Mary Ann Moon

The incidence of methicillin-resistant Staphylococcus aureus bloodstream infections related to the placement of central lines has declined in recent years in all major types of adult ICUs and has remained stable in nonneonatal pediatric ICUs, according to a report.

These findings suggest that prevention efforts are succeeding for this subgroup of MRSA patients, said Dr. Deron C. Burton and associates at the Centers for Disease Control and Prevention.

To characterize trends in MRSA incidence, the researchers assessed surveillance data reported to the CDC by 1,684 ICUs in 43 states from 1997 through 2007. In all, 33,587 central line-associated bloodstream infections were reported, of which 2,498 (7%) were MRSA.

The incidence of central line-associated bloodstream MRSA infections rose from 1997 to 2001, but then declined through 2007, resulting in an overall estimated decline of approximately 50% over the entire study period, the investigators said (JAMA 2009;301:727-36).

The incidence declined in recent years in all six major subtypes of adult ICUs: surgical; medical; combined medical-surgical without a major teaching affiliation; combined medical-surgical with a major teaching affiliation; cardiothoracic; and coronary units.

For nonneonatal pediatric ICUs, the incidence of central line-associated bloodstream MRSA infections remained stable from 1997 through 2007. These findings stand “in sharp contrast to trends in percent MRSA” (a different measure, representing pooled mean percent resistance), which can be “misleading.”

“The percent MRSA trend [erroneously] suggests a steady worsening” of the MRSA central line-associated bloodstream infections during the study period, Dr. Burton and colleagues noted.

In an editorial, Dr. Michael William Climo of Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Va., said that the decline in this specific subset of MRSA infections occurred against the backdrop of an increase in overall MRSA infections.

It is likely that this reduction was “related to a range of interventions that have been implemented during the last decade, including better hand hygiene practices, adoption of standardized line insertion and care practices, proper barrier precautions, improved catheter technology, and shorter periods of indwelling catheter use in patients,” Dr. Climo said (JAMA 2009;301:772-3).

The report offers “encouraging news,” commented Kathy Warye, CEO of the Association for Professionals in Infection Control and Epidemiology. The findings show that health care-associated infections “can be prevented in a very vulnerable group of patients when institutions consistently implement evidence-based prevention strategies,” Ms. Warye said in a statement. Noting that 67% of MRSA cases occur outside the ICU, she urged further action.

Central line-associated bloodstream MRSA infections declined approximately 50% in 1997-2007. (Above, scanning electron micrograph magnified 9560x.) CDC/Janice Haney Carr/Jeff Hageman, M.H.S.

The incidence of methicillin-resistant Staphylococcus aureus bloodstream infections related to the placement of central lines has declined in recent years in all major types of adult ICUs and has remained stable in nonneonatal pediatric ICUs, according to a report.

These findings suggest that prevention efforts are succeeding for this subgroup of MRSA patients, said Dr. Deron C. Burton and associates at the Centers for Disease Control and Prevention.

To characterize trends in MRSA incidence, the researchers assessed surveillance data reported to the CDC by 1,684 ICUs in 43 states from 1997 through 2007. In all, 33,587 central line-associated bloodstream infections were reported, of which 2,498 (7%) were MRSA.

The incidence of central line-associated bloodstream MRSA infections rose from 1997 to 2001, but then declined through 2007, resulting in an overall estimated decline of approximately 50% over the entire study period, the investigators said (JAMA 2009;301:727-36).

The incidence declined in recent years in all six major subtypes of adult ICUs: surgical; medical; combined medical-surgical without a major teaching affiliation; combined medical-surgical with a major teaching affiliation; cardiothoracic; and coronary units.

For nonneonatal pediatric ICUs, the incidence of central line-associated bloodstream MRSA infections remained stable from 1997 through 2007. These findings stand “in sharp contrast to trends in percent MRSA” (a different measure, representing pooled mean percent resistance), which can be “misleading.”

“The percent MRSA trend [erroneously] suggests a steady worsening” of the MRSA central line-associated bloodstream infections during the study period, Dr. Burton and colleagues noted.

In an editorial, Dr. Michael William Climo of Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Va., said that the decline in this specific subset of MRSA infections occurred against the backdrop of an increase in overall MRSA infections.

It is likely that this reduction was “related to a range of interventions that have been implemented during the last decade, including better hand hygiene practices, adoption of standardized line insertion and care practices, proper barrier precautions, improved catheter technology, and shorter periods of indwelling catheter use in patients,” Dr. Climo said (JAMA 2009;301:772-3).

The report offers “encouraging news,” commented Kathy Warye, CEO of the Association for Professionals in Infection Control and Epidemiology. The findings show that health care-associated infections “can be prevented in a very vulnerable group of patients when institutions consistently implement evidence-based prevention strategies,” Ms. Warye said in a statement. Noting that 67% of MRSA cases occur outside the ICU, she urged further action.

Central line-associated bloodstream MRSA infections declined approximately 50% in 1997-2007. (Above, scanning electron micrograph magnified 9560x.) CDC/Janice Haney Carr/Jeff Hageman, M.H.S.

The incidence of methicillin-resistant Staphylococcus aureus bloodstream infections related to the placement of central lines has declined in recent years in all major types of adult ICUs and has remained stable in nonneonatal pediatric ICUs, according to a report.

These findings suggest that prevention efforts are succeeding for this subgroup of MRSA patients, said Dr. Deron C. Burton and associates at the Centers for Disease Control and Prevention.

To characterize trends in MRSA incidence, the researchers assessed surveillance data reported to the CDC by 1,684 ICUs in 43 states from 1997 through 2007. In all, 33,587 central line-associated bloodstream infections were reported, of which 2,498 (7%) were MRSA.

The incidence of central line-associated bloodstream MRSA infections rose from 1997 to 2001, but then declined through 2007, resulting in an overall estimated decline of approximately 50% over the entire study period, the investigators said (JAMA 2009;301:727-36).

The incidence declined in recent years in all six major subtypes of adult ICUs: surgical; medical; combined medical-surgical without a major teaching affiliation; combined medical-surgical with a major teaching affiliation; cardiothoracic; and coronary units.

For nonneonatal pediatric ICUs, the incidence of central line-associated bloodstream MRSA infections remained stable from 1997 through 2007. These findings stand “in sharp contrast to trends in percent MRSA” (a different measure, representing pooled mean percent resistance), which can be “misleading.”

“The percent MRSA trend [erroneously] suggests a steady worsening” of the MRSA central line-associated bloodstream infections during the study period, Dr. Burton and colleagues noted.

In an editorial, Dr. Michael William Climo of Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Va., said that the decline in this specific subset of MRSA infections occurred against the backdrop of an increase in overall MRSA infections.

It is likely that this reduction was “related to a range of interventions that have been implemented during the last decade, including better hand hygiene practices, adoption of standardized line insertion and care practices, proper barrier precautions, improved catheter technology, and shorter periods of indwelling catheter use in patients,” Dr. Climo said (JAMA 2009;301:772-3).

The report offers “encouraging news,” commented Kathy Warye, CEO of the Association for Professionals in Infection Control and Epidemiology. The findings show that health care-associated infections “can be prevented in a very vulnerable group of patients when institutions consistently implement evidence-based prevention strategies,” Ms. Warye said in a statement. Noting that 67% of MRSA cases occur outside the ICU, she urged further action.

Central line-associated bloodstream MRSA infections declined approximately 50% in 1997-2007. (Above, scanning electron micrograph magnified 9560x.) CDC/Janice Haney Carr/Jeff Hageman, M.H.S.

Most young women who received chest radiation for childhood cancer are not being appropriately screened for breast cancer, despite their high risk, according to a recent report.

The primary barrier to screening is not a lack of medical contact; rather, it is that their physicians do not advise them to get mammography, most likely because the clinicians are not aware of these patients' high risk, said Dr. Kevin C. Oeffinger of Memorial Sloan-Kettering Cancer Center, New York, and his associates (JAMA 2009;301:404–14).

Experts recommend that women who were treated with moderate- to high-dose chest radiation for a pediatric malignancy initiate breast cancer surveillance starting at age 25 years, or 8 years after undergoing radiotherapy, whichever comes last. The median age of breast cancer diagnosis in these patients is 32–35 years, and their previous exposure to radiation or anthracycline limits their treatment options.

There are an estimated 20,000–25,000 such women in the United States, and as many as 20% of female cancer survivors worldwide fall into this category.

Dr. Oeffinger and his colleagues studied breast cancer surveillance using the large, geographically diverse population of women participating in the Childhood Cancer Survivor Study. This study follows more than 9,000 survivors who were diagnosed between 1970 and 1986 as having leukemia, brain tumors, Hodgkin's lymphoma, non-Hodgkin's lymphoma, renal tumors, neuroblastomas, soft-tissue sarcomas, or bone tumors.

A random sample of 551 CCSS participants now aged 25–50 years who received at least 20 Gy of chest radiation therapy as children were surveyed regarding breast cancer surveillance. Two comparison groups—561 CCSS subjects who had not undergone chest radiation and 622 siblings of CCSS subjects who had never had cancer—also were assessed.

Nearly half of the women under age 40 years who had been exposed to pediatric radiotherapy had never had a mammogram, and only 23% had undergone mammography within the preceding year. This “much lower than expected” rate was still somewhat higher than the rates in the CCSS siblings (11%) and the cancer survivors who had not undergone chest radiotherapy (15%).

Women in this age group who said their physicians had recommended mammography were three times more likely to undergo screening than were those who said their physicians had not recommended mammography. However, only one-third of these high-risk women said that their physicians had recommended mammography.

The two most commonly reported barriers to screening in this age group were “doctor didn't order it” (31%) and “I'm too young” (30%).

Women aged 40–50 years who had been exposed to radiotherapy fared slightly better, but still only 53% engaged in regular breast cancer screening. In this age group, the most commonly reported barriers to screening were “put it off,” “didn't get around to it,” “too expensive,” or “no insurance.”

In contrast, nearly 90% of the study participants reported having a recent Pap smear, so medical access and knowledge of general women's health issues were not lacking. Instead, “one of the primary barriers is likely a lack of clinician familiarity with childhood cancer survivors and their risk of breast cancer,” Dr. Oeffinger and his colleagues said.

Experts recommend these women start breast surveillance 8 years after radiotherapy or at age 25 years, whichever comes first. ©Brand X Pictures

Most young women who received chest radiation for childhood cancer are not being appropriately screened for breast cancer, despite their high risk, according to a recent report.

The primary barrier to screening is not a lack of medical contact; rather, it is that their physicians do not advise them to get mammography, most likely because the clinicians are not aware of these patients' high risk, said Dr. Kevin C. Oeffinger of Memorial Sloan-Kettering Cancer Center, New York, and his associates (JAMA 2009;301:404–14).

Experts recommend that women who were treated with moderate- to high-dose chest radiation for a pediatric malignancy initiate breast cancer surveillance starting at age 25 years, or 8 years after undergoing radiotherapy, whichever comes last. The median age of breast cancer diagnosis in these patients is 32–35 years, and their previous exposure to radiation or anthracycline limits their treatment options.

There are an estimated 20,000–25,000 such women in the United States, and as many as 20% of female cancer survivors worldwide fall into this category.

Dr. Oeffinger and his colleagues studied breast cancer surveillance using the large, geographically diverse population of women participating in the Childhood Cancer Survivor Study. This study follows more than 9,000 survivors who were diagnosed between 1970 and 1986 as having leukemia, brain tumors, Hodgkin's lymphoma, non-Hodgkin's lymphoma, renal tumors, neuroblastomas, soft-tissue sarcomas, or bone tumors.

A random sample of 551 CCSS participants now aged 25–50 years who received at least 20 Gy of chest radiation therapy as children were surveyed regarding breast cancer surveillance. Two comparison groups—561 CCSS subjects who had not undergone chest radiation and 622 siblings of CCSS subjects who had never had cancer—also were assessed.

Nearly half of the women under age 40 years who had been exposed to pediatric radiotherapy had never had a mammogram, and only 23% had undergone mammography within the preceding year. This “much lower than expected” rate was still somewhat higher than the rates in the CCSS siblings (11%) and the cancer survivors who had not undergone chest radiotherapy (15%).

Women in this age group who said their physicians had recommended mammography were three times more likely to undergo screening than were those who said their physicians had not recommended mammography. However, only one-third of these high-risk women said that their physicians had recommended mammography.

The two most commonly reported barriers to screening in this age group were “doctor didn't order it” (31%) and “I'm too young” (30%).

Women aged 40–50 years who had been exposed to radiotherapy fared slightly better, but still only 53% engaged in regular breast cancer screening. In this age group, the most commonly reported barriers to screening were “put it off,” “didn't get around to it,” “too expensive,” or “no insurance.”

In contrast, nearly 90% of the study participants reported having a recent Pap smear, so medical access and knowledge of general women's health issues were not lacking. Instead, “one of the primary barriers is likely a lack of clinician familiarity with childhood cancer survivors and their risk of breast cancer,” Dr. Oeffinger and his colleagues said.

Experts recommend these women start breast surveillance 8 years after radiotherapy or at age 25 years, whichever comes first. ©Brand X Pictures

Most young women who received chest radiation for childhood cancer are not being appropriately screened for breast cancer, despite their high risk, according to a recent report.

The primary barrier to screening is not a lack of medical contact; rather, it is that their physicians do not advise them to get mammography, most likely because the clinicians are not aware of these patients' high risk, said Dr. Kevin C. Oeffinger of Memorial Sloan-Kettering Cancer Center, New York, and his associates (JAMA 2009;301:404–14).

Experts recommend that women who were treated with moderate- to high-dose chest radiation for a pediatric malignancy initiate breast cancer surveillance starting at age 25 years, or 8 years after undergoing radiotherapy, whichever comes last. The median age of breast cancer diagnosis in these patients is 32–35 years, and their previous exposure to radiation or anthracycline limits their treatment options.

There are an estimated 20,000–25,000 such women in the United States, and as many as 20% of female cancer survivors worldwide fall into this category.

Dr. Oeffinger and his colleagues studied breast cancer surveillance using the large, geographically diverse population of women participating in the Childhood Cancer Survivor Study. This study follows more than 9,000 survivors who were diagnosed between 1970 and 1986 as having leukemia, brain tumors, Hodgkin's lymphoma, non-Hodgkin's lymphoma, renal tumors, neuroblastomas, soft-tissue sarcomas, or bone tumors.

A random sample of 551 CCSS participants now aged 25–50 years who received at least 20 Gy of chest radiation therapy as children were surveyed regarding breast cancer surveillance. Two comparison groups—561 CCSS subjects who had not undergone chest radiation and 622 siblings of CCSS subjects who had never had cancer—also were assessed.

Nearly half of the women under age 40 years who had been exposed to pediatric radiotherapy had never had a mammogram, and only 23% had undergone mammography within the preceding year. This “much lower than expected” rate was still somewhat higher than the rates in the CCSS siblings (11%) and the cancer survivors who had not undergone chest radiotherapy (15%).

Women in this age group who said their physicians had recommended mammography were three times more likely to undergo screening than were those who said their physicians had not recommended mammography. However, only one-third of these high-risk women said that their physicians had recommended mammography.

The two most commonly reported barriers to screening in this age group were “doctor didn't order it” (31%) and “I'm too young” (30%).

Women aged 40–50 years who had been exposed to radiotherapy fared slightly better, but still only 53% engaged in regular breast cancer screening. In this age group, the most commonly reported barriers to screening were “put it off,” “didn't get around to it,” “too expensive,” or “no insurance.”

In contrast, nearly 90% of the study participants reported having a recent Pap smear, so medical access and knowledge of general women's health issues were not lacking. Instead, “one of the primary barriers is likely a lack of clinician familiarity with childhood cancer survivors and their risk of breast cancer,” Dr. Oeffinger and his colleagues said.

Experts recommend these women start breast surveillance 8 years after radiotherapy or at age 25 years, whichever comes first. ©Brand X Pictures

Treadmill exercise three times a week improved walking endurance, lower extremity blood flow, and quality of life in patients with peripheral arterial disease, according to findings from a randomized trial.

The intervention increased brachial arterial flow-mediated dilation, which in PAD patients is associated with lower rates of cardiovascular events. This suggests that treadmill exercise may confer systemic vascular benefits in PAD, said Dr. Mary M. McDermott of Northwestern University, Chicago, and her associates.

“Based on findings reported in this trial, physicians should recommend supervised treadmill exercise programs for PAD patients, regardless of whether they have classic symptoms of intermittent claudication,” they said.

The investigators compared two 6-month exercise interventions with no intervention in 156 PAD patients with an average age of 73 years.

Fifty-one patients were randomly assigned to supervised treadmill exercise three times per week, beginning with 15-minute sessions and working up to 40-minute sessions. Fifty-two patients were assigned to lower-extremity resistance training three times per week, performing three sets of eight repetitions of knee extensions, leg presses, and leg curls using standard equipment, as well as squat and toe-rise exercises. The remaining 53 patients served as controls.

After 6 months, patients in the treadmill group increased their distance in a 6-minute walk test by a mean of 21 meters, while those in the control group decreased their distance by a mean of 15 meters—a net difference of 36 meters between the two exercise groups, the investigators said (JAMA 2009:301:165–74).

The treadmill group also showed increased brachial arterial flow-mediated dilation, greater improvement in overall physical functioning, and better quality of life, compared with controls.

Patients in the resistance-training group showed no change in their 6-minute walk performance or in brachial arterial flow-mediated dilation, but showed significant increases in stair climbing, overall physical functioning, and quality of life, compared with controls.

Patients without classic symptoms of intermittent claudication, as well as those who did have intermittent claudication, benefited from both interventions. This is the first randomized controlled clinical trial of exercise in PAD to include subjects without intermittent claudication, Dr. McDermott and her colleagues noted.

The exercise interventions were associated with three serious adverse events. One patient had a cardiac arrest during treadmill exercise, and another developed chest pain on the treadmill, which required coronary catheterization. A third patient fell and fractured her arm during follow-up walk testing.

Dr. McDermott reports having received consulting fees and honoraria from Sanofi-Aventis and Bristol-Myers Squibb. She is also a contributing editor for the JAMA.

Physicians should recommend supervised treadmill exercise programs for PAD patients, regardless of whether they have classic symptoms of claudication. ©Pavel

Treadmill exercise three times a week improved walking endurance, lower extremity blood flow, and quality of life in patients with peripheral arterial disease, according to findings from a randomized trial.

The intervention increased brachial arterial flow-mediated dilation, which in PAD patients is associated with lower rates of cardiovascular events. This suggests that treadmill exercise may confer systemic vascular benefits in PAD, said Dr. Mary M. McDermott of Northwestern University, Chicago, and her associates.

“Based on findings reported in this trial, physicians should recommend supervised treadmill exercise programs for PAD patients, regardless of whether they have classic symptoms of intermittent claudication,” they said.

The investigators compared two 6-month exercise interventions with no intervention in 156 PAD patients with an average age of 73 years.

Fifty-one patients were randomly assigned to supervised treadmill exercise three times per week, beginning with 15-minute sessions and working up to 40-minute sessions. Fifty-two patients were assigned to lower-extremity resistance training three times per week, performing three sets of eight repetitions of knee extensions, leg presses, and leg curls using standard equipment, as well as squat and toe-rise exercises. The remaining 53 patients served as controls.

After 6 months, patients in the treadmill group increased their distance in a 6-minute walk test by a mean of 21 meters, while those in the control group decreased their distance by a mean of 15 meters—a net difference of 36 meters between the two exercise groups, the investigators said (JAMA 2009:301:165–74).

The treadmill group also showed increased brachial arterial flow-mediated dilation, greater improvement in overall physical functioning, and better quality of life, compared with controls.

Patients in the resistance-training group showed no change in their 6-minute walk performance or in brachial arterial flow-mediated dilation, but showed significant increases in stair climbing, overall physical functioning, and quality of life, compared with controls.

Patients without classic symptoms of intermittent claudication, as well as those who did have intermittent claudication, benefited from both interventions. This is the first randomized controlled clinical trial of exercise in PAD to include subjects without intermittent claudication, Dr. McDermott and her colleagues noted.

The exercise interventions were associated with three serious adverse events. One patient had a cardiac arrest during treadmill exercise, and another developed chest pain on the treadmill, which required coronary catheterization. A third patient fell and fractured her arm during follow-up walk testing.

Dr. McDermott reports having received consulting fees and honoraria from Sanofi-Aventis and Bristol-Myers Squibb. She is also a contributing editor for the JAMA.

Physicians should recommend supervised treadmill exercise programs for PAD patients, regardless of whether they have classic symptoms of claudication. ©Pavel

Treadmill exercise three times a week improved walking endurance, lower extremity blood flow, and quality of life in patients with peripheral arterial disease, according to findings from a randomized trial.

The intervention increased brachial arterial flow-mediated dilation, which in PAD patients is associated with lower rates of cardiovascular events. This suggests that treadmill exercise may confer systemic vascular benefits in PAD, said Dr. Mary M. McDermott of Northwestern University, Chicago, and her associates.

“Based on findings reported in this trial, physicians should recommend supervised treadmill exercise programs for PAD patients, regardless of whether they have classic symptoms of intermittent claudication,” they said.

The investigators compared two 6-month exercise interventions with no intervention in 156 PAD patients with an average age of 73 years.

Fifty-one patients were randomly assigned to supervised treadmill exercise three times per week, beginning with 15-minute sessions and working up to 40-minute sessions. Fifty-two patients were assigned to lower-extremity resistance training three times per week, performing three sets of eight repetitions of knee extensions, leg presses, and leg curls using standard equipment, as well as squat and toe-rise exercises. The remaining 53 patients served as controls.

After 6 months, patients in the treadmill group increased their distance in a 6-minute walk test by a mean of 21 meters, while those in the control group decreased their distance by a mean of 15 meters—a net difference of 36 meters between the two exercise groups, the investigators said (JAMA 2009:301:165–74).

The treadmill group also showed increased brachial arterial flow-mediated dilation, greater improvement in overall physical functioning, and better quality of life, compared with controls.

Patients in the resistance-training group showed no change in their 6-minute walk performance or in brachial arterial flow-mediated dilation, but showed significant increases in stair climbing, overall physical functioning, and quality of life, compared with controls.

Patients without classic symptoms of intermittent claudication, as well as those who did have intermittent claudication, benefited from both interventions. This is the first randomized controlled clinical trial of exercise in PAD to include subjects without intermittent claudication, Dr. McDermott and her colleagues noted.

The exercise interventions were associated with three serious adverse events. One patient had a cardiac arrest during treadmill exercise, and another developed chest pain on the treadmill, which required coronary catheterization. A third patient fell and fractured her arm during follow-up walk testing.

Dr. McDermott reports having received consulting fees and honoraria from Sanofi-Aventis and Bristol-Myers Squibb. She is also a contributing editor for the JAMA.

Physicians should recommend supervised treadmill exercise programs for PAD patients, regardless of whether they have classic symptoms of claudication. ©Pavel

A recently reported association between topical tretinoin and increased mortality is not causal and most likely is due to chance, according to a report.

The interim finding of an unexpected rise in lung cancer incidence and all-cause mortality prompted the premature halt of the Department of Veterans Affairs Topical Tretinoin Chemoprevention (VATTC) trial, a large 6-year study designed to determine whether the treatment could prevent basal and squamous cell skin cancers in patients who already had at least two such keratinocyte carcinomas. Increased lung cancer incidence and mortality had previously been reported with systemically administered compounds closely related to tretinoin.

Dr. Martin A. Weinstock of the Providence (R.I.) VA Medical Center, and his associates in the VATTC trial conducted a post hoc analysis of the mortality data and confirmed an association with mortality—but no definitive causal links. “We do not conclude that this trial provides appropriate grounds for hesitating to use topical tretinoin in clinical practice,” they wrote in the Archives of Dermatology.

In an editorial comment accompanying the report, Dr. Lisa M. Schilling and Dr. Robert P. Dellavalle said that even though the investigators “chalk their results up as a chance finding,” debate about the safety of topical tretinoin will likely continue. Until further evidence emerges to definitively establish the safety or harmfulness of the treatment, physicians should “at a minimum” discuss the VATTC results with their patients who use tretinoin cream—particularly with elderly men, who composed the bulk of the study population.

“This dialogue should include that the results of the VATTC may have been due to chance, but also that the outcome of death was not initially anticipated,” Dr. Schilling and Dr. Dellavalle noted. In addition, “owing to the ad hoc analysis, various important risk factors, such as smoking status, might not have been completely ascertained.”

In their post hoc study, Dr. Weinstock and his associates at six VA medical centers randomly assigned 566 patients to use tretinoin 0.1% cream on the face and ears once or twice daily, and 565 patients to use only the vehicle cream as a control. The mean patient age was 71 years, and 97% were men.

Six months before the scheduled end of the trial, the intervention was terminated because of a statistically significant excess of deaths at that time (82 deaths) in the treatment group, compared with the control group (53 deaths). More deaths were later identified, for a total of 122 in the intervention group and 90 in the control group.

The VATTC trial data showed no dose-response relationship between exposure to topical tretinoin and death risk, as well as no interaction between the medication and smoking in mediating mortality risk. Moreover, “we found it difficult to construct biologically plausible mechanisms that would explain a direct causal link … and we were unable to conceive of a plausible mechanism by which tretinoin could indirectly lead to a fatal outcome,” they wrote (Arch. Dermatol. 2009;145:18–24).

That implausibility, together with “lack of specificity of causes of death, inconsistency with previous experience, weakness of other supportive evidence in our data, and weak statistical signal” led the researchers to their conclusions.

In their editorial comment, Dr. Schilling and Dr. Dellavalle of the VA Medical Center in Denver noted that, unlike other researchers, Dr. Weinstock and the VATTC investigators publicized their unexpected mortality data (Arch. Dermatol. 2009;145:76).

“We highly commend Weinstock et al. for reporting and highlighting these results,” they said.

Dr. Weinstock has received support from Galderma Laboratories L.P., Johnson & Johnson, and Ligand Pharmaceuticals Inc.

This trial does not provide appropriate grounds for hesitating to use topical tretinoin in clinical practice. DR. WEINSTOCK

A recently reported association between topical tretinoin and increased mortality is not causal and most likely is due to chance, according to a report.

The interim finding of an unexpected rise in lung cancer incidence and all-cause mortality prompted the premature halt of the Department of Veterans Affairs Topical Tretinoin Chemoprevention (VATTC) trial, a large 6-year study designed to determine whether the treatment could prevent basal and squamous cell skin cancers in patients who already had at least two such keratinocyte carcinomas. Increased lung cancer incidence and mortality had previously been reported with systemically administered compounds closely related to tretinoin.

Dr. Martin A. Weinstock of the Providence (R.I.) VA Medical Center, and his associates in the VATTC trial conducted a post hoc analysis of the mortality data and confirmed an association with mortality—but no definitive causal links. “We do not conclude that this trial provides appropriate grounds for hesitating to use topical tretinoin in clinical practice,” they wrote in the Archives of Dermatology.

In an editorial comment accompanying the report, Dr. Lisa M. Schilling and Dr. Robert P. Dellavalle said that even though the investigators “chalk their results up as a chance finding,” debate about the safety of topical tretinoin will likely continue. Until further evidence emerges to definitively establish the safety or harmfulness of the treatment, physicians should “at a minimum” discuss the VATTC results with their patients who use tretinoin cream—particularly with elderly men, who composed the bulk of the study population.

“This dialogue should include that the results of the VATTC may have been due to chance, but also that the outcome of death was not initially anticipated,” Dr. Schilling and Dr. Dellavalle noted. In addition, “owing to the ad hoc analysis, various important risk factors, such as smoking status, might not have been completely ascertained.”

In their post hoc study, Dr. Weinstock and his associates at six VA medical centers randomly assigned 566 patients to use tretinoin 0.1% cream on the face and ears once or twice daily, and 565 patients to use only the vehicle cream as a control. The mean patient age was 71 years, and 97% were men.

Six months before the scheduled end of the trial, the intervention was terminated because of a statistically significant excess of deaths at that time (82 deaths) in the treatment group, compared with the control group (53 deaths). More deaths were later identified, for a total of 122 in the intervention group and 90 in the control group.

The VATTC trial data showed no dose-response relationship between exposure to topical tretinoin and death risk, as well as no interaction between the medication and smoking in mediating mortality risk. Moreover, “we found it difficult to construct biologically plausible mechanisms that would explain a direct causal link … and we were unable to conceive of a plausible mechanism by which tretinoin could indirectly lead to a fatal outcome,” they wrote (Arch. Dermatol. 2009;145:18–24).

That implausibility, together with “lack of specificity of causes of death, inconsistency with previous experience, weakness of other supportive evidence in our data, and weak statistical signal” led the researchers to their conclusions.

In their editorial comment, Dr. Schilling and Dr. Dellavalle of the VA Medical Center in Denver noted that, unlike other researchers, Dr. Weinstock and the VATTC investigators publicized their unexpected mortality data (Arch. Dermatol. 2009;145:76).

“We highly commend Weinstock et al. for reporting and highlighting these results,” they said.

Dr. Weinstock has received support from Galderma Laboratories L.P., Johnson & Johnson, and Ligand Pharmaceuticals Inc.

This trial does not provide appropriate grounds for hesitating to use topical tretinoin in clinical practice. DR. WEINSTOCK

A recently reported association between topical tretinoin and increased mortality is not causal and most likely is due to chance, according to a report.

The interim finding of an unexpected rise in lung cancer incidence and all-cause mortality prompted the premature halt of the Department of Veterans Affairs Topical Tretinoin Chemoprevention (VATTC) trial, a large 6-year study designed to determine whether the treatment could prevent basal and squamous cell skin cancers in patients who already had at least two such keratinocyte carcinomas. Increased lung cancer incidence and mortality had previously been reported with systemically administered compounds closely related to tretinoin.

Dr. Martin A. Weinstock of the Providence (R.I.) VA Medical Center, and his associates in the VATTC trial conducted a post hoc analysis of the mortality data and confirmed an association with mortality—but no definitive causal links. “We do not conclude that this trial provides appropriate grounds for hesitating to use topical tretinoin in clinical practice,” they wrote in the Archives of Dermatology.

In an editorial comment accompanying the report, Dr. Lisa M. Schilling and Dr. Robert P. Dellavalle said that even though the investigators “chalk their results up as a chance finding,” debate about the safety of topical tretinoin will likely continue. Until further evidence emerges to definitively establish the safety or harmfulness of the treatment, physicians should “at a minimum” discuss the VATTC results with their patients who use tretinoin cream—particularly with elderly men, who composed the bulk of the study population.

“This dialogue should include that the results of the VATTC may have been due to chance, but also that the outcome of death was not initially anticipated,” Dr. Schilling and Dr. Dellavalle noted. In addition, “owing to the ad hoc analysis, various important risk factors, such as smoking status, might not have been completely ascertained.”

In their post hoc study, Dr. Weinstock and his associates at six VA medical centers randomly assigned 566 patients to use tretinoin 0.1% cream on the face and ears once or twice daily, and 565 patients to use only the vehicle cream as a control. The mean patient age was 71 years, and 97% were men.

Six months before the scheduled end of the trial, the intervention was terminated because of a statistically significant excess of deaths at that time (82 deaths) in the treatment group, compared with the control group (53 deaths). More deaths were later identified, for a total of 122 in the intervention group and 90 in the control group.

The VATTC trial data showed no dose-response relationship between exposure to topical tretinoin and death risk, as well as no interaction between the medication and smoking in mediating mortality risk. Moreover, “we found it difficult to construct biologically plausible mechanisms that would explain a direct causal link … and we were unable to conceive of a plausible mechanism by which tretinoin could indirectly lead to a fatal outcome,” they wrote (Arch. Dermatol. 2009;145:18–24).

That implausibility, together with “lack of specificity of causes of death, inconsistency with previous experience, weakness of other supportive evidence in our data, and weak statistical signal” led the researchers to their conclusions.

In their editorial comment, Dr. Schilling and Dr. Dellavalle of the VA Medical Center in Denver noted that, unlike other researchers, Dr. Weinstock and the VATTC investigators publicized their unexpected mortality data (Arch. Dermatol. 2009;145:76).

“We highly commend Weinstock et al. for reporting and highlighting these results,” they said.

Dr. Weinstock has received support from Galderma Laboratories L.P., Johnson & Johnson, and Ligand Pharmaceuticals Inc.

This trial does not provide appropriate grounds for hesitating to use topical tretinoin in clinical practice. DR. WEINSTOCK

Most young women who received chest radiation for childhood cancer are not being appropriately screened for breast cancer, despite their high risk.

The primary barrier to screening is not a lack of medical contact; rather, it is that their physicians do not advise them to get mammography, most likely because they are not aware of these patients' high risk, said Dr. Kevin C. Oeffinger of Memorial Sloan-Kettering Cancer Center, New York, and his associates.

Experts recommend that women who were treated with moderate- to high-dose chest radiation for a pediatric malignancy initiate breast cancer surveillance starting at age 25 years, or 8 years after undergoing radiotherapy, whichever comes last. The median age of breast cancer diagnosis in these patients is 32–35 years, and their previous exposure to radiation or anthracycline limits their treatment options.

There are an estimated 20,000–25,000 such women in the United States, and as many as 20% of female cancer survivors worldwide fall into this category.

Dr. Oeffinger and his colleagues studied breast cancer surveillance using the large, geographically diverse population of women participating in the Childhood Cancer Survivor Study. This study follows more than 9,000 cancer survivors who were diagnosed between 1970 and 1986.

A random sample of 551 CCSS participants now aged 25–50 years who received at least 20 Gy of chest radiation therapy as children were surveyed regarding breast cancer surveillance. Two comparison groups—561 CCSS subjects who had not undergone chest radiation and 622 siblings of CCSS subjects who had never had cancer—also were assessed.

Nearly half of the women under age 40 years who had been exposed to pediatric radiotherapy had never had a mammogram, and only 23% had undergone mammography within the preceding year. This “much lower than expected” rate was still somewhat higher than the rates in the CCSS siblings (11%) and the cancer survivors who had not undergone chest radiotherapy (15%). Only one-third of the high-risk women said that their physicians had advised mammography (JAMA 2009;301:404–14).

Most young women who received chest radiation for childhood cancer are not being appropriately screened for breast cancer, despite their high risk.

The primary barrier to screening is not a lack of medical contact; rather, it is that their physicians do not advise them to get mammography, most likely because they are not aware of these patients' high risk, said Dr. Kevin C. Oeffinger of Memorial Sloan-Kettering Cancer Center, New York, and his associates.

Experts recommend that women who were treated with moderate- to high-dose chest radiation for a pediatric malignancy initiate breast cancer surveillance starting at age 25 years, or 8 years after undergoing radiotherapy, whichever comes last. The median age of breast cancer diagnosis in these patients is 32–35 years, and their previous exposure to radiation or anthracycline limits their treatment options.

There are an estimated 20,000–25,000 such women in the United States, and as many as 20% of female cancer survivors worldwide fall into this category.

Dr. Oeffinger and his colleagues studied breast cancer surveillance using the large, geographically diverse population of women participating in the Childhood Cancer Survivor Study. This study follows more than 9,000 cancer survivors who were diagnosed between 1970 and 1986.

A random sample of 551 CCSS participants now aged 25–50 years who received at least 20 Gy of chest radiation therapy as children were surveyed regarding breast cancer surveillance. Two comparison groups—561 CCSS subjects who had not undergone chest radiation and 622 siblings of CCSS subjects who had never had cancer—also were assessed.

Nearly half of the women under age 40 years who had been exposed to pediatric radiotherapy had never had a mammogram, and only 23% had undergone mammography within the preceding year. This “much lower than expected” rate was still somewhat higher than the rates in the CCSS siblings (11%) and the cancer survivors who had not undergone chest radiotherapy (15%). Only one-third of the high-risk women said that their physicians had advised mammography (JAMA 2009;301:404–14).

Most young women who received chest radiation for childhood cancer are not being appropriately screened for breast cancer, despite their high risk.

The primary barrier to screening is not a lack of medical contact; rather, it is that their physicians do not advise them to get mammography, most likely because they are not aware of these patients' high risk, said Dr. Kevin C. Oeffinger of Memorial Sloan-Kettering Cancer Center, New York, and his associates.

Experts recommend that women who were treated with moderate- to high-dose chest radiation for a pediatric malignancy initiate breast cancer surveillance starting at age 25 years, or 8 years after undergoing radiotherapy, whichever comes last. The median age of breast cancer diagnosis in these patients is 32–35 years, and their previous exposure to radiation or anthracycline limits their treatment options.

There are an estimated 20,000–25,000 such women in the United States, and as many as 20% of female cancer survivors worldwide fall into this category.

Dr. Oeffinger and his colleagues studied breast cancer surveillance using the large, geographically diverse population of women participating in the Childhood Cancer Survivor Study. This study follows more than 9,000 cancer survivors who were diagnosed between 1970 and 1986.

A random sample of 551 CCSS participants now aged 25–50 years who received at least 20 Gy of chest radiation therapy as children were surveyed regarding breast cancer surveillance. Two comparison groups—561 CCSS subjects who had not undergone chest radiation and 622 siblings of CCSS subjects who had never had cancer—also were assessed.

Nearly half of the women under age 40 years who had been exposed to pediatric radiotherapy had never had a mammogram, and only 23% had undergone mammography within the preceding year. This “much lower than expected” rate was still somewhat higher than the rates in the CCSS siblings (11%) and the cancer survivors who had not undergone chest radiotherapy (15%). Only one-third of the high-risk women said that their physicians had advised mammography (JAMA 2009;301:404–14).

The number of pediatric head-and-neck infections caused by methicillin-resistant Staphylococcus aureus shot up at an “alarming” rate across the United States between 2001 and 2006.

Sixty percent of these methicillin-resistant S. aureus (MRSA) cases were community acquired rather than nosocomial, and nearly half were resistant to clindamycin—reversals of the patterns that these infections have shown until now.

Dr. Iman Naseri of the department of otolaryngology, head and neck surgery, at Emory University, Atlanta, and associates used a national microbiology database to assess trends in MRSA prevalence. It includes strain-specific antimicrobial drug resistance test results from laboratories serving more than 300 hospitals.

They reviewed reports on 21,009 patients aged 0–18 years (mean, 7 years) whose head and neck infections were cultured between 2001 and 2006. The cultures were taken from the oropharynx/neck (60%), nasal or sinus cavity (38%), and middle or external ear (2%).

Overall, 4,534 samples (22%) were infected with MRSA. In 2001, about 12% of S. aureus infections were methicillin resistant. This proportion rose steadily during the 5 years of the study to more than 28% (Arch. of Otolaryngol. Head Neck Surg. 2009;135:14–6).

The highest rate of infection occurred in the otologic cultures, which also had the highest prevalence of clindamycin resistance of the three sites.

The number of pediatric head-and-neck infections caused by methicillin-resistant Staphylococcus aureus shot up at an “alarming” rate across the United States between 2001 and 2006.

Sixty percent of these methicillin-resistant S. aureus (MRSA) cases were community acquired rather than nosocomial, and nearly half were resistant to clindamycin—reversals of the patterns that these infections have shown until now.

Dr. Iman Naseri of the department of otolaryngology, head and neck surgery, at Emory University, Atlanta, and associates used a national microbiology database to assess trends in MRSA prevalence. It includes strain-specific antimicrobial drug resistance test results from laboratories serving more than 300 hospitals.

They reviewed reports on 21,009 patients aged 0–18 years (mean, 7 years) whose head and neck infections were cultured between 2001 and 2006. The cultures were taken from the oropharynx/neck (60%), nasal or sinus cavity (38%), and middle or external ear (2%).

Overall, 4,534 samples (22%) were infected with MRSA. In 2001, about 12% of S. aureus infections were methicillin resistant. This proportion rose steadily during the 5 years of the study to more than 28% (Arch. of Otolaryngol. Head Neck Surg. 2009;135:14–6).

The highest rate of infection occurred in the otologic cultures, which also had the highest prevalence of clindamycin resistance of the three sites.

The number of pediatric head-and-neck infections caused by methicillin-resistant Staphylococcus aureus shot up at an “alarming” rate across the United States between 2001 and 2006.

Sixty percent of these methicillin-resistant S. aureus (MRSA) cases were community acquired rather than nosocomial, and nearly half were resistant to clindamycin—reversals of the patterns that these infections have shown until now.

Dr. Iman Naseri of the department of otolaryngology, head and neck surgery, at Emory University, Atlanta, and associates used a national microbiology database to assess trends in MRSA prevalence. It includes strain-specific antimicrobial drug resistance test results from laboratories serving more than 300 hospitals.

They reviewed reports on 21,009 patients aged 0–18 years (mean, 7 years) whose head and neck infections were cultured between 2001 and 2006. The cultures were taken from the oropharynx/neck (60%), nasal or sinus cavity (38%), and middle or external ear (2%).

Overall, 4,534 samples (22%) were infected with MRSA. In 2001, about 12% of S. aureus infections were methicillin resistant. This proportion rose steadily during the 5 years of the study to more than 28% (Arch. of Otolaryngol. Head Neck Surg. 2009;135:14–6).

The highest rate of infection occurred in the otologic cultures, which also had the highest prevalence of clindamycin resistance of the three sites.

The combination of aerobic and resistance exercise markedly reduced insulin resistance in older patients who had abdominal obesity, according to a report in the Archives of Internal Medicine.

Doing 90 minutes of moderate-intensity aerobic exercise combined with 60 minutes of resistance exercise 3 days per week also improved functional limitations, decreased abdominal and visceral fat, increased skeletal muscle mass, and improved cardiorespiratory fitness in these patients, staving off both disease and disability.

“It is difficult to imagine a more effective strategy for improving overall health in the elderly,” said Lance E. Davidson, Ph.D., of Queen's University, Kingston, Ont., and his associates.

The researchers conducted what they described as the first randomized controlled trial to assess the effects of aerobic and resistance exercise, alone and in combination, on insulin resistance in older nondiabetic subjects. The 6-month study involved 117 sedentary, abdominally obese men and women aged 60–80 years.

The study subjects were assigned to do aerobic exercise only, resistance exercise only, a combination of the two, or no exercise (control group). All exercise sessions were done under direct supervision and included heart rate monitoring.

The aerobic exercise group showed an “impressive” (31%) improvement in insulin resistance, comparable to the exercise response reported for younger adults. The drop in insulin resistance was even better (43%) in the aerobic-plus-resistance exercise group, Dr. Davidson and his colleagues said (Arch. Intern. Med. 2009;169:122–31).

Similarly, functional limitations—including the ability to rise from a chair and the number of steps that could be taken within 2 minutes—improved in all the exercise groups; the increase was greatest in the combined exercise group.

Total body fat and abdominal fat decreased with both aerobic exercise alone and aerobic-plus-resistance exercise, but not with resistance exercise alone. Conversely, skeletal muscle mass, as well as the ratio of fat to skeletal muscle mass, improved with resistance exercise and combined exercise but not with aerobic exercise alone.

These findings “lend empirical support to the recently revised public health guidelines for physical activity in older adults endorsed by the American Heart Association and the American College of Sports Medicine,” the investigators said.

Moreover, since an estimated 62% of elderly women and 74% of elderly men in the United States have abdominal obesity, “it is likely that a sizable proportion of the older adult population would benefit from the exercise modalities studied,” they added.

Aerobic exercise helped decrease both abdominal fat and total body fat, the study found. ©PhotoDisc

The combination of aerobic and resistance exercise markedly reduced insulin resistance in older patients who had abdominal obesity, according to a report in the Archives of Internal Medicine.

Doing 90 minutes of moderate-intensity aerobic exercise combined with 60 minutes of resistance exercise 3 days per week also improved functional limitations, decreased abdominal and visceral fat, increased skeletal muscle mass, and improved cardiorespiratory fitness in these patients, staving off both disease and disability.

“It is difficult to imagine a more effective strategy for improving overall health in the elderly,” said Lance E. Davidson, Ph.D., of Queen's University, Kingston, Ont., and his associates.

The researchers conducted what they described as the first randomized controlled trial to assess the effects of aerobic and resistance exercise, alone and in combination, on insulin resistance in older nondiabetic subjects. The 6-month study involved 117 sedentary, abdominally obese men and women aged 60–80 years.

The study subjects were assigned to do aerobic exercise only, resistance exercise only, a combination of the two, or no exercise (control group). All exercise sessions were done under direct supervision and included heart rate monitoring.

The aerobic exercise group showed an “impressive” (31%) improvement in insulin resistance, comparable to the exercise response reported for younger adults. The drop in insulin resistance was even better (43%) in the aerobic-plus-resistance exercise group, Dr. Davidson and his colleagues said (Arch. Intern. Med. 2009;169:122–31).

Similarly, functional limitations—including the ability to rise from a chair and the number of steps that could be taken within 2 minutes—improved in all the exercise groups; the increase was greatest in the combined exercise group.

Total body fat and abdominal fat decreased with both aerobic exercise alone and aerobic-plus-resistance exercise, but not with resistance exercise alone. Conversely, skeletal muscle mass, as well as the ratio of fat to skeletal muscle mass, improved with resistance exercise and combined exercise but not with aerobic exercise alone.

These findings “lend empirical support to the recently revised public health guidelines for physical activity in older adults endorsed by the American Heart Association and the American College of Sports Medicine,” the investigators said.

Moreover, since an estimated 62% of elderly women and 74% of elderly men in the United States have abdominal obesity, “it is likely that a sizable proportion of the older adult population would benefit from the exercise modalities studied,” they added.

Aerobic exercise helped decrease both abdominal fat and total body fat, the study found. ©PhotoDisc

The combination of aerobic and resistance exercise markedly reduced insulin resistance in older patients who had abdominal obesity, according to a report in the Archives of Internal Medicine.

Doing 90 minutes of moderate-intensity aerobic exercise combined with 60 minutes of resistance exercise 3 days per week also improved functional limitations, decreased abdominal and visceral fat, increased skeletal muscle mass, and improved cardiorespiratory fitness in these patients, staving off both disease and disability.

“It is difficult to imagine a more effective strategy for improving overall health in the elderly,” said Lance E. Davidson, Ph.D., of Queen's University, Kingston, Ont., and his associates.

The researchers conducted what they described as the first randomized controlled trial to assess the effects of aerobic and resistance exercise, alone and in combination, on insulin resistance in older nondiabetic subjects. The 6-month study involved 117 sedentary, abdominally obese men and women aged 60–80 years.

The study subjects were assigned to do aerobic exercise only, resistance exercise only, a combination of the two, or no exercise (control group). All exercise sessions were done under direct supervision and included heart rate monitoring.

The aerobic exercise group showed an “impressive” (31%) improvement in insulin resistance, comparable to the exercise response reported for younger adults. The drop in insulin resistance was even better (43%) in the aerobic-plus-resistance exercise group, Dr. Davidson and his colleagues said (Arch. Intern. Med. 2009;169:122–31).

Similarly, functional limitations—including the ability to rise from a chair and the number of steps that could be taken within 2 minutes—improved in all the exercise groups; the increase was greatest in the combined exercise group.

Total body fat and abdominal fat decreased with both aerobic exercise alone and aerobic-plus-resistance exercise, but not with resistance exercise alone. Conversely, skeletal muscle mass, as well as the ratio of fat to skeletal muscle mass, improved with resistance exercise and combined exercise but not with aerobic exercise alone.

These findings “lend empirical support to the recently revised public health guidelines for physical activity in older adults endorsed by the American Heart Association and the American College of Sports Medicine,” the investigators said.

Moreover, since an estimated 62% of elderly women and 74% of elderly men in the United States have abdominal obesity, “it is likely that a sizable proportion of the older adult population would benefit from the exercise modalities studied,” they added.

Aerobic exercise helped decrease both abdominal fat and total body fat, the study found. ©PhotoDisc

In most present-day middle-aged populations, the risk of developing type 2 diabetes is inversely related to birth weight, according to a report in JAMA.

In other words, adults at highest risk for type 2 diabetes had the lowest birth weights, independent of potentially confounding factors such as body size and socioeconomic status in adulthood, wrote Peter H. Whincup, Ph.D., of the University of London, and his associates.

However, this association may not hold true for long. It likely reflects fetal undernutrition during the mid-20th century. The current epidemic of overweight and obesity may well reverse this association, with people who had very high birth weights eventually showing a greater propensity to develop diabetes later in life, the researchers said.

The association between low birth weight and later development of diabetes has been known since the early 1990s, but the strength and consistency of the link and its independence from confounding factors has been questioned.

Dr. Whincup and associates performed a meta-analysis of 30 studies published between 1950 and early 2008 involving 6,090 cases of diabetes among 152,084 subjects (JAMA 2008;300:2886-97). Twenty-three of the 30 showed an inverse association between birth weight and later diabetes risk, and the association was statistically significant in 9 of them. Two involved Native American populations with exceptionally high prevalences of obesity, gestational diabetes, and type 2 diabetes. In these, birth weight showed a positive, not an inverse, correlation with later diabetes risk.

In most present-day middle-aged populations, the risk of developing type 2 diabetes is inversely related to birth weight, according to a report in JAMA.

In other words, adults at highest risk for type 2 diabetes had the lowest birth weights, independent of potentially confounding factors such as body size and socioeconomic status in adulthood, wrote Peter H. Whincup, Ph.D., of the University of London, and his associates.

However, this association may not hold true for long. It likely reflects fetal undernutrition during the mid-20th century. The current epidemic of overweight and obesity may well reverse this association, with people who had very high birth weights eventually showing a greater propensity to develop diabetes later in life, the researchers said.

The association between low birth weight and later development of diabetes has been known since the early 1990s, but the strength and consistency of the link and its independence from confounding factors has been questioned.

Dr. Whincup and associates performed a meta-analysis of 30 studies published between 1950 and early 2008 involving 6,090 cases of diabetes among 152,084 subjects (JAMA 2008;300:2886-97). Twenty-three of the 30 showed an inverse association between birth weight and later diabetes risk, and the association was statistically significant in 9 of them. Two involved Native American populations with exceptionally high prevalences of obesity, gestational diabetes, and type 2 diabetes. In these, birth weight showed a positive, not an inverse, correlation with later diabetes risk.

In most present-day middle-aged populations, the risk of developing type 2 diabetes is inversely related to birth weight, according to a report in JAMA.

In other words, adults at highest risk for type 2 diabetes had the lowest birth weights, independent of potentially confounding factors such as body size and socioeconomic status in adulthood, wrote Peter H. Whincup, Ph.D., of the University of London, and his associates.

However, this association may not hold true for long. It likely reflects fetal undernutrition during the mid-20th century. The current epidemic of overweight and obesity may well reverse this association, with people who had very high birth weights eventually showing a greater propensity to develop diabetes later in life, the researchers said.

The association between low birth weight and later development of diabetes has been known since the early 1990s, but the strength and consistency of the link and its independence from confounding factors has been questioned.

Dr. Whincup and associates performed a meta-analysis of 30 studies published between 1950 and early 2008 involving 6,090 cases of diabetes among 152,084 subjects (JAMA 2008;300:2886-97). Twenty-three of the 30 showed an inverse association between birth weight and later diabetes risk, and the association was statistically significant in 9 of them. Two involved Native American populations with exceptionally high prevalences of obesity, gestational diabetes, and type 2 diabetes. In these, birth weight showed a positive, not an inverse, correlation with later diabetes risk.

The use of a simple safety checklist dramatically reduced mortality and morbidity in a study of more than 7,600 consecutive surgery patients in diverse clinical settings around the world.

The 19-item checklist, which was based on the 2008 World Health Organization guidelines for improving the safety of surgical patients, cut the rate of postoperative complications by 36% on average, “and death rates fell by a similar amount,” said Dr. Alex B. Haynes of the Harvard School of Public Health, Boston, and his associates in the Safe Surgery Saves Lives study.

The overall complication rate decreased from 11% at baseline to 7% after introduction of the checklist, and in-hospital mortality decreased from 1.5% to 0.8%. Overall rates of surgical site infection and unplanned reoperation also markedly declined.

“Applied on a global basis, this checklist program has the potential to prevent large numbers of deaths and disabling complications,” the investigators noted.

The medical literature suggests that at least half of all surgical complications are avoidable. The investigators designed the checklist and assessed its use in a prospective study at eight hospitals in North America, Europe, Asia, the Middle East, and Africa.

Each hospital identified one to four operating rooms to serve as study rooms. Consecutive inpatients undergoing noncardiac surgery in those rooms were enrolled. The 3,733 patients who underwent surgery during a baseline period served as a comparison group for the 3,955 patients who underwent surgery after implementation of the checklist.

“The checklist consists of oral confirmation by surgical teams of the completion of the basic steps for ensuring safe delivery of anesthesia, prophylaxis against infection, effective teamwork, and other essential practices in surgery,” and is used before anesthesia is administered, immediately before incision, and before the patient is removed from the operating room, according to the investigators.

They evaluated adherence to a subgroup of six key safety measures as a gauge of overall adherence: objective assessment of the patient's airway status; use of pulse oximetry at initiation of anesthesia; presence of at least two peripheral IV lines or a central venous line before incision in cases where blood loss was expected to be 500 mL or more; administration of prophylactic antibiotics within 1 hour before incision; oral confirmation of the patient's identity, the operative site, and the procedure to be performed, before commencing; and completion of a sponge count at the end of the operation.

After the intervention was implemented, it was still commonplace for some of the 19 individual steps in the checklist to be omitted. However, adherence to the key safety indicators increased by two-thirds. Appropriate use of prophylactic antibiotics, for example, rose from 56% to 83%, a single change that could reduce the rate of surgical site infection by as much as 88%, Dr. Haynes and his associates noted.

These “substantial and robust” improvements were seen at every study site, at high-income as well as low-income locations, the investigators said (doi:10.1056/NEJMsa0810119).

Implementation of the checklist should be very feasible, since it was “neither costly nor lengthy. All sites were able to introduce the checklist over a period of 1 week to 1 month.” Moreover, only two items on the checklist were potentially expensive: the use of pulse oximetry and the use of prophylactic antibiotics. Both of these were available at all the study sites before the intervention but had not been used consistently, Dr. Haynes and his colleagues said.

The use of a simple safety checklist dramatically reduced mortality and morbidity in a study of more than 7,600 consecutive surgery patients in diverse clinical settings around the world.

The 19-item checklist, which was based on the 2008 World Health Organization guidelines for improving the safety of surgical patients, cut the rate of postoperative complications by 36% on average, “and death rates fell by a similar amount,” said Dr. Alex B. Haynes of the Harvard School of Public Health, Boston, and his associates in the Safe Surgery Saves Lives study.

The overall complication rate decreased from 11% at baseline to 7% after introduction of the checklist, and in-hospital mortality decreased from 1.5% to 0.8%. Overall rates of surgical site infection and unplanned reoperation also markedly declined.

“Applied on a global basis, this checklist program has the potential to prevent large numbers of deaths and disabling complications,” the investigators noted.

The medical literature suggests that at least half of all surgical complications are avoidable. The investigators designed the checklist and assessed its use in a prospective study at eight hospitals in North America, Europe, Asia, the Middle East, and Africa.

Each hospital identified one to four operating rooms to serve as study rooms. Consecutive inpatients undergoing noncardiac surgery in those rooms were enrolled. The 3,733 patients who underwent surgery during a baseline period served as a comparison group for the 3,955 patients who underwent surgery after implementation of the checklist.

“The checklist consists of oral confirmation by surgical teams of the completion of the basic steps for ensuring safe delivery of anesthesia, prophylaxis against infection, effective teamwork, and other essential practices in surgery,” and is used before anesthesia is administered, immediately before incision, and before the patient is removed from the operating room, according to the investigators.

They evaluated adherence to a subgroup of six key safety measures as a gauge of overall adherence: objective assessment of the patient's airway status; use of pulse oximetry at initiation of anesthesia; presence of at least two peripheral IV lines or a central venous line before incision in cases where blood loss was expected to be 500 mL or more; administration of prophylactic antibiotics within 1 hour before incision; oral confirmation of the patient's identity, the operative site, and the procedure to be performed, before commencing; and completion of a sponge count at the end of the operation.

After the intervention was implemented, it was still commonplace for some of the 19 individual steps in the checklist to be omitted. However, adherence to the key safety indicators increased by two-thirds. Appropriate use of prophylactic antibiotics, for example, rose from 56% to 83%, a single change that could reduce the rate of surgical site infection by as much as 88%, Dr. Haynes and his associates noted.

These “substantial and robust” improvements were seen at every study site, at high-income as well as low-income locations, the investigators said (doi:10.1056/NEJMsa0810119).

Implementation of the checklist should be very feasible, since it was “neither costly nor lengthy. All sites were able to introduce the checklist over a period of 1 week to 1 month.” Moreover, only two items on the checklist were potentially expensive: the use of pulse oximetry and the use of prophylactic antibiotics. Both of these were available at all the study sites before the intervention but had not been used consistently, Dr. Haynes and his colleagues said.

The use of a simple safety checklist dramatically reduced mortality and morbidity in a study of more than 7,600 consecutive surgery patients in diverse clinical settings around the world.

The 19-item checklist, which was based on the 2008 World Health Organization guidelines for improving the safety of surgical patients, cut the rate of postoperative complications by 36% on average, “and death rates fell by a similar amount,” said Dr. Alex B. Haynes of the Harvard School of Public Health, Boston, and his associates in the Safe Surgery Saves Lives study.

The overall complication rate decreased from 11% at baseline to 7% after introduction of the checklist, and in-hospital mortality decreased from 1.5% to 0.8%. Overall rates of surgical site infection and unplanned reoperation also markedly declined.

“Applied on a global basis, this checklist program has the potential to prevent large numbers of deaths and disabling complications,” the investigators noted.

The medical literature suggests that at least half of all surgical complications are avoidable. The investigators designed the checklist and assessed its use in a prospective study at eight hospitals in North America, Europe, Asia, the Middle East, and Africa.

Each hospital identified one to four operating rooms to serve as study rooms. Consecutive inpatients undergoing noncardiac surgery in those rooms were enrolled. The 3,733 patients who underwent surgery during a baseline period served as a comparison group for the 3,955 patients who underwent surgery after implementation of the checklist.

“The checklist consists of oral confirmation by surgical teams of the completion of the basic steps for ensuring safe delivery of anesthesia, prophylaxis against infection, effective teamwork, and other essential practices in surgery,” and is used before anesthesia is administered, immediately before incision, and before the patient is removed from the operating room, according to the investigators.

They evaluated adherence to a subgroup of six key safety measures as a gauge of overall adherence: objective assessment of the patient's airway status; use of pulse oximetry at initiation of anesthesia; presence of at least two peripheral IV lines or a central venous line before incision in cases where blood loss was expected to be 500 mL or more; administration of prophylactic antibiotics within 1 hour before incision; oral confirmation of the patient's identity, the operative site, and the procedure to be performed, before commencing; and completion of a sponge count at the end of the operation.

After the intervention was implemented, it was still commonplace for some of the 19 individual steps in the checklist to be omitted. However, adherence to the key safety indicators increased by two-thirds. Appropriate use of prophylactic antibiotics, for example, rose from 56% to 83%, a single change that could reduce the rate of surgical site infection by as much as 88%, Dr. Haynes and his associates noted.

These “substantial and robust” improvements were seen at every study site, at high-income as well as low-income locations, the investigators said (doi:10.1056/NEJMsa0810119).

Implementation of the checklist should be very feasible, since it was “neither costly nor lengthy. All sites were able to introduce the checklist over a period of 1 week to 1 month.” Moreover, only two items on the checklist were potentially expensive: the use of pulse oximetry and the use of prophylactic antibiotics. Both of these were available at all the study sites before the intervention but had not been used consistently, Dr. Haynes and his colleagues said.

An estimated 50,000 women of childbearing age undergo inpatient bariatric surgery each year, and an unknown number have outpatient bariatric procedures, according to a report in the Journal of the American Medical Association.

Unfortunately, data about the surgery's effects on pregnancy, fertility, and contraception are still so limited that researchers are precluded from drawing firm conclusions and clinicians cannot make informed decisions regarding these patients, said Dr. Melinda A. Maggard of the Rand Corp., Santa Monica, Calif., and her associates.

The investigators used data from a national health care sample to assess trends in inpatient bariatric surgeries between 1998 and 2005, the most recent year for which information was available. This sample included data on up to 8 million hospitalizations at approximately 1,000 medical centers.

Outpatient bariatric surgeries were not assessed in this study.

The rate of inpatient bariatric procedures—laparoscopic adjustable gastric banding, vertical-banded gastroplasty, Roux-en-Y gastric bypass, and biliopancreatic diversion/duodenal switch—increased by 800% during this interval, from just more than 12,000 to more than 113,500 cases annually.

From 2003 to 2005, women of childbearing age (ages 18–45) accounted for around half of these surgeries (50,000) annually.

Dr. Maggard and her colleagues also reviewed 75 studies in the literature that compared ob.gyn. data between women who underwent bariatric surgery and those who did not.

“The available evidence suggests that risks for maternal complications, such as gestational diabetes and preeclampsia, may be lower following surgically induced weight loss than the risks in obese women, and may approach community rates,” they said (JAMA 2008;300:2286–96).

However, there have been 20 reports of complications during pregnancy that were directly related to the bariatric surgery, including bowel obstructions, band malfunctions, ulcers, and staple-line stricture. Three mothers and five neonates in these cases died.

Bariatric surgery doesn't appear to strongly influence the rate of cesarean deliveries or that of delivery complications such as blood loss or operative injury.

However, few studies have assessed such outcomes in this patient population, the researchers wrote.

Neonatal complications such as preterm delivery and low birth weight may be less common in pregnancies following bariatric surgery.

Similarly, neonatal outcomes such as macrosomia appear to be less frequent. However, the rate of miscarriage appears to be higher in women who have undergone bariatric surgery than in those who have not.

Moreover, two studies reported higher than expected rates of neural tube defects in neonates of women who had undergone bariatric surgery, possibly related to the mothers' noncompliance with vitamin supplementation.

Nutritional problems during these pregnancies seem to be uncommon and, like neural tube defects, are often attributed to the women's noncompliance with taking the recommended nutritional supplements.

Most studies of fertility after bariatric surgery were small and incomplete, the researchers reported. However, their results suggested that the procedures normalized hormone levels and menstrual irregularities, thus improving fertility.

Dr. Maggard and her associates also reported finding that no randomized trials have yet explored the theoretical possibility that bariatric surgery impairs absorption of oral contraceptives, rendering them less effective.

Risks for maternal complications may be lower following surgically induced weight loss. DR. MAGGARD

An estimated 50,000 women of childbearing age undergo inpatient bariatric surgery each year, and an unknown number have outpatient bariatric procedures, according to a report in the Journal of the American Medical Association.

Unfortunately, data about the surgery's effects on pregnancy, fertility, and contraception are still so limited that researchers are precluded from drawing firm conclusions and clinicians cannot make informed decisions regarding these patients, said Dr. Melinda A. Maggard of the Rand Corp., Santa Monica, Calif., and her associates.

The investigators used data from a national health care sample to assess trends in inpatient bariatric surgeries between 1998 and 2005, the most recent year for which information was available. This sample included data on up to 8 million hospitalizations at approximately 1,000 medical centers.

Outpatient bariatric surgeries were not assessed in this study.

The rate of inpatient bariatric procedures—laparoscopic adjustable gastric banding, vertical-banded gastroplasty, Roux-en-Y gastric bypass, and biliopancreatic diversion/duodenal switch—increased by 800% during this interval, from just more than 12,000 to more than 113,500 cases annually.

From 2003 to 2005, women of childbearing age (ages 18–45) accounted for around half of these surgeries (50,000) annually.

Dr. Maggard and her colleagues also reviewed 75 studies in the literature that compared ob.gyn. data between women who underwent bariatric surgery and those who did not.

“The available evidence suggests that risks for maternal complications, such as gestational diabetes and preeclampsia, may be lower following surgically induced weight loss than the risks in obese women, and may approach community rates,” they said (JAMA 2008;300:2286–96).

However, there have been 20 reports of complications during pregnancy that were directly related to the bariatric surgery, including bowel obstructions, band malfunctions, ulcers, and staple-line stricture. Three mothers and five neonates in these cases died.

Bariatric surgery doesn't appear to strongly influence the rate of cesarean deliveries or that of delivery complications such as blood loss or operative injury.

However, few studies have assessed such outcomes in this patient population, the researchers wrote.

Neonatal complications such as preterm delivery and low birth weight may be less common in pregnancies following bariatric surgery.

Similarly, neonatal outcomes such as macrosomia appear to be less frequent. However, the rate of miscarriage appears to be higher in women who have undergone bariatric surgery than in those who have not.

Moreover, two studies reported higher than expected rates of neural tube defects in neonates of women who had undergone bariatric surgery, possibly related to the mothers' noncompliance with vitamin supplementation.

Nutritional problems during these pregnancies seem to be uncommon and, like neural tube defects, are often attributed to the women's noncompliance with taking the recommended nutritional supplements.

Most studies of fertility after bariatric surgery were small and incomplete, the researchers reported. However, their results suggested that the procedures normalized hormone levels and menstrual irregularities, thus improving fertility.

Dr. Maggard and her associates also reported finding that no randomized trials have yet explored the theoretical possibility that bariatric surgery impairs absorption of oral contraceptives, rendering them less effective.

Risks for maternal complications may be lower following surgically induced weight loss. DR. MAGGARD

An estimated 50,000 women of childbearing age undergo inpatient bariatric surgery each year, and an unknown number have outpatient bariatric procedures, according to a report in the Journal of the American Medical Association.

Unfortunately, data about the surgery's effects on pregnancy, fertility, and contraception are still so limited that researchers are precluded from drawing firm conclusions and clinicians cannot make informed decisions regarding these patients, said Dr. Melinda A. Maggard of the Rand Corp., Santa Monica, Calif., and her associates.

The investigators used data from a national health care sample to assess trends in inpatient bariatric surgeries between 1998 and 2005, the most recent year for which information was available. This sample included data on up to 8 million hospitalizations at approximately 1,000 medical centers.

Outpatient bariatric surgeries were not assessed in this study.

The rate of inpatient bariatric procedures—laparoscopic adjustable gastric banding, vertical-banded gastroplasty, Roux-en-Y gastric bypass, and biliopancreatic diversion/duodenal switch—increased by 800% during this interval, from just more than 12,000 to more than 113,500 cases annually.

From 2003 to 2005, women of childbearing age (ages 18–45) accounted for around half of these surgeries (50,000) annually.

Dr. Maggard and her colleagues also reviewed 75 studies in the literature that compared ob.gyn. data between women who underwent bariatric surgery and those who did not.

“The available evidence suggests that risks for maternal complications, such as gestational diabetes and preeclampsia, may be lower following surgically induced weight loss than the risks in obese women, and may approach community rates,” they said (JAMA 2008;300:2286–96).

However, there have been 20 reports of complications during pregnancy that were directly related to the bariatric surgery, including bowel obstructions, band malfunctions, ulcers, and staple-line stricture. Three mothers and five neonates in these cases died.

Bariatric surgery doesn't appear to strongly influence the rate of cesarean deliveries or that of delivery complications such as blood loss or operative injury.

However, few studies have assessed such outcomes in this patient population, the researchers wrote.

Neonatal complications such as preterm delivery and low birth weight may be less common in pregnancies following bariatric surgery.

Similarly, neonatal outcomes such as macrosomia appear to be less frequent. However, the rate of miscarriage appears to be higher in women who have undergone bariatric surgery than in those who have not.

Moreover, two studies reported higher than expected rates of neural tube defects in neonates of women who had undergone bariatric surgery, possibly related to the mothers' noncompliance with vitamin supplementation.

Nutritional problems during these pregnancies seem to be uncommon and, like neural tube defects, are often attributed to the women's noncompliance with taking the recommended nutritional supplements.

Most studies of fertility after bariatric surgery were small and incomplete, the researchers reported. However, their results suggested that the procedures normalized hormone levels and menstrual irregularities, thus improving fertility.

Dr. Maggard and her associates also reported finding that no randomized trials have yet explored the theoretical possibility that bariatric surgery impairs absorption of oral contraceptives, rendering them less effective.

Risks for maternal complications may be lower following surgically induced weight loss. DR. MAGGARD