscopic structures, atypical pigment network, and any blue or white colors that appear on dermoscopy.

When used by six clinicians who were new to dermoscopy, the checklist yielded a sensitivity of 96% and a specificity of 33% (Dermatology 2004;208:27–31).

"The value of both of these algorithms is in screening," he said. "These are good techniques that all of us can use. When in doubt, biopsy."

To get started in dermoscopy, Dr. Steger recommends reading dermatology literature on the topic and taking one of the introductory courses offered by the American Academy of Dermatology and other organizations.

He also recommends "Dermoscopy: The Essentials," by Robert H. Johr, M.D., et al. (Philadelphia: Mosby, 2004).

SAN DIEGO — Dermoscopy can help you reliably diagnose melanomas as small as 3 mm, James W. Steger, M.D., said at a melanoma update sponsored by the Scripps Clinic.

"The best method of diagnosis is not your naked eye by itself or dermoscopy by itself, but using your clinical judgment and both of those things," said Dr. Steger, who chairs the department of dermatology at Naval Medical Center San Diego.

Dermoscopy is a technique of subsurface imaging of color and structures using magnification and either an optical clearing medium such as oil, alcohol, or water, or polarized light. The technique is widely used in Italy, Germany, and Austria, but only about 20% of dermatologists in the United States use it.

In a prospective study of 349 patients with 375 pigmented lesions that required biopsy for diagnosis, 161 of the lesions ranged in size from 1 to 6 mm. Of these, 13 (8%) were melanomas (Eur. J. Dermatol. 2002;12:573–6).

Clinical diagnosis alone detected 10 of 13 melanomas correctly, for a sensitivity of 77% and specificity of 74%. Dermoscopy alone also detected 10 of 13 melanomas correctly, for a sensitivity of 77% and a specificity of 72%.

Another challenging area for dermatologists is diagnosing early-stage nodular melanomas. Dr. Steger explained that nodular melanomas grow relatively fast and differ clinically from superficial spreading malignant melanomas. Small nodular melanomas are usually symmetrical and of a single color.

"They tend to be elevated and dome shaped. And they tend to be firm because of all the cellularity in those tumors," he explained. "When they get mature, they start to weep, encrust, and ulcerate."

Consequently, he added, the ABCD rule for the diagnosis of superficial spreading malignant melanomas does not apply to nodular melanomas. Instead, consider the EFG rule, where E means the lesion is elevated, F means the lesion is firm, and G means it's been growing progressively for 1 month. The G "is of primary importance" according to the new rule's originator, John W. Kelly, M.D., Director, Victorian Melanoma Service, Alfred Hospital, Melbourne (The Melanoma Letter 2004;22:2).

Dr. Steger added that on dermoscopy, "some clinically amelanotic lesions may show areas of light or medium brown pigmentation. Atypical vascular patterns may also be seen."

If you plan to learn dermoscopy, the easiest screening algorithms to use include the three-color test and the three-criteria checklist, Dr. Steger said.

In a study of the three-color test, the presence of three or more colors seen in the lesion on dermoscopy yielded sensitivity for melanoma that ranged from 92% to 97% (Br. J. Dermatol. 2002;146:481–4). However, melanoma was wrongly diagnosed about 50% of the time.

"So you'll be biopsying more benign lesions [with the three-color test], but that's OK," Dr. Steger added.

The three-criteria checklist includes asymmetry of color of dermoscopic structures, atypical pigment network, and any blue or white colors that appear on dermoscopy.

When used by six clinicians who were new to dermoscopy, the checklist yielded a sensitivity of 96% and a specificity of 33% (Dermatology 2004;208:27–31).

"The value of both of these algorithms is in screening," he said. "These are good techniques that all of us can use. When in doubt, biopsy."

To get started in dermoscopy, Dr. Steger recommends reading dermatology literature on the topic and taking one of the introductory courses offered by the American Academy of Dermatology and other organizations.

He also recommends "Dermoscopy: The Essentials," by Robert H. Johr, M.D., et al. (Philadelphia: Mosby, 2004).

SAN DIEGO — Dermoscopy can help you reliably diagnose melanomas as small as 3 mm, James W. Steger, M.D., said at a melanoma update sponsored by the Scripps Clinic.

"The best method of diagnosis is not your naked eye by itself or dermoscopy by itself, but using your clinical judgment and both of those things," said Dr. Steger, who chairs the department of dermatology at Naval Medical Center San Diego.

Dermoscopy is a technique of subsurface imaging of color and structures using magnification and either an optical clearing medium such as oil, alcohol, or water, or polarized light. The technique is widely used in Italy, Germany, and Austria, but only about 20% of dermatologists in the United States use it.

In a prospective study of 349 patients with 375 pigmented lesions that required biopsy for diagnosis, 161 of the lesions ranged in size from 1 to 6 mm. Of these, 13 (8%) were melanomas (Eur. J. Dermatol. 2002;12:573–6).

Clinical diagnosis alone detected 10 of 13 melanomas correctly, for a sensitivity of 77% and specificity of 74%. Dermoscopy alone also detected 10 of 13 melanomas correctly, for a sensitivity of 77% and a specificity of 72%.

Another challenging area for dermatologists is diagnosing early-stage nodular melanomas. Dr. Steger explained that nodular melanomas grow relatively fast and differ clinically from superficial spreading malignant melanomas. Small nodular melanomas are usually symmetrical and of a single color.

"They tend to be elevated and dome shaped. And they tend to be firm because of all the cellularity in those tumors," he explained. "When they get mature, they start to weep, encrust, and ulcerate."

Consequently, he added, the ABCD rule for the diagnosis of superficial spreading malignant melanomas does not apply to nodular melanomas. Instead, consider the EFG rule, where E means the lesion is elevated, F means the lesion is firm, and G means it's been growing progressively for 1 month. The G "is of primary importance" according to the new rule's originator, John W. Kelly, M.D., Director, Victorian Melanoma Service, Alfred Hospital, Melbourne (The Melanoma Letter 2004;22:2).

Dr. Steger added that on dermoscopy, "some clinically amelanotic lesions may show areas of light or medium brown pigmentation. Atypical vascular patterns may also be seen."

If you plan to learn dermoscopy, the easiest screening algorithms to use include the three-color test and the three-criteria checklist, Dr. Steger said.

In a study of the three-color test, the presence of three or more colors seen in the lesion on dermoscopy yielded sensitivity for melanoma that ranged from 92% to 97% (Br. J. Dermatol. 2002;146:481–4). However, melanoma was wrongly diagnosed about 50% of the time.

"So you'll be biopsying more benign lesions [with the three-color test], but that's OK," Dr. Steger added.

The three-criteria checklist includes asymmetry of color of dermoscopic structures, atypical pigment network, and any blue or white colors that appear on dermoscopy.

When used by six clinicians who were new to dermoscopy, the checklist yielded a sensitivity of 96% and a specificity of 33% (Dermatology 2004;208:27–31).

"The value of both of these algorithms is in screening," he said. "These are good techniques that all of us can use. When in doubt, biopsy."

To get started in dermoscopy, Dr. Steger recommends reading dermatology literature on the topic and taking one of the introductory courses offered by the American Academy of Dermatology and other organizations.

He also recommends "Dermoscopy: The Essentials," by Robert H. Johr, M.D., et al. (Philadelphia: Mosby, 2004).

LAS VEGAS — In multiple gestations, don't rely solely on the mother's perception of how the fetuses are positioned when monitorig fetal heart rates, Patricia M. Witcher, a registered nurse clinician, advised at a conference on fetal monitoring sponsored by Symposia Medicus.

She acknowledged that sometimes clinicians find themselves doing just that, “especially with women who have been admitted in an inpatient antepartum setting who are due to have quadruplets. She'll say, '[Baby] A is here, B is here, C is here, and D is here.' You can't rely on that.”

An ideal way to identify each fetus before heart rate monitoring would be to use ultrasound, but “that's not realistic because most people who initiate monitoring don't do ultrasound,” said Ms. Witcher, a nurse at Northside Hospital in Atlanta who specializes in labor and delivery and high-risk obstetrics.

The best way to identify each fetus is by doing simultaneous monitoring and looking for divergence of fetal heart rate tracings. “That's really the only way we have of ensuring that we have a heart rate for each fetus,” she said.

She recommends drawing a quadrant on the fetal heart rate tracing that represents the four quadrants of the mother's pelvis. Mark the fetus lowest in the pelvis as “A” and assign subsequent letters to the rest. Using a number system is another option.

“Identification of each fetus is extremely important,” she commented. “I can't tell you how many cases I see where it's not clearly labeled which fetus is which. You can figure it out if you see long-term monitoring, whether there have been interruptions in that segment. You can figure out, 'This baby was in trouble before the mother got up to go to the bathroom, so this must be baby B again,' or whichever baby is having problems.”

In a case of twins, some monitors will print the tracings of fetus A in a dark line and that of fetus B in a light line. Others use different colors of ink to help clinicians differentiate fetuses.

Ms. Witcher added that twins are synchronous in that they tend to exhibit accelerations within 15 seconds of each other in about 51% of cases.

“Synchrony is not an indicator of discordancy,” she said.

“It does not tell you whether you have discordant twins or not. If you don't have synchronous fetal heart rate patterns, it's not any indication that you have a problem with one versus the other. It's just the luck of the draw in timing if you display accelerations at the same time in those babies.”

LAS VEGAS — In multiple gestations, don't rely solely on the mother's perception of how the fetuses are positioned when monitorig fetal heart rates, Patricia M. Witcher, a registered nurse clinician, advised at a conference on fetal monitoring sponsored by Symposia Medicus.

She acknowledged that sometimes clinicians find themselves doing just that, “especially with women who have been admitted in an inpatient antepartum setting who are due to have quadruplets. She'll say, '[Baby] A is here, B is here, C is here, and D is here.' You can't rely on that.”

An ideal way to identify each fetus before heart rate monitoring would be to use ultrasound, but “that's not realistic because most people who initiate monitoring don't do ultrasound,” said Ms. Witcher, a nurse at Northside Hospital in Atlanta who specializes in labor and delivery and high-risk obstetrics.

The best way to identify each fetus is by doing simultaneous monitoring and looking for divergence of fetal heart rate tracings. “That's really the only way we have of ensuring that we have a heart rate for each fetus,” she said.

She recommends drawing a quadrant on the fetal heart rate tracing that represents the four quadrants of the mother's pelvis. Mark the fetus lowest in the pelvis as “A” and assign subsequent letters to the rest. Using a number system is another option.

“Identification of each fetus is extremely important,” she commented. “I can't tell you how many cases I see where it's not clearly labeled which fetus is which. You can figure it out if you see long-term monitoring, whether there have been interruptions in that segment. You can figure out, 'This baby was in trouble before the mother got up to go to the bathroom, so this must be baby B again,' or whichever baby is having problems.”

In a case of twins, some monitors will print the tracings of fetus A in a dark line and that of fetus B in a light line. Others use different colors of ink to help clinicians differentiate fetuses.

Ms. Witcher added that twins are synchronous in that they tend to exhibit accelerations within 15 seconds of each other in about 51% of cases.

“Synchrony is not an indicator of discordancy,” she said.

“It does not tell you whether you have discordant twins or not. If you don't have synchronous fetal heart rate patterns, it's not any indication that you have a problem with one versus the other. It's just the luck of the draw in timing if you display accelerations at the same time in those babies.”

LAS VEGAS — In multiple gestations, don't rely solely on the mother's perception of how the fetuses are positioned when monitorig fetal heart rates, Patricia M. Witcher, a registered nurse clinician, advised at a conference on fetal monitoring sponsored by Symposia Medicus.

She acknowledged that sometimes clinicians find themselves doing just that, “especially with women who have been admitted in an inpatient antepartum setting who are due to have quadruplets. She'll say, '[Baby] A is here, B is here, C is here, and D is here.' You can't rely on that.”

An ideal way to identify each fetus before heart rate monitoring would be to use ultrasound, but “that's not realistic because most people who initiate monitoring don't do ultrasound,” said Ms. Witcher, a nurse at Northside Hospital in Atlanta who specializes in labor and delivery and high-risk obstetrics.

The best way to identify each fetus is by doing simultaneous monitoring and looking for divergence of fetal heart rate tracings. “That's really the only way we have of ensuring that we have a heart rate for each fetus,” she said.

She recommends drawing a quadrant on the fetal heart rate tracing that represents the four quadrants of the mother's pelvis. Mark the fetus lowest in the pelvis as “A” and assign subsequent letters to the rest. Using a number system is another option.

“Identification of each fetus is extremely important,” she commented. “I can't tell you how many cases I see where it's not clearly labeled which fetus is which. You can figure it out if you see long-term monitoring, whether there have been interruptions in that segment. You can figure out, 'This baby was in trouble before the mother got up to go to the bathroom, so this must be baby B again,' or whichever baby is having problems.”

In a case of twins, some monitors will print the tracings of fetus A in a dark line and that of fetus B in a light line. Others use different colors of ink to help clinicians differentiate fetuses.

Ms. Witcher added that twins are synchronous in that they tend to exhibit accelerations within 15 seconds of each other in about 51% of cases.

“Synchrony is not an indicator of discordancy,” she said.

“It does not tell you whether you have discordant twins or not. If you don't have synchronous fetal heart rate patterns, it's not any indication that you have a problem with one versus the other. It's just the luck of the draw in timing if you display accelerations at the same time in those babies.”

SAN DIEGO — Most patients with chronic obstructive pulmonary disease have at least moderate levels of anxiety or depression, results from a Veterans Affairs hospital study showed.

In fact, most such patients have anxiety as well as depressive symptoms, often at moderate to severe levels, Mark E. Kunik, M.D., reported at the annual meeting of the American Association for Geriatric Psychiatry.

In a study that was part of a larger randomized, controlled trial of cognitive behavioral therapy for cognitively intact COPD patients who are anxious or depressed, Dr. Kunik and his associates at the Michael E. DeBakey VA Medical Center, Houston, screened 557 men with COPD or related diagnoses by telephone with five questions from the Primary Care Evaluation of Mental Disorders (PRIME-MD):

1. During the past month, have you been bothered often by “nerves” or feeling anxious or on edge?

2. During the past month, have you been bothered often by worrying about a lot of different things?

3. During the past month, have you had an anxiety attack (suddenly feeling fear or panic)?

4. During the past month, have you been bothered often by feeling down, depressed, or hopeless?

5. During the past month, have you been bothered often by having little interest or pleasure in doing things?

Patients who screened positive by phone were assessed at the medical center with the Beck Depression Inventory, the Beck Anxiety Inventory, spirometry, the Mini Mental State Examination, and the structured clinical interview for DSM-III-R (SCID). Of the 557 men, 204 met eligibility for the trial.

Of the 204 eligible men, 24 (12%) met SCID criteria for depressive disorder only, 48 (23%) met SCID criteria for anxiety disorder only, and 53 (26%) met criteria for co-occurring depressive and anxiety disorder, whereas 79 (39%) did not meet SCID criteria for anxiety or depression, reported Dr. Kunik, a geropsychiatry health services researcher at the medical center.

When the 204 patients were asked if they were currently receiving treatment for their depression or anxiety, 31% said they were. But a chart review revealed that only 20% were receiving anxiolytics or antidepressants.

Of the 91 patients who had severe levels of depression or anxiety, less than half (46%) were receiving treatment for depression and/or anxiety, and about 31% were taking an antidepressant or an anxiolytic. “I find that the most troublesome finding of the study,” he said.

A limitation of the study, he noted, was that the sample consisted only of males in the VA.

SAN DIEGO — Most patients with chronic obstructive pulmonary disease have at least moderate levels of anxiety or depression, results from a Veterans Affairs hospital study showed.

In fact, most such patients have anxiety as well as depressive symptoms, often at moderate to severe levels, Mark E. Kunik, M.D., reported at the annual meeting of the American Association for Geriatric Psychiatry.

In a study that was part of a larger randomized, controlled trial of cognitive behavioral therapy for cognitively intact COPD patients who are anxious or depressed, Dr. Kunik and his associates at the Michael E. DeBakey VA Medical Center, Houston, screened 557 men with COPD or related diagnoses by telephone with five questions from the Primary Care Evaluation of Mental Disorders (PRIME-MD):

1. During the past month, have you been bothered often by “nerves” or feeling anxious or on edge?

2. During the past month, have you been bothered often by worrying about a lot of different things?

3. During the past month, have you had an anxiety attack (suddenly feeling fear or panic)?

4. During the past month, have you been bothered often by feeling down, depressed, or hopeless?

5. During the past month, have you been bothered often by having little interest or pleasure in doing things?

Patients who screened positive by phone were assessed at the medical center with the Beck Depression Inventory, the Beck Anxiety Inventory, spirometry, the Mini Mental State Examination, and the structured clinical interview for DSM-III-R (SCID). Of the 557 men, 204 met eligibility for the trial.

Of the 204 eligible men, 24 (12%) met SCID criteria for depressive disorder only, 48 (23%) met SCID criteria for anxiety disorder only, and 53 (26%) met criteria for co-occurring depressive and anxiety disorder, whereas 79 (39%) did not meet SCID criteria for anxiety or depression, reported Dr. Kunik, a geropsychiatry health services researcher at the medical center.

When the 204 patients were asked if they were currently receiving treatment for their depression or anxiety, 31% said they were. But a chart review revealed that only 20% were receiving anxiolytics or antidepressants.

Of the 91 patients who had severe levels of depression or anxiety, less than half (46%) were receiving treatment for depression and/or anxiety, and about 31% were taking an antidepressant or an anxiolytic. “I find that the most troublesome finding of the study,” he said.

A limitation of the study, he noted, was that the sample consisted only of males in the VA.

SAN DIEGO — Most patients with chronic obstructive pulmonary disease have at least moderate levels of anxiety or depression, results from a Veterans Affairs hospital study showed.

In fact, most such patients have anxiety as well as depressive symptoms, often at moderate to severe levels, Mark E. Kunik, M.D., reported at the annual meeting of the American Association for Geriatric Psychiatry.

In a study that was part of a larger randomized, controlled trial of cognitive behavioral therapy for cognitively intact COPD patients who are anxious or depressed, Dr. Kunik and his associates at the Michael E. DeBakey VA Medical Center, Houston, screened 557 men with COPD or related diagnoses by telephone with five questions from the Primary Care Evaluation of Mental Disorders (PRIME-MD):

1. During the past month, have you been bothered often by “nerves” or feeling anxious or on edge?

2. During the past month, have you been bothered often by worrying about a lot of different things?

3. During the past month, have you had an anxiety attack (suddenly feeling fear or panic)?

4. During the past month, have you been bothered often by feeling down, depressed, or hopeless?

5. During the past month, have you been bothered often by having little interest or pleasure in doing things?

Patients who screened positive by phone were assessed at the medical center with the Beck Depression Inventory, the Beck Anxiety Inventory, spirometry, the Mini Mental State Examination, and the structured clinical interview for DSM-III-R (SCID). Of the 557 men, 204 met eligibility for the trial.

Of the 204 eligible men, 24 (12%) met SCID criteria for depressive disorder only, 48 (23%) met SCID criteria for anxiety disorder only, and 53 (26%) met criteria for co-occurring depressive and anxiety disorder, whereas 79 (39%) did not meet SCID criteria for anxiety or depression, reported Dr. Kunik, a geropsychiatry health services researcher at the medical center.

When the 204 patients were asked if they were currently receiving treatment for their depression or anxiety, 31% said they were. But a chart review revealed that only 20% were receiving anxiolytics or antidepressants.

Of the 91 patients who had severe levels of depression or anxiety, less than half (46%) were receiving treatment for depression and/or anxiety, and about 31% were taking an antidepressant or an anxiolytic. “I find that the most troublesome finding of the study,” he said.

A limitation of the study, he noted, was that the sample consisted only of males in the VA.

Patients with primary rectal cancer who undergo short-term preoperative radiotherapy before total mesorectal excision experienced more sexual dysfunction and slower recovery than patients who did not undergo radiotherapy, results from a large, multicenter, randomized trial have shown.

But overall health-related quality of life (HRQL) measures did not differ significantly between the two treatment groups.

“Our study is the first prospective randomized study addressing both HRQL and sexual functioning,” wrote the investigators, led by Corrie Marijnen, M.D., of the department of clinical oncology at Leiden University Medical Center, the Netherlands.

The investigators randomized 990 rectal cancer patients to receive preoperative radiotherapy (PRT) followed by standard total mesorectal excision (TME) or TME alone. Patients in the PRT arm received a total dose of 25 Gy in five fractions over 5–7 days (J. Clin. Oncol. 2005;23:1847–58).

All patients filled out HRQL surveys before treatment and at 3, 6, 12, 18, and 24 months postoperatively. The survey consisted of a measure of overall perceived health from the Rotterdam Symptom Checklist, as well as questions about cancer symptoms, voiding and defecation problems, and sexual function.

No significant differences were observed between the two treatment groups in terms of overall perceived health. The only HRQL measure that was significantly different between the two groups was activity level at 3 months, which was worse for those who received PRT.

“However, compared with baseline, PRT-positive patients did worse at 3 months for both [visual analogue] score and physical symptom scale, whereas this was not the case for PRT-negative patients,” Dr. Marijnen and his associates wrote. “From 6 months onward this difference no longer existed, suggesting it takes PRT-positive patients longer to recuperate from surgery.”

In terms of sexual functioning, significantly more men and women in the PRT arm reported a significant decline in sexual activity postoperatively, compared with those who did not undergo PRT.

For males, postoperative ejaculation problems were significantly more pronounced in those who received PRT. “Irradiated men show a decrease in erectile function for up to 2 years, suggesting late radiation damage to the small vessels,” the investigators wrote.

For females, vaginal dryness and pain during intercourse worsened in both treatment arms, but there were no significant differences between the two groups.

“We therefore conclude that short-term PRT does lead to a significant deterioration in sexual functioning, but this is not reflected in worse valuation of HRQL,” they said. “An explanation for this might be the fact that patients consider sexual functioning least important for their HRQL.”

Patients with primary rectal cancer who undergo short-term preoperative radiotherapy before total mesorectal excision experienced more sexual dysfunction and slower recovery than patients who did not undergo radiotherapy, results from a large, multicenter, randomized trial have shown.

But overall health-related quality of life (HRQL) measures did not differ significantly between the two treatment groups.

“Our study is the first prospective randomized study addressing both HRQL and sexual functioning,” wrote the investigators, led by Corrie Marijnen, M.D., of the department of clinical oncology at Leiden University Medical Center, the Netherlands.

The investigators randomized 990 rectal cancer patients to receive preoperative radiotherapy (PRT) followed by standard total mesorectal excision (TME) or TME alone. Patients in the PRT arm received a total dose of 25 Gy in five fractions over 5–7 days (J. Clin. Oncol. 2005;23:1847–58).

All patients filled out HRQL surveys before treatment and at 3, 6, 12, 18, and 24 months postoperatively. The survey consisted of a measure of overall perceived health from the Rotterdam Symptom Checklist, as well as questions about cancer symptoms, voiding and defecation problems, and sexual function.

No significant differences were observed between the two treatment groups in terms of overall perceived health. The only HRQL measure that was significantly different between the two groups was activity level at 3 months, which was worse for those who received PRT.

“However, compared with baseline, PRT-positive patients did worse at 3 months for both [visual analogue] score and physical symptom scale, whereas this was not the case for PRT-negative patients,” Dr. Marijnen and his associates wrote. “From 6 months onward this difference no longer existed, suggesting it takes PRT-positive patients longer to recuperate from surgery.”

In terms of sexual functioning, significantly more men and women in the PRT arm reported a significant decline in sexual activity postoperatively, compared with those who did not undergo PRT.

For males, postoperative ejaculation problems were significantly more pronounced in those who received PRT. “Irradiated men show a decrease in erectile function for up to 2 years, suggesting late radiation damage to the small vessels,” the investigators wrote.

For females, vaginal dryness and pain during intercourse worsened in both treatment arms, but there were no significant differences between the two groups.

“We therefore conclude that short-term PRT does lead to a significant deterioration in sexual functioning, but this is not reflected in worse valuation of HRQL,” they said. “An explanation for this might be the fact that patients consider sexual functioning least important for their HRQL.”

Patients with primary rectal cancer who undergo short-term preoperative radiotherapy before total mesorectal excision experienced more sexual dysfunction and slower recovery than patients who did not undergo radiotherapy, results from a large, multicenter, randomized trial have shown.

But overall health-related quality of life (HRQL) measures did not differ significantly between the two treatment groups.

“Our study is the first prospective randomized study addressing both HRQL and sexual functioning,” wrote the investigators, led by Corrie Marijnen, M.D., of the department of clinical oncology at Leiden University Medical Center, the Netherlands.

The investigators randomized 990 rectal cancer patients to receive preoperative radiotherapy (PRT) followed by standard total mesorectal excision (TME) or TME alone. Patients in the PRT arm received a total dose of 25 Gy in five fractions over 5–7 days (J. Clin. Oncol. 2005;23:1847–58).

All patients filled out HRQL surveys before treatment and at 3, 6, 12, 18, and 24 months postoperatively. The survey consisted of a measure of overall perceived health from the Rotterdam Symptom Checklist, as well as questions about cancer symptoms, voiding and defecation problems, and sexual function.

No significant differences were observed between the two treatment groups in terms of overall perceived health. The only HRQL measure that was significantly different between the two groups was activity level at 3 months, which was worse for those who received PRT.

“However, compared with baseline, PRT-positive patients did worse at 3 months for both [visual analogue] score and physical symptom scale, whereas this was not the case for PRT-negative patients,” Dr. Marijnen and his associates wrote. “From 6 months onward this difference no longer existed, suggesting it takes PRT-positive patients longer to recuperate from surgery.”

In terms of sexual functioning, significantly more men and women in the PRT arm reported a significant decline in sexual activity postoperatively, compared with those who did not undergo PRT.

For males, postoperative ejaculation problems were significantly more pronounced in those who received PRT. “Irradiated men show a decrease in erectile function for up to 2 years, suggesting late radiation damage to the small vessels,” the investigators wrote.

For females, vaginal dryness and pain during intercourse worsened in both treatment arms, but there were no significant differences between the two groups.

“We therefore conclude that short-term PRT does lead to a significant deterioration in sexual functioning, but this is not reflected in worse valuation of HRQL,” they said. “An explanation for this might be the fact that patients consider sexual functioning least important for their HRQL.”