Mary Ann Moon

A diet rich in certain foods such as nuts, fish, and vegetables and low in high-fat dairy foods and red meat appears to exert a preventive effect on the development of Alzheimer's disease, according to a study.

“Our findings provide support for further exploration of food-combination–based dietary behavior for the prevention of this important public health problem,” wrote Yian Gu, Ph.D., of the Taub Institute for Research in Alzheimer's Disease and the Aging Brain at Columbia University, New York, and associates.

The researchers sought to assess food combinations rather than individual nutrients in relation to Alzheimer's risk, so they studied dietary data obtained by food frequency questionnaires in two multiethnic cohorts: elderly subjects participating in the 1992 and the 1999 Washington Heights–Inwood Columbia Aging Project (WHICAP). Their study included 2,148 individuals who underwent serial batteries of neuropsychological tests, assessments of social and occupational function, and specific testing for cognitive deficits and dementia.

During an average follow-up of 4 years, 253 of these subjects developed Alzheimer's. Subjects were diagnosed for dementia with criteria developed by the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer Disease and Related Disorders Association. Some of the patients also may have had a stroke.

The investigators calculated dietary patterns based on variations in the content of seven key nutrients that have been most consistently related to dementia risk in the literature. Only one dietary pattern was found to be strongly associated with AD prevention: a diet rich in omega-3 polyunsaturated fatty acids, omega-6 polyunsaturated fatty acids, vitamin E, and folate and poor in saturated fatty acids and vitamin B₁₂.

This pattern correlated with high intakes of salad dressing, nuts, fish, tomatoes, poultry, cruciferous and dark leafy green vegetables, and low intakes of high-fat dairy foods such as butter, red meats, and organ meats, Dr. Gu and colleagues said (Arch. Neurol. 2010 April 12 [doi:10.1001/archneurol.2010.84]).

The protective effect of such a diet did not change after the data were adjusted to account for age, level of education, ethnicity, and sex. Further analysis adjusting for smoking status, body mass index, caloric intake, comorbidities, and apolipoprotein E genotype only slightly attenuated the results. Similarly, adding data on alcohol consumption and use of nutritional supplements did not substantially change the association between this dietary pattern and lower risk of AD. The results were “essentially unchanged” when the analysis was repeated in the subgroup of subjects who developed AD without concomitant stroke.

The study was limited by the use of a single measurement of diet that did not capture long-term dietary habits.

Disclosures: This study was funded by the National Institute on Aging. No financial conflicts of interest were reported.

A diet rich in certain foods such as nuts, fish, and vegetables and low in high-fat dairy foods and red meat appears to exert a preventive effect on the development of Alzheimer's disease, according to a study.

“Our findings provide support for further exploration of food-combination–based dietary behavior for the prevention of this important public health problem,” wrote Yian Gu, Ph.D., of the Taub Institute for Research in Alzheimer's Disease and the Aging Brain at Columbia University, New York, and associates.

The researchers sought to assess food combinations rather than individual nutrients in relation to Alzheimer's risk, so they studied dietary data obtained by food frequency questionnaires in two multiethnic cohorts: elderly subjects participating in the 1992 and the 1999 Washington Heights–Inwood Columbia Aging Project (WHICAP). Their study included 2,148 individuals who underwent serial batteries of neuropsychological tests, assessments of social and occupational function, and specific testing for cognitive deficits and dementia.

During an average follow-up of 4 years, 253 of these subjects developed Alzheimer's. Subjects were diagnosed for dementia with criteria developed by the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer Disease and Related Disorders Association. Some of the patients also may have had a stroke.

The investigators calculated dietary patterns based on variations in the content of seven key nutrients that have been most consistently related to dementia risk in the literature. Only one dietary pattern was found to be strongly associated with AD prevention: a diet rich in omega-3 polyunsaturated fatty acids, omega-6 polyunsaturated fatty acids, vitamin E, and folate and poor in saturated fatty acids and vitamin B₁₂.

This pattern correlated with high intakes of salad dressing, nuts, fish, tomatoes, poultry, cruciferous and dark leafy green vegetables, and low intakes of high-fat dairy foods such as butter, red meats, and organ meats, Dr. Gu and colleagues said (Arch. Neurol. 2010 April 12 [doi:10.1001/archneurol.2010.84]).

The protective effect of such a diet did not change after the data were adjusted to account for age, level of education, ethnicity, and sex. Further analysis adjusting for smoking status, body mass index, caloric intake, comorbidities, and apolipoprotein E genotype only slightly attenuated the results. Similarly, adding data on alcohol consumption and use of nutritional supplements did not substantially change the association between this dietary pattern and lower risk of AD. The results were “essentially unchanged” when the analysis was repeated in the subgroup of subjects who developed AD without concomitant stroke.

The study was limited by the use of a single measurement of diet that did not capture long-term dietary habits.

Disclosures: This study was funded by the National Institute on Aging. No financial conflicts of interest were reported.

A diet rich in certain foods such as nuts, fish, and vegetables and low in high-fat dairy foods and red meat appears to exert a preventive effect on the development of Alzheimer's disease, according to a study.

“Our findings provide support for further exploration of food-combination–based dietary behavior for the prevention of this important public health problem,” wrote Yian Gu, Ph.D., of the Taub Institute for Research in Alzheimer's Disease and the Aging Brain at Columbia University, New York, and associates.

The researchers sought to assess food combinations rather than individual nutrients in relation to Alzheimer's risk, so they studied dietary data obtained by food frequency questionnaires in two multiethnic cohorts: elderly subjects participating in the 1992 and the 1999 Washington Heights–Inwood Columbia Aging Project (WHICAP). Their study included 2,148 individuals who underwent serial batteries of neuropsychological tests, assessments of social and occupational function, and specific testing for cognitive deficits and dementia.

During an average follow-up of 4 years, 253 of these subjects developed Alzheimer's. Subjects were diagnosed for dementia with criteria developed by the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer Disease and Related Disorders Association. Some of the patients also may have had a stroke.

The investigators calculated dietary patterns based on variations in the content of seven key nutrients that have been most consistently related to dementia risk in the literature. Only one dietary pattern was found to be strongly associated with AD prevention: a diet rich in omega-3 polyunsaturated fatty acids, omega-6 polyunsaturated fatty acids, vitamin E, and folate and poor in saturated fatty acids and vitamin B₁₂.

This pattern correlated with high intakes of salad dressing, nuts, fish, tomatoes, poultry, cruciferous and dark leafy green vegetables, and low intakes of high-fat dairy foods such as butter, red meats, and organ meats, Dr. Gu and colleagues said (Arch. Neurol. 2010 April 12 [doi:10.1001/archneurol.2010.84]).

The protective effect of such a diet did not change after the data were adjusted to account for age, level of education, ethnicity, and sex. Further analysis adjusting for smoking status, body mass index, caloric intake, comorbidities, and apolipoprotein E genotype only slightly attenuated the results. Similarly, adding data on alcohol consumption and use of nutritional supplements did not substantially change the association between this dietary pattern and lower risk of AD. The results were “essentially unchanged” when the analysis was repeated in the subgroup of subjects who developed AD without concomitant stroke.

The study was limited by the use of a single measurement of diet that did not capture long-term dietary habits.

Disclosures: This study was funded by the National Institute on Aging. No financial conflicts of interest were reported.

Ten different gene susceptibility loci have been identified as associated with generalized vitiligo, in a study published online April 21 in the New England Journal of Medicine.

Many of the loci are also associated with other autoimmune diseases, several of which have been linked epidemiologically with vitiligo, said Dr. Ying Jin, of the Human Medical Genetics Program at the University of Colorado, Aurora, and associates.

Generalized vitiligo, which results from the autoimmune loss of melanocytes, has been assumed to arise from the effects of multiple susceptibility genes and unknown environmental factors. Dr. Jin and colleagues performed a genome-wide association study to identify the genetic loci, genotyping 1,514 patients in North America and the United Kingdom who were of white European ancestry.

A total of 579,146 single-nucleotide polymorphisms (SNPs) of these subjects were compared with those of 2,813 unaffected control subjects from a National Institutes of Health database. Genotyping of the SNPs that showed genome-wide significance or near significance was then carried out in two replication studies: one comprised 677 patients and 1,106 controls, and the other comprised 183 simplex trios with the disorder and 332 multiplex families.

Generalized vitiligo was significantly associated with SNPs at or near the HLA-A*02 allele and the HLA-DRB1*04 allele, both of which have been reported previously to be associated with other autoimmune diseases.

Generalized vitiligo also was associated with the following genes: RERE (highly expressed in lymphoid cells and thought to regulate apoptosis), PTPN22 (involved in T-cell-receptor signaling), LPP (associated with celiac disease and rheumatoid arthritis), IL2RA (associated with type 1 diabetes, Graves' disease, multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosus), GZMB (involved in immune-induced apoptosis), UBASH3A (associated with T-cell signalling and type 1 diabetes), C1QTNF6, and TYR.

"Most of these genes encode immune-system proteins involved in the biologic pathways that probably influence the development of autoimmunity," the investigators said (N. Engl. J. Med. 2010 April 21 [doi:10.1056/NEJMoa0908547]).

The exception - the TYR gene - was "perhaps the most interesting association that we found," they noted.

The TYR gene encodes tyrosinase, which is not a component of the immune system but "is an enzyme of the melanocyte that catalyzes the rate-limiting steps of melanin biosynthesis. It is also a major autoantigen in generalized vitiligo."

The TYR SNPs that were associated with generalized vitiligo also have been associated previously with susceptibility to malignant melanoma, but in a mutually exclusive fashion.

This study was supported by the National Institutes of Health and a grant from the Anna and John Sie Foundation. No relevant conflicts of interest were reported.

Ten different gene susceptibility loci have been identified as associated with generalized vitiligo, in a study published online April 21 in the New England Journal of Medicine.

Many of the loci are also associated with other autoimmune diseases, several of which have been linked epidemiologically with vitiligo, said Dr. Ying Jin, of the Human Medical Genetics Program at the University of Colorado, Aurora, and associates.

Generalized vitiligo, which results from the autoimmune loss of melanocytes, has been assumed to arise from the effects of multiple susceptibility genes and unknown environmental factors. Dr. Jin and colleagues performed a genome-wide association study to identify the genetic loci, genotyping 1,514 patients in North America and the United Kingdom who were of white European ancestry.

A total of 579,146 single-nucleotide polymorphisms (SNPs) of these subjects were compared with those of 2,813 unaffected control subjects from a National Institutes of Health database. Genotyping of the SNPs that showed genome-wide significance or near significance was then carried out in two replication studies: one comprised 677 patients and 1,106 controls, and the other comprised 183 simplex trios with the disorder and 332 multiplex families.

Generalized vitiligo was significantly associated with SNPs at or near the HLA-A*02 allele and the HLA-DRB1*04 allele, both of which have been reported previously to be associated with other autoimmune diseases.

Generalized vitiligo also was associated with the following genes: RERE (highly expressed in lymphoid cells and thought to regulate apoptosis), PTPN22 (involved in T-cell-receptor signaling), LPP (associated with celiac disease and rheumatoid arthritis), IL2RA (associated with type 1 diabetes, Graves' disease, multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosus), GZMB (involved in immune-induced apoptosis), UBASH3A (associated with T-cell signalling and type 1 diabetes), C1QTNF6, and TYR.

"Most of these genes encode immune-system proteins involved in the biologic pathways that probably influence the development of autoimmunity," the investigators said (N. Engl. J. Med. 2010 April 21 [doi:10.1056/NEJMoa0908547]).

The exception - the TYR gene - was "perhaps the most interesting association that we found," they noted.

The TYR gene encodes tyrosinase, which is not a component of the immune system but "is an enzyme of the melanocyte that catalyzes the rate-limiting steps of melanin biosynthesis. It is also a major autoantigen in generalized vitiligo."

The TYR SNPs that were associated with generalized vitiligo also have been associated previously with susceptibility to malignant melanoma, but in a mutually exclusive fashion.

This study was supported by the National Institutes of Health and a grant from the Anna and John Sie Foundation. No relevant conflicts of interest were reported.

Ten different gene susceptibility loci have been identified as associated with generalized vitiligo, in a study published online April 21 in the New England Journal of Medicine.

Many of the loci are also associated with other autoimmune diseases, several of which have been linked epidemiologically with vitiligo, said Dr. Ying Jin, of the Human Medical Genetics Program at the University of Colorado, Aurora, and associates.

Generalized vitiligo, which results from the autoimmune loss of melanocytes, has been assumed to arise from the effects of multiple susceptibility genes and unknown environmental factors. Dr. Jin and colleagues performed a genome-wide association study to identify the genetic loci, genotyping 1,514 patients in North America and the United Kingdom who were of white European ancestry.

A total of 579,146 single-nucleotide polymorphisms (SNPs) of these subjects were compared with those of 2,813 unaffected control subjects from a National Institutes of Health database. Genotyping of the SNPs that showed genome-wide significance or near significance was then carried out in two replication studies: one comprised 677 patients and 1,106 controls, and the other comprised 183 simplex trios with the disorder and 332 multiplex families.

Generalized vitiligo was significantly associated with SNPs at or near the HLA-A*02 allele and the HLA-DRB1*04 allele, both of which have been reported previously to be associated with other autoimmune diseases.

Generalized vitiligo also was associated with the following genes: RERE (highly expressed in lymphoid cells and thought to regulate apoptosis), PTPN22 (involved in T-cell-receptor signaling), LPP (associated with celiac disease and rheumatoid arthritis), IL2RA (associated with type 1 diabetes, Graves' disease, multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosus), GZMB (involved in immune-induced apoptosis), UBASH3A (associated with T-cell signalling and type 1 diabetes), C1QTNF6, and TYR.

"Most of these genes encode immune-system proteins involved in the biologic pathways that probably influence the development of autoimmunity," the investigators said (N. Engl. J. Med. 2010 April 21 [doi:10.1056/NEJMoa0908547]).

The exception - the TYR gene - was "perhaps the most interesting association that we found," they noted.

The TYR gene encodes tyrosinase, which is not a component of the immune system but "is an enzyme of the melanocyte that catalyzes the rate-limiting steps of melanin biosynthesis. It is also a major autoantigen in generalized vitiligo."

The TYR SNPs that were associated with generalized vitiligo also have been associated previously with susceptibility to malignant melanoma, but in a mutually exclusive fashion.

This study was supported by the National Institutes of Health and a grant from the Anna and John Sie Foundation. No relevant conflicts of interest were reported.

Indoor tanning is an addictive behavior for a substantial portion of adolescents and young adults, findings in the April issue of the Archives of Dermatology suggest.

Any efforts to reduce skin cancer risk must address the addictive nature of indoor tanning for these members of the population, said Catherine E. Mosher, Ph.D., of the department of psychiatry and behavioral sciences, Memorial Sloan-Kettering Cancer Center, New York, and Sharon Danoff-Burg, Ph.D., of the department of psychology at the State University of New York, Albany.

They studied the self-reported indoor tanning habits of more than 400 students at a state university in the northeastern United States. The students completed anonymous questionnaires that also detailed their substance use. They also completed the Beck Depression Inventory and the Beck Anxiety Inventory, and addictive behavior was assessed using two measures to identify substance related disorders.

Nearly 40% of the 237 students who used indoor tanning met modified Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) criteria for addiction to the behavior, they reported.

Students in this subgroup were more likely to report the recent use of two or more controlled substances (excluding alcohol), compared with those who occasionally or never used indoor tanning. A total of 42% of those who qualified as addicted to indoor tanning reported this level of substance use, compared with only 16% of the subjects who never used indoor tanning and 17% of those who occasionally did.

Students who met the criteria for addiction to indoor tanning also were approximately two times more likely to report symptoms of anxiety or depression than students who were not addicted to indoor tanning.

Taken together with the results of previous studies, these findings "suggest that individuals who use drugs may be more likely to develop dependence on indoor tanning because of a similar addictive process. In addition, tanning and drug use may be reinforced by peer group norms," the investigators wrote (Arch. Dermatol. 2010;146:412-7).

The study findings corroborate those of earlier research and extend "prior work by relating indoor tanning addiction to substance use and affective disturbance," Dr. Mosher and Dr. Danoff-Burg noted.

The results suggest that treating an underlying mood disorder "may be a necessary step in reducing skin cancer risk among those who frequently tan indoors.

"Researchers have hypothesized that those who tan regularly year round may require more intensive intervention efforts, such as motivational interviewing, relative to those who tan periodically in response to mood changes or special events," the investigators wrote.

Future studies "should evaluate the usefulness of incorporating a brief anxiety and depression screening for individuals who tan indoors," they wrote. Those found to have such symptoms can then be referred to mental health professionals for diagnosis and treatment.

This study was funded in part by the National Cancer Institute. No financial conflicts of interest were reported.

Indoor tanning is an addictive behavior for a substantial portion of adolescents and young adults, findings in the April issue of the Archives of Dermatology suggest.

Any efforts to reduce skin cancer risk must address the addictive nature of indoor tanning for these members of the population, said Catherine E. Mosher, Ph.D., of the department of psychiatry and behavioral sciences, Memorial Sloan-Kettering Cancer Center, New York, and Sharon Danoff-Burg, Ph.D., of the department of psychology at the State University of New York, Albany.

They studied the self-reported indoor tanning habits of more than 400 students at a state university in the northeastern United States. The students completed anonymous questionnaires that also detailed their substance use. They also completed the Beck Depression Inventory and the Beck Anxiety Inventory, and addictive behavior was assessed using two measures to identify substance related disorders.

Nearly 40% of the 237 students who used indoor tanning met modified Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) criteria for addiction to the behavior, they reported.

Students in this subgroup were more likely to report the recent use of two or more controlled substances (excluding alcohol), compared with those who occasionally or never used indoor tanning. A total of 42% of those who qualified as addicted to indoor tanning reported this level of substance use, compared with only 16% of the subjects who never used indoor tanning and 17% of those who occasionally did.

Students who met the criteria for addiction to indoor tanning also were approximately two times more likely to report symptoms of anxiety or depression than students who were not addicted to indoor tanning.

Taken together with the results of previous studies, these findings "suggest that individuals who use drugs may be more likely to develop dependence on indoor tanning because of a similar addictive process. In addition, tanning and drug use may be reinforced by peer group norms," the investigators wrote (Arch. Dermatol. 2010;146:412-7).

The study findings corroborate those of earlier research and extend "prior work by relating indoor tanning addiction to substance use and affective disturbance," Dr. Mosher and Dr. Danoff-Burg noted.

The results suggest that treating an underlying mood disorder "may be a necessary step in reducing skin cancer risk among those who frequently tan indoors.

"Researchers have hypothesized that those who tan regularly year round may require more intensive intervention efforts, such as motivational interviewing, relative to those who tan periodically in response to mood changes or special events," the investigators wrote.

Future studies "should evaluate the usefulness of incorporating a brief anxiety and depression screening for individuals who tan indoors," they wrote. Those found to have such symptoms can then be referred to mental health professionals for diagnosis and treatment.

This study was funded in part by the National Cancer Institute. No financial conflicts of interest were reported.

Indoor tanning is an addictive behavior for a substantial portion of adolescents and young adults, findings in the April issue of the Archives of Dermatology suggest.

Any efforts to reduce skin cancer risk must address the addictive nature of indoor tanning for these members of the population, said Catherine E. Mosher, Ph.D., of the department of psychiatry and behavioral sciences, Memorial Sloan-Kettering Cancer Center, New York, and Sharon Danoff-Burg, Ph.D., of the department of psychology at the State University of New York, Albany.

They studied the self-reported indoor tanning habits of more than 400 students at a state university in the northeastern United States. The students completed anonymous questionnaires that also detailed their substance use. They also completed the Beck Depression Inventory and the Beck Anxiety Inventory, and addictive behavior was assessed using two measures to identify substance related disorders.

Nearly 40% of the 237 students who used indoor tanning met modified Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) criteria for addiction to the behavior, they reported.

Students in this subgroup were more likely to report the recent use of two or more controlled substances (excluding alcohol), compared with those who occasionally or never used indoor tanning. A total of 42% of those who qualified as addicted to indoor tanning reported this level of substance use, compared with only 16% of the subjects who never used indoor tanning and 17% of those who occasionally did.

Students who met the criteria for addiction to indoor tanning also were approximately two times more likely to report symptoms of anxiety or depression than students who were not addicted to indoor tanning.

Taken together with the results of previous studies, these findings "suggest that individuals who use drugs may be more likely to develop dependence on indoor tanning because of a similar addictive process. In addition, tanning and drug use may be reinforced by peer group norms," the investigators wrote (Arch. Dermatol. 2010;146:412-7).

The study findings corroborate those of earlier research and extend "prior work by relating indoor tanning addiction to substance use and affective disturbance," Dr. Mosher and Dr. Danoff-Burg noted.

The results suggest that treating an underlying mood disorder "may be a necessary step in reducing skin cancer risk among those who frequently tan indoors.

"Researchers have hypothesized that those who tan regularly year round may require more intensive intervention efforts, such as motivational interviewing, relative to those who tan periodically in response to mood changes or special events," the investigators wrote.

Future studies "should evaluate the usefulness of incorporating a brief anxiety and depression screening for individuals who tan indoors," they wrote. Those found to have such symptoms can then be referred to mental health professionals for diagnosis and treatment.

This study was funded in part by the National Cancer Institute. No financial conflicts of interest were reported.

Dutasteride reduced the risk of prostate cancer in men at high risk for the malignancy who participated in an international randomized clinical trial.

During the 4-year study involving more than 6,700 men, about 20% of those taking dutasteride were found to have prostate cancer on random biopsies, compared with 25% of those taking placebo. This reduction was seen chiefly in tumors with Gleason scores of 5–6; the number of higher-grade tumors did not differ significantly between the two groups, said Dr. Gerald L. Andriole of Washington University, St. Louis, and his associates.

In an editorial, Dr. Patrick C. Walsh of the James Buchanan Brady Urological Institute, Baltimore, argued that real-world patients have biopsies only when indicated by the findings on prostate-specific antigen testing or digital rectal exams. In the trial, dutasteride failed to reduce the risk of prostate cancer in this subgroup (N. Engl. J. Med. 2010;362:1237–8). The drug reduced the risk only of low-grade tumors, not the risk of lethal tumors, Dr. Walsh noted.

The study included men at high risk because of their age (50–75 years), an elevated PSA level, and a prostate biopsy within the preceding 6 months due to suspicion of prostate cancer, Dr. Andriole and his colleagues said (N. Engl. J. Med. 2010;362:1192–202). After randomization, 3,305 men were assigned to oral dutasteride and 3,424 to placebo. They were followed every 6 months using digital exams, PSA testing, and the International Prostate Symptom Score (IPSS). They underwent ultrasound assessment at baseline, 2 years, and 4 years, as well as transrectal, ultrasound-guided biopsy at 2 and 4 years, or at any time the procedure was clinically indicated. The primary end point was prostate cancer detected on these biopsies.

In all, 659 men in the dutasteride group (19.9%) and 858 in the placebo group (25.1%) were found to have prostate cancer on biopsy. The risk of the malignancy was lower than the risk in the placebo group regardless of patient age, family history of prostate cancer, baseline PSA level, baseline prostate volume, body mass index, or baseline IPSS, the investigators said. Mortality was not significantly different between men taking dutasteride (1.7%) and those taking placebo (1.9%), and there were no deaths from prostate cancer. The number of high-grade tumors also was not significantly different between the two groups.

Dutasteride reduced the risk of acute urinary retention, urinary tract infection, and the need for surgery to address benign prostatic hyperplasia. However, this benefit may have been offset by increases in loss of libido and erectile dysfunction. The drug was associated with an unexpected rise in the composite end point of “cardiac failure,” which included heart failure, ventricular failure, cardiopulmonary failure, and congestive cardiomyopathy. However, it did not raise the rate of cardiovascular events or cardiovascular mortality, compared with placebo. Fewer than 5% of the men taking dutasteride discontinued the medication, they added.

In his editorial, Dr. Walsh noted that “as the authors point out,” the reduction in prostate cancer “most likely represents shrinkage or inhibition of the growth of existing tumors rather than prevention of cancer.” Like the related drug finasteride, dutasteride “merely temporarily shrink[s] tumors that have a low potential for being lethal,” he said. Moreover, using either drug “may be somewhat risky” because both suppress PSA levels, which may give patients a false sense of security. “And if prostate cancer develops, the diagnosis may be delayed until they have high-grade disease that may be difficult to cure,” Dr. Walsh added.

Disclosures: The study was designed and funded by GlaxoSmithKline. Dr. Andriole reported receiving fees from GlaxoSmithKline and several other pharmaceutical companies, as well as owning stock or stock options in Cambridge Endo, Envisioneering Medical Technologies, and Viking Medical. Dr. Walsh's financial disclosures are available at NEJM.org

Dutasteride reduced the risk of prostate cancer in men at high risk for the malignancy who participated in an international randomized clinical trial.

During the 4-year study involving more than 6,700 men, about 20% of those taking dutasteride were found to have prostate cancer on random biopsies, compared with 25% of those taking placebo. This reduction was seen chiefly in tumors with Gleason scores of 5–6; the number of higher-grade tumors did not differ significantly between the two groups, said Dr. Gerald L. Andriole of Washington University, St. Louis, and his associates.

In an editorial, Dr. Patrick C. Walsh of the James Buchanan Brady Urological Institute, Baltimore, argued that real-world patients have biopsies only when indicated by the findings on prostate-specific antigen testing or digital rectal exams. In the trial, dutasteride failed to reduce the risk of prostate cancer in this subgroup (N. Engl. J. Med. 2010;362:1237–8). The drug reduced the risk only of low-grade tumors, not the risk of lethal tumors, Dr. Walsh noted.

The study included men at high risk because of their age (50–75 years), an elevated PSA level, and a prostate biopsy within the preceding 6 months due to suspicion of prostate cancer, Dr. Andriole and his colleagues said (N. Engl. J. Med. 2010;362:1192–202). After randomization, 3,305 men were assigned to oral dutasteride and 3,424 to placebo. They were followed every 6 months using digital exams, PSA testing, and the International Prostate Symptom Score (IPSS). They underwent ultrasound assessment at baseline, 2 years, and 4 years, as well as transrectal, ultrasound-guided biopsy at 2 and 4 years, or at any time the procedure was clinically indicated. The primary end point was prostate cancer detected on these biopsies.

In all, 659 men in the dutasteride group (19.9%) and 858 in the placebo group (25.1%) were found to have prostate cancer on biopsy. The risk of the malignancy was lower than the risk in the placebo group regardless of patient age, family history of prostate cancer, baseline PSA level, baseline prostate volume, body mass index, or baseline IPSS, the investigators said. Mortality was not significantly different between men taking dutasteride (1.7%) and those taking placebo (1.9%), and there were no deaths from prostate cancer. The number of high-grade tumors also was not significantly different between the two groups.

Dutasteride reduced the risk of acute urinary retention, urinary tract infection, and the need for surgery to address benign prostatic hyperplasia. However, this benefit may have been offset by increases in loss of libido and erectile dysfunction. The drug was associated with an unexpected rise in the composite end point of “cardiac failure,” which included heart failure, ventricular failure, cardiopulmonary failure, and congestive cardiomyopathy. However, it did not raise the rate of cardiovascular events or cardiovascular mortality, compared with placebo. Fewer than 5% of the men taking dutasteride discontinued the medication, they added.

In his editorial, Dr. Walsh noted that “as the authors point out,” the reduction in prostate cancer “most likely represents shrinkage or inhibition of the growth of existing tumors rather than prevention of cancer.” Like the related drug finasteride, dutasteride “merely temporarily shrink[s] tumors that have a low potential for being lethal,” he said. Moreover, using either drug “may be somewhat risky” because both suppress PSA levels, which may give patients a false sense of security. “And if prostate cancer develops, the diagnosis may be delayed until they have high-grade disease that may be difficult to cure,” Dr. Walsh added.

Disclosures: The study was designed and funded by GlaxoSmithKline. Dr. Andriole reported receiving fees from GlaxoSmithKline and several other pharmaceutical companies, as well as owning stock or stock options in Cambridge Endo, Envisioneering Medical Technologies, and Viking Medical. Dr. Walsh's financial disclosures are available at NEJM.org

Dutasteride reduced the risk of prostate cancer in men at high risk for the malignancy who participated in an international randomized clinical trial.

During the 4-year study involving more than 6,700 men, about 20% of those taking dutasteride were found to have prostate cancer on random biopsies, compared with 25% of those taking placebo. This reduction was seen chiefly in tumors with Gleason scores of 5–6; the number of higher-grade tumors did not differ significantly between the two groups, said Dr. Gerald L. Andriole of Washington University, St. Louis, and his associates.

In an editorial, Dr. Patrick C. Walsh of the James Buchanan Brady Urological Institute, Baltimore, argued that real-world patients have biopsies only when indicated by the findings on prostate-specific antigen testing or digital rectal exams. In the trial, dutasteride failed to reduce the risk of prostate cancer in this subgroup (N. Engl. J. Med. 2010;362:1237–8). The drug reduced the risk only of low-grade tumors, not the risk of lethal tumors, Dr. Walsh noted.

The study included men at high risk because of their age (50–75 years), an elevated PSA level, and a prostate biopsy within the preceding 6 months due to suspicion of prostate cancer, Dr. Andriole and his colleagues said (N. Engl. J. Med. 2010;362:1192–202). After randomization, 3,305 men were assigned to oral dutasteride and 3,424 to placebo. They were followed every 6 months using digital exams, PSA testing, and the International Prostate Symptom Score (IPSS). They underwent ultrasound assessment at baseline, 2 years, and 4 years, as well as transrectal, ultrasound-guided biopsy at 2 and 4 years, or at any time the procedure was clinically indicated. The primary end point was prostate cancer detected on these biopsies.

In all, 659 men in the dutasteride group (19.9%) and 858 in the placebo group (25.1%) were found to have prostate cancer on biopsy. The risk of the malignancy was lower than the risk in the placebo group regardless of patient age, family history of prostate cancer, baseline PSA level, baseline prostate volume, body mass index, or baseline IPSS, the investigators said. Mortality was not significantly different between men taking dutasteride (1.7%) and those taking placebo (1.9%), and there were no deaths from prostate cancer. The number of high-grade tumors also was not significantly different between the two groups.

Dutasteride reduced the risk of acute urinary retention, urinary tract infection, and the need for surgery to address benign prostatic hyperplasia. However, this benefit may have been offset by increases in loss of libido and erectile dysfunction. The drug was associated with an unexpected rise in the composite end point of “cardiac failure,” which included heart failure, ventricular failure, cardiopulmonary failure, and congestive cardiomyopathy. However, it did not raise the rate of cardiovascular events or cardiovascular mortality, compared with placebo. Fewer than 5% of the men taking dutasteride discontinued the medication, they added.

In his editorial, Dr. Walsh noted that “as the authors point out,” the reduction in prostate cancer “most likely represents shrinkage or inhibition of the growth of existing tumors rather than prevention of cancer.” Like the related drug finasteride, dutasteride “merely temporarily shrink[s] tumors that have a low potential for being lethal,” he said. Moreover, using either drug “may be somewhat risky” because both suppress PSA levels, which may give patients a false sense of security. “And if prostate cancer develops, the diagnosis may be delayed until they have high-grade disease that may be difficult to cure,” Dr. Walsh added.

Disclosures: The study was designed and funded by GlaxoSmithKline. Dr. Andriole reported receiving fees from GlaxoSmithKline and several other pharmaceutical companies, as well as owning stock or stock options in Cambridge Endo, Envisioneering Medical Technologies, and Viking Medical. Dr. Walsh's financial disclosures are available at NEJM.org

Physical activity may cancel out the effects of the “obesity gene” in adolescents, as it has been shown to do in adults.

“To our knowledge, our study is the first to report an interaction between the FTO rs9939609 polymorphism and physical activity level on adiposity indices using objectively assessed physical activity in adolescents,” said Jonatan R. Ruiz, Ph.D. of the Karolinska Institute, Huddinge, Swedenoand his associates.

The investigators genotyped and assessed body mass index, waist circumference, and body fat percentage in 752 adolescents participating in the Healthy Lifestyle in Europe by Nutrition in Adolescence Cross-Sectional Study (HELENA-CSS) They also assessed subjects' physical activity level using an accelerometer attached to the lower back rather than by using subjective measures such as questionnaires.

As expected, the fat mass- and obesity-associated (FTO) gene variant known as rs9939609 was significantly associated with higher BMI, greater waist circumference, and higher percentage of body fat.

However, there was no such association in the subgroup of carriers who participated in at least 60 minutes per day of moderate to vigorous physical activity, Dr. Ruiz and his colleagues said (Arch. Pediatr. Adolesc. Med. 2010;164:328–33).

The U.S. Department of Health and Human Services recommended this level of activity in recently released guidelines. Therefore, the study findings “have important public health implications and indicate that meeting the physical activity recommendations may offset the genetic predisposition to obesity associated with the FTO polymorphism in adolescents,” the researchers added.

This study was supported by several European government organizations. No financial conflicts of interest were reported.

Physical activity may cancel out the effects of the “obesity gene” in adolescents, as it has been shown to do in adults.

“To our knowledge, our study is the first to report an interaction between the FTO rs9939609 polymorphism and physical activity level on adiposity indices using objectively assessed physical activity in adolescents,” said Jonatan R. Ruiz, Ph.D. of the Karolinska Institute, Huddinge, Swedenoand his associates.

The investigators genotyped and assessed body mass index, waist circumference, and body fat percentage in 752 adolescents participating in the Healthy Lifestyle in Europe by Nutrition in Adolescence Cross-Sectional Study (HELENA-CSS) They also assessed subjects' physical activity level using an accelerometer attached to the lower back rather than by using subjective measures such as questionnaires.

As expected, the fat mass- and obesity-associated (FTO) gene variant known as rs9939609 was significantly associated with higher BMI, greater waist circumference, and higher percentage of body fat.

However, there was no such association in the subgroup of carriers who participated in at least 60 minutes per day of moderate to vigorous physical activity, Dr. Ruiz and his colleagues said (Arch. Pediatr. Adolesc. Med. 2010;164:328–33).

The U.S. Department of Health and Human Services recommended this level of activity in recently released guidelines. Therefore, the study findings “have important public health implications and indicate that meeting the physical activity recommendations may offset the genetic predisposition to obesity associated with the FTO polymorphism in adolescents,” the researchers added.

This study was supported by several European government organizations. No financial conflicts of interest were reported.

Physical activity may cancel out the effects of the “obesity gene” in adolescents, as it has been shown to do in adults.

“To our knowledge, our study is the first to report an interaction between the FTO rs9939609 polymorphism and physical activity level on adiposity indices using objectively assessed physical activity in adolescents,” said Jonatan R. Ruiz, Ph.D. of the Karolinska Institute, Huddinge, Swedenoand his associates.

The investigators genotyped and assessed body mass index, waist circumference, and body fat percentage in 752 adolescents participating in the Healthy Lifestyle in Europe by Nutrition in Adolescence Cross-Sectional Study (HELENA-CSS) They also assessed subjects' physical activity level using an accelerometer attached to the lower back rather than by using subjective measures such as questionnaires.

As expected, the fat mass- and obesity-associated (FTO) gene variant known as rs9939609 was significantly associated with higher BMI, greater waist circumference, and higher percentage of body fat.

However, there was no such association in the subgroup of carriers who participated in at least 60 minutes per day of moderate to vigorous physical activity, Dr. Ruiz and his colleagues said (Arch. Pediatr. Adolesc. Med. 2010;164:328–33).

The U.S. Department of Health and Human Services recommended this level of activity in recently released guidelines. Therefore, the study findings “have important public health implications and indicate that meeting the physical activity recommendations may offset the genetic predisposition to obesity associated with the FTO polymorphism in adolescents,” the researchers added.

This study was supported by several European government organizations. No financial conflicts of interest were reported.

Obese and overweight patients do not appear to receive inferior health care, compared with normal-weight patients, according to a recent report.

In fact, patients with a higher body mass index may be more likely than normal-weight patients to undergo lipid screening and hemoglobin A_1c testing; vaccination for influenza and pneumococcus; and screening for breast, colorectal, and cervical cancer, said Dr. Virginia W. Chang of the University of Pennsylvania, Philadelphia, and associates.

“While it may be true that physicians often harbor negative attitudes toward obesity, such attitudes may not be borne out in lower quality of care,” they noted (JAMA 2010;303:1274–81).

The investigators examined whether quality of care differs by patient weight status because in many studies, physicians have admitted to feeling discomfort with and dislike toward overweight patients, reluctance to treat them, and dissatisfaction with managing their care.

In addition, more than half of overweight patients in one study reported being stigmatized by a physician on multiple occasions, and physicians have been cited by overweight people as one of their most common sources of weight-related bias.

Dr. Chang and her colleagues assessed the issue using data from two large patient populations: nationally representative samples of 36,122 Medicare beneficiaries and 33,550 VA patients. The prevalence of obesity was 20% in the Medicare group and 39% in the VA group.

Eight quality-of-care measures were examined: whether diabetic patients received eye examinations, lipid screening, and HbA_1c testing; whether appropriate patients received influenza and pneumococcal vaccines; and whether appropriate patients were offered mammography, Pap smears, and colorectal cancer screening.

“Across all measures in both Medicare and VHA samples, there was no instance in which obese or overweight individuals were estimated to have significantly lower odds of recommended care relative to normal-weight individuals,” the researchers wrote.

Moreover, overweight and obese patients “often had higher estimated odds of care, and the increase in odds from normal, to overweight, to obese sometimes exhibited a monotonic pattern,” they added.

Dr. Chang and her associates noted that this study did not address health conditions and needs other than the eight specific indicators assessed here, “and obese patients may have experienced inferior care along other dimensions of medical care.”

In addition, “it is important to note that our findings may not be generalizable to quality of care in younger populations, in which the stigma and stereotypes associated with obesity may be more salient,” they said.

This study was supported by the Veterans Health Administration and the Robert Wood Johnson Foundation. No financial conflicts of interest were reported.

Obese and overweight patients do not appear to receive inferior health care, compared with normal-weight patients, according to a recent report.

In fact, patients with a higher body mass index may be more likely than normal-weight patients to undergo lipid screening and hemoglobin A_1c testing; vaccination for influenza and pneumococcus; and screening for breast, colorectal, and cervical cancer, said Dr. Virginia W. Chang of the University of Pennsylvania, Philadelphia, and associates.

“While it may be true that physicians often harbor negative attitudes toward obesity, such attitudes may not be borne out in lower quality of care,” they noted (JAMA 2010;303:1274–81).

The investigators examined whether quality of care differs by patient weight status because in many studies, physicians have admitted to feeling discomfort with and dislike toward overweight patients, reluctance to treat them, and dissatisfaction with managing their care.

In addition, more than half of overweight patients in one study reported being stigmatized by a physician on multiple occasions, and physicians have been cited by overweight people as one of their most common sources of weight-related bias.

Dr. Chang and her colleagues assessed the issue using data from two large patient populations: nationally representative samples of 36,122 Medicare beneficiaries and 33,550 VA patients. The prevalence of obesity was 20% in the Medicare group and 39% in the VA group.

Eight quality-of-care measures were examined: whether diabetic patients received eye examinations, lipid screening, and HbA_1c testing; whether appropriate patients received influenza and pneumococcal vaccines; and whether appropriate patients were offered mammography, Pap smears, and colorectal cancer screening.

“Across all measures in both Medicare and VHA samples, there was no instance in which obese or overweight individuals were estimated to have significantly lower odds of recommended care relative to normal-weight individuals,” the researchers wrote.

Moreover, overweight and obese patients “often had higher estimated odds of care, and the increase in odds from normal, to overweight, to obese sometimes exhibited a monotonic pattern,” they added.

Dr. Chang and her associates noted that this study did not address health conditions and needs other than the eight specific indicators assessed here, “and obese patients may have experienced inferior care along other dimensions of medical care.”

In addition, “it is important to note that our findings may not be generalizable to quality of care in younger populations, in which the stigma and stereotypes associated with obesity may be more salient,” they said.

This study was supported by the Veterans Health Administration and the Robert Wood Johnson Foundation. No financial conflicts of interest were reported.

Obese and overweight patients do not appear to receive inferior health care, compared with normal-weight patients, according to a recent report.

In fact, patients with a higher body mass index may be more likely than normal-weight patients to undergo lipid screening and hemoglobin A_1c testing; vaccination for influenza and pneumococcus; and screening for breast, colorectal, and cervical cancer, said Dr. Virginia W. Chang of the University of Pennsylvania, Philadelphia, and associates.

“While it may be true that physicians often harbor negative attitudes toward obesity, such attitudes may not be borne out in lower quality of care,” they noted (JAMA 2010;303:1274–81).

The investigators examined whether quality of care differs by patient weight status because in many studies, physicians have admitted to feeling discomfort with and dislike toward overweight patients, reluctance to treat them, and dissatisfaction with managing their care.

In addition, more than half of overweight patients in one study reported being stigmatized by a physician on multiple occasions, and physicians have been cited by overweight people as one of their most common sources of weight-related bias.

Dr. Chang and her colleagues assessed the issue using data from two large patient populations: nationally representative samples of 36,122 Medicare beneficiaries and 33,550 VA patients. The prevalence of obesity was 20% in the Medicare group and 39% in the VA group.

Eight quality-of-care measures were examined: whether diabetic patients received eye examinations, lipid screening, and HbA_1c testing; whether appropriate patients received influenza and pneumococcal vaccines; and whether appropriate patients were offered mammography, Pap smears, and colorectal cancer screening.

“Across all measures in both Medicare and VHA samples, there was no instance in which obese or overweight individuals were estimated to have significantly lower odds of recommended care relative to normal-weight individuals,” the researchers wrote.

Moreover, overweight and obese patients “often had higher estimated odds of care, and the increase in odds from normal, to overweight, to obese sometimes exhibited a monotonic pattern,” they added.

Dr. Chang and her associates noted that this study did not address health conditions and needs other than the eight specific indicators assessed here, “and obese patients may have experienced inferior care along other dimensions of medical care.”

In addition, “it is important to note that our findings may not be generalizable to quality of care in younger populations, in which the stigma and stereotypes associated with obesity may be more salient,” they said.

This study was supported by the Veterans Health Administration and the Robert Wood Johnson Foundation. No financial conflicts of interest were reported.

Physical activity prevents weight gain in middle-aged and older women only if they are already of low or ideal weight, not in those with body mass indexes of 25 or more, according to a large 13-year study.

Even the lighter women must sustain vigorous physical activity—1 hour or more of moderate-intensity activity every day, on average—to prevent weight gain over time. Women who exercise regularly but do so at lower intensity gain weight at the same rate as those who are inactive, said I-Min Lee, Sc.D., of Brigham and Women's Hospital, Boston, and her associates (JAMA 2010;303:1173–9).

These findings imply that following federal and other recommendations advocating 150 minutes of physical activity per week isn't sufficient to prevent weight gain in most middle-aged women, although it may well provide other health benefits, the investigators noted.

Dr. Lee and her colleagues assessed weight changes associated with various levels of physical activity, they said, because different expert groups have recommended widely varying levels of activity. For example, the federal government, the American College of Sports Medicine, and the American Heart Association recommend a minimum of 150 minutes per week, while the Institute of Medicine suggests nearly 3 times that amount, 420 minutes per week, to avoid becoming overweight or obese.

The researchers examined the issue using data from the Women's Health Study, a prospective cohort study of healthy women who had a mean age of 54 years at baseline in 1992. The team assessed 34,079 of these subjects who have been followed up on periodically since the main portion of that study was concluded in 2004.

At baseline, approximately half the women were classified as inactive, performing less than 150 minutes per week of moderate-level physical activity such as brisk walking, hiking, running, bicycling, tennis, swimming, weight training, or aerobic dance or exercise. Another 29% performed an intermediate amount of physical activity, and 22% performed a high level, putting in 21 or more hours of such activity per week.

In an initial data analysis, all three groups showed similar patterns of weight gain over a mean 13 years of follow-up. In particular, the inactive group gained a mean of 0.12 kg and the intermediate group gained 0.11 kg, an insignificant difference.

Further analysis showed, however, that women starting with body mass indexes (BMIs) lower than 25 demonstrated an inverse correlation between physical activity and weight gain, Dr. Lee and her associates said.

Another analysis examined the likelihood of gaining 2.3 kg or more over the course of 3 years. Again, there was no correlation between activity level and weight gain except in the subgroup of women with BMIs lower than 25. Only in those women did a high level of activity prevent weight gain.

Finally, an analysis of the subgroup of women of normal weight who maintained that weight throughout follow-up showed that they spent at least 60 minutes per day performing moderately intense activity, an amount closer to the Institute of Medicine recommendations than to others.

These findings indicate that once women are overweight, “it may be too late” for physical activity to stave off further weight gain, the investigators said.

This study was supported by the National Institutes of Health. Dr. Lee reported serving as a consultant to Virgin HealthMiles and sitting on its scientific advisory board. The authors reported no other financial conflict of interest.

Regular, low-intensity exercise promotes health but may not help overweight middle-aged or older women lose weight.

Source © Elena Korenbaum/iStockphoto.com

Physical activity prevents weight gain in middle-aged and older women only if they are already of low or ideal weight, not in those with body mass indexes of 25 or more, according to a large 13-year study.

Even the lighter women must sustain vigorous physical activity—1 hour or more of moderate-intensity activity every day, on average—to prevent weight gain over time. Women who exercise regularly but do so at lower intensity gain weight at the same rate as those who are inactive, said I-Min Lee, Sc.D., of Brigham and Women's Hospital, Boston, and her associates (JAMA 2010;303:1173–9).

These findings imply that following federal and other recommendations advocating 150 minutes of physical activity per week isn't sufficient to prevent weight gain in most middle-aged women, although it may well provide other health benefits, the investigators noted.

Dr. Lee and her colleagues assessed weight changes associated with various levels of physical activity, they said, because different expert groups have recommended widely varying levels of activity. For example, the federal government, the American College of Sports Medicine, and the American Heart Association recommend a minimum of 150 minutes per week, while the Institute of Medicine suggests nearly 3 times that amount, 420 minutes per week, to avoid becoming overweight or obese.

The researchers examined the issue using data from the Women's Health Study, a prospective cohort study of healthy women who had a mean age of 54 years at baseline in 1992. The team assessed 34,079 of these subjects who have been followed up on periodically since the main portion of that study was concluded in 2004.

At baseline, approximately half the women were classified as inactive, performing less than 150 minutes per week of moderate-level physical activity such as brisk walking, hiking, running, bicycling, tennis, swimming, weight training, or aerobic dance or exercise. Another 29% performed an intermediate amount of physical activity, and 22% performed a high level, putting in 21 or more hours of such activity per week.

In an initial data analysis, all three groups showed similar patterns of weight gain over a mean 13 years of follow-up. In particular, the inactive group gained a mean of 0.12 kg and the intermediate group gained 0.11 kg, an insignificant difference.

Further analysis showed, however, that women starting with body mass indexes (BMIs) lower than 25 demonstrated an inverse correlation between physical activity and weight gain, Dr. Lee and her associates said.

Another analysis examined the likelihood of gaining 2.3 kg or more over the course of 3 years. Again, there was no correlation between activity level and weight gain except in the subgroup of women with BMIs lower than 25. Only in those women did a high level of activity prevent weight gain.

Finally, an analysis of the subgroup of women of normal weight who maintained that weight throughout follow-up showed that they spent at least 60 minutes per day performing moderately intense activity, an amount closer to the Institute of Medicine recommendations than to others.

These findings indicate that once women are overweight, “it may be too late” for physical activity to stave off further weight gain, the investigators said.

This study was supported by the National Institutes of Health. Dr. Lee reported serving as a consultant to Virgin HealthMiles and sitting on its scientific advisory board. The authors reported no other financial conflict of interest.

Regular, low-intensity exercise promotes health but may not help overweight middle-aged or older women lose weight.

Source © Elena Korenbaum/iStockphoto.com

Physical activity prevents weight gain in middle-aged and older women only if they are already of low or ideal weight, not in those with body mass indexes of 25 or more, according to a large 13-year study.

Even the lighter women must sustain vigorous physical activity—1 hour or more of moderate-intensity activity every day, on average—to prevent weight gain over time. Women who exercise regularly but do so at lower intensity gain weight at the same rate as those who are inactive, said I-Min Lee, Sc.D., of Brigham and Women's Hospital, Boston, and her associates (JAMA 2010;303:1173–9).

These findings imply that following federal and other recommendations advocating 150 minutes of physical activity per week isn't sufficient to prevent weight gain in most middle-aged women, although it may well provide other health benefits, the investigators noted.

Dr. Lee and her colleagues assessed weight changes associated with various levels of physical activity, they said, because different expert groups have recommended widely varying levels of activity. For example, the federal government, the American College of Sports Medicine, and the American Heart Association recommend a minimum of 150 minutes per week, while the Institute of Medicine suggests nearly 3 times that amount, 420 minutes per week, to avoid becoming overweight or obese.

The researchers examined the issue using data from the Women's Health Study, a prospective cohort study of healthy women who had a mean age of 54 years at baseline in 1992. The team assessed 34,079 of these subjects who have been followed up on periodically since the main portion of that study was concluded in 2004.

At baseline, approximately half the women were classified as inactive, performing less than 150 minutes per week of moderate-level physical activity such as brisk walking, hiking, running, bicycling, tennis, swimming, weight training, or aerobic dance or exercise. Another 29% performed an intermediate amount of physical activity, and 22% performed a high level, putting in 21 or more hours of such activity per week.

In an initial data analysis, all three groups showed similar patterns of weight gain over a mean 13 years of follow-up. In particular, the inactive group gained a mean of 0.12 kg and the intermediate group gained 0.11 kg, an insignificant difference.

Further analysis showed, however, that women starting with body mass indexes (BMIs) lower than 25 demonstrated an inverse correlation between physical activity and weight gain, Dr. Lee and her associates said.

Another analysis examined the likelihood of gaining 2.3 kg or more over the course of 3 years. Again, there was no correlation between activity level and weight gain except in the subgroup of women with BMIs lower than 25. Only in those women did a high level of activity prevent weight gain.

Finally, an analysis of the subgroup of women of normal weight who maintained that weight throughout follow-up showed that they spent at least 60 minutes per day performing moderately intense activity, an amount closer to the Institute of Medicine recommendations than to others.

These findings indicate that once women are overweight, “it may be too late” for physical activity to stave off further weight gain, the investigators said.

This study was supported by the National Institutes of Health. Dr. Lee reported serving as a consultant to Virgin HealthMiles and sitting on its scientific advisory board. The authors reported no other financial conflict of interest.

Regular, low-intensity exercise promotes health but may not help overweight middle-aged or older women lose weight.

Source © Elena Korenbaum/iStockphoto.com

Current methods for profiling individual physicians as to whether they provide low-cost or high-cost care are often inaccurate and produce misleading results, according to a report.

Health plans use cost profiling to limit how many physicians get in-network contracts and to allot bonuses to the physicians whose “resource use” is lower than average. In each case, there must be a method for determining physicians' costs, yet the accuracy of these methods has never been proved, according to John L. Adams, Ph.D., of RAND Corp., and his associates.

“To our knowledge, the reliability of physician cost profiling has not been previously addressed,” they noted.

Dr. Adams and his colleagues assessed the reliability of current methods of cost profiling using claims data from four Massachusetts insurance companies concerning 1.1 million adult patients treated during 2004-2005. A total of 12,789 physicians were included in the study. They were predominantly men who were board certified, had been trained in the United States, and had been in practice for more than 10 years.

The physicians worked in 28 specialties, including cardiology, endocrinology, gastroenterology, and obstetrics and gynecology. Family physicians, general physicians, and internal medicine physicians comprised approximately one-third of the sample.

The investigators estimated the reliability of cost profiles on a scale of 0-1, with 0 representing completely unreliable profiles and 1 representing completely reliable profiles. They then estimated the proportion of physicians in each specialty whose cost performance would be calculated inaccurately.

Overall, only 41% of physicians across all specialties had cost profile scores of 0.70 or greater, a commonly used threshold of acceptable accuracy. Only 47% of internists, 30% of cardiologists, 41% of family or general physicians, 57% of ob.gyns., 59% of gastroenterologists, and 22% of endocrinologists received scores of 0.70.

Overall, only 9% of physicians in the study had scores of 0.90 or greater, indicating optimal accuracy.

The proportion of physicians who were classified as “lower cost” but who were not in fact lower cost ranged from 29% to 67%, depending on the specialty. Fully 50% of internists, 40% of cardiologists, 39% of family or general physicians, 36% of ob.gyns., 32% of gastroenterologists, and 50% of endocrinologists were misclassified as “lower-cost” providers when they were not.

Also, 22% of internists were misclassified as “higher cost” when they were not in fact higher cost. This same misclassification occurred for 14% of cardiologists, 16% of family or general physicians, 10% of ob.gyns., 11% of gastroenterologists, and 19% of endocrinologists.

These findings indicate that standard methods of cost profiling are highly unreliable, and that many individuals and groups are basing important decisions on inaccuracies. “Consumers, physicians, and purchasers are all at risk of being misled by the results produced by these tools,” the investigators concluded (N. Engl. J. Med. 2010;362:1014-21).

The study findings also suggest that using cost profiles that are based on these unreliable methods will not reduce health care spending, they added.

Disclosures: This study was supported by the Department of Labor, the National Institutes of Health, and the Robert Wood Johnson Foundation. The investigators' disclosures can be found at nejm.org

My Take

Abandon Flawed Evaluation Programs

The RAND Corp. study verifies the American Medical Association's long-standing contention that there are serious flaws in health insurer programs that attempt to rate physicians based on cost of care.

The RAND study shows that physician ratings conducted by insurers can be wrong up to two-thirds of the time for some groups of physicians. Inaccurate information can erode patient confidence and trust in caring physicians, and disrupt patients' relationships with physicians who have cared for them for years.

Patients should always be able to trust that the information they receive on physicians is valid and reliable, especially when the data are used by insurers to influence or restrict patients' choice of physicians.

Given the potential for irreparable damage to the patient-physician relationship, the AMA calls on the health insurance industry to abandon flawed physician evaluation and ranking programs, and join with the AMA to create constructive programs that produce meaningful data for increasing the quality and efficiency of health care.

J. JAMES ROHACK, M.D., is president of the American Medical Association. He reported having no conflicts of interest.

Current methods for profiling individual physicians as to whether they provide low-cost or high-cost care are often inaccurate and produce misleading results, according to a report.

Health plans use cost profiling to limit how many physicians get in-network contracts and to allot bonuses to the physicians whose “resource use” is lower than average. In each case, there must be a method for determining physicians' costs, yet the accuracy of these methods has never been proved, according to John L. Adams, Ph.D., of RAND Corp., and his associates.

“To our knowledge, the reliability of physician cost profiling has not been previously addressed,” they noted.

Dr. Adams and his colleagues assessed the reliability of current methods of cost profiling using claims data from four Massachusetts insurance companies concerning 1.1 million adult patients treated during 2004-2005. A total of 12,789 physicians were included in the study. They were predominantly men who were board certified, had been trained in the United States, and had been in practice for more than 10 years.

The physicians worked in 28 specialties, including cardiology, endocrinology, gastroenterology, and obstetrics and gynecology. Family physicians, general physicians, and internal medicine physicians comprised approximately one-third of the sample.

The investigators estimated the reliability of cost profiles on a scale of 0-1, with 0 representing completely unreliable profiles and 1 representing completely reliable profiles. They then estimated the proportion of physicians in each specialty whose cost performance would be calculated inaccurately.

Overall, only 41% of physicians across all specialties had cost profile scores of 0.70 or greater, a commonly used threshold of acceptable accuracy. Only 47% of internists, 30% of cardiologists, 41% of family or general physicians, 57% of ob.gyns., 59% of gastroenterologists, and 22% of endocrinologists received scores of 0.70.

Overall, only 9% of physicians in the study had scores of 0.90 or greater, indicating optimal accuracy.

The proportion of physicians who were classified as “lower cost” but who were not in fact lower cost ranged from 29% to 67%, depending on the specialty. Fully 50% of internists, 40% of cardiologists, 39% of family or general physicians, 36% of ob.gyns., 32% of gastroenterologists, and 50% of endocrinologists were misclassified as “lower-cost” providers when they were not.

Also, 22% of internists were misclassified as “higher cost” when they were not in fact higher cost. This same misclassification occurred for 14% of cardiologists, 16% of family or general physicians, 10% of ob.gyns., 11% of gastroenterologists, and 19% of endocrinologists.

These findings indicate that standard methods of cost profiling are highly unreliable, and that many individuals and groups are basing important decisions on inaccuracies. “Consumers, physicians, and purchasers are all at risk of being misled by the results produced by these tools,” the investigators concluded (N. Engl. J. Med. 2010;362:1014-21).

The study findings also suggest that using cost profiles that are based on these unreliable methods will not reduce health care spending, they added.

Disclosures: This study was supported by the Department of Labor, the National Institutes of Health, and the Robert Wood Johnson Foundation. The investigators' disclosures can be found at nejm.org

My Take

Abandon Flawed Evaluation Programs

The RAND Corp. study verifies the American Medical Association's long-standing contention that there are serious flaws in health insurer programs that attempt to rate physicians based on cost of care.

The RAND study shows that physician ratings conducted by insurers can be wrong up to two-thirds of the time for some groups of physicians. Inaccurate information can erode patient confidence and trust in caring physicians, and disrupt patients' relationships with physicians who have cared for them for years.

Patients should always be able to trust that the information they receive on physicians is valid and reliable, especially when the data are used by insurers to influence or restrict patients' choice of physicians.

Given the potential for irreparable damage to the patient-physician relationship, the AMA calls on the health insurance industry to abandon flawed physician evaluation and ranking programs, and join with the AMA to create constructive programs that produce meaningful data for increasing the quality and efficiency of health care.

J. JAMES ROHACK, M.D., is president of the American Medical Association. He reported having no conflicts of interest.

Current methods for profiling individual physicians as to whether they provide low-cost or high-cost care are often inaccurate and produce misleading results, according to a report.

Health plans use cost profiling to limit how many physicians get in-network contracts and to allot bonuses to the physicians whose “resource use” is lower than average. In each case, there must be a method for determining physicians' costs, yet the accuracy of these methods has never been proved, according to John L. Adams, Ph.D., of RAND Corp., and his associates.

“To our knowledge, the reliability of physician cost profiling has not been previously addressed,” they noted.

Dr. Adams and his colleagues assessed the reliability of current methods of cost profiling using claims data from four Massachusetts insurance companies concerning 1.1 million adult patients treated during 2004-2005. A total of 12,789 physicians were included in the study. They were predominantly men who were board certified, had been trained in the United States, and had been in practice for more than 10 years.

The physicians worked in 28 specialties, including cardiology, endocrinology, gastroenterology, and obstetrics and gynecology. Family physicians, general physicians, and internal medicine physicians comprised approximately one-third of the sample.

The investigators estimated the reliability of cost profiles on a scale of 0-1, with 0 representing completely unreliable profiles and 1 representing completely reliable profiles. They then estimated the proportion of physicians in each specialty whose cost performance would be calculated inaccurately.

Overall, only 41% of physicians across all specialties had cost profile scores of 0.70 or greater, a commonly used threshold of acceptable accuracy. Only 47% of internists, 30% of cardiologists, 41% of family or general physicians, 57% of ob.gyns., 59% of gastroenterologists, and 22% of endocrinologists received scores of 0.70.

Overall, only 9% of physicians in the study had scores of 0.90 or greater, indicating optimal accuracy.

The proportion of physicians who were classified as “lower cost” but who were not in fact lower cost ranged from 29% to 67%, depending on the specialty. Fully 50% of internists, 40% of cardiologists, 39% of family or general physicians, 36% of ob.gyns., 32% of gastroenterologists, and 50% of endocrinologists were misclassified as “lower-cost” providers when they were not.

Also, 22% of internists were misclassified as “higher cost” when they were not in fact higher cost. This same misclassification occurred for 14% of cardiologists, 16% of family or general physicians, 10% of ob.gyns., 11% of gastroenterologists, and 19% of endocrinologists.

These findings indicate that standard methods of cost profiling are highly unreliable, and that many individuals and groups are basing important decisions on inaccuracies. “Consumers, physicians, and purchasers are all at risk of being misled by the results produced by these tools,” the investigators concluded (N. Engl. J. Med. 2010;362:1014-21).

The study findings also suggest that using cost profiles that are based on these unreliable methods will not reduce health care spending, they added.

Disclosures: This study was supported by the Department of Labor, the National Institutes of Health, and the Robert Wood Johnson Foundation. The investigators' disclosures can be found at nejm.org

My Take

Abandon Flawed Evaluation Programs

The RAND Corp. study verifies the American Medical Association's long-standing contention that there are serious flaws in health insurer programs that attempt to rate physicians based on cost of care.

The RAND study shows that physician ratings conducted by insurers can be wrong up to two-thirds of the time for some groups of physicians. Inaccurate information can erode patient confidence and trust in caring physicians, and disrupt patients' relationships with physicians who have cared for them for years.

Patients should always be able to trust that the information they receive on physicians is valid and reliable, especially when the data are used by insurers to influence or restrict patients' choice of physicians.

Given the potential for irreparable damage to the patient-physician relationship, the AMA calls on the health insurance industry to abandon flawed physician evaluation and ranking programs, and join with the AMA to create constructive programs that produce meaningful data for increasing the quality and efficiency of health care.

J. JAMES ROHACK, M.D., is president of the American Medical Association. He reported having no conflicts of interest.

A review of the recent literature confirms that “comparative effectiveness” research—studies designed to help physicians use existing treatments and treatment strategies more effectively—is severely lacking.

Fewer than a third of the studies published in the six top journals covering general and internal medicine qualified as comparative effectiveness (CE) research. This finding “supports concerns that only limited clinical research is currently devoted to helping physicians” improve the use of existing therapies and determine which interventions and strategies are the most effective, safe, and cost-efficient, said Dr. Michael Hochman and Dr. Danny McCormick of Cambridge (Mass.) Health Alliance and Harvard Medical School, Boston.

Congress recently passed legislation to provide more than $1 billion to support CE studies, and President Obama's budget for 2011 recommends further funding of CE research. Noting that few data are available on the current status of CE research, Dr. Hochman and Dr. McCormick reviewed all clinical studies assessing medications that were published between June 2008 and October 2009 in the six “highest impact” medical journals: New England Journal of Medicine, Lancet, JAMA, Annals of Internal Medicine, British Medical Journal, and Archives of Internal Medicine.

These publications “are the most widely read, quoted, and covered by the media, and thus are disproportionately likely to influence clinicians,” the researchers said (JAMA 2010;303:951-8).

Of the 328 randomized trials, observational studies, or meta-analyses involving medications that were included in the analysis, only 104 (32%) were CE studies.

Only 11% of the CE studies compared medications with nonpharmacologic treatments, confirming that there is a relative lack of such research. CE studies that compare medications with nonpharmacologic interventions are particularly important because they help clinicians “make fundamental therapeutic decisions,” Dr. Hochman and Dr. McCormick said.

Nearly 90% of the CE studies relied on noncommercial funding, primarily from government sources, a finding that highlights how essential such funding is. “Commercial entities presumably devote much of their research to the development of novel therapies and to funding inactive-comparator studies aimed at expanding indications for their products,” they noted.

Most of the randomized trials in this analysis used an “inactive comparator” such as placebo, rather than comparing a medication against existing treatments. Such trials were disproportionately funded by commercial sources and disproportionately likely to show that a medication had positive results.

In addition, 24% of the randomized trials that did use an active comparator sought to show only the noninferiority of a medication to that comparator; there was no effort to clarify the optimal therapy, only to test equivalency. Such trials were exclusively funded by commercial sources.

Only 19% of the CE studies focused on patient safety, which implies that safety concerns are not adequately emphasized.

Only 2% of the CE studies and 1% of all studies in the analysis included formal cost-effectiveness analyses, which are critical to promoting efficient health care. This absence “may reflect policies or editorial priorities of journal editors favoring publication of clinical outcome reports rather than a true dearth of cost-effectiveness studies,” the authors said.

Overall, the findings “underscore the importance of the recent legislation passed in the United States to expand public funding for CE studies. In particular, our findings suggest government and noncommercial support should be increased for studies involving nonpharmacologic therapies, for studies comparing different therapeutic strategies, and for studies focusing on the comparative safety and cost of different therapies,” Dr. Hochman and Dr. McCormick said.

Disclosures: The investigators reported no financial conflicts of interest.

A review of the recent literature confirms that “comparative effectiveness” research—studies designed to help physicians use existing treatments and treatment strategies more effectively—is severely lacking.

Fewer than a third of the studies published in the six top journals covering general and internal medicine qualified as comparative effectiveness (CE) research. This finding “supports concerns that only limited clinical research is currently devoted to helping physicians” improve the use of existing therapies and determine which interventions and strategies are the most effective, safe, and cost-efficient, said Dr. Michael Hochman and Dr. Danny McCormick of Cambridge (Mass.) Health Alliance and Harvard Medical School, Boston.

Congress recently passed legislation to provide more than $1 billion to support CE studies, and President Obama's budget for 2011 recommends further funding of CE research. Noting that few data are available on the current status of CE research, Dr. Hochman and Dr. McCormick reviewed all clinical studies assessing medications that were published between June 2008 and October 2009 in the six “highest impact” medical journals: New England Journal of Medicine, Lancet, JAMA, Annals of Internal Medicine, British Medical Journal, and Archives of Internal Medicine.

These publications “are the most widely read, quoted, and covered by the media, and thus are disproportionately likely to influence clinicians,” the researchers said (JAMA 2010;303:951-8).

Of the 328 randomized trials, observational studies, or meta-analyses involving medications that were included in the analysis, only 104 (32%) were CE studies.

Only 11% of the CE studies compared medications with nonpharmacologic treatments, confirming that there is a relative lack of such research. CE studies that compare medications with nonpharmacologic interventions are particularly important because they help clinicians “make fundamental therapeutic decisions,” Dr. Hochman and Dr. McCormick said.

Nearly 90% of the CE studies relied on noncommercial funding, primarily from government sources, a finding that highlights how essential such funding is. “Commercial entities presumably devote much of their research to the development of novel therapies and to funding inactive-comparator studies aimed at expanding indications for their products,” they noted.

Most of the randomized trials in this analysis used an “inactive comparator” such as placebo, rather than comparing a medication against existing treatments. Such trials were disproportionately funded by commercial sources and disproportionately likely to show that a medication had positive results.

In addition, 24% of the randomized trials that did use an active comparator sought to show only the noninferiority of a medication to that comparator; there was no effort to clarify the optimal therapy, only to test equivalency. Such trials were exclusively funded by commercial sources.

Only 19% of the CE studies focused on patient safety, which implies that safety concerns are not adequately emphasized.

Only 2% of the CE studies and 1% of all studies in the analysis included formal cost-effectiveness analyses, which are critical to promoting efficient health care. This absence “may reflect policies or editorial priorities of journal editors favoring publication of clinical outcome reports rather than a true dearth of cost-effectiveness studies,” the authors said.

Overall, the findings “underscore the importance of the recent legislation passed in the United States to expand public funding for CE studies. In particular, our findings suggest government and noncommercial support should be increased for studies involving nonpharmacologic therapies, for studies comparing different therapeutic strategies, and for studies focusing on the comparative safety and cost of different therapies,” Dr. Hochman and Dr. McCormick said.

Disclosures: The investigators reported no financial conflicts of interest.

A review of the recent literature confirms that “comparative effectiveness” research—studies designed to help physicians use existing treatments and treatment strategies more effectively—is severely lacking.

Fewer than a third of the studies published in the six top journals covering general and internal medicine qualified as comparative effectiveness (CE) research. This finding “supports concerns that only limited clinical research is currently devoted to helping physicians” improve the use of existing therapies and determine which interventions and strategies are the most effective, safe, and cost-efficient, said Dr. Michael Hochman and Dr. Danny McCormick of Cambridge (Mass.) Health Alliance and Harvard Medical School, Boston.

Congress recently passed legislation to provide more than $1 billion to support CE studies, and President Obama's budget for 2011 recommends further funding of CE research. Noting that few data are available on the current status of CE research, Dr. Hochman and Dr. McCormick reviewed all clinical studies assessing medications that were published between June 2008 and October 2009 in the six “highest impact” medical journals: New England Journal of Medicine, Lancet, JAMA, Annals of Internal Medicine, British Medical Journal, and Archives of Internal Medicine.

These publications “are the most widely read, quoted, and covered by the media, and thus are disproportionately likely to influence clinicians,” the researchers said (JAMA 2010;303:951-8).

Of the 328 randomized trials, observational studies, or meta-analyses involving medications that were included in the analysis, only 104 (32%) were CE studies.

Only 11% of the CE studies compared medications with nonpharmacologic treatments, confirming that there is a relative lack of such research. CE studies that compare medications with nonpharmacologic interventions are particularly important because they help clinicians “make fundamental therapeutic decisions,” Dr. Hochman and Dr. McCormick said.

Nearly 90% of the CE studies relied on noncommercial funding, primarily from government sources, a finding that highlights how essential such funding is. “Commercial entities presumably devote much of their research to the development of novel therapies and to funding inactive-comparator studies aimed at expanding indications for their products,” they noted.

Most of the randomized trials in this analysis used an “inactive comparator” such as placebo, rather than comparing a medication against existing treatments. Such trials were disproportionately funded by commercial sources and disproportionately likely to show that a medication had positive results.

In addition, 24% of the randomized trials that did use an active comparator sought to show only the noninferiority of a medication to that comparator; there was no effort to clarify the optimal therapy, only to test equivalency. Such trials were exclusively funded by commercial sources.

Only 19% of the CE studies focused on patient safety, which implies that safety concerns are not adequately emphasized.

Only 2% of the CE studies and 1% of all studies in the analysis included formal cost-effectiveness analyses, which are critical to promoting efficient health care. This absence “may reflect policies or editorial priorities of journal editors favoring publication of clinical outcome reports rather than a true dearth of cost-effectiveness studies,” the authors said.

Overall, the findings “underscore the importance of the recent legislation passed in the United States to expand public funding for CE studies. In particular, our findings suggest government and noncommercial support should be increased for studies involving nonpharmacologic therapies, for studies comparing different therapeutic strategies, and for studies focusing on the comparative safety and cost of different therapies,” Dr. Hochman and Dr. McCormick said.

Disclosures: The investigators reported no financial conflicts of interest.

A new model for internal medicine residencies, stressing education but reducing trainee workload, markedly increased satisfaction among interns, residents, and the attending physicians training them, according to a report.

The new residency approach was designed to increase trainees' opportunities to pursue subjects in depth, engage in reflection, spend more time with patients, and interact more with teachers and mentors—in short, to make internal medicine residency “an educational experience rather than an exercise in technical training,” said Dr. Graham T. McMahon of Brigham and Women's Hospital, Boston, and his associates.

In a direct comparison with the existing internal medicine residency program at a community teaching hospital affiliated with Brigham and Women's, the new model met many leading recommendations for graduate medical education reform without negatively affecting patient care.

The Integrated Teaching Unit (ITU) model included a reduced clinical workload and decreased call frequency for the trainees. Each ITU training team consisted of two attending physicians—one a hospitalist and the other an internist or specialist—who had been rated as superior in teaching ability. Each team supervised two residents and three interns.

Dr. McMahon and his colleagues said that bedside teaching was enhanced by the participation of both attendings, who were compensated for their extra time, as well as by the multidisciplinary nature of the instructors.

The researchers assessed the 1-year experience of two ITU teams that cared for 1,892 medical inpatients and two regular (control) residency teams that cared for 2,096 medical inpatients. Trainees spent time on both ITU and regular residency teams. The regular training teams were made up of multiple attending physicians who volunteered to participate.

In the ITU program, trainees spent twice as much time (20% of total time vs. 10% compared with controls in the regular program) pursuing educational activities such as self-directed learning, didactic sessions, and conferences. They spent significantly less time (37% of total time vs. 45% compared with controls) doing “indirect” patient care such as reviewing charts, writing notes, and entering orders.

The two groups spent a similar amount of time at the bedside, but ITU trainees “had a significantly lower patient census, meaning that the time they spent per patient at the bedside was greater (by almost 50%),” the investigators wrote.

Residents and interns reported significantly higher satisfaction with their training in the ITU program, saying that they learned more new skills, received more feedback from attendings, and participated in more patient follow-up than those in the regular program. They reported that they used the additional time in their workdays for reflection and self-appraisal.

Attending physicians also reported the ITU model was closer than the existing model to their teaching ideal. Not only were their teaching skills well used, they said, but also they learned from their teaching teammates.

Trainees and attendings reported liking the increased exchange of ideas, the deeper insights into clinical thinking, and the mix of teaching styles that the dual-attending supervision allowed.

Patient responses on surveys of their satisfaction with their hospital experience and with their physicians did not differ between the training styles. There also was no significant difference in rate of hospital readmission within 30 days, cause of death, or ratings on 11 measures of quality of hospital care.

“Our study shows that an educationally centered program, constructed to address the educational needs of trainees, can be successfully introduced without adversely affecting the quality of care,” Dr. McMahon and his associates said (N. Engl. J. Med. 2010;362:1304-11).

In an editorial, Dr. Kenneth M. Ludmerer of Washington University, St. Louis, said the comparison in the study “clearly demonstrates” the benefits of a rich learning environment. The study “helps to point out where our priorities in residency education should be,” he said (N. Engl. J. Med. 2010;362:1337-8).

Dr. Ludmerer added that the study could not assess all patient benefits with the ITU model, but those plausibly include “the traditional hallmark of good care,” physician thoroughness. In this context, the word does not mean ordering every test, he said.

“Rather, it means paying attention to detail, being careful, not missing things, and not jumping to conclusions. It is reasonable to hypothesize that residents who have the time to be careful will order fewer unnecessary tests and procedures, use resources more efficiently, and make fewer avoidable mistakes,” he noted.

Disclosures: Dr. McMahon and his associates reported no financial conflicts of interest.

A new model for internal medicine residencies, stressing education but reducing trainee workload, markedly increased satisfaction among interns, residents, and the attending physicians training them, according to a report.

The new residency approach was designed to increase trainees' opportunities to pursue subjects in depth, engage in reflection, spend more time with patients, and interact more with teachers and mentors—in short, to make internal medicine residency “an educational experience rather than an exercise in technical training,” said Dr. Graham T. McMahon of Brigham and Women's Hospital, Boston, and his associates.

In a direct comparison with the existing internal medicine residency program at a community teaching hospital affiliated with Brigham and Women's, the new model met many leading recommendations for graduate medical education reform without negatively affecting patient care.

The Integrated Teaching Unit (ITU) model included a reduced clinical workload and decreased call frequency for the trainees. Each ITU training team consisted of two attending physicians—one a hospitalist and the other an internist or specialist—who had been rated as superior in teaching ability. Each team supervised two residents and three interns.

Dr. McMahon and his colleagues said that bedside teaching was enhanced by the participation of both attendings, who were compensated for their extra time, as well as by the multidisciplinary nature of the instructors.

The researchers assessed the 1-year experience of two ITU teams that cared for 1,892 medical inpatients and two regular (control) residency teams that cared for 2,096 medical inpatients. Trainees spent time on both ITU and regular residency teams. The regular training teams were made up of multiple attending physicians who volunteered to participate.

In the ITU program, trainees spent twice as much time (20% of total time vs. 10% compared with controls in the regular program) pursuing educational activities such as self-directed learning, didactic sessions, and conferences. They spent significantly less time (37% of total time vs. 45% compared with controls) doing “indirect” patient care such as reviewing charts, writing notes, and entering orders.

The two groups spent a similar amount of time at the bedside, but ITU trainees “had a significantly lower patient census, meaning that the time they spent per patient at the bedside was greater (by almost 50%),” the investigators wrote.

Residents and interns reported significantly higher satisfaction with their training in the ITU program, saying that they learned more new skills, received more feedback from attendings, and participated in more patient follow-up than those in the regular program. They reported that they used the additional time in their workdays for reflection and self-appraisal.

Attending physicians also reported the ITU model was closer than the existing model to their teaching ideal. Not only were their teaching skills well used, they said, but also they learned from their teaching teammates.

Trainees and attendings reported liking the increased exchange of ideas, the deeper insights into clinical thinking, and the mix of teaching styles that the dual-attending supervision allowed.

Patient responses on surveys of their satisfaction with their hospital experience and with their physicians did not differ between the training styles. There also was no significant difference in rate of hospital readmission within 30 days, cause of death, or ratings on 11 measures of quality of hospital care.

“Our study shows that an educationally centered program, constructed to address the educational needs of trainees, can be successfully introduced without adversely affecting the quality of care,” Dr. McMahon and his associates said (N. Engl. J. Med. 2010;362:1304-11).

In an editorial, Dr. Kenneth M. Ludmerer of Washington University, St. Louis, said the comparison in the study “clearly demonstrates” the benefits of a rich learning environment. The study “helps to point out where our priorities in residency education should be,” he said (N. Engl. J. Med. 2010;362:1337-8).

Dr. Ludmerer added that the study could not assess all patient benefits with the ITU model, but those plausibly include “the traditional hallmark of good care,” physician thoroughness. In this context, the word does not mean ordering every test, he said.

“Rather, it means paying attention to detail, being careful, not missing things, and not jumping to conclusions. It is reasonable to hypothesize that residents who have the time to be careful will order fewer unnecessary tests and procedures, use resources more efficiently, and make fewer avoidable mistakes,” he noted.

Disclosures: Dr. McMahon and his associates reported no financial conflicts of interest.

A new model for internal medicine residencies, stressing education but reducing trainee workload, markedly increased satisfaction among interns, residents, and the attending physicians training them, according to a report.

The new residency approach was designed to increase trainees' opportunities to pursue subjects in depth, engage in reflection, spend more time with patients, and interact more with teachers and mentors—in short, to make internal medicine residency “an educational experience rather than an exercise in technical training,” said Dr. Graham T. McMahon of Brigham and Women's Hospital, Boston, and his associates.

In a direct comparison with the existing internal medicine residency program at a community teaching hospital affiliated with Brigham and Women's, the new model met many leading recommendations for graduate medical education reform without negatively affecting patient care.

The Integrated Teaching Unit (ITU) model included a reduced clinical workload and decreased call frequency for the trainees. Each ITU training team consisted of two attending physicians—one a hospitalist and the other an internist or specialist—who had been rated as superior in teaching ability. Each team supervised two residents and three interns.

Dr. McMahon and his colleagues said that bedside teaching was enhanced by the participation of both attendings, who were compensated for their extra time, as well as by the multidisciplinary nature of the instructors.

The researchers assessed the 1-year experience of two ITU teams that cared for 1,892 medical inpatients and two regular (control) residency teams that cared for 2,096 medical inpatients. Trainees spent time on both ITU and regular residency teams. The regular training teams were made up of multiple attending physicians who volunteered to participate.

In the ITU program, trainees spent twice as much time (20% of total time vs. 10% compared with controls in the regular program) pursuing educational activities such as self-directed learning, didactic sessions, and conferences. They spent significantly less time (37% of total time vs. 45% compared with controls) doing “indirect” patient care such as reviewing charts, writing notes, and entering orders.

The two groups spent a similar amount of time at the bedside, but ITU trainees “had a significantly lower patient census, meaning that the time they spent per patient at the bedside was greater (by almost 50%),” the investigators wrote.

Residents and interns reported significantly higher satisfaction with their training in the ITU program, saying that they learned more new skills, received more feedback from attendings, and participated in more patient follow-up than those in the regular program. They reported that they used the additional time in their workdays for reflection and self-appraisal.

Attending physicians also reported the ITU model was closer than the existing model to their teaching ideal. Not only were their teaching skills well used, they said, but also they learned from their teaching teammates.

Trainees and attendings reported liking the increased exchange of ideas, the deeper insights into clinical thinking, and the mix of teaching styles that the dual-attending supervision allowed.

Patient responses on surveys of their satisfaction with their hospital experience and with their physicians did not differ between the training styles. There also was no significant difference in rate of hospital readmission within 30 days, cause of death, or ratings on 11 measures of quality of hospital care.

“Our study shows that an educationally centered program, constructed to address the educational needs of trainees, can be successfully introduced without adversely affecting the quality of care,” Dr. McMahon and his associates said (N. Engl. J. Med. 2010;362:1304-11).

In an editorial, Dr. Kenneth M. Ludmerer of Washington University, St. Louis, said the comparison in the study “clearly demonstrates” the benefits of a rich learning environment. The study “helps to point out where our priorities in residency education should be,” he said (N. Engl. J. Med. 2010;362:1337-8).

Dr. Ludmerer added that the study could not assess all patient benefits with the ITU model, but those plausibly include “the traditional hallmark of good care,” physician thoroughness. In this context, the word does not mean ordering every test, he said.

“Rather, it means paying attention to detail, being careful, not missing things, and not jumping to conclusions. It is reasonable to hypothesize that residents who have the time to be careful will order fewer unnecessary tests and procedures, use resources more efficiently, and make fewer avoidable mistakes,” he noted.

Disclosures: Dr. McMahon and his associates reported no financial conflicts of interest.