Jeff Evans

ORLANDO, FLA. — Posttreatment sexual function in prostate cancer patients differs initially between the various primary treatments, but becomes nearly equal among all modalities after 4 years, Joycelyn L. Speight, M.D., reported at a symposium on prostate cancer sponsored by the American Society of Clinical Oncology.

Still, some data on patients in a prostate cancer registry suggest that brachytherapy may offer modest advantages in preserving sexual function, at least for some patients, said Dr. Speight, of the University of California, San Francisco.

Sexual function after radiation- and brachytherapy (BT)-based treatment regimens tends to be highest immediately after treatment, then declines slowly during the ensuing 4 years. After radical prostatectomy, sexual function is lowest immediately after treatment and then slowly improves during the next 4 years, she reported.

“All of the treatments for prostate cancer can have an impact on health-related quality of life, and this often influences the patient's treatment choice,” she said.

The findings were obtained from self-reports of sexual function and quality of life submitted by 2,903 patients in the CaPSURE registry (Cancer of the Prostate Strategic Urologic Research Endeavor) every 6 months for up to 4 years after treatment.

The validated questionnaires consisted of the Rand 36-item health survey, the UCLA prostate cancer index, and a 12-item medical health checklist.

In patients who received 6 months or less of neoadjuvant androgen deprivation therapy (ADT), brachytherapy (BT) was associated with the least change and decline in sexual function and significantly better overall sexual function 4 years after treatment than other treatment modalities.

But in patients who received more than 6 months of neoadjuvant ADT, all therapies provided similar levels of sexual function 4 years after treatment.

Patients who received external beam radiotherapy (EBRT) alone, BT alone, or EBRT plus a BT boost were significantly older on average than were patients who received nerve-sparing or non-nerve-sparing radical prostatectomy (70 years vs. 63 years), and were significantly more likely to have at least one comorbid condition such as diabetes, hypertension, or coronary artery disease (82% vs. 53%). The group treated with EBRT and/or BT also was significantly more likely to have received neoadjuvant ADT for more than 6 months prior to treatment, compared with the prostatectomy group (38% vs. 8%).

Regardless of treatment, all patients who received more than 6 months of neoadjuvant ADT showed clinically significant improvement in sexual function between treatment and year 1.

After the first year, sexual function levels reached a plateau for all groups that received more than 6 months of neoadjuvant ADT, Dr. Speight said at the symposium, which was cosponsored by the Society of Urologic Oncology and the American Society for Therapeutic Radiology and Oncology.

By year 4, patients who received EBRT, BT, or EBRT plus BT had the same level of sexual function regardless of whether they received more than 6 months of neoadjuvant ADT. But patients who received nerve-sparing or non-nerve-sparing radical prostatectomy with more than 6 months of neoadjuvant ADT had significantly better sexual function after 4 years than those who had 6 months or less of neoadjuvant ADT.

Sexual function was evaluated on a scale of 0 to 100, with higher scores meaning better function. At 4 years after treatment, no group scored higher than 34 on average.

Immediately after treatment, no group had an average score lower than 12. No data were available on sexual function prior to treatment.

ORLANDO, FLA. — Posttreatment sexual function in prostate cancer patients differs initially between the various primary treatments, but becomes nearly equal among all modalities after 4 years, Joycelyn L. Speight, M.D., reported at a symposium on prostate cancer sponsored by the American Society of Clinical Oncology.

Still, some data on patients in a prostate cancer registry suggest that brachytherapy may offer modest advantages in preserving sexual function, at least for some patients, said Dr. Speight, of the University of California, San Francisco.

Sexual function after radiation- and brachytherapy (BT)-based treatment regimens tends to be highest immediately after treatment, then declines slowly during the ensuing 4 years. After radical prostatectomy, sexual function is lowest immediately after treatment and then slowly improves during the next 4 years, she reported.

“All of the treatments for prostate cancer can have an impact on health-related quality of life, and this often influences the patient's treatment choice,” she said.

The findings were obtained from self-reports of sexual function and quality of life submitted by 2,903 patients in the CaPSURE registry (Cancer of the Prostate Strategic Urologic Research Endeavor) every 6 months for up to 4 years after treatment.

The validated questionnaires consisted of the Rand 36-item health survey, the UCLA prostate cancer index, and a 12-item medical health checklist.

In patients who received 6 months or less of neoadjuvant androgen deprivation therapy (ADT), brachytherapy (BT) was associated with the least change and decline in sexual function and significantly better overall sexual function 4 years after treatment than other treatment modalities.

But in patients who received more than 6 months of neoadjuvant ADT, all therapies provided similar levels of sexual function 4 years after treatment.

Patients who received external beam radiotherapy (EBRT) alone, BT alone, or EBRT plus a BT boost were significantly older on average than were patients who received nerve-sparing or non-nerve-sparing radical prostatectomy (70 years vs. 63 years), and were significantly more likely to have at least one comorbid condition such as diabetes, hypertension, or coronary artery disease (82% vs. 53%). The group treated with EBRT and/or BT also was significantly more likely to have received neoadjuvant ADT for more than 6 months prior to treatment, compared with the prostatectomy group (38% vs. 8%).

Regardless of treatment, all patients who received more than 6 months of neoadjuvant ADT showed clinically significant improvement in sexual function between treatment and year 1.

After the first year, sexual function levels reached a plateau for all groups that received more than 6 months of neoadjuvant ADT, Dr. Speight said at the symposium, which was cosponsored by the Society of Urologic Oncology and the American Society for Therapeutic Radiology and Oncology.

By year 4, patients who received EBRT, BT, or EBRT plus BT had the same level of sexual function regardless of whether they received more than 6 months of neoadjuvant ADT. But patients who received nerve-sparing or non-nerve-sparing radical prostatectomy with more than 6 months of neoadjuvant ADT had significantly better sexual function after 4 years than those who had 6 months or less of neoadjuvant ADT.

Sexual function was evaluated on a scale of 0 to 100, with higher scores meaning better function. At 4 years after treatment, no group scored higher than 34 on average.

Immediately after treatment, no group had an average score lower than 12. No data were available on sexual function prior to treatment.

ORLANDO, FLA. — Posttreatment sexual function in prostate cancer patients differs initially between the various primary treatments, but becomes nearly equal among all modalities after 4 years, Joycelyn L. Speight, M.D., reported at a symposium on prostate cancer sponsored by the American Society of Clinical Oncology.

Still, some data on patients in a prostate cancer registry suggest that brachytherapy may offer modest advantages in preserving sexual function, at least for some patients, said Dr. Speight, of the University of California, San Francisco.

Sexual function after radiation- and brachytherapy (BT)-based treatment regimens tends to be highest immediately after treatment, then declines slowly during the ensuing 4 years. After radical prostatectomy, sexual function is lowest immediately after treatment and then slowly improves during the next 4 years, she reported.

“All of the treatments for prostate cancer can have an impact on health-related quality of life, and this often influences the patient's treatment choice,” she said.

The findings were obtained from self-reports of sexual function and quality of life submitted by 2,903 patients in the CaPSURE registry (Cancer of the Prostate Strategic Urologic Research Endeavor) every 6 months for up to 4 years after treatment.

The validated questionnaires consisted of the Rand 36-item health survey, the UCLA prostate cancer index, and a 12-item medical health checklist.

In patients who received 6 months or less of neoadjuvant androgen deprivation therapy (ADT), brachytherapy (BT) was associated with the least change and decline in sexual function and significantly better overall sexual function 4 years after treatment than other treatment modalities.

But in patients who received more than 6 months of neoadjuvant ADT, all therapies provided similar levels of sexual function 4 years after treatment.

Patients who received external beam radiotherapy (EBRT) alone, BT alone, or EBRT plus a BT boost were significantly older on average than were patients who received nerve-sparing or non-nerve-sparing radical prostatectomy (70 years vs. 63 years), and were significantly more likely to have at least one comorbid condition such as diabetes, hypertension, or coronary artery disease (82% vs. 53%). The group treated with EBRT and/or BT also was significantly more likely to have received neoadjuvant ADT for more than 6 months prior to treatment, compared with the prostatectomy group (38% vs. 8%).

Regardless of treatment, all patients who received more than 6 months of neoadjuvant ADT showed clinically significant improvement in sexual function between treatment and year 1.

After the first year, sexual function levels reached a plateau for all groups that received more than 6 months of neoadjuvant ADT, Dr. Speight said at the symposium, which was cosponsored by the Society of Urologic Oncology and the American Society for Therapeutic Radiology and Oncology.

By year 4, patients who received EBRT, BT, or EBRT plus BT had the same level of sexual function regardless of whether they received more than 6 months of neoadjuvant ADT. But patients who received nerve-sparing or non-nerve-sparing radical prostatectomy with more than 6 months of neoadjuvant ADT had significantly better sexual function after 4 years than those who had 6 months or less of neoadjuvant ADT.

Sexual function was evaluated on a scale of 0 to 100, with higher scores meaning better function. At 4 years after treatment, no group scored higher than 34 on average.

Immediately after treatment, no group had an average score lower than 12. No data were available on sexual function prior to treatment.

Nicotine patches may help more adolescent patients addicted to tobacco to abstain from smoking than placebo, according to the results of one of the few double-blind, randomized trials of its kind.

In the pilot study, significantly more adolescents who received patches had continuous abstinence from cigarette smoking after 2 weeks (6 of 34, 18%) than those who received placebo (1 of 40, 3%).

Patients treated with nicotine gum abstained from smoking after 2 weeks at a rate similar to placebo patients (3 of 46, 7%), reported Eric T. Moolchan, M.D., and his colleagues at the National Institute on Drug Abuse (Pediatrics 2005;115:e407–14).

Each group had slightly higher rates of abstinence at the end of the first week of treatment—when follow-up monitoring of patients might begin in a standard medical practice.

But 2 weeks after randomization, cessation rates had fallen among all three groups.

At the end of the 3-month study, however, abstinence rates among the patch and placebo groups had climbed. Specifically, those rates stood at 21% in patch patients, 9% in gum patients, and 5% in placebo patients.

“To date, most of the studies [on nicotine replacement therapy for adolescent smokers] have not found much effect, but most of the studies have been very small and have limitations in their design,” said Douglas M. Ziedonis, M.D., director of the division of addiction psychiatry at the Robert Wood Johnson Medical School, New Brunswick, N.J., who was asked to comment on the study.

All patients in the study received weekly, 45-minute sessions of cognitive-behavioral therapy.

Psychosocial treatment in adult smokers improves the results of nicotine replacement medications by about 50%, Dr. Ziedonis said. But in the United States, only 3% of adults who are trying to quit get both medication and psychosocial treatment.

“With any other addiction, we would think it's crazy not to provide psychosocial treatment and medication,” he said in a telephone interview.

The study included adolescents aged 15 years on average who began smoking around age 11 years.

These highly tobacco-dependent patients smoked an average of about 19 cigarettes per day.

“It is important to note that 75% of the adolescents [in this study] had co-occurring mental illness,” Dr. Ziedonis said.

The most common diagnoses included oppositional defiant disorder (40%), conduct disorder (15%), premenstrual dysphoric disorder (11%), and attention-deficit hyperactivity disorder (7%).

The Substance Abuse and Mental Health Services Administration now defines the combination of tobacco addiction and mental illness as a type of co-occurring disorder.

“Unfortunately, I think of all the addictions, mental health staff have been the least trained on tobacco, even though they see that [addiction] the most,” Dr. Ziedonis said.

Even though nicotine patches and gum are sold over-the-counter (OTC), they cannot be sold legally to a person younger than 18 years of age.

An older family member could buy an OTC product for an adolescent, or a physician could prescribe a smoking cessation product or provide a written recommendation for an OTC product, he advised.

In many states, internet sites and telephone lines offer help to teenagers who want to quit smoking, in addition to “quit centers” where adolescents can get OTC nicotine replacement products and counseling in an individual or group format, Dr. Ziedonis pointed out.

Many quit centers require parental permission to distribute OTC medication, he said.

In the trial, all groups self-reported a mean reduction in cigarettes smoked per day that exceeded 80% at the end of treatment.

But objective measurement of smoking through expired carbon monoxide and levels of thiocyanate in saliva did not change from baseline to the end of treatment in any group.

The investigators suspected that the discrepancy between self-reports of reduced smoking and biomarkers of smoke exposure may have occurred because of compensatory smoking through deeper inhalation or inaccurate reporting by the adolescents.

“Although these results do not answer definitely the question of the efficacy of the patch or gum for treating adolescent smokers, the current findings lend empirical support to the U.S. Public Health Service clinical practice guideline for pediatricians, family practitioners, and other practitioners to prescribe or to recommend more consistently the nicotine patch, in addition to developmentally appropriate behavioral and counseling support, for adolescent smokers who are attempting to quit,” the researchers wrote.

The investigators designed the study to have sufficient statistical power to detect a significant reduction in cigarette smoking but not a cessation effect. A previous report noted that a reduction in exposure to tobacco may be an adequate intermediate treatment goal for adolescent smokers since they often encounter “lower systemic support for quit attempts, and potentially less motivation, preparation, and success in achieving total cessation,” than adults, Dr. Moolchan and his associates wrote.

Adverse events that were reported significantly more often with patches (pruritus, erythema, and shoulder or arm pain) or with gum (pruritus, sore throat, and hiccups) than with placebo occurred at rates similar to those observed in previous studies with adults.

Nicotine patches may help more adolescent patients addicted to tobacco to abstain from smoking than placebo, according to the results of one of the few double-blind, randomized trials of its kind.

In the pilot study, significantly more adolescents who received patches had continuous abstinence from cigarette smoking after 2 weeks (6 of 34, 18%) than those who received placebo (1 of 40, 3%).

Patients treated with nicotine gum abstained from smoking after 2 weeks at a rate similar to placebo patients (3 of 46, 7%), reported Eric T. Moolchan, M.D., and his colleagues at the National Institute on Drug Abuse (Pediatrics 2005;115:e407–14).

Each group had slightly higher rates of abstinence at the end of the first week of treatment—when follow-up monitoring of patients might begin in a standard medical practice.

But 2 weeks after randomization, cessation rates had fallen among all three groups.

At the end of the 3-month study, however, abstinence rates among the patch and placebo groups had climbed. Specifically, those rates stood at 21% in patch patients, 9% in gum patients, and 5% in placebo patients.

“To date, most of the studies [on nicotine replacement therapy for adolescent smokers] have not found much effect, but most of the studies have been very small and have limitations in their design,” said Douglas M. Ziedonis, M.D., director of the division of addiction psychiatry at the Robert Wood Johnson Medical School, New Brunswick, N.J., who was asked to comment on the study.

All patients in the study received weekly, 45-minute sessions of cognitive-behavioral therapy.

Psychosocial treatment in adult smokers improves the results of nicotine replacement medications by about 50%, Dr. Ziedonis said. But in the United States, only 3% of adults who are trying to quit get both medication and psychosocial treatment.

“With any other addiction, we would think it's crazy not to provide psychosocial treatment and medication,” he said in a telephone interview.

The study included adolescents aged 15 years on average who began smoking around age 11 years.

These highly tobacco-dependent patients smoked an average of about 19 cigarettes per day.

“It is important to note that 75% of the adolescents [in this study] had co-occurring mental illness,” Dr. Ziedonis said.

The most common diagnoses included oppositional defiant disorder (40%), conduct disorder (15%), premenstrual dysphoric disorder (11%), and attention-deficit hyperactivity disorder (7%).

The Substance Abuse and Mental Health Services Administration now defines the combination of tobacco addiction and mental illness as a type of co-occurring disorder.

“Unfortunately, I think of all the addictions, mental health staff have been the least trained on tobacco, even though they see that [addiction] the most,” Dr. Ziedonis said.

Even though nicotine patches and gum are sold over-the-counter (OTC), they cannot be sold legally to a person younger than 18 years of age.

An older family member could buy an OTC product for an adolescent, or a physician could prescribe a smoking cessation product or provide a written recommendation for an OTC product, he advised.

In many states, internet sites and telephone lines offer help to teenagers who want to quit smoking, in addition to “quit centers” where adolescents can get OTC nicotine replacement products and counseling in an individual or group format, Dr. Ziedonis pointed out.

Many quit centers require parental permission to distribute OTC medication, he said.

In the trial, all groups self-reported a mean reduction in cigarettes smoked per day that exceeded 80% at the end of treatment.

But objective measurement of smoking through expired carbon monoxide and levels of thiocyanate in saliva did not change from baseline to the end of treatment in any group.

The investigators suspected that the discrepancy between self-reports of reduced smoking and biomarkers of smoke exposure may have occurred because of compensatory smoking through deeper inhalation or inaccurate reporting by the adolescents.

“Although these results do not answer definitely the question of the efficacy of the patch or gum for treating adolescent smokers, the current findings lend empirical support to the U.S. Public Health Service clinical practice guideline for pediatricians, family practitioners, and other practitioners to prescribe or to recommend more consistently the nicotine patch, in addition to developmentally appropriate behavioral and counseling support, for adolescent smokers who are attempting to quit,” the researchers wrote.

The investigators designed the study to have sufficient statistical power to detect a significant reduction in cigarette smoking but not a cessation effect. A previous report noted that a reduction in exposure to tobacco may be an adequate intermediate treatment goal for adolescent smokers since they often encounter “lower systemic support for quit attempts, and potentially less motivation, preparation, and success in achieving total cessation,” than adults, Dr. Moolchan and his associates wrote.

Adverse events that were reported significantly more often with patches (pruritus, erythema, and shoulder or arm pain) or with gum (pruritus, sore throat, and hiccups) than with placebo occurred at rates similar to those observed in previous studies with adults.

Nicotine patches may help more adolescent patients addicted to tobacco to abstain from smoking than placebo, according to the results of one of the few double-blind, randomized trials of its kind.

In the pilot study, significantly more adolescents who received patches had continuous abstinence from cigarette smoking after 2 weeks (6 of 34, 18%) than those who received placebo (1 of 40, 3%).

Patients treated with nicotine gum abstained from smoking after 2 weeks at a rate similar to placebo patients (3 of 46, 7%), reported Eric T. Moolchan, M.D., and his colleagues at the National Institute on Drug Abuse (Pediatrics 2005;115:e407–14).

Each group had slightly higher rates of abstinence at the end of the first week of treatment—when follow-up monitoring of patients might begin in a standard medical practice.

But 2 weeks after randomization, cessation rates had fallen among all three groups.

At the end of the 3-month study, however, abstinence rates among the patch and placebo groups had climbed. Specifically, those rates stood at 21% in patch patients, 9% in gum patients, and 5% in placebo patients.

“To date, most of the studies [on nicotine replacement therapy for adolescent smokers] have not found much effect, but most of the studies have been very small and have limitations in their design,” said Douglas M. Ziedonis, M.D., director of the division of addiction psychiatry at the Robert Wood Johnson Medical School, New Brunswick, N.J., who was asked to comment on the study.

All patients in the study received weekly, 45-minute sessions of cognitive-behavioral therapy.

Psychosocial treatment in adult smokers improves the results of nicotine replacement medications by about 50%, Dr. Ziedonis said. But in the United States, only 3% of adults who are trying to quit get both medication and psychosocial treatment.

“With any other addiction, we would think it's crazy not to provide psychosocial treatment and medication,” he said in a telephone interview.

The study included adolescents aged 15 years on average who began smoking around age 11 years.

These highly tobacco-dependent patients smoked an average of about 19 cigarettes per day.

“It is important to note that 75% of the adolescents [in this study] had co-occurring mental illness,” Dr. Ziedonis said.

The most common diagnoses included oppositional defiant disorder (40%), conduct disorder (15%), premenstrual dysphoric disorder (11%), and attention-deficit hyperactivity disorder (7%).

The Substance Abuse and Mental Health Services Administration now defines the combination of tobacco addiction and mental illness as a type of co-occurring disorder.

“Unfortunately, I think of all the addictions, mental health staff have been the least trained on tobacco, even though they see that [addiction] the most,” Dr. Ziedonis said.

Even though nicotine patches and gum are sold over-the-counter (OTC), they cannot be sold legally to a person younger than 18 years of age.

An older family member could buy an OTC product for an adolescent, or a physician could prescribe a smoking cessation product or provide a written recommendation for an OTC product, he advised.

In many states, internet sites and telephone lines offer help to teenagers who want to quit smoking, in addition to “quit centers” where adolescents can get OTC nicotine replacement products and counseling in an individual or group format, Dr. Ziedonis pointed out.

Many quit centers require parental permission to distribute OTC medication, he said.

In the trial, all groups self-reported a mean reduction in cigarettes smoked per day that exceeded 80% at the end of treatment.

But objective measurement of smoking through expired carbon monoxide and levels of thiocyanate in saliva did not change from baseline to the end of treatment in any group.

The investigators suspected that the discrepancy between self-reports of reduced smoking and biomarkers of smoke exposure may have occurred because of compensatory smoking through deeper inhalation or inaccurate reporting by the adolescents.

“Although these results do not answer definitely the question of the efficacy of the patch or gum for treating adolescent smokers, the current findings lend empirical support to the U.S. Public Health Service clinical practice guideline for pediatricians, family practitioners, and other practitioners to prescribe or to recommend more consistently the nicotine patch, in addition to developmentally appropriate behavioral and counseling support, for adolescent smokers who are attempting to quit,” the researchers wrote.

The investigators designed the study to have sufficient statistical power to detect a significant reduction in cigarette smoking but not a cessation effect. A previous report noted that a reduction in exposure to tobacco may be an adequate intermediate treatment goal for adolescent smokers since they often encounter “lower systemic support for quit attempts, and potentially less motivation, preparation, and success in achieving total cessation,” than adults, Dr. Moolchan and his associates wrote.

Adverse events that were reported significantly more often with patches (pruritus, erythema, and shoulder or arm pain) or with gum (pruritus, sore throat, and hiccups) than with placebo occurred at rates similar to those observed in previous studies with adults.

ATLANTA – Valproate appears to have a beneficial effect on the manic symptoms of child and adolescent patients with bipolar disorder, but no large scale double-blind, placebo-controlled trials have tested the anticonvulsant in young people.

A search for clinical studies of valproate in children and adolescents with bipolar disorder published from 1990 to 2003 identified nine studies, Lee S. Cohen, M.D., reported at the American Psychiatric Association's Institute on Psychiatric Services.

Of 128 patients in the metaanalysis, 92 (72%) had a positive response to valproate on one of several structured assessment scales. None of the patients had epilepsy.

In three studies that reported the effectiveness of valproate on a manic rating scale (Young Mania Rating Scale or the Modified Mania Rating Scale), 63 (65%) of 97 patients had more than 50% reduction in symptoms when valproate was part of the treatment regimen, noted Dr. Cohen of Columbia University, New York.

Some of the studies used valproate (Depacon); others used divalproex (Depakote) or valproic acid (Depakene).

In five studies that reported the blood serum level of valproate, 95 patients had an average concentration of 87 mcg/mL, although the mean dose varied between the studies because of differences in age. The metaanalysis, presented during a poster session, was funded by Abbott Laboratories, which manufactures different types of valproate (Depakote, Depakene, and Depacon).

ATLANTA – Valproate appears to have a beneficial effect on the manic symptoms of child and adolescent patients with bipolar disorder, but no large scale double-blind, placebo-controlled trials have tested the anticonvulsant in young people.

A search for clinical studies of valproate in children and adolescents with bipolar disorder published from 1990 to 2003 identified nine studies, Lee S. Cohen, M.D., reported at the American Psychiatric Association's Institute on Psychiatric Services.

Of 128 patients in the metaanalysis, 92 (72%) had a positive response to valproate on one of several structured assessment scales. None of the patients had epilepsy.

In three studies that reported the effectiveness of valproate on a manic rating scale (Young Mania Rating Scale or the Modified Mania Rating Scale), 63 (65%) of 97 patients had more than 50% reduction in symptoms when valproate was part of the treatment regimen, noted Dr. Cohen of Columbia University, New York.

Some of the studies used valproate (Depacon); others used divalproex (Depakote) or valproic acid (Depakene).

In five studies that reported the blood serum level of valproate, 95 patients had an average concentration of 87 mcg/mL, although the mean dose varied between the studies because of differences in age. The metaanalysis, presented during a poster session, was funded by Abbott Laboratories, which manufactures different types of valproate (Depakote, Depakene, and Depacon).

ATLANTA – Valproate appears to have a beneficial effect on the manic symptoms of child and adolescent patients with bipolar disorder, but no large scale double-blind, placebo-controlled trials have tested the anticonvulsant in young people.

A search for clinical studies of valproate in children and adolescents with bipolar disorder published from 1990 to 2003 identified nine studies, Lee S. Cohen, M.D., reported at the American Psychiatric Association's Institute on Psychiatric Services.

Of 128 patients in the metaanalysis, 92 (72%) had a positive response to valproate on one of several structured assessment scales. None of the patients had epilepsy.

In three studies that reported the effectiveness of valproate on a manic rating scale (Young Mania Rating Scale or the Modified Mania Rating Scale), 63 (65%) of 97 patients had more than 50% reduction in symptoms when valproate was part of the treatment regimen, noted Dr. Cohen of Columbia University, New York.

Some of the studies used valproate (Depacon); others used divalproex (Depakote) or valproic acid (Depakene).

In five studies that reported the blood serum level of valproate, 95 patients had an average concentration of 87 mcg/mL, although the mean dose varied between the studies because of differences in age. The metaanalysis, presented during a poster session, was funded by Abbott Laboratories, which manufactures different types of valproate (Depakote, Depakene, and Depacon).

Risk Factors for Nighttime Heartburn

Consumption of carbonated soft drinks and the use of benzodiazepines are newly identified risk factors for nighttime heartburn, according to the largest prospective, observational study of its kind.

Of 15,314 individuals older than 40 years who responded to a question about nighttime heartburn on a survey, 25% reported heartburn that awakened them two or more times per month, reported Ronnie Fass, M.D., of the University of Arizona, Tucson, and associates (Chest 2005;127:1658–66).

Multivariate logistic regression analysis showed that carbonated soft drink intake and the use of benzodiazepines were significant predictors of heartburn during sleep, in addition to high body mass index, hypertension, and asthma, Dr. Fass reported.

Insomnia and the symptom complex of snoring and sleepiness also significantly predicted heartburn during sleep.

However, these factors may be the consequences rather than the causes of heartburn during sleep, the study investigators noted.

Metformin, Nonalcoholic Fatty Liver

Metformin appears to improve ALT levels and metabolic syndrome criteria significantly more than a prescriptive diet or vitamin E supplements in patients with nonalcoholic fatty liver disease, reported Elisabetta Bugianesi, M.D., of the University of Turin (Italy) and her associates.

In a randomized study, ALT levels dropped within the normal range of less than 40 U/L after 12 months of treatment in significantly more patients who received no more than 2,000 mg of metformin per day (31 of 55) than patients randomized to a diet with a 500 kcal deficit per day (8 of 27) or to supplementation with 400 IU of vitamin E per day (4 of 28) (Am. J. Gastroenterol. 2005;100:1082–90).

In a multivariate analysis, normal ALT at the end of the 12-month study period was significantly associated with a change in body mass index and metformin treatment. Compared with the diet and vitamin E groups together, patients on metformin had a significant trend toward improvement in fasting glucose, insulin, and insulin resistance according to the homeostasis model assessment technique.

Fluorescence Endoscopy for Barrett's

Surveillance of Barrett's esophagus with autofluorescence endoscopy performed with a videoendoscope, rather than a fiberoptic endoscope, may enhance detection of dysplasia or early cancer, reported Mohammed A. Kara, M.D., and his colleagues at the Academic Medical Center, Amsterdam.

In a randomized, crossover study of 47 patients, autofluorescence endoscopy with a fiberoptic endoscope had the same sensitivity in detecting high-grade dysplasia or early cancer (62%) as did standard white-light videoendoscopy. The sensitivities were 69% for fluorescence endoscopy and 85% for standard endoscopy when the results of random biopsy specimens with high-grade dysplasia or early cancer were included in the analysis (Gastrointest. Endosc. 2005;61:671–8).

In a separate study, Dr. Kara and his associates improved autofluorescence endoscopy by using a videoendoscope that incorporates information from reflected light and displays dysplastic or neoplastic lesions as blue or violet and nondysplastic Barrett's esophagus as green. In a high-risk referral group of 60 patients with Barrett's esophagus, 14 (23%) had high-grade dysplasia or early cancer detected with standard white-light endoscopy or autofluorescence endoscopy with a videoendoscope; the modified form of autofluorescence endoscopy detected an additional 6 patients (bringing the total detection rate to 33%). (Gastrointest. Endosc. 2005;61:679–85).

Hyperhomocysteinemia in Hepatitis C

Chronic hepatitis C patients with hyperhomocysteinemia are at high risk for steatosis and progression of liver fibrosis, according to prospective data on 116 patients.

Luigi E. Adinolfi, M.D., and his colleagues at the Second University of Naples (Italy) reported that the degree of steatosis in those patients was correlated with hyperhomocysteinemia and with the C677T polymorphism of the MTHFR gene—a mutation known to be associated with hyperhomocysteinemia. The prevalence of steatosis and of high-grade steatosis was 41% and 11%, respectively, in patients without the polymorphism; 61% and 49% in patients heterozygous for the polymorphism; and 79% and 64% in patients homozygous for the polymorphism (Hepatology 2005;41:995–1003).

In multivariate analyses, progression of liver fibrosis was independently associated with steatosis, homocysteine levels were independently associated with steatosis and the MTHFR polymorphism, and steatosis grades greater than 1 were independently associated with levels of homocysteinemia and liver fibrosis scores.

Risk Factors for Nighttime Heartburn

Consumption of carbonated soft drinks and the use of benzodiazepines are newly identified risk factors for nighttime heartburn, according to the largest prospective, observational study of its kind.

Of 15,314 individuals older than 40 years who responded to a question about nighttime heartburn on a survey, 25% reported heartburn that awakened them two or more times per month, reported Ronnie Fass, M.D., of the University of Arizona, Tucson, and associates (Chest 2005;127:1658–66).

Multivariate logistic regression analysis showed that carbonated soft drink intake and the use of benzodiazepines were significant predictors of heartburn during sleep, in addition to high body mass index, hypertension, and asthma, Dr. Fass reported.

Insomnia and the symptom complex of snoring and sleepiness also significantly predicted heartburn during sleep.

However, these factors may be the consequences rather than the causes of heartburn during sleep, the study investigators noted.

Metformin, Nonalcoholic Fatty Liver

Metformin appears to improve ALT levels and metabolic syndrome criteria significantly more than a prescriptive diet or vitamin E supplements in patients with nonalcoholic fatty liver disease, reported Elisabetta Bugianesi, M.D., of the University of Turin (Italy) and her associates.

In a randomized study, ALT levels dropped within the normal range of less than 40 U/L after 12 months of treatment in significantly more patients who received no more than 2,000 mg of metformin per day (31 of 55) than patients randomized to a diet with a 500 kcal deficit per day (8 of 27) or to supplementation with 400 IU of vitamin E per day (4 of 28) (Am. J. Gastroenterol. 2005;100:1082–90).

In a multivariate analysis, normal ALT at the end of the 12-month study period was significantly associated with a change in body mass index and metformin treatment. Compared with the diet and vitamin E groups together, patients on metformin had a significant trend toward improvement in fasting glucose, insulin, and insulin resistance according to the homeostasis model assessment technique.

Fluorescence Endoscopy for Barrett's

Surveillance of Barrett's esophagus with autofluorescence endoscopy performed with a videoendoscope, rather than a fiberoptic endoscope, may enhance detection of dysplasia or early cancer, reported Mohammed A. Kara, M.D., and his colleagues at the Academic Medical Center, Amsterdam.

In a randomized, crossover study of 47 patients, autofluorescence endoscopy with a fiberoptic endoscope had the same sensitivity in detecting high-grade dysplasia or early cancer (62%) as did standard white-light videoendoscopy. The sensitivities were 69% for fluorescence endoscopy and 85% for standard endoscopy when the results of random biopsy specimens with high-grade dysplasia or early cancer were included in the analysis (Gastrointest. Endosc. 2005;61:671–8).

In a separate study, Dr. Kara and his associates improved autofluorescence endoscopy by using a videoendoscope that incorporates information from reflected light and displays dysplastic or neoplastic lesions as blue or violet and nondysplastic Barrett's esophagus as green. In a high-risk referral group of 60 patients with Barrett's esophagus, 14 (23%) had high-grade dysplasia or early cancer detected with standard white-light endoscopy or autofluorescence endoscopy with a videoendoscope; the modified form of autofluorescence endoscopy detected an additional 6 patients (bringing the total detection rate to 33%). (Gastrointest. Endosc. 2005;61:679–85).

Hyperhomocysteinemia in Hepatitis C

Chronic hepatitis C patients with hyperhomocysteinemia are at high risk for steatosis and progression of liver fibrosis, according to prospective data on 116 patients.

Luigi E. Adinolfi, M.D., and his colleagues at the Second University of Naples (Italy) reported that the degree of steatosis in those patients was correlated with hyperhomocysteinemia and with the C677T polymorphism of the MTHFR gene—a mutation known to be associated with hyperhomocysteinemia. The prevalence of steatosis and of high-grade steatosis was 41% and 11%, respectively, in patients without the polymorphism; 61% and 49% in patients heterozygous for the polymorphism; and 79% and 64% in patients homozygous for the polymorphism (Hepatology 2005;41:995–1003).

In multivariate analyses, progression of liver fibrosis was independently associated with steatosis, homocysteine levels were independently associated with steatosis and the MTHFR polymorphism, and steatosis grades greater than 1 were independently associated with levels of homocysteinemia and liver fibrosis scores.

Risk Factors for Nighttime Heartburn

Consumption of carbonated soft drinks and the use of benzodiazepines are newly identified risk factors for nighttime heartburn, according to the largest prospective, observational study of its kind.

Of 15,314 individuals older than 40 years who responded to a question about nighttime heartburn on a survey, 25% reported heartburn that awakened them two or more times per month, reported Ronnie Fass, M.D., of the University of Arizona, Tucson, and associates (Chest 2005;127:1658–66).

Multivariate logistic regression analysis showed that carbonated soft drink intake and the use of benzodiazepines were significant predictors of heartburn during sleep, in addition to high body mass index, hypertension, and asthma, Dr. Fass reported.

Insomnia and the symptom complex of snoring and sleepiness also significantly predicted heartburn during sleep.

However, these factors may be the consequences rather than the causes of heartburn during sleep, the study investigators noted.

Metformin, Nonalcoholic Fatty Liver

Metformin appears to improve ALT levels and metabolic syndrome criteria significantly more than a prescriptive diet or vitamin E supplements in patients with nonalcoholic fatty liver disease, reported Elisabetta Bugianesi, M.D., of the University of Turin (Italy) and her associates.

In a randomized study, ALT levels dropped within the normal range of less than 40 U/L after 12 months of treatment in significantly more patients who received no more than 2,000 mg of metformin per day (31 of 55) than patients randomized to a diet with a 500 kcal deficit per day (8 of 27) or to supplementation with 400 IU of vitamin E per day (4 of 28) (Am. J. Gastroenterol. 2005;100:1082–90).

In a multivariate analysis, normal ALT at the end of the 12-month study period was significantly associated with a change in body mass index and metformin treatment. Compared with the diet and vitamin E groups together, patients on metformin had a significant trend toward improvement in fasting glucose, insulin, and insulin resistance according to the homeostasis model assessment technique.

Fluorescence Endoscopy for Barrett's

Surveillance of Barrett's esophagus with autofluorescence endoscopy performed with a videoendoscope, rather than a fiberoptic endoscope, may enhance detection of dysplasia or early cancer, reported Mohammed A. Kara, M.D., and his colleagues at the Academic Medical Center, Amsterdam.

In a randomized, crossover study of 47 patients, autofluorescence endoscopy with a fiberoptic endoscope had the same sensitivity in detecting high-grade dysplasia or early cancer (62%) as did standard white-light videoendoscopy. The sensitivities were 69% for fluorescence endoscopy and 85% for standard endoscopy when the results of random biopsy specimens with high-grade dysplasia or early cancer were included in the analysis (Gastrointest. Endosc. 2005;61:671–8).

In a separate study, Dr. Kara and his associates improved autofluorescence endoscopy by using a videoendoscope that incorporates information from reflected light and displays dysplastic or neoplastic lesions as blue or violet and nondysplastic Barrett's esophagus as green. In a high-risk referral group of 60 patients with Barrett's esophagus, 14 (23%) had high-grade dysplasia or early cancer detected with standard white-light endoscopy or autofluorescence endoscopy with a videoendoscope; the modified form of autofluorescence endoscopy detected an additional 6 patients (bringing the total detection rate to 33%). (Gastrointest. Endosc. 2005;61:679–85).

Hyperhomocysteinemia in Hepatitis C

Chronic hepatitis C patients with hyperhomocysteinemia are at high risk for steatosis and progression of liver fibrosis, according to prospective data on 116 patients.

Luigi E. Adinolfi, M.D., and his colleagues at the Second University of Naples (Italy) reported that the degree of steatosis in those patients was correlated with hyperhomocysteinemia and with the C677T polymorphism of the MTHFR gene—a mutation known to be associated with hyperhomocysteinemia. The prevalence of steatosis and of high-grade steatosis was 41% and 11%, respectively, in patients without the polymorphism; 61% and 49% in patients heterozygous for the polymorphism; and 79% and 64% in patients homozygous for the polymorphism (Hepatology 2005;41:995–1003).

In multivariate analyses, progression of liver fibrosis was independently associated with steatosis, homocysteine levels were independently associated with steatosis and the MTHFR polymorphism, and steatosis grades greater than 1 were independently associated with levels of homocysteinemia and liver fibrosis scores.

Repeat Capsule Endoscopy Useful

Performance of repeat capsule endoscopy in patients with obscure GI bleeding who had a negative or suboptimal first capsule endoscopy often reveals new findings and leads to changes in patient management, according to findings from a retrospective study.

Bradford H. Jones, M.D., and his colleagues at the Mayo Clinic Scottsdale (Ariz.) reviewed the cases of 294 patients who were evaluated with capsule endoscopy for obscure GI bleeding. Of the 24 patients who had a second capsule endoscopy, 18 had an abnormality on the repeat procedure that was not reported on the first one. These patients with new findings had significantly more prior bleeding episodes and fewer prior procedures than those who did not have new findings (Am. J. Gastroenterol. 2005;100:1058-64).

Of 10 patients who had repeat capsule endoscopy because of poor visualization on the first exam, 8 had new findings that led to a change in management.

Rectal Ca After Prostate Irradiation

Men who receive radiation therapy for prostate cancer have a higher risk of rectal cancer than do those who undergo surgery, reported Nancy N. Baxter, M.D., and her associates at the University of Minnesota, Minneapolis.

In a population-based study of 85,815 men treated for prostate cancer, those who received radiation therapy had a significant, 70% increase in the risk of rectal cancer, compared with men who had surgery; the mean follow-up time was about 9 years. Potentially irradiated areas (the cecum, rectosigmoid, or sigmoid) and nonirradiated areas (the remainder of the colon) did not show any increases in cancer risk (Gastroenterology 2005;128:819-24).

The investigators included only men who had survived at least 5 years (to eliminate any men who had rectal cancer prior to prostate cancer treatment) and excluded those with previous colorectal cancer or colorectal cancer that developed in the first 5 years after treatment. “Men undergoing radiation for prostate cancer should undergo endoscopic evaluation beginning 5 years after radiation,” the investigators wrote.

Iron Exposure in Hemochromatosis

The duration of hepatic iron exposure in patients with hereditary hemochromatosis may help predict the severity of fibrosis seen on a liver biopsy or an MRI scan, reported John K. Olynyk, M.D., of Fremantle (Australia) Hospital, and his colleagues.

In a retrospective study of 60 patients with the disease who had a liver biopsy, the researchers determined that the product of patient age and hepatic iron concentration distinguished patients with high-grade fibrosis from those with low-grade fibrosis at 100% sensitivity and 86% specificity. Patients with other inherited or acquired forms of chronic liver injury were excluded. “This may explain why some hereditary hemochromatosis subjects with relatively lower hepatic iron concentration levels may still develop significant fibrosis provided they have been exposed for a sufficient duration,” the researchers reported (Am. J. Gastroenterol. 2005;100:837-41).

The results of a separate prospective pilot study in 10 other patients with hereditary hemochromatosis showed that the replacement of a liver biopsy with an MRI measurement of hepatic iron concentration could differentiate high-grade from low-grade fibrosis with 100% sensitivity and 80% specificity.

Intrahepatic Cholangiocarcinoma

Several new risk factors for intrahepatic cholangiocarcinoma have been established in U.S. patients, according to findings from a case-control study.

Yasser H. Shaib, M.D., of Baylor College of Medicine, Houston, and his associates determined that nonspecific cirrhosis; alcoholic liver disease; HIV infection; hepatitis C virus infection; several bile duct diseases (cholangitis, choledocholithiasis, and cholestasis); smoking; diabetes; and inflammatory bowel disease were significant, independent risk factors for intrahepatic cholangiocarcinoma (ICC) in a multivariate logistic regression analysis.

The previously unidentified risk factors in U.S. patients included hepatitis C, chronic liver disease of any etiology, HIV infection, diabetes, and smoking (Gastroenterology 2005;128:620-6).

The investigators adjusted the analysis for age, gender, race, geographic location, and Medicare/Medicaid dual-enrollment status. The study included 625 ICC patients aged 65 years and older from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry and 90,834 individuals without ICC or any other cancer from a random sample of 5% of Medicare-enrolled beneficiaries living in the geographic regions covered by the SEER registry.

Repeat Capsule Endoscopy Useful

Performance of repeat capsule endoscopy in patients with obscure GI bleeding who had a negative or suboptimal first capsule endoscopy often reveals new findings and leads to changes in patient management, according to findings from a retrospective study.

Bradford H. Jones, M.D., and his colleagues at the Mayo Clinic Scottsdale (Ariz.) reviewed the cases of 294 patients who were evaluated with capsule endoscopy for obscure GI bleeding. Of the 24 patients who had a second capsule endoscopy, 18 had an abnormality on the repeat procedure that was not reported on the first one. These patients with new findings had significantly more prior bleeding episodes and fewer prior procedures than those who did not have new findings (Am. J. Gastroenterol. 2005;100:1058-64).

Of 10 patients who had repeat capsule endoscopy because of poor visualization on the first exam, 8 had new findings that led to a change in management.

Rectal Ca After Prostate Irradiation

Men who receive radiation therapy for prostate cancer have a higher risk of rectal cancer than do those who undergo surgery, reported Nancy N. Baxter, M.D., and her associates at the University of Minnesota, Minneapolis.

In a population-based study of 85,815 men treated for prostate cancer, those who received radiation therapy had a significant, 70% increase in the risk of rectal cancer, compared with men who had surgery; the mean follow-up time was about 9 years. Potentially irradiated areas (the cecum, rectosigmoid, or sigmoid) and nonirradiated areas (the remainder of the colon) did not show any increases in cancer risk (Gastroenterology 2005;128:819-24).

The investigators included only men who had survived at least 5 years (to eliminate any men who had rectal cancer prior to prostate cancer treatment) and excluded those with previous colorectal cancer or colorectal cancer that developed in the first 5 years after treatment. “Men undergoing radiation for prostate cancer should undergo endoscopic evaluation beginning 5 years after radiation,” the investigators wrote.

Iron Exposure in Hemochromatosis

The duration of hepatic iron exposure in patients with hereditary hemochromatosis may help predict the severity of fibrosis seen on a liver biopsy or an MRI scan, reported John K. Olynyk, M.D., of Fremantle (Australia) Hospital, and his colleagues.

In a retrospective study of 60 patients with the disease who had a liver biopsy, the researchers determined that the product of patient age and hepatic iron concentration distinguished patients with high-grade fibrosis from those with low-grade fibrosis at 100% sensitivity and 86% specificity. Patients with other inherited or acquired forms of chronic liver injury were excluded. “This may explain why some hereditary hemochromatosis subjects with relatively lower hepatic iron concentration levels may still develop significant fibrosis provided they have been exposed for a sufficient duration,” the researchers reported (Am. J. Gastroenterol. 2005;100:837-41).

The results of a separate prospective pilot study in 10 other patients with hereditary hemochromatosis showed that the replacement of a liver biopsy with an MRI measurement of hepatic iron concentration could differentiate high-grade from low-grade fibrosis with 100% sensitivity and 80% specificity.

Intrahepatic Cholangiocarcinoma

Several new risk factors for intrahepatic cholangiocarcinoma have been established in U.S. patients, according to findings from a case-control study.

Yasser H. Shaib, M.D., of Baylor College of Medicine, Houston, and his associates determined that nonspecific cirrhosis; alcoholic liver disease; HIV infection; hepatitis C virus infection; several bile duct diseases (cholangitis, choledocholithiasis, and cholestasis); smoking; diabetes; and inflammatory bowel disease were significant, independent risk factors for intrahepatic cholangiocarcinoma (ICC) in a multivariate logistic regression analysis.

The previously unidentified risk factors in U.S. patients included hepatitis C, chronic liver disease of any etiology, HIV infection, diabetes, and smoking (Gastroenterology 2005;128:620-6).

The investigators adjusted the analysis for age, gender, race, geographic location, and Medicare/Medicaid dual-enrollment status. The study included 625 ICC patients aged 65 years and older from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry and 90,834 individuals without ICC or any other cancer from a random sample of 5% of Medicare-enrolled beneficiaries living in the geographic regions covered by the SEER registry.

Repeat Capsule Endoscopy Useful

Performance of repeat capsule endoscopy in patients with obscure GI bleeding who had a negative or suboptimal first capsule endoscopy often reveals new findings and leads to changes in patient management, according to findings from a retrospective study.

Bradford H. Jones, M.D., and his colleagues at the Mayo Clinic Scottsdale (Ariz.) reviewed the cases of 294 patients who were evaluated with capsule endoscopy for obscure GI bleeding. Of the 24 patients who had a second capsule endoscopy, 18 had an abnormality on the repeat procedure that was not reported on the first one. These patients with new findings had significantly more prior bleeding episodes and fewer prior procedures than those who did not have new findings (Am. J. Gastroenterol. 2005;100:1058-64).

Of 10 patients who had repeat capsule endoscopy because of poor visualization on the first exam, 8 had new findings that led to a change in management.

Rectal Ca After Prostate Irradiation

Men who receive radiation therapy for prostate cancer have a higher risk of rectal cancer than do those who undergo surgery, reported Nancy N. Baxter, M.D., and her associates at the University of Minnesota, Minneapolis.

In a population-based study of 85,815 men treated for prostate cancer, those who received radiation therapy had a significant, 70% increase in the risk of rectal cancer, compared with men who had surgery; the mean follow-up time was about 9 years. Potentially irradiated areas (the cecum, rectosigmoid, or sigmoid) and nonirradiated areas (the remainder of the colon) did not show any increases in cancer risk (Gastroenterology 2005;128:819-24).

The investigators included only men who had survived at least 5 years (to eliminate any men who had rectal cancer prior to prostate cancer treatment) and excluded those with previous colorectal cancer or colorectal cancer that developed in the first 5 years after treatment. “Men undergoing radiation for prostate cancer should undergo endoscopic evaluation beginning 5 years after radiation,” the investigators wrote.

Iron Exposure in Hemochromatosis

The duration of hepatic iron exposure in patients with hereditary hemochromatosis may help predict the severity of fibrosis seen on a liver biopsy or an MRI scan, reported John K. Olynyk, M.D., of Fremantle (Australia) Hospital, and his colleagues.

In a retrospective study of 60 patients with the disease who had a liver biopsy, the researchers determined that the product of patient age and hepatic iron concentration distinguished patients with high-grade fibrosis from those with low-grade fibrosis at 100% sensitivity and 86% specificity. Patients with other inherited or acquired forms of chronic liver injury were excluded. “This may explain why some hereditary hemochromatosis subjects with relatively lower hepatic iron concentration levels may still develop significant fibrosis provided they have been exposed for a sufficient duration,” the researchers reported (Am. J. Gastroenterol. 2005;100:837-41).

The results of a separate prospective pilot study in 10 other patients with hereditary hemochromatosis showed that the replacement of a liver biopsy with an MRI measurement of hepatic iron concentration could differentiate high-grade from low-grade fibrosis with 100% sensitivity and 80% specificity.

Intrahepatic Cholangiocarcinoma

Several new risk factors for intrahepatic cholangiocarcinoma have been established in U.S. patients, according to findings from a case-control study.

Yasser H. Shaib, M.D., of Baylor College of Medicine, Houston, and his associates determined that nonspecific cirrhosis; alcoholic liver disease; HIV infection; hepatitis C virus infection; several bile duct diseases (cholangitis, choledocholithiasis, and cholestasis); smoking; diabetes; and inflammatory bowel disease were significant, independent risk factors for intrahepatic cholangiocarcinoma (ICC) in a multivariate logistic regression analysis.

The previously unidentified risk factors in U.S. patients included hepatitis C, chronic liver disease of any etiology, HIV infection, diabetes, and smoking (Gastroenterology 2005;128:620-6).

The investigators adjusted the analysis for age, gender, race, geographic location, and Medicare/Medicaid dual-enrollment status. The study included 625 ICC patients aged 65 years and older from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry and 90,834 individuals without ICC or any other cancer from a random sample of 5% of Medicare-enrolled beneficiaries living in the geographic regions covered by the SEER registry.

TUCSON, ARIZ. — Nasopharyngeal shedding of aerosolized microbes may be a vector for perioperative contamination in the operating room, Charles E. Edmiston Jr., Ph.D., reported at the annual meeting of the Central Surgical Association.

Barriers to contamination, such as surgical masks, may not adequately contain microbial aerosols, especially when they are worn for long durations, added Dr. Edmiston of the Medical College of Wisconsin, Milwaukee.

“Ten to fifteen years ago we would have never talked about this, because you primarily looked upon infections that occurred during the perioperative or even postoperative period as being mediated merely by contact,” he said.

Over an 18-month period, Dr. Edmiston and his collaborators matched cultures obtained from air in the operating room with nasal cultures taken from an 11-member vascular surgery team during 70 vascular reconstruction procedures. An air-sampling device used a 0.45-μm filter to collect the air at four points located within 0.5-1 m or 4-5.5 m from the surgical wound.

The investigators recovered strains of coagulase-negative staphylococci, such as Staphylococcus aureus, during 60 (86%) of the 70 procedures; these strains were collected 0.5-1 m away from the wound in 36 of the procedures. Another third of the isolates were S. epidermis.

Gram-negative bacteria grew in cultures after the perioperative sampling period in 23 (33%) of the 70 procedures. Three of the isolates—Stenotrophomonas maltophilia, Burkholderia cepacia, and Aeromonas species—entered the operating room as an aerosol when surgical team members turned on the faucet of a utility sink. Most of the recovered strains showed patterns of resistance to multiple drug groups, such as the aminoglycosides, β-lactams, and fluoroquinolones.

In several selected cultures, Dr. Edmiston and his colleagues used pulsed-field gel electrophoresis, a tool commonly employed by molecular epidemiologists to investigate infectious disease outbreaks. They discovered that isolates derived from air samples were often from the same clonal family of isolates obtained from the nasal cultures of the surgical team.

In one instance, Dr. Edmiston found that S. aureus isolates taken from a senior member of the surgical team matched those from air samples taken within 1 m of the wound during an operation in which the senior member was present.

In three separate procedures, the investigators found that a vascular fellow had spread the same strain of S. aureus from his anterior nostril to within 1 m of a wound.

“It became obvious that the shedding phenomenon was occurring during the intraoperative period,” Dr. Edmiston said.

Although none of the 70 patients developed surgical-site or prosthetic-device infections after their procedures, the microbes recovered from the operating room air and nasal cultures are the same kinds commonly implicated in such infections, which can occur even months to years after the surgery, Dr. Edmiston said.

Four other reports in the literature have used molecular techniques to link the operative team with postoperative surgical-site infections, he noted.

To determine the effect of standard tie-back surgical masks on nasopharyngeal shedding, the researchers measured the air at four points in a room with conditions identical to those in an operating room. The 22 healthy volunteers and 8 volunteers with rhinorrhea sat in the room for 90 or 180 minutes and alternately read out loud or silently for 15 minutes at a time with or without the masks on.

At 90 minutes, the masks significantly reduced the amount of microbial nasopharyngeal shedding in healthy volunteers from 12.5 colony-forming units per cubic meter in those who did not wear a mask to 5.6 cfu/m3 in those who did wear one. In the volunteers with rhinorrhea, shedding declined significantly from 24.3 cfu/m3 in those without masks to 11.3 cfu/m3 in individuals who wore masks.

Masks were ineffective at significantly reducing the amount of nasopharyngeal shedding at 180 minutes. In healthy volunteers, nonmasked individuals had more shedding (21.8 cfu/m3) than did masked individuals (12.3 cfu/m3), but the difference was not significant. No difference in microbial shedding occurred in volunteers with rhinorrhea according to whether they wore a mask (37.8 cfu/m3) or not (53.8 cfu/m3).

“In essence, what's occurring is you have this venting phenomenon over the top of the mask and around the sides of the mask,” Dr. Edmiston explained.

Dr. Edmiston said he doubted that U.S. surgeons with colds or symptoms of rhinorrhea would give up operating until they had recovered. Instead, improvement in surgical mask design, antiseptic-impregnated devices, or prevention of microbial adherence to device surfaces may make more of an impact than anything else.

Dr. Edmiston may only have proved that the airflow system in operating rooms works, since no patient became infected, noted Mark Malangoni, M.D., who was designated to comment on the paper. Airflow comes into the operating room over the patient, pushing air away from him or her to the sides of the room and toward the floor where return air systems exist. Dr. Malangoni, outgoing president of the association, added that he would have been more convinced if Dr. Edmiston had a way to sample the air directly over the patient.

Dr. Edmiston contended, however, that the movement of seven to eight people in the operating room—maybe five or six of whom are within a half meter of the surgical wound—creates a vortexing of aerosols that may spread out across the room despite specialized airflow.

TUCSON, ARIZ. — Nasopharyngeal shedding of aerosolized microbes may be a vector for perioperative contamination in the operating room, Charles E. Edmiston Jr., Ph.D., reported at the annual meeting of the Central Surgical Association.

Barriers to contamination, such as surgical masks, may not adequately contain microbial aerosols, especially when they are worn for long durations, added Dr. Edmiston of the Medical College of Wisconsin, Milwaukee.

“Ten to fifteen years ago we would have never talked about this, because you primarily looked upon infections that occurred during the perioperative or even postoperative period as being mediated merely by contact,” he said.

Over an 18-month period, Dr. Edmiston and his collaborators matched cultures obtained from air in the operating room with nasal cultures taken from an 11-member vascular surgery team during 70 vascular reconstruction procedures. An air-sampling device used a 0.45-μm filter to collect the air at four points located within 0.5-1 m or 4-5.5 m from the surgical wound.

The investigators recovered strains of coagulase-negative staphylococci, such as Staphylococcus aureus, during 60 (86%) of the 70 procedures; these strains were collected 0.5-1 m away from the wound in 36 of the procedures. Another third of the isolates were S. epidermis.

Gram-negative bacteria grew in cultures after the perioperative sampling period in 23 (33%) of the 70 procedures. Three of the isolates—Stenotrophomonas maltophilia, Burkholderia cepacia, and Aeromonas species—entered the operating room as an aerosol when surgical team members turned on the faucet of a utility sink. Most of the recovered strains showed patterns of resistance to multiple drug groups, such as the aminoglycosides, β-lactams, and fluoroquinolones.

In several selected cultures, Dr. Edmiston and his colleagues used pulsed-field gel electrophoresis, a tool commonly employed by molecular epidemiologists to investigate infectious disease outbreaks. They discovered that isolates derived from air samples were often from the same clonal family of isolates obtained from the nasal cultures of the surgical team.

In one instance, Dr. Edmiston found that S. aureus isolates taken from a senior member of the surgical team matched those from air samples taken within 1 m of the wound during an operation in which the senior member was present.

In three separate procedures, the investigators found that a vascular fellow had spread the same strain of S. aureus from his anterior nostril to within 1 m of a wound.

“It became obvious that the shedding phenomenon was occurring during the intraoperative period,” Dr. Edmiston said.

Although none of the 70 patients developed surgical-site or prosthetic-device infections after their procedures, the microbes recovered from the operating room air and nasal cultures are the same kinds commonly implicated in such infections, which can occur even months to years after the surgery, Dr. Edmiston said.

Four other reports in the literature have used molecular techniques to link the operative team with postoperative surgical-site infections, he noted.

To determine the effect of standard tie-back surgical masks on nasopharyngeal shedding, the researchers measured the air at four points in a room with conditions identical to those in an operating room. The 22 healthy volunteers and 8 volunteers with rhinorrhea sat in the room for 90 or 180 minutes and alternately read out loud or silently for 15 minutes at a time with or without the masks on.

At 90 minutes, the masks significantly reduced the amount of microbial nasopharyngeal shedding in healthy volunteers from 12.5 colony-forming units per cubic meter in those who did not wear a mask to 5.6 cfu/m3 in those who did wear one. In the volunteers with rhinorrhea, shedding declined significantly from 24.3 cfu/m3 in those without masks to 11.3 cfu/m3 in individuals who wore masks.

Masks were ineffective at significantly reducing the amount of nasopharyngeal shedding at 180 minutes. In healthy volunteers, nonmasked individuals had more shedding (21.8 cfu/m3) than did masked individuals (12.3 cfu/m3), but the difference was not significant. No difference in microbial shedding occurred in volunteers with rhinorrhea according to whether they wore a mask (37.8 cfu/m3) or not (53.8 cfu/m3).

“In essence, what's occurring is you have this venting phenomenon over the top of the mask and around the sides of the mask,” Dr. Edmiston explained.

Dr. Edmiston said he doubted that U.S. surgeons with colds or symptoms of rhinorrhea would give up operating until they had recovered. Instead, improvement in surgical mask design, antiseptic-impregnated devices, or prevention of microbial adherence to device surfaces may make more of an impact than anything else.

Dr. Edmiston may only have proved that the airflow system in operating rooms works, since no patient became infected, noted Mark Malangoni, M.D., who was designated to comment on the paper. Airflow comes into the operating room over the patient, pushing air away from him or her to the sides of the room and toward the floor where return air systems exist. Dr. Malangoni, outgoing president of the association, added that he would have been more convinced if Dr. Edmiston had a way to sample the air directly over the patient.

Dr. Edmiston contended, however, that the movement of seven to eight people in the operating room—maybe five or six of whom are within a half meter of the surgical wound—creates a vortexing of aerosols that may spread out across the room despite specialized airflow.

TUCSON, ARIZ. — Nasopharyngeal shedding of aerosolized microbes may be a vector for perioperative contamination in the operating room, Charles E. Edmiston Jr., Ph.D., reported at the annual meeting of the Central Surgical Association.

Barriers to contamination, such as surgical masks, may not adequately contain microbial aerosols, especially when they are worn for long durations, added Dr. Edmiston of the Medical College of Wisconsin, Milwaukee.

“Ten to fifteen years ago we would have never talked about this, because you primarily looked upon infections that occurred during the perioperative or even postoperative period as being mediated merely by contact,” he said.

Over an 18-month period, Dr. Edmiston and his collaborators matched cultures obtained from air in the operating room with nasal cultures taken from an 11-member vascular surgery team during 70 vascular reconstruction procedures. An air-sampling device used a 0.45-μm filter to collect the air at four points located within 0.5-1 m or 4-5.5 m from the surgical wound.

The investigators recovered strains of coagulase-negative staphylococci, such as Staphylococcus aureus, during 60 (86%) of the 70 procedures; these strains were collected 0.5-1 m away from the wound in 36 of the procedures. Another third of the isolates were S. epidermis.

Gram-negative bacteria grew in cultures after the perioperative sampling period in 23 (33%) of the 70 procedures. Three of the isolates—Stenotrophomonas maltophilia, Burkholderia cepacia, and Aeromonas species—entered the operating room as an aerosol when surgical team members turned on the faucet of a utility sink. Most of the recovered strains showed patterns of resistance to multiple drug groups, such as the aminoglycosides, β-lactams, and fluoroquinolones.

In several selected cultures, Dr. Edmiston and his colleagues used pulsed-field gel electrophoresis, a tool commonly employed by molecular epidemiologists to investigate infectious disease outbreaks. They discovered that isolates derived from air samples were often from the same clonal family of isolates obtained from the nasal cultures of the surgical team.

In one instance, Dr. Edmiston found that S. aureus isolates taken from a senior member of the surgical team matched those from air samples taken within 1 m of the wound during an operation in which the senior member was present.

In three separate procedures, the investigators found that a vascular fellow had spread the same strain of S. aureus from his anterior nostril to within 1 m of a wound.

“It became obvious that the shedding phenomenon was occurring during the intraoperative period,” Dr. Edmiston said.

Although none of the 70 patients developed surgical-site or prosthetic-device infections after their procedures, the microbes recovered from the operating room air and nasal cultures are the same kinds commonly implicated in such infections, which can occur even months to years after the surgery, Dr. Edmiston said.

Four other reports in the literature have used molecular techniques to link the operative team with postoperative surgical-site infections, he noted.

To determine the effect of standard tie-back surgical masks on nasopharyngeal shedding, the researchers measured the air at four points in a room with conditions identical to those in an operating room. The 22 healthy volunteers and 8 volunteers with rhinorrhea sat in the room for 90 or 180 minutes and alternately read out loud or silently for 15 minutes at a time with or without the masks on.

At 90 minutes, the masks significantly reduced the amount of microbial nasopharyngeal shedding in healthy volunteers from 12.5 colony-forming units per cubic meter in those who did not wear a mask to 5.6 cfu/m3 in those who did wear one. In the volunteers with rhinorrhea, shedding declined significantly from 24.3 cfu/m3 in those without masks to 11.3 cfu/m3 in individuals who wore masks.

Masks were ineffective at significantly reducing the amount of nasopharyngeal shedding at 180 minutes. In healthy volunteers, nonmasked individuals had more shedding (21.8 cfu/m3) than did masked individuals (12.3 cfu/m3), but the difference was not significant. No difference in microbial shedding occurred in volunteers with rhinorrhea according to whether they wore a mask (37.8 cfu/m3) or not (53.8 cfu/m3).

“In essence, what's occurring is you have this venting phenomenon over the top of the mask and around the sides of the mask,” Dr. Edmiston explained.

Dr. Edmiston said he doubted that U.S. surgeons with colds or symptoms of rhinorrhea would give up operating until they had recovered. Instead, improvement in surgical mask design, antiseptic-impregnated devices, or prevention of microbial adherence to device surfaces may make more of an impact than anything else.

Dr. Edmiston may only have proved that the airflow system in operating rooms works, since no patient became infected, noted Mark Malangoni, M.D., who was designated to comment on the paper. Airflow comes into the operating room over the patient, pushing air away from him or her to the sides of the room and toward the floor where return air systems exist. Dr. Malangoni, outgoing president of the association, added that he would have been more convinced if Dr. Edmiston had a way to sample the air directly over the patient.

Dr. Edmiston contended, however, that the movement of seven to eight people in the operating room—maybe five or six of whom are within a half meter of the surgical wound—creates a vortexing of aerosols that may spread out across the room despite specialized airflow.

TUCSON, ARIZ. — Nasopharyngeal shedding of aerosolized microbes may be a vector for perioperative contamination in the operating room, Charles E. Edmiston Jr., Ph.D., reported at the annual meeting of the Central Surgical Association.

Barriers to contamination, such as surgical masks, may not adequately contain microbial aerosols, especially when they are worn for long durations, added Dr. Edmiston of the Medical College of Wisconsin, Milwaukee.

“Ten to fifteen years ago we would have never talked about this, because you primarily looked upon infections that occurred during the perioperative or even postoperative period as being mediated merely by contact,” he said.

Over an 18-month period, Dr. Edmiston and his collaborators matched cultures obtained from air in the operating room with nasal cultures taken from an 11-member vascular surgery team during 70 vascular reconstruction procedures. An air-sampling device used a 0.45-μm filter to collect the air at four points located within 0.5-1 m or 4-5.5 m from the surgical wound.

The investigators recovered strains of coagulase-negative staphylococci, such as Staphylococcus aureus, during 60 (86%) of the 70 procedures; these strains were collected 0.5-1 m away from the wound in 36 of the procedures. Another third of the isolates were S. epidermis.

Gram-negative bacteria grew in cultures after the perioperative sampling period in 23 (33%) of the 70 procedures. Three of the isolates—Stenotrophomonas maltophilia, Burkholderia cepacia, and Aeromonas species—entered the operating room as an aerosol when surgical team members turned on the faucet of a utility sink. Most of the recovered strains showed patterns of resistance to multiple drug groups, such as the aminoglycosides, β-lactams, and fluoroquinolones.

In several selected cultures, Dr. Edmiston and his colleagues used pulsed-field gel electrophoresis, a tool commonly employed by molecular epidemiologists to investigate infectious disease outbreaks. They discovered that isolates derived from air samples were often from the same clonal family of isolates obtained from the nasal cultures of the surgical team.

In one instance, Dr. Edmiston found that S. aureus isolates taken from a senior member of the surgical team matched those from air samples taken within 1 m of the wound during an operation in which the senior member was present.

In three separate procedures, the investigators found that a vascular fellow had spread the same strain of S. aureus from his anterior nostril to within 1 m of a wound.

“It became obvious that the shedding phenomenon was occurring during the intraoperative period,” Dr. Edmiston said.

Although none of the 70 patients developed surgical-site or prosthetic-device infections after their procedures, the microbes recovered from the operating room air and nasal cultures are the same kinds commonly implicated in such infections, which can occur even months to years after the surgery, Dr. Edmiston said.

Four other reports in the literature have used molecular techniques to link the operative team with postoperative surgical-site infections, he noted.

To determine the effect of standard tie-back surgical masks on nasopharyngeal shedding, the researchers measured the air at four points in a room with conditions identical to those in an operating room. Twenty-two healthy volunteers and eight volunteers with rhinorrhea sat in the room for 90 or 180 minutes and alternately read out loud or silently for 15 minutes at a time with or without the masks on.

At 90 minutes, the masks significantly reduced the amount of microbial nasopharyngeal shedding in healthy volunteers from 12.5 colony-forming units per cubic meter in those who did not wear a mask to 5.6 cfu/m3 in those who did wear one. In the volunteers with rhinorrhea, shedding declined significantly from 24.3 cfu/m3 in those without masks to 11.3 cfu/m3 in individuals who wore masks.

Masks were ineffective at significantly reducing the amount of nasopharyngeal shedding at 180 minutes. In healthy volunteers, nonmasked individuals had more shedding (21.8 cfu/m3) than did masked individuals (12.3 cfu/m3), but the difference was not significant. No difference in microbial shedding occurred in volunteers with rhinorrhea according to whether they wore a mask (37.8 cfu/m3) or not (53.8 cfu/m3).

“In essence, what's occurring is you have this venting phenomenon over the top of the mask and around the sides of the mask,” Dr. Edmiston explained.

Dr. Edmiston may only have proved that the airflow system in operating rooms works, since no patient became infected, noted Mark Malangoni, M.D., who was designated to comment on the paper. Airflow comes into the operating room over the patient, pushing air away from him or her to the sides of the room and toward the floor where return air systems exist. Dr. Malangoni, outgoing president of the association, added that he would have been more convinced if Dr. Edmiston had a way to sample the air directly over the patient.

Dr. Edmiston contended, however, that the movement of seven to eight people in the operating room—maybe five or six of whom are within a half meter of the surgical wound—creates a vortexing of aerosols that may spread out across the room despite specialized airflow.

TUCSON, ARIZ. — Nasopharyngeal shedding of aerosolized microbes may be a vector for perioperative contamination in the operating room, Charles E. Edmiston Jr., Ph.D., reported at the annual meeting of the Central Surgical Association.

Barriers to contamination, such as surgical masks, may not adequately contain microbial aerosols, especially when they are worn for long durations, added Dr. Edmiston of the Medical College of Wisconsin, Milwaukee.

“Ten to fifteen years ago we would have never talked about this, because you primarily looked upon infections that occurred during the perioperative or even postoperative period as being mediated merely by contact,” he said.

Over an 18-month period, Dr. Edmiston and his collaborators matched cultures obtained from air in the operating room with nasal cultures taken from an 11-member vascular surgery team during 70 vascular reconstruction procedures. An air-sampling device used a 0.45-μm filter to collect the air at four points located within 0.5-1 m or 4-5.5 m from the surgical wound.

The investigators recovered strains of coagulase-negative staphylococci, such as Staphylococcus aureus, during 60 (86%) of the 70 procedures; these strains were collected 0.5-1 m away from the wound in 36 of the procedures. Another third of the isolates were S. epidermis.

Gram-negative bacteria grew in cultures after the perioperative sampling period in 23 (33%) of the 70 procedures. Three of the isolates—Stenotrophomonas maltophilia, Burkholderia cepacia, and Aeromonas species—entered the operating room as an aerosol when surgical team members turned on the faucet of a utility sink. Most of the recovered strains showed patterns of resistance to multiple drug groups, such as the aminoglycosides, β-lactams, and fluoroquinolones.

In several selected cultures, Dr. Edmiston and his colleagues used pulsed-field gel electrophoresis, a tool commonly employed by molecular epidemiologists to investigate infectious disease outbreaks. They discovered that isolates derived from air samples were often from the same clonal family of isolates obtained from the nasal cultures of the surgical team.

In one instance, Dr. Edmiston found that S. aureus isolates taken from a senior member of the surgical team matched those from air samples taken within 1 m of the wound during an operation in which the senior member was present.

In three separate procedures, the investigators found that a vascular fellow had spread the same strain of S. aureus from his anterior nostril to within 1 m of a wound.

“It became obvious that the shedding phenomenon was occurring during the intraoperative period,” Dr. Edmiston said.

Although none of the 70 patients developed surgical-site or prosthetic-device infections after their procedures, the microbes recovered from the operating room air and nasal cultures are the same kinds commonly implicated in such infections, which can occur even months to years after the surgery, Dr. Edmiston said.

Four other reports in the literature have used molecular techniques to link the operative team with postoperative surgical-site infections, he noted.

To determine the effect of standard tie-back surgical masks on nasopharyngeal shedding, the researchers measured the air at four points in a room with conditions identical to those in an operating room. Twenty-two healthy volunteers and eight volunteers with rhinorrhea sat in the room for 90 or 180 minutes and alternately read out loud or silently for 15 minutes at a time with or without the masks on.

At 90 minutes, the masks significantly reduced the amount of microbial nasopharyngeal shedding in healthy volunteers from 12.5 colony-forming units per cubic meter in those who did not wear a mask to 5.6 cfu/m3 in those who did wear one. In the volunteers with rhinorrhea, shedding declined significantly from 24.3 cfu/m3 in those without masks to 11.3 cfu/m3 in individuals who wore masks.

Masks were ineffective at significantly reducing the amount of nasopharyngeal shedding at 180 minutes. In healthy volunteers, nonmasked individuals had more shedding (21.8 cfu/m3) than did masked individuals (12.3 cfu/m3), but the difference was not significant. No difference in microbial shedding occurred in volunteers with rhinorrhea according to whether they wore a mask (37.8 cfu/m3) or not (53.8 cfu/m3).

“In essence, what's occurring is you have this venting phenomenon over the top of the mask and around the sides of the mask,” Dr. Edmiston explained.

Dr. Edmiston may only have proved that the airflow system in operating rooms works, since no patient became infected, noted Mark Malangoni, M.D., who was designated to comment on the paper. Airflow comes into the operating room over the patient, pushing air away from him or her to the sides of the room and toward the floor where return air systems exist. Dr. Malangoni, outgoing president of the association, added that he would have been more convinced if Dr. Edmiston had a way to sample the air directly over the patient.

Dr. Edmiston contended, however, that the movement of seven to eight people in the operating room—maybe five or six of whom are within a half meter of the surgical wound—creates a vortexing of aerosols that may spread out across the room despite specialized airflow.

TUCSON, ARIZ. — Nasopharyngeal shedding of aerosolized microbes may be a vector for perioperative contamination in the operating room, Charles E. Edmiston Jr., Ph.D., reported at the annual meeting of the Central Surgical Association.

Barriers to contamination, such as surgical masks, may not adequately contain microbial aerosols, especially when they are worn for long durations, added Dr. Edmiston of the Medical College of Wisconsin, Milwaukee.

“Ten to fifteen years ago we would have never talked about this, because you primarily looked upon infections that occurred during the perioperative or even postoperative period as being mediated merely by contact,” he said.

Over an 18-month period, Dr. Edmiston and his collaborators matched cultures obtained from air in the operating room with nasal cultures taken from an 11-member vascular surgery team during 70 vascular reconstruction procedures. An air-sampling device used a 0.45-μm filter to collect the air at four points located within 0.5-1 m or 4-5.5 m from the surgical wound.

The investigators recovered strains of coagulase-negative staphylococci, such as Staphylococcus aureus, during 60 (86%) of the 70 procedures; these strains were collected 0.5-1 m away from the wound in 36 of the procedures. Another third of the isolates were S. epidermis.

Gram-negative bacteria grew in cultures after the perioperative sampling period in 23 (33%) of the 70 procedures. Three of the isolates—Stenotrophomonas maltophilia, Burkholderia cepacia, and Aeromonas species—entered the operating room as an aerosol when surgical team members turned on the faucet of a utility sink. Most of the recovered strains showed patterns of resistance to multiple drug groups, such as the aminoglycosides, β-lactams, and fluoroquinolones.

In several selected cultures, Dr. Edmiston and his colleagues used pulsed-field gel electrophoresis, a tool commonly employed by molecular epidemiologists to investigate infectious disease outbreaks. They discovered that isolates derived from air samples were often from the same clonal family of isolates obtained from the nasal cultures of the surgical team.

In one instance, Dr. Edmiston found that S. aureus isolates taken from a senior member of the surgical team matched those from air samples taken within 1 m of the wound during an operation in which the senior member was present.

In three separate procedures, the investigators found that a vascular fellow had spread the same strain of S. aureus from his anterior nostril to within 1 m of a wound.

“It became obvious that the shedding phenomenon was occurring during the intraoperative period,” Dr. Edmiston said.

Although none of the 70 patients developed surgical-site or prosthetic-device infections after their procedures, the microbes recovered from the operating room air and nasal cultures are the same kinds commonly implicated in such infections, which can occur even months to years after the surgery, Dr. Edmiston said.

Four other reports in the literature have used molecular techniques to link the operative team with postoperative surgical-site infections, he noted.

To determine the effect of standard tie-back surgical masks on nasopharyngeal shedding, the researchers measured the air at four points in a room with conditions identical to those in an operating room. Twenty-two healthy volunteers and eight volunteers with rhinorrhea sat in the room for 90 or 180 minutes and alternately read out loud or silently for 15 minutes at a time with or without the masks on.

At 90 minutes, the masks significantly reduced the amount of microbial nasopharyngeal shedding in healthy volunteers from 12.5 colony-forming units per cubic meter in those who did not wear a mask to 5.6 cfu/m3 in those who did wear one. In the volunteers with rhinorrhea, shedding declined significantly from 24.3 cfu/m3 in those without masks to 11.3 cfu/m3 in individuals who wore masks.

Masks were ineffective at significantly reducing the amount of nasopharyngeal shedding at 180 minutes. In healthy volunteers, nonmasked individuals had more shedding (21.8 cfu/m3) than did masked individuals (12.3 cfu/m3), but the difference was not significant. No difference in microbial shedding occurred in volunteers with rhinorrhea according to whether they wore a mask (37.8 cfu/m3) or not (53.8 cfu/m3).

“In essence, what's occurring is you have this venting phenomenon over the top of the mask and around the sides of the mask,” Dr. Edmiston explained.

Dr. Edmiston may only have proved that the airflow system in operating rooms works, since no patient became infected, noted Mark Malangoni, M.D., who was designated to comment on the paper. Airflow comes into the operating room over the patient, pushing air away from him or her to the sides of the room and toward the floor where return air systems exist. Dr. Malangoni, outgoing president of the association, added that he would have been more convinced if Dr. Edmiston had a way to sample the air directly over the patient.

Dr. Edmiston contended, however, that the movement of seven to eight people in the operating room—maybe five or six of whom are within a half meter of the surgical wound—creates a vortexing of aerosols that may spread out across the room despite specialized airflow.

Fatty Liver Disease Histopathology

Histopathologic markers of nonalcoholic fatty liver disease are more common among whites than African Americans, even when features of the metabolic syndrome are present, according to the results of a prospective study.

Steven F. Solga, M.D., of Johns Hopkins University, Baltimore, and his colleagues obtained liver biopsies during Roux-en-Y gastric bypass surgeries performed in 2001-2003 in 189 patients who did not report past or current alcoholic use. The 26 African Americans and 163 whites in the study were severely obese and had similar rates of three metabolic syndrome features: hypertension, diabetes mellitus, and hyperlipidemia (Surgery for Obesity and Related Diseases 2005;1:6-11).

Compared with whites, African Americans had significantly lower rates of moderate or severe steatosis (incidence of 40% vs. 8%), inflammation (71% vs. 42%), fibrosis (48% vs. 31%), and nonalcoholic steatohepatitis (59% vs. 27%).

Hemophilia in Chronic Hepatitis C

Treatment of chronic hepatitis C with ribavirin and interferon alfa-2b in patients with hemophilia appeared to reduce patients' use of clotting factors in a small case series, reported Takashi Honda, M.D., and associates at Nagoya (Japan) University.

In a series of eight consecutive hemophiliac patients with chronic hepatitis C virus (HCV) infection treated at one center with a combination of ribavirin and interferon alfa-2b, five patients had moderate or severe hemophilia that required significantly less use of clotting factors on average during each month of treatment than in the 6 months prior to combination therapy (1,605 U/mo vs. 3,783 U/mo). Each patient received 600-800 mg of ribavirin per day for 24 weeks and an interferon alfa-2b regimen of 6 million units daily for 2 weeks and then three times per week for 22 weeks. Three patients with mild hemophilia were not included in the analysis because they rarely used clotting factors (JAMA 2005;293:1190-2).

Several patients continued to use less clotting factor after combination therapy stopped. “This strongly suggests that the reduced use of clotting factors was associated with the addition of ribavirin,” the investigators wrote. The findings may reflect a change in coagulation status.

Diabetes and Hepatocellular Carcinoma

Diabetes is an independent risk factor for hepatocellular carcinoma. This finding holds regardless of the presence of other risk factors for the disease, according to results from the first population-based case-control study to examine the association in U.S. patients.

Diabetes was independently associated with about a threefold higher risk of hepatocellular carcinoma (HCC) in a multivariate logistic regression analysis of data from 2,061 patients with HCC and 6,183 control patients without cancer. The percentage of HCC patients with diabetes (43%) was significantly greater than the proportion of controls with diabetes (19%).

But when cases of diabetes diagnosed in the 2 years prior to the date of HCC diagnosis were excluded, the proportions of patients with diabetes dropped to 32% for the HCC group and 12% for the control group (Gut 2005;54:533-9).

The results did not change appreciably when Jessica A. Davila, Ph.D., of the Houston Veterans Affairs Medical Center, and her associates restricted their analysis to patients without hepatitis C or B virus infection, alcoholic liver disease, or hemochromatosis.

Noninvasive HBV Fibrosis Detection

A formula using four regularly measured biomarkers can help to predict the absence of significant liver fibrosis in chronic hepatitis B patients, thereby allowing some patients to avoid or postpone liver biopsy, reported Alex Yui Hui, M.D., and colleagues at the Chinese University of Hong Kong.

Studies of a series of patients with HBV DNA levels greater than 105 copies per mL showed that a model incorporating bilirubin and albumin concentrations, platelet count, and body mass index could predict the absence of significant fibrosis, defined as an Ishak score of 3 or higher (Am. J. Gastroenterol. 2005;100:616-23).

The formula gave a negative predictive value (NPV) of 95% and 79% in a training set of 147 patients, 89% and 81% in a validation set of 75 patients, and 92% and 81% in the total cohort of 222 patients; the NPV varied depending on the use of a predictive probability with a low cutoff of 0.15 or a high cutoff of 0.5, respectively. “It is possible that our noninvasive fibrosis index combined with the biochemical, serological, and virological data will provide sufficient information that liver biopsy could be avoided or postponed in some patients,” the investigators wrote.

Fatty Liver Disease Histopathology

Histopathologic markers of nonalcoholic fatty liver disease are more common among whites than African Americans, even when features of the metabolic syndrome are present, according to the results of a prospective study.

Steven F. Solga, M.D., of Johns Hopkins University, Baltimore, and his colleagues obtained liver biopsies during Roux-en-Y gastric bypass surgeries performed in 2001-2003 in 189 patients who did not report past or current alcoholic use. The 26 African Americans and 163 whites in the study were severely obese and had similar rates of three metabolic syndrome features: hypertension, diabetes mellitus, and hyperlipidemia (Surgery for Obesity and Related Diseases 2005;1:6-11).

Compared with whites, African Americans had significantly lower rates of moderate or severe steatosis (incidence of 40% vs. 8%), inflammation (71% vs. 42%), fibrosis (48% vs. 31%), and nonalcoholic steatohepatitis (59% vs. 27%).

Hemophilia in Chronic Hepatitis C

Treatment of chronic hepatitis C with ribavirin and interferon alfa-2b in patients with hemophilia appeared to reduce patients' use of clotting factors in a small case series, reported Takashi Honda, M.D., and associates at Nagoya (Japan) University.

In a series of eight consecutive hemophiliac patients with chronic hepatitis C virus (HCV) infection treated at one center with a combination of ribavirin and interferon alfa-2b, five patients had moderate or severe hemophilia that required significantly less use of clotting factors on average during each month of treatment than in the 6 months prior to combination therapy (1,605 U/mo vs. 3,783 U/mo). Each patient received 600-800 mg of ribavirin per day for 24 weeks and an interferon alfa-2b regimen of 6 million units daily for 2 weeks and then three times per week for 22 weeks. Three patients with mild hemophilia were not included in the analysis because they rarely used clotting factors (JAMA 2005;293:1190-2).

Several patients continued to use less clotting factor after combination therapy stopped. “This strongly suggests that the reduced use of clotting factors was associated with the addition of ribavirin,” the investigators wrote. The findings may reflect a change in coagulation status.

Diabetes and Hepatocellular Carcinoma

Diabetes is an independent risk factor for hepatocellular carcinoma. This finding holds regardless of the presence of other risk factors for the disease, according to results from the first population-based case-control study to examine the association in U.S. patients.

Diabetes was independently associated with about a threefold higher risk of hepatocellular carcinoma (HCC) in a multivariate logistic regression analysis of data from 2,061 patients with HCC and 6,183 control patients without cancer. The percentage of HCC patients with diabetes (43%) was significantly greater than the proportion of controls with diabetes (19%).

But when cases of diabetes diagnosed in the 2 years prior to the date of HCC diagnosis were excluded, the proportions of patients with diabetes dropped to 32% for the HCC group and 12% for the control group (Gut 2005;54:533-9).

The results did not change appreciably when Jessica A. Davila, Ph.D., of the Houston Veterans Affairs Medical Center, and her associates restricted their analysis to patients without hepatitis C or B virus infection, alcoholic liver disease, or hemochromatosis.

Noninvasive HBV Fibrosis Detection

A formula using four regularly measured biomarkers can help to predict the absence of significant liver fibrosis in chronic hepatitis B patients, thereby allowing some patients to avoid or postpone liver biopsy, reported Alex Yui Hui, M.D., and colleagues at the Chinese University of Hong Kong.

Studies of a series of patients with HBV DNA levels greater than 105 copies per mL showed that a model incorporating bilirubin and albumin concentrations, platelet count, and body mass index could predict the absence of significant fibrosis, defined as an Ishak score of 3 or higher (Am. J. Gastroenterol. 2005;100:616-23).

The formula gave a negative predictive value (NPV) of 95% and 79% in a training set of 147 patients, 89% and 81% in a validation set of 75 patients, and 92% and 81% in the total cohort of 222 patients; the NPV varied depending on the use of a predictive probability with a low cutoff of 0.15 or a high cutoff of 0.5, respectively. “It is possible that our noninvasive fibrosis index combined with the biochemical, serological, and virological data will provide sufficient information that liver biopsy could be avoided or postponed in some patients,” the investigators wrote.

Fatty Liver Disease Histopathology

Histopathologic markers of nonalcoholic fatty liver disease are more common among whites than African Americans, even when features of the metabolic syndrome are present, according to the results of a prospective study.

Steven F. Solga, M.D., of Johns Hopkins University, Baltimore, and his colleagues obtained liver biopsies during Roux-en-Y gastric bypass surgeries performed in 2001-2003 in 189 patients who did not report past or current alcoholic use. The 26 African Americans and 163 whites in the study were severely obese and had similar rates of three metabolic syndrome features: hypertension, diabetes mellitus, and hyperlipidemia (Surgery for Obesity and Related Diseases 2005;1:6-11).

Compared with whites, African Americans had significantly lower rates of moderate or severe steatosis (incidence of 40% vs. 8%), inflammation (71% vs. 42%), fibrosis (48% vs. 31%), and nonalcoholic steatohepatitis (59% vs. 27%).

Hemophilia in Chronic Hepatitis C

Treatment of chronic hepatitis C with ribavirin and interferon alfa-2b in patients with hemophilia appeared to reduce patients' use of clotting factors in a small case series, reported Takashi Honda, M.D., and associates at Nagoya (Japan) University.

In a series of eight consecutive hemophiliac patients with chronic hepatitis C virus (HCV) infection treated at one center with a combination of ribavirin and interferon alfa-2b, five patients had moderate or severe hemophilia that required significantly less use of clotting factors on average during each month of treatment than in the 6 months prior to combination therapy (1,605 U/mo vs. 3,783 U/mo). Each patient received 600-800 mg of ribavirin per day for 24 weeks and an interferon alfa-2b regimen of 6 million units daily for 2 weeks and then three times per week for 22 weeks. Three patients with mild hemophilia were not included in the analysis because they rarely used clotting factors (JAMA 2005;293:1190-2).

Several patients continued to use less clotting factor after combination therapy stopped. “This strongly suggests that the reduced use of clotting factors was associated with the addition of ribavirin,” the investigators wrote. The findings may reflect a change in coagulation status.

Diabetes and Hepatocellular Carcinoma

Diabetes is an independent risk factor for hepatocellular carcinoma. This finding holds regardless of the presence of other risk factors for the disease, according to results from the first population-based case-control study to examine the association in U.S. patients.

Diabetes was independently associated with about a threefold higher risk of hepatocellular carcinoma (HCC) in a multivariate logistic regression analysis of data from 2,061 patients with HCC and 6,183 control patients without cancer. The percentage of HCC patients with diabetes (43%) was significantly greater than the proportion of controls with diabetes (19%).

But when cases of diabetes diagnosed in the 2 years prior to the date of HCC diagnosis were excluded, the proportions of patients with diabetes dropped to 32% for the HCC group and 12% for the control group (Gut 2005;54:533-9).

The results did not change appreciably when Jessica A. Davila, Ph.D., of the Houston Veterans Affairs Medical Center, and her associates restricted their analysis to patients without hepatitis C or B virus infection, alcoholic liver disease, or hemochromatosis.

Noninvasive HBV Fibrosis Detection

A formula using four regularly measured biomarkers can help to predict the absence of significant liver fibrosis in chronic hepatitis B patients, thereby allowing some patients to avoid or postpone liver biopsy, reported Alex Yui Hui, M.D., and colleagues at the Chinese University of Hong Kong.

Studies of a series of patients with HBV DNA levels greater than 105 copies per mL showed that a model incorporating bilirubin and albumin concentrations, platelet count, and body mass index could predict the absence of significant fibrosis, defined as an Ishak score of 3 or higher (Am. J. Gastroenterol. 2005;100:616-23).

The formula gave a negative predictive value (NPV) of 95% and 79% in a training set of 147 patients, 89% and 81% in a validation set of 75 patients, and 92% and 81% in the total cohort of 222 patients; the NPV varied depending on the use of a predictive probability with a low cutoff of 0.15 or a high cutoff of 0.5, respectively. “It is possible that our noninvasive fibrosis index combined with the biochemical, serological, and virological data will provide sufficient information that liver biopsy could be avoided or postponed in some patients,” the investigators wrote.

TUCSON, ARIZ. — Heller myotomy performed with robotic telesurgery for the treatment of achalasia appears to cause fewer esophageal perforations and an equivalent functional outcome, compared with the traditional laparoscopic technique, W. Scott Melvin, M.D., said at the annual meeting of the Central Surgical Association.

Laparoscopic Heller myotomy for achalasia requires advanced laparoscopic skills, especially in performing what may be the toughest part of the operation—dividing the muscle fibers of the esophagus, where perforation can occur, noted Dr. Melvin, director of the Center for Minimally Invasive Surgery at Ohio State University, Columbus.

The difficulty of the procedure has contributed to a substantial rate of intraoperative esophageal perforations, which occurred in 51 (11%) of 479 laparoscopic Heller myotomies performed for achalasia in all series reported during the past 7 years.

To assess robotic Heller myotomy as an achalasia treatment, Dr. Melvin and his colleagues conducted a prospective study of 104 patients treated with the da Vinci robotic surgery system (made by Intuitive Surgical Inc.) and partial fundoplication at three centers in 2000-2004. Only patients with previous surgical myotomy were excluded from the study. The patients' hospital stay averaged 1.5 days.

No esophageal perforations occurred intraoperatively or postoperatively. Eight minor complications occurred, including urinary retention and postoperative pyrexia, Dr. Melvin said. One patient needed conversion to an open surgery because of bleeding, and another to a standard laparoscopic surgery because the robotic system failed.

No reoperative procedures were necessary in 79 patients who had an average follow-up of 16 months. According to a survey completed by these 79 patients, symptoms improved from a mean score of 5 prior to surgery to 0.48 during the follow-up period.

The hardest part of the computer-assisted surgery often was at the gastroesophageal junction, where some patients had scarring from undergoing previous therapies such as Botox injection or balloon dilatation, Dr. Melvin said.

The operative time for the computer-assisted surgery at first averaged 162 minutes but fell to 113 minutes in the study's last 2 years.

TUCSON, ARIZ. — Heller myotomy performed with robotic telesurgery for the treatment of achalasia appears to cause fewer esophageal perforations and an equivalent functional outcome, compared with the traditional laparoscopic technique, W. Scott Melvin, M.D., said at the annual meeting of the Central Surgical Association.

Laparoscopic Heller myotomy for achalasia requires advanced laparoscopic skills, especially in performing what may be the toughest part of the operation—dividing the muscle fibers of the esophagus, where perforation can occur, noted Dr. Melvin, director of the Center for Minimally Invasive Surgery at Ohio State University, Columbus.

The difficulty of the procedure has contributed to a substantial rate of intraoperative esophageal perforations, which occurred in 51 (11%) of 479 laparoscopic Heller myotomies performed for achalasia in all series reported during the past 7 years.

To assess robotic Heller myotomy as an achalasia treatment, Dr. Melvin and his colleagues conducted a prospective study of 104 patients treated with the da Vinci robotic surgery system (made by Intuitive Surgical Inc.) and partial fundoplication at three centers in 2000-2004. Only patients with previous surgical myotomy were excluded from the study. The patients' hospital stay averaged 1.5 days.

No esophageal perforations occurred intraoperatively or postoperatively. Eight minor complications occurred, including urinary retention and postoperative pyrexia, Dr. Melvin said. One patient needed conversion to an open surgery because of bleeding, and another to a standard laparoscopic surgery because the robotic system failed.

No reoperative procedures were necessary in 79 patients who had an average follow-up of 16 months. According to a survey completed by these 79 patients, symptoms improved from a mean score of 5 prior to surgery to 0.48 during the follow-up period.

The hardest part of the computer-assisted surgery often was at the gastroesophageal junction, where some patients had scarring from undergoing previous therapies such as Botox injection or balloon dilatation, Dr. Melvin said.

The operative time for the computer-assisted surgery at first averaged 162 minutes but fell to 113 minutes in the study's last 2 years.

TUCSON, ARIZ. — Heller myotomy performed with robotic telesurgery for the treatment of achalasia appears to cause fewer esophageal perforations and an equivalent functional outcome, compared with the traditional laparoscopic technique, W. Scott Melvin, M.D., said at the annual meeting of the Central Surgical Association.

Laparoscopic Heller myotomy for achalasia requires advanced laparoscopic skills, especially in performing what may be the toughest part of the operation—dividing the muscle fibers of the esophagus, where perforation can occur, noted Dr. Melvin, director of the Center for Minimally Invasive Surgery at Ohio State University, Columbus.

The difficulty of the procedure has contributed to a substantial rate of intraoperative esophageal perforations, which occurred in 51 (11%) of 479 laparoscopic Heller myotomies performed for achalasia in all series reported during the past 7 years.

To assess robotic Heller myotomy as an achalasia treatment, Dr. Melvin and his colleagues conducted a prospective study of 104 patients treated with the da Vinci robotic surgery system (made by Intuitive Surgical Inc.) and partial fundoplication at three centers in 2000-2004. Only patients with previous surgical myotomy were excluded from the study. The patients' hospital stay averaged 1.5 days.

No esophageal perforations occurred intraoperatively or postoperatively. Eight minor complications occurred, including urinary retention and postoperative pyrexia, Dr. Melvin said. One patient needed conversion to an open surgery because of bleeding, and another to a standard laparoscopic surgery because the robotic system failed.

No reoperative procedures were necessary in 79 patients who had an average follow-up of 16 months. According to a survey completed by these 79 patients, symptoms improved from a mean score of 5 prior to surgery to 0.48 during the follow-up period.

The hardest part of the computer-assisted surgery often was at the gastroesophageal junction, where some patients had scarring from undergoing previous therapies such as Botox injection or balloon dilatation, Dr. Melvin said.

The operative time for the computer-assisted surgery at first averaged 162 minutes but fell to 113 minutes in the study's last 2 years.

BOSTON — Physicians who rely on the histopathologic features of regression could mistake dysplastic nevi for regressed malignant melanoma, Ashraf Hassanein, M.D., reported in a poster presentation at the annual meeting of the American Society of Dermatopathology.

Dr. Hassanein and his associates in the departments of pathology and dermatology at the University of Florida, Gainesville, applied two sets of criteria that are used to evaluate complete and partial regression in melanoma to 777 shave or punch biopsies of benign and dysplastic melanocytic nevi taken from the backs of patients between 2002-2004.

All subtypes of nevi on the back had evidence of focal regression-like changes. Histopathologic changes that mimicked partial regression occurred with increasing prevalence in 229 junctional dysplastic nevi according to the degree of cytologic atypia they exhibited: mild atypia (10%); moderate atypia (19%); and severe atypia (39%).

“It may be possible that nevi with regression have been lumped into subtypes of melanoma regression studies in the past, hence, diluting the value of histologic regression as an independent prognostic or predictive variable in recurrence or metastases,” Dr. Hassanein suggested.

BOSTON — Physicians who rely on the histopathologic features of regression could mistake dysplastic nevi for regressed malignant melanoma, Ashraf Hassanein, M.D., reported in a poster presentation at the annual meeting of the American Society of Dermatopathology.

Dr. Hassanein and his associates in the departments of pathology and dermatology at the University of Florida, Gainesville, applied two sets of criteria that are used to evaluate complete and partial regression in melanoma to 777 shave or punch biopsies of benign and dysplastic melanocytic nevi taken from the backs of patients between 2002-2004.

All subtypes of nevi on the back had evidence of focal regression-like changes. Histopathologic changes that mimicked partial regression occurred with increasing prevalence in 229 junctional dysplastic nevi according to the degree of cytologic atypia they exhibited: mild atypia (10%); moderate atypia (19%); and severe atypia (39%).

“It may be possible that nevi with regression have been lumped into subtypes of melanoma regression studies in the past, hence, diluting the value of histologic regression as an independent prognostic or predictive variable in recurrence or metastases,” Dr. Hassanein suggested.

BOSTON — Physicians who rely on the histopathologic features of regression could mistake dysplastic nevi for regressed malignant melanoma, Ashraf Hassanein, M.D., reported in a poster presentation at the annual meeting of the American Society of Dermatopathology.

Dr. Hassanein and his associates in the departments of pathology and dermatology at the University of Florida, Gainesville, applied two sets of criteria that are used to evaluate complete and partial regression in melanoma to 777 shave or punch biopsies of benign and dysplastic melanocytic nevi taken from the backs of patients between 2002-2004.

All subtypes of nevi on the back had evidence of focal regression-like changes. Histopathologic changes that mimicked partial regression occurred with increasing prevalence in 229 junctional dysplastic nevi according to the degree of cytologic atypia they exhibited: mild atypia (10%); moderate atypia (19%); and severe atypia (39%).

“It may be possible that nevi with regression have been lumped into subtypes of melanoma regression studies in the past, hence, diluting the value of histologic regression as an independent prognostic or predictive variable in recurrence or metastases,” Dr. Hassanein suggested.