Mary Ann Moon

A strategy for on-site treatment—rather than automatic hospitalization—of nursing home residents who develop pneumonia reduced hospitalizations by more than half and substantially lowered treatment costs without damaging clinical outcomes, according to Dr. Mark Loeb of McMaster University, Hamilton, Ont., and his associates.

The researchers developed an algorithm, or “clinical pathway,” for treating elderly nursing home patients who had pneumonia, and then tested it in a trial involving 661 patients at 20 facilities in southern Ontario. Patients with pneumonia who had a pulse of up to 100 beats/min, a respiratory rate of fewer than 30 breaths/min, systolic blood pressure of at least 90 mm Hg, oxygen saturation of at least 92%, and the ability to eat and drink were randomly assigned to receive usual care (347 subjects) or to be treated on-site (314 subjects).

For on-site treatment, a study nurse performed chest x-rays as needed, empirically administered oral levofloxacin once daily for 10 days, gave IV hydration as needed, administered oxygen as needed, and monitored vital signs. Subjects were transferred to a hospital if at any time they deteriorated to the point at which they no longer met the enrollment criteria.

Of the on-site treatment group, 34 patients (10%) required hospitalization, compared with 76 (22%) in the usual care group. After the data were adjusted for possible confounding factors, the mean rate of hospital admission was 8% for the on-site treatment group, compared with 20% for the usual care group. The mean number of days spent in the hospital was more than twice as many in the usual care group (1.74 days) as in the on-site treatment group (0.79 days), the researchers said (JAMA 2006;295:2503–10).

The results were similar when the analysis was restricted to patients with pneumonia confirmed by x-ray. In this subgroup, 18% of those in the on-site treatment group were hospitalized, compared with 30% of the usual care group, and the mean admission rates were 9% vs. 29%, respectively.

There were no significant differences between the two groups in mortality, adverse events, health-related quality of life, or functional status. In contrast, the differences in health care costs were substantial.

The initial cost for the on-site treatment approach—which included oxygen therapy, hydration therapy, mobile x-rays, nursing care, and administrative costs—was $87 (in Canadian dollars) per patient above the cost of usual care. However, this was more than offset by reductions in professional billings, transportation fees, and hospitalization costs, which amounted to $1,103 (Canadian) in savings per patient. This would translate to $1,517 savings per patient in U.S. dollars, Dr. Loeb and his associates said.

Their results also suggest that automatically transferring nursing home residents to a hospital when they develop pneumonia has little effect on their clinical outcomes or mortality, the investigators added.

A strategy for on-site treatment—rather than automatic hospitalization—of nursing home residents who develop pneumonia reduced hospitalizations by more than half and substantially lowered treatment costs without damaging clinical outcomes, according to Dr. Mark Loeb of McMaster University, Hamilton, Ont., and his associates.

The researchers developed an algorithm, or “clinical pathway,” for treating elderly nursing home patients who had pneumonia, and then tested it in a trial involving 661 patients at 20 facilities in southern Ontario. Patients with pneumonia who had a pulse of up to 100 beats/min, a respiratory rate of fewer than 30 breaths/min, systolic blood pressure of at least 90 mm Hg, oxygen saturation of at least 92%, and the ability to eat and drink were randomly assigned to receive usual care (347 subjects) or to be treated on-site (314 subjects).

For on-site treatment, a study nurse performed chest x-rays as needed, empirically administered oral levofloxacin once daily for 10 days, gave IV hydration as needed, administered oxygen as needed, and monitored vital signs. Subjects were transferred to a hospital if at any time they deteriorated to the point at which they no longer met the enrollment criteria.

Of the on-site treatment group, 34 patients (10%) required hospitalization, compared with 76 (22%) in the usual care group. After the data were adjusted for possible confounding factors, the mean rate of hospital admission was 8% for the on-site treatment group, compared with 20% for the usual care group. The mean number of days spent in the hospital was more than twice as many in the usual care group (1.74 days) as in the on-site treatment group (0.79 days), the researchers said (JAMA 2006;295:2503–10).

The results were similar when the analysis was restricted to patients with pneumonia confirmed by x-ray. In this subgroup, 18% of those in the on-site treatment group were hospitalized, compared with 30% of the usual care group, and the mean admission rates were 9% vs. 29%, respectively.

There were no significant differences between the two groups in mortality, adverse events, health-related quality of life, or functional status. In contrast, the differences in health care costs were substantial.

The initial cost for the on-site treatment approach—which included oxygen therapy, hydration therapy, mobile x-rays, nursing care, and administrative costs—was $87 (in Canadian dollars) per patient above the cost of usual care. However, this was more than offset by reductions in professional billings, transportation fees, and hospitalization costs, which amounted to $1,103 (Canadian) in savings per patient. This would translate to $1,517 savings per patient in U.S. dollars, Dr. Loeb and his associates said.

Their results also suggest that automatically transferring nursing home residents to a hospital when they develop pneumonia has little effect on their clinical outcomes or mortality, the investigators added.

A strategy for on-site treatment—rather than automatic hospitalization—of nursing home residents who develop pneumonia reduced hospitalizations by more than half and substantially lowered treatment costs without damaging clinical outcomes, according to Dr. Mark Loeb of McMaster University, Hamilton, Ont., and his associates.

The researchers developed an algorithm, or “clinical pathway,” for treating elderly nursing home patients who had pneumonia, and then tested it in a trial involving 661 patients at 20 facilities in southern Ontario. Patients with pneumonia who had a pulse of up to 100 beats/min, a respiratory rate of fewer than 30 breaths/min, systolic blood pressure of at least 90 mm Hg, oxygen saturation of at least 92%, and the ability to eat and drink were randomly assigned to receive usual care (347 subjects) or to be treated on-site (314 subjects).

For on-site treatment, a study nurse performed chest x-rays as needed, empirically administered oral levofloxacin once daily for 10 days, gave IV hydration as needed, administered oxygen as needed, and monitored vital signs. Subjects were transferred to a hospital if at any time they deteriorated to the point at which they no longer met the enrollment criteria.

Of the on-site treatment group, 34 patients (10%) required hospitalization, compared with 76 (22%) in the usual care group. After the data were adjusted for possible confounding factors, the mean rate of hospital admission was 8% for the on-site treatment group, compared with 20% for the usual care group. The mean number of days spent in the hospital was more than twice as many in the usual care group (1.74 days) as in the on-site treatment group (0.79 days), the researchers said (JAMA 2006;295:2503–10).

The results were similar when the analysis was restricted to patients with pneumonia confirmed by x-ray. In this subgroup, 18% of those in the on-site treatment group were hospitalized, compared with 30% of the usual care group, and the mean admission rates were 9% vs. 29%, respectively.

There were no significant differences between the two groups in mortality, adverse events, health-related quality of life, or functional status. In contrast, the differences in health care costs were substantial.

The initial cost for the on-site treatment approach—which included oxygen therapy, hydration therapy, mobile x-rays, nursing care, and administrative costs—was $87 (in Canadian dollars) per patient above the cost of usual care. However, this was more than offset by reductions in professional billings, transportation fees, and hospitalization costs, which amounted to $1,103 (Canadian) in savings per patient. This would translate to $1,517 savings per patient in U.S. dollars, Dr. Loeb and his associates said.

Their results also suggest that automatically transferring nursing home residents to a hospital when they develop pneumonia has little effect on their clinical outcomes or mortality, the investigators added.

The American Heart Association's updated guidelines on cardiovascular health for Americans are moving beyond diet to lifestyle.

The guidelines, last issued in 2000, were revised after a panel of nutrition and cardiovascular disease experts reviewed the scientific literature published in the intervening 6 years. “The key message of the [updated] recommendations is to focus on long-term, permanent changes in how we eat and live. The best way to lower cardiovascular risk is to combine physical activity with heart-healthy eating habits, coupled with weight control and avoiding tobacco products,” said Dr. Alice H. Lichtenstein, chair of the association's nutrition committee, in a statement accompanying release of the new guidelines.

Thirty minutes or more of physical activity per day is recommended, even if it is broken up into small increments.

“Achieving a physically active lifestyle requires effective time management, with a particular focus on reducing sedentary activities such as screen time (e.g., watching television, surfing the Web, playing computer games) and making daily choices to move rather than be moved (e.g., taking the stairs instead of the elevator),” the recommendations state (Circulation 2006;doi:10.1161/CIRCULATIONAHA. 106.176158).

The current recommendations advise consuming lower amounts of saturated fat, from less than 10% to less than 7% of the diet, and—for the first time—advise limiting trans fats to less than 1% of the diet. The guidelines also call for increasing consumption of vegetables, fruits, and whole grain foods; eating fish at least twice a week; and minimizing intake of high-sugar drinks and foods.

The point is not to meticulously calculate the amount and types of fats and other potentially harmful dietary components, but to more generally avoid foods made with hydrogenated fats or added salt and sugar, as well as to choose foods that minimize these components, such as leaner meats and lower-fat dairy products.

The recommendations specifically address adhering to a heart-healthy diet and restricting portion size when consuming food prepared at restaurants, grocery stores, schools, and fast-food outlets, because food eaten outside the home constitutes an estimated one-third of the calories that Americans consume, said Dr. Lichtenstein, who is also Gershoff professor of nutrition science and policy at Tufts University, Boston, and her associates.

The guidelines now include sections with practical tips for clinicians to recommend and for patients to follow. And for the first time, restaurants, the food industry, schools, and local governments are called on to take practical steps to encourage physical activity and discourage unhealthy eating. These measures include reformulating processed foods, packaging foods in smaller portions, providing more vegetable options, and providing safe venues for walking and biking.

The American Heart Association's updated guidelines on cardiovascular health for Americans are moving beyond diet to lifestyle.

The guidelines, last issued in 2000, were revised after a panel of nutrition and cardiovascular disease experts reviewed the scientific literature published in the intervening 6 years. “The key message of the [updated] recommendations is to focus on long-term, permanent changes in how we eat and live. The best way to lower cardiovascular risk is to combine physical activity with heart-healthy eating habits, coupled with weight control and avoiding tobacco products,” said Dr. Alice H. Lichtenstein, chair of the association's nutrition committee, in a statement accompanying release of the new guidelines.

Thirty minutes or more of physical activity per day is recommended, even if it is broken up into small increments.

“Achieving a physically active lifestyle requires effective time management, with a particular focus on reducing sedentary activities such as screen time (e.g., watching television, surfing the Web, playing computer games) and making daily choices to move rather than be moved (e.g., taking the stairs instead of the elevator),” the recommendations state (Circulation 2006;doi:10.1161/CIRCULATIONAHA. 106.176158).

The current recommendations advise consuming lower amounts of saturated fat, from less than 10% to less than 7% of the diet, and—for the first time—advise limiting trans fats to less than 1% of the diet. The guidelines also call for increasing consumption of vegetables, fruits, and whole grain foods; eating fish at least twice a week; and minimizing intake of high-sugar drinks and foods.

The point is not to meticulously calculate the amount and types of fats and other potentially harmful dietary components, but to more generally avoid foods made with hydrogenated fats or added salt and sugar, as well as to choose foods that minimize these components, such as leaner meats and lower-fat dairy products.

The recommendations specifically address adhering to a heart-healthy diet and restricting portion size when consuming food prepared at restaurants, grocery stores, schools, and fast-food outlets, because food eaten outside the home constitutes an estimated one-third of the calories that Americans consume, said Dr. Lichtenstein, who is also Gershoff professor of nutrition science and policy at Tufts University, Boston, and her associates.

The guidelines now include sections with practical tips for clinicians to recommend and for patients to follow. And for the first time, restaurants, the food industry, schools, and local governments are called on to take practical steps to encourage physical activity and discourage unhealthy eating. These measures include reformulating processed foods, packaging foods in smaller portions, providing more vegetable options, and providing safe venues for walking and biking.

The American Heart Association's updated guidelines on cardiovascular health for Americans are moving beyond diet to lifestyle.

The guidelines, last issued in 2000, were revised after a panel of nutrition and cardiovascular disease experts reviewed the scientific literature published in the intervening 6 years. “The key message of the [updated] recommendations is to focus on long-term, permanent changes in how we eat and live. The best way to lower cardiovascular risk is to combine physical activity with heart-healthy eating habits, coupled with weight control and avoiding tobacco products,” said Dr. Alice H. Lichtenstein, chair of the association's nutrition committee, in a statement accompanying release of the new guidelines.

Thirty minutes or more of physical activity per day is recommended, even if it is broken up into small increments.

“Achieving a physically active lifestyle requires effective time management, with a particular focus on reducing sedentary activities such as screen time (e.g., watching television, surfing the Web, playing computer games) and making daily choices to move rather than be moved (e.g., taking the stairs instead of the elevator),” the recommendations state (Circulation 2006;doi:10.1161/CIRCULATIONAHA. 106.176158).

The current recommendations advise consuming lower amounts of saturated fat, from less than 10% to less than 7% of the diet, and—for the first time—advise limiting trans fats to less than 1% of the diet. The guidelines also call for increasing consumption of vegetables, fruits, and whole grain foods; eating fish at least twice a week; and minimizing intake of high-sugar drinks and foods.

The point is not to meticulously calculate the amount and types of fats and other potentially harmful dietary components, but to more generally avoid foods made with hydrogenated fats or added salt and sugar, as well as to choose foods that minimize these components, such as leaner meats and lower-fat dairy products.

The recommendations specifically address adhering to a heart-healthy diet and restricting portion size when consuming food prepared at restaurants, grocery stores, schools, and fast-food outlets, because food eaten outside the home constitutes an estimated one-third of the calories that Americans consume, said Dr. Lichtenstein, who is also Gershoff professor of nutrition science and policy at Tufts University, Boston, and her associates.

The guidelines now include sections with practical tips for clinicians to recommend and for patients to follow. And for the first time, restaurants, the food industry, schools, and local governments are called on to take practical steps to encourage physical activity and discourage unhealthy eating. These measures include reformulating processed foods, packaging foods in smaller portions, providing more vegetable options, and providing safe venues for walking and biking.

Women whose sexual partners consistently used condoms were 70% less likely to acquire genital human papillomavirus infection than were those whose partners did not, in a prospective study specifically designed to determine whether condoms prevent HPV transmission.

“Even women whose partners used condoms more than half the time had a 50% risk reduction, as compared with those whose partners used condoms less than 5% of the time,” reported Dr. Rachel L. Winer and her associates at the University of Washington, Seattle.

Several previous studies have suggested that condom use doesn't reduce the risk of HPV infection in women. Even though these studies were cross-sectional and were not explicitly designed to evaluate condom use, opponents of birth control have seized on those results as ammunition in their attack on condom use. They've pressured the Food and Drug Administration to warn the public that condoms fail to prevent STD transmission, Markus J. Steiner, Ph.D., and Dr. Willard Cates Jr. said in an editorial comment accompanying this report.

In contrast to those previous studies, the prospective, longitudinal study by Dr. Winer and her associates “was designed to evaluate more accurately the temporal relationship between condom use and HPV infection,” the researchers said (N. Engl. J. Med. 2006;354:2645–54).

They assessed 210 healthy female students aged 18–22 years who had never had vaginal intercourse or who had had first intercourse with a single male partner within the preceding 3 months. The subjects completed a Web-based diary every 2 weeks concerning their sexual behavior and underwent gynecologic examination that included HPV testing every 4 months.

“Evidence suggests that computer-assisted questionnaires yield more truthful reporting of sensitive behavior than do face-to-face interviews,” the investigators noted.

During a mean follow-up of 34 months, the subjects' diary data were 91% complete. The 12-month cumulative incidence of a first HPV infection after first intercourse was 37%.

Women whose partners used condoms 100% of the time were 70% less likely to acquire HPV infection than those whose partners used condoms less than 5% of the time, after the data were adjusted to account for the number of new partners the women had and the estimated number of previous partners the men had.

A linear dose-response effect was seen, in which incident HPV infection decreased as the percentage of time a condom was used increased.

A similar inverse association was noted between the frequency of condom use and the incidence of cervical squamous intraepithelial lesions. No incident lesions were detected in women who reported 100% condom use, compared with 14 incident lesions found in women whose partners used condoms less consistently or not at all.

“This trend is consistent with previous data indicating that condom use by their male partners protects some women against high-grade cervical neoplasia and invasive cervical cancer,” Dr. Winer and her associates said.

Of note was the finding that among couples with 100% condom use, those who reported having some genital skin-to-skin contact had a similarly low incidence of HPV infection as did those who avoided all genital skin-to-skin contact. This suggests that brief episodes of skin-to-skin genital contact “are not particularly efficient for male-to-female HPV transmission,” the researchers added.

The newly sexually active women in this study “reported a yearly median number of instances of intercourse (48) and a yearly median number of new partners (1) that were similar to those reported in a large national survey of a random sample of women of a similar age,” indicating that these results are somewhat generalizable. The results may not apply to older women or to those of lower socioeconomic status, however.

In their editorial comment, Dr. Steiner and Dr. Cates of the Institute for Family Health at Family Health International, Research Triangle Park, N.C., said that people can now be assured that condom use can reduce the risk of most STDs, including HPV (N. Engl. J. Med. 2006;354:2642–3).

Women whose sexual partners consistently used condoms were 70% less likely to acquire genital human papillomavirus infection than were those whose partners did not, in a prospective study specifically designed to determine whether condoms prevent HPV transmission.

“Even women whose partners used condoms more than half the time had a 50% risk reduction, as compared with those whose partners used condoms less than 5% of the time,” reported Dr. Rachel L. Winer and her associates at the University of Washington, Seattle.

Several previous studies have suggested that condom use doesn't reduce the risk of HPV infection in women. Even though these studies were cross-sectional and were not explicitly designed to evaluate condom use, opponents of birth control have seized on those results as ammunition in their attack on condom use. They've pressured the Food and Drug Administration to warn the public that condoms fail to prevent STD transmission, Markus J. Steiner, Ph.D., and Dr. Willard Cates Jr. said in an editorial comment accompanying this report.

In contrast to those previous studies, the prospective, longitudinal study by Dr. Winer and her associates “was designed to evaluate more accurately the temporal relationship between condom use and HPV infection,” the researchers said (N. Engl. J. Med. 2006;354:2645–54).

They assessed 210 healthy female students aged 18–22 years who had never had vaginal intercourse or who had had first intercourse with a single male partner within the preceding 3 months. The subjects completed a Web-based diary every 2 weeks concerning their sexual behavior and underwent gynecologic examination that included HPV testing every 4 months.

“Evidence suggests that computer-assisted questionnaires yield more truthful reporting of sensitive behavior than do face-to-face interviews,” the investigators noted.

During a mean follow-up of 34 months, the subjects' diary data were 91% complete. The 12-month cumulative incidence of a first HPV infection after first intercourse was 37%.

Women whose partners used condoms 100% of the time were 70% less likely to acquire HPV infection than those whose partners used condoms less than 5% of the time, after the data were adjusted to account for the number of new partners the women had and the estimated number of previous partners the men had.

A linear dose-response effect was seen, in which incident HPV infection decreased as the percentage of time a condom was used increased.

A similar inverse association was noted between the frequency of condom use and the incidence of cervical squamous intraepithelial lesions. No incident lesions were detected in women who reported 100% condom use, compared with 14 incident lesions found in women whose partners used condoms less consistently or not at all.

“This trend is consistent with previous data indicating that condom use by their male partners protects some women against high-grade cervical neoplasia and invasive cervical cancer,” Dr. Winer and her associates said.

Of note was the finding that among couples with 100% condom use, those who reported having some genital skin-to-skin contact had a similarly low incidence of HPV infection as did those who avoided all genital skin-to-skin contact. This suggests that brief episodes of skin-to-skin genital contact “are not particularly efficient for male-to-female HPV transmission,” the researchers added.

The newly sexually active women in this study “reported a yearly median number of instances of intercourse (48) and a yearly median number of new partners (1) that were similar to those reported in a large national survey of a random sample of women of a similar age,” indicating that these results are somewhat generalizable. The results may not apply to older women or to those of lower socioeconomic status, however.

In their editorial comment, Dr. Steiner and Dr. Cates of the Institute for Family Health at Family Health International, Research Triangle Park, N.C., said that people can now be assured that condom use can reduce the risk of most STDs, including HPV (N. Engl. J. Med. 2006;354:2642–3).

Women whose sexual partners consistently used condoms were 70% less likely to acquire genital human papillomavirus infection than were those whose partners did not, in a prospective study specifically designed to determine whether condoms prevent HPV transmission.

“Even women whose partners used condoms more than half the time had a 50% risk reduction, as compared with those whose partners used condoms less than 5% of the time,” reported Dr. Rachel L. Winer and her associates at the University of Washington, Seattle.

Several previous studies have suggested that condom use doesn't reduce the risk of HPV infection in women. Even though these studies were cross-sectional and were not explicitly designed to evaluate condom use, opponents of birth control have seized on those results as ammunition in their attack on condom use. They've pressured the Food and Drug Administration to warn the public that condoms fail to prevent STD transmission, Markus J. Steiner, Ph.D., and Dr. Willard Cates Jr. said in an editorial comment accompanying this report.

In contrast to those previous studies, the prospective, longitudinal study by Dr. Winer and her associates “was designed to evaluate more accurately the temporal relationship between condom use and HPV infection,” the researchers said (N. Engl. J. Med. 2006;354:2645–54).

They assessed 210 healthy female students aged 18–22 years who had never had vaginal intercourse or who had had first intercourse with a single male partner within the preceding 3 months. The subjects completed a Web-based diary every 2 weeks concerning their sexual behavior and underwent gynecologic examination that included HPV testing every 4 months.

“Evidence suggests that computer-assisted questionnaires yield more truthful reporting of sensitive behavior than do face-to-face interviews,” the investigators noted.

During a mean follow-up of 34 months, the subjects' diary data were 91% complete. The 12-month cumulative incidence of a first HPV infection after first intercourse was 37%.

Women whose partners used condoms 100% of the time were 70% less likely to acquire HPV infection than those whose partners used condoms less than 5% of the time, after the data were adjusted to account for the number of new partners the women had and the estimated number of previous partners the men had.

A linear dose-response effect was seen, in which incident HPV infection decreased as the percentage of time a condom was used increased.

A similar inverse association was noted between the frequency of condom use and the incidence of cervical squamous intraepithelial lesions. No incident lesions were detected in women who reported 100% condom use, compared with 14 incident lesions found in women whose partners used condoms less consistently or not at all.

“This trend is consistent with previous data indicating that condom use by their male partners protects some women against high-grade cervical neoplasia and invasive cervical cancer,” Dr. Winer and her associates said.

Of note was the finding that among couples with 100% condom use, those who reported having some genital skin-to-skin contact had a similarly low incidence of HPV infection as did those who avoided all genital skin-to-skin contact. This suggests that brief episodes of skin-to-skin genital contact “are not particularly efficient for male-to-female HPV transmission,” the researchers added.

The newly sexually active women in this study “reported a yearly median number of instances of intercourse (48) and a yearly median number of new partners (1) that were similar to those reported in a large national survey of a random sample of women of a similar age,” indicating that these results are somewhat generalizable. The results may not apply to older women or to those of lower socioeconomic status, however.

In their editorial comment, Dr. Steiner and Dr. Cates of the Institute for Family Health at Family Health International, Research Triangle Park, N.C., said that people can now be assured that condom use can reduce the risk of most STDs, including HPV (N. Engl. J. Med. 2006;354:2642–3).

Both diagnostic and therapeutic injections for shoulder pain are often placed inaccurately, even when clinicians are convinced they've injected the subacromial bursa rather than other structures, reported Dr. Hans-Erik Henkus of Medisch Centrum Haaglanden, the Hague, and his associates.

They found that only 66% of subacromial injections were accurate in a series of 33 patients, suggesting that the technique is “a poor tool” for diagnosing the source of shoulder pain and “worrisome” as a therapeutic strategy, the researchers said.

Rather than easing pain and restoring function, inaccurate injections worsen both.

Injecting a local anesthetic around the shoulder area is a widely used method for determining the source of the pain and for predicting the success of subacromial decompression surgery. Injecting corticosteroids is done to reduce inflammation and pain. Both strategies are “based on the assumption that these injections can be given with great accuracy,” Dr. Henkus and his associates wrote (Arthroscopy 2006;22:277–82).

But few studies have examined the accuracy of shoulder injections.

The investigators assessed the technique in 33 patients with nontraumatic shoulder pain localized to the deltoid region. The 11 men and 22 women, with an average age of 46 years, were unable to lie on the affected side. Abduction, retroversion, or internal rotation of the glenohumeral joint against resistance provoked further pain.

With the subjects in an upright seated position, an experienced orthopedic surgeon injected all the shoulders with a mixture of bupivacaine, methylprednisolone, and a contrast agent. The surgeon was randomly assigned to approach either anteromedially (16 cases) or posteriorly (17 cases). An MRI was performed immediately to determine the location of the infiltration.

The subacromial bursa was accurately targeted in only 22 (66%) of cases, even though the surgeon was confident that the injections had been accurate in 30 cases (91%) and “doubtful” in only 3.

Three injections infiltrated only the deltoid muscle and subcutaneous tissue, two the glenohumeral joint only, two the acromioclavicular joint only, and three the rotator cuff only.

Even when the subacromial bursa was correctly targeted, many surrounding tissues were infiltrated as well. The rotator cuff was infiltrated 13 times, the deltoid muscle 3 times, and the coracoacromial ligament 2 times.

Pain was reduced and function improved in the cases in which the subacromial bursa alone was injected. However, pain increased and function declined or showed no change when other structures, particularly the rotator cuff, were infiltrated.

“The rotator cuff muscle or tendon was hit in 17 patients,” a “worrisome” incidence that could well have caused rotator cuff rupture, particularly if corticosteroids had been injected, the investigators noted.

Neither the type of approach (anterior or posterior) nor the patient's body mass index had any influence on the accuracy of injection placement.

Given that a single faulty injection to any of a variety of structures could produce either a false-positive or a false-negative result, these findings indicate that “the diagnostic use of local injections in the subacromial bursa [is] a poor tool,” they said.

Both diagnostic and therapeutic injections for shoulder pain are often placed inaccurately, even when clinicians are convinced they've injected the subacromial bursa rather than other structures, reported Dr. Hans-Erik Henkus of Medisch Centrum Haaglanden, the Hague, and his associates.

They found that only 66% of subacromial injections were accurate in a series of 33 patients, suggesting that the technique is “a poor tool” for diagnosing the source of shoulder pain and “worrisome” as a therapeutic strategy, the researchers said.

Rather than easing pain and restoring function, inaccurate injections worsen both.

Injecting a local anesthetic around the shoulder area is a widely used method for determining the source of the pain and for predicting the success of subacromial decompression surgery. Injecting corticosteroids is done to reduce inflammation and pain. Both strategies are “based on the assumption that these injections can be given with great accuracy,” Dr. Henkus and his associates wrote (Arthroscopy 2006;22:277–82).

But few studies have examined the accuracy of shoulder injections.

The investigators assessed the technique in 33 patients with nontraumatic shoulder pain localized to the deltoid region. The 11 men and 22 women, with an average age of 46 years, were unable to lie on the affected side. Abduction, retroversion, or internal rotation of the glenohumeral joint against resistance provoked further pain.

With the subjects in an upright seated position, an experienced orthopedic surgeon injected all the shoulders with a mixture of bupivacaine, methylprednisolone, and a contrast agent. The surgeon was randomly assigned to approach either anteromedially (16 cases) or posteriorly (17 cases). An MRI was performed immediately to determine the location of the infiltration.

The subacromial bursa was accurately targeted in only 22 (66%) of cases, even though the surgeon was confident that the injections had been accurate in 30 cases (91%) and “doubtful” in only 3.

Three injections infiltrated only the deltoid muscle and subcutaneous tissue, two the glenohumeral joint only, two the acromioclavicular joint only, and three the rotator cuff only.

Even when the subacromial bursa was correctly targeted, many surrounding tissues were infiltrated as well. The rotator cuff was infiltrated 13 times, the deltoid muscle 3 times, and the coracoacromial ligament 2 times.

Pain was reduced and function improved in the cases in which the subacromial bursa alone was injected. However, pain increased and function declined or showed no change when other structures, particularly the rotator cuff, were infiltrated.

“The rotator cuff muscle or tendon was hit in 17 patients,” a “worrisome” incidence that could well have caused rotator cuff rupture, particularly if corticosteroids had been injected, the investigators noted.

Neither the type of approach (anterior or posterior) nor the patient's body mass index had any influence on the accuracy of injection placement.

Given that a single faulty injection to any of a variety of structures could produce either a false-positive or a false-negative result, these findings indicate that “the diagnostic use of local injections in the subacromial bursa [is] a poor tool,” they said.

Both diagnostic and therapeutic injections for shoulder pain are often placed inaccurately, even when clinicians are convinced they've injected the subacromial bursa rather than other structures, reported Dr. Hans-Erik Henkus of Medisch Centrum Haaglanden, the Hague, and his associates.

They found that only 66% of subacromial injections were accurate in a series of 33 patients, suggesting that the technique is “a poor tool” for diagnosing the source of shoulder pain and “worrisome” as a therapeutic strategy, the researchers said.

Rather than easing pain and restoring function, inaccurate injections worsen both.

Injecting a local anesthetic around the shoulder area is a widely used method for determining the source of the pain and for predicting the success of subacromial decompression surgery. Injecting corticosteroids is done to reduce inflammation and pain. Both strategies are “based on the assumption that these injections can be given with great accuracy,” Dr. Henkus and his associates wrote (Arthroscopy 2006;22:277–82).

But few studies have examined the accuracy of shoulder injections.

The investigators assessed the technique in 33 patients with nontraumatic shoulder pain localized to the deltoid region. The 11 men and 22 women, with an average age of 46 years, were unable to lie on the affected side. Abduction, retroversion, or internal rotation of the glenohumeral joint against resistance provoked further pain.

With the subjects in an upright seated position, an experienced orthopedic surgeon injected all the shoulders with a mixture of bupivacaine, methylprednisolone, and a contrast agent. The surgeon was randomly assigned to approach either anteromedially (16 cases) or posteriorly (17 cases). An MRI was performed immediately to determine the location of the infiltration.

The subacromial bursa was accurately targeted in only 22 (66%) of cases, even though the surgeon was confident that the injections had been accurate in 30 cases (91%) and “doubtful” in only 3.

Three injections infiltrated only the deltoid muscle and subcutaneous tissue, two the glenohumeral joint only, two the acromioclavicular joint only, and three the rotator cuff only.

Even when the subacromial bursa was correctly targeted, many surrounding tissues were infiltrated as well. The rotator cuff was infiltrated 13 times, the deltoid muscle 3 times, and the coracoacromial ligament 2 times.

Pain was reduced and function improved in the cases in which the subacromial bursa alone was injected. However, pain increased and function declined or showed no change when other structures, particularly the rotator cuff, were infiltrated.

“The rotator cuff muscle or tendon was hit in 17 patients,” a “worrisome” incidence that could well have caused rotator cuff rupture, particularly if corticosteroids had been injected, the investigators noted.

Neither the type of approach (anterior or posterior) nor the patient's body mass index had any influence on the accuracy of injection placement.

Given that a single faulty injection to any of a variety of structures could produce either a false-positive or a false-negative result, these findings indicate that “the diagnostic use of local injections in the subacromial bursa [is] a poor tool,” they said.

Both thiazide diuretics and β-blockers taken to treat hypertension appear to raise the risk of type 2 diabetes, reported Dr. Eric N. Taylor of Harvard Medical School, Boston, and associates.

They used data from three large cohort studies to determine whether various antihypertensive agents were associated with incident cases of type 2 diabetes. They analyzed data on more than 14,000 younger women (aged 25–42 years at baseline) in the Nurses' Health Study II, more than 41,000 older women (aged 30–55 at baseline) in the Nurses' Health Study I, and more than 19,000 men (aged 40–75 at baseline) in the Health Professionals Follow-Up Study.

All the subjects were taking medication for hypertension. During follow-ups of 10 years (NHS II participants), 8 years (NHS I participants), and 16 years (HPFS participants), 3,589 of these subjects developed type 2 diabetes.

The use of thiazide diuretics significantly raised the risk of incident diabetes in all three cohorts. The use of β-blockers was not assessed separately from other antihypertensives in the younger women, but it significantly raised the risk of incident diabetes in the older women and in the men, Dr. Taylor and his associates wrote (Diabetes Care 2006;29:1065–70).

There was no association between the use of calcium channel blockers or other antihypertensive medications and diabetes risk.

Both thiazide diuretics and β-blockers taken to treat hypertension appear to raise the risk of type 2 diabetes, reported Dr. Eric N. Taylor of Harvard Medical School, Boston, and associates.

They used data from three large cohort studies to determine whether various antihypertensive agents were associated with incident cases of type 2 diabetes. They analyzed data on more than 14,000 younger women (aged 25–42 years at baseline) in the Nurses' Health Study II, more than 41,000 older women (aged 30–55 at baseline) in the Nurses' Health Study I, and more than 19,000 men (aged 40–75 at baseline) in the Health Professionals Follow-Up Study.

All the subjects were taking medication for hypertension. During follow-ups of 10 years (NHS II participants), 8 years (NHS I participants), and 16 years (HPFS participants), 3,589 of these subjects developed type 2 diabetes.

The use of thiazide diuretics significantly raised the risk of incident diabetes in all three cohorts. The use of β-blockers was not assessed separately from other antihypertensives in the younger women, but it significantly raised the risk of incident diabetes in the older women and in the men, Dr. Taylor and his associates wrote (Diabetes Care 2006;29:1065–70).

There was no association between the use of calcium channel blockers or other antihypertensive medications and diabetes risk.

Both thiazide diuretics and β-blockers taken to treat hypertension appear to raise the risk of type 2 diabetes, reported Dr. Eric N. Taylor of Harvard Medical School, Boston, and associates.

They used data from three large cohort studies to determine whether various antihypertensive agents were associated with incident cases of type 2 diabetes. They analyzed data on more than 14,000 younger women (aged 25–42 years at baseline) in the Nurses' Health Study II, more than 41,000 older women (aged 30–55 at baseline) in the Nurses' Health Study I, and more than 19,000 men (aged 40–75 at baseline) in the Health Professionals Follow-Up Study.

All the subjects were taking medication for hypertension. During follow-ups of 10 years (NHS II participants), 8 years (NHS I participants), and 16 years (HPFS participants), 3,589 of these subjects developed type 2 diabetes.

The use of thiazide diuretics significantly raised the risk of incident diabetes in all three cohorts. The use of β-blockers was not assessed separately from other antihypertensives in the younger women, but it significantly raised the risk of incident diabetes in the older women and in the men, Dr. Taylor and his associates wrote (Diabetes Care 2006;29:1065–70).

There was no association between the use of calcium channel blockers or other antihypertensive medications and diabetes risk.

The 30-day mortality for bariatric surgery was 0.4% when the procedure was done at academic medical centers with a high volume of this surgery, reported Dr. Ninh T. Nguyen, chief of the GI surgery division at the University of California, Irvine, and his associates.

Some researchers and clinicians became concerned about high perioperative mortality when a recent study in Washington state reported a 1.9% 30-day mortality for bariatric surgery, and a national study involving over 16,000 Medicare patients reported a 2% 30-day mortality, Dr. Nguyen and his associates said.

They evaluated the perioperative outcomes of 1,144 bariatric surgeries performed at facilities affiliated with a university health system. A total of 29 of the 93 member academic medical centers participated; each facility provided the medical records of about 40 consecutive bariatric surgeries performed between October 2003 and March 2004.

Most of these medical centers performed a high volume of bariatric procedures. The analysis was restricted to routine or elective procedures in patients with a body mass index (kg/m

The findings of this study may not reflect outcomes in nonacademic medical centers or hospitals that perform a lower volume of bariatric procedures. The results also may not be generalizable to emergency or open procedures or to patients who are male, nonwhite, or less affluent or who have a BMI less than 35 or greater than 70, the investigators noted (Arch. Surg. 2006;141:445–50).

The 30-day mortality in these 1,144 cases was 0.4%, and the in-hospital mortality was 0.2%. Causes of death were multiple system failure (three patients) and pulmonary embolism (one patient). These results show that bariatric surgery performed at academic medical centers is safe, with low perioperative mortality, Dr. Nguyen and his associates said.

The 30-day readmission rate was 6.6%. Readmissions were needed for dehydration and vomiting, as well as other complications. The complication rate was 16% and included cases of anastomotic leakage (1.6%), wound infection (2.6%), pneumonia (1.9%), cardiac arrhythmia (1.7%), bowel obstruction (1.5%), urinary tract infection (1%), GI or abdominal hemorrhage (1.0%), and deep vein thrombosis/pulmonary embolism (0.3%).

“Another important finding from this study is that the practice of bariatric surgery has shifted from open surgery to laparoscopic surgery. To our knowledge, this is the first study to document greater use of laparoscopic bariatric surgery than open bariatric surgery. Laparoscopy was used in 76% of gastric bypass procedures and in 92% of restrictive procedures,” the researchers said.

In a discussion accompanying the report, Dr. Ravi Moonka, a surgeon at the Virginia Mason Medical Center, Seattle, followed up on an observation that less than one-third of the medical centers affiliated with the university health system opted to participate in this study, saying that those “presumably are the centers that think they have good results.”

In that case, the study findings reflect “what excellent centers do and not what the average center does,” he said (Arch. Surg. 2006;141:450).

Dr. Moonka also noted that these findings cannot be generalized to many practices, including his own, because he performs open procedures, usually treats patients with greater BMIs, and often operates on male patients.

The 30-day mortality for bariatric surgery was 0.4% when the procedure was done at academic medical centers with a high volume of this surgery, reported Dr. Ninh T. Nguyen, chief of the GI surgery division at the University of California, Irvine, and his associates.

Some researchers and clinicians became concerned about high perioperative mortality when a recent study in Washington state reported a 1.9% 30-day mortality for bariatric surgery, and a national study involving over 16,000 Medicare patients reported a 2% 30-day mortality, Dr. Nguyen and his associates said.

They evaluated the perioperative outcomes of 1,144 bariatric surgeries performed at facilities affiliated with a university health system. A total of 29 of the 93 member academic medical centers participated; each facility provided the medical records of about 40 consecutive bariatric surgeries performed between October 2003 and March 2004.

Most of these medical centers performed a high volume of bariatric procedures. The analysis was restricted to routine or elective procedures in patients with a body mass index (kg/m

The findings of this study may not reflect outcomes in nonacademic medical centers or hospitals that perform a lower volume of bariatric procedures. The results also may not be generalizable to emergency or open procedures or to patients who are male, nonwhite, or less affluent or who have a BMI less than 35 or greater than 70, the investigators noted (Arch. Surg. 2006;141:445–50).

The 30-day mortality in these 1,144 cases was 0.4%, and the in-hospital mortality was 0.2%. Causes of death were multiple system failure (three patients) and pulmonary embolism (one patient). These results show that bariatric surgery performed at academic medical centers is safe, with low perioperative mortality, Dr. Nguyen and his associates said.

The 30-day readmission rate was 6.6%. Readmissions were needed for dehydration and vomiting, as well as other complications. The complication rate was 16% and included cases of anastomotic leakage (1.6%), wound infection (2.6%), pneumonia (1.9%), cardiac arrhythmia (1.7%), bowel obstruction (1.5%), urinary tract infection (1%), GI or abdominal hemorrhage (1.0%), and deep vein thrombosis/pulmonary embolism (0.3%).

“Another important finding from this study is that the practice of bariatric surgery has shifted from open surgery to laparoscopic surgery. To our knowledge, this is the first study to document greater use of laparoscopic bariatric surgery than open bariatric surgery. Laparoscopy was used in 76% of gastric bypass procedures and in 92% of restrictive procedures,” the researchers said.

In a discussion accompanying the report, Dr. Ravi Moonka, a surgeon at the Virginia Mason Medical Center, Seattle, followed up on an observation that less than one-third of the medical centers affiliated with the university health system opted to participate in this study, saying that those “presumably are the centers that think they have good results.”

In that case, the study findings reflect “what excellent centers do and not what the average center does,” he said (Arch. Surg. 2006;141:450).

Dr. Moonka also noted that these findings cannot be generalized to many practices, including his own, because he performs open procedures, usually treats patients with greater BMIs, and often operates on male patients.

The 30-day mortality for bariatric surgery was 0.4% when the procedure was done at academic medical centers with a high volume of this surgery, reported Dr. Ninh T. Nguyen, chief of the GI surgery division at the University of California, Irvine, and his associates.

Some researchers and clinicians became concerned about high perioperative mortality when a recent study in Washington state reported a 1.9% 30-day mortality for bariatric surgery, and a national study involving over 16,000 Medicare patients reported a 2% 30-day mortality, Dr. Nguyen and his associates said.

They evaluated the perioperative outcomes of 1,144 bariatric surgeries performed at facilities affiliated with a university health system. A total of 29 of the 93 member academic medical centers participated; each facility provided the medical records of about 40 consecutive bariatric surgeries performed between October 2003 and March 2004.

Most of these medical centers performed a high volume of bariatric procedures. The analysis was restricted to routine or elective procedures in patients with a body mass index (kg/m

The findings of this study may not reflect outcomes in nonacademic medical centers or hospitals that perform a lower volume of bariatric procedures. The results also may not be generalizable to emergency or open procedures or to patients who are male, nonwhite, or less affluent or who have a BMI less than 35 or greater than 70, the investigators noted (Arch. Surg. 2006;141:445–50).

The 30-day mortality in these 1,144 cases was 0.4%, and the in-hospital mortality was 0.2%. Causes of death were multiple system failure (three patients) and pulmonary embolism (one patient). These results show that bariatric surgery performed at academic medical centers is safe, with low perioperative mortality, Dr. Nguyen and his associates said.

The 30-day readmission rate was 6.6%. Readmissions were needed for dehydration and vomiting, as well as other complications. The complication rate was 16% and included cases of anastomotic leakage (1.6%), wound infection (2.6%), pneumonia (1.9%), cardiac arrhythmia (1.7%), bowel obstruction (1.5%), urinary tract infection (1%), GI or abdominal hemorrhage (1.0%), and deep vein thrombosis/pulmonary embolism (0.3%).

“Another important finding from this study is that the practice of bariatric surgery has shifted from open surgery to laparoscopic surgery. To our knowledge, this is the first study to document greater use of laparoscopic bariatric surgery than open bariatric surgery. Laparoscopy was used in 76% of gastric bypass procedures and in 92% of restrictive procedures,” the researchers said.

In a discussion accompanying the report, Dr. Ravi Moonka, a surgeon at the Virginia Mason Medical Center, Seattle, followed up on an observation that less than one-third of the medical centers affiliated with the university health system opted to participate in this study, saying that those “presumably are the centers that think they have good results.”

In that case, the study findings reflect “what excellent centers do and not what the average center does,” he said (Arch. Surg. 2006;141:450).

Dr. Moonka also noted that these findings cannot be generalized to many practices, including his own, because he performs open procedures, usually treats patients with greater BMIs, and often operates on male patients.

Americans are much less healthy than their British counterparts, at all levels of socioeconomic status, reported James Banks, Ph.D., of University College, London, and his associates.

In both countries, people with the highest levels of education and income are the healthiest, while those of low education and income are the unhealthiest. But the overall differences in health status between the two countries is so profound that the wealthiest Americans have comparable rates of diabetes and heart disease to people at the lowest levels of education and income in England.

Dr. Banks and his associates compared rates of seven major diagnoses among populations of comparable socioeconomic positions in nationally representative samples from the United States and England. To minimize the effects of racial and age differences between the populations, they restricted their study to only non-Hispanic white men and women aged 55–64 years.

The analysis included health-related data on 2,097 Americans and 5,526 British subjects. All were interviewed in 2002 and underwent physical examinations that included laboratory tests to verify their self-report of conditions such as diabetes.

Overall, Americans were more likely to have diabetes, hypertension, heart disease, a history of myocardial infarction or stroke, lung disease, and cancer than British subjects. Diabetes prevalence was twice as high in the United States (13%) as it was in England (6%), the rate of hypertension was nearly 9% higher, and the rate of heart disease was almost 6% higher, the investigators said (JAMA 2006;295:2037–45).

Regarding markers of future cardiovascular risk, 40% of Americans had high levels of C-reactive protein and 24% had high levels of fibrinogen, compared with 30% and 10%, respectively, among the British participants. Similarly, only 28% of Americans had heart-healthy levels of HDL cholesterol, compared with 44% of the European comparison group.

The study was not designed to explain the reasons underlying the large discrepancy in health status between England and the United States, and the investigators did not offer any potential explanations. However, they were able to rule out possible causes.

The discrepancy was not because of differences between the two populations in major risk factors. Smoking status was remarkably similar between the two countries. And although obesity was much more common in Americans, while heavy drinking was much more common in England, “very little of the overall between-country differences in health conditions are due to differences in … behavioral risk factors,” the researchers noted.

Nor did differences in access to health care account for the wide gap in health status. The British participants may have nationalized health care, but most of the Americans in the survey had full insurance coverage. “Health insurance cannot be the central reason for the better health outcomes in England because the top [socioeconomic] tier of the U.S. population have close to universal access but their health outcomes are often worse than those of their English counterparts,” the investigators wrote.

ELSEVIER GLOBAL MEDICAL NEWS

Americans are much less healthy than their British counterparts, at all levels of socioeconomic status, reported James Banks, Ph.D., of University College, London, and his associates.

In both countries, people with the highest levels of education and income are the healthiest, while those of low education and income are the unhealthiest. But the overall differences in health status between the two countries is so profound that the wealthiest Americans have comparable rates of diabetes and heart disease to people at the lowest levels of education and income in England.

Dr. Banks and his associates compared rates of seven major diagnoses among populations of comparable socioeconomic positions in nationally representative samples from the United States and England. To minimize the effects of racial and age differences between the populations, they restricted their study to only non-Hispanic white men and women aged 55–64 years.

The analysis included health-related data on 2,097 Americans and 5,526 British subjects. All were interviewed in 2002 and underwent physical examinations that included laboratory tests to verify their self-report of conditions such as diabetes.

Overall, Americans were more likely to have diabetes, hypertension, heart disease, a history of myocardial infarction or stroke, lung disease, and cancer than British subjects. Diabetes prevalence was twice as high in the United States (13%) as it was in England (6%), the rate of hypertension was nearly 9% higher, and the rate of heart disease was almost 6% higher, the investigators said (JAMA 2006;295:2037–45).

Regarding markers of future cardiovascular risk, 40% of Americans had high levels of C-reactive protein and 24% had high levels of fibrinogen, compared with 30% and 10%, respectively, among the British participants. Similarly, only 28% of Americans had heart-healthy levels of HDL cholesterol, compared with 44% of the European comparison group.

The study was not designed to explain the reasons underlying the large discrepancy in health status between England and the United States, and the investigators did not offer any potential explanations. However, they were able to rule out possible causes.

The discrepancy was not because of differences between the two populations in major risk factors. Smoking status was remarkably similar between the two countries. And although obesity was much more common in Americans, while heavy drinking was much more common in England, “very little of the overall between-country differences in health conditions are due to differences in … behavioral risk factors,” the researchers noted.

Nor did differences in access to health care account for the wide gap in health status. The British participants may have nationalized health care, but most of the Americans in the survey had full insurance coverage. “Health insurance cannot be the central reason for the better health outcomes in England because the top [socioeconomic] tier of the U.S. population have close to universal access but their health outcomes are often worse than those of their English counterparts,” the investigators wrote.

ELSEVIER GLOBAL MEDICAL NEWS

Americans are much less healthy than their British counterparts, at all levels of socioeconomic status, reported James Banks, Ph.D., of University College, London, and his associates.

In both countries, people with the highest levels of education and income are the healthiest, while those of low education and income are the unhealthiest. But the overall differences in health status between the two countries is so profound that the wealthiest Americans have comparable rates of diabetes and heart disease to people at the lowest levels of education and income in England.

Dr. Banks and his associates compared rates of seven major diagnoses among populations of comparable socioeconomic positions in nationally representative samples from the United States and England. To minimize the effects of racial and age differences between the populations, they restricted their study to only non-Hispanic white men and women aged 55–64 years.

The analysis included health-related data on 2,097 Americans and 5,526 British subjects. All were interviewed in 2002 and underwent physical examinations that included laboratory tests to verify their self-report of conditions such as diabetes.

Overall, Americans were more likely to have diabetes, hypertension, heart disease, a history of myocardial infarction or stroke, lung disease, and cancer than British subjects. Diabetes prevalence was twice as high in the United States (13%) as it was in England (6%), the rate of hypertension was nearly 9% higher, and the rate of heart disease was almost 6% higher, the investigators said (JAMA 2006;295:2037–45).

Regarding markers of future cardiovascular risk, 40% of Americans had high levels of C-reactive protein and 24% had high levels of fibrinogen, compared with 30% and 10%, respectively, among the British participants. Similarly, only 28% of Americans had heart-healthy levels of HDL cholesterol, compared with 44% of the European comparison group.

The study was not designed to explain the reasons underlying the large discrepancy in health status between England and the United States, and the investigators did not offer any potential explanations. However, they were able to rule out possible causes.

The discrepancy was not because of differences between the two populations in major risk factors. Smoking status was remarkably similar between the two countries. And although obesity was much more common in Americans, while heavy drinking was much more common in England, “very little of the overall between-country differences in health conditions are due to differences in … behavioral risk factors,” the researchers noted.

Nor did differences in access to health care account for the wide gap in health status. The British participants may have nationalized health care, but most of the Americans in the survey had full insurance coverage. “Health insurance cannot be the central reason for the better health outcomes in England because the top [socioeconomic] tier of the U.S. population have close to universal access but their health outcomes are often worse than those of their English counterparts,” the investigators wrote.

ELSEVIER GLOBAL MEDICAL NEWS

A higher-dose influenza vaccine than is currently recommended appears to be more immunogenic in the elderly, reported Dr. Wendy A. Keitel of Baylor College of Medicine, Houston, and her associates.

“For reasons unknown, vaccine efficacy among elderly persons has been variable. A progressive reduction in immune competence is described with increasing age, and reduced antibody responses to inactivated influenza vaccines have been noted in elderly persons,” the investigators said.

They assessed the immunogenicity of several doses of a 2002 U.S. vaccine formulation in 202 healthy subjects aged 65–88 years.

The subjects were randomly assigned to receive a single intramuscular injection of trivalent inactivated subvirion influenza vaccine containing 15, 30, or 60 mcg of hemagglutinin per strain, or a placebo injection. The usual recommended dose is 15 mcg.

One month later, mean titers of antibodies to all the viral strains showed significant increases that corresponded to increasing vaccine dose. The percentage of subjects who attained protective titers of antibodies also rose with increasing vaccine dose, the researchers said (Arch. Intern. Med. 2006;166:1121–7).

Among subjects who had the lowest antibody titers at baseline, the antibody response to the 60-mcg dose was nearly double that to the 15-mcg dose of the vaccine.

All vaccine doses were deemed safe and well tolerated. There were significant dose-related rises in the frequencies of injection-site pain and redness or swelling, but most of these reactions were mild and transient.

There were no dose-related differences in systemic symptoms and no serious adverse events attributed to the vaccines.

Further, larger-scale trials are warranted to confirm the finding that enhanced-potency vaccines are safe and effective in the elderly, Dr. Keitel and her associates said.

The vaccines for this study were provided by the drug manufacturer Aventis Pasteur.

A higher-dose influenza vaccine than is currently recommended appears to be more immunogenic in the elderly, reported Dr. Wendy A. Keitel of Baylor College of Medicine, Houston, and her associates.

“For reasons unknown, vaccine efficacy among elderly persons has been variable. A progressive reduction in immune competence is described with increasing age, and reduced antibody responses to inactivated influenza vaccines have been noted in elderly persons,” the investigators said.

They assessed the immunogenicity of several doses of a 2002 U.S. vaccine formulation in 202 healthy subjects aged 65–88 years.

The subjects were randomly assigned to receive a single intramuscular injection of trivalent inactivated subvirion influenza vaccine containing 15, 30, or 60 mcg of hemagglutinin per strain, or a placebo injection. The usual recommended dose is 15 mcg.

One month later, mean titers of antibodies to all the viral strains showed significant increases that corresponded to increasing vaccine dose. The percentage of subjects who attained protective titers of antibodies also rose with increasing vaccine dose, the researchers said (Arch. Intern. Med. 2006;166:1121–7).

Among subjects who had the lowest antibody titers at baseline, the antibody response to the 60-mcg dose was nearly double that to the 15-mcg dose of the vaccine.

All vaccine doses were deemed safe and well tolerated. There were significant dose-related rises in the frequencies of injection-site pain and redness or swelling, but most of these reactions were mild and transient.

There were no dose-related differences in systemic symptoms and no serious adverse events attributed to the vaccines.

Further, larger-scale trials are warranted to confirm the finding that enhanced-potency vaccines are safe and effective in the elderly, Dr. Keitel and her associates said.

The vaccines for this study were provided by the drug manufacturer Aventis Pasteur.

A higher-dose influenza vaccine than is currently recommended appears to be more immunogenic in the elderly, reported Dr. Wendy A. Keitel of Baylor College of Medicine, Houston, and her associates.

“For reasons unknown, vaccine efficacy among elderly persons has been variable. A progressive reduction in immune competence is described with increasing age, and reduced antibody responses to inactivated influenza vaccines have been noted in elderly persons,” the investigators said.

They assessed the immunogenicity of several doses of a 2002 U.S. vaccine formulation in 202 healthy subjects aged 65–88 years.

The subjects were randomly assigned to receive a single intramuscular injection of trivalent inactivated subvirion influenza vaccine containing 15, 30, or 60 mcg of hemagglutinin per strain, or a placebo injection. The usual recommended dose is 15 mcg.

One month later, mean titers of antibodies to all the viral strains showed significant increases that corresponded to increasing vaccine dose. The percentage of subjects who attained protective titers of antibodies also rose with increasing vaccine dose, the researchers said (Arch. Intern. Med. 2006;166:1121–7).

Among subjects who had the lowest antibody titers at baseline, the antibody response to the 60-mcg dose was nearly double that to the 15-mcg dose of the vaccine.

All vaccine doses were deemed safe and well tolerated. There were significant dose-related rises in the frequencies of injection-site pain and redness or swelling, but most of these reactions were mild and transient.

There were no dose-related differences in systemic symptoms and no serious adverse events attributed to the vaccines.

Further, larger-scale trials are warranted to confirm the finding that enhanced-potency vaccines are safe and effective in the elderly, Dr. Keitel and her associates said.

The vaccines for this study were provided by the drug manufacturer Aventis Pasteur.

Policosanol Did Not Improve Lipids

The supplement policosanol, which is touted for its lipid-lowering effects and is popular worldwide, did not lower lipids appreciably in a multicenter, randomized clinical trial, reported Dr. Heiner K. Berthold and associates at the University of Cologne, Germany.

Dozens of studies have reported that policosanol, a mixture of long-chain primary alcohols derived primarily from sugar cane wax, lowers LDL cholesterol as effectively as do statins, without side effects. But “virtually all of the published scientific literature supporting the beneficial effects of policosanol on lipids has been authored by a single research group from Cuba,” they wrote.

Almost all of these studies were funded by “a commercial enterprise founded by the Center of Natural Products” in Cuba to market Cuban policosanol. “Our trial is the first study to investigate sugar cane-derived policosanol independently from [this] research group but still using Cuban policosanol,” they said (JAMA 2006;295: 2262–9).

Dr. Berthold and colleagues randomly assigned 129 hypercholesterolemic patients at 14 clinical centers in Germany to one of five groups, to receive 10, 20, 40, or 80 mg of policosanol or placebo daily for 12 weeks. The usual recommended doses are 10 and 20 mg/d. All the patients were white; their mean age was 56 years, and their mean LDL cholesterol level was 187 mg/dL at baseline.

Policosanol did not decrease LDL cholesterol at any dose, beyond the small (less than 10%) reduction noted with placebo. Policosanol also had no appreciable effect on total cholesterol, HDL cholesterol, very-low-density lipoprotein cholesterol, triglycerides, or lipoprotein (a).

“A considerable health-food-store and Internet market has extended the development of nonprescription policosanol, and worldwide sales are constantly increasing,” they noted, calling for other independent studies of policosanol's purported efficacy to counterbalance the vast body of available positive trials.

Diabetics Benefit From Statins

Lipid-lowering agents, particularly statins, significantly reduce cardiovascular risk in people with diabetes, to the extent that these patients may benefit from the drugs even more than nondiabetics do, said Dr. Joào Costa of the University of Lisbon and associates.

They conducted a metaanalysis of 12 large studies that addressed lipid-lowering treatments and also included diabetic patients in all treatment arms.

Lipid-lowering drugs were equally effective in diabetic and nondiabetic patients for primary prevention. The use of statins or gemfibrozil reduced the risk of a first major coronary event by 21% in diabetic patients and by 23% in nondiabetics. The results were similar for secondary prevention, except that diabetic patients benefited more than did nondiabetics.

The use of statins or gemfibrozil reduced the risk of coronary artery disease death, nonfatal MI, revascularization procedures, and stroke to a greater degree in diabetic patients than it did in nondiabetic patients.

The magnitude of change in blood lipids for diabetic patients was comparable to that for nondiabetics. “Most trials showed a decrease of 15%–20% in total cholesterol and increases of 5%–7.5% in HDL cholesterol,” the investigators said (BMJ 2006 April 3 [Epub doi:10.1136/bmj.38793.468449.AE]).

“Our metaanalysis clearly confirms that reduction of LDL cholesterol concentrations results in an important decrease in major coronary events in diabetic patients and shows similar relative risk reductions and odds ratios for … diabetic and nondiabetic patients … in primary and secondary prevention. However, the absolute risk difference was three times higher in secondary prevention, reflecting the higher baseline cardiovascular risk of [diabetic] patients,” they noted. Despite the well-documented benefits of statins, “they are not being optimally used in patients at higher risk—the ones most likely to benefit.”

A recent cohort study of nearly 400,000 patients over age 65 showed that only 19% of those with a history of diabetes or cardiovascular disease were prescribed statins, Dr. Costa and associates added.

“Our results support the use of statins not only for secondary prevention but also for primary prevention in [diabetic] patients,” they said.

Statins May Decrease Cataract Risk

Statins, particularly simvastatin, appear to lower the risk of nuclear cataracts, the most common type of age-related cataracts, results of a large, prospective study suggest.

Both oxidative stress and inflammation have been posited as contributors to age-related cataracts, especially nuclear cataracts, and statin therapy is known to counter both effects, wrote study investigators Dr. Barbara E. K. Klein and her associates at the University of Wisconsin, Madison.

The investigators used data from the Beaver Dam Eye Study, a longitudinal community survey of eye health in which subjects have been examined every 5 years since 1987–1988, to assess whether the use of statins for cardiovascular indications affected the development of cataracts.

Of 1,299 subjects evaluated in the latest follow-up exam, 210 had developed nuclear cataracts since the previous follow-up. The incidence of cataracts was significantly lower in subjects who took statins than in those who didn't (12% vs. 17%), the researchers said (JAMA 2006;295:2752–8).

Compared with those who didn't take statins, subjects who took simvastatin had an odds ratio of 0.28 for developing nuclear cataracts, those who took atorvastatin had an odds ratio of 0.73, and those who took all other statins had an odds ratio of 0.67.

Both the duration of statin use and the drug dosage may influence the protective effect against cataracts, but this study was not designed to assess either factor, the researchers noted.

Policosanol Did Not Improve Lipids

The supplement policosanol, which is touted for its lipid-lowering effects and is popular worldwide, did not lower lipids appreciably in a multicenter, randomized clinical trial, reported Dr. Heiner K. Berthold and associates at the University of Cologne, Germany.

Dozens of studies have reported that policosanol, a mixture of long-chain primary alcohols derived primarily from sugar cane wax, lowers LDL cholesterol as effectively as do statins, without side effects. But “virtually all of the published scientific literature supporting the beneficial effects of policosanol on lipids has been authored by a single research group from Cuba,” they wrote.

Almost all of these studies were funded by “a commercial enterprise founded by the Center of Natural Products” in Cuba to market Cuban policosanol. “Our trial is the first study to investigate sugar cane-derived policosanol independently from [this] research group but still using Cuban policosanol,” they said (JAMA 2006;295: 2262–9).

Dr. Berthold and colleagues randomly assigned 129 hypercholesterolemic patients at 14 clinical centers in Germany to one of five groups, to receive 10, 20, 40, or 80 mg of policosanol or placebo daily for 12 weeks. The usual recommended doses are 10 and 20 mg/d. All the patients were white; their mean age was 56 years, and their mean LDL cholesterol level was 187 mg/dL at baseline.

Policosanol did not decrease LDL cholesterol at any dose, beyond the small (less than 10%) reduction noted with placebo. Policosanol also had no appreciable effect on total cholesterol, HDL cholesterol, very-low-density lipoprotein cholesterol, triglycerides, or lipoprotein (a).

“A considerable health-food-store and Internet market has extended the development of nonprescription policosanol, and worldwide sales are constantly increasing,” they noted, calling for other independent studies of policosanol's purported efficacy to counterbalance the vast body of available positive trials.

Diabetics Benefit From Statins

Lipid-lowering agents, particularly statins, significantly reduce cardiovascular risk in people with diabetes, to the extent that these patients may benefit from the drugs even more than nondiabetics do, said Dr. Joào Costa of the University of Lisbon and associates.

They conducted a metaanalysis of 12 large studies that addressed lipid-lowering treatments and also included diabetic patients in all treatment arms.

Lipid-lowering drugs were equally effective in diabetic and nondiabetic patients for primary prevention. The use of statins or gemfibrozil reduced the risk of a first major coronary event by 21% in diabetic patients and by 23% in nondiabetics. The results were similar for secondary prevention, except that diabetic patients benefited more than did nondiabetics.

The use of statins or gemfibrozil reduced the risk of coronary artery disease death, nonfatal MI, revascularization procedures, and stroke to a greater degree in diabetic patients than it did in nondiabetic patients.

The magnitude of change in blood lipids for diabetic patients was comparable to that for nondiabetics. “Most trials showed a decrease of 15%–20% in total cholesterol and increases of 5%–7.5% in HDL cholesterol,” the investigators said (BMJ 2006 April 3 [Epub doi:10.1136/bmj.38793.468449.AE]).

“Our metaanalysis clearly confirms that reduction of LDL cholesterol concentrations results in an important decrease in major coronary events in diabetic patients and shows similar relative risk reductions and odds ratios for … diabetic and nondiabetic patients … in primary and secondary prevention. However, the absolute risk difference was three times higher in secondary prevention, reflecting the higher baseline cardiovascular risk of [diabetic] patients,” they noted. Despite the well-documented benefits of statins, “they are not being optimally used in patients at higher risk—the ones most likely to benefit.”

A recent cohort study of nearly 400,000 patients over age 65 showed that only 19% of those with a history of diabetes or cardiovascular disease were prescribed statins, Dr. Costa and associates added.

“Our results support the use of statins not only for secondary prevention but also for primary prevention in [diabetic] patients,” they said.

Statins May Decrease Cataract Risk

Statins, particularly simvastatin, appear to lower the risk of nuclear cataracts, the most common type of age-related cataracts, results of a large, prospective study suggest.

Both oxidative stress and inflammation have been posited as contributors to age-related cataracts, especially nuclear cataracts, and statin therapy is known to counter both effects, wrote study investigators Dr. Barbara E. K. Klein and her associates at the University of Wisconsin, Madison.

The investigators used data from the Beaver Dam Eye Study, a longitudinal community survey of eye health in which subjects have been examined every 5 years since 1987–1988, to assess whether the use of statins for cardiovascular indications affected the development of cataracts.

Of 1,299 subjects evaluated in the latest follow-up exam, 210 had developed nuclear cataracts since the previous follow-up. The incidence of cataracts was significantly lower in subjects who took statins than in those who didn't (12% vs. 17%), the researchers said (JAMA 2006;295:2752–8).

Compared with those who didn't take statins, subjects who took simvastatin had an odds ratio of 0.28 for developing nuclear cataracts, those who took atorvastatin had an odds ratio of 0.73, and those who took all other statins had an odds ratio of 0.67.

Both the duration of statin use and the drug dosage may influence the protective effect against cataracts, but this study was not designed to assess either factor, the researchers noted.

Policosanol Did Not Improve Lipids

The supplement policosanol, which is touted for its lipid-lowering effects and is popular worldwide, did not lower lipids appreciably in a multicenter, randomized clinical trial, reported Dr. Heiner K. Berthold and associates at the University of Cologne, Germany.

Dozens of studies have reported that policosanol, a mixture of long-chain primary alcohols derived primarily from sugar cane wax, lowers LDL cholesterol as effectively as do statins, without side effects. But “virtually all of the published scientific literature supporting the beneficial effects of policosanol on lipids has been authored by a single research group from Cuba,” they wrote.

Almost all of these studies were funded by “a commercial enterprise founded by the Center of Natural Products” in Cuba to market Cuban policosanol. “Our trial is the first study to investigate sugar cane-derived policosanol independently from [this] research group but still using Cuban policosanol,” they said (JAMA 2006;295: 2262–9).

Dr. Berthold and colleagues randomly assigned 129 hypercholesterolemic patients at 14 clinical centers in Germany to one of five groups, to receive 10, 20, 40, or 80 mg of policosanol or placebo daily for 12 weeks. The usual recommended doses are 10 and 20 mg/d. All the patients were white; their mean age was 56 years, and their mean LDL cholesterol level was 187 mg/dL at baseline.

Policosanol did not decrease LDL cholesterol at any dose, beyond the small (less than 10%) reduction noted with placebo. Policosanol also had no appreciable effect on total cholesterol, HDL cholesterol, very-low-density lipoprotein cholesterol, triglycerides, or lipoprotein (a).

“A considerable health-food-store and Internet market has extended the development of nonprescription policosanol, and worldwide sales are constantly increasing,” they noted, calling for other independent studies of policosanol's purported efficacy to counterbalance the vast body of available positive trials.

Diabetics Benefit From Statins

Lipid-lowering agents, particularly statins, significantly reduce cardiovascular risk in people with diabetes, to the extent that these patients may benefit from the drugs even more than nondiabetics do, said Dr. Joào Costa of the University of Lisbon and associates.

They conducted a metaanalysis of 12 large studies that addressed lipid-lowering treatments and also included diabetic patients in all treatment arms.

Lipid-lowering drugs were equally effective in diabetic and nondiabetic patients for primary prevention. The use of statins or gemfibrozil reduced the risk of a first major coronary event by 21% in diabetic patients and by 23% in nondiabetics. The results were similar for secondary prevention, except that diabetic patients benefited more than did nondiabetics.

The use of statins or gemfibrozil reduced the risk of coronary artery disease death, nonfatal MI, revascularization procedures, and stroke to a greater degree in diabetic patients than it did in nondiabetic patients.

The magnitude of change in blood lipids for diabetic patients was comparable to that for nondiabetics. “Most trials showed a decrease of 15%–20% in total cholesterol and increases of 5%–7.5% in HDL cholesterol,” the investigators said (BMJ 2006 April 3 [Epub doi:10.1136/bmj.38793.468449.AE]).

“Our metaanalysis clearly confirms that reduction of LDL cholesterol concentrations results in an important decrease in major coronary events in diabetic patients and shows similar relative risk reductions and odds ratios for … diabetic and nondiabetic patients … in primary and secondary prevention. However, the absolute risk difference was three times higher in secondary prevention, reflecting the higher baseline cardiovascular risk of [diabetic] patients,” they noted. Despite the well-documented benefits of statins, “they are not being optimally used in patients at higher risk—the ones most likely to benefit.”

A recent cohort study of nearly 400,000 patients over age 65 showed that only 19% of those with a history of diabetes or cardiovascular disease were prescribed statins, Dr. Costa and associates added.

“Our results support the use of statins not only for secondary prevention but also for primary prevention in [diabetic] patients,” they said.

Statins May Decrease Cataract Risk

Statins, particularly simvastatin, appear to lower the risk of nuclear cataracts, the most common type of age-related cataracts, results of a large, prospective study suggest.

Both oxidative stress and inflammation have been posited as contributors to age-related cataracts, especially nuclear cataracts, and statin therapy is known to counter both effects, wrote study investigators Dr. Barbara E. K. Klein and her associates at the University of Wisconsin, Madison.

The investigators used data from the Beaver Dam Eye Study, a longitudinal community survey of eye health in which subjects have been examined every 5 years since 1987–1988, to assess whether the use of statins for cardiovascular indications affected the development of cataracts.

Of 1,299 subjects evaluated in the latest follow-up exam, 210 had developed nuclear cataracts since the previous follow-up. The incidence of cataracts was significantly lower in subjects who took statins than in those who didn't (12% vs. 17%), the researchers said (JAMA 2006;295:2752–8).

Compared with those who didn't take statins, subjects who took simvastatin had an odds ratio of 0.28 for developing nuclear cataracts, those who took atorvastatin had an odds ratio of 0.73, and those who took all other statins had an odds ratio of 0.67.

Both the duration of statin use and the drug dosage may influence the protective effect against cataracts, but this study was not designed to assess either factor, the researchers noted.

A new system for scoring the severity of foot ulcers in diabetic patients helps clinicians predict the likelihood of healing, hospitalization, local surgery, and amputation, according to Dr. Stefan Beckert and his associates at the University of Tübingen (Germany).

Although other researchers have made attempts to establish classification systems that help gauge the severity of foot ulcers, most have been too complicated for widespread clinical application. Some systems required extensive diagnostic work-ups and complex grading schedules, and no simple severity scores have been adopted into routine clinical practice.

Dr. Beckert and his associates followed 1,000 consecutive diabetic patients with foot ulcers to develop such a score, which they termed the Diabetic Ulcer Severity Score (DUSS), and to test its practical use in predicting outcomes.

The median subject age was 69 years, and subjects were followed for up to 1 year after presenting for outpatient foot ulcer care. Treatment was given by an interdisciplinary team of a general and vascular surgeon, a radiologist, a diabetologist, an orthotist, and a wound care nurse. It consisted of sharp debridement, advanced local surgery such as limited bone resections if necessary, moist wound therapy, and adequate pressure off-loading.

Four factors—pedal pulses, bone involvement, site of ulceration, and number of ulcerations—were found to predict outcome, and a simple scoring system was developed to rate these factors, the investigators said (Diabetes Care 2006;29:988–92).

Absent pedal pulses were scored as 1, while present pedal pulses were scored as 0. Bone involvement, defined as the ability to probe the ulcer to the bone, was scored as a 1, while lack of bone involvement was scored as a 0. Ulceration was scored as a 0 if it involved only the toe and as a 1 if it involved the foot. And multiple wounds were scored as a 1 while single wounds were scored as a 0.

The overall DUSS was determined by adding these four components, so possible scores ranged from a minimum of 0 to a maximum of 4. Patients with a DUSS of 0 had a 93% probability of healing. The probability of healing decreased steadily with increasing DUSS, to a low of 57% for scores of 4.

Local surgery was required for 9% of patients with a DUSS of 0, 17% of those with a DUSS of 1, 27% for those with a score of 2, 37% for those with a DUSS of 3, and 50% of those with a DUSS of 4. Similarly, hospitalization was required for 39% of patients with a DUSS of 0, 49% of those with a DUSS of 1, 63% of those with a DUSS of 2, 72% of those with a DUSS of 3, and 92% of those with a DUSS of 4.

The likelihood of amputation followed this same pattern for the most part. Patients with a DUSS of 0 had no risk of amputation, those with a DUSS of 1 had a 2% risk, those with a DUSS of 2 had an 8% risk, and those with a DUSS of 3 had an 11% risk. However, the pattern did not hold for patients with a DUSS of 4 (4% risk), most likely because of the small number of patients in this subgroup and the low number of amputations overall.

The DUSS proved to be a simple prognostic tool that “can be easily applied in daily clinical practice,” Dr. Beckert and his associates said. It also “may contribute to a better and realistic calculation of health care costs in patients with diabetic foot ulcers,” they said.

A new system for scoring the severity of foot ulcers in diabetic patients helps clinicians predict the likelihood of healing, hospitalization, local surgery, and amputation, according to Dr. Stefan Beckert and his associates at the University of Tübingen (Germany).

Although other researchers have made attempts to establish classification systems that help gauge the severity of foot ulcers, most have been too complicated for widespread clinical application. Some systems required extensive diagnostic work-ups and complex grading schedules, and no simple severity scores have been adopted into routine clinical practice.

Dr. Beckert and his associates followed 1,000 consecutive diabetic patients with foot ulcers to develop such a score, which they termed the Diabetic Ulcer Severity Score (DUSS), and to test its practical use in predicting outcomes.

The median subject age was 69 years, and subjects were followed for up to 1 year after presenting for outpatient foot ulcer care. Treatment was given by an interdisciplinary team of a general and vascular surgeon, a radiologist, a diabetologist, an orthotist, and a wound care nurse. It consisted of sharp debridement, advanced local surgery such as limited bone resections if necessary, moist wound therapy, and adequate pressure off-loading.

Four factors—pedal pulses, bone involvement, site of ulceration, and number of ulcerations—were found to predict outcome, and a simple scoring system was developed to rate these factors, the investigators said (Diabetes Care 2006;29:988–92).

Absent pedal pulses were scored as 1, while present pedal pulses were scored as 0. Bone involvement, defined as the ability to probe the ulcer to the bone, was scored as a 1, while lack of bone involvement was scored as a 0. Ulceration was scored as a 0 if it involved only the toe and as a 1 if it involved the foot. And multiple wounds were scored as a 1 while single wounds were scored as a 0.

The overall DUSS was determined by adding these four components, so possible scores ranged from a minimum of 0 to a maximum of 4. Patients with a DUSS of 0 had a 93% probability of healing. The probability of healing decreased steadily with increasing DUSS, to a low of 57% for scores of 4.

Local surgery was required for 9% of patients with a DUSS of 0, 17% of those with a DUSS of 1, 27% for those with a score of 2, 37% for those with a DUSS of 3, and 50% of those with a DUSS of 4. Similarly, hospitalization was required for 39% of patients with a DUSS of 0, 49% of those with a DUSS of 1, 63% of those with a DUSS of 2, 72% of those with a DUSS of 3, and 92% of those with a DUSS of 4.

The likelihood of amputation followed this same pattern for the most part. Patients with a DUSS of 0 had no risk of amputation, those with a DUSS of 1 had a 2% risk, those with a DUSS of 2 had an 8% risk, and those with a DUSS of 3 had an 11% risk. However, the pattern did not hold for patients with a DUSS of 4 (4% risk), most likely because of the small number of patients in this subgroup and the low number of amputations overall.

The DUSS proved to be a simple prognostic tool that “can be easily applied in daily clinical practice,” Dr. Beckert and his associates said. It also “may contribute to a better and realistic calculation of health care costs in patients with diabetic foot ulcers,” they said.

A new system for scoring the severity of foot ulcers in diabetic patients helps clinicians predict the likelihood of healing, hospitalization, local surgery, and amputation, according to Dr. Stefan Beckert and his associates at the University of Tübingen (Germany).

Although other researchers have made attempts to establish classification systems that help gauge the severity of foot ulcers, most have been too complicated for widespread clinical application. Some systems required extensive diagnostic work-ups and complex grading schedules, and no simple severity scores have been adopted into routine clinical practice.

Dr. Beckert and his associates followed 1,000 consecutive diabetic patients with foot ulcers to develop such a score, which they termed the Diabetic Ulcer Severity Score (DUSS), and to test its practical use in predicting outcomes.

The median subject age was 69 years, and subjects were followed for up to 1 year after presenting for outpatient foot ulcer care. Treatment was given by an interdisciplinary team of a general and vascular surgeon, a radiologist, a diabetologist, an orthotist, and a wound care nurse. It consisted of sharp debridement, advanced local surgery such as limited bone resections if necessary, moist wound therapy, and adequate pressure off-loading.

Four factors—pedal pulses, bone involvement, site of ulceration, and number of ulcerations—were found to predict outcome, and a simple scoring system was developed to rate these factors, the investigators said (Diabetes Care 2006;29:988–92).

Absent pedal pulses were scored as 1, while present pedal pulses were scored as 0. Bone involvement, defined as the ability to probe the ulcer to the bone, was scored as a 1, while lack of bone involvement was scored as a 0. Ulceration was scored as a 0 if it involved only the toe and as a 1 if it involved the foot. And multiple wounds were scored as a 1 while single wounds were scored as a 0.

The overall DUSS was determined by adding these four components, so possible scores ranged from a minimum of 0 to a maximum of 4. Patients with a DUSS of 0 had a 93% probability of healing. The probability of healing decreased steadily with increasing DUSS, to a low of 57% for scores of 4.

Local surgery was required for 9% of patients with a DUSS of 0, 17% of those with a DUSS of 1, 27% for those with a score of 2, 37% for those with a DUSS of 3, and 50% of those with a DUSS of 4. Similarly, hospitalization was required for 39% of patients with a DUSS of 0, 49% of those with a DUSS of 1, 63% of those with a DUSS of 2, 72% of those with a DUSS of 3, and 92% of those with a DUSS of 4.

The likelihood of amputation followed this same pattern for the most part. Patients with a DUSS of 0 had no risk of amputation, those with a DUSS of 1 had a 2% risk, those with a DUSS of 2 had an 8% risk, and those with a DUSS of 3 had an 11% risk. However, the pattern did not hold for patients with a DUSS of 4 (4% risk), most likely because of the small number of patients in this subgroup and the low number of amputations overall.

The DUSS proved to be a simple prognostic tool that “can be easily applied in daily clinical practice,” Dr. Beckert and his associates said. It also “may contribute to a better and realistic calculation of health care costs in patients with diabetic foot ulcers,” they said.