Mary Ann Moon

The risk of serious medical and social disabilities in adulthood increases sharply with decreasing gestational age at birth, according to a report in the New England Journal of Medicine.

Even young adults who were born preterm but have no lingering medical disabilities are at high risk of failing to complete high school, earning a low income, and failing to marry or have children, said Dr. Dag Moster of the University of Bergen (Norway) and his associates.

The researchers assessed the relationship between gestational age at birth and outcomes in adulthood because “the increased prevalence of medical disabilities, learning difficulties, and behavioral and psychological problems among surviving preterm infants has raised concerns that these infants may have difficulties in coping with adult life.”

They examined the issue using data from compulsory national registries of birth, education, job-related income, disability payments, and criminal records, tracking a cohort of 867,692 people born during 1967-1983 and followed until when they were aged 20-36 years.

The risk of serious medical disabilities such as cerebral palsy, blindness or severely impaired vision, hearing loss, and epilepsy increased markedly with decreasing gestational age, as did the risk of mental retardation and psychological, behavioral, and emotional disorders.

“At 19-35 years of age, nearly 1 of 9 persons who had been born at 23-27 weeks of gestation received a disability pension, as compared with 1 of 12 who had been born at 28-30 weeks, 1 of 24 born at 31-33 weeks, 1 of 42 born at 34-36 weeks, and 1 of 59 born at term,” Dr. Moster and his associates said (N. Engl. J. Med. 2008;359:262-73).

Even when people with residual medical disabilities were excluded from the analysis, a lower gestational age at birth was associated with a reduced likelihood of completing high school or higher education and of earning a high income. It also was linked to a low likelihood of finding a life partner and of having children.

“We also observed a significant association of autism spectrum disorders with very low gestational age,” but “caution is warranted interpreting this finding given the small number of cases in the very premature groups,” the researchers noted.

These results are consistent with those of other studies showing a link between preterm birth and “specific difficulties in the areas of motor, cognitive, behavioral, psychological, and social function among preschool and school-aged children,” Dr. Moster and his colleagues said.

The adverse outcomes in adulthood “may represent long-term effects of subtle brain dysfunction caused by preterm birth,” or they may be related to biologic and social factors underlying both the preterm birth and its later sequelae, they added.

Despite their study's findings on disability prevalence, the researchers wrote, “It should be recognized that a large proportion of the adults who were born prematurely and did not have severe medical disabilities completed higher education and seem to be functioning well.”

The risk of serious medical and social disabilities in adulthood increases sharply with decreasing gestational age at birth, according to a report in the New England Journal of Medicine.

Even young adults who were born preterm but have no lingering medical disabilities are at high risk of failing to complete high school, earning a low income, and failing to marry or have children, said Dr. Dag Moster of the University of Bergen (Norway) and his associates.

The researchers assessed the relationship between gestational age at birth and outcomes in adulthood because “the increased prevalence of medical disabilities, learning difficulties, and behavioral and psychological problems among surviving preterm infants has raised concerns that these infants may have difficulties in coping with adult life.”

They examined the issue using data from compulsory national registries of birth, education, job-related income, disability payments, and criminal records, tracking a cohort of 867,692 people born during 1967-1983 and followed until when they were aged 20-36 years.

The risk of serious medical disabilities such as cerebral palsy, blindness or severely impaired vision, hearing loss, and epilepsy increased markedly with decreasing gestational age, as did the risk of mental retardation and psychological, behavioral, and emotional disorders.

“At 19-35 years of age, nearly 1 of 9 persons who had been born at 23-27 weeks of gestation received a disability pension, as compared with 1 of 12 who had been born at 28-30 weeks, 1 of 24 born at 31-33 weeks, 1 of 42 born at 34-36 weeks, and 1 of 59 born at term,” Dr. Moster and his associates said (N. Engl. J. Med. 2008;359:262-73).

Even when people with residual medical disabilities were excluded from the analysis, a lower gestational age at birth was associated with a reduced likelihood of completing high school or higher education and of earning a high income. It also was linked to a low likelihood of finding a life partner and of having children.

“We also observed a significant association of autism spectrum disorders with very low gestational age,” but “caution is warranted interpreting this finding given the small number of cases in the very premature groups,” the researchers noted.

These results are consistent with those of other studies showing a link between preterm birth and “specific difficulties in the areas of motor, cognitive, behavioral, psychological, and social function among preschool and school-aged children,” Dr. Moster and his colleagues said.

The adverse outcomes in adulthood “may represent long-term effects of subtle brain dysfunction caused by preterm birth,” or they may be related to biologic and social factors underlying both the preterm birth and its later sequelae, they added.

Despite their study's findings on disability prevalence, the researchers wrote, “It should be recognized that a large proportion of the adults who were born prematurely and did not have severe medical disabilities completed higher education and seem to be functioning well.”

The risk of serious medical and social disabilities in adulthood increases sharply with decreasing gestational age at birth, according to a report in the New England Journal of Medicine.

Even young adults who were born preterm but have no lingering medical disabilities are at high risk of failing to complete high school, earning a low income, and failing to marry or have children, said Dr. Dag Moster of the University of Bergen (Norway) and his associates.

The researchers assessed the relationship between gestational age at birth and outcomes in adulthood because “the increased prevalence of medical disabilities, learning difficulties, and behavioral and psychological problems among surviving preterm infants has raised concerns that these infants may have difficulties in coping with adult life.”

They examined the issue using data from compulsory national registries of birth, education, job-related income, disability payments, and criminal records, tracking a cohort of 867,692 people born during 1967-1983 and followed until when they were aged 20-36 years.

The risk of serious medical disabilities such as cerebral palsy, blindness or severely impaired vision, hearing loss, and epilepsy increased markedly with decreasing gestational age, as did the risk of mental retardation and psychological, behavioral, and emotional disorders.

“At 19-35 years of age, nearly 1 of 9 persons who had been born at 23-27 weeks of gestation received a disability pension, as compared with 1 of 12 who had been born at 28-30 weeks, 1 of 24 born at 31-33 weeks, 1 of 42 born at 34-36 weeks, and 1 of 59 born at term,” Dr. Moster and his associates said (N. Engl. J. Med. 2008;359:262-73).

Even when people with residual medical disabilities were excluded from the analysis, a lower gestational age at birth was associated with a reduced likelihood of completing high school or higher education and of earning a high income. It also was linked to a low likelihood of finding a life partner and of having children.

“We also observed a significant association of autism spectrum disorders with very low gestational age,” but “caution is warranted interpreting this finding given the small number of cases in the very premature groups,” the researchers noted.

These results are consistent with those of other studies showing a link between preterm birth and “specific difficulties in the areas of motor, cognitive, behavioral, psychological, and social function among preschool and school-aged children,” Dr. Moster and his colleagues said.

The adverse outcomes in adulthood “may represent long-term effects of subtle brain dysfunction caused by preterm birth,” or they may be related to biologic and social factors underlying both the preterm birth and its later sequelae, they added.

Despite their study's findings on disability prevalence, the researchers wrote, “It should be recognized that a large proportion of the adults who were born prematurely and did not have severe medical disabilities completed higher education and seem to be functioning well.”

Women who lose 10% or more of their body weight through diet and exercise must engage in 275 minutes per week of physical activity to maintain that weight loss beyond the initial 6 months, according to a report.

The level of physical activity needed to sustain weight loss over the long term “is about twice the public health recommendation” of 30 minutes of moderate-intensity activity on most days of the week, said Dr. John M. Jakicic of the University of Pittsburgh's Physical Activity and Weight Management Research Center and his associates.

They studied the effect of exercise on weight loss in 191 overweight women who participated in a 2-year intervention. They were aged 21-45 years, were sedentary, and had a body mass index of 27-40 kg/m

The women were prescribed a 1,500-calorie per day diet and were assigned to one of four levels of exercise. They attended weekly group meetings focused on strategies for modifying eating and exercise behaviors for the first 6 months of the intervention and monthly meetings thereafter. They also received brief periodic phone calls from the intervention team for support and encouragement.

A total of 170 subjects (89%) completed the full 2 years of the intervention. Weight loss and regain was similar across all categories of exercise intensity and duration.

As a group, they lost a mean of 8 kg by 6-month follow-up, then gradually regained about half of that amount so that the mean weight loss totaled 4.2 kg at 2 years.

Exercise followed the same pattern as weight fluctuation, increasing for the first 6 months of intervention and gradually decreasing over time. “The inability to sustain weight loss appears to mirror the inability to sustain physical activity,” said the authors (Arch. Intern. Med. 2008;168:1550-9).

Subjects who achieved and maintained a weight loss of 10% or more of their initial body weight—only 25% of the total—engaged in at least 1,800 kcal/wk of physical activity, which corresponds to 275 minutes a week above their baseline level of activity. The findings clarify the amount of physical activity necessary to achieve and sustain weight loss and demonstrate the difficulty women have in sustaining this level of activity, the authors added.

Women need 275 minutes of exercise a week to maintain their weight loss. ©Andres Rodriguez/

Women who lose 10% or more of their body weight through diet and exercise must engage in 275 minutes per week of physical activity to maintain that weight loss beyond the initial 6 months, according to a report.

The level of physical activity needed to sustain weight loss over the long term “is about twice the public health recommendation” of 30 minutes of moderate-intensity activity on most days of the week, said Dr. John M. Jakicic of the University of Pittsburgh's Physical Activity and Weight Management Research Center and his associates.

They studied the effect of exercise on weight loss in 191 overweight women who participated in a 2-year intervention. They were aged 21-45 years, were sedentary, and had a body mass index of 27-40 kg/m

The women were prescribed a 1,500-calorie per day diet and were assigned to one of four levels of exercise. They attended weekly group meetings focused on strategies for modifying eating and exercise behaviors for the first 6 months of the intervention and monthly meetings thereafter. They also received brief periodic phone calls from the intervention team for support and encouragement.

A total of 170 subjects (89%) completed the full 2 years of the intervention. Weight loss and regain was similar across all categories of exercise intensity and duration.

As a group, they lost a mean of 8 kg by 6-month follow-up, then gradually regained about half of that amount so that the mean weight loss totaled 4.2 kg at 2 years.

Exercise followed the same pattern as weight fluctuation, increasing for the first 6 months of intervention and gradually decreasing over time. “The inability to sustain weight loss appears to mirror the inability to sustain physical activity,” said the authors (Arch. Intern. Med. 2008;168:1550-9).

Subjects who achieved and maintained a weight loss of 10% or more of their initial body weight—only 25% of the total—engaged in at least 1,800 kcal/wk of physical activity, which corresponds to 275 minutes a week above their baseline level of activity. The findings clarify the amount of physical activity necessary to achieve and sustain weight loss and demonstrate the difficulty women have in sustaining this level of activity, the authors added.

Women need 275 minutes of exercise a week to maintain their weight loss. ©Andres Rodriguez/

Women who lose 10% or more of their body weight through diet and exercise must engage in 275 minutes per week of physical activity to maintain that weight loss beyond the initial 6 months, according to a report.

The level of physical activity needed to sustain weight loss over the long term “is about twice the public health recommendation” of 30 minutes of moderate-intensity activity on most days of the week, said Dr. John M. Jakicic of the University of Pittsburgh's Physical Activity and Weight Management Research Center and his associates.

They studied the effect of exercise on weight loss in 191 overweight women who participated in a 2-year intervention. They were aged 21-45 years, were sedentary, and had a body mass index of 27-40 kg/m

The women were prescribed a 1,500-calorie per day diet and were assigned to one of four levels of exercise. They attended weekly group meetings focused on strategies for modifying eating and exercise behaviors for the first 6 months of the intervention and monthly meetings thereafter. They also received brief periodic phone calls from the intervention team for support and encouragement.

A total of 170 subjects (89%) completed the full 2 years of the intervention. Weight loss and regain was similar across all categories of exercise intensity and duration.

As a group, they lost a mean of 8 kg by 6-month follow-up, then gradually regained about half of that amount so that the mean weight loss totaled 4.2 kg at 2 years.

Exercise followed the same pattern as weight fluctuation, increasing for the first 6 months of intervention and gradually decreasing over time. “The inability to sustain weight loss appears to mirror the inability to sustain physical activity,” said the authors (Arch. Intern. Med. 2008;168:1550-9).

Subjects who achieved and maintained a weight loss of 10% or more of their initial body weight—only 25% of the total—engaged in at least 1,800 kcal/wk of physical activity, which corresponds to 275 minutes a week above their baseline level of activity. The findings clarify the amount of physical activity necessary to achieve and sustain weight loss and demonstrate the difficulty women have in sustaining this level of activity, the authors added.

Women need 275 minutes of exercise a week to maintain their weight loss. ©Andres Rodriguez/

Pregnancy does not raise the risk of developing any of the most prevalent mental disorders, with the notable exception of postpartum depression, according to a report in the July issue of the Archives of General Psychiatry.

“Pregnancy is traditionally viewed as a stressful period that may provoke mental illness. However, [except for] major depressive disorder among postpartum women, rates of the most prevalent psychiatric disorders are not significantly higher and, in some cases, are even lower in pregnant and postpartum women than in nonpregnant women of childbearing age,” said Dr. Oriana Vesga-López of the New York State Psychiatric Institute and her associates.

Pregnant and postpartum women are widely considered to be vulnerable to psychiatric disorders, but no study to date has used methods that permit accurate estimation of the prevalence of a wide range of such disorders among pregnant women in the general U.S. population.

“Furthermore, we know of no previous study that included nonpregnant women of comparable age drawn from the general population to identify the specific contribution of pregnancy or the postpartum period to the risk of psychiatric disorders,” Dr. Vesga-López and her associates noted.

They studied the issue using a nationally representative sample of 43,093 adults surveyed in person as part of the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions conducted by professional lay interviewers in the U.S. Census Bureau.

This included nearly 15,000 women of childbearing age, of whom 453 were pregnant at the time of the survey, 994 were postpartum, and 13,025 were neither (“nonpregnant”).

The survey included a diagnostic interview to screen for self-reported Axis I diagnoses, including substance use, mood disorders, and anxiety disorders.

To gauge possible psychotic disorders, respondents were asked whether they had ever been told by a physician or other health professional that they had schizophrenia or a psychotic disorder.

The 1-year prevalence of psychiatric disorders ranged from 0.4% (psychotic disorders) to 14.6% (substance use disorders) in pregnant and postpartum subjects, compared with 0.3%-19.9% for the same diagnoses in nonpregnant women, the researchers said (Arch. Gen. Psychiatry 2008;65:805-15).

The prevalence of substance use was actually lower in pregnant and postpartum women than in nonpregnant women, and the prevalence of social anxiety disorder was markedly lower.

Factors that heightened the risk of psychiatric disorder in pregnant women included younger age, single marital status, recent exposure to traumatic or stressful life events, pregnancy complications, and poor overall health.

The presence of any of these factors should alert clinicians who treat women and their children that targeted intervention might be necessary, Dr. Vesga-López and her associates said.

Despite the relatively high prevalence of psychiatric disorders in both pregnant and nonpregnant women in this study, the rate of treatment for psychiatric disorders was “very low” in both groups. This finding was particularly striking in pregnant women, given their usual access to health care during and immediately after pregnancy.

“Their failure to receive psychiatric treatment suggests the existence of important barriers to mental health care for this population,” including the failure of clinicians to recognize psychiatric symptoms or to consider them a normal response to the physiologic and psychosocial changes of pregnancy, the investigators noted.

The researchers wrote that considering the importance of this period of life for mothers and their offspring, “urgent action is needed to increase detection and treatment of psychiatric disorders among pregnant and postpartum women in the United States.”

The study was funded by National Institutes of Health grants, and grants from the American Foundation for Suicide Prevention and the New York State Psychiatric Institute.

Dr. Vesga-López stated that she had no conflicts of interest to disclose.

Pregnancy does not raise the risk of developing any of the most prevalent mental disorders, with the notable exception of postpartum depression, according to a report in the July issue of the Archives of General Psychiatry.

“Pregnancy is traditionally viewed as a stressful period that may provoke mental illness. However, [except for] major depressive disorder among postpartum women, rates of the most prevalent psychiatric disorders are not significantly higher and, in some cases, are even lower in pregnant and postpartum women than in nonpregnant women of childbearing age,” said Dr. Oriana Vesga-López of the New York State Psychiatric Institute and her associates.

Pregnant and postpartum women are widely considered to be vulnerable to psychiatric disorders, but no study to date has used methods that permit accurate estimation of the prevalence of a wide range of such disorders among pregnant women in the general U.S. population.

“Furthermore, we know of no previous study that included nonpregnant women of comparable age drawn from the general population to identify the specific contribution of pregnancy or the postpartum period to the risk of psychiatric disorders,” Dr. Vesga-López and her associates noted.

They studied the issue using a nationally representative sample of 43,093 adults surveyed in person as part of the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions conducted by professional lay interviewers in the U.S. Census Bureau.

This included nearly 15,000 women of childbearing age, of whom 453 were pregnant at the time of the survey, 994 were postpartum, and 13,025 were neither (“nonpregnant”).

The survey included a diagnostic interview to screen for self-reported Axis I diagnoses, including substance use, mood disorders, and anxiety disorders.

To gauge possible psychotic disorders, respondents were asked whether they had ever been told by a physician or other health professional that they had schizophrenia or a psychotic disorder.

The 1-year prevalence of psychiatric disorders ranged from 0.4% (psychotic disorders) to 14.6% (substance use disorders) in pregnant and postpartum subjects, compared with 0.3%-19.9% for the same diagnoses in nonpregnant women, the researchers said (Arch. Gen. Psychiatry 2008;65:805-15).

The prevalence of substance use was actually lower in pregnant and postpartum women than in nonpregnant women, and the prevalence of social anxiety disorder was markedly lower.

Factors that heightened the risk of psychiatric disorder in pregnant women included younger age, single marital status, recent exposure to traumatic or stressful life events, pregnancy complications, and poor overall health.

The presence of any of these factors should alert clinicians who treat women and their children that targeted intervention might be necessary, Dr. Vesga-López and her associates said.

Despite the relatively high prevalence of psychiatric disorders in both pregnant and nonpregnant women in this study, the rate of treatment for psychiatric disorders was “very low” in both groups. This finding was particularly striking in pregnant women, given their usual access to health care during and immediately after pregnancy.

“Their failure to receive psychiatric treatment suggests the existence of important barriers to mental health care for this population,” including the failure of clinicians to recognize psychiatric symptoms or to consider them a normal response to the physiologic and psychosocial changes of pregnancy, the investigators noted.

The researchers wrote that considering the importance of this period of life for mothers and their offspring, “urgent action is needed to increase detection and treatment of psychiatric disorders among pregnant and postpartum women in the United States.”

The study was funded by National Institutes of Health grants, and grants from the American Foundation for Suicide Prevention and the New York State Psychiatric Institute.

Dr. Vesga-López stated that she had no conflicts of interest to disclose.

Pregnancy does not raise the risk of developing any of the most prevalent mental disorders, with the notable exception of postpartum depression, according to a report in the July issue of the Archives of General Psychiatry.

“Pregnancy is traditionally viewed as a stressful period that may provoke mental illness. However, [except for] major depressive disorder among postpartum women, rates of the most prevalent psychiatric disorders are not significantly higher and, in some cases, are even lower in pregnant and postpartum women than in nonpregnant women of childbearing age,” said Dr. Oriana Vesga-López of the New York State Psychiatric Institute and her associates.

Pregnant and postpartum women are widely considered to be vulnerable to psychiatric disorders, but no study to date has used methods that permit accurate estimation of the prevalence of a wide range of such disorders among pregnant women in the general U.S. population.

“Furthermore, we know of no previous study that included nonpregnant women of comparable age drawn from the general population to identify the specific contribution of pregnancy or the postpartum period to the risk of psychiatric disorders,” Dr. Vesga-López and her associates noted.

They studied the issue using a nationally representative sample of 43,093 adults surveyed in person as part of the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions conducted by professional lay interviewers in the U.S. Census Bureau.

This included nearly 15,000 women of childbearing age, of whom 453 were pregnant at the time of the survey, 994 were postpartum, and 13,025 were neither (“nonpregnant”).

The survey included a diagnostic interview to screen for self-reported Axis I diagnoses, including substance use, mood disorders, and anxiety disorders.

To gauge possible psychotic disorders, respondents were asked whether they had ever been told by a physician or other health professional that they had schizophrenia or a psychotic disorder.

The 1-year prevalence of psychiatric disorders ranged from 0.4% (psychotic disorders) to 14.6% (substance use disorders) in pregnant and postpartum subjects, compared with 0.3%-19.9% for the same diagnoses in nonpregnant women, the researchers said (Arch. Gen. Psychiatry 2008;65:805-15).

The prevalence of substance use was actually lower in pregnant and postpartum women than in nonpregnant women, and the prevalence of social anxiety disorder was markedly lower.

Factors that heightened the risk of psychiatric disorder in pregnant women included younger age, single marital status, recent exposure to traumatic or stressful life events, pregnancy complications, and poor overall health.

The presence of any of these factors should alert clinicians who treat women and their children that targeted intervention might be necessary, Dr. Vesga-López and her associates said.

Despite the relatively high prevalence of psychiatric disorders in both pregnant and nonpregnant women in this study, the rate of treatment for psychiatric disorders was “very low” in both groups. This finding was particularly striking in pregnant women, given their usual access to health care during and immediately after pregnancy.

“Their failure to receive psychiatric treatment suggests the existence of important barriers to mental health care for this population,” including the failure of clinicians to recognize psychiatric symptoms or to consider them a normal response to the physiologic and psychosocial changes of pregnancy, the investigators noted.

The researchers wrote that considering the importance of this period of life for mothers and their offspring, “urgent action is needed to increase detection and treatment of psychiatric disorders among pregnant and postpartum women in the United States.”

The study was funded by National Institutes of Health grants, and grants from the American Foundation for Suicide Prevention and the New York State Psychiatric Institute.

Dr. Vesga-López stated that she had no conflicts of interest to disclose.

Compared with conservative management, invasive treatment of unstable angina with non-ST-segment elevation myocardial infarction does not benefit women who show no elevation of biomarkers of necrosis, according to a meta-analysis of eight clinical trials.

Moreover, invasive therapy potentially increases the risk of death or subsequent MI in this group of low-risk women with NSTEMI, reported Dr. Michelle O'Donoghue of Brigham and Women's Hospital, Boston, and her associates.

In contrast, invasive therapy does benefit women who have unstable angina with NSTEMI who show elevated biomarkers of necrosis, and their benefit is comparable with that of men with NSTEMI, the meta-analysis shows.

These findings support the recently updated American College of Cardiology/American Heart Association guidelines “that now recommend a conservative strategy be used in low-risk women with NSTE ACS [non-ST-elevation acute coronary syndromes],” Dr. O'Donoghue and her associates said.

The investigators undertook a meta-analysis of the issue because “individual trials have not been large enough to explore outcomes reliably within subgroups,” and previous analyses have yielded disparate results. The meta-analysis included 10,412 patients randomly assigned to receive conservative or invasive treatment for NSTE ACS.

“Among women with an elevated cardiac biomarker, an invasive strategy significantly decreased the odds of death, MI, or rehospitalization with ACS by 33%, which was comparable with the benefit observed overall in men,” the researchers said (JAMA 2008;300:71-80).

“In contrast, women without biomarker elevation did not appear to have a significant benefit from an invasive strategy and had a nonsignificant higher odds of death or MI compared with those treated conservatively,” they noted.

For both men and women, those randomly assigned to an invasive strategy had a higher rate of death or MI before hospital discharge than did those randomly assigned to conservative management, but after discharge, showed a significant reduction in death or MI rates.

“We also observed that women are significantly less likely than men to have obstructive CAD [coronary artery disease] at the time of angiography, despite a clinical presentation consistent with NSTE ACS. Overall, 24% of women randomized to an invasive strategy had no evidence of significant epicardial CAD at angiography, vs. only 8% of men” Dr. O'Donoghue and her associates added.

These results “emphasize the need for larger prospective trials to specifically examine the benefit of an invasive strategy in women,” they noted.

Compared with conservative management, invasive treatment of unstable angina with non-ST-segment elevation myocardial infarction does not benefit women who show no elevation of biomarkers of necrosis, according to a meta-analysis of eight clinical trials.

Moreover, invasive therapy potentially increases the risk of death or subsequent MI in this group of low-risk women with NSTEMI, reported Dr. Michelle O'Donoghue of Brigham and Women's Hospital, Boston, and her associates.

In contrast, invasive therapy does benefit women who have unstable angina with NSTEMI who show elevated biomarkers of necrosis, and their benefit is comparable with that of men with NSTEMI, the meta-analysis shows.

These findings support the recently updated American College of Cardiology/American Heart Association guidelines “that now recommend a conservative strategy be used in low-risk women with NSTE ACS [non-ST-elevation acute coronary syndromes],” Dr. O'Donoghue and her associates said.

The investigators undertook a meta-analysis of the issue because “individual trials have not been large enough to explore outcomes reliably within subgroups,” and previous analyses have yielded disparate results. The meta-analysis included 10,412 patients randomly assigned to receive conservative or invasive treatment for NSTE ACS.

“Among women with an elevated cardiac biomarker, an invasive strategy significantly decreased the odds of death, MI, or rehospitalization with ACS by 33%, which was comparable with the benefit observed overall in men,” the researchers said (JAMA 2008;300:71-80).

“In contrast, women without biomarker elevation did not appear to have a significant benefit from an invasive strategy and had a nonsignificant higher odds of death or MI compared with those treated conservatively,” they noted.

For both men and women, those randomly assigned to an invasive strategy had a higher rate of death or MI before hospital discharge than did those randomly assigned to conservative management, but after discharge, showed a significant reduction in death or MI rates.

“We also observed that women are significantly less likely than men to have obstructive CAD [coronary artery disease] at the time of angiography, despite a clinical presentation consistent with NSTE ACS. Overall, 24% of women randomized to an invasive strategy had no evidence of significant epicardial CAD at angiography, vs. only 8% of men” Dr. O'Donoghue and her associates added.

These results “emphasize the need for larger prospective trials to specifically examine the benefit of an invasive strategy in women,” they noted.

Compared with conservative management, invasive treatment of unstable angina with non-ST-segment elevation myocardial infarction does not benefit women who show no elevation of biomarkers of necrosis, according to a meta-analysis of eight clinical trials.

Moreover, invasive therapy potentially increases the risk of death or subsequent MI in this group of low-risk women with NSTEMI, reported Dr. Michelle O'Donoghue of Brigham and Women's Hospital, Boston, and her associates.

In contrast, invasive therapy does benefit women who have unstable angina with NSTEMI who show elevated biomarkers of necrosis, and their benefit is comparable with that of men with NSTEMI, the meta-analysis shows.

These findings support the recently updated American College of Cardiology/American Heart Association guidelines “that now recommend a conservative strategy be used in low-risk women with NSTE ACS [non-ST-elevation acute coronary syndromes],” Dr. O'Donoghue and her associates said.

The investigators undertook a meta-analysis of the issue because “individual trials have not been large enough to explore outcomes reliably within subgroups,” and previous analyses have yielded disparate results. The meta-analysis included 10,412 patients randomly assigned to receive conservative or invasive treatment for NSTE ACS.

“Among women with an elevated cardiac biomarker, an invasive strategy significantly decreased the odds of death, MI, or rehospitalization with ACS by 33%, which was comparable with the benefit observed overall in men,” the researchers said (JAMA 2008;300:71-80).

“In contrast, women without biomarker elevation did not appear to have a significant benefit from an invasive strategy and had a nonsignificant higher odds of death or MI compared with those treated conservatively,” they noted.

For both men and women, those randomly assigned to an invasive strategy had a higher rate of death or MI before hospital discharge than did those randomly assigned to conservative management, but after discharge, showed a significant reduction in death or MI rates.

“We also observed that women are significantly less likely than men to have obstructive CAD [coronary artery disease] at the time of angiography, despite a clinical presentation consistent with NSTE ACS. Overall, 24% of women randomized to an invasive strategy had no evidence of significant epicardial CAD at angiography, vs. only 8% of men” Dr. O'Donoghue and her associates added.

These results “emphasize the need for larger prospective trials to specifically examine the benefit of an invasive strategy in women,” they noted.

Both the Mediterranean diet and the low-carbohydrate (Atkins) diet proved to be as safe and effective for inducing weight loss in moderately obese subjects as was the American Heart Association's low-fat, restricted-calorie diet, according to a report.

In a 2-year randomized controlled trial in which adherence rates ranged from 78% to 90%, the low-carb and Mediterranean diets produced beneficial metabolic effects in addition to weight loss, suggesting that their dietary strategies might be considered for use in clinical practice and that “diets might be individualized according to personal preferences and metabolic needs,” said Dr. Iris Shai of Ben-Gurion University of the Negev, Beer-Sheva, Israel, and her associates.

In particular, the low-carbohydrate diet that allows unrestricted caloric intake as long as carbohydrate content is kept to a minimum “may be optimal for [patients] who will not follow a restricted-calorie dietary regimen,” they noted.

The researchers compared the three diets in a workplace study involving 322 participants with a mean body mass index (BMI) of 31 kg/m

The participants were weighed monthly in the workplace, and adherence to diets was monitored with food frequency questionnaires. At 2 years, the adherence rates were 78% with the low-carbohydrate diet, 85% with the Mediterranean diet, and 90% with the AHA low-fat, low-calorie diet.

“We believe that similar strategies to maintain adherence could be applied elsewhere” outside of the workplace environment, Dr. Shai and her associates wrote.

Daily energy intake decreased significantly and to a similar extent in all three groups. The mean weight loss was 3.3 kg with the AHA diet, 4.6 kg with the Mediterranean diet, and 5.5 kg with the low-carbohydrate diet, the investigators said (New Engl. J. Med. 2008;359:229–41).

All three groups also had significant and similar decreases in BMI, waist circumference, blood pressure, and insulin levels.

The low-carbohydrate diet produced the greatest improvement in lipid profiles, with a 20% relative decrease in the total cholesterol to HDL cholesterol ratio, compared with a 12% decrease for the AHA diet.

Both the Mediterranean diet and the low-carbohydrate (Atkins) diet proved to be as safe and effective for inducing weight loss in moderately obese subjects as was the American Heart Association's low-fat, restricted-calorie diet, according to a report.

In a 2-year randomized controlled trial in which adherence rates ranged from 78% to 90%, the low-carb and Mediterranean diets produced beneficial metabolic effects in addition to weight loss, suggesting that their dietary strategies might be considered for use in clinical practice and that “diets might be individualized according to personal preferences and metabolic needs,” said Dr. Iris Shai of Ben-Gurion University of the Negev, Beer-Sheva, Israel, and her associates.

In particular, the low-carbohydrate diet that allows unrestricted caloric intake as long as carbohydrate content is kept to a minimum “may be optimal for [patients] who will not follow a restricted-calorie dietary regimen,” they noted.

The researchers compared the three diets in a workplace study involving 322 participants with a mean body mass index (BMI) of 31 kg/m

The participants were weighed monthly in the workplace, and adherence to diets was monitored with food frequency questionnaires. At 2 years, the adherence rates were 78% with the low-carbohydrate diet, 85% with the Mediterranean diet, and 90% with the AHA low-fat, low-calorie diet.

“We believe that similar strategies to maintain adherence could be applied elsewhere” outside of the workplace environment, Dr. Shai and her associates wrote.

Daily energy intake decreased significantly and to a similar extent in all three groups. The mean weight loss was 3.3 kg with the AHA diet, 4.6 kg with the Mediterranean diet, and 5.5 kg with the low-carbohydrate diet, the investigators said (New Engl. J. Med. 2008;359:229–41).

All three groups also had significant and similar decreases in BMI, waist circumference, blood pressure, and insulin levels.

The low-carbohydrate diet produced the greatest improvement in lipid profiles, with a 20% relative decrease in the total cholesterol to HDL cholesterol ratio, compared with a 12% decrease for the AHA diet.

Both the Mediterranean diet and the low-carbohydrate (Atkins) diet proved to be as safe and effective for inducing weight loss in moderately obese subjects as was the American Heart Association's low-fat, restricted-calorie diet, according to a report.

In a 2-year randomized controlled trial in which adherence rates ranged from 78% to 90%, the low-carb and Mediterranean diets produced beneficial metabolic effects in addition to weight loss, suggesting that their dietary strategies might be considered for use in clinical practice and that “diets might be individualized according to personal preferences and metabolic needs,” said Dr. Iris Shai of Ben-Gurion University of the Negev, Beer-Sheva, Israel, and her associates.

In particular, the low-carbohydrate diet that allows unrestricted caloric intake as long as carbohydrate content is kept to a minimum “may be optimal for [patients] who will not follow a restricted-calorie dietary regimen,” they noted.

The researchers compared the three diets in a workplace study involving 322 participants with a mean body mass index (BMI) of 31 kg/m

The participants were weighed monthly in the workplace, and adherence to diets was monitored with food frequency questionnaires. At 2 years, the adherence rates were 78% with the low-carbohydrate diet, 85% with the Mediterranean diet, and 90% with the AHA low-fat, low-calorie diet.

“We believe that similar strategies to maintain adherence could be applied elsewhere” outside of the workplace environment, Dr. Shai and her associates wrote.

Daily energy intake decreased significantly and to a similar extent in all three groups. The mean weight loss was 3.3 kg with the AHA diet, 4.6 kg with the Mediterranean diet, and 5.5 kg with the low-carbohydrate diet, the investigators said (New Engl. J. Med. 2008;359:229–41).

All three groups also had significant and similar decreases in BMI, waist circumference, blood pressure, and insulin levels.

The low-carbohydrate diet produced the greatest improvement in lipid profiles, with a 20% relative decrease in the total cholesterol to HDL cholesterol ratio, compared with a 12% decrease for the AHA diet.

Antidepressants that block action on the serotonin reuptake mechanism seem to raise the risk of upper gastrointestinal bleeding to the same degree that antiplatelet drugs do, according to data from a case-control study involving over 11,000 subjects.

Both selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) increased the risk of upper gastrointestinal bleeding, particularly when taken with NSAIDs or antiplatelet drugs, wrote Dr. Francisco J. de Abajo of the Spanish Agency for Medicines and Healthcare Products, Madrid, and his associates.

Use of acid suppressors lowered these bleeding risks, they noted.

The researchers used a large, general practice database from the United Kingdom to study whether serotonin reuptake inhibitors raise the risk of serious bleeding. They matched 1,321 cases of upper GI bleeding from erosion, peptic ulcer, or inflammation of the gastric or duodenal mucosa with 10,000 control subjects who had no GI bleeding.

The proportion of subjects currently using SSRIs (5.3%) or SNRIs (1.1%) was significantly higher in cases than in controls (3.0% and 0.3%, respectively). When SSRIs and SNRIs were combined into a single category of “serotonin reuptake inhibitors,” the odds of use of the antidepressants were nearly twice as high in cases as in controls.

The magnitude of the effect that serotonin reuptake inhibitors exerted on upper GI tract bleeding was similar to that exerted by antiplatelet agents, Dr. de Abajo and his associates said (Arch. Gen. Psychiatry 2008;65:795–803).

No significant association was found between upper GI bleeding and any other type of antidepressant. Moreover, “[we] did not identify a dose-response effect or a clear-cut duration effect in current users of SSRIs or SNRIs, although the effect was more consistent when treatment duration was longer than 3 months,” they said.

The increased risk of bleeding was further augmented by the use of NSAIDs or antiplatelet drugs. In contrast, the use of proton pump inhibitors or H2 antihistamines to suppress stomach acid “greatly reduced” the risk of GI bleeding related to serotonin reuptake inhibitors, as well as the combined effect of these drugs plus NSAIDs or antiplatelet drugs.

The researchers estimated it would be necessary to treat about 2,000 patients a year with serotonin reuptake inhibitors for 1 case of upper GI tract bleeding to be attributed to them, “indicating that the risk is rather low in the general population treated with these drugs. However, when serotonin reuptake inhibitors are combined with NSAIDs or antiplatelet drugs, the number of patients needed to be treated per year for 1 case of upper GI tract bleeding decreases remarkably [to 250–500 patients per year]. In such a high-risk population, the use of acid-suppressing agents would save a relevant number of cases and is worthwhile.”

The study was supported in part by AstraZeneca.

Antidepressants that block action on the serotonin reuptake mechanism seem to raise the risk of upper gastrointestinal bleeding to the same degree that antiplatelet drugs do, according to data from a case-control study involving over 11,000 subjects.

Both selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) increased the risk of upper gastrointestinal bleeding, particularly when taken with NSAIDs or antiplatelet drugs, wrote Dr. Francisco J. de Abajo of the Spanish Agency for Medicines and Healthcare Products, Madrid, and his associates.

Use of acid suppressors lowered these bleeding risks, they noted.

The researchers used a large, general practice database from the United Kingdom to study whether serotonin reuptake inhibitors raise the risk of serious bleeding. They matched 1,321 cases of upper GI bleeding from erosion, peptic ulcer, or inflammation of the gastric or duodenal mucosa with 10,000 control subjects who had no GI bleeding.

The proportion of subjects currently using SSRIs (5.3%) or SNRIs (1.1%) was significantly higher in cases than in controls (3.0% and 0.3%, respectively). When SSRIs and SNRIs were combined into a single category of “serotonin reuptake inhibitors,” the odds of use of the antidepressants were nearly twice as high in cases as in controls.

The magnitude of the effect that serotonin reuptake inhibitors exerted on upper GI tract bleeding was similar to that exerted by antiplatelet agents, Dr. de Abajo and his associates said (Arch. Gen. Psychiatry 2008;65:795–803).

No significant association was found between upper GI bleeding and any other type of antidepressant. Moreover, “[we] did not identify a dose-response effect or a clear-cut duration effect in current users of SSRIs or SNRIs, although the effect was more consistent when treatment duration was longer than 3 months,” they said.

The increased risk of bleeding was further augmented by the use of NSAIDs or antiplatelet drugs. In contrast, the use of proton pump inhibitors or H2 antihistamines to suppress stomach acid “greatly reduced” the risk of GI bleeding related to serotonin reuptake inhibitors, as well as the combined effect of these drugs plus NSAIDs or antiplatelet drugs.

The researchers estimated it would be necessary to treat about 2,000 patients a year with serotonin reuptake inhibitors for 1 case of upper GI tract bleeding to be attributed to them, “indicating that the risk is rather low in the general population treated with these drugs. However, when serotonin reuptake inhibitors are combined with NSAIDs or antiplatelet drugs, the number of patients needed to be treated per year for 1 case of upper GI tract bleeding decreases remarkably [to 250–500 patients per year]. In such a high-risk population, the use of acid-suppressing agents would save a relevant number of cases and is worthwhile.”

The study was supported in part by AstraZeneca.

Antidepressants that block action on the serotonin reuptake mechanism seem to raise the risk of upper gastrointestinal bleeding to the same degree that antiplatelet drugs do, according to data from a case-control study involving over 11,000 subjects.

Both selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) increased the risk of upper gastrointestinal bleeding, particularly when taken with NSAIDs or antiplatelet drugs, wrote Dr. Francisco J. de Abajo of the Spanish Agency for Medicines and Healthcare Products, Madrid, and his associates.

Use of acid suppressors lowered these bleeding risks, they noted.

The researchers used a large, general practice database from the United Kingdom to study whether serotonin reuptake inhibitors raise the risk of serious bleeding. They matched 1,321 cases of upper GI bleeding from erosion, peptic ulcer, or inflammation of the gastric or duodenal mucosa with 10,000 control subjects who had no GI bleeding.

The proportion of subjects currently using SSRIs (5.3%) or SNRIs (1.1%) was significantly higher in cases than in controls (3.0% and 0.3%, respectively). When SSRIs and SNRIs were combined into a single category of “serotonin reuptake inhibitors,” the odds of use of the antidepressants were nearly twice as high in cases as in controls.

The magnitude of the effect that serotonin reuptake inhibitors exerted on upper GI tract bleeding was similar to that exerted by antiplatelet agents, Dr. de Abajo and his associates said (Arch. Gen. Psychiatry 2008;65:795–803).

No significant association was found between upper GI bleeding and any other type of antidepressant. Moreover, “[we] did not identify a dose-response effect or a clear-cut duration effect in current users of SSRIs or SNRIs, although the effect was more consistent when treatment duration was longer than 3 months,” they said.

The increased risk of bleeding was further augmented by the use of NSAIDs or antiplatelet drugs. In contrast, the use of proton pump inhibitors or H2 antihistamines to suppress stomach acid “greatly reduced” the risk of GI bleeding related to serotonin reuptake inhibitors, as well as the combined effect of these drugs plus NSAIDs or antiplatelet drugs.

The researchers estimated it would be necessary to treat about 2,000 patients a year with serotonin reuptake inhibitors for 1 case of upper GI tract bleeding to be attributed to them, “indicating that the risk is rather low in the general population treated with these drugs. However, when serotonin reuptake inhibitors are combined with NSAIDs or antiplatelet drugs, the number of patients needed to be treated per year for 1 case of upper GI tract bleeding decreases remarkably [to 250–500 patients per year]. In such a high-risk population, the use of acid-suppressing agents would save a relevant number of cases and is worthwhile.”

The study was supported in part by AstraZeneca.

Pregnancy does not raise the risk of developing any of the most prevalent mental disorders, with the notable exception of postpartum depression, according to the findings of a survey.

Pregnant and postpartum women are widely considered to be vulnerable to psychiatric disorders, but no study to date has used methods that permit accurate estimation of the prevalence of a wide range of such disorders among pregnant women in the general U.S. population, said Dr. Oriana Vesga-López of the New York State Psychiatric Institute and her associates.

Dr. Vesga-López and her associates studied the issue using a nationally representative sample of 43,093 adults surveyed in person as part of the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions conducted by professional lay interviewers in the U.S. Census Bureau. This included nearly 15,000 women of childbearing age, of whom 453 were pregnant, 994 were postpartum, and 13,025 were neither (“nonpregnant”).

The survey included a diagnostic interview to screen for self-reported Axis I diagnoses, including substance use, mood disorders, and anxiety disorders. To gauge psychotic disorders, respondents were asked whether they had ever been told by a health professional that they had schizophrenia or a psychotic disorder.

The 1-year prevalence of psychiatric disorders ranged from 0.4% (psychotic disorders) to 14.6% (substance use disorders) in pregnant and postpartum subjects, compared with 0.3%–19.9% for the same diagnoses in nonpregnant women, the researchers said (Arch. Gen. Psychiatry 2008;65:805–15).

The prevalence of substance use was actually lower in pregnant and postpartum women than in nonpregnant women, and the prevalence of social anxiety disorder was markedly lower.

Factors that heightened the risk of psychiatric disorder in pregnant women included younger age, single marital status, recent exposure to traumatic or stressful life events, pregnancy complications, and poor overall health. The presence of any of these factors should alert providers who treat women and their children that targeted intervention might be necessary, Dr. Vesga-López and her associates said.

Despite the relatively high prevalence of psychiatric disorders in both pregnant and nonpregnant women in this study, the rate of treatment for psychiatric disorders was “very low” in both groups. This finding was particularly striking in pregnant women, given their usual access to health care during and immediately after pregnancy.

“Their failure to receive psychiatric treatment suggests the existence of important barriers to mental health care for this population,” including the failure to recognize psychiatric symptoms or to consider them a normal response to the changes of pregnancy, the researchers noted.

The study was funded by National Institutes of Health grants, and grants from the American Foundation for Suicide Prevention and the New York State Psychiatric Institute. Dr. Vesga-López had no disclosures.

Pregnancy does not raise the risk of developing any of the most prevalent mental disorders, with the notable exception of postpartum depression, according to the findings of a survey.

Pregnant and postpartum women are widely considered to be vulnerable to psychiatric disorders, but no study to date has used methods that permit accurate estimation of the prevalence of a wide range of such disorders among pregnant women in the general U.S. population, said Dr. Oriana Vesga-López of the New York State Psychiatric Institute and her associates.

Dr. Vesga-López and her associates studied the issue using a nationally representative sample of 43,093 adults surveyed in person as part of the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions conducted by professional lay interviewers in the U.S. Census Bureau. This included nearly 15,000 women of childbearing age, of whom 453 were pregnant, 994 were postpartum, and 13,025 were neither (“nonpregnant”).

The survey included a diagnostic interview to screen for self-reported Axis I diagnoses, including substance use, mood disorders, and anxiety disorders. To gauge psychotic disorders, respondents were asked whether they had ever been told by a health professional that they had schizophrenia or a psychotic disorder.

The 1-year prevalence of psychiatric disorders ranged from 0.4% (psychotic disorders) to 14.6% (substance use disorders) in pregnant and postpartum subjects, compared with 0.3%–19.9% for the same diagnoses in nonpregnant women, the researchers said (Arch. Gen. Psychiatry 2008;65:805–15).

The prevalence of substance use was actually lower in pregnant and postpartum women than in nonpregnant women, and the prevalence of social anxiety disorder was markedly lower.

Factors that heightened the risk of psychiatric disorder in pregnant women included younger age, single marital status, recent exposure to traumatic or stressful life events, pregnancy complications, and poor overall health. The presence of any of these factors should alert providers who treat women and their children that targeted intervention might be necessary, Dr. Vesga-López and her associates said.

Despite the relatively high prevalence of psychiatric disorders in both pregnant and nonpregnant women in this study, the rate of treatment for psychiatric disorders was “very low” in both groups. This finding was particularly striking in pregnant women, given their usual access to health care during and immediately after pregnancy.

“Their failure to receive psychiatric treatment suggests the existence of important barriers to mental health care for this population,” including the failure to recognize psychiatric symptoms or to consider them a normal response to the changes of pregnancy, the researchers noted.

The study was funded by National Institutes of Health grants, and grants from the American Foundation for Suicide Prevention and the New York State Psychiatric Institute. Dr. Vesga-López had no disclosures.

Pregnancy does not raise the risk of developing any of the most prevalent mental disorders, with the notable exception of postpartum depression, according to the findings of a survey.

Pregnant and postpartum women are widely considered to be vulnerable to psychiatric disorders, but no study to date has used methods that permit accurate estimation of the prevalence of a wide range of such disorders among pregnant women in the general U.S. population, said Dr. Oriana Vesga-López of the New York State Psychiatric Institute and her associates.

Dr. Vesga-López and her associates studied the issue using a nationally representative sample of 43,093 adults surveyed in person as part of the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions conducted by professional lay interviewers in the U.S. Census Bureau. This included nearly 15,000 women of childbearing age, of whom 453 were pregnant, 994 were postpartum, and 13,025 were neither (“nonpregnant”).

The survey included a diagnostic interview to screen for self-reported Axis I diagnoses, including substance use, mood disorders, and anxiety disorders. To gauge psychotic disorders, respondents were asked whether they had ever been told by a health professional that they had schizophrenia or a psychotic disorder.

The 1-year prevalence of psychiatric disorders ranged from 0.4% (psychotic disorders) to 14.6% (substance use disorders) in pregnant and postpartum subjects, compared with 0.3%–19.9% for the same diagnoses in nonpregnant women, the researchers said (Arch. Gen. Psychiatry 2008;65:805–15).

The prevalence of substance use was actually lower in pregnant and postpartum women than in nonpregnant women, and the prevalence of social anxiety disorder was markedly lower.

Factors that heightened the risk of psychiatric disorder in pregnant women included younger age, single marital status, recent exposure to traumatic or stressful life events, pregnancy complications, and poor overall health. The presence of any of these factors should alert providers who treat women and their children that targeted intervention might be necessary, Dr. Vesga-López and her associates said.

Despite the relatively high prevalence of psychiatric disorders in both pregnant and nonpregnant women in this study, the rate of treatment for psychiatric disorders was “very low” in both groups. This finding was particularly striking in pregnant women, given their usual access to health care during and immediately after pregnancy.

“Their failure to receive psychiatric treatment suggests the existence of important barriers to mental health care for this population,” including the failure to recognize psychiatric symptoms or to consider them a normal response to the changes of pregnancy, the researchers noted.

The study was funded by National Institutes of Health grants, and grants from the American Foundation for Suicide Prevention and the New York State Psychiatric Institute. Dr. Vesga-López had no disclosures.

The ankle-brachial index, a measurement that is commonly used by vascular specialists but not by other providers, adds such important information to cardiovascular risk assessment that it could now be incorporated into that process routinely, according to investigators who performed a meta-analysis of longitudinal studies of the index and the incidence of cardiovascular events.

The index is the ratio of systolic blood pressure taken at the ankle to that in the arm. It is routinely used to assess the severity of peripheral artery disease but is also a good indicator of generalized atherosclerosis. A low ankle-brachial index (ABI) is thought to predict coronary and cerebrovascular events and mortality.

To determine whether the ABI improves cardiovascular risk assessment independently of the Framingham score in the general population, the Ankle Brachial Index Collaboration was formed, comprising investigators from all major observational studies that had “investigated longitudinally the ABI and incidence of cardiovascular events and mortality in general populations.”

The collaboration performed a meta-analysis of 16 population-based cohort studies in Europe, Australia, and the United States, said Dr. Gerry Fowkes of the University of Edinburgh's School of Public Health Sciences and corresponding author for the collaboration.

Data processing and statistical analysis in this meta-analysis was provided by a grant from Sanofi-Aventis/Bristol-Myers Squibb Co.

The meta-analysis included 24,955 men and 23,339 women aged 47–78 years who had no known cardiovascular disease at baseline and who were followed for a median of 3–17 years.

There were more than 9,000 deaths overall, and about one-fourth of those were due to coronary heart disease or stroke.

“We found that the ABI provided independent risk information compared with the Framingham score and, when combined with the Framingham score, a low ABI approximately doubled the risk of total mortality, [cardiovascular] mortality, and major coronary events across all Framingham risk categories,” Dr. Fowkes and his associates reported (JAMA 2008;300:197–208).

An estimated 20% of the male subjects would have had their category of risk lowered if their ABI had been added to their Framingham score, which “would likely have an effect on decisions to commence preventive treatment such as lipid-lowering therapy,” the authors wrote.

More important, in an estimated 1 in 3 female subjects, the category of risk would have risen from low to a higher level if their ABI had been added to their Framingham score, Dr. Fowkes and his associates noted.

The ABI is “quick and easy” to measure in the primary care or community clinic setting, can be performed by a trained nurse or other support staff, and requires only the use of a relatively inexpensive ($600) hand-held Doppler device, the researchers said.

Nevertheless, it is rarely used in routine clinical practice outside of vascular specialties, primarily because most providers are unaware of its value in predicting cardiovascular risk and do not know how to perform it.

The findings of this study, together with those of other recent studies, demonstrate that the incorporation of the ABI into routine cardiovascular risk assessment “may indeed be justified.”

“A new risk equation incorporating the ABI and relevant Framingham risk variables could more accurately predict risk, and our intention is to develop and validate such a model in our combined data set,” Dr. Fowkes and his associates asserted.

Dr. Fowkes has received honoraria and consulting fees from Sanofi-Aventis/Bristol-Myers Squibb.

The ankle-brachial index, a measurement that is commonly used by vascular specialists but not by other providers, adds such important information to cardiovascular risk assessment that it could now be incorporated into that process routinely, according to investigators who performed a meta-analysis of longitudinal studies of the index and the incidence of cardiovascular events.

The index is the ratio of systolic blood pressure taken at the ankle to that in the arm. It is routinely used to assess the severity of peripheral artery disease but is also a good indicator of generalized atherosclerosis. A low ankle-brachial index (ABI) is thought to predict coronary and cerebrovascular events and mortality.

To determine whether the ABI improves cardiovascular risk assessment independently of the Framingham score in the general population, the Ankle Brachial Index Collaboration was formed, comprising investigators from all major observational studies that had “investigated longitudinally the ABI and incidence of cardiovascular events and mortality in general populations.”

The collaboration performed a meta-analysis of 16 population-based cohort studies in Europe, Australia, and the United States, said Dr. Gerry Fowkes of the University of Edinburgh's School of Public Health Sciences and corresponding author for the collaboration.

Data processing and statistical analysis in this meta-analysis was provided by a grant from Sanofi-Aventis/Bristol-Myers Squibb Co.

The meta-analysis included 24,955 men and 23,339 women aged 47–78 years who had no known cardiovascular disease at baseline and who were followed for a median of 3–17 years.

There were more than 9,000 deaths overall, and about one-fourth of those were due to coronary heart disease or stroke.

“We found that the ABI provided independent risk information compared with the Framingham score and, when combined with the Framingham score, a low ABI approximately doubled the risk of total mortality, [cardiovascular] mortality, and major coronary events across all Framingham risk categories,” Dr. Fowkes and his associates reported (JAMA 2008;300:197–208).

An estimated 20% of the male subjects would have had their category of risk lowered if their ABI had been added to their Framingham score, which “would likely have an effect on decisions to commence preventive treatment such as lipid-lowering therapy,” the authors wrote.

More important, in an estimated 1 in 3 female subjects, the category of risk would have risen from low to a higher level if their ABI had been added to their Framingham score, Dr. Fowkes and his associates noted.

The ABI is “quick and easy” to measure in the primary care or community clinic setting, can be performed by a trained nurse or other support staff, and requires only the use of a relatively inexpensive ($600) hand-held Doppler device, the researchers said.

Nevertheless, it is rarely used in routine clinical practice outside of vascular specialties, primarily because most providers are unaware of its value in predicting cardiovascular risk and do not know how to perform it.

The findings of this study, together with those of other recent studies, demonstrate that the incorporation of the ABI into routine cardiovascular risk assessment “may indeed be justified.”

“A new risk equation incorporating the ABI and relevant Framingham risk variables could more accurately predict risk, and our intention is to develop and validate such a model in our combined data set,” Dr. Fowkes and his associates asserted.

Dr. Fowkes has received honoraria and consulting fees from Sanofi-Aventis/Bristol-Myers Squibb.

The ankle-brachial index, a measurement that is commonly used by vascular specialists but not by other providers, adds such important information to cardiovascular risk assessment that it could now be incorporated into that process routinely, according to investigators who performed a meta-analysis of longitudinal studies of the index and the incidence of cardiovascular events.

The index is the ratio of systolic blood pressure taken at the ankle to that in the arm. It is routinely used to assess the severity of peripheral artery disease but is also a good indicator of generalized atherosclerosis. A low ankle-brachial index (ABI) is thought to predict coronary and cerebrovascular events and mortality.

To determine whether the ABI improves cardiovascular risk assessment independently of the Framingham score in the general population, the Ankle Brachial Index Collaboration was formed, comprising investigators from all major observational studies that had “investigated longitudinally the ABI and incidence of cardiovascular events and mortality in general populations.”

The collaboration performed a meta-analysis of 16 population-based cohort studies in Europe, Australia, and the United States, said Dr. Gerry Fowkes of the University of Edinburgh's School of Public Health Sciences and corresponding author for the collaboration.

Data processing and statistical analysis in this meta-analysis was provided by a grant from Sanofi-Aventis/Bristol-Myers Squibb Co.

The meta-analysis included 24,955 men and 23,339 women aged 47–78 years who had no known cardiovascular disease at baseline and who were followed for a median of 3–17 years.

There were more than 9,000 deaths overall, and about one-fourth of those were due to coronary heart disease or stroke.

“We found that the ABI provided independent risk information compared with the Framingham score and, when combined with the Framingham score, a low ABI approximately doubled the risk of total mortality, [cardiovascular] mortality, and major coronary events across all Framingham risk categories,” Dr. Fowkes and his associates reported (JAMA 2008;300:197–208).

An estimated 20% of the male subjects would have had their category of risk lowered if their ABI had been added to their Framingham score, which “would likely have an effect on decisions to commence preventive treatment such as lipid-lowering therapy,” the authors wrote.

More important, in an estimated 1 in 3 female subjects, the category of risk would have risen from low to a higher level if their ABI had been added to their Framingham score, Dr. Fowkes and his associates noted.

The ABI is “quick and easy” to measure in the primary care or community clinic setting, can be performed by a trained nurse or other support staff, and requires only the use of a relatively inexpensive ($600) hand-held Doppler device, the researchers said.

Nevertheless, it is rarely used in routine clinical practice outside of vascular specialties, primarily because most providers are unaware of its value in predicting cardiovascular risk and do not know how to perform it.

The findings of this study, together with those of other recent studies, demonstrate that the incorporation of the ABI into routine cardiovascular risk assessment “may indeed be justified.”

“A new risk equation incorporating the ABI and relevant Framingham risk variables could more accurately predict risk, and our intention is to develop and validate such a model in our combined data set,” Dr. Fowkes and his associates asserted.

Dr. Fowkes has received honoraria and consulting fees from Sanofi-Aventis/Bristol-Myers Squibb.

Compared with conservative management, invasive treatment of unstable angina with non-ST-segment elevation myocardial infarction does not benefit women who show no elevation of biomarkers of necrosis, according to a meta-analysis of eight clinical trials.

Moreover, invasive therapy potentially increases the risk of death or subsequent MI in this group of low-risk women with NSTEMI, reported Dr. Michelle O'Donoghue of Brigham and Women's Hospital, Boston, and her associates.

In contrast, invasive therapy does benefit women who have unstable angina with NSTEMI who show elevated biomarkers of necrosis, and their benefit is comparable with that of men with NSTEMI, the meta-analysis shows.

These findings support the recently updated guidelines from the American College of Cardiology and the American Heart Association “that now recommend a conservative strategy be used in low-risk women with NSTE ACS [non-ST-elevation acute coronary syndromes],” wrote the authors.

The researchers undertook a meta-analysis of the issue because “individual trials have not been large enough to explore outcomes reliably within subgroups,” and previous analyses have yielded disparate results. The meta-analysis included 10,412 patients randomly assigned to receive conservative or invasive treatment for non-ST-elevation ACS.

“Among women with an elevated cardiac biomarker, an invasive strategy significantly decreased the odds of death, MI, or rehospitalization with ACS by 33%, which was comparable with the benefit observed overall in men,” the authors said (JAMA 2008;300:71–80).

“In contrast, women without biomarker elevation did not appear to have a significant benefit from an invasive strategy and had a nonsignificant higher odds of death or MI compared with those treated conservatively,” they noted.

For both men and women, those randomly assigned to an invasive strategy had a higher rate of death or MI before hospital discharge than did those randomly assigned to conservative management, but after discharge, showed a significant reduction in death or MI rates.

“Women are significantly less likely than men to have obstructive CAD [coronary artery disease] at the time of angiography, despite a clinical presentation consistent with NSTE ACS. Overall, 24% of women randomized to an invasive strategy had no evidence of significant epicardial CAD at angiography, vs. only 8% of men,” the authors wrote.

The results “emphasize the need for larger prospective trials to specifically examine the benefit of an invasive strategy in women, both overall and within high-risk subgroups,” the investigators noted.

Compared with conservative management, invasive treatment of unstable angina with non-ST-segment elevation myocardial infarction does not benefit women who show no elevation of biomarkers of necrosis, according to a meta-analysis of eight clinical trials.

Moreover, invasive therapy potentially increases the risk of death or subsequent MI in this group of low-risk women with NSTEMI, reported Dr. Michelle O'Donoghue of Brigham and Women's Hospital, Boston, and her associates.

In contrast, invasive therapy does benefit women who have unstable angina with NSTEMI who show elevated biomarkers of necrosis, and their benefit is comparable with that of men with NSTEMI, the meta-analysis shows.

These findings support the recently updated guidelines from the American College of Cardiology and the American Heart Association “that now recommend a conservative strategy be used in low-risk women with NSTE ACS [non-ST-elevation acute coronary syndromes],” wrote the authors.

The researchers undertook a meta-analysis of the issue because “individual trials have not been large enough to explore outcomes reliably within subgroups,” and previous analyses have yielded disparate results. The meta-analysis included 10,412 patients randomly assigned to receive conservative or invasive treatment for non-ST-elevation ACS.

“Among women with an elevated cardiac biomarker, an invasive strategy significantly decreased the odds of death, MI, or rehospitalization with ACS by 33%, which was comparable with the benefit observed overall in men,” the authors said (JAMA 2008;300:71–80).

“In contrast, women without biomarker elevation did not appear to have a significant benefit from an invasive strategy and had a nonsignificant higher odds of death or MI compared with those treated conservatively,” they noted.

For both men and women, those randomly assigned to an invasive strategy had a higher rate of death or MI before hospital discharge than did those randomly assigned to conservative management, but after discharge, showed a significant reduction in death or MI rates.

“Women are significantly less likely than men to have obstructive CAD [coronary artery disease] at the time of angiography, despite a clinical presentation consistent with NSTE ACS. Overall, 24% of women randomized to an invasive strategy had no evidence of significant epicardial CAD at angiography, vs. only 8% of men,” the authors wrote.

The results “emphasize the need for larger prospective trials to specifically examine the benefit of an invasive strategy in women, both overall and within high-risk subgroups,” the investigators noted.

Compared with conservative management, invasive treatment of unstable angina with non-ST-segment elevation myocardial infarction does not benefit women who show no elevation of biomarkers of necrosis, according to a meta-analysis of eight clinical trials.

Moreover, invasive therapy potentially increases the risk of death or subsequent MI in this group of low-risk women with NSTEMI, reported Dr. Michelle O'Donoghue of Brigham and Women's Hospital, Boston, and her associates.

In contrast, invasive therapy does benefit women who have unstable angina with NSTEMI who show elevated biomarkers of necrosis, and their benefit is comparable with that of men with NSTEMI, the meta-analysis shows.

These findings support the recently updated guidelines from the American College of Cardiology and the American Heart Association “that now recommend a conservative strategy be used in low-risk women with NSTE ACS [non-ST-elevation acute coronary syndromes],” wrote the authors.

The researchers undertook a meta-analysis of the issue because “individual trials have not been large enough to explore outcomes reliably within subgroups,” and previous analyses have yielded disparate results. The meta-analysis included 10,412 patients randomly assigned to receive conservative or invasive treatment for non-ST-elevation ACS.

“Among women with an elevated cardiac biomarker, an invasive strategy significantly decreased the odds of death, MI, or rehospitalization with ACS by 33%, which was comparable with the benefit observed overall in men,” the authors said (JAMA 2008;300:71–80).

“In contrast, women without biomarker elevation did not appear to have a significant benefit from an invasive strategy and had a nonsignificant higher odds of death or MI compared with those treated conservatively,” they noted.

For both men and women, those randomly assigned to an invasive strategy had a higher rate of death or MI before hospital discharge than did those randomly assigned to conservative management, but after discharge, showed a significant reduction in death or MI rates.

“Women are significantly less likely than men to have obstructive CAD [coronary artery disease] at the time of angiography, despite a clinical presentation consistent with NSTE ACS. Overall, 24% of women randomized to an invasive strategy had no evidence of significant epicardial CAD at angiography, vs. only 8% of men,” the authors wrote.

The results “emphasize the need for larger prospective trials to specifically examine the benefit of an invasive strategy in women, both overall and within high-risk subgroups,” the investigators noted.

Overweight or obese children who have nonalcoholic fatty liver disease appear to be at high risk of developing cardiovascular disease, according to study findings.

This subset of overweight children also appears to have a high incidence of metabolic syndrome and to be at risk for developing type 2 diabetes and end-stage liver disease, reported Dr. Jeffrey B. Schwimmer of the University of California, San Diego, and his associates.

The investigators examined the link between nonalcoholic fatty liver disease (NAFLD) and metabolic syndrome because data on this association in the pediatric population are sparse.

The study findings showed that cardiovascular health must be addressed in any overweight child found to have NAFLD. Those who are unable to improve sufficiently with lifestyle modification “will likely receive pharmacotherapy for … hypertension or dyslipidemia,” even though the data on such medications in this population are insufficient, and it is unclear whether such treatments “have a beneficial, neutral, or deleterious effect on the natural history of NAFLD,” the researchers wrote.

The researchers studied 300 overweight or obese boys and girls aged 5–17 years (mean age 13 years). Half of these subjects had biopsy-proven NAFLD and the other half, who served as controls, did not. The two groups were well matched for age and severity of obesity. The researchers used overweight or obese children as controls because the “vast majority” of children with NAFLD are overweight or obese, they noted.

Metabolic syndrome was defined as a clustering of at least three of five risk factors for cardiovascular disease and type 2 diabetes: abdominal obesity, high triglycerides, low HDL cholesterol, elevated blood pressure, and impaired fasting glucose. The incidence of all these measures was significantly greater in the children with NAFLD than in the control children. The incidence of metabolic syndrome was significantly higher in the children with NAFLD (50%) than in the controls (15%).

Moreover, after the data were adjusted to account for age, sex, race, body mass index, and hyperinsulinemia, children with metabolic syndrome had five times the odds of having NAFLD than did those without metabolic syndrome, the investigators said (Circulation 2008 doi:10.1161/circulationAHA.107.739920

This “demonstrates that obese children and adolescents with a definitive diagnosis of NAFLD have a more severe cardiovascular risk profile than [do] age-, sex-, and BMI-matched peers,” Dr. Schwimmer and his associates noted.

The findings also suggest that fat accumulation in the liver “may play a more important role than obesity itself in determining the risk for 'weight-related' metabolic comorbidities,” they added.

ELSEVIER GLOBAL MEDICAL NEWS

Overweight or obese children who have nonalcoholic fatty liver disease appear to be at high risk of developing cardiovascular disease, according to study findings.

This subset of overweight children also appears to have a high incidence of metabolic syndrome and to be at risk for developing type 2 diabetes and end-stage liver disease, reported Dr. Jeffrey B. Schwimmer of the University of California, San Diego, and his associates.

The investigators examined the link between nonalcoholic fatty liver disease (NAFLD) and metabolic syndrome because data on this association in the pediatric population are sparse.

The study findings showed that cardiovascular health must be addressed in any overweight child found to have NAFLD. Those who are unable to improve sufficiently with lifestyle modification “will likely receive pharmacotherapy for … hypertension or dyslipidemia,” even though the data on such medications in this population are insufficient, and it is unclear whether such treatments “have a beneficial, neutral, or deleterious effect on the natural history of NAFLD,” the researchers wrote.

The researchers studied 300 overweight or obese boys and girls aged 5–17 years (mean age 13 years). Half of these subjects had biopsy-proven NAFLD and the other half, who served as controls, did not. The two groups were well matched for age and severity of obesity. The researchers used overweight or obese children as controls because the “vast majority” of children with NAFLD are overweight or obese, they noted.

Metabolic syndrome was defined as a clustering of at least three of five risk factors for cardiovascular disease and type 2 diabetes: abdominal obesity, high triglycerides, low HDL cholesterol, elevated blood pressure, and impaired fasting glucose. The incidence of all these measures was significantly greater in the children with NAFLD than in the control children. The incidence of metabolic syndrome was significantly higher in the children with NAFLD (50%) than in the controls (15%).

Moreover, after the data were adjusted to account for age, sex, race, body mass index, and hyperinsulinemia, children with metabolic syndrome had five times the odds of having NAFLD than did those without metabolic syndrome, the investigators said (Circulation 2008 doi:10.1161/circulationAHA.107.739920

This “demonstrates that obese children and adolescents with a definitive diagnosis of NAFLD have a more severe cardiovascular risk profile than [do] age-, sex-, and BMI-matched peers,” Dr. Schwimmer and his associates noted.

The findings also suggest that fat accumulation in the liver “may play a more important role than obesity itself in determining the risk for 'weight-related' metabolic comorbidities,” they added.

ELSEVIER GLOBAL MEDICAL NEWS

Overweight or obese children who have nonalcoholic fatty liver disease appear to be at high risk of developing cardiovascular disease, according to study findings.

This subset of overweight children also appears to have a high incidence of metabolic syndrome and to be at risk for developing type 2 diabetes and end-stage liver disease, reported Dr. Jeffrey B. Schwimmer of the University of California, San Diego, and his associates.

The investigators examined the link between nonalcoholic fatty liver disease (NAFLD) and metabolic syndrome because data on this association in the pediatric population are sparse.

The study findings showed that cardiovascular health must be addressed in any overweight child found to have NAFLD. Those who are unable to improve sufficiently with lifestyle modification “will likely receive pharmacotherapy for … hypertension or dyslipidemia,” even though the data on such medications in this population are insufficient, and it is unclear whether such treatments “have a beneficial, neutral, or deleterious effect on the natural history of NAFLD,” the researchers wrote.

The researchers studied 300 overweight or obese boys and girls aged 5–17 years (mean age 13 years). Half of these subjects had biopsy-proven NAFLD and the other half, who served as controls, did not. The two groups were well matched for age and severity of obesity. The researchers used overweight or obese children as controls because the “vast majority” of children with NAFLD are overweight or obese, they noted.

Metabolic syndrome was defined as a clustering of at least three of five risk factors for cardiovascular disease and type 2 diabetes: abdominal obesity, high triglycerides, low HDL cholesterol, elevated blood pressure, and impaired fasting glucose. The incidence of all these measures was significantly greater in the children with NAFLD than in the control children. The incidence of metabolic syndrome was significantly higher in the children with NAFLD (50%) than in the controls (15%).

Moreover, after the data were adjusted to account for age, sex, race, body mass index, and hyperinsulinemia, children with metabolic syndrome had five times the odds of having NAFLD than did those without metabolic syndrome, the investigators said (Circulation 2008 doi:10.1161/circulationAHA.107.739920

This “demonstrates that obese children and adolescents with a definitive diagnosis of NAFLD have a more severe cardiovascular risk profile than [do] age-, sex-, and BMI-matched peers,” Dr. Schwimmer and his associates noted.

The findings also suggest that fat accumulation in the liver “may play a more important role than obesity itself in determining the risk for 'weight-related' metabolic comorbidities,” they added.

ELSEVIER GLOBAL MEDICAL NEWS