Mary Ann Moon

The cardiovascular risk profile of professional football payers—and, by implication, other very large athletes—is similar to that of the general population, according to a cross-sectional study funded by the National Football League.

It appears that high levels of physical activity offset the harmful cardiovascular effects of a body size large enough to fit the criteria for obesity, said Dr. Andrew M. Tucker of Union Memorial Hospital, Baltimore, and his associates.

Body mass index has increased significantly among offensive and defensive linemen during the past 30 years. That, taken together with sporadic premature deaths among these athletes, has raised concern that football players and other large athletes may be at increased cardiovascular risk.

Dr. Tucker and his colleagues assessed 504 active, veteran players on 12 of the 32 NFL teams using a device that measured body composition rather than BMI.

“Reliance on BMI alone as a size indicator for CVD risk may not be appropriate in NFL players because BMI does not take into account lean muscle mass,” they noted.

The findings from their investigation were compared with those of an age- and race-equivalent population sample from the Coronary Artery Risk Development in Young Adults (CARDIA) study. The 504 football players, who were an average of approximately 30 kg heavier than the control group, represented 26% of the total number of veteran players at the time of the study.

“Despite their large size, the NFL group had lower mean fasting glucose compared with the CARDIA group, and there were no significant differences in total cholesterol, LDL-C, HDL-C, or triglycerides between the groups,” the investigators said (JAMA 2009;301:2111–9).

As has been reported previously, “high physical activity in the player group appears to have substantially mitigated the effect of large size.”

Prevalence of above-normal blood pressure did not differ significantly between black (75%) and white (82%) players. No significant link was found between players' position on the team and hypertension or prehypertension.

The athletes differed from general population in one critical respect: they were much more likely to have hypertension or prehypertension.

The combined prevalence of hypertension and prehypertension was high in all player groups, ranging from 96 of 105 (91%) in the largest players to 15 of 19 (78%) in the smallest players compared with 581 of 1,957 (30%) in the CARDIA group.

This unexpected finding has prompted an NFL-wide investigation to determine the underlying cause of players' increased blood pressure, the researchers said.

There was an array of limitations to the study, the authors noted. The limitations ranged from speculation that players may have underreported use of anti-hypertension medicines, to potential seasonal differences on blood pressure to the fact that only one automated pressure measurement was taken from the NFL group.

Smoking was self reported in both the NFL group and the CARDIA group.

The investigators disclosed no conflicts of interest.

Reliance on BMI alone as a size indicator for CVD risk may not be appropriate in NFL players who have high lean muscle mass. ©

The cardiovascular risk profile of professional football payers—and, by implication, other very large athletes—is similar to that of the general population, according to a cross-sectional study funded by the National Football League.

It appears that high levels of physical activity offset the harmful cardiovascular effects of a body size large enough to fit the criteria for obesity, said Dr. Andrew M. Tucker of Union Memorial Hospital, Baltimore, and his associates.

Body mass index has increased significantly among offensive and defensive linemen during the past 30 years. That, taken together with sporadic premature deaths among these athletes, has raised concern that football players and other large athletes may be at increased cardiovascular risk.

Dr. Tucker and his colleagues assessed 504 active, veteran players on 12 of the 32 NFL teams using a device that measured body composition rather than BMI.

“Reliance on BMI alone as a size indicator for CVD risk may not be appropriate in NFL players because BMI does not take into account lean muscle mass,” they noted.

The findings from their investigation were compared with those of an age- and race-equivalent population sample from the Coronary Artery Risk Development in Young Adults (CARDIA) study. The 504 football players, who were an average of approximately 30 kg heavier than the control group, represented 26% of the total number of veteran players at the time of the study.

“Despite their large size, the NFL group had lower mean fasting glucose compared with the CARDIA group, and there were no significant differences in total cholesterol, LDL-C, HDL-C, or triglycerides between the groups,” the investigators said (JAMA 2009;301:2111–9).

As has been reported previously, “high physical activity in the player group appears to have substantially mitigated the effect of large size.”

Prevalence of above-normal blood pressure did not differ significantly between black (75%) and white (82%) players. No significant link was found between players' position on the team and hypertension or prehypertension.

The athletes differed from general population in one critical respect: they were much more likely to have hypertension or prehypertension.

The combined prevalence of hypertension and prehypertension was high in all player groups, ranging from 96 of 105 (91%) in the largest players to 15 of 19 (78%) in the smallest players compared with 581 of 1,957 (30%) in the CARDIA group.

This unexpected finding has prompted an NFL-wide investigation to determine the underlying cause of players' increased blood pressure, the researchers said.

There was an array of limitations to the study, the authors noted. The limitations ranged from speculation that players may have underreported use of anti-hypertension medicines, to potential seasonal differences on blood pressure to the fact that only one automated pressure measurement was taken from the NFL group.

Smoking was self reported in both the NFL group and the CARDIA group.

The investigators disclosed no conflicts of interest.

Reliance on BMI alone as a size indicator for CVD risk may not be appropriate in NFL players who have high lean muscle mass. ©

The cardiovascular risk profile of professional football payers—and, by implication, other very large athletes—is similar to that of the general population, according to a cross-sectional study funded by the National Football League.

It appears that high levels of physical activity offset the harmful cardiovascular effects of a body size large enough to fit the criteria for obesity, said Dr. Andrew M. Tucker of Union Memorial Hospital, Baltimore, and his associates.

Body mass index has increased significantly among offensive and defensive linemen during the past 30 years. That, taken together with sporadic premature deaths among these athletes, has raised concern that football players and other large athletes may be at increased cardiovascular risk.

Dr. Tucker and his colleagues assessed 504 active, veteran players on 12 of the 32 NFL teams using a device that measured body composition rather than BMI.

“Reliance on BMI alone as a size indicator for CVD risk may not be appropriate in NFL players because BMI does not take into account lean muscle mass,” they noted.

The findings from their investigation were compared with those of an age- and race-equivalent population sample from the Coronary Artery Risk Development in Young Adults (CARDIA) study. The 504 football players, who were an average of approximately 30 kg heavier than the control group, represented 26% of the total number of veteran players at the time of the study.

“Despite their large size, the NFL group had lower mean fasting glucose compared with the CARDIA group, and there were no significant differences in total cholesterol, LDL-C, HDL-C, or triglycerides between the groups,” the investigators said (JAMA 2009;301:2111–9).

As has been reported previously, “high physical activity in the player group appears to have substantially mitigated the effect of large size.”

Prevalence of above-normal blood pressure did not differ significantly between black (75%) and white (82%) players. No significant link was found between players' position on the team and hypertension or prehypertension.

The athletes differed from general population in one critical respect: they were much more likely to have hypertension or prehypertension.

The combined prevalence of hypertension and prehypertension was high in all player groups, ranging from 96 of 105 (91%) in the largest players to 15 of 19 (78%) in the smallest players compared with 581 of 1,957 (30%) in the CARDIA group.

This unexpected finding has prompted an NFL-wide investigation to determine the underlying cause of players' increased blood pressure, the researchers said.

There was an array of limitations to the study, the authors noted. The limitations ranged from speculation that players may have underreported use of anti-hypertension medicines, to potential seasonal differences on blood pressure to the fact that only one automated pressure measurement was taken from the NFL group.

Smoking was self reported in both the NFL group and the CARDIA group.

The investigators disclosed no conflicts of interest.

Reliance on BMI alone as a size indicator for CVD risk may not be appropriate in NFL players who have high lean muscle mass. ©

The combination of oral dexamethasone and nebulized epinephrine appeared to reduce hospital admission, hasten discharge from the emergency department, and decrease the duration of symptoms in infants with bronchiolitis.

The researchers compared each of the drugs alone and in combination against placebo in a study of 800 infants aged 6 weeks to 1 year who presented to the ED with a first episode of bronchiolitis and signs of upper respiratory infection.

Hospitalizations for the disorder have almost doubled over the past 10–15 years in the United States and Canada, and treatment is controversial. “Bronchodilators and corticosteroids are widely used but not routinely recommended,” said Dr. Amy C. Plint of Children's Hospital of Eastern Ontario, Ottawa, and her associates.

They conducted a randomized, double-blind, clinical trial at eight Canadian pediatric emergency departments. The patients had scores of 4–15 on the respiratory distress assessment index.

The primary outcome—hospital admission within 7 days of the ED visit—occurred in only 17% of the infants who received combined dexamethasone and epinephrine, compared with 24% of those who received epinephrine only, 26% of those who received dexamethasone only, and 26% of those who received placebo only. That represents a relative risk reduction of 35% with the combined therapy, the investigators said (N. Engl. J. Med. 2009;360:2079–89).

The benefit of dexamethasone plus epinephrine was evident within 3 days of presentation, and it was not affected by the duration or severity of the illness, whether the patient proved to have respiratory syncytial virus, or whether the patient had a history of atopy.

“We also found an apparent benefit from the combined therapy on our secondary outcomes: Infants in this group were discharged earlier from medical care and resumed quiet breathing and normal feeding sooner than did those in the placebo group,” Dr. Plint and her colleagues said. “In contrast, neither dexamethasone alone nor epinephrine alone had any effect on these outcomes.”

There were no serious short-term adverse events related to treatment. However, “we do not have findings from long-term follow-up to establish whether our study treatments caused adrenal suppression, arrest of somatic growth, or neurodevelopmental delay,” as has been suggested by some researchers.

“Given the unexpected synergy we found between epinephrine and dexamethasone, and the lack of any apparent benefit when either drug is used alone, our results should be considered exploratory,” Dr. Plint and her associates noted. “Confirmation of our findings by a study powered specifically to compare combined epinephrine and dexamethasone therapy with placebo is needed.”

In an editorial comment accompanying the report, Dr. Urs Frey of the University Hospital of Bern (Switzerland) and Dr. Erika von Mutius of University Children's Hospital, Munich, said that the effect size of the treatment benefit was small.

“Given [that] 11 infants would have to be treated to prevent one hospital admission, it does not seem practical to apply [this] treatment, especially considering the potential effects of high-dose corticosteroids on brain and lung development in such young children,” they noted (N. Engl. J. Med. 2009;360:2130–1).

Instead, “it is essential during the first episode [of bronchiolitis in a preschooler] to provide supportive care—including supplemental oxygen, hydration, nutrition, and short-term bronchodilation—[but] the key intervention is close follow-up,” they said.

Dr. Frey reported receiving a travel grant from GlaxoSmithKline PLC and research support from VoluSense AS. Dr. von Mutius reported receiving consulting fees from GlaxoSmithKline, UCB SA, and ProtectImmun GmbH, lecture fees from Novartis and Alk-Scherax-Abelló Arzneimittel GmbH, and grant support from Airsonett AB. Dr. von Mutius also was named as an inventor on a pending patent for protection from allergies and inflammatory disorders.

The combination of oral dexamethasone and nebulized epinephrine appeared to reduce hospital admission, hasten discharge from the emergency department, and decrease the duration of symptoms in infants with bronchiolitis.

The researchers compared each of the drugs alone and in combination against placebo in a study of 800 infants aged 6 weeks to 1 year who presented to the ED with a first episode of bronchiolitis and signs of upper respiratory infection.

Hospitalizations for the disorder have almost doubled over the past 10–15 years in the United States and Canada, and treatment is controversial. “Bronchodilators and corticosteroids are widely used but not routinely recommended,” said Dr. Amy C. Plint of Children's Hospital of Eastern Ontario, Ottawa, and her associates.

They conducted a randomized, double-blind, clinical trial at eight Canadian pediatric emergency departments. The patients had scores of 4–15 on the respiratory distress assessment index.

The primary outcome—hospital admission within 7 days of the ED visit—occurred in only 17% of the infants who received combined dexamethasone and epinephrine, compared with 24% of those who received epinephrine only, 26% of those who received dexamethasone only, and 26% of those who received placebo only. That represents a relative risk reduction of 35% with the combined therapy, the investigators said (N. Engl. J. Med. 2009;360:2079–89).

The benefit of dexamethasone plus epinephrine was evident within 3 days of presentation, and it was not affected by the duration or severity of the illness, whether the patient proved to have respiratory syncytial virus, or whether the patient had a history of atopy.

“We also found an apparent benefit from the combined therapy on our secondary outcomes: Infants in this group were discharged earlier from medical care and resumed quiet breathing and normal feeding sooner than did those in the placebo group,” Dr. Plint and her colleagues said. “In contrast, neither dexamethasone alone nor epinephrine alone had any effect on these outcomes.”

There were no serious short-term adverse events related to treatment. However, “we do not have findings from long-term follow-up to establish whether our study treatments caused adrenal suppression, arrest of somatic growth, or neurodevelopmental delay,” as has been suggested by some researchers.

“Given the unexpected synergy we found between epinephrine and dexamethasone, and the lack of any apparent benefit when either drug is used alone, our results should be considered exploratory,” Dr. Plint and her associates noted. “Confirmation of our findings by a study powered specifically to compare combined epinephrine and dexamethasone therapy with placebo is needed.”

In an editorial comment accompanying the report, Dr. Urs Frey of the University Hospital of Bern (Switzerland) and Dr. Erika von Mutius of University Children's Hospital, Munich, said that the effect size of the treatment benefit was small.

“Given [that] 11 infants would have to be treated to prevent one hospital admission, it does not seem practical to apply [this] treatment, especially considering the potential effects of high-dose corticosteroids on brain and lung development in such young children,” they noted (N. Engl. J. Med. 2009;360:2130–1).

Instead, “it is essential during the first episode [of bronchiolitis in a preschooler] to provide supportive care—including supplemental oxygen, hydration, nutrition, and short-term bronchodilation—[but] the key intervention is close follow-up,” they said.

Dr. Frey reported receiving a travel grant from GlaxoSmithKline PLC and research support from VoluSense AS. Dr. von Mutius reported receiving consulting fees from GlaxoSmithKline, UCB SA, and ProtectImmun GmbH, lecture fees from Novartis and Alk-Scherax-Abelló Arzneimittel GmbH, and grant support from Airsonett AB. Dr. von Mutius also was named as an inventor on a pending patent for protection from allergies and inflammatory disorders.

The combination of oral dexamethasone and nebulized epinephrine appeared to reduce hospital admission, hasten discharge from the emergency department, and decrease the duration of symptoms in infants with bronchiolitis.

The researchers compared each of the drugs alone and in combination against placebo in a study of 800 infants aged 6 weeks to 1 year who presented to the ED with a first episode of bronchiolitis and signs of upper respiratory infection.

Hospitalizations for the disorder have almost doubled over the past 10–15 years in the United States and Canada, and treatment is controversial. “Bronchodilators and corticosteroids are widely used but not routinely recommended,” said Dr. Amy C. Plint of Children's Hospital of Eastern Ontario, Ottawa, and her associates.

They conducted a randomized, double-blind, clinical trial at eight Canadian pediatric emergency departments. The patients had scores of 4–15 on the respiratory distress assessment index.

The primary outcome—hospital admission within 7 days of the ED visit—occurred in only 17% of the infants who received combined dexamethasone and epinephrine, compared with 24% of those who received epinephrine only, 26% of those who received dexamethasone only, and 26% of those who received placebo only. That represents a relative risk reduction of 35% with the combined therapy, the investigators said (N. Engl. J. Med. 2009;360:2079–89).

The benefit of dexamethasone plus epinephrine was evident within 3 days of presentation, and it was not affected by the duration or severity of the illness, whether the patient proved to have respiratory syncytial virus, or whether the patient had a history of atopy.

“We also found an apparent benefit from the combined therapy on our secondary outcomes: Infants in this group were discharged earlier from medical care and resumed quiet breathing and normal feeding sooner than did those in the placebo group,” Dr. Plint and her colleagues said. “In contrast, neither dexamethasone alone nor epinephrine alone had any effect on these outcomes.”

There were no serious short-term adverse events related to treatment. However, “we do not have findings from long-term follow-up to establish whether our study treatments caused adrenal suppression, arrest of somatic growth, or neurodevelopmental delay,” as has been suggested by some researchers.

“Given the unexpected synergy we found between epinephrine and dexamethasone, and the lack of any apparent benefit when either drug is used alone, our results should be considered exploratory,” Dr. Plint and her associates noted. “Confirmation of our findings by a study powered specifically to compare combined epinephrine and dexamethasone therapy with placebo is needed.”

In an editorial comment accompanying the report, Dr. Urs Frey of the University Hospital of Bern (Switzerland) and Dr. Erika von Mutius of University Children's Hospital, Munich, said that the effect size of the treatment benefit was small.

“Given [that] 11 infants would have to be treated to prevent one hospital admission, it does not seem practical to apply [this] treatment, especially considering the potential effects of high-dose corticosteroids on brain and lung development in such young children,” they noted (N. Engl. J. Med. 2009;360:2130–1).

Instead, “it is essential during the first episode [of bronchiolitis in a preschooler] to provide supportive care—including supplemental oxygen, hydration, nutrition, and short-term bronchodilation—[but] the key intervention is close follow-up,” they said.

Dr. Frey reported receiving a travel grant from GlaxoSmithKline PLC and research support from VoluSense AS. Dr. von Mutius reported receiving consulting fees from GlaxoSmithKline, UCB SA, and ProtectImmun GmbH, lecture fees from Novartis and Alk-Scherax-Abelló Arzneimittel GmbH, and grant support from Airsonett AB. Dr. von Mutius also was named as an inventor on a pending patent for protection from allergies and inflammatory disorders.

A home-based diet and exercise program reduced the rate of functional decline in a study of more than 600 overweight and older cancer survivors, according to a trial involving more than 600 people.

Even modest lifestyle changes elicited by the program produced clinically meaningful improvements in physical function and health-related quality of life for patients who were 5 years or more beyond their cancer diagnosis, said Miriam C. Morey, Ph.D., of Duke University's Center for the Study of Aging and Human Development, Durham, N.C., and her associates.

The researchers conducted a clinical trial in which 319 subjects were randomly assigned to the diet and exercise intervention and 322 were assigned to a control group with no intervention. The study participants were long-term survivors of breast, prostate, and colorectal cancer with no evidence of progressive disease and no additional cancers.

The 1-year intervention was conducted using telephone counseling and materials delivered by mail to the subjects' homes in 21 U.S. states, Canada, and the United Kingdom. The program included a workbook tailored to each participant's needs, with recommendations for strength training (15 minutes daily), endurance training (30 minutes daily), increased intake of fruit and vegetables, restriction of saturated fat, and a goal of a 10% weight loss by the end of the program. It also provided subjects with pedometers, exercise bands for resistance training, guides for exercising and food portioning, and record logs for self-monitoring (JAMA 2009;301:1883–91)

Counseling was conducted during 15 telephone counseling sessions, each 15- to 30-minutes long. There were also eight automated telephone calls during the 12-month period, and participants received quarterly newsletters tailored for each individual to depict his or her progress. There were 50 dropouts in the intervention group and 33 in the control group.

After 1 year, global physical function declined half as much in the intervention group as in the controls—by 2.15 points on the Short-Form 36 physical function subscale in the intervention group and 4.84 points in the controls. A 2-point decline on this scale “is considered too small to be clinically detectable,” while a 6-point decline is associated with higher mortality, said Dr. Morey and her colleagues, who reported no conflicts of interest. Health-related quality of life decreased in every subscale among the controls, but decreases were of lower magnitude in the intervention group.

The proportion of subjects who met recommendations for strength training was 28% with the intervention, compared with 11% among controls. A mean of 15% of the intervention group and 11% of the control group met recommendations for endurance exercise.

Sixteen percent of the intervention group met guidelines for fruit and vegetable intake, compared with 4% of the control group. And the intervention group reported a mean weight loss of 2.06 kg, compared with 0.92 kg for the control group.

A home-based diet and exercise program reduced the rate of functional decline in a study of more than 600 overweight and older cancer survivors, according to a trial involving more than 600 people.

Even modest lifestyle changes elicited by the program produced clinically meaningful improvements in physical function and health-related quality of life for patients who were 5 years or more beyond their cancer diagnosis, said Miriam C. Morey, Ph.D., of Duke University's Center for the Study of Aging and Human Development, Durham, N.C., and her associates.

The researchers conducted a clinical trial in which 319 subjects were randomly assigned to the diet and exercise intervention and 322 were assigned to a control group with no intervention. The study participants were long-term survivors of breast, prostate, and colorectal cancer with no evidence of progressive disease and no additional cancers.

The 1-year intervention was conducted using telephone counseling and materials delivered by mail to the subjects' homes in 21 U.S. states, Canada, and the United Kingdom. The program included a workbook tailored to each participant's needs, with recommendations for strength training (15 minutes daily), endurance training (30 minutes daily), increased intake of fruit and vegetables, restriction of saturated fat, and a goal of a 10% weight loss by the end of the program. It also provided subjects with pedometers, exercise bands for resistance training, guides for exercising and food portioning, and record logs for self-monitoring (JAMA 2009;301:1883–91)

Counseling was conducted during 15 telephone counseling sessions, each 15- to 30-minutes long. There were also eight automated telephone calls during the 12-month period, and participants received quarterly newsletters tailored for each individual to depict his or her progress. There were 50 dropouts in the intervention group and 33 in the control group.

After 1 year, global physical function declined half as much in the intervention group as in the controls—by 2.15 points on the Short-Form 36 physical function subscale in the intervention group and 4.84 points in the controls. A 2-point decline on this scale “is considered too small to be clinically detectable,” while a 6-point decline is associated with higher mortality, said Dr. Morey and her colleagues, who reported no conflicts of interest. Health-related quality of life decreased in every subscale among the controls, but decreases were of lower magnitude in the intervention group.

The proportion of subjects who met recommendations for strength training was 28% with the intervention, compared with 11% among controls. A mean of 15% of the intervention group and 11% of the control group met recommendations for endurance exercise.

Sixteen percent of the intervention group met guidelines for fruit and vegetable intake, compared with 4% of the control group. And the intervention group reported a mean weight loss of 2.06 kg, compared with 0.92 kg for the control group.

A home-based diet and exercise program reduced the rate of functional decline in a study of more than 600 overweight and older cancer survivors, according to a trial involving more than 600 people.

Even modest lifestyle changes elicited by the program produced clinically meaningful improvements in physical function and health-related quality of life for patients who were 5 years or more beyond their cancer diagnosis, said Miriam C. Morey, Ph.D., of Duke University's Center for the Study of Aging and Human Development, Durham, N.C., and her associates.

The researchers conducted a clinical trial in which 319 subjects were randomly assigned to the diet and exercise intervention and 322 were assigned to a control group with no intervention. The study participants were long-term survivors of breast, prostate, and colorectal cancer with no evidence of progressive disease and no additional cancers.

The 1-year intervention was conducted using telephone counseling and materials delivered by mail to the subjects' homes in 21 U.S. states, Canada, and the United Kingdom. The program included a workbook tailored to each participant's needs, with recommendations for strength training (15 minutes daily), endurance training (30 minutes daily), increased intake of fruit and vegetables, restriction of saturated fat, and a goal of a 10% weight loss by the end of the program. It also provided subjects with pedometers, exercise bands for resistance training, guides for exercising and food portioning, and record logs for self-monitoring (JAMA 2009;301:1883–91)

Counseling was conducted during 15 telephone counseling sessions, each 15- to 30-minutes long. There were also eight automated telephone calls during the 12-month period, and participants received quarterly newsletters tailored for each individual to depict his or her progress. There were 50 dropouts in the intervention group and 33 in the control group.

After 1 year, global physical function declined half as much in the intervention group as in the controls—by 2.15 points on the Short-Form 36 physical function subscale in the intervention group and 4.84 points in the controls. A 2-point decline on this scale “is considered too small to be clinically detectable,” while a 6-point decline is associated with higher mortality, said Dr. Morey and her colleagues, who reported no conflicts of interest. Health-related quality of life decreased in every subscale among the controls, but decreases were of lower magnitude in the intervention group.

The proportion of subjects who met recommendations for strength training was 28% with the intervention, compared with 11% among controls. A mean of 15% of the intervention group and 11% of the control group met recommendations for endurance exercise.

Sixteen percent of the intervention group met guidelines for fruit and vegetable intake, compared with 4% of the control group. And the intervention group reported a mean weight loss of 2.06 kg, compared with 0.92 kg for the control group.

Adolescents who own alcohol-branded merchandise appear more likely to begin drinking and to progress to binge drinking than those who do not, according to a study of more than 6,000 youth.

The researchers described their study as “the first… to examine the longitudinal relationship between [alcohol-branded merchandise] ownership, attitudinal susceptibility, and measures of alcohol use in a multiple-wave study that includes binge drinking as an outcome.” The results “clearly demonstrate that alcohol-branded merchandise ownership is more than a simple marker of an adolescent with favorable attitudes toward alcohol use,” said Dr. Auden C. McClure of the department of pediatrics, Dartmouth Medical School, Hanover, N.H., and associates.

The researchers also found that more than 3 million adolescents across the country own such merchandise–chiefly T-shirts, jackets, hats, and headbands produced predominantly by large beer companies. Teens can buy the items directly at several national chain stores and at mall or beach outlets, as well as be given items by friends and family members.

Dr. McClure and colleagues surveyed 6,522 U.S. teens aged 10-14 years in 2003 concerning health behaviors and media influences. The subjects were reassessed every 8 months for 2 years; the primary behavioral outcomes studied were the transition from never drinking to trying alcohol and the transition from never binge drinking to binge drinking.

The prevalence of owning alcohol-branded merchandise ranged from 11% at 8 months to 20% at 24 months, “which extrapolates to 2.1 to 3.1 million U.S. adolescents.” Most subjects owned branded clothing such as T-shirts and jackets (64%) or headwear (24%), but there also was a wide array of other branded items such as jewelry, key chains, shot glasses, posters, and pens. These adolescents were able to recall the specific alcohol brand on the items in 92% of cases.

A total of 82% of the brands were beer brands, 18% were distilled alcohol brands, and less than 1% were wine brands. A total of 71% of the subjects said the item was a gift from a family member or friend, 24% said they had bought it themselves, and the remainder said they had found the item, won it, or gotten it free as a giveaway at an event.

Ownership of alcohol-branded items led to initiation of alcohol use as well as to initiation of binge drinking, independently of several known social, personality, and environmental risk factors for alcohol use, Dr. McClure and associates said (Arch. Ped. Adoles. Med. 2009;163:211-7).

Owning alcohol-branded merchandise prompted a favorable attitude toward drinking and was associated with exposure to drinking in movies, peer drinking, and personality traits such as sensation seeking and rebelliousness. It was not related to parenting style or parental alcohol use, but was linked with the teen's ability to obtain alcohol in the home, which “suggests that alcohol-specific parenting practices may influence ownership” of branded merchandise and subsequent drinking behavior.

Owning alcohol-branded merchandise was not associated with academic performance, parental education level, household income, or television viewing.

In an editorial comment accompanying this report, David H. Jernigan, Ph.D. of Johns Hopkins Bloomberg School of Public Health, Baltimore, noted that a nationwide ban on apparel or other merchandise bearing tobacco brand names was instituted when research demonstrated that such merchandising promoted youth smoking. But no such ban is yet in place for alcohol-branded merchandise–though most states have the power to enact such bans, he said (Arch. Ped. Adoles. Med. 2009;163:278-9).

Dr. Jernigan also said that this “important new evidence… points to an urgent need for action.

“Political will is needed both to improve data collection and reporting and to move toward restrictions that will give people a chance to grow up alcohol free,” Dr. Jernigan wrote, adding that the current study provides important new evidence that points to an urgent need for action.”

Adolescents who own alcohol-branded merchandise appear more likely to begin drinking and to progress to binge drinking than those who do not, according to a study of more than 6,000 youth.

The researchers described their study as “the first… to examine the longitudinal relationship between [alcohol-branded merchandise] ownership, attitudinal susceptibility, and measures of alcohol use in a multiple-wave study that includes binge drinking as an outcome.” The results “clearly demonstrate that alcohol-branded merchandise ownership is more than a simple marker of an adolescent with favorable attitudes toward alcohol use,” said Dr. Auden C. McClure of the department of pediatrics, Dartmouth Medical School, Hanover, N.H., and associates.

The researchers also found that more than 3 million adolescents across the country own such merchandise–chiefly T-shirts, jackets, hats, and headbands produced predominantly by large beer companies. Teens can buy the items directly at several national chain stores and at mall or beach outlets, as well as be given items by friends and family members.

Dr. McClure and colleagues surveyed 6,522 U.S. teens aged 10-14 years in 2003 concerning health behaviors and media influences. The subjects were reassessed every 8 months for 2 years; the primary behavioral outcomes studied were the transition from never drinking to trying alcohol and the transition from never binge drinking to binge drinking.

The prevalence of owning alcohol-branded merchandise ranged from 11% at 8 months to 20% at 24 months, “which extrapolates to 2.1 to 3.1 million U.S. adolescents.” Most subjects owned branded clothing such as T-shirts and jackets (64%) or headwear (24%), but there also was a wide array of other branded items such as jewelry, key chains, shot glasses, posters, and pens. These adolescents were able to recall the specific alcohol brand on the items in 92% of cases.

A total of 82% of the brands were beer brands, 18% were distilled alcohol brands, and less than 1% were wine brands. A total of 71% of the subjects said the item was a gift from a family member or friend, 24% said they had bought it themselves, and the remainder said they had found the item, won it, or gotten it free as a giveaway at an event.

Ownership of alcohol-branded items led to initiation of alcohol use as well as to initiation of binge drinking, independently of several known social, personality, and environmental risk factors for alcohol use, Dr. McClure and associates said (Arch. Ped. Adoles. Med. 2009;163:211-7).

Owning alcohol-branded merchandise prompted a favorable attitude toward drinking and was associated with exposure to drinking in movies, peer drinking, and personality traits such as sensation seeking and rebelliousness. It was not related to parenting style or parental alcohol use, but was linked with the teen's ability to obtain alcohol in the home, which “suggests that alcohol-specific parenting practices may influence ownership” of branded merchandise and subsequent drinking behavior.

Owning alcohol-branded merchandise was not associated with academic performance, parental education level, household income, or television viewing.

In an editorial comment accompanying this report, David H. Jernigan, Ph.D. of Johns Hopkins Bloomberg School of Public Health, Baltimore, noted that a nationwide ban on apparel or other merchandise bearing tobacco brand names was instituted when research demonstrated that such merchandising promoted youth smoking. But no such ban is yet in place for alcohol-branded merchandise–though most states have the power to enact such bans, he said (Arch. Ped. Adoles. Med. 2009;163:278-9).

Dr. Jernigan also said that this “important new evidence… points to an urgent need for action.

“Political will is needed both to improve data collection and reporting and to move toward restrictions that will give people a chance to grow up alcohol free,” Dr. Jernigan wrote, adding that the current study provides important new evidence that points to an urgent need for action.”

Adolescents who own alcohol-branded merchandise appear more likely to begin drinking and to progress to binge drinking than those who do not, according to a study of more than 6,000 youth.

The researchers described their study as “the first… to examine the longitudinal relationship between [alcohol-branded merchandise] ownership, attitudinal susceptibility, and measures of alcohol use in a multiple-wave study that includes binge drinking as an outcome.” The results “clearly demonstrate that alcohol-branded merchandise ownership is more than a simple marker of an adolescent with favorable attitudes toward alcohol use,” said Dr. Auden C. McClure of the department of pediatrics, Dartmouth Medical School, Hanover, N.H., and associates.

The researchers also found that more than 3 million adolescents across the country own such merchandise–chiefly T-shirts, jackets, hats, and headbands produced predominantly by large beer companies. Teens can buy the items directly at several national chain stores and at mall or beach outlets, as well as be given items by friends and family members.

Dr. McClure and colleagues surveyed 6,522 U.S. teens aged 10-14 years in 2003 concerning health behaviors and media influences. The subjects were reassessed every 8 months for 2 years; the primary behavioral outcomes studied were the transition from never drinking to trying alcohol and the transition from never binge drinking to binge drinking.

The prevalence of owning alcohol-branded merchandise ranged from 11% at 8 months to 20% at 24 months, “which extrapolates to 2.1 to 3.1 million U.S. adolescents.” Most subjects owned branded clothing such as T-shirts and jackets (64%) or headwear (24%), but there also was a wide array of other branded items such as jewelry, key chains, shot glasses, posters, and pens. These adolescents were able to recall the specific alcohol brand on the items in 92% of cases.

A total of 82% of the brands were beer brands, 18% were distilled alcohol brands, and less than 1% were wine brands. A total of 71% of the subjects said the item was a gift from a family member or friend, 24% said they had bought it themselves, and the remainder said they had found the item, won it, or gotten it free as a giveaway at an event.

Ownership of alcohol-branded items led to initiation of alcohol use as well as to initiation of binge drinking, independently of several known social, personality, and environmental risk factors for alcohol use, Dr. McClure and associates said (Arch. Ped. Adoles. Med. 2009;163:211-7).

Owning alcohol-branded merchandise prompted a favorable attitude toward drinking and was associated with exposure to drinking in movies, peer drinking, and personality traits such as sensation seeking and rebelliousness. It was not related to parenting style or parental alcohol use, but was linked with the teen's ability to obtain alcohol in the home, which “suggests that alcohol-specific parenting practices may influence ownership” of branded merchandise and subsequent drinking behavior.

Owning alcohol-branded merchandise was not associated with academic performance, parental education level, household income, or television viewing.

In an editorial comment accompanying this report, David H. Jernigan, Ph.D. of Johns Hopkins Bloomberg School of Public Health, Baltimore, noted that a nationwide ban on apparel or other merchandise bearing tobacco brand names was instituted when research demonstrated that such merchandising promoted youth smoking. But no such ban is yet in place for alcohol-branded merchandise–though most states have the power to enact such bans, he said (Arch. Ped. Adoles. Med. 2009;163:278-9).

Dr. Jernigan also said that this “important new evidence… points to an urgent need for action.

“Political will is needed both to improve data collection and reporting and to move toward restrictions that will give people a chance to grow up alcohol free,” Dr. Jernigan wrote, adding that the current study provides important new evidence that points to an urgent need for action.”

Brown adipose tissue is present in adults and appears to play an active role in metabolism, rather than being vestigial and without physiologic purpose, according to three reports.

Both the presence and the activity of reservoirs of brown adipose tissue seem to be inversely associated with overall adiposity and with measures of the metabolic syndrome, the three studies' investigators said.

“These studies … are a powerful proof of concept that this tissue might be used as a target for interventions, pharmacologic and environmental, aimed at modulating energy expenditure,” Dr. Francesco S. Celi of the National Institute of Diabetes and Digestive and Kidney Diseases said in an accompanying editorial (N. Engl. J. Med. 2009;360:1553-6).

Brown adipose tissue helps newborns maintain body temperature but has been thought to regress with age until it is all but lost in adulthood. It was thought to have marginal physiological relevance after infancy. But recent studies using combined PET and CT techniques have suggested that pockets of brown adipose tissue are present in some adults and may be metabolically active in response to cold exposure.

In the first report, Dr. Kirsi A. Virtanen of the University of Turku, Finland, and associates scanned and sampled tissue from putative adipose pockets in five healthy volunteers using PET-CT scanning after cold provocation. Previous research had identified the supraclavicular area as the most prominent site for deposits of brown adipose cells.

Glucose uptake in these pockets increased by a factor of 15 upon exposure to cold, compared with glucose uptake in adjacent white adipose tissue. The pockets of fat also expressed several markers of brown, but not white, adipose tissue, and the biopsy samples showed multilocular, intracellular lipid droplets characteristic of brown fat.

“These findings constitute direct identification of functional human brown adipose tissue,” the researchers said. “We speculate that in humans, activated brown adipose tissue has the potential to contribute substantially to energy expenditure,” they added (N. Engl. J. Med. 2009;360:1518-25).

In the second study, Dr. Aaron M. Cypess of the Joslin Diabetes Center, Boston, and associates analyzed PET-CT images from 1,972 patients who had undergone whole-body scanning for a variety of diagnostic reasons in 2003-2006. They focused on the supraclavicular region after finding that brown adipose tissue had been present in samples from 34 previous patients who had undergone neck surgery for different indications.

They found substantial pockets of brown adipose tissue in 7.5 % of women and 3.1% of men, but noted that this likely underestimates the actual prevalence in the general population because the tissue was not being stimulated by exposure to cold at the time of scanning in these subjects (N. Engl. J. Med. 2009;360:1509-17).

Dr. Cypess and his colleagues found an inverse correlation between the metabolic activity of brown adipose tissue and subject age, body mass index, and fasting plasma glucose level.

In the third report, Wouter D. van Marken Lichtenbelt, Ph.D., and associates at Maastricht (the Netherlands) University Medical Center used PET-CT to assess cold-stimulated activity of brown adipose tissue in relation to metabolic measures in 24 healthy men. Ten of the men were lean and 14 were overweight or obese.

Brown adipose tissue was present in all but the most obese of these men, a 95% rate that is much higher than has previously been reported. The tissue's activity, measured by energy expenditure at rest and core vs. surface body temperatures, correlated inversely with BMI and percentage of body fat.

Dr. Cypess reported receiving grant support from the Eli Lilly Foundation and being the sole inventor on a pending patent application to use infrared thermography to monitor brown adipose tissue. His study was supported in part by Pfizer, Merck, and the Eli Lilly Foundation. No conflicts of interests were reported by the other researchers.

Brown adipose tissue is present in adults and appears to play an active role in metabolism, rather than being vestigial and without physiologic purpose, according to three reports.

Both the presence and the activity of reservoirs of brown adipose tissue seem to be inversely associated with overall adiposity and with measures of the metabolic syndrome, the three studies' investigators said.

“These studies … are a powerful proof of concept that this tissue might be used as a target for interventions, pharmacologic and environmental, aimed at modulating energy expenditure,” Dr. Francesco S. Celi of the National Institute of Diabetes and Digestive and Kidney Diseases said in an accompanying editorial (N. Engl. J. Med. 2009;360:1553-6).

Brown adipose tissue helps newborns maintain body temperature but has been thought to regress with age until it is all but lost in adulthood. It was thought to have marginal physiological relevance after infancy. But recent studies using combined PET and CT techniques have suggested that pockets of brown adipose tissue are present in some adults and may be metabolically active in response to cold exposure.

In the first report, Dr. Kirsi A. Virtanen of the University of Turku, Finland, and associates scanned and sampled tissue from putative adipose pockets in five healthy volunteers using PET-CT scanning after cold provocation. Previous research had identified the supraclavicular area as the most prominent site for deposits of brown adipose cells.

Glucose uptake in these pockets increased by a factor of 15 upon exposure to cold, compared with glucose uptake in adjacent white adipose tissue. The pockets of fat also expressed several markers of brown, but not white, adipose tissue, and the biopsy samples showed multilocular, intracellular lipid droplets characteristic of brown fat.

“These findings constitute direct identification of functional human brown adipose tissue,” the researchers said. “We speculate that in humans, activated brown adipose tissue has the potential to contribute substantially to energy expenditure,” they added (N. Engl. J. Med. 2009;360:1518-25).

In the second study, Dr. Aaron M. Cypess of the Joslin Diabetes Center, Boston, and associates analyzed PET-CT images from 1,972 patients who had undergone whole-body scanning for a variety of diagnostic reasons in 2003-2006. They focused on the supraclavicular region after finding that brown adipose tissue had been present in samples from 34 previous patients who had undergone neck surgery for different indications.

They found substantial pockets of brown adipose tissue in 7.5 % of women and 3.1% of men, but noted that this likely underestimates the actual prevalence in the general population because the tissue was not being stimulated by exposure to cold at the time of scanning in these subjects (N. Engl. J. Med. 2009;360:1509-17).

Dr. Cypess and his colleagues found an inverse correlation between the metabolic activity of brown adipose tissue and subject age, body mass index, and fasting plasma glucose level.

In the third report, Wouter D. van Marken Lichtenbelt, Ph.D., and associates at Maastricht (the Netherlands) University Medical Center used PET-CT to assess cold-stimulated activity of brown adipose tissue in relation to metabolic measures in 24 healthy men. Ten of the men were lean and 14 were overweight or obese.

Brown adipose tissue was present in all but the most obese of these men, a 95% rate that is much higher than has previously been reported. The tissue's activity, measured by energy expenditure at rest and core vs. surface body temperatures, correlated inversely with BMI and percentage of body fat.

Dr. Cypess reported receiving grant support from the Eli Lilly Foundation and being the sole inventor on a pending patent application to use infrared thermography to monitor brown adipose tissue. His study was supported in part by Pfizer, Merck, and the Eli Lilly Foundation. No conflicts of interests were reported by the other researchers.

Brown adipose tissue is present in adults and appears to play an active role in metabolism, rather than being vestigial and without physiologic purpose, according to three reports.

Both the presence and the activity of reservoirs of brown adipose tissue seem to be inversely associated with overall adiposity and with measures of the metabolic syndrome, the three studies' investigators said.

“These studies … are a powerful proof of concept that this tissue might be used as a target for interventions, pharmacologic and environmental, aimed at modulating energy expenditure,” Dr. Francesco S. Celi of the National Institute of Diabetes and Digestive and Kidney Diseases said in an accompanying editorial (N. Engl. J. Med. 2009;360:1553-6).

Brown adipose tissue helps newborns maintain body temperature but has been thought to regress with age until it is all but lost in adulthood. It was thought to have marginal physiological relevance after infancy. But recent studies using combined PET and CT techniques have suggested that pockets of brown adipose tissue are present in some adults and may be metabolically active in response to cold exposure.

In the first report, Dr. Kirsi A. Virtanen of the University of Turku, Finland, and associates scanned and sampled tissue from putative adipose pockets in five healthy volunteers using PET-CT scanning after cold provocation. Previous research had identified the supraclavicular area as the most prominent site for deposits of brown adipose cells.

Glucose uptake in these pockets increased by a factor of 15 upon exposure to cold, compared with glucose uptake in adjacent white adipose tissue. The pockets of fat also expressed several markers of brown, but not white, adipose tissue, and the biopsy samples showed multilocular, intracellular lipid droplets characteristic of brown fat.

“These findings constitute direct identification of functional human brown adipose tissue,” the researchers said. “We speculate that in humans, activated brown adipose tissue has the potential to contribute substantially to energy expenditure,” they added (N. Engl. J. Med. 2009;360:1518-25).

In the second study, Dr. Aaron M. Cypess of the Joslin Diabetes Center, Boston, and associates analyzed PET-CT images from 1,972 patients who had undergone whole-body scanning for a variety of diagnostic reasons in 2003-2006. They focused on the supraclavicular region after finding that brown adipose tissue had been present in samples from 34 previous patients who had undergone neck surgery for different indications.

They found substantial pockets of brown adipose tissue in 7.5 % of women and 3.1% of men, but noted that this likely underestimates the actual prevalence in the general population because the tissue was not being stimulated by exposure to cold at the time of scanning in these subjects (N. Engl. J. Med. 2009;360:1509-17).

Dr. Cypess and his colleagues found an inverse correlation between the metabolic activity of brown adipose tissue and subject age, body mass index, and fasting plasma glucose level.

In the third report, Wouter D. van Marken Lichtenbelt, Ph.D., and associates at Maastricht (the Netherlands) University Medical Center used PET-CT to assess cold-stimulated activity of brown adipose tissue in relation to metabolic measures in 24 healthy men. Ten of the men were lean and 14 were overweight or obese.

Brown adipose tissue was present in all but the most obese of these men, a 95% rate that is much higher than has previously been reported. The tissue's activity, measured by energy expenditure at rest and core vs. surface body temperatures, correlated inversely with BMI and percentage of body fat.

Dr. Cypess reported receiving grant support from the Eli Lilly Foundation and being the sole inventor on a pending patent application to use infrared thermography to monitor brown adipose tissue. His study was supported in part by Pfizer, Merck, and the Eli Lilly Foundation. No conflicts of interests were reported by the other researchers.

A large maternity hospital markedly decreased its excessive rate of labor inductions simply by strictly enforcing American College of Obstetricians and Gynecologists's recommendations for averting inappropriate inductions.

By requiring physicians to justify ordering elective labor inductions that might be deemed inappropriate, the hospital cut the overall rate of inductions by one-third, decreased the rate of inductions performed before 39 weeks by 64%, and reduced the rate of cesarean delivery among nulliparas undergoing induction by 60%, reported Dr. John M. Fisch and his associates at Magee-Womens Hospital (Obstet. Gynecol. 2009;113:797–803).

ACOG 2004 guidelines permit elective inductions only after 39 weeks, advise that the procedure be done in nulliparas only if the Bishop score is 8 or more (and in multiparas only if the Bishop score is 6 or more), and do not allow the use of cervical ripening. These guidelines were immediately implemented at Magee-Womens Hospital, a tertiary care center with 36 ob.gyn. residents and more than 100 practicing physicians caring for both clinic and private patients.

However, an audit of actual practice there between 2004 and 2005 showed little adherence to the guidelines and minimal improvement in the “unacceptably high” rate of inductions (28% in 2003).

The hospital then began a program to enforce the recommendations. The process for scheduling an induction was computerized, allowing data on all inductions to be monitored easily. This allowed program overseers to track individual physician patterns of delivery, and to discover that some physicians induced more than 30% of their deliveries while others did not induce at all.

The number of induction slots was reduced from 13 to 8, and staff in charge of scheduling inductions were instructed to remind physicians to adhere to ACOG's induction guidelines if they were not doing so. These staff also were empowered to involve the nurse manager or the medical director of the birth center in any inductions that did not meet ACOG criteria.

An audit form was attached to the front of the chart of every patient who presented to the labor and delivery unit for induction, and information such as gestational age, stated reasons for induction, attending physician, parity, Bishop score, and delivery outcomes was tracked.

Inductions that went forward even though they did not meet the criteria were reviewed by a multidisciplinary team each month and discussed with the attending physician. Peer review was performed, and letters sent from the vice president of medical affairs were included in the physicians' permanent recredentialing files.

With this enforcement, the overall induction rate decreased from 25% in 2004 to 17% in 2007. The rate of inductions at less than 39 weeks fell from 12% to 4%, and the rate of cesarean deliveries among nulliparas who had been induced dropped from 35% to 14%.

“Initial reaction to the guidelines ranged from skeptical to hostile, as physicians objected to oversight of their medical decision making,” Dr. Fisch and his colleagues noted.

The hospital sidestepped much of this resistance by presenting this program not as an effort to reduce inductions but as an effort to improve maternal and fetal outcomes by adhering to ACOG standards. Also, “due to the sensitive nature of altering physician practice patterns within such a large group of practitioners,” the task force that implemented the program was carefully chosen and included stakeholders from several disciplines.

Other obstacles were overcome by negotiation. For example, physicians initially resisted cooperating with the induction scheduler, who reminded them of the ACOG recommendations whenever they attempted to schedule an induction and brought in the director of the nursing unit or, if necessary, the medical director of the birth center. “This process evolved over time to the point where an attending will go directly to the medical director if they feel that approval will be needed to schedule an induction,” the researchers noted.

“A major strength of this study is its applicability for use at other institutions faced with an unacceptably high induction rate. … This article provides a blueprint for the development and implementation of a program” to reduce the risks associated with labor induction, which include infection, cesarean delivery, and neonatal ICU admission.

Noting that women who have induced labor spend more time in the hospital and incur greater costs for care than do those with spontaneous labor, Dr. Fisch and his associates calculated that their program has likely averted 71 unnecessary inductions and 5 unnecessary cesarean births per month.

“This accounts for 284 more hours in the hospital and a cost of $29,235 more per month,” which “translates into a total cost savings of 3,408 hours and $350,820 per year,” they said.

The investigators added that in the future, “individual provider induction rates may be monitored and evaluated, especially if the induction rates and subsequent cesarean birth rates are excessive.”

A large maternity hospital markedly decreased its excessive rate of labor inductions simply by strictly enforcing American College of Obstetricians and Gynecologists's recommendations for averting inappropriate inductions.

By requiring physicians to justify ordering elective labor inductions that might be deemed inappropriate, the hospital cut the overall rate of inductions by one-third, decreased the rate of inductions performed before 39 weeks by 64%, and reduced the rate of cesarean delivery among nulliparas undergoing induction by 60%, reported Dr. John M. Fisch and his associates at Magee-Womens Hospital (Obstet. Gynecol. 2009;113:797–803).

ACOG 2004 guidelines permit elective inductions only after 39 weeks, advise that the procedure be done in nulliparas only if the Bishop score is 8 or more (and in multiparas only if the Bishop score is 6 or more), and do not allow the use of cervical ripening. These guidelines were immediately implemented at Magee-Womens Hospital, a tertiary care center with 36 ob.gyn. residents and more than 100 practicing physicians caring for both clinic and private patients.

However, an audit of actual practice there between 2004 and 2005 showed little adherence to the guidelines and minimal improvement in the “unacceptably high” rate of inductions (28% in 2003).

The hospital then began a program to enforce the recommendations. The process for scheduling an induction was computerized, allowing data on all inductions to be monitored easily. This allowed program overseers to track individual physician patterns of delivery, and to discover that some physicians induced more than 30% of their deliveries while others did not induce at all.

The number of induction slots was reduced from 13 to 8, and staff in charge of scheduling inductions were instructed to remind physicians to adhere to ACOG's induction guidelines if they were not doing so. These staff also were empowered to involve the nurse manager or the medical director of the birth center in any inductions that did not meet ACOG criteria.

An audit form was attached to the front of the chart of every patient who presented to the labor and delivery unit for induction, and information such as gestational age, stated reasons for induction, attending physician, parity, Bishop score, and delivery outcomes was tracked.

Inductions that went forward even though they did not meet the criteria were reviewed by a multidisciplinary team each month and discussed with the attending physician. Peer review was performed, and letters sent from the vice president of medical affairs were included in the physicians' permanent recredentialing files.

With this enforcement, the overall induction rate decreased from 25% in 2004 to 17% in 2007. The rate of inductions at less than 39 weeks fell from 12% to 4%, and the rate of cesarean deliveries among nulliparas who had been induced dropped from 35% to 14%.

“Initial reaction to the guidelines ranged from skeptical to hostile, as physicians objected to oversight of their medical decision making,” Dr. Fisch and his colleagues noted.

The hospital sidestepped much of this resistance by presenting this program not as an effort to reduce inductions but as an effort to improve maternal and fetal outcomes by adhering to ACOG standards. Also, “due to the sensitive nature of altering physician practice patterns within such a large group of practitioners,” the task force that implemented the program was carefully chosen and included stakeholders from several disciplines.

Other obstacles were overcome by negotiation. For example, physicians initially resisted cooperating with the induction scheduler, who reminded them of the ACOG recommendations whenever they attempted to schedule an induction and brought in the director of the nursing unit or, if necessary, the medical director of the birth center. “This process evolved over time to the point where an attending will go directly to the medical director if they feel that approval will be needed to schedule an induction,” the researchers noted.

“A major strength of this study is its applicability for use at other institutions faced with an unacceptably high induction rate. … This article provides a blueprint for the development and implementation of a program” to reduce the risks associated with labor induction, which include infection, cesarean delivery, and neonatal ICU admission.

Noting that women who have induced labor spend more time in the hospital and incur greater costs for care than do those with spontaneous labor, Dr. Fisch and his associates calculated that their program has likely averted 71 unnecessary inductions and 5 unnecessary cesarean births per month.

“This accounts for 284 more hours in the hospital and a cost of $29,235 more per month,” which “translates into a total cost savings of 3,408 hours and $350,820 per year,” they said.

The investigators added that in the future, “individual provider induction rates may be monitored and evaluated, especially if the induction rates and subsequent cesarean birth rates are excessive.”

A large maternity hospital markedly decreased its excessive rate of labor inductions simply by strictly enforcing American College of Obstetricians and Gynecologists's recommendations for averting inappropriate inductions.

By requiring physicians to justify ordering elective labor inductions that might be deemed inappropriate, the hospital cut the overall rate of inductions by one-third, decreased the rate of inductions performed before 39 weeks by 64%, and reduced the rate of cesarean delivery among nulliparas undergoing induction by 60%, reported Dr. John M. Fisch and his associates at Magee-Womens Hospital (Obstet. Gynecol. 2009;113:797–803).

ACOG 2004 guidelines permit elective inductions only after 39 weeks, advise that the procedure be done in nulliparas only if the Bishop score is 8 or more (and in multiparas only if the Bishop score is 6 or more), and do not allow the use of cervical ripening. These guidelines were immediately implemented at Magee-Womens Hospital, a tertiary care center with 36 ob.gyn. residents and more than 100 practicing physicians caring for both clinic and private patients.

However, an audit of actual practice there between 2004 and 2005 showed little adherence to the guidelines and minimal improvement in the “unacceptably high” rate of inductions (28% in 2003).

The hospital then began a program to enforce the recommendations. The process for scheduling an induction was computerized, allowing data on all inductions to be monitored easily. This allowed program overseers to track individual physician patterns of delivery, and to discover that some physicians induced more than 30% of their deliveries while others did not induce at all.

The number of induction slots was reduced from 13 to 8, and staff in charge of scheduling inductions were instructed to remind physicians to adhere to ACOG's induction guidelines if they were not doing so. These staff also were empowered to involve the nurse manager or the medical director of the birth center in any inductions that did not meet ACOG criteria.

An audit form was attached to the front of the chart of every patient who presented to the labor and delivery unit for induction, and information such as gestational age, stated reasons for induction, attending physician, parity, Bishop score, and delivery outcomes was tracked.

Inductions that went forward even though they did not meet the criteria were reviewed by a multidisciplinary team each month and discussed with the attending physician. Peer review was performed, and letters sent from the vice president of medical affairs were included in the physicians' permanent recredentialing files.

With this enforcement, the overall induction rate decreased from 25% in 2004 to 17% in 2007. The rate of inductions at less than 39 weeks fell from 12% to 4%, and the rate of cesarean deliveries among nulliparas who had been induced dropped from 35% to 14%.

“Initial reaction to the guidelines ranged from skeptical to hostile, as physicians objected to oversight of their medical decision making,” Dr. Fisch and his colleagues noted.

The hospital sidestepped much of this resistance by presenting this program not as an effort to reduce inductions but as an effort to improve maternal and fetal outcomes by adhering to ACOG standards. Also, “due to the sensitive nature of altering physician practice patterns within such a large group of practitioners,” the task force that implemented the program was carefully chosen and included stakeholders from several disciplines.

Other obstacles were overcome by negotiation. For example, physicians initially resisted cooperating with the induction scheduler, who reminded them of the ACOG recommendations whenever they attempted to schedule an induction and brought in the director of the nursing unit or, if necessary, the medical director of the birth center. “This process evolved over time to the point where an attending will go directly to the medical director if they feel that approval will be needed to schedule an induction,” the researchers noted.

“A major strength of this study is its applicability for use at other institutions faced with an unacceptably high induction rate. … This article provides a blueprint for the development and implementation of a program” to reduce the risks associated with labor induction, which include infection, cesarean delivery, and neonatal ICU admission.

Noting that women who have induced labor spend more time in the hospital and incur greater costs for care than do those with spontaneous labor, Dr. Fisch and his associates calculated that their program has likely averted 71 unnecessary inductions and 5 unnecessary cesarean births per month.

“This accounts for 284 more hours in the hospital and a cost of $29,235 more per month,” which “translates into a total cost savings of 3,408 hours and $350,820 per year,” they said.

The investigators added that in the future, “individual provider induction rates may be monitored and evaluated, especially if the induction rates and subsequent cesarean birth rates are excessive.”

One-third of women with inflammatory bowel disease don't undergo screening for cervical dysplasia or cancer as recommended, according to Dr. Millie D. Long and her colleagues.

This is particularly alarming because many of these women appear to be at increased risk for abnormal cervical cytology because they take immunosuppressants to control the inflammatory bowel disease (IBD), wrote Dr. Long and her associates at the University of North Carolina, Chapel Hill.

The investigators assessed rates of cervical screening because two recent studies suggested that women with IBD are at increased risk for abnormal results on Pap smears. The authors used a database of insurance claims from patients enrolled in 87 health plans in 33 states. The large, diverse study population was representative of the entire U. S. population. The study was published in Clinical Gastroenterology and Hepatology ahead of print (doi:10.1016/j.cgh.2009.03.01).

Among all female patients aged 20–64 years in the database, the researchers identified 9,356 who had Crohn's disease or ulcerative colitis. Another 25,849 women without IBD who were matched for age, health plan, and geographic region served as control subjects. The mean subject age was 44 years.

Only 70% of the women with IBD and 65% of the control subjects underwent Pap smear screening during a 3-year observation period. Such screening is recommended for this age group in several sets of treatment guidelines, including those of the American College of Obstetricians and Gynecologists, the American Cancer Society, and the U.S. Preventive Services Task Force, they noted.

When the data were categorized by type of IBD, the results did not differ: Approximately one-third of the women with ulcerative colitis and one-third of those with Crohn's disease failed to undergo cervical screening.

A subgroup of 7,415 IBD patients filled two or more prescriptions for immunosuppressant medications during the study. These included prednisone, azathioprine, 6-mercaptopurine, methotrexate, infliximab, and adalimumab.

Only half of this subgroup of women taking immunosuppressants underwent Pap screening during a 15-month period, a finding the investigators termed “quite concerning.”

If studies in the literature are correct that the use of immunosuppressants raises the risk for cervical abnormalities, “then it appears that the women at highest risk for cervical pathology are the ones who, paradoxically, are the least likely to be screened,” said Dr. Long.

The investigators also found that women who saw primary care providers were more than twice as likely to receive Pap smears as were those who did not see primary care providers. This finding “suggests that women with IBD ought to be co-managed by a primary care provider along with a gastroenterologist,” they added.

Women who had Medicaid coverage, a proxy measure for low socioeconomic status, were the least likely of all to receive a Pap smear, at 44%, compared with 71% of women covered by commercial insurance. This finding “highlights the fact that our health system must strive for more equitable care, even among IBD patients,” the investigators said.

Older women also were less likely than were younger women to undergo cervical screening. This pattern has been observed in the general population.

“This suboptimal preventive care is particularly alarming, given the abundant evidence that Pap smear screening can reduce the incidence of and mortality from cervical cancer.”

“Indeed, although this malignancy is largely preventable with proper screening, it is estimated that 50% of women who receive diagnoses of cervical cancer have never been screened,” they wrote.

This study was supported in part by the National Institutes of Health's digestive disease epidemiology training program and the Center for Gastrointestinal Biology and Disease, a part of the National Institute of Diabetes and Digestive and Kidney Diseases.

One-third of women with inflammatory bowel disease don't undergo screening for cervical dysplasia or cancer as recommended, according to Dr. Millie D. Long and her colleagues.

This is particularly alarming because many of these women appear to be at increased risk for abnormal cervical cytology because they take immunosuppressants to control the inflammatory bowel disease (IBD), wrote Dr. Long and her associates at the University of North Carolina, Chapel Hill.

The investigators assessed rates of cervical screening because two recent studies suggested that women with IBD are at increased risk for abnormal results on Pap smears. The authors used a database of insurance claims from patients enrolled in 87 health plans in 33 states. The large, diverse study population was representative of the entire U. S. population. The study was published in Clinical Gastroenterology and Hepatology ahead of print (doi:10.1016/j.cgh.2009.03.01).

Among all female patients aged 20–64 years in the database, the researchers identified 9,356 who had Crohn's disease or ulcerative colitis. Another 25,849 women without IBD who were matched for age, health plan, and geographic region served as control subjects. The mean subject age was 44 years.

Only 70% of the women with IBD and 65% of the control subjects underwent Pap smear screening during a 3-year observation period. Such screening is recommended for this age group in several sets of treatment guidelines, including those of the American College of Obstetricians and Gynecologists, the American Cancer Society, and the U.S. Preventive Services Task Force, they noted.

When the data were categorized by type of IBD, the results did not differ: Approximately one-third of the women with ulcerative colitis and one-third of those with Crohn's disease failed to undergo cervical screening.

A subgroup of 7,415 IBD patients filled two or more prescriptions for immunosuppressant medications during the study. These included prednisone, azathioprine, 6-mercaptopurine, methotrexate, infliximab, and adalimumab.

Only half of this subgroup of women taking immunosuppressants underwent Pap screening during a 15-month period, a finding the investigators termed “quite concerning.”

If studies in the literature are correct that the use of immunosuppressants raises the risk for cervical abnormalities, “then it appears that the women at highest risk for cervical pathology are the ones who, paradoxically, are the least likely to be screened,” said Dr. Long.

The investigators also found that women who saw primary care providers were more than twice as likely to receive Pap smears as were those who did not see primary care providers. This finding “suggests that women with IBD ought to be co-managed by a primary care provider along with a gastroenterologist,” they added.

Women who had Medicaid coverage, a proxy measure for low socioeconomic status, were the least likely of all to receive a Pap smear, at 44%, compared with 71% of women covered by commercial insurance. This finding “highlights the fact that our health system must strive for more equitable care, even among IBD patients,” the investigators said.

Older women also were less likely than were younger women to undergo cervical screening. This pattern has been observed in the general population.

“This suboptimal preventive care is particularly alarming, given the abundant evidence that Pap smear screening can reduce the incidence of and mortality from cervical cancer.”

“Indeed, although this malignancy is largely preventable with proper screening, it is estimated that 50% of women who receive diagnoses of cervical cancer have never been screened,” they wrote.

This study was supported in part by the National Institutes of Health's digestive disease epidemiology training program and the Center for Gastrointestinal Biology and Disease, a part of the National Institute of Diabetes and Digestive and Kidney Diseases.

One-third of women with inflammatory bowel disease don't undergo screening for cervical dysplasia or cancer as recommended, according to Dr. Millie D. Long and her colleagues.

This is particularly alarming because many of these women appear to be at increased risk for abnormal cervical cytology because they take immunosuppressants to control the inflammatory bowel disease (IBD), wrote Dr. Long and her associates at the University of North Carolina, Chapel Hill.

The investigators assessed rates of cervical screening because two recent studies suggested that women with IBD are at increased risk for abnormal results on Pap smears. The authors used a database of insurance claims from patients enrolled in 87 health plans in 33 states. The large, diverse study population was representative of the entire U. S. population. The study was published in Clinical Gastroenterology and Hepatology ahead of print (doi:10.1016/j.cgh.2009.03.01).

Among all female patients aged 20–64 years in the database, the researchers identified 9,356 who had Crohn's disease or ulcerative colitis. Another 25,849 women without IBD who were matched for age, health plan, and geographic region served as control subjects. The mean subject age was 44 years.

Only 70% of the women with IBD and 65% of the control subjects underwent Pap smear screening during a 3-year observation period. Such screening is recommended for this age group in several sets of treatment guidelines, including those of the American College of Obstetricians and Gynecologists, the American Cancer Society, and the U.S. Preventive Services Task Force, they noted.

When the data were categorized by type of IBD, the results did not differ: Approximately one-third of the women with ulcerative colitis and one-third of those with Crohn's disease failed to undergo cervical screening.

A subgroup of 7,415 IBD patients filled two or more prescriptions for immunosuppressant medications during the study. These included prednisone, azathioprine, 6-mercaptopurine, methotrexate, infliximab, and adalimumab.

Only half of this subgroup of women taking immunosuppressants underwent Pap screening during a 15-month period, a finding the investigators termed “quite concerning.”

If studies in the literature are correct that the use of immunosuppressants raises the risk for cervical abnormalities, “then it appears that the women at highest risk for cervical pathology are the ones who, paradoxically, are the least likely to be screened,” said Dr. Long.

The investigators also found that women who saw primary care providers were more than twice as likely to receive Pap smears as were those who did not see primary care providers. This finding “suggests that women with IBD ought to be co-managed by a primary care provider along with a gastroenterologist,” they added.

Women who had Medicaid coverage, a proxy measure for low socioeconomic status, were the least likely of all to receive a Pap smear, at 44%, compared with 71% of women covered by commercial insurance. This finding “highlights the fact that our health system must strive for more equitable care, even among IBD patients,” the investigators said.

Older women also were less likely than were younger women to undergo cervical screening. This pattern has been observed in the general population.

“This suboptimal preventive care is particularly alarming, given the abundant evidence that Pap smear screening can reduce the incidence of and mortality from cervical cancer.”

“Indeed, although this malignancy is largely preventable with proper screening, it is estimated that 50% of women who receive diagnoses of cervical cancer have never been screened,” they wrote.

This study was supported in part by the National Institutes of Health's digestive disease epidemiology training program and the Center for Gastrointestinal Biology and Disease, a part of the National Institute of Diabetes and Digestive and Kidney Diseases.

Cognitive-behavioral therapy provided in the primary care setting is beneficial for older patients with generalized anxiety disorder, according to data from a randomized clinical trial.

Although cognitive-behavior therapy (CBT) has been found to be effective in younger patients with generalized anxiety disorder (GAD) or panic attack and in older people with depression, this framework has not been studied extensively in the primary care setting in older patients with GAD.

In what they described as the first randomized clinical trial of this approach, Melinda A. Stanley, Ph.D., of Baylor College of Medicine, Houston, and her associates assessed the treatment in 134 patients with a diagnosis of GAD aged 60 and older (JAMA 2009;301:1460–7).

A total of 70 study subjects (mean age, 67 years) were randomly assigned to receive up to 10 individual 1-hour sessions of CBT over the course of 12 weeks in a primary care clinic. The program included patient education, motivational interviewing, relaxation training, problem-solving skills training, exposure therapy, and sleep management.

Brief telephone “booster” sessions also were offered at 4, 7, 10, and 13 months.

The remaining 64 subjects received usual care for GAD, which included medication plus biweekly 15-minute phone calls over 3 months to provide support and safety for patients.

The study sample was not representative of older patients in primary care, because there was a preponderance of women and most of the subjects were well educated.

The CBT and phone calls were provided by three master's degree-level therapists with at least 2 years of CBT experience; one predoctoral intern with more than 3 years' experience with CBT, specifically for anxiety; and one post-BA-level therapist with 5 years' experience with CBT, specifically for late-life anxiety.

After 3 months, the patients who received CBT showed significantly greater improvement on the Penn State Worry Questionnaire, a 16-item self-report scale, compared with improvements gained by the usual care group. The CBT group also showed significantly greater improvement on the Beck Depression Inventory II and the mental health component of the Medical Outcomes Study, a measure of health-related quality of life.

The results showed that for those patients who received CBT, the severity of worrying and depressive symptoms decreased, while general mental health improved. These benefits persisted throughout the 12 months of follow-up, the investigators said.

However, results on the Generalized Anxiety Disorder Severity Scale and the Hamilton Anxiety Scale were not significantly different between the CBT group and the control group.

The rates at which patients began or discontinued taking antianxiety medications were no different between the two groups, nor were changes in medication dosages.

“This study paves the way for future research to test sustainable models of care in more demographically heterogenous groups. In future studies, it will be important to examine the impact of treatment delivered by clinicians without specialized CBT expertise,” Dr. Stanley and her associates wrote.

None of the authors reported any financial disclosures. The study was funded by grants from the National Institute of Mental Health and the Houston VA Health Services Research and Development Center of Excellence.

Cognitive-behavioral therapy provided in the primary care setting is beneficial for older patients with generalized anxiety disorder, according to data from a randomized clinical trial.

Although cognitive-behavior therapy (CBT) has been found to be effective in younger patients with generalized anxiety disorder (GAD) or panic attack and in older people with depression, this framework has not been studied extensively in the primary care setting in older patients with GAD.

In what they described as the first randomized clinical trial of this approach, Melinda A. Stanley, Ph.D., of Baylor College of Medicine, Houston, and her associates assessed the treatment in 134 patients with a diagnosis of GAD aged 60 and older (JAMA 2009;301:1460–7).

A total of 70 study subjects (mean age, 67 years) were randomly assigned to receive up to 10 individual 1-hour sessions of CBT over the course of 12 weeks in a primary care clinic. The program included patient education, motivational interviewing, relaxation training, problem-solving skills training, exposure therapy, and sleep management.

Brief telephone “booster” sessions also were offered at 4, 7, 10, and 13 months.

The remaining 64 subjects received usual care for GAD, which included medication plus biweekly 15-minute phone calls over 3 months to provide support and safety for patients.

The study sample was not representative of older patients in primary care, because there was a preponderance of women and most of the subjects were well educated.

The CBT and phone calls were provided by three master's degree-level therapists with at least 2 years of CBT experience; one predoctoral intern with more than 3 years' experience with CBT, specifically for anxiety; and one post-BA-level therapist with 5 years' experience with CBT, specifically for late-life anxiety.

After 3 months, the patients who received CBT showed significantly greater improvement on the Penn State Worry Questionnaire, a 16-item self-report scale, compared with improvements gained by the usual care group. The CBT group also showed significantly greater improvement on the Beck Depression Inventory II and the mental health component of the Medical Outcomes Study, a measure of health-related quality of life.

The results showed that for those patients who received CBT, the severity of worrying and depressive symptoms decreased, while general mental health improved. These benefits persisted throughout the 12 months of follow-up, the investigators said.

However, results on the Generalized Anxiety Disorder Severity Scale and the Hamilton Anxiety Scale were not significantly different between the CBT group and the control group.

The rates at which patients began or discontinued taking antianxiety medications were no different between the two groups, nor were changes in medication dosages.

“This study paves the way for future research to test sustainable models of care in more demographically heterogenous groups. In future studies, it will be important to examine the impact of treatment delivered by clinicians without specialized CBT expertise,” Dr. Stanley and her associates wrote.

None of the authors reported any financial disclosures. The study was funded by grants from the National Institute of Mental Health and the Houston VA Health Services Research and Development Center of Excellence.

Cognitive-behavioral therapy provided in the primary care setting is beneficial for older patients with generalized anxiety disorder, according to data from a randomized clinical trial.

Although cognitive-behavior therapy (CBT) has been found to be effective in younger patients with generalized anxiety disorder (GAD) or panic attack and in older people with depression, this framework has not been studied extensively in the primary care setting in older patients with GAD.

In what they described as the first randomized clinical trial of this approach, Melinda A. Stanley, Ph.D., of Baylor College of Medicine, Houston, and her associates assessed the treatment in 134 patients with a diagnosis of GAD aged 60 and older (JAMA 2009;301:1460–7).

A total of 70 study subjects (mean age, 67 years) were randomly assigned to receive up to 10 individual 1-hour sessions of CBT over the course of 12 weeks in a primary care clinic. The program included patient education, motivational interviewing, relaxation training, problem-solving skills training, exposure therapy, and sleep management.

Brief telephone “booster” sessions also were offered at 4, 7, 10, and 13 months.

The remaining 64 subjects received usual care for GAD, which included medication plus biweekly 15-minute phone calls over 3 months to provide support and safety for patients.

The study sample was not representative of older patients in primary care, because there was a preponderance of women and most of the subjects were well educated.

The CBT and phone calls were provided by three master's degree-level therapists with at least 2 years of CBT experience; one predoctoral intern with more than 3 years' experience with CBT, specifically for anxiety; and one post-BA-level therapist with 5 years' experience with CBT, specifically for late-life anxiety.

After 3 months, the patients who received CBT showed significantly greater improvement on the Penn State Worry Questionnaire, a 16-item self-report scale, compared with improvements gained by the usual care group. The CBT group also showed significantly greater improvement on the Beck Depression Inventory II and the mental health component of the Medical Outcomes Study, a measure of health-related quality of life.

The results showed that for those patients who received CBT, the severity of worrying and depressive symptoms decreased, while general mental health improved. These benefits persisted throughout the 12 months of follow-up, the investigators said.

However, results on the Generalized Anxiety Disorder Severity Scale and the Hamilton Anxiety Scale were not significantly different between the CBT group and the control group.

The rates at which patients began or discontinued taking antianxiety medications were no different between the two groups, nor were changes in medication dosages.

“This study paves the way for future research to test sustainable models of care in more demographically heterogenous groups. In future studies, it will be important to examine the impact of treatment delivered by clinicians without specialized CBT expertise,” Dr. Stanley and her associates wrote.

None of the authors reported any financial disclosures. The study was funded by grants from the National Institute of Mental Health and the Houston VA Health Services Research and Development Center of Excellence.

Alcohol abuse and dependence appear to lead to major depression, rather than vice versa, according to a collection of statistical analyses reported in the Archives of General Psychiatry.

Researchers used data from the ChristChurch Health and Development Study, a cohort of 635 boys and 630 girls born in urban New Zealand in 1977 and followed through age 25, to examine the well-known relationship between alcohol abuse or dependence and depression. They used several advanced statistical modeling methods to explore possible causal pathways between the two disorders, said David M. Fergusson, Ph.D., and his associates at the University of Otago, Christchurch.

At age 24-25 years, approximately 14% of the sample met DSM-IV criteria for alcohol dependence (6%) or abuse (8%), and 14% met criteria for major depression.

At all ages, there were clear and significant trends for alcohol abuse to be associated with depression, such that subjects who abused alcohol were nearly twice as likely to fulfill criteria for major depression as were those who did not abuse alcohol. In contrast, major depression did not appear to predispose subjects to alcohol abuse.

In addition, the relationship between alcohol abuse and depression was not found to arise from some common factor underlying both disorders, Dr. Fergusson and his colleagues said (Arch. Gen. Psych. 2009;66:260-6).

It is possible that the use of alcohol may trigger a response in genetically susceptible individuals that raises the risk of depression. Other research also suggests that alcohol's action as a depressant may lead to periods of depressed affect among drinkers, the investigators added.

The researchers noted that these results contradict those of previous studies, some of which have suggested that the causal relationship moves in the opposite direction because some people with depressive symptoms self-medicate with alcohol.

The current study might be more able to detect the true direction of the causal relationship because of its use of numerous complex statistical methods as well as its use of repeated structured mental health assessments over time, Dr. Fergusson and his associates said.

Alcohol abuse and dependence appear to lead to major depression, rather than vice versa, according to a collection of statistical analyses reported in the Archives of General Psychiatry.

Researchers used data from the ChristChurch Health and Development Study, a cohort of 635 boys and 630 girls born in urban New Zealand in 1977 and followed through age 25, to examine the well-known relationship between alcohol abuse or dependence and depression. They used several advanced statistical modeling methods to explore possible causal pathways between the two disorders, said David M. Fergusson, Ph.D., and his associates at the University of Otago, Christchurch.

At age 24-25 years, approximately 14% of the sample met DSM-IV criteria for alcohol dependence (6%) or abuse (8%), and 14% met criteria for major depression.

At all ages, there were clear and significant trends for alcohol abuse to be associated with depression, such that subjects who abused alcohol were nearly twice as likely to fulfill criteria for major depression as were those who did not abuse alcohol. In contrast, major depression did not appear to predispose subjects to alcohol abuse.

In addition, the relationship between alcohol abuse and depression was not found to arise from some common factor underlying both disorders, Dr. Fergusson and his colleagues said (Arch. Gen. Psych. 2009;66:260-6).

It is possible that the use of alcohol may trigger a response in genetically susceptible individuals that raises the risk of depression. Other research also suggests that alcohol's action as a depressant may lead to periods of depressed affect among drinkers, the investigators added.

The researchers noted that these results contradict those of previous studies, some of which have suggested that the causal relationship moves in the opposite direction because some people with depressive symptoms self-medicate with alcohol.

The current study might be more able to detect the true direction of the causal relationship because of its use of numerous complex statistical methods as well as its use of repeated structured mental health assessments over time, Dr. Fergusson and his associates said.

Alcohol abuse and dependence appear to lead to major depression, rather than vice versa, according to a collection of statistical analyses reported in the Archives of General Psychiatry.

Researchers used data from the ChristChurch Health and Development Study, a cohort of 635 boys and 630 girls born in urban New Zealand in 1977 and followed through age 25, to examine the well-known relationship between alcohol abuse or dependence and depression. They used several advanced statistical modeling methods to explore possible causal pathways between the two disorders, said David M. Fergusson, Ph.D., and his associates at the University of Otago, Christchurch.

At age 24-25 years, approximately 14% of the sample met DSM-IV criteria for alcohol dependence (6%) or abuse (8%), and 14% met criteria for major depression.

At all ages, there were clear and significant trends for alcohol abuse to be associated with depression, such that subjects who abused alcohol were nearly twice as likely to fulfill criteria for major depression as were those who did not abuse alcohol. In contrast, major depression did not appear to predispose subjects to alcohol abuse.

In addition, the relationship between alcohol abuse and depression was not found to arise from some common factor underlying both disorders, Dr. Fergusson and his colleagues said (Arch. Gen. Psych. 2009;66:260-6).

It is possible that the use of alcohol may trigger a response in genetically susceptible individuals that raises the risk of depression. Other research also suggests that alcohol's action as a depressant may lead to periods of depressed affect among drinkers, the investigators added.

The researchers noted that these results contradict those of previous studies, some of which have suggested that the causal relationship moves in the opposite direction because some people with depressive symptoms self-medicate with alcohol.

The current study might be more able to detect the true direction of the causal relationship because of its use of numerous complex statistical methods as well as its use of repeated structured mental health assessments over time, Dr. Fergusson and his associates said.

A collaborative intervention designed to help primary care practitioners improve management of chronic pain was found to be modestly but significantly effective, according to data from a cluster randomized trial.

The intervention resulted in greater use of adjunctive pain medications and treatments, which meant that practitioners were acting in better accordance with guidelines for chronic pain management, said Dr. Steven K. Dobscha of the Portland Center for the Study of Chronic, Comorbid Mental and Physical Disorders at the Portland (Ore.) Veterans Affairs Medical Center and his associates.

The investigators assessed the collaborative intervention in three urban and two rural primary care clinics of the VA medical center. A total of 22 physicians, internal medicine fellows, and nurse practitioners were randomly assigned to provide usual treatment to 214 chronic pain patients, and 20 practitioners were assigned to provide care according to the collaborative intervention to 187 patients.

All patients had a diagnosis of moderate or severe musculoskeletal pain with a median of 10 years' duration, and two-thirds had more than one such diagnosis. The mean patient age was 61 years. Depression, PTSD, and panic attacks were common.

A team including a full-time psychologist care manager and an internist implemented the intervention, which included leading workshops to introduce both clinicians and patients to the intervention, assessing patients and their barriers to treatment, screening for comorbid psychiatric disorders, developing individualized functional goals, providing patient support, and providing feedback to the clinicians.

Patients in the intervention group were more likely to be prescribed adjunctive medications such as antidepressants, NSAIDs, and capsaicin, and were more likely to receive long-acting rather than standard opioids. They also were more likely to receive physical therapy than were those in the usual-care group.

After 1 year, patients in the intervention group reported “generally modest” but significant decreases in pain intensity and in pain-related disability, compared with those in the usual-care group.

A total of 22% of the intervention patients showed 30% reductions in measures of pain and disability, compared with 14% of the usual-care patients, Dr. Dobscha and his colleagues said (JAMA 2009;301:1242-52).

The intervention was similarly effective in the subgroup of chronic pain patients who had concomitant depression, showing that “improvements in pain intensity and disability can be achieved even among patients with depression,” the researchers noted.

However, there were no differences between the two treatment groups in health-related quality of life, satisfaction with health care treatment, or subjective assessments of treatment effectiveness.

The authors had no financial disclosures relating to this study.

A collaborative intervention designed to help primary care practitioners improve management of chronic pain was found to be modestly but significantly effective, according to data from a cluster randomized trial.

The intervention resulted in greater use of adjunctive pain medications and treatments, which meant that practitioners were acting in better accordance with guidelines for chronic pain management, said Dr. Steven K. Dobscha of the Portland Center for the Study of Chronic, Comorbid Mental and Physical Disorders at the Portland (Ore.) Veterans Affairs Medical Center and his associates.

The investigators assessed the collaborative intervention in three urban and two rural primary care clinics of the VA medical center. A total of 22 physicians, internal medicine fellows, and nurse practitioners were randomly assigned to provide usual treatment to 214 chronic pain patients, and 20 practitioners were assigned to provide care according to the collaborative intervention to 187 patients.

All patients had a diagnosis of moderate or severe musculoskeletal pain with a median of 10 years' duration, and two-thirds had more than one such diagnosis. The mean patient age was 61 years. Depression, PTSD, and panic attacks were common.

A team including a full-time psychologist care manager and an internist implemented the intervention, which included leading workshops to introduce both clinicians and patients to the intervention, assessing patients and their barriers to treatment, screening for comorbid psychiatric disorders, developing individualized functional goals, providing patient support, and providing feedback to the clinicians.

Patients in the intervention group were more likely to be prescribed adjunctive medications such as antidepressants, NSAIDs, and capsaicin, and were more likely to receive long-acting rather than standard opioids. They also were more likely to receive physical therapy than were those in the usual-care group.

After 1 year, patients in the intervention group reported “generally modest” but significant decreases in pain intensity and in pain-related disability, compared with those in the usual-care group.

A total of 22% of the intervention patients showed 30% reductions in measures of pain and disability, compared with 14% of the usual-care patients, Dr. Dobscha and his colleagues said (JAMA 2009;301:1242-52).

The intervention was similarly effective in the subgroup of chronic pain patients who had concomitant depression, showing that “improvements in pain intensity and disability can be achieved even among patients with depression,” the researchers noted.

However, there were no differences between the two treatment groups in health-related quality of life, satisfaction with health care treatment, or subjective assessments of treatment effectiveness.

The authors had no financial disclosures relating to this study.

A collaborative intervention designed to help primary care practitioners improve management of chronic pain was found to be modestly but significantly effective, according to data from a cluster randomized trial.

The intervention resulted in greater use of adjunctive pain medications and treatments, which meant that practitioners were acting in better accordance with guidelines for chronic pain management, said Dr. Steven K. Dobscha of the Portland Center for the Study of Chronic, Comorbid Mental and Physical Disorders at the Portland (Ore.) Veterans Affairs Medical Center and his associates.

The investigators assessed the collaborative intervention in three urban and two rural primary care clinics of the VA medical center. A total of 22 physicians, internal medicine fellows, and nurse practitioners were randomly assigned to provide usual treatment to 214 chronic pain patients, and 20 practitioners were assigned to provide care according to the collaborative intervention to 187 patients.

All patients had a diagnosis of moderate or severe musculoskeletal pain with a median of 10 years' duration, and two-thirds had more than one such diagnosis. The mean patient age was 61 years. Depression, PTSD, and panic attacks were common.

A team including a full-time psychologist care manager and an internist implemented the intervention, which included leading workshops to introduce both clinicians and patients to the intervention, assessing patients and their barriers to treatment, screening for comorbid psychiatric disorders, developing individualized functional goals, providing patient support, and providing feedback to the clinicians.

Patients in the intervention group were more likely to be prescribed adjunctive medications such as antidepressants, NSAIDs, and capsaicin, and were more likely to receive long-acting rather than standard opioids. They also were more likely to receive physical therapy than were those in the usual-care group.

After 1 year, patients in the intervention group reported “generally modest” but significant decreases in pain intensity and in pain-related disability, compared with those in the usual-care group.

A total of 22% of the intervention patients showed 30% reductions in measures of pain and disability, compared with 14% of the usual-care patients, Dr. Dobscha and his colleagues said (JAMA 2009;301:1242-52).

The intervention was similarly effective in the subgroup of chronic pain patients who had concomitant depression, showing that “improvements in pain intensity and disability can be achieved even among patients with depression,” the researchers noted.

However, there were no differences between the two treatment groups in health-related quality of life, satisfaction with health care treatment, or subjective assessments of treatment effectiveness.

The authors had no financial disclosures relating to this study.