Doug Brunk

Rubella virus is no longer a major public health threat in this country, but U.S. clinicians should remain vigilant in their vaccination efforts, according to Julie Gerberding, M.D., director of the Centers for Disease Control and Prevention.

In 2004, only nine cases of rubella were reported in the United States. These cases were in mothers who became infected in their respective countries of origin and who then brought the virus to the United States, and in children who were born to families from other parts of the world, Dr. Gerberding said during a media advisory on rubella sponsored by the Centers for Disease Control and Prevention.

“This is a major milestone in the path toward eliminating rubella in other parts of the world, including the Western hemisphere and other regions that have committed [to] this very important health goal,” she said.

Despite the achievement, Dr. Gerberding advised clinicians in the United States and elsewhere to remain vigilant about vaccinating children. “Because we are at constant risk for reintroduction of the virus from other parts of the world, we cannot afford to relax our emphasis on immunization now,” she remarked.

“This is exactly the time when we need to strengthen our emphasis on immunization even further,” Dr. Gerberding added.

Vaccination is also recommended for adolescents and adults without documented evidence of immunity—especially expectant mothers.

Thirty years ago, a rubella epidemic in the United States caused an estimated 12.5 million cases of rubella and 20,000 cases of congenital rubella syndrome, which caused thousands of fetal deaths and left scores more babies deaf, blind, and mentally challenged.

The incidence of rubella in the United States declined sharply after the rubella vaccine was licensed in 1969. By 1983, fewer than 1,000 cases were reported per year, and 2001 marked the first year in which fewer than 100 cases were reported.

Dr. Gerberding credited the current success to “the wonderful people in the immunization communities across the United States who have been working hard to vaccinate children.”

She added that “there is amazing progress under way in other parts of the Western hemisphere, but there are still parts of the world where immunization is not common enough to prevent children from developing congenital rubella syndrome.”

Even though rubella vaccine is available as a single preparation, the CDC recommends that it be given as an MMR vaccine.

The first dose should be given on or after the first birthday, and the second dose should be given between the ages of 4 and 6 years, or when the child starts kindergarten or first grade.

In 2003, the ministers of health of all countries in the Americas resolved to eliminate rubella and congenital rubella syndrome by 2010. Mirta Roses Periago, M.D., who directs the Pan American Health Organization, reported that there were about 1,600 cases of rubella in the Americas in 2004.

“Most of the countries in the region have incorporated the [MMR] vaccine, but many others are catching up in terms of deciding to immunize the population,” Dr. Periago said during the media advisory. “The success is also opening the possibility for improving the access to other populations for influenza, for the [human] papillomavirus vaccine, and the HIV-AIDS vaccine.”

Despite the claims of studies published in the late 1990s that suggest an association between MMR and the development of autism and other developmental problems in children, Dr. Gerberding said, “right now there is no evidence of autism or other harm associated with the MMR vaccine in the area of developmental delays or disabilities. The evidence indicates that this is a safe and effective vaccine. It saves lives. It also protects children now and will protect them as they become adults.”

Rubella virus is no longer a major public health threat in this country, but U.S. clinicians should remain vigilant in their vaccination efforts, according to Julie Gerberding, M.D., director of the Centers for Disease Control and Prevention.

In 2004, only nine cases of rubella were reported in the United States. These cases were in mothers who became infected in their respective countries of origin and who then brought the virus to the United States, and in children who were born to families from other parts of the world, Dr. Gerberding said during a media advisory on rubella sponsored by the Centers for Disease Control and Prevention.

“This is a major milestone in the path toward eliminating rubella in other parts of the world, including the Western hemisphere and other regions that have committed [to] this very important health goal,” she said.

Despite the achievement, Dr. Gerberding advised clinicians in the United States and elsewhere to remain vigilant about vaccinating children. “Because we are at constant risk for reintroduction of the virus from other parts of the world, we cannot afford to relax our emphasis on immunization now,” she remarked.

“This is exactly the time when we need to strengthen our emphasis on immunization even further,” Dr. Gerberding added.

Vaccination is also recommended for adolescents and adults without documented evidence of immunity—especially expectant mothers.

Thirty years ago, a rubella epidemic in the United States caused an estimated 12.5 million cases of rubella and 20,000 cases of congenital rubella syndrome, which caused thousands of fetal deaths and left scores more babies deaf, blind, and mentally challenged.

The incidence of rubella in the United States declined sharply after the rubella vaccine was licensed in 1969. By 1983, fewer than 1,000 cases were reported per year, and 2001 marked the first year in which fewer than 100 cases were reported.

Dr. Gerberding credited the current success to “the wonderful people in the immunization communities across the United States who have been working hard to vaccinate children.”

She added that “there is amazing progress under way in other parts of the Western hemisphere, but there are still parts of the world where immunization is not common enough to prevent children from developing congenital rubella syndrome.”

Even though rubella vaccine is available as a single preparation, the CDC recommends that it be given as an MMR vaccine.

The first dose should be given on or after the first birthday, and the second dose should be given between the ages of 4 and 6 years, or when the child starts kindergarten or first grade.

In 2003, the ministers of health of all countries in the Americas resolved to eliminate rubella and congenital rubella syndrome by 2010. Mirta Roses Periago, M.D., who directs the Pan American Health Organization, reported that there were about 1,600 cases of rubella in the Americas in 2004.

“Most of the countries in the region have incorporated the [MMR] vaccine, but many others are catching up in terms of deciding to immunize the population,” Dr. Periago said during the media advisory. “The success is also opening the possibility for improving the access to other populations for influenza, for the [human] papillomavirus vaccine, and the HIV-AIDS vaccine.”

Despite the claims of studies published in the late 1990s that suggest an association between MMR and the development of autism and other developmental problems in children, Dr. Gerberding said, “right now there is no evidence of autism or other harm associated with the MMR vaccine in the area of developmental delays or disabilities. The evidence indicates that this is a safe and effective vaccine. It saves lives. It also protects children now and will protect them as they become adults.”

Rubella virus is no longer a major public health threat in this country, but U.S. clinicians should remain vigilant in their vaccination efforts, according to Julie Gerberding, M.D., director of the Centers for Disease Control and Prevention.

In 2004, only nine cases of rubella were reported in the United States. These cases were in mothers who became infected in their respective countries of origin and who then brought the virus to the United States, and in children who were born to families from other parts of the world, Dr. Gerberding said during a media advisory on rubella sponsored by the Centers for Disease Control and Prevention.

“This is a major milestone in the path toward eliminating rubella in other parts of the world, including the Western hemisphere and other regions that have committed [to] this very important health goal,” she said.

Despite the achievement, Dr. Gerberding advised clinicians in the United States and elsewhere to remain vigilant about vaccinating children. “Because we are at constant risk for reintroduction of the virus from other parts of the world, we cannot afford to relax our emphasis on immunization now,” she remarked.

“This is exactly the time when we need to strengthen our emphasis on immunization even further,” Dr. Gerberding added.

Vaccination is also recommended for adolescents and adults without documented evidence of immunity—especially expectant mothers.

Thirty years ago, a rubella epidemic in the United States caused an estimated 12.5 million cases of rubella and 20,000 cases of congenital rubella syndrome, which caused thousands of fetal deaths and left scores more babies deaf, blind, and mentally challenged.

The incidence of rubella in the United States declined sharply after the rubella vaccine was licensed in 1969. By 1983, fewer than 1,000 cases were reported per year, and 2001 marked the first year in which fewer than 100 cases were reported.

Dr. Gerberding credited the current success to “the wonderful people in the immunization communities across the United States who have been working hard to vaccinate children.”

She added that “there is amazing progress under way in other parts of the Western hemisphere, but there are still parts of the world where immunization is not common enough to prevent children from developing congenital rubella syndrome.”

Even though rubella vaccine is available as a single preparation, the CDC recommends that it be given as an MMR vaccine.

The first dose should be given on or after the first birthday, and the second dose should be given between the ages of 4 and 6 years, or when the child starts kindergarten or first grade.

In 2003, the ministers of health of all countries in the Americas resolved to eliminate rubella and congenital rubella syndrome by 2010. Mirta Roses Periago, M.D., who directs the Pan American Health Organization, reported that there were about 1,600 cases of rubella in the Americas in 2004.

“Most of the countries in the region have incorporated the [MMR] vaccine, but many others are catching up in terms of deciding to immunize the population,” Dr. Periago said during the media advisory. “The success is also opening the possibility for improving the access to other populations for influenza, for the [human] papillomavirus vaccine, and the HIV-AIDS vaccine.”

Despite the claims of studies published in the late 1990s that suggest an association between MMR and the development of autism and other developmental problems in children, Dr. Gerberding said, “right now there is no evidence of autism or other harm associated with the MMR vaccine in the area of developmental delays or disabilities. The evidence indicates that this is a safe and effective vaccine. It saves lives. It also protects children now and will protect them as they become adults.”

SAN DIEGO — Children born to preeclamptic mothers are more likely to have pulmonary hypertension, compared with children born from uncomplicated pregnancies, results from a small study have demonstrated.

The finding provides “the very first evidence that preeclampsia leaves a persistent and potentially fatal imprint in the pulmonary circulation of the offspring, which predisposes them to exaggerated hypoxic pulmonary hypertension in later life,” Pierre-Yves Jayet, M.D., reported at a meeting sponsored by the American Physiological Society.

As part of an ongoing collaboration between the University Hospital in Lausanne, Switzerland, the Swiss Cardiovascular Research Institute in Bern, and the Bolivian High Altitude Research Institute in La Paz.

Dr. Jayet and his associates hypothesized that children born to mothers who had preeclampsia are predisposed to pulmonary hypertension at high altitude. To test this hypothesis, the investigators used echocardiography to measure systolic pulmonary artery pressure in 11 children aged 6-8 years who were born to preeclamptic mothers from La Paz, where the elevation ranges from 12,000 to 13,000 feet above sea level.

For a control group, they evaluated 13 age- and gender-matched children in La Paz born from normal pregnancies, said Dr. Jayet of the department of internal medicine at University Hospital in Lausanne.

The mean systolic pulmonary artery pressure was about 33% higher in children born to preeclamptic mothers, compared with those born from uncomplicated pregnancies (36 mm Hg vs. 27 mm Hg, respectively). Dr. Jayet noted that the hypoxic pulmonary vasoconstriction was not related to more severe hypoxemia or exaggerated polyglobulia.

He said the next step is to study animal models to determine the underlying mechanism of action that causes pulmonary vascular damage in children of preeclamptic mothers.

The Swiss National Science Foundation supported the study.

SAN DIEGO — Children born to preeclamptic mothers are more likely to have pulmonary hypertension, compared with children born from uncomplicated pregnancies, results from a small study have demonstrated.

The finding provides “the very first evidence that preeclampsia leaves a persistent and potentially fatal imprint in the pulmonary circulation of the offspring, which predisposes them to exaggerated hypoxic pulmonary hypertension in later life,” Pierre-Yves Jayet, M.D., reported at a meeting sponsored by the American Physiological Society.

As part of an ongoing collaboration between the University Hospital in Lausanne, Switzerland, the Swiss Cardiovascular Research Institute in Bern, and the Bolivian High Altitude Research Institute in La Paz.

Dr. Jayet and his associates hypothesized that children born to mothers who had preeclampsia are predisposed to pulmonary hypertension at high altitude. To test this hypothesis, the investigators used echocardiography to measure systolic pulmonary artery pressure in 11 children aged 6-8 years who were born to preeclamptic mothers from La Paz, where the elevation ranges from 12,000 to 13,000 feet above sea level.

For a control group, they evaluated 13 age- and gender-matched children in La Paz born from normal pregnancies, said Dr. Jayet of the department of internal medicine at University Hospital in Lausanne.

The mean systolic pulmonary artery pressure was about 33% higher in children born to preeclamptic mothers, compared with those born from uncomplicated pregnancies (36 mm Hg vs. 27 mm Hg, respectively). Dr. Jayet noted that the hypoxic pulmonary vasoconstriction was not related to more severe hypoxemia or exaggerated polyglobulia.

He said the next step is to study animal models to determine the underlying mechanism of action that causes pulmonary vascular damage in children of preeclamptic mothers.

The Swiss National Science Foundation supported the study.

SAN DIEGO — Children born to preeclamptic mothers are more likely to have pulmonary hypertension, compared with children born from uncomplicated pregnancies, results from a small study have demonstrated.

The finding provides “the very first evidence that preeclampsia leaves a persistent and potentially fatal imprint in the pulmonary circulation of the offspring, which predisposes them to exaggerated hypoxic pulmonary hypertension in later life,” Pierre-Yves Jayet, M.D., reported at a meeting sponsored by the American Physiological Society.

As part of an ongoing collaboration between the University Hospital in Lausanne, Switzerland, the Swiss Cardiovascular Research Institute in Bern, and the Bolivian High Altitude Research Institute in La Paz.

Dr. Jayet and his associates hypothesized that children born to mothers who had preeclampsia are predisposed to pulmonary hypertension at high altitude. To test this hypothesis, the investigators used echocardiography to measure systolic pulmonary artery pressure in 11 children aged 6-8 years who were born to preeclamptic mothers from La Paz, where the elevation ranges from 12,000 to 13,000 feet above sea level.

For a control group, they evaluated 13 age- and gender-matched children in La Paz born from normal pregnancies, said Dr. Jayet of the department of internal medicine at University Hospital in Lausanne.

The mean systolic pulmonary artery pressure was about 33% higher in children born to preeclamptic mothers, compared with those born from uncomplicated pregnancies (36 mm Hg vs. 27 mm Hg, respectively). Dr. Jayet noted that the hypoxic pulmonary vasoconstriction was not related to more severe hypoxemia or exaggerated polyglobulia.

He said the next step is to study animal models to determine the underlying mechanism of action that causes pulmonary vascular damage in children of preeclamptic mothers.

The Swiss National Science Foundation supported the study.

SAN DIEGO — An 11-month-old Asian American boy acquired Kawasaki disease during an extended hospital stay, Wilbert H. Mason, M.D., reported in a poster session at an international Kawasaki disease symposium.

In a later interview, he said this marks the first case of nosocomially acquired Kawasaki disease that he is aware of. “We think of Kawasaki disease as being developed in the community due to in an infectious agent of some sort,” said Dr. Mason, professor of clinical pediatrics at the University of Southern California and head of the division of infectious diseases at Children's Hospital Los Angeles. “It's a lesson to us that there are a number of viral infections that can be nosocomially acquired, and you can add Kawasaki disease to the list of those.”

The boy arrived at Children's Hospital after being transferred from another hospital with increasing lethargy and weak cry. He was diagnosed with infant botulism and required ventilation for 5.5 months in the ICU.

The boy was transferred to a rehabilitation unit 181 days after hospital admission. On day 32 following the transfer, the boy developed high fever, rash, conjunctivitis, red lips and buccal mucosa, palmar erythema, and tachycardia with an extra heart sound. The patient appeared toxic. On day 4 of fever, he was diagnosed with Kawasaki disease and received intravenous gamma globulin 400 mg/kg/four times a day and aspirin 100 mg/kg/four times a day. Echocardiogram was normal. The patient responded well to therapy.

Dr. Mason noted that the rug in the rehab unit where the boy stayed had been replaced 42 days before the onset of Kawasaki disease. “The association may well be coincidental, and it should be viewed in that context.” The symposium was sponsored by the American Heart Association.

SAN DIEGO — An 11-month-old Asian American boy acquired Kawasaki disease during an extended hospital stay, Wilbert H. Mason, M.D., reported in a poster session at an international Kawasaki disease symposium.

In a later interview, he said this marks the first case of nosocomially acquired Kawasaki disease that he is aware of. “We think of Kawasaki disease as being developed in the community due to in an infectious agent of some sort,” said Dr. Mason, professor of clinical pediatrics at the University of Southern California and head of the division of infectious diseases at Children's Hospital Los Angeles. “It's a lesson to us that there are a number of viral infections that can be nosocomially acquired, and you can add Kawasaki disease to the list of those.”

The boy arrived at Children's Hospital after being transferred from another hospital with increasing lethargy and weak cry. He was diagnosed with infant botulism and required ventilation for 5.5 months in the ICU.

The boy was transferred to a rehabilitation unit 181 days after hospital admission. On day 32 following the transfer, the boy developed high fever, rash, conjunctivitis, red lips and buccal mucosa, palmar erythema, and tachycardia with an extra heart sound. The patient appeared toxic. On day 4 of fever, he was diagnosed with Kawasaki disease and received intravenous gamma globulin 400 mg/kg/four times a day and aspirin 100 mg/kg/four times a day. Echocardiogram was normal. The patient responded well to therapy.

Dr. Mason noted that the rug in the rehab unit where the boy stayed had been replaced 42 days before the onset of Kawasaki disease. “The association may well be coincidental, and it should be viewed in that context.” The symposium was sponsored by the American Heart Association.

SAN DIEGO — An 11-month-old Asian American boy acquired Kawasaki disease during an extended hospital stay, Wilbert H. Mason, M.D., reported in a poster session at an international Kawasaki disease symposium.

In a later interview, he said this marks the first case of nosocomially acquired Kawasaki disease that he is aware of. “We think of Kawasaki disease as being developed in the community due to in an infectious agent of some sort,” said Dr. Mason, professor of clinical pediatrics at the University of Southern California and head of the division of infectious diseases at Children's Hospital Los Angeles. “It's a lesson to us that there are a number of viral infections that can be nosocomially acquired, and you can add Kawasaki disease to the list of those.”

The boy arrived at Children's Hospital after being transferred from another hospital with increasing lethargy and weak cry. He was diagnosed with infant botulism and required ventilation for 5.5 months in the ICU.

The boy was transferred to a rehabilitation unit 181 days after hospital admission. On day 32 following the transfer, the boy developed high fever, rash, conjunctivitis, red lips and buccal mucosa, palmar erythema, and tachycardia with an extra heart sound. The patient appeared toxic. On day 4 of fever, he was diagnosed with Kawasaki disease and received intravenous gamma globulin 400 mg/kg/four times a day and aspirin 100 mg/kg/four times a day. Echocardiogram was normal. The patient responded well to therapy.

Dr. Mason noted that the rug in the rehab unit where the boy stayed had been replaced 42 days before the onset of Kawasaki disease. “The association may well be coincidental, and it should be viewed in that context.” The symposium was sponsored by the American Heart Association.

SAN DIEGO — Children on warfarin should get an international normalized ratio measurement within 2-3 days of starting antibiotic therapy, since they may experience significant changes in INR value, Kathy Hinoki, R.N., reported in a poster session at an international Kawasaki disease symposium.

“I have proactively cut back on a warfarin or coumadin dose when the parent has told me the child is sick and has been started on an antibiotic,” Ms. Hinoki, a cardiology nurse with Children's Hospital Los Angeles, said in an interview.

“This prevents the lab values from getting out of whack and [lessens the] risk for bleeding.”

She noted that while pediatricians typically order antibiotic for warfarin-treated children, “they usually don't have the background about the seriousness of the warfarin-antibiotic interaction, so they probably should consult with someone who [has the expertise].”

In a 5-year study of 3,582 lab encounters in the anticoagulation clinic at Children's Hospital Los Angeles, Ms. Hinoki and her associates selected 28 children who had a stable INR on the same dose of warfarin for greater than three consecutive lab encounters prior to the initiation of antibiotic therapy.

The three most common reasons for anticoagulation were prosthetic valves, Fontan procedure, and Kawasaki disease.

The investigators measured the INR within 1-7 days after the antibiotics were started, and they calculated the percent change in INR.

Of the 28 cases, eight females and four males demonstrated INR increases of more than 20%. Of the 16 children who demonstrated either no change or a decrease in INR, 12 were males and 4 were females.

Ms. Hinoki noted that erythromycin, cefuroxime, clindamycin, levofloxacin, and doxycycline were associated with significant increases in INR, while ampicillin, cephalexin, and amoxicillin-clavulanic acid were associated with no changes in INR. Griseofulvin and azithromycin appeared to cause mild to moderate decreases in INR.

Age, ethnicity, and cardiac diagnosis appeared to have no impact on drug interactions.

“There's much more research to do, because antibiotics are constantly changing,” said Ms. Hinoki, who runs the hospital's anticoagulation program.

The symposium was sponsored by the American Heart Association.

SAN DIEGO — Children on warfarin should get an international normalized ratio measurement within 2-3 days of starting antibiotic therapy, since they may experience significant changes in INR value, Kathy Hinoki, R.N., reported in a poster session at an international Kawasaki disease symposium.

“I have proactively cut back on a warfarin or coumadin dose when the parent has told me the child is sick and has been started on an antibiotic,” Ms. Hinoki, a cardiology nurse with Children's Hospital Los Angeles, said in an interview.

“This prevents the lab values from getting out of whack and [lessens the] risk for bleeding.”

She noted that while pediatricians typically order antibiotic for warfarin-treated children, “they usually don't have the background about the seriousness of the warfarin-antibiotic interaction, so they probably should consult with someone who [has the expertise].”

In a 5-year study of 3,582 lab encounters in the anticoagulation clinic at Children's Hospital Los Angeles, Ms. Hinoki and her associates selected 28 children who had a stable INR on the same dose of warfarin for greater than three consecutive lab encounters prior to the initiation of antibiotic therapy.

The three most common reasons for anticoagulation were prosthetic valves, Fontan procedure, and Kawasaki disease.

The investigators measured the INR within 1-7 days after the antibiotics were started, and they calculated the percent change in INR.

Of the 28 cases, eight females and four males demonstrated INR increases of more than 20%. Of the 16 children who demonstrated either no change or a decrease in INR, 12 were males and 4 were females.

Ms. Hinoki noted that erythromycin, cefuroxime, clindamycin, levofloxacin, and doxycycline were associated with significant increases in INR, while ampicillin, cephalexin, and amoxicillin-clavulanic acid were associated with no changes in INR. Griseofulvin and azithromycin appeared to cause mild to moderate decreases in INR.

Age, ethnicity, and cardiac diagnosis appeared to have no impact on drug interactions.

“There's much more research to do, because antibiotics are constantly changing,” said Ms. Hinoki, who runs the hospital's anticoagulation program.

The symposium was sponsored by the American Heart Association.

SAN DIEGO — Children on warfarin should get an international normalized ratio measurement within 2-3 days of starting antibiotic therapy, since they may experience significant changes in INR value, Kathy Hinoki, R.N., reported in a poster session at an international Kawasaki disease symposium.

“I have proactively cut back on a warfarin or coumadin dose when the parent has told me the child is sick and has been started on an antibiotic,” Ms. Hinoki, a cardiology nurse with Children's Hospital Los Angeles, said in an interview.

“This prevents the lab values from getting out of whack and [lessens the] risk for bleeding.”

She noted that while pediatricians typically order antibiotic for warfarin-treated children, “they usually don't have the background about the seriousness of the warfarin-antibiotic interaction, so they probably should consult with someone who [has the expertise].”

In a 5-year study of 3,582 lab encounters in the anticoagulation clinic at Children's Hospital Los Angeles, Ms. Hinoki and her associates selected 28 children who had a stable INR on the same dose of warfarin for greater than three consecutive lab encounters prior to the initiation of antibiotic therapy.

The three most common reasons for anticoagulation were prosthetic valves, Fontan procedure, and Kawasaki disease.

The investigators measured the INR within 1-7 days after the antibiotics were started, and they calculated the percent change in INR.

Of the 28 cases, eight females and four males demonstrated INR increases of more than 20%. Of the 16 children who demonstrated either no change or a decrease in INR, 12 were males and 4 were females.

Ms. Hinoki noted that erythromycin, cefuroxime, clindamycin, levofloxacin, and doxycycline were associated with significant increases in INR, while ampicillin, cephalexin, and amoxicillin-clavulanic acid were associated with no changes in INR. Griseofulvin and azithromycin appeared to cause mild to moderate decreases in INR.

Age, ethnicity, and cardiac diagnosis appeared to have no impact on drug interactions.

“There's much more research to do, because antibiotics are constantly changing,” said Ms. Hinoki, who runs the hospital's anticoagulation program.

The symposium was sponsored by the American Heart Association.

SAN DIEGO — Deep vein thrombosis prophylaxis practice in hospitalized, acutely ill patients is clearly underused in the United States and Europe, results from a large international trial suggest.

“Despite the [American College of Chest Physicians] consensus guideline recommendations of 2001 and 2002 and evidence from clinical studies showing the benefits of DVT prophylaxis in acutely ill medical patients, only 44% received in-hospital prophylaxis,” Victor F. Tapson, M.D., reported in a poster session at the annual meeting of the American Society of Hematology.

The finding is part of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE). Funded by an unrestricted grant from Aventis Pharmaceuticals Inc., the purpose of the multicenter registry is to assess routine clinical practices for providing hospitalized, acutely ill patients with venous thromboembolism prophylaxis and to test predictive models of the relationship between patient characteristics, prophylaxis use, and key clinical end points.

For the trial, patients aged 18 years and older who were hospitalized for at least 3 days were enrolled consecutively. Data were recorded at discharge and 3 months after discharge.

Dr. Tapson reported on 4,315 patients from 37 hospitals in 11 countries who were enrolled between Jan. 1, 2002, and June 30, 2004. Half were female and the mean age was 69.

Less than half of the patients (44%) received in-hospital DVT prophylaxis, said Dr. Tapson, of Duke University Medical Center, Durham, N.C. Low-molecular-weight heparin and unfractionated heparin were used most often. Low-molecular-weight heparin regimens were usually given once daily.

Unfractionated heparin regimens varied. Outside of the United States, most regimens (85%) were given every 12 hours. In the United States a similar number of patients received unfractionated heparin every 12 hours (55%) or every 8 hours (40%). Aspirin was given as DVT prophylaxis to 7% of patients in the United States and 3% to patients in other countries.

“Unfractionated heparin is used more for medical patient prophylaxis than low-molecular-weight heparin in the United States while the reverse is true in Europe and certain other parts of the world,” Dr. Tapson said in an interview. “Low-molecular-weight heparin has considerable advantages including once-daily injection and, for example, a lower risk of heparin-induced thrombocytopenia This is very relevant to the primary care physician, particularly those that do inpatient work. They need to consider prophylaxis for every medical patient admitted, as most need it.”

As for mechanical methods of DVT prophylaxis, U.S. clinicians used pneumatic compression more often, compared with those in other countries (19% vs. 0.3%). Foreign clinicians used elastic stockings more often, than U.S. doctors (8% vs. 2%).

SAN DIEGO — Deep vein thrombosis prophylaxis practice in hospitalized, acutely ill patients is clearly underused in the United States and Europe, results from a large international trial suggest.

“Despite the [American College of Chest Physicians] consensus guideline recommendations of 2001 and 2002 and evidence from clinical studies showing the benefits of DVT prophylaxis in acutely ill medical patients, only 44% received in-hospital prophylaxis,” Victor F. Tapson, M.D., reported in a poster session at the annual meeting of the American Society of Hematology.

The finding is part of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE). Funded by an unrestricted grant from Aventis Pharmaceuticals Inc., the purpose of the multicenter registry is to assess routine clinical practices for providing hospitalized, acutely ill patients with venous thromboembolism prophylaxis and to test predictive models of the relationship between patient characteristics, prophylaxis use, and key clinical end points.

For the trial, patients aged 18 years and older who were hospitalized for at least 3 days were enrolled consecutively. Data were recorded at discharge and 3 months after discharge.

Dr. Tapson reported on 4,315 patients from 37 hospitals in 11 countries who were enrolled between Jan. 1, 2002, and June 30, 2004. Half were female and the mean age was 69.

Less than half of the patients (44%) received in-hospital DVT prophylaxis, said Dr. Tapson, of Duke University Medical Center, Durham, N.C. Low-molecular-weight heparin and unfractionated heparin were used most often. Low-molecular-weight heparin regimens were usually given once daily.

Unfractionated heparin regimens varied. Outside of the United States, most regimens (85%) were given every 12 hours. In the United States a similar number of patients received unfractionated heparin every 12 hours (55%) or every 8 hours (40%). Aspirin was given as DVT prophylaxis to 7% of patients in the United States and 3% to patients in other countries.

“Unfractionated heparin is used more for medical patient prophylaxis than low-molecular-weight heparin in the United States while the reverse is true in Europe and certain other parts of the world,” Dr. Tapson said in an interview. “Low-molecular-weight heparin has considerable advantages including once-daily injection and, for example, a lower risk of heparin-induced thrombocytopenia This is very relevant to the primary care physician, particularly those that do inpatient work. They need to consider prophylaxis for every medical patient admitted, as most need it.”

As for mechanical methods of DVT prophylaxis, U.S. clinicians used pneumatic compression more often, compared with those in other countries (19% vs. 0.3%). Foreign clinicians used elastic stockings more often, than U.S. doctors (8% vs. 2%).

SAN DIEGO — Deep vein thrombosis prophylaxis practice in hospitalized, acutely ill patients is clearly underused in the United States and Europe, results from a large international trial suggest.

“Despite the [American College of Chest Physicians] consensus guideline recommendations of 2001 and 2002 and evidence from clinical studies showing the benefits of DVT prophylaxis in acutely ill medical patients, only 44% received in-hospital prophylaxis,” Victor F. Tapson, M.D., reported in a poster session at the annual meeting of the American Society of Hematology.

The finding is part of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE). Funded by an unrestricted grant from Aventis Pharmaceuticals Inc., the purpose of the multicenter registry is to assess routine clinical practices for providing hospitalized, acutely ill patients with venous thromboembolism prophylaxis and to test predictive models of the relationship between patient characteristics, prophylaxis use, and key clinical end points.

For the trial, patients aged 18 years and older who were hospitalized for at least 3 days were enrolled consecutively. Data were recorded at discharge and 3 months after discharge.

Dr. Tapson reported on 4,315 patients from 37 hospitals in 11 countries who were enrolled between Jan. 1, 2002, and June 30, 2004. Half were female and the mean age was 69.

Less than half of the patients (44%) received in-hospital DVT prophylaxis, said Dr. Tapson, of Duke University Medical Center, Durham, N.C. Low-molecular-weight heparin and unfractionated heparin were used most often. Low-molecular-weight heparin regimens were usually given once daily.

Unfractionated heparin regimens varied. Outside of the United States, most regimens (85%) were given every 12 hours. In the United States a similar number of patients received unfractionated heparin every 12 hours (55%) or every 8 hours (40%). Aspirin was given as DVT prophylaxis to 7% of patients in the United States and 3% to patients in other countries.

“Unfractionated heparin is used more for medical patient prophylaxis than low-molecular-weight heparin in the United States while the reverse is true in Europe and certain other parts of the world,” Dr. Tapson said in an interview. “Low-molecular-weight heparin has considerable advantages including once-daily injection and, for example, a lower risk of heparin-induced thrombocytopenia This is very relevant to the primary care physician, particularly those that do inpatient work. They need to consider prophylaxis for every medical patient admitted, as most need it.”

As for mechanical methods of DVT prophylaxis, U.S. clinicians used pneumatic compression more often, compared with those in other countries (19% vs. 0.3%). Foreign clinicians used elastic stockings more often, than U.S. doctors (8% vs. 2%).

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.

“We need to develop interventions that are aimed at the level of diagnosis, acute treatment, and long-term management that targets both anxiety and depression,” Dr. Kunik said.

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. The rest did not have COPD by spirometry, did not have anxiety or depression based on the Beck scales, or were excluded for other reasons.

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 we looked at the spectrum of diagnosis, the most common was major depressive disorder (23%), followed by generalized anxiety disorder (19%),” he said. “One of the surprises is that there wasn't more panic disorder.”

A limitation of the study, he noted, was that the sample consisted only of males in the VA system. “Anxiety and depression occur more frequently in females,” Dr. Kunik said. “That's a key limitation.”

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.

“We need to develop interventions that are aimed at the level of diagnosis, acute treatment, and long-term management that targets both anxiety and depression,” Dr. Kunik said.

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. The rest did not have COPD by spirometry, did not have anxiety or depression based on the Beck scales, or were excluded for other reasons.

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 we looked at the spectrum of diagnosis, the most common was major depressive disorder (23%), followed by generalized anxiety disorder (19%),” he said. “One of the surprises is that there wasn't more panic disorder.”

A limitation of the study, he noted, was that the sample consisted only of males in the VA system. “Anxiety and depression occur more frequently in females,” Dr. Kunik said. “That's a key limitation.”

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.

“We need to develop interventions that are aimed at the level of diagnosis, acute treatment, and long-term management that targets both anxiety and depression,” Dr. Kunik said.

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. The rest did not have COPD by spirometry, did not have anxiety or depression based on the Beck scales, or were excluded for other reasons.

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 we looked at the spectrum of diagnosis, the most common was major depressive disorder (23%), followed by generalized anxiety disorder (19%),” he said. “One of the surprises is that there wasn't more panic disorder.”

A limitation of the study, he noted, was that the sample consisted only of males in the VA system. “Anxiety and depression occur more frequently in females,” Dr. Kunik said. “That's a key limitation.”

Daily cigarette smokers are 1.82 times more likely to have suicidal thoughts or to attempt suicide, compared with those who had smoked in the past, results from a large prospective study have demonstrated.

Previous studies have suggested that there is a link between cigarette smoking and suicidal behavior, but this study controlled for major depression and alcohol or drug use disorders, reported the researchers, who were led by Naomi Breslau, Ph.D., of the department of epidemiology at Michigan State University in East Lansing.

“Limitations of the study are that we have no data on completed suicide and that the number of suicide attempts was small and therefore was combined with suicidal thoughts,” the researchers said (Arch. Gen. Psychiatry 2005;62:328-34).

“To analyze these rare outcomes, a much larger sample and longer follow-up period are needed. Whether the results can be extrapolated to attempted or completed suicide is uncertain. However, suicidal behaviors are established predictors of completed suicide. These antecedents and their potential etiologies are therefore of scientific and public health interest,” they said.

Dr. Breslau and her associates prospectively studied 990 men and women aged 21-30 who were randomly selected from a Michigan HMO.

The researchers asked study participants about lifetime history of psychiatric disorders and daily smoking and administered the National Institute of Mental Health Diagnostic Interview Schedule for DSM-III-R at their baseline interview in 1989 and in follow-up interviews in 1992, 1994, and 1999-2001.

Current smokers were defined as those who reported smoking within the preceding 12 months of an assessment; past smokers were defined as those who had smoked previously but not in the preceding 12 months.

Of the 990 men and women, 63% were female, 80% were white, 29% completed college, and 46% were married.

The researchers found that current daily smokers were significantly more likely to have suicidal thoughts or to attempt suicide, compared with past smokers (odds ratio of 1.82 vs. odds ratio of 1.09, respectively).

After adjusting for suicidal predisposition indicated by prior suicidality and controlling for prior psychiatric disorders, current daily smokers were significantly more likely to have suicidal thoughts or to attempt suicide, compared with past smokers (odds ratio of 1.74 vs. odds ratio of 1.14, respectively), the investigators said.

The National Institute of Mental Health provided funding for the study.

Daily cigarette smokers are 1.82 times more likely to have suicidal thoughts or to attempt suicide, compared with those who had smoked in the past, results from a large prospective study have demonstrated.

Previous studies have suggested that there is a link between cigarette smoking and suicidal behavior, but this study controlled for major depression and alcohol or drug use disorders, reported the researchers, who were led by Naomi Breslau, Ph.D., of the department of epidemiology at Michigan State University in East Lansing.

“Limitations of the study are that we have no data on completed suicide and that the number of suicide attempts was small and therefore was combined with suicidal thoughts,” the researchers said (Arch. Gen. Psychiatry 2005;62:328-34).

“To analyze these rare outcomes, a much larger sample and longer follow-up period are needed. Whether the results can be extrapolated to attempted or completed suicide is uncertain. However, suicidal behaviors are established predictors of completed suicide. These antecedents and their potential etiologies are therefore of scientific and public health interest,” they said.

Dr. Breslau and her associates prospectively studied 990 men and women aged 21-30 who were randomly selected from a Michigan HMO.

The researchers asked study participants about lifetime history of psychiatric disorders and daily smoking and administered the National Institute of Mental Health Diagnostic Interview Schedule for DSM-III-R at their baseline interview in 1989 and in follow-up interviews in 1992, 1994, and 1999-2001.

Current smokers were defined as those who reported smoking within the preceding 12 months of an assessment; past smokers were defined as those who had smoked previously but not in the preceding 12 months.

Of the 990 men and women, 63% were female, 80% were white, 29% completed college, and 46% were married.

The researchers found that current daily smokers were significantly more likely to have suicidal thoughts or to attempt suicide, compared with past smokers (odds ratio of 1.82 vs. odds ratio of 1.09, respectively).

After adjusting for suicidal predisposition indicated by prior suicidality and controlling for prior psychiatric disorders, current daily smokers were significantly more likely to have suicidal thoughts or to attempt suicide, compared with past smokers (odds ratio of 1.74 vs. odds ratio of 1.14, respectively), the investigators said.

The National Institute of Mental Health provided funding for the study.

Daily cigarette smokers are 1.82 times more likely to have suicidal thoughts or to attempt suicide, compared with those who had smoked in the past, results from a large prospective study have demonstrated.

Previous studies have suggested that there is a link between cigarette smoking and suicidal behavior, but this study controlled for major depression and alcohol or drug use disorders, reported the researchers, who were led by Naomi Breslau, Ph.D., of the department of epidemiology at Michigan State University in East Lansing.

“Limitations of the study are that we have no data on completed suicide and that the number of suicide attempts was small and therefore was combined with suicidal thoughts,” the researchers said (Arch. Gen. Psychiatry 2005;62:328-34).

“To analyze these rare outcomes, a much larger sample and longer follow-up period are needed. Whether the results can be extrapolated to attempted or completed suicide is uncertain. However, suicidal behaviors are established predictors of completed suicide. These antecedents and their potential etiologies are therefore of scientific and public health interest,” they said.

Dr. Breslau and her associates prospectively studied 990 men and women aged 21-30 who were randomly selected from a Michigan HMO.

The researchers asked study participants about lifetime history of psychiatric disorders and daily smoking and administered the National Institute of Mental Health Diagnostic Interview Schedule for DSM-III-R at their baseline interview in 1989 and in follow-up interviews in 1992, 1994, and 1999-2001.

Current smokers were defined as those who reported smoking within the preceding 12 months of an assessment; past smokers were defined as those who had smoked previously but not in the preceding 12 months.

Of the 990 men and women, 63% were female, 80% were white, 29% completed college, and 46% were married.

The researchers found that current daily smokers were significantly more likely to have suicidal thoughts or to attempt suicide, compared with past smokers (odds ratio of 1.82 vs. odds ratio of 1.09, respectively).

After adjusting for suicidal predisposition indicated by prior suicidality and controlling for prior psychiatric disorders, current daily smokers were significantly more likely to have suicidal thoughts or to attempt suicide, compared with past smokers (odds ratio of 1.74 vs. odds ratio of 1.14, respectively), the investigators said.

The National Institute of Mental Health provided funding for the study.

SAN DIEGO – Data increasingly support the use of individualized cognitive-behavioral therapy in primary care as a treatment for late-life generalized anxiety disorder, Melinda A. Stanley, Ph.D., said at the annual meeting of the American Association of Geriatric Psychiatry.

“A CBT approach is time-limited, directive, and collaborative, which makes it more palatable,” said Dr. Stanley, a psychologist of the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston. “We also have a fair amount of efficacy data now for younger adult populations with GAD that cognitive-behavior therapy can be effective.”

In a pilot study that was published in 2003, Dr. Stanley and her associates enrolled 12 elderly patients with generalized anxiety disorder (GAD) and a Mini-Mental State Examination score of 24 or greater in a randomized trial of individualized CBT treatment vs. “usual care” for late-life GAD. Patients were recruited from primary care waiting rooms, physician referral, or self-referral.

The mean age of patients was 71 years; 83% were women and about 50% were white. Half of the study participants were using psychotropic medications, she said.

The six patients in the CBT group received 8-10 sessions of CBT that included components of problem-solving training, sleep management skills, and increased attention to learning and memory difficulties (Am. J. Geriatr. Psychiatry 2003;11:92-6).

“We also are able to administer the intervention with more flexibility, primarily because we're administering it to individuals rather than to groups,” Dr. Stanley explained when describing the treatment approach, which continues to be studied.

“We can vary the number and scheduling of the sessions. We can do home visits if necessary, and we can change the emphasis on different treatment components as needed. For example, some patients come to us who don't have much in the way of [sleep] difficulty, so we don't spend much time teaching behavioral sleep skills,” she explained.

The treatment lasted for an average of 8 weeks.

Patients in the control group received usual care with telephone follow-up. “We called them biweekly to make sure no emergency services were needed and to try and reduce hospital admission,” she said.

Compared with controls, patients in the CBT group experienced statistically significant improvements in GAD severity, worry as measured by the Penn State Worry Questionnaire, and depression based on the Beck Depression Inventory, Dr. Stanley said.

In addition, patients in the CBT group experienced large effect sizes, compared with controls, in several measures: anxiety based on the Beck Anxiety Inventory; quality of life based on the Quality of Life Inventory; and perceived mental health, general health, and social functioning based on the 36-item short-form health survey (SF-36). However, these differences trended toward statistical significance.

There were no differences between the two groups in terms of the number of mental health referrals or visits, total number of medical visits, or number of new psychotropic medications.

On the basis of results of the pilot study, Dr. Stanley and her associates have launched a larger trial funded by the National Institute of Mental Health. The goal is to randomly assign 150 older primary care patients with GAD to receive either CBT or usual care with an evaluation of outcome made by an independent investigator.

“All of the baseline posttreatment follow-up assessments are being done by people who have no other connection to the study,” she reported. “They're all being done via telephone, and we're following them for 1 year.” No outcome data are available yet.

SAN DIEGO – Data increasingly support the use of individualized cognitive-behavioral therapy in primary care as a treatment for late-life generalized anxiety disorder, Melinda A. Stanley, Ph.D., said at the annual meeting of the American Association of Geriatric Psychiatry.

“A CBT approach is time-limited, directive, and collaborative, which makes it more palatable,” said Dr. Stanley, a psychologist of the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston. “We also have a fair amount of efficacy data now for younger adult populations with GAD that cognitive-behavior therapy can be effective.”

In a pilot study that was published in 2003, Dr. Stanley and her associates enrolled 12 elderly patients with generalized anxiety disorder (GAD) and a Mini-Mental State Examination score of 24 or greater in a randomized trial of individualized CBT treatment vs. “usual care” for late-life GAD. Patients were recruited from primary care waiting rooms, physician referral, or self-referral.

The mean age of patients was 71 years; 83% were women and about 50% were white. Half of the study participants were using psychotropic medications, she said.

The six patients in the CBT group received 8-10 sessions of CBT that included components of problem-solving training, sleep management skills, and increased attention to learning and memory difficulties (Am. J. Geriatr. Psychiatry 2003;11:92-6).

“We also are able to administer the intervention with more flexibility, primarily because we're administering it to individuals rather than to groups,” Dr. Stanley explained when describing the treatment approach, which continues to be studied.

“We can vary the number and scheduling of the sessions. We can do home visits if necessary, and we can change the emphasis on different treatment components as needed. For example, some patients come to us who don't have much in the way of [sleep] difficulty, so we don't spend much time teaching behavioral sleep skills,” she explained.

The treatment lasted for an average of 8 weeks.

Patients in the control group received usual care with telephone follow-up. “We called them biweekly to make sure no emergency services were needed and to try and reduce hospital admission,” she said.

Compared with controls, patients in the CBT group experienced statistically significant improvements in GAD severity, worry as measured by the Penn State Worry Questionnaire, and depression based on the Beck Depression Inventory, Dr. Stanley said.

In addition, patients in the CBT group experienced large effect sizes, compared with controls, in several measures: anxiety based on the Beck Anxiety Inventory; quality of life based on the Quality of Life Inventory; and perceived mental health, general health, and social functioning based on the 36-item short-form health survey (SF-36). However, these differences trended toward statistical significance.

There were no differences between the two groups in terms of the number of mental health referrals or visits, total number of medical visits, or number of new psychotropic medications.

On the basis of results of the pilot study, Dr. Stanley and her associates have launched a larger trial funded by the National Institute of Mental Health. The goal is to randomly assign 150 older primary care patients with GAD to receive either CBT or usual care with an evaluation of outcome made by an independent investigator.

“All of the baseline posttreatment follow-up assessments are being done by people who have no other connection to the study,” she reported. “They're all being done via telephone, and we're following them for 1 year.” No outcome data are available yet.

SAN DIEGO – Data increasingly support the use of individualized cognitive-behavioral therapy in primary care as a treatment for late-life generalized anxiety disorder, Melinda A. Stanley, Ph.D., said at the annual meeting of the American Association of Geriatric Psychiatry.

“A CBT approach is time-limited, directive, and collaborative, which makes it more palatable,” said Dr. Stanley, a psychologist of the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston. “We also have a fair amount of efficacy data now for younger adult populations with GAD that cognitive-behavior therapy can be effective.”

In a pilot study that was published in 2003, Dr. Stanley and her associates enrolled 12 elderly patients with generalized anxiety disorder (GAD) and a Mini-Mental State Examination score of 24 or greater in a randomized trial of individualized CBT treatment vs. “usual care” for late-life GAD. Patients were recruited from primary care waiting rooms, physician referral, or self-referral.

The mean age of patients was 71 years; 83% were women and about 50% were white. Half of the study participants were using psychotropic medications, she said.

The six patients in the CBT group received 8-10 sessions of CBT that included components of problem-solving training, sleep management skills, and increased attention to learning and memory difficulties (Am. J. Geriatr. Psychiatry 2003;11:92-6).

“We also are able to administer the intervention with more flexibility, primarily because we're administering it to individuals rather than to groups,” Dr. Stanley explained when describing the treatment approach, which continues to be studied.

“We can vary the number and scheduling of the sessions. We can do home visits if necessary, and we can change the emphasis on different treatment components as needed. For example, some patients come to us who don't have much in the way of [sleep] difficulty, so we don't spend much time teaching behavioral sleep skills,” she explained.

The treatment lasted for an average of 8 weeks.

Patients in the control group received usual care with telephone follow-up. “We called them biweekly to make sure no emergency services were needed and to try and reduce hospital admission,” she said.

Compared with controls, patients in the CBT group experienced statistically significant improvements in GAD severity, worry as measured by the Penn State Worry Questionnaire, and depression based on the Beck Depression Inventory, Dr. Stanley said.

In addition, patients in the CBT group experienced large effect sizes, compared with controls, in several measures: anxiety based on the Beck Anxiety Inventory; quality of life based on the Quality of Life Inventory; and perceived mental health, general health, and social functioning based on the 36-item short-form health survey (SF-36). However, these differences trended toward statistical significance.

There were no differences between the two groups in terms of the number of mental health referrals or visits, total number of medical visits, or number of new psychotropic medications.

On the basis of results of the pilot study, Dr. Stanley and her associates have launched a larger trial funded by the National Institute of Mental Health. The goal is to randomly assign 150 older primary care patients with GAD to receive either CBT or usual care with an evaluation of outcome made by an independent investigator.

“All of the baseline posttreatment follow-up assessments are being done by people who have no other connection to the study,” she reported. “They're all being done via telephone, and we're following them for 1 year.” No outcome data are available yet.

SAN DIEGO – Older adults with depression who received collaborative care from a primary care physician and a care manager had significantly less suicidal ideation compared with their counterparts who received usual care, results from a 2-year study have demonstrated.

The finding supports the use of collaborative care to reduce the risk of suicide in elderly patients, Jürgen Unützer, M.D., said at the annual meeting of the American Association for Geriatric Psychiatry.

Less than 10% of older adults with depression see a mental health professional. And when a primary care physician refers an older adult to a mental health professional, only about half follow through on the referral, said Dr. Unützer, professor and vice-chair of the department of psychiatry and behavioral health sciences at the University of Washington, Seattle.

In a randomized study, Project IMPACT (Improving Mood: Promoting Access to Collaborative Care), Dr. Unützer and his associates enrolled 1,801 older adults with a Structured Clinical Interview for DSM-III-R diagnosis of major depression and/or dysthymia to receive collaborative care for depression or usual care as recommended by their primary physicians. The 2-year study took place at 18 primary care clinics in five states.

Overall, 895 patients received usual care and 906 received collaborative stepped care at their primary care clinics. All patients were observed at baseline and at 3, 6, 12, 18, and 24 months. Patients in the usual care arm were told, “We're going to observe you, but you can do what you would normally do” for your depression, he said.

Patients in the collaborative care arm were encouraged to choose treatment in consultation with their primary care physicians. Care managers–usually a nurse or a psychologist–helped physicians follow and manage these patients by providing patient education, monitoring symptoms via interviews, and administering the Patient Health Questionnaire-9. They also helped with treatment such as behavior activation, support of prescribed antidepressant medication, and brief psychotherapy.

“We also added a consulting psychiatrist who would come to the clinic once a week for 1-2 hours and go over the caseload of all the patients these care managers were following and provide feedback on the care and, if needed, see a patient in consultation,” Dr. Unützer added.

Overall, about 17% of patients in the study met criteria for major depression, 32% met criteria for dysthymia, and 53% met criteria for both. “This is a pretty depressed group of older adults,” he said.

At 1 year, the percentage of patients in the usual care group who reported thoughts of suicide had risen from 13% to 16%, compared with a decrease from 15% to 10% in the collaborative care group. The rates were similar at 2 years: 14% for usual care and 10% for collaborative care.

In addition, between baseline and 1 year, the number of patients in the usual care group who reported having any bothersome thoughts about death or dying slightly improved from 58% to 51%, while patients in the collaborative care group greatly improved from 56% to 32%.

In surveys conducted 2 years after baseline, there was little change in the rate for patients in the usual care group (50%), but a higher number of patients in the collaborative care group reported having thoughts about death or dying (42%).

Dr. Unützer and his associates intervened 135 times for 108 patients whom they deemed at high risk for suicide. Of these, 89 times were for patients in the usual care group, while 49 times were for patients in the collaborative care group. There were no completed suicides.

Patient characteristics that were significantly associated with the rate of suicidal ideation at 1 and 2 years were advancing age, male gender, number of comorbid medical conditions, baseline anxiety status, baseline depression severity, and baseline overall quality of life.

SAN DIEGO – Older adults with depression who received collaborative care from a primary care physician and a care manager had significantly less suicidal ideation compared with their counterparts who received usual care, results from a 2-year study have demonstrated.

The finding supports the use of collaborative care to reduce the risk of suicide in elderly patients, Jürgen Unützer, M.D., said at the annual meeting of the American Association for Geriatric Psychiatry.

Less than 10% of older adults with depression see a mental health professional. And when a primary care physician refers an older adult to a mental health professional, only about half follow through on the referral, said Dr. Unützer, professor and vice-chair of the department of psychiatry and behavioral health sciences at the University of Washington, Seattle.

In a randomized study, Project IMPACT (Improving Mood: Promoting Access to Collaborative Care), Dr. Unützer and his associates enrolled 1,801 older adults with a Structured Clinical Interview for DSM-III-R diagnosis of major depression and/or dysthymia to receive collaborative care for depression or usual care as recommended by their primary physicians. The 2-year study took place at 18 primary care clinics in five states.

Overall, 895 patients received usual care and 906 received collaborative stepped care at their primary care clinics. All patients were observed at baseline and at 3, 6, 12, 18, and 24 months. Patients in the usual care arm were told, “We're going to observe you, but you can do what you would normally do” for your depression, he said.

Patients in the collaborative care arm were encouraged to choose treatment in consultation with their primary care physicians. Care managers–usually a nurse or a psychologist–helped physicians follow and manage these patients by providing patient education, monitoring symptoms via interviews, and administering the Patient Health Questionnaire-9. They also helped with treatment such as behavior activation, support of prescribed antidepressant medication, and brief psychotherapy.

“We also added a consulting psychiatrist who would come to the clinic once a week for 1-2 hours and go over the caseload of all the patients these care managers were following and provide feedback on the care and, if needed, see a patient in consultation,” Dr. Unützer added.

Overall, about 17% of patients in the study met criteria for major depression, 32% met criteria for dysthymia, and 53% met criteria for both. “This is a pretty depressed group of older adults,” he said.

At 1 year, the percentage of patients in the usual care group who reported thoughts of suicide had risen from 13% to 16%, compared with a decrease from 15% to 10% in the collaborative care group. The rates were similar at 2 years: 14% for usual care and 10% for collaborative care.

In addition, between baseline and 1 year, the number of patients in the usual care group who reported having any bothersome thoughts about death or dying slightly improved from 58% to 51%, while patients in the collaborative care group greatly improved from 56% to 32%.

In surveys conducted 2 years after baseline, there was little change in the rate for patients in the usual care group (50%), but a higher number of patients in the collaborative care group reported having thoughts about death or dying (42%).

Dr. Unützer and his associates intervened 135 times for 108 patients whom they deemed at high risk for suicide. Of these, 89 times were for patients in the usual care group, while 49 times were for patients in the collaborative care group. There were no completed suicides.

Patient characteristics that were significantly associated with the rate of suicidal ideation at 1 and 2 years were advancing age, male gender, number of comorbid medical conditions, baseline anxiety status, baseline depression severity, and baseline overall quality of life.

SAN DIEGO – Older adults with depression who received collaborative care from a primary care physician and a care manager had significantly less suicidal ideation compared with their counterparts who received usual care, results from a 2-year study have demonstrated.

The finding supports the use of collaborative care to reduce the risk of suicide in elderly patients, Jürgen Unützer, M.D., said at the annual meeting of the American Association for Geriatric Psychiatry.

Less than 10% of older adults with depression see a mental health professional. And when a primary care physician refers an older adult to a mental health professional, only about half follow through on the referral, said Dr. Unützer, professor and vice-chair of the department of psychiatry and behavioral health sciences at the University of Washington, Seattle.

In a randomized study, Project IMPACT (Improving Mood: Promoting Access to Collaborative Care), Dr. Unützer and his associates enrolled 1,801 older adults with a Structured Clinical Interview for DSM-III-R diagnosis of major depression and/or dysthymia to receive collaborative care for depression or usual care as recommended by their primary physicians. The 2-year study took place at 18 primary care clinics in five states.

Overall, 895 patients received usual care and 906 received collaborative stepped care at their primary care clinics. All patients were observed at baseline and at 3, 6, 12, 18, and 24 months. Patients in the usual care arm were told, “We're going to observe you, but you can do what you would normally do” for your depression, he said.

Patients in the collaborative care arm were encouraged to choose treatment in consultation with their primary care physicians. Care managers–usually a nurse or a psychologist–helped physicians follow and manage these patients by providing patient education, monitoring symptoms via interviews, and administering the Patient Health Questionnaire-9. They also helped with treatment such as behavior activation, support of prescribed antidepressant medication, and brief psychotherapy.

“We also added a consulting psychiatrist who would come to the clinic once a week for 1-2 hours and go over the caseload of all the patients these care managers were following and provide feedback on the care and, if needed, see a patient in consultation,” Dr. Unützer added.

Overall, about 17% of patients in the study met criteria for major depression, 32% met criteria for dysthymia, and 53% met criteria for both. “This is a pretty depressed group of older adults,” he said.

At 1 year, the percentage of patients in the usual care group who reported thoughts of suicide had risen from 13% to 16%, compared with a decrease from 15% to 10% in the collaborative care group. The rates were similar at 2 years: 14% for usual care and 10% for collaborative care.

In addition, between baseline and 1 year, the number of patients in the usual care group who reported having any bothersome thoughts about death or dying slightly improved from 58% to 51%, while patients in the collaborative care group greatly improved from 56% to 32%.

In surveys conducted 2 years after baseline, there was little change in the rate for patients in the usual care group (50%), but a higher number of patients in the collaborative care group reported having thoughts about death or dying (42%).

Dr. Unützer and his associates intervened 135 times for 108 patients whom they deemed at high risk for suicide. Of these, 89 times were for patients in the usual care group, while 49 times were for patients in the collaborative care group. There were no completed suicides.

Patient characteristics that were significantly associated with the rate of suicidal ideation at 1 and 2 years were advancing age, male gender, number of comorbid medical conditions, baseline anxiety status, baseline depression severity, and baseline overall quality of life.

Laparoscopic radiofrequency thermal ablation appears to be a useful adjunct to chemotherapy for treating colorectal liver metastases. The survival benefit conferred by the technique is associated with three factors—serum carcinoembryonic antigen less than 200 ng/mL, dominant lesion less than 3.0 cm in diameter, and having one to three tumors vs. more than three tumors—results from a prospective study have shown.

Although earlier studies suggested that radiofrequency thermal ablation (RFA) favorably affected survival in this population of patients, “there are little data on predictors of survival,” Eren Berber, M.D., and his associates wrote (J. Clin. Oncol. 2005;23:1358-64). “The aim of this study was to determine factors that might predict survival at the time of RFA in patients with colorectal liver metastases.”

Dr. Berber and his associates studied 135 patients with primary or metastatic liver tumors who underwent laparoscopic RFA in the department of general surgery at the Cleveland Clinic Foundation. The patients were not candidates for resection, and 80% had intrahepatic tumor progression despite chemotherapy. Their mean age was 62, and most (85) were men. The mean number of liver tumors was 3.2; the largest tumors had a mean diameter of 4.1 cm.

Investigators performed triphasic CT scans of the liver within 1 week before surgery. After undergoing laparoscopic RFA, most patients were kept in the hospital overnight for observation and sent home the next morning. CT scans and lab tests were repeated at 1 week and every 3 months postoperatively.

Median survival for all patients was 28.9 months after RFA and 44.9 months after the diagnosis of liver metastasis. Patients with a serum carcinoembryonic antigen (CEA) of less than 200 ng/mL at the time of RFA lived a median of 34 months, while those whose CEA exceeded 200 ng/mL lived a median of 16 months. The size and number of tumors also affected survival.

Those with a dominant lesion less than 3 cm in diameter had a median survival of 38 months, while those whose dominant lesions were 3-5 cm had a median survival of 34 months. Patients whose dominant lesions were larger than 5 cm had a median survival of 21 months.

“Survival approached significance for patients with one to three tumors versus more than three tumors (29 vs. 22 months),” the investigators wrote.

“There was no survival advantage based on sex, age, colon versus rectal primary, nodal status at time of diagnosis, metachronous versus synchronous disease, bilobar versus unilobar disease, pretreatment chemotherapy, or documented extrahepatic disease at the time of treatment,” they said.

The only significant predictor of mortality by the Cox proportional hazards model was largest liver tumor size greater than 5 cm. Patients whose largest tumor was this size were 2.5 times more likely to die than those whose largest tumor was less than 3 cm.

“Overall, the results of this prospective study are encouraging and suggest a survival advantage when compared with chemotherapy alone,” wrote the investigators, who noted that historical survival with chemotherapy alone is 11-14 months. “Although our sample size might be insufficient for making decisive conclusions on the nonsignificance of the potential risk factors, we believe that RFA is a useful adjunct to chemotherapy in this group of patients.”

Laparoscopic radiofrequency thermal ablation appears to be a useful adjunct to chemotherapy for treating colorectal liver metastases. The survival benefit conferred by the technique is associated with three factors—serum carcinoembryonic antigen less than 200 ng/mL, dominant lesion less than 3.0 cm in diameter, and having one to three tumors vs. more than three tumors—results from a prospective study have shown.

Although earlier studies suggested that radiofrequency thermal ablation (RFA) favorably affected survival in this population of patients, “there are little data on predictors of survival,” Eren Berber, M.D., and his associates wrote (J. Clin. Oncol. 2005;23:1358-64). “The aim of this study was to determine factors that might predict survival at the time of RFA in patients with colorectal liver metastases.”

Dr. Berber and his associates studied 135 patients with primary or metastatic liver tumors who underwent laparoscopic RFA in the department of general surgery at the Cleveland Clinic Foundation. The patients were not candidates for resection, and 80% had intrahepatic tumor progression despite chemotherapy. Their mean age was 62, and most (85) were men. The mean number of liver tumors was 3.2; the largest tumors had a mean diameter of 4.1 cm.

Investigators performed triphasic CT scans of the liver within 1 week before surgery. After undergoing laparoscopic RFA, most patients were kept in the hospital overnight for observation and sent home the next morning. CT scans and lab tests were repeated at 1 week and every 3 months postoperatively.

Median survival for all patients was 28.9 months after RFA and 44.9 months after the diagnosis of liver metastasis. Patients with a serum carcinoembryonic antigen (CEA) of less than 200 ng/mL at the time of RFA lived a median of 34 months, while those whose CEA exceeded 200 ng/mL lived a median of 16 months. The size and number of tumors also affected survival.

Those with a dominant lesion less than 3 cm in diameter had a median survival of 38 months, while those whose dominant lesions were 3-5 cm had a median survival of 34 months. Patients whose dominant lesions were larger than 5 cm had a median survival of 21 months.

“Survival approached significance for patients with one to three tumors versus more than three tumors (29 vs. 22 months),” the investigators wrote.

“There was no survival advantage based on sex, age, colon versus rectal primary, nodal status at time of diagnosis, metachronous versus synchronous disease, bilobar versus unilobar disease, pretreatment chemotherapy, or documented extrahepatic disease at the time of treatment,” they said.

The only significant predictor of mortality by the Cox proportional hazards model was largest liver tumor size greater than 5 cm. Patients whose largest tumor was this size were 2.5 times more likely to die than those whose largest tumor was less than 3 cm.

“Overall, the results of this prospective study are encouraging and suggest a survival advantage when compared with chemotherapy alone,” wrote the investigators, who noted that historical survival with chemotherapy alone is 11-14 months. “Although our sample size might be insufficient for making decisive conclusions on the nonsignificance of the potential risk factors, we believe that RFA is a useful adjunct to chemotherapy in this group of patients.”

Laparoscopic radiofrequency thermal ablation appears to be a useful adjunct to chemotherapy for treating colorectal liver metastases. The survival benefit conferred by the technique is associated with three factors—serum carcinoembryonic antigen less than 200 ng/mL, dominant lesion less than 3.0 cm in diameter, and having one to three tumors vs. more than three tumors—results from a prospective study have shown.

Although earlier studies suggested that radiofrequency thermal ablation (RFA) favorably affected survival in this population of patients, “there are little data on predictors of survival,” Eren Berber, M.D., and his associates wrote (J. Clin. Oncol. 2005;23:1358-64). “The aim of this study was to determine factors that might predict survival at the time of RFA in patients with colorectal liver metastases.”

Dr. Berber and his associates studied 135 patients with primary or metastatic liver tumors who underwent laparoscopic RFA in the department of general surgery at the Cleveland Clinic Foundation. The patients were not candidates for resection, and 80% had intrahepatic tumor progression despite chemotherapy. Their mean age was 62, and most (85) were men. The mean number of liver tumors was 3.2; the largest tumors had a mean diameter of 4.1 cm.

Investigators performed triphasic CT scans of the liver within 1 week before surgery. After undergoing laparoscopic RFA, most patients were kept in the hospital overnight for observation and sent home the next morning. CT scans and lab tests were repeated at 1 week and every 3 months postoperatively.

Median survival for all patients was 28.9 months after RFA and 44.9 months after the diagnosis of liver metastasis. Patients with a serum carcinoembryonic antigen (CEA) of less than 200 ng/mL at the time of RFA lived a median of 34 months, while those whose CEA exceeded 200 ng/mL lived a median of 16 months. The size and number of tumors also affected survival.

Those with a dominant lesion less than 3 cm in diameter had a median survival of 38 months, while those whose dominant lesions were 3-5 cm had a median survival of 34 months. Patients whose dominant lesions were larger than 5 cm had a median survival of 21 months.

“Survival approached significance for patients with one to three tumors versus more than three tumors (29 vs. 22 months),” the investigators wrote.

“There was no survival advantage based on sex, age, colon versus rectal primary, nodal status at time of diagnosis, metachronous versus synchronous disease, bilobar versus unilobar disease, pretreatment chemotherapy, or documented extrahepatic disease at the time of treatment,” they said.

The only significant predictor of mortality by the Cox proportional hazards model was largest liver tumor size greater than 5 cm. Patients whose largest tumor was this size were 2.5 times more likely to die than those whose largest tumor was less than 3 cm.

“Overall, the results of this prospective study are encouraging and suggest a survival advantage when compared with chemotherapy alone,” wrote the investigators, who noted that historical survival with chemotherapy alone is 11-14 months. “Although our sample size might be insufficient for making decisive conclusions on the nonsignificance of the potential risk factors, we believe that RFA is a useful adjunct to chemotherapy in this group of patients.”