Patrice Wendling

MONTREAL — Chest pain in patients with low coronary calcium scores may serve as a red flag for the presence of obstructive soft or uncalcified coronary atherosclerosis, Dr. John S. Ho said during a poster presentation at the annual meeting of the American Society of Nuclear Cardiology.

Dr. Ho based this conclusion on an analysis of 353 patients who underwent myocardial perfusion imaging (MPI) between 1998 and 2005, and whose calcium score was quantified with electron beam CT as 0–10 Agatston units.

Only 7 (2%) of 353 of patients had an abnormal scan. Despite these small numbers, the investigators were able to show a highly significant association between a history of chest pain and an increased frequency of an ischemic MPI study. Among symptomatic patients, 4% had an abnormal perfusion study, which is more than 10 times the frequency of an abnormal scan in those without chest pain.

Contrary to conventional thinking, the presence of traditional coronary risk factors—such as age, gender, family history of premature coronary heart disease, hyperlipidemia, and diabetes—was not predictive of an abnormal study, said Dr. Ho, a cardiologist with the Cooper Clinic in Dallas.

The absence of significant coronary artery calcification is associated with a low risk of subsequent adverse cardiovascular events, but rare cases of clinically significant ischemic heart disease do occur in individuals with a very low calcium score. Such cases are thought to be the result of a significant burden of soft or uncalcified plaque, predominantly in younger, female individuals, he said.

Overall, 50% of patients in the study had hyperlipidemia, 4.5% had diabetes mellitus, 34% had hypertension, 13% were current smokers, and 67% were overweight. Furthermore, 38% had a family history of heart disease, 30% had an abnormal ECG, and 30% had chest pain. Their mean age was 55 years, and 58% were male.

Some physicians believe that Framingham risk factors explain 90% of atherosclerosis, but Dr. Ho said that clinically, some patients have no risk factors or well-controlled risk factors and still have extensive disease. “Using coronary calcium is a measure of atherosclerosis, and a more direct means with which we can assess risk,” he said.

The protocol at the Cooper Clinic is to utilize calcium scoring for both asymptomatic and symptomatic at-risk patients. In patients with chest pain, the decision to perform nuclear stress testing is based on clinical judgment, Framingham risk scores, and Forester evaluation of chest pain, Dr. Ho said.

'Using coronary calcium is a measure of atherosclerosis, and a more direct means [to] assess risk.' DR. HO

MONTREAL — Chest pain in patients with low coronary calcium scores may serve as a red flag for the presence of obstructive soft or uncalcified coronary atherosclerosis, Dr. John S. Ho said during a poster presentation at the annual meeting of the American Society of Nuclear Cardiology.

Dr. Ho based this conclusion on an analysis of 353 patients who underwent myocardial perfusion imaging (MPI) between 1998 and 2005, and whose calcium score was quantified with electron beam CT as 0–10 Agatston units.

Only 7 (2%) of 353 of patients had an abnormal scan. Despite these small numbers, the investigators were able to show a highly significant association between a history of chest pain and an increased frequency of an ischemic MPI study. Among symptomatic patients, 4% had an abnormal perfusion study, which is more than 10 times the frequency of an abnormal scan in those without chest pain.

Contrary to conventional thinking, the presence of traditional coronary risk factors—such as age, gender, family history of premature coronary heart disease, hyperlipidemia, and diabetes—was not predictive of an abnormal study, said Dr. Ho, a cardiologist with the Cooper Clinic in Dallas.

The absence of significant coronary artery calcification is associated with a low risk of subsequent adverse cardiovascular events, but rare cases of clinically significant ischemic heart disease do occur in individuals with a very low calcium score. Such cases are thought to be the result of a significant burden of soft or uncalcified plaque, predominantly in younger, female individuals, he said.

Overall, 50% of patients in the study had hyperlipidemia, 4.5% had diabetes mellitus, 34% had hypertension, 13% were current smokers, and 67% were overweight. Furthermore, 38% had a family history of heart disease, 30% had an abnormal ECG, and 30% had chest pain. Their mean age was 55 years, and 58% were male.

Some physicians believe that Framingham risk factors explain 90% of atherosclerosis, but Dr. Ho said that clinically, some patients have no risk factors or well-controlled risk factors and still have extensive disease. “Using coronary calcium is a measure of atherosclerosis, and a more direct means with which we can assess risk,” he said.

The protocol at the Cooper Clinic is to utilize calcium scoring for both asymptomatic and symptomatic at-risk patients. In patients with chest pain, the decision to perform nuclear stress testing is based on clinical judgment, Framingham risk scores, and Forester evaluation of chest pain, Dr. Ho said.

'Using coronary calcium is a measure of atherosclerosis, and a more direct means [to] assess risk.' DR. HO

MONTREAL — Chest pain in patients with low coronary calcium scores may serve as a red flag for the presence of obstructive soft or uncalcified coronary atherosclerosis, Dr. John S. Ho said during a poster presentation at the annual meeting of the American Society of Nuclear Cardiology.

Dr. Ho based this conclusion on an analysis of 353 patients who underwent myocardial perfusion imaging (MPI) between 1998 and 2005, and whose calcium score was quantified with electron beam CT as 0–10 Agatston units.

Only 7 (2%) of 353 of patients had an abnormal scan. Despite these small numbers, the investigators were able to show a highly significant association between a history of chest pain and an increased frequency of an ischemic MPI study. Among symptomatic patients, 4% had an abnormal perfusion study, which is more than 10 times the frequency of an abnormal scan in those without chest pain.

Contrary to conventional thinking, the presence of traditional coronary risk factors—such as age, gender, family history of premature coronary heart disease, hyperlipidemia, and diabetes—was not predictive of an abnormal study, said Dr. Ho, a cardiologist with the Cooper Clinic in Dallas.

The absence of significant coronary artery calcification is associated with a low risk of subsequent adverse cardiovascular events, but rare cases of clinically significant ischemic heart disease do occur in individuals with a very low calcium score. Such cases are thought to be the result of a significant burden of soft or uncalcified plaque, predominantly in younger, female individuals, he said.

Overall, 50% of patients in the study had hyperlipidemia, 4.5% had diabetes mellitus, 34% had hypertension, 13% were current smokers, and 67% were overweight. Furthermore, 38% had a family history of heart disease, 30% had an abnormal ECG, and 30% had chest pain. Their mean age was 55 years, and 58% were male.

Some physicians believe that Framingham risk factors explain 90% of atherosclerosis, but Dr. Ho said that clinically, some patients have no risk factors or well-controlled risk factors and still have extensive disease. “Using coronary calcium is a measure of atherosclerosis, and a more direct means with which we can assess risk,” he said.

The protocol at the Cooper Clinic is to utilize calcium scoring for both asymptomatic and symptomatic at-risk patients. In patients with chest pain, the decision to perform nuclear stress testing is based on clinical judgment, Framingham risk scores, and Forester evaluation of chest pain, Dr. Ho said.

'Using coronary calcium is a measure of atherosclerosis, and a more direct means [to] assess risk.' DR. HO

CHICAGO—Milk may be a useful oral contrast agent for computed tomographic imaging of the gastrointestinal tract, and may offer several advantages over standard contrast agents, research has shown.

In a study of 168 adult patients undergoing CT imaging for abdominal discomfort, drinking milk achieved bowel distension and enhancement comparable to that seen after using the negative contrast agent VoLumen (E-Z-EM), Dr. Lisa Shah-Patel and her colleagues reported at the annual meeting of the Radiological Society of North America.

Milk was better tolerated and was less expensive at $1.39 per patient, compared with $18 per patient for VoLumen.

“Milk may be an ideal contrast agent and play a large role for those who refuse to drink traditional contrast agents, such as children,” Dr. Lisa Shah-Patel said at a press briefing during the meeting.

Another advantage is that using milk as a contrast agent may skirt the “almost overwhelming” regulatory compliance issues associated with the Joint Commission on Accreditation of Healthcare Organization's decision that oral CT contrast agents be considered drugs, said Dr. Michael Brant-Zawadzki, chair of the RSNA public information committee.

About 40–50 million CT scans are performed annually in the United States; about 30%–40% are pelvic/abdominal scans.

Although it is less common to use negative contrast agents such as milk or VoLumen, they may be particularly useful in patients with inflammatory bowel disease or infiltrating cancers where it is important to enhance the view of the bowel wall, Dr. Brant-Zawadzki said. Increased blood supply to the bowel wall can't be distinguished from a positive contrast agent, as both appear white on a scan. But with negative contrast agents, the bowel lumen appears dark and the wall appears white.

In the study, patients drank either 1,200 mL of VoLumen or 600–1,000 mL of whole (4%) milk, in two doses.

CT images were evaluated independently by two radiologists who were blinded to the contrast agent used. They evaluated the images for luminal distension of the antrum, duodenum, jejunum, and ileum on a 3-point scale where 1 was minimal distension (1 cm), 2 was good distention (1–2 cm), and 3 was excellent distension (more than 2 cm). All patients were asked to complete a questionnaire regarding their gastrointestinal symptoms.

Among the 62 patients receiving VoLumen, 2 cm distension was seen in the duodenum in 37 cases (60%), in the jejunum in 22 cases (35%), and in the ileum in 47 cases (76%). Among 106 patients receiving milk, 2 cm distension was seen in the duodenum in 84 cases (79%), in the jejunum in 38 cases (36%), and in the ileum in 81 cases (76%).

Antral wall distension exceeded 1 cm in virtually all patients who received VoLumen (100%) and milk (99%). Antral and ileal wall enhancement also were comparable in the VoLumen group (92% antrum, 95% ileum) and the milk group (96% antrum, 94% ileum), the authors found.

Abdominal symptoms such as cramps, flatulence, diarrhea, nausea, and vomiting were reported by 42% of patients who drank VoLumen and 25% of those drinking milk. Of patients who drank VoLumen, 40% reported they would rather drink milk; 85% of patients who drank milk did not object. The objections to consuming milk were primarily related to the volume that patients needed to drink, which was roughly 4.5 cups, she said.

Currently, milk is being used as a contrast agent only in select outpatients in a nonemergency department setting, said Dr. Shah-Patel, a second-year radiology resident at St. Luke's-Roosevelt Hospital in New York City. Whole milk is preferred because of its higher fat content.

CHICAGO—Milk may be a useful oral contrast agent for computed tomographic imaging of the gastrointestinal tract, and may offer several advantages over standard contrast agents, research has shown.

In a study of 168 adult patients undergoing CT imaging for abdominal discomfort, drinking milk achieved bowel distension and enhancement comparable to that seen after using the negative contrast agent VoLumen (E-Z-EM), Dr. Lisa Shah-Patel and her colleagues reported at the annual meeting of the Radiological Society of North America.

Milk was better tolerated and was less expensive at $1.39 per patient, compared with $18 per patient for VoLumen.

“Milk may be an ideal contrast agent and play a large role for those who refuse to drink traditional contrast agents, such as children,” Dr. Lisa Shah-Patel said at a press briefing during the meeting.

Another advantage is that using milk as a contrast agent may skirt the “almost overwhelming” regulatory compliance issues associated with the Joint Commission on Accreditation of Healthcare Organization's decision that oral CT contrast agents be considered drugs, said Dr. Michael Brant-Zawadzki, chair of the RSNA public information committee.

About 40–50 million CT scans are performed annually in the United States; about 30%–40% are pelvic/abdominal scans.

Although it is less common to use negative contrast agents such as milk or VoLumen, they may be particularly useful in patients with inflammatory bowel disease or infiltrating cancers where it is important to enhance the view of the bowel wall, Dr. Brant-Zawadzki said. Increased blood supply to the bowel wall can't be distinguished from a positive contrast agent, as both appear white on a scan. But with negative contrast agents, the bowel lumen appears dark and the wall appears white.

In the study, patients drank either 1,200 mL of VoLumen or 600–1,000 mL of whole (4%) milk, in two doses.

CT images were evaluated independently by two radiologists who were blinded to the contrast agent used. They evaluated the images for luminal distension of the antrum, duodenum, jejunum, and ileum on a 3-point scale where 1 was minimal distension (1 cm), 2 was good distention (1–2 cm), and 3 was excellent distension (more than 2 cm). All patients were asked to complete a questionnaire regarding their gastrointestinal symptoms.

Among the 62 patients receiving VoLumen, 2 cm distension was seen in the duodenum in 37 cases (60%), in the jejunum in 22 cases (35%), and in the ileum in 47 cases (76%). Among 106 patients receiving milk, 2 cm distension was seen in the duodenum in 84 cases (79%), in the jejunum in 38 cases (36%), and in the ileum in 81 cases (76%).

Antral wall distension exceeded 1 cm in virtually all patients who received VoLumen (100%) and milk (99%). Antral and ileal wall enhancement also were comparable in the VoLumen group (92% antrum, 95% ileum) and the milk group (96% antrum, 94% ileum), the authors found.

Abdominal symptoms such as cramps, flatulence, diarrhea, nausea, and vomiting were reported by 42% of patients who drank VoLumen and 25% of those drinking milk. Of patients who drank VoLumen, 40% reported they would rather drink milk; 85% of patients who drank milk did not object. The objections to consuming milk were primarily related to the volume that patients needed to drink, which was roughly 4.5 cups, she said.

Currently, milk is being used as a contrast agent only in select outpatients in a nonemergency department setting, said Dr. Shah-Patel, a second-year radiology resident at St. Luke's-Roosevelt Hospital in New York City. Whole milk is preferred because of its higher fat content.

CHICAGO—Milk may be a useful oral contrast agent for computed tomographic imaging of the gastrointestinal tract, and may offer several advantages over standard contrast agents, research has shown.

In a study of 168 adult patients undergoing CT imaging for abdominal discomfort, drinking milk achieved bowel distension and enhancement comparable to that seen after using the negative contrast agent VoLumen (E-Z-EM), Dr. Lisa Shah-Patel and her colleagues reported at the annual meeting of the Radiological Society of North America.

Milk was better tolerated and was less expensive at $1.39 per patient, compared with $18 per patient for VoLumen.

“Milk may be an ideal contrast agent and play a large role for those who refuse to drink traditional contrast agents, such as children,” Dr. Lisa Shah-Patel said at a press briefing during the meeting.

Another advantage is that using milk as a contrast agent may skirt the “almost overwhelming” regulatory compliance issues associated with the Joint Commission on Accreditation of Healthcare Organization's decision that oral CT contrast agents be considered drugs, said Dr. Michael Brant-Zawadzki, chair of the RSNA public information committee.

About 40–50 million CT scans are performed annually in the United States; about 30%–40% are pelvic/abdominal scans.

Although it is less common to use negative contrast agents such as milk or VoLumen, they may be particularly useful in patients with inflammatory bowel disease or infiltrating cancers where it is important to enhance the view of the bowel wall, Dr. Brant-Zawadzki said. Increased blood supply to the bowel wall can't be distinguished from a positive contrast agent, as both appear white on a scan. But with negative contrast agents, the bowel lumen appears dark and the wall appears white.

In the study, patients drank either 1,200 mL of VoLumen or 600–1,000 mL of whole (4%) milk, in two doses.

CT images were evaluated independently by two radiologists who were blinded to the contrast agent used. They evaluated the images for luminal distension of the antrum, duodenum, jejunum, and ileum on a 3-point scale where 1 was minimal distension (1 cm), 2 was good distention (1–2 cm), and 3 was excellent distension (more than 2 cm). All patients were asked to complete a questionnaire regarding their gastrointestinal symptoms.

Among the 62 patients receiving VoLumen, 2 cm distension was seen in the duodenum in 37 cases (60%), in the jejunum in 22 cases (35%), and in the ileum in 47 cases (76%). Among 106 patients receiving milk, 2 cm distension was seen in the duodenum in 84 cases (79%), in the jejunum in 38 cases (36%), and in the ileum in 81 cases (76%).

Antral wall distension exceeded 1 cm in virtually all patients who received VoLumen (100%) and milk (99%). Antral and ileal wall enhancement also were comparable in the VoLumen group (92% antrum, 95% ileum) and the milk group (96% antrum, 94% ileum), the authors found.

Abdominal symptoms such as cramps, flatulence, diarrhea, nausea, and vomiting were reported by 42% of patients who drank VoLumen and 25% of those drinking milk. Of patients who drank VoLumen, 40% reported they would rather drink milk; 85% of patients who drank milk did not object. The objections to consuming milk were primarily related to the volume that patients needed to drink, which was roughly 4.5 cups, she said.

Currently, milk is being used as a contrast agent only in select outpatients in a nonemergency department setting, said Dr. Shah-Patel, a second-year radiology resident at St. Luke's-Roosevelt Hospital in New York City. Whole milk is preferred because of its higher fat content.

TUCSON, ARIZ.—Patients with a parental history of stroke should be screened early for raised blood pressure, Dr. Nigel Hart said at the annual meeting of the North American Primary Care Research Group.

The recommendation was drawn from Dr. Hart's Stroke Offspring Study in which systolic and diastolic blood pressures were significantly higher in patients with a parental history of stroke, compared with matched controls. Stroke offspring also consumed more alcohol than their paired controls but did not differ significantly in body mass index, lipids, diabetes mellitus, diet, smoking status, or exercise.

“These results suggest higher blood pressure in stroke offspring may contribute to their increased risk of stroke,” said Dr. Hart of Queen's University, in Belfast, Ireland.

Questionnaires were sent to randomly selected individuals, aged 40–64 years, from 11 general practices representing 6% of the population of Northern Ireland. From the returns, those with a parental history of stroke (cases) were matched on age, gender, and socioeconomic status to those with no parental history of stroke (controls).

Matched pairs answered questions about smoking, alcohol, and medical history, and underwent a clinical evaluation. A total of 458 individuals were screened, and complete data were available on 398 individuals or 199 case-control pairs.

Systolic and diastolic blood pressures were significantly higher in cases than in controls (systolic 146.2 mm Hg vs. 140.6 mm Hg and diastolic 87.7 mm Hg vs. 85.0 mm Hg). There were no significant differences between groups in total cholesterol, homosysteine levels, smoking status, or presence of diabetes, they reported.

The only variable that differed statistically between groups was alcohol intake: Cases drank 3.7 more alcohol units per week than controls (13.8 U vs. 10.1 U). A pint of beer is equal to 2 units, while a glass of wine or hard liquor is equal to 1 unit. The mean paired difference in diastolic (2.4 mm Hg) and systolic (5.5 mm Hg) blood pressures was statistically significant between groups even after adjusting for alcohol consumption using a stepwise logistic analysis, he said.

TUCSON, ARIZ.—Patients with a parental history of stroke should be screened early for raised blood pressure, Dr. Nigel Hart said at the annual meeting of the North American Primary Care Research Group.

The recommendation was drawn from Dr. Hart's Stroke Offspring Study in which systolic and diastolic blood pressures were significantly higher in patients with a parental history of stroke, compared with matched controls. Stroke offspring also consumed more alcohol than their paired controls but did not differ significantly in body mass index, lipids, diabetes mellitus, diet, smoking status, or exercise.

“These results suggest higher blood pressure in stroke offspring may contribute to their increased risk of stroke,” said Dr. Hart of Queen's University, in Belfast, Ireland.

Questionnaires were sent to randomly selected individuals, aged 40–64 years, from 11 general practices representing 6% of the population of Northern Ireland. From the returns, those with a parental history of stroke (cases) were matched on age, gender, and socioeconomic status to those with no parental history of stroke (controls).

Matched pairs answered questions about smoking, alcohol, and medical history, and underwent a clinical evaluation. A total of 458 individuals were screened, and complete data were available on 398 individuals or 199 case-control pairs.

Systolic and diastolic blood pressures were significantly higher in cases than in controls (systolic 146.2 mm Hg vs. 140.6 mm Hg and diastolic 87.7 mm Hg vs. 85.0 mm Hg). There were no significant differences between groups in total cholesterol, homosysteine levels, smoking status, or presence of diabetes, they reported.

The only variable that differed statistically between groups was alcohol intake: Cases drank 3.7 more alcohol units per week than controls (13.8 U vs. 10.1 U). A pint of beer is equal to 2 units, while a glass of wine or hard liquor is equal to 1 unit. The mean paired difference in diastolic (2.4 mm Hg) and systolic (5.5 mm Hg) blood pressures was statistically significant between groups even after adjusting for alcohol consumption using a stepwise logistic analysis, he said.

TUCSON, ARIZ.—Patients with a parental history of stroke should be screened early for raised blood pressure, Dr. Nigel Hart said at the annual meeting of the North American Primary Care Research Group.

The recommendation was drawn from Dr. Hart's Stroke Offspring Study in which systolic and diastolic blood pressures were significantly higher in patients with a parental history of stroke, compared with matched controls. Stroke offspring also consumed more alcohol than their paired controls but did not differ significantly in body mass index, lipids, diabetes mellitus, diet, smoking status, or exercise.

“These results suggest higher blood pressure in stroke offspring may contribute to their increased risk of stroke,” said Dr. Hart of Queen's University, in Belfast, Ireland.

Questionnaires were sent to randomly selected individuals, aged 40–64 years, from 11 general practices representing 6% of the population of Northern Ireland. From the returns, those with a parental history of stroke (cases) were matched on age, gender, and socioeconomic status to those with no parental history of stroke (controls).

Matched pairs answered questions about smoking, alcohol, and medical history, and underwent a clinical evaluation. A total of 458 individuals were screened, and complete data were available on 398 individuals or 199 case-control pairs.

Systolic and diastolic blood pressures were significantly higher in cases than in controls (systolic 146.2 mm Hg vs. 140.6 mm Hg and diastolic 87.7 mm Hg vs. 85.0 mm Hg). There were no significant differences between groups in total cholesterol, homosysteine levels, smoking status, or presence of diabetes, they reported.

The only variable that differed statistically between groups was alcohol intake: Cases drank 3.7 more alcohol units per week than controls (13.8 U vs. 10.1 U). A pint of beer is equal to 2 units, while a glass of wine or hard liquor is equal to 1 unit. The mean paired difference in diastolic (2.4 mm Hg) and systolic (5.5 mm Hg) blood pressures was statistically significant between groups even after adjusting for alcohol consumption using a stepwise logistic analysis, he said.

TUCSON, ARIZ.—Physicians are divided over whether it is ethical to use free sample medications in their primary care practices, Nancy Sohler, Ph.D., and Dr. Diane McKee reported at the annual meeting of the North American Primary Care Research Group.

Accepting samples was viewed either as being ethically questionable or as a useful way of helping provide health care to low-income patients, according to findings from a study of 24 family medicine and general internal medicine physicians, nurses, and administrators. The respondents were all in practices affiliated with a large urban medical center serving low- and middle-income patients in New York.

Interactions with pharmaceutical representatives were viewed as a direct conflict of interest, an influence that could be controlled, or a source of useful information that helped keep the practice up to date on new medications. Of the total, 10 respondents felt that they could control the influence of drug firm representatives by keeping them away from residents, by setting limits on what gifts or favors could be accepted, or by always being mindful that representatives are selling a product, Dr. Sohler said in an interview.

For the respondents who drew a hard ethical line, "it was not that they thought giving out samples [to patients] was unethical, but that it wasn't good practice," she said. "They understood why others did it, but they worried about conflicts of interest with their interactions with the reps."

Those who accepted samples said that inadequacies in the health care system forced them to rely on gifts to care for their most needy patients.

All the respondents evaluated marketing practices from the perspective of protecting and serving their patients, said Dr. Sohler, professor of community health and social medicine, City University of New York, New York. None of the respondents was concerned that physicians were ignoring clinical symptoms to prescribe the "right drugs."

The study included in-depth, qualitative interviews and was prompted by an administrative decision at the medical center to ban samples and pharmaceutical representatives from the community practices. That decision left many providers uncertain about how to care for patients without adequate health care coverage.

Others suggested that the policy was changed because the administration at the medical center didn't want physicians taking the time to talk to sales representatives, didn't trust that staff would avoid entering into agreements with pharmaceutical firms, and did want a single policy, because teaching sites had a "no-rep" policy and other sites didn't need samples.

Dr. Sohler asserted that further study would be needed to determine whether samples help poor patients more than they harm them, and to assess whether pharmaceutical company representatives influence prescribing practices in mostly helpful or harmful ways.

"The empirical, quantitative evidence isn't good on whether free medications help or harm our patients," she said. "We realize that all marketing has an influence, but we don't know if it harms our patients.

"People are drawing on their different values and perspectives to make a decision," Dr. Sohler concluded. "We need hard evidence to make a policy, but in the meantime, we should keep these perspectives in mind as the data come in."

TUCSON, ARIZ.—Physicians are divided over whether it is ethical to use free sample medications in their primary care practices, Nancy Sohler, Ph.D., and Dr. Diane McKee reported at the annual meeting of the North American Primary Care Research Group.

Accepting samples was viewed either as being ethically questionable or as a useful way of helping provide health care to low-income patients, according to findings from a study of 24 family medicine and general internal medicine physicians, nurses, and administrators. The respondents were all in practices affiliated with a large urban medical center serving low- and middle-income patients in New York.

Interactions with pharmaceutical representatives were viewed as a direct conflict of interest, an influence that could be controlled, or a source of useful information that helped keep the practice up to date on new medications. Of the total, 10 respondents felt that they could control the influence of drug firm representatives by keeping them away from residents, by setting limits on what gifts or favors could be accepted, or by always being mindful that representatives are selling a product, Dr. Sohler said in an interview.

For the respondents who drew a hard ethical line, "it was not that they thought giving out samples [to patients] was unethical, but that it wasn't good practice," she said. "They understood why others did it, but they worried about conflicts of interest with their interactions with the reps."

Those who accepted samples said that inadequacies in the health care system forced them to rely on gifts to care for their most needy patients.

All the respondents evaluated marketing practices from the perspective of protecting and serving their patients, said Dr. Sohler, professor of community health and social medicine, City University of New York, New York. None of the respondents was concerned that physicians were ignoring clinical symptoms to prescribe the "right drugs."

The study included in-depth, qualitative interviews and was prompted by an administrative decision at the medical center to ban samples and pharmaceutical representatives from the community practices. That decision left many providers uncertain about how to care for patients without adequate health care coverage.

Others suggested that the policy was changed because the administration at the medical center didn't want physicians taking the time to talk to sales representatives, didn't trust that staff would avoid entering into agreements with pharmaceutical firms, and did want a single policy, because teaching sites had a "no-rep" policy and other sites didn't need samples.

Dr. Sohler asserted that further study would be needed to determine whether samples help poor patients more than they harm them, and to assess whether pharmaceutical company representatives influence prescribing practices in mostly helpful or harmful ways.

"The empirical, quantitative evidence isn't good on whether free medications help or harm our patients," she said. "We realize that all marketing has an influence, but we don't know if it harms our patients.

"People are drawing on their different values and perspectives to make a decision," Dr. Sohler concluded. "We need hard evidence to make a policy, but in the meantime, we should keep these perspectives in mind as the data come in."

TUCSON, ARIZ.—Physicians are divided over whether it is ethical to use free sample medications in their primary care practices, Nancy Sohler, Ph.D., and Dr. Diane McKee reported at the annual meeting of the North American Primary Care Research Group.

Accepting samples was viewed either as being ethically questionable or as a useful way of helping provide health care to low-income patients, according to findings from a study of 24 family medicine and general internal medicine physicians, nurses, and administrators. The respondents were all in practices affiliated with a large urban medical center serving low- and middle-income patients in New York.

Interactions with pharmaceutical representatives were viewed as a direct conflict of interest, an influence that could be controlled, or a source of useful information that helped keep the practice up to date on new medications. Of the total, 10 respondents felt that they could control the influence of drug firm representatives by keeping them away from residents, by setting limits on what gifts or favors could be accepted, or by always being mindful that representatives are selling a product, Dr. Sohler said in an interview.

For the respondents who drew a hard ethical line, "it was not that they thought giving out samples [to patients] was unethical, but that it wasn't good practice," she said. "They understood why others did it, but they worried about conflicts of interest with their interactions with the reps."

Those who accepted samples said that inadequacies in the health care system forced them to rely on gifts to care for their most needy patients.

All the respondents evaluated marketing practices from the perspective of protecting and serving their patients, said Dr. Sohler, professor of community health and social medicine, City University of New York, New York. None of the respondents was concerned that physicians were ignoring clinical symptoms to prescribe the "right drugs."

The study included in-depth, qualitative interviews and was prompted by an administrative decision at the medical center to ban samples and pharmaceutical representatives from the community practices. That decision left many providers uncertain about how to care for patients without adequate health care coverage.

Others suggested that the policy was changed because the administration at the medical center didn't want physicians taking the time to talk to sales representatives, didn't trust that staff would avoid entering into agreements with pharmaceutical firms, and did want a single policy, because teaching sites had a "no-rep" policy and other sites didn't need samples.

Dr. Sohler asserted that further study would be needed to determine whether samples help poor patients more than they harm them, and to assess whether pharmaceutical company representatives influence prescribing practices in mostly helpful or harmful ways.

"The empirical, quantitative evidence isn't good on whether free medications help or harm our patients," she said. "We realize that all marketing has an influence, but we don't know if it harms our patients.

"People are drawing on their different values and perspectives to make a decision," Dr. Sohler concluded. "We need hard evidence to make a policy, but in the meantime, we should keep these perspectives in mind as the data come in."

TUCSON, ARIZ.—Physicians and their patients seldom discuss the costs of new medications and other acquisition issues during office visits, Dr. Derjung Mimi Tarn and associates reported in a poster presentation at the annual meeting of the North American Primary Care Research Group.

The investigators audiotaped the clinic visits of 185 patients who were receiving 243 new medication prescriptions. The researchers found that discussions about cost occurred in only 28 of the encounters. Patients rarely initiated conversations about cost, doing so for only four new prescriptions.

Physicians talked about cost or insurance for 12% of the 243 prescriptions, mentioned whether the medication was generic or brand name for only 2% of the prescriptions, talked about how to obtain the medication for 19%, about how long the supply would last for 9%, and about refills for 5%.

The analysis was based on the taped clinic visits that were conducted in 1999 at the University of California's Davis Medical Group and Kaiser Permanente, both in Sacramento, Calif., as part of the Physician Patient Communication Project. The project included 15 family physicians, 18 internists, and 11 cardiologists. The patients' mean age was 55 years, 83% were Caucasian, and more than 75% paid less than half of prescription drug costs. Overall, 31% were seen by family physicians, 47% by internists, and 23% by cardiologists (percentages do not total 100 because of rounding).

As patient age increased, the chances of physicians discussing cost decreased, according to a multivariate analysis that adjusted for medication class, over-the-counter and as-needed medication status, patient gender and race, prescription drug coverage, number of continued medications, and number of new medications prescribed.

One possible explanation for that finding may be that time constraints and multiple health concerns were a factor, Dr. Tarn said in an interview.

Patients with a yearly income of less than $20,000 had significantly more conversations about medication costs than did those with an annual income of $40,000–$60,000 (odds ratio 8.27 vs. 0.29, respectively).

Family physicians (OR 0.003) and internal medicine physicians (OR 0.02) were less likely to discuss cost than were cardiologists. The investigators suggested that cardiologists may encounter more patients with chronic conditions and thus are more aware of cost issues, or perhaps that in this setting, they were prescribing more brand name or expensive medications and have had more problems with insurers not covering these drugs, said Dr. Tarn, department of family medicine, David Geffen School of Medicine, University of California, Los Angeles.

The results don't necessarily mean that primary care physicians are really doing that much worse, as the study did not evaluate previous interactions. It may be that primary care physicians have been seeing these patients for years, have a much closer relationship, and have had these types of discussions with their patients in previous visits, she said.

Other study results have also shown that physicians and patients seldom discuss cost because they are uncomfortable about raising the subject. However, both parties need to be more aware of the issue, because high medication costs are strongly associated with medication underutilization and noncompliance, she said.

"Patients really shouldn't be scared to ask if there are cost issues" or to ask if it's the cheapest medication available, Dr. Tarn said.

"On the flip side, previous studies have shown that doctors aren't very good at recognizing whether patients are having trouble with costs. A simple exchange can bring out a lot of concerns with patients."

TUCSON, ARIZ.—Physicians and their patients seldom discuss the costs of new medications and other acquisition issues during office visits, Dr. Derjung Mimi Tarn and associates reported in a poster presentation at the annual meeting of the North American Primary Care Research Group.

The investigators audiotaped the clinic visits of 185 patients who were receiving 243 new medication prescriptions. The researchers found that discussions about cost occurred in only 28 of the encounters. Patients rarely initiated conversations about cost, doing so for only four new prescriptions.

Physicians talked about cost or insurance for 12% of the 243 prescriptions, mentioned whether the medication was generic or brand name for only 2% of the prescriptions, talked about how to obtain the medication for 19%, about how long the supply would last for 9%, and about refills for 5%.

The analysis was based on the taped clinic visits that were conducted in 1999 at the University of California's Davis Medical Group and Kaiser Permanente, both in Sacramento, Calif., as part of the Physician Patient Communication Project. The project included 15 family physicians, 18 internists, and 11 cardiologists. The patients' mean age was 55 years, 83% were Caucasian, and more than 75% paid less than half of prescription drug costs. Overall, 31% were seen by family physicians, 47% by internists, and 23% by cardiologists (percentages do not total 100 because of rounding).

As patient age increased, the chances of physicians discussing cost decreased, according to a multivariate analysis that adjusted for medication class, over-the-counter and as-needed medication status, patient gender and race, prescription drug coverage, number of continued medications, and number of new medications prescribed.

One possible explanation for that finding may be that time constraints and multiple health concerns were a factor, Dr. Tarn said in an interview.

Patients with a yearly income of less than $20,000 had significantly more conversations about medication costs than did those with an annual income of $40,000–$60,000 (odds ratio 8.27 vs. 0.29, respectively).

Family physicians (OR 0.003) and internal medicine physicians (OR 0.02) were less likely to discuss cost than were cardiologists. The investigators suggested that cardiologists may encounter more patients with chronic conditions and thus are more aware of cost issues, or perhaps that in this setting, they were prescribing more brand name or expensive medications and have had more problems with insurers not covering these drugs, said Dr. Tarn, department of family medicine, David Geffen School of Medicine, University of California, Los Angeles.

The results don't necessarily mean that primary care physicians are really doing that much worse, as the study did not evaluate previous interactions. It may be that primary care physicians have been seeing these patients for years, have a much closer relationship, and have had these types of discussions with their patients in previous visits, she said.

Other study results have also shown that physicians and patients seldom discuss cost because they are uncomfortable about raising the subject. However, both parties need to be more aware of the issue, because high medication costs are strongly associated with medication underutilization and noncompliance, she said.

"Patients really shouldn't be scared to ask if there are cost issues" or to ask if it's the cheapest medication available, Dr. Tarn said.

"On the flip side, previous studies have shown that doctors aren't very good at recognizing whether patients are having trouble with costs. A simple exchange can bring out a lot of concerns with patients."

TUCSON, ARIZ.—Physicians and their patients seldom discuss the costs of new medications and other acquisition issues during office visits, Dr. Derjung Mimi Tarn and associates reported in a poster presentation at the annual meeting of the North American Primary Care Research Group.

The investigators audiotaped the clinic visits of 185 patients who were receiving 243 new medication prescriptions. The researchers found that discussions about cost occurred in only 28 of the encounters. Patients rarely initiated conversations about cost, doing so for only four new prescriptions.

Physicians talked about cost or insurance for 12% of the 243 prescriptions, mentioned whether the medication was generic or brand name for only 2% of the prescriptions, talked about how to obtain the medication for 19%, about how long the supply would last for 9%, and about refills for 5%.

The analysis was based on the taped clinic visits that were conducted in 1999 at the University of California's Davis Medical Group and Kaiser Permanente, both in Sacramento, Calif., as part of the Physician Patient Communication Project. The project included 15 family physicians, 18 internists, and 11 cardiologists. The patients' mean age was 55 years, 83% were Caucasian, and more than 75% paid less than half of prescription drug costs. Overall, 31% were seen by family physicians, 47% by internists, and 23% by cardiologists (percentages do not total 100 because of rounding).

As patient age increased, the chances of physicians discussing cost decreased, according to a multivariate analysis that adjusted for medication class, over-the-counter and as-needed medication status, patient gender and race, prescription drug coverage, number of continued medications, and number of new medications prescribed.

One possible explanation for that finding may be that time constraints and multiple health concerns were a factor, Dr. Tarn said in an interview.

Patients with a yearly income of less than $20,000 had significantly more conversations about medication costs than did those with an annual income of $40,000–$60,000 (odds ratio 8.27 vs. 0.29, respectively).

Family physicians (OR 0.003) and internal medicine physicians (OR 0.02) were less likely to discuss cost than were cardiologists. The investigators suggested that cardiologists may encounter more patients with chronic conditions and thus are more aware of cost issues, or perhaps that in this setting, they were prescribing more brand name or expensive medications and have had more problems with insurers not covering these drugs, said Dr. Tarn, department of family medicine, David Geffen School of Medicine, University of California, Los Angeles.

The results don't necessarily mean that primary care physicians are really doing that much worse, as the study did not evaluate previous interactions. It may be that primary care physicians have been seeing these patients for years, have a much closer relationship, and have had these types of discussions with their patients in previous visits, she said.

Other study results have also shown that physicians and patients seldom discuss cost because they are uncomfortable about raising the subject. However, both parties need to be more aware of the issue, because high medication costs are strongly associated with medication underutilization and noncompliance, she said.

"Patients really shouldn't be scared to ask if there are cost issues" or to ask if it's the cheapest medication available, Dr. Tarn said.

"On the flip side, previous studies have shown that doctors aren't very good at recognizing whether patients are having trouble with costs. A simple exchange can bring out a lot of concerns with patients."

TUCSON, ARIZ. — There are 1.2 million previously unidentified normal-weight adolescents nationally who may be at increased risk of insulin resistance, Dr. Ann Rodden, said at the annual meeting of the North American Primary Care Research Group.

Adolescents with a body mass index (BMI) in the 75th to 84.9th percentile and those who have low levels of physical activity were at increased risk for insulin resistance, according to data obtained in a secondary analysis of the National Health and Nutrition Examination Survey (NHANES) during 1999–2002.

Prevalence estimates suggest that more than 8.5 million American adolescents have insulin resistance. Of these, more than 1.2 million are in the 75th to 84.9th BMI percentile. The American Diabetes Association considers adolescents with a BMI at or above the 85th percentile to be at risk for insulin resistance, said Dr. Rodden, department of family medicine, Medical University of South Carolina, Charleston.

“There is a population of adolescents that right now we do not consider to be at risk of insulin resistance and that we should be looking at in addition to those already identified,” she said.

The analysis was based on a nationally representative sample of 1,806 nondiabetic, nonpregnant adolescents aged 12–19 years who were participating in the NHANES study. Insulin resistance was calculated using the Homeostasis Model Assessment (HOMA) method, with a value of more than 3.16 used as the cutoff for insulin resistance.

Of these, 581 adolescents had insulin resistance, representing 30,855,840 adolescents in the U.S. population. Their mean age was 15 years. Overall, 28% of all females and 27% of all males who were evaluated had insulin resistance. Among individual ethnic groups, whites were less likely to have insulin resistance (28.2%) than were blacks (34.9%) or Hispanics (34.5%). Among those who reported physical activity levels of less than an hour a week of heavy activity, 38% had insulin resistance.

Only 9.2% of those in the under-50th BMI percentile and 13.3% in the 50th to 74.9th percentile had insulin resistance. Of note was that about one-third (33.8%) of normal-weight adolescents in the 75th to 84.9th BMI percentile had insulin resistance, as did 37.8% in the 85th to 94.9th percentile and 72.8% in the 95th or higher BMI percentile, Dr Rodden reported.

With a logistic regression analysis adjusting for age, ethnicity, gender, poverty income ratio, and carbohydrate intake, the odds of developing insulin resistance were four times higher for adolescents in the 75th to 84.9th percentile (odds ratio 4.28) and the 85th to 94.9th percentile (OR 4.30), and nearly 18 times higher for overweight adolescents in the 95th or higher percentile (OR 17.91). The risk was not significantly increased for adolescents in the two lowest BMI percentiles.

Being less active was also significantly associated with increased risk of insulin resistance, particularly among those with less than an hour a week of heavy activity (OR 4.38). But cardiovascular fitness level was not. This finding suggests that physical activity may have metabolic benefits irrespective of the level of fitness achieved, Dr. Rodden said.

The study was limited by the lack of a universally accepted definition for insulin resistance in adolescents, and self-reported physical activity data.

TUCSON, ARIZ. — There are 1.2 million previously unidentified normal-weight adolescents nationally who may be at increased risk of insulin resistance, Dr. Ann Rodden, said at the annual meeting of the North American Primary Care Research Group.

Adolescents with a body mass index (BMI) in the 75th to 84.9th percentile and those who have low levels of physical activity were at increased risk for insulin resistance, according to data obtained in a secondary analysis of the National Health and Nutrition Examination Survey (NHANES) during 1999–2002.

Prevalence estimates suggest that more than 8.5 million American adolescents have insulin resistance. Of these, more than 1.2 million are in the 75th to 84.9th BMI percentile. The American Diabetes Association considers adolescents with a BMI at or above the 85th percentile to be at risk for insulin resistance, said Dr. Rodden, department of family medicine, Medical University of South Carolina, Charleston.

“There is a population of adolescents that right now we do not consider to be at risk of insulin resistance and that we should be looking at in addition to those already identified,” she said.

The analysis was based on a nationally representative sample of 1,806 nondiabetic, nonpregnant adolescents aged 12–19 years who were participating in the NHANES study. Insulin resistance was calculated using the Homeostasis Model Assessment (HOMA) method, with a value of more than 3.16 used as the cutoff for insulin resistance.

Of these, 581 adolescents had insulin resistance, representing 30,855,840 adolescents in the U.S. population. Their mean age was 15 years. Overall, 28% of all females and 27% of all males who were evaluated had insulin resistance. Among individual ethnic groups, whites were less likely to have insulin resistance (28.2%) than were blacks (34.9%) or Hispanics (34.5%). Among those who reported physical activity levels of less than an hour a week of heavy activity, 38% had insulin resistance.

Only 9.2% of those in the under-50th BMI percentile and 13.3% in the 50th to 74.9th percentile had insulin resistance. Of note was that about one-third (33.8%) of normal-weight adolescents in the 75th to 84.9th BMI percentile had insulin resistance, as did 37.8% in the 85th to 94.9th percentile and 72.8% in the 95th or higher BMI percentile, Dr Rodden reported.

With a logistic regression analysis adjusting for age, ethnicity, gender, poverty income ratio, and carbohydrate intake, the odds of developing insulin resistance were four times higher for adolescents in the 75th to 84.9th percentile (odds ratio 4.28) and the 85th to 94.9th percentile (OR 4.30), and nearly 18 times higher for overweight adolescents in the 95th or higher percentile (OR 17.91). The risk was not significantly increased for adolescents in the two lowest BMI percentiles.

Being less active was also significantly associated with increased risk of insulin resistance, particularly among those with less than an hour a week of heavy activity (OR 4.38). But cardiovascular fitness level was not. This finding suggests that physical activity may have metabolic benefits irrespective of the level of fitness achieved, Dr. Rodden said.

The study was limited by the lack of a universally accepted definition for insulin resistance in adolescents, and self-reported physical activity data.

TUCSON, ARIZ. — There are 1.2 million previously unidentified normal-weight adolescents nationally who may be at increased risk of insulin resistance, Dr. Ann Rodden, said at the annual meeting of the North American Primary Care Research Group.

Adolescents with a body mass index (BMI) in the 75th to 84.9th percentile and those who have low levels of physical activity were at increased risk for insulin resistance, according to data obtained in a secondary analysis of the National Health and Nutrition Examination Survey (NHANES) during 1999–2002.

Prevalence estimates suggest that more than 8.5 million American adolescents have insulin resistance. Of these, more than 1.2 million are in the 75th to 84.9th BMI percentile. The American Diabetes Association considers adolescents with a BMI at or above the 85th percentile to be at risk for insulin resistance, said Dr. Rodden, department of family medicine, Medical University of South Carolina, Charleston.

“There is a population of adolescents that right now we do not consider to be at risk of insulin resistance and that we should be looking at in addition to those already identified,” she said.

The analysis was based on a nationally representative sample of 1,806 nondiabetic, nonpregnant adolescents aged 12–19 years who were participating in the NHANES study. Insulin resistance was calculated using the Homeostasis Model Assessment (HOMA) method, with a value of more than 3.16 used as the cutoff for insulin resistance.

Of these, 581 adolescents had insulin resistance, representing 30,855,840 adolescents in the U.S. population. Their mean age was 15 years. Overall, 28% of all females and 27% of all males who were evaluated had insulin resistance. Among individual ethnic groups, whites were less likely to have insulin resistance (28.2%) than were blacks (34.9%) or Hispanics (34.5%). Among those who reported physical activity levels of less than an hour a week of heavy activity, 38% had insulin resistance.

Only 9.2% of those in the under-50th BMI percentile and 13.3% in the 50th to 74.9th percentile had insulin resistance. Of note was that about one-third (33.8%) of normal-weight adolescents in the 75th to 84.9th BMI percentile had insulin resistance, as did 37.8% in the 85th to 94.9th percentile and 72.8% in the 95th or higher BMI percentile, Dr Rodden reported.

With a logistic regression analysis adjusting for age, ethnicity, gender, poverty income ratio, and carbohydrate intake, the odds of developing insulin resistance were four times higher for adolescents in the 75th to 84.9th percentile (odds ratio 4.28) and the 85th to 94.9th percentile (OR 4.30), and nearly 18 times higher for overweight adolescents in the 95th or higher percentile (OR 17.91). The risk was not significantly increased for adolescents in the two lowest BMI percentiles.

Being less active was also significantly associated with increased risk of insulin resistance, particularly among those with less than an hour a week of heavy activity (OR 4.38). But cardiovascular fitness level was not. This finding suggests that physical activity may have metabolic benefits irrespective of the level of fitness achieved, Dr. Rodden said.

The study was limited by the lack of a universally accepted definition for insulin resistance in adolescents, and self-reported physical activity data.

TUCSON, ARIZ. — Providing physicians with semiannual or quarterly feedback on their ability to manage their patients' glycemic control, as reflected by hemoglobin A_1c levels, could improve suboptimal diabetes care in primary care settings, Dr. Yar Pye and colleagues reported in a poster at the annual meeting of the North American Primary Care Research Group.

Dr. Pye reported on data from a 30-month observational study in which physicians received feedback regularly with regard to their patients' average hemoglobin A_1c values, the percentage of patients with data on HbA_1c for the last 6 months, and the percentage of patients with controlled and uncontrolled diabetes. The physicians also were informed about the average HbA_1c level for the whole clinic and their peers, Dr. Pye said in an interview. Patients were not given the information.

There were 360 nonpregnant diabetic patients, aged 27–89 years, being seen at the Lutheran Family Medical Center in Brooklyn, N.Y., where Dr. Pye practices. Two-thirds were female; the median age was 61 years.

Performance profiles were sent once in 2004, twice in 2005, and quarterly in 2006 until June 2006. Patients who did not have an HbA_1c value for the previous 6 months or who had uncontrolled diabetes, defined as a HbA_1c of more than 9.5%, were telephoned by staff or notified by mail for retesting and further treatment.

The average HbA_1c level decreased from 8.3% in December 2004 to 7.7% in June 2006, the authors wrote. During the same time period, the percentage of diabetic patients with a known HbA_1c increased from 75% to 83%, while the percentage of patients with uncontrolled diabetes decreased from 23% to 16%.

HbA_1c, which is not subject to the fluctuations seen with daily blood glucose monitoring, is being used increasingly as a target in glycemic control. In 2006, New York City took an unprecedented step when it mandated that all laboratories report HbA_1c test results directly to the New York City Department of Health.

The Canadian Institute for Health Information recently introduced semiannual tracking of HbA_1c as one of 105 primary health care indicators, Dr. Pye said. The American Diabetes Association recommends that HbA_1c be measured in patients with diabetes at least twice yearly.

TUCSON, ARIZ. — Providing physicians with semiannual or quarterly feedback on their ability to manage their patients' glycemic control, as reflected by hemoglobin A_1c levels, could improve suboptimal diabetes care in primary care settings, Dr. Yar Pye and colleagues reported in a poster at the annual meeting of the North American Primary Care Research Group.

Dr. Pye reported on data from a 30-month observational study in which physicians received feedback regularly with regard to their patients' average hemoglobin A_1c values, the percentage of patients with data on HbA_1c for the last 6 months, and the percentage of patients with controlled and uncontrolled diabetes. The physicians also were informed about the average HbA_1c level for the whole clinic and their peers, Dr. Pye said in an interview. Patients were not given the information.

There were 360 nonpregnant diabetic patients, aged 27–89 years, being seen at the Lutheran Family Medical Center in Brooklyn, N.Y., where Dr. Pye practices. Two-thirds were female; the median age was 61 years.

Performance profiles were sent once in 2004, twice in 2005, and quarterly in 2006 until June 2006. Patients who did not have an HbA_1c value for the previous 6 months or who had uncontrolled diabetes, defined as a HbA_1c of more than 9.5%, were telephoned by staff or notified by mail for retesting and further treatment.

The average HbA_1c level decreased from 8.3% in December 2004 to 7.7% in June 2006, the authors wrote. During the same time period, the percentage of diabetic patients with a known HbA_1c increased from 75% to 83%, while the percentage of patients with uncontrolled diabetes decreased from 23% to 16%.

HbA_1c, which is not subject to the fluctuations seen with daily blood glucose monitoring, is being used increasingly as a target in glycemic control. In 2006, New York City took an unprecedented step when it mandated that all laboratories report HbA_1c test results directly to the New York City Department of Health.

The Canadian Institute for Health Information recently introduced semiannual tracking of HbA_1c as one of 105 primary health care indicators, Dr. Pye said. The American Diabetes Association recommends that HbA_1c be measured in patients with diabetes at least twice yearly.

TUCSON, ARIZ. — Providing physicians with semiannual or quarterly feedback on their ability to manage their patients' glycemic control, as reflected by hemoglobin A_1c levels, could improve suboptimal diabetes care in primary care settings, Dr. Yar Pye and colleagues reported in a poster at the annual meeting of the North American Primary Care Research Group.

Dr. Pye reported on data from a 30-month observational study in which physicians received feedback regularly with regard to their patients' average hemoglobin A_1c values, the percentage of patients with data on HbA_1c for the last 6 months, and the percentage of patients with controlled and uncontrolled diabetes. The physicians also were informed about the average HbA_1c level for the whole clinic and their peers, Dr. Pye said in an interview. Patients were not given the information.

There were 360 nonpregnant diabetic patients, aged 27–89 years, being seen at the Lutheran Family Medical Center in Brooklyn, N.Y., where Dr. Pye practices. Two-thirds were female; the median age was 61 years.

Performance profiles were sent once in 2004, twice in 2005, and quarterly in 2006 until June 2006. Patients who did not have an HbA_1c value for the previous 6 months or who had uncontrolled diabetes, defined as a HbA_1c of more than 9.5%, were telephoned by staff or notified by mail for retesting and further treatment.

The average HbA_1c level decreased from 8.3% in December 2004 to 7.7% in June 2006, the authors wrote. During the same time period, the percentage of diabetic patients with a known HbA_1c increased from 75% to 83%, while the percentage of patients with uncontrolled diabetes decreased from 23% to 16%.

HbA_1c, which is not subject to the fluctuations seen with daily blood glucose monitoring, is being used increasingly as a target in glycemic control. In 2006, New York City took an unprecedented step when it mandated that all laboratories report HbA_1c test results directly to the New York City Department of Health.

The Canadian Institute for Health Information recently introduced semiannual tracking of HbA_1c as one of 105 primary health care indicators, Dr. Pye said. The American Diabetes Association recommends that HbA_1c be measured in patients with diabetes at least twice yearly.

TUCSON, ARIZ. — Physicians are divided over whether it is ethical to use free sample medications in their primary care practices, Nancy Sohler, Ph.D., and Dr. Diane McKee reported at the annual meeting of the North American Primary Care Research Group.

Accepting samples was viewed either as being ethically questionable or as a useful way of helping provide health care to low-income patients, according to findings from a study of 24 family medicine and general internal medicine physicians, nurses, and administrators in practices affiliated with a large urban medical center serving low- and middle-income patients in New York.

Interactions with pharmaceutical representatives were viewed as a direct conflict of interest, an influence that could be controlled, or a source of useful information that helped keep the practice up to date on new medications. Of the total, 10 respondents felt that they could control the influence of drug firm representatives by keeping them away from residents, by setting limits on what gifts or favors could be accepted, or by always being mindful that representatives are selling a product, Dr. Sohler said in an interview.

For the respondents who drew a hard ethical line, “it wasn't that they thought giving out samples [to patients] was unethical, but that it wasn't good practice,” she said. “They understood why others did it, but they worried about conflicts of interest with their interactions with the reps.”

Those who accepted samples said inadequacies in the health care system forced them to rely on gifts to care for their most needy patients.

All of the respondents evaluated marketing practices from the perspective of protecting and serving their patients, said Dr. Sohler, professor of community health and social medicine, City University of New York (N.Y.). None of the respondents expressed concern that physicians were ignoring clinical symptoms to prescribe the “right drugs.”

The study included in-depth, qualitative interviews and was prompted by an administrative decision at the medical center to ban samples and pharmaceutical representatives from the community practices. That decision left many providers uncertain about how to care for patients without adequate health care coverage.

Others suggested that the policy was changed because the administration didn't want physicians taking the time to talk to sales representatives, didn't trust that staff would avoid entering into agreements with pharmaceutical firms, and did want a single policy, because teaching sites had a “no-rep” policy and other sites didn't need samples.

Dr. Sohler said further study would be needed to determine whether samples help poor patients more than they harm them, and whether representatives influence prescribing practices in mostly helpful or harmful ways.

“The empirical, quantitative evidence isn't good on whether free medications help or harm our patients,” Dr. Sohler said. “We realize that all marketing has an influence, but we don't know if it harms our patients.

“People are drawing on their different values and perspectives to make a decision. We need hard evidence to make a policy, but in the meantime, we should keep these perspectives in mind as the data come in.”

TUCSON, ARIZ. — Physicians are divided over whether it is ethical to use free sample medications in their primary care practices, Nancy Sohler, Ph.D., and Dr. Diane McKee reported at the annual meeting of the North American Primary Care Research Group.

Accepting samples was viewed either as being ethically questionable or as a useful way of helping provide health care to low-income patients, according to findings from a study of 24 family medicine and general internal medicine physicians, nurses, and administrators in practices affiliated with a large urban medical center serving low- and middle-income patients in New York.

Interactions with pharmaceutical representatives were viewed as a direct conflict of interest, an influence that could be controlled, or a source of useful information that helped keep the practice up to date on new medications. Of the total, 10 respondents felt that they could control the influence of drug firm representatives by keeping them away from residents, by setting limits on what gifts or favors could be accepted, or by always being mindful that representatives are selling a product, Dr. Sohler said in an interview.

For the respondents who drew a hard ethical line, “it wasn't that they thought giving out samples [to patients] was unethical, but that it wasn't good practice,” she said. “They understood why others did it, but they worried about conflicts of interest with their interactions with the reps.”

Those who accepted samples said inadequacies in the health care system forced them to rely on gifts to care for their most needy patients.

All of the respondents evaluated marketing practices from the perspective of protecting and serving their patients, said Dr. Sohler, professor of community health and social medicine, City University of New York (N.Y.). None of the respondents expressed concern that physicians were ignoring clinical symptoms to prescribe the “right drugs.”

The study included in-depth, qualitative interviews and was prompted by an administrative decision at the medical center to ban samples and pharmaceutical representatives from the community practices. That decision left many providers uncertain about how to care for patients without adequate health care coverage.

Others suggested that the policy was changed because the administration didn't want physicians taking the time to talk to sales representatives, didn't trust that staff would avoid entering into agreements with pharmaceutical firms, and did want a single policy, because teaching sites had a “no-rep” policy and other sites didn't need samples.

Dr. Sohler said further study would be needed to determine whether samples help poor patients more than they harm them, and whether representatives influence prescribing practices in mostly helpful or harmful ways.

“The empirical, quantitative evidence isn't good on whether free medications help or harm our patients,” Dr. Sohler said. “We realize that all marketing has an influence, but we don't know if it harms our patients.

“People are drawing on their different values and perspectives to make a decision. We need hard evidence to make a policy, but in the meantime, we should keep these perspectives in mind as the data come in.”

TUCSON, ARIZ. — Physicians are divided over whether it is ethical to use free sample medications in their primary care practices, Nancy Sohler, Ph.D., and Dr. Diane McKee reported at the annual meeting of the North American Primary Care Research Group.

Accepting samples was viewed either as being ethically questionable or as a useful way of helping provide health care to low-income patients, according to findings from a study of 24 family medicine and general internal medicine physicians, nurses, and administrators in practices affiliated with a large urban medical center serving low- and middle-income patients in New York.

Interactions with pharmaceutical representatives were viewed as a direct conflict of interest, an influence that could be controlled, or a source of useful information that helped keep the practice up to date on new medications. Of the total, 10 respondents felt that they could control the influence of drug firm representatives by keeping them away from residents, by setting limits on what gifts or favors could be accepted, or by always being mindful that representatives are selling a product, Dr. Sohler said in an interview.

For the respondents who drew a hard ethical line, “it wasn't that they thought giving out samples [to patients] was unethical, but that it wasn't good practice,” she said. “They understood why others did it, but they worried about conflicts of interest with their interactions with the reps.”

Those who accepted samples said inadequacies in the health care system forced them to rely on gifts to care for their most needy patients.

All of the respondents evaluated marketing practices from the perspective of protecting and serving their patients, said Dr. Sohler, professor of community health and social medicine, City University of New York (N.Y.). None of the respondents expressed concern that physicians were ignoring clinical symptoms to prescribe the “right drugs.”

The study included in-depth, qualitative interviews and was prompted by an administrative decision at the medical center to ban samples and pharmaceutical representatives from the community practices. That decision left many providers uncertain about how to care for patients without adequate health care coverage.

Others suggested that the policy was changed because the administration didn't want physicians taking the time to talk to sales representatives, didn't trust that staff would avoid entering into agreements with pharmaceutical firms, and did want a single policy, because teaching sites had a “no-rep” policy and other sites didn't need samples.

Dr. Sohler said further study would be needed to determine whether samples help poor patients more than they harm them, and whether representatives influence prescribing practices in mostly helpful or harmful ways.

“The empirical, quantitative evidence isn't good on whether free medications help or harm our patients,” Dr. Sohler said. “We realize that all marketing has an influence, but we don't know if it harms our patients.

“People are drawing on their different values and perspectives to make a decision. We need hard evidence to make a policy, but in the meantime, we should keep these perspectives in mind as the data come in.”

TUCSON, ARIZ. — The benefits of adopting healthy lifestyle habits later in life are significant, Dr. Dana King and colleagues reported at the annual meeting of the North American Primary Care Research Group.

He presented a secondary analysis of the Atherosclerosis Risk in Communities (ARIC) cohort study of 15,792 adults who were aged 45–64 years at the outset. Participants were reexamined every 3 years, with the first baseline screening occurring in 1987–89, and the fourth and final screening in 1996–1998. Telephone visits were conducted annually.

At baseline, only 1,344 (8.5%) had all four of the healthy lifestyle habits examined: They ate at least five fruits and vegetables a day, walked 150 minutes a week or more, were not obese, and did not smoke, “That [low rate was] tremendously disappointing,” said Dr. King, of the department of family medicine at the Medical University of South Carolina, Charleston.

Those less likely to have all four healthy habits tended to be male, black, and aged 45–54 years, and to have hypertension or diabetes mellitus, less than a college education, and an annual family income of less than $35,000.

After 6 years, an additional 970 participants switched to a healthier lifestyle. Women were more likely to switch than men (9.1% vs. 7.4%), he said. The most common changes were improved diet, increased exercise, and smoking cessation. Almost no one changed his or her body mass index category significantly, he said.

For those who adopted all four habits, the benefits were substantial. Using an adjusted logistic regression analysis, the relative risk of cardiovascular disease was reduced by 35% and all-cause mortality by 40% in only 4 years, he said. Adopting only three habits was not as beneficial, resulting in a 25% reduction in all-cause mortality and a nonsignificant reduction in cardiovascular disease compared with those who have fewer healthy habits.

Dr. King called the results surprising and powerful because of the substantial benefit in cardiovascular disease and mortality seen after a relatively short period of 4 years. Other studies, such as the Women's Health Study and the Health Professionals Follow-up Study, have shown similar results. But these studies investigated individual habits and didn't focus on people who adopted new, healthy lifestyles in middle age, he said.

“The present study adds new information that adopting a healthy lifestyle later in life is not futile,” Dr. King said. “Doing all the habits is the way to go.”

Limitations of the study included self-report data for diet and exercise and a short mortality and cardiovascular follow-up period, Dr. King noted.

TUCSON, ARIZ. — The benefits of adopting healthy lifestyle habits later in life are significant, Dr. Dana King and colleagues reported at the annual meeting of the North American Primary Care Research Group.

He presented a secondary analysis of the Atherosclerosis Risk in Communities (ARIC) cohort study of 15,792 adults who were aged 45–64 years at the outset. Participants were reexamined every 3 years, with the first baseline screening occurring in 1987–89, and the fourth and final screening in 1996–1998. Telephone visits were conducted annually.

At baseline, only 1,344 (8.5%) had all four of the healthy lifestyle habits examined: They ate at least five fruits and vegetables a day, walked 150 minutes a week or more, were not obese, and did not smoke, “That [low rate was] tremendously disappointing,” said Dr. King, of the department of family medicine at the Medical University of South Carolina, Charleston.

Those less likely to have all four healthy habits tended to be male, black, and aged 45–54 years, and to have hypertension or diabetes mellitus, less than a college education, and an annual family income of less than $35,000.

After 6 years, an additional 970 participants switched to a healthier lifestyle. Women were more likely to switch than men (9.1% vs. 7.4%), he said. The most common changes were improved diet, increased exercise, and smoking cessation. Almost no one changed his or her body mass index category significantly, he said.

For those who adopted all four habits, the benefits were substantial. Using an adjusted logistic regression analysis, the relative risk of cardiovascular disease was reduced by 35% and all-cause mortality by 40% in only 4 years, he said. Adopting only three habits was not as beneficial, resulting in a 25% reduction in all-cause mortality and a nonsignificant reduction in cardiovascular disease compared with those who have fewer healthy habits.

Dr. King called the results surprising and powerful because of the substantial benefit in cardiovascular disease and mortality seen after a relatively short period of 4 years. Other studies, such as the Women's Health Study and the Health Professionals Follow-up Study, have shown similar results. But these studies investigated individual habits and didn't focus on people who adopted new, healthy lifestyles in middle age, he said.

“The present study adds new information that adopting a healthy lifestyle later in life is not futile,” Dr. King said. “Doing all the habits is the way to go.”

Limitations of the study included self-report data for diet and exercise and a short mortality and cardiovascular follow-up period, Dr. King noted.

TUCSON, ARIZ. — The benefits of adopting healthy lifestyle habits later in life are significant, Dr. Dana King and colleagues reported at the annual meeting of the North American Primary Care Research Group.

He presented a secondary analysis of the Atherosclerosis Risk in Communities (ARIC) cohort study of 15,792 adults who were aged 45–64 years at the outset. Participants were reexamined every 3 years, with the first baseline screening occurring in 1987–89, and the fourth and final screening in 1996–1998. Telephone visits were conducted annually.

At baseline, only 1,344 (8.5%) had all four of the healthy lifestyle habits examined: They ate at least five fruits and vegetables a day, walked 150 minutes a week or more, were not obese, and did not smoke, “That [low rate was] tremendously disappointing,” said Dr. King, of the department of family medicine at the Medical University of South Carolina, Charleston.

Those less likely to have all four healthy habits tended to be male, black, and aged 45–54 years, and to have hypertension or diabetes mellitus, less than a college education, and an annual family income of less than $35,000.

After 6 years, an additional 970 participants switched to a healthier lifestyle. Women were more likely to switch than men (9.1% vs. 7.4%), he said. The most common changes were improved diet, increased exercise, and smoking cessation. Almost no one changed his or her body mass index category significantly, he said.

For those who adopted all four habits, the benefits were substantial. Using an adjusted logistic regression analysis, the relative risk of cardiovascular disease was reduced by 35% and all-cause mortality by 40% in only 4 years, he said. Adopting only three habits was not as beneficial, resulting in a 25% reduction in all-cause mortality and a nonsignificant reduction in cardiovascular disease compared with those who have fewer healthy habits.

Dr. King called the results surprising and powerful because of the substantial benefit in cardiovascular disease and mortality seen after a relatively short period of 4 years. Other studies, such as the Women's Health Study and the Health Professionals Follow-up Study, have shown similar results. But these studies investigated individual habits and didn't focus on people who adopted new, healthy lifestyles in middle age, he said.

“The present study adds new information that adopting a healthy lifestyle later in life is not futile,” Dr. King said. “Doing all the habits is the way to go.”

Limitations of the study included self-report data for diet and exercise and a short mortality and cardiovascular follow-up period, Dr. King noted.

CHICAGO — Injection of adult autologous stem cells shows an excellent success rate for the treatment of urinary stress incontinence, compared with collagen injections, Dr. Matthias Schurich said at the annual meeting of the Radiological Society of North America.

In the study of both women and men, 50 (79%) of the 63 patients randomized to transurethral ultrasound-guided injection of adult stem cells were completely continent after follow-up lasting 6–30 months, compared with only 2 (7%) of the 28 patients treated with endoscopic injection of collagen after 6–12 months, he reported on behalf of principal investigator Dr. Ferdinand Frauscher and his colleagues at the Medical University Innsbruck (Austria).

The long, successful follow-up period for the stem cell injections is noteworthy because endoscopic collagen injections work well initially, but the effect is known to wear off relatively quickly, Dr. Schurich said in an interview.

The success rate for stem cell injections was significantly higher for women than for men, with 39 (93%) of 42 women continent and 11 (52%) of 21 men continent at follow-up.

This could be because most of the men had undergone radical prostatectomy with resulting scarring and little or no sphincter muscle remaining to be bulked up by the stem cells, explained Dr. Schurich, who is also with the university.

The autologous stem cells were obtained from skeletal muscle biopsies of the patient's arm and were cultured to yield roughly 50 million fibroblasts and 50 million myoblasts.

The fibroblasts were injected into the urethral submucosa, whereas the myoblasts were implanted into the rhabdosphincter.

Overall, the 63 patients (aged 36–84 years) were treated with autologous stem cells between September 2002 and February 2005.

During the same period, 21 women and 7 men (aged 31–84 years) also diagnosed with urinary stress incontinence were treated with standard transurethral endoscopic injections of collagen.

Patients were randomly assigned to the groups according to capacity in the cell culture laboratory.

Compared with baseline, the stem cell-treated patients demonstrated significant improvements in incontinence scores (5.95 vs. 0.44), thickness of the urethra (3.75 mm vs. 5.3 mm) and rhabdosphincter (2.10 mm vs. 3.30 mm), contractility of the rhabdosphincter (0.56 mm vs. 1.46 mm), and quality-of-life scores (51.3 vs. 104.0) at follow-up.

In addition to the 50 patients whose incontinence was cured, 6 had substantial improvement in symptoms and 7 experienced no improvement.

Incontinence scores and quality-of-life scores improved significantly among collagen-treated patients, but the improvements were “clinically irrelevant for the majority of patients,” Dr. Schurich said.

Urethral submucosa shows thinning of the rhabdosphincter (S) with atrophy (A).

After injection of stem cells, the sphincter appears hyperechoic (S). Photos courtesy Dr. Ferdinand Frauscher

CHICAGO — Injection of adult autologous stem cells shows an excellent success rate for the treatment of urinary stress incontinence, compared with collagen injections, Dr. Matthias Schurich said at the annual meeting of the Radiological Society of North America.

In the study of both women and men, 50 (79%) of the 63 patients randomized to transurethral ultrasound-guided injection of adult stem cells were completely continent after follow-up lasting 6–30 months, compared with only 2 (7%) of the 28 patients treated with endoscopic injection of collagen after 6–12 months, he reported on behalf of principal investigator Dr. Ferdinand Frauscher and his colleagues at the Medical University Innsbruck (Austria).

The long, successful follow-up period for the stem cell injections is noteworthy because endoscopic collagen injections work well initially, but the effect is known to wear off relatively quickly, Dr. Schurich said in an interview.

The success rate for stem cell injections was significantly higher for women than for men, with 39 (93%) of 42 women continent and 11 (52%) of 21 men continent at follow-up.

This could be because most of the men had undergone radical prostatectomy with resulting scarring and little or no sphincter muscle remaining to be bulked up by the stem cells, explained Dr. Schurich, who is also with the university.

The autologous stem cells were obtained from skeletal muscle biopsies of the patient's arm and were cultured to yield roughly 50 million fibroblasts and 50 million myoblasts.

The fibroblasts were injected into the urethral submucosa, whereas the myoblasts were implanted into the rhabdosphincter.

Overall, the 63 patients (aged 36–84 years) were treated with autologous stem cells between September 2002 and February 2005.

During the same period, 21 women and 7 men (aged 31–84 years) also diagnosed with urinary stress incontinence were treated with standard transurethral endoscopic injections of collagen.

Patients were randomly assigned to the groups according to capacity in the cell culture laboratory.

Compared with baseline, the stem cell-treated patients demonstrated significant improvements in incontinence scores (5.95 vs. 0.44), thickness of the urethra (3.75 mm vs. 5.3 mm) and rhabdosphincter (2.10 mm vs. 3.30 mm), contractility of the rhabdosphincter (0.56 mm vs. 1.46 mm), and quality-of-life scores (51.3 vs. 104.0) at follow-up.

In addition to the 50 patients whose incontinence was cured, 6 had substantial improvement in symptoms and 7 experienced no improvement.

Incontinence scores and quality-of-life scores improved significantly among collagen-treated patients, but the improvements were “clinically irrelevant for the majority of patients,” Dr. Schurich said.

Urethral submucosa shows thinning of the rhabdosphincter (S) with atrophy (A).

After injection of stem cells, the sphincter appears hyperechoic (S). Photos courtesy Dr. Ferdinand Frauscher

CHICAGO — Injection of adult autologous stem cells shows an excellent success rate for the treatment of urinary stress incontinence, compared with collagen injections, Dr. Matthias Schurich said at the annual meeting of the Radiological Society of North America.

In the study of both women and men, 50 (79%) of the 63 patients randomized to transurethral ultrasound-guided injection of adult stem cells were completely continent after follow-up lasting 6–30 months, compared with only 2 (7%) of the 28 patients treated with endoscopic injection of collagen after 6–12 months, he reported on behalf of principal investigator Dr. Ferdinand Frauscher and his colleagues at the Medical University Innsbruck (Austria).

The long, successful follow-up period for the stem cell injections is noteworthy because endoscopic collagen injections work well initially, but the effect is known to wear off relatively quickly, Dr. Schurich said in an interview.

The success rate for stem cell injections was significantly higher for women than for men, with 39 (93%) of 42 women continent and 11 (52%) of 21 men continent at follow-up.

This could be because most of the men had undergone radical prostatectomy with resulting scarring and little or no sphincter muscle remaining to be bulked up by the stem cells, explained Dr. Schurich, who is also with the university.

The autologous stem cells were obtained from skeletal muscle biopsies of the patient's arm and were cultured to yield roughly 50 million fibroblasts and 50 million myoblasts.

The fibroblasts were injected into the urethral submucosa, whereas the myoblasts were implanted into the rhabdosphincter.

Overall, the 63 patients (aged 36–84 years) were treated with autologous stem cells between September 2002 and February 2005.

During the same period, 21 women and 7 men (aged 31–84 years) also diagnosed with urinary stress incontinence were treated with standard transurethral endoscopic injections of collagen.

Patients were randomly assigned to the groups according to capacity in the cell culture laboratory.

Compared with baseline, the stem cell-treated patients demonstrated significant improvements in incontinence scores (5.95 vs. 0.44), thickness of the urethra (3.75 mm vs. 5.3 mm) and rhabdosphincter (2.10 mm vs. 3.30 mm), contractility of the rhabdosphincter (0.56 mm vs. 1.46 mm), and quality-of-life scores (51.3 vs. 104.0) at follow-up.

In addition to the 50 patients whose incontinence was cured, 6 had substantial improvement in symptoms and 7 experienced no improvement.

Incontinence scores and quality-of-life scores improved significantly among collagen-treated patients, but the improvements were “clinically irrelevant for the majority of patients,” Dr. Schurich said.

Urethral submucosa shows thinning of the rhabdosphincter (S) with atrophy (A).

After injection of stem cells, the sphincter appears hyperechoic (S). Photos courtesy Dr. Ferdinand Frauscher