Jeff Evans

WASHINGTON — Short-term use of a percutaneous ventricular assist device during high-risk surgery or in cases of near-death heart failure can help support patients long enough for them to recover or receive additional treatment, Reynolds M. Delgado III, M.D., said at the annual conference of the American Society for Artificial Internal Organs.

Dr. Delgado and his colleagues at the Texas Heart Institute have used the TandemHeart in four different scenarios as:

▸ A supportive device during high-risk percutaneous transluminal coronary angioplasty in nine patients.

▸ A bridge to recovery in two patients with acute cardiogenic shock.

▸ Circulatory support in five patients during high-risk cardiac surgery (coronary artery bypass and/or mitral valve surgery).

▸ A bridge to an implanted left ventricular assist device (LVAD) in seven patients.

Blood flow in the TandemHeart, made by CardiacAssist Inc., follows a path from a cannula in the femoral vein that pierces the intraatrial septum and takes oxygenated blood from the left atrium back to a continuously flowing extracorporeal pump (attached to the patient's leg), which distributes the blood through a cannula in one or both femoral arteries.

“The tricky part of this procedure is the transseptal cannulation; putting this venous catheter across the septum requires some special skill. A subset of cardiologists are able to do this—perhaps 10% or less,” said Dr. Delgado, medical director of mechanical assist devices in heart failure at the institute, located at St. Luke's Episcopal Hospital, Houston.

None of the high-risk percutaneous transluminal coronary angioplasty patients were candidates for surgery. They had high-risk coronary anatomy and were at risk for imminent death without intervention. The investigators successfully performed the procedure without complications in eight of these nine patients; one patient had a perforated left atrium. Overall, eight patients were discharged from the hospital with good long-term outcomes while one patient died of multiorgan failure after surgery, said Dr. Delgado, a cardiologist. Dr. Delgado reported that he was an investigator on a previous trial sponsored by CardiacAssist but has no financial conflicts of interest with the company.

Both cardiogenic shock patients successfully underwent the implantation procedure. After 7 days, one patient successfully recovered from heart failure due to acute myocarditis. The other patient initially suffered an acute MI and then cardiac arrest just prior to implantation of the TandemHeart; the patient died despite successful implantation.

Of five patients who underwent high-risk cardiac surgery, all had successful implantation, but one patient with coagulopathy and multiorgan failure died of major intraoperative bleeding.

Seven patients were successfully bridged from the TandemHeart to an LVAD. However, four of these patients did not survive long term with an LVAD, primarily because of multiorgan failure that existed prior to the implantation of the TandemHeart.

On average, the 23 patients in the study were aged 68 years and were on percutaneous ventricular assist device support for 2.8 days; 20 patients were male.

WASHINGTON — Short-term use of a percutaneous ventricular assist device during high-risk surgery or in cases of near-death heart failure can help support patients long enough for them to recover or receive additional treatment, Reynolds M. Delgado III, M.D., said at the annual conference of the American Society for Artificial Internal Organs.

Dr. Delgado and his colleagues at the Texas Heart Institute have used the TandemHeart in four different scenarios as:

▸ A supportive device during high-risk percutaneous transluminal coronary angioplasty in nine patients.

▸ A bridge to recovery in two patients with acute cardiogenic shock.

▸ Circulatory support in five patients during high-risk cardiac surgery (coronary artery bypass and/or mitral valve surgery).

▸ A bridge to an implanted left ventricular assist device (LVAD) in seven patients.

Blood flow in the TandemHeart, made by CardiacAssist Inc., follows a path from a cannula in the femoral vein that pierces the intraatrial septum and takes oxygenated blood from the left atrium back to a continuously flowing extracorporeal pump (attached to the patient's leg), which distributes the blood through a cannula in one or both femoral arteries.

“The tricky part of this procedure is the transseptal cannulation; putting this venous catheter across the septum requires some special skill. A subset of cardiologists are able to do this—perhaps 10% or less,” said Dr. Delgado, medical director of mechanical assist devices in heart failure at the institute, located at St. Luke's Episcopal Hospital, Houston.

None of the high-risk percutaneous transluminal coronary angioplasty patients were candidates for surgery. They had high-risk coronary anatomy and were at risk for imminent death without intervention. The investigators successfully performed the procedure without complications in eight of these nine patients; one patient had a perforated left atrium. Overall, eight patients were discharged from the hospital with good long-term outcomes while one patient died of multiorgan failure after surgery, said Dr. Delgado, a cardiologist. Dr. Delgado reported that he was an investigator on a previous trial sponsored by CardiacAssist but has no financial conflicts of interest with the company.

Both cardiogenic shock patients successfully underwent the implantation procedure. After 7 days, one patient successfully recovered from heart failure due to acute myocarditis. The other patient initially suffered an acute MI and then cardiac arrest just prior to implantation of the TandemHeart; the patient died despite successful implantation.

Of five patients who underwent high-risk cardiac surgery, all had successful implantation, but one patient with coagulopathy and multiorgan failure died of major intraoperative bleeding.

Seven patients were successfully bridged from the TandemHeart to an LVAD. However, four of these patients did not survive long term with an LVAD, primarily because of multiorgan failure that existed prior to the implantation of the TandemHeart.

On average, the 23 patients in the study were aged 68 years and were on percutaneous ventricular assist device support for 2.8 days; 20 patients were male.

WASHINGTON — Short-term use of a percutaneous ventricular assist device during high-risk surgery or in cases of near-death heart failure can help support patients long enough for them to recover or receive additional treatment, Reynolds M. Delgado III, M.D., said at the annual conference of the American Society for Artificial Internal Organs.

Dr. Delgado and his colleagues at the Texas Heart Institute have used the TandemHeart in four different scenarios as:

▸ A supportive device during high-risk percutaneous transluminal coronary angioplasty in nine patients.

▸ A bridge to recovery in two patients with acute cardiogenic shock.

▸ Circulatory support in five patients during high-risk cardiac surgery (coronary artery bypass and/or mitral valve surgery).

▸ A bridge to an implanted left ventricular assist device (LVAD) in seven patients.

Blood flow in the TandemHeart, made by CardiacAssist Inc., follows a path from a cannula in the femoral vein that pierces the intraatrial septum and takes oxygenated blood from the left atrium back to a continuously flowing extracorporeal pump (attached to the patient's leg), which distributes the blood through a cannula in one or both femoral arteries.

“The tricky part of this procedure is the transseptal cannulation; putting this venous catheter across the septum requires some special skill. A subset of cardiologists are able to do this—perhaps 10% or less,” said Dr. Delgado, medical director of mechanical assist devices in heart failure at the institute, located at St. Luke's Episcopal Hospital, Houston.

None of the high-risk percutaneous transluminal coronary angioplasty patients were candidates for surgery. They had high-risk coronary anatomy and were at risk for imminent death without intervention. The investigators successfully performed the procedure without complications in eight of these nine patients; one patient had a perforated left atrium. Overall, eight patients were discharged from the hospital with good long-term outcomes while one patient died of multiorgan failure after surgery, said Dr. Delgado, a cardiologist. Dr. Delgado reported that he was an investigator on a previous trial sponsored by CardiacAssist but has no financial conflicts of interest with the company.

Both cardiogenic shock patients successfully underwent the implantation procedure. After 7 days, one patient successfully recovered from heart failure due to acute myocarditis. The other patient initially suffered an acute MI and then cardiac arrest just prior to implantation of the TandemHeart; the patient died despite successful implantation.

Of five patients who underwent high-risk cardiac surgery, all had successful implantation, but one patient with coagulopathy and multiorgan failure died of major intraoperative bleeding.

Seven patients were successfully bridged from the TandemHeart to an LVAD. However, four of these patients did not survive long term with an LVAD, primarily because of multiorgan failure that existed prior to the implantation of the TandemHeart.

On average, the 23 patients in the study were aged 68 years and were on percutaneous ventricular assist device support for 2.8 days; 20 patients were male.

NEW YORK — Observation units may be an answer that overcrowded emergency departments seek to reduce ambulance diversion, Robbin S. Dick, M.D., said at the annual meeting of the Society for Academic Emergency Medicine.

“Ambulance diversion has become a crisis in many cities in the United States. Sometimes every hospital is on divert at the same time, with ambulances driving around looking for a place to deliver the patient,” said Dr. Dick of the department of emergency medicine at the University of Rochester (N.Y.).

“I think [the observation unit] is going to be the solution for emergency departments that are high in volume” and have high admission and inpatient occupancy rates, he predicted.

While observation units show promise, some experts cautioned that true solutions must reach beyond the ED to reform the hospital systems and practices that ultimately fuel overcrowding.

A Diverting Solution

In hospitals with an inpatient occupancy rate of 90%, observation units may provide breathing room for seasonal and monthly fluxes in EDs that see patient volumes of 50,000–70,000 or more per year and have admission rates of 20% or higher, Dr. Dick told this newspaper.

Ambulances can be diverted for a variety of reasons: ED overcrowding, large numbers of patients presenting to an ED, staff shortages (mostly nurses), closure of other EDs, and ED boarding patients—those who remain in the ED waiting for an inpatient bed to open up.

In the last 7 years, Rochester experienced the closure of two emergency departments, each of which had a patient volume of about 30,000 per year, he said.

Strong Memorial Hospital, a teaching institution in Rochester where Dr. Dick practices, had almost 4,000 hours of ED overcrowding in 2003, which averages out to more than 300 hours per month. “Rochester is a poster child for ED overcrowding,” Dr. Dick quipped.

Rochester follows a community-wide standard in which an ambulance can be diverted if three out of four criteria are met: No inpatient beds are available, no ICU beds are available, a 4-hour or longer wait exists for treat-and-release patients, and more than 40% of the beds in the ED are occupied by inpatients.

In January 2004, Strong Memorial opened a 24-bed observation unit for ED patients. The new unit accepted patients who are commonly observed as a part of treatment, such as those with chest pain, heart failure, asthma, or kidney stones. Stable ED boarding patients who were awaiting an inpatient bed and ED patients who required consultation or extended testing also went to the observation unit.

During 2004, more than 6,800 patients came through the unit; 90% of the patients required observation of their condition, 5% were ED boarding patients, and 5% required additional consultation or testing.

The unit averaged 95% occupancy and admitted a mean of 19 patients per day to the inpatient floor—a 12% rate of admission overall.

In a prospective study, Dr. Dick and his colleagues found that the observation unit significantly reduced the number of ambulance diversion hours from 3,447 in 2003 (40% of the time) to 1,585 in 2004 (18% of the time). This decline occurred despite increases in both ED patient volume (from 87,101 in 2003 to 88,962 in 2004) and ambulance arrivals (from 25,774 in 2003 to 29,441 in 2004). The ED admitted about 800 more patients in 2004 than in 2003.

Dr. Dick said he chose ambulance diversion time as the primary end point rather than ED boarding time because diversion time is the one indicator that stands out regardless of the primary cause of overcrowding, such as a decrease in nursing staff or bed availability in the hospital.

Diversionary hours will increase along with the primary cause of overcrowding even when other factors remain the same.

The study's results could be limited, Dr. Dick acknowledged, if the decrease in ambulance diversion hours was due to unrecognized changes in community factors. But “we don't know of anything specifically that changed during 2004,” he added.

Building Buy-In

To establish the unit at Strong Memorial, Dr. Dick had to create new protocols to drive the unit and change the mindset of practitioners, especially nurses, to be comfortable with the fact that the unit's occupancy will turn over every 24 hours.

The availability of the observation unit has not led physicians to keep ED patients longer or admit them to the unit rather than immediately as an inpatient, Dr. Dick said.

In the Strong Memorial ED, an emergency physician decides whether a patient can or cannot go home after an evaluation. A utilization review nurse decides if the patient satisfies InterQual criteria for admission to an inpatient floor bed or if the patient can be sent to the observation unit.

In the first year and a half of the unit's operation, Dr. Dick and another emergency physician devoted all their practice to the observation unit, which had a nursing staff separate from the rest of the hospital.

Residents were slated in June 2005 to begin rotations for the first time through the observation unit.

The ED has plans to increase the observation unit to 36 beds or possibly even 48 beds in the near future, he said.

Observation Units: Silver Bullet?

A 10-bed observation unit that has operated for about 9 years in the ED at Brigham and Women's Hospital, Boston, has also had a dramatic effect on the flow of care through the department, said Richard Zane, M.D., vice chair of emergency medicine at Brigham and Women's.

The unit has allowed for not only more “timely and appropriate work-ups in the ED, but also the ability to offload lower-acuity patients from inpatient services. This frees up inpatient capacity for higher-acuity patients,” Dr. Zane said.

“We've been successful in prescreening patients who will not require inpatient work-up after the observation unit. We very much try to avoid having [the observation unit] used as a holding unit until patients get a bed,” he added.

While observation units are potentially beneficial in increasing patient care capacity, “I would view them, not infrequently, as an incomplete solution,” cautioned Randall B. Case, M.D., an emergency physician and a vice president at Siemens Medical Solutions' Healthcare Services Corporation.

“There are other systemic issues within the [hospital] that often are the root-cause issues behind emergency department crowding,” said Dr. Case, who recently chaired ACEP's Emergency Medicine Practice Committee. Last year, the Committee studied the various causes of ED crowding and concluded that “the most common root cause for ED crowding is delayed inpatient cycle time.”

In many cases, “the real reason the ED gets crowded is that the inpatient units manifest some inefficiency, or delay, in discharging their patients,” Dr. Case said. Until those patients' beds are freed up, there is no place for the admitted ED patients to go.

“If this is the case on a regular basis at your institution, then it might be more effective to address the systemic inefficiency directly, rather than relying on observation beds as an inpatient capacity buffer,” Dr. Case explained.

“It's thought in the literature that every observation bed provides you the equivalent of about 2.5 inpatient beds, only because you're pushing patients through the system in an active manner,” Dr. Dick explained.

“I don't think that adding 24 beds in the ED—where you haven't really fixed the boarder problem or the movement of patients through the system per se—would have as big of an impact as an active ongoing observation unit that has a physician on site,” he said.

Even if observation units are just one of the many solutions to ED overcrowding, they are rapidly becoming the standard, Dr. Zane said. The vast number of new emergency departments that are being built or renovated are including observation units, he added.

NEW YORK — Observation units may be an answer that overcrowded emergency departments seek to reduce ambulance diversion, Robbin S. Dick, M.D., said at the annual meeting of the Society for Academic Emergency Medicine.

“Ambulance diversion has become a crisis in many cities in the United States. Sometimes every hospital is on divert at the same time, with ambulances driving around looking for a place to deliver the patient,” said Dr. Dick of the department of emergency medicine at the University of Rochester (N.Y.).

“I think [the observation unit] is going to be the solution for emergency departments that are high in volume” and have high admission and inpatient occupancy rates, he predicted.

While observation units show promise, some experts cautioned that true solutions must reach beyond the ED to reform the hospital systems and practices that ultimately fuel overcrowding.

A Diverting Solution

In hospitals with an inpatient occupancy rate of 90%, observation units may provide breathing room for seasonal and monthly fluxes in EDs that see patient volumes of 50,000–70,000 or more per year and have admission rates of 20% or higher, Dr. Dick told this newspaper.

Ambulances can be diverted for a variety of reasons: ED overcrowding, large numbers of patients presenting to an ED, staff shortages (mostly nurses), closure of other EDs, and ED boarding patients—those who remain in the ED waiting for an inpatient bed to open up.

In the last 7 years, Rochester experienced the closure of two emergency departments, each of which had a patient volume of about 30,000 per year, he said.

Strong Memorial Hospital, a teaching institution in Rochester where Dr. Dick practices, had almost 4,000 hours of ED overcrowding in 2003, which averages out to more than 300 hours per month. “Rochester is a poster child for ED overcrowding,” Dr. Dick quipped.

Rochester follows a community-wide standard in which an ambulance can be diverted if three out of four criteria are met: No inpatient beds are available, no ICU beds are available, a 4-hour or longer wait exists for treat-and-release patients, and more than 40% of the beds in the ED are occupied by inpatients.

In January 2004, Strong Memorial opened a 24-bed observation unit for ED patients. The new unit accepted patients who are commonly observed as a part of treatment, such as those with chest pain, heart failure, asthma, or kidney stones. Stable ED boarding patients who were awaiting an inpatient bed and ED patients who required consultation or extended testing also went to the observation unit.

During 2004, more than 6,800 patients came through the unit; 90% of the patients required observation of their condition, 5% were ED boarding patients, and 5% required additional consultation or testing.

The unit averaged 95% occupancy and admitted a mean of 19 patients per day to the inpatient floor—a 12% rate of admission overall.

In a prospective study, Dr. Dick and his colleagues found that the observation unit significantly reduced the number of ambulance diversion hours from 3,447 in 2003 (40% of the time) to 1,585 in 2004 (18% of the time). This decline occurred despite increases in both ED patient volume (from 87,101 in 2003 to 88,962 in 2004) and ambulance arrivals (from 25,774 in 2003 to 29,441 in 2004). The ED admitted about 800 more patients in 2004 than in 2003.

Dr. Dick said he chose ambulance diversion time as the primary end point rather than ED boarding time because diversion time is the one indicator that stands out regardless of the primary cause of overcrowding, such as a decrease in nursing staff or bed availability in the hospital.

Diversionary hours will increase along with the primary cause of overcrowding even when other factors remain the same.

The study's results could be limited, Dr. Dick acknowledged, if the decrease in ambulance diversion hours was due to unrecognized changes in community factors. But “we don't know of anything specifically that changed during 2004,” he added.

Building Buy-In

To establish the unit at Strong Memorial, Dr. Dick had to create new protocols to drive the unit and change the mindset of practitioners, especially nurses, to be comfortable with the fact that the unit's occupancy will turn over every 24 hours.

The availability of the observation unit has not led physicians to keep ED patients longer or admit them to the unit rather than immediately as an inpatient, Dr. Dick said.

In the Strong Memorial ED, an emergency physician decides whether a patient can or cannot go home after an evaluation. A utilization review nurse decides if the patient satisfies InterQual criteria for admission to an inpatient floor bed or if the patient can be sent to the observation unit.

In the first year and a half of the unit's operation, Dr. Dick and another emergency physician devoted all their practice to the observation unit, which had a nursing staff separate from the rest of the hospital.

Residents were slated in June 2005 to begin rotations for the first time through the observation unit.

The ED has plans to increase the observation unit to 36 beds or possibly even 48 beds in the near future, he said.

Observation Units: Silver Bullet?

A 10-bed observation unit that has operated for about 9 years in the ED at Brigham and Women's Hospital, Boston, has also had a dramatic effect on the flow of care through the department, said Richard Zane, M.D., vice chair of emergency medicine at Brigham and Women's.

The unit has allowed for not only more “timely and appropriate work-ups in the ED, but also the ability to offload lower-acuity patients from inpatient services. This frees up inpatient capacity for higher-acuity patients,” Dr. Zane said.

“We've been successful in prescreening patients who will not require inpatient work-up after the observation unit. We very much try to avoid having [the observation unit] used as a holding unit until patients get a bed,” he added.

While observation units are potentially beneficial in increasing patient care capacity, “I would view them, not infrequently, as an incomplete solution,” cautioned Randall B. Case, M.D., an emergency physician and a vice president at Siemens Medical Solutions' Healthcare Services Corporation.

“There are other systemic issues within the [hospital] that often are the root-cause issues behind emergency department crowding,” said Dr. Case, who recently chaired ACEP's Emergency Medicine Practice Committee. Last year, the Committee studied the various causes of ED crowding and concluded that “the most common root cause for ED crowding is delayed inpatient cycle time.”

In many cases, “the real reason the ED gets crowded is that the inpatient units manifest some inefficiency, or delay, in discharging their patients,” Dr. Case said. Until those patients' beds are freed up, there is no place for the admitted ED patients to go.

“If this is the case on a regular basis at your institution, then it might be more effective to address the systemic inefficiency directly, rather than relying on observation beds as an inpatient capacity buffer,” Dr. Case explained.

“It's thought in the literature that every observation bed provides you the equivalent of about 2.5 inpatient beds, only because you're pushing patients through the system in an active manner,” Dr. Dick explained.

“I don't think that adding 24 beds in the ED—where you haven't really fixed the boarder problem or the movement of patients through the system per se—would have as big of an impact as an active ongoing observation unit that has a physician on site,” he said.

Even if observation units are just one of the many solutions to ED overcrowding, they are rapidly becoming the standard, Dr. Zane said. The vast number of new emergency departments that are being built or renovated are including observation units, he added.

NEW YORK — Observation units may be an answer that overcrowded emergency departments seek to reduce ambulance diversion, Robbin S. Dick, M.D., said at the annual meeting of the Society for Academic Emergency Medicine.

“Ambulance diversion has become a crisis in many cities in the United States. Sometimes every hospital is on divert at the same time, with ambulances driving around looking for a place to deliver the patient,” said Dr. Dick of the department of emergency medicine at the University of Rochester (N.Y.).

“I think [the observation unit] is going to be the solution for emergency departments that are high in volume” and have high admission and inpatient occupancy rates, he predicted.

While observation units show promise, some experts cautioned that true solutions must reach beyond the ED to reform the hospital systems and practices that ultimately fuel overcrowding.

A Diverting Solution

In hospitals with an inpatient occupancy rate of 90%, observation units may provide breathing room for seasonal and monthly fluxes in EDs that see patient volumes of 50,000–70,000 or more per year and have admission rates of 20% or higher, Dr. Dick told this newspaper.

Ambulances can be diverted for a variety of reasons: ED overcrowding, large numbers of patients presenting to an ED, staff shortages (mostly nurses), closure of other EDs, and ED boarding patients—those who remain in the ED waiting for an inpatient bed to open up.

In the last 7 years, Rochester experienced the closure of two emergency departments, each of which had a patient volume of about 30,000 per year, he said.

Strong Memorial Hospital, a teaching institution in Rochester where Dr. Dick practices, had almost 4,000 hours of ED overcrowding in 2003, which averages out to more than 300 hours per month. “Rochester is a poster child for ED overcrowding,” Dr. Dick quipped.

Rochester follows a community-wide standard in which an ambulance can be diverted if three out of four criteria are met: No inpatient beds are available, no ICU beds are available, a 4-hour or longer wait exists for treat-and-release patients, and more than 40% of the beds in the ED are occupied by inpatients.

In January 2004, Strong Memorial opened a 24-bed observation unit for ED patients. The new unit accepted patients who are commonly observed as a part of treatment, such as those with chest pain, heart failure, asthma, or kidney stones. Stable ED boarding patients who were awaiting an inpatient bed and ED patients who required consultation or extended testing also went to the observation unit.

During 2004, more than 6,800 patients came through the unit; 90% of the patients required observation of their condition, 5% were ED boarding patients, and 5% required additional consultation or testing.

The unit averaged 95% occupancy and admitted a mean of 19 patients per day to the inpatient floor—a 12% rate of admission overall.

In a prospective study, Dr. Dick and his colleagues found that the observation unit significantly reduced the number of ambulance diversion hours from 3,447 in 2003 (40% of the time) to 1,585 in 2004 (18% of the time). This decline occurred despite increases in both ED patient volume (from 87,101 in 2003 to 88,962 in 2004) and ambulance arrivals (from 25,774 in 2003 to 29,441 in 2004). The ED admitted about 800 more patients in 2004 than in 2003.

Dr. Dick said he chose ambulance diversion time as the primary end point rather than ED boarding time because diversion time is the one indicator that stands out regardless of the primary cause of overcrowding, such as a decrease in nursing staff or bed availability in the hospital.

Diversionary hours will increase along with the primary cause of overcrowding even when other factors remain the same.

The study's results could be limited, Dr. Dick acknowledged, if the decrease in ambulance diversion hours was due to unrecognized changes in community factors. But “we don't know of anything specifically that changed during 2004,” he added.

Building Buy-In

To establish the unit at Strong Memorial, Dr. Dick had to create new protocols to drive the unit and change the mindset of practitioners, especially nurses, to be comfortable with the fact that the unit's occupancy will turn over every 24 hours.

The availability of the observation unit has not led physicians to keep ED patients longer or admit them to the unit rather than immediately as an inpatient, Dr. Dick said.

In the Strong Memorial ED, an emergency physician decides whether a patient can or cannot go home after an evaluation. A utilization review nurse decides if the patient satisfies InterQual criteria for admission to an inpatient floor bed or if the patient can be sent to the observation unit.

In the first year and a half of the unit's operation, Dr. Dick and another emergency physician devoted all their practice to the observation unit, which had a nursing staff separate from the rest of the hospital.

Residents were slated in June 2005 to begin rotations for the first time through the observation unit.

The ED has plans to increase the observation unit to 36 beds or possibly even 48 beds in the near future, he said.

Observation Units: Silver Bullet?

A 10-bed observation unit that has operated for about 9 years in the ED at Brigham and Women's Hospital, Boston, has also had a dramatic effect on the flow of care through the department, said Richard Zane, M.D., vice chair of emergency medicine at Brigham and Women's.

The unit has allowed for not only more “timely and appropriate work-ups in the ED, but also the ability to offload lower-acuity patients from inpatient services. This frees up inpatient capacity for higher-acuity patients,” Dr. Zane said.

“We've been successful in prescreening patients who will not require inpatient work-up after the observation unit. We very much try to avoid having [the observation unit] used as a holding unit until patients get a bed,” he added.

While observation units are potentially beneficial in increasing patient care capacity, “I would view them, not infrequently, as an incomplete solution,” cautioned Randall B. Case, M.D., an emergency physician and a vice president at Siemens Medical Solutions' Healthcare Services Corporation.

“There are other systemic issues within the [hospital] that often are the root-cause issues behind emergency department crowding,” said Dr. Case, who recently chaired ACEP's Emergency Medicine Practice Committee. Last year, the Committee studied the various causes of ED crowding and concluded that “the most common root cause for ED crowding is delayed inpatient cycle time.”

In many cases, “the real reason the ED gets crowded is that the inpatient units manifest some inefficiency, or delay, in discharging their patients,” Dr. Case said. Until those patients' beds are freed up, there is no place for the admitted ED patients to go.

“If this is the case on a regular basis at your institution, then it might be more effective to address the systemic inefficiency directly, rather than relying on observation beds as an inpatient capacity buffer,” Dr. Case explained.

“It's thought in the literature that every observation bed provides you the equivalent of about 2.5 inpatient beds, only because you're pushing patients through the system in an active manner,” Dr. Dick explained.

“I don't think that adding 24 beds in the ED—where you haven't really fixed the boarder problem or the movement of patients through the system per se—would have as big of an impact as an active ongoing observation unit that has a physician on site,” he said.

Even if observation units are just one of the many solutions to ED overcrowding, they are rapidly becoming the standard, Dr. Zane said. The vast number of new emergency departments that are being built or renovated are including observation units, he added.

Human metapneumovirus may be underreported as a pathogen in bronchiolitis and may lead to admittance to intensive care, especially when it infects infants in combination with human respiratory syncytial virus, reported Malcolm G. Semple, M.D., of the University of Liverpool (England), and his associates.

During the 2001–2002 winter season at one hospital, dual infection human metapneumovirus (hMPV) and human respiratory syncytial virus (hRSV) occurred at a significantly higher rate in infants with bronchiolitis who were admitted to the pediatric intensive care unit on mechanical ventilation (72%, 18 of 25) than in infants with bronchiolitis who were sent to the general wards (10%, 15 of 171). The investigators said that the temporal distribution of hMPV infections in infants in the pediatric ICU made it unlikely that the infections were nosocomial. In a subset of infants with complete clinical information, dual infection with hMPV and hRSV was not statistically significantly associated with disease severity in the retrospective study (J. Infect. Dis. 2005;191:382–6).

In nasopharyngeal aspirate and bronchoalveolar lavage samples that were taken at the same time from nine hMPV-infected infants on mechanical ventilation, hMPV was detected in only one nasopharyngeal aspirate and in all nine bronchoalveolar lavages. Of 18 infants who had mechanical ventilation, hMPV infection was found in bronchoalveolar lavages from 15 infants and in nasopharyngeal aspirates from 4 infants.

The discordance in the incidence of hMPV infection detected in bronchoalveolar lavages and nasopharyngeal aspirates raises the possibility that “hMPV infection during endemic seasons may be more common than is currently recognized and that it has been undetected because sampling from the lower respiratory tract is not possible on infants who do not require mechanical ventilation,” Dr. Semple wrote.

Human metapneumovirus may be underreported as a pathogen in bronchiolitis and may lead to admittance to intensive care, especially when it infects infants in combination with human respiratory syncytial virus, reported Malcolm G. Semple, M.D., of the University of Liverpool (England), and his associates.

During the 2001–2002 winter season at one hospital, dual infection human metapneumovirus (hMPV) and human respiratory syncytial virus (hRSV) occurred at a significantly higher rate in infants with bronchiolitis who were admitted to the pediatric intensive care unit on mechanical ventilation (72%, 18 of 25) than in infants with bronchiolitis who were sent to the general wards (10%, 15 of 171). The investigators said that the temporal distribution of hMPV infections in infants in the pediatric ICU made it unlikely that the infections were nosocomial. In a subset of infants with complete clinical information, dual infection with hMPV and hRSV was not statistically significantly associated with disease severity in the retrospective study (J. Infect. Dis. 2005;191:382–6).

In nasopharyngeal aspirate and bronchoalveolar lavage samples that were taken at the same time from nine hMPV-infected infants on mechanical ventilation, hMPV was detected in only one nasopharyngeal aspirate and in all nine bronchoalveolar lavages. Of 18 infants who had mechanical ventilation, hMPV infection was found in bronchoalveolar lavages from 15 infants and in nasopharyngeal aspirates from 4 infants.

The discordance in the incidence of hMPV infection detected in bronchoalveolar lavages and nasopharyngeal aspirates raises the possibility that “hMPV infection during endemic seasons may be more common than is currently recognized and that it has been undetected because sampling from the lower respiratory tract is not possible on infants who do not require mechanical ventilation,” Dr. Semple wrote.

Human metapneumovirus may be underreported as a pathogen in bronchiolitis and may lead to admittance to intensive care, especially when it infects infants in combination with human respiratory syncytial virus, reported Malcolm G. Semple, M.D., of the University of Liverpool (England), and his associates.

During the 2001–2002 winter season at one hospital, dual infection human metapneumovirus (hMPV) and human respiratory syncytial virus (hRSV) occurred at a significantly higher rate in infants with bronchiolitis who were admitted to the pediatric intensive care unit on mechanical ventilation (72%, 18 of 25) than in infants with bronchiolitis who were sent to the general wards (10%, 15 of 171). The investigators said that the temporal distribution of hMPV infections in infants in the pediatric ICU made it unlikely that the infections were nosocomial. In a subset of infants with complete clinical information, dual infection with hMPV and hRSV was not statistically significantly associated with disease severity in the retrospective study (J. Infect. Dis. 2005;191:382–6).

In nasopharyngeal aspirate and bronchoalveolar lavage samples that were taken at the same time from nine hMPV-infected infants on mechanical ventilation, hMPV was detected in only one nasopharyngeal aspirate and in all nine bronchoalveolar lavages. Of 18 infants who had mechanical ventilation, hMPV infection was found in bronchoalveolar lavages from 15 infants and in nasopharyngeal aspirates from 4 infants.

The discordance in the incidence of hMPV infection detected in bronchoalveolar lavages and nasopharyngeal aspirates raises the possibility that “hMPV infection during endemic seasons may be more common than is currently recognized and that it has been undetected because sampling from the lower respiratory tract is not possible on infants who do not require mechanical ventilation,” Dr. Semple wrote.

Shorter Tx of Chronic Hepatitis C

Twelve weeks of interferon alfa-2b plus ribavirin is just as effective as 24 weeks of the treatment in maintaining a sustained response in patients with genotype 2 or 3 chronic hepatitis C infection who respond to treatment at 4 weeks, according to the results of an open-label, randomized trial.

Alessandra Mangia, M.D., of Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy, and her colleagues conducted a trial with 70 patients randomized to a standard treatment that lasted 24 weeks (controls) while 213 patients were randomized to an experimental group in which those who had an early virologic response (EVR) at week 4 received 12 weeks of treatment and those who did not have an EVR received 24 weeks of therapy (N. Engl. J. Med. 2005;352:2609–17).

Among patients who had an EVR at week 4, the rate of sustained virologic response (SVR) did not differ between control patients who received 24 weeks of therapy and those who received 12 weeks of therapy, either at the end of treatment (93% vs. 95%, respectively) or at the end of an additional 24 weeks of follow-up (91% vs. 85%). The number of patients who reported side effects that required withdrawal from the study was significantly lower among patients treated for 12 weeks than among those treated for 24 weeks (one vs. eight patients).

Vitamin B₆ Intake and Colorectal Ca

High intake of vitamin B₆ is associated with a protective effect against colorectal cancer in women, especially those who drink alcohol, reported Susanna C. Larsson of the Karolinska Institutet, Stockholm, and her associates.

In a population-based cohort study of 61,433 women, those who were in the top 20% of vitamin B₆ intake had a 34% lower relative risk (RR)of colorectal cancer than women who were in the bottom 20% of vitamin B₆ intake; this reduction was significant. Among women who drank at least 30 g alcohol (about two drinks) per week, those with the highest intake of vitamin B₆ had a 72% lower RR of colorectal cancer than women with the lowest intake (Gastroenterology 2005;128:1830–7).

The recommended daily intake of vitamin B₆ for nonpregnant women in the United States is 1.3–1.5 mg. “Findings from our study suggest that women who consume alcohol may benefit from a vitamin B₆ intake above the recommendations,” the researchers wrote.

Phospholipid Tx for Ulcerative Colitis

Ingestion of phosphatidylcholine capsules during a 3-month period resulted in high rates of response and remission in patients with chronically active ulcerative colitis, according to the results of a double-blind, randomized study of 60 patients.

Release of phosphatidylcholine (PC) into the colon from capsules prompted clinical remission in significantly more patients (53%, 16 of 30) than did placebo capsules (10%, 3 of 30), reported Wolfgang Stremmel, M.D., of University Hospital Heidelberg (Germany), and his colleagues (Gut 2005;54:966–71).

Significantly more PC patients had a clinical response to treatment (90%, 27 of 30) than did those who took placebo (10%, 3 of 30); response was measured with the clinical activity index. About half of the patients in each group experienced bloating; no major adverse events occurred. The researchers noted that the effect of PC had a gradual onset and was first seen after 2–4 weeks of treatment.

H. pylori, Thrombocytopenic Purpura

Eradication of Helicobacter pylori significantly improves platelet counts in patients with chronic idiopathic thrombocytopenic purpura, reported Takayoshi Suzuki, M.D., and associates from Tokai University, Isehara, Kanagawa, Japan.

Of 25 patients with chronic idiopathic thrombocytopenic purpura who tested positive for H. pylori in a randomized, placebo-controlled trial, triple therapy eradicated the bacteria in 11 of 13 patients in the eradication group.

Platelet counts improved in 6 of 13 eradication patients—either a complete response defined as more than 150 × 103 platelets/μL or a partial response defined as an increase of more than 50 × 103 platelets/μL—but in no placebo patients. Eradication patients increased their platelet counts from an average of 54.7 × 103 platelets/μL at baseline to 114.5 × 103 platelets/μL after 6 months of observation, whereas the platelet counts of control patients did not change from a level of about 48 × 103 platelets/μL (Am. J. Gastroenterol. 2005;100:1265–70).

When the investigators gave eradication therapy to 10 of the placebo patients after 6 months of observation, 4 patients had increased platelet counts; this yielded 10 of 23 patients overall with an increased platelet count. Those 10 patients had significantly higher levels of serum anti-CagA IgG antibodies than the 13 patients who did not respond to eradication therapy.

Shorter Tx of Chronic Hepatitis C

Twelve weeks of interferon alfa-2b plus ribavirin is just as effective as 24 weeks of the treatment in maintaining a sustained response in patients with genotype 2 or 3 chronic hepatitis C infection who respond to treatment at 4 weeks, according to the results of an open-label, randomized trial.

Alessandra Mangia, M.D., of Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy, and her colleagues conducted a trial with 70 patients randomized to a standard treatment that lasted 24 weeks (controls) while 213 patients were randomized to an experimental group in which those who had an early virologic response (EVR) at week 4 received 12 weeks of treatment and those who did not have an EVR received 24 weeks of therapy (N. Engl. J. Med. 2005;352:2609–17).

Among patients who had an EVR at week 4, the rate of sustained virologic response (SVR) did not differ between control patients who received 24 weeks of therapy and those who received 12 weeks of therapy, either at the end of treatment (93% vs. 95%, respectively) or at the end of an additional 24 weeks of follow-up (91% vs. 85%). The number of patients who reported side effects that required withdrawal from the study was significantly lower among patients treated for 12 weeks than among those treated for 24 weeks (one vs. eight patients).

Vitamin B₆ Intake and Colorectal Ca

High intake of vitamin B₆ is associated with a protective effect against colorectal cancer in women, especially those who drink alcohol, reported Susanna C. Larsson of the Karolinska Institutet, Stockholm, and her associates.

In a population-based cohort study of 61,433 women, those who were in the top 20% of vitamin B₆ intake had a 34% lower relative risk (RR)of colorectal cancer than women who were in the bottom 20% of vitamin B₆ intake; this reduction was significant. Among women who drank at least 30 g alcohol (about two drinks) per week, those with the highest intake of vitamin B₆ had a 72% lower RR of colorectal cancer than women with the lowest intake (Gastroenterology 2005;128:1830–7).

The recommended daily intake of vitamin B₆ for nonpregnant women in the United States is 1.3–1.5 mg. “Findings from our study suggest that women who consume alcohol may benefit from a vitamin B₆ intake above the recommendations,” the researchers wrote.

Phospholipid Tx for Ulcerative Colitis

Ingestion of phosphatidylcholine capsules during a 3-month period resulted in high rates of response and remission in patients with chronically active ulcerative colitis, according to the results of a double-blind, randomized study of 60 patients.

Release of phosphatidylcholine (PC) into the colon from capsules prompted clinical remission in significantly more patients (53%, 16 of 30) than did placebo capsules (10%, 3 of 30), reported Wolfgang Stremmel, M.D., of University Hospital Heidelberg (Germany), and his colleagues (Gut 2005;54:966–71).

Significantly more PC patients had a clinical response to treatment (90%, 27 of 30) than did those who took placebo (10%, 3 of 30); response was measured with the clinical activity index. About half of the patients in each group experienced bloating; no major adverse events occurred. The researchers noted that the effect of PC had a gradual onset and was first seen after 2–4 weeks of treatment.

H. pylori, Thrombocytopenic Purpura

Eradication of Helicobacter pylori significantly improves platelet counts in patients with chronic idiopathic thrombocytopenic purpura, reported Takayoshi Suzuki, M.D., and associates from Tokai University, Isehara, Kanagawa, Japan.

Of 25 patients with chronic idiopathic thrombocytopenic purpura who tested positive for H. pylori in a randomized, placebo-controlled trial, triple therapy eradicated the bacteria in 11 of 13 patients in the eradication group.

Platelet counts improved in 6 of 13 eradication patients—either a complete response defined as more than 150 × 103 platelets/μL or a partial response defined as an increase of more than 50 × 103 platelets/μL—but in no placebo patients. Eradication patients increased their platelet counts from an average of 54.7 × 103 platelets/μL at baseline to 114.5 × 103 platelets/μL after 6 months of observation, whereas the platelet counts of control patients did not change from a level of about 48 × 103 platelets/μL (Am. J. Gastroenterol. 2005;100:1265–70).

When the investigators gave eradication therapy to 10 of the placebo patients after 6 months of observation, 4 patients had increased platelet counts; this yielded 10 of 23 patients overall with an increased platelet count. Those 10 patients had significantly higher levels of serum anti-CagA IgG antibodies than the 13 patients who did not respond to eradication therapy.

Shorter Tx of Chronic Hepatitis C

Twelve weeks of interferon alfa-2b plus ribavirin is just as effective as 24 weeks of the treatment in maintaining a sustained response in patients with genotype 2 or 3 chronic hepatitis C infection who respond to treatment at 4 weeks, according to the results of an open-label, randomized trial.

Alessandra Mangia, M.D., of Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy, and her colleagues conducted a trial with 70 patients randomized to a standard treatment that lasted 24 weeks (controls) while 213 patients were randomized to an experimental group in which those who had an early virologic response (EVR) at week 4 received 12 weeks of treatment and those who did not have an EVR received 24 weeks of therapy (N. Engl. J. Med. 2005;352:2609–17).

Among patients who had an EVR at week 4, the rate of sustained virologic response (SVR) did not differ between control patients who received 24 weeks of therapy and those who received 12 weeks of therapy, either at the end of treatment (93% vs. 95%, respectively) or at the end of an additional 24 weeks of follow-up (91% vs. 85%). The number of patients who reported side effects that required withdrawal from the study was significantly lower among patients treated for 12 weeks than among those treated for 24 weeks (one vs. eight patients).

Vitamin B₆ Intake and Colorectal Ca

High intake of vitamin B₆ is associated with a protective effect against colorectal cancer in women, especially those who drink alcohol, reported Susanna C. Larsson of the Karolinska Institutet, Stockholm, and her associates.

In a population-based cohort study of 61,433 women, those who were in the top 20% of vitamin B₆ intake had a 34% lower relative risk (RR)of colorectal cancer than women who were in the bottom 20% of vitamin B₆ intake; this reduction was significant. Among women who drank at least 30 g alcohol (about two drinks) per week, those with the highest intake of vitamin B₆ had a 72% lower RR of colorectal cancer than women with the lowest intake (Gastroenterology 2005;128:1830–7).

The recommended daily intake of vitamin B₆ for nonpregnant women in the United States is 1.3–1.5 mg. “Findings from our study suggest that women who consume alcohol may benefit from a vitamin B₆ intake above the recommendations,” the researchers wrote.

Phospholipid Tx for Ulcerative Colitis

Ingestion of phosphatidylcholine capsules during a 3-month period resulted in high rates of response and remission in patients with chronically active ulcerative colitis, according to the results of a double-blind, randomized study of 60 patients.

Release of phosphatidylcholine (PC) into the colon from capsules prompted clinical remission in significantly more patients (53%, 16 of 30) than did placebo capsules (10%, 3 of 30), reported Wolfgang Stremmel, M.D., of University Hospital Heidelberg (Germany), and his colleagues (Gut 2005;54:966–71).

Significantly more PC patients had a clinical response to treatment (90%, 27 of 30) than did those who took placebo (10%, 3 of 30); response was measured with the clinical activity index. About half of the patients in each group experienced bloating; no major adverse events occurred. The researchers noted that the effect of PC had a gradual onset and was first seen after 2–4 weeks of treatment.

H. pylori, Thrombocytopenic Purpura

Eradication of Helicobacter pylori significantly improves platelet counts in patients with chronic idiopathic thrombocytopenic purpura, reported Takayoshi Suzuki, M.D., and associates from Tokai University, Isehara, Kanagawa, Japan.

Of 25 patients with chronic idiopathic thrombocytopenic purpura who tested positive for H. pylori in a randomized, placebo-controlled trial, triple therapy eradicated the bacteria in 11 of 13 patients in the eradication group.

Platelet counts improved in 6 of 13 eradication patients—either a complete response defined as more than 150 × 103 platelets/μL or a partial response defined as an increase of more than 50 × 103 platelets/μL—but in no placebo patients. Eradication patients increased their platelet counts from an average of 54.7 × 103 platelets/μL at baseline to 114.5 × 103 platelets/μL after 6 months of observation, whereas the platelet counts of control patients did not change from a level of about 48 × 103 platelets/μL (Am. J. Gastroenterol. 2005;100:1265–70).

When the investigators gave eradication therapy to 10 of the placebo patients after 6 months of observation, 4 patients had increased platelet counts; this yielded 10 of 23 patients overall with an increased platelet count. Those 10 patients had significantly higher levels of serum anti-CagA IgG antibodies than the 13 patients who did not respond to eradication therapy.

TUCSON, ARIZ. — High levels of survivin gene expression may identify patients with Barrett's esophagus who are at risk for developing precancerous dysplasia, Daniel Vallböhmer, M.D., reported at the annual meeting of the Central Surgical Association.

The development of adenocarcinoma associated with Barrett's esophagus is thought to be a “multistep process” following a sequence of reflux, metaplasia, dysplasia, and then adenocarcinoma.

Researchers know that acid reflux damage to the esophagus and genetic factors initiate the replacement of squamous epithelium with cardiac mucosa, and then the intestinal metaplasia characteristic of Barrett's esophagus, said Dr. Vallböhmer of the division of thoracic and foregut surgery at the University of Southern California, Los Angeles.

Clinicians are often unable to classify patients by the steps in the sequence, he said, even after endoscopy or histology has been performed. “The major goal is to develop markers that can predict which patients with intestinal metaplasia or low-grade dysplasia will develop cancer” and which ones will not, although he noted that “we are far” from being able to do that.

Dr. Vallböhmer and his colleagues targeted their research on survivin, a member of the inhibitor-of-apoptosis family of proteins.

Avoidance of apoptosis is one of six major pathways described as necessary for the development of adenocarcinoma. The others are growth self-sufficiency, insensitivity to antigrowth signals, limitless replicative potential, sustained angiogenesis, and invasion (Lancet 2002;360:1587–9).

The investigators obtained endoscopic biopsies from 17 control patients with nonacid reflux and no esophagitis, 16 control patients with acid reflux and esophagitis, 12 patients with low- or high-grade dysplasia, and 45 patients with esophageal adenocarcinoma. They used a laser to microdissect tissue of interest from each biopsy specimen.

All patients stopped taking proton pump inhibitors 2 weeks before they underwent endoscopic biopsies.

The levels of survivin expressed in esophageal biopsies increased with the severity of histopathology in the biopsies.

The control groups and patients with Barrett's metaplasia had similar, low levels of survivin expression. But the expression of survivin significantly increased in a stepwise manner from patients with Barrett's intestinal metaplasia to patients with dysplasia and then to patients with adenocarcinoma.

“Survivin gene expression might be used in the future to distinguish Barrett's metaplasia from dysplasia,” Dr. Vallböhmer said.

The investigators were not able to find any clinicopathological factors that were significantly associated with the expression of survivin in adenocarcinomas, leading them to think that survivin expression “may not be a useful marker in determining the prognosis of esophageal adenocarcinoma,” he said.

But the findings lead us further into an understanding of the molecular biologic mechanisms related to the progression from an irritated, injured esophageal epithelium to precancerous lesions and frank esophageal cancer, Rodney Landreneau, M.D., told this newspaper. He agreed with the investigators that “these findings alone do not give us insight into relative cancer risk or prognosis for patients with histologic evidence of mucosal dysplasia and survivin expression.”

According to Dr. Landreneau, professor of cardiothoracic surgery at the University of Pittsburgh, the findings may be an event related to repeated acid reflux injury and a marker of ongoing repair or the patients' response to the injurious effects of chronic reflux.

“Certainly this interesting finding should be explored further to determine the prognostic significance and possible means of reversing these molecular changes if they are involved in the evolutionary pathway toward the development of esophageal cancer,” Dr. Landreneau said.

TUCSON, ARIZ. — High levels of survivin gene expression may identify patients with Barrett's esophagus who are at risk for developing precancerous dysplasia, Daniel Vallböhmer, M.D., reported at the annual meeting of the Central Surgical Association.

The development of adenocarcinoma associated with Barrett's esophagus is thought to be a “multistep process” following a sequence of reflux, metaplasia, dysplasia, and then adenocarcinoma.

Researchers know that acid reflux damage to the esophagus and genetic factors initiate the replacement of squamous epithelium with cardiac mucosa, and then the intestinal metaplasia characteristic of Barrett's esophagus, said Dr. Vallböhmer of the division of thoracic and foregut surgery at the University of Southern California, Los Angeles.

Clinicians are often unable to classify patients by the steps in the sequence, he said, even after endoscopy or histology has been performed. “The major goal is to develop markers that can predict which patients with intestinal metaplasia or low-grade dysplasia will develop cancer” and which ones will not, although he noted that “we are far” from being able to do that.

Dr. Vallböhmer and his colleagues targeted their research on survivin, a member of the inhibitor-of-apoptosis family of proteins.

Avoidance of apoptosis is one of six major pathways described as necessary for the development of adenocarcinoma. The others are growth self-sufficiency, insensitivity to antigrowth signals, limitless replicative potential, sustained angiogenesis, and invasion (Lancet 2002;360:1587–9).

The investigators obtained endoscopic biopsies from 17 control patients with nonacid reflux and no esophagitis, 16 control patients with acid reflux and esophagitis, 12 patients with low- or high-grade dysplasia, and 45 patients with esophageal adenocarcinoma. They used a laser to microdissect tissue of interest from each biopsy specimen.

All patients stopped taking proton pump inhibitors 2 weeks before they underwent endoscopic biopsies.

The levels of survivin expressed in esophageal biopsies increased with the severity of histopathology in the biopsies.

The control groups and patients with Barrett's metaplasia had similar, low levels of survivin expression. But the expression of survivin significantly increased in a stepwise manner from patients with Barrett's intestinal metaplasia to patients with dysplasia and then to patients with adenocarcinoma.

“Survivin gene expression might be used in the future to distinguish Barrett's metaplasia from dysplasia,” Dr. Vallböhmer said.

The investigators were not able to find any clinicopathological factors that were significantly associated with the expression of survivin in adenocarcinomas, leading them to think that survivin expression “may not be a useful marker in determining the prognosis of esophageal adenocarcinoma,” he said.

But the findings lead us further into an understanding of the molecular biologic mechanisms related to the progression from an irritated, injured esophageal epithelium to precancerous lesions and frank esophageal cancer, Rodney Landreneau, M.D., told this newspaper. He agreed with the investigators that “these findings alone do not give us insight into relative cancer risk or prognosis for patients with histologic evidence of mucosal dysplasia and survivin expression.”

According to Dr. Landreneau, professor of cardiothoracic surgery at the University of Pittsburgh, the findings may be an event related to repeated acid reflux injury and a marker of ongoing repair or the patients' response to the injurious effects of chronic reflux.

“Certainly this interesting finding should be explored further to determine the prognostic significance and possible means of reversing these molecular changes if they are involved in the evolutionary pathway toward the development of esophageal cancer,” Dr. Landreneau said.

TUCSON, ARIZ. — High levels of survivin gene expression may identify patients with Barrett's esophagus who are at risk for developing precancerous dysplasia, Daniel Vallböhmer, M.D., reported at the annual meeting of the Central Surgical Association.

The development of adenocarcinoma associated with Barrett's esophagus is thought to be a “multistep process” following a sequence of reflux, metaplasia, dysplasia, and then adenocarcinoma.

Researchers know that acid reflux damage to the esophagus and genetic factors initiate the replacement of squamous epithelium with cardiac mucosa, and then the intestinal metaplasia characteristic of Barrett's esophagus, said Dr. Vallböhmer of the division of thoracic and foregut surgery at the University of Southern California, Los Angeles.

Clinicians are often unable to classify patients by the steps in the sequence, he said, even after endoscopy or histology has been performed. “The major goal is to develop markers that can predict which patients with intestinal metaplasia or low-grade dysplasia will develop cancer” and which ones will not, although he noted that “we are far” from being able to do that.

Dr. Vallböhmer and his colleagues targeted their research on survivin, a member of the inhibitor-of-apoptosis family of proteins.

Avoidance of apoptosis is one of six major pathways described as necessary for the development of adenocarcinoma. The others are growth self-sufficiency, insensitivity to antigrowth signals, limitless replicative potential, sustained angiogenesis, and invasion (Lancet 2002;360:1587–9).

The investigators obtained endoscopic biopsies from 17 control patients with nonacid reflux and no esophagitis, 16 control patients with acid reflux and esophagitis, 12 patients with low- or high-grade dysplasia, and 45 patients with esophageal adenocarcinoma. They used a laser to microdissect tissue of interest from each biopsy specimen.

All patients stopped taking proton pump inhibitors 2 weeks before they underwent endoscopic biopsies.

The levels of survivin expressed in esophageal biopsies increased with the severity of histopathology in the biopsies.

The control groups and patients with Barrett's metaplasia had similar, low levels of survivin expression. But the expression of survivin significantly increased in a stepwise manner from patients with Barrett's intestinal metaplasia to patients with dysplasia and then to patients with adenocarcinoma.

“Survivin gene expression might be used in the future to distinguish Barrett's metaplasia from dysplasia,” Dr. Vallböhmer said.

The investigators were not able to find any clinicopathological factors that were significantly associated with the expression of survivin in adenocarcinomas, leading them to think that survivin expression “may not be a useful marker in determining the prognosis of esophageal adenocarcinoma,” he said.

But the findings lead us further into an understanding of the molecular biologic mechanisms related to the progression from an irritated, injured esophageal epithelium to precancerous lesions and frank esophageal cancer, Rodney Landreneau, M.D., told this newspaper. He agreed with the investigators that “these findings alone do not give us insight into relative cancer risk or prognosis for patients with histologic evidence of mucosal dysplasia and survivin expression.”

According to Dr. Landreneau, professor of cardiothoracic surgery at the University of Pittsburgh, the findings may be an event related to repeated acid reflux injury and a marker of ongoing repair or the patients' response to the injurious effects of chronic reflux.

“Certainly this interesting finding should be explored further to determine the prognostic significance and possible means of reversing these molecular changes if they are involved in the evolutionary pathway toward the development of esophageal cancer,” Dr. Landreneau said.

ORLANDO, FLA. — Crohn's disease patients with two allelic variants of the NOD2/CARD15 gene have an increased risk of upper GI disease involvement, Houssam E. Mardini, M.D., reported at the annual meeting of the American College of Gastroenterology.

Genetic testing of patients in an inflammatory bowel disease database revealed that six of nine patients with Crohn's disease in the upper GI tract had two allelic variants of the NOD2/CARD15 gene.

In comparison, a significantly lower percentage of patients without upper GI disease had two allelic variants of the gene (4% of 169). “Our data suggest that patients with two NOD2/CARD15 allelic variants should be carefully evaluated for upper GI involvement,” Dr. Mardini and his associates said in a poster presentation.

NOD2/CARD15 is so far the only gene that is highly associated with Crohn's disease. Four of the patients with upper GI disease had homozygous allelic variants, whereas none of the patients without upper GI disease were homozygous for an allelic variant. Wild type alleles of NOD2/CARD15 occurred in 68% of the patients without upper GI disease; another 28% of those without upper GI disease had one allelic variant.

Compared with patients who did not have upper GI disease, significantly more of the patients with upper GI involvement had a family history of inflammatory bowel disease (19% vs. 44%), were male (41% vs. 78%), and were younger at diagnosis (25 years vs. 17 years). Osteopenia or osteoporosis developed significantly more often in patients with upper GI disease than in those without (33% vs. 9%).

ORLANDO, FLA. — Crohn's disease patients with two allelic variants of the NOD2/CARD15 gene have an increased risk of upper GI disease involvement, Houssam E. Mardini, M.D., reported at the annual meeting of the American College of Gastroenterology.

Genetic testing of patients in an inflammatory bowel disease database revealed that six of nine patients with Crohn's disease in the upper GI tract had two allelic variants of the NOD2/CARD15 gene.

In comparison, a significantly lower percentage of patients without upper GI disease had two allelic variants of the gene (4% of 169). “Our data suggest that patients with two NOD2/CARD15 allelic variants should be carefully evaluated for upper GI involvement,” Dr. Mardini and his associates said in a poster presentation.

NOD2/CARD15 is so far the only gene that is highly associated with Crohn's disease. Four of the patients with upper GI disease had homozygous allelic variants, whereas none of the patients without upper GI disease were homozygous for an allelic variant. Wild type alleles of NOD2/CARD15 occurred in 68% of the patients without upper GI disease; another 28% of those without upper GI disease had one allelic variant.

Compared with patients who did not have upper GI disease, significantly more of the patients with upper GI involvement had a family history of inflammatory bowel disease (19% vs. 44%), were male (41% vs. 78%), and were younger at diagnosis (25 years vs. 17 years). Osteopenia or osteoporosis developed significantly more often in patients with upper GI disease than in those without (33% vs. 9%).

ORLANDO, FLA. — Crohn's disease patients with two allelic variants of the NOD2/CARD15 gene have an increased risk of upper GI disease involvement, Houssam E. Mardini, M.D., reported at the annual meeting of the American College of Gastroenterology.

Genetic testing of patients in an inflammatory bowel disease database revealed that six of nine patients with Crohn's disease in the upper GI tract had two allelic variants of the NOD2/CARD15 gene.

In comparison, a significantly lower percentage of patients without upper GI disease had two allelic variants of the gene (4% of 169). “Our data suggest that patients with two NOD2/CARD15 allelic variants should be carefully evaluated for upper GI involvement,” Dr. Mardini and his associates said in a poster presentation.

NOD2/CARD15 is so far the only gene that is highly associated with Crohn's disease. Four of the patients with upper GI disease had homozygous allelic variants, whereas none of the patients without upper GI disease were homozygous for an allelic variant. Wild type alleles of NOD2/CARD15 occurred in 68% of the patients without upper GI disease; another 28% of those without upper GI disease had one allelic variant.

Compared with patients who did not have upper GI disease, significantly more of the patients with upper GI involvement had a family history of inflammatory bowel disease (19% vs. 44%), were male (41% vs. 78%), and were younger at diagnosis (25 years vs. 17 years). Osteopenia or osteoporosis developed significantly more often in patients with upper GI disease than in those without (33% vs. 9%).

AUSTIN, TEX. — Athletes with a low-grade stress fracture in a lower extremity can return to play successfully within the same season when managed with activities below the pain threshold, Elizabeth A. Arendt, M.D., said at the annual meeting of the American Medical Society for Sports Medicine.

Her experience during the past 10 years at the University of Minnesota, Minneapolis, suggests that pain-free activities that gradually progress from non-weight- bearing to nonpounding, weight-bearing exercises and then to sport-specific training may help an athlete return to play sooner than with complete rest.

“I don't find that this is always that easy to use in a clinical practice where you may be finding people trying to go back to work or mothers who are having pressures from home,” said Dr. Arendt, medical director of varsity athletics at the university. But “if you have a patient who you believe is intelligent enough to understand the negative consequences of noncompliance, then I think you could use this.”

She and her colleagues conducted a 10-year review of stress fractures in athletes at the university. During that period, 73 of about 6,000 athletes had symptoms of a stress fracture. Of those 73 athletes, 67 were positive for a stress fracture, according to MRI scans or radiographs (Am. J. Sports Med. 2003;31:959–68).

Of all stress fractures, most occurred in distance runners (35%), track athletes (16%), and gymnasts (16%). The tibia was the bone most commonly afflicted with a stress fracture (36%), but the foot was the most common anatomical region (44%). Distance runners suffered 8 of the 9 femur stress fractures overall, while track-and-field athletes and gymnasts developed 11 of the 17 total midfoot stress fractures.

About 44% of the stress fractures occurred in freshmen or transfer students who were new to the program or in athletes who had a new coach.

Stress fractures were always managed the same way during the 10-year period. In the first phase of rehabilitation, athletes controlled pain by reducing their activities and applying ice; no medications other than acetaminophen were allowed. They were allowed to do any activity that could be done pain free for about 3–5 days. Athletes would use crutches to avoid bearing weight on the injured leg until they could walk pain free. Every other day would include a trial of walking. Athletes could perform non-weight-bearing cross-training exercises such as swimming, stationary biking, or flotation running, unless they had pain during the activity.

During the second phase, athletes performed nonpounding, weight-bearing exercises with equipment such as a stair climber, ski machine, or elliptical trainer. Muscles specific to the athlete's sport were strengthened and stretched, while anatomic and training factors associated with the injury were discussed and modified if possible.

Athletes most often get a stress fracture because of a training error rather than an anatomic problem, Dr. Arendt said.

The final phase of rehabilitation for runners involved gradual reentry into running on alternate days or 10 minutes of play for athletes competing in team sports.

“After the first year or two of using this theory, we got the athletes back so much faster than when we didn't put them on crutches that the athletes themselves were widely compliant with our program,” she said.

This management strategy “does take some discussion with the athlete,” she noted. “But the reason I think this works with the division I athletes is that they're highly motivated to get better.”

One of the most important things to teach patients is that a stress fracture is the end result of the continuum of a biologic response to stress placed on bone, she said. Because of this, some clinicians have suggested that another term such as a stress nodule in bone or a bone strain should replace the overarching term of stress fracture.

AUSTIN, TEX. — Athletes with a low-grade stress fracture in a lower extremity can return to play successfully within the same season when managed with activities below the pain threshold, Elizabeth A. Arendt, M.D., said at the annual meeting of the American Medical Society for Sports Medicine.

Her experience during the past 10 years at the University of Minnesota, Minneapolis, suggests that pain-free activities that gradually progress from non-weight- bearing to nonpounding, weight-bearing exercises and then to sport-specific training may help an athlete return to play sooner than with complete rest.

“I don't find that this is always that easy to use in a clinical practice where you may be finding people trying to go back to work or mothers who are having pressures from home,” said Dr. Arendt, medical director of varsity athletics at the university. But “if you have a patient who you believe is intelligent enough to understand the negative consequences of noncompliance, then I think you could use this.”

She and her colleagues conducted a 10-year review of stress fractures in athletes at the university. During that period, 73 of about 6,000 athletes had symptoms of a stress fracture. Of those 73 athletes, 67 were positive for a stress fracture, according to MRI scans or radiographs (Am. J. Sports Med. 2003;31:959–68).

Of all stress fractures, most occurred in distance runners (35%), track athletes (16%), and gymnasts (16%). The tibia was the bone most commonly afflicted with a stress fracture (36%), but the foot was the most common anatomical region (44%). Distance runners suffered 8 of the 9 femur stress fractures overall, while track-and-field athletes and gymnasts developed 11 of the 17 total midfoot stress fractures.

About 44% of the stress fractures occurred in freshmen or transfer students who were new to the program or in athletes who had a new coach.

Stress fractures were always managed the same way during the 10-year period. In the first phase of rehabilitation, athletes controlled pain by reducing their activities and applying ice; no medications other than acetaminophen were allowed. They were allowed to do any activity that could be done pain free for about 3–5 days. Athletes would use crutches to avoid bearing weight on the injured leg until they could walk pain free. Every other day would include a trial of walking. Athletes could perform non-weight-bearing cross-training exercises such as swimming, stationary biking, or flotation running, unless they had pain during the activity.

During the second phase, athletes performed nonpounding, weight-bearing exercises with equipment such as a stair climber, ski machine, or elliptical trainer. Muscles specific to the athlete's sport were strengthened and stretched, while anatomic and training factors associated with the injury were discussed and modified if possible.

Athletes most often get a stress fracture because of a training error rather than an anatomic problem, Dr. Arendt said.

The final phase of rehabilitation for runners involved gradual reentry into running on alternate days or 10 minutes of play for athletes competing in team sports.

“After the first year or two of using this theory, we got the athletes back so much faster than when we didn't put them on crutches that the athletes themselves were widely compliant with our program,” she said.

This management strategy “does take some discussion with the athlete,” she noted. “But the reason I think this works with the division I athletes is that they're highly motivated to get better.”

One of the most important things to teach patients is that a stress fracture is the end result of the continuum of a biologic response to stress placed on bone, she said. Because of this, some clinicians have suggested that another term such as a stress nodule in bone or a bone strain should replace the overarching term of stress fracture.

AUSTIN, TEX. — Athletes with a low-grade stress fracture in a lower extremity can return to play successfully within the same season when managed with activities below the pain threshold, Elizabeth A. Arendt, M.D., said at the annual meeting of the American Medical Society for Sports Medicine.

Her experience during the past 10 years at the University of Minnesota, Minneapolis, suggests that pain-free activities that gradually progress from non-weight- bearing to nonpounding, weight-bearing exercises and then to sport-specific training may help an athlete return to play sooner than with complete rest.

“I don't find that this is always that easy to use in a clinical practice where you may be finding people trying to go back to work or mothers who are having pressures from home,” said Dr. Arendt, medical director of varsity athletics at the university. But “if you have a patient who you believe is intelligent enough to understand the negative consequences of noncompliance, then I think you could use this.”

She and her colleagues conducted a 10-year review of stress fractures in athletes at the university. During that period, 73 of about 6,000 athletes had symptoms of a stress fracture. Of those 73 athletes, 67 were positive for a stress fracture, according to MRI scans or radiographs (Am. J. Sports Med. 2003;31:959–68).

Of all stress fractures, most occurred in distance runners (35%), track athletes (16%), and gymnasts (16%). The tibia was the bone most commonly afflicted with a stress fracture (36%), but the foot was the most common anatomical region (44%). Distance runners suffered 8 of the 9 femur stress fractures overall, while track-and-field athletes and gymnasts developed 11 of the 17 total midfoot stress fractures.

About 44% of the stress fractures occurred in freshmen or transfer students who were new to the program or in athletes who had a new coach.

Stress fractures were always managed the same way during the 10-year period. In the first phase of rehabilitation, athletes controlled pain by reducing their activities and applying ice; no medications other than acetaminophen were allowed. They were allowed to do any activity that could be done pain free for about 3–5 days. Athletes would use crutches to avoid bearing weight on the injured leg until they could walk pain free. Every other day would include a trial of walking. Athletes could perform non-weight-bearing cross-training exercises such as swimming, stationary biking, or flotation running, unless they had pain during the activity.

During the second phase, athletes performed nonpounding, weight-bearing exercises with equipment such as a stair climber, ski machine, or elliptical trainer. Muscles specific to the athlete's sport were strengthened and stretched, while anatomic and training factors associated with the injury were discussed and modified if possible.

Athletes most often get a stress fracture because of a training error rather than an anatomic problem, Dr. Arendt said.

The final phase of rehabilitation for runners involved gradual reentry into running on alternate days or 10 minutes of play for athletes competing in team sports.

“After the first year or two of using this theory, we got the athletes back so much faster than when we didn't put them on crutches that the athletes themselves were widely compliant with our program,” she said.

This management strategy “does take some discussion with the athlete,” she noted. “But the reason I think this works with the division I athletes is that they're highly motivated to get better.”

One of the most important things to teach patients is that a stress fracture is the end result of the continuum of a biologic response to stress placed on bone, she said. Because of this, some clinicians have suggested that another term such as a stress nodule in bone or a bone strain should replace the overarching term of stress fracture.

AUSTIN, TEX. — Subtle clues in test results will help to differentiate athlete's heart from hypertrophic or dilated cardiomyopathy, Christine E. Lawless, M.D., reported at the annual meeting of the American Medical Society for Sports Medicine.

It's tough to distinguish athlete's heart from hypertrophic cardiomyopathy (HCM) when an athlete's left ventricular wall is thickened in a nondilated, normally contractile left ventricle with no systolic anterior motion of the mitral valve, said Dr. Lawless, a cardiologist in group practice in Winfield, Ill.

About 20% of highly trained athletes have what looks like left ventricular hypertrophy, with a left ventricular wall thickness between 1.3 cm and 1.5 cm; normal thickness is 1 cm.

Physicians should suspect HCM rather than athlete's heart if the patient has an unusual pattern of left ventricular hypertrophy, a small left ventricular cavity, left atrial enlargement, an unusual ECG pattern, or abnormal left ventricular filling. Other risk factors for HCM include female gender and a family history of hypertrophy (Circulation 1995;91:1596–601).

“If the thickness decreases with deconditioning, then you know that would be athletic adaptation to exercise,” she advised.

In one case, a 48-year-old man who had run 18 marathons over a period of 25 years was referred to Dr. Lawless after an irregular heartbeat was found during a physical for a new job.

He had a normal cardiovascular examination but showed atrial fibrillation on an ECG, which can be seen both in athletes as they age and in patients with a cardiomyopathy, she said. An echocardiogram showed asymmetric septal hypertrophy, systolic anterior motion of the mitral valve, and moderate mitral valve regurgitation.

At that point, Dr. Lawless was going to err on the side of diagnosing the runner with HCM, but a later echocardiogram showed that his abnormalities had normalized after deconditioning.

“He was one of these folks who fell in the gray zone,” Dr. Lawless said.

Genetic testing for 11 mutant genes in HCM will help to detect about 65% of HCMs, she added, but insurance may not cover testing, which can cost up to $4,500.

A slightly dilated left ventricle may also be the result of athletic conditioning, and not an early manifestation of dilated cardiomyopathy, if the left ventricular ejection fraction (LVEF) is normal, Dr. Lawless said.

Close to 15% of highly trained athletes appear to have a dilated ventricle with an end-diastolic dimension of about 6.0 cm, compared with a normal value of 5.6 cm.

Several years ago, Dr. Lawless saw a 39-year-old male cyclist whose father had had a cardiac arrest as a result of dilated cardiomyopathy.

The cyclist had a normal cardiac exam besides premature ventricular contractions. Although his left ventricular septal thickness was within the normal range, he had a lower than normal LVEF and larger than normal left ventricular end-systolic and end-diastolic dimensions.

Cyclists are known to have a smaller left ventricular end-systolic dimension than patients with dilated cardiomyopathy.

After deconditioning did not improve the cyclist's LVEF or end-diastolic dimension, she placed him on an ACE inhibitor and a β-blocker.

After a course of these medications, he underwent “reverse remodeling” and showed an increase in LVEF and no change in end-diastolic dimension.

Dr. Lawless allowed the man to return to cycling following the reverse remodeling, but cardiologists vary in their opinion on whether patients who normalize their left ventricular ejection fraction can return to sports participation.

“I think a lot of us look at the intensity of the sport, the triggers for sudden death in that particular sport, and we use our best judgment,” she said.

AUSTIN, TEX. — Subtle clues in test results will help to differentiate athlete's heart from hypertrophic or dilated cardiomyopathy, Christine E. Lawless, M.D., reported at the annual meeting of the American Medical Society for Sports Medicine.

It's tough to distinguish athlete's heart from hypertrophic cardiomyopathy (HCM) when an athlete's left ventricular wall is thickened in a nondilated, normally contractile left ventricle with no systolic anterior motion of the mitral valve, said Dr. Lawless, a cardiologist in group practice in Winfield, Ill.

About 20% of highly trained athletes have what looks like left ventricular hypertrophy, with a left ventricular wall thickness between 1.3 cm and 1.5 cm; normal thickness is 1 cm.

Physicians should suspect HCM rather than athlete's heart if the patient has an unusual pattern of left ventricular hypertrophy, a small left ventricular cavity, left atrial enlargement, an unusual ECG pattern, or abnormal left ventricular filling. Other risk factors for HCM include female gender and a family history of hypertrophy (Circulation 1995;91:1596–601).

“If the thickness decreases with deconditioning, then you know that would be athletic adaptation to exercise,” she advised.

In one case, a 48-year-old man who had run 18 marathons over a period of 25 years was referred to Dr. Lawless after an irregular heartbeat was found during a physical for a new job.

He had a normal cardiovascular examination but showed atrial fibrillation on an ECG, which can be seen both in athletes as they age and in patients with a cardiomyopathy, she said. An echocardiogram showed asymmetric septal hypertrophy, systolic anterior motion of the mitral valve, and moderate mitral valve regurgitation.

At that point, Dr. Lawless was going to err on the side of diagnosing the runner with HCM, but a later echocardiogram showed that his abnormalities had normalized after deconditioning.

“He was one of these folks who fell in the gray zone,” Dr. Lawless said.

Genetic testing for 11 mutant genes in HCM will help to detect about 65% of HCMs, she added, but insurance may not cover testing, which can cost up to $4,500.

A slightly dilated left ventricle may also be the result of athletic conditioning, and not an early manifestation of dilated cardiomyopathy, if the left ventricular ejection fraction (LVEF) is normal, Dr. Lawless said.

Close to 15% of highly trained athletes appear to have a dilated ventricle with an end-diastolic dimension of about 6.0 cm, compared with a normal value of 5.6 cm.

Several years ago, Dr. Lawless saw a 39-year-old male cyclist whose father had had a cardiac arrest as a result of dilated cardiomyopathy.

The cyclist had a normal cardiac exam besides premature ventricular contractions. Although his left ventricular septal thickness was within the normal range, he had a lower than normal LVEF and larger than normal left ventricular end-systolic and end-diastolic dimensions.

Cyclists are known to have a smaller left ventricular end-systolic dimension than patients with dilated cardiomyopathy.

After deconditioning did not improve the cyclist's LVEF or end-diastolic dimension, she placed him on an ACE inhibitor and a β-blocker.

After a course of these medications, he underwent “reverse remodeling” and showed an increase in LVEF and no change in end-diastolic dimension.

Dr. Lawless allowed the man to return to cycling following the reverse remodeling, but cardiologists vary in their opinion on whether patients who normalize their left ventricular ejection fraction can return to sports participation.

“I think a lot of us look at the intensity of the sport, the triggers for sudden death in that particular sport, and we use our best judgment,” she said.

AUSTIN, TEX. — Subtle clues in test results will help to differentiate athlete's heart from hypertrophic or dilated cardiomyopathy, Christine E. Lawless, M.D., reported at the annual meeting of the American Medical Society for Sports Medicine.

It's tough to distinguish athlete's heart from hypertrophic cardiomyopathy (HCM) when an athlete's left ventricular wall is thickened in a nondilated, normally contractile left ventricle with no systolic anterior motion of the mitral valve, said Dr. Lawless, a cardiologist in group practice in Winfield, Ill.

About 20% of highly trained athletes have what looks like left ventricular hypertrophy, with a left ventricular wall thickness between 1.3 cm and 1.5 cm; normal thickness is 1 cm.

Physicians should suspect HCM rather than athlete's heart if the patient has an unusual pattern of left ventricular hypertrophy, a small left ventricular cavity, left atrial enlargement, an unusual ECG pattern, or abnormal left ventricular filling. Other risk factors for HCM include female gender and a family history of hypertrophy (Circulation 1995;91:1596–601).

“If the thickness decreases with deconditioning, then you know that would be athletic adaptation to exercise,” she advised.

In one case, a 48-year-old man who had run 18 marathons over a period of 25 years was referred to Dr. Lawless after an irregular heartbeat was found during a physical for a new job.

He had a normal cardiovascular examination but showed atrial fibrillation on an ECG, which can be seen both in athletes as they age and in patients with a cardiomyopathy, she said. An echocardiogram showed asymmetric septal hypertrophy, systolic anterior motion of the mitral valve, and moderate mitral valve regurgitation.

At that point, Dr. Lawless was going to err on the side of diagnosing the runner with HCM, but a later echocardiogram showed that his abnormalities had normalized after deconditioning.

“He was one of these folks who fell in the gray zone,” Dr. Lawless said.

Genetic testing for 11 mutant genes in HCM will help to detect about 65% of HCMs, she added, but insurance may not cover testing, which can cost up to $4,500.

A slightly dilated left ventricle may also be the result of athletic conditioning, and not an early manifestation of dilated cardiomyopathy, if the left ventricular ejection fraction (LVEF) is normal, Dr. Lawless said.

Close to 15% of highly trained athletes appear to have a dilated ventricle with an end-diastolic dimension of about 6.0 cm, compared with a normal value of 5.6 cm.

Several years ago, Dr. Lawless saw a 39-year-old male cyclist whose father had had a cardiac arrest as a result of dilated cardiomyopathy.

The cyclist had a normal cardiac exam besides premature ventricular contractions. Although his left ventricular septal thickness was within the normal range, he had a lower than normal LVEF and larger than normal left ventricular end-systolic and end-diastolic dimensions.

Cyclists are known to have a smaller left ventricular end-systolic dimension than patients with dilated cardiomyopathy.

After deconditioning did not improve the cyclist's LVEF or end-diastolic dimension, she placed him on an ACE inhibitor and a β-blocker.

After a course of these medications, he underwent “reverse remodeling” and showed an increase in LVEF and no change in end-diastolic dimension.

Dr. Lawless allowed the man to return to cycling following the reverse remodeling, but cardiologists vary in their opinion on whether patients who normalize their left ventricular ejection fraction can return to sports participation.

“I think a lot of us look at the intensity of the sport, the triggers for sudden death in that particular sport, and we use our best judgment,” she said.

Infliximab for Ulcerative Colitis

Infliximab significantly reduced the rate of colectomy in patients who had severe or moderately severe ulcerative colitis that was refractory to conventional treatment, reported Gunnar Järnerot, M.D., of Örebro (Sweden) University Hospital, and associates.

In an interim analysis of a randomized, double-blind trial that was ended early because of slow enrollment and ethical issues, significantly fewer patients (7 of 24) who received an infusion of infliximab had a colectomy within 90 days than did patients who received placebo (14 of 21). Treatment with infliximab was associated with a significant, nearly fivefold higher likelihood of remaining free of colectomy than was placebo. Two additional patients in each group had a colectomy after 6 months of follow-up (Gastroenterology 2005;128:1805–11).

Maintenance treatment with repeated infliximab infusions will probably be needed for patients with ulcerative colitis, just as it has been for patients with Crohn's disease, especially “in patients who escape a colectomy to avoid further hospitalizations and risk of later surgery,” Geert D'Haens, M.D., of the Imelda GI Clinical Research Center, Bonheiden, Belgium, said in an editorial (Gastroenterology 2005;128:2161–4). Centocor, the maker of infliximab (Remicade), did not sponsor the trial.

Mycobacterial Cause of Crohn's?

Mycobacterium avium subspecies paratuberculosis is present in gut tissues from a significantly greater percentage of patients with Crohn's disease than from those with ulcerative colitis or diseases not specifically related to inflammatory bowel disease, according to a prospective study.

Nested polymerase chain reaction detected the DNA sequence IS900, which identifies Mycobacterium avium subspecies paratuberculosis (MAP), in 52 of 100 diseased biopsy samples from patients with Crohn's disease vs. 2 of 100 samples from patients with ulcerative colitis and 5 of 100 normal tissue biopsies from patients with diseases not specifically related to inflammatory bowel disease (Gut 2005;54:944–9).

Frank Autschbach, M.D., of the University of Heidelberg (Germany) and his colleagues reported that in patients with Crohn's disease, MAP was significantly more prevalent in diseased locations of the colon than the ileum, and in patients who had the disease for less than 15 years, compared with those who had it for 15 years or more. MAP did not occur more often with either stricturing or penetrating phenotypes of the disease. The investigators' findings are in direct contrast with reports on strong associations between polymorphisms of the NOD2 and CARD15 genes and patients with early-onset ileal Crohn's disease with a stricturing phenotype, said R. Balfour Sartor, M.D., of the University of North Carolina, Chapel Hill, in an editorial (Gut 2005;54:896–8).

Maintaining Remission in Crohn's

Withdrawal from azathioprine is not equivalent to continued therapy with the drug in Crohn's disease patients who have been in clinical remission for at least 3.5 years while on azathioprine, according to a randomized, double-blind trial.

Marc Lémann, M.D., of the Centre Hospitalier Universitaire Lariboisière-Saint-Louis, Paris, and his associates found that 3 (8%) of 40 patients who continued to receive azathioprine relapsed after 18 months vs. 9 (21%) of 43 patients on placebo. The trial was designed to determine whether withdrawal from azathioprine had an efficacy similar to continued treatment with azathioprine. The investigators determined that baseline levels of C-reactive protein of 20 mg/L or greater and hemoglobin less than 12 g/dL, as well as 50 or more months without steroids, were independent factors associated with a higher rate of relapse during the 18-month study (Gastroenterology 2005;128:1812–8).

Sleep Apnea: Risk for Liver Injury

Severe obstructive sleep apnea appears to be a risk factor for elevated liver enzymes and steatohepatitis, independent of body weight, reported Florence Tanné of Hôpital Saint-Antoine, Paris, and colleagues.

In a prospective study of 163 patients who were evaluated for clinical suspicion of obstructive sleep apnea (OSA), the researchers found that OSA was severe in 44 patients, moderate in 84, and absent in 35 patients. Body mass index and severe OSA were independently associated with elevated liver enzymes in a multivariate analysis. Of 32 patients with elevated liver enzymes, 18 underwent liver biopsy (Hepatology 2005;41:1290–6).

In 12 of 13 patients with a liver biopsy who had steatosis, evidence of steatohepatitis (lobular necrosis or hepatocyte ballooning) was seen. Patients with severe OSA had significantly higher levels of insulin, greater insulin resistance, and higher percentages of steatosis and scores of lobular necrosis and fibrosis than did those with either moderate OSA or no OSA.

Infliximab for Ulcerative Colitis

Infliximab significantly reduced the rate of colectomy in patients who had severe or moderately severe ulcerative colitis that was refractory to conventional treatment, reported Gunnar Järnerot, M.D., of Örebro (Sweden) University Hospital, and associates.

In an interim analysis of a randomized, double-blind trial that was ended early because of slow enrollment and ethical issues, significantly fewer patients (7 of 24) who received an infusion of infliximab had a colectomy within 90 days than did patients who received placebo (14 of 21). Treatment with infliximab was associated with a significant, nearly fivefold higher likelihood of remaining free of colectomy than was placebo. Two additional patients in each group had a colectomy after 6 months of follow-up (Gastroenterology 2005;128:1805–11).

Maintenance treatment with repeated infliximab infusions will probably be needed for patients with ulcerative colitis, just as it has been for patients with Crohn's disease, especially “in patients who escape a colectomy to avoid further hospitalizations and risk of later surgery,” Geert D'Haens, M.D., of the Imelda GI Clinical Research Center, Bonheiden, Belgium, said in an editorial (Gastroenterology 2005;128:2161–4). Centocor, the maker of infliximab (Remicade), did not sponsor the trial.

Mycobacterial Cause of Crohn's?

Mycobacterium avium subspecies paratuberculosis is present in gut tissues from a significantly greater percentage of patients with Crohn's disease than from those with ulcerative colitis or diseases not specifically related to inflammatory bowel disease, according to a prospective study.

Nested polymerase chain reaction detected the DNA sequence IS900, which identifies Mycobacterium avium subspecies paratuberculosis (MAP), in 52 of 100 diseased biopsy samples from patients with Crohn's disease vs. 2 of 100 samples from patients with ulcerative colitis and 5 of 100 normal tissue biopsies from patients with diseases not specifically related to inflammatory bowel disease (Gut 2005;54:944–9).

Frank Autschbach, M.D., of the University of Heidelberg (Germany) and his colleagues reported that in patients with Crohn's disease, MAP was significantly more prevalent in diseased locations of the colon than the ileum, and in patients who had the disease for less than 15 years, compared with those who had it for 15 years or more. MAP did not occur more often with either stricturing or penetrating phenotypes of the disease. The investigators' findings are in direct contrast with reports on strong associations between polymorphisms of the NOD2 and CARD15 genes and patients with early-onset ileal Crohn's disease with a stricturing phenotype, said R. Balfour Sartor, M.D., of the University of North Carolina, Chapel Hill, in an editorial (Gut 2005;54:896–8).

Maintaining Remission in Crohn's

Withdrawal from azathioprine is not equivalent to continued therapy with the drug in Crohn's disease patients who have been in clinical remission for at least 3.5 years while on azathioprine, according to a randomized, double-blind trial.

Marc Lémann, M.D., of the Centre Hospitalier Universitaire Lariboisière-Saint-Louis, Paris, and his associates found that 3 (8%) of 40 patients who continued to receive azathioprine relapsed after 18 months vs. 9 (21%) of 43 patients on placebo. The trial was designed to determine whether withdrawal from azathioprine had an efficacy similar to continued treatment with azathioprine. The investigators determined that baseline levels of C-reactive protein of 20 mg/L or greater and hemoglobin less than 12 g/dL, as well as 50 or more months without steroids, were independent factors associated with a higher rate of relapse during the 18-month study (Gastroenterology 2005;128:1812–8).

Sleep Apnea: Risk for Liver Injury

Severe obstructive sleep apnea appears to be a risk factor for elevated liver enzymes and steatohepatitis, independent of body weight, reported Florence Tanné of Hôpital Saint-Antoine, Paris, and colleagues.

In a prospective study of 163 patients who were evaluated for clinical suspicion of obstructive sleep apnea (OSA), the researchers found that OSA was severe in 44 patients, moderate in 84, and absent in 35 patients. Body mass index and severe OSA were independently associated with elevated liver enzymes in a multivariate analysis. Of 32 patients with elevated liver enzymes, 18 underwent liver biopsy (Hepatology 2005;41:1290–6).

In 12 of 13 patients with a liver biopsy who had steatosis, evidence of steatohepatitis (lobular necrosis or hepatocyte ballooning) was seen. Patients with severe OSA had significantly higher levels of insulin, greater insulin resistance, and higher percentages of steatosis and scores of lobular necrosis and fibrosis than did those with either moderate OSA or no OSA.

Infliximab for Ulcerative Colitis

Infliximab significantly reduced the rate of colectomy in patients who had severe or moderately severe ulcerative colitis that was refractory to conventional treatment, reported Gunnar Järnerot, M.D., of Örebro (Sweden) University Hospital, and associates.

In an interim analysis of a randomized, double-blind trial that was ended early because of slow enrollment and ethical issues, significantly fewer patients (7 of 24) who received an infusion of infliximab had a colectomy within 90 days than did patients who received placebo (14 of 21). Treatment with infliximab was associated with a significant, nearly fivefold higher likelihood of remaining free of colectomy than was placebo. Two additional patients in each group had a colectomy after 6 months of follow-up (Gastroenterology 2005;128:1805–11).

Maintenance treatment with repeated infliximab infusions will probably be needed for patients with ulcerative colitis, just as it has been for patients with Crohn's disease, especially “in patients who escape a colectomy to avoid further hospitalizations and risk of later surgery,” Geert D'Haens, M.D., of the Imelda GI Clinical Research Center, Bonheiden, Belgium, said in an editorial (Gastroenterology 2005;128:2161–4). Centocor, the maker of infliximab (Remicade), did not sponsor the trial.

Mycobacterial Cause of Crohn's?

Mycobacterium avium subspecies paratuberculosis is present in gut tissues from a significantly greater percentage of patients with Crohn's disease than from those with ulcerative colitis or diseases not specifically related to inflammatory bowel disease, according to a prospective study.

Nested polymerase chain reaction detected the DNA sequence IS900, which identifies Mycobacterium avium subspecies paratuberculosis (MAP), in 52 of 100 diseased biopsy samples from patients with Crohn's disease vs. 2 of 100 samples from patients with ulcerative colitis and 5 of 100 normal tissue biopsies from patients with diseases not specifically related to inflammatory bowel disease (Gut 2005;54:944–9).

Frank Autschbach, M.D., of the University of Heidelberg (Germany) and his colleagues reported that in patients with Crohn's disease, MAP was significantly more prevalent in diseased locations of the colon than the ileum, and in patients who had the disease for less than 15 years, compared with those who had it for 15 years or more. MAP did not occur more often with either stricturing or penetrating phenotypes of the disease. The investigators' findings are in direct contrast with reports on strong associations between polymorphisms of the NOD2 and CARD15 genes and patients with early-onset ileal Crohn's disease with a stricturing phenotype, said R. Balfour Sartor, M.D., of the University of North Carolina, Chapel Hill, in an editorial (Gut 2005;54:896–8).

Maintaining Remission in Crohn's

Withdrawal from azathioprine is not equivalent to continued therapy with the drug in Crohn's disease patients who have been in clinical remission for at least 3.5 years while on azathioprine, according to a randomized, double-blind trial.

Marc Lémann, M.D., of the Centre Hospitalier Universitaire Lariboisière-Saint-Louis, Paris, and his associates found that 3 (8%) of 40 patients who continued to receive azathioprine relapsed after 18 months vs. 9 (21%) of 43 patients on placebo. The trial was designed to determine whether withdrawal from azathioprine had an efficacy similar to continued treatment with azathioprine. The investigators determined that baseline levels of C-reactive protein of 20 mg/L or greater and hemoglobin less than 12 g/dL, as well as 50 or more months without steroids, were independent factors associated with a higher rate of relapse during the 18-month study (Gastroenterology 2005;128:1812–8).

Sleep Apnea: Risk for Liver Injury

Severe obstructive sleep apnea appears to be a risk factor for elevated liver enzymes and steatohepatitis, independent of body weight, reported Florence Tanné of Hôpital Saint-Antoine, Paris, and colleagues.

In a prospective study of 163 patients who were evaluated for clinical suspicion of obstructive sleep apnea (OSA), the researchers found that OSA was severe in 44 patients, moderate in 84, and absent in 35 patients. Body mass index and severe OSA were independently associated with elevated liver enzymes in a multivariate analysis. Of 32 patients with elevated liver enzymes, 18 underwent liver biopsy (Hepatology 2005;41:1290–6).

In 12 of 13 patients with a liver biopsy who had steatosis, evidence of steatohepatitis (lobular necrosis or hepatocyte ballooning) was seen. Patients with severe OSA had significantly higher levels of insulin, greater insulin resistance, and higher percentages of steatosis and scores of lobular necrosis and fibrosis than did those with either moderate OSA or no OSA.

BETHESDA, MD. — High-resolution peripheral quantitative CT is a promising technology for identifying osteoporosis-related changes in bone microarchitecture, according to results of a prospective study.

Data from the noninvasive technique suggests that the imaging procedure will provide new insight into the degradation of bone mineral architecture that occurs in osteoporosis, Stéphanie Boutroy, Ph.D., said at a meeting on bone quality.

Dr. Boutroy of France's National Institute of Health and Medical Research, Lyon, described her findings from an investigation of the scanning technique in 108 healthy premenopausal women (aged 19–45 years), 109 osteopenic, postmenopausal women (aged 52–88 years), and 33 osteoporotic, postmenopausal women (aged 61–84 years). The women were classified as osteopenic or osteoporotic based on bone mineral density (BMD) measures taken by dual x-ray absorptiometry of the femoral neck or spine.

Initially, eight healthy women underwent three separate scanning sessions within 1 month to determine the short-term reproducibility of the density and architecture parameters of the scanning protocol. In the three sessions, trabecular and cortical volumetric BMD measurements varied by only 0.5%–1.3% in each of those eight patients. Similarly, trabecular architecture values varied by 0.9%–3.1% for each patient between sessions.

When Dr. Boutroy examined the relationship between volumetric BMD and architectural parameters, she found that total density, as expected, was strongly correlated to trabecular and cortical density. Trabecular and cortical density were strongly correlated to trabecular architecture and cortical thickness.

At the distal radius, osteoporotic women had significantly lower total volumetric BMD and cortical thickness compared with osteopenic women. Osteoporotic women also had comparatively lower trabecular density, number, thickness, and separation. No differences were found in cortical density or the distribution of trabeculae between the groups, Dr. Boutroy said at the meeting, sponsored by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the American Society for Bone and Mineral Research.

At the tibia, osteoporotic women had significantly lower measurements on all parameters (total volumetric BMD, cortical and trabecular density, and trabecular number, thickness, and separation) than osteopenic women.

Dr. Boutroy said she has no financial interest in the companies that manufacture high-resolution peripheral quantitative CT devices.

This high-resolution peripheral quantitative CT scan of an osteoporotic woman's tibia shows worsening trabecular connectivity, separation, and distribution. Courtesy Dr. Stéphanie Boutroy

BETHESDA, MD. — High-resolution peripheral quantitative CT is a promising technology for identifying osteoporosis-related changes in bone microarchitecture, according to results of a prospective study.

Data from the noninvasive technique suggests that the imaging procedure will provide new insight into the degradation of bone mineral architecture that occurs in osteoporosis, Stéphanie Boutroy, Ph.D., said at a meeting on bone quality.

Dr. Boutroy of France's National Institute of Health and Medical Research, Lyon, described her findings from an investigation of the scanning technique in 108 healthy premenopausal women (aged 19–45 years), 109 osteopenic, postmenopausal women (aged 52–88 years), and 33 osteoporotic, postmenopausal women (aged 61–84 years). The women were classified as osteopenic or osteoporotic based on bone mineral density (BMD) measures taken by dual x-ray absorptiometry of the femoral neck or spine.

Initially, eight healthy women underwent three separate scanning sessions within 1 month to determine the short-term reproducibility of the density and architecture parameters of the scanning protocol. In the three sessions, trabecular and cortical volumetric BMD measurements varied by only 0.5%–1.3% in each of those eight patients. Similarly, trabecular architecture values varied by 0.9%–3.1% for each patient between sessions.

When Dr. Boutroy examined the relationship between volumetric BMD and architectural parameters, she found that total density, as expected, was strongly correlated to trabecular and cortical density. Trabecular and cortical density were strongly correlated to trabecular architecture and cortical thickness.

At the distal radius, osteoporotic women had significantly lower total volumetric BMD and cortical thickness compared with osteopenic women. Osteoporotic women also had comparatively lower trabecular density, number, thickness, and separation. No differences were found in cortical density or the distribution of trabeculae between the groups, Dr. Boutroy said at the meeting, sponsored by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the American Society for Bone and Mineral Research.

At the tibia, osteoporotic women had significantly lower measurements on all parameters (total volumetric BMD, cortical and trabecular density, and trabecular number, thickness, and separation) than osteopenic women.

Dr. Boutroy said she has no financial interest in the companies that manufacture high-resolution peripheral quantitative CT devices.

This high-resolution peripheral quantitative CT scan of an osteoporotic woman's tibia shows worsening trabecular connectivity, separation, and distribution. Courtesy Dr. Stéphanie Boutroy

BETHESDA, MD. — High-resolution peripheral quantitative CT is a promising technology for identifying osteoporosis-related changes in bone microarchitecture, according to results of a prospective study.

Data from the noninvasive technique suggests that the imaging procedure will provide new insight into the degradation of bone mineral architecture that occurs in osteoporosis, Stéphanie Boutroy, Ph.D., said at a meeting on bone quality.

Dr. Boutroy of France's National Institute of Health and Medical Research, Lyon, described her findings from an investigation of the scanning technique in 108 healthy premenopausal women (aged 19–45 years), 109 osteopenic, postmenopausal women (aged 52–88 years), and 33 osteoporotic, postmenopausal women (aged 61–84 years). The women were classified as osteopenic or osteoporotic based on bone mineral density (BMD) measures taken by dual x-ray absorptiometry of the femoral neck or spine.

Initially, eight healthy women underwent three separate scanning sessions within 1 month to determine the short-term reproducibility of the density and architecture parameters of the scanning protocol. In the three sessions, trabecular and cortical volumetric BMD measurements varied by only 0.5%–1.3% in each of those eight patients. Similarly, trabecular architecture values varied by 0.9%–3.1% for each patient between sessions.

When Dr. Boutroy examined the relationship between volumetric BMD and architectural parameters, she found that total density, as expected, was strongly correlated to trabecular and cortical density. Trabecular and cortical density were strongly correlated to trabecular architecture and cortical thickness.

At the distal radius, osteoporotic women had significantly lower total volumetric BMD and cortical thickness compared with osteopenic women. Osteoporotic women also had comparatively lower trabecular density, number, thickness, and separation. No differences were found in cortical density or the distribution of trabeculae between the groups, Dr. Boutroy said at the meeting, sponsored by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the American Society for Bone and Mineral Research.

At the tibia, osteoporotic women had significantly lower measurements on all parameters (total volumetric BMD, cortical and trabecular density, and trabecular number, thickness, and separation) than osteopenic women.

Dr. Boutroy said she has no financial interest in the companies that manufacture high-resolution peripheral quantitative CT devices.

This high-resolution peripheral quantitative CT scan of an osteoporotic woman's tibia shows worsening trabecular connectivity, separation, and distribution. Courtesy Dr. Stéphanie Boutroy