Doug Brunk

Children with mild to moderate persistent asthma who have low pulmonary function and/or elevated signs of allergic inflammation should be treated with inhaled corticosteroids.

Other asthmatic children could receive a trial of either inhaled corticosteroids (ICSs) or leukotriene receptor antagonists (LTRAs) with an assessment of response.

Those are the key conclusions of a study that sought to determine whether responses to fluticasone and montelukast are the same for all children with asthma or whether some pediatric patients who do not respond to one medication may respond to the other.

“There is increasing evidence that children respond differently to the various treatment options for asthma,” James Kiley, Ph.D., director of the division of lung diseases at the National Heart, Lung, and Blood Institute, said in a statement.

“If we can pinpoint in advance which children will do better with a certain type of therapy, we can improve their lives more quickly and save them the risk of trying medications that are less effective for them. This study adds important information for identifying which children are more likely to respond well to inhaled corticosteroids,” the NHLBI statement continued.

For the study, Stanley J. Szefler, M.D., and his associates administered fluticasone and montelukast separately for 8 weeks to 126 children aged 6-17 years with mild to moderate persistent asthma (J. Allergy Clin. Immunol. 2005;115:233-42).

Response was defined as achieving a 7.5% or greater improvement on a single measurement of forced expiratory volume in 1 second (FEV₁) after 8 weeks of treatment on each drug.

Of the 126 children, 17% responded to both medications, 23% responded to fluticasone alone, 5% responded to montelukast alone, and 55% responded to neither medication.

Certain factors predicted responses to one medication but not to the other. For example, compared with children who failed to respond to either medication, those who responded to fluticasone alone had lower pulmonary function and methacholine PC20 values at baseline, as well as higher exhaled nitric oxide levels, total eosinophil counts, IgE levels, and eosinophil cationic protein levels.

“Our findings thus suggest that children with higher levels of eosinophilic airway inflammation might respond to ICSs but not to LTRAs,” the investigators wrote. “The group that responded to montelukast alone, although small in proportion (5%), was younger in age and had a shorter duration of disease. Perhaps leukotriene-driven inflammation is an important feature of asthma in young children, or perhaps this represents a specific phenotype of the disease.”

The investigators added that children who responded to both medications had significantly lower levels of pulmonary function and higher levels of urinary leukotriene E4 at baseline, compared with those who failed to respond to either medication.

“These data reveal an asthma phenotype with impaired lung function and overexpressed leukotriene production that is responsive to both ICSs and LTRAs,” they wrote.

The investigators said the main limitation of the study was the reliance on a single FEV₁ measurement.

They concluded that the overall findings “suggest that asthma therapy might soon move from the current approach based on mean responses in populations to one in which the treatment that is most likely to expeditiously achieve a favorable response is identified for each individual patient on the basis of her or his phenotypic and possibly genotypic characteristics.”

GlaxoSmithKline Inc. and Merck & Co. Inc. donated the drugs and placebo agents used in the study.

Children with mild to moderate persistent asthma who have low pulmonary function and/or elevated signs of allergic inflammation should be treated with inhaled corticosteroids.

Other asthmatic children could receive a trial of either inhaled corticosteroids (ICSs) or leukotriene receptor antagonists (LTRAs) with an assessment of response.

Those are the key conclusions of a study that sought to determine whether responses to fluticasone and montelukast are the same for all children with asthma or whether some pediatric patients who do not respond to one medication may respond to the other.

“There is increasing evidence that children respond differently to the various treatment options for asthma,” James Kiley, Ph.D., director of the division of lung diseases at the National Heart, Lung, and Blood Institute, said in a statement.

“If we can pinpoint in advance which children will do better with a certain type of therapy, we can improve their lives more quickly and save them the risk of trying medications that are less effective for them. This study adds important information for identifying which children are more likely to respond well to inhaled corticosteroids,” the NHLBI statement continued.

For the study, Stanley J. Szefler, M.D., and his associates administered fluticasone and montelukast separately for 8 weeks to 126 children aged 6-17 years with mild to moderate persistent asthma (J. Allergy Clin. Immunol. 2005;115:233-42).

Response was defined as achieving a 7.5% or greater improvement on a single measurement of forced expiratory volume in 1 second (FEV₁) after 8 weeks of treatment on each drug.

Of the 126 children, 17% responded to both medications, 23% responded to fluticasone alone, 5% responded to montelukast alone, and 55% responded to neither medication.

Certain factors predicted responses to one medication but not to the other. For example, compared with children who failed to respond to either medication, those who responded to fluticasone alone had lower pulmonary function and methacholine PC20 values at baseline, as well as higher exhaled nitric oxide levels, total eosinophil counts, IgE levels, and eosinophil cationic protein levels.

“Our findings thus suggest that children with higher levels of eosinophilic airway inflammation might respond to ICSs but not to LTRAs,” the investigators wrote. “The group that responded to montelukast alone, although small in proportion (5%), was younger in age and had a shorter duration of disease. Perhaps leukotriene-driven inflammation is an important feature of asthma in young children, or perhaps this represents a specific phenotype of the disease.”

The investigators added that children who responded to both medications had significantly lower levels of pulmonary function and higher levels of urinary leukotriene E4 at baseline, compared with those who failed to respond to either medication.

“These data reveal an asthma phenotype with impaired lung function and overexpressed leukotriene production that is responsive to both ICSs and LTRAs,” they wrote.

The investigators said the main limitation of the study was the reliance on a single FEV₁ measurement.

They concluded that the overall findings “suggest that asthma therapy might soon move from the current approach based on mean responses in populations to one in which the treatment that is most likely to expeditiously achieve a favorable response is identified for each individual patient on the basis of her or his phenotypic and possibly genotypic characteristics.”

GlaxoSmithKline Inc. and Merck & Co. Inc. donated the drugs and placebo agents used in the study.

Children with mild to moderate persistent asthma who have low pulmonary function and/or elevated signs of allergic inflammation should be treated with inhaled corticosteroids.

Other asthmatic children could receive a trial of either inhaled corticosteroids (ICSs) or leukotriene receptor antagonists (LTRAs) with an assessment of response.

Those are the key conclusions of a study that sought to determine whether responses to fluticasone and montelukast are the same for all children with asthma or whether some pediatric patients who do not respond to one medication may respond to the other.

“There is increasing evidence that children respond differently to the various treatment options for asthma,” James Kiley, Ph.D., director of the division of lung diseases at the National Heart, Lung, and Blood Institute, said in a statement.

“If we can pinpoint in advance which children will do better with a certain type of therapy, we can improve their lives more quickly and save them the risk of trying medications that are less effective for them. This study adds important information for identifying which children are more likely to respond well to inhaled corticosteroids,” the NHLBI statement continued.

For the study, Stanley J. Szefler, M.D., and his associates administered fluticasone and montelukast separately for 8 weeks to 126 children aged 6-17 years with mild to moderate persistent asthma (J. Allergy Clin. Immunol. 2005;115:233-42).

Response was defined as achieving a 7.5% or greater improvement on a single measurement of forced expiratory volume in 1 second (FEV₁) after 8 weeks of treatment on each drug.

Of the 126 children, 17% responded to both medications, 23% responded to fluticasone alone, 5% responded to montelukast alone, and 55% responded to neither medication.

Certain factors predicted responses to one medication but not to the other. For example, compared with children who failed to respond to either medication, those who responded to fluticasone alone had lower pulmonary function and methacholine PC20 values at baseline, as well as higher exhaled nitric oxide levels, total eosinophil counts, IgE levels, and eosinophil cationic protein levels.

“Our findings thus suggest that children with higher levels of eosinophilic airway inflammation might respond to ICSs but not to LTRAs,” the investigators wrote. “The group that responded to montelukast alone, although small in proportion (5%), was younger in age and had a shorter duration of disease. Perhaps leukotriene-driven inflammation is an important feature of asthma in young children, or perhaps this represents a specific phenotype of the disease.”

The investigators added that children who responded to both medications had significantly lower levels of pulmonary function and higher levels of urinary leukotriene E4 at baseline, compared with those who failed to respond to either medication.

“These data reveal an asthma phenotype with impaired lung function and overexpressed leukotriene production that is responsive to both ICSs and LTRAs,” they wrote.

The investigators said the main limitation of the study was the reliance on a single FEV₁ measurement.

They concluded that the overall findings “suggest that asthma therapy might soon move from the current approach based on mean responses in populations to one in which the treatment that is most likely to expeditiously achieve a favorable response is identified for each individual patient on the basis of her or his phenotypic and possibly genotypic characteristics.”

GlaxoSmithKline Inc. and Merck & Co. Inc. donated the drugs and placebo agents used in the study.

SEATTLE — When it comes to initiating therapy with drotrecogin alfa in patients with severe sepsis, the earlier the better.

That's the key message from a large study of patients who received drotrecogin alfa (Xigris) at 139 hospitals in the United States between November 2001 and June 2003, Frank Ernst, Pharm. D., reported at the annual meeting of the American College of Chest Physicians.

Drotrecogin alfa (activated) is recombinant human activated protein C; it mimics endogenous protein C, which inhibits coagulation and inflammation when activated.

Waiting 2 or more days to initiate the drug predicted hospital mortality, whereas earlier initiation predicted lower hospital costs and shorter lengths of stay among survivors, reported Mr. Ernst, a pharmacist at Eli Lilly and Co., Indianapolis.

In a study funded by Lilly, Mr. Ernst and his associates studied database records of 1,179 patients who received drotrecogin alfa during their hospital stay following evident severe sepsis, defined as concurrent antibiotic use plus ventilator and/or vasopressor use. The records were obtained from a large national database of hospital discharge records maintained by Solucient, a health information technology company.

Of the 1,179 patients, 509 received drotrecogin alfa on the same day that they had evident severe sepsis (same-day patients), 354 received the drug the day after they had evident severe sepsis (next-day patients), and 323 received the drug 2 days or more after they had evident severe sepsis (day 2-plus patients).

At ICU admission, day 2-plus patients had fewer organ dysfunctions than did patients in the other two groups. But between ICU admission and initiation of drotrecogin alfa, organ dysfunctions increased significantly more among day 2-plus patients than did next-day and same-day patients.

Hospital mortality was predicted by ventilator use (odds ratio [OR] 5.1), vasopressor use (OR 2.6), and initiation of drotrecogin alfa on day-2 plus (OR 1.7).

Among survivors, 7% shorter length of stay and 10% lower adjusted post-drotrecogin alfa administration costs were predicted by same-day or next-day initiation.

Limitations of the study were its retrospective design and the fact that the database used contained limited clinical information, Mr. Ernst noted.

SEATTLE — When it comes to initiating therapy with drotrecogin alfa in patients with severe sepsis, the earlier the better.

That's the key message from a large study of patients who received drotrecogin alfa (Xigris) at 139 hospitals in the United States between November 2001 and June 2003, Frank Ernst, Pharm. D., reported at the annual meeting of the American College of Chest Physicians.

Drotrecogin alfa (activated) is recombinant human activated protein C; it mimics endogenous protein C, which inhibits coagulation and inflammation when activated.

Waiting 2 or more days to initiate the drug predicted hospital mortality, whereas earlier initiation predicted lower hospital costs and shorter lengths of stay among survivors, reported Mr. Ernst, a pharmacist at Eli Lilly and Co., Indianapolis.

In a study funded by Lilly, Mr. Ernst and his associates studied database records of 1,179 patients who received drotrecogin alfa during their hospital stay following evident severe sepsis, defined as concurrent antibiotic use plus ventilator and/or vasopressor use. The records were obtained from a large national database of hospital discharge records maintained by Solucient, a health information technology company.

Of the 1,179 patients, 509 received drotrecogin alfa on the same day that they had evident severe sepsis (same-day patients), 354 received the drug the day after they had evident severe sepsis (next-day patients), and 323 received the drug 2 days or more after they had evident severe sepsis (day 2-plus patients).

At ICU admission, day 2-plus patients had fewer organ dysfunctions than did patients in the other two groups. But between ICU admission and initiation of drotrecogin alfa, organ dysfunctions increased significantly more among day 2-plus patients than did next-day and same-day patients.

Hospital mortality was predicted by ventilator use (odds ratio [OR] 5.1), vasopressor use (OR 2.6), and initiation of drotrecogin alfa on day-2 plus (OR 1.7).

Among survivors, 7% shorter length of stay and 10% lower adjusted post-drotrecogin alfa administration costs were predicted by same-day or next-day initiation.

Limitations of the study were its retrospective design and the fact that the database used contained limited clinical information, Mr. Ernst noted.

SEATTLE — When it comes to initiating therapy with drotrecogin alfa in patients with severe sepsis, the earlier the better.

That's the key message from a large study of patients who received drotrecogin alfa (Xigris) at 139 hospitals in the United States between November 2001 and June 2003, Frank Ernst, Pharm. D., reported at the annual meeting of the American College of Chest Physicians.

Drotrecogin alfa (activated) is recombinant human activated protein C; it mimics endogenous protein C, which inhibits coagulation and inflammation when activated.

Waiting 2 or more days to initiate the drug predicted hospital mortality, whereas earlier initiation predicted lower hospital costs and shorter lengths of stay among survivors, reported Mr. Ernst, a pharmacist at Eli Lilly and Co., Indianapolis.

In a study funded by Lilly, Mr. Ernst and his associates studied database records of 1,179 patients who received drotrecogin alfa during their hospital stay following evident severe sepsis, defined as concurrent antibiotic use plus ventilator and/or vasopressor use. The records were obtained from a large national database of hospital discharge records maintained by Solucient, a health information technology company.

Of the 1,179 patients, 509 received drotrecogin alfa on the same day that they had evident severe sepsis (same-day patients), 354 received the drug the day after they had evident severe sepsis (next-day patients), and 323 received the drug 2 days or more after they had evident severe sepsis (day 2-plus patients).

At ICU admission, day 2-plus patients had fewer organ dysfunctions than did patients in the other two groups. But between ICU admission and initiation of drotrecogin alfa, organ dysfunctions increased significantly more among day 2-plus patients than did next-day and same-day patients.

Hospital mortality was predicted by ventilator use (odds ratio [OR] 5.1), vasopressor use (OR 2.6), and initiation of drotrecogin alfa on day-2 plus (OR 1.7).

Among survivors, 7% shorter length of stay and 10% lower adjusted post-drotrecogin alfa administration costs were predicted by same-day or next-day initiation.

Limitations of the study were its retrospective design and the fact that the database used contained limited clinical information, Mr. Ernst noted.

LA JOLLA, CALIF. – When you refer a patient to a provider of complementary and alternative medicine, keep in mind five liability management strategies, David M. Eisenberg, M.D., advised at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

The strategies, which he developed in collaboration with Michael H. Cohen, J.D. (Ann. Intern. Med. 2002;136:596-603), include the following:

Determine the clinical risk level. Decide whether to:

▸ Recommend yet continue to monitor the therapy.

▸ Tolerate, provide caution, and closely monitor safety.

▸ Avoid and discourage the therapy.

Document the literature supporting the therapeutic choice.

“It's very important to put this in the chart,” said Dr. Eisenberg, an internist who directs the division for research and education in complementary and integrative medical therapies at the Osher Institute, Harvard Medical School, Boston. “By the way, that is also true when we're using a novel or experimental drug with an inpatient. This is the same approach.”

If treatment with a certain herb is recommended, “document the choice of herb, any recommendation regarding product or brand, and any discussion regarding therapeutic dose, and associated uncertainties regarding use of the herb,” he said.

He also makes it a practice to keep a backup file of articles supporting the discussion or recommendation. “You could say this is a bit too conservative, like have suspenders and a belt,” he said at the meeting, cosponsored by the University of California, San Diego. “But I think this is the best advice.”

Continue conventional monitoring. “A lot of times we recommend something or accept that a patient is going to do something, and then we don't monitor or follow up,” Dr. Eisenberg said. “Undue reliance on CAM may lead to a charge that the patient was dissuaded from necessary conventional medical care.”

He added that maintaining conventional treatment “helps demonstrate that the physician has followed the standard of care, even if CAM is included.”

Provide adequate informed consent. Describe the risks and benefits of using the CAM therapy and of delaying or deferring the conventional therapy, and spell out potential adverse interactions. That is a lot to consider, but such information would be helpful “in the eyes of the law if something went wrong,” he said. “You have to ask yourself, could I really defend this action or recommendation?”

Also, clear communication with the patient has been shown to reduce the risk of being sued for malpractice. “Inadequate informed consent is also a theory for malpractice liability in and of itself,” Dr. Eisenberg said.

Familiarize yourself with providers to whom you refer. Ask yourself, would I refer a friend to this person? “If the answer is 'I'm not sure,' then get some help in making the correct referral,” he advised.

Understand any regulations regarding the use of CAM therapies by your relevant state regulatory board. “You have to check the regulations and scope of practice,” he said. “From a conservative legal standpoint, referring to somebody who does not own a license to treat a patient is risky business. Don't do it.”

He pointed out that, in general, a physician is not liable merely for making a referral to a specialist. But he cited three exceptions to the general rule:

▸ The referral led to delay or deferral of necessary medical treatment. “Do your day job first,” he said.

▸ The referring provider knew or should have known that the referred-to provider was incompetent.

▸ The referred-to provider is considered to be the physician's agent, either because state law requires supervision or an extended form of consultation, or there is a “joint treatment” agreement between the physician and the CAM provider.

Dr. Eisenberg also discussed the notion of a “legal catch-22” when referring a patient for CAM.

For example, if a physician seeks a distant, independent contractor type of relationship with a CAM provider, “there is probably less shared liability risk, but there is probably more risk of harm to the patient because you're referring to a stranger,” he noted.

“Conversely, there is higher risk of shared liability if you refer to CAM providers you know or have an ongoing professional relationship with, but there's probably less chance of harm [to the patient] because you're involved.”

LA JOLLA, CALIF. – When you refer a patient to a provider of complementary and alternative medicine, keep in mind five liability management strategies, David M. Eisenberg, M.D., advised at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

The strategies, which he developed in collaboration with Michael H. Cohen, J.D. (Ann. Intern. Med. 2002;136:596-603), include the following:

Determine the clinical risk level. Decide whether to:

▸ Recommend yet continue to monitor the therapy.

▸ Tolerate, provide caution, and closely monitor safety.

▸ Avoid and discourage the therapy.

Document the literature supporting the therapeutic choice.

“It's very important to put this in the chart,” said Dr. Eisenberg, an internist who directs the division for research and education in complementary and integrative medical therapies at the Osher Institute, Harvard Medical School, Boston. “By the way, that is also true when we're using a novel or experimental drug with an inpatient. This is the same approach.”

If treatment with a certain herb is recommended, “document the choice of herb, any recommendation regarding product or brand, and any discussion regarding therapeutic dose, and associated uncertainties regarding use of the herb,” he said.

He also makes it a practice to keep a backup file of articles supporting the discussion or recommendation. “You could say this is a bit too conservative, like have suspenders and a belt,” he said at the meeting, cosponsored by the University of California, San Diego. “But I think this is the best advice.”

Continue conventional monitoring. “A lot of times we recommend something or accept that a patient is going to do something, and then we don't monitor or follow up,” Dr. Eisenberg said. “Undue reliance on CAM may lead to a charge that the patient was dissuaded from necessary conventional medical care.”

He added that maintaining conventional treatment “helps demonstrate that the physician has followed the standard of care, even if CAM is included.”

Provide adequate informed consent. Describe the risks and benefits of using the CAM therapy and of delaying or deferring the conventional therapy, and spell out potential adverse interactions. That is a lot to consider, but such information would be helpful “in the eyes of the law if something went wrong,” he said. “You have to ask yourself, could I really defend this action or recommendation?”

Also, clear communication with the patient has been shown to reduce the risk of being sued for malpractice. “Inadequate informed consent is also a theory for malpractice liability in and of itself,” Dr. Eisenberg said.

Familiarize yourself with providers to whom you refer. Ask yourself, would I refer a friend to this person? “If the answer is 'I'm not sure,' then get some help in making the correct referral,” he advised.

Understand any regulations regarding the use of CAM therapies by your relevant state regulatory board. “You have to check the regulations and scope of practice,” he said. “From a conservative legal standpoint, referring to somebody who does not own a license to treat a patient is risky business. Don't do it.”

He pointed out that, in general, a physician is not liable merely for making a referral to a specialist. But he cited three exceptions to the general rule:

▸ The referral led to delay or deferral of necessary medical treatment. “Do your day job first,” he said.

▸ The referring provider knew or should have known that the referred-to provider was incompetent.

▸ The referred-to provider is considered to be the physician's agent, either because state law requires supervision or an extended form of consultation, or there is a “joint treatment” agreement between the physician and the CAM provider.

Dr. Eisenberg also discussed the notion of a “legal catch-22” when referring a patient for CAM.

For example, if a physician seeks a distant, independent contractor type of relationship with a CAM provider, “there is probably less shared liability risk, but there is probably more risk of harm to the patient because you're referring to a stranger,” he noted.

“Conversely, there is higher risk of shared liability if you refer to CAM providers you know or have an ongoing professional relationship with, but there's probably less chance of harm [to the patient] because you're involved.”

LA JOLLA, CALIF. – When you refer a patient to a provider of complementary and alternative medicine, keep in mind five liability management strategies, David M. Eisenberg, M.D., advised at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

The strategies, which he developed in collaboration with Michael H. Cohen, J.D. (Ann. Intern. Med. 2002;136:596-603), include the following:

Determine the clinical risk level. Decide whether to:

▸ Recommend yet continue to monitor the therapy.

▸ Tolerate, provide caution, and closely monitor safety.

▸ Avoid and discourage the therapy.

Document the literature supporting the therapeutic choice.

“It's very important to put this in the chart,” said Dr. Eisenberg, an internist who directs the division for research and education in complementary and integrative medical therapies at the Osher Institute, Harvard Medical School, Boston. “By the way, that is also true when we're using a novel or experimental drug with an inpatient. This is the same approach.”

If treatment with a certain herb is recommended, “document the choice of herb, any recommendation regarding product or brand, and any discussion regarding therapeutic dose, and associated uncertainties regarding use of the herb,” he said.

He also makes it a practice to keep a backup file of articles supporting the discussion or recommendation. “You could say this is a bit too conservative, like have suspenders and a belt,” he said at the meeting, cosponsored by the University of California, San Diego. “But I think this is the best advice.”

Continue conventional monitoring. “A lot of times we recommend something or accept that a patient is going to do something, and then we don't monitor or follow up,” Dr. Eisenberg said. “Undue reliance on CAM may lead to a charge that the patient was dissuaded from necessary conventional medical care.”

He added that maintaining conventional treatment “helps demonstrate that the physician has followed the standard of care, even if CAM is included.”

Provide adequate informed consent. Describe the risks and benefits of using the CAM therapy and of delaying or deferring the conventional therapy, and spell out potential adverse interactions. That is a lot to consider, but such information would be helpful “in the eyes of the law if something went wrong,” he said. “You have to ask yourself, could I really defend this action or recommendation?”

Also, clear communication with the patient has been shown to reduce the risk of being sued for malpractice. “Inadequate informed consent is also a theory for malpractice liability in and of itself,” Dr. Eisenberg said.

Familiarize yourself with providers to whom you refer. Ask yourself, would I refer a friend to this person? “If the answer is 'I'm not sure,' then get some help in making the correct referral,” he advised.

Understand any regulations regarding the use of CAM therapies by your relevant state regulatory board. “You have to check the regulations and scope of practice,” he said. “From a conservative legal standpoint, referring to somebody who does not own a license to treat a patient is risky business. Don't do it.”

He pointed out that, in general, a physician is not liable merely for making a referral to a specialist. But he cited three exceptions to the general rule:

▸ The referral led to delay or deferral of necessary medical treatment. “Do your day job first,” he said.

▸ The referring provider knew or should have known that the referred-to provider was incompetent.

▸ The referred-to provider is considered to be the physician's agent, either because state law requires supervision or an extended form of consultation, or there is a “joint treatment” agreement between the physician and the CAM provider.

Dr. Eisenberg also discussed the notion of a “legal catch-22” when referring a patient for CAM.

For example, if a physician seeks a distant, independent contractor type of relationship with a CAM provider, “there is probably less shared liability risk, but there is probably more risk of harm to the patient because you're referring to a stranger,” he noted.

“Conversely, there is higher risk of shared liability if you refer to CAM providers you know or have an ongoing professional relationship with, but there's probably less chance of harm [to the patient] because you're involved.”

SEATTLE – Many adults who have obstructive sleep apnea or insomnia also have attention-deficit disorder as well as neuromuscular and psychiatric conditions, results from a detailed analysis suggest.

“The sleep specialist isn't done when he says, 'It's sleep apnea. Use continuous positive airway pressure,' or 'It's insomnia; take a sleeping pill,'” Clifford G. Risk, M.D., said at a press briefing during the annual meeting of the American College of Chest Physicians. “He has to work out what the concurrent conditions are at the same time he's trying to improve the insomnia or sleep apnea. The assessment of patients with a sleep disorder and impaired daytime cognition may represent a complex interlay between the sleep disorder and comorbid dual diagnoses.”

He and his associates at a sleep disorder center in Marlborough, Mass., evaluated 58 patients who presented with sleep apnea or insomnia. Investigators administered a wide battery of standardized tests to assess the severity of obstructive sleep apnea, attention-deficit problems, depression, and insomnia.

All patients received treatment for their respective conditions, including continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea, cognitive behavior therapy and/or hypnotic medication for insomnia, and psychiatric evaluation and possible medication for primary ADD.

Of the 34 patients who were found to have sleep apnea, 16 had baseline Adult Self-Report Scale (ASRS) symptom checklist scores that suggested moderate or severe impairment of attention. After CPAP treatment, 60% of these patients substantially improved their attention scores. “However, 40% continued to report serious attention deficits following treatment, and required further neuropsychiatric evaluation and specific interventions,” said Dr. Risk, who directs the sleep disorder center.

Of the 24 patients who had insomnia, 54% had baseline ASRS scores that suggested moderate or severe impairment of attention. Nine patients suffered from a primary muscular disorder, including fibromyalgia, chronic fatigue, multiple sclerosis, peripheral neuropathy, and postpolio syndrome; 15 suffered from a primary psychological disorder, including depression, bipolar disorder, and anxiety.

There were serious rheumatologic and neurologic diseases causing sleep disturbances in patients with insomnia, Dr. Risk said. “If they slept through the night, we found that they were mostly in stage 1 or 2 sleep. They never got to restorative sleep stage 3 or 4. So they had a lack of restorative sleep due to a light or fragmented sleep.”

He and his associates have begun trying to identify reversible risk factors in each patient with insomnia to design specific interventions that may be of benefit.

SEATTLE – Many adults who have obstructive sleep apnea or insomnia also have attention-deficit disorder as well as neuromuscular and psychiatric conditions, results from a detailed analysis suggest.

“The sleep specialist isn't done when he says, 'It's sleep apnea. Use continuous positive airway pressure,' or 'It's insomnia; take a sleeping pill,'” Clifford G. Risk, M.D., said at a press briefing during the annual meeting of the American College of Chest Physicians. “He has to work out what the concurrent conditions are at the same time he's trying to improve the insomnia or sleep apnea. The assessment of patients with a sleep disorder and impaired daytime cognition may represent a complex interlay between the sleep disorder and comorbid dual diagnoses.”

He and his associates at a sleep disorder center in Marlborough, Mass., evaluated 58 patients who presented with sleep apnea or insomnia. Investigators administered a wide battery of standardized tests to assess the severity of obstructive sleep apnea, attention-deficit problems, depression, and insomnia.

All patients received treatment for their respective conditions, including continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea, cognitive behavior therapy and/or hypnotic medication for insomnia, and psychiatric evaluation and possible medication for primary ADD.

Of the 34 patients who were found to have sleep apnea, 16 had baseline Adult Self-Report Scale (ASRS) symptom checklist scores that suggested moderate or severe impairment of attention. After CPAP treatment, 60% of these patients substantially improved their attention scores. “However, 40% continued to report serious attention deficits following treatment, and required further neuropsychiatric evaluation and specific interventions,” said Dr. Risk, who directs the sleep disorder center.

Of the 24 patients who had insomnia, 54% had baseline ASRS scores that suggested moderate or severe impairment of attention. Nine patients suffered from a primary muscular disorder, including fibromyalgia, chronic fatigue, multiple sclerosis, peripheral neuropathy, and postpolio syndrome; 15 suffered from a primary psychological disorder, including depression, bipolar disorder, and anxiety.

There were serious rheumatologic and neurologic diseases causing sleep disturbances in patients with insomnia, Dr. Risk said. “If they slept through the night, we found that they were mostly in stage 1 or 2 sleep. They never got to restorative sleep stage 3 or 4. So they had a lack of restorative sleep due to a light or fragmented sleep.”

He and his associates have begun trying to identify reversible risk factors in each patient with insomnia to design specific interventions that may be of benefit.

SEATTLE – Many adults who have obstructive sleep apnea or insomnia also have attention-deficit disorder as well as neuromuscular and psychiatric conditions, results from a detailed analysis suggest.

“The sleep specialist isn't done when he says, 'It's sleep apnea. Use continuous positive airway pressure,' or 'It's insomnia; take a sleeping pill,'” Clifford G. Risk, M.D., said at a press briefing during the annual meeting of the American College of Chest Physicians. “He has to work out what the concurrent conditions are at the same time he's trying to improve the insomnia or sleep apnea. The assessment of patients with a sleep disorder and impaired daytime cognition may represent a complex interlay between the sleep disorder and comorbid dual diagnoses.”

He and his associates at a sleep disorder center in Marlborough, Mass., evaluated 58 patients who presented with sleep apnea or insomnia. Investigators administered a wide battery of standardized tests to assess the severity of obstructive sleep apnea, attention-deficit problems, depression, and insomnia.

All patients received treatment for their respective conditions, including continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea, cognitive behavior therapy and/or hypnotic medication for insomnia, and psychiatric evaluation and possible medication for primary ADD.

Of the 34 patients who were found to have sleep apnea, 16 had baseline Adult Self-Report Scale (ASRS) symptom checklist scores that suggested moderate or severe impairment of attention. After CPAP treatment, 60% of these patients substantially improved their attention scores. “However, 40% continued to report serious attention deficits following treatment, and required further neuropsychiatric evaluation and specific interventions,” said Dr. Risk, who directs the sleep disorder center.

Of the 24 patients who had insomnia, 54% had baseline ASRS scores that suggested moderate or severe impairment of attention. Nine patients suffered from a primary muscular disorder, including fibromyalgia, chronic fatigue, multiple sclerosis, peripheral neuropathy, and postpolio syndrome; 15 suffered from a primary psychological disorder, including depression, bipolar disorder, and anxiety.

There were serious rheumatologic and neurologic diseases causing sleep disturbances in patients with insomnia, Dr. Risk said. “If they slept through the night, we found that they were mostly in stage 1 or 2 sleep. They never got to restorative sleep stage 3 or 4. So they had a lack of restorative sleep due to a light or fragmented sleep.”

He and his associates have begun trying to identify reversible risk factors in each patient with insomnia to design specific interventions that may be of benefit.

SAN DIEGO – A multisymptom scale identified elderly primary care patients with depression and anxiety symptoms who were missed by the standard 15-item Geriatric Depression Scale, results from a large pilot study have found.

The finding suggests that elderly patients may respond better to less-overt questions about depressive symptoms, Angela Hoth, Pharm.D., said in an interview during a poster session at the annual meeting of the American Association for Geriatric Psychiatry.

“We're finding that a lot of people will deny that they have depressive symptoms as defined by the GDS, or they don't associate those particular symptoms with what they're feeling,” said Dr. Hoth, a clinical pharmacy specialist with the Iowa City VA Medical Center.

“If we asked them questions about symptoms, like 'How are you feeling physically over time?' and 'How is that affecting your overall quality of life?' we were able to pick up some patients that the standard GDS didn't pick up. We might be able to avoid missing some people in primary care by asking them more about their symptoms and relating that back to depression, rather than asking them the regular DSM-type of symptom questions,” she explained.

The instrument used by the investigators is the Elderly Symptom Assessment Scale (ESAS), a measure developed to identify adverse drug events in VA patients. It contains six depression-related items (sadness, concentration, memory, fatigue, sleep, appetite) and three anxiety-related items (anxiety, irritability, and restlessness). Results are reported as a symptom count, with a range of 0-9. The ESAS contains 47 overall symptoms.

For the study, Dr. Hoth and her associates simultaneously administered the GDS and the ESAS to 351 cognitively intact VA outpatients. They categorized patients as depressed or nondepressed based on scores from both scales.

Of the 351 patients, 94 (27%) screened positive for depression by the GDS and 121 (34%) by the ESAS. The ESAS identified 64 depressed patients classified as nondepressed by the GDS. Dr. Hoth considered this the “greatest surprise” of the study.

“The other major finding was that patients who were very somatic had a lot more anxiety as part of their depression,” she added. “This is not dissimilar from the medical literature, but in a veteran population that is significant, at least for how we're going to approach treating them, because a lot of them don't want to admit they're depressed. There's still a lot of stigma.”

She and her associates plan to implement the scale in a depression clinic they are launching in the primary care division of the Iowa City VA Medical Center.

SAN DIEGO – A multisymptom scale identified elderly primary care patients with depression and anxiety symptoms who were missed by the standard 15-item Geriatric Depression Scale, results from a large pilot study have found.

The finding suggests that elderly patients may respond better to less-overt questions about depressive symptoms, Angela Hoth, Pharm.D., said in an interview during a poster session at the annual meeting of the American Association for Geriatric Psychiatry.

“We're finding that a lot of people will deny that they have depressive symptoms as defined by the GDS, or they don't associate those particular symptoms with what they're feeling,” said Dr. Hoth, a clinical pharmacy specialist with the Iowa City VA Medical Center.

“If we asked them questions about symptoms, like 'How are you feeling physically over time?' and 'How is that affecting your overall quality of life?' we were able to pick up some patients that the standard GDS didn't pick up. We might be able to avoid missing some people in primary care by asking them more about their symptoms and relating that back to depression, rather than asking them the regular DSM-type of symptom questions,” she explained.

The instrument used by the investigators is the Elderly Symptom Assessment Scale (ESAS), a measure developed to identify adverse drug events in VA patients. It contains six depression-related items (sadness, concentration, memory, fatigue, sleep, appetite) and three anxiety-related items (anxiety, irritability, and restlessness). Results are reported as a symptom count, with a range of 0-9. The ESAS contains 47 overall symptoms.

For the study, Dr. Hoth and her associates simultaneously administered the GDS and the ESAS to 351 cognitively intact VA outpatients. They categorized patients as depressed or nondepressed based on scores from both scales.

Of the 351 patients, 94 (27%) screened positive for depression by the GDS and 121 (34%) by the ESAS. The ESAS identified 64 depressed patients classified as nondepressed by the GDS. Dr. Hoth considered this the “greatest surprise” of the study.

“The other major finding was that patients who were very somatic had a lot more anxiety as part of their depression,” she added. “This is not dissimilar from the medical literature, but in a veteran population that is significant, at least for how we're going to approach treating them, because a lot of them don't want to admit they're depressed. There's still a lot of stigma.”

She and her associates plan to implement the scale in a depression clinic they are launching in the primary care division of the Iowa City VA Medical Center.

SAN DIEGO – A multisymptom scale identified elderly primary care patients with depression and anxiety symptoms who were missed by the standard 15-item Geriatric Depression Scale, results from a large pilot study have found.

The finding suggests that elderly patients may respond better to less-overt questions about depressive symptoms, Angela Hoth, Pharm.D., said in an interview during a poster session at the annual meeting of the American Association for Geriatric Psychiatry.

“We're finding that a lot of people will deny that they have depressive symptoms as defined by the GDS, or they don't associate those particular symptoms with what they're feeling,” said Dr. Hoth, a clinical pharmacy specialist with the Iowa City VA Medical Center.

“If we asked them questions about symptoms, like 'How are you feeling physically over time?' and 'How is that affecting your overall quality of life?' we were able to pick up some patients that the standard GDS didn't pick up. We might be able to avoid missing some people in primary care by asking them more about their symptoms and relating that back to depression, rather than asking them the regular DSM-type of symptom questions,” she explained.

The instrument used by the investigators is the Elderly Symptom Assessment Scale (ESAS), a measure developed to identify adverse drug events in VA patients. It contains six depression-related items (sadness, concentration, memory, fatigue, sleep, appetite) and three anxiety-related items (anxiety, irritability, and restlessness). Results are reported as a symptom count, with a range of 0-9. The ESAS contains 47 overall symptoms.

For the study, Dr. Hoth and her associates simultaneously administered the GDS and the ESAS to 351 cognitively intact VA outpatients. They categorized patients as depressed or nondepressed based on scores from both scales.

Of the 351 patients, 94 (27%) screened positive for depression by the GDS and 121 (34%) by the ESAS. The ESAS identified 64 depressed patients classified as nondepressed by the GDS. Dr. Hoth considered this the “greatest surprise” of the study.

“The other major finding was that patients who were very somatic had a lot more anxiety as part of their depression,” she added. “This is not dissimilar from the medical literature, but in a veteran population that is significant, at least for how we're going to approach treating them, because a lot of them don't want to admit they're depressed. There's still a lot of stigma.”

She and her associates plan to implement the scale in a depression clinic they are launching in the primary care division of the Iowa City VA Medical Center.

SAN DIEGO – Use of memantine in patients with moderate to severe Alzheimer's disease significantly reduced their behavioral disturbances and psychiatric symptoms, compared with placebo, Jeffrey L. Cummings, M.D., reported in a poster session at the annual meeting of the American Association for Geriatric Psychiatry.

“We think this represents an important, newly recognized benefit for the use of memantine in patients with Alzheimer's disease,” Dr. Cummings, who is the director of the University of California, Los Angeles, Alzheimer's Disease Research Center, said in an interview with this newspaper.

“The question we posed was, does a drug like memantine, which is used for cognitive improvement, have any effect on agitation?” Dr. Cummings explained.

“What we saw was that in several analyses–whether we looked at week 12 or week 24, whether we looked at patients who were asymptomatic at baseline or symptomatic at baseline–memantine reduced agitation,” Dr. Cummings added.

For the 24-week study, Dr. Cummings and his associates randomized 403 patients at 37 clinical centers who had moderate to severe Alzheimer's disease to receive either memantine 10 mg b.i.d. or placebo.

The memantine was titrated up weekly in 5-mg increments from a starting dose of 5 mg/day during week 1 to 20 mg/day at week 4.

All patients remained on donepezil throughout the study.

The study's investigators used the Neuropsychiatric Inventory to assess the patients' behavioral symptoms at baseline, week 12, and week 24.

Of the 403 community-dwelling patients, 202 received memantine and 201 received placebo.

The mean age of study participants was 76 years, and 65% were female. Most (91%) were white.

When compared with patients in the placebo group at 12 weeks, those patients who were in the memantine group had significant improvements on the Neuropsychiatric Inventory domains of agitation/aggression (-0.4 vs. 0.2), irritability/lability (-0.4 vs. 0.1), and appetite/eating change (-0.4 vs. 0.1), in which a negative value denotes improvement and a positive value signifies worsening of symptoms, Dr. Cummings said at the meeting.

Patients' improvements in all of these Neuropsychiatric Inventory domains remained statistically significant at 24 weeks.

“I was surprised by the magnitude and consistency of the effect,” Dr. Cummings told this newspaper.

The study investigators also observed that, in patients who were asymptomatic at baseline, memantine treatment resulted in significantly less emergence of agitation/aggression and appetite/eating changes by week 24, compared with those patients who were taking a placebo.

According to Dr. Cummings, this is the first study to look at the effect of memantine on behavior in Alzheimer's disease.

Forest Laboratories Inc., the company that manufactures memantine, supported the study.

SAN DIEGO – Use of memantine in patients with moderate to severe Alzheimer's disease significantly reduced their behavioral disturbances and psychiatric symptoms, compared with placebo, Jeffrey L. Cummings, M.D., reported in a poster session at the annual meeting of the American Association for Geriatric Psychiatry.

“We think this represents an important, newly recognized benefit for the use of memantine in patients with Alzheimer's disease,” Dr. Cummings, who is the director of the University of California, Los Angeles, Alzheimer's Disease Research Center, said in an interview with this newspaper.

“The question we posed was, does a drug like memantine, which is used for cognitive improvement, have any effect on agitation?” Dr. Cummings explained.

“What we saw was that in several analyses–whether we looked at week 12 or week 24, whether we looked at patients who were asymptomatic at baseline or symptomatic at baseline–memantine reduced agitation,” Dr. Cummings added.

For the 24-week study, Dr. Cummings and his associates randomized 403 patients at 37 clinical centers who had moderate to severe Alzheimer's disease to receive either memantine 10 mg b.i.d. or placebo.

The memantine was titrated up weekly in 5-mg increments from a starting dose of 5 mg/day during week 1 to 20 mg/day at week 4.

All patients remained on donepezil throughout the study.

The study's investigators used the Neuropsychiatric Inventory to assess the patients' behavioral symptoms at baseline, week 12, and week 24.

Of the 403 community-dwelling patients, 202 received memantine and 201 received placebo.

The mean age of study participants was 76 years, and 65% were female. Most (91%) were white.

When compared with patients in the placebo group at 12 weeks, those patients who were in the memantine group had significant improvements on the Neuropsychiatric Inventory domains of agitation/aggression (-0.4 vs. 0.2), irritability/lability (-0.4 vs. 0.1), and appetite/eating change (-0.4 vs. 0.1), in which a negative value denotes improvement and a positive value signifies worsening of symptoms, Dr. Cummings said at the meeting.

Patients' improvements in all of these Neuropsychiatric Inventory domains remained statistically significant at 24 weeks.

“I was surprised by the magnitude and consistency of the effect,” Dr. Cummings told this newspaper.

The study investigators also observed that, in patients who were asymptomatic at baseline, memantine treatment resulted in significantly less emergence of agitation/aggression and appetite/eating changes by week 24, compared with those patients who were taking a placebo.

According to Dr. Cummings, this is the first study to look at the effect of memantine on behavior in Alzheimer's disease.

Forest Laboratories Inc., the company that manufactures memantine, supported the study.

SAN DIEGO – Use of memantine in patients with moderate to severe Alzheimer's disease significantly reduced their behavioral disturbances and psychiatric symptoms, compared with placebo, Jeffrey L. Cummings, M.D., reported in a poster session at the annual meeting of the American Association for Geriatric Psychiatry.

“We think this represents an important, newly recognized benefit for the use of memantine in patients with Alzheimer's disease,” Dr. Cummings, who is the director of the University of California, Los Angeles, Alzheimer's Disease Research Center, said in an interview with this newspaper.

“The question we posed was, does a drug like memantine, which is used for cognitive improvement, have any effect on agitation?” Dr. Cummings explained.

“What we saw was that in several analyses–whether we looked at week 12 or week 24, whether we looked at patients who were asymptomatic at baseline or symptomatic at baseline–memantine reduced agitation,” Dr. Cummings added.

For the 24-week study, Dr. Cummings and his associates randomized 403 patients at 37 clinical centers who had moderate to severe Alzheimer's disease to receive either memantine 10 mg b.i.d. or placebo.

The memantine was titrated up weekly in 5-mg increments from a starting dose of 5 mg/day during week 1 to 20 mg/day at week 4.

All patients remained on donepezil throughout the study.

The study's investigators used the Neuropsychiatric Inventory to assess the patients' behavioral symptoms at baseline, week 12, and week 24.

Of the 403 community-dwelling patients, 202 received memantine and 201 received placebo.

The mean age of study participants was 76 years, and 65% were female. Most (91%) were white.

When compared with patients in the placebo group at 12 weeks, those patients who were in the memantine group had significant improvements on the Neuropsychiatric Inventory domains of agitation/aggression (-0.4 vs. 0.2), irritability/lability (-0.4 vs. 0.1), and appetite/eating change (-0.4 vs. 0.1), in which a negative value denotes improvement and a positive value signifies worsening of symptoms, Dr. Cummings said at the meeting.

Patients' improvements in all of these Neuropsychiatric Inventory domains remained statistically significant at 24 weeks.

“I was surprised by the magnitude and consistency of the effect,” Dr. Cummings told this newspaper.

The study investigators also observed that, in patients who were asymptomatic at baseline, memantine treatment resulted in significantly less emergence of agitation/aggression and appetite/eating changes by week 24, compared with those patients who were taking a placebo.

According to Dr. Cummings, this is the first study to look at the effect of memantine on behavior in Alzheimer's disease.

Forest Laboratories Inc., the company that manufactures memantine, supported the study.

By the time children of overweight mothers reach 6 years of age, they are 15 times more likely to be obese, compared with children of lean mothers, results from a novel study suggest.

“These are kids at extraordinary risk for developing obesity,” the study's lead author, Robert Berkowitz, M.D., said in an interview. “These are not kids who are going to get thin later.”

The finding suggests that children of overweight mothers could become a target group for obesity prevention efforts, said Dr. Berkowitz, chair of adolescent psychiatry and executive director of the behavioral health center at the Children's Hospital of Philadelphia.

“Common sense prevention approaches [for children] include regular activity that's healthy and safe, cutting down on TV watching and computer game usage, and eating a healthy, low-fat diet with fruits and vegetables and portion control,” he told this newspaper. “But we don't know that for sure because we haven't done the obesity prevention treatment at such a young age.”

For the study, which is the largest of its kind, he and his associates followed 33 children at high risk of obesity and 37 children at low risk of obesity based on the mother's prepregnancy body mass index (Am. J. Clin. Nutr. 2005;81:140-6). Mothers of high-risk children had a mean prepregnancy BMI of 30.3 kg/m2 while mothers of low-risk children had a mean BMI of 19.5 kg/m2. The study was confined to white children because they have different growth patterns compared with nonwhite children.

Investigators examined the children from 3 months of age to 6 years, including measurements of height, weight, skin fold thickness, and fat mass and lean mass by dual-energy x-ray absorptiometry (DXA). They defined childhood overweight as a BMI at or above the 85th percentile for age and gender according to the National Center for Health Statistics/Centers for Disease Control and Prevention growth charts.

By age 2, no clinical differences were observed between the high- and low-risk groups, but by age 4 years, weight, BMI, lean body mass, and waist circumference were significantly greater among high-risk children, compared with their low-risk counterparts. Dr. Berkowitz said these factors translated into an 11-fold risk of obesity developing in high-risk children.

By age 6 years, the weight, BMI, lean body mass, and waist circumference had increased even more among high-risk children compared with their low-risk counterparts. Skin fold thickness also increased. In addition, for the first time, fat mass was greater in high-risk children compared with their low-risk counterparts (6.7 kg vs. 3.8 kg, respectively). So was percentage of body fat (24.7% vs. 18.8%, respectively). Dr. Berkowitz said these factors translated into a 15-fold risk of obesity developing in high-risk children.

Harsohena Kaur, M.D., a pediatrician at the University of Kansas, Kansas City, called the study “another piece of the puzzle” in gaining a better understanding of the epidemic of childhood obesity.

“As pediatricians, we have been seeing bigger and bigger babies who are becoming bigger and bigger toddlers,” said Dr. Kaur, whose research interests include childhood obesity. “They seem to be bigger across the board. I have no idea how that's going to impact everything 20 years from now. This study is scary in that sense.”

Dr. Berkowitz said he was surprised there were no clinical differences between the high- and low-risk groups of children in the first 2 years of life. “The kids at 1 and 2 years were identical in measures of height and weight and skin fold and body composition,” he said.

He added that efforts to prevent obesity in high-risk children should begin between ages 4 and 6 years. “Before that, you really can/t tell which of the kids of overweight moms are going to become overweight,” he said.

A study limitation, he said, was its relatively small sample size. The National Institutes of Health supported the study.

By the time children of overweight mothers reach 6 years of age, they are 15 times more likely to be obese, compared with children of lean mothers, results from a novel study suggest.

“These are kids at extraordinary risk for developing obesity,” the study's lead author, Robert Berkowitz, M.D., said in an interview. “These are not kids who are going to get thin later.”

The finding suggests that children of overweight mothers could become a target group for obesity prevention efforts, said Dr. Berkowitz, chair of adolescent psychiatry and executive director of the behavioral health center at the Children's Hospital of Philadelphia.

“Common sense prevention approaches [for children] include regular activity that's healthy and safe, cutting down on TV watching and computer game usage, and eating a healthy, low-fat diet with fruits and vegetables and portion control,” he told this newspaper. “But we don't know that for sure because we haven't done the obesity prevention treatment at such a young age.”

For the study, which is the largest of its kind, he and his associates followed 33 children at high risk of obesity and 37 children at low risk of obesity based on the mother's prepregnancy body mass index (Am. J. Clin. Nutr. 2005;81:140-6). Mothers of high-risk children had a mean prepregnancy BMI of 30.3 kg/m2 while mothers of low-risk children had a mean BMI of 19.5 kg/m2. The study was confined to white children because they have different growth patterns compared with nonwhite children.

Investigators examined the children from 3 months of age to 6 years, including measurements of height, weight, skin fold thickness, and fat mass and lean mass by dual-energy x-ray absorptiometry (DXA). They defined childhood overweight as a BMI at or above the 85th percentile for age and gender according to the National Center for Health Statistics/Centers for Disease Control and Prevention growth charts.

By age 2, no clinical differences were observed between the high- and low-risk groups, but by age 4 years, weight, BMI, lean body mass, and waist circumference were significantly greater among high-risk children, compared with their low-risk counterparts. Dr. Berkowitz said these factors translated into an 11-fold risk of obesity developing in high-risk children.

By age 6 years, the weight, BMI, lean body mass, and waist circumference had increased even more among high-risk children compared with their low-risk counterparts. Skin fold thickness also increased. In addition, for the first time, fat mass was greater in high-risk children compared with their low-risk counterparts (6.7 kg vs. 3.8 kg, respectively). So was percentage of body fat (24.7% vs. 18.8%, respectively). Dr. Berkowitz said these factors translated into a 15-fold risk of obesity developing in high-risk children.

Harsohena Kaur, M.D., a pediatrician at the University of Kansas, Kansas City, called the study “another piece of the puzzle” in gaining a better understanding of the epidemic of childhood obesity.

“As pediatricians, we have been seeing bigger and bigger babies who are becoming bigger and bigger toddlers,” said Dr. Kaur, whose research interests include childhood obesity. “They seem to be bigger across the board. I have no idea how that's going to impact everything 20 years from now. This study is scary in that sense.”

Dr. Berkowitz said he was surprised there were no clinical differences between the high- and low-risk groups of children in the first 2 years of life. “The kids at 1 and 2 years were identical in measures of height and weight and skin fold and body composition,” he said.

He added that efforts to prevent obesity in high-risk children should begin between ages 4 and 6 years. “Before that, you really can/t tell which of the kids of overweight moms are going to become overweight,” he said.

A study limitation, he said, was its relatively small sample size. The National Institutes of Health supported the study.

By the time children of overweight mothers reach 6 years of age, they are 15 times more likely to be obese, compared with children of lean mothers, results from a novel study suggest.

“These are kids at extraordinary risk for developing obesity,” the study's lead author, Robert Berkowitz, M.D., said in an interview. “These are not kids who are going to get thin later.”

The finding suggests that children of overweight mothers could become a target group for obesity prevention efforts, said Dr. Berkowitz, chair of adolescent psychiatry and executive director of the behavioral health center at the Children's Hospital of Philadelphia.

“Common sense prevention approaches [for children] include regular activity that's healthy and safe, cutting down on TV watching and computer game usage, and eating a healthy, low-fat diet with fruits and vegetables and portion control,” he told this newspaper. “But we don't know that for sure because we haven't done the obesity prevention treatment at such a young age.”

For the study, which is the largest of its kind, he and his associates followed 33 children at high risk of obesity and 37 children at low risk of obesity based on the mother's prepregnancy body mass index (Am. J. Clin. Nutr. 2005;81:140-6). Mothers of high-risk children had a mean prepregnancy BMI of 30.3 kg/m2 while mothers of low-risk children had a mean BMI of 19.5 kg/m2. The study was confined to white children because they have different growth patterns compared with nonwhite children.

Investigators examined the children from 3 months of age to 6 years, including measurements of height, weight, skin fold thickness, and fat mass and lean mass by dual-energy x-ray absorptiometry (DXA). They defined childhood overweight as a BMI at or above the 85th percentile for age and gender according to the National Center for Health Statistics/Centers for Disease Control and Prevention growth charts.

By age 2, no clinical differences were observed between the high- and low-risk groups, but by age 4 years, weight, BMI, lean body mass, and waist circumference were significantly greater among high-risk children, compared with their low-risk counterparts. Dr. Berkowitz said these factors translated into an 11-fold risk of obesity developing in high-risk children.

By age 6 years, the weight, BMI, lean body mass, and waist circumference had increased even more among high-risk children compared with their low-risk counterparts. Skin fold thickness also increased. In addition, for the first time, fat mass was greater in high-risk children compared with their low-risk counterparts (6.7 kg vs. 3.8 kg, respectively). So was percentage of body fat (24.7% vs. 18.8%, respectively). Dr. Berkowitz said these factors translated into a 15-fold risk of obesity developing in high-risk children.

Harsohena Kaur, M.D., a pediatrician at the University of Kansas, Kansas City, called the study “another piece of the puzzle” in gaining a better understanding of the epidemic of childhood obesity.

“As pediatricians, we have been seeing bigger and bigger babies who are becoming bigger and bigger toddlers,” said Dr. Kaur, whose research interests include childhood obesity. “They seem to be bigger across the board. I have no idea how that's going to impact everything 20 years from now. This study is scary in that sense.”

Dr. Berkowitz said he was surprised there were no clinical differences between the high- and low-risk groups of children in the first 2 years of life. “The kids at 1 and 2 years were identical in measures of height and weight and skin fold and body composition,” he said.

He added that efforts to prevent obesity in high-risk children should begin between ages 4 and 6 years. “Before that, you really can/t tell which of the kids of overweight moms are going to become overweight,” he said.

A study limitation, he said, was its relatively small sample size. The National Institutes of Health supported the study.

Brooke Jackson, M.D., describes herself as a “late bloomer” to the notion of exercising on a regular basis.

Her turning point came in 1997, when she moved to Houston for her Mohs fellowship at Baylor College of Medicine. One day she spotted a newspaper ad placed by a group of local runners.

“The ad said, 'We'll train you to run a marathon,'” Dr. Jackson recalled. “I had no intention of ever doing a marathon. I had never run a race in my life. I just figured it would be nice to get out with a group of people and run a little bit. I'd be happy getting up to 5 miles.”

Only 6 months later, she found herself at the starting line of her first marathon, “wondering what I had gotten myself into,” she said. “I had such a good time doing it that I went back the next year.”

After running her second marathon and completing her Mohs fellowship, Dr. Jackson moved to Chicago's South Side in 1999 to set up a dermatology practice. One of her first priorities was finding a group of people to run with. “A couple of nights a week, most running stores will have a group of people that will go out and run 3, 4, or 5 miles,” she said. “I joined that group. That's how I met my husband.”

She also formed a marathon-training group as a way to meet people and inspire others to exercise. In that first year, 75 people joined the group. By 2003, the number grew to 400.

The way she sees it, running is “something you can do anywhere, at any time, with anybody,” said Dr. Jackson. “It's a great way to meet people and take care of yourself, too. I'm a firm believer that until you take good care of yourself, you really aren't in the position to take care of anybody else.”

Although the clinical benefits of even moderate exercise—like a brisk walk—are well known, few physicians make concerted efforts to incorporate it into their daily routine, according to Tedd Mitchell, M.D. He described the fitness levels and habits of physicians, priests, preachers, and rabbis as “abysmal” compared with that of the general population because of the service-related nature of their work. In these professions, “it's all about everyone else, not about you,” noted Dr. Mitchell, an internist who is vice president of the Cooper Clinic in Dallas.

One reason physicians as a group may not exercise “is because inconsistency is built into your schedule,” he said. “You have call; that affects your routine. Your day-to-day schedule is not that of a banker, so it makes it more difficult to follow any type of routine consistently, whether it's exercise or good nutrition.”

He shared the following tips that he and his associates share with patients who attend the Cooper Clinic:

▸ Know the “FIT” principle of aerobic training. “F” stands for frequency of exercise sessions, “I” stands for intensity of the exercise, and “T” stands for length of time per session.

Of the three variables, frequency is the most important, said Dr. Mitchell, who is also a member of the President's Council on Physical Fitness and Sports.

“Think of exercise as another medication,” he said. “If you're not taking your medicine regularly, you don't get the benefit. It's the same thing with exercise. From a frequency standpoint, if your weight is not an issue and all you're after is some health benefits, exercising three times a week is okay. However, if you have any tendency toward high cholesterol, triglycerides, blood pressure, weight, or stress, you need it five times a week.”

Once you establish the frequency, the next most important variable is the length of time you exercise. “Thirty minutes is great,” he said. “You can walk for 30 minutes or jog for 20.”

Intensity is the last variable you tackle. Consistent, moderate exercise is what you're after. “Physicians tend to work out infrequently and hard,” Dr. Mitchell noted. “That formula is backward for the benefits, but it's just right for pulling hamstrings.”

▸ Exercise in the morning. People who routinely exercise in the morning are more likely to do it long term compared with people who try to exercise at other times of the day, “because you can control the morning schedule better than you can control anything else,” Dr. Mitchell said. “Even the surgeons can do this. Rather than always taking the 7 a.m. time slot in the [operating room], give yourself an 8 a.m. time slot and get the activity done.”

Nicolette Horbach, M.D., started working out at a local gym with a personal trainer 4 years ago. She meets with the trainer at 7 a.m. on 2 days during the workweek. “I plan to see patients on those days at 8:45 a.m. instead of at 8 a.m.” said Dr. Horbach, a urogynecologist in private practice in Annandale, Va. “That extra 45 minutes gives me the time to do what I need to do.”

▸ Keep it simple and practical. “You're better off having a treadmill at your house that you can use every morning than you are joining the best club in town if it means you've got to get in a car and drive over there,” Dr. Mitchell said.

At his ob.gyn. group practice in Naperville, Ill., Christopher Olson, M.D., converted a procedure room into an exercise room with a step machine, a stationary bike, and some free weights. Intended for use by his entire staff, the exercise room is where Dr. Olson typically works out during the Chicago winter months, although he prefers outdoor activities like jogging and golf during warmer months. “There's a shower in the office, too, so it makes it harder to come up with excuses” for not using the room, said Dr. Olson.

He added that his office, house, and nearest golf club are within 1.5 miles of each other, “so I can play six holes at dusk and be home for dinner, and it's very convenient,” he said. “To me, one of the secrets to playing hard and working hard is that I try to keep everything very convenient. If it's not convenient, I'm never going to do it.”

If you travel frequently, bring along your running or walking shoes and carve out some time for exercise when you reach your destination. “Running is one of the things that you can do anywhere, so there's no excuse,” Dr. Jackson said. “It doesn't take a lot of time. All you need is a pair of shoes.”

▸ Keep it short. Physicians tend to embrace the notion of “all or none” or “no pain, no gain,” Dr. Mitchell said. “If you could walk 30 minutes in the morning on a treadmill or around the neighborhood at a brisk pace, or if you could jog for 20 minutes, you will get far better benefit doing that than joining a club and going over there once or twice a week and [overdoing] it,” he noted.

▸ Keep it consistent. Schedule each session of preferred physical activity just as you schedule patient appointments and everything else. “Keep a workweek mind-set,” Dr. Mitchell advised. “For example, I went up to Washington a couple weeks ago and we had meetings all day for the president's council. As we were setting meeting times, I said, 'Don't start them before this time, because I'm going to exercise.'”

Planning and Problem Solving Are Key

The skinny on exercise boils down to this:

If you can find time for three 10-minute walks a day, you'll achieve certain health benefits.

“I don't care how busy you are. You can find a way to do that on most days if you do a little planning and problem solving,” said 65-year-old Steven N. Blair, president and CEO of the Cooper Institute in Dallas and primary author of Active Living Every Day: 20 Weeks to Lifelong Vitality (Champaign, Ill.: Human Kinetics Publishers, 2001).

Mr. Blair has been a daily runner for more than 35 years. Although his habit of being physically active is long established, he still asks himself two questions every evening: “What's my schedule tomorrow?” and “When do I have time to fit in my exercise?”

“I always start with my personal assumption that I'm going to get some exercise tomorrow,” said Mr. Blair. “Exercise is a high priority. I know it's very important to health, so I'm going to find [a way] to do it tomorrow sometime.”

He offered the following hypothetical schedule to illustrate how he would manage to meet his exercise goal despite apparent obstacles.

“Tomorrow I leave the house at 6 a.m. and I'm flying to Seattle to give a presentation,” he said. “I arrive in Seattle at 5 p.m. and my talk is at 6 p.m. It doesn't look like I'll be able to run, but I am changing planes in Denver, and I have an hour and a half layover. I can't run in the Denver airport, but I sure can get a 30-minute walk in.”

Findings from studies conducted at the Cooper Institute have concluded that patients who use such planning and problem-solving techniques are more likely to establish long-term exercise habits than are those who don't. These same patients will also make commitments like, “I vow to be active nearly every day.”

The consensus public health recommendations on physical activity that emerged in the mid-1990s from the Centers for Disease Control and Prevention, the American College of Sports Medicine, and the U.S. Surgeon General's report recommended that people accumulate at least 30 minutes of moderate intensity activity on most days of the week.

“'Most' means 5 days, so 30 minutes of walking 5 days a week,” Dr. Blair said. “ 'Accumulate' means you don't have to go for a 30-minute walk. You can go for two 15-minute walks or three 10-minute walks, or four 8-minute walks.”

Brooke Jackson, M.D., describes herself as a “late bloomer” to the notion of exercising on a regular basis.

Her turning point came in 1997, when she moved to Houston for her Mohs fellowship at Baylor College of Medicine. One day she spotted a newspaper ad placed by a group of local runners.

“The ad said, 'We'll train you to run a marathon,'” Dr. Jackson recalled. “I had no intention of ever doing a marathon. I had never run a race in my life. I just figured it would be nice to get out with a group of people and run a little bit. I'd be happy getting up to 5 miles.”

Only 6 months later, she found herself at the starting line of her first marathon, “wondering what I had gotten myself into,” she said. “I had such a good time doing it that I went back the next year.”

After running her second marathon and completing her Mohs fellowship, Dr. Jackson moved to Chicago's South Side in 1999 to set up a dermatology practice. One of her first priorities was finding a group of people to run with. “A couple of nights a week, most running stores will have a group of people that will go out and run 3, 4, or 5 miles,” she said. “I joined that group. That's how I met my husband.”

She also formed a marathon-training group as a way to meet people and inspire others to exercise. In that first year, 75 people joined the group. By 2003, the number grew to 400.

The way she sees it, running is “something you can do anywhere, at any time, with anybody,” said Dr. Jackson. “It's a great way to meet people and take care of yourself, too. I'm a firm believer that until you take good care of yourself, you really aren't in the position to take care of anybody else.”

Although the clinical benefits of even moderate exercise—like a brisk walk—are well known, few physicians make concerted efforts to incorporate it into their daily routine, according to Tedd Mitchell, M.D. He described the fitness levels and habits of physicians, priests, preachers, and rabbis as “abysmal” compared with that of the general population because of the service-related nature of their work. In these professions, “it's all about everyone else, not about you,” noted Dr. Mitchell, an internist who is vice president of the Cooper Clinic in Dallas.

One reason physicians as a group may not exercise “is because inconsistency is built into your schedule,” he said. “You have call; that affects your routine. Your day-to-day schedule is not that of a banker, so it makes it more difficult to follow any type of routine consistently, whether it's exercise or good nutrition.”

He shared the following tips that he and his associates share with patients who attend the Cooper Clinic:

▸ Know the “FIT” principle of aerobic training. “F” stands for frequency of exercise sessions, “I” stands for intensity of the exercise, and “T” stands for length of time per session.

Of the three variables, frequency is the most important, said Dr. Mitchell, who is also a member of the President's Council on Physical Fitness and Sports.

“Think of exercise as another medication,” he said. “If you're not taking your medicine regularly, you don't get the benefit. It's the same thing with exercise. From a frequency standpoint, if your weight is not an issue and all you're after is some health benefits, exercising three times a week is okay. However, if you have any tendency toward high cholesterol, triglycerides, blood pressure, weight, or stress, you need it five times a week.”

Once you establish the frequency, the next most important variable is the length of time you exercise. “Thirty minutes is great,” he said. “You can walk for 30 minutes or jog for 20.”

Intensity is the last variable you tackle. Consistent, moderate exercise is what you're after. “Physicians tend to work out infrequently and hard,” Dr. Mitchell noted. “That formula is backward for the benefits, but it's just right for pulling hamstrings.”

▸ Exercise in the morning. People who routinely exercise in the morning are more likely to do it long term compared with people who try to exercise at other times of the day, “because you can control the morning schedule better than you can control anything else,” Dr. Mitchell said. “Even the surgeons can do this. Rather than always taking the 7 a.m. time slot in the [operating room], give yourself an 8 a.m. time slot and get the activity done.”

Nicolette Horbach, M.D., started working out at a local gym with a personal trainer 4 years ago. She meets with the trainer at 7 a.m. on 2 days during the workweek. “I plan to see patients on those days at 8:45 a.m. instead of at 8 a.m.” said Dr. Horbach, a urogynecologist in private practice in Annandale, Va. “That extra 45 minutes gives me the time to do what I need to do.”

▸ Keep it simple and practical. “You're better off having a treadmill at your house that you can use every morning than you are joining the best club in town if it means you've got to get in a car and drive over there,” Dr. Mitchell said.

At his ob.gyn. group practice in Naperville, Ill., Christopher Olson, M.D., converted a procedure room into an exercise room with a step machine, a stationary bike, and some free weights. Intended for use by his entire staff, the exercise room is where Dr. Olson typically works out during the Chicago winter months, although he prefers outdoor activities like jogging and golf during warmer months. “There's a shower in the office, too, so it makes it harder to come up with excuses” for not using the room, said Dr. Olson.

He added that his office, house, and nearest golf club are within 1.5 miles of each other, “so I can play six holes at dusk and be home for dinner, and it's very convenient,” he said. “To me, one of the secrets to playing hard and working hard is that I try to keep everything very convenient. If it's not convenient, I'm never going to do it.”

If you travel frequently, bring along your running or walking shoes and carve out some time for exercise when you reach your destination. “Running is one of the things that you can do anywhere, so there's no excuse,” Dr. Jackson said. “It doesn't take a lot of time. All you need is a pair of shoes.”

▸ Keep it short. Physicians tend to embrace the notion of “all or none” or “no pain, no gain,” Dr. Mitchell said. “If you could walk 30 minutes in the morning on a treadmill or around the neighborhood at a brisk pace, or if you could jog for 20 minutes, you will get far better benefit doing that than joining a club and going over there once or twice a week and [overdoing] it,” he noted.

▸ Keep it consistent. Schedule each session of preferred physical activity just as you schedule patient appointments and everything else. “Keep a workweek mind-set,” Dr. Mitchell advised. “For example, I went up to Washington a couple weeks ago and we had meetings all day for the president's council. As we were setting meeting times, I said, 'Don't start them before this time, because I'm going to exercise.'”

Planning and Problem Solving Are Key

The skinny on exercise boils down to this:

If you can find time for three 10-minute walks a day, you'll achieve certain health benefits.

“I don't care how busy you are. You can find a way to do that on most days if you do a little planning and problem solving,” said 65-year-old Steven N. Blair, president and CEO of the Cooper Institute in Dallas and primary author of Active Living Every Day: 20 Weeks to Lifelong Vitality (Champaign, Ill.: Human Kinetics Publishers, 2001).

Mr. Blair has been a daily runner for more than 35 years. Although his habit of being physically active is long established, he still asks himself two questions every evening: “What's my schedule tomorrow?” and “When do I have time to fit in my exercise?”

“I always start with my personal assumption that I'm going to get some exercise tomorrow,” said Mr. Blair. “Exercise is a high priority. I know it's very important to health, so I'm going to find [a way] to do it tomorrow sometime.”

He offered the following hypothetical schedule to illustrate how he would manage to meet his exercise goal despite apparent obstacles.

“Tomorrow I leave the house at 6 a.m. and I'm flying to Seattle to give a presentation,” he said. “I arrive in Seattle at 5 p.m. and my talk is at 6 p.m. It doesn't look like I'll be able to run, but I am changing planes in Denver, and I have an hour and a half layover. I can't run in the Denver airport, but I sure can get a 30-minute walk in.”

Findings from studies conducted at the Cooper Institute have concluded that patients who use such planning and problem-solving techniques are more likely to establish long-term exercise habits than are those who don't. These same patients will also make commitments like, “I vow to be active nearly every day.”

The consensus public health recommendations on physical activity that emerged in the mid-1990s from the Centers for Disease Control and Prevention, the American College of Sports Medicine, and the U.S. Surgeon General's report recommended that people accumulate at least 30 minutes of moderate intensity activity on most days of the week.

“'Most' means 5 days, so 30 minutes of walking 5 days a week,” Dr. Blair said. “ 'Accumulate' means you don't have to go for a 30-minute walk. You can go for two 15-minute walks or three 10-minute walks, or four 8-minute walks.”

Brooke Jackson, M.D., describes herself as a “late bloomer” to the notion of exercising on a regular basis.

Her turning point came in 1997, when she moved to Houston for her Mohs fellowship at Baylor College of Medicine. One day she spotted a newspaper ad placed by a group of local runners.

“The ad said, 'We'll train you to run a marathon,'” Dr. Jackson recalled. “I had no intention of ever doing a marathon. I had never run a race in my life. I just figured it would be nice to get out with a group of people and run a little bit. I'd be happy getting up to 5 miles.”

Only 6 months later, she found herself at the starting line of her first marathon, “wondering what I had gotten myself into,” she said. “I had such a good time doing it that I went back the next year.”

After running her second marathon and completing her Mohs fellowship, Dr. Jackson moved to Chicago's South Side in 1999 to set up a dermatology practice. One of her first priorities was finding a group of people to run with. “A couple of nights a week, most running stores will have a group of people that will go out and run 3, 4, or 5 miles,” she said. “I joined that group. That's how I met my husband.”

She also formed a marathon-training group as a way to meet people and inspire others to exercise. In that first year, 75 people joined the group. By 2003, the number grew to 400.

The way she sees it, running is “something you can do anywhere, at any time, with anybody,” said Dr. Jackson. “It's a great way to meet people and take care of yourself, too. I'm a firm believer that until you take good care of yourself, you really aren't in the position to take care of anybody else.”

Although the clinical benefits of even moderate exercise—like a brisk walk—are well known, few physicians make concerted efforts to incorporate it into their daily routine, according to Tedd Mitchell, M.D. He described the fitness levels and habits of physicians, priests, preachers, and rabbis as “abysmal” compared with that of the general population because of the service-related nature of their work. In these professions, “it's all about everyone else, not about you,” noted Dr. Mitchell, an internist who is vice president of the Cooper Clinic in Dallas.

One reason physicians as a group may not exercise “is because inconsistency is built into your schedule,” he said. “You have call; that affects your routine. Your day-to-day schedule is not that of a banker, so it makes it more difficult to follow any type of routine consistently, whether it's exercise or good nutrition.”

He shared the following tips that he and his associates share with patients who attend the Cooper Clinic:

▸ Know the “FIT” principle of aerobic training. “F” stands for frequency of exercise sessions, “I” stands for intensity of the exercise, and “T” stands for length of time per session.

Of the three variables, frequency is the most important, said Dr. Mitchell, who is also a member of the President's Council on Physical Fitness and Sports.

“Think of exercise as another medication,” he said. “If you're not taking your medicine regularly, you don't get the benefit. It's the same thing with exercise. From a frequency standpoint, if your weight is not an issue and all you're after is some health benefits, exercising three times a week is okay. However, if you have any tendency toward high cholesterol, triglycerides, blood pressure, weight, or stress, you need it five times a week.”

Once you establish the frequency, the next most important variable is the length of time you exercise. “Thirty minutes is great,” he said. “You can walk for 30 minutes or jog for 20.”

Intensity is the last variable you tackle. Consistent, moderate exercise is what you're after. “Physicians tend to work out infrequently and hard,” Dr. Mitchell noted. “That formula is backward for the benefits, but it's just right for pulling hamstrings.”

▸ Exercise in the morning. People who routinely exercise in the morning are more likely to do it long term compared with people who try to exercise at other times of the day, “because you can control the morning schedule better than you can control anything else,” Dr. Mitchell said. “Even the surgeons can do this. Rather than always taking the 7 a.m. time slot in the [operating room], give yourself an 8 a.m. time slot and get the activity done.”

Nicolette Horbach, M.D., started working out at a local gym with a personal trainer 4 years ago. She meets with the trainer at 7 a.m. on 2 days during the workweek. “I plan to see patients on those days at 8:45 a.m. instead of at 8 a.m.” said Dr. Horbach, a urogynecologist in private practice in Annandale, Va. “That extra 45 minutes gives me the time to do what I need to do.”

▸ Keep it simple and practical. “You're better off having a treadmill at your house that you can use every morning than you are joining the best club in town if it means you've got to get in a car and drive over there,” Dr. Mitchell said.

At his ob.gyn. group practice in Naperville, Ill., Christopher Olson, M.D., converted a procedure room into an exercise room with a step machine, a stationary bike, and some free weights. Intended for use by his entire staff, the exercise room is where Dr. Olson typically works out during the Chicago winter months, although he prefers outdoor activities like jogging and golf during warmer months. “There's a shower in the office, too, so it makes it harder to come up with excuses” for not using the room, said Dr. Olson.

He added that his office, house, and nearest golf club are within 1.5 miles of each other, “so I can play six holes at dusk and be home for dinner, and it's very convenient,” he said. “To me, one of the secrets to playing hard and working hard is that I try to keep everything very convenient. If it's not convenient, I'm never going to do it.”

If you travel frequently, bring along your running or walking shoes and carve out some time for exercise when you reach your destination. “Running is one of the things that you can do anywhere, so there's no excuse,” Dr. Jackson said. “It doesn't take a lot of time. All you need is a pair of shoes.”

▸ Keep it short. Physicians tend to embrace the notion of “all or none” or “no pain, no gain,” Dr. Mitchell said. “If you could walk 30 minutes in the morning on a treadmill or around the neighborhood at a brisk pace, or if you could jog for 20 minutes, you will get far better benefit doing that than joining a club and going over there once or twice a week and [overdoing] it,” he noted.

▸ Keep it consistent. Schedule each session of preferred physical activity just as you schedule patient appointments and everything else. “Keep a workweek mind-set,” Dr. Mitchell advised. “For example, I went up to Washington a couple weeks ago and we had meetings all day for the president's council. As we were setting meeting times, I said, 'Don't start them before this time, because I'm going to exercise.'”

Planning and Problem Solving Are Key

The skinny on exercise boils down to this:

If you can find time for three 10-minute walks a day, you'll achieve certain health benefits.

“I don't care how busy you are. You can find a way to do that on most days if you do a little planning and problem solving,” said 65-year-old Steven N. Blair, president and CEO of the Cooper Institute in Dallas and primary author of Active Living Every Day: 20 Weeks to Lifelong Vitality (Champaign, Ill.: Human Kinetics Publishers, 2001).

Mr. Blair has been a daily runner for more than 35 years. Although his habit of being physically active is long established, he still asks himself two questions every evening: “What's my schedule tomorrow?” and “When do I have time to fit in my exercise?”

“I always start with my personal assumption that I'm going to get some exercise tomorrow,” said Mr. Blair. “Exercise is a high priority. I know it's very important to health, so I'm going to find [a way] to do it tomorrow sometime.”

He offered the following hypothetical schedule to illustrate how he would manage to meet his exercise goal despite apparent obstacles.

“Tomorrow I leave the house at 6 a.m. and I'm flying to Seattle to give a presentation,” he said. “I arrive in Seattle at 5 p.m. and my talk is at 6 p.m. It doesn't look like I'll be able to run, but I am changing planes in Denver, and I have an hour and a half layover. I can't run in the Denver airport, but I sure can get a 30-minute walk in.”

Findings from studies conducted at the Cooper Institute have concluded that patients who use such planning and problem-solving techniques are more likely to establish long-term exercise habits than are those who don't. These same patients will also make commitments like, “I vow to be active nearly every day.”

The consensus public health recommendations on physical activity that emerged in the mid-1990s from the Centers for Disease Control and Prevention, the American College of Sports Medicine, and the U.S. Surgeon General's report recommended that people accumulate at least 30 minutes of moderate intensity activity on most days of the week.

“'Most' means 5 days, so 30 minutes of walking 5 days a week,” Dr. Blair said. “ 'Accumulate' means you don't have to go for a 30-minute walk. You can go for two 15-minute walks or three 10-minute walks, or four 8-minute walks.”

SAN DIEGO — There is no one technique or strategy that will protect you from the risk of physical attacks in your workplace by patients or coworkers, Donna Pence declared at a conference sponsored by the Chadwick Center for Children and Families at Children's Hospital and Health Center, San Diego.

“There is nothing about who and what you are that makes you immune from people intent on doing bad things,” said Ms. Pence, training coordinator for San Diego State University's Public Child Welfare Training Academy. “Not looks, not money, not profession, not uniform, not where you live, not how religious you are, or how good you are.”

The best self-protection involves a combination of factors, including being aware of your capabilities, your environment, your habits, realistic hazards, and your options should a violent episode occur. She offered the following tips:

▸ Do some self-reflection. What is your history of violence and anger and your response to it? Have you been in situations where you felt threatened, and now you feel hypervigilant? Your personal history of violence “will affect your response to situations,” said Ms. Pence, who spent 25 years as a special agent with the Tennessee Bureau of Investigation. “It will impact the lens through which you view [someone's] behavior. That can be good, but it also could lead you to jump the gun and have a perception of violence and danger when it doesn't really exist.”

▸ Make an effort to understand your colleague's attitudes about personal safety and anger in the workplace. Are you allowed to talk about it? Are you encouraged to talk about it? “Is there a forum where you can ventilate about any anxieties you have about a client, or any anger you may have toward the client?” she asked. “Because if you're angry and they're angry, that's not a real healthy combination.”

Also, ask yourself, are there people in the office who can hear you if you yell for help? Is there an emergency buzzer nearby? If somebody enters the office and a buzzer goes off, do we have a plan on what to do?

▸ Think twice before visiting a patient in his or her home. Look at prior referrals. Consult with social workers or other physicians to see if the patient has a history of violent behavior. “If I have somebody who's been arrested for drugs, weapons, domestic violence, or child abuse, I'm going to think twice before going out to their turf by myself,” she said.

To protect against workplace violence and abuse, Ms. Pence recommended working on “target hardening.” Target hardening is a military term that refers to the notion that you are the person you are trying to make most safe.

“Until you recognize your personal, physical, mental, and environmental culpabilities and the possibility of victimization and do what you can realistically to reduce these, you're not a hard target,” she explained. This means:

▸ You must be aware.

▸ You must think in a different way. For example, “Don't walk down a sidewalk that has doors on one side and bushes on the other.” Also, when you approach a parking lot, don't skirt the edge of it. Rather, “walk toward the middle of the parking lot and look to the left and right.”

▸ You must act in a different way. “The way you walk, look, and carry yourself makes a difference in the degree of vulnerability that is ascribed to you by someone looking to attack,” she said. “Look confident, look aware, and be in the present.”

▸ You must recognize your personal vulnerabilities. Ask yourself, how could I defend myself in the event of a personal attack? “For example, I'm not a long distance runner,” Ms. Pence said. “I don't aspire to be a runner. That's a realistic assessment of my physical abilities. If there are areas where you have a deficit, ask, what can I do to enhance my abilities? Maybe it's learning some form of self-protection or learning verbal de-escalation techniques.”

SAN DIEGO — There is no one technique or strategy that will protect you from the risk of physical attacks in your workplace by patients or coworkers, Donna Pence declared at a conference sponsored by the Chadwick Center for Children and Families at Children's Hospital and Health Center, San Diego.

“There is nothing about who and what you are that makes you immune from people intent on doing bad things,” said Ms. Pence, training coordinator for San Diego State University's Public Child Welfare Training Academy. “Not looks, not money, not profession, not uniform, not where you live, not how religious you are, or how good you are.”

The best self-protection involves a combination of factors, including being aware of your capabilities, your environment, your habits, realistic hazards, and your options should a violent episode occur. She offered the following tips:

▸ Do some self-reflection. What is your history of violence and anger and your response to it? Have you been in situations where you felt threatened, and now you feel hypervigilant? Your personal history of violence “will affect your response to situations,” said Ms. Pence, who spent 25 years as a special agent with the Tennessee Bureau of Investigation. “It will impact the lens through which you view [someone's] behavior. That can be good, but it also could lead you to jump the gun and have a perception of violence and danger when it doesn't really exist.”

▸ Make an effort to understand your colleague's attitudes about personal safety and anger in the workplace. Are you allowed to talk about it? Are you encouraged to talk about it? “Is there a forum where you can ventilate about any anxieties you have about a client, or any anger you may have toward the client?” she asked. “Because if you're angry and they're angry, that's not a real healthy combination.”

Also, ask yourself, are there people in the office who can hear you if you yell for help? Is there an emergency buzzer nearby? If somebody enters the office and a buzzer goes off, do we have a plan on what to do?

▸ Think twice before visiting a patient in his or her home. Look at prior referrals. Consult with social workers or other physicians to see if the patient has a history of violent behavior. “If I have somebody who's been arrested for drugs, weapons, domestic violence, or child abuse, I'm going to think twice before going out to their turf by myself,” she said.

To protect against workplace violence and abuse, Ms. Pence recommended working on “target hardening.” Target hardening is a military term that refers to the notion that you are the person you are trying to make most safe.

“Until you recognize your personal, physical, mental, and environmental culpabilities and the possibility of victimization and do what you can realistically to reduce these, you're not a hard target,” she explained. This means:

▸ You must be aware.

▸ You must think in a different way. For example, “Don't walk down a sidewalk that has doors on one side and bushes on the other.” Also, when you approach a parking lot, don't skirt the edge of it. Rather, “walk toward the middle of the parking lot and look to the left and right.”

▸ You must act in a different way. “The way you walk, look, and carry yourself makes a difference in the degree of vulnerability that is ascribed to you by someone looking to attack,” she said. “Look confident, look aware, and be in the present.”

▸ You must recognize your personal vulnerabilities. Ask yourself, how could I defend myself in the event of a personal attack? “For example, I'm not a long distance runner,” Ms. Pence said. “I don't aspire to be a runner. That's a realistic assessment of my physical abilities. If there are areas where you have a deficit, ask, what can I do to enhance my abilities? Maybe it's learning some form of self-protection or learning verbal de-escalation techniques.”

SAN DIEGO — There is no one technique or strategy that will protect you from the risk of physical attacks in your workplace by patients or coworkers, Donna Pence declared at a conference sponsored by the Chadwick Center for Children and Families at Children's Hospital and Health Center, San Diego.

“There is nothing about who and what you are that makes you immune from people intent on doing bad things,” said Ms. Pence, training coordinator for San Diego State University's Public Child Welfare Training Academy. “Not looks, not money, not profession, not uniform, not where you live, not how religious you are, or how good you are.”

The best self-protection involves a combination of factors, including being aware of your capabilities, your environment, your habits, realistic hazards, and your options should a violent episode occur. She offered the following tips:

▸ Do some self-reflection. What is your history of violence and anger and your response to it? Have you been in situations where you felt threatened, and now you feel hypervigilant? Your personal history of violence “will affect your response to situations,” said Ms. Pence, who spent 25 years as a special agent with the Tennessee Bureau of Investigation. “It will impact the lens through which you view [someone's] behavior. That can be good, but it also could lead you to jump the gun and have a perception of violence and danger when it doesn't really exist.”

▸ Make an effort to understand your colleague's attitudes about personal safety and anger in the workplace. Are you allowed to talk about it? Are you encouraged to talk about it? “Is there a forum where you can ventilate about any anxieties you have about a client, or any anger you may have toward the client?” she asked. “Because if you're angry and they're angry, that's not a real healthy combination.”

Also, ask yourself, are there people in the office who can hear you if you yell for help? Is there an emergency buzzer nearby? If somebody enters the office and a buzzer goes off, do we have a plan on what to do?

▸ Think twice before visiting a patient in his or her home. Look at prior referrals. Consult with social workers or other physicians to see if the patient has a history of violent behavior. “If I have somebody who's been arrested for drugs, weapons, domestic violence, or child abuse, I'm going to think twice before going out to their turf by myself,” she said.

To protect against workplace violence and abuse, Ms. Pence recommended working on “target hardening.” Target hardening is a military term that refers to the notion that you are the person you are trying to make most safe.

“Until you recognize your personal, physical, mental, and environmental culpabilities and the possibility of victimization and do what you can realistically to reduce these, you're not a hard target,” she explained. This means:

▸ You must be aware.

▸ You must think in a different way. For example, “Don't walk down a sidewalk that has doors on one side and bushes on the other.” Also, when you approach a parking lot, don't skirt the edge of it. Rather, “walk toward the middle of the parking lot and look to the left and right.”

▸ You must act in a different way. “The way you walk, look, and carry yourself makes a difference in the degree of vulnerability that is ascribed to you by someone looking to attack,” she said. “Look confident, look aware, and be in the present.”

▸ You must recognize your personal vulnerabilities. Ask yourself, how could I defend myself in the event of a personal attack? “For example, I'm not a long distance runner,” Ms. Pence said. “I don't aspire to be a runner. That's a realistic assessment of my physical abilities. If there are areas where you have a deficit, ask, what can I do to enhance my abilities? Maybe it's learning some form of self-protection or learning verbal de-escalation techniques.”

LA JOLLA, CALIF. — When you refer a patient to a provider of complementary and alternative medicine, keep in mind five liability management strategies, David M. Eisenberg, M.D., advised at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

The strategies, which he developed in collaboration with Michael H. Cohen, J.D. (Ann. Intern. Med. 2002;136:596–603), include the following:

Determine the clinical risk level. Decide whether to:

▸ Recommend yet continue to monitor the therapy.

▸ Tolerate, provide caution, and closely monitor safety.

▸ Avoid and/or actively discourage the therapy.

Document the literature supporting the therapeutic choice.

“It's very important to put this in the chart,” said Dr. Eisenberg, an internist who directs the division for research and education in complementary and integrative medical therapies at the Osher Institute, Harvard Medical School, Boston. “By the way, that is also true when we're using a novel or experimental drug with an inpatient. This is the same approach.”

If treatment with a certain herb is recommended, “document the choice of herb, any recommendation regarding product or brand, and any discussion regarding therapeutic dose, and associated uncertainties regarding use of the herb,” he said.

He also makes it a practice to keep a backup file of articles supporting the discussion or recommendation. “You could say this is a bit too conservative, like have suspenders and a belt,” he said at the meeting, cosponsored by the University of California, San Diego. “But I think this is the best advice.”

Continue conventional monitoring. “A lot of times we recommend something or accept that a patient is going to do something, and then we don't monitor or follow up,” Dr. Eisenberg said. “Undue reliance on CAM may lead to a charge that the patient was dissuaded from necessary conventional medical care.”

He added that maintaining conventional treatment “helps demonstrate that the physician has followed the standard of care, even if CAM is included.”

Provide adequate informed consent. Describe the risks and benefits of using the CAM therapy and of delaying or deferring the conventional therapy, and spell out potential adverse interactions. That is a lot to consider, but such information would be helpful “in the eyes of the law if something went wrong,” he said. “You have to ask yourself, could I really defend this action or recommendation?”

Also, clear communication with the patient has been shown to reduce the risk of being sued for malpractice. “Inadequate informed consent is also a theory for malpractice liability in and of itself,” Dr. Eisenberg said.

Familiarize yourself with providers to whom you refer. Ask yourself, would I refer a friend to this person? “If the answer is 'I'm not sure,' then get some help in making the correct referral,” he advised.

Understand any regulations regarding the use of CAM therapies by your relevant state regulatory board.

“You have to check the regulations and scope of practice,” he said. “From a conservative legal standpoint, referring to somebody who does not own a license to treat a patient is risky business. Don't do it.”

He pointed out that, in general, a physician is not liable merely for making a referral to a specialist. But he cited three exceptions to the general rule:

▸ The referral led to delay or deferral of necessary medical treatment. “Do your day job first,” he said.

▸ The referring provider knew or should have known that the referred-to provider was incompetent.

▸ The referred-to provider is considered to be the physician's agent, either because state law requires supervision or an extended form of consultation, or there is a “joint treatment” agreement between the physician and the CAM provider.

Dr. Eisenberg also discussed the notion of a “legal catch-22” when referring a patient for CAM.

For example, if a physician seeks a distant, independent contractor type of relationship with a CAM provider, “there is probably less shared liability risk, but there is probably more risk of harm to the patient because you're referring to a stranger,” he noted. “Conversely, there is higher risk of shared liability if you refer to CAM providers you know or have an ongoing professional relationship with, but there's probably less chance of harm [to the patient] because you're involved.”

LA JOLLA, CALIF. — When you refer a patient to a provider of complementary and alternative medicine, keep in mind five liability management strategies, David M. Eisenberg, M.D., advised at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

The strategies, which he developed in collaboration with Michael H. Cohen, J.D. (Ann. Intern. Med. 2002;136:596–603), include the following:

Determine the clinical risk level. Decide whether to:

▸ Recommend yet continue to monitor the therapy.

▸ Tolerate, provide caution, and closely monitor safety.

▸ Avoid and/or actively discourage the therapy.

Document the literature supporting the therapeutic choice.

“It's very important to put this in the chart,” said Dr. Eisenberg, an internist who directs the division for research and education in complementary and integrative medical therapies at the Osher Institute, Harvard Medical School, Boston. “By the way, that is also true when we're using a novel or experimental drug with an inpatient. This is the same approach.”

If treatment with a certain herb is recommended, “document the choice of herb, any recommendation regarding product or brand, and any discussion regarding therapeutic dose, and associated uncertainties regarding use of the herb,” he said.

He also makes it a practice to keep a backup file of articles supporting the discussion or recommendation. “You could say this is a bit too conservative, like have suspenders and a belt,” he said at the meeting, cosponsored by the University of California, San Diego. “But I think this is the best advice.”

Continue conventional monitoring. “A lot of times we recommend something or accept that a patient is going to do something, and then we don't monitor or follow up,” Dr. Eisenberg said. “Undue reliance on CAM may lead to a charge that the patient was dissuaded from necessary conventional medical care.”

He added that maintaining conventional treatment “helps demonstrate that the physician has followed the standard of care, even if CAM is included.”

Provide adequate informed consent. Describe the risks and benefits of using the CAM therapy and of delaying or deferring the conventional therapy, and spell out potential adverse interactions. That is a lot to consider, but such information would be helpful “in the eyes of the law if something went wrong,” he said. “You have to ask yourself, could I really defend this action or recommendation?”

Also, clear communication with the patient has been shown to reduce the risk of being sued for malpractice. “Inadequate informed consent is also a theory for malpractice liability in and of itself,” Dr. Eisenberg said.

Familiarize yourself with providers to whom you refer. Ask yourself, would I refer a friend to this person? “If the answer is 'I'm not sure,' then get some help in making the correct referral,” he advised.

Understand any regulations regarding the use of CAM therapies by your relevant state regulatory board.

“You have to check the regulations and scope of practice,” he said. “From a conservative legal standpoint, referring to somebody who does not own a license to treat a patient is risky business. Don't do it.”

He pointed out that, in general, a physician is not liable merely for making a referral to a specialist. But he cited three exceptions to the general rule:

▸ The referral led to delay or deferral of necessary medical treatment. “Do your day job first,” he said.

▸ The referring provider knew or should have known that the referred-to provider was incompetent.

▸ The referred-to provider is considered to be the physician's agent, either because state law requires supervision or an extended form of consultation, or there is a “joint treatment” agreement between the physician and the CAM provider.

Dr. Eisenberg also discussed the notion of a “legal catch-22” when referring a patient for CAM.

For example, if a physician seeks a distant, independent contractor type of relationship with a CAM provider, “there is probably less shared liability risk, but there is probably more risk of harm to the patient because you're referring to a stranger,” he noted. “Conversely, there is higher risk of shared liability if you refer to CAM providers you know or have an ongoing professional relationship with, but there's probably less chance of harm [to the patient] because you're involved.”

LA JOLLA, CALIF. — When you refer a patient to a provider of complementary and alternative medicine, keep in mind five liability management strategies, David M. Eisenberg, M.D., advised at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

The strategies, which he developed in collaboration with Michael H. Cohen, J.D. (Ann. Intern. Med. 2002;136:596–603), include the following:

Determine the clinical risk level. Decide whether to:

▸ Recommend yet continue to monitor the therapy.

▸ Tolerate, provide caution, and closely monitor safety.

▸ Avoid and/or actively discourage the therapy.

Document the literature supporting the therapeutic choice.

“It's very important to put this in the chart,” said Dr. Eisenberg, an internist who directs the division for research and education in complementary and integrative medical therapies at the Osher Institute, Harvard Medical School, Boston. “By the way, that is also true when we're using a novel or experimental drug with an inpatient. This is the same approach.”

If treatment with a certain herb is recommended, “document the choice of herb, any recommendation regarding product or brand, and any discussion regarding therapeutic dose, and associated uncertainties regarding use of the herb,” he said.

He also makes it a practice to keep a backup file of articles supporting the discussion or recommendation. “You could say this is a bit too conservative, like have suspenders and a belt,” he said at the meeting, cosponsored by the University of California, San Diego. “But I think this is the best advice.”

Continue conventional monitoring. “A lot of times we recommend something or accept that a patient is going to do something, and then we don't monitor or follow up,” Dr. Eisenberg said. “Undue reliance on CAM may lead to a charge that the patient was dissuaded from necessary conventional medical care.”

He added that maintaining conventional treatment “helps demonstrate that the physician has followed the standard of care, even if CAM is included.”

Provide adequate informed consent. Describe the risks and benefits of using the CAM therapy and of delaying or deferring the conventional therapy, and spell out potential adverse interactions. That is a lot to consider, but such information would be helpful “in the eyes of the law if something went wrong,” he said. “You have to ask yourself, could I really defend this action or recommendation?”

Also, clear communication with the patient has been shown to reduce the risk of being sued for malpractice. “Inadequate informed consent is also a theory for malpractice liability in and of itself,” Dr. Eisenberg said.

Familiarize yourself with providers to whom you refer. Ask yourself, would I refer a friend to this person? “If the answer is 'I'm not sure,' then get some help in making the correct referral,” he advised.

Understand any regulations regarding the use of CAM therapies by your relevant state regulatory board.

“You have to check the regulations and scope of practice,” he said. “From a conservative legal standpoint, referring to somebody who does not own a license to treat a patient is risky business. Don't do it.”

He pointed out that, in general, a physician is not liable merely for making a referral to a specialist. But he cited three exceptions to the general rule:

▸ The referral led to delay or deferral of necessary medical treatment. “Do your day job first,” he said.

▸ The referring provider knew or should have known that the referred-to provider was incompetent.

▸ The referred-to provider is considered to be the physician's agent, either because state law requires supervision or an extended form of consultation, or there is a “joint treatment” agreement between the physician and the CAM provider.

Dr. Eisenberg also discussed the notion of a “legal catch-22” when referring a patient for CAM.

For example, if a physician seeks a distant, independent contractor type of relationship with a CAM provider, “there is probably less shared liability risk, but there is probably more risk of harm to the patient because you're referring to a stranger,” he noted. “Conversely, there is higher risk of shared liability if you refer to CAM providers you know or have an ongoing professional relationship with, but there's probably less chance of harm [to the patient] because you're involved.”