Mary Ann Moon

Periodontitis Linked to HT

For the first time, periodontal disease has been linked with renal insufficiency and its attendant hypertension in a community-based study of atherosclerosis risk.

Noting that periodontitis has been linked to both cardiovascular and cerebrovascular disease, Abhijit V. Kshirsagar, M.D., and his associates at the University of North Carolina, Chapel Hill, assessed whether it might also be linked to chronic kidney disease, which has similar risk factors, including inflammation. In their study of 5,537 middle-aged adults residing in four U.S. communities, 41% were found to have early periodontitis, 17% had severe periodontitis, and the rest had healthy gums (Am. J. Kidney Dis. 2005;45:650–7).

Those with either early or severe dental disease were twice as likely as were the others to have impaired renal function and its attendant hypertension.

Combining CABG and Endarterectomy

Performing carotid endarterectomy at the same time as coronary artery bypass grafting (CABG) to head off a potential stroke actually seems to raise the risk of stroke, reported Michael D. Hill, M.D., of the University of Calgary (Alta.), and his associates. CABG candidates who have severe carotid stenosis are at increased risk of stroke as a complication of the procedure, compared with those without stenosis. Many centers now offer combined carotid endarterectomy and CABG procedures for such patients, in the hope of preventing this complication from arising. Some do the combined procedures routinely, even for patients with milder carotid stenosis, even though “it is not clearly known whether this is appropriate,” the investigators noted (Neurology 2005;64:1435–7).

In their study of 131,762 patients who underwent CABG in Canada during 1992–2001, including 669 who had simultaneous CABG plus carotid endarterectomy, the rate of stroke or death was nearly three times higher in the combined-procedure group (13.0%) than in the CABG-only group (4.9%). Yet utilization of the combined procedure rose steadily over the 9-year study period, increasing by as much as sevenfold in some areas.

In an editorial, Patrick Pullicino, M.D., of New Jersey Medical School, Newark, and Jonathan Halperin, M.D., of Mount Sinai Medical Center, New York, said, “The onus is now on surgeons who perform [carotid endarterectomy plus CABG] to show that it can be performed with acceptable risks” (Neurology 2005;64:1332–3).

Preinfarction Angina May Be Good Sign

Transient angina in the 24 hours before onset of MI appears to be associated with limited infarct size, preservation of myocardial viability, and preservation of left ventricular function, reported Ignacio Iglesias-Garriz, M.D., and his associates at Hospital de León (Spain).

Positive outcomes following so-called preinfarction angina (PA) have been noted in many studies. Dr. Iglesias-Garriz and his associates examined this link in a study of 78 patients with ST-segment elevation acute MI who underwent primary coronary intervention; 32 of them had experienced typical transient chest pain at rest in the day preceding the infarct (Chest 2005;127:1116–21).

Those with PA had smaller infarct size, with a mean percentage of necrotic left ventricle of 18.0%, compared with 27.0% for those who had no PA. Those with PA also had a higher rate of ST-segment resolution (65.6% vs. 45.7%) and a lower incidence of left ventricular systolic dysfunction (3.2% vs. 18.6%).

These favorable findings are probably due to “a better myocardial tissue perfusion if PA is present,” the researchers said. It is also possible that angina “triggers an intracellular signal that intrinsically preserves cells from death,” they added.

Homocysteine, AV Fistula Thrombosis

High homocysteine levels predict which hemodialysis patients are likely to develop thrombosis of the native arteriovenous fistula that allows vascular access for the procedure, reported Francesca Mallamaci, M.D., of the Institute of Biomedicine, Calabria, Italy, and her associates.

In what they described as the first prospective cohort study to show a direct link between hyperhomocysteinemia and vascular access failure, the researchers followed 205 hemodialysis patients with native AV fistulas in either the upper or the lower arm for a mean of 32 months. The 78 patients who developed one or more vascular access thromboses had significantly higher homocysteine levels (3.91 mg/L) than did patients without thromboses (3.45 mg/L). The relative risk for thrombotic events was nearly twice as high in the one-third of patients with the highest homocysteine levels than in the one-third who had the lowest levels (Am. J. Kidney Dis. 2005;45:702–7). Further study should examine whether reducing homocysteine levels will prevent vascular access failure in hemodialysis patients, they added.

Periodontitis Linked to HT

For the first time, periodontal disease has been linked with renal insufficiency and its attendant hypertension in a community-based study of atherosclerosis risk.

Noting that periodontitis has been linked to both cardiovascular and cerebrovascular disease, Abhijit V. Kshirsagar, M.D., and his associates at the University of North Carolina, Chapel Hill, assessed whether it might also be linked to chronic kidney disease, which has similar risk factors, including inflammation. In their study of 5,537 middle-aged adults residing in four U.S. communities, 41% were found to have early periodontitis, 17% had severe periodontitis, and the rest had healthy gums (Am. J. Kidney Dis. 2005;45:650–7).

Those with either early or severe dental disease were twice as likely as were the others to have impaired renal function and its attendant hypertension.

Combining CABG and Endarterectomy

Performing carotid endarterectomy at the same time as coronary artery bypass grafting (CABG) to head off a potential stroke actually seems to raise the risk of stroke, reported Michael D. Hill, M.D., of the University of Calgary (Alta.), and his associates. CABG candidates who have severe carotid stenosis are at increased risk of stroke as a complication of the procedure, compared with those without stenosis. Many centers now offer combined carotid endarterectomy and CABG procedures for such patients, in the hope of preventing this complication from arising. Some do the combined procedures routinely, even for patients with milder carotid stenosis, even though “it is not clearly known whether this is appropriate,” the investigators noted (Neurology 2005;64:1435–7).

In their study of 131,762 patients who underwent CABG in Canada during 1992–2001, including 669 who had simultaneous CABG plus carotid endarterectomy, the rate of stroke or death was nearly three times higher in the combined-procedure group (13.0%) than in the CABG-only group (4.9%). Yet utilization of the combined procedure rose steadily over the 9-year study period, increasing by as much as sevenfold in some areas.

In an editorial, Patrick Pullicino, M.D., of New Jersey Medical School, Newark, and Jonathan Halperin, M.D., of Mount Sinai Medical Center, New York, said, “The onus is now on surgeons who perform [carotid endarterectomy plus CABG] to show that it can be performed with acceptable risks” (Neurology 2005;64:1332–3).

Preinfarction Angina May Be Good Sign

Transient angina in the 24 hours before onset of MI appears to be associated with limited infarct size, preservation of myocardial viability, and preservation of left ventricular function, reported Ignacio Iglesias-Garriz, M.D., and his associates at Hospital de León (Spain).

Positive outcomes following so-called preinfarction angina (PA) have been noted in many studies. Dr. Iglesias-Garriz and his associates examined this link in a study of 78 patients with ST-segment elevation acute MI who underwent primary coronary intervention; 32 of them had experienced typical transient chest pain at rest in the day preceding the infarct (Chest 2005;127:1116–21).

Those with PA had smaller infarct size, with a mean percentage of necrotic left ventricle of 18.0%, compared with 27.0% for those who had no PA. Those with PA also had a higher rate of ST-segment resolution (65.6% vs. 45.7%) and a lower incidence of left ventricular systolic dysfunction (3.2% vs. 18.6%).

These favorable findings are probably due to “a better myocardial tissue perfusion if PA is present,” the researchers said. It is also possible that angina “triggers an intracellular signal that intrinsically preserves cells from death,” they added.

Homocysteine, AV Fistula Thrombosis

High homocysteine levels predict which hemodialysis patients are likely to develop thrombosis of the native arteriovenous fistula that allows vascular access for the procedure, reported Francesca Mallamaci, M.D., of the Institute of Biomedicine, Calabria, Italy, and her associates.

In what they described as the first prospective cohort study to show a direct link between hyperhomocysteinemia and vascular access failure, the researchers followed 205 hemodialysis patients with native AV fistulas in either the upper or the lower arm for a mean of 32 months. The 78 patients who developed one or more vascular access thromboses had significantly higher homocysteine levels (3.91 mg/L) than did patients without thromboses (3.45 mg/L). The relative risk for thrombotic events was nearly twice as high in the one-third of patients with the highest homocysteine levels than in the one-third who had the lowest levels (Am. J. Kidney Dis. 2005;45:702–7). Further study should examine whether reducing homocysteine levels will prevent vascular access failure in hemodialysis patients, they added.

Periodontitis Linked to HT

For the first time, periodontal disease has been linked with renal insufficiency and its attendant hypertension in a community-based study of atherosclerosis risk.

Noting that periodontitis has been linked to both cardiovascular and cerebrovascular disease, Abhijit V. Kshirsagar, M.D., and his associates at the University of North Carolina, Chapel Hill, assessed whether it might also be linked to chronic kidney disease, which has similar risk factors, including inflammation. In their study of 5,537 middle-aged adults residing in four U.S. communities, 41% were found to have early periodontitis, 17% had severe periodontitis, and the rest had healthy gums (Am. J. Kidney Dis. 2005;45:650–7).

Those with either early or severe dental disease were twice as likely as were the others to have impaired renal function and its attendant hypertension.

Combining CABG and Endarterectomy

Performing carotid endarterectomy at the same time as coronary artery bypass grafting (CABG) to head off a potential stroke actually seems to raise the risk of stroke, reported Michael D. Hill, M.D., of the University of Calgary (Alta.), and his associates. CABG candidates who have severe carotid stenosis are at increased risk of stroke as a complication of the procedure, compared with those without stenosis. Many centers now offer combined carotid endarterectomy and CABG procedures for such patients, in the hope of preventing this complication from arising. Some do the combined procedures routinely, even for patients with milder carotid stenosis, even though “it is not clearly known whether this is appropriate,” the investigators noted (Neurology 2005;64:1435–7).

In their study of 131,762 patients who underwent CABG in Canada during 1992–2001, including 669 who had simultaneous CABG plus carotid endarterectomy, the rate of stroke or death was nearly three times higher in the combined-procedure group (13.0%) than in the CABG-only group (4.9%). Yet utilization of the combined procedure rose steadily over the 9-year study period, increasing by as much as sevenfold in some areas.

In an editorial, Patrick Pullicino, M.D., of New Jersey Medical School, Newark, and Jonathan Halperin, M.D., of Mount Sinai Medical Center, New York, said, “The onus is now on surgeons who perform [carotid endarterectomy plus CABG] to show that it can be performed with acceptable risks” (Neurology 2005;64:1332–3).

Preinfarction Angina May Be Good Sign

Transient angina in the 24 hours before onset of MI appears to be associated with limited infarct size, preservation of myocardial viability, and preservation of left ventricular function, reported Ignacio Iglesias-Garriz, M.D., and his associates at Hospital de León (Spain).

Positive outcomes following so-called preinfarction angina (PA) have been noted in many studies. Dr. Iglesias-Garriz and his associates examined this link in a study of 78 patients with ST-segment elevation acute MI who underwent primary coronary intervention; 32 of them had experienced typical transient chest pain at rest in the day preceding the infarct (Chest 2005;127:1116–21).

Those with PA had smaller infarct size, with a mean percentage of necrotic left ventricle of 18.0%, compared with 27.0% for those who had no PA. Those with PA also had a higher rate of ST-segment resolution (65.6% vs. 45.7%) and a lower incidence of left ventricular systolic dysfunction (3.2% vs. 18.6%).

These favorable findings are probably due to “a better myocardial tissue perfusion if PA is present,” the researchers said. It is also possible that angina “triggers an intracellular signal that intrinsically preserves cells from death,” they added.

Homocysteine, AV Fistula Thrombosis

High homocysteine levels predict which hemodialysis patients are likely to develop thrombosis of the native arteriovenous fistula that allows vascular access for the procedure, reported Francesca Mallamaci, M.D., of the Institute of Biomedicine, Calabria, Italy, and her associates.

In what they described as the first prospective cohort study to show a direct link between hyperhomocysteinemia and vascular access failure, the researchers followed 205 hemodialysis patients with native AV fistulas in either the upper or the lower arm for a mean of 32 months. The 78 patients who developed one or more vascular access thromboses had significantly higher homocysteine levels (3.91 mg/L) than did patients without thromboses (3.45 mg/L). The relative risk for thrombotic events was nearly twice as high in the one-third of patients with the highest homocysteine levels than in the one-third who had the lowest levels (Am. J. Kidney Dis. 2005;45:702–7). Further study should examine whether reducing homocysteine levels will prevent vascular access failure in hemodialysis patients, they added.

Response to Nitro Not Diagnostic

For patients who present with acute, severe chest pain, response to nitroglycerin does not confirm a cardiac etiology, according to Deborah B. Diercks, M.D., of the University of California, Davis, Medical Center, and her associates.

Many emergency departments use the drug to diagnose coronary disease in those who present with chest pain, the investigators said (Ann. Emerg. Med. [Epub ahead of print] March 2005. DOI:10.1016/j.annemergmed.2004.12.009).

In their prospective study of 664 patients who presented with chest pain over the course of 1 year, patients who proved to have noncardiac pain showed the same response to nitroglycerin as those who turned out to have a cardiac etiology (68 with acute MI and 54 with unstable angina). Overall, 125 subjects (19%) reported no change in chest pain after taking nitroglycerin, 206 (31%) had a minimal reduction, 145 (22%) had a moderate reduction, and 188 (28%) reported significant or complete relief from chest pain.

Nitroglycerin may have relieved noncardiac chest pain by virtue of a placebo effect or its relaxing effect on smooth muscle, such as that lining the esophagus.

CPAP Lowers CV Risk

Risk for both fatal and nonfatal cardiovascular events is much higher in men with severe obstructive sleep apnea than in men with milder forms of the disorder or men who snore but don't have apnea, but treatment with continuous positive airway pressure (CPAP) normalizes this risk, according to Jose M. Marin, M.D., of Miguel Servet University Hospital, Zaragoza, Spain (Lancet 2005;365:1046-53).

They conducted a 10-year follow-up study of 667 men with severe obstructive sleep apnea (OSA), 409 with mild to moderate OSA, 389 with snoring but no OSA, and 277 healthy controls. Men with untreated severe OSA had 2.13 nonfatal and 1.06 fatal CV events per 100 person-years. In contrast, the rates were markedly lower for healthy men (0.45 and 0.30), snorers (0.58 and 0.34), and those with milder OSA (0.89 and 0.55).

Men with severe OSA who used CPAP had cardiovascular event rates that were comparable with those of snorers and men with milder apnea (0.64 and 0.35).

Waist Size and Insulin Resistance

Waist circumference is a simple and powerful predictor of a patient's risk for developing insulin resistance, reported Hans Wahrenberg, M.D., and his associates at Karolinska University Hospital, Stockholm.

They analyzed data collected from 2,746 healthy volunteers aged 18-72 years to determine whether different body measurements and biochemical markers could predict development of insulin resistance (BMJ [Epub ahead of print], April 2005. Article DOI 10.1136/bmj.38429.473310.AE. Available at

www.bmj.com

In this retrospective study, both men and women with a waist circumference of less than 100 cm were found to have zero risk for insulin resistance. A waist size less than 100 cm was the strongest predictor that insulin resistance would not develop, ahead of body mass index, waist-to-hip ratio, measures of total body fat, triglyceride level, HDL level, and blood pressure, they said.

Telephonic ECG After AF Ablation

Transtelephonic ECG monitoring is better than standard ECG and 24-hour Holter monitoring at detecting asymptomatic relapses in atrial fibrillation after patients have undergone radiofrequency catheter ablation, reported Gaetano Senatore, M.D., of Ospedale Civile di Cirie', Italy, and associates.

The down side of this improved detection of residual atrial fibrillation (AF) is that ablation now appears much less successful than clinicians had thought, Dr. Senatore and associates noted. In a study of 72 patients who underwent ablation for refractory AF, patients obtained 30-second readings on a transtelephonic ECG monitor every day, and whenever they felt palpitations, for 90 days. They also underwent standard ECG and Holter monitoring at 30 and 120 days postablation. The transtelephonic recordings documented AF recurrences in 20 patients (27.8%), compared with only 10 patients (13.9%) identified by the standard methods. Half of the affected patients had asymptomatic episodes of AF (J. Am. Coll. Cardiol. 2005;45:873-6).

The ablation procedure's success rate was 86% according to standard monitoring methods, but dropped to 72% with the more accurate method. Most published success rates for ablation have been based on the results of standard monitoring, and so are probably overestimated, Dr. Senatore and associates said. More importantly, “physicians usually consider AF as cured if sinus rhythm is documented on routine ECG or 24-hour Holter monitoring, and they often stop anticoagulation.” These results show that many such patients continue to have asymptomatic AF and should continue to receive anticoagulation.

Response to Nitro Not Diagnostic

For patients who present with acute, severe chest pain, response to nitroglycerin does not confirm a cardiac etiology, according to Deborah B. Diercks, M.D., of the University of California, Davis, Medical Center, and her associates.

Many emergency departments use the drug to diagnose coronary disease in those who present with chest pain, the investigators said (Ann. Emerg. Med. [Epub ahead of print] March 2005. DOI:10.1016/j.annemergmed.2004.12.009).

In their prospective study of 664 patients who presented with chest pain over the course of 1 year, patients who proved to have noncardiac pain showed the same response to nitroglycerin as those who turned out to have a cardiac etiology (68 with acute MI and 54 with unstable angina). Overall, 125 subjects (19%) reported no change in chest pain after taking nitroglycerin, 206 (31%) had a minimal reduction, 145 (22%) had a moderate reduction, and 188 (28%) reported significant or complete relief from chest pain.

Nitroglycerin may have relieved noncardiac chest pain by virtue of a placebo effect or its relaxing effect on smooth muscle, such as that lining the esophagus.

CPAP Lowers CV Risk

Risk for both fatal and nonfatal cardiovascular events is much higher in men with severe obstructive sleep apnea than in men with milder forms of the disorder or men who snore but don't have apnea, but treatment with continuous positive airway pressure (CPAP) normalizes this risk, according to Jose M. Marin, M.D., of Miguel Servet University Hospital, Zaragoza, Spain (Lancet 2005;365:1046-53).

They conducted a 10-year follow-up study of 667 men with severe obstructive sleep apnea (OSA), 409 with mild to moderate OSA, 389 with snoring but no OSA, and 277 healthy controls. Men with untreated severe OSA had 2.13 nonfatal and 1.06 fatal CV events per 100 person-years. In contrast, the rates were markedly lower for healthy men (0.45 and 0.30), snorers (0.58 and 0.34), and those with milder OSA (0.89 and 0.55).

Men with severe OSA who used CPAP had cardiovascular event rates that were comparable with those of snorers and men with milder apnea (0.64 and 0.35).

Waist Size and Insulin Resistance

Waist circumference is a simple and powerful predictor of a patient's risk for developing insulin resistance, reported Hans Wahrenberg, M.D., and his associates at Karolinska University Hospital, Stockholm.

They analyzed data collected from 2,746 healthy volunteers aged 18-72 years to determine whether different body measurements and biochemical markers could predict development of insulin resistance (BMJ [Epub ahead of print], April 2005. Article DOI 10.1136/bmj.38429.473310.AE. Available at

www.bmj.com

In this retrospective study, both men and women with a waist circumference of less than 100 cm were found to have zero risk for insulin resistance. A waist size less than 100 cm was the strongest predictor that insulin resistance would not develop, ahead of body mass index, waist-to-hip ratio, measures of total body fat, triglyceride level, HDL level, and blood pressure, they said.

Telephonic ECG After AF Ablation

Transtelephonic ECG monitoring is better than standard ECG and 24-hour Holter monitoring at detecting asymptomatic relapses in atrial fibrillation after patients have undergone radiofrequency catheter ablation, reported Gaetano Senatore, M.D., of Ospedale Civile di Cirie', Italy, and associates.

The down side of this improved detection of residual atrial fibrillation (AF) is that ablation now appears much less successful than clinicians had thought, Dr. Senatore and associates noted. In a study of 72 patients who underwent ablation for refractory AF, patients obtained 30-second readings on a transtelephonic ECG monitor every day, and whenever they felt palpitations, for 90 days. They also underwent standard ECG and Holter monitoring at 30 and 120 days postablation. The transtelephonic recordings documented AF recurrences in 20 patients (27.8%), compared with only 10 patients (13.9%) identified by the standard methods. Half of the affected patients had asymptomatic episodes of AF (J. Am. Coll. Cardiol. 2005;45:873-6).

The ablation procedure's success rate was 86% according to standard monitoring methods, but dropped to 72% with the more accurate method. Most published success rates for ablation have been based on the results of standard monitoring, and so are probably overestimated, Dr. Senatore and associates said. More importantly, “physicians usually consider AF as cured if sinus rhythm is documented on routine ECG or 24-hour Holter monitoring, and they often stop anticoagulation.” These results show that many such patients continue to have asymptomatic AF and should continue to receive anticoagulation.

Response to Nitro Not Diagnostic

For patients who present with acute, severe chest pain, response to nitroglycerin does not confirm a cardiac etiology, according to Deborah B. Diercks, M.D., of the University of California, Davis, Medical Center, and her associates.

Many emergency departments use the drug to diagnose coronary disease in those who present with chest pain, the investigators said (Ann. Emerg. Med. [Epub ahead of print] March 2005. DOI:10.1016/j.annemergmed.2004.12.009).

In their prospective study of 664 patients who presented with chest pain over the course of 1 year, patients who proved to have noncardiac pain showed the same response to nitroglycerin as those who turned out to have a cardiac etiology (68 with acute MI and 54 with unstable angina). Overall, 125 subjects (19%) reported no change in chest pain after taking nitroglycerin, 206 (31%) had a minimal reduction, 145 (22%) had a moderate reduction, and 188 (28%) reported significant or complete relief from chest pain.

Nitroglycerin may have relieved noncardiac chest pain by virtue of a placebo effect or its relaxing effect on smooth muscle, such as that lining the esophagus.

CPAP Lowers CV Risk

Risk for both fatal and nonfatal cardiovascular events is much higher in men with severe obstructive sleep apnea than in men with milder forms of the disorder or men who snore but don't have apnea, but treatment with continuous positive airway pressure (CPAP) normalizes this risk, according to Jose M. Marin, M.D., of Miguel Servet University Hospital, Zaragoza, Spain (Lancet 2005;365:1046-53).

They conducted a 10-year follow-up study of 667 men with severe obstructive sleep apnea (OSA), 409 with mild to moderate OSA, 389 with snoring but no OSA, and 277 healthy controls. Men with untreated severe OSA had 2.13 nonfatal and 1.06 fatal CV events per 100 person-years. In contrast, the rates were markedly lower for healthy men (0.45 and 0.30), snorers (0.58 and 0.34), and those with milder OSA (0.89 and 0.55).

Men with severe OSA who used CPAP had cardiovascular event rates that were comparable with those of snorers and men with milder apnea (0.64 and 0.35).

Waist Size and Insulin Resistance

Waist circumference is a simple and powerful predictor of a patient's risk for developing insulin resistance, reported Hans Wahrenberg, M.D., and his associates at Karolinska University Hospital, Stockholm.

They analyzed data collected from 2,746 healthy volunteers aged 18-72 years to determine whether different body measurements and biochemical markers could predict development of insulin resistance (BMJ [Epub ahead of print], April 2005. Article DOI 10.1136/bmj.38429.473310.AE. Available at

www.bmj.com

In this retrospective study, both men and women with a waist circumference of less than 100 cm were found to have zero risk for insulin resistance. A waist size less than 100 cm was the strongest predictor that insulin resistance would not develop, ahead of body mass index, waist-to-hip ratio, measures of total body fat, triglyceride level, HDL level, and blood pressure, they said.

Telephonic ECG After AF Ablation

Transtelephonic ECG monitoring is better than standard ECG and 24-hour Holter monitoring at detecting asymptomatic relapses in atrial fibrillation after patients have undergone radiofrequency catheter ablation, reported Gaetano Senatore, M.D., of Ospedale Civile di Cirie', Italy, and associates.

The down side of this improved detection of residual atrial fibrillation (AF) is that ablation now appears much less successful than clinicians had thought, Dr. Senatore and associates noted. In a study of 72 patients who underwent ablation for refractory AF, patients obtained 30-second readings on a transtelephonic ECG monitor every day, and whenever they felt palpitations, for 90 days. They also underwent standard ECG and Holter monitoring at 30 and 120 days postablation. The transtelephonic recordings documented AF recurrences in 20 patients (27.8%), compared with only 10 patients (13.9%) identified by the standard methods. Half of the affected patients had asymptomatic episodes of AF (J. Am. Coll. Cardiol. 2005;45:873-6).

The ablation procedure's success rate was 86% according to standard monitoring methods, but dropped to 72% with the more accurate method. Most published success rates for ablation have been based on the results of standard monitoring, and so are probably overestimated, Dr. Senatore and associates said. More importantly, “physicians usually consider AF as cured if sinus rhythm is documented on routine ECG or 24-hour Holter monitoring, and they often stop anticoagulation.” These results show that many such patients continue to have asymptomatic AF and should continue to receive anticoagulation.

WASHINGTON — Women who have vulvar disease should be asked specifically about bladder and bowel pain, and treated accordingly, Colleen M. Kennedy, M.D., advised.

Such women are twice as likely as are general gynecology patients to have bladder pain and bowel pain. “We hypothesize that certain vulvar or vaginal diseases are not isolated clinical entities, but rather represent symptoms of a global or generalized pelvic floor disorder,” she said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Kennedy and her associates at the University of Iowa, Iowa City, assessed the rates of painful bladder syndrome (interstitial cystitis) and irritable bowel syndrome in 324 women who were being treated at a vulvar disease clinic, and compared them with the rates among 321 control subjects attending a general gynecology clinic.

Of the women with vulvar disease, 12% reported bladder pain, vs. 6% of the controls. Similarly, 23% of those with vulvar disease had bowel pain, vs. 11% of controls.

The data showed that women with bladder pain were 2.2 times more likely than those without to have been treated for vulvar disease. Women with vulvar disease had a mean score of 20.3 on the Urinary Distress Inventory's pain subscale, compared with 5.3 for women without vulvar disease.

Likewise, women with functional bowel disorders were 2.1 times more likely than were those without such disorders to have been treated for vulvar disease.

The higher prevalence of painful bladder and painful bowel syndromes in women with vulvar disease may reflect a common etiology for all these disorders. The design of this study, however, did not allow the researchers to tease out whether there is a common etiology “or whether treatments for one disorder may exacerbate or cause the other disorders.

“From a clinical point of view, it is clear that women with vulvar disease should be queried about bladder and bowel pain, and treated accordingly,” Dr. Kennedy said.

That the study also showed that women with vulvar disease had nearly a fourfold higher risk of undergoing hysterectomy than did the general gynecology patients. “To our knowledge, ours is the first large clinic comparison to report this association,” she said.

WASHINGTON — Women who have vulvar disease should be asked specifically about bladder and bowel pain, and treated accordingly, Colleen M. Kennedy, M.D., advised.

Such women are twice as likely as are general gynecology patients to have bladder pain and bowel pain. “We hypothesize that certain vulvar or vaginal diseases are not isolated clinical entities, but rather represent symptoms of a global or generalized pelvic floor disorder,” she said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Kennedy and her associates at the University of Iowa, Iowa City, assessed the rates of painful bladder syndrome (interstitial cystitis) and irritable bowel syndrome in 324 women who were being treated at a vulvar disease clinic, and compared them with the rates among 321 control subjects attending a general gynecology clinic.

Of the women with vulvar disease, 12% reported bladder pain, vs. 6% of the controls. Similarly, 23% of those with vulvar disease had bowel pain, vs. 11% of controls.

The data showed that women with bladder pain were 2.2 times more likely than those without to have been treated for vulvar disease. Women with vulvar disease had a mean score of 20.3 on the Urinary Distress Inventory's pain subscale, compared with 5.3 for women without vulvar disease.

Likewise, women with functional bowel disorders were 2.1 times more likely than were those without such disorders to have been treated for vulvar disease.

The higher prevalence of painful bladder and painful bowel syndromes in women with vulvar disease may reflect a common etiology for all these disorders. The design of this study, however, did not allow the researchers to tease out whether there is a common etiology “or whether treatments for one disorder may exacerbate or cause the other disorders.

“From a clinical point of view, it is clear that women with vulvar disease should be queried about bladder and bowel pain, and treated accordingly,” Dr. Kennedy said.

That the study also showed that women with vulvar disease had nearly a fourfold higher risk of undergoing hysterectomy than did the general gynecology patients. “To our knowledge, ours is the first large clinic comparison to report this association,” she said.

WASHINGTON — Women who have vulvar disease should be asked specifically about bladder and bowel pain, and treated accordingly, Colleen M. Kennedy, M.D., advised.

Such women are twice as likely as are general gynecology patients to have bladder pain and bowel pain. “We hypothesize that certain vulvar or vaginal diseases are not isolated clinical entities, but rather represent symptoms of a global or generalized pelvic floor disorder,” she said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Kennedy and her associates at the University of Iowa, Iowa City, assessed the rates of painful bladder syndrome (interstitial cystitis) and irritable bowel syndrome in 324 women who were being treated at a vulvar disease clinic, and compared them with the rates among 321 control subjects attending a general gynecology clinic.

Of the women with vulvar disease, 12% reported bladder pain, vs. 6% of the controls. Similarly, 23% of those with vulvar disease had bowel pain, vs. 11% of controls.

The data showed that women with bladder pain were 2.2 times more likely than those without to have been treated for vulvar disease. Women with vulvar disease had a mean score of 20.3 on the Urinary Distress Inventory's pain subscale, compared with 5.3 for women without vulvar disease.

Likewise, women with functional bowel disorders were 2.1 times more likely than were those without such disorders to have been treated for vulvar disease.

The higher prevalence of painful bladder and painful bowel syndromes in women with vulvar disease may reflect a common etiology for all these disorders. The design of this study, however, did not allow the researchers to tease out whether there is a common etiology “or whether treatments for one disorder may exacerbate or cause the other disorders.

“From a clinical point of view, it is clear that women with vulvar disease should be queried about bladder and bowel pain, and treated accordingly,” Dr. Kennedy said.

That the study also showed that women with vulvar disease had nearly a fourfold higher risk of undergoing hysterectomy than did the general gynecology patients. “To our knowledge, ours is the first large clinic comparison to report this association,” she said.

WASHINGTON — Neonatal outcomes were the same for uninsured mothers as for those who had health insurance in a study of nearly 8,000 births in Tennessee, Mark F. Sewell, M.D., reported at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Uninsured women were more likely to deliver prematurely, but that did not adversely affect the outcomes of their infants, whose overall morbidity and mortality were comparable with those for the infants of insured mothers, said Dr. Sewell of MetroHealth Medical Center, Cleveland.

Dr. Sewell conducted a secondary analysis of the medical charts of pregnant women who had participated in a prospective study in Tennessee.

The study involved 7,932 singleton deliveries at six hospitals in Shelby County between 1997 and 1998.

A total of 7,503 of these women had some form of public, private, or military health insurance, and 429 (5%) had no insurance. This rate is slightly higher than the national average of 3%, he noted.

Uninsured women were more likely to be Hispanic than white, African American, or of other ethnic backgrounds. They were less likely to receive prenatal care, and those who did obtain prenatal care did so on average 1 month later in their pregnancies than insured women.

Uninsured mothers were more likely to have preterm delivery than were insured mothers (21% vs. 15%). Nevertheless, there were no differences between the two groups in perinatal or neonatal outcomes as measured by the rates of low birth weight, low Apgar scores, morbidity, and mortality.

The preterm infants of uninsured mothers had higher birth weights than the preterm infants of insured mothers.

It is possible that undiagnosed diabetes among these predominantly Hispanic mothers may account for this difference, Dr. Sewell said.

In the discussion period following his presentation, L. Wayne Hess, M.D., chairman of ob.gyn. at Lehigh Valley Hospital, Allentown, Pa., said that Dr. Sewell's study “showed just what you would expect.”

“Most physicians are dedicated and give the same quality of care regardless of the patient's ability to pay,” said Dr. Hess, who is also professor of ob.gyn. at Pennsylvania State University, Hershey.

Dr. Sewell noted that in 2003, 3% of pregnant women in the United States had no health insurance.

There are an estimated 120,000 births every year in this country to uninsured mothers, he commented.

WASHINGTON — Neonatal outcomes were the same for uninsured mothers as for those who had health insurance in a study of nearly 8,000 births in Tennessee, Mark F. Sewell, M.D., reported at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Uninsured women were more likely to deliver prematurely, but that did not adversely affect the outcomes of their infants, whose overall morbidity and mortality were comparable with those for the infants of insured mothers, said Dr. Sewell of MetroHealth Medical Center, Cleveland.

Dr. Sewell conducted a secondary analysis of the medical charts of pregnant women who had participated in a prospective study in Tennessee.

The study involved 7,932 singleton deliveries at six hospitals in Shelby County between 1997 and 1998.

A total of 7,503 of these women had some form of public, private, or military health insurance, and 429 (5%) had no insurance. This rate is slightly higher than the national average of 3%, he noted.

Uninsured women were more likely to be Hispanic than white, African American, or of other ethnic backgrounds. They were less likely to receive prenatal care, and those who did obtain prenatal care did so on average 1 month later in their pregnancies than insured women.

Uninsured mothers were more likely to have preterm delivery than were insured mothers (21% vs. 15%). Nevertheless, there were no differences between the two groups in perinatal or neonatal outcomes as measured by the rates of low birth weight, low Apgar scores, morbidity, and mortality.

The preterm infants of uninsured mothers had higher birth weights than the preterm infants of insured mothers.

It is possible that undiagnosed diabetes among these predominantly Hispanic mothers may account for this difference, Dr. Sewell said.

In the discussion period following his presentation, L. Wayne Hess, M.D., chairman of ob.gyn. at Lehigh Valley Hospital, Allentown, Pa., said that Dr. Sewell's study “showed just what you would expect.”

“Most physicians are dedicated and give the same quality of care regardless of the patient's ability to pay,” said Dr. Hess, who is also professor of ob.gyn. at Pennsylvania State University, Hershey.

Dr. Sewell noted that in 2003, 3% of pregnant women in the United States had no health insurance.

There are an estimated 120,000 births every year in this country to uninsured mothers, he commented.

WASHINGTON — Neonatal outcomes were the same for uninsured mothers as for those who had health insurance in a study of nearly 8,000 births in Tennessee, Mark F. Sewell, M.D., reported at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Uninsured women were more likely to deliver prematurely, but that did not adversely affect the outcomes of their infants, whose overall morbidity and mortality were comparable with those for the infants of insured mothers, said Dr. Sewell of MetroHealth Medical Center, Cleveland.

Dr. Sewell conducted a secondary analysis of the medical charts of pregnant women who had participated in a prospective study in Tennessee.

The study involved 7,932 singleton deliveries at six hospitals in Shelby County between 1997 and 1998.

A total of 7,503 of these women had some form of public, private, or military health insurance, and 429 (5%) had no insurance. This rate is slightly higher than the national average of 3%, he noted.

Uninsured women were more likely to be Hispanic than white, African American, or of other ethnic backgrounds. They were less likely to receive prenatal care, and those who did obtain prenatal care did so on average 1 month later in their pregnancies than insured women.

Uninsured mothers were more likely to have preterm delivery than were insured mothers (21% vs. 15%). Nevertheless, there were no differences between the two groups in perinatal or neonatal outcomes as measured by the rates of low birth weight, low Apgar scores, morbidity, and mortality.

The preterm infants of uninsured mothers had higher birth weights than the preterm infants of insured mothers.

It is possible that undiagnosed diabetes among these predominantly Hispanic mothers may account for this difference, Dr. Sewell said.

In the discussion period following his presentation, L. Wayne Hess, M.D., chairman of ob.gyn. at Lehigh Valley Hospital, Allentown, Pa., said that Dr. Sewell's study “showed just what you would expect.”

“Most physicians are dedicated and give the same quality of care regardless of the patient's ability to pay,” said Dr. Hess, who is also professor of ob.gyn. at Pennsylvania State University, Hershey.

Dr. Sewell noted that in 2003, 3% of pregnant women in the United States had no health insurance.

There are an estimated 120,000 births every year in this country to uninsured mothers, he commented.

Vitamin E: No CV Benefit, Possible Harm

Long-term use of the antioxidant vitamin E does not prevent cardiovascular disease, and it may actually raise the risk of heart failure in high-risk patients, reported Eva Lonn, M.D., of McMaster University in Hamilton, Ont., and her associates.

Despite previous studies that reported promising data on vitamin E, Dr. Lonn and her colleagues in the large, international Heart Outcomes Prevention Evaluation (HOPE) study found that vitamin E provided no cardiovascular benefit in patients with known vascular disease or diabetes. They extended the follow-up of that study to determine whether longer-term treatment might show that vitamin E prevents cardiovascular disease. In the extended study, 3,994 subjects took either daily vitamin E (400 IU) or placebo for an average of 7 years. Vitamin E had no effect on rates of MI, stroke, cardiovascular death, unstable angina, revascularization procedures, or total mortality (JAMA 2005;293:1338-47).

“We observed an unexpected and disturbing increase in heart failure rates in patients assigned to vitamin E. Although this finding could be due to chance, several factors persuade us to believe that it may be real,” they said. Patients with vascular disease or diabetes should not use the supplements until more research is done.

Sudden Death in Obstructive Apnea

People with obstructive sleep apnea show a marked rise in the incidence of sudden cardiac death during sleeping hours, a striking contrast to the nighttime nadir in sudden cardiac death seen in the general population, said Apoor S. Gami, M.D., and associates at the Mayo Clinic, Rochester, Minn.

The investigators reviewed the records of Minnesota residents who underwent sleep studies between 1987 and 2003 and identified 112 of these people who had sudden cardiac death during that period. A total of 78 of these patients had obstructive sleep apnea (OSA), and 34 had other sleep disorders or no sleep disorder.

The frequency of sudden cardiac death occurring between midnight and 6 a.m. was much higher in those with OSA (46%) than in the others (21%) and was higher than that reported in the general population (16%) or the frequency that would be expected by chance (25%). In addition, the severity of OSA correlated with the risk of sudden cardiac death during sleep hours; subjects who died during sleep hours had more severe apnea than those who died at other times of day, the investigators said (N. Engl. J. Med. 2005:352:1206-14).

The mean age at sudden cardiac death was the same for those who died during sleep hours and those who died at other times, and the same as that reported for sudden cardiac death in the general population. This suggests that OSA “does not hasten sudden death from cardiac causes.”

Pulmonary Effects of Antihypertensives

The antihypertensive agent celiprolol, a cardioselective β-blocker, produced fewer adverse pulmonary effects than propranolol and metoprolol in a small study of patients with mild to moderate chronic obstructive pulmonary disease, according to Hanneke van der Woude, M.D., of Martini Hospital, Groningen, the Netherlands, and associates.

Although the adverse effects of β-blockers on asthma are well known, their effects on COPD have been unclear. In this randomized trial of 15 patients, forced expiratory volume in 1 second deteriorated only with propranolol treatment, and airway hyperresponsiveness increased with both propranolol and metoprolol. Propranolol also markedly impaired the bronchodilating effect of the rescue agent formoterol. But celiprolol showed none of these adverse effects, the investigators said (Chest 2005;127:818-24).

Oral Tobacco Raises BP, Heart Rate

Chewing tobacco raises blood pressure, heart rate, and plasma epinephrine, which may contribute to intravascular thrombosis and cardiac arrhythmias, reported Robert Wolk, M.D., of the Mayo Clinic, Rochester, Minn., and his associates.

Noting that the cardiovascular effects of smokeless tobacco are not well understood and that more than 5,000,000 adults and 750,000 adolescents use it, the researchers studied the acute effects of smokeless tobacco on 16 healthy men (mean age 21) who were regular users. Heart rate, blood pressure, and plasma epinephrine levels rose significantly after subjects used 3.0 g of chewing tobacco for 30 minutes but did not change when subjects used a placebo snuff (J. Am. Coll. Cardiol. 2005;45:910-4).

Norepinephrine levels and peripheral vascular resistance did not change despite the marked increase in blood pressure. The findings suggest that chewing tobacco is “a powerful autonomic and hemodynamic stimulus,” and that its pressor effect “results most likely from an increase in cardiac output,” the investigators said.

Vitamin E: No CV Benefit, Possible Harm

Long-term use of the antioxidant vitamin E does not prevent cardiovascular disease, and it may actually raise the risk of heart failure in high-risk patients, reported Eva Lonn, M.D., of McMaster University in Hamilton, Ont., and her associates.

Despite previous studies that reported promising data on vitamin E, Dr. Lonn and her colleagues in the large, international Heart Outcomes Prevention Evaluation (HOPE) study found that vitamin E provided no cardiovascular benefit in patients with known vascular disease or diabetes. They extended the follow-up of that study to determine whether longer-term treatment might show that vitamin E prevents cardiovascular disease. In the extended study, 3,994 subjects took either daily vitamin E (400 IU) or placebo for an average of 7 years. Vitamin E had no effect on rates of MI, stroke, cardiovascular death, unstable angina, revascularization procedures, or total mortality (JAMA 2005;293:1338-47).

“We observed an unexpected and disturbing increase in heart failure rates in patients assigned to vitamin E. Although this finding could be due to chance, several factors persuade us to believe that it may be real,” they said. Patients with vascular disease or diabetes should not use the supplements until more research is done.

Sudden Death in Obstructive Apnea

People with obstructive sleep apnea show a marked rise in the incidence of sudden cardiac death during sleeping hours, a striking contrast to the nighttime nadir in sudden cardiac death seen in the general population, said Apoor S. Gami, M.D., and associates at the Mayo Clinic, Rochester, Minn.

The investigators reviewed the records of Minnesota residents who underwent sleep studies between 1987 and 2003 and identified 112 of these people who had sudden cardiac death during that period. A total of 78 of these patients had obstructive sleep apnea (OSA), and 34 had other sleep disorders or no sleep disorder.

The frequency of sudden cardiac death occurring between midnight and 6 a.m. was much higher in those with OSA (46%) than in the others (21%) and was higher than that reported in the general population (16%) or the frequency that would be expected by chance (25%). In addition, the severity of OSA correlated with the risk of sudden cardiac death during sleep hours; subjects who died during sleep hours had more severe apnea than those who died at other times of day, the investigators said (N. Engl. J. Med. 2005:352:1206-14).

The mean age at sudden cardiac death was the same for those who died during sleep hours and those who died at other times, and the same as that reported for sudden cardiac death in the general population. This suggests that OSA “does not hasten sudden death from cardiac causes.”

Pulmonary Effects of Antihypertensives

The antihypertensive agent celiprolol, a cardioselective β-blocker, produced fewer adverse pulmonary effects than propranolol and metoprolol in a small study of patients with mild to moderate chronic obstructive pulmonary disease, according to Hanneke van der Woude, M.D., of Martini Hospital, Groningen, the Netherlands, and associates.

Although the adverse effects of β-blockers on asthma are well known, their effects on COPD have been unclear. In this randomized trial of 15 patients, forced expiratory volume in 1 second deteriorated only with propranolol treatment, and airway hyperresponsiveness increased with both propranolol and metoprolol. Propranolol also markedly impaired the bronchodilating effect of the rescue agent formoterol. But celiprolol showed none of these adverse effects, the investigators said (Chest 2005;127:818-24).

Oral Tobacco Raises BP, Heart Rate

Chewing tobacco raises blood pressure, heart rate, and plasma epinephrine, which may contribute to intravascular thrombosis and cardiac arrhythmias, reported Robert Wolk, M.D., of the Mayo Clinic, Rochester, Minn., and his associates.

Noting that the cardiovascular effects of smokeless tobacco are not well understood and that more than 5,000,000 adults and 750,000 adolescents use it, the researchers studied the acute effects of smokeless tobacco on 16 healthy men (mean age 21) who were regular users. Heart rate, blood pressure, and plasma epinephrine levels rose significantly after subjects used 3.0 g of chewing tobacco for 30 minutes but did not change when subjects used a placebo snuff (J. Am. Coll. Cardiol. 2005;45:910-4).

Norepinephrine levels and peripheral vascular resistance did not change despite the marked increase in blood pressure. The findings suggest that chewing tobacco is “a powerful autonomic and hemodynamic stimulus,” and that its pressor effect “results most likely from an increase in cardiac output,” the investigators said.

Vitamin E: No CV Benefit, Possible Harm

Long-term use of the antioxidant vitamin E does not prevent cardiovascular disease, and it may actually raise the risk of heart failure in high-risk patients, reported Eva Lonn, M.D., of McMaster University in Hamilton, Ont., and her associates.

Despite previous studies that reported promising data on vitamin E, Dr. Lonn and her colleagues in the large, international Heart Outcomes Prevention Evaluation (HOPE) study found that vitamin E provided no cardiovascular benefit in patients with known vascular disease or diabetes. They extended the follow-up of that study to determine whether longer-term treatment might show that vitamin E prevents cardiovascular disease. In the extended study, 3,994 subjects took either daily vitamin E (400 IU) or placebo for an average of 7 years. Vitamin E had no effect on rates of MI, stroke, cardiovascular death, unstable angina, revascularization procedures, or total mortality (JAMA 2005;293:1338-47).

“We observed an unexpected and disturbing increase in heart failure rates in patients assigned to vitamin E. Although this finding could be due to chance, several factors persuade us to believe that it may be real,” they said. Patients with vascular disease or diabetes should not use the supplements until more research is done.

Sudden Death in Obstructive Apnea

People with obstructive sleep apnea show a marked rise in the incidence of sudden cardiac death during sleeping hours, a striking contrast to the nighttime nadir in sudden cardiac death seen in the general population, said Apoor S. Gami, M.D., and associates at the Mayo Clinic, Rochester, Minn.

The investigators reviewed the records of Minnesota residents who underwent sleep studies between 1987 and 2003 and identified 112 of these people who had sudden cardiac death during that period. A total of 78 of these patients had obstructive sleep apnea (OSA), and 34 had other sleep disorders or no sleep disorder.

The frequency of sudden cardiac death occurring between midnight and 6 a.m. was much higher in those with OSA (46%) than in the others (21%) and was higher than that reported in the general population (16%) or the frequency that would be expected by chance (25%). In addition, the severity of OSA correlated with the risk of sudden cardiac death during sleep hours; subjects who died during sleep hours had more severe apnea than those who died at other times of day, the investigators said (N. Engl. J. Med. 2005:352:1206-14).

The mean age at sudden cardiac death was the same for those who died during sleep hours and those who died at other times, and the same as that reported for sudden cardiac death in the general population. This suggests that OSA “does not hasten sudden death from cardiac causes.”

Pulmonary Effects of Antihypertensives

The antihypertensive agent celiprolol, a cardioselective β-blocker, produced fewer adverse pulmonary effects than propranolol and metoprolol in a small study of patients with mild to moderate chronic obstructive pulmonary disease, according to Hanneke van der Woude, M.D., of Martini Hospital, Groningen, the Netherlands, and associates.

Although the adverse effects of β-blockers on asthma are well known, their effects on COPD have been unclear. In this randomized trial of 15 patients, forced expiratory volume in 1 second deteriorated only with propranolol treatment, and airway hyperresponsiveness increased with both propranolol and metoprolol. Propranolol also markedly impaired the bronchodilating effect of the rescue agent formoterol. But celiprolol showed none of these adverse effects, the investigators said (Chest 2005;127:818-24).

Oral Tobacco Raises BP, Heart Rate

Chewing tobacco raises blood pressure, heart rate, and plasma epinephrine, which may contribute to intravascular thrombosis and cardiac arrhythmias, reported Robert Wolk, M.D., of the Mayo Clinic, Rochester, Minn., and his associates.

Noting that the cardiovascular effects of smokeless tobacco are not well understood and that more than 5,000,000 adults and 750,000 adolescents use it, the researchers studied the acute effects of smokeless tobacco on 16 healthy men (mean age 21) who were regular users. Heart rate, blood pressure, and plasma epinephrine levels rose significantly after subjects used 3.0 g of chewing tobacco for 30 minutes but did not change when subjects used a placebo snuff (J. Am. Coll. Cardiol. 2005;45:910-4).

Norepinephrine levels and peripheral vascular resistance did not change despite the marked increase in blood pressure. The findings suggest that chewing tobacco is “a powerful autonomic and hemodynamic stimulus,” and that its pressor effect “results most likely from an increase in cardiac output,” the investigators said.

Head cooling, started within 6 hours of birth and continued for 72 hours, appears to improve later neurodevelopmental outcomes in neonates with moderate hypoxic-ischemic encephalopathy, reported Peter D. Gluckman, M.D., of the University of Auckland and his associates in the “CoolCap” study.

This is the first large randomized trial to be published on the technique of selective head cooling for this disorder. The method uses a “relatively low-tech” fitted cap through which cold water (initially 8°C–12°C) circulates. The concurrent use of a radiant heater above the neonate's abdomen, which is controlled to maintain the rectal temperature at 34°C–35°C, ensures that only mild systemic hypothermia occurs while the brain is cooled.

At least four other large studies of this technique in the United States, United Kingdom, and Germany are planned for the next year or two, and if they bear out the CoolCap results “we shall soon have the first useful treatment for hypoxic-ischemic encephalopathy,” Richard Cooke, M.D., said in an editorial comment accompanying the CoolCap findings (Lancet 2005;365:632-4).

According to the CoolCap investigators, neonatal encephalopathy is a progressive syndrome that begins with the initial insult to the brain but continues after resuscitation. At birth, many affected infants “show initial transient recovery of cerebral oxidative metabolism followed by secondary deterioration with cerebral energy failure 6-15 hours after birth.

This delay offers the potential for therapeutic intervention.

“The severity of this secondary deterioration is closely correlated with neurodevelopmental outcome at 1 and 4 years of age. … Essentially, experimental hypothermia is effective only if it is started in [this] latent phase, before the onset of secondary deterioration,” Dr. Gluckman and his associates noted (Lancet 2005;365:663-70).

In their study, 234 term neonates with acute encephalopathy were treated from 1999 to 2002 at 25 perinatal centers in New Zealand, the United States, and the United Kingdom. All had experienced perinatal hypoxia or ischemia, showed abnormal results on neurological examination, and had an abnormal amplitude-integrated EEG (aEEG). The researchers used this last criterion to screen out infants with mild encephalopathy, who would be expected to have a normal prognosis.

All subjects had a 10-minute Apgar score of 5 or less; required continued ventilation or had severe acidosis; showed lethargy, stupor, or coma; and showed hypotonia, abnormal reflexes, an absent or weak sucking reflex, and/or seizures. Infants were excluded from the study if encephalopathy occurred together with major congenital abnormalities, head trauma, or severe growth restriction.

The neonates were randomly assigned to receive either head cooling (116 subjects) or conventional treatment (118 subjects). No cases of ventricular arrhythmia occurred with the cooling treatment, and no other adverse effects were noted except for mild, transient edema beneath the cooling cap.

At 18 months of age, 218 of the subjects were available for neurological exam, visual and auditory assessment, and neurodevelopmental assessment. “Of 108 cooled infants, about half had an unfavorable outcome, compared with two-thirds of control infants,” the investigators said, noting that this result did not achieve statistical significance.

However, head cooling had no effect at all on the subgroup of 46 neonates with the most severe aEEG changes. When that group was removed from the analysis, outcomes were highly significantly better in the cooled infants, who showed a greater than 50% reduction in severe neuromotor disability.

Only six such infants would need to be treated for one to show clear benefit, Dr. Gluckman and his associates said.

Head cooling, started within 6 hours of birth and continued for 72 hours, appears to improve later neurodevelopmental outcomes in neonates with moderate hypoxic-ischemic encephalopathy, reported Peter D. Gluckman, M.D., of the University of Auckland and his associates in the “CoolCap” study.

This is the first large randomized trial to be published on the technique of selective head cooling for this disorder. The method uses a “relatively low-tech” fitted cap through which cold water (initially 8°C–12°C) circulates. The concurrent use of a radiant heater above the neonate's abdomen, which is controlled to maintain the rectal temperature at 34°C–35°C, ensures that only mild systemic hypothermia occurs while the brain is cooled.

At least four other large studies of this technique in the United States, United Kingdom, and Germany are planned for the next year or two, and if they bear out the CoolCap results “we shall soon have the first useful treatment for hypoxic-ischemic encephalopathy,” Richard Cooke, M.D., said in an editorial comment accompanying the CoolCap findings (Lancet 2005;365:632-4).

According to the CoolCap investigators, neonatal encephalopathy is a progressive syndrome that begins with the initial insult to the brain but continues after resuscitation. At birth, many affected infants “show initial transient recovery of cerebral oxidative metabolism followed by secondary deterioration with cerebral energy failure 6-15 hours after birth.

This delay offers the potential for therapeutic intervention.

“The severity of this secondary deterioration is closely correlated with neurodevelopmental outcome at 1 and 4 years of age. … Essentially, experimental hypothermia is effective only if it is started in [this] latent phase, before the onset of secondary deterioration,” Dr. Gluckman and his associates noted (Lancet 2005;365:663-70).

In their study, 234 term neonates with acute encephalopathy were treated from 1999 to 2002 at 25 perinatal centers in New Zealand, the United States, and the United Kingdom. All had experienced perinatal hypoxia or ischemia, showed abnormal results on neurological examination, and had an abnormal amplitude-integrated EEG (aEEG). The researchers used this last criterion to screen out infants with mild encephalopathy, who would be expected to have a normal prognosis.

All subjects had a 10-minute Apgar score of 5 or less; required continued ventilation or had severe acidosis; showed lethargy, stupor, or coma; and showed hypotonia, abnormal reflexes, an absent or weak sucking reflex, and/or seizures. Infants were excluded from the study if encephalopathy occurred together with major congenital abnormalities, head trauma, or severe growth restriction.

The neonates were randomly assigned to receive either head cooling (116 subjects) or conventional treatment (118 subjects). No cases of ventricular arrhythmia occurred with the cooling treatment, and no other adverse effects were noted except for mild, transient edema beneath the cooling cap.

At 18 months of age, 218 of the subjects were available for neurological exam, visual and auditory assessment, and neurodevelopmental assessment. “Of 108 cooled infants, about half had an unfavorable outcome, compared with two-thirds of control infants,” the investigators said, noting that this result did not achieve statistical significance.

However, head cooling had no effect at all on the subgroup of 46 neonates with the most severe aEEG changes. When that group was removed from the analysis, outcomes were highly significantly better in the cooled infants, who showed a greater than 50% reduction in severe neuromotor disability.

Only six such infants would need to be treated for one to show clear benefit, Dr. Gluckman and his associates said.

Head cooling, started within 6 hours of birth and continued for 72 hours, appears to improve later neurodevelopmental outcomes in neonates with moderate hypoxic-ischemic encephalopathy, reported Peter D. Gluckman, M.D., of the University of Auckland and his associates in the “CoolCap” study.

This is the first large randomized trial to be published on the technique of selective head cooling for this disorder. The method uses a “relatively low-tech” fitted cap through which cold water (initially 8°C–12°C) circulates. The concurrent use of a radiant heater above the neonate's abdomen, which is controlled to maintain the rectal temperature at 34°C–35°C, ensures that only mild systemic hypothermia occurs while the brain is cooled.

At least four other large studies of this technique in the United States, United Kingdom, and Germany are planned for the next year or two, and if they bear out the CoolCap results “we shall soon have the first useful treatment for hypoxic-ischemic encephalopathy,” Richard Cooke, M.D., said in an editorial comment accompanying the CoolCap findings (Lancet 2005;365:632-4).

According to the CoolCap investigators, neonatal encephalopathy is a progressive syndrome that begins with the initial insult to the brain but continues after resuscitation. At birth, many affected infants “show initial transient recovery of cerebral oxidative metabolism followed by secondary deterioration with cerebral energy failure 6-15 hours after birth.

This delay offers the potential for therapeutic intervention.

“The severity of this secondary deterioration is closely correlated with neurodevelopmental outcome at 1 and 4 years of age. … Essentially, experimental hypothermia is effective only if it is started in [this] latent phase, before the onset of secondary deterioration,” Dr. Gluckman and his associates noted (Lancet 2005;365:663-70).

In their study, 234 term neonates with acute encephalopathy were treated from 1999 to 2002 at 25 perinatal centers in New Zealand, the United States, and the United Kingdom. All had experienced perinatal hypoxia or ischemia, showed abnormal results on neurological examination, and had an abnormal amplitude-integrated EEG (aEEG). The researchers used this last criterion to screen out infants with mild encephalopathy, who would be expected to have a normal prognosis.

All subjects had a 10-minute Apgar score of 5 or less; required continued ventilation or had severe acidosis; showed lethargy, stupor, or coma; and showed hypotonia, abnormal reflexes, an absent or weak sucking reflex, and/or seizures. Infants were excluded from the study if encephalopathy occurred together with major congenital abnormalities, head trauma, or severe growth restriction.

The neonates were randomly assigned to receive either head cooling (116 subjects) or conventional treatment (118 subjects). No cases of ventricular arrhythmia occurred with the cooling treatment, and no other adverse effects were noted except for mild, transient edema beneath the cooling cap.

At 18 months of age, 218 of the subjects were available for neurological exam, visual and auditory assessment, and neurodevelopmental assessment. “Of 108 cooled infants, about half had an unfavorable outcome, compared with two-thirds of control infants,” the investigators said, noting that this result did not achieve statistical significance.

However, head cooling had no effect at all on the subgroup of 46 neonates with the most severe aEEG changes. When that group was removed from the analysis, outcomes were highly significantly better in the cooled infants, who showed a greater than 50% reduction in severe neuromotor disability.

Only six such infants would need to be treated for one to show clear benefit, Dr. Gluckman and his associates said.

Carvedilol for Post-MI Arrhythmia

Carvedilol has a “striking” antiarrhythmic effect after acute MI, suppressing both atrial and ventricular arrhythmias and benefiting even high-risk patients already taking an ACE inhibitor, reported John McMurray, M.D., of the Western Infirmary, Glasgow, Scotland, and his associates.

Their study, Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction (CAPRICORN), was a multinational trial of patients with acute MI and ventricular systolic dysfunction, followed an average of 1.3 years. Most subjects were taking ACE inhibitors; 975 were assigned to receive carvedilol and 984 to receive a placebo in the blinded trial.

Carvedilol cut the incidence of malignant arrhythmias by 70%. The combined rate of ventricular tachycardia, ventricular fibrillation, and ventricular flutter was 0.9% in the treatment group and 3.9% in the placebo group. The drug also markedly reduced the risk of atrial arrhythmias, an effect that has never been tested before in a blinded, placebo-controlled trial, the investigators said (J. Am. Coll. Cardiol. 2005;45:525-30).

These findings “reinforce the value of β-blockers as essential treatment in patients with acute infarction,” they noted. The Capricorn study was funded by GlaxoSmithKline and Roche Pharmaceuticals.

Disparities in Hypertension Care

Ethnic disparities in the diagnosis, treatment, and control of hypertension persist, with African Americans continuing to show a higher prevalence than other populations and with Mexican Americans having the lowest rates of treatment and blood pressure control, according to the Centers for Disease Control and Prevention, Atlanta.

The latest CDC analysis showed a prevalence of 40.5% among non-Hispanic blacks, 27.4% among non-Hispanic whites, and 25.1% among Mexican Americans. Overall, only 29% of hypertensive adults had controlled blood pressure. The rate of control was the same, 29.8%, in blacks and whites but substantially lower in Mexican Americans, at 17.3% (MMWR 2005;54:7-9).

“Public health officials and clinicians need to increase their efforts to treat and control BP levels … and promote physical activity, nutrition changes (e.g., reducing high salt/sodium) weight reduction or management, stress reduction, and routine BP screening,” the CDC said.

Statins Don't Cut Dementia Risk

Statins do not appear to decrease the risk of Alzheimer's disease and other dementias, as at least six observational studies have suggested, said Peter P. Zandi, Ph.D., of Johns Hopkins University, Baltimore, and his associates.

Three randomized trials have found no such protective effect. To shed light on the issue, Dr. Zandi and his associates analyzed data from a study of nearly 5,000 elderly residents of Cache County, Utah.

Initial analyses suggested that statin use lowered the risk of dementia, but that link disappeared after adjustment for age, sex, and other facators. The protective effect of statins seen in cross-sectional studies is an artifact of the study design and is not borne out by prospective analyses, they said (Arch. Gen. Psychiatry 2005;62:217-24).

Some researchers have called for randomized, controlled clinical trials to definitively determine whether statins protect against dementia. However, the results of this study suggest that “costly randomized prevention trials of statins [would be] premature,” Dr. Zandi and his associates commented.

Migraineurs at Higher CVD Risk

People who have migraine headaches, particularly those who experience auras, are at greater risk for early-onset cardiovascular disease than people without migraines, according to Ann I. Scher, Ph.D., of the National Institute on Aging, Bethesda, Md., and her associates.

The association between migraine and early ischemic stroke is well known, but the possible link with coronary heart disease before age 45 years “has not been definitively answered” until now, the investigators said (Neurology 2005;64:614-20).

They studied 620 migraineurs and 5,135 people without migraine. The average age of subjects was 42 years. Migraineurs had a higher prevalence of hypercholesterolemia, a low HDL cholesterol level, or a high ratio of total cholesterol to HDL cholesterol. They also had a higher prevalence of hypertension, existing coronary disease, and stroke. People who experienced migraine headaches with aura were at particular risk—“roughly twice or more as likely as the nonmigraine group to have a clinically relevant Framingham risk score,” the researchers said.

This study wasn't designed to determine why migraineurs are at higher CVD risk. But it did show that migraineurs were more likely to report that either their mothers or their fathers had an early MI. This “intriguing” finding “suggests the influence of genetic factors that predispose toward both migraine and CHD,” the authors noted.

Carvedilol for Post-MI Arrhythmia

Carvedilol has a “striking” antiarrhythmic effect after acute MI, suppressing both atrial and ventricular arrhythmias and benefiting even high-risk patients already taking an ACE inhibitor, reported John McMurray, M.D., of the Western Infirmary, Glasgow, Scotland, and his associates.

Their study, Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction (CAPRICORN), was a multinational trial of patients with acute MI and ventricular systolic dysfunction, followed an average of 1.3 years. Most subjects were taking ACE inhibitors; 975 were assigned to receive carvedilol and 984 to receive a placebo in the blinded trial.

Carvedilol cut the incidence of malignant arrhythmias by 70%. The combined rate of ventricular tachycardia, ventricular fibrillation, and ventricular flutter was 0.9% in the treatment group and 3.9% in the placebo group. The drug also markedly reduced the risk of atrial arrhythmias, an effect that has never been tested before in a blinded, placebo-controlled trial, the investigators said (J. Am. Coll. Cardiol. 2005;45:525-30).

These findings “reinforce the value of β-blockers as essential treatment in patients with acute infarction,” they noted. The Capricorn study was funded by GlaxoSmithKline and Roche Pharmaceuticals.

Disparities in Hypertension Care

Ethnic disparities in the diagnosis, treatment, and control of hypertension persist, with African Americans continuing to show a higher prevalence than other populations and with Mexican Americans having the lowest rates of treatment and blood pressure control, according to the Centers for Disease Control and Prevention, Atlanta.

The latest CDC analysis showed a prevalence of 40.5% among non-Hispanic blacks, 27.4% among non-Hispanic whites, and 25.1% among Mexican Americans. Overall, only 29% of hypertensive adults had controlled blood pressure. The rate of control was the same, 29.8%, in blacks and whites but substantially lower in Mexican Americans, at 17.3% (MMWR 2005;54:7-9).

“Public health officials and clinicians need to increase their efforts to treat and control BP levels … and promote physical activity, nutrition changes (e.g., reducing high salt/sodium) weight reduction or management, stress reduction, and routine BP screening,” the CDC said.

Statins Don't Cut Dementia Risk

Statins do not appear to decrease the risk of Alzheimer's disease and other dementias, as at least six observational studies have suggested, said Peter P. Zandi, Ph.D., of Johns Hopkins University, Baltimore, and his associates.

Three randomized trials have found no such protective effect. To shed light on the issue, Dr. Zandi and his associates analyzed data from a study of nearly 5,000 elderly residents of Cache County, Utah.

Initial analyses suggested that statin use lowered the risk of dementia, but that link disappeared after adjustment for age, sex, and other facators. The protective effect of statins seen in cross-sectional studies is an artifact of the study design and is not borne out by prospective analyses, they said (Arch. Gen. Psychiatry 2005;62:217-24).

Some researchers have called for randomized, controlled clinical trials to definitively determine whether statins protect against dementia. However, the results of this study suggest that “costly randomized prevention trials of statins [would be] premature,” Dr. Zandi and his associates commented.

Migraineurs at Higher CVD Risk

People who have migraine headaches, particularly those who experience auras, are at greater risk for early-onset cardiovascular disease than people without migraines, according to Ann I. Scher, Ph.D., of the National Institute on Aging, Bethesda, Md., and her associates.

The association between migraine and early ischemic stroke is well known, but the possible link with coronary heart disease before age 45 years “has not been definitively answered” until now, the investigators said (Neurology 2005;64:614-20).

They studied 620 migraineurs and 5,135 people without migraine. The average age of subjects was 42 years. Migraineurs had a higher prevalence of hypercholesterolemia, a low HDL cholesterol level, or a high ratio of total cholesterol to HDL cholesterol. They also had a higher prevalence of hypertension, existing coronary disease, and stroke. People who experienced migraine headaches with aura were at particular risk—“roughly twice or more as likely as the nonmigraine group to have a clinically relevant Framingham risk score,” the researchers said.

This study wasn't designed to determine why migraineurs are at higher CVD risk. But it did show that migraineurs were more likely to report that either their mothers or their fathers had an early MI. This “intriguing” finding “suggests the influence of genetic factors that predispose toward both migraine and CHD,” the authors noted.

Carvedilol for Post-MI Arrhythmia

Carvedilol has a “striking” antiarrhythmic effect after acute MI, suppressing both atrial and ventricular arrhythmias and benefiting even high-risk patients already taking an ACE inhibitor, reported John McMurray, M.D., of the Western Infirmary, Glasgow, Scotland, and his associates.

Their study, Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction (CAPRICORN), was a multinational trial of patients with acute MI and ventricular systolic dysfunction, followed an average of 1.3 years. Most subjects were taking ACE inhibitors; 975 were assigned to receive carvedilol and 984 to receive a placebo in the blinded trial.

Carvedilol cut the incidence of malignant arrhythmias by 70%. The combined rate of ventricular tachycardia, ventricular fibrillation, and ventricular flutter was 0.9% in the treatment group and 3.9% in the placebo group. The drug also markedly reduced the risk of atrial arrhythmias, an effect that has never been tested before in a blinded, placebo-controlled trial, the investigators said (J. Am. Coll. Cardiol. 2005;45:525-30).

These findings “reinforce the value of β-blockers as essential treatment in patients with acute infarction,” they noted. The Capricorn study was funded by GlaxoSmithKline and Roche Pharmaceuticals.

Disparities in Hypertension Care

Ethnic disparities in the diagnosis, treatment, and control of hypertension persist, with African Americans continuing to show a higher prevalence than other populations and with Mexican Americans having the lowest rates of treatment and blood pressure control, according to the Centers for Disease Control and Prevention, Atlanta.

The latest CDC analysis showed a prevalence of 40.5% among non-Hispanic blacks, 27.4% among non-Hispanic whites, and 25.1% among Mexican Americans. Overall, only 29% of hypertensive adults had controlled blood pressure. The rate of control was the same, 29.8%, in blacks and whites but substantially lower in Mexican Americans, at 17.3% (MMWR 2005;54:7-9).

“Public health officials and clinicians need to increase their efforts to treat and control BP levels … and promote physical activity, nutrition changes (e.g., reducing high salt/sodium) weight reduction or management, stress reduction, and routine BP screening,” the CDC said.

Statins Don't Cut Dementia Risk

Statins do not appear to decrease the risk of Alzheimer's disease and other dementias, as at least six observational studies have suggested, said Peter P. Zandi, Ph.D., of Johns Hopkins University, Baltimore, and his associates.

Three randomized trials have found no such protective effect. To shed light on the issue, Dr. Zandi and his associates analyzed data from a study of nearly 5,000 elderly residents of Cache County, Utah.

Initial analyses suggested that statin use lowered the risk of dementia, but that link disappeared after adjustment for age, sex, and other facators. The protective effect of statins seen in cross-sectional studies is an artifact of the study design and is not borne out by prospective analyses, they said (Arch. Gen. Psychiatry 2005;62:217-24).

Some researchers have called for randomized, controlled clinical trials to definitively determine whether statins protect against dementia. However, the results of this study suggest that “costly randomized prevention trials of statins [would be] premature,” Dr. Zandi and his associates commented.

Migraineurs at Higher CVD Risk

People who have migraine headaches, particularly those who experience auras, are at greater risk for early-onset cardiovascular disease than people without migraines, according to Ann I. Scher, Ph.D., of the National Institute on Aging, Bethesda, Md., and her associates.

The association between migraine and early ischemic stroke is well known, but the possible link with coronary heart disease before age 45 years “has not been definitively answered” until now, the investigators said (Neurology 2005;64:614-20).

They studied 620 migraineurs and 5,135 people without migraine. The average age of subjects was 42 years. Migraineurs had a higher prevalence of hypercholesterolemia, a low HDL cholesterol level, or a high ratio of total cholesterol to HDL cholesterol. They also had a higher prevalence of hypertension, existing coronary disease, and stroke. People who experienced migraine headaches with aura were at particular risk—“roughly twice or more as likely as the nonmigraine group to have a clinically relevant Framingham risk score,” the researchers said.

This study wasn't designed to determine why migraineurs are at higher CVD risk. But it did show that migraineurs were more likely to report that either their mothers or their fathers had an early MI. This “intriguing” finding “suggests the influence of genetic factors that predispose toward both migraine and CHD,” the authors noted.

ICD Beats Amiodarone in Heart Failure

In a direct comparison of the two therapies developed specifically to prevent sudden cardiac death in patients with heart failure, only the implantable cardioverter defibrillator (ICD) succeeded in doing so. Conservatively programmed, shock-only, single-lead ICD therapy cut mortality by 23%; amiodarone had no effect on survival, said Gust H. Bardy, M.D., of the Seattle Institute for Cardiac Research, and associates.

The benefits of both therapies have remained uncertain, so 2,521 patients with heart failure were enrolled in the Sudden Cardiac Death in Heart Failure Trial and followed for a median of 45 months. All received optimal conventional treatment. In addition, 845 were randomly assigned to receive amiodarone, 847 received placebo, and 829 received an ICD. The ICD was programmed to treat only rapid, sustained ventricular tachycardia or fibrillation.

Even though they found a 5% rate of acute device-related complications and a 9% rate of chronic complications, the survival benefit “outweighs any shortcomings of this approach,” the researchers added (N. Engl. J. Med. 2005;352:225-37).

“We cannot emphasize too strongly that we evaluated only very conservatively programmed ICDs with a conservative detection algorithm and shock-only therapy … considerable caution should be used in extrapolating our results to other approaches to ICD therapy,” they noted.

Thrombolysis-Induced Ocular Bleeding

Hemorrhage is a well-known complication of thrombolytic therapy, but possible involvement of the retina is less well known, said Riyaz A. Kaba, M.D., and associates at Hillingdon Hospital, Uxbridge, England.

They reported the case of a 66-year-old man who received thrombolytic therapy when he presented with acute MI. Within a few hours, he had impaired vision in his left eye. Fundoscopic examination revealed subretinal hemorrhage, predominantly at the macular and posterior pole, and a large pool of blood between the retina and the vitreous base (Lancet 2005;365:330).

The vitreous hemorrhage brought on by thrombolysis persisted at 3-month follow-up, and vision in the patient's left eye remained impaired.

Electrical Stimulation After Stroke

Early, intensive electrical stimulation of the leg muscles to mimic normal walking aided recovery of walking ability after stroke, said Tiebin Yan, M.D., of the Hong Kong Polytechnic University, and associates.

Of 41 patients aged 45-85 years who had an acute unilateral stroke within the carotid artery system, 13 were randomly assigned to receive functional electrical stimulation of the quadriceps, hamstring, tibialis anterior, and medial gastrocnemius muscles in a sequence that mimicked a normal gait. The 30-minute stimulation sessions were given 5 days a week for 3 weeks, starting within 3 days after transfer from an acute care facility. Another 13 patients who had no electrical muscle stimulation formed the control group, while 15 patients who had sham stimulation sessions formed the placebo group. All also received standard daily rehabilitative physiotherapy and occupational therapy, the researchers said (Stroke 2005;36:80-5).

Nearly 85% of the treatment group, compared with only 53% of the sham treatment group and 46% of the control group, recovered their walking ability and returned home to live independently. The treated patients also showed less muscle spasticity than those in the other groups.

Deep Sternal Wound Infection Is Risky

The detrimental effects of deep sternal wound infection after coronary artery bypass grafting (CABG) extend well beyond the first 30 days, when patients typically appear to have fully recovered. This complication raises the risk of death threefold over the next 10 years at least, reported Ioannis K. Toumpoulis, M.D., of Columbia University, New York, and associates.

The long-term effects of deep sternal wound infection have not been well studied. To assess the impact of the infection on long-term survival, the researchers reviewed 3,760 consecutive cases of CABG performed at St. Luke's-Roosevelt Hospital Center from 1992 to 2002. Thirty-day mortality was the same in the 40 patients with deep sternal wound infection as in the unaffected patients.

But in patients who had developed the infection, overall mortality was markedly higher at 1 year (33.8%), 5 years (49.2%), and 10 years after CABG (59.4%) than it was in patients who had not developed deep sternal wound infection (6.4%, 16.8%, and 32.7%, respectively). The exact mechanism by which this complication continues to affect patient health for years after they have “recovered” remains unknown, the investigators noted (Chest 2005;127:464-71).

All patients who develop deep sternal wound infection should be followed carefully and monitored frequently thereafter, they added.

ICD Beats Amiodarone in Heart Failure

In a direct comparison of the two therapies developed specifically to prevent sudden cardiac death in patients with heart failure, only the implantable cardioverter defibrillator (ICD) succeeded in doing so. Conservatively programmed, shock-only, single-lead ICD therapy cut mortality by 23%; amiodarone had no effect on survival, said Gust H. Bardy, M.D., of the Seattle Institute for Cardiac Research, and associates.

The benefits of both therapies have remained uncertain, so 2,521 patients with heart failure were enrolled in the Sudden Cardiac Death in Heart Failure Trial and followed for a median of 45 months. All received optimal conventional treatment. In addition, 845 were randomly assigned to receive amiodarone, 847 received placebo, and 829 received an ICD. The ICD was programmed to treat only rapid, sustained ventricular tachycardia or fibrillation.

Even though they found a 5% rate of acute device-related complications and a 9% rate of chronic complications, the survival benefit “outweighs any shortcomings of this approach,” the researchers added (N. Engl. J. Med. 2005;352:225-37).

“We cannot emphasize too strongly that we evaluated only very conservatively programmed ICDs with a conservative detection algorithm and shock-only therapy … considerable caution should be used in extrapolating our results to other approaches to ICD therapy,” they noted.

Thrombolysis-Induced Ocular Bleeding

Hemorrhage is a well-known complication of thrombolytic therapy, but possible involvement of the retina is less well known, said Riyaz A. Kaba, M.D., and associates at Hillingdon Hospital, Uxbridge, England.

They reported the case of a 66-year-old man who received thrombolytic therapy when he presented with acute MI. Within a few hours, he had impaired vision in his left eye. Fundoscopic examination revealed subretinal hemorrhage, predominantly at the macular and posterior pole, and a large pool of blood between the retina and the vitreous base (Lancet 2005;365:330).

The vitreous hemorrhage brought on by thrombolysis persisted at 3-month follow-up, and vision in the patient's left eye remained impaired.

Electrical Stimulation After Stroke

Early, intensive electrical stimulation of the leg muscles to mimic normal walking aided recovery of walking ability after stroke, said Tiebin Yan, M.D., of the Hong Kong Polytechnic University, and associates.

Of 41 patients aged 45-85 years who had an acute unilateral stroke within the carotid artery system, 13 were randomly assigned to receive functional electrical stimulation of the quadriceps, hamstring, tibialis anterior, and medial gastrocnemius muscles in a sequence that mimicked a normal gait. The 30-minute stimulation sessions were given 5 days a week for 3 weeks, starting within 3 days after transfer from an acute care facility. Another 13 patients who had no electrical muscle stimulation formed the control group, while 15 patients who had sham stimulation sessions formed the placebo group. All also received standard daily rehabilitative physiotherapy and occupational therapy, the researchers said (Stroke 2005;36:80-5).

Nearly 85% of the treatment group, compared with only 53% of the sham treatment group and 46% of the control group, recovered their walking ability and returned home to live independently. The treated patients also showed less muscle spasticity than those in the other groups.

Deep Sternal Wound Infection Is Risky

The detrimental effects of deep sternal wound infection after coronary artery bypass grafting (CABG) extend well beyond the first 30 days, when patients typically appear to have fully recovered. This complication raises the risk of death threefold over the next 10 years at least, reported Ioannis K. Toumpoulis, M.D., of Columbia University, New York, and associates.

The long-term effects of deep sternal wound infection have not been well studied. To assess the impact of the infection on long-term survival, the researchers reviewed 3,760 consecutive cases of CABG performed at St. Luke's-Roosevelt Hospital Center from 1992 to 2002. Thirty-day mortality was the same in the 40 patients with deep sternal wound infection as in the unaffected patients.

But in patients who had developed the infection, overall mortality was markedly higher at 1 year (33.8%), 5 years (49.2%), and 10 years after CABG (59.4%) than it was in patients who had not developed deep sternal wound infection (6.4%, 16.8%, and 32.7%, respectively). The exact mechanism by which this complication continues to affect patient health for years after they have “recovered” remains unknown, the investigators noted (Chest 2005;127:464-71).

All patients who develop deep sternal wound infection should be followed carefully and monitored frequently thereafter, they added.

ICD Beats Amiodarone in Heart Failure

In a direct comparison of the two therapies developed specifically to prevent sudden cardiac death in patients with heart failure, only the implantable cardioverter defibrillator (ICD) succeeded in doing so. Conservatively programmed, shock-only, single-lead ICD therapy cut mortality by 23%; amiodarone had no effect on survival, said Gust H. Bardy, M.D., of the Seattle Institute for Cardiac Research, and associates.

The benefits of both therapies have remained uncertain, so 2,521 patients with heart failure were enrolled in the Sudden Cardiac Death in Heart Failure Trial and followed for a median of 45 months. All received optimal conventional treatment. In addition, 845 were randomly assigned to receive amiodarone, 847 received placebo, and 829 received an ICD. The ICD was programmed to treat only rapid, sustained ventricular tachycardia or fibrillation.

Even though they found a 5% rate of acute device-related complications and a 9% rate of chronic complications, the survival benefit “outweighs any shortcomings of this approach,” the researchers added (N. Engl. J. Med. 2005;352:225-37).

“We cannot emphasize too strongly that we evaluated only very conservatively programmed ICDs with a conservative detection algorithm and shock-only therapy … considerable caution should be used in extrapolating our results to other approaches to ICD therapy,” they noted.

Thrombolysis-Induced Ocular Bleeding

Hemorrhage is a well-known complication of thrombolytic therapy, but possible involvement of the retina is less well known, said Riyaz A. Kaba, M.D., and associates at Hillingdon Hospital, Uxbridge, England.

They reported the case of a 66-year-old man who received thrombolytic therapy when he presented with acute MI. Within a few hours, he had impaired vision in his left eye. Fundoscopic examination revealed subretinal hemorrhage, predominantly at the macular and posterior pole, and a large pool of blood between the retina and the vitreous base (Lancet 2005;365:330).

The vitreous hemorrhage brought on by thrombolysis persisted at 3-month follow-up, and vision in the patient's left eye remained impaired.

Electrical Stimulation After Stroke

Early, intensive electrical stimulation of the leg muscles to mimic normal walking aided recovery of walking ability after stroke, said Tiebin Yan, M.D., of the Hong Kong Polytechnic University, and associates.

Of 41 patients aged 45-85 years who had an acute unilateral stroke within the carotid artery system, 13 were randomly assigned to receive functional electrical stimulation of the quadriceps, hamstring, tibialis anterior, and medial gastrocnemius muscles in a sequence that mimicked a normal gait. The 30-minute stimulation sessions were given 5 days a week for 3 weeks, starting within 3 days after transfer from an acute care facility. Another 13 patients who had no electrical muscle stimulation formed the control group, while 15 patients who had sham stimulation sessions formed the placebo group. All also received standard daily rehabilitative physiotherapy and occupational therapy, the researchers said (Stroke 2005;36:80-5).

Nearly 85% of the treatment group, compared with only 53% of the sham treatment group and 46% of the control group, recovered their walking ability and returned home to live independently. The treated patients also showed less muscle spasticity than those in the other groups.

Deep Sternal Wound Infection Is Risky

The detrimental effects of deep sternal wound infection after coronary artery bypass grafting (CABG) extend well beyond the first 30 days, when patients typically appear to have fully recovered. This complication raises the risk of death threefold over the next 10 years at least, reported Ioannis K. Toumpoulis, M.D., of Columbia University, New York, and associates.

The long-term effects of deep sternal wound infection have not been well studied. To assess the impact of the infection on long-term survival, the researchers reviewed 3,760 consecutive cases of CABG performed at St. Luke's-Roosevelt Hospital Center from 1992 to 2002. Thirty-day mortality was the same in the 40 patients with deep sternal wound infection as in the unaffected patients.

But in patients who had developed the infection, overall mortality was markedly higher at 1 year (33.8%), 5 years (49.2%), and 10 years after CABG (59.4%) than it was in patients who had not developed deep sternal wound infection (6.4%, 16.8%, and 32.7%, respectively). The exact mechanism by which this complication continues to affect patient health for years after they have “recovered” remains unknown, the investigators noted (Chest 2005;127:464-71).

All patients who develop deep sternal wound infection should be followed carefully and monitored frequently thereafter, they added.

WASHINGTON — Urinary cytology was found to be “of limited use” in detecting whether pelvic cancer has invaded the bladder, Kelly L. Molpus, M.D., reported at the annual meeting of the Central Association of Obstetricians and Gynecologists.

He and his associates hypothesized that a pelvic tumor that has invaded the bladder might shed malignant cells that could be detected by microscopic examination of the urine, in much the same way that peritoneal “washes” are examined for the microscopic spread of ovarian or other cancers.

In a retrospective study using databases at two medical centers, the researchers reviewed the findings on urine samples collected from 93 women with pelvic cancer (mean age 48 years) who were treated between 1999 and 2004. The samples were collected when the women underwent cystoscopy for staging of their pelvic cancer.

Most of the women had primary cervical cancer. Six had locally extensive endometrial cancer; three each had vulvar, vaginal, or recurrent cervical cancer; one had ovarian cancer; and one had a primary rectal cancer that also involved the vagina, said Dr. Molpus, the McClure L. Smith Professor of Gynecologic Oncology at the University of Nebraska, Omaha.

Two-thirds of the samples were classified as normal on urinary cytology. The other one-third showed some abnormality, but these turned out to reflect benign changes such as inflammation or subclinical cystitis in most cases.

Urinary cytology detected malignant cells in only four women (4.3%), all of whom had extensive, locally advanced tumors. It failed to detect bladder invasion in three. In contrast, biopsy confirmed cancerous invasion of the bladder in all seven subjects (7.5%).

Thus, urinary cytology showed only a 57% sensitivity as a screen for detecting bladder invasion. It yielded “no additional information on the extent of disease in any patient with known stage I or II pelvic cancer,” so it was deemed to be “of limited diagnostic value,” Dr. Molpus said.

However, given its 100% specificity and 100% positive predictive value in this study, urinary cytology may be useful in specific situations, such as when bladder biopsy results are inconclusive or biopsy samples are inadequate or unavailable, he said.

WASHINGTON — Urinary cytology was found to be “of limited use” in detecting whether pelvic cancer has invaded the bladder, Kelly L. Molpus, M.D., reported at the annual meeting of the Central Association of Obstetricians and Gynecologists.

He and his associates hypothesized that a pelvic tumor that has invaded the bladder might shed malignant cells that could be detected by microscopic examination of the urine, in much the same way that peritoneal “washes” are examined for the microscopic spread of ovarian or other cancers.

In a retrospective study using databases at two medical centers, the researchers reviewed the findings on urine samples collected from 93 women with pelvic cancer (mean age 48 years) who were treated between 1999 and 2004. The samples were collected when the women underwent cystoscopy for staging of their pelvic cancer.

Most of the women had primary cervical cancer. Six had locally extensive endometrial cancer; three each had vulvar, vaginal, or recurrent cervical cancer; one had ovarian cancer; and one had a primary rectal cancer that also involved the vagina, said Dr. Molpus, the McClure L. Smith Professor of Gynecologic Oncology at the University of Nebraska, Omaha.

Two-thirds of the samples were classified as normal on urinary cytology. The other one-third showed some abnormality, but these turned out to reflect benign changes such as inflammation or subclinical cystitis in most cases.

Urinary cytology detected malignant cells in only four women (4.3%), all of whom had extensive, locally advanced tumors. It failed to detect bladder invasion in three. In contrast, biopsy confirmed cancerous invasion of the bladder in all seven subjects (7.5%).

Thus, urinary cytology showed only a 57% sensitivity as a screen for detecting bladder invasion. It yielded “no additional information on the extent of disease in any patient with known stage I or II pelvic cancer,” so it was deemed to be “of limited diagnostic value,” Dr. Molpus said.

However, given its 100% specificity and 100% positive predictive value in this study, urinary cytology may be useful in specific situations, such as when bladder biopsy results are inconclusive or biopsy samples are inadequate or unavailable, he said.

WASHINGTON — Urinary cytology was found to be “of limited use” in detecting whether pelvic cancer has invaded the bladder, Kelly L. Molpus, M.D., reported at the annual meeting of the Central Association of Obstetricians and Gynecologists.

He and his associates hypothesized that a pelvic tumor that has invaded the bladder might shed malignant cells that could be detected by microscopic examination of the urine, in much the same way that peritoneal “washes” are examined for the microscopic spread of ovarian or other cancers.

In a retrospective study using databases at two medical centers, the researchers reviewed the findings on urine samples collected from 93 women with pelvic cancer (mean age 48 years) who were treated between 1999 and 2004. The samples were collected when the women underwent cystoscopy for staging of their pelvic cancer.

Most of the women had primary cervical cancer. Six had locally extensive endometrial cancer; three each had vulvar, vaginal, or recurrent cervical cancer; one had ovarian cancer; and one had a primary rectal cancer that also involved the vagina, said Dr. Molpus, the McClure L. Smith Professor of Gynecologic Oncology at the University of Nebraska, Omaha.

Two-thirds of the samples were classified as normal on urinary cytology. The other one-third showed some abnormality, but these turned out to reflect benign changes such as inflammation or subclinical cystitis in most cases.

Urinary cytology detected malignant cells in only four women (4.3%), all of whom had extensive, locally advanced tumors. It failed to detect bladder invasion in three. In contrast, biopsy confirmed cancerous invasion of the bladder in all seven subjects (7.5%).

Thus, urinary cytology showed only a 57% sensitivity as a screen for detecting bladder invasion. It yielded “no additional information on the extent of disease in any patient with known stage I or II pelvic cancer,” so it was deemed to be “of limited diagnostic value,” Dr. Molpus said.

However, given its 100% specificity and 100% positive predictive value in this study, urinary cytology may be useful in specific situations, such as when bladder biopsy results are inconclusive or biopsy samples are inadequate or unavailable, he said.

WASHINGTON — Acute fatty liver of pregnancy must be ruled out in any woman who presents in the third trimester with nausea, vomiting, epigastric pain, or malaise, Michael F. Fesenmeier, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

The disorder is rare, estimated to affect only 1 in 7,000-16,000 pregnancies. But it is deadly. Maternal and neonatal mortality rates of 75% have been reported in some studies.

“Physicians must be diligent in diagnosing acute fatty liver of pregnancy, and be prepared for its high morbidity and mortality,” said Dr. Fesenmeier of the University of Cincinnati Medical Center.

He and his associates assessed the clinical presentations and outcomes of all 16 women treated for acute fatty liver of pregnancy (AFLP) at three tertiary-care centers in Ohio and Kentucky between 1993 and 2003. The average gestational age at diagnosis was 35.2 weeks (range, 30.0-37.2 weeks). There were 13 singleton and 3 twin pregnancies.

Nausea and vomiting were the most common presenting symptoms, affecting 12 patients (75%). The average duration of nausea and vomiting before the women presented for emergency care was 3-4 days, but some women went undiagnosed for much longer, including one who was undiagnosed for 3 weeks. That patient died within a month of delivery.

Other symptoms included epigastric pain in seven patients (43%), jaundice in six (38%), malaise in five (31%), and loss of consciousness in one (6%), he said in a poster presentation at the meeting.

There were two maternal deaths from multiorgan failure (12.5% maternal mortality) and three fetal deaths (15% infant mortality). Ten women (62%) developed acute tubular necrosis, seven (43%) developed pulmonary edema, seven (43%) developed disseminated intravascular coagulation, and six (38%) developed pancreatitis.

The average length of stay was 15 days, with a range of 5-58 days. Three were referred for liver transplantation at discharge.

Clinical and laboratory findings of AFLP often overlap with those of HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), and pancreatitis. “We recommend that patients who present with nausea, vomiting, epigastric pain, or malaise in the third trimester should receive evaluation of liver enzymes, renal function, and a complete blood count to rule out the diagnosis of AFLP,” Dr. Fesenmeier said.

WASHINGTON — Acute fatty liver of pregnancy must be ruled out in any woman who presents in the third trimester with nausea, vomiting, epigastric pain, or malaise, Michael F. Fesenmeier, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

The disorder is rare, estimated to affect only 1 in 7,000-16,000 pregnancies. But it is deadly. Maternal and neonatal mortality rates of 75% have been reported in some studies.

“Physicians must be diligent in diagnosing acute fatty liver of pregnancy, and be prepared for its high morbidity and mortality,” said Dr. Fesenmeier of the University of Cincinnati Medical Center.

He and his associates assessed the clinical presentations and outcomes of all 16 women treated for acute fatty liver of pregnancy (AFLP) at three tertiary-care centers in Ohio and Kentucky between 1993 and 2003. The average gestational age at diagnosis was 35.2 weeks (range, 30.0-37.2 weeks). There were 13 singleton and 3 twin pregnancies.

Nausea and vomiting were the most common presenting symptoms, affecting 12 patients (75%). The average duration of nausea and vomiting before the women presented for emergency care was 3-4 days, but some women went undiagnosed for much longer, including one who was undiagnosed for 3 weeks. That patient died within a month of delivery.

Other symptoms included epigastric pain in seven patients (43%), jaundice in six (38%), malaise in five (31%), and loss of consciousness in one (6%), he said in a poster presentation at the meeting.

There were two maternal deaths from multiorgan failure (12.5% maternal mortality) and three fetal deaths (15% infant mortality). Ten women (62%) developed acute tubular necrosis, seven (43%) developed pulmonary edema, seven (43%) developed disseminated intravascular coagulation, and six (38%) developed pancreatitis.

The average length of stay was 15 days, with a range of 5-58 days. Three were referred for liver transplantation at discharge.

Clinical and laboratory findings of AFLP often overlap with those of HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), and pancreatitis. “We recommend that patients who present with nausea, vomiting, epigastric pain, or malaise in the third trimester should receive evaluation of liver enzymes, renal function, and a complete blood count to rule out the diagnosis of AFLP,” Dr. Fesenmeier said.

WASHINGTON — Acute fatty liver of pregnancy must be ruled out in any woman who presents in the third trimester with nausea, vomiting, epigastric pain, or malaise, Michael F. Fesenmeier, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

The disorder is rare, estimated to affect only 1 in 7,000-16,000 pregnancies. But it is deadly. Maternal and neonatal mortality rates of 75% have been reported in some studies.

“Physicians must be diligent in diagnosing acute fatty liver of pregnancy, and be prepared for its high morbidity and mortality,” said Dr. Fesenmeier of the University of Cincinnati Medical Center.

He and his associates assessed the clinical presentations and outcomes of all 16 women treated for acute fatty liver of pregnancy (AFLP) at three tertiary-care centers in Ohio and Kentucky between 1993 and 2003. The average gestational age at diagnosis was 35.2 weeks (range, 30.0-37.2 weeks). There were 13 singleton and 3 twin pregnancies.

Nausea and vomiting were the most common presenting symptoms, affecting 12 patients (75%). The average duration of nausea and vomiting before the women presented for emergency care was 3-4 days, but some women went undiagnosed for much longer, including one who was undiagnosed for 3 weeks. That patient died within a month of delivery.

Other symptoms included epigastric pain in seven patients (43%), jaundice in six (38%), malaise in five (31%), and loss of consciousness in one (6%), he said in a poster presentation at the meeting.

There were two maternal deaths from multiorgan failure (12.5% maternal mortality) and three fetal deaths (15% infant mortality). Ten women (62%) developed acute tubular necrosis, seven (43%) developed pulmonary edema, seven (43%) developed disseminated intravascular coagulation, and six (38%) developed pancreatitis.

The average length of stay was 15 days, with a range of 5-58 days. Three were referred for liver transplantation at discharge.

Clinical and laboratory findings of AFLP often overlap with those of HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), and pancreatitis. “We recommend that patients who present with nausea, vomiting, epigastric pain, or malaise in the third trimester should receive evaluation of liver enzymes, renal function, and a complete blood count to rule out the diagnosis of AFLP,” Dr. Fesenmeier said.