Patrice Wendling

TUCSON, ARIZ. — Medicine is a high-risk profession for psychiatric morbidities. But several strategies can help reduce the risk of hitting bottom, Dan Shapiro, Ph.D., said at a psychopharmacology conference sponsored by the University of Arizona.

“Physicians are like big ships,” said Dr. Shapiro, a psychologist at the university who specializes in treating physicians. “By the time you can see that they are sinking, it's too late.”

One of his more radical solutions is the creation of a no-fault malpractice system in which physicians would be granted no-fault judgments in exchange for disclosing mistakes. Physicians and patients would share the cost of reimbursing injured patients by contributing to a shared local fund. Serious mistakes would be voluntarily reported to a local commission, which would also have the duty of compensating injured patients according to preestablished guidelines. State boards would investigate physicians and nurses who failed to come forward.

The system would improve the dismal rate of medical error reporting and address one of the biggest stresses for physicians. “Many physicians who are defendants say that being sued was the worst experience of their life,” said Dr. Shapiro, who is also an author and a cancer survivor. Being lied about in court or characterized as an uncaring, negligent physician is emotionally traumatic to physicians. For those who did cause harm, the scars can last for years. His efforts to treat one such physician are detailed in his book, “Delivering Doctor Amelia.”

Medical errors are a common topic when Dr. Shapiro asks physicians to take 15 minutes to write openly and honestly to a patient about something left unresolved. The patient need not be living, and the letter is never sent. Most physicians start writing immediately, about 10% have trouble getting started, and 5% ultimately never write a letter. The letters are read aloud, which can be cathartic for a group of people who in large part have been competing with rather than relating to peers since grade school. “Physicians are starving at a banquet of social support,” he said of the need to improve social connections.

When a few excerpts were shared at this conference, the audience went silent, heads nodded, and tearful faces filled the room. The mood lifted only when a letter addressed to “Dear fibromyalgia patients” was read and when an audience member asked whether such a letter could be addressed to an administrator.

Other suggestions from Dr. Shapiro included improving the work environment and improving physician self-care, typically by reducing hours, increasing sleep and exercise, and improving diets. Hospitals often bring in experts to discuss the symptoms of depression and stress. But the key is to address the problem of self-care where it starts—in residency, he said. Administrators and staff should model and demand self-care among residents, and give up the “hazing” model of training. At Arizona, for example, residents in family practice are being asked to establish self-care goals that are followed for compliance.

Part of the problem is that physicians celebrate self-denial instead of self-care, said Dr. Shapiro, who recalled a physician patient who started their session by remarking that he had had to use the rest room for the past 6 hours but hadn't. “I told him, 'Go pee. That will be more therapeutic than anything I'll do for you in my lifetime.'” Studies have shown that 80% of physicians worked when they were ill, that 52% prescribed for themselves, and that they visited their own doctor at a rate equal to one-fourth the national average. Another red flag is the internal use of self-deprecation as a motivator, one of the best predictors of depression, he said.

The results of unchecked emotional exhaustion and depression on the medical profession can be devastating, as evidenced by the reported higher rate of suicide among physicians, compared with the general population.

TUCSON, ARIZ. — Medicine is a high-risk profession for psychiatric morbidities. But several strategies can help reduce the risk of hitting bottom, Dan Shapiro, Ph.D., said at a psychopharmacology conference sponsored by the University of Arizona.

“Physicians are like big ships,” said Dr. Shapiro, a psychologist at the university who specializes in treating physicians. “By the time you can see that they are sinking, it's too late.”

One of his more radical solutions is the creation of a no-fault malpractice system in which physicians would be granted no-fault judgments in exchange for disclosing mistakes. Physicians and patients would share the cost of reimbursing injured patients by contributing to a shared local fund. Serious mistakes would be voluntarily reported to a local commission, which would also have the duty of compensating injured patients according to preestablished guidelines. State boards would investigate physicians and nurses who failed to come forward.

The system would improve the dismal rate of medical error reporting and address one of the biggest stresses for physicians. “Many physicians who are defendants say that being sued was the worst experience of their life,” said Dr. Shapiro, who is also an author and a cancer survivor. Being lied about in court or characterized as an uncaring, negligent physician is emotionally traumatic to physicians. For those who did cause harm, the scars can last for years. His efforts to treat one such physician are detailed in his book, “Delivering Doctor Amelia.”

Medical errors are a common topic when Dr. Shapiro asks physicians to take 15 minutes to write openly and honestly to a patient about something left unresolved. The patient need not be living, and the letter is never sent. Most physicians start writing immediately, about 10% have trouble getting started, and 5% ultimately never write a letter. The letters are read aloud, which can be cathartic for a group of people who in large part have been competing with rather than relating to peers since grade school. “Physicians are starving at a banquet of social support,” he said of the need to improve social connections.

When a few excerpts were shared at this conference, the audience went silent, heads nodded, and tearful faces filled the room. The mood lifted only when a letter addressed to “Dear fibromyalgia patients” was read and when an audience member asked whether such a letter could be addressed to an administrator.

Other suggestions from Dr. Shapiro included improving the work environment and improving physician self-care, typically by reducing hours, increasing sleep and exercise, and improving diets. Hospitals often bring in experts to discuss the symptoms of depression and stress. But the key is to address the problem of self-care where it starts—in residency, he said. Administrators and staff should model and demand self-care among residents, and give up the “hazing” model of training. At Arizona, for example, residents in family practice are being asked to establish self-care goals that are followed for compliance.

Part of the problem is that physicians celebrate self-denial instead of self-care, said Dr. Shapiro, who recalled a physician patient who started their session by remarking that he had had to use the rest room for the past 6 hours but hadn't. “I told him, 'Go pee. That will be more therapeutic than anything I'll do for you in my lifetime.'” Studies have shown that 80% of physicians worked when they were ill, that 52% prescribed for themselves, and that they visited their own doctor at a rate equal to one-fourth the national average. Another red flag is the internal use of self-deprecation as a motivator, one of the best predictors of depression, he said.

The results of unchecked emotional exhaustion and depression on the medical profession can be devastating, as evidenced by the reported higher rate of suicide among physicians, compared with the general population.

TUCSON, ARIZ. — Medicine is a high-risk profession for psychiatric morbidities. But several strategies can help reduce the risk of hitting bottom, Dan Shapiro, Ph.D., said at a psychopharmacology conference sponsored by the University of Arizona.

“Physicians are like big ships,” said Dr. Shapiro, a psychologist at the university who specializes in treating physicians. “By the time you can see that they are sinking, it's too late.”

One of his more radical solutions is the creation of a no-fault malpractice system in which physicians would be granted no-fault judgments in exchange for disclosing mistakes. Physicians and patients would share the cost of reimbursing injured patients by contributing to a shared local fund. Serious mistakes would be voluntarily reported to a local commission, which would also have the duty of compensating injured patients according to preestablished guidelines. State boards would investigate physicians and nurses who failed to come forward.

The system would improve the dismal rate of medical error reporting and address one of the biggest stresses for physicians. “Many physicians who are defendants say that being sued was the worst experience of their life,” said Dr. Shapiro, who is also an author and a cancer survivor. Being lied about in court or characterized as an uncaring, negligent physician is emotionally traumatic to physicians. For those who did cause harm, the scars can last for years. His efforts to treat one such physician are detailed in his book, “Delivering Doctor Amelia.”

Medical errors are a common topic when Dr. Shapiro asks physicians to take 15 minutes to write openly and honestly to a patient about something left unresolved. The patient need not be living, and the letter is never sent. Most physicians start writing immediately, about 10% have trouble getting started, and 5% ultimately never write a letter. The letters are read aloud, which can be cathartic for a group of people who in large part have been competing with rather than relating to peers since grade school. “Physicians are starving at a banquet of social support,” he said of the need to improve social connections.

When a few excerpts were shared at this conference, the audience went silent, heads nodded, and tearful faces filled the room. The mood lifted only when a letter addressed to “Dear fibromyalgia patients” was read and when an audience member asked whether such a letter could be addressed to an administrator.

Other suggestions from Dr. Shapiro included improving the work environment and improving physician self-care, typically by reducing hours, increasing sleep and exercise, and improving diets. Hospitals often bring in experts to discuss the symptoms of depression and stress. But the key is to address the problem of self-care where it starts—in residency, he said. Administrators and staff should model and demand self-care among residents, and give up the “hazing” model of training. At Arizona, for example, residents in family practice are being asked to establish self-care goals that are followed for compliance.

Part of the problem is that physicians celebrate self-denial instead of self-care, said Dr. Shapiro, who recalled a physician patient who started their session by remarking that he had had to use the rest room for the past 6 hours but hadn't. “I told him, 'Go pee. That will be more therapeutic than anything I'll do for you in my lifetime.'” Studies have shown that 80% of physicians worked when they were ill, that 52% prescribed for themselves, and that they visited their own doctor at a rate equal to one-fourth the national average. Another red flag is the internal use of self-deprecation as a motivator, one of the best predictors of depression, he said.

The results of unchecked emotional exhaustion and depression on the medical profession can be devastating, as evidenced by the reported higher rate of suicide among physicians, compared with the general population.

PITTSBURGH — The same genetic variation that has been associated with aggressive behaviors in certain psychiatric and criminal populations may predict confrontational and antagonistic behavior among men, Stephen B. Manuck, Ph.D., reported at the International Congress of Neuroendocrinology.

Men who reported a history of fights, conflicts with authority figures, or breaking objects in bouts of anger are more likely to carry the 3-repeat or “low-activity” monoamine oxidase A (MAOA) allele, Dr. Manuck and his colleagues found. MAOA is an enzyme that inactivates serotonin, a neurotransmitter thought to exert largely inhibitory effects.

Most white men possess either the 3-repeat or 4-repeat (high-activity) allele, at a frequency of about 35% and 60%, respectively. But this does not mean that all men with the 3-repeat allele are genetically wired to be aggressive.

The allele appears to be predictive of aggression only among men who have generally cynical and hostile attitudes, whose fathers never completed high school, and who report unaffectionate parenting in childhood, said Dr. Manuck of the department of psychology, University of Pittsburgh.

The study involved 531 white men of European ancestry in good general health who were selected from the university's Adult Health and Behavior registry. Their mean age was 44 years (range 30–54 years); 67% were married; and 86% were employed either full or part time. They were well educated, with a mean of 16.2 years of education. Incomes varied across a range from less than $25,000 to more than $80,000 per year. DNA available on registry participants was used for genotyping. The Life History of Aggression interview and personality measurements with multiple informants were used to assess behavioral attributes.

Overall, 188 men had a high lifetime history of aggression, and 192 had a low history of aggression. Forty-three percent of men in the high-aggressive group carried the 3-repeat allele, compared with 32% in the low-aggressive group. The 3-repeat allele was associated with lifetime histories of aggressive and antisocial behavior in the overall sample—even when excluding the most aggressive 20% of the study participants and after adjusting for variation in socioeconomic indicators, Dr. Manuck said at the meeting, which was sponsored by the University of Pittsburgh and the American Neuroendocrine Society.

Socioeconomic status in childhood did not significantly differ between more and less aggressive men. But both educational attainment and income among high-aggressive men were significantly lower than in their less-aggressive counterparts.

Men with the 3-repeat allele who had a less-hostile disposition and those whose fathers had attained a higher level of education were no more aggressive than were men carrying the 4-repeat allele. Among men with the 4-repeat allele, hostile attitudes and a low level of parental education were unrelated to histories of aggression.

“These findings suggest that MAOA variation is associated with expressed aggression, but only in individuals whose beliefs and attitudes give license to such behavior,” Dr. Manuck said.

PITTSBURGH — The same genetic variation that has been associated with aggressive behaviors in certain psychiatric and criminal populations may predict confrontational and antagonistic behavior among men, Stephen B. Manuck, Ph.D., reported at the International Congress of Neuroendocrinology.

Men who reported a history of fights, conflicts with authority figures, or breaking objects in bouts of anger are more likely to carry the 3-repeat or “low-activity” monoamine oxidase A (MAOA) allele, Dr. Manuck and his colleagues found. MAOA is an enzyme that inactivates serotonin, a neurotransmitter thought to exert largely inhibitory effects.

Most white men possess either the 3-repeat or 4-repeat (high-activity) allele, at a frequency of about 35% and 60%, respectively. But this does not mean that all men with the 3-repeat allele are genetically wired to be aggressive.

The allele appears to be predictive of aggression only among men who have generally cynical and hostile attitudes, whose fathers never completed high school, and who report unaffectionate parenting in childhood, said Dr. Manuck of the department of psychology, University of Pittsburgh.

The study involved 531 white men of European ancestry in good general health who were selected from the university's Adult Health and Behavior registry. Their mean age was 44 years (range 30–54 years); 67% were married; and 86% were employed either full or part time. They were well educated, with a mean of 16.2 years of education. Incomes varied across a range from less than $25,000 to more than $80,000 per year. DNA available on registry participants was used for genotyping. The Life History of Aggression interview and personality measurements with multiple informants were used to assess behavioral attributes.

Overall, 188 men had a high lifetime history of aggression, and 192 had a low history of aggression. Forty-three percent of men in the high-aggressive group carried the 3-repeat allele, compared with 32% in the low-aggressive group. The 3-repeat allele was associated with lifetime histories of aggressive and antisocial behavior in the overall sample—even when excluding the most aggressive 20% of the study participants and after adjusting for variation in socioeconomic indicators, Dr. Manuck said at the meeting, which was sponsored by the University of Pittsburgh and the American Neuroendocrine Society.

Socioeconomic status in childhood did not significantly differ between more and less aggressive men. But both educational attainment and income among high-aggressive men were significantly lower than in their less-aggressive counterparts.

Men with the 3-repeat allele who had a less-hostile disposition and those whose fathers had attained a higher level of education were no more aggressive than were men carrying the 4-repeat allele. Among men with the 4-repeat allele, hostile attitudes and a low level of parental education were unrelated to histories of aggression.

“These findings suggest that MAOA variation is associated with expressed aggression, but only in individuals whose beliefs and attitudes give license to such behavior,” Dr. Manuck said.

PITTSBURGH — The same genetic variation that has been associated with aggressive behaviors in certain psychiatric and criminal populations may predict confrontational and antagonistic behavior among men, Stephen B. Manuck, Ph.D., reported at the International Congress of Neuroendocrinology.

Men who reported a history of fights, conflicts with authority figures, or breaking objects in bouts of anger are more likely to carry the 3-repeat or “low-activity” monoamine oxidase A (MAOA) allele, Dr. Manuck and his colleagues found. MAOA is an enzyme that inactivates serotonin, a neurotransmitter thought to exert largely inhibitory effects.

Most white men possess either the 3-repeat or 4-repeat (high-activity) allele, at a frequency of about 35% and 60%, respectively. But this does not mean that all men with the 3-repeat allele are genetically wired to be aggressive.

The allele appears to be predictive of aggression only among men who have generally cynical and hostile attitudes, whose fathers never completed high school, and who report unaffectionate parenting in childhood, said Dr. Manuck of the department of psychology, University of Pittsburgh.

The study involved 531 white men of European ancestry in good general health who were selected from the university's Adult Health and Behavior registry. Their mean age was 44 years (range 30–54 years); 67% were married; and 86% were employed either full or part time. They were well educated, with a mean of 16.2 years of education. Incomes varied across a range from less than $25,000 to more than $80,000 per year. DNA available on registry participants was used for genotyping. The Life History of Aggression interview and personality measurements with multiple informants were used to assess behavioral attributes.

Overall, 188 men had a high lifetime history of aggression, and 192 had a low history of aggression. Forty-three percent of men in the high-aggressive group carried the 3-repeat allele, compared with 32% in the low-aggressive group. The 3-repeat allele was associated with lifetime histories of aggressive and antisocial behavior in the overall sample—even when excluding the most aggressive 20% of the study participants and after adjusting for variation in socioeconomic indicators, Dr. Manuck said at the meeting, which was sponsored by the University of Pittsburgh and the American Neuroendocrine Society.

Socioeconomic status in childhood did not significantly differ between more and less aggressive men. But both educational attainment and income among high-aggressive men were significantly lower than in their less-aggressive counterparts.

Men with the 3-repeat allele who had a less-hostile disposition and those whose fathers had attained a higher level of education were no more aggressive than were men carrying the 4-repeat allele. Among men with the 4-repeat allele, hostile attitudes and a low level of parental education were unrelated to histories of aggression.

“These findings suggest that MAOA variation is associated with expressed aggression, but only in individuals whose beliefs and attitudes give license to such behavior,” Dr. Manuck said.

PITTSBURGH — High levels of adiponectin are common in centenarian women and appear to be associated with a favorable metabolic profile, Dr. Agnieszka Baranowska-Bik and colleagues reported in a poster at the International Congress of Neuroendocrinology.

Adiponectin, a peptide produced and secreted in fat cells, has anti-inflammatory and athero-protective properties. Low plasma levels of adiponectin are associated with atherogenesis, insulin resistance, and obesity.

Dr. Baranowska-Bik and colleagues in the neuroendocrinology department at the Medical Centre of Postgraduate Education in Warsaw evaluated fasting plasma levels of adiponectin, leptin, and insulin in 133 women: 25 were aged 100–102 years, 26 were aged 64–67 years, 45 were aged 20–43 years, and 37 were obese women aged 26–54 years. In the centenarian group, plasma concentrations of adiponectin were significantly higher and leptin and insulin levels were significantly lower, compared with elderly, young, and obese women. Average plasma adiponectin levels were 17 μg/mL in the centenarian group, 10 μg/mL in the elderly, 11 μg/mL in the young, and 8 μg/mL in the obese.

Adiponectin levels correlated positively with HDL levels and inversely with insulin resistance index, total cholesterol, LDL, triglycerides, blood pressure, and body mass index.

PITTSBURGH — High levels of adiponectin are common in centenarian women and appear to be associated with a favorable metabolic profile, Dr. Agnieszka Baranowska-Bik and colleagues reported in a poster at the International Congress of Neuroendocrinology.

Adiponectin, a peptide produced and secreted in fat cells, has anti-inflammatory and athero-protective properties. Low plasma levels of adiponectin are associated with atherogenesis, insulin resistance, and obesity.

Dr. Baranowska-Bik and colleagues in the neuroendocrinology department at the Medical Centre of Postgraduate Education in Warsaw evaluated fasting plasma levels of adiponectin, leptin, and insulin in 133 women: 25 were aged 100–102 years, 26 were aged 64–67 years, 45 were aged 20–43 years, and 37 were obese women aged 26–54 years. In the centenarian group, plasma concentrations of adiponectin were significantly higher and leptin and insulin levels were significantly lower, compared with elderly, young, and obese women. Average plasma adiponectin levels were 17 μg/mL in the centenarian group, 10 μg/mL in the elderly, 11 μg/mL in the young, and 8 μg/mL in the obese.

Adiponectin levels correlated positively with HDL levels and inversely with insulin resistance index, total cholesterol, LDL, triglycerides, blood pressure, and body mass index.

PITTSBURGH — High levels of adiponectin are common in centenarian women and appear to be associated with a favorable metabolic profile, Dr. Agnieszka Baranowska-Bik and colleagues reported in a poster at the International Congress of Neuroendocrinology.

Adiponectin, a peptide produced and secreted in fat cells, has anti-inflammatory and athero-protective properties. Low plasma levels of adiponectin are associated with atherogenesis, insulin resistance, and obesity.

Dr. Baranowska-Bik and colleagues in the neuroendocrinology department at the Medical Centre of Postgraduate Education in Warsaw evaluated fasting plasma levels of adiponectin, leptin, and insulin in 133 women: 25 were aged 100–102 years, 26 were aged 64–67 years, 45 were aged 20–43 years, and 37 were obese women aged 26–54 years. In the centenarian group, plasma concentrations of adiponectin were significantly higher and leptin and insulin levels were significantly lower, compared with elderly, young, and obese women. Average plasma adiponectin levels were 17 μg/mL in the centenarian group, 10 μg/mL in the elderly, 11 μg/mL in the young, and 8 μg/mL in the obese.

Adiponectin levels correlated positively with HDL levels and inversely with insulin resistance index, total cholesterol, LDL, triglycerides, blood pressure, and body mass index.

TUCSON, ARIZ. – Medicine is a high-risk profession for psychiatric morbidities. But several strategies can help reduce the risk of hitting bottom, Dan Shapiro, Ph.D., said at a psychopharmacology conference sponsored by the University of Arizona.

“Physicians are like big ships,” said Dr. Shapiro, a psychologist at the university who specializes in treating physicians. “By the time you can see that they are sinking, it's too late.”

One of his more radical solutions is the creation of a no-fault malpractice system in which physicians would be granted no-fault judgments in exchange for disclosing mistakes. Physicians and patients would share the cost of reimbursing injured patients by contributing to a shared local fund. Serious mistakes would be voluntarily reported to a local commission, which would also have the duty of compensating injured patients according to preestablished guidelines. State boards would investigate physicians and nurses who failed to come forward.

The system would improve the dismal rate of medical error reporting and address one of the biggest stresses for physicians. “Many physicians who are defendants say that being sued was the worst experience of their life,” said Dr. Shapiro, who is also an author and cancer survivor. Being lied about in court or characterized as an uncaring, negligent physician is emotionally traumatic to physicians. For those who did cause harm, the scars can last for years. His efforts to treat one such physician are detailed in his book “Delivering Doctor Amelia.”

Medical errors are a common topic when Dr. Shapiro asks physicians to take 15 minutes to write openly and honestly to a patient about something left unresolved. The patient need not be living, and the letter is never sent. Most physicians start writing immediately, about 10% have trouble getting started, and 5% ultimately never write a letter. The letters are read aloud, which can be cathartic for a group of people who in large part have been competing rather than relating with peers since grade school.

When a few excerpts were shared at this conference, the audience went silent and tearful faces filled the room. The mood lifted only when a letter was read addressed to “Dear fibromyalgia patients” and when an audience member asked whether such a letter could be addressed to an administrator.

Other suggestions from Dr. Shapiro included improving the work environment and improving physician self-care, typically by reducing hours, increasing sleep and exercise, and improving diets. Hospitals often bring in experts to discuss the symptoms of depression and stress. But the key is to address the problem of self-care where it starts–in residency, he said. Administrators and staff should model and demand self-care among residents, and give up the “hazing” model of training. At Arizona, for example, residents in family practice are being asked to establish self-care goals that are followed for compliance.

Part of the problem is that physicians celebrate self-denial instead of self-care, said Dr. Shapiro, who recalled a physician patient who started their session by remarking that he had had to use the restroom for the past 6 hours, but hadn't. “I told him, 'Go pee. That will be more therapeutic than anything I'll do for you in my lifetime.'” Studies have shown that 80% of physicians worked when they were ill, that 52% prescribed for themselves, and that they visited their own doctors at a rate equal to one-fourth the national average.

The results of unchecked emotional exhaustion and depression on the medical profession can be devastating, as evidenced by the reported higher rate of suicide among physicians, compared with the general population. A metaanalysis reported an aggregated suicide rate ratio for male physicians, compared with the general population, of 1.41 and a ratio of 2.27 for female physicians (Am. J. Psychiatry 2004;161:2295–302). Single women physicians without social support seemed to be most at risk, he said.

TUCSON, ARIZ. – Medicine is a high-risk profession for psychiatric morbidities. But several strategies can help reduce the risk of hitting bottom, Dan Shapiro, Ph.D., said at a psychopharmacology conference sponsored by the University of Arizona.

“Physicians are like big ships,” said Dr. Shapiro, a psychologist at the university who specializes in treating physicians. “By the time you can see that they are sinking, it's too late.”

One of his more radical solutions is the creation of a no-fault malpractice system in which physicians would be granted no-fault judgments in exchange for disclosing mistakes. Physicians and patients would share the cost of reimbursing injured patients by contributing to a shared local fund. Serious mistakes would be voluntarily reported to a local commission, which would also have the duty of compensating injured patients according to preestablished guidelines. State boards would investigate physicians and nurses who failed to come forward.

The system would improve the dismal rate of medical error reporting and address one of the biggest stresses for physicians. “Many physicians who are defendants say that being sued was the worst experience of their life,” said Dr. Shapiro, who is also an author and cancer survivor. Being lied about in court or characterized as an uncaring, negligent physician is emotionally traumatic to physicians. For those who did cause harm, the scars can last for years. His efforts to treat one such physician are detailed in his book “Delivering Doctor Amelia.”

Medical errors are a common topic when Dr. Shapiro asks physicians to take 15 minutes to write openly and honestly to a patient about something left unresolved. The patient need not be living, and the letter is never sent. Most physicians start writing immediately, about 10% have trouble getting started, and 5% ultimately never write a letter. The letters are read aloud, which can be cathartic for a group of people who in large part have been competing rather than relating with peers since grade school.

When a few excerpts were shared at this conference, the audience went silent and tearful faces filled the room. The mood lifted only when a letter was read addressed to “Dear fibromyalgia patients” and when an audience member asked whether such a letter could be addressed to an administrator.

Other suggestions from Dr. Shapiro included improving the work environment and improving physician self-care, typically by reducing hours, increasing sleep and exercise, and improving diets. Hospitals often bring in experts to discuss the symptoms of depression and stress. But the key is to address the problem of self-care where it starts–in residency, he said. Administrators and staff should model and demand self-care among residents, and give up the “hazing” model of training. At Arizona, for example, residents in family practice are being asked to establish self-care goals that are followed for compliance.

Part of the problem is that physicians celebrate self-denial instead of self-care, said Dr. Shapiro, who recalled a physician patient who started their session by remarking that he had had to use the restroom for the past 6 hours, but hadn't. “I told him, 'Go pee. That will be more therapeutic than anything I'll do for you in my lifetime.'” Studies have shown that 80% of physicians worked when they were ill, that 52% prescribed for themselves, and that they visited their own doctors at a rate equal to one-fourth the national average.

The results of unchecked emotional exhaustion and depression on the medical profession can be devastating, as evidenced by the reported higher rate of suicide among physicians, compared with the general population. A metaanalysis reported an aggregated suicide rate ratio for male physicians, compared with the general population, of 1.41 and a ratio of 2.27 for female physicians (Am. J. Psychiatry 2004;161:2295–302). Single women physicians without social support seemed to be most at risk, he said.

TUCSON, ARIZ. – Medicine is a high-risk profession for psychiatric morbidities. But several strategies can help reduce the risk of hitting bottom, Dan Shapiro, Ph.D., said at a psychopharmacology conference sponsored by the University of Arizona.

“Physicians are like big ships,” said Dr. Shapiro, a psychologist at the university who specializes in treating physicians. “By the time you can see that they are sinking, it's too late.”

One of his more radical solutions is the creation of a no-fault malpractice system in which physicians would be granted no-fault judgments in exchange for disclosing mistakes. Physicians and patients would share the cost of reimbursing injured patients by contributing to a shared local fund. Serious mistakes would be voluntarily reported to a local commission, which would also have the duty of compensating injured patients according to preestablished guidelines. State boards would investigate physicians and nurses who failed to come forward.

The system would improve the dismal rate of medical error reporting and address one of the biggest stresses for physicians. “Many physicians who are defendants say that being sued was the worst experience of their life,” said Dr. Shapiro, who is also an author and cancer survivor. Being lied about in court or characterized as an uncaring, negligent physician is emotionally traumatic to physicians. For those who did cause harm, the scars can last for years. His efforts to treat one such physician are detailed in his book “Delivering Doctor Amelia.”

Medical errors are a common topic when Dr. Shapiro asks physicians to take 15 minutes to write openly and honestly to a patient about something left unresolved. The patient need not be living, and the letter is never sent. Most physicians start writing immediately, about 10% have trouble getting started, and 5% ultimately never write a letter. The letters are read aloud, which can be cathartic for a group of people who in large part have been competing rather than relating with peers since grade school.

When a few excerpts were shared at this conference, the audience went silent and tearful faces filled the room. The mood lifted only when a letter was read addressed to “Dear fibromyalgia patients” and when an audience member asked whether such a letter could be addressed to an administrator.

Other suggestions from Dr. Shapiro included improving the work environment and improving physician self-care, typically by reducing hours, increasing sleep and exercise, and improving diets. Hospitals often bring in experts to discuss the symptoms of depression and stress. But the key is to address the problem of self-care where it starts–in residency, he said. Administrators and staff should model and demand self-care among residents, and give up the “hazing” model of training. At Arizona, for example, residents in family practice are being asked to establish self-care goals that are followed for compliance.

Part of the problem is that physicians celebrate self-denial instead of self-care, said Dr. Shapiro, who recalled a physician patient who started their session by remarking that he had had to use the restroom for the past 6 hours, but hadn't. “I told him, 'Go pee. That will be more therapeutic than anything I'll do for you in my lifetime.'” Studies have shown that 80% of physicians worked when they were ill, that 52% prescribed for themselves, and that they visited their own doctors at a rate equal to one-fourth the national average.

The results of unchecked emotional exhaustion and depression on the medical profession can be devastating, as evidenced by the reported higher rate of suicide among physicians, compared with the general population. A metaanalysis reported an aggregated suicide rate ratio for male physicians, compared with the general population, of 1.41 and a ratio of 2.27 for female physicians (Am. J. Psychiatry 2004;161:2295–302). Single women physicians without social support seemed to be most at risk, he said.

PITTSBURGH — Treatment with the investigational drug capromorelin brings growth hormone levels in the elderly back into the normal range for young adults, and improves some measures of function, results from a phase II trial showed.

These results suggest the possibility that chronic treatment with the oral growth hormone secretagogue could prolong the capacity for independent living in older men and women, Dr. George Merriam and his associates reported at the International Congress of Neuroendocrinology.

He presented data from a double-blind, multicenter study in which 395 generally healthy men and women with some functional limitations were randomized to 12 months of treatment with placebo or one of four active doses of capromorelin: 10 mg three times weekly, 3 mg twice daily, 10 mg daily at bedtime, or 10 mg twice daily.

Their ages ranged from 65 to 84 years, and all had a body mass index of less than 30 kg/m

Each dose of capromorelin stimulated an acute rise in growth hormone levels, reported Dr. Merriam, of the University of Washington in Seattle. Capromorelin stimulated a dose-related increase in circulating IGF-I levels, with the greatest increases at the highest dose. These increases were sustained for the duration of treatment, but returned to baseline after the drug was discontinued.

Patients on active treatment gained a mean of 1.6 kg more than placebo after 6 months, and 1.3 kg after 12 months. This reflected an increase of 1.4 kg in lean body mass after 6 months and 1.6 kg after 12 months.

Tandem walk times improved significantly at 6 months and even more so at 12 months, compared with placebo. Stair climbing power improved significantly at 12 months. Nonsignificant trends toward improvement were seen in the 6-minute walk, chair rises, and tandem stand tests.

The drug was generally well tolerated. Insomnia and statistically significant increases in fasting glucose levels were reported in the active treatment groups. But glucose levels remained within the normal range, said Dr. Merriam who has no financial interest in Pfizer Inc., which is developing the drug and sponsored the study.

The physical function results are similar to those recently reported for Merck's investigational growth hormone secretagogue, MK677, which has a similar structure to capromorelin, he said. But both drugs face an uphill regulatory battle because the Food and Drug Administration does not consider aging to be a disease.

“These are very encouraging data, but they're not the sort of thing that can be sent into the FDA and get an approval from,” Dr. Merriam said. “It's too small, too limited a study.”

PITTSBURGH — Treatment with the investigational drug capromorelin brings growth hormone levels in the elderly back into the normal range for young adults, and improves some measures of function, results from a phase II trial showed.

These results suggest the possibility that chronic treatment with the oral growth hormone secretagogue could prolong the capacity for independent living in older men and women, Dr. George Merriam and his associates reported at the International Congress of Neuroendocrinology.

He presented data from a double-blind, multicenter study in which 395 generally healthy men and women with some functional limitations were randomized to 12 months of treatment with placebo or one of four active doses of capromorelin: 10 mg three times weekly, 3 mg twice daily, 10 mg daily at bedtime, or 10 mg twice daily.

Their ages ranged from 65 to 84 years, and all had a body mass index of less than 30 kg/m

Each dose of capromorelin stimulated an acute rise in growth hormone levels, reported Dr. Merriam, of the University of Washington in Seattle. Capromorelin stimulated a dose-related increase in circulating IGF-I levels, with the greatest increases at the highest dose. These increases were sustained for the duration of treatment, but returned to baseline after the drug was discontinued.

Patients on active treatment gained a mean of 1.6 kg more than placebo after 6 months, and 1.3 kg after 12 months. This reflected an increase of 1.4 kg in lean body mass after 6 months and 1.6 kg after 12 months.

Tandem walk times improved significantly at 6 months and even more so at 12 months, compared with placebo. Stair climbing power improved significantly at 12 months. Nonsignificant trends toward improvement were seen in the 6-minute walk, chair rises, and tandem stand tests.

The drug was generally well tolerated. Insomnia and statistically significant increases in fasting glucose levels were reported in the active treatment groups. But glucose levels remained within the normal range, said Dr. Merriam who has no financial interest in Pfizer Inc., which is developing the drug and sponsored the study.

The physical function results are similar to those recently reported for Merck's investigational growth hormone secretagogue, MK677, which has a similar structure to capromorelin, he said. But both drugs face an uphill regulatory battle because the Food and Drug Administration does not consider aging to be a disease.

“These are very encouraging data, but they're not the sort of thing that can be sent into the FDA and get an approval from,” Dr. Merriam said. “It's too small, too limited a study.”

PITTSBURGH — Treatment with the investigational drug capromorelin brings growth hormone levels in the elderly back into the normal range for young adults, and improves some measures of function, results from a phase II trial showed.

These results suggest the possibility that chronic treatment with the oral growth hormone secretagogue could prolong the capacity for independent living in older men and women, Dr. George Merriam and his associates reported at the International Congress of Neuroendocrinology.

He presented data from a double-blind, multicenter study in which 395 generally healthy men and women with some functional limitations were randomized to 12 months of treatment with placebo or one of four active doses of capromorelin: 10 mg three times weekly, 3 mg twice daily, 10 mg daily at bedtime, or 10 mg twice daily.

Their ages ranged from 65 to 84 years, and all had a body mass index of less than 30 kg/m

Each dose of capromorelin stimulated an acute rise in growth hormone levels, reported Dr. Merriam, of the University of Washington in Seattle. Capromorelin stimulated a dose-related increase in circulating IGF-I levels, with the greatest increases at the highest dose. These increases were sustained for the duration of treatment, but returned to baseline after the drug was discontinued.

Patients on active treatment gained a mean of 1.6 kg more than placebo after 6 months, and 1.3 kg after 12 months. This reflected an increase of 1.4 kg in lean body mass after 6 months and 1.6 kg after 12 months.

Tandem walk times improved significantly at 6 months and even more so at 12 months, compared with placebo. Stair climbing power improved significantly at 12 months. Nonsignificant trends toward improvement were seen in the 6-minute walk, chair rises, and tandem stand tests.

The drug was generally well tolerated. Insomnia and statistically significant increases in fasting glucose levels were reported in the active treatment groups. But glucose levels remained within the normal range, said Dr. Merriam who has no financial interest in Pfizer Inc., which is developing the drug and sponsored the study.

The physical function results are similar to those recently reported for Merck's investigational growth hormone secretagogue, MK677, which has a similar structure to capromorelin, he said. But both drugs face an uphill regulatory battle because the Food and Drug Administration does not consider aging to be a disease.

“These are very encouraging data, but they're not the sort of thing that can be sent into the FDA and get an approval from,” Dr. Merriam said. “It's too small, too limited a study.”

MONTREAL — A diagnosis of chronic lung disease of prematurity did not predict reduced lung function in childhood in a study of long-term respiratory outcomes in children born extremely prematurely.

But the study provided evidence that postnatal corticosteroid use is associated with reduced childhood lung function, although a causal relationship could not be definitively established, Ms. Lucia Smith said at the Seventh International Congress on Pediatric Pulmonology.

The lack of association of reduced lung function with chronic lung disease of prematurity (CLDP) runs contrary to traditional opinion in the literature, which suggests lung function is significantly reduced in children with CLDP.

“Most older studies have tended to compare children with CLDP with term controls rather than preterm controls, but our results are consistent with results in recent studies in CLDP cohorts,” Ms. Smith said in an interview.

The cross-sectional study included 126 children born between 1992 and 1994 at a mean gestational age of 27 weeks, who were recruited from the New South Wales, Australia, neonatal intensive care units database, and 34 age-matched controls who were born full term. The average weight at birth was 862 g for the children born prematurely, compared with 3,420 g for the children born full term.

Medical records available for 104 preterm children showed 37 (35.5%) had CLDP, defined as any infant who was still dependent on supplemental oxygen at 36 weeks, and 46 of the 104 (44%) had received systemic corticosteroids at any time during the initial neonatal intensive care unit stay immediately after birth.

There was no difference in spirometry between children born prematurely who were diagnosed with CLDP as neonates and those who were not, said Ms. Smith, a PhD candidate at the University of Sydney, New South Wales, and her associates.

Spirometry values were significantly lower in the preterm group, compared with controls: mean forced vital capacity, 96% vs. 102%; mean forced expiratory volume in 1 second (FEV₁), 85% vs. 95%; and forced expiratory flow at 25%–75% of forced vital capacity (FEF_25%–75%), 72% vs. 91%.

The preterm children who received postnatal corticosteroids had significantly lower flows than those who did not (FEV₁, 82% vs. 88% and FEF_25%–75%, 65% vs. 78%). These measures were within “normal limits” for lung function, Ms. Smith said.

In a regression analysis, cumulative steroid use, age of first steroid dose, birth weight, gestation, number of days intubated, or maximum oxygen concentration had no relationship with lung function.

“Our results highlight the fact that the definition of CLDP uses an arbitrary cut off of oxygen requirement at 36 weeks' gestational age,” Ms. Smith said. “There are no standardized criteria to assist the decision to cease supplemental oxygen, and it is likely to differ in different neonatal units.”

In reality, a number of children in the non-CLDP group may have only just come off supplemental oxygen by 36 weeks, she said. Likewise, some in the CLDP group may not have needed oxygen at 36 weeks, Ms. Smith added, thus the lack of association of reduced lung function with CLDP.

In a question-and-answer session, audience members called the corticosteroid data fascinating, but posited that a number of the preterm children must have fallen outside of “normal” limits for lung function. Ms. Smith said there was a range of results, particularly in airway flow, both for those preterm children who received steroids and those who did not. Data that were not presented indicate that fitness and exercise tolerance are markedly reduced in the entire preterm group, with results less than 50% of those in the control group, she said.

MONTREAL — A diagnosis of chronic lung disease of prematurity did not predict reduced lung function in childhood in a study of long-term respiratory outcomes in children born extremely prematurely.

But the study provided evidence that postnatal corticosteroid use is associated with reduced childhood lung function, although a causal relationship could not be definitively established, Ms. Lucia Smith said at the Seventh International Congress on Pediatric Pulmonology.

The lack of association of reduced lung function with chronic lung disease of prematurity (CLDP) runs contrary to traditional opinion in the literature, which suggests lung function is significantly reduced in children with CLDP.

“Most older studies have tended to compare children with CLDP with term controls rather than preterm controls, but our results are consistent with results in recent studies in CLDP cohorts,” Ms. Smith said in an interview.

The cross-sectional study included 126 children born between 1992 and 1994 at a mean gestational age of 27 weeks, who were recruited from the New South Wales, Australia, neonatal intensive care units database, and 34 age-matched controls who were born full term. The average weight at birth was 862 g for the children born prematurely, compared with 3,420 g for the children born full term.

Medical records available for 104 preterm children showed 37 (35.5%) had CLDP, defined as any infant who was still dependent on supplemental oxygen at 36 weeks, and 46 of the 104 (44%) had received systemic corticosteroids at any time during the initial neonatal intensive care unit stay immediately after birth.

There was no difference in spirometry between children born prematurely who were diagnosed with CLDP as neonates and those who were not, said Ms. Smith, a PhD candidate at the University of Sydney, New South Wales, and her associates.

Spirometry values were significantly lower in the preterm group, compared with controls: mean forced vital capacity, 96% vs. 102%; mean forced expiratory volume in 1 second (FEV₁), 85% vs. 95%; and forced expiratory flow at 25%–75% of forced vital capacity (FEF_25%–75%), 72% vs. 91%.

The preterm children who received postnatal corticosteroids had significantly lower flows than those who did not (FEV₁, 82% vs. 88% and FEF_25%–75%, 65% vs. 78%). These measures were within “normal limits” for lung function, Ms. Smith said.

In a regression analysis, cumulative steroid use, age of first steroid dose, birth weight, gestation, number of days intubated, or maximum oxygen concentration had no relationship with lung function.

“Our results highlight the fact that the definition of CLDP uses an arbitrary cut off of oxygen requirement at 36 weeks' gestational age,” Ms. Smith said. “There are no standardized criteria to assist the decision to cease supplemental oxygen, and it is likely to differ in different neonatal units.”

In reality, a number of children in the non-CLDP group may have only just come off supplemental oxygen by 36 weeks, she said. Likewise, some in the CLDP group may not have needed oxygen at 36 weeks, Ms. Smith added, thus the lack of association of reduced lung function with CLDP.

In a question-and-answer session, audience members called the corticosteroid data fascinating, but posited that a number of the preterm children must have fallen outside of “normal” limits for lung function. Ms. Smith said there was a range of results, particularly in airway flow, both for those preterm children who received steroids and those who did not. Data that were not presented indicate that fitness and exercise tolerance are markedly reduced in the entire preterm group, with results less than 50% of those in the control group, she said.

MONTREAL — A diagnosis of chronic lung disease of prematurity did not predict reduced lung function in childhood in a study of long-term respiratory outcomes in children born extremely prematurely.

But the study provided evidence that postnatal corticosteroid use is associated with reduced childhood lung function, although a causal relationship could not be definitively established, Ms. Lucia Smith said at the Seventh International Congress on Pediatric Pulmonology.

The lack of association of reduced lung function with chronic lung disease of prematurity (CLDP) runs contrary to traditional opinion in the literature, which suggests lung function is significantly reduced in children with CLDP.

“Most older studies have tended to compare children with CLDP with term controls rather than preterm controls, but our results are consistent with results in recent studies in CLDP cohorts,” Ms. Smith said in an interview.

The cross-sectional study included 126 children born between 1992 and 1994 at a mean gestational age of 27 weeks, who were recruited from the New South Wales, Australia, neonatal intensive care units database, and 34 age-matched controls who were born full term. The average weight at birth was 862 g for the children born prematurely, compared with 3,420 g for the children born full term.

Medical records available for 104 preterm children showed 37 (35.5%) had CLDP, defined as any infant who was still dependent on supplemental oxygen at 36 weeks, and 46 of the 104 (44%) had received systemic corticosteroids at any time during the initial neonatal intensive care unit stay immediately after birth.

There was no difference in spirometry between children born prematurely who were diagnosed with CLDP as neonates and those who were not, said Ms. Smith, a PhD candidate at the University of Sydney, New South Wales, and her associates.

Spirometry values were significantly lower in the preterm group, compared with controls: mean forced vital capacity, 96% vs. 102%; mean forced expiratory volume in 1 second (FEV₁), 85% vs. 95%; and forced expiratory flow at 25%–75% of forced vital capacity (FEF_25%–75%), 72% vs. 91%.

The preterm children who received postnatal corticosteroids had significantly lower flows than those who did not (FEV₁, 82% vs. 88% and FEF_25%–75%, 65% vs. 78%). These measures were within “normal limits” for lung function, Ms. Smith said.

In a regression analysis, cumulative steroid use, age of first steroid dose, birth weight, gestation, number of days intubated, or maximum oxygen concentration had no relationship with lung function.

“Our results highlight the fact that the definition of CLDP uses an arbitrary cut off of oxygen requirement at 36 weeks' gestational age,” Ms. Smith said. “There are no standardized criteria to assist the decision to cease supplemental oxygen, and it is likely to differ in different neonatal units.”

In reality, a number of children in the non-CLDP group may have only just come off supplemental oxygen by 36 weeks, she said. Likewise, some in the CLDP group may not have needed oxygen at 36 weeks, Ms. Smith added, thus the lack of association of reduced lung function with CLDP.

In a question-and-answer session, audience members called the corticosteroid data fascinating, but posited that a number of the preterm children must have fallen outside of “normal” limits for lung function. Ms. Smith said there was a range of results, particularly in airway flow, both for those preterm children who received steroids and those who did not. Data that were not presented indicate that fitness and exercise tolerance are markedly reduced in the entire preterm group, with results less than 50% of those in the control group, she said.

NICE, FRANCE — A provocative study has identified an association between the use of statins and favorable outcomes during influenza epidemics.

In the retrospective cohort analysis, statin therapy was associated with substantial reductions in mainly respiratory diseases, but also in death from all causes, Dr. Theo Verheij said at the 16th European Congress of Clinical Microbiology and Infectious Diseases.

As for the mechanism, it is theorized that statins could have anti-inflammatory properties or an effect on immune status, he said. Three small studies have shown that statins have an anti-inflammatory effect in patients with bacteremia. In addition, a recent study identified an association between statin use and reduced sepsis in patients hospitalized for acute coronary syndrome, ischemic stroke, or revascularization (Lancet 2006;367:372–3).

Dr. Verheij and his colleagues assessed patients, aged 50 years or older, from the primary care network of the University Medical Center in Utrecht, the Netherlands. The patients were followed up during eight epidemic and nonepidemic influenza seasons from 1998 to 2003, said Dr. Verheij, a professor of general practice with the university.

The primary end point was a composite of community-acquired pneumonia, prednisone-treated acute respiratory disease, myocardial infarction, stroke, and death from all causes. Adjustments were made in the analysis for age, gender, insurance, number of general practice visits, concomitant medicine use, medical conditions including diabetes mellitus and psychiatric disorders, and influenza vaccination.

A total of 22,638 patients provided 130,558 person-periods (each influenza season was considered a period). Statin therapy (simvastatin, pravastatin, fluvastatin, atorvastatin, and rosuvastatin) was used in 6,982 (5.3%) person-periods and influenza vaccinations in 36,556 (28%). The primary end point occurred in 3.2% of person-periods, and most events (72%) were respiratory, he reported.

During influenza epidemics, statin therapy was associated with a 33% reduction in the primary end point (relative risk 0.67), a 26% reduction in respiratory disease (RR 0.74), and a 51% reduction in all-cause mortality (RR 0.49); these results were significantly different from outcomes in patients who were not using statins. The risk of pneumonia was reduced by 28% (RR 0.62) and the risk of acute respiratory disease was reduced by 21% (RR 0.79).

The findings were consistent across subgroups defined by age, cardiovascular disease, or exposure to influenza vaccination. In nonepidemic influenza seasons, there was no significant reduction in risk, except for all-cause death.

A dose-response relationship convinced the investigators that statin therapy provided a protective effect, Dr. Verheij said. Statin therapy was associated with a 33% reduction of any event among patients taking less than two daily defined doses and a 44% reduction among those taking two or more daily defined doses (RR 0.67 and 0.56, respectively, compared with patients who did not use statins).

The findings should be used to direct future studies into potential implications, particularly during pandemics, he said.

ELSEVIER GLOBAL MEDICAL NEWS

NICE, FRANCE — A provocative study has identified an association between the use of statins and favorable outcomes during influenza epidemics.

In the retrospective cohort analysis, statin therapy was associated with substantial reductions in mainly respiratory diseases, but also in death from all causes, Dr. Theo Verheij said at the 16th European Congress of Clinical Microbiology and Infectious Diseases.

As for the mechanism, it is theorized that statins could have anti-inflammatory properties or an effect on immune status, he said. Three small studies have shown that statins have an anti-inflammatory effect in patients with bacteremia. In addition, a recent study identified an association between statin use and reduced sepsis in patients hospitalized for acute coronary syndrome, ischemic stroke, or revascularization (Lancet 2006;367:372–3).

Dr. Verheij and his colleagues assessed patients, aged 50 years or older, from the primary care network of the University Medical Center in Utrecht, the Netherlands. The patients were followed up during eight epidemic and nonepidemic influenza seasons from 1998 to 2003, said Dr. Verheij, a professor of general practice with the university.

The primary end point was a composite of community-acquired pneumonia, prednisone-treated acute respiratory disease, myocardial infarction, stroke, and death from all causes. Adjustments were made in the analysis for age, gender, insurance, number of general practice visits, concomitant medicine use, medical conditions including diabetes mellitus and psychiatric disorders, and influenza vaccination.

A total of 22,638 patients provided 130,558 person-periods (each influenza season was considered a period). Statin therapy (simvastatin, pravastatin, fluvastatin, atorvastatin, and rosuvastatin) was used in 6,982 (5.3%) person-periods and influenza vaccinations in 36,556 (28%). The primary end point occurred in 3.2% of person-periods, and most events (72%) were respiratory, he reported.

During influenza epidemics, statin therapy was associated with a 33% reduction in the primary end point (relative risk 0.67), a 26% reduction in respiratory disease (RR 0.74), and a 51% reduction in all-cause mortality (RR 0.49); these results were significantly different from outcomes in patients who were not using statins. The risk of pneumonia was reduced by 28% (RR 0.62) and the risk of acute respiratory disease was reduced by 21% (RR 0.79).

The findings were consistent across subgroups defined by age, cardiovascular disease, or exposure to influenza vaccination. In nonepidemic influenza seasons, there was no significant reduction in risk, except for all-cause death.

A dose-response relationship convinced the investigators that statin therapy provided a protective effect, Dr. Verheij said. Statin therapy was associated with a 33% reduction of any event among patients taking less than two daily defined doses and a 44% reduction among those taking two or more daily defined doses (RR 0.67 and 0.56, respectively, compared with patients who did not use statins).

The findings should be used to direct future studies into potential implications, particularly during pandemics, he said.

ELSEVIER GLOBAL MEDICAL NEWS

NICE, FRANCE — A provocative study has identified an association between the use of statins and favorable outcomes during influenza epidemics.

In the retrospective cohort analysis, statin therapy was associated with substantial reductions in mainly respiratory diseases, but also in death from all causes, Dr. Theo Verheij said at the 16th European Congress of Clinical Microbiology and Infectious Diseases.

As for the mechanism, it is theorized that statins could have anti-inflammatory properties or an effect on immune status, he said. Three small studies have shown that statins have an anti-inflammatory effect in patients with bacteremia. In addition, a recent study identified an association between statin use and reduced sepsis in patients hospitalized for acute coronary syndrome, ischemic stroke, or revascularization (Lancet 2006;367:372–3).

Dr. Verheij and his colleagues assessed patients, aged 50 years or older, from the primary care network of the University Medical Center in Utrecht, the Netherlands. The patients were followed up during eight epidemic and nonepidemic influenza seasons from 1998 to 2003, said Dr. Verheij, a professor of general practice with the university.

The primary end point was a composite of community-acquired pneumonia, prednisone-treated acute respiratory disease, myocardial infarction, stroke, and death from all causes. Adjustments were made in the analysis for age, gender, insurance, number of general practice visits, concomitant medicine use, medical conditions including diabetes mellitus and psychiatric disorders, and influenza vaccination.

A total of 22,638 patients provided 130,558 person-periods (each influenza season was considered a period). Statin therapy (simvastatin, pravastatin, fluvastatin, atorvastatin, and rosuvastatin) was used in 6,982 (5.3%) person-periods and influenza vaccinations in 36,556 (28%). The primary end point occurred in 3.2% of person-periods, and most events (72%) were respiratory, he reported.

During influenza epidemics, statin therapy was associated with a 33% reduction in the primary end point (relative risk 0.67), a 26% reduction in respiratory disease (RR 0.74), and a 51% reduction in all-cause mortality (RR 0.49); these results were significantly different from outcomes in patients who were not using statins. The risk of pneumonia was reduced by 28% (RR 0.62) and the risk of acute respiratory disease was reduced by 21% (RR 0.79).

The findings were consistent across subgroups defined by age, cardiovascular disease, or exposure to influenza vaccination. In nonepidemic influenza seasons, there was no significant reduction in risk, except for all-cause death.

A dose-response relationship convinced the investigators that statin therapy provided a protective effect, Dr. Verheij said. Statin therapy was associated with a 33% reduction of any event among patients taking less than two daily defined doses and a 44% reduction among those taking two or more daily defined doses (RR 0.67 and 0.56, respectively, compared with patients who did not use statins).

The findings should be used to direct future studies into potential implications, particularly during pandemics, he said.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — A nasal spray formulation of the osteoporosis drug, teriparatide, has cleared its first scientific hurdle.

Intranasal parathyroid hormone (PTH1–34) demonstrated a similar absorption profile as the approved injectable product, Forteo, in a phase I, pharmacokinetics study, Dr. Gordon Brandt and colleagues reported in a poster at the annual meeting of the American Association of Clinical Endocrinologists.

Twelve healthy men and women, ages 20–40 years, received a 20-mcg injection of teriparatide on day 1, followed by single doses of teriparatide nasal spray on 4 subsequent days. Two nasal formulations at two dose levels were evaluated: Formulation No. 1 was given at 200 mcg and 400 mcg and formulation No. 2 at 500 mcg and 1,000 mcg. Blood samples were collected up to 4 hours post treatment.

The times of maximal drug concentration for teriparatide nasal spray and Forteo were not statistically different, reported Dr. Brandt, executive vice president, clinical research and medical affairs, Nastech Pharmaceutical Co., Bothell, Wash., which sponsored the study.

While Forteo achieves a 50-pg/mL peak blood level after subcutaneous administration, the tested doses of nasal spray delivered up to a 400-pg/mL peak blood level, Dr. Brandt said in an interview. “In this first-in-man study, we administered higher doses than are required, so in subsequent studies we will adjust the doses,” he said.

Still, while the bioavailability of Forteo was 95%, the bioavailability of the nasal formulation No. 1 was only about 5%–8% and 12%–15% for the second formulation.

Intersubject variability for the nasal sprays was similar to or lower than Forteo, suggesting that intranasal dosing may provide consistent dosing. “I think the take-home is that contrary to what you might think, the nasal spray in fact doesn't result in markedly greater variability than an injection,” he said.

There was no nasal irritation with the nasal sprays. Interestingly, two patients developed hypercalcemia after the Forteo injection, whereas there were no reports of hypercalcemia following any nasal spray dosing.

Procter & Gamble has signed an agreement with Nastech to further develop the nasal spray formulation, Dr. Brandt said. The U.S. Food and Drug Administration has put the nasal formulation on a 505(b)(2) regulatory path, which requires only a single noninferiority study of the nasal sprays versus Forteo. The timing of this study has not been announced. In a separate poster at the same meeting, cost and side effects were identified as significant barriers for patients considering teriparatide.

In a retrospective study of 84 patients who had received a recommendation for teriparatide for severe osteoporosis since 2004, 28 patients (33%) refused the drug primarily because of cost, concerns about subcutaneous injections, or anxiety surrounding the incidence of osteosarcomas in rat studies, Dr. Pauline Camacho and Laurie Bachrach, of Loyola University Health System, Chicago, reported. A 28-day supply of teriparatide averaged $96.50.

Of the 56 patients who tried teriparatide, only 34 took the drug for 1 year. At 1 year, the mean change in bone mineral density of the lumbar spine was 6.9%.

Of the 52 patients who responded to a survey about side effects, 26 reported one or more.

CHICAGO — A nasal spray formulation of the osteoporosis drug, teriparatide, has cleared its first scientific hurdle.

Intranasal parathyroid hormone (PTH1–34) demonstrated a similar absorption profile as the approved injectable product, Forteo, in a phase I, pharmacokinetics study, Dr. Gordon Brandt and colleagues reported in a poster at the annual meeting of the American Association of Clinical Endocrinologists.

Twelve healthy men and women, ages 20–40 years, received a 20-mcg injection of teriparatide on day 1, followed by single doses of teriparatide nasal spray on 4 subsequent days. Two nasal formulations at two dose levels were evaluated: Formulation No. 1 was given at 200 mcg and 400 mcg and formulation No. 2 at 500 mcg and 1,000 mcg. Blood samples were collected up to 4 hours post treatment.

The times of maximal drug concentration for teriparatide nasal spray and Forteo were not statistically different, reported Dr. Brandt, executive vice president, clinical research and medical affairs, Nastech Pharmaceutical Co., Bothell, Wash., which sponsored the study.

While Forteo achieves a 50-pg/mL peak blood level after subcutaneous administration, the tested doses of nasal spray delivered up to a 400-pg/mL peak blood level, Dr. Brandt said in an interview. “In this first-in-man study, we administered higher doses than are required, so in subsequent studies we will adjust the doses,” he said.

Still, while the bioavailability of Forteo was 95%, the bioavailability of the nasal formulation No. 1 was only about 5%–8% and 12%–15% for the second formulation.

Intersubject variability for the nasal sprays was similar to or lower than Forteo, suggesting that intranasal dosing may provide consistent dosing. “I think the take-home is that contrary to what you might think, the nasal spray in fact doesn't result in markedly greater variability than an injection,” he said.

There was no nasal irritation with the nasal sprays. Interestingly, two patients developed hypercalcemia after the Forteo injection, whereas there were no reports of hypercalcemia following any nasal spray dosing.

Procter & Gamble has signed an agreement with Nastech to further develop the nasal spray formulation, Dr. Brandt said. The U.S. Food and Drug Administration has put the nasal formulation on a 505(b)(2) regulatory path, which requires only a single noninferiority study of the nasal sprays versus Forteo. The timing of this study has not been announced. In a separate poster at the same meeting, cost and side effects were identified as significant barriers for patients considering teriparatide.

In a retrospective study of 84 patients who had received a recommendation for teriparatide for severe osteoporosis since 2004, 28 patients (33%) refused the drug primarily because of cost, concerns about subcutaneous injections, or anxiety surrounding the incidence of osteosarcomas in rat studies, Dr. Pauline Camacho and Laurie Bachrach, of Loyola University Health System, Chicago, reported. A 28-day supply of teriparatide averaged $96.50.

Of the 56 patients who tried teriparatide, only 34 took the drug for 1 year. At 1 year, the mean change in bone mineral density of the lumbar spine was 6.9%.

Of the 52 patients who responded to a survey about side effects, 26 reported one or more.

CHICAGO — A nasal spray formulation of the osteoporosis drug, teriparatide, has cleared its first scientific hurdle.

Intranasal parathyroid hormone (PTH1–34) demonstrated a similar absorption profile as the approved injectable product, Forteo, in a phase I, pharmacokinetics study, Dr. Gordon Brandt and colleagues reported in a poster at the annual meeting of the American Association of Clinical Endocrinologists.

Twelve healthy men and women, ages 20–40 years, received a 20-mcg injection of teriparatide on day 1, followed by single doses of teriparatide nasal spray on 4 subsequent days. Two nasal formulations at two dose levels were evaluated: Formulation No. 1 was given at 200 mcg and 400 mcg and formulation No. 2 at 500 mcg and 1,000 mcg. Blood samples were collected up to 4 hours post treatment.

The times of maximal drug concentration for teriparatide nasal spray and Forteo were not statistically different, reported Dr. Brandt, executive vice president, clinical research and medical affairs, Nastech Pharmaceutical Co., Bothell, Wash., which sponsored the study.

While Forteo achieves a 50-pg/mL peak blood level after subcutaneous administration, the tested doses of nasal spray delivered up to a 400-pg/mL peak blood level, Dr. Brandt said in an interview. “In this first-in-man study, we administered higher doses than are required, so in subsequent studies we will adjust the doses,” he said.

Still, while the bioavailability of Forteo was 95%, the bioavailability of the nasal formulation No. 1 was only about 5%–8% and 12%–15% for the second formulation.

Intersubject variability for the nasal sprays was similar to or lower than Forteo, suggesting that intranasal dosing may provide consistent dosing. “I think the take-home is that contrary to what you might think, the nasal spray in fact doesn't result in markedly greater variability than an injection,” he said.

There was no nasal irritation with the nasal sprays. Interestingly, two patients developed hypercalcemia after the Forteo injection, whereas there were no reports of hypercalcemia following any nasal spray dosing.

Procter & Gamble has signed an agreement with Nastech to further develop the nasal spray formulation, Dr. Brandt said. The U.S. Food and Drug Administration has put the nasal formulation on a 505(b)(2) regulatory path, which requires only a single noninferiority study of the nasal sprays versus Forteo. The timing of this study has not been announced. In a separate poster at the same meeting, cost and side effects were identified as significant barriers for patients considering teriparatide.

In a retrospective study of 84 patients who had received a recommendation for teriparatide for severe osteoporosis since 2004, 28 patients (33%) refused the drug primarily because of cost, concerns about subcutaneous injections, or anxiety surrounding the incidence of osteosarcomas in rat studies, Dr. Pauline Camacho and Laurie Bachrach, of Loyola University Health System, Chicago, reported. A 28-day supply of teriparatide averaged $96.50.

Of the 56 patients who tried teriparatide, only 34 took the drug for 1 year. At 1 year, the mean change in bone mineral density of the lumbar spine was 6.9%.

Of the 52 patients who responded to a survey about side effects, 26 reported one or more.

CHICAGO — Transnasal esophagoscopy easily identified esophageal abnormalities without sedation in an office-based setting during a small, prospective study.

The procedure, which allows endoscopic visualization of the aerodigestive tract from the nasal vestibule to the gastric cardia, is currently limited to a small number of U.S. centers. But the findings suggest that office-based transnasal esophagoscopy could make screening more accessible in patients with esophageal reflux, globus, and dysphagia, Dr. Thomas Takoudes said at the Combined Otolaryngology Spring Meetings.

Esophageal reflux affects up to 40% of adult Americans, many of whom will develop Barrett's esophagus, a known risk factor for esophageal cancer. “Given the incidence of severe reflux, this [procedure] should be as accessible as digital rectal exams and [prostate-specific antigen] tests for prostate cancer and Pap tests for cervical cancer,” he said.

The study included 21 consecutive transnasal esophago-scopy procedures performed in 19 patients over a 6-month period. Dr. Takoudes used the Vision-Sciences Inc. esophagoscope, which has a single-use, disposable sheath. In all of the patients, the nose was sprayed with oxymetazoline and lidocaine to reduce discomfort.

No complications were observed. “With this procedure, the tube goes through the nose without sedation, and a half an hour later, they go home or to work. It's so much easier for the patient,” he said.

Indications for the procedure were: laryngopharyngeal reflux with failed proton pump inhibitor therapy in 11 patients (58%); dysphagia without a history of reflux in 7 (37%); head/neck cancer in 2 (11%); and abnormal esophagus on CT scan in 1 patient (5%). Some patients had multiple indications.

One procedure could not be completed due to patient discomfort.

Significant findings were identified in 10 of 20 procedures (50%), including two cases of diverticulum, two Candida esophagitis, two hiatal hernia, two patulous esophagus, two abnormal motility, two Barrett's esophagus, and one achalasia, said Dr. Takoudes, of the Ear, Nose, & Throat Medical and Surgical Group in New Haven, Conn. Multiple findings were seen in some patients.

Use of transnasal esophagoscopy as a screening tool was validated in a recent large study in which significant findings were identified in half of 592 procedures performed for reflux, globus, or dysphagia. The study was performed in a tertiary care center (Laryngoscope 2005;115:321–3).

Procedure failure rates were similar in both studies; 3% at the tertiary care center and 5% in the office-based setting, Dr. Takoudes said.

Dr. Thomas Takoudes demonstrates the procedure, which is limited to a small number of U.S. centers. COURTESY DR. THOMAS TAKOUDES

CHICAGO — Transnasal esophagoscopy easily identified esophageal abnormalities without sedation in an office-based setting during a small, prospective study.

The procedure, which allows endoscopic visualization of the aerodigestive tract from the nasal vestibule to the gastric cardia, is currently limited to a small number of U.S. centers. But the findings suggest that office-based transnasal esophagoscopy could make screening more accessible in patients with esophageal reflux, globus, and dysphagia, Dr. Thomas Takoudes said at the Combined Otolaryngology Spring Meetings.

Esophageal reflux affects up to 40% of adult Americans, many of whom will develop Barrett's esophagus, a known risk factor for esophageal cancer. “Given the incidence of severe reflux, this [procedure] should be as accessible as digital rectal exams and [prostate-specific antigen] tests for prostate cancer and Pap tests for cervical cancer,” he said.

The study included 21 consecutive transnasal esophago-scopy procedures performed in 19 patients over a 6-month period. Dr. Takoudes used the Vision-Sciences Inc. esophagoscope, which has a single-use, disposable sheath. In all of the patients, the nose was sprayed with oxymetazoline and lidocaine to reduce discomfort.

No complications were observed. “With this procedure, the tube goes through the nose without sedation, and a half an hour later, they go home or to work. It's so much easier for the patient,” he said.

Indications for the procedure were: laryngopharyngeal reflux with failed proton pump inhibitor therapy in 11 patients (58%); dysphagia without a history of reflux in 7 (37%); head/neck cancer in 2 (11%); and abnormal esophagus on CT scan in 1 patient (5%). Some patients had multiple indications.

One procedure could not be completed due to patient discomfort.

Significant findings were identified in 10 of 20 procedures (50%), including two cases of diverticulum, two Candida esophagitis, two hiatal hernia, two patulous esophagus, two abnormal motility, two Barrett's esophagus, and one achalasia, said Dr. Takoudes, of the Ear, Nose, & Throat Medical and Surgical Group in New Haven, Conn. Multiple findings were seen in some patients.

Use of transnasal esophagoscopy as a screening tool was validated in a recent large study in which significant findings were identified in half of 592 procedures performed for reflux, globus, or dysphagia. The study was performed in a tertiary care center (Laryngoscope 2005;115:321–3).

Procedure failure rates were similar in both studies; 3% at the tertiary care center and 5% in the office-based setting, Dr. Takoudes said.

Dr. Thomas Takoudes demonstrates the procedure, which is limited to a small number of U.S. centers. COURTESY DR. THOMAS TAKOUDES

CHICAGO — Transnasal esophagoscopy easily identified esophageal abnormalities without sedation in an office-based setting during a small, prospective study.

The procedure, which allows endoscopic visualization of the aerodigestive tract from the nasal vestibule to the gastric cardia, is currently limited to a small number of U.S. centers. But the findings suggest that office-based transnasal esophagoscopy could make screening more accessible in patients with esophageal reflux, globus, and dysphagia, Dr. Thomas Takoudes said at the Combined Otolaryngology Spring Meetings.

Esophageal reflux affects up to 40% of adult Americans, many of whom will develop Barrett's esophagus, a known risk factor for esophageal cancer. “Given the incidence of severe reflux, this [procedure] should be as accessible as digital rectal exams and [prostate-specific antigen] tests for prostate cancer and Pap tests for cervical cancer,” he said.

The study included 21 consecutive transnasal esophago-scopy procedures performed in 19 patients over a 6-month period. Dr. Takoudes used the Vision-Sciences Inc. esophagoscope, which has a single-use, disposable sheath. In all of the patients, the nose was sprayed with oxymetazoline and lidocaine to reduce discomfort.

No complications were observed. “With this procedure, the tube goes through the nose without sedation, and a half an hour later, they go home or to work. It's so much easier for the patient,” he said.

Indications for the procedure were: laryngopharyngeal reflux with failed proton pump inhibitor therapy in 11 patients (58%); dysphagia without a history of reflux in 7 (37%); head/neck cancer in 2 (11%); and abnormal esophagus on CT scan in 1 patient (5%). Some patients had multiple indications.

One procedure could not be completed due to patient discomfort.

Significant findings were identified in 10 of 20 procedures (50%), including two cases of diverticulum, two Candida esophagitis, two hiatal hernia, two patulous esophagus, two abnormal motility, two Barrett's esophagus, and one achalasia, said Dr. Takoudes, of the Ear, Nose, & Throat Medical and Surgical Group in New Haven, Conn. Multiple findings were seen in some patients.

Use of transnasal esophagoscopy as a screening tool was validated in a recent large study in which significant findings were identified in half of 592 procedures performed for reflux, globus, or dysphagia. The study was performed in a tertiary care center (Laryngoscope 2005;115:321–3).

Procedure failure rates were similar in both studies; 3% at the tertiary care center and 5% in the office-based setting, Dr. Takoudes said.

Dr. Thomas Takoudes demonstrates the procedure, which is limited to a small number of U.S. centers. COURTESY DR. THOMAS TAKOUDES

CHICAGO — Immunologic thrombocytopenia was associated with an increased prevalence of thyroid disease in a retrospective longitudinal study.

The finding argues for routine screening for thyroid disease in patients with immunologic thrombocytopenia. The study also indicated that treating the thyroid disease did not influence the long-term course of the thrombocytopenia, Dr. Adriana Ioachimescu and her colleagues at the Cleveland Clinic Foundation reported in a poster at the annual meeting of the American Association of Clinical Endocrinologists.

American Society of Hematology guidelines on immunologic thrombocytopenia, last updated in 1996, state that thyroid function evaluation has “uncertain appropriateness” in adults with immunologic thrombocytopenia. Testing is considered appropriate only before elective splenectomy to rule out occult hyper- or hypothyroidism.

Thyroid function tests, available in 80 of 98 patients consecutively diagnosed with immunologic thrombocytopenia by a single provider between 1988 and 2005, indicated 20% had thyroid disease. Ten were hypothyroid and six were hyperthyroid. Patient ages ranged from 21 to 75 years, and the average follow-up was 131 months. The onset of the two conditions was simultaneous in 4 of the 16 cases.

The study represents the largest cohort and longest follow-up of patients with both conditions, Dr. Ioachimescu said in an interview. Only three studies evaluating the association between the two disorders have been published since 1931. Based on these studies, the estimated prevalence of thyroid disease in patients with immunologic thrombocytopenia would be 5%–14%, she said. The prevalence of hyper- or hypothyroidism is about 5%–6% in the general population.

In Dr. Ioachimescu's study, all patients with hypothyroidism received thyroid supplementation and eventually reached a normal level of thyroid-stimulating hormone. Five of the six patients with hyperthyroidism became hypothyroid after radioactive iodine treatment, and needed thyroid hormone supplementation. The sixth patient with hyperthyroidism remained euthyroid after methimazole therapy.

Of the 16 patients with thyroid disease, 14 required treatment for their thrombocytopenia; medical therapy was provided in 13, and splenectomy was performed in 6.

Previous case reports of patients with both disorders have shown significant increases in platelet count after thyroid treatment. In the current study, platelet counts transiently increased in three patients after normal thyroid function was restored. No changes were seen in the other 13 patients. The discrepancy between findings could be due to publication bias, as case reports and case series tend to present positive findings, or because prior reported cases were associated with more severe hyperthyroidism, which affected platelet counts, she said.

Further studies are needed to determine if thyroid autoantibodies have a direct impact on the platelet count or whether they simply represent a marker of the autoimmune thyroid disease, Dr. Ioachimescu reported.

CHICAGO — Immunologic thrombocytopenia was associated with an increased prevalence of thyroid disease in a retrospective longitudinal study.

The finding argues for routine screening for thyroid disease in patients with immunologic thrombocytopenia. The study also indicated that treating the thyroid disease did not influence the long-term course of the thrombocytopenia, Dr. Adriana Ioachimescu and her colleagues at the Cleveland Clinic Foundation reported in a poster at the annual meeting of the American Association of Clinical Endocrinologists.

American Society of Hematology guidelines on immunologic thrombocytopenia, last updated in 1996, state that thyroid function evaluation has “uncertain appropriateness” in adults with immunologic thrombocytopenia. Testing is considered appropriate only before elective splenectomy to rule out occult hyper- or hypothyroidism.

Thyroid function tests, available in 80 of 98 patients consecutively diagnosed with immunologic thrombocytopenia by a single provider between 1988 and 2005, indicated 20% had thyroid disease. Ten were hypothyroid and six were hyperthyroid. Patient ages ranged from 21 to 75 years, and the average follow-up was 131 months. The onset of the two conditions was simultaneous in 4 of the 16 cases.

The study represents the largest cohort and longest follow-up of patients with both conditions, Dr. Ioachimescu said in an interview. Only three studies evaluating the association between the two disorders have been published since 1931. Based on these studies, the estimated prevalence of thyroid disease in patients with immunologic thrombocytopenia would be 5%–14%, she said. The prevalence of hyper- or hypothyroidism is about 5%–6% in the general population.

In Dr. Ioachimescu's study, all patients with hypothyroidism received thyroid supplementation and eventually reached a normal level of thyroid-stimulating hormone. Five of the six patients with hyperthyroidism became hypothyroid after radioactive iodine treatment, and needed thyroid hormone supplementation. The sixth patient with hyperthyroidism remained euthyroid after methimazole therapy.

Of the 16 patients with thyroid disease, 14 required treatment for their thrombocytopenia; medical therapy was provided in 13, and splenectomy was performed in 6.

Previous case reports of patients with both disorders have shown significant increases in platelet count after thyroid treatment. In the current study, platelet counts transiently increased in three patients after normal thyroid function was restored. No changes were seen in the other 13 patients. The discrepancy between findings could be due to publication bias, as case reports and case series tend to present positive findings, or because prior reported cases were associated with more severe hyperthyroidism, which affected platelet counts, she said.

Further studies are needed to determine if thyroid autoantibodies have a direct impact on the platelet count or whether they simply represent a marker of the autoimmune thyroid disease, Dr. Ioachimescu reported.

CHICAGO — Immunologic thrombocytopenia was associated with an increased prevalence of thyroid disease in a retrospective longitudinal study.

The finding argues for routine screening for thyroid disease in patients with immunologic thrombocytopenia. The study also indicated that treating the thyroid disease did not influence the long-term course of the thrombocytopenia, Dr. Adriana Ioachimescu and her colleagues at the Cleveland Clinic Foundation reported in a poster at the annual meeting of the American Association of Clinical Endocrinologists.

American Society of Hematology guidelines on immunologic thrombocytopenia, last updated in 1996, state that thyroid function evaluation has “uncertain appropriateness” in adults with immunologic thrombocytopenia. Testing is considered appropriate only before elective splenectomy to rule out occult hyper- or hypothyroidism.

Thyroid function tests, available in 80 of 98 patients consecutively diagnosed with immunologic thrombocytopenia by a single provider between 1988 and 2005, indicated 20% had thyroid disease. Ten were hypothyroid and six were hyperthyroid. Patient ages ranged from 21 to 75 years, and the average follow-up was 131 months. The onset of the two conditions was simultaneous in 4 of the 16 cases.

The study represents the largest cohort and longest follow-up of patients with both conditions, Dr. Ioachimescu said in an interview. Only three studies evaluating the association between the two disorders have been published since 1931. Based on these studies, the estimated prevalence of thyroid disease in patients with immunologic thrombocytopenia would be 5%–14%, she said. The prevalence of hyper- or hypothyroidism is about 5%–6% in the general population.

In Dr. Ioachimescu's study, all patients with hypothyroidism received thyroid supplementation and eventually reached a normal level of thyroid-stimulating hormone. Five of the six patients with hyperthyroidism became hypothyroid after radioactive iodine treatment, and needed thyroid hormone supplementation. The sixth patient with hyperthyroidism remained euthyroid after methimazole therapy.

Of the 16 patients with thyroid disease, 14 required treatment for their thrombocytopenia; medical therapy was provided in 13, and splenectomy was performed in 6.

Previous case reports of patients with both disorders have shown significant increases in platelet count after thyroid treatment. In the current study, platelet counts transiently increased in three patients after normal thyroid function was restored. No changes were seen in the other 13 patients. The discrepancy between findings could be due to publication bias, as case reports and case series tend to present positive findings, or because prior reported cases were associated with more severe hyperthyroidism, which affected platelet counts, she said.

Further studies are needed to determine if thyroid autoantibodies have a direct impact on the platelet count or whether they simply represent a marker of the autoimmune thyroid disease, Dr. Ioachimescu reported.