Mary Ann Moon

Major Finding: An elevated BMI during adolescence, even within the range currently considered normal, strongly predicted the diagnosis of CHD on angiography by the age of 45 years.

Data Source: A prospective cohort study of 37,674 healthy military men who were followed from approximately age 25 years for a median of 17 years for the development of angiography-proven CHD and type 2 diabetes.

Disclosures: The Chaim Sheba Medical Center, Tel-Hashomer, Israel, and the Israel Defense Forces Medical Corps supported the study. The authors reported that they had no conflicts of interest.

Among males, an elevated body mass index during adolescence was a strong predictor of angiography-proven coronary heart disease in young adulthood, according to large, prospective study.

Male adolescents who were in the top 10% of body mass index had a risk for developing coronary heart disease at ages 25-45 years that was nearly seven times higher than the risk in adolescents in the lowest 10% of BMI, according to Dr. Amir Tirosh, of the division of endocrinology, diabetes, and hypertension at Brigham and Women's Hospital, Boston, and his associates (N. Engl. J. Med. 2011;364:1315-25).

“Although obesity in adulthood is a well-documented risk factor for both type 2 diabetes and CHD, it [has been] unclear whether a longer history of relative overweight, starting earlier in life, poses an additional risk,” Dr. Tirosh and his associates said.

“Given the current obesity pandemic, it is important to determine whether elevated BMI in childhood [or] adolescence … contributes independently to the risk of disease,” they noted.

Dr. Tirosh and his colleagues examined the issue with the use of data from the Israel Defense Forces' ongoing Metabolic, Lifestyle, and Nutrition Assessment in Young Adults study.

All men in the Israeli military are examined every 3-5 years, beginning at about age 25 and continuing throughout their military careers, and the information is recorded in a database.

Also recorded are the weight and height measurements obtained during the men's medical examination at induction into the military, usually at age 17.

The researchers used those data to calculate body mass index in adolescence.

For this study, Dr. Tirosh and his associates analyzed data on 37,674 male military personnel who were followed prospectively for a mean of 17 years, starting at about age 25, and whose body mass index during adolescence was tracked retrospectively. At that time, body mass index ranged from 15 to 36 kg/m

During follow-up, there were 327 incident cases of angiography-proven CHD, which were diagnosed when the subjects were aged 25-45 years. After the data were adjusted to account for potential confounders such as subject age, presence or absence of a family history of CHD, blood pressure, physical activity level, smoking status, and lipid profile, elevated adolescent body mass index was a significant predictor of CHD across the entire BMI range, reported Dr. Tirosh and his colleagues.

The nearly 4,000 subjects whose body mass index was in the 90th percentile and above had a hazard ratio of 6.85 for developing CHD, compared with those subjects who were in the 10th percentile and below.

The excess CHD risk was present even at BMIs that are “well within the range currently considered to be normal,” rising 12% for every 1-unit increment in BMI, Dr. Tirosh and his associates reported.

“Our study may help to redefine what constitutes a 'normal' or 'healthy' BMI in adolescence and to highlight the role of elevated BMI at different ages in the pathogenesis of different diseases,” the researchers said.

In contrast to CHD risk, the risk of type 2 diabetes did not correlate with adolescent body mass index once the data were adjusted to account for potential confounders.

Diabetes was more influenced by recent BMI and weight gain, “suggesting that BMI in adolescence has a more reversible or shorter term effect on the risk of diabetes as compared with its effect on the risk of CHD,” they reported.

“Our results might be explained by the fact that diabetes represents a more functional pathomechanism than CHD, which relies on anatomical changes (atherosclerosis),” Dr. Tirosh and his colleagues said.

Because the study involved only young Israeli military men, the findings may not be generalizable to other patient populations, they added.

CHD risk was sevenfold higher in young men whose teen BMI had been in the top 10%, vs. the lowest 10%.

Source Courtesy Bill Branson/National Cancer Institute

Major Finding: An elevated BMI during adolescence, even within the range currently considered normal, strongly predicted the diagnosis of CHD on angiography by the age of 45 years.

Data Source: A prospective cohort study of 37,674 healthy military men who were followed from approximately age 25 years for a median of 17 years for the development of angiography-proven CHD and type 2 diabetes.

Disclosures: The Chaim Sheba Medical Center, Tel-Hashomer, Israel, and the Israel Defense Forces Medical Corps supported the study. The authors reported that they had no conflicts of interest.

Among males, an elevated body mass index during adolescence was a strong predictor of angiography-proven coronary heart disease in young adulthood, according to large, prospective study.

Male adolescents who were in the top 10% of body mass index had a risk for developing coronary heart disease at ages 25-45 years that was nearly seven times higher than the risk in adolescents in the lowest 10% of BMI, according to Dr. Amir Tirosh, of the division of endocrinology, diabetes, and hypertension at Brigham and Women's Hospital, Boston, and his associates (N. Engl. J. Med. 2011;364:1315-25).

“Although obesity in adulthood is a well-documented risk factor for both type 2 diabetes and CHD, it [has been] unclear whether a longer history of relative overweight, starting earlier in life, poses an additional risk,” Dr. Tirosh and his associates said.

“Given the current obesity pandemic, it is important to determine whether elevated BMI in childhood [or] adolescence … contributes independently to the risk of disease,” they noted.

Dr. Tirosh and his colleagues examined the issue with the use of data from the Israel Defense Forces' ongoing Metabolic, Lifestyle, and Nutrition Assessment in Young Adults study.

All men in the Israeli military are examined every 3-5 years, beginning at about age 25 and continuing throughout their military careers, and the information is recorded in a database.

Also recorded are the weight and height measurements obtained during the men's medical examination at induction into the military, usually at age 17.

The researchers used those data to calculate body mass index in adolescence.

For this study, Dr. Tirosh and his associates analyzed data on 37,674 male military personnel who were followed prospectively for a mean of 17 years, starting at about age 25, and whose body mass index during adolescence was tracked retrospectively. At that time, body mass index ranged from 15 to 36 kg/m

During follow-up, there were 327 incident cases of angiography-proven CHD, which were diagnosed when the subjects were aged 25-45 years. After the data were adjusted to account for potential confounders such as subject age, presence or absence of a family history of CHD, blood pressure, physical activity level, smoking status, and lipid profile, elevated adolescent body mass index was a significant predictor of CHD across the entire BMI range, reported Dr. Tirosh and his colleagues.

The nearly 4,000 subjects whose body mass index was in the 90th percentile and above had a hazard ratio of 6.85 for developing CHD, compared with those subjects who were in the 10th percentile and below.

The excess CHD risk was present even at BMIs that are “well within the range currently considered to be normal,” rising 12% for every 1-unit increment in BMI, Dr. Tirosh and his associates reported.

“Our study may help to redefine what constitutes a 'normal' or 'healthy' BMI in adolescence and to highlight the role of elevated BMI at different ages in the pathogenesis of different diseases,” the researchers said.

In contrast to CHD risk, the risk of type 2 diabetes did not correlate with adolescent body mass index once the data were adjusted to account for potential confounders.

Diabetes was more influenced by recent BMI and weight gain, “suggesting that BMI in adolescence has a more reversible or shorter term effect on the risk of diabetes as compared with its effect on the risk of CHD,” they reported.

“Our results might be explained by the fact that diabetes represents a more functional pathomechanism than CHD, which relies on anatomical changes (atherosclerosis),” Dr. Tirosh and his colleagues said.

Because the study involved only young Israeli military men, the findings may not be generalizable to other patient populations, they added.

CHD risk was sevenfold higher in young men whose teen BMI had been in the top 10%, vs. the lowest 10%.

Source Courtesy Bill Branson/National Cancer Institute

Major Finding: An elevated BMI during adolescence, even within the range currently considered normal, strongly predicted the diagnosis of CHD on angiography by the age of 45 years.

Data Source: A prospective cohort study of 37,674 healthy military men who were followed from approximately age 25 years for a median of 17 years for the development of angiography-proven CHD and type 2 diabetes.

Disclosures: The Chaim Sheba Medical Center, Tel-Hashomer, Israel, and the Israel Defense Forces Medical Corps supported the study. The authors reported that they had no conflicts of interest.

Among males, an elevated body mass index during adolescence was a strong predictor of angiography-proven coronary heart disease in young adulthood, according to large, prospective study.

Male adolescents who were in the top 10% of body mass index had a risk for developing coronary heart disease at ages 25-45 years that was nearly seven times higher than the risk in adolescents in the lowest 10% of BMI, according to Dr. Amir Tirosh, of the division of endocrinology, diabetes, and hypertension at Brigham and Women's Hospital, Boston, and his associates (N. Engl. J. Med. 2011;364:1315-25).

“Although obesity in adulthood is a well-documented risk factor for both type 2 diabetes and CHD, it [has been] unclear whether a longer history of relative overweight, starting earlier in life, poses an additional risk,” Dr. Tirosh and his associates said.

“Given the current obesity pandemic, it is important to determine whether elevated BMI in childhood [or] adolescence … contributes independently to the risk of disease,” they noted.

Dr. Tirosh and his colleagues examined the issue with the use of data from the Israel Defense Forces' ongoing Metabolic, Lifestyle, and Nutrition Assessment in Young Adults study.

All men in the Israeli military are examined every 3-5 years, beginning at about age 25 and continuing throughout their military careers, and the information is recorded in a database.

Also recorded are the weight and height measurements obtained during the men's medical examination at induction into the military, usually at age 17.

The researchers used those data to calculate body mass index in adolescence.

For this study, Dr. Tirosh and his associates analyzed data on 37,674 male military personnel who were followed prospectively for a mean of 17 years, starting at about age 25, and whose body mass index during adolescence was tracked retrospectively. At that time, body mass index ranged from 15 to 36 kg/m

During follow-up, there were 327 incident cases of angiography-proven CHD, which were diagnosed when the subjects were aged 25-45 years. After the data were adjusted to account for potential confounders such as subject age, presence or absence of a family history of CHD, blood pressure, physical activity level, smoking status, and lipid profile, elevated adolescent body mass index was a significant predictor of CHD across the entire BMI range, reported Dr. Tirosh and his colleagues.

The nearly 4,000 subjects whose body mass index was in the 90th percentile and above had a hazard ratio of 6.85 for developing CHD, compared with those subjects who were in the 10th percentile and below.

The excess CHD risk was present even at BMIs that are “well within the range currently considered to be normal,” rising 12% for every 1-unit increment in BMI, Dr. Tirosh and his associates reported.

“Our study may help to redefine what constitutes a 'normal' or 'healthy' BMI in adolescence and to highlight the role of elevated BMI at different ages in the pathogenesis of different diseases,” the researchers said.

In contrast to CHD risk, the risk of type 2 diabetes did not correlate with adolescent body mass index once the data were adjusted to account for potential confounders.

Diabetes was more influenced by recent BMI and weight gain, “suggesting that BMI in adolescence has a more reversible or shorter term effect on the risk of diabetes as compared with its effect on the risk of CHD,” they reported.

“Our results might be explained by the fact that diabetes represents a more functional pathomechanism than CHD, which relies on anatomical changes (atherosclerosis),” Dr. Tirosh and his colleagues said.

Because the study involved only young Israeli military men, the findings may not be generalizable to other patient populations, they added.

CHD risk was sevenfold higher in young men whose teen BMI had been in the top 10%, vs. the lowest 10%.

Source Courtesy Bill Branson/National Cancer Institute

Major Finding: The short-term increase in risks of stroke, DVT, and pulmonary embolism did not persist over the long term after unopposed estrogen therapy; the equivalent risks of CHD, colorectal cancer, and total mortality did persist; the reduction in hip fracture risk did not persist; and the reduction in breast cancer risk did persist.

Data Source: Extended (10-year) follow-up of approximately 78% of subjects who participated in the Women's Health Initiative-Estrogen Alone trial (3,778 postmenopausal women who took conjugated equine estrogen and 3,867 who took matching placebo for a median of 6 years).

Disclosures: The WHI was funded by the National Heart, Lung, and Blood Institute, the National Institutes of Health, and the U.S. Department of Health and Human Services. Wyeth Ayerst donated the study drugs. Dr. LaCroix reported ties to Warner Chilcott, Sanofi-Aventis, Amgen, and Pfizer. Her associates reported ties to numerous other industry sources.

The most recent findings from the Women's Health Initiative study of short-term unopposed estrogen therapy suggest that after 10 years, the treatment neither increases nor decreases risks for coronary heart disease, deep vein thrombosis, stroke, hip fracture, colorectal cancer, or total mortality, according to a report.

This portion of the WHI study was halted early when interim analysis in 2004 showed an increased risk of stroke in women taking conjugated equine estrogens (CEE) compared with those taking placebo.

“All previous reports of this trial were limited to outcomes occurring during the intervention phase. [Now] we report data on postintervention outcomes through a mean of 10.7 years of follow-up,” said Andrea Z. LaCroix, Ph.D., of Fred Hutchinson Cancer Research Center, Seattle, and her associates (JAMA 2011;305:1305–14).

In the estrogen-only portion of the WHI study, 10,739 postmenopausal women who had undergone hysterectomy had been randomly assigned to receive either CEE or placebo.

They were followed during this intervention phase for a median of 6 years, but the median “adherent time” – the interval during which the women actually took more than 80% of their study pills – was only 3.5 years because more than half stopped taking the pills even before the early halt of the trial.

Approximately 78% of the surviving study subjects (3,778 who took CEE and 3,867 who took placebo) agreed to participate in the extended follow-up reported here.

The increased risks of stroke, deep vein thrombosis, and pulmonary embolism that had been noted during the intervention phase did not persist during extended follow-up.

In addition, active treatment, which had showed no effect on CHD risks during the intervention, continued to show no effect on CHD risks.

For all cardiovascular events, the cumulative hazard ratio was 2.26% with active treatment and 2.12% with placebo, a nonsignificant difference.

Colorectal cancer incidence did not differ between women who received CEE and those who received placebo during the intervention phase, and this lack of effect persisted during extended follow-up.

Hip fracture risk had been reduced with CEE therapy during the intervention phase, but this benefit did not persist during the extended follow-up.

Numerically, hip fracture incidence was slightly higher in the CEE group than in the placebo group, they reported.

Total mortality risk remained similar between the two study groups both during the intervention and during extended follow-up.

Only one benefit of CEE therapy that was seen during the intervention phase persisted in the extended follow-up and became statistically significant: Breast cancer incidence was 0.27% with active treatment and 0.35% with placebo.

The researchers noted that these results differ from those of the other portion of the WHI trial in which subjects received combined estrogen-plus-progestin.

In that study arm, active treatment impeded mammographic accuracy and was associated with significantly higher rates of breast cancer and breast cancer mortality, they noted.

The women's age at commencing treatment showed a significant interaction with outcomes, both during the intervention phase and during extended follow-up.

The results suggest that there may be greater benefit and safety for women who start CEE in their early 50s, and less benefit with more potential harm for women who are older when they begin treatment.

“Among younger women, no new safety concerns emerged and some risk reductions became apparent during the postintervention period.

“Among older women, risks of colorectal cancer, death, and the global index of chronic diseases were elevated over the cumulative follow-up period,” Dr. LaCroix and her associates said.

View on The News

Findings Don't Jibe With Others

“The lack of an adverse effect of unopposed estrogen when used for a short period in the WHI does not counter the larger,” longstanding, corroborated body of evidence that the treatment generally elevates the risk of breast cancer, said Dr. Emily S. Jungheim and Dr. Graham A. Colditz.

One can question whether results in the WHI study population, in which nearly 70% of the subjects were older than 60 years at baseline, can even be applied to younger women, particularly with regard to breast cancer risk and hormone therapy.

In addition, the duration of CEE use in the WHI remains problematic. The median “adherent time” was 3.5 years.

“Thus, the WHI results do not address the balance of risks and benefits associated with longer term estrogen use,” they concluded.

DR. JUNGHEIM and DR. COLDITZ are at Washington University, St. Louis. These remarks were taken from their accompanying editorial comment (JAMA 2011;305:1354–5). They reported no relevant financial disclosures.

Major Finding: The short-term increase in risks of stroke, DVT, and pulmonary embolism did not persist over the long term after unopposed estrogen therapy; the equivalent risks of CHD, colorectal cancer, and total mortality did persist; the reduction in hip fracture risk did not persist; and the reduction in breast cancer risk did persist.

Data Source: Extended (10-year) follow-up of approximately 78% of subjects who participated in the Women's Health Initiative-Estrogen Alone trial (3,778 postmenopausal women who took conjugated equine estrogen and 3,867 who took matching placebo for a median of 6 years).

Disclosures: The WHI was funded by the National Heart, Lung, and Blood Institute, the National Institutes of Health, and the U.S. Department of Health and Human Services. Wyeth Ayerst donated the study drugs. Dr. LaCroix reported ties to Warner Chilcott, Sanofi-Aventis, Amgen, and Pfizer. Her associates reported ties to numerous other industry sources.

The most recent findings from the Women's Health Initiative study of short-term unopposed estrogen therapy suggest that after 10 years, the treatment neither increases nor decreases risks for coronary heart disease, deep vein thrombosis, stroke, hip fracture, colorectal cancer, or total mortality, according to a report.

This portion of the WHI study was halted early when interim analysis in 2004 showed an increased risk of stroke in women taking conjugated equine estrogens (CEE) compared with those taking placebo.

“All previous reports of this trial were limited to outcomes occurring during the intervention phase. [Now] we report data on postintervention outcomes through a mean of 10.7 years of follow-up,” said Andrea Z. LaCroix, Ph.D., of Fred Hutchinson Cancer Research Center, Seattle, and her associates (JAMA 2011;305:1305–14).

In the estrogen-only portion of the WHI study, 10,739 postmenopausal women who had undergone hysterectomy had been randomly assigned to receive either CEE or placebo.

They were followed during this intervention phase for a median of 6 years, but the median “adherent time” – the interval during which the women actually took more than 80% of their study pills – was only 3.5 years because more than half stopped taking the pills even before the early halt of the trial.

Approximately 78% of the surviving study subjects (3,778 who took CEE and 3,867 who took placebo) agreed to participate in the extended follow-up reported here.

The increased risks of stroke, deep vein thrombosis, and pulmonary embolism that had been noted during the intervention phase did not persist during extended follow-up.

In addition, active treatment, which had showed no effect on CHD risks during the intervention, continued to show no effect on CHD risks.

For all cardiovascular events, the cumulative hazard ratio was 2.26% with active treatment and 2.12% with placebo, a nonsignificant difference.

Colorectal cancer incidence did not differ between women who received CEE and those who received placebo during the intervention phase, and this lack of effect persisted during extended follow-up.

Hip fracture risk had been reduced with CEE therapy during the intervention phase, but this benefit did not persist during the extended follow-up.

Numerically, hip fracture incidence was slightly higher in the CEE group than in the placebo group, they reported.

Total mortality risk remained similar between the two study groups both during the intervention and during extended follow-up.

Only one benefit of CEE therapy that was seen during the intervention phase persisted in the extended follow-up and became statistically significant: Breast cancer incidence was 0.27% with active treatment and 0.35% with placebo.

The researchers noted that these results differ from those of the other portion of the WHI trial in which subjects received combined estrogen-plus-progestin.

In that study arm, active treatment impeded mammographic accuracy and was associated with significantly higher rates of breast cancer and breast cancer mortality, they noted.

The women's age at commencing treatment showed a significant interaction with outcomes, both during the intervention phase and during extended follow-up.

The results suggest that there may be greater benefit and safety for women who start CEE in their early 50s, and less benefit with more potential harm for women who are older when they begin treatment.

“Among younger women, no new safety concerns emerged and some risk reductions became apparent during the postintervention period.

“Among older women, risks of colorectal cancer, death, and the global index of chronic diseases were elevated over the cumulative follow-up period,” Dr. LaCroix and her associates said.

View on The News

Findings Don't Jibe With Others

“The lack of an adverse effect of unopposed estrogen when used for a short period in the WHI does not counter the larger,” longstanding, corroborated body of evidence that the treatment generally elevates the risk of breast cancer, said Dr. Emily S. Jungheim and Dr. Graham A. Colditz.

One can question whether results in the WHI study population, in which nearly 70% of the subjects were older than 60 years at baseline, can even be applied to younger women, particularly with regard to breast cancer risk and hormone therapy.

In addition, the duration of CEE use in the WHI remains problematic. The median “adherent time” was 3.5 years.

“Thus, the WHI results do not address the balance of risks and benefits associated with longer term estrogen use,” they concluded.

DR. JUNGHEIM and DR. COLDITZ are at Washington University, St. Louis. These remarks were taken from their accompanying editorial comment (JAMA 2011;305:1354–5). They reported no relevant financial disclosures.

Major Finding: The short-term increase in risks of stroke, DVT, and pulmonary embolism did not persist over the long term after unopposed estrogen therapy; the equivalent risks of CHD, colorectal cancer, and total mortality did persist; the reduction in hip fracture risk did not persist; and the reduction in breast cancer risk did persist.

Data Source: Extended (10-year) follow-up of approximately 78% of subjects who participated in the Women's Health Initiative-Estrogen Alone trial (3,778 postmenopausal women who took conjugated equine estrogen and 3,867 who took matching placebo for a median of 6 years).

Disclosures: The WHI was funded by the National Heart, Lung, and Blood Institute, the National Institutes of Health, and the U.S. Department of Health and Human Services. Wyeth Ayerst donated the study drugs. Dr. LaCroix reported ties to Warner Chilcott, Sanofi-Aventis, Amgen, and Pfizer. Her associates reported ties to numerous other industry sources.

The most recent findings from the Women's Health Initiative study of short-term unopposed estrogen therapy suggest that after 10 years, the treatment neither increases nor decreases risks for coronary heart disease, deep vein thrombosis, stroke, hip fracture, colorectal cancer, or total mortality, according to a report.

This portion of the WHI study was halted early when interim analysis in 2004 showed an increased risk of stroke in women taking conjugated equine estrogens (CEE) compared with those taking placebo.

“All previous reports of this trial were limited to outcomes occurring during the intervention phase. [Now] we report data on postintervention outcomes through a mean of 10.7 years of follow-up,” said Andrea Z. LaCroix, Ph.D., of Fred Hutchinson Cancer Research Center, Seattle, and her associates (JAMA 2011;305:1305–14).

In the estrogen-only portion of the WHI study, 10,739 postmenopausal women who had undergone hysterectomy had been randomly assigned to receive either CEE or placebo.

They were followed during this intervention phase for a median of 6 years, but the median “adherent time” – the interval during which the women actually took more than 80% of their study pills – was only 3.5 years because more than half stopped taking the pills even before the early halt of the trial.

Approximately 78% of the surviving study subjects (3,778 who took CEE and 3,867 who took placebo) agreed to participate in the extended follow-up reported here.

The increased risks of stroke, deep vein thrombosis, and pulmonary embolism that had been noted during the intervention phase did not persist during extended follow-up.

In addition, active treatment, which had showed no effect on CHD risks during the intervention, continued to show no effect on CHD risks.

For all cardiovascular events, the cumulative hazard ratio was 2.26% with active treatment and 2.12% with placebo, a nonsignificant difference.

Colorectal cancer incidence did not differ between women who received CEE and those who received placebo during the intervention phase, and this lack of effect persisted during extended follow-up.

Hip fracture risk had been reduced with CEE therapy during the intervention phase, but this benefit did not persist during the extended follow-up.

Numerically, hip fracture incidence was slightly higher in the CEE group than in the placebo group, they reported.

Total mortality risk remained similar between the two study groups both during the intervention and during extended follow-up.

Only one benefit of CEE therapy that was seen during the intervention phase persisted in the extended follow-up and became statistically significant: Breast cancer incidence was 0.27% with active treatment and 0.35% with placebo.

The researchers noted that these results differ from those of the other portion of the WHI trial in which subjects received combined estrogen-plus-progestin.

In that study arm, active treatment impeded mammographic accuracy and was associated with significantly higher rates of breast cancer and breast cancer mortality, they noted.

The women's age at commencing treatment showed a significant interaction with outcomes, both during the intervention phase and during extended follow-up.

The results suggest that there may be greater benefit and safety for women who start CEE in their early 50s, and less benefit with more potential harm for women who are older when they begin treatment.

“Among younger women, no new safety concerns emerged and some risk reductions became apparent during the postintervention period.

“Among older women, risks of colorectal cancer, death, and the global index of chronic diseases were elevated over the cumulative follow-up period,” Dr. LaCroix and her associates said.

View on The News

Findings Don't Jibe With Others

“The lack of an adverse effect of unopposed estrogen when used for a short period in the WHI does not counter the larger,” longstanding, corroborated body of evidence that the treatment generally elevates the risk of breast cancer, said Dr. Emily S. Jungheim and Dr. Graham A. Colditz.

One can question whether results in the WHI study population, in which nearly 70% of the subjects were older than 60 years at baseline, can even be applied to younger women, particularly with regard to breast cancer risk and hormone therapy.

In addition, the duration of CEE use in the WHI remains problematic. The median “adherent time” was 3.5 years.

“Thus, the WHI results do not address the balance of risks and benefits associated with longer term estrogen use,” they concluded.

DR. JUNGHEIM and DR. COLDITZ are at Washington University, St. Louis. These remarks were taken from their accompanying editorial comment (JAMA 2011;305:1354–5). They reported no relevant financial disclosures.

A genetic variant in the MUC5B gene appears to be associated with both idiopathic pulmonary fibrosis and familial interstitial pneumonia, according to a report in the April 21 issue of the New England Journal of Medicine.

The MUC5B gene encodes mucin 5B, a gel-forming protein that is usually found in the lungs and is overexpressed in pulmonary diseases such as asthma, bronchitis, chronic obstructive pulmonary disorder, and cystic fibrosis. "In the aggregate, our findings suggest that dysregulated MUC5B expression in the lung may be involved in the pathogenesis of pulmonary fibrosis," said Max A. Seibold, Ph.D., of National Jewish Health, Denver, and his associates.

In addition, the link with familial interstitial pneumonia "could provide insight into the particular clinical manifestations of this complex disease process and consequently lead to earlier detection, more predictable prognosis, and personalized therapeutic strategies," they said.

Until now, the genetic mutations that have been implicated in both idiopathic pulmonary fibrosis (IPF) and familial interstitial pneumonia (FIP) have accounted for only a small proportion of the population risk for the disorders. The investigators searched further for other related mutations, beginning with a genomewide linkage scan in 82 families with FIP.

The results led the researchers to assess genetic variation in particular regions of three gel-forming mucin genes, using blood samples from a separate cohort of 83 subjects who had FIP, 492 subjects who had IPF, and 322 controls. One single-nucleotide polymorphism (SNP) in the putative promoter of the MUC5B gene was particularly strongly associated with both disorders. The minor allele of this SNP (rs35705950) was found at a frequency of 34% among subjects with FIP and 38% among those with IPF, compared with only 9% among controls.

A subsequent analysis demonstrated that rs35705950 exerted an effect in both disorders that was strongly independent of that of other, known mucin variants.

Next, the investigators evaluated the effect of rs35705950 on MUC5B expression in lung tissue from 33 subjects with IPF and 47 control subjects. They found that MUC5B expression was 14 times higher in samples from affected patients than in those from control subjects.

Finally, immunohistochemical staining of the lung tissue from IPF patients showed regions of dense accumulation of MUC5B in areas of microscopic honeycombing that are characteristic of IPF lesions. There was patchy staining of the metaplastic epithelia lining the honeycomb cysts, and of the mucous plugs within the cysts, the investigators said (N. Engl. J. Med. 2011;364:1503-12).

"The prevailing opinion is that IPF develops as a result of excessive, sequential lung injury or aberrant wound healing." The mechanisms by which this genetic variant interacts with excessive lung injury or aberrant repair is not yet known, they added.

"Our results could potentially alter the clinical approach to interstitial pneumonia," Dr. Seibold and his colleagues said.

"The implication of secreted airway mucins in the pathogenesis of [pulmonary fibrosis] suggests that the air space plays a role in the development of idiopathic [interstitial pneumonia]. Although identification of rs35705950 ... can be used to target persons at risk for the development of idiopathic [interstitial pneumonia] (especially those who are members of families subject to idiopathic [interstitial pneumonia]), our observations that the biologic features of mucins may be important etiologic factors in this disease could reorient the focus of pathogenic and therapeutic studies in interstitial lung disease to lung mucins, the air space, and the bronchoalveolar unit," they noted.

This study was supported by the National Institute of Environmental Health Sciences, the National Cancer Institute, the American Lung Association, the Cystic Fibrosis Foundation, the Chapman Foundation, InterMune, and the National Heart, Lung, and Blood Institute. Dr. Seibold’s associates reported ties to numerous academic, government, and industry sources. Dr. Boucher reported ties to Parion Sciences, Inspire Pharmaceuticals, and Pulmatrix.

A genetic variant in the MUC5B gene appears to be associated with both idiopathic pulmonary fibrosis and familial interstitial pneumonia, according to a report in the April 21 issue of the New England Journal of Medicine.

The MUC5B gene encodes mucin 5B, a gel-forming protein that is usually found in the lungs and is overexpressed in pulmonary diseases such as asthma, bronchitis, chronic obstructive pulmonary disorder, and cystic fibrosis. "In the aggregate, our findings suggest that dysregulated MUC5B expression in the lung may be involved in the pathogenesis of pulmonary fibrosis," said Max A. Seibold, Ph.D., of National Jewish Health, Denver, and his associates.

In addition, the link with familial interstitial pneumonia "could provide insight into the particular clinical manifestations of this complex disease process and consequently lead to earlier detection, more predictable prognosis, and personalized therapeutic strategies," they said.

Until now, the genetic mutations that have been implicated in both idiopathic pulmonary fibrosis (IPF) and familial interstitial pneumonia (FIP) have accounted for only a small proportion of the population risk for the disorders. The investigators searched further for other related mutations, beginning with a genomewide linkage scan in 82 families with FIP.

The results led the researchers to assess genetic variation in particular regions of three gel-forming mucin genes, using blood samples from a separate cohort of 83 subjects who had FIP, 492 subjects who had IPF, and 322 controls. One single-nucleotide polymorphism (SNP) in the putative promoter of the MUC5B gene was particularly strongly associated with both disorders. The minor allele of this SNP (rs35705950) was found at a frequency of 34% among subjects with FIP and 38% among those with IPF, compared with only 9% among controls.

A subsequent analysis demonstrated that rs35705950 exerted an effect in both disorders that was strongly independent of that of other, known mucin variants.

Next, the investigators evaluated the effect of rs35705950 on MUC5B expression in lung tissue from 33 subjects with IPF and 47 control subjects. They found that MUC5B expression was 14 times higher in samples from affected patients than in those from control subjects.

Finally, immunohistochemical staining of the lung tissue from IPF patients showed regions of dense accumulation of MUC5B in areas of microscopic honeycombing that are characteristic of IPF lesions. There was patchy staining of the metaplastic epithelia lining the honeycomb cysts, and of the mucous plugs within the cysts, the investigators said (N. Engl. J. Med. 2011;364:1503-12).

"The prevailing opinion is that IPF develops as a result of excessive, sequential lung injury or aberrant wound healing." The mechanisms by which this genetic variant interacts with excessive lung injury or aberrant repair is not yet known, they added.

"Our results could potentially alter the clinical approach to interstitial pneumonia," Dr. Seibold and his colleagues said.

"The implication of secreted airway mucins in the pathogenesis of [pulmonary fibrosis] suggests that the air space plays a role in the development of idiopathic [interstitial pneumonia]. Although identification of rs35705950 ... can be used to target persons at risk for the development of idiopathic [interstitial pneumonia] (especially those who are members of families subject to idiopathic [interstitial pneumonia]), our observations that the biologic features of mucins may be important etiologic factors in this disease could reorient the focus of pathogenic and therapeutic studies in interstitial lung disease to lung mucins, the air space, and the bronchoalveolar unit," they noted.

This study was supported by the National Institute of Environmental Health Sciences, the National Cancer Institute, the American Lung Association, the Cystic Fibrosis Foundation, the Chapman Foundation, InterMune, and the National Heart, Lung, and Blood Institute. Dr. Seibold’s associates reported ties to numerous academic, government, and industry sources. Dr. Boucher reported ties to Parion Sciences, Inspire Pharmaceuticals, and Pulmatrix.

A genetic variant in the MUC5B gene appears to be associated with both idiopathic pulmonary fibrosis and familial interstitial pneumonia, according to a report in the April 21 issue of the New England Journal of Medicine.

The MUC5B gene encodes mucin 5B, a gel-forming protein that is usually found in the lungs and is overexpressed in pulmonary diseases such as asthma, bronchitis, chronic obstructive pulmonary disorder, and cystic fibrosis. "In the aggregate, our findings suggest that dysregulated MUC5B expression in the lung may be involved in the pathogenesis of pulmonary fibrosis," said Max A. Seibold, Ph.D., of National Jewish Health, Denver, and his associates.

In addition, the link with familial interstitial pneumonia "could provide insight into the particular clinical manifestations of this complex disease process and consequently lead to earlier detection, more predictable prognosis, and personalized therapeutic strategies," they said.

Until now, the genetic mutations that have been implicated in both idiopathic pulmonary fibrosis (IPF) and familial interstitial pneumonia (FIP) have accounted for only a small proportion of the population risk for the disorders. The investigators searched further for other related mutations, beginning with a genomewide linkage scan in 82 families with FIP.

The results led the researchers to assess genetic variation in particular regions of three gel-forming mucin genes, using blood samples from a separate cohort of 83 subjects who had FIP, 492 subjects who had IPF, and 322 controls. One single-nucleotide polymorphism (SNP) in the putative promoter of the MUC5B gene was particularly strongly associated with both disorders. The minor allele of this SNP (rs35705950) was found at a frequency of 34% among subjects with FIP and 38% among those with IPF, compared with only 9% among controls.

A subsequent analysis demonstrated that rs35705950 exerted an effect in both disorders that was strongly independent of that of other, known mucin variants.

Next, the investigators evaluated the effect of rs35705950 on MUC5B expression in lung tissue from 33 subjects with IPF and 47 control subjects. They found that MUC5B expression was 14 times higher in samples from affected patients than in those from control subjects.

Finally, immunohistochemical staining of the lung tissue from IPF patients showed regions of dense accumulation of MUC5B in areas of microscopic honeycombing that are characteristic of IPF lesions. There was patchy staining of the metaplastic epithelia lining the honeycomb cysts, and of the mucous plugs within the cysts, the investigators said (N. Engl. J. Med. 2011;364:1503-12).

"The prevailing opinion is that IPF develops as a result of excessive, sequential lung injury or aberrant wound healing." The mechanisms by which this genetic variant interacts with excessive lung injury or aberrant repair is not yet known, they added.

"Our results could potentially alter the clinical approach to interstitial pneumonia," Dr. Seibold and his colleagues said.

"The implication of secreted airway mucins in the pathogenesis of [pulmonary fibrosis] suggests that the air space plays a role in the development of idiopathic [interstitial pneumonia]. Although identification of rs35705950 ... can be used to target persons at risk for the development of idiopathic [interstitial pneumonia] (especially those who are members of families subject to idiopathic [interstitial pneumonia]), our observations that the biologic features of mucins may be important etiologic factors in this disease could reorient the focus of pathogenic and therapeutic studies in interstitial lung disease to lung mucins, the air space, and the bronchoalveolar unit," they noted.

This study was supported by the National Institute of Environmental Health Sciences, the National Cancer Institute, the American Lung Association, the Cystic Fibrosis Foundation, the Chapman Foundation, InterMune, and the National Heart, Lung, and Blood Institute. Dr. Seibold’s associates reported ties to numerous academic, government, and industry sources. Dr. Boucher reported ties to Parion Sciences, Inspire Pharmaceuticals, and Pulmatrix.

A genetic variant in the MUC5B gene appears to be associated with both idiopathic pulmonary fibrosis and familial interstitial pneumonia, according to a report in the April 21 issue of the New England Journal of Medicine.

The MUC5B gene encodes mucin 5B, a gel-forming protein that is usually found in the lungs and is overexpressed in pulmonary diseases such as asthma, bronchitis, chronic obstructive pulmonary disorder, and cystic fibrosis. "In the aggregate, our findings suggest that dysregulated MUC5B expression in the lung may be involved in the pathogenesis of pulmonary fibrosis," said Max A. Seibold, Ph.D., of National Jewish Health, Denver, and his associates.

In addition, the link with familial interstitial pneumonia "could provide insight into the particular clinical manifestations of this complex disease process and consequently lead to earlier detection, more predictable prognosis, and personalized therapeutic strategies," they said.

Until now, the genetic mutations that have been implicated in both idiopathic pulmonary fibrosis (IPF) and familial interstitial pneumonia (FIP) have accounted for only a small proportion of the population risk for the disorders. The investigators searched further for other related mutations, beginning with a genomewide linkage scan in 82 families with FIP.

The results led the researchers to assess genetic variation in particular regions of three gel-forming mucin genes, using blood samples from a separate cohort of 83 subjects who had FIP, 492 subjects who had IPF, and 322 controls. One single-nucleotide polymorphism (SNP) in the putative promoter of the MUC5B gene was particularly strongly associated with both disorders. The minor allele of this SNP (rs35705950) was found at a frequency of 34% among subjects with FIP and 38% among those with IPF, compared with only 9% among controls.

A subsequent analysis demonstrated that rs35705950 exerted an effect in both disorders that was strongly independent of that of other, known mucin variants.

Next, the investigators evaluated the effect of rs35705950 on MUC5B expression in lung tissue from 33 subjects with IPF and 47 control subjects. They found that MUC5B expression was 14 times higher in samples from affected patients than in those from control subjects.

Finally, immunohistochemical staining of the lung tissue from IPF patients showed regions of dense accumulation of MUC5B in areas of microscopic honeycombing that are characteristic of IPF lesions. There was patchy staining of the metaplastic epithelia lining the honeycomb cysts, and of the mucous plugs within the cysts, the investigators said (N. Engl. J. Med. 2011;364:1503-12).

"The prevailing opinion is that IPF develops as a result of excessive, sequential lung injury or aberrant wound healing." The mechanisms by which this genetic variant interacts with excessive lung injury or aberrant repair is not yet known, they added.

"Our results could potentially alter the clinical approach to interstitial pneumonia," Dr. Seibold and his colleagues said.

"The implication of secreted airway mucins in the pathogenesis of [pulmonary fibrosis] suggests that the air space plays a role in the development of idiopathic [interstitial pneumonia]. Although identification of rs35705950 ... can be used to target persons at risk for the development of idiopathic [interstitial pneumonia] (especially those who are members of families subject to idiopathic [interstitial pneumonia]), our observations that the biologic features of mucins may be important etiologic factors in this disease could reorient the focus of pathogenic and therapeutic studies in interstitial lung disease to lung mucins, the air space, and the bronchoalveolar unit," they noted.

This study was supported by the National Institute of Environmental Health Sciences, the National Cancer Institute, the American Lung Association, the Cystic Fibrosis Foundation, the Chapman Foundation, InterMune, and the National Heart, Lung, and Blood Institute. Dr. Seibold’s associates reported ties to numerous academic, government, and industry sources. Dr. Boucher reported ties to Parion Sciences, Inspire Pharmaceuticals, and Pulmatrix.

A genetic variant in the MUC5B gene appears to be associated with both idiopathic pulmonary fibrosis and familial interstitial pneumonia, according to a report in the April 21 issue of the New England Journal of Medicine.

The MUC5B gene encodes mucin 5B, a gel-forming protein that is usually found in the lungs and is overexpressed in pulmonary diseases such as asthma, bronchitis, chronic obstructive pulmonary disorder, and cystic fibrosis. "In the aggregate, our findings suggest that dysregulated MUC5B expression in the lung may be involved in the pathogenesis of pulmonary fibrosis," said Max A. Seibold, Ph.D., of National Jewish Health, Denver, and his associates.

In addition, the link with familial interstitial pneumonia "could provide insight into the particular clinical manifestations of this complex disease process and consequently lead to earlier detection, more predictable prognosis, and personalized therapeutic strategies," they said.

Until now, the genetic mutations that have been implicated in both idiopathic pulmonary fibrosis (IPF) and familial interstitial pneumonia (FIP) have accounted for only a small proportion of the population risk for the disorders. The investigators searched further for other related mutations, beginning with a genomewide linkage scan in 82 families with FIP.

The results led the researchers to assess genetic variation in particular regions of three gel-forming mucin genes, using blood samples from a separate cohort of 83 subjects who had FIP, 492 subjects who had IPF, and 322 controls. One single-nucleotide polymorphism (SNP) in the putative promoter of the MUC5B gene was particularly strongly associated with both disorders. The minor allele of this SNP (rs35705950) was found at a frequency of 34% among subjects with FIP and 38% among those with IPF, compared with only 9% among controls.

A subsequent analysis demonstrated that rs35705950 exerted an effect in both disorders that was strongly independent of that of other, known mucin variants.

Next, the investigators evaluated the effect of rs35705950 on MUC5B expression in lung tissue from 33 subjects with IPF and 47 control subjects. They found that MUC5B expression was 14 times higher in samples from affected patients than in those from control subjects.

Finally, immunohistochemical staining of the lung tissue from IPF patients showed regions of dense accumulation of MUC5B in areas of microscopic honeycombing that are characteristic of IPF lesions. There was patchy staining of the metaplastic epithelia lining the honeycomb cysts, and of the mucous plugs within the cysts, the investigators said (N. Engl. J. Med. 2011;364:1503-12).

"The prevailing opinion is that IPF develops as a result of excessive, sequential lung injury or aberrant wound healing." The mechanisms by which this genetic variant interacts with excessive lung injury or aberrant repair is not yet known, they added.

"Our results could potentially alter the clinical approach to interstitial pneumonia," Dr. Seibold and his colleagues said.

"The implication of secreted airway mucins in the pathogenesis of [pulmonary fibrosis] suggests that the air space plays a role in the development of idiopathic [interstitial pneumonia]. Although identification of rs35705950 ... can be used to target persons at risk for the development of idiopathic [interstitial pneumonia] (especially those who are members of families subject to idiopathic [interstitial pneumonia]), our observations that the biologic features of mucins may be important etiologic factors in this disease could reorient the focus of pathogenic and therapeutic studies in interstitial lung disease to lung mucins, the air space, and the bronchoalveolar unit," they noted.

This study was supported by the National Institute of Environmental Health Sciences, the National Cancer Institute, the American Lung Association, the Cystic Fibrosis Foundation, the Chapman Foundation, InterMune, and the National Heart, Lung, and Blood Institute. Dr. Seibold’s associates reported ties to numerous academic, government, and industry sources. Dr. Boucher reported ties to Parion Sciences, Inspire Pharmaceuticals, and Pulmatrix.

A genetic variant in the MUC5B gene appears to be associated with both idiopathic pulmonary fibrosis and familial interstitial pneumonia, according to a report in the April 21 issue of the New England Journal of Medicine.

The MUC5B gene encodes mucin 5B, a gel-forming protein that is usually found in the lungs and is overexpressed in pulmonary diseases such as asthma, bronchitis, chronic obstructive pulmonary disorder, and cystic fibrosis. "In the aggregate, our findings suggest that dysregulated MUC5B expression in the lung may be involved in the pathogenesis of pulmonary fibrosis," said Max A. Seibold, Ph.D., of National Jewish Health, Denver, and his associates.

In addition, the link with familial interstitial pneumonia "could provide insight into the particular clinical manifestations of this complex disease process and consequently lead to earlier detection, more predictable prognosis, and personalized therapeutic strategies," they said.

Until now, the genetic mutations that have been implicated in both idiopathic pulmonary fibrosis (IPF) and familial interstitial pneumonia (FIP) have accounted for only a small proportion of the population risk for the disorders. The investigators searched further for other related mutations, beginning with a genomewide linkage scan in 82 families with FIP.

The results led the researchers to assess genetic variation in particular regions of three gel-forming mucin genes, using blood samples from a separate cohort of 83 subjects who had FIP, 492 subjects who had IPF, and 322 controls. One single-nucleotide polymorphism (SNP) in the putative promoter of the MUC5B gene was particularly strongly associated with both disorders. The minor allele of this SNP (rs35705950) was found at a frequency of 34% among subjects with FIP and 38% among those with IPF, compared with only 9% among controls.

A subsequent analysis demonstrated that rs35705950 exerted an effect in both disorders that was strongly independent of that of other, known mucin variants.

Next, the investigators evaluated the effect of rs35705950 on MUC5B expression in lung tissue from 33 subjects with IPF and 47 control subjects. They found that MUC5B expression was 14 times higher in samples from affected patients than in those from control subjects.

Finally, immunohistochemical staining of the lung tissue from IPF patients showed regions of dense accumulation of MUC5B in areas of microscopic honeycombing that are characteristic of IPF lesions. There was patchy staining of the metaplastic epithelia lining the honeycomb cysts, and of the mucous plugs within the cysts, the investigators said (N. Engl. J. Med. 2011;364:1503-12).

"The prevailing opinion is that IPF develops as a result of excessive, sequential lung injury or aberrant wound healing." The mechanisms by which this genetic variant interacts with excessive lung injury or aberrant repair is not yet known, they added.

"Our results could potentially alter the clinical approach to interstitial pneumonia," Dr. Seibold and his colleagues said.

"The implication of secreted airway mucins in the pathogenesis of [pulmonary fibrosis] suggests that the air space plays a role in the development of idiopathic [interstitial pneumonia]. Although identification of rs35705950 ... can be used to target persons at risk for the development of idiopathic [interstitial pneumonia] (especially those who are members of families subject to idiopathic [interstitial pneumonia]), our observations that the biologic features of mucins may be important etiologic factors in this disease could reorient the focus of pathogenic and therapeutic studies in interstitial lung disease to lung mucins, the air space, and the bronchoalveolar unit," they noted.

This study was supported by the National Institute of Environmental Health Sciences, the National Cancer Institute, the American Lung Association, the Cystic Fibrosis Foundation, the Chapman Foundation, InterMune, and the National Heart, Lung, and Blood Institute. Dr. Seibold’s associates reported ties to numerous academic, government, and industry sources. Dr. Boucher reported ties to Parion Sciences, Inspire Pharmaceuticals, and Pulmatrix.

Separate research groups offer two new methods for predicting which patients with chronic kidney disease are likely to progress to end-stage renal disease and other complications, according to studies published in the April 20 issue of JAMA.

Ultimately, the methods could help more accurately identify individuals who are at low and high risk for CKD progression, and allow for more appropriate use of health care resources for this population.

In the first report, a "triple-marker" approach using serum creatinine, serum cystatin C, and albuminuria levels yielded more accurate risk prediction than is achieved with current staging systems that are based primarily on creatinine-estimated glomerular filtration rates, said Dr. Carmen A. Peralta of the San Francisco VA Medical Center and her associates.

They assessed the triple-marker technique using a large, population-based cohort of adults (aged 45 years and older) who were participating in a stroke study. A subgroup of 26,643 of these subjects had undergone evaluation of kidney function as part of that study.

Patients in Dr. Peralta’s analysis had a mean age of 65 years. In all, 40% were black, more than half were women, 21% had diabetes, and 59% had hypertension. During a median follow-up of approximately 5 years, 177 subjects developed end-stage renal disease (ESRD) and 1,940 died of all causes.

Adding either the cystatin C or the albuminuria measures to creatinine-based estimated GFR greatly improved the ability to predict the development of ESRD as well as mortality. Using all three measures together improved it even further.

The rate of ESRD was 103-fold higher in subjects who were identified as being at risk via the triple-marker method than in those who were identified via creatinine level alone. Similarly, mortality was nearly eight times higher among those identified as being at risk via the triple-marker method than in those identified via creatinine level alone, the investigators said (JAMA 2011;305:1545-52).

Moreover, one in six subjects who were found to have CKD by the triple-marker method were not identified at all by creatinine level alone, suggesting that people could have occult CKD that would not be diagnosed according to standard methods.

In addition, 25% of subjects who were labeled as having CKD by creatinine-based GFR estimate alone were found not to have CKD when cystatin C and albuminuria levels were added into the risk stratification. This suggests that one-fourth of people screened by standard methods alone may be treated as though they’re at increased risk of ESRD or death when they are not.

Thus, using the triple-marker method "could both reduce unwarranted referrals and unnecessary work-ups for low-risk individuals and would prioritize specialty care and interventions to individuals at highest risk," Dr. Peralta and her colleagues said.

"Several groups are currently advocating new international guidelines that more accurately reflect prognosis of CKD and have proposed adding [albumin:creatinine ratio] to staging of CKD. Our results suggest that a triple-marker approach using both [albuminuria] and cystatin C to confirm CKD more accurately discriminates prognosis for death and progression to ESRD than creatinine and [albuminuria] alone," they added.

In the second report, investigators developed seven possible models for predicting CKD progression, using various combinations of more than 20 candidate variables that are known to affect renal function. To do so, they first assessed these variables in a Canadian cohort of 3,449 adults who were treated at nephrology clinics for stage 3-5 CKD.

These study subjects, who were followed from 2001 through 2008, helped determine which variables were best associated with CKD progression, said Dr. Navdeep Tangri of Tufts Medical Center, Boston, and his associates.

One of the seven models was particularly accurate at predicting CKD progression. It factored in patient age and sex, as well as the estimated GFR, albuminuria, serum calcium, serum phosphate, serum bicarbonate, and serum albumin levels. These are basic laboratory measurements "that are obtained routinely in patients with CKD," Dr. Tangri and his colleagues said (JAMA 2011;305:1553-9).

All seven models were tested in a validation cohort of 4,942 patients in a British Columbia registry who had stage 3-5 CKD. The same model was found to be the most accurate in predicting disease progression in that cohort.

"Using our models, lower-risk patients could be managed by the primary care physician without additional testing or treatment of CKD complications," whereas higher-risk patients could receive "more intensive testing, intervention, and early nephrology care," they said.

The models also could be used to triage patients with stage 4 CKD "regarding dialysis education, creation of vascular access, and preemptive transplantation"; to select stage 3 patients for public health interventions; and to select high-risk patients for enrollment in clinical trials, the researchers added.

Dr. Peralta’s study was supported by the National Institute of Neurological Disorders and Stroke, Amgen Corp., the National Institute of Diabetes and Digestive and Kidney Diseases, the Robert Wood Johnson Foundation, and the American Heart Association. Several associates also reported ties to Amgen. Dr. Tangri’s study was supported by a joint initiative of the Kidney Foundation of Canada, the Canadian Institute of Health Research, and the Canadian Society of Nephrology, as well as by the Change Foundation of Ontario. Dr. Tangri and associates reported no financial conflicts of interest.

Separate research groups offer two new methods for predicting which patients with chronic kidney disease are likely to progress to end-stage renal disease and other complications, according to studies published in the April 20 issue of JAMA.

Ultimately, the methods could help more accurately identify individuals who are at low and high risk for CKD progression, and allow for more appropriate use of health care resources for this population.

In the first report, a "triple-marker" approach using serum creatinine, serum cystatin C, and albuminuria levels yielded more accurate risk prediction than is achieved with current staging systems that are based primarily on creatinine-estimated glomerular filtration rates, said Dr. Carmen A. Peralta of the San Francisco VA Medical Center and her associates.

They assessed the triple-marker technique using a large, population-based cohort of adults (aged 45 years and older) who were participating in a stroke study. A subgroup of 26,643 of these subjects had undergone evaluation of kidney function as part of that study.

Patients in Dr. Peralta’s analysis had a mean age of 65 years. In all, 40% were black, more than half were women, 21% had diabetes, and 59% had hypertension. During a median follow-up of approximately 5 years, 177 subjects developed end-stage renal disease (ESRD) and 1,940 died of all causes.

Adding either the cystatin C or the albuminuria measures to creatinine-based estimated GFR greatly improved the ability to predict the development of ESRD as well as mortality. Using all three measures together improved it even further.

The rate of ESRD was 103-fold higher in subjects who were identified as being at risk via the triple-marker method than in those who were identified via creatinine level alone. Similarly, mortality was nearly eight times higher among those identified as being at risk via the triple-marker method than in those identified via creatinine level alone, the investigators said (JAMA 2011;305:1545-52).

Moreover, one in six subjects who were found to have CKD by the triple-marker method were not identified at all by creatinine level alone, suggesting that people could have occult CKD that would not be diagnosed according to standard methods.

In addition, 25% of subjects who were labeled as having CKD by creatinine-based GFR estimate alone were found not to have CKD when cystatin C and albuminuria levels were added into the risk stratification. This suggests that one-fourth of people screened by standard methods alone may be treated as though they’re at increased risk of ESRD or death when they are not.

Thus, using the triple-marker method "could both reduce unwarranted referrals and unnecessary work-ups for low-risk individuals and would prioritize specialty care and interventions to individuals at highest risk," Dr. Peralta and her colleagues said.

"Several groups are currently advocating new international guidelines that more accurately reflect prognosis of CKD and have proposed adding [albumin:creatinine ratio] to staging of CKD. Our results suggest that a triple-marker approach using both [albuminuria] and cystatin C to confirm CKD more accurately discriminates prognosis for death and progression to ESRD than creatinine and [albuminuria] alone," they added.

In the second report, investigators developed seven possible models for predicting CKD progression, using various combinations of more than 20 candidate variables that are known to affect renal function. To do so, they first assessed these variables in a Canadian cohort of 3,449 adults who were treated at nephrology clinics for stage 3-5 CKD.

These study subjects, who were followed from 2001 through 2008, helped determine which variables were best associated with CKD progression, said Dr. Navdeep Tangri of Tufts Medical Center, Boston, and his associates.

One of the seven models was particularly accurate at predicting CKD progression. It factored in patient age and sex, as well as the estimated GFR, albuminuria, serum calcium, serum phosphate, serum bicarbonate, and serum albumin levels. These are basic laboratory measurements "that are obtained routinely in patients with CKD," Dr. Tangri and his colleagues said (JAMA 2011;305:1553-9).

All seven models were tested in a validation cohort of 4,942 patients in a British Columbia registry who had stage 3-5 CKD. The same model was found to be the most accurate in predicting disease progression in that cohort.

"Using our models, lower-risk patients could be managed by the primary care physician without additional testing or treatment of CKD complications," whereas higher-risk patients could receive "more intensive testing, intervention, and early nephrology care," they said.

The models also could be used to triage patients with stage 4 CKD "regarding dialysis education, creation of vascular access, and preemptive transplantation"; to select stage 3 patients for public health interventions; and to select high-risk patients for enrollment in clinical trials, the researchers added.

Dr. Peralta’s study was supported by the National Institute of Neurological Disorders and Stroke, Amgen Corp., the National Institute of Diabetes and Digestive and Kidney Diseases, the Robert Wood Johnson Foundation, and the American Heart Association. Several associates also reported ties to Amgen. Dr. Tangri’s study was supported by a joint initiative of the Kidney Foundation of Canada, the Canadian Institute of Health Research, and the Canadian Society of Nephrology, as well as by the Change Foundation of Ontario. Dr. Tangri and associates reported no financial conflicts of interest.

Separate research groups offer two new methods for predicting which patients with chronic kidney disease are likely to progress to end-stage renal disease and other complications, according to studies published in the April 20 issue of JAMA.

Ultimately, the methods could help more accurately identify individuals who are at low and high risk for CKD progression, and allow for more appropriate use of health care resources for this population.

In the first report, a "triple-marker" approach using serum creatinine, serum cystatin C, and albuminuria levels yielded more accurate risk prediction than is achieved with current staging systems that are based primarily on creatinine-estimated glomerular filtration rates, said Dr. Carmen A. Peralta of the San Francisco VA Medical Center and her associates.

They assessed the triple-marker technique using a large, population-based cohort of adults (aged 45 years and older) who were participating in a stroke study. A subgroup of 26,643 of these subjects had undergone evaluation of kidney function as part of that study.

Patients in Dr. Peralta’s analysis had a mean age of 65 years. In all, 40% were black, more than half were women, 21% had diabetes, and 59% had hypertension. During a median follow-up of approximately 5 years, 177 subjects developed end-stage renal disease (ESRD) and 1,940 died of all causes.

Adding either the cystatin C or the albuminuria measures to creatinine-based estimated GFR greatly improved the ability to predict the development of ESRD as well as mortality. Using all three measures together improved it even further.

The rate of ESRD was 103-fold higher in subjects who were identified as being at risk via the triple-marker method than in those who were identified via creatinine level alone. Similarly, mortality was nearly eight times higher among those identified as being at risk via the triple-marker method than in those identified via creatinine level alone, the investigators said (JAMA 2011;305:1545-52).

Moreover, one in six subjects who were found to have CKD by the triple-marker method were not identified at all by creatinine level alone, suggesting that people could have occult CKD that would not be diagnosed according to standard methods.

In addition, 25% of subjects who were labeled as having CKD by creatinine-based GFR estimate alone were found not to have CKD when cystatin C and albuminuria levels were added into the risk stratification. This suggests that one-fourth of people screened by standard methods alone may be treated as though they’re at increased risk of ESRD or death when they are not.

Thus, using the triple-marker method "could both reduce unwarranted referrals and unnecessary work-ups for low-risk individuals and would prioritize specialty care and interventions to individuals at highest risk," Dr. Peralta and her colleagues said.

"Several groups are currently advocating new international guidelines that more accurately reflect prognosis of CKD and have proposed adding [albumin:creatinine ratio] to staging of CKD. Our results suggest that a triple-marker approach using both [albuminuria] and cystatin C to confirm CKD more accurately discriminates prognosis for death and progression to ESRD than creatinine and [albuminuria] alone," they added.

In the second report, investigators developed seven possible models for predicting CKD progression, using various combinations of more than 20 candidate variables that are known to affect renal function. To do so, they first assessed these variables in a Canadian cohort of 3,449 adults who were treated at nephrology clinics for stage 3-5 CKD.

These study subjects, who were followed from 2001 through 2008, helped determine which variables were best associated with CKD progression, said Dr. Navdeep Tangri of Tufts Medical Center, Boston, and his associates.

One of the seven models was particularly accurate at predicting CKD progression. It factored in patient age and sex, as well as the estimated GFR, albuminuria, serum calcium, serum phosphate, serum bicarbonate, and serum albumin levels. These are basic laboratory measurements "that are obtained routinely in patients with CKD," Dr. Tangri and his colleagues said (JAMA 2011;305:1553-9).

All seven models were tested in a validation cohort of 4,942 patients in a British Columbia registry who had stage 3-5 CKD. The same model was found to be the most accurate in predicting disease progression in that cohort.

"Using our models, lower-risk patients could be managed by the primary care physician without additional testing or treatment of CKD complications," whereas higher-risk patients could receive "more intensive testing, intervention, and early nephrology care," they said.

The models also could be used to triage patients with stage 4 CKD "regarding dialysis education, creation of vascular access, and preemptive transplantation"; to select stage 3 patients for public health interventions; and to select high-risk patients for enrollment in clinical trials, the researchers added.

Dr. Peralta’s study was supported by the National Institute of Neurological Disorders and Stroke, Amgen Corp., the National Institute of Diabetes and Digestive and Kidney Diseases, the Robert Wood Johnson Foundation, and the American Heart Association. Several associates also reported ties to Amgen. Dr. Tangri’s study was supported by a joint initiative of the Kidney Foundation of Canada, the Canadian Institute of Health Research, and the Canadian Society of Nephrology, as well as by the Change Foundation of Ontario. Dr. Tangri and associates reported no financial conflicts of interest.

Separate research groups offer two new methods for predicting which patients with chronic kidney disease are likely to progress to end-stage renal disease and other complications, according to studies published in the April 20 issue of JAMA.

Ultimately, the methods could help more accurately identify individuals who are at low and high risk for CKD progression, and allow for more appropriate use of health care resources for this population.

In the first report, a "triple-marker" approach using serum creatinine, serum cystatin C, and albuminuria levels yielded more accurate risk prediction than is achieved with current staging systems that are based primarily on creatinine-estimated glomerular filtration rates, said Dr. Carmen A. Peralta of the San Francisco VA Medical Center and her associates.

They assessed the triple-marker technique using a large, population-based cohort of adults (aged 45 years and older) who were participating in a stroke study. A subgroup of 26,643 of these subjects had undergone evaluation of kidney function as part of that study.

Patients in Dr. Peralta’s analysis had a mean age of 65 years. In all, 40% were black, more than half were women, 21% had diabetes, and 59% had hypertension. During a median follow-up of approximately 5 years, 177 subjects developed end-stage renal disease (ESRD) and 1,940 died of all causes.

Adding either the cystatin C or the albuminuria measures to creatinine-based estimated GFR greatly improved the ability to predict the development of ESRD as well as mortality. Using all three measures together improved it even further.

The rate of ESRD was 103-fold higher in subjects who were identified as being at risk via the triple-marker method than in those who were identified via creatinine level alone. Similarly, mortality was nearly eight times higher among those identified as being at risk via the triple-marker method than in those identified via creatinine level alone, the investigators said (JAMA 2011;305:1545-52).

Moreover, one in six subjects who were found to have CKD by the triple-marker method were not identified at all by creatinine level alone, suggesting that people could have occult CKD that would not be diagnosed according to standard methods.

In addition, 25% of subjects who were labeled as having CKD by creatinine-based GFR estimate alone were found not to have CKD when cystatin C and albuminuria levels were added into the risk stratification. This suggests that one-fourth of people screened by standard methods alone may be treated as though they’re at increased risk of ESRD or death when they are not.

Thus, using the triple-marker method "could both reduce unwarranted referrals and unnecessary work-ups for low-risk individuals and would prioritize specialty care and interventions to individuals at highest risk," Dr. Peralta and her colleagues said.

"Several groups are currently advocating new international guidelines that more accurately reflect prognosis of CKD and have proposed adding [albumin:creatinine ratio] to staging of CKD. Our results suggest that a triple-marker approach using both [albuminuria] and cystatin C to confirm CKD more accurately discriminates prognosis for death and progression to ESRD than creatinine and [albuminuria] alone," they added.

In the second report, investigators developed seven possible models for predicting CKD progression, using various combinations of more than 20 candidate variables that are known to affect renal function. To do so, they first assessed these variables in a Canadian cohort of 3,449 adults who were treated at nephrology clinics for stage 3-5 CKD.

These study subjects, who were followed from 2001 through 2008, helped determine which variables were best associated with CKD progression, said Dr. Navdeep Tangri of Tufts Medical Center, Boston, and his associates.

One of the seven models was particularly accurate at predicting CKD progression. It factored in patient age and sex, as well as the estimated GFR, albuminuria, serum calcium, serum phosphate, serum bicarbonate, and serum albumin levels. These are basic laboratory measurements "that are obtained routinely in patients with CKD," Dr. Tangri and his colleagues said (JAMA 2011;305:1553-9).

All seven models were tested in a validation cohort of 4,942 patients in a British Columbia registry who had stage 3-5 CKD. The same model was found to be the most accurate in predicting disease progression in that cohort.

"Using our models, lower-risk patients could be managed by the primary care physician without additional testing or treatment of CKD complications," whereas higher-risk patients could receive "more intensive testing, intervention, and early nephrology care," they said.

The models also could be used to triage patients with stage 4 CKD "regarding dialysis education, creation of vascular access, and preemptive transplantation"; to select stage 3 patients for public health interventions; and to select high-risk patients for enrollment in clinical trials, the researchers added.

Dr. Peralta’s study was supported by the National Institute of Neurological Disorders and Stroke, Amgen Corp., the National Institute of Diabetes and Digestive and Kidney Diseases, the Robert Wood Johnson Foundation, and the American Heart Association. Several associates also reported ties to Amgen. Dr. Tangri’s study was supported by a joint initiative of the Kidney Foundation of Canada, the Canadian Institute of Health Research, and the Canadian Society of Nephrology, as well as by the Change Foundation of Ontario. Dr. Tangri and associates reported no financial conflicts of interest.

Separate research groups offer two new methods for predicting which patients with chronic kidney disease are likely to progress to end-stage renal disease and other complications, according to studies published in the April 20 issue of JAMA.

Ultimately, the methods could help more accurately identify individuals who are at low and high risk for CKD progression, and allow for more appropriate use of health care resources for this population.

In the first report, a "triple-marker" approach using serum creatinine, serum cystatin C, and albuminuria levels yielded more accurate risk prediction than is achieved with current staging systems that are based primarily on creatinine-estimated glomerular filtration rates, said Dr. Carmen A. Peralta of the San Francisco VA Medical Center and her associates.

They assessed the triple-marker technique using a large, population-based cohort of adults (aged 45 years and older) who were participating in a stroke study. A subgroup of 26,643 of these subjects had undergone evaluation of kidney function as part of that study.

Patients in Dr. Peralta’s analysis had a mean age of 65 years. In all, 40% were black, more than half were women, 21% had diabetes, and 59% had hypertension. During a median follow-up of approximately 5 years, 177 subjects developed end-stage renal disease (ESRD) and 1,940 died of all causes.

Adding either the cystatin C or the albuminuria measures to creatinine-based estimated GFR greatly improved the ability to predict the development of ESRD as well as mortality. Using all three measures together improved it even further.

The rate of ESRD was 103-fold higher in subjects who were identified as being at risk via the triple-marker method than in those who were identified via creatinine level alone. Similarly, mortality was nearly eight times higher among those identified as being at risk via the triple-marker method than in those identified via creatinine level alone, the investigators said (JAMA 2011;305:1545-52).

Moreover, one in six subjects who were found to have CKD by the triple-marker method were not identified at all by creatinine level alone, suggesting that people could have occult CKD that would not be diagnosed according to standard methods.

In addition, 25% of subjects who were labeled as having CKD by creatinine-based GFR estimate alone were found not to have CKD when cystatin C and albuminuria levels were added into the risk stratification. This suggests that one-fourth of people screened by standard methods alone may be treated as though they’re at increased risk of ESRD or death when they are not.

Thus, using the triple-marker method "could both reduce unwarranted referrals and unnecessary work-ups for low-risk individuals and would prioritize specialty care and interventions to individuals at highest risk," Dr. Peralta and her colleagues said.

"Several groups are currently advocating new international guidelines that more accurately reflect prognosis of CKD and have proposed adding [albumin:creatinine ratio] to staging of CKD. Our results suggest that a triple-marker approach using both [albuminuria] and cystatin C to confirm CKD more accurately discriminates prognosis for death and progression to ESRD than creatinine and [albuminuria] alone," they added.

In the second report, investigators developed seven possible models for predicting CKD progression, using various combinations of more than 20 candidate variables that are known to affect renal function. To do so, they first assessed these variables in a Canadian cohort of 3,449 adults who were treated at nephrology clinics for stage 3-5 CKD.

These study subjects, who were followed from 2001 through 2008, helped determine which variables were best associated with CKD progression, said Dr. Navdeep Tangri of Tufts Medical Center, Boston, and his associates.

One of the seven models was particularly accurate at predicting CKD progression. It factored in patient age and sex, as well as the estimated GFR, albuminuria, serum calcium, serum phosphate, serum bicarbonate, and serum albumin levels. These are basic laboratory measurements "that are obtained routinely in patients with CKD," Dr. Tangri and his colleagues said (JAMA 2011;305:1553-9).

All seven models were tested in a validation cohort of 4,942 patients in a British Columbia registry who had stage 3-5 CKD. The same model was found to be the most accurate in predicting disease progression in that cohort.

"Using our models, lower-risk patients could be managed by the primary care physician without additional testing or treatment of CKD complications," whereas higher-risk patients could receive "more intensive testing, intervention, and early nephrology care," they said.

The models also could be used to triage patients with stage 4 CKD "regarding dialysis education, creation of vascular access, and preemptive transplantation"; to select stage 3 patients for public health interventions; and to select high-risk patients for enrollment in clinical trials, the researchers added.

Dr. Peralta’s study was supported by the National Institute of Neurological Disorders and Stroke, Amgen Corp., the National Institute of Diabetes and Digestive and Kidney Diseases, the Robert Wood Johnson Foundation, and the American Heart Association. Several associates also reported ties to Amgen. Dr. Tangri’s study was supported by a joint initiative of the Kidney Foundation of Canada, the Canadian Institute of Health Research, and the Canadian Society of Nephrology, as well as by the Change Foundation of Ontario. Dr. Tangri and associates reported no financial conflicts of interest.

Separate research groups offer two new methods for predicting which patients with chronic kidney disease are likely to progress to end-stage renal disease and other complications, according to studies published in the April 20 issue of JAMA.

Ultimately, the methods could help more accurately identify individuals who are at low and high risk for CKD progression, and allow for more appropriate use of health care resources for this population.

In the first report, a "triple-marker" approach using serum creatinine, serum cystatin C, and albuminuria levels yielded more accurate risk prediction than is achieved with current staging systems that are based primarily on creatinine-estimated glomerular filtration rates, said Dr. Carmen A. Peralta of the San Francisco VA Medical Center and her associates.

They assessed the triple-marker technique using a large, population-based cohort of adults (aged 45 years and older) who were participating in a stroke study. A subgroup of 26,643 of these subjects had undergone evaluation of kidney function as part of that study.

Patients in Dr. Peralta’s analysis had a mean age of 65 years. In all, 40% were black, more than half were women, 21% had diabetes, and 59% had hypertension. During a median follow-up of approximately 5 years, 177 subjects developed end-stage renal disease (ESRD) and 1,940 died of all causes.

Adding either the cystatin C or the albuminuria measures to creatinine-based estimated GFR greatly improved the ability to predict the development of ESRD as well as mortality. Using all three measures together improved it even further.

The rate of ESRD was 103-fold higher in subjects who were identified as being at risk via the triple-marker method than in those who were identified via creatinine level alone. Similarly, mortality was nearly eight times higher among those identified as being at risk via the triple-marker method than in those identified via creatinine level alone, the investigators said (JAMA 2011;305:1545-52).

Moreover, one in six subjects who were found to have CKD by the triple-marker method were not identified at all by creatinine level alone, suggesting that people could have occult CKD that would not be diagnosed according to standard methods.

In addition, 25% of subjects who were labeled as having CKD by creatinine-based GFR estimate alone were found not to have CKD when cystatin C and albuminuria levels were added into the risk stratification. This suggests that one-fourth of people screened by standard methods alone may be treated as though they’re at increased risk of ESRD or death when they are not.

Thus, using the triple-marker method "could both reduce unwarranted referrals and unnecessary work-ups for low-risk individuals and would prioritize specialty care and interventions to individuals at highest risk," Dr. Peralta and her colleagues said.

"Several groups are currently advocating new international guidelines that more accurately reflect prognosis of CKD and have proposed adding [albumin:creatinine ratio] to staging of CKD. Our results suggest that a triple-marker approach using both [albuminuria] and cystatin C to confirm CKD more accurately discriminates prognosis for death and progression to ESRD than creatinine and [albuminuria] alone," they added.

In the second report, investigators developed seven possible models for predicting CKD progression, using various combinations of more than 20 candidate variables that are known to affect renal function. To do so, they first assessed these variables in a Canadian cohort of 3,449 adults who were treated at nephrology clinics for stage 3-5 CKD.

These study subjects, who were followed from 2001 through 2008, helped determine which variables were best associated with CKD progression, said Dr. Navdeep Tangri of Tufts Medical Center, Boston, and his associates.

One of the seven models was particularly accurate at predicting CKD progression. It factored in patient age and sex, as well as the estimated GFR, albuminuria, serum calcium, serum phosphate, serum bicarbonate, and serum albumin levels. These are basic laboratory measurements "that are obtained routinely in patients with CKD," Dr. Tangri and his colleagues said (JAMA 2011;305:1553-9).

All seven models were tested in a validation cohort of 4,942 patients in a British Columbia registry who had stage 3-5 CKD. The same model was found to be the most accurate in predicting disease progression in that cohort.

"Using our models, lower-risk patients could be managed by the primary care physician without additional testing or treatment of CKD complications," whereas higher-risk patients could receive "more intensive testing, intervention, and early nephrology care," they said.

The models also could be used to triage patients with stage 4 CKD "regarding dialysis education, creation of vascular access, and preemptive transplantation"; to select stage 3 patients for public health interventions; and to select high-risk patients for enrollment in clinical trials, the researchers added.

Dr. Peralta’s study was supported by the National Institute of Neurological Disorders and Stroke, Amgen Corp., the National Institute of Diabetes and Digestive and Kidney Diseases, the Robert Wood Johnson Foundation, and the American Heart Association. Several associates also reported ties to Amgen. Dr. Tangri’s study was supported by a joint initiative of the Kidney Foundation of Canada, the Canadian Institute of Health Research, and the Canadian Society of Nephrology, as well as by the Change Foundation of Ontario. Dr. Tangri and associates reported no financial conflicts of interest.

Mortality after primary total hip arthroplasty has declined somewhat over time, and mortality after revision arthroplasty has remained stable, according to a report in the April 20 issue of JAMA.

In the 18-year longitudinal study of Medicare data, both of these reassuring trends occurred despite a substantial increase in patient complexity, said Dr. Peter Cram of the University of Iowa, Iowa City.

However, two concerning trends also were noted: The number of total hip arthroplasty patients discharged to postacute care facilities (such as nursing homes and rehabilitation centers) instead of to home increased substantially, and the number of hospital readmissions following total hip arthroplasty rose markedly.

Dr. Cram and his colleagues noted that objective evaluations of total hip arthroplasty outcomes are lacking in the literature. It is generally assumed that increasing experience with the procedure has inevitably produced better patient outcomes, "but rigorous empirical data documenting such improvement are limited."

They assessed trends in patient outcomes using data on Medicare fee-for-service beneficiaries who underwent primary (1,453,493 patients) or revision (348,596 patients) total hip arthroplasties over an 18-year period. "More than 60% of all total hip arthroplasty procedures are performed on Medicare enrollees, making this an appropriate data set for studying" the surgery.

During 1991-2008, the medical complexity of patients who underwent these procedures increased. For primary arthroplasty, the mean patient age rose from 74 to 75 years, the prevalence of diabetes more than doubled from 7% to 15%, and the prevalence of obesity more than tripled from 2% to 7%. The prevalence of heart failure climbed from just under 3% to just over 4%, and that of renal failure rose tenfold, from 0.4% to 4%. The mean number of comorbid conditions doubled from one to two.

Despite the increasing patient complexity, the mean 30-day mortality for primary total hip arthroplasty dropped from 0.7% to 0.3% during this interval, and mean 90-day mortality decreased from 1.3% to 0.7%, the investigators said (JAMA 2011;305:1560-7).

For revision hip arthroplasty, which often is done in an emergent setting, 30-day mortality remained steady at approximately 2% and 90-day mortality was steady at 4.5% throughout the study period.

For primary hip arthroplasty, hospital length of stay also decreased approximately 60% over time, from 9.1 days to 3.7 days. But this trend is not as encouraging as it appears to be at first glance, because the number of patients discharged to home declined dramatically, whereas the proportion discharged to skilled or intermediate care facilities approximately doubled.

In addition, the 30-day readmission rate, which some consider a gauge of the inappropriateness of a short length of stay (LOS), also rose markedly from 5.9% to 8.5%. The patterns were similar for revision hip arthroplasty, Dr. Cram and his associates said.

These LOS findings "may have policy implications." Hospitals clearly are motivated "to reduce LOS under the Medicare prospective payment system," but these results indicate that the practice is not benefiting patients.

This study was supported by the National Center for Research Resources, the Robert Wood Johnson Physician Faculty Scholars Program, and the National Heart, Lung, and Blood Institute. No financial conflicts of interest were reported.

Mortality after primary total hip arthroplasty has declined somewhat over time, and mortality after revision arthroplasty has remained stable, according to a report in the April 20 issue of JAMA.

In the 18-year longitudinal study of Medicare data, both of these reassuring trends occurred despite a substantial increase in patient complexity, said Dr. Peter Cram of the University of Iowa, Iowa City.

However, two concerning trends also were noted: The number of total hip arthroplasty patients discharged to postacute care facilities (such as nursing homes and rehabilitation centers) instead of to home increased substantially, and the number of hospital readmissions following total hip arthroplasty rose markedly.

Dr. Cram and his colleagues noted that objective evaluations of total hip arthroplasty outcomes are lacking in the literature. It is generally assumed that increasing experience with the procedure has inevitably produced better patient outcomes, "but rigorous empirical data documenting such improvement are limited."

They assessed trends in patient outcomes using data on Medicare fee-for-service beneficiaries who underwent primary (1,453,493 patients) or revision (348,596 patients) total hip arthroplasties over an 18-year period. "More than 60% of all total hip arthroplasty procedures are performed on Medicare enrollees, making this an appropriate data set for studying" the surgery.

During 1991-2008, the medical complexity of patients who underwent these procedures increased. For primary arthroplasty, the mean patient age rose from 74 to 75 years, the prevalence of diabetes more than doubled from 7% to 15%, and the prevalence of obesity more than tripled from 2% to 7%. The prevalence of heart failure climbed from just under 3% to just over 4%, and that of renal failure rose tenfold, from 0.4% to 4%. The mean number of comorbid conditions doubled from one to two.

Despite the increasing patient complexity, the mean 30-day mortality for primary total hip arthroplasty dropped from 0.7% to 0.3% during this interval, and mean 90-day mortality decreased from 1.3% to 0.7%, the investigators said (JAMA 2011;305:1560-7).

For revision hip arthroplasty, which often is done in an emergent setting, 30-day mortality remained steady at approximately 2% and 90-day mortality was steady at 4.5% throughout the study period.

For primary hip arthroplasty, hospital length of stay also decreased approximately 60% over time, from 9.1 days to 3.7 days. But this trend is not as encouraging as it appears to be at first glance, because the number of patients discharged to home declined dramatically, whereas the proportion discharged to skilled or intermediate care facilities approximately doubled.

In addition, the 30-day readmission rate, which some consider a gauge of the inappropriateness of a short length of stay (LOS), also rose markedly from 5.9% to 8.5%. The patterns were similar for revision hip arthroplasty, Dr. Cram and his associates said.

These LOS findings "may have policy implications." Hospitals clearly are motivated "to reduce LOS under the Medicare prospective payment system," but these results indicate that the practice is not benefiting patients.

This study was supported by the National Center for Research Resources, the Robert Wood Johnson Physician Faculty Scholars Program, and the National Heart, Lung, and Blood Institute. No financial conflicts of interest were reported.

Mortality after primary total hip arthroplasty has declined somewhat over time, and mortality after revision arthroplasty has remained stable, according to a report in the April 20 issue of JAMA.

In the 18-year longitudinal study of Medicare data, both of these reassuring trends occurred despite a substantial increase in patient complexity, said Dr. Peter Cram of the University of Iowa, Iowa City.

However, two concerning trends also were noted: The number of total hip arthroplasty patients discharged to postacute care facilities (such as nursing homes and rehabilitation centers) instead of to home increased substantially, and the number of hospital readmissions following total hip arthroplasty rose markedly.

Dr. Cram and his colleagues noted that objective evaluations of total hip arthroplasty outcomes are lacking in the literature. It is generally assumed that increasing experience with the procedure has inevitably produced better patient outcomes, "but rigorous empirical data documenting such improvement are limited."

They assessed trends in patient outcomes using data on Medicare fee-for-service beneficiaries who underwent primary (1,453,493 patients) or revision (348,596 patients) total hip arthroplasties over an 18-year period. "More than 60% of all total hip arthroplasty procedures are performed on Medicare enrollees, making this an appropriate data set for studying" the surgery.

During 1991-2008, the medical complexity of patients who underwent these procedures increased. For primary arthroplasty, the mean patient age rose from 74 to 75 years, the prevalence of diabetes more than doubled from 7% to 15%, and the prevalence of obesity more than tripled from 2% to 7%. The prevalence of heart failure climbed from just under 3% to just over 4%, and that of renal failure rose tenfold, from 0.4% to 4%. The mean number of comorbid conditions doubled from one to two.

Despite the increasing patient complexity, the mean 30-day mortality for primary total hip arthroplasty dropped from 0.7% to 0.3% during this interval, and mean 90-day mortality decreased from 1.3% to 0.7%, the investigators said (JAMA 2011;305:1560-7).

For revision hip arthroplasty, which often is done in an emergent setting, 30-day mortality remained steady at approximately 2% and 90-day mortality was steady at 4.5% throughout the study period.

For primary hip arthroplasty, hospital length of stay also decreased approximately 60% over time, from 9.1 days to 3.7 days. But this trend is not as encouraging as it appears to be at first glance, because the number of patients discharged to home declined dramatically, whereas the proportion discharged to skilled or intermediate care facilities approximately doubled.

In addition, the 30-day readmission rate, which some consider a gauge of the inappropriateness of a short length of stay (LOS), also rose markedly from 5.9% to 8.5%. The patterns were similar for revision hip arthroplasty, Dr. Cram and his associates said.

These LOS findings "may have policy implications." Hospitals clearly are motivated "to reduce LOS under the Medicare prospective payment system," but these results indicate that the practice is not benefiting patients.

This study was supported by the National Center for Research Resources, the Robert Wood Johnson Physician Faculty Scholars Program, and the National Heart, Lung, and Blood Institute. No financial conflicts of interest were reported.

Mortality after primary total hip arthroplasty has declined somewhat over time, and mortality after revision arthroplasty has remained stable, according to a report in the April 20 issue of JAMA.

In the 18-year longitudinal study of Medicare data, both of these reassuring trends occurred despite a substantial increase in patient complexity, said Dr. Peter Cram of the University of Iowa, Iowa City.

However, two concerning trends also were noted: The number of total hip arthroplasty patients discharged to postacute care facilities (such as nursing homes and rehabilitation centers) instead of to home increased substantially, and the number of hospital readmissions following total hip arthroplasty rose markedly.

Dr. Cram and his colleagues noted that objective evaluations of total hip arthroplasty outcomes are lacking in the literature. It is generally assumed that increasing experience with the procedure has inevitably produced better patient outcomes, "but rigorous empirical data documenting such improvement are limited."

They assessed trends in patient outcomes using data on Medicare fee-for-service beneficiaries who underwent primary (1,453,493 patients) or revision (348,596 patients) total hip arthroplasties over an 18-year period. "More than 60% of all total hip arthroplasty procedures are performed on Medicare enrollees, making this an appropriate data set for studying" the surgery.

During 1991-2008, the medical complexity of patients who underwent these procedures increased. For primary arthroplasty, the mean patient age rose from 74 to 75 years, the prevalence of diabetes more than doubled from 7% to 15%, and the prevalence of obesity more than tripled from 2% to 7%. The prevalence of heart failure climbed from just under 3% to just over 4%, and that of renal failure rose tenfold, from 0.4% to 4%. The mean number of comorbid conditions doubled from one to two.

Despite the increasing patient complexity, the mean 30-day mortality for primary total hip arthroplasty dropped from 0.7% to 0.3% during this interval, and mean 90-day mortality decreased from 1.3% to 0.7%, the investigators said (JAMA 2011;305:1560-7).

For revision hip arthroplasty, which often is done in an emergent setting, 30-day mortality remained steady at approximately 2% and 90-day mortality was steady at 4.5% throughout the study period.

For primary hip arthroplasty, hospital length of stay also decreased approximately 60% over time, from 9.1 days to 3.7 days. But this trend is not as encouraging as it appears to be at first glance, because the number of patients discharged to home declined dramatically, whereas the proportion discharged to skilled or intermediate care facilities approximately doubled.

In addition, the 30-day readmission rate, which some consider a gauge of the inappropriateness of a short length of stay (LOS), also rose markedly from 5.9% to 8.5%. The patterns were similar for revision hip arthroplasty, Dr. Cram and his associates said.

These LOS findings "may have policy implications." Hospitals clearly are motivated "to reduce LOS under the Medicare prospective payment system," but these results indicate that the practice is not benefiting patients.

This study was supported by the National Center for Research Resources, the Robert Wood Johnson Physician Faculty Scholars Program, and the National Heart, Lung, and Blood Institute. No financial conflicts of interest were reported.

Mortality after primary total hip arthroplasty has declined somewhat over time, and mortality after revision arthroplasty has remained stable, according to a report in the April 20 issue of JAMA.

In the 18-year longitudinal study of Medicare data, both of these reassuring trends occurred despite a substantial increase in patient complexity, said Dr. Peter Cram of the University of Iowa, Iowa City.

However, two concerning trends also were noted: The number of total hip arthroplasty patients discharged to postacute care facilities (such as nursing homes and rehabilitation centers) instead of to home increased substantially, and the number of hospital readmissions following total hip arthroplasty rose markedly.

Dr. Cram and his colleagues noted that objective evaluations of total hip arthroplasty outcomes are lacking in the literature. It is generally assumed that increasing experience with the procedure has inevitably produced better patient outcomes, "but rigorous empirical data documenting such improvement are limited."

They assessed trends in patient outcomes using data on Medicare fee-for-service beneficiaries who underwent primary (1,453,493 patients) or revision (348,596 patients) total hip arthroplasties over an 18-year period. "More than 60% of all total hip arthroplasty procedures are performed on Medicare enrollees, making this an appropriate data set for studying" the surgery.

During 1991-2008, the medical complexity of patients who underwent these procedures increased. For primary arthroplasty, the mean patient age rose from 74 to 75 years, the prevalence of diabetes more than doubled from 7% to 15%, and the prevalence of obesity more than tripled from 2% to 7%. The prevalence of heart failure climbed from just under 3% to just over 4%, and that of renal failure rose tenfold, from 0.4% to 4%. The mean number of comorbid conditions doubled from one to two.

Despite the increasing patient complexity, the mean 30-day mortality for primary total hip arthroplasty dropped from 0.7% to 0.3% during this interval, and mean 90-day mortality decreased from 1.3% to 0.7%, the investigators said (JAMA 2011;305:1560-7).

For revision hip arthroplasty, which often is done in an emergent setting, 30-day mortality remained steady at approximately 2% and 90-day mortality was steady at 4.5% throughout the study period.

For primary hip arthroplasty, hospital length of stay also decreased approximately 60% over time, from 9.1 days to 3.7 days. But this trend is not as encouraging as it appears to be at first glance, because the number of patients discharged to home declined dramatically, whereas the proportion discharged to skilled or intermediate care facilities approximately doubled.

In addition, the 30-day readmission rate, which some consider a gauge of the inappropriateness of a short length of stay (LOS), also rose markedly from 5.9% to 8.5%. The patterns were similar for revision hip arthroplasty, Dr. Cram and his associates said.

These LOS findings "may have policy implications." Hospitals clearly are motivated "to reduce LOS under the Medicare prospective payment system," but these results indicate that the practice is not benefiting patients.

This study was supported by the National Center for Research Resources, the Robert Wood Johnson Physician Faculty Scholars Program, and the National Heart, Lung, and Blood Institute. No financial conflicts of interest were reported.

Mortality after primary total hip arthroplasty has declined somewhat over time, and mortality after revision arthroplasty has remained stable, according to a report in the April 20 issue of JAMA.

In the 18-year longitudinal study of Medicare data, both of these reassuring trends occurred despite a substantial increase in patient complexity, said Dr. Peter Cram of the University of Iowa, Iowa City.

However, two concerning trends also were noted: The number of total hip arthroplasty patients discharged to postacute care facilities (such as nursing homes and rehabilitation centers) instead of to home increased substantially, and the number of hospital readmissions following total hip arthroplasty rose markedly.

Dr. Cram and his colleagues noted that objective evaluations of total hip arthroplasty outcomes are lacking in the literature. It is generally assumed that increasing experience with the procedure has inevitably produced better patient outcomes, "but rigorous empirical data documenting such improvement are limited."

They assessed trends in patient outcomes using data on Medicare fee-for-service beneficiaries who underwent primary (1,453,493 patients) or revision (348,596 patients) total hip arthroplasties over an 18-year period. "More than 60% of all total hip arthroplasty procedures are performed on Medicare enrollees, making this an appropriate data set for studying" the surgery.

During 1991-2008, the medical complexity of patients who underwent these procedures increased. For primary arthroplasty, the mean patient age rose from 74 to 75 years, the prevalence of diabetes more than doubled from 7% to 15%, and the prevalence of obesity more than tripled from 2% to 7%. The prevalence of heart failure climbed from just under 3% to just over 4%, and that of renal failure rose tenfold, from 0.4% to 4%. The mean number of comorbid conditions doubled from one to two.

Despite the increasing patient complexity, the mean 30-day mortality for primary total hip arthroplasty dropped from 0.7% to 0.3% during this interval, and mean 90-day mortality decreased from 1.3% to 0.7%, the investigators said (JAMA 2011;305:1560-7).

For revision hip arthroplasty, which often is done in an emergent setting, 30-day mortality remained steady at approximately 2% and 90-day mortality was steady at 4.5% throughout the study period.

For primary hip arthroplasty, hospital length of stay also decreased approximately 60% over time, from 9.1 days to 3.7 days. But this trend is not as encouraging as it appears to be at first glance, because the number of patients discharged to home declined dramatically, whereas the proportion discharged to skilled or intermediate care facilities approximately doubled.

In addition, the 30-day readmission rate, which some consider a gauge of the inappropriateness of a short length of stay (LOS), also rose markedly from 5.9% to 8.5%. The patterns were similar for revision hip arthroplasty, Dr. Cram and his associates said.

These LOS findings "may have policy implications." Hospitals clearly are motivated "to reduce LOS under the Medicare prospective payment system," but these results indicate that the practice is not benefiting patients.

This study was supported by the National Center for Research Resources, the Robert Wood Johnson Physician Faculty Scholars Program, and the National Heart, Lung, and Blood Institute. No financial conflicts of interest were reported.

Mortality after primary total hip arthroplasty has declined somewhat over time, and mortality after revision arthroplasty has remained stable, according to a report in the April 20 issue of JAMA.

In the 18-year longitudinal study of Medicare data, both of these reassuring trends occurred despite a substantial increase in patient complexity, said Dr. Peter Cram of the University of Iowa, Iowa City.

However, two concerning trends also were noted: The number of total hip arthroplasty patients discharged to postacute care facilities (such as nursing homes and rehabilitation centers) instead of to home increased substantially, and the number of hospital readmissions following total hip arthroplasty rose markedly.

Dr. Cram and his colleagues noted that objective evaluations of total hip arthroplasty outcomes are lacking in the literature. It is generally assumed that increasing experience with the procedure has inevitably produced better patient outcomes, "but rigorous empirical data documenting such improvement are limited."

They assessed trends in patient outcomes using data on Medicare fee-for-service beneficiaries who underwent primary (1,453,493 patients) or revision (348,596 patients) total hip arthroplasties over an 18-year period. "More than 60% of all total hip arthroplasty procedures are performed on Medicare enrollees, making this an appropriate data set for studying" the surgery.

During 1991-2008, the medical complexity of patients who underwent these procedures increased. For primary arthroplasty, the mean patient age rose from 74 to 75 years, the prevalence of diabetes more than doubled from 7% to 15%, and the prevalence of obesity more than tripled from 2% to 7%. The prevalence of heart failure climbed from just under 3% to just over 4%, and that of renal failure rose tenfold, from 0.4% to 4%. The mean number of comorbid conditions doubled from one to two.

Despite the increasing patient complexity, the mean 30-day mortality for primary total hip arthroplasty dropped from 0.7% to 0.3% during this interval, and mean 90-day mortality decreased from 1.3% to 0.7%, the investigators said (JAMA 2011;305:1560-7).

For revision hip arthroplasty, which often is done in an emergent setting, 30-day mortality remained steady at approximately 2% and 90-day mortality was steady at 4.5% throughout the study period.

For primary hip arthroplasty, hospital length of stay also decreased approximately 60% over time, from 9.1 days to 3.7 days. But this trend is not as encouraging as it appears to be at first glance, because the number of patients discharged to home declined dramatically, whereas the proportion discharged to skilled or intermediate care facilities approximately doubled.

In addition, the 30-day readmission rate, which some consider a gauge of the inappropriateness of a short length of stay (LOS), also rose markedly from 5.9% to 8.5%. The patterns were similar for revision hip arthroplasty, Dr. Cram and his associates said.

These LOS findings "may have policy implications." Hospitals clearly are motivated "to reduce LOS under the Medicare prospective payment system," but these results indicate that the practice is not benefiting patients.

This study was supported by the National Center for Research Resources, the Robert Wood Johnson Physician Faculty Scholars Program, and the National Heart, Lung, and Blood Institute. No financial conflicts of interest were reported.

Mortality after primary total hip arthroplasty has declined somewhat over time, and mortality after revision arthroplasty has remained stable, according to a report in the April 20 issue of JAMA.

In the 18-year longitudinal study of Medicare data, both of these reassuring trends occurred despite a substantial increase in patient complexity, said Dr. Peter Cram of the University of Iowa, Iowa City.

However, two concerning trends also were noted: The number of total hip arthroplasty patients discharged to postacute care facilities (such as nursing homes and rehabilitation centers) instead of to home increased substantially, and the number of hospital readmissions following total hip arthroplasty rose markedly.

Dr. Cram and his colleagues noted that objective evaluations of total hip arthroplasty outcomes are lacking in the literature. It is generally assumed that increasing experience with the procedure has inevitably produced better patient outcomes, "but rigorous empirical data documenting such improvement are limited."

They assessed trends in patient outcomes using data on Medicare fee-for-service beneficiaries who underwent primary (1,453,493 patients) or revision (348,596 patients) total hip arthroplasties over an 18-year period. "More than 60% of all total hip arthroplasty procedures are performed on Medicare enrollees, making this an appropriate data set for studying" the surgery.

During 1991-2008, the medical complexity of patients who underwent these procedures increased. For primary arthroplasty, the mean patient age rose from 74 to 75 years, the prevalence of diabetes more than doubled from 7% to 15%, and the prevalence of obesity more than tripled from 2% to 7%. The prevalence of heart failure climbed from just under 3% to just over 4%, and that of renal failure rose tenfold, from 0.4% to 4%. The mean number of comorbid conditions doubled from one to two.

Despite the increasing patient complexity, the mean 30-day mortality for primary total hip arthroplasty dropped from 0.7% to 0.3% during this interval, and mean 90-day mortality decreased from 1.3% to 0.7%, the investigators said (JAMA 2011;305:1560-7).

For revision hip arthroplasty, which often is done in an emergent setting, 30-day mortality remained steady at approximately 2% and 90-day mortality was steady at 4.5% throughout the study period.

For primary hip arthroplasty, hospital length of stay also decreased approximately 60% over time, from 9.1 days to 3.7 days. But this trend is not as encouraging as it appears to be at first glance, because the number of patients discharged to home declined dramatically, whereas the proportion discharged to skilled or intermediate care facilities approximately doubled.

In addition, the 30-day readmission rate, which some consider a gauge of the inappropriateness of a short length of stay (LOS), also rose markedly from 5.9% to 8.5%. The patterns were similar for revision hip arthroplasty, Dr. Cram and his associates said.

These LOS findings "may have policy implications." Hospitals clearly are motivated "to reduce LOS under the Medicare prospective payment system," but these results indicate that the practice is not benefiting patients.

This study was supported by the National Center for Research Resources, the Robert Wood Johnson Physician Faculty Scholars Program, and the National Heart, Lung, and Blood Institute. No financial conflicts of interest were reported.

Mortality after primary total hip arthroplasty has declined somewhat over time, and mortality after revision arthroplasty has remained stable, according to a report in the April 20 issue of JAMA.

In the 18-year longitudinal study of Medicare data, both of these reassuring trends occurred despite a substantial increase in patient complexity, said Dr. Peter Cram of the University of Iowa, Iowa City.

However, two concerning trends also were noted: The number of total hip arthroplasty patients discharged to postacute care facilities (such as nursing homes and rehabilitation centers) instead of to home increased substantially, and the number of hospital readmissions following total hip arthroplasty rose markedly.

Dr. Cram and his colleagues noted that objective evaluations of total hip arthroplasty outcomes are lacking in the literature. It is generally assumed that increasing experience with the procedure has inevitably produced better patient outcomes, "but rigorous empirical data documenting such improvement are limited."

They assessed trends in patient outcomes using data on Medicare fee-for-service beneficiaries who underwent primary (1,453,493 patients) or revision (348,596 patients) total hip arthroplasties over an 18-year period. "More than 60% of all total hip arthroplasty procedures are performed on Medicare enrollees, making this an appropriate data set for studying" the surgery.

During 1991-2008, the medical complexity of patients who underwent these procedures increased. For primary arthroplasty, the mean patient age rose from 74 to 75 years, the prevalence of diabetes more than doubled from 7% to 15%, and the prevalence of obesity more than tripled from 2% to 7%. The prevalence of heart failure climbed from just under 3% to just over 4%, and that of renal failure rose tenfold, from 0.4% to 4%. The mean number of comorbid conditions doubled from one to two.

Despite the increasing patient complexity, the mean 30-day mortality for primary total hip arthroplasty dropped from 0.7% to 0.3% during this interval, and mean 90-day mortality decreased from 1.3% to 0.7%, the investigators said (JAMA 2011;305:1560-7).

For revision hip arthroplasty, which often is done in an emergent setting, 30-day mortality remained steady at approximately 2% and 90-day mortality was steady at 4.5% throughout the study period.

For primary hip arthroplasty, hospital length of stay also decreased approximately 60% over time, from 9.1 days to 3.7 days. But this trend is not as encouraging as it appears to be at first glance, because the number of patients discharged to home declined dramatically, whereas the proportion discharged to skilled or intermediate care facilities approximately doubled.

In addition, the 30-day readmission rate, which some consider a gauge of the inappropriateness of a short length of stay (LOS), also rose markedly from 5.9% to 8.5%. The patterns were similar for revision hip arthroplasty, Dr. Cram and his associates said.

These LOS findings "may have policy implications." Hospitals clearly are motivated "to reduce LOS under the Medicare prospective payment system," but these results indicate that the practice is not benefiting patients.

This study was supported by the National Center for Research Resources, the Robert Wood Johnson Physician Faculty Scholars Program, and the National Heart, Lung, and Blood Institute. No financial conflicts of interest were reported.

A simple bedside technique – gently probing the loosely closed surgical incision to clean it – dramatically reduced infections of contaminated abdominal surgical wounds without increasing pain, according to a report in the April issue of Archives of Surgery.

Use of this wound-probing technique for surgical incisions "will reduce surgical site infection and decrease hospital stay, both of which may result in improved rates of long-term outcomes such as fascial dehiscence and incisional hernias, reduced labor for wound care by nursing staff and physicians, improved cosmetic outcome with primary closure, and possibly reduced overall cost," said Dr. Shirin Towfigh of Cedars-Sinai Medical Center, Los Angeles, and her associates.

"We recommend that wound probing be practiced in the first-line management of incisions after open surgery, such as bowel resection, in the face of contamination," they noted.

Until now, no local wound therapy – including topical antibiotics, subcutaneous drain placement, or delayed primary closure – has been proved to decrease surgical site infection in a rigorous clinical trial. "There is no standard wound management for contaminated wounds, [and] the topic has not been aggressively pursued for decades," the investigators said.

According to surveillance of nosocomial infections in the United States, the infection rate for contaminated surgical wounds is 7% overall, and can rise as high as 50% in certain subgroups of patients.

Some surgeons, including Dr. Towfigh, routinely use this probing technique and report good results anecdotally. In what they described as the first prospective clinical trial of the technique, Dr. Towfigh and her colleagues assessed surgical site infections in 76 adults who underwent appendectomy for perforated appendicitis at a single academic medical center over a 3-year period.

Half of the patients were randomly assigned to have standard primary skin closure with staples (control group), and the other half had loose primary skin closure with staples placed at 2-cm intervals. Postoperatively, the control group had daily swabbing of their closed incision with povidone iodine.

The intervention group had this standard postoperative care followed by wound probing in which dry, sterile, cotton-tip applicators were used to penetrate the skin and soft tissue between the staples, reaching down to the external oblique fascia. Any fluid that was extruded was blotted dry, and the wound was covered with a dry dressing. This process was repeated once daily until the wound was dry and no longer penetrable in this fashion, which usually took 3 days.

The two study groups were similar in terms of demographic characteristics as well as comorbidities that might affect wound healing, such as the presence of diabetes, larger abdominal girth, and higher body mass index. Both groups had similar incisional lengths (approximately 8 cm).

Study subjects were assessed throughout hospitalization, as well as at 2 weeks and 3 months following hospital discharge; 64% of subjects completed the 3-month follow-up. The primary outcome measure was the rate of surgical site infections, defined by both subjective daily evaluation by a surgical team blinded to treatment assignment and objective scores on the ASEPSIS (Additional Treatment, Presence of Serous Discharge, Erythema, Purulent Exudate, and Separation of the Deep Tissues, Isolation of Bacteria, and Duration of Inpatient Stay) instrument.

Only one patient (3%) in the intervention group developed surgical site infection, compared with seven patients (19%) in the control group (P = .03). Moreover, patients in the intervention group did not report greater pain than did those in the control group, either immediately after surgery or at follow-up, Dr. Towfigh and her associates said (Arch. Surg. 2011;146:448-52).

By reducing surgical site infections, the intervention also significantly decreased length of stay, compared with the control group (5 days vs. 7 days, respectively; P = .049), as well as the amount of time that caregivers spent on wound care.

"When primary closure fails or is deemed inappropriate, the wound is opened and allowed to close by secondary intention [that is, packing an open wound multiple times a day]. Closure by secondary intention can be painful to the patient, can be labor intensive, and has a poor cosmetic outcome. Nevertheless it is the most widely used closure technique in adults with contaminated wounds," the researchers said.

"We recommend that wound probing be practiced for contaminated wounds due to open appendectomy for perforated appendicitis. We believe that our results can also be extrapolated to other contaminated abdominal wounds regardless of their incisional length," they added.

The exact mechanism by which this technique prevents surgical site infection is not yet clear, but the investigators surmised that it "allows for drainage of contaminated fluid within the soft tissue, thus reducing the bacterial count while maintaining a moist wound for improved healing.

"We are currently analyzing the bacteriology data gathered from this study to gain insight into the process," Dr. Towfigh and her associates added.

This study was supported in part by a James H. Zumberge Faculty Research and Innovation grant from the University of Southern California, Los Angeles. No financial conflicts of interest were reported.

A simple bedside technique – gently probing the loosely closed surgical incision to clean it – dramatically reduced infections of contaminated abdominal surgical wounds without increasing pain, according to a report in the April issue of Archives of Surgery.

Use of this wound-probing technique for surgical incisions "will reduce surgical site infection and decrease hospital stay, both of which may result in improved rates of long-term outcomes such as fascial dehiscence and incisional hernias, reduced labor for wound care by nursing staff and physicians, improved cosmetic outcome with primary closure, and possibly reduced overall cost," said Dr. Shirin Towfigh of Cedars-Sinai Medical Center, Los Angeles, and her associates.

"We recommend that wound probing be practiced in the first-line management of incisions after open surgery, such as bowel resection, in the face of contamination," they noted.

Until now, no local wound therapy – including topical antibiotics, subcutaneous drain placement, or delayed primary closure – has been proved to decrease surgical site infection in a rigorous clinical trial. "There is no standard wound management for contaminated wounds, [and] the topic has not been aggressively pursued for decades," the investigators said.

According to surveillance of nosocomial infections in the United States, the infection rate for contaminated surgical wounds is 7% overall, and can rise as high as 50% in certain subgroups of patients.

Some surgeons, including Dr. Towfigh, routinely use this probing technique and report good results anecdotally. In what they described as the first prospective clinical trial of the technique, Dr. Towfigh and her colleagues assessed surgical site infections in 76 adults who underwent appendectomy for perforated appendicitis at a single academic medical center over a 3-year period.

Half of the patients were randomly assigned to have standard primary skin closure with staples (control group), and the other half had loose primary skin closure with staples placed at 2-cm intervals. Postoperatively, the control group had daily swabbing of their closed incision with povidone iodine.

The intervention group had this standard postoperative care followed by wound probing in which dry, sterile, cotton-tip applicators were used to penetrate the skin and soft tissue between the staples, reaching down to the external oblique fascia. Any fluid that was extruded was blotted dry, and the wound was covered with a dry dressing. This process was repeated once daily until the wound was dry and no longer penetrable in this fashion, which usually took 3 days.

The two study groups were similar in terms of demographic characteristics as well as comorbidities that might affect wound healing, such as the presence of diabetes, larger abdominal girth, and higher body mass index. Both groups had similar incisional lengths (approximately 8 cm).

Study subjects were assessed throughout hospitalization, as well as at 2 weeks and 3 months following hospital discharge; 64% of subjects completed the 3-month follow-up. The primary outcome measure was the rate of surgical site infections, defined by both subjective daily evaluation by a surgical team blinded to treatment assignment and objective scores on the ASEPSIS (Additional Treatment, Presence of Serous Discharge, Erythema, Purulent Exudate, and Separation of the Deep Tissues, Isolation of Bacteria, and Duration of Inpatient Stay) instrument.

Only one patient (3%) in the intervention group developed surgical site infection, compared with seven patients (19%) in the control group (P = .03). Moreover, patients in the intervention group did not report greater pain than did those in the control group, either immediately after surgery or at follow-up, Dr. Towfigh and her associates said (Arch. Surg. 2011;146:448-52).

By reducing surgical site infections, the intervention also significantly decreased length of stay, compared with the control group (5 days vs. 7 days, respectively; P = .049), as well as the amount of time that caregivers spent on wound care.

"When primary closure fails or is deemed inappropriate, the wound is opened and allowed to close by secondary intention [that is, packing an open wound multiple times a day]. Closure by secondary intention can be painful to the patient, can be labor intensive, and has a poor cosmetic outcome. Nevertheless it is the most widely used closure technique in adults with contaminated wounds," the researchers said.

"We recommend that wound probing be practiced for contaminated wounds due to open appendectomy for perforated appendicitis. We believe that our results can also be extrapolated to other contaminated abdominal wounds regardless of their incisional length," they added.

The exact mechanism by which this technique prevents surgical site infection is not yet clear, but the investigators surmised that it "allows for drainage of contaminated fluid within the soft tissue, thus reducing the bacterial count while maintaining a moist wound for improved healing.

"We are currently analyzing the bacteriology data gathered from this study to gain insight into the process," Dr. Towfigh and her associates added.

This study was supported in part by a James H. Zumberge Faculty Research and Innovation grant from the University of Southern California, Los Angeles. No financial conflicts of interest were reported.

A simple bedside technique – gently probing the loosely closed surgical incision to clean it – dramatically reduced infections of contaminated abdominal surgical wounds without increasing pain, according to a report in the April issue of Archives of Surgery.

Use of this wound-probing technique for surgical incisions "will reduce surgical site infection and decrease hospital stay, both of which may result in improved rates of long-term outcomes such as fascial dehiscence and incisional hernias, reduced labor for wound care by nursing staff and physicians, improved cosmetic outcome with primary closure, and possibly reduced overall cost," said Dr. Shirin Towfigh of Cedars-Sinai Medical Center, Los Angeles, and her associates.

"We recommend that wound probing be practiced in the first-line management of incisions after open surgery, such as bowel resection, in the face of contamination," they noted.

Until now, no local wound therapy – including topical antibiotics, subcutaneous drain placement, or delayed primary closure – has been proved to decrease surgical site infection in a rigorous clinical trial. "There is no standard wound management for contaminated wounds, [and] the topic has not been aggressively pursued for decades," the investigators said.

According to surveillance of nosocomial infections in the United States, the infection rate for contaminated surgical wounds is 7% overall, and can rise as high as 50% in certain subgroups of patients.

Some surgeons, including Dr. Towfigh, routinely use this probing technique and report good results anecdotally. In what they described as the first prospective clinical trial of the technique, Dr. Towfigh and her colleagues assessed surgical site infections in 76 adults who underwent appendectomy for perforated appendicitis at a single academic medical center over a 3-year period.

Half of the patients were randomly assigned to have standard primary skin closure with staples (control group), and the other half had loose primary skin closure with staples placed at 2-cm intervals. Postoperatively, the control group had daily swabbing of their closed incision with povidone iodine.

The intervention group had this standard postoperative care followed by wound probing in which dry, sterile, cotton-tip applicators were used to penetrate the skin and soft tissue between the staples, reaching down to the external oblique fascia. Any fluid that was extruded was blotted dry, and the wound was covered with a dry dressing. This process was repeated once daily until the wound was dry and no longer penetrable in this fashion, which usually took 3 days.

The two study groups were similar in terms of demographic characteristics as well as comorbidities that might affect wound healing, such as the presence of diabetes, larger abdominal girth, and higher body mass index. Both groups had similar incisional lengths (approximately 8 cm).

Study subjects were assessed throughout hospitalization, as well as at 2 weeks and 3 months following hospital discharge; 64% of subjects completed the 3-month follow-up. The primary outcome measure was the rate of surgical site infections, defined by both subjective daily evaluation by a surgical team blinded to treatment assignment and objective scores on the ASEPSIS (Additional Treatment, Presence of Serous Discharge, Erythema, Purulent Exudate, and Separation of the Deep Tissues, Isolation of Bacteria, and Duration of Inpatient Stay) instrument.

Only one patient (3%) in the intervention group developed surgical site infection, compared with seven patients (19%) in the control group (P = .03). Moreover, patients in the intervention group did not report greater pain than did those in the control group, either immediately after surgery or at follow-up, Dr. Towfigh and her associates said (Arch. Surg. 2011;146:448-52).

By reducing surgical site infections, the intervention also significantly decreased length of stay, compared with the control group (5 days vs. 7 days, respectively; P = .049), as well as the amount of time that caregivers spent on wound care.

"When primary closure fails or is deemed inappropriate, the wound is opened and allowed to close by secondary intention [that is, packing an open wound multiple times a day]. Closure by secondary intention can be painful to the patient, can be labor intensive, and has a poor cosmetic outcome. Nevertheless it is the most widely used closure technique in adults with contaminated wounds," the researchers said.

"We recommend that wound probing be practiced for contaminated wounds due to open appendectomy for perforated appendicitis. We believe that our results can also be extrapolated to other contaminated abdominal wounds regardless of their incisional length," they added.

The exact mechanism by which this technique prevents surgical site infection is not yet clear, but the investigators surmised that it "allows for drainage of contaminated fluid within the soft tissue, thus reducing the bacterial count while maintaining a moist wound for improved healing.

"We are currently analyzing the bacteriology data gathered from this study to gain insight into the process," Dr. Towfigh and her associates added.

This study was supported in part by a James H. Zumberge Faculty Research and Innovation grant from the University of Southern California, Los Angeles. No financial conflicts of interest were reported.