Michele G. Sullivan

BOSTON — Intravenous N-acetylcysteine increases transplant-free survival in patients with early-stage acute liver failure, Dr. William Lee said at the annual meeting of the American Association for the Study of Liver Diseases.

However, the drug appears to hold little benefit for patients in the later stages of the disease. “These patients typically survive only a very short period of time, and it's probably not of value to them,” said Dr. Lee of the University of Texas Southwestern Medical Center at Dallas.

He presented the results of a randomized, controlled trial in which 173 patients with acute, non-acetaminophen-related liver failure received either N-acetylcysteine (NAC) or placebo. The patients' mean age was 41 years. Their liver failure had a variety of etiologies, including viral hepatitis B (21%), drug-induced liver injury (26%), and autoimmune hepatitis (15%).

Patients were stratified into early- and late-stage liver failure by their hepatic encephalopathy scores. Early-stage patients (115) had a score of I (forgetfulness, agitation) or II (disorientation, asterixis). Late-stage patients (58) had a score of III (somnolence) or IV (coma).

Patients in the active group received an initial loading dose of NAC 150 mg/kg, followed by continuous infusions at lower doses for the next 72 hours.

Overall survival at 3 weeks was not significantly different between the active and placebo groups (70% vs. 67%). Nor was there a significant difference in transplant-free survival (27% vs. 45%). However, when Dr. Lee examined survival by encephalopathy grade, significant differences did emerge. Mean transplant-free survival in those with encephalopathy grades I and II was 52% in the active group, compared with 30% in the placebo group. NAC was associated with an 11-fold increase in the chance of transplant-free survival.

Overall, there were no significant differences in transplantation between the active and placebo groups (32% vs. 45%), length of hospital stay, or organ failure.

Although the drug appears both safe and effective at improving transplant-free survival for early-stage patients, “it is not a substitute for early referral for liver transplant,” Dr. Lee emphasized.

The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Food and Drug Administration's orphan products division.

BOSTON — Intravenous N-acetylcysteine increases transplant-free survival in patients with early-stage acute liver failure, Dr. William Lee said at the annual meeting of the American Association for the Study of Liver Diseases.

However, the drug appears to hold little benefit for patients in the later stages of the disease. “These patients typically survive only a very short period of time, and it's probably not of value to them,” said Dr. Lee of the University of Texas Southwestern Medical Center at Dallas.

He presented the results of a randomized, controlled trial in which 173 patients with acute, non-acetaminophen-related liver failure received either N-acetylcysteine (NAC) or placebo. The patients' mean age was 41 years. Their liver failure had a variety of etiologies, including viral hepatitis B (21%), drug-induced liver injury (26%), and autoimmune hepatitis (15%).

Patients were stratified into early- and late-stage liver failure by their hepatic encephalopathy scores. Early-stage patients (115) had a score of I (forgetfulness, agitation) or II (disorientation, asterixis). Late-stage patients (58) had a score of III (somnolence) or IV (coma).

Patients in the active group received an initial loading dose of NAC 150 mg/kg, followed by continuous infusions at lower doses for the next 72 hours.

Overall survival at 3 weeks was not significantly different between the active and placebo groups (70% vs. 67%). Nor was there a significant difference in transplant-free survival (27% vs. 45%). However, when Dr. Lee examined survival by encephalopathy grade, significant differences did emerge. Mean transplant-free survival in those with encephalopathy grades I and II was 52% in the active group, compared with 30% in the placebo group. NAC was associated with an 11-fold increase in the chance of transplant-free survival.

Overall, there were no significant differences in transplantation between the active and placebo groups (32% vs. 45%), length of hospital stay, or organ failure.

Although the drug appears both safe and effective at improving transplant-free survival for early-stage patients, “it is not a substitute for early referral for liver transplant,” Dr. Lee emphasized.

The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Food and Drug Administration's orphan products division.

BOSTON — Intravenous N-acetylcysteine increases transplant-free survival in patients with early-stage acute liver failure, Dr. William Lee said at the annual meeting of the American Association for the Study of Liver Diseases.

However, the drug appears to hold little benefit for patients in the later stages of the disease. “These patients typically survive only a very short period of time, and it's probably not of value to them,” said Dr. Lee of the University of Texas Southwestern Medical Center at Dallas.

He presented the results of a randomized, controlled trial in which 173 patients with acute, non-acetaminophen-related liver failure received either N-acetylcysteine (NAC) or placebo. The patients' mean age was 41 years. Their liver failure had a variety of etiologies, including viral hepatitis B (21%), drug-induced liver injury (26%), and autoimmune hepatitis (15%).

Patients were stratified into early- and late-stage liver failure by their hepatic encephalopathy scores. Early-stage patients (115) had a score of I (forgetfulness, agitation) or II (disorientation, asterixis). Late-stage patients (58) had a score of III (somnolence) or IV (coma).

Patients in the active group received an initial loading dose of NAC 150 mg/kg, followed by continuous infusions at lower doses for the next 72 hours.

Overall survival at 3 weeks was not significantly different between the active and placebo groups (70% vs. 67%). Nor was there a significant difference in transplant-free survival (27% vs. 45%). However, when Dr. Lee examined survival by encephalopathy grade, significant differences did emerge. Mean transplant-free survival in those with encephalopathy grades I and II was 52% in the active group, compared with 30% in the placebo group. NAC was associated with an 11-fold increase in the chance of transplant-free survival.

Overall, there were no significant differences in transplantation between the active and placebo groups (32% vs. 45%), length of hospital stay, or organ failure.

Although the drug appears both safe and effective at improving transplant-free survival for early-stage patients, “it is not a substitute for early referral for liver transplant,” Dr. Lee emphasized.

The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Food and Drug Administration's orphan products division.

NEW ORLEANS — Rather than unlocking a Pandora's box of nattering e-mails, an electronic patient portal that allows messaging and even access to test results can improve patient satisfaction and decrease patient visits.

“Many physicians think that this type of access is frightening,” Dr. Gretchen P. Purcell said at the annual clinical congress of the American College of Surgeons. “They think they'll be barraged with messages, that patients will misinterpret their test results, and that physicians could even be held legally liable if they don't respond in time to an urgent message.”

But health care providers, who are about 10 years behind the curve in the digital world, need to face up to the facts of the 21st century, said Dr. Purcell of the surgery department at the Children's Hospital at Vanderbilt in Nashville, Tenn. “Patients are demanding the same kind of online access to their medical information as they have for all other aspects of their lives. Those health care institutions that do not have a patient portal now probably will within the next 5 years.”

Patient portals can be designed to suit the needs of different practices and to fulfill various functions. At a minimum, they allow patients to pay bills, schedule or change appointments, and request prescription refills. Other portals are more robust and give patients the ability to review medical records, view test results, and send messages to their health care provider, said Dr. Purcell, who is also with the biomedical informatics department at Vanderbilt Medical Center.

Among the most controversial topics are messaging and the ability to access test results, she said.

“Messaging is probably the function physicians fear the most. Many think it's the equivalent of getting and sending personal e-mail, and this brings up all kinds of worries about security and privacy.”

E-mail and messaging, however, are not the same things. Messages don't go to a personal e-mail account; instead, they go to a dedicated in-box. “This message box is routinely checked by an administrative assistant or nurse—someone who can often answer many of the questions, and who would involve the physician only when necessary—similar to phone call triage.”

There also are concerns that these electronic exchanges aren't part of a patient's documented record. “Some portals can make messaging part of the medical record, and some physicians have found ways to charge for this 'online consultation,'” Dr. Purcell said.

It's important to set clear expectations about response time and emergency issues. Most messaging systems tell patients that they may have to wait 2–3 business days for a personal reply and advise them to call 911 for a medical emergency.

It's not unreasonable to assume that electronic communication could allow patients to bombard offices with questions and requests. Although data are still limited, the studies that are out there suggest just the opposite, Dr. Purcell said.

Two studies published in 2005 indicate that messaging increases patient satisfaction without any corresponding increase in workload. The first study randomized 200 patients to secure messaging or usual care. Only 46% of the patients who were given access sent any messages at all; the average was just 1.5 messages per patient per year. And although messaging didn't reduce the number of telephone calls the office received, the number of office visits in the intervention group did go down (Int. J. Med. Inform. 2005;74:705–10).

The second study randomized 606 patients to a patient communication portal or to a Web site with general health information. Only 31% of the patients given access used the portal. The message box received only one message per day per 250 patients. Again, there was no difference in the number of office telephone calls between the groups, but the patients in the portal group reported better satisfaction with communication and overall care, even if they never used the portal (J. Med. Internet Res. 2005;7:e48).

NEW ORLEANS — Rather than unlocking a Pandora's box of nattering e-mails, an electronic patient portal that allows messaging and even access to test results can improve patient satisfaction and decrease patient visits.

“Many physicians think that this type of access is frightening,” Dr. Gretchen P. Purcell said at the annual clinical congress of the American College of Surgeons. “They think they'll be barraged with messages, that patients will misinterpret their test results, and that physicians could even be held legally liable if they don't respond in time to an urgent message.”

But health care providers, who are about 10 years behind the curve in the digital world, need to face up to the facts of the 21st century, said Dr. Purcell of the surgery department at the Children's Hospital at Vanderbilt in Nashville, Tenn. “Patients are demanding the same kind of online access to their medical information as they have for all other aspects of their lives. Those health care institutions that do not have a patient portal now probably will within the next 5 years.”

Patient portals can be designed to suit the needs of different practices and to fulfill various functions. At a minimum, they allow patients to pay bills, schedule or change appointments, and request prescription refills. Other portals are more robust and give patients the ability to review medical records, view test results, and send messages to their health care provider, said Dr. Purcell, who is also with the biomedical informatics department at Vanderbilt Medical Center.

Among the most controversial topics are messaging and the ability to access test results, she said.

“Messaging is probably the function physicians fear the most. Many think it's the equivalent of getting and sending personal e-mail, and this brings up all kinds of worries about security and privacy.”

E-mail and messaging, however, are not the same things. Messages don't go to a personal e-mail account; instead, they go to a dedicated in-box. “This message box is routinely checked by an administrative assistant or nurse—someone who can often answer many of the questions, and who would involve the physician only when necessary—similar to phone call triage.”

There also are concerns that these electronic exchanges aren't part of a patient's documented record. “Some portals can make messaging part of the medical record, and some physicians have found ways to charge for this 'online consultation,'” Dr. Purcell said.

It's important to set clear expectations about response time and emergency issues. Most messaging systems tell patients that they may have to wait 2–3 business days for a personal reply and advise them to call 911 for a medical emergency.

It's not unreasonable to assume that electronic communication could allow patients to bombard offices with questions and requests. Although data are still limited, the studies that are out there suggest just the opposite, Dr. Purcell said.

Two studies published in 2005 indicate that messaging increases patient satisfaction without any corresponding increase in workload. The first study randomized 200 patients to secure messaging or usual care. Only 46% of the patients who were given access sent any messages at all; the average was just 1.5 messages per patient per year. And although messaging didn't reduce the number of telephone calls the office received, the number of office visits in the intervention group did go down (Int. J. Med. Inform. 2005;74:705–10).

The second study randomized 606 patients to a patient communication portal or to a Web site with general health information. Only 31% of the patients given access used the portal. The message box received only one message per day per 250 patients. Again, there was no difference in the number of office telephone calls between the groups, but the patients in the portal group reported better satisfaction with communication and overall care, even if they never used the portal (J. Med. Internet Res. 2005;7:e48).

NEW ORLEANS — Rather than unlocking a Pandora's box of nattering e-mails, an electronic patient portal that allows messaging and even access to test results can improve patient satisfaction and decrease patient visits.

“Many physicians think that this type of access is frightening,” Dr. Gretchen P. Purcell said at the annual clinical congress of the American College of Surgeons. “They think they'll be barraged with messages, that patients will misinterpret their test results, and that physicians could even be held legally liable if they don't respond in time to an urgent message.”

But health care providers, who are about 10 years behind the curve in the digital world, need to face up to the facts of the 21st century, said Dr. Purcell of the surgery department at the Children's Hospital at Vanderbilt in Nashville, Tenn. “Patients are demanding the same kind of online access to their medical information as they have for all other aspects of their lives. Those health care institutions that do not have a patient portal now probably will within the next 5 years.”

Patient portals can be designed to suit the needs of different practices and to fulfill various functions. At a minimum, they allow patients to pay bills, schedule or change appointments, and request prescription refills. Other portals are more robust and give patients the ability to review medical records, view test results, and send messages to their health care provider, said Dr. Purcell, who is also with the biomedical informatics department at Vanderbilt Medical Center.

Among the most controversial topics are messaging and the ability to access test results, she said.

“Messaging is probably the function physicians fear the most. Many think it's the equivalent of getting and sending personal e-mail, and this brings up all kinds of worries about security and privacy.”

E-mail and messaging, however, are not the same things. Messages don't go to a personal e-mail account; instead, they go to a dedicated in-box. “This message box is routinely checked by an administrative assistant or nurse—someone who can often answer many of the questions, and who would involve the physician only when necessary—similar to phone call triage.”

There also are concerns that these electronic exchanges aren't part of a patient's documented record. “Some portals can make messaging part of the medical record, and some physicians have found ways to charge for this 'online consultation,'” Dr. Purcell said.

It's important to set clear expectations about response time and emergency issues. Most messaging systems tell patients that they may have to wait 2–3 business days for a personal reply and advise them to call 911 for a medical emergency.

It's not unreasonable to assume that electronic communication could allow patients to bombard offices with questions and requests. Although data are still limited, the studies that are out there suggest just the opposite, Dr. Purcell said.

Two studies published in 2005 indicate that messaging increases patient satisfaction without any corresponding increase in workload. The first study randomized 200 patients to secure messaging or usual care. Only 46% of the patients who were given access sent any messages at all; the average was just 1.5 messages per patient per year. And although messaging didn't reduce the number of telephone calls the office received, the number of office visits in the intervention group did go down (Int. J. Med. Inform. 2005;74:705–10).

The second study randomized 606 patients to a patient communication portal or to a Web site with general health information. Only 31% of the patients given access used the portal. The message box received only one message per day per 250 patients. Again, there was no difference in the number of office telephone calls between the groups, but the patients in the portal group reported better satisfaction with communication and overall care, even if they never used the portal (J. Med. Internet Res. 2005;7:e48).

NEW ORLEANS — Minority and uninsured patients are significantly more likely to die after injury than are white, insured patients, Dr. Adil H. Haider reported at the annual clinical congress of the American College of Surgeons.

He concluded that black uninsured patients were 78% more likely to die after trauma, and that Hispanic patients without insurance were more than 130% more likely to die than white insured patients, even after controlling for numerous confounding factors.

Dr. Haider, a trauma surgeon at Johns Hopkins University, Baltimore, extracted his data from the 2001–2005 National Trauma Data Bank. He assessed mortality after moderate to severe trauma in 377,000 patients: 69% were white, 19% black, and 11% Hispanic. Patients included in the study were adults between the ages of 18 and 65 (mean age 36 years), and 70% were male.

Overall, 53% of patients had some kind of commercial medical insurance, and 47% were either self-pay or Medicaid recipients. Blacks were most likely to be uninsured (69%), followed by Hispanics (62%) and whites (38%).

Hispanics had the highest crude mortality, with 9% dying after their injury, compared with 8% of blacks and 5.5% of whites. Mortality was also significantly different between insured and uninsured patients (8% vs. 4% in the unadjusted analysis).

The adjusted mortality analysis controlled for injury severity using the Injury Severity Score, Revised Trauma Score, and Abbreviated Injury Scale. Dr Haider also controlled for age, gender, severe extremity injury, type of injury (blunt vs. penetrating), and mechanism of injury, based on ICD-9 codes.

The multivariate analysis showed that race and insurance were still significantly associated with the risk of death. Compared with whites, blacks were 17% more likely to die and Hispanics 47% more likely to die. Uninsured patients were 46% more likely to die than were insured patients.

To further stratify the effect of race and insurance, Dr. Haider broke down the groups according to both factors. Compared with insured white patients, insured black patients and uninsured Hispanic patients were still significantly more likely to die (20% and 51%, respectively).

Uninsured white and black patients were significantly more likely to die (55% and 78%, respectively), than were insured white patients. Uninsured Hispanic patients faced the highest risk—they were 2.3 times more likely than insured white patients to die from similar injuries.

Black uninsured patients were 78% more likely to die after trauma than white insured patients. DR. HAIDER

NEW ORLEANS — Minority and uninsured patients are significantly more likely to die after injury than are white, insured patients, Dr. Adil H. Haider reported at the annual clinical congress of the American College of Surgeons.

He concluded that black uninsured patients were 78% more likely to die after trauma, and that Hispanic patients without insurance were more than 130% more likely to die than white insured patients, even after controlling for numerous confounding factors.

Dr. Haider, a trauma surgeon at Johns Hopkins University, Baltimore, extracted his data from the 2001–2005 National Trauma Data Bank. He assessed mortality after moderate to severe trauma in 377,000 patients: 69% were white, 19% black, and 11% Hispanic. Patients included in the study were adults between the ages of 18 and 65 (mean age 36 years), and 70% were male.

Overall, 53% of patients had some kind of commercial medical insurance, and 47% were either self-pay or Medicaid recipients. Blacks were most likely to be uninsured (69%), followed by Hispanics (62%) and whites (38%).

Hispanics had the highest crude mortality, with 9% dying after their injury, compared with 8% of blacks and 5.5% of whites. Mortality was also significantly different between insured and uninsured patients (8% vs. 4% in the unadjusted analysis).

The adjusted mortality analysis controlled for injury severity using the Injury Severity Score, Revised Trauma Score, and Abbreviated Injury Scale. Dr Haider also controlled for age, gender, severe extremity injury, type of injury (blunt vs. penetrating), and mechanism of injury, based on ICD-9 codes.

The multivariate analysis showed that race and insurance were still significantly associated with the risk of death. Compared with whites, blacks were 17% more likely to die and Hispanics 47% more likely to die. Uninsured patients were 46% more likely to die than were insured patients.

To further stratify the effect of race and insurance, Dr. Haider broke down the groups according to both factors. Compared with insured white patients, insured black patients and uninsured Hispanic patients were still significantly more likely to die (20% and 51%, respectively).

Uninsured white and black patients were significantly more likely to die (55% and 78%, respectively), than were insured white patients. Uninsured Hispanic patients faced the highest risk—they were 2.3 times more likely than insured white patients to die from similar injuries.

Black uninsured patients were 78% more likely to die after trauma than white insured patients. DR. HAIDER

NEW ORLEANS — Minority and uninsured patients are significantly more likely to die after injury than are white, insured patients, Dr. Adil H. Haider reported at the annual clinical congress of the American College of Surgeons.

He concluded that black uninsured patients were 78% more likely to die after trauma, and that Hispanic patients without insurance were more than 130% more likely to die than white insured patients, even after controlling for numerous confounding factors.

Dr. Haider, a trauma surgeon at Johns Hopkins University, Baltimore, extracted his data from the 2001–2005 National Trauma Data Bank. He assessed mortality after moderate to severe trauma in 377,000 patients: 69% were white, 19% black, and 11% Hispanic. Patients included in the study were adults between the ages of 18 and 65 (mean age 36 years), and 70% were male.

Overall, 53% of patients had some kind of commercial medical insurance, and 47% were either self-pay or Medicaid recipients. Blacks were most likely to be uninsured (69%), followed by Hispanics (62%) and whites (38%).

Hispanics had the highest crude mortality, with 9% dying after their injury, compared with 8% of blacks and 5.5% of whites. Mortality was also significantly different between insured and uninsured patients (8% vs. 4% in the unadjusted analysis).

The adjusted mortality analysis controlled for injury severity using the Injury Severity Score, Revised Trauma Score, and Abbreviated Injury Scale. Dr Haider also controlled for age, gender, severe extremity injury, type of injury (blunt vs. penetrating), and mechanism of injury, based on ICD-9 codes.

The multivariate analysis showed that race and insurance were still significantly associated with the risk of death. Compared with whites, blacks were 17% more likely to die and Hispanics 47% more likely to die. Uninsured patients were 46% more likely to die than were insured patients.

To further stratify the effect of race and insurance, Dr. Haider broke down the groups according to both factors. Compared with insured white patients, insured black patients and uninsured Hispanic patients were still significantly more likely to die (20% and 51%, respectively).

Uninsured white and black patients were significantly more likely to die (55% and 78%, respectively), than were insured white patients. Uninsured Hispanic patients faced the highest risk—they were 2.3 times more likely than insured white patients to die from similar injuries.

Black uninsured patients were 78% more likely to die after trauma than white insured patients. DR. HAIDER

WASHINGTON — A population difference in tumor biology probably accounts for most of the 50% lower rate of thyroid cancer in blacks, compared with whites, Dr. Luc Morris said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

Lack of insurance and low income may contribute to the lower incidence in blacks by limiting early detection, but those factors don't entirely explain the difference between the groups, Dr. Morris said in an interview. “Even though we have statistically significant evidence for this and it's a real effect, it is not big enough to account for this really large disparity.”

The incidence of thyroid cancer in the United States has increased dramatically over the past 30 years in both populations, probably as a result of improved screening, said Dr. Morris of the department of otolaryngology at New York University, New York. Nonetheless, whites are twice as likely to develop the disease, with an incidence of 10/100,000, compared with 5/100,000 among blacks. “With this large a disparity, the question arises, is this a true population difference with a biological explanation?”

To address this idea, Dr. Morris and his colleagues analyzed statistics from two national databases: the Healthcare Costs and Utilization Project and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database. They looked for three possible trends: If underdiagnosis in blacks was the primary reason for the difference, they expected to see black patients presenting at an older age with larger, more advanced tumors and higher mortality. If less-aggressive disease was the most accurate model, Dr. Morris said, the opposite picture would emerge. “And if there were truly a lower incidence of disease in the black population, one would expect no difference in these parameters.”

They reviewed 54,000 cases of thyroid cancer in the SEER database from 1973 to 2003. It revealed a slower annual increase in disease in blacks over the period (2% vs. 2.8%), a difference of 1,800 cases a year.

Regions of the country with more uninsured patients showed a lower incidence of thyroid cancer, whereas those with more insured patients had higher rates, suggesting a difference in early detection. A regression analysis suggested that this effect could account for up to half of the black-white difference in national disease incidence. But this should be interpreted cautiously, Dr. Morris said, because neither database contained enough socioeconomic information for a multifactorial analysis.

Clinical differences emerged as well. Blacks were 8% more likely to present at an older age (over 45 years), 12% more likely to have a tumor larger than 1 cm, and 13% more likely to have a tumor larger than 4 cm. But they were 11% less likely to have nodal metastases and 4% less likely to have either extrathyroidal or advanced disease, suggesting a less-aggressive disease course. There was no difference in mortality.

Because most of these risk ratios are similar, they reflect differences that, although statistically significant, probably are clinically small, Dr. Morris said. “The clinical and sociodemographic data are supportive of a role for socioeconomic status, a small detection bias favoring white patients, and slightly less-aggressive behavior of thyroid cancer in black patients. But all of these effects are quite small in comparison to the substantial black-white gap in cancer incidence.”

Nor can environmental factors account for the disparity, since the only two known environmental risk factors for thyroid cancer—radiation exposure and iodine deficiency—are almost unheard of in the United States, he added. “This is probably a true population difference, but we don't have an explanation of why this might be.”

Genetic differences may be the answer, but studies have yet to confirm this hypothesis. “We are just beginning to learn about the genetics of thyroid cancer, and no one has studied whether there are racial differences in the prevalence of these mutations.”

'This is probably a true population difference, but we don't have an explanation of why this might be.' DR. MORRIS

WASHINGTON — A population difference in tumor biology probably accounts for most of the 50% lower rate of thyroid cancer in blacks, compared with whites, Dr. Luc Morris said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

Lack of insurance and low income may contribute to the lower incidence in blacks by limiting early detection, but those factors don't entirely explain the difference between the groups, Dr. Morris said in an interview. “Even though we have statistically significant evidence for this and it's a real effect, it is not big enough to account for this really large disparity.”

The incidence of thyroid cancer in the United States has increased dramatically over the past 30 years in both populations, probably as a result of improved screening, said Dr. Morris of the department of otolaryngology at New York University, New York. Nonetheless, whites are twice as likely to develop the disease, with an incidence of 10/100,000, compared with 5/100,000 among blacks. “With this large a disparity, the question arises, is this a true population difference with a biological explanation?”

To address this idea, Dr. Morris and his colleagues analyzed statistics from two national databases: the Healthcare Costs and Utilization Project and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database. They looked for three possible trends: If underdiagnosis in blacks was the primary reason for the difference, they expected to see black patients presenting at an older age with larger, more advanced tumors and higher mortality. If less-aggressive disease was the most accurate model, Dr. Morris said, the opposite picture would emerge. “And if there were truly a lower incidence of disease in the black population, one would expect no difference in these parameters.”

They reviewed 54,000 cases of thyroid cancer in the SEER database from 1973 to 2003. It revealed a slower annual increase in disease in blacks over the period (2% vs. 2.8%), a difference of 1,800 cases a year.

Regions of the country with more uninsured patients showed a lower incidence of thyroid cancer, whereas those with more insured patients had higher rates, suggesting a difference in early detection. A regression analysis suggested that this effect could account for up to half of the black-white difference in national disease incidence. But this should be interpreted cautiously, Dr. Morris said, because neither database contained enough socioeconomic information for a multifactorial analysis.

Clinical differences emerged as well. Blacks were 8% more likely to present at an older age (over 45 years), 12% more likely to have a tumor larger than 1 cm, and 13% more likely to have a tumor larger than 4 cm. But they were 11% less likely to have nodal metastases and 4% less likely to have either extrathyroidal or advanced disease, suggesting a less-aggressive disease course. There was no difference in mortality.

Because most of these risk ratios are similar, they reflect differences that, although statistically significant, probably are clinically small, Dr. Morris said. “The clinical and sociodemographic data are supportive of a role for socioeconomic status, a small detection bias favoring white patients, and slightly less-aggressive behavior of thyroid cancer in black patients. But all of these effects are quite small in comparison to the substantial black-white gap in cancer incidence.”

Nor can environmental factors account for the disparity, since the only two known environmental risk factors for thyroid cancer—radiation exposure and iodine deficiency—are almost unheard of in the United States, he added. “This is probably a true population difference, but we don't have an explanation of why this might be.”

Genetic differences may be the answer, but studies have yet to confirm this hypothesis. “We are just beginning to learn about the genetics of thyroid cancer, and no one has studied whether there are racial differences in the prevalence of these mutations.”

'This is probably a true population difference, but we don't have an explanation of why this might be.' DR. MORRIS

WASHINGTON — A population difference in tumor biology probably accounts for most of the 50% lower rate of thyroid cancer in blacks, compared with whites, Dr. Luc Morris said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

Lack of insurance and low income may contribute to the lower incidence in blacks by limiting early detection, but those factors don't entirely explain the difference between the groups, Dr. Morris said in an interview. “Even though we have statistically significant evidence for this and it's a real effect, it is not big enough to account for this really large disparity.”

The incidence of thyroid cancer in the United States has increased dramatically over the past 30 years in both populations, probably as a result of improved screening, said Dr. Morris of the department of otolaryngology at New York University, New York. Nonetheless, whites are twice as likely to develop the disease, with an incidence of 10/100,000, compared with 5/100,000 among blacks. “With this large a disparity, the question arises, is this a true population difference with a biological explanation?”

To address this idea, Dr. Morris and his colleagues analyzed statistics from two national databases: the Healthcare Costs and Utilization Project and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database. They looked for three possible trends: If underdiagnosis in blacks was the primary reason for the difference, they expected to see black patients presenting at an older age with larger, more advanced tumors and higher mortality. If less-aggressive disease was the most accurate model, Dr. Morris said, the opposite picture would emerge. “And if there were truly a lower incidence of disease in the black population, one would expect no difference in these parameters.”

They reviewed 54,000 cases of thyroid cancer in the SEER database from 1973 to 2003. It revealed a slower annual increase in disease in blacks over the period (2% vs. 2.8%), a difference of 1,800 cases a year.

Regions of the country with more uninsured patients showed a lower incidence of thyroid cancer, whereas those with more insured patients had higher rates, suggesting a difference in early detection. A regression analysis suggested that this effect could account for up to half of the black-white difference in national disease incidence. But this should be interpreted cautiously, Dr. Morris said, because neither database contained enough socioeconomic information for a multifactorial analysis.

Clinical differences emerged as well. Blacks were 8% more likely to present at an older age (over 45 years), 12% more likely to have a tumor larger than 1 cm, and 13% more likely to have a tumor larger than 4 cm. But they were 11% less likely to have nodal metastases and 4% less likely to have either extrathyroidal or advanced disease, suggesting a less-aggressive disease course. There was no difference in mortality.

Because most of these risk ratios are similar, they reflect differences that, although statistically significant, probably are clinically small, Dr. Morris said. “The clinical and sociodemographic data are supportive of a role for socioeconomic status, a small detection bias favoring white patients, and slightly less-aggressive behavior of thyroid cancer in black patients. But all of these effects are quite small in comparison to the substantial black-white gap in cancer incidence.”

Nor can environmental factors account for the disparity, since the only two known environmental risk factors for thyroid cancer—radiation exposure and iodine deficiency—are almost unheard of in the United States, he added. “This is probably a true population difference, but we don't have an explanation of why this might be.”

Genetic differences may be the answer, but studies have yet to confirm this hypothesis. “We are just beginning to learn about the genetics of thyroid cancer, and no one has studied whether there are racial differences in the prevalence of these mutations.”

'This is probably a true population difference, but we don't have an explanation of why this might be.' DR. MORRIS

You might not expect a hospital to advertise its errors, but that's what the public wants. And that's what the New York City Health and Hospitals Corporation is doing, according to Alan Aviles, the group's president.

The group's 11 hospitals plan to publicize their overall mortality rates, heart attack mortality rates, and rates of nosocomial infections, including central line, ventilator-associated, and surgical site infections.

Nineteen states, including New York, have legislation requiring the public reporting of nosocomial rates.

Legislation adopted in 2005 requires New York hospitals to report to the state health department their incidence of central line bloodstream infections, and coronary artery bypass graft and colon surgery site infections. It's unclear when that information might be made public and whether it will appear as aggregate or facility-specific information. But Mr. Aviles has taken the bull by the horns, because hospitals can't do a better job until they can see the job they're already doing, he said in an interview.

“One of the biggest problems in this industry is the extent to which we keep this kind of quality-related data close to the vest. The practical result of that attitude is that we expect our physicians to make improvements while they're groping around in the dark.”

Publicly disclosing what has always been considered a hospital's deepest secrets is the only way to fix them, he said.

Mr. Aviles has faced naysayers, including those within his own system who worried that public scrutiny could nick their competitive edge among the city's 60 hospitals. “There was concern that we could be impacted competitively if the public either misinterpreted the data or if the numbers aren't as good as those of the competition,” he said. “But people know that medical errors and hospital-acquired infections cause thousands of needless deaths each year. … Transparency can only help.”

To that end, Mr. Aviles and his team have set a lofty goal: By 2010, they want to have the safest hospitals in the country.

There's no mistaking the single-mindedness behind that goal, said Jim Conway, senior vice president of the Institute for Healthcare Improvement (IHI). “It's extraordinarily courageous and extraordinarily hard,” he said in an interview. “They're willing to be held accountable not only to their own staff, but to consumers, patients, and families.”

The nonprofit IHI supports transformational change in health care quality and safety, both in the United States and internationally. Its “Five Million Lives Campaign,” launched in 2006, aims to protect patients from 5 million incidents of medical harm by the end of 2008. To achieve that, at least 4,000 hospitals will have to commit to improving patient safety. At present, 3,500 are involved.

The lofty goals set by the IHI and Mr. Aviles' group are a hallmark of successful change, Mr. Conway said. Another example is Ascension Health System, which comprises 65 hospitals across the United States and aims to eliminate all preventable harm in all of their hospitals in 2008. “We're seeing the fruits of that goal. In almost every tracked indicator, their performance is much better than almost any other system in the country. For pressure ulcers, for example, the rate in their lowest-performing hospital is one-sixth that of the national average,” Mr. Conway added.

Cincinnati Children's Hospital is trying to eliminate 80% of preventable serious harm, including hospital-acquired infections, by July 2008, according to Mr. Conway. Beth Israel Deaconess Medical Center in Boston has become the first hospital to post its 2007 Joint Commission Accreditation Survey findings on its Web site. The center also publicly posts its commitments to quality improvement, including the complete elimination of ventilator-associated pneumonia and central line infections.

“What drives organizations to accomplish goals like these?” Mr. Conway asked. “They have a great vision, and they have a solid sense of their current reality. They understand the gap between where they are and where they need to be, and they use that tension to drive change.”

Goals in these organizations are specific and measurable—eliminating 100% of central line infections by a certain date, for instance, as opposed to a broader aim of delivering the best health care.

“We've come to understand that 'some' is not a number and 'soon' is not a time,” Mr. Conway said. Just as important, everyone from the chief surgeon to housekeeping is considered responsible, he added.

Such efforts may be unusual now, but they are the wave of the future, Mr. Conway said. The public wants the information, states are requiring its disclosure, and the federal government is now refusing to pay for illnesses that could have been prevented—including hospital-acquired infections.

“We're going to see more and more hospitals taking responsibility like this,” he predicted. “This is the end of the beginning, and the beginning of something new.”

Advocates Want National Reporting Law

States may prove an invaluable laboratory for the eventual adoption of a national law requiring all hospitals to publicly report their rates of nosocomial infections, according to Lisa McGiffert, manager of the Consumers Union's Stop Hospital Infections campaign.

To date, 19 states have adopted such laws, which vary widely in the type of data collected and in their dissemination, Ms. McGiffert said in an interview.

There is some benefit to having the states figure out the best method for collecting and sharing this information, she said. “We feel that it's very important to engage in this exercise before there are any national standards created. When that does happen, we want the law to be based on real-life experience, not someone's theoretical ideas of how it should go.”

The nonprofit Stop Hospital Infections project, run by the same company that publishes Consumer Reports, works to enact state laws that publicly disclose hospital rates of nosocomial infections. But the group's ultimate goal is a national law that would enact a uniform data collection and reporting system.

A prototype bill, the Healthy Hospitals Act of 2007, was introduced into the House last February, Ms. McGiffert said. Sponsored by Rep. Tim Murphy (R-Pa.), the bill would require public reporting of health care-associated infections data by hospitals and ambulatory surgical centers.

H.R. 1174 implies a stick but offers a carrot. Hospitals with poor results could suffer if consumers choose a competing facility that has a better rating, but they would also be eligible for financial incentives or grants under Medicaid if they improved their infection rates.

Just when such a bill might come up for voting is unknown. In the meantime, the group continues to promote legislative action on the state level. All but four states (Arizona, Montana, North Dakota, and Wyoming) have at least debated legislation requiring some form of public disclosure of hospital infection and error rates. New Jersey has adopted a public reporting bill that awaits the governor's signature.

An overview of the existing legislation may be found at

www.stophospitalinfections.org

You might not expect a hospital to advertise its errors, but that's what the public wants. And that's what the New York City Health and Hospitals Corporation is doing, according to Alan Aviles, the group's president.

The group's 11 hospitals plan to publicize their overall mortality rates, heart attack mortality rates, and rates of nosocomial infections, including central line, ventilator-associated, and surgical site infections.

Nineteen states, including New York, have legislation requiring the public reporting of nosocomial rates.

Legislation adopted in 2005 requires New York hospitals to report to the state health department their incidence of central line bloodstream infections, and coronary artery bypass graft and colon surgery site infections. It's unclear when that information might be made public and whether it will appear as aggregate or facility-specific information. But Mr. Aviles has taken the bull by the horns, because hospitals can't do a better job until they can see the job they're already doing, he said in an interview.

“One of the biggest problems in this industry is the extent to which we keep this kind of quality-related data close to the vest. The practical result of that attitude is that we expect our physicians to make improvements while they're groping around in the dark.”

Publicly disclosing what has always been considered a hospital's deepest secrets is the only way to fix them, he said.

Mr. Aviles has faced naysayers, including those within his own system who worried that public scrutiny could nick their competitive edge among the city's 60 hospitals. “There was concern that we could be impacted competitively if the public either misinterpreted the data or if the numbers aren't as good as those of the competition,” he said. “But people know that medical errors and hospital-acquired infections cause thousands of needless deaths each year. … Transparency can only help.”

To that end, Mr. Aviles and his team have set a lofty goal: By 2010, they want to have the safest hospitals in the country.

There's no mistaking the single-mindedness behind that goal, said Jim Conway, senior vice president of the Institute for Healthcare Improvement (IHI). “It's extraordinarily courageous and extraordinarily hard,” he said in an interview. “They're willing to be held accountable not only to their own staff, but to consumers, patients, and families.”

The nonprofit IHI supports transformational change in health care quality and safety, both in the United States and internationally. Its “Five Million Lives Campaign,” launched in 2006, aims to protect patients from 5 million incidents of medical harm by the end of 2008. To achieve that, at least 4,000 hospitals will have to commit to improving patient safety. At present, 3,500 are involved.

The lofty goals set by the IHI and Mr. Aviles' group are a hallmark of successful change, Mr. Conway said. Another example is Ascension Health System, which comprises 65 hospitals across the United States and aims to eliminate all preventable harm in all of their hospitals in 2008. “We're seeing the fruits of that goal. In almost every tracked indicator, their performance is much better than almost any other system in the country. For pressure ulcers, for example, the rate in their lowest-performing hospital is one-sixth that of the national average,” Mr. Conway added.

Cincinnati Children's Hospital is trying to eliminate 80% of preventable serious harm, including hospital-acquired infections, by July 2008, according to Mr. Conway. Beth Israel Deaconess Medical Center in Boston has become the first hospital to post its 2007 Joint Commission Accreditation Survey findings on its Web site. The center also publicly posts its commitments to quality improvement, including the complete elimination of ventilator-associated pneumonia and central line infections.

“What drives organizations to accomplish goals like these?” Mr. Conway asked. “They have a great vision, and they have a solid sense of their current reality. They understand the gap between where they are and where they need to be, and they use that tension to drive change.”

Goals in these organizations are specific and measurable—eliminating 100% of central line infections by a certain date, for instance, as opposed to a broader aim of delivering the best health care.

“We've come to understand that 'some' is not a number and 'soon' is not a time,” Mr. Conway said. Just as important, everyone from the chief surgeon to housekeeping is considered responsible, he added.

Such efforts may be unusual now, but they are the wave of the future, Mr. Conway said. The public wants the information, states are requiring its disclosure, and the federal government is now refusing to pay for illnesses that could have been prevented—including hospital-acquired infections.

“We're going to see more and more hospitals taking responsibility like this,” he predicted. “This is the end of the beginning, and the beginning of something new.”

Advocates Want National Reporting Law

States may prove an invaluable laboratory for the eventual adoption of a national law requiring all hospitals to publicly report their rates of nosocomial infections, according to Lisa McGiffert, manager of the Consumers Union's Stop Hospital Infections campaign.

To date, 19 states have adopted such laws, which vary widely in the type of data collected and in their dissemination, Ms. McGiffert said in an interview.

There is some benefit to having the states figure out the best method for collecting and sharing this information, she said. “We feel that it's very important to engage in this exercise before there are any national standards created. When that does happen, we want the law to be based on real-life experience, not someone's theoretical ideas of how it should go.”

The nonprofit Stop Hospital Infections project, run by the same company that publishes Consumer Reports, works to enact state laws that publicly disclose hospital rates of nosocomial infections. But the group's ultimate goal is a national law that would enact a uniform data collection and reporting system.

A prototype bill, the Healthy Hospitals Act of 2007, was introduced into the House last February, Ms. McGiffert said. Sponsored by Rep. Tim Murphy (R-Pa.), the bill would require public reporting of health care-associated infections data by hospitals and ambulatory surgical centers.

H.R. 1174 implies a stick but offers a carrot. Hospitals with poor results could suffer if consumers choose a competing facility that has a better rating, but they would also be eligible for financial incentives or grants under Medicaid if they improved their infection rates.

Just when such a bill might come up for voting is unknown. In the meantime, the group continues to promote legislative action on the state level. All but four states (Arizona, Montana, North Dakota, and Wyoming) have at least debated legislation requiring some form of public disclosure of hospital infection and error rates. New Jersey has adopted a public reporting bill that awaits the governor's signature.

An overview of the existing legislation may be found at

www.stophospitalinfections.org

You might not expect a hospital to advertise its errors, but that's what the public wants. And that's what the New York City Health and Hospitals Corporation is doing, according to Alan Aviles, the group's president.

The group's 11 hospitals plan to publicize their overall mortality rates, heart attack mortality rates, and rates of nosocomial infections, including central line, ventilator-associated, and surgical site infections.

Nineteen states, including New York, have legislation requiring the public reporting of nosocomial rates.

Legislation adopted in 2005 requires New York hospitals to report to the state health department their incidence of central line bloodstream infections, and coronary artery bypass graft and colon surgery site infections. It's unclear when that information might be made public and whether it will appear as aggregate or facility-specific information. But Mr. Aviles has taken the bull by the horns, because hospitals can't do a better job until they can see the job they're already doing, he said in an interview.

“One of the biggest problems in this industry is the extent to which we keep this kind of quality-related data close to the vest. The practical result of that attitude is that we expect our physicians to make improvements while they're groping around in the dark.”

Publicly disclosing what has always been considered a hospital's deepest secrets is the only way to fix them, he said.

Mr. Aviles has faced naysayers, including those within his own system who worried that public scrutiny could nick their competitive edge among the city's 60 hospitals. “There was concern that we could be impacted competitively if the public either misinterpreted the data or if the numbers aren't as good as those of the competition,” he said. “But people know that medical errors and hospital-acquired infections cause thousands of needless deaths each year. … Transparency can only help.”

To that end, Mr. Aviles and his team have set a lofty goal: By 2010, they want to have the safest hospitals in the country.

There's no mistaking the single-mindedness behind that goal, said Jim Conway, senior vice president of the Institute for Healthcare Improvement (IHI). “It's extraordinarily courageous and extraordinarily hard,” he said in an interview. “They're willing to be held accountable not only to their own staff, but to consumers, patients, and families.”

The nonprofit IHI supports transformational change in health care quality and safety, both in the United States and internationally. Its “Five Million Lives Campaign,” launched in 2006, aims to protect patients from 5 million incidents of medical harm by the end of 2008. To achieve that, at least 4,000 hospitals will have to commit to improving patient safety. At present, 3,500 are involved.

The lofty goals set by the IHI and Mr. Aviles' group are a hallmark of successful change, Mr. Conway said. Another example is Ascension Health System, which comprises 65 hospitals across the United States and aims to eliminate all preventable harm in all of their hospitals in 2008. “We're seeing the fruits of that goal. In almost every tracked indicator, their performance is much better than almost any other system in the country. For pressure ulcers, for example, the rate in their lowest-performing hospital is one-sixth that of the national average,” Mr. Conway added.

Cincinnati Children's Hospital is trying to eliminate 80% of preventable serious harm, including hospital-acquired infections, by July 2008, according to Mr. Conway. Beth Israel Deaconess Medical Center in Boston has become the first hospital to post its 2007 Joint Commission Accreditation Survey findings on its Web site. The center also publicly posts its commitments to quality improvement, including the complete elimination of ventilator-associated pneumonia and central line infections.

“What drives organizations to accomplish goals like these?” Mr. Conway asked. “They have a great vision, and they have a solid sense of their current reality. They understand the gap between where they are and where they need to be, and they use that tension to drive change.”

Goals in these organizations are specific and measurable—eliminating 100% of central line infections by a certain date, for instance, as opposed to a broader aim of delivering the best health care.

“We've come to understand that 'some' is not a number and 'soon' is not a time,” Mr. Conway said. Just as important, everyone from the chief surgeon to housekeeping is considered responsible, he added.

Such efforts may be unusual now, but they are the wave of the future, Mr. Conway said. The public wants the information, states are requiring its disclosure, and the federal government is now refusing to pay for illnesses that could have been prevented—including hospital-acquired infections.

“We're going to see more and more hospitals taking responsibility like this,” he predicted. “This is the end of the beginning, and the beginning of something new.”

Advocates Want National Reporting Law

States may prove an invaluable laboratory for the eventual adoption of a national law requiring all hospitals to publicly report their rates of nosocomial infections, according to Lisa McGiffert, manager of the Consumers Union's Stop Hospital Infections campaign.

To date, 19 states have adopted such laws, which vary widely in the type of data collected and in their dissemination, Ms. McGiffert said in an interview.

There is some benefit to having the states figure out the best method for collecting and sharing this information, she said. “We feel that it's very important to engage in this exercise before there are any national standards created. When that does happen, we want the law to be based on real-life experience, not someone's theoretical ideas of how it should go.”

The nonprofit Stop Hospital Infections project, run by the same company that publishes Consumer Reports, works to enact state laws that publicly disclose hospital rates of nosocomial infections. But the group's ultimate goal is a national law that would enact a uniform data collection and reporting system.

A prototype bill, the Healthy Hospitals Act of 2007, was introduced into the House last February, Ms. McGiffert said. Sponsored by Rep. Tim Murphy (R-Pa.), the bill would require public reporting of health care-associated infections data by hospitals and ambulatory surgical centers.

H.R. 1174 implies a stick but offers a carrot. Hospitals with poor results could suffer if consumers choose a competing facility that has a better rating, but they would also be eligible for financial incentives or grants under Medicaid if they improved their infection rates.

Just when such a bill might come up for voting is unknown. In the meantime, the group continues to promote legislative action on the state level. All but four states (Arizona, Montana, North Dakota, and Wyoming) have at least debated legislation requiring some form of public disclosure of hospital infection and error rates. New Jersey has adopted a public reporting bill that awaits the governor's signature.

An overview of the existing legislation may be found at

www.stophospitalinfections.org

NEW ORLEANS — Rather than unlocking a Pandora's box of nattering e-mails, an electronic patient portal that allows messaging and even access to test results can improve patient satisfaction and decrease patient visits, says one expert.

“Many physicians think that this type of access is frightening,” Dr. Gretchen P. Purcell said at the annual clinical congress of the American College of Surgeons. “They think they'll be barraged with messages, that patients will misinterpret their test results, and that physicians could even be held legally liable if they don't respond in time to an urgent message.”

But health care providers, who are about 10 years behind the curve in the digital world, need to face up to the facts of the 21st century, said Dr. Purcell of the surgery department at the Children's Hospital at Vanderbilt in Nashville, Tenn. “Patients are demanding the same kind of online access to their medical information as they have for all other aspects of their lives. Those health care institutions that do not have a patient portal now probably will within the next 5 years.”

Patient portals can be designed to suit the needs of different practices and to fulfill various functions. At a minimum, they allow patients to pay bills, schedule or change appointments, and request prescription refills. Other portals are more robust and give patients the ability to review medical records, view test results, and send messages to their health care providers, said Dr. Purcell, who is also with the biomedical informatics department at Vanderbilt Medical Center.

Messaging and the ability to access test results are controversial topics, she said. “Messaging is probably the function physicians fear the most. Many think it's the equivalent of getting and sending personal e-mail, and this brings up all kinds of worries about security and privacy.”

E-mail and messaging, however, are not the same things. Messages don't go to a personal e-mail account; instead, they go to a dedicated in-box. “This message box is routinely checked by an administrative assistant or nurse—someone who can often answer many of the questions, and who would involve the physician only when necessary—similar to phone call triage.”

There also are concerns that these electronic exchanges aren't part of a patient's documented record. “Some portals can make messaging part of the medical record, and some physicians have found ways to charge for this 'online consultation,'” Dr. Purcell said.

It's important to set clear expectations about response time and emergency issues. Most messaging systems tell patients that they may have to wait 2–3 business days for a personal reply and advise them to call 911 for a medical emergency.

It's not unreasonable to assume that electronic communication could allow patients to bombard offices with questions and requests. Although data are still limited, the studies that are out there suggest just the opposite, Dr. Purcell said.

Two studies published in 2005 indicate that messaging increases patient satisfaction without any corresponding increase in workload. The first study randomized 200 patients to secure messaging or usual care. Only 46% of the patients who were given access sent any messages at all; the average was just 1.5 messages per patient per year. And although messaging didn't reduce the number of telephone calls the office received, the number of office visits in the intervention group did go down (Int. J. Med. Inform. 2005;74:705–10).

The second study randomized 606 patients to a patient communication portal or to a Web site with general health information. Only 31% of the patients given access used the portal. The message box received only one message per day per 250 patients. Again, there was no difference in the number of office telephone calls between the groups, but the patients in the portal group reported better satisfaction with communication and overall care, even if they never used the portal (J. Med. Internet Res. 2005;7:e48).

The same study indicated that secure messaging probably would not overwhelm anyone during working hours, Dr. Purcell said. “Patients tended to use the portal during nonclinic hours—the most convenient time for them—with about 73% of messaging occurring from 5 p.m. until midnight.” Patients may even be willing to pay for the added convenience of messaging, the authors concluded. Of 341 patients surveyed, 162 (48%) were willing to pay for online correspondence with their physician, with $2 cited as the median payment they thought fair.

MyHealthAtVanderbilt (www.myhealthatvanderbilt.com

NEW ORLEANS — Rather than unlocking a Pandora's box of nattering e-mails, an electronic patient portal that allows messaging and even access to test results can improve patient satisfaction and decrease patient visits, says one expert.

“Many physicians think that this type of access is frightening,” Dr. Gretchen P. Purcell said at the annual clinical congress of the American College of Surgeons. “They think they'll be barraged with messages, that patients will misinterpret their test results, and that physicians could even be held legally liable if they don't respond in time to an urgent message.”

But health care providers, who are about 10 years behind the curve in the digital world, need to face up to the facts of the 21st century, said Dr. Purcell of the surgery department at the Children's Hospital at Vanderbilt in Nashville, Tenn. “Patients are demanding the same kind of online access to their medical information as they have for all other aspects of their lives. Those health care institutions that do not have a patient portal now probably will within the next 5 years.”

Patient portals can be designed to suit the needs of different practices and to fulfill various functions. At a minimum, they allow patients to pay bills, schedule or change appointments, and request prescription refills. Other portals are more robust and give patients the ability to review medical records, view test results, and send messages to their health care providers, said Dr. Purcell, who is also with the biomedical informatics department at Vanderbilt Medical Center.

Messaging and the ability to access test results are controversial topics, she said. “Messaging is probably the function physicians fear the most. Many think it's the equivalent of getting and sending personal e-mail, and this brings up all kinds of worries about security and privacy.”

E-mail and messaging, however, are not the same things. Messages don't go to a personal e-mail account; instead, they go to a dedicated in-box. “This message box is routinely checked by an administrative assistant or nurse—someone who can often answer many of the questions, and who would involve the physician only when necessary—similar to phone call triage.”

There also are concerns that these electronic exchanges aren't part of a patient's documented record. “Some portals can make messaging part of the medical record, and some physicians have found ways to charge for this 'online consultation,'” Dr. Purcell said.

It's important to set clear expectations about response time and emergency issues. Most messaging systems tell patients that they may have to wait 2–3 business days for a personal reply and advise them to call 911 for a medical emergency.

It's not unreasonable to assume that electronic communication could allow patients to bombard offices with questions and requests. Although data are still limited, the studies that are out there suggest just the opposite, Dr. Purcell said.

Two studies published in 2005 indicate that messaging increases patient satisfaction without any corresponding increase in workload. The first study randomized 200 patients to secure messaging or usual care. Only 46% of the patients who were given access sent any messages at all; the average was just 1.5 messages per patient per year. And although messaging didn't reduce the number of telephone calls the office received, the number of office visits in the intervention group did go down (Int. J. Med. Inform. 2005;74:705–10).

The second study randomized 606 patients to a patient communication portal or to a Web site with general health information. Only 31% of the patients given access used the portal. The message box received only one message per day per 250 patients. Again, there was no difference in the number of office telephone calls between the groups, but the patients in the portal group reported better satisfaction with communication and overall care, even if they never used the portal (J. Med. Internet Res. 2005;7:e48).

The same study indicated that secure messaging probably would not overwhelm anyone during working hours, Dr. Purcell said. “Patients tended to use the portal during nonclinic hours—the most convenient time for them—with about 73% of messaging occurring from 5 p.m. until midnight.” Patients may even be willing to pay for the added convenience of messaging, the authors concluded. Of 341 patients surveyed, 162 (48%) were willing to pay for online correspondence with their physician, with $2 cited as the median payment they thought fair.

MyHealthAtVanderbilt (www.myhealthatvanderbilt.com

NEW ORLEANS — Rather than unlocking a Pandora's box of nattering e-mails, an electronic patient portal that allows messaging and even access to test results can improve patient satisfaction and decrease patient visits, says one expert.

“Many physicians think that this type of access is frightening,” Dr. Gretchen P. Purcell said at the annual clinical congress of the American College of Surgeons. “They think they'll be barraged with messages, that patients will misinterpret their test results, and that physicians could even be held legally liable if they don't respond in time to an urgent message.”

But health care providers, who are about 10 years behind the curve in the digital world, need to face up to the facts of the 21st century, said Dr. Purcell of the surgery department at the Children's Hospital at Vanderbilt in Nashville, Tenn. “Patients are demanding the same kind of online access to their medical information as they have for all other aspects of their lives. Those health care institutions that do not have a patient portal now probably will within the next 5 years.”

Patient portals can be designed to suit the needs of different practices and to fulfill various functions. At a minimum, they allow patients to pay bills, schedule or change appointments, and request prescription refills. Other portals are more robust and give patients the ability to review medical records, view test results, and send messages to their health care providers, said Dr. Purcell, who is also with the biomedical informatics department at Vanderbilt Medical Center.

Messaging and the ability to access test results are controversial topics, she said. “Messaging is probably the function physicians fear the most. Many think it's the equivalent of getting and sending personal e-mail, and this brings up all kinds of worries about security and privacy.”

E-mail and messaging, however, are not the same things. Messages don't go to a personal e-mail account; instead, they go to a dedicated in-box. “This message box is routinely checked by an administrative assistant or nurse—someone who can often answer many of the questions, and who would involve the physician only when necessary—similar to phone call triage.”

There also are concerns that these electronic exchanges aren't part of a patient's documented record. “Some portals can make messaging part of the medical record, and some physicians have found ways to charge for this 'online consultation,'” Dr. Purcell said.

It's important to set clear expectations about response time and emergency issues. Most messaging systems tell patients that they may have to wait 2–3 business days for a personal reply and advise them to call 911 for a medical emergency.

It's not unreasonable to assume that electronic communication could allow patients to bombard offices with questions and requests. Although data are still limited, the studies that are out there suggest just the opposite, Dr. Purcell said.

Two studies published in 2005 indicate that messaging increases patient satisfaction without any corresponding increase in workload. The first study randomized 200 patients to secure messaging or usual care. Only 46% of the patients who were given access sent any messages at all; the average was just 1.5 messages per patient per year. And although messaging didn't reduce the number of telephone calls the office received, the number of office visits in the intervention group did go down (Int. J. Med. Inform. 2005;74:705–10).

The second study randomized 606 patients to a patient communication portal or to a Web site with general health information. Only 31% of the patients given access used the portal. The message box received only one message per day per 250 patients. Again, there was no difference in the number of office telephone calls between the groups, but the patients in the portal group reported better satisfaction with communication and overall care, even if they never used the portal (J. Med. Internet Res. 2005;7:e48).

The same study indicated that secure messaging probably would not overwhelm anyone during working hours, Dr. Purcell said. “Patients tended to use the portal during nonclinic hours—the most convenient time for them—with about 73% of messaging occurring from 5 p.m. until midnight.” Patients may even be willing to pay for the added convenience of messaging, the authors concluded. Of 341 patients surveyed, 162 (48%) were willing to pay for online correspondence with their physician, with $2 cited as the median payment they thought fair.

MyHealthAtVanderbilt (www.myhealthatvanderbilt.com

Medically induced abortions were just as safe as surgical abortions with regard to the outcomes of future pregnancies, according to a large study conducted in Denmark.

The population-based study of almost 12,000 pregnancies that occurred subsequent to elective abortions in the first trimester showed no significant differences in the risk of ectopic pregnancy, preterm birth, miscarriage, or low birth weight, reported study authors Dr. Jun Zhang, of the National Institute of Child Health and Human Development, and colleagues (N. Engl. J. Med. 2007;357;648–53).

The investigators examined data on all women living in Denmark who had undergone an abortion for nonmedical reasons between 1999 and 2004 and had at least one subsequent pregnancy between 1999 and 2005. The first pregnancy after each abortion was included in the study.

Data for each of the 11,682 women in the study were linked to the Danish National Birth Registry and National Patient Registry.

Of the 11,814 pregnancies in these women, 9,104 were preceded by a surgical abortion, and 2,710 were preceded by a medical abortion involving mifepristone and misoprostol, or misoprostol alone.

Most of the subsequent pregnancies (85%) resulted in live births; there were 1,486 miscarriages (13%), 274 ectopic pregnancies (2%), and 36 stillbirths (0.3%).

The incidence of ectopic pregnancy, miscarriage, preterm birth (defined as gestation less than 37 completed weeks), and low birth weight (defined as less than 2,500 g) was not significantly different between the groups, even after the investigators adjusted for maternal age, parity, interpregnancy interval, maternal residence, cohabitation status, and gestational age at the time of the abortion. (See table below.)

There were too few stillbirths to make a meaningful comparison between groups, the authors said.

The findings differ from those of a previous study, which showed a significant association between medical abortion and ectopic pregnancy (Am. J. Epidemiol. 2003;157:185–94).

However, that case-control study relied on self-report of abortion and pregnancy outcomes, rather than a clinical registry, Dr. Zhang and coauthors pointed out.

A recent Chinese multicenter cohort study found results similar to the Danish study, the authors noted. That study of almost 10,000 women found no difference in low birth weight or preterm birth between women who had a previous surgical or medical abortion (Am. J. Epidemiol. 2004;160:110–7).

None of the investigators in the Danish study reported conflicts of interest relative to the research.

ELSEVIER GLOBAL MEDICAL NEWS

Medically induced abortions were just as safe as surgical abortions with regard to the outcomes of future pregnancies, according to a large study conducted in Denmark.

The population-based study of almost 12,000 pregnancies that occurred subsequent to elective abortions in the first trimester showed no significant differences in the risk of ectopic pregnancy, preterm birth, miscarriage, or low birth weight, reported study authors Dr. Jun Zhang, of the National Institute of Child Health and Human Development, and colleagues (N. Engl. J. Med. 2007;357;648–53).

The investigators examined data on all women living in Denmark who had undergone an abortion for nonmedical reasons between 1999 and 2004 and had at least one subsequent pregnancy between 1999 and 2005. The first pregnancy after each abortion was included in the study.

Data for each of the 11,682 women in the study were linked to the Danish National Birth Registry and National Patient Registry.

Of the 11,814 pregnancies in these women, 9,104 were preceded by a surgical abortion, and 2,710 were preceded by a medical abortion involving mifepristone and misoprostol, or misoprostol alone.

Most of the subsequent pregnancies (85%) resulted in live births; there were 1,486 miscarriages (13%), 274 ectopic pregnancies (2%), and 36 stillbirths (0.3%).

The incidence of ectopic pregnancy, miscarriage, preterm birth (defined as gestation less than 37 completed weeks), and low birth weight (defined as less than 2,500 g) was not significantly different between the groups, even after the investigators adjusted for maternal age, parity, interpregnancy interval, maternal residence, cohabitation status, and gestational age at the time of the abortion. (See table below.)

There were too few stillbirths to make a meaningful comparison between groups, the authors said.

The findings differ from those of a previous study, which showed a significant association between medical abortion and ectopic pregnancy (Am. J. Epidemiol. 2003;157:185–94).

However, that case-control study relied on self-report of abortion and pregnancy outcomes, rather than a clinical registry, Dr. Zhang and coauthors pointed out.

A recent Chinese multicenter cohort study found results similar to the Danish study, the authors noted. That study of almost 10,000 women found no difference in low birth weight or preterm birth between women who had a previous surgical or medical abortion (Am. J. Epidemiol. 2004;160:110–7).

None of the investigators in the Danish study reported conflicts of interest relative to the research.

ELSEVIER GLOBAL MEDICAL NEWS

Medically induced abortions were just as safe as surgical abortions with regard to the outcomes of future pregnancies, according to a large study conducted in Denmark.

The population-based study of almost 12,000 pregnancies that occurred subsequent to elective abortions in the first trimester showed no significant differences in the risk of ectopic pregnancy, preterm birth, miscarriage, or low birth weight, reported study authors Dr. Jun Zhang, of the National Institute of Child Health and Human Development, and colleagues (N. Engl. J. Med. 2007;357;648–53).

The investigators examined data on all women living in Denmark who had undergone an abortion for nonmedical reasons between 1999 and 2004 and had at least one subsequent pregnancy between 1999 and 2005. The first pregnancy after each abortion was included in the study.

Data for each of the 11,682 women in the study were linked to the Danish National Birth Registry and National Patient Registry.

Of the 11,814 pregnancies in these women, 9,104 were preceded by a surgical abortion, and 2,710 were preceded by a medical abortion involving mifepristone and misoprostol, or misoprostol alone.

Most of the subsequent pregnancies (85%) resulted in live births; there were 1,486 miscarriages (13%), 274 ectopic pregnancies (2%), and 36 stillbirths (0.3%).

The incidence of ectopic pregnancy, miscarriage, preterm birth (defined as gestation less than 37 completed weeks), and low birth weight (defined as less than 2,500 g) was not significantly different between the groups, even after the investigators adjusted for maternal age, parity, interpregnancy interval, maternal residence, cohabitation status, and gestational age at the time of the abortion. (See table below.)

There were too few stillbirths to make a meaningful comparison between groups, the authors said.

The findings differ from those of a previous study, which showed a significant association between medical abortion and ectopic pregnancy (Am. J. Epidemiol. 2003;157:185–94).

However, that case-control study relied on self-report of abortion and pregnancy outcomes, rather than a clinical registry, Dr. Zhang and coauthors pointed out.

A recent Chinese multicenter cohort study found results similar to the Danish study, the authors noted. That study of almost 10,000 women found no difference in low birth weight or preterm birth between women who had a previous surgical or medical abortion (Am. J. Epidemiol. 2004;160:110–7).

None of the investigators in the Danish study reported conflicts of interest relative to the research.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – Naltrexone may have little positive effect either on drinking behavior in older women with alcoholism comorbid with depression or on drug-using behavior in women with alcoholism and comorbid cocaine dependence.

Data presented at the annual meeting of the Research Society for Alcoholism–a subanalysis of a 2005 drug trial and a preview of a trial in press–hint that naltrexone may have very different effects in women than men, according to William Dundon, Ph.D., of the University of Pennsylvania, Philadelphia.

“Women metabolize alcohol differently than men, and respond to naltrexone differently as well,” he said in an interview. Although most trials haven't seen a significant difference in gender response to the drug, that may reflect a demographic problem rather than a true drug response. “The number of women in most of these studies is generally less than men, so these studies are not necessarily powered to see a gender effect,” Dr. Dundon said.

Naltrexone blocks the mu-opiate receptors, moderating the sense of euphoria that alcohol provides, said Dr. Dundon, a researcher at the university's Center for the Studies of Addiction. Genetic makeup may also play a significant part in a given patient's response to the drug. Dr. David Oslin, also of the university, has recently identified a genetic variant–a polymorphism of the mu-receptor gene–that seems to predict naltrexone response (Addict. Biol. 2006;11:397–403).

Dr. Dundon presented a recent gender subanalysis of a 2005 study by Dr. Oslin, demonstrating a poor naltrexone response in older women with comorbid alcoholism and depression (Am. J. Geriatr. Psychiatry 2005;13:491–500).

This study comprised 74 older adults (mean age 63 years) with alcohol dependence and depressive disorder. Most subjects (59) were male; there were only 15 female subjects. All of the patients received sertraline (Zoloft) 100 mg/day for their depression, as well as 10 sessions of therapy focused on both alcohol use and depression. They were also randomized to either placebo or naltrexone (50 mg/day).

At the end of the 12-week trial, 42% of the patients were considered well, with no relapse to heavy drinking and with remission of depressive symptoms. An additional 24% remained depressed, but did not have a drinking relapse.

There were no significant differences between the placebo/sertraline group and the naltrexone/sertraline groups in terms of outcome measures: relapse to heavy drinking, abstinence, remission of depression, or overall improvement.

The gender subanalysis showed a slightly different picture, Dr. Dundon said.

Men with positive outcomes did equally well on either regimen, with 40% of the placebo/sertraline and 45% of the naltrexone/sertraline groups considered well by 12 weeks. In women, though, only about 25% of those in the naltrexone/sertraline group were considered well by the trial's end, compared with 70% of those in the placebo/sertraline group.

Because so few women were in the trial, Dr. Dundon said it's impossible to make clinical recommendations about naltrexone's suitability for older women with comorbid depression and alcoholism.

CHICAGO – Naltrexone may have little positive effect either on drinking behavior in older women with alcoholism comorbid with depression or on drug-using behavior in women with alcoholism and comorbid cocaine dependence.

Data presented at the annual meeting of the Research Society for Alcoholism–a subanalysis of a 2005 drug trial and a preview of a trial in press–hint that naltrexone may have very different effects in women than men, according to William Dundon, Ph.D., of the University of Pennsylvania, Philadelphia.

“Women metabolize alcohol differently than men, and respond to naltrexone differently as well,” he said in an interview. Although most trials haven't seen a significant difference in gender response to the drug, that may reflect a demographic problem rather than a true drug response. “The number of women in most of these studies is generally less than men, so these studies are not necessarily powered to see a gender effect,” Dr. Dundon said.

Naltrexone blocks the mu-opiate receptors, moderating the sense of euphoria that alcohol provides, said Dr. Dundon, a researcher at the university's Center for the Studies of Addiction. Genetic makeup may also play a significant part in a given patient's response to the drug. Dr. David Oslin, also of the university, has recently identified a genetic variant–a polymorphism of the mu-receptor gene–that seems to predict naltrexone response (Addict. Biol. 2006;11:397–403).

Dr. Dundon presented a recent gender subanalysis of a 2005 study by Dr. Oslin, demonstrating a poor naltrexone response in older women with comorbid alcoholism and depression (Am. J. Geriatr. Psychiatry 2005;13:491–500).

This study comprised 74 older adults (mean age 63 years) with alcohol dependence and depressive disorder. Most subjects (59) were male; there were only 15 female subjects. All of the patients received sertraline (Zoloft) 100 mg/day for their depression, as well as 10 sessions of therapy focused on both alcohol use and depression. They were also randomized to either placebo or naltrexone (50 mg/day).

At the end of the 12-week trial, 42% of the patients were considered well, with no relapse to heavy drinking and with remission of depressive symptoms. An additional 24% remained depressed, but did not have a drinking relapse.

There were no significant differences between the placebo/sertraline group and the naltrexone/sertraline groups in terms of outcome measures: relapse to heavy drinking, abstinence, remission of depression, or overall improvement.

The gender subanalysis showed a slightly different picture, Dr. Dundon said.

Men with positive outcomes did equally well on either regimen, with 40% of the placebo/sertraline and 45% of the naltrexone/sertraline groups considered well by 12 weeks. In women, though, only about 25% of those in the naltrexone/sertraline group were considered well by the trial's end, compared with 70% of those in the placebo/sertraline group.

Because so few women were in the trial, Dr. Dundon said it's impossible to make clinical recommendations about naltrexone's suitability for older women with comorbid depression and alcoholism.

CHICAGO – Naltrexone may have little positive effect either on drinking behavior in older women with alcoholism comorbid with depression or on drug-using behavior in women with alcoholism and comorbid cocaine dependence.

Data presented at the annual meeting of the Research Society for Alcoholism–a subanalysis of a 2005 drug trial and a preview of a trial in press–hint that naltrexone may have very different effects in women than men, according to William Dundon, Ph.D., of the University of Pennsylvania, Philadelphia.

“Women metabolize alcohol differently than men, and respond to naltrexone differently as well,” he said in an interview. Although most trials haven't seen a significant difference in gender response to the drug, that may reflect a demographic problem rather than a true drug response. “The number of women in most of these studies is generally less than men, so these studies are not necessarily powered to see a gender effect,” Dr. Dundon said.

Naltrexone blocks the mu-opiate receptors, moderating the sense of euphoria that alcohol provides, said Dr. Dundon, a researcher at the university's Center for the Studies of Addiction. Genetic makeup may also play a significant part in a given patient's response to the drug. Dr. David Oslin, also of the university, has recently identified a genetic variant–a polymorphism of the mu-receptor gene–that seems to predict naltrexone response (Addict. Biol. 2006;11:397–403).

Dr. Dundon presented a recent gender subanalysis of a 2005 study by Dr. Oslin, demonstrating a poor naltrexone response in older women with comorbid alcoholism and depression (Am. J. Geriatr. Psychiatry 2005;13:491–500).

This study comprised 74 older adults (mean age 63 years) with alcohol dependence and depressive disorder. Most subjects (59) were male; there were only 15 female subjects. All of the patients received sertraline (Zoloft) 100 mg/day for their depression, as well as 10 sessions of therapy focused on both alcohol use and depression. They were also randomized to either placebo or naltrexone (50 mg/day).

At the end of the 12-week trial, 42% of the patients were considered well, with no relapse to heavy drinking and with remission of depressive symptoms. An additional 24% remained depressed, but did not have a drinking relapse.

There were no significant differences between the placebo/sertraline group and the naltrexone/sertraline groups in terms of outcome measures: relapse to heavy drinking, abstinence, remission of depression, or overall improvement.

The gender subanalysis showed a slightly different picture, Dr. Dundon said.

Men with positive outcomes did equally well on either regimen, with 40% of the placebo/sertraline and 45% of the naltrexone/sertraline groups considered well by 12 weeks. In women, though, only about 25% of those in the naltrexone/sertraline group were considered well by the trial's end, compared with 70% of those in the placebo/sertraline group.

Because so few women were in the trial, Dr. Dundon said it's impossible to make clinical recommendations about naltrexone's suitability for older women with comorbid depression and alcoholism.

An in-home program that teaches problem-solving skills to patients with age-related macular degeneration decreased the incidence of new-onset depression, a recent study suggests.

In addition, the program appeared to shorten the course of depression that did occur, Dr. Barry W. Rovner of Jefferson Medical College, Philadelphia, and his colleagues reported.

Significant gains seen at the 2-month follow-up visit had dissipated by 6 months, but the project illustrates the practicality of using behavioral therapy to prevent depression in patients with chronic illness, rather than medications to treat depression after it has occurred, they wrote (Arch. Gen. Psychiatry 2007; 64:886–92).

Dr. Rovner and his associates randomized 206 patients (mean age 81 years) with age-related macular degeneration in both eyes to the problem-solving treatment or to usual care. The problem-solving therapy consisted of six in-home sessions delivered by trained therapists. The sessions focused on defining problems; establishing realistic goals; generating, choosing, and implementing solutions; and evaluating outcomes.

At the 2-month follow-up visit, 11 patients in the active group had developed depression (9 major and 2 minor depression). In the control group, however, 23 patients developed depression (14 major and 9 minor), which is a significant difference.

The lower incidence of depression appeared related to an ability to maintain favorite activities. Patients who received the therapy were almost 50% less likely to have given up a valued activity than were those who received usual care, the investigators noted.

Patients in the therapy group also reported improved scores on a scale measuring subjective visual function, despite the fact that they did not show objective improvement in visual acuity. Control patients reported a decline on the subjective visual function scale.

By 6 months, however, those differences had disappeared: Twenty percent of the treatment group and 26% of the control group had developed a depressive disorder. The difference was driven by more new-onset depression in the active group between 2 and 6 months. “This suggests that additional problem-solving therapy treatment may have been necessary to prevent depression in these subjects,” Dr. Rovner and his associates said.

They did note after 6 months a significant difference in the course of depression that had developed at the 2-month visit. Only 4 of the 11 depressed patients in the active group remained depressed at 6 months, compared with 16 of the 22 depressed controls, they noted.

Rather than viewing the short-lived effects of the treatment as a failure, health care professionals should consider the study in light of the possibilities it engenders, Dr. Charles R. Reynolds III and associates wrote in an accompanying editorial (Arch. Gen. Psychiatry 2007;64:884–5). In patients with chronic illness, it may be better to prevent depression than to wait until it occurs.

“For many patients, taking an antidepressant medication to prevent depression when they don't feel depressed may be a hard sell,” wrote Dr. Reynolds of the University of Pittsburgh, and his colleagues. “Teaching those more effective coping skills through the use of a brief, depression-specific, behaviorally oriented psychotherapy may be more acceptable to both patients and health care professionals.”

An in-home program that teaches problem-solving skills to patients with age-related macular degeneration decreased the incidence of new-onset depression, a recent study suggests.

In addition, the program appeared to shorten the course of depression that did occur, Dr. Barry W. Rovner of Jefferson Medical College, Philadelphia, and his colleagues reported.

Significant gains seen at the 2-month follow-up visit had dissipated by 6 months, but the project illustrates the practicality of using behavioral therapy to prevent depression in patients with chronic illness, rather than medications to treat depression after it has occurred, they wrote (Arch. Gen. Psychiatry 2007; 64:886–92).

Dr. Rovner and his associates randomized 206 patients (mean age 81 years) with age-related macular degeneration in both eyes to the problem-solving treatment or to usual care. The problem-solving therapy consisted of six in-home sessions delivered by trained therapists. The sessions focused on defining problems; establishing realistic goals; generating, choosing, and implementing solutions; and evaluating outcomes.

At the 2-month follow-up visit, 11 patients in the active group had developed depression (9 major and 2 minor depression). In the control group, however, 23 patients developed depression (14 major and 9 minor), which is a significant difference.

The lower incidence of depression appeared related to an ability to maintain favorite activities. Patients who received the therapy were almost 50% less likely to have given up a valued activity than were those who received usual care, the investigators noted.

Patients in the therapy group also reported improved scores on a scale measuring subjective visual function, despite the fact that they did not show objective improvement in visual acuity. Control patients reported a decline on the subjective visual function scale.

By 6 months, however, those differences had disappeared: Twenty percent of the treatment group and 26% of the control group had developed a depressive disorder. The difference was driven by more new-onset depression in the active group between 2 and 6 months. “This suggests that additional problem-solving therapy treatment may have been necessary to prevent depression in these subjects,” Dr. Rovner and his associates said.

They did note after 6 months a significant difference in the course of depression that had developed at the 2-month visit. Only 4 of the 11 depressed patients in the active group remained depressed at 6 months, compared with 16 of the 22 depressed controls, they noted.

Rather than viewing the short-lived effects of the treatment as a failure, health care professionals should consider the study in light of the possibilities it engenders, Dr. Charles R. Reynolds III and associates wrote in an accompanying editorial (Arch. Gen. Psychiatry 2007;64:884–5). In patients with chronic illness, it may be better to prevent depression than to wait until it occurs.

“For many patients, taking an antidepressant medication to prevent depression when they don't feel depressed may be a hard sell,” wrote Dr. Reynolds of the University of Pittsburgh, and his colleagues. “Teaching those more effective coping skills through the use of a brief, depression-specific, behaviorally oriented psychotherapy may be more acceptable to both patients and health care professionals.”

An in-home program that teaches problem-solving skills to patients with age-related macular degeneration decreased the incidence of new-onset depression, a recent study suggests.

In addition, the program appeared to shorten the course of depression that did occur, Dr. Barry W. Rovner of Jefferson Medical College, Philadelphia, and his colleagues reported.

Significant gains seen at the 2-month follow-up visit had dissipated by 6 months, but the project illustrates the practicality of using behavioral therapy to prevent depression in patients with chronic illness, rather than medications to treat depression after it has occurred, they wrote (Arch. Gen. Psychiatry 2007; 64:886–92).

Dr. Rovner and his associates randomized 206 patients (mean age 81 years) with age-related macular degeneration in both eyes to the problem-solving treatment or to usual care. The problem-solving therapy consisted of six in-home sessions delivered by trained therapists. The sessions focused on defining problems; establishing realistic goals; generating, choosing, and implementing solutions; and evaluating outcomes.

At the 2-month follow-up visit, 11 patients in the active group had developed depression (9 major and 2 minor depression). In the control group, however, 23 patients developed depression (14 major and 9 minor), which is a significant difference.

The lower incidence of depression appeared related to an ability to maintain favorite activities. Patients who received the therapy were almost 50% less likely to have given up a valued activity than were those who received usual care, the investigators noted.

Patients in the therapy group also reported improved scores on a scale measuring subjective visual function, despite the fact that they did not show objective improvement in visual acuity. Control patients reported a decline on the subjective visual function scale.

By 6 months, however, those differences had disappeared: Twenty percent of the treatment group and 26% of the control group had developed a depressive disorder. The difference was driven by more new-onset depression in the active group between 2 and 6 months. “This suggests that additional problem-solving therapy treatment may have been necessary to prevent depression in these subjects,” Dr. Rovner and his associates said.

They did note after 6 months a significant difference in the course of depression that had developed at the 2-month visit. Only 4 of the 11 depressed patients in the active group remained depressed at 6 months, compared with 16 of the 22 depressed controls, they noted.

Rather than viewing the short-lived effects of the treatment as a failure, health care professionals should consider the study in light of the possibilities it engenders, Dr. Charles R. Reynolds III and associates wrote in an accompanying editorial (Arch. Gen. Psychiatry 2007;64:884–5). In patients with chronic illness, it may be better to prevent depression than to wait until it occurs.

“For many patients, taking an antidepressant medication to prevent depression when they don't feel depressed may be a hard sell,” wrote Dr. Reynolds of the University of Pittsburgh, and his colleagues. “Teaching those more effective coping skills through the use of a brief, depression-specific, behaviorally oriented psychotherapy may be more acceptable to both patients and health care professionals.”

CHICAGO – An intervention that allows at-risk adolescents to explore the strengths and weaknesses of their individual personalities can delay the onset of risky drinking for at least 6 months, possibly decreasing the growth of alcohol use later in the teen years.

Patricia Conrod, Ph.D., developed different programs for each of four personality types who manifest a high risk of early-onset drinking and substance abuse: sensation-seeking, negative thinking, anxiety-sensitivity, and impulsivity. The manualized program, delivered in school and consisting of two 90-minute sessions, was so effective that it prevented early-onset drinking in 50% of the sensation-seeking group and in one of every four of those who participated overall, Dr. Conrod said at the annual meeting of the Research Society for Alcoholism.

“I believe that because each intervention targeted a dominant personality trait for each adolescent, the students experienced the interventions as meaningful and relevant,” Dr. Conrod said in an interview. “They told us that this is the first time that they have ever spoken about their emotions and are considering for the first time the notion that they have personal control over their emotional reactions and behavior.”

Furthermore, she said, the young people found it helpful to learn that others were struggling with similar issues.

Dr. Conrod, a clinical lecturer at the Institute of Psychiatry, King's College London, first developed the program in Canada, where it proved similarly successful in a study of 300 high school students with a mean age of 16 years (J. Clin. Child Adolesc. Psychol. 2006;35:550–63). The current study examined the program's effect in younger students (mean age 14 years).

More than 2,600 students in 13 London high schools completed the Substance Use Risk Profile Scale, which assesses the four dimensions of personality that are linked to different motivations for drug use and misuse. Those who scored more than one standard deviation above the school mean on one of the personality risk subscales were randomized to either the intervention group corresponding with their personality type, or to no intervention except standard drug education.

The final study group comprised 348 students. The intervention groups received the two 90-minute in-school sessions. The manuals contained real-life experiences shared by other high-risk youth of that personality. The first session included goal-setting exercises to explore personality and ways of coping with it; psychoeducational strategies teaching students about their personality and associated problematic coping behaviors; and cognitive-behavioral exercises.

The second session involved discussion of personality-specific cognitive distortions that resulted in problematic behavior. The negative thinking group focused on challenging negative thoughts; the anxiety-sensitivity group explored catastrophic thoughts; the impulsivity group focused on aggressive thinking and acting without thought; and the sensation-seekers examined reward seeking and boredom susceptibility.

The control group received the standard drug education sessions contained in the national curriculum.

All students reported their alcohol use at baseline and at 6 and 12 months. All of the control groups except for the impulsivity group demonstrated an increase in drinking between 6 and 12 months. The sensation-seeking control group demonstrated a sharp increase in drinking by 6 months, which then leveled off. Most notable was the marked increase in binge drinking among sensation-seeking youth who had already started to drink at baseline, with a 50% increase in binge drinking by 6 months in this group.

These measures of alcohol use indicate the natural history of drinking behavior in high-risk groups, Dr. Conrod said. “Youth with these personality risk factors show a rapid escalation in drinking behavior between the ages of 14 and 15, such that by age 15, the majority of high-risk youth are misusing alcohol and binge drinking.”

Students in the intervention group showed a different pattern of alcohol use. By 12 months, they showed no significant changes in their drinking status. There was no significant increase in binge drinking among the intervention groups from baseline to 6 months, although there was a significant increase (8%) from 6 to 12 months, which suggested that the 10% increase in the control group was maintained, while the intervention group experienced a 6-month delay in the onset of bingeing.

When the intervention groups were examined separately, the effect on the sensation-seekers was most pronounced, with a number needed to treat of only two. The program had a significant effect on the negative thinkers at 6 months, but not 12. There were no significant changes at either time for the impulsivity group or the anxiety sensitivity group–perhaps because these groups do not begin their drinking careers quite as early as the other two groups, Dr. Conrod said, “as the previous study with older high-risk adolescents did show improvements in these groups.”

She will continue to follow all the students for 2 years. It would be reasonable to expect the impulsivity and anxiety-sensitivity youth to begin to manifest risk at future follow-up periods, but remains unclear whether the interventions will produce an effect on drinking behavior so far down the road, she said.

“One promising finding is that [a 2006 study] showed the impulsivity and anxiety-sensitivity interventions reduced antisocial behavior and panic anxiety, and each of these symptoms appears to be linked to future drinking behavior,” she said. “Therefore, it is possible that by reducing these groups' primary susceptibility to specific behavioral and emotional problems, the personality-targeted interventions will indirectly prevent alcohol problems in the future.”

The study should be interpreted in the light of findings that rates of adult alcohol dependence can be reduced by 10% for each year that drinking is delayed in adolescence, she said. “An intervention that can stem the natural growth of drinking in early-onset drinkers may prove to be a method of reversing the risk associated with early-onset use, possibly by delaying the onset of heavy drinking until after a crucial period of neurodevelopment when executive functions and reward responding mature.”

The program is extremely cost effective, she added, with a price tag of about $120 to prevent one case of binge drinking over 1 year.

CHICAGO – An intervention that allows at-risk adolescents to explore the strengths and weaknesses of their individual personalities can delay the onset of risky drinking for at least 6 months, possibly decreasing the growth of alcohol use later in the teen years.

Patricia Conrod, Ph.D., developed different programs for each of four personality types who manifest a high risk of early-onset drinking and substance abuse: sensation-seeking, negative thinking, anxiety-sensitivity, and impulsivity. The manualized program, delivered in school and consisting of two 90-minute sessions, was so effective that it prevented early-onset drinking in 50% of the sensation-seeking group and in one of every four of those who participated overall, Dr. Conrod said at the annual meeting of the Research Society for Alcoholism.

“I believe that because each intervention targeted a dominant personality trait for each adolescent, the students experienced the interventions as meaningful and relevant,” Dr. Conrod said in an interview. “They told us that this is the first time that they have ever spoken about their emotions and are considering for the first time the notion that they have personal control over their emotional reactions and behavior.”

Furthermore, she said, the young people found it helpful to learn that others were struggling with similar issues.

Dr. Conrod, a clinical lecturer at the Institute of Psychiatry, King's College London, first developed the program in Canada, where it proved similarly successful in a study of 300 high school students with a mean age of 16 years (J. Clin. Child Adolesc. Psychol. 2006;35:550–63). The current study examined the program's effect in younger students (mean age 14 years).

More than 2,600 students in 13 London high schools completed the Substance Use Risk Profile Scale, which assesses the four dimensions of personality that are linked to different motivations for drug use and misuse. Those who scored more than one standard deviation above the school mean on one of the personality risk subscales were randomized to either the intervention group corresponding with their personality type, or to no intervention except standard drug education.

The final study group comprised 348 students. The intervention groups received the two 90-minute in-school sessions. The manuals contained real-life experiences shared by other high-risk youth of that personality. The first session included goal-setting exercises to explore personality and ways of coping with it; psychoeducational strategies teaching students about their personality and associated problematic coping behaviors; and cognitive-behavioral exercises.

The second session involved discussion of personality-specific cognitive distortions that resulted in problematic behavior. The negative thinking group focused on challenging negative thoughts; the anxiety-sensitivity group explored catastrophic thoughts; the impulsivity group focused on aggressive thinking and acting without thought; and the sensation-seekers examined reward seeking and boredom susceptibility.

The control group received the standard drug education sessions contained in the national curriculum.

All students reported their alcohol use at baseline and at 6 and 12 months. All of the control groups except for the impulsivity group demonstrated an increase in drinking between 6 and 12 months. The sensation-seeking control group demonstrated a sharp increase in drinking by 6 months, which then leveled off. Most notable was the marked increase in binge drinking among sensation-seeking youth who had already started to drink at baseline, with a 50% increase in binge drinking by 6 months in this group.

These measures of alcohol use indicate the natural history of drinking behavior in high-risk groups, Dr. Conrod said. “Youth with these personality risk factors show a rapid escalation in drinking behavior between the ages of 14 and 15, such that by age 15, the majority of high-risk youth are misusing alcohol and binge drinking.”

Students in the intervention group showed a different pattern of alcohol use. By 12 months, they showed no significant changes in their drinking status. There was no significant increase in binge drinking among the intervention groups from baseline to 6 months, although there was a significant increase (8%) from 6 to 12 months, which suggested that the 10% increase in the control group was maintained, while the intervention group experienced a 6-month delay in the onset of bingeing.

When the intervention groups were examined separately, the effect on the sensation-seekers was most pronounced, with a number needed to treat of only two. The program had a significant effect on the negative thinkers at 6 months, but not 12. There were no significant changes at either time for the impulsivity group or the anxiety sensitivity group–perhaps because these groups do not begin their drinking careers quite as early as the other two groups, Dr. Conrod said, “as the previous study with older high-risk adolescents did show improvements in these groups.”

She will continue to follow all the students for 2 years. It would be reasonable to expect the impulsivity and anxiety-sensitivity youth to begin to manifest risk at future follow-up periods, but remains unclear whether the interventions will produce an effect on drinking behavior so far down the road, she said.

“One promising finding is that [a 2006 study] showed the impulsivity and anxiety-sensitivity interventions reduced antisocial behavior and panic anxiety, and each of these symptoms appears to be linked to future drinking behavior,” she said. “Therefore, it is possible that by reducing these groups' primary susceptibility to specific behavioral and emotional problems, the personality-targeted interventions will indirectly prevent alcohol problems in the future.”

The study should be interpreted in the light of findings that rates of adult alcohol dependence can be reduced by 10% for each year that drinking is delayed in adolescence, she said. “An intervention that can stem the natural growth of drinking in early-onset drinkers may prove to be a method of reversing the risk associated with early-onset use, possibly by delaying the onset of heavy drinking until after a crucial period of neurodevelopment when executive functions and reward responding mature.”

The program is extremely cost effective, she added, with a price tag of about $120 to prevent one case of binge drinking over 1 year.

CHICAGO – An intervention that allows at-risk adolescents to explore the strengths and weaknesses of their individual personalities can delay the onset of risky drinking for at least 6 months, possibly decreasing the growth of alcohol use later in the teen years.

Patricia Conrod, Ph.D., developed different programs for each of four personality types who manifest a high risk of early-onset drinking and substance abuse: sensation-seeking, negative thinking, anxiety-sensitivity, and impulsivity. The manualized program, delivered in school and consisting of two 90-minute sessions, was so effective that it prevented early-onset drinking in 50% of the sensation-seeking group and in one of every four of those who participated overall, Dr. Conrod said at the annual meeting of the Research Society for Alcoholism.

“I believe that because each intervention targeted a dominant personality trait for each adolescent, the students experienced the interventions as meaningful and relevant,” Dr. Conrod said in an interview. “They told us that this is the first time that they have ever spoken about their emotions and are considering for the first time the notion that they have personal control over their emotional reactions and behavior.”

Furthermore, she said, the young people found it helpful to learn that others were struggling with similar issues.

Dr. Conrod, a clinical lecturer at the Institute of Psychiatry, King's College London, first developed the program in Canada, where it proved similarly successful in a study of 300 high school students with a mean age of 16 years (J. Clin. Child Adolesc. Psychol. 2006;35:550–63). The current study examined the program's effect in younger students (mean age 14 years).

More than 2,600 students in 13 London high schools completed the Substance Use Risk Profile Scale, which assesses the four dimensions of personality that are linked to different motivations for drug use and misuse. Those who scored more than one standard deviation above the school mean on one of the personality risk subscales were randomized to either the intervention group corresponding with their personality type, or to no intervention except standard drug education.

The final study group comprised 348 students. The intervention groups received the two 90-minute in-school sessions. The manuals contained real-life experiences shared by other high-risk youth of that personality. The first session included goal-setting exercises to explore personality and ways of coping with it; psychoeducational strategies teaching students about their personality and associated problematic coping behaviors; and cognitive-behavioral exercises.

The second session involved discussion of personality-specific cognitive distortions that resulted in problematic behavior. The negative thinking group focused on challenging negative thoughts; the anxiety-sensitivity group explored catastrophic thoughts; the impulsivity group focused on aggressive thinking and acting without thought; and the sensation-seekers examined reward seeking and boredom susceptibility.

The control group received the standard drug education sessions contained in the national curriculum.

All students reported their alcohol use at baseline and at 6 and 12 months. All of the control groups except for the impulsivity group demonstrated an increase in drinking between 6 and 12 months. The sensation-seeking control group demonstrated a sharp increase in drinking by 6 months, which then leveled off. Most notable was the marked increase in binge drinking among sensation-seeking youth who had already started to drink at baseline, with a 50% increase in binge drinking by 6 months in this group.

These measures of alcohol use indicate the natural history of drinking behavior in high-risk groups, Dr. Conrod said. “Youth with these personality risk factors show a rapid escalation in drinking behavior between the ages of 14 and 15, such that by age 15, the majority of high-risk youth are misusing alcohol and binge drinking.”

Students in the intervention group showed a different pattern of alcohol use. By 12 months, they showed no significant changes in their drinking status. There was no significant increase in binge drinking among the intervention groups from baseline to 6 months, although there was a significant increase (8%) from 6 to 12 months, which suggested that the 10% increase in the control group was maintained, while the intervention group experienced a 6-month delay in the onset of bingeing.

When the intervention groups were examined separately, the effect on the sensation-seekers was most pronounced, with a number needed to treat of only two. The program had a significant effect on the negative thinkers at 6 months, but not 12. There were no significant changes at either time for the impulsivity group or the anxiety sensitivity group–perhaps because these groups do not begin their drinking careers quite as early as the other two groups, Dr. Conrod said, “as the previous study with older high-risk adolescents did show improvements in these groups.”

She will continue to follow all the students for 2 years. It would be reasonable to expect the impulsivity and anxiety-sensitivity youth to begin to manifest risk at future follow-up periods, but remains unclear whether the interventions will produce an effect on drinking behavior so far down the road, she said.

“One promising finding is that [a 2006 study] showed the impulsivity and anxiety-sensitivity interventions reduced antisocial behavior and panic anxiety, and each of these symptoms appears to be linked to future drinking behavior,” she said. “Therefore, it is possible that by reducing these groups' primary susceptibility to specific behavioral and emotional problems, the personality-targeted interventions will indirectly prevent alcohol problems in the future.”

The study should be interpreted in the light of findings that rates of adult alcohol dependence can be reduced by 10% for each year that drinking is delayed in adolescence, she said. “An intervention that can stem the natural growth of drinking in early-onset drinkers may prove to be a method of reversing the risk associated with early-onset use, possibly by delaying the onset of heavy drinking until after a crucial period of neurodevelopment when executive functions and reward responding mature.”

The program is extremely cost effective, she added, with a price tag of about $120 to prevent one case of binge drinking over 1 year.