Mary Ann Moon

Stents for Limb Ischemia

Percutaneous angioplasty with stent placement improved ankle-brachial indexes, prevented amputations, healed ulcerations, relieved pain, and improved ambulation—all with minimal adverse effects—in patients who had either critical limb ischemia or severe, lifestyle-limiting claudication, reported Andrew J. Feiring, M.D., and his associates at Columbia St. Mary's Medical Center, Milwaukee.

Until now, patients with these conditions had a “dismal” clinical course, with a 20%-30% 1-year mortality and the expectation that if they survived, they would have continued pain and infection, eventually requiring amputation. Tibial bypass has been the only treatment to improve hemodynamics, as measured by the ankle-brachial index, but most patients forgo the surgery because of its considerable associated morbidity and mortality.

The investigators attempted stent placement in 82 patients with 92 involved limbs. Mean age was 74.2 years; one-third of the subjects were over age 80, and most had numerous comorbidities (J. Am. Coll. Cardiol. 2004;44:2307-14).

In 6 patients, the angioplasty wire could not cross the arterial occlusion, but blood flow to the ankle was restored in each of the remaining 76 patients (86 limbs). There were no procedure-related deaths, MIs, amputations, embolizations, thromboses, or perforations, and 93% of patients were discharged within 1 day.

Global Trends in Hypertension

More than 25% of the world's adults— nearly 1 billion people—had hypertension in 2000, and that proportion will rise to 29% by 2025, according to Patricia M. Kearney, M.D., of Tulane University School of Public Health and Tropical Medicine, New Orleans, and her associates.

To estimate worldwide prevalence, the researchers pooled data from 30 national and regional population-based studies involving as many as 484,000 subjects each. Overall, 26% of the population had hypertension in 2000, with 333 million affected people living in economically developed countries and 639 million in developing countries. Given the aging of the population, that number is projected to increase by 60% to a total of 1.56 billion people by 2025, the investigators said (Lancet 2005;365:217-23).

Hypertension was more common in developed countries, affecting 37% of the population there, compared with 23% of people in developing nations. But the much larger populations of developing countries results in a considerably larger absolute number of individuals affected.

CV Events Down 50% in Diabetics

People with diabetes have benefited just like those without diabetes from the decline in cardiovascular disease rates over the last several decades, according to Caroline S. Fox, M.D., of the National Institutes of Health, Bethesda, Md., and her associates.

Using data from the Framingham Heart Study, the researchers tracked cardiovascular events in 4,118 subjects (including 113 with diabetes) who were examined in the 1950s and 1960s and in 4,063 subjects (including 317 with diabetes) who were examined in the 1970s, 1980s, and 1990s. The incidence of cardiovascular events in subjects with diabetes was 286 per 10,000 person-years in the earlier period, and declined by half to 147 events per 10,000 person-years in the later period. Subjects without diabetes showed a statistically similar decline in cardiovascular events (JAMA 2004;292:2495-9).

However, the absolute risk of cardiovascular events remains at twofold greater for people with diabetes, compared with nondiabetics, the investigators said.

Hypoglycemia Mimics Stroke

Hypoglycemia can masquerade as stroke in elderly patients, particularly when it progresses to the point where brain function is impaired, said M.S. Kühne, M.D., and associates at St. Claraspital in Basel, Switzerland.

They reported the case of a 90-year-old woman with a recent history of falling who was found lying on the floor of her home. On arrival at the hospital, the woman was confused, had difficulty speaking, and showed paresis of her left arm with absent reflexes. Cranial CT results were normal, but the woman had a low plasma glucose level that resolved, along with all symptoms, after she received an infusion of glucose solution. A PET scan revealed a pancreatic insulinoma. The patient refused surgery but responded well to monthly administration of long-acting octreotide (Lancet 2004;364:2152).

Insulinomas often produce neurologic signs and symptoms such as confusion, coma, convulsion, and visual disturbances; paralyses—such as the one in this patient—and paresthesias are less common. The correct diagnosis can be confirmed by a 72-hour fast, which will decrease the patient's plasma glucose level and reproduce the neuroglycopenic symptoms.

Stents for Limb Ischemia

Percutaneous angioplasty with stent placement improved ankle-brachial indexes, prevented amputations, healed ulcerations, relieved pain, and improved ambulation—all with minimal adverse effects—in patients who had either critical limb ischemia or severe, lifestyle-limiting claudication, reported Andrew J. Feiring, M.D., and his associates at Columbia St. Mary's Medical Center, Milwaukee.

Until now, patients with these conditions had a “dismal” clinical course, with a 20%-30% 1-year mortality and the expectation that if they survived, they would have continued pain and infection, eventually requiring amputation. Tibial bypass has been the only treatment to improve hemodynamics, as measured by the ankle-brachial index, but most patients forgo the surgery because of its considerable associated morbidity and mortality.

The investigators attempted stent placement in 82 patients with 92 involved limbs. Mean age was 74.2 years; one-third of the subjects were over age 80, and most had numerous comorbidities (J. Am. Coll. Cardiol. 2004;44:2307-14).

In 6 patients, the angioplasty wire could not cross the arterial occlusion, but blood flow to the ankle was restored in each of the remaining 76 patients (86 limbs). There were no procedure-related deaths, MIs, amputations, embolizations, thromboses, or perforations, and 93% of patients were discharged within 1 day.

Global Trends in Hypertension

More than 25% of the world's adults— nearly 1 billion people—had hypertension in 2000, and that proportion will rise to 29% by 2025, according to Patricia M. Kearney, M.D., of Tulane University School of Public Health and Tropical Medicine, New Orleans, and her associates.

To estimate worldwide prevalence, the researchers pooled data from 30 national and regional population-based studies involving as many as 484,000 subjects each. Overall, 26% of the population had hypertension in 2000, with 333 million affected people living in economically developed countries and 639 million in developing countries. Given the aging of the population, that number is projected to increase by 60% to a total of 1.56 billion people by 2025, the investigators said (Lancet 2005;365:217-23).

Hypertension was more common in developed countries, affecting 37% of the population there, compared with 23% of people in developing nations. But the much larger populations of developing countries results in a considerably larger absolute number of individuals affected.

CV Events Down 50% in Diabetics

People with diabetes have benefited just like those without diabetes from the decline in cardiovascular disease rates over the last several decades, according to Caroline S. Fox, M.D., of the National Institutes of Health, Bethesda, Md., and her associates.

Using data from the Framingham Heart Study, the researchers tracked cardiovascular events in 4,118 subjects (including 113 with diabetes) who were examined in the 1950s and 1960s and in 4,063 subjects (including 317 with diabetes) who were examined in the 1970s, 1980s, and 1990s. The incidence of cardiovascular events in subjects with diabetes was 286 per 10,000 person-years in the earlier period, and declined by half to 147 events per 10,000 person-years in the later period. Subjects without diabetes showed a statistically similar decline in cardiovascular events (JAMA 2004;292:2495-9).

However, the absolute risk of cardiovascular events remains at twofold greater for people with diabetes, compared with nondiabetics, the investigators said.

Hypoglycemia Mimics Stroke

Hypoglycemia can masquerade as stroke in elderly patients, particularly when it progresses to the point where brain function is impaired, said M.S. Kühne, M.D., and associates at St. Claraspital in Basel, Switzerland.

They reported the case of a 90-year-old woman with a recent history of falling who was found lying on the floor of her home. On arrival at the hospital, the woman was confused, had difficulty speaking, and showed paresis of her left arm with absent reflexes. Cranial CT results were normal, but the woman had a low plasma glucose level that resolved, along with all symptoms, after she received an infusion of glucose solution. A PET scan revealed a pancreatic insulinoma. The patient refused surgery but responded well to monthly administration of long-acting octreotide (Lancet 2004;364:2152).

Insulinomas often produce neurologic signs and symptoms such as confusion, coma, convulsion, and visual disturbances; paralyses—such as the one in this patient—and paresthesias are less common. The correct diagnosis can be confirmed by a 72-hour fast, which will decrease the patient's plasma glucose level and reproduce the neuroglycopenic symptoms.

Stents for Limb Ischemia

Percutaneous angioplasty with stent placement improved ankle-brachial indexes, prevented amputations, healed ulcerations, relieved pain, and improved ambulation—all with minimal adverse effects—in patients who had either critical limb ischemia or severe, lifestyle-limiting claudication, reported Andrew J. Feiring, M.D., and his associates at Columbia St. Mary's Medical Center, Milwaukee.

Until now, patients with these conditions had a “dismal” clinical course, with a 20%-30% 1-year mortality and the expectation that if they survived, they would have continued pain and infection, eventually requiring amputation. Tibial bypass has been the only treatment to improve hemodynamics, as measured by the ankle-brachial index, but most patients forgo the surgery because of its considerable associated morbidity and mortality.

The investigators attempted stent placement in 82 patients with 92 involved limbs. Mean age was 74.2 years; one-third of the subjects were over age 80, and most had numerous comorbidities (J. Am. Coll. Cardiol. 2004;44:2307-14).

In 6 patients, the angioplasty wire could not cross the arterial occlusion, but blood flow to the ankle was restored in each of the remaining 76 patients (86 limbs). There were no procedure-related deaths, MIs, amputations, embolizations, thromboses, or perforations, and 93% of patients were discharged within 1 day.

Global Trends in Hypertension

More than 25% of the world's adults— nearly 1 billion people—had hypertension in 2000, and that proportion will rise to 29% by 2025, according to Patricia M. Kearney, M.D., of Tulane University School of Public Health and Tropical Medicine, New Orleans, and her associates.

To estimate worldwide prevalence, the researchers pooled data from 30 national and regional population-based studies involving as many as 484,000 subjects each. Overall, 26% of the population had hypertension in 2000, with 333 million affected people living in economically developed countries and 639 million in developing countries. Given the aging of the population, that number is projected to increase by 60% to a total of 1.56 billion people by 2025, the investigators said (Lancet 2005;365:217-23).

Hypertension was more common in developed countries, affecting 37% of the population there, compared with 23% of people in developing nations. But the much larger populations of developing countries results in a considerably larger absolute number of individuals affected.

CV Events Down 50% in Diabetics

People with diabetes have benefited just like those without diabetes from the decline in cardiovascular disease rates over the last several decades, according to Caroline S. Fox, M.D., of the National Institutes of Health, Bethesda, Md., and her associates.

Using data from the Framingham Heart Study, the researchers tracked cardiovascular events in 4,118 subjects (including 113 with diabetes) who were examined in the 1950s and 1960s and in 4,063 subjects (including 317 with diabetes) who were examined in the 1970s, 1980s, and 1990s. The incidence of cardiovascular events in subjects with diabetes was 286 per 10,000 person-years in the earlier period, and declined by half to 147 events per 10,000 person-years in the later period. Subjects without diabetes showed a statistically similar decline in cardiovascular events (JAMA 2004;292:2495-9).

However, the absolute risk of cardiovascular events remains at twofold greater for people with diabetes, compared with nondiabetics, the investigators said.

Hypoglycemia Mimics Stroke

Hypoglycemia can masquerade as stroke in elderly patients, particularly when it progresses to the point where brain function is impaired, said M.S. Kühne, M.D., and associates at St. Claraspital in Basel, Switzerland.

They reported the case of a 90-year-old woman with a recent history of falling who was found lying on the floor of her home. On arrival at the hospital, the woman was confused, had difficulty speaking, and showed paresis of her left arm with absent reflexes. Cranial CT results were normal, but the woman had a low plasma glucose level that resolved, along with all symptoms, after she received an infusion of glucose solution. A PET scan revealed a pancreatic insulinoma. The patient refused surgery but responded well to monthly administration of long-acting octreotide (Lancet 2004;364:2152).

Insulinomas often produce neurologic signs and symptoms such as confusion, coma, convulsion, and visual disturbances; paralyses—such as the one in this patient—and paresthesias are less common. The correct diagnosis can be confirmed by a 72-hour fast, which will decrease the patient's plasma glucose level and reproduce the neuroglycopenic symptoms.

The longest follow-up of patients randomly assigned to receive either statin therapy or placebo has shown that the drugs do not raise cancer incidence or cancer mortality, though they do continue to exert beneficial cardiovascular effects, said Timo E. Strandberg, M.D., of Kuopio (Finland) University, and associates.

“Most statin trials, which generally last 5–6 years, have not shown any rise in cancer incidence in statin-treated participants, but in two studies some excess of cancer was reported,” Dr. Strandberg and associates said. They examined cancer risk by extending the follow-up in their trial of more than 4,000 subjects in five Nordic countries (Lancet 2004;364:771–7).

During 10 years of follow-up, 100 subjects who had received placebo and 85 who had received simvastatin died from cancer, reflecting a slight but statistically insignificant reduction in cancer mortality with statin use. Similarly, the risk of developing cancer was 12% lower in the statin group than in the placebo group, a nonsignificant difference, the investigators said.

The longest follow-up of patients randomly assigned to receive either statin therapy or placebo has shown that the drugs do not raise cancer incidence or cancer mortality, though they do continue to exert beneficial cardiovascular effects, said Timo E. Strandberg, M.D., of Kuopio (Finland) University, and associates.

“Most statin trials, which generally last 5–6 years, have not shown any rise in cancer incidence in statin-treated participants, but in two studies some excess of cancer was reported,” Dr. Strandberg and associates said. They examined cancer risk by extending the follow-up in their trial of more than 4,000 subjects in five Nordic countries (Lancet 2004;364:771–7).

During 10 years of follow-up, 100 subjects who had received placebo and 85 who had received simvastatin died from cancer, reflecting a slight but statistically insignificant reduction in cancer mortality with statin use. Similarly, the risk of developing cancer was 12% lower in the statin group than in the placebo group, a nonsignificant difference, the investigators said.

The longest follow-up of patients randomly assigned to receive either statin therapy or placebo has shown that the drugs do not raise cancer incidence or cancer mortality, though they do continue to exert beneficial cardiovascular effects, said Timo E. Strandberg, M.D., of Kuopio (Finland) University, and associates.

“Most statin trials, which generally last 5–6 years, have not shown any rise in cancer incidence in statin-treated participants, but in two studies some excess of cancer was reported,” Dr. Strandberg and associates said. They examined cancer risk by extending the follow-up in their trial of more than 4,000 subjects in five Nordic countries (Lancet 2004;364:771–7).

During 10 years of follow-up, 100 subjects who had received placebo and 85 who had received simvastatin died from cancer, reflecting a slight but statistically insignificant reduction in cancer mortality with statin use. Similarly, the risk of developing cancer was 12% lower in the statin group than in the placebo group, a nonsignificant difference, the investigators said.

Drainage, Chemo for Malignant Effusions

Neoplastic pericardial effusions should be treated aggressively with intracavitary infusions of thiotepa, a low-cost, low-risk procedure that extends life expectancy and improves quality of life, according to Alessandro Martinoni, M.D., and associates at the University of Milan's European Institute of Oncology.

Malignant pericardial effusions are common in cancer patients, and until now the resulting pericardial tamponade has been the immediate cause of death in 85% of affected patients. But developing the condition should no longer “be considered as a terminal event, but [rather] as a treatable condition requiring true therapeutic intervention instead of a mere palliative approach,” the investigators noted (Chest 2004;126:1412–6).

They performed percutaneous pericardiocentesis in 33 patients with metastatic breast, lung, skin, or endometrial cancers. All had pericardial effusions causing severe dyspnea, weakness, chest pain, and tachycardia, and 24 had cardiac tamponade. The malignant effusions were drained and thiotepa was administered in stages over a 5-day period. “All patients showed rapid and almost complete improvement of symptoms,” without any adverse effects, pain, or myelosuppression.

Pericardial effusions recurred in only three patients (9%) over several months of follow-up, and resolved with a repeat pericardiocentesis and thiotepa infusion. The treatment thus not only eliminated existing neoplastic effusion but also inhibited further effusion from developing. Median patient survival was 115 days (range 22–1,108 days), an “unexpected” result considering their extremely poor prognoses.

New Marker for HF Mortality in Elderly

The serum level of cystatin-C appears to be a stronger predictor of mortality in elderly people with heart failure than serum creatinine, reported Michael G. Shlipak, M.D., of San Francisco Veterans Affairs Medical Center, and his associates.

Cystatin-C, a serine protease inhibitor released by all functioning cells, can be used as a serum measure of renal function. Unlike creatinine, cystatin-C does not appear to be influenced by patient age, gender, or body mass, and so should be a particularly useful marker in elderly heart failure (HF) patients, the investigators said (J. Am. Coll. Cardiol. 2005;45:268–71).

They conducted a pilot study comparing cystatin-C with creatinine as a predictor of mortality, using data from a community-based longitudinal study of nearly 6,000 elderly subjects. During a median follow-up of 6.5 years, cystatin-C level was a better predictor of mortality in those who had HF. If larger studies confirm this finding, this new marker of renal function could replace traditional markers in risk assessment for HF patients, they said.

Injected Anti-VEGF for Macular Disease

Intravitreous injections of pegaptanib, an agent that blocks the activity of vascular endothelial growth factor, arrests the loss of visual acuity in patients with age-related macular degeneration due to choroidal neovascularization, according to Evangelos S. Gragoudas, M.D., of the Massachusetts Eye and Ear Infirmary, Boston, and associates.

They conducted two concurrent randomized trials involving 1,186 patients aged 50 years and older treated at 117 medical centers worldwide. The subjects, who had a broad spectrum of lesion sizes, angiographic types of lesions, and baseline levels of visual loss, were randomly assigned to receive either pegaptanib or sham eye injections every 6 weeks for 48 weeks.

Reductions in both moderate and severe losses of visual acuity were noted as early as at the time of the second injection, and benefit increased over time. The treatment also reduced the chance that patients would progress to legal blindness, and it actually improved vision in 33% of patients, the investigators said (N. Engl. J. Med. 2004;351:2805–16).

Racial Disparity Persists in ICD Use

The racial disparity in the use of implantable cardioverter defibrillators improved throughout the 1990s but still remained “substantial” by the year 2000, reported Peter W. Groeneveld of Veterans Affairs Medical Center, Philadelphia, and his associates.

The researchers analyzed Medicare data on more than 570,000 elderly patients hospitalized with ventricular arrhythmias during 1990–2000. At the beginning of that period, subjects of any race living in geographic areas where at least 10% of the population was African American had a 19%–23% lower chance of receiving an implantable cardioverter defibrillator (ICD) than did those living in areas with smaller black populations. But by 2000, ICD implantation rates had essentially equalized among geographic groups. For the study, geographic areas were defined using zip codes, and demographic data were obtained from the 1990 and 2000 U.S. Census.

It appears that early in the decade, ICD use “may have insufficiently 'penetrated' the health care systems where black patients were more likely to receive care.” Although this geographic situation has largely been ameliorated, a racial disparity still persists. “Even as late as 1999–2000, elderly black patients with ventricular arrhythmias continued to have approximately two-thirds the likelihood of receiving an ICD” as whites, the investigators said (J. Am. Coll. Cardiol. 2005;45:72–8).

Drainage, Chemo for Malignant Effusions

Neoplastic pericardial effusions should be treated aggressively with intracavitary infusions of thiotepa, a low-cost, low-risk procedure that extends life expectancy and improves quality of life, according to Alessandro Martinoni, M.D., and associates at the University of Milan's European Institute of Oncology.

Malignant pericardial effusions are common in cancer patients, and until now the resulting pericardial tamponade has been the immediate cause of death in 85% of affected patients. But developing the condition should no longer “be considered as a terminal event, but [rather] as a treatable condition requiring true therapeutic intervention instead of a mere palliative approach,” the investigators noted (Chest 2004;126:1412–6).

They performed percutaneous pericardiocentesis in 33 patients with metastatic breast, lung, skin, or endometrial cancers. All had pericardial effusions causing severe dyspnea, weakness, chest pain, and tachycardia, and 24 had cardiac tamponade. The malignant effusions were drained and thiotepa was administered in stages over a 5-day period. “All patients showed rapid and almost complete improvement of symptoms,” without any adverse effects, pain, or myelosuppression.

Pericardial effusions recurred in only three patients (9%) over several months of follow-up, and resolved with a repeat pericardiocentesis and thiotepa infusion. The treatment thus not only eliminated existing neoplastic effusion but also inhibited further effusion from developing. Median patient survival was 115 days (range 22–1,108 days), an “unexpected” result considering their extremely poor prognoses.

New Marker for HF Mortality in Elderly

The serum level of cystatin-C appears to be a stronger predictor of mortality in elderly people with heart failure than serum creatinine, reported Michael G. Shlipak, M.D., of San Francisco Veterans Affairs Medical Center, and his associates.

Cystatin-C, a serine protease inhibitor released by all functioning cells, can be used as a serum measure of renal function. Unlike creatinine, cystatin-C does not appear to be influenced by patient age, gender, or body mass, and so should be a particularly useful marker in elderly heart failure (HF) patients, the investigators said (J. Am. Coll. Cardiol. 2005;45:268–71).

They conducted a pilot study comparing cystatin-C with creatinine as a predictor of mortality, using data from a community-based longitudinal study of nearly 6,000 elderly subjects. During a median follow-up of 6.5 years, cystatin-C level was a better predictor of mortality in those who had HF. If larger studies confirm this finding, this new marker of renal function could replace traditional markers in risk assessment for HF patients, they said.

Injected Anti-VEGF for Macular Disease

Intravitreous injections of pegaptanib, an agent that blocks the activity of vascular endothelial growth factor, arrests the loss of visual acuity in patients with age-related macular degeneration due to choroidal neovascularization, according to Evangelos S. Gragoudas, M.D., of the Massachusetts Eye and Ear Infirmary, Boston, and associates.

They conducted two concurrent randomized trials involving 1,186 patients aged 50 years and older treated at 117 medical centers worldwide. The subjects, who had a broad spectrum of lesion sizes, angiographic types of lesions, and baseline levels of visual loss, were randomly assigned to receive either pegaptanib or sham eye injections every 6 weeks for 48 weeks.

Reductions in both moderate and severe losses of visual acuity were noted as early as at the time of the second injection, and benefit increased over time. The treatment also reduced the chance that patients would progress to legal blindness, and it actually improved vision in 33% of patients, the investigators said (N. Engl. J. Med. 2004;351:2805–16).

Racial Disparity Persists in ICD Use

The racial disparity in the use of implantable cardioverter defibrillators improved throughout the 1990s but still remained “substantial” by the year 2000, reported Peter W. Groeneveld of Veterans Affairs Medical Center, Philadelphia, and his associates.

The researchers analyzed Medicare data on more than 570,000 elderly patients hospitalized with ventricular arrhythmias during 1990–2000. At the beginning of that period, subjects of any race living in geographic areas where at least 10% of the population was African American had a 19%–23% lower chance of receiving an implantable cardioverter defibrillator (ICD) than did those living in areas with smaller black populations. But by 2000, ICD implantation rates had essentially equalized among geographic groups. For the study, geographic areas were defined using zip codes, and demographic data were obtained from the 1990 and 2000 U.S. Census.

It appears that early in the decade, ICD use “may have insufficiently 'penetrated' the health care systems where black patients were more likely to receive care.” Although this geographic situation has largely been ameliorated, a racial disparity still persists. “Even as late as 1999–2000, elderly black patients with ventricular arrhythmias continued to have approximately two-thirds the likelihood of receiving an ICD” as whites, the investigators said (J. Am. Coll. Cardiol. 2005;45:72–8).

Drainage, Chemo for Malignant Effusions

Neoplastic pericardial effusions should be treated aggressively with intracavitary infusions of thiotepa, a low-cost, low-risk procedure that extends life expectancy and improves quality of life, according to Alessandro Martinoni, M.D., and associates at the University of Milan's European Institute of Oncology.

Malignant pericardial effusions are common in cancer patients, and until now the resulting pericardial tamponade has been the immediate cause of death in 85% of affected patients. But developing the condition should no longer “be considered as a terminal event, but [rather] as a treatable condition requiring true therapeutic intervention instead of a mere palliative approach,” the investigators noted (Chest 2004;126:1412–6).

They performed percutaneous pericardiocentesis in 33 patients with metastatic breast, lung, skin, or endometrial cancers. All had pericardial effusions causing severe dyspnea, weakness, chest pain, and tachycardia, and 24 had cardiac tamponade. The malignant effusions were drained and thiotepa was administered in stages over a 5-day period. “All patients showed rapid and almost complete improvement of symptoms,” without any adverse effects, pain, or myelosuppression.

Pericardial effusions recurred in only three patients (9%) over several months of follow-up, and resolved with a repeat pericardiocentesis and thiotepa infusion. The treatment thus not only eliminated existing neoplastic effusion but also inhibited further effusion from developing. Median patient survival was 115 days (range 22–1,108 days), an “unexpected” result considering their extremely poor prognoses.

New Marker for HF Mortality in Elderly

The serum level of cystatin-C appears to be a stronger predictor of mortality in elderly people with heart failure than serum creatinine, reported Michael G. Shlipak, M.D., of San Francisco Veterans Affairs Medical Center, and his associates.

Cystatin-C, a serine protease inhibitor released by all functioning cells, can be used as a serum measure of renal function. Unlike creatinine, cystatin-C does not appear to be influenced by patient age, gender, or body mass, and so should be a particularly useful marker in elderly heart failure (HF) patients, the investigators said (J. Am. Coll. Cardiol. 2005;45:268–71).

They conducted a pilot study comparing cystatin-C with creatinine as a predictor of mortality, using data from a community-based longitudinal study of nearly 6,000 elderly subjects. During a median follow-up of 6.5 years, cystatin-C level was a better predictor of mortality in those who had HF. If larger studies confirm this finding, this new marker of renal function could replace traditional markers in risk assessment for HF patients, they said.

Injected Anti-VEGF for Macular Disease

Intravitreous injections of pegaptanib, an agent that blocks the activity of vascular endothelial growth factor, arrests the loss of visual acuity in patients with age-related macular degeneration due to choroidal neovascularization, according to Evangelos S. Gragoudas, M.D., of the Massachusetts Eye and Ear Infirmary, Boston, and associates.

They conducted two concurrent randomized trials involving 1,186 patients aged 50 years and older treated at 117 medical centers worldwide. The subjects, who had a broad spectrum of lesion sizes, angiographic types of lesions, and baseline levels of visual loss, were randomly assigned to receive either pegaptanib or sham eye injections every 6 weeks for 48 weeks.

Reductions in both moderate and severe losses of visual acuity were noted as early as at the time of the second injection, and benefit increased over time. The treatment also reduced the chance that patients would progress to legal blindness, and it actually improved vision in 33% of patients, the investigators said (N. Engl. J. Med. 2004;351:2805–16).

Racial Disparity Persists in ICD Use

The racial disparity in the use of implantable cardioverter defibrillators improved throughout the 1990s but still remained “substantial” by the year 2000, reported Peter W. Groeneveld of Veterans Affairs Medical Center, Philadelphia, and his associates.

The researchers analyzed Medicare data on more than 570,000 elderly patients hospitalized with ventricular arrhythmias during 1990–2000. At the beginning of that period, subjects of any race living in geographic areas where at least 10% of the population was African American had a 19%–23% lower chance of receiving an implantable cardioverter defibrillator (ICD) than did those living in areas with smaller black populations. But by 2000, ICD implantation rates had essentially equalized among geographic groups. For the study, geographic areas were defined using zip codes, and demographic data were obtained from the 1990 and 2000 U.S. Census.

It appears that early in the decade, ICD use “may have insufficiently 'penetrated' the health care systems where black patients were more likely to receive care.” Although this geographic situation has largely been ameliorated, a racial disparity still persists. “Even as late as 1999–2000, elderly black patients with ventricular arrhythmias continued to have approximately two-thirds the likelihood of receiving an ICD” as whites, the investigators said (J. Am. Coll. Cardiol. 2005;45:72–8).

Impaired fetal growth does not raise cholesterol levels in adulthood appreciably, according to Rachel Huxley, D.Phil., of the University of Sydney, and her associates.

Proponents of the “fetal origins” hypothesis hold that fetal undernutrition is linked to higher risk of coronary heart disease and related conditions such as high blood pressure, impaired glucose tolerance, and high cholesterol. But it can be argued that there were many methodologic flaws in the collection and interpretation of data supporting this hypothesis. Dr. Huxley and her associates conducted a systematic review of 79 relevant studies involving a total of 74,122 subjects, including 25 studies involving more than 45,000 subjects that were never included in previous examinations of this issue.

They found that for every 1-kg decrease in birth weight, there is only a 2.0-mg/dL rise in cholesterol in later life, which they characterized as a weak link unlikely to affect public health. “Assuming that nutritional intervention in pregnancy could increase birth weight by as much as 100 g, this association would translate into only approximately 0.19 mg/dL lower total cholesterol level,” which would reduce coronary disease risk by less than 0.025%. In contrast, dietary intervention in adulthood can reduce cholesterol level by 15 mg/dL, for a 15% lower CHD risk, they said (JAMA 2004;292:2755–64).

Impaired fetal growth does not raise cholesterol levels in adulthood appreciably, according to Rachel Huxley, D.Phil., of the University of Sydney, and her associates.

Proponents of the “fetal origins” hypothesis hold that fetal undernutrition is linked to higher risk of coronary heart disease and related conditions such as high blood pressure, impaired glucose tolerance, and high cholesterol. But it can be argued that there were many methodologic flaws in the collection and interpretation of data supporting this hypothesis. Dr. Huxley and her associates conducted a systematic review of 79 relevant studies involving a total of 74,122 subjects, including 25 studies involving more than 45,000 subjects that were never included in previous examinations of this issue.

They found that for every 1-kg decrease in birth weight, there is only a 2.0-mg/dL rise in cholesterol in later life, which they characterized as a weak link unlikely to affect public health. “Assuming that nutritional intervention in pregnancy could increase birth weight by as much as 100 g, this association would translate into only approximately 0.19 mg/dL lower total cholesterol level,” which would reduce coronary disease risk by less than 0.025%. In contrast, dietary intervention in adulthood can reduce cholesterol level by 15 mg/dL, for a 15% lower CHD risk, they said (JAMA 2004;292:2755–64).

Impaired fetal growth does not raise cholesterol levels in adulthood appreciably, according to Rachel Huxley, D.Phil., of the University of Sydney, and her associates.

Proponents of the “fetal origins” hypothesis hold that fetal undernutrition is linked to higher risk of coronary heart disease and related conditions such as high blood pressure, impaired glucose tolerance, and high cholesterol. But it can be argued that there were many methodologic flaws in the collection and interpretation of data supporting this hypothesis. Dr. Huxley and her associates conducted a systematic review of 79 relevant studies involving a total of 74,122 subjects, including 25 studies involving more than 45,000 subjects that were never included in previous examinations of this issue.

They found that for every 1-kg decrease in birth weight, there is only a 2.0-mg/dL rise in cholesterol in later life, which they characterized as a weak link unlikely to affect public health. “Assuming that nutritional intervention in pregnancy could increase birth weight by as much as 100 g, this association would translate into only approximately 0.19 mg/dL lower total cholesterol level,” which would reduce coronary disease risk by less than 0.025%. In contrast, dietary intervention in adulthood can reduce cholesterol level by 15 mg/dL, for a 15% lower CHD risk, they said (JAMA 2004;292:2755–64).

WASHINGTON — A paradoxical benefit of cigarette smoking during pregnancy finally may have been explained.

Smoking has long been linked to a decreased rate of preeclampsia. But rather than protecting against the disorder, smoking may mask the true incidence of preeclampsia by indirectly inducing preterm delivery, so that smokers' infants are simply born before preeclampsia can be manifested, Ahmad O. Hammoud, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

A 1999 study published in the New England Journal of Medicine found that the risk of developing preeclampsia was 32% lower in women who smoked than in nonsmokers. And most studies—a total of 99—cited in a review of the literature since 1959 also showed that smoking was associated with decreased risk. But this link “has always been questioned,” because it is counterintuitive that smoking could benefit pregnancy and because many of these studies had relatively small sample sizes, said Dr. Hammoud, a fourth-year resident in the department of ob.gyn. at Wayne State University, Detroit.

He and his associates examined the issue using a large German database of 170,254 singleton deliveries that took place at 29 hospitals across Germany during the late 1990s. Mean maternal age was 29 years. Overall, 23% of the women were smokers, and the overall rate of preeclampsia was 3.5%.

The incidence of preeclampsia was 2.5% among nonsmokers, compared with only 1.9% among smokers. Moreover, the incidence of preeclampsia showed a clear inverse correlation with the number of cigarettes smoked per day. Nonsmokers had the highest rate of preeclampsia, followed by women who smoked 1–5 cigarettes per day, then by women who smoked 6–10 cigarettes per day, and finally, by women who smoked more than 10 cigarettes per day.

“The new finding in our study was that the incidence of preeclampsia was not uniformly low in all smokers. It increased with advancing gestational age and was especially high in smokers who made it to 40 weeks or more,” Dr. Hammoud said.

“We postulate that placental damage from smoking leads to severe complications, such as placental abruption and restricted fetal growth, which in turn lead to preterm delivery before preeclampsia is manifested. So what smokers actually have is just an apparent decrease in preeclampsia,” he said.

This hypothesis is supported by the finding that smokers had a higher rate of placental abruption than nonsmokers and that fetal weight was adversely affected by smoking in a dose-response fashion, he noted.

WASHINGTON — A paradoxical benefit of cigarette smoking during pregnancy finally may have been explained.

Smoking has long been linked to a decreased rate of preeclampsia. But rather than protecting against the disorder, smoking may mask the true incidence of preeclampsia by indirectly inducing preterm delivery, so that smokers' infants are simply born before preeclampsia can be manifested, Ahmad O. Hammoud, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

A 1999 study published in the New England Journal of Medicine found that the risk of developing preeclampsia was 32% lower in women who smoked than in nonsmokers. And most studies—a total of 99—cited in a review of the literature since 1959 also showed that smoking was associated with decreased risk. But this link “has always been questioned,” because it is counterintuitive that smoking could benefit pregnancy and because many of these studies had relatively small sample sizes, said Dr. Hammoud, a fourth-year resident in the department of ob.gyn. at Wayne State University, Detroit.

He and his associates examined the issue using a large German database of 170,254 singleton deliveries that took place at 29 hospitals across Germany during the late 1990s. Mean maternal age was 29 years. Overall, 23% of the women were smokers, and the overall rate of preeclampsia was 3.5%.

The incidence of preeclampsia was 2.5% among nonsmokers, compared with only 1.9% among smokers. Moreover, the incidence of preeclampsia showed a clear inverse correlation with the number of cigarettes smoked per day. Nonsmokers had the highest rate of preeclampsia, followed by women who smoked 1–5 cigarettes per day, then by women who smoked 6–10 cigarettes per day, and finally, by women who smoked more than 10 cigarettes per day.

“The new finding in our study was that the incidence of preeclampsia was not uniformly low in all smokers. It increased with advancing gestational age and was especially high in smokers who made it to 40 weeks or more,” Dr. Hammoud said.

“We postulate that placental damage from smoking leads to severe complications, such as placental abruption and restricted fetal growth, which in turn lead to preterm delivery before preeclampsia is manifested. So what smokers actually have is just an apparent decrease in preeclampsia,” he said.

This hypothesis is supported by the finding that smokers had a higher rate of placental abruption than nonsmokers and that fetal weight was adversely affected by smoking in a dose-response fashion, he noted.

WASHINGTON — A paradoxical benefit of cigarette smoking during pregnancy finally may have been explained.

Smoking has long been linked to a decreased rate of preeclampsia. But rather than protecting against the disorder, smoking may mask the true incidence of preeclampsia by indirectly inducing preterm delivery, so that smokers' infants are simply born before preeclampsia can be manifested, Ahmad O. Hammoud, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

A 1999 study published in the New England Journal of Medicine found that the risk of developing preeclampsia was 32% lower in women who smoked than in nonsmokers. And most studies—a total of 99—cited in a review of the literature since 1959 also showed that smoking was associated with decreased risk. But this link “has always been questioned,” because it is counterintuitive that smoking could benefit pregnancy and because many of these studies had relatively small sample sizes, said Dr. Hammoud, a fourth-year resident in the department of ob.gyn. at Wayne State University, Detroit.

He and his associates examined the issue using a large German database of 170,254 singleton deliveries that took place at 29 hospitals across Germany during the late 1990s. Mean maternal age was 29 years. Overall, 23% of the women were smokers, and the overall rate of preeclampsia was 3.5%.

The incidence of preeclampsia was 2.5% among nonsmokers, compared with only 1.9% among smokers. Moreover, the incidence of preeclampsia showed a clear inverse correlation with the number of cigarettes smoked per day. Nonsmokers had the highest rate of preeclampsia, followed by women who smoked 1–5 cigarettes per day, then by women who smoked 6–10 cigarettes per day, and finally, by women who smoked more than 10 cigarettes per day.

“The new finding in our study was that the incidence of preeclampsia was not uniformly low in all smokers. It increased with advancing gestational age and was especially high in smokers who made it to 40 weeks or more,” Dr. Hammoud said.

“We postulate that placental damage from smoking leads to severe complications, such as placental abruption and restricted fetal growth, which in turn lead to preterm delivery before preeclampsia is manifested. So what smokers actually have is just an apparent decrease in preeclampsia,” he said.

This hypothesis is supported by the finding that smokers had a higher rate of placental abruption than nonsmokers and that fetal weight was adversely affected by smoking in a dose-response fashion, he noted.

BETHESDA, MD. – American children aren't getting enough sleep.

Children in every age group “don't even meet the low end of the range recommended by experts” for sleep in a 24-hour period, according to a national survey, Mary A. Carskadon, Ph.D., said at a conference on sleep disorders sponsored by the National Institutes of Health.

Dr. Carskadon was referring to the results of the National Sleep Foundation's annual Sleep in America poll, which included data on children's sleep for the first time this year. The NSF found that televisions and computers in children's bedrooms are the main contributors to sleep loss. In the phone survey of a random sample of 1,473 parents and caregivers, respondents reported that nearly half (43%) of school-aged children, one-third of preschool children, and “an astounding 20% of infants and toddlers” had TVs in their bedrooms, Dr. Carskadon said.

These children go to sleep an average of 20 minutes later and sleep 40 minutes less per night than children with no TV in their rooms, for a loss of more than 2 hours of sleep every week. Many never “catch up” on their sleep on the weekends, as approximately one-fourth of children 3–10 years old actually sleep less on weekends than on weekdays, said Dr. Carskadon, professor of psychiatry and human behavior at Brown University, Providence, R.I.

For these children, bedtimes are delayed, overall sleep time is decreased, and daytime sleepiness is common. “A paper coming out soon in the Archives of Pediatrics and Adolescent Medicine shows that among young adolescents, watching TV in the bedroom at night predicts major sleep disturbances such as insomnia in young adulthood,” she added.

Most of the parents polled reported that their children get “the right amount” of sleep, apparently unaware that the actual number of hours they say their children sleep falls far short of the experts' recommendations.

The other major culprit in children's sleep loss is caffeine consumption. The NSF poll showed that 26% of children 3–10 years old drink at least one caffeinated beverage every day. Those who have caffeinated drinks sleep less than children who don't ingest caffeine (an average of 9.1 versus 9.7 hours per night), for a loss of about 3.5 hours every week.

Dr. Carskadon noted that myriad caffeinated drinks are specifically targeted to children and adolescents, and coffee shops offer chocolate drinks, teas, and coffee concoctions with flavors calculated to appeal to children and teenagers.

Early school start times are another contributor to children's sleep loss.

With the delay in circadian phase and the delay in the melatonin secretory phase that accompany puberty, preadolescents and adolescents in particular “are under enormous physiological pressure to delay their sleep cycle”–to stay awake until late at night and to rise late in the morning.

“These kids' circadian cycles are already hammered by their biology. Add to that the ridiculously early school start times across much of the country, and sleep gets squeezed right out of their schedules,” Dr. Carskadon said.

Extracurricular activities also affect sleep. Many high school athletes are required to practice every morning before school, at 4 a.m. and 5 a.m. sessions, or after school every day until 6 p.m. to 8 p.m. Games and competitions routinely extend until 10 p.m. or later, excluding travel time.

According to the NSF survey, parents also reported that a majority of children's physicians (52%) never ask about their children's sleep habits, even though most parents (69%) said their children have sleep problems such as difficulty falling asleep, nighttime wakening, and snoring, at least a few nights every week.

The survey also found that the older the child, the less likely a physician was to ask about sleep, even though older children and teens are more likely to have frequent sleep problems than younger children.

Children's Sleep Can Be Improved

Dr. Carskadon discussed several recommendations aimed at improving the quantity and quality of children's sleep:

▸ Make adequate sleep a priority for families. Help parents determine the amount of sleep each family member needs, and urge them to ensure that those needs are met. To motivate parents to regulate their children's sleep, emphasize the strong links between poor sleep and bad behavior, poor school performance, depressed mood, high risk for accidents and injuries, and high risk for alcohol and drug use later in life.

▸ Promote good sleep habits. Advise parents to schedule leisure activities like television viewing, video games, and Internet surfing for specific times and places–and never in children's bedrooms. They also should promote regular bedtime routines, and create quiet and comfortable settings for sleep.

▸ ILimit sleep disrupters. Tell parents that caffeine should not be part of a child's diet, and remind them that some unlikely drinks, such as citrus-flavored sodas, can have high caffeine contents. Lobby parents and schools to limit the hours of extracurricular activities and to change early school start times. It may help to cite research on a Minneapolis school district that found grades markedly improved, tardiness and absenteeism greatly declined, and the graduation rate rose when school start times were delayed.

▸ Regularly ask patients and parents about sleep. Children's sleep problems too often go undetected and untreated. Since depression in particular can be related to sleep disturbances, both as a consequence and as a cause of inadequate sleep, “all children and teenagers who appear to be depressed must be queried about sleep,” Dr. Carskadon noted.

BETHESDA, MD. – American children aren't getting enough sleep.

Children in every age group “don't even meet the low end of the range recommended by experts” for sleep in a 24-hour period, according to a national survey, Mary A. Carskadon, Ph.D., said at a conference on sleep disorders sponsored by the National Institutes of Health.

Dr. Carskadon was referring to the results of the National Sleep Foundation's annual Sleep in America poll, which included data on children's sleep for the first time this year. The NSF found that televisions and computers in children's bedrooms are the main contributors to sleep loss. In the phone survey of a random sample of 1,473 parents and caregivers, respondents reported that nearly half (43%) of school-aged children, one-third of preschool children, and “an astounding 20% of infants and toddlers” had TVs in their bedrooms, Dr. Carskadon said.

These children go to sleep an average of 20 minutes later and sleep 40 minutes less per night than children with no TV in their rooms, for a loss of more than 2 hours of sleep every week. Many never “catch up” on their sleep on the weekends, as approximately one-fourth of children 3–10 years old actually sleep less on weekends than on weekdays, said Dr. Carskadon, professor of psychiatry and human behavior at Brown University, Providence, R.I.

For these children, bedtimes are delayed, overall sleep time is decreased, and daytime sleepiness is common. “A paper coming out soon in the Archives of Pediatrics and Adolescent Medicine shows that among young adolescents, watching TV in the bedroom at night predicts major sleep disturbances such as insomnia in young adulthood,” she added.

Most of the parents polled reported that their children get “the right amount” of sleep, apparently unaware that the actual number of hours they say their children sleep falls far short of the experts' recommendations.

The other major culprit in children's sleep loss is caffeine consumption. The NSF poll showed that 26% of children 3–10 years old drink at least one caffeinated beverage every day. Those who have caffeinated drinks sleep less than children who don't ingest caffeine (an average of 9.1 versus 9.7 hours per night), for a loss of about 3.5 hours every week.

Dr. Carskadon noted that myriad caffeinated drinks are specifically targeted to children and adolescents, and coffee shops offer chocolate drinks, teas, and coffee concoctions with flavors calculated to appeal to children and teenagers.

Early school start times are another contributor to children's sleep loss.

With the delay in circadian phase and the delay in the melatonin secretory phase that accompany puberty, preadolescents and adolescents in particular “are under enormous physiological pressure to delay their sleep cycle”–to stay awake until late at night and to rise late in the morning.

“These kids' circadian cycles are already hammered by their biology. Add to that the ridiculously early school start times across much of the country, and sleep gets squeezed right out of their schedules,” Dr. Carskadon said.

Extracurricular activities also affect sleep. Many high school athletes are required to practice every morning before school, at 4 a.m. and 5 a.m. sessions, or after school every day until 6 p.m. to 8 p.m. Games and competitions routinely extend until 10 p.m. or later, excluding travel time.

According to the NSF survey, parents also reported that a majority of children's physicians (52%) never ask about their children's sleep habits, even though most parents (69%) said their children have sleep problems such as difficulty falling asleep, nighttime wakening, and snoring, at least a few nights every week.

The survey also found that the older the child, the less likely a physician was to ask about sleep, even though older children and teens are more likely to have frequent sleep problems than younger children.

Children's Sleep Can Be Improved

Dr. Carskadon discussed several recommendations aimed at improving the quantity and quality of children's sleep:

▸ Make adequate sleep a priority for families. Help parents determine the amount of sleep each family member needs, and urge them to ensure that those needs are met. To motivate parents to regulate their children's sleep, emphasize the strong links between poor sleep and bad behavior, poor school performance, depressed mood, high risk for accidents and injuries, and high risk for alcohol and drug use later in life.

▸ Promote good sleep habits. Advise parents to schedule leisure activities like television viewing, video games, and Internet surfing for specific times and places–and never in children's bedrooms. They also should promote regular bedtime routines, and create quiet and comfortable settings for sleep.

▸ ILimit sleep disrupters. Tell parents that caffeine should not be part of a child's diet, and remind them that some unlikely drinks, such as citrus-flavored sodas, can have high caffeine contents. Lobby parents and schools to limit the hours of extracurricular activities and to change early school start times. It may help to cite research on a Minneapolis school district that found grades markedly improved, tardiness and absenteeism greatly declined, and the graduation rate rose when school start times were delayed.

▸ Regularly ask patients and parents about sleep. Children's sleep problems too often go undetected and untreated. Since depression in particular can be related to sleep disturbances, both as a consequence and as a cause of inadequate sleep, “all children and teenagers who appear to be depressed must be queried about sleep,” Dr. Carskadon noted.

BETHESDA, MD. – American children aren't getting enough sleep.

Children in every age group “don't even meet the low end of the range recommended by experts” for sleep in a 24-hour period, according to a national survey, Mary A. Carskadon, Ph.D., said at a conference on sleep disorders sponsored by the National Institutes of Health.

Dr. Carskadon was referring to the results of the National Sleep Foundation's annual Sleep in America poll, which included data on children's sleep for the first time this year. The NSF found that televisions and computers in children's bedrooms are the main contributors to sleep loss. In the phone survey of a random sample of 1,473 parents and caregivers, respondents reported that nearly half (43%) of school-aged children, one-third of preschool children, and “an astounding 20% of infants and toddlers” had TVs in their bedrooms, Dr. Carskadon said.

These children go to sleep an average of 20 minutes later and sleep 40 minutes less per night than children with no TV in their rooms, for a loss of more than 2 hours of sleep every week. Many never “catch up” on their sleep on the weekends, as approximately one-fourth of children 3–10 years old actually sleep less on weekends than on weekdays, said Dr. Carskadon, professor of psychiatry and human behavior at Brown University, Providence, R.I.

For these children, bedtimes are delayed, overall sleep time is decreased, and daytime sleepiness is common. “A paper coming out soon in the Archives of Pediatrics and Adolescent Medicine shows that among young adolescents, watching TV in the bedroom at night predicts major sleep disturbances such as insomnia in young adulthood,” she added.

Most of the parents polled reported that their children get “the right amount” of sleep, apparently unaware that the actual number of hours they say their children sleep falls far short of the experts' recommendations.

The other major culprit in children's sleep loss is caffeine consumption. The NSF poll showed that 26% of children 3–10 years old drink at least one caffeinated beverage every day. Those who have caffeinated drinks sleep less than children who don't ingest caffeine (an average of 9.1 versus 9.7 hours per night), for a loss of about 3.5 hours every week.

Dr. Carskadon noted that myriad caffeinated drinks are specifically targeted to children and adolescents, and coffee shops offer chocolate drinks, teas, and coffee concoctions with flavors calculated to appeal to children and teenagers.

Early school start times are another contributor to children's sleep loss.

With the delay in circadian phase and the delay in the melatonin secretory phase that accompany puberty, preadolescents and adolescents in particular “are under enormous physiological pressure to delay their sleep cycle”–to stay awake until late at night and to rise late in the morning.

“These kids' circadian cycles are already hammered by their biology. Add to that the ridiculously early school start times across much of the country, and sleep gets squeezed right out of their schedules,” Dr. Carskadon said.

Extracurricular activities also affect sleep. Many high school athletes are required to practice every morning before school, at 4 a.m. and 5 a.m. sessions, or after school every day until 6 p.m. to 8 p.m. Games and competitions routinely extend until 10 p.m. or later, excluding travel time.

According to the NSF survey, parents also reported that a majority of children's physicians (52%) never ask about their children's sleep habits, even though most parents (69%) said their children have sleep problems such as difficulty falling asleep, nighttime wakening, and snoring, at least a few nights every week.

The survey also found that the older the child, the less likely a physician was to ask about sleep, even though older children and teens are more likely to have frequent sleep problems than younger children.

Children's Sleep Can Be Improved

Dr. Carskadon discussed several recommendations aimed at improving the quantity and quality of children's sleep:

▸ Make adequate sleep a priority for families. Help parents determine the amount of sleep each family member needs, and urge them to ensure that those needs are met. To motivate parents to regulate their children's sleep, emphasize the strong links between poor sleep and bad behavior, poor school performance, depressed mood, high risk for accidents and injuries, and high risk for alcohol and drug use later in life.

▸ Promote good sleep habits. Advise parents to schedule leisure activities like television viewing, video games, and Internet surfing for specific times and places–and never in children's bedrooms. They also should promote regular bedtime routines, and create quiet and comfortable settings for sleep.

▸ ILimit sleep disrupters. Tell parents that caffeine should not be part of a child's diet, and remind them that some unlikely drinks, such as citrus-flavored sodas, can have high caffeine contents. Lobby parents and schools to limit the hours of extracurricular activities and to change early school start times. It may help to cite research on a Minneapolis school district that found grades markedly improved, tardiness and absenteeism greatly declined, and the graduation rate rose when school start times were delayed.

▸ Regularly ask patients and parents about sleep. Children's sleep problems too often go undetected and untreated. Since depression in particular can be related to sleep disturbances, both as a consequence and as a cause of inadequate sleep, “all children and teenagers who appear to be depressed must be queried about sleep,” Dr. Carskadon noted.

Retinopathy Predicts Heart Failure

Middle-aged people with retinopathy are twice as likely to develop heart failure as those without retinopathy, even in the absence of diabetes, hypertension, coronary disease, and other risk factors.

Noting that the retinal circulation reveals systemic microvascular disease, Tien Y. Wong, M.D., of the University of Melbourne's Centre for Eye Research, and associates examined the relationship between heart failure and signs of retinopathy including microaneurysms, retinal hemorrhages, and soft exudates (cotton-wool spots). They used data including retinal photographs from a population-based study of 11,612 subjects aged 49–73 years living in four diverse U.S. communities.

Over a mean follow-up of 6.2 years, heart failure developed in 15.1% of subjects with retinopathy and 4.8% of those without retinal lesions. This risk for developing heart failure remained high after the data were adjusted for CHD, blood pressure, blood glucose level, and smoking; it persisted in both men and women and across all ethnic groups (JAMA 2005;293:63–9).

The findings suggest that systemic microvascular disease plays a role in the pathogenesis of heart failure and that ophthalmologic exams may help assess risk. The results also suggest that the microcirculation should be targeted in efforts to reduce cardiovascular disease. Antihypertensive agents such as ACE inhibitors should be considered because they affect microvessel structure in addition to lowering blood pressure.

Statins Don't Raise Cancer Risk

The longest follow-up of patients randomly assigned to receive either statin therapy or placebo has shown that the drugs do not raise cancer incidence or cancer mortality, said Timo E. Strandberg, M.D., of Kuopio (Finland) University, and associates.

“Most statin trials, which generally last 5–6 years, have not shown any rise in cancer incidence in statin-treated participants, but in two studies some excess of cancer was reported,” Dr. Strandberg and associates said. They examined cancer risk by extending the follow-up in their trial of more than 4,000 subjects in five Nordic countries (Lancet 2004;364:771–7).

During 10 years of follow-up, 100 subjects who had received placebo and 85 who had received simvastatin died from cancer, reflecting a slight but statistically insignificant reduction in cancer mortality with statin use. Similarly, the risk of developing cancer was 12% lower in the statin group than in the placebo group, a nonsignificant difference.

Detox Drug Affects QT Interval

The alpha-2 agonist lofexidine, used with methadone for opioid detoxification, induced QT prolongation in a subject enrolled in a study of the safety of the drug as a daily therapy, reported John Schmittner, M.D., and his associates at the National Institute on Drug Abuse, Baltimore.

Lofexidine has not previously produced ECG changes in human studies, but in animal studies, it has prolonged the QT interval at high doses. In the present case, a 44-year-old woman had a normal QT/QTc of 428/449 ms while taking methadone alone. She became hypotensive, bradycardic, and drowsy after her first dose of lofexidine, and her QT/QTc increased to 612/601 ms. The drug was discontinued, and her QT interval returned to normal within 24 hours (Br. Med. J. 2004;329:1075).

Britannia Pharmaceuticals, the manufacturer of lofexidine (BritLofex), has added a warning about adverse ECG changes to its summary of product characteristics. “Before initiating lofexidine, clinicians may want to screen patients who might be at risk for repolarization abnormalities,” the researchers noted.

'Fetal Origin' Hypothesis Discounted

Impaired growth of the fetus does not increase cholesterol levels in adulthood appreciably, said Rachel Huxley, D.Phil., of the University of Sydney, and her colleagues.

Proponents of the “fetal origin” hypothesis hold that fetal undernutrition is linked to coronary heart disease and related conditions. But it can be argued that there were methodologic flaws in the collection and interpretation of data supporting the hypothesis. Dr. Huxley and her associates conducted a systematic review of 79 relevant studies involving 74,122 subjects, including 25 studies involving more than 45,000 subjects that were never included in previous examinations of this issue.

For every 1-kg decrease in birth weight, there is a 2.0-mg/dL rise in cholesterol in later life, which they characterized as a weak link unlikely to affect public health. “Assuming that nutritional intervention in pregnancy could increase birth weight by as much as 100 g, this association would translate into only approximately 0.19 mg/dL lower total cholesterol level,” which would reduce coronary disease risk by less than 0.025%. In contrast, dietary intervention in adulthood can reduce cholesterol level by 15 mg/dL, for a 15% lower CHD risk, they said (JAMA 2004;292:2755–64).

Retinopathy Predicts Heart Failure

Middle-aged people with retinopathy are twice as likely to develop heart failure as those without retinopathy, even in the absence of diabetes, hypertension, coronary disease, and other risk factors.

Noting that the retinal circulation reveals systemic microvascular disease, Tien Y. Wong, M.D., of the University of Melbourne's Centre for Eye Research, and associates examined the relationship between heart failure and signs of retinopathy including microaneurysms, retinal hemorrhages, and soft exudates (cotton-wool spots). They used data including retinal photographs from a population-based study of 11,612 subjects aged 49–73 years living in four diverse U.S. communities.

Over a mean follow-up of 6.2 years, heart failure developed in 15.1% of subjects with retinopathy and 4.8% of those without retinal lesions. This risk for developing heart failure remained high after the data were adjusted for CHD, blood pressure, blood glucose level, and smoking; it persisted in both men and women and across all ethnic groups (JAMA 2005;293:63–9).

The findings suggest that systemic microvascular disease plays a role in the pathogenesis of heart failure and that ophthalmologic exams may help assess risk. The results also suggest that the microcirculation should be targeted in efforts to reduce cardiovascular disease. Antihypertensive agents such as ACE inhibitors should be considered because they affect microvessel structure in addition to lowering blood pressure.

Statins Don't Raise Cancer Risk

The longest follow-up of patients randomly assigned to receive either statin therapy or placebo has shown that the drugs do not raise cancer incidence or cancer mortality, said Timo E. Strandberg, M.D., of Kuopio (Finland) University, and associates.

“Most statin trials, which generally last 5–6 years, have not shown any rise in cancer incidence in statin-treated participants, but in two studies some excess of cancer was reported,” Dr. Strandberg and associates said. They examined cancer risk by extending the follow-up in their trial of more than 4,000 subjects in five Nordic countries (Lancet 2004;364:771–7).

During 10 years of follow-up, 100 subjects who had received placebo and 85 who had received simvastatin died from cancer, reflecting a slight but statistically insignificant reduction in cancer mortality with statin use. Similarly, the risk of developing cancer was 12% lower in the statin group than in the placebo group, a nonsignificant difference.

Detox Drug Affects QT Interval

The alpha-2 agonist lofexidine, used with methadone for opioid detoxification, induced QT prolongation in a subject enrolled in a study of the safety of the drug as a daily therapy, reported John Schmittner, M.D., and his associates at the National Institute on Drug Abuse, Baltimore.

Lofexidine has not previously produced ECG changes in human studies, but in animal studies, it has prolonged the QT interval at high doses. In the present case, a 44-year-old woman had a normal QT/QTc of 428/449 ms while taking methadone alone. She became hypotensive, bradycardic, and drowsy after her first dose of lofexidine, and her QT/QTc increased to 612/601 ms. The drug was discontinued, and her QT interval returned to normal within 24 hours (Br. Med. J. 2004;329:1075).

Britannia Pharmaceuticals, the manufacturer of lofexidine (BritLofex), has added a warning about adverse ECG changes to its summary of product characteristics. “Before initiating lofexidine, clinicians may want to screen patients who might be at risk for repolarization abnormalities,” the researchers noted.

'Fetal Origin' Hypothesis Discounted

Impaired growth of the fetus does not increase cholesterol levels in adulthood appreciably, said Rachel Huxley, D.Phil., of the University of Sydney, and her colleagues.

Proponents of the “fetal origin” hypothesis hold that fetal undernutrition is linked to coronary heart disease and related conditions. But it can be argued that there were methodologic flaws in the collection and interpretation of data supporting the hypothesis. Dr. Huxley and her associates conducted a systematic review of 79 relevant studies involving 74,122 subjects, including 25 studies involving more than 45,000 subjects that were never included in previous examinations of this issue.

For every 1-kg decrease in birth weight, there is a 2.0-mg/dL rise in cholesterol in later life, which they characterized as a weak link unlikely to affect public health. “Assuming that nutritional intervention in pregnancy could increase birth weight by as much as 100 g, this association would translate into only approximately 0.19 mg/dL lower total cholesterol level,” which would reduce coronary disease risk by less than 0.025%. In contrast, dietary intervention in adulthood can reduce cholesterol level by 15 mg/dL, for a 15% lower CHD risk, they said (JAMA 2004;292:2755–64).

Retinopathy Predicts Heart Failure

Middle-aged people with retinopathy are twice as likely to develop heart failure as those without retinopathy, even in the absence of diabetes, hypertension, coronary disease, and other risk factors.

Noting that the retinal circulation reveals systemic microvascular disease, Tien Y. Wong, M.D., of the University of Melbourne's Centre for Eye Research, and associates examined the relationship between heart failure and signs of retinopathy including microaneurysms, retinal hemorrhages, and soft exudates (cotton-wool spots). They used data including retinal photographs from a population-based study of 11,612 subjects aged 49–73 years living in four diverse U.S. communities.

Over a mean follow-up of 6.2 years, heart failure developed in 15.1% of subjects with retinopathy and 4.8% of those without retinal lesions. This risk for developing heart failure remained high after the data were adjusted for CHD, blood pressure, blood glucose level, and smoking; it persisted in both men and women and across all ethnic groups (JAMA 2005;293:63–9).

The findings suggest that systemic microvascular disease plays a role in the pathogenesis of heart failure and that ophthalmologic exams may help assess risk. The results also suggest that the microcirculation should be targeted in efforts to reduce cardiovascular disease. Antihypertensive agents such as ACE inhibitors should be considered because they affect microvessel structure in addition to lowering blood pressure.

Statins Don't Raise Cancer Risk

The longest follow-up of patients randomly assigned to receive either statin therapy or placebo has shown that the drugs do not raise cancer incidence or cancer mortality, said Timo E. Strandberg, M.D., of Kuopio (Finland) University, and associates.

“Most statin trials, which generally last 5–6 years, have not shown any rise in cancer incidence in statin-treated participants, but in two studies some excess of cancer was reported,” Dr. Strandberg and associates said. They examined cancer risk by extending the follow-up in their trial of more than 4,000 subjects in five Nordic countries (Lancet 2004;364:771–7).

During 10 years of follow-up, 100 subjects who had received placebo and 85 who had received simvastatin died from cancer, reflecting a slight but statistically insignificant reduction in cancer mortality with statin use. Similarly, the risk of developing cancer was 12% lower in the statin group than in the placebo group, a nonsignificant difference.

Detox Drug Affects QT Interval

The alpha-2 agonist lofexidine, used with methadone for opioid detoxification, induced QT prolongation in a subject enrolled in a study of the safety of the drug as a daily therapy, reported John Schmittner, M.D., and his associates at the National Institute on Drug Abuse, Baltimore.

Lofexidine has not previously produced ECG changes in human studies, but in animal studies, it has prolonged the QT interval at high doses. In the present case, a 44-year-old woman had a normal QT/QTc of 428/449 ms while taking methadone alone. She became hypotensive, bradycardic, and drowsy after her first dose of lofexidine, and her QT/QTc increased to 612/601 ms. The drug was discontinued, and her QT interval returned to normal within 24 hours (Br. Med. J. 2004;329:1075).

Britannia Pharmaceuticals, the manufacturer of lofexidine (BritLofex), has added a warning about adverse ECG changes to its summary of product characteristics. “Before initiating lofexidine, clinicians may want to screen patients who might be at risk for repolarization abnormalities,” the researchers noted.

'Fetal Origin' Hypothesis Discounted

Impaired growth of the fetus does not increase cholesterol levels in adulthood appreciably, said Rachel Huxley, D.Phil., of the University of Sydney, and her colleagues.

Proponents of the “fetal origin” hypothesis hold that fetal undernutrition is linked to coronary heart disease and related conditions. But it can be argued that there were methodologic flaws in the collection and interpretation of data supporting the hypothesis. Dr. Huxley and her associates conducted a systematic review of 79 relevant studies involving 74,122 subjects, including 25 studies involving more than 45,000 subjects that were never included in previous examinations of this issue.

For every 1-kg decrease in birth weight, there is a 2.0-mg/dL rise in cholesterol in later life, which they characterized as a weak link unlikely to affect public health. “Assuming that nutritional intervention in pregnancy could increase birth weight by as much as 100 g, this association would translate into only approximately 0.19 mg/dL lower total cholesterol level,” which would reduce coronary disease risk by less than 0.025%. In contrast, dietary intervention in adulthood can reduce cholesterol level by 15 mg/dL, for a 15% lower CHD risk, they said (JAMA 2004;292:2755–64).

Fingerprick sites should be inspected regularly for skin necrosis in diabetic patients who have peripheral vascular disease, said Olivier Giannini, M.D., and Michael Mayr, M.D., of the University Hospitals of Basel (Switzerland).

The physicians reported the case of a 59-year-old diabetic man who was hospitalized for amputation of the lower right leg because of severe arterial occlusive disease. While recovering from the surgery, the patient took fingerprick blood samples to monitor his blood sugar. Within a few days, multiple small, well-circumscribed areas of skin necrosis around the fingerprick sites quickly progressed to full necrosis of the distal phalange, despite treatment with iloprost infusions, the investigators said (Lancet 2004;364:980).

Regular inspection of these sites may prevent such deterioration. If it does develop, capillary blood samples could be drawn from the thenar eminence, rather than the fingertips, they added.

Fingerprick sites should be inspected regularly for skin necrosis in diabetic patients who have peripheral vascular disease, said Olivier Giannini, M.D., and Michael Mayr, M.D., of the University Hospitals of Basel (Switzerland).

The physicians reported the case of a 59-year-old diabetic man who was hospitalized for amputation of the lower right leg because of severe arterial occlusive disease. While recovering from the surgery, the patient took fingerprick blood samples to monitor his blood sugar. Within a few days, multiple small, well-circumscribed areas of skin necrosis around the fingerprick sites quickly progressed to full necrosis of the distal phalange, despite treatment with iloprost infusions, the investigators said (Lancet 2004;364:980).

Regular inspection of these sites may prevent such deterioration. If it does develop, capillary blood samples could be drawn from the thenar eminence, rather than the fingertips, they added.

Fingerprick sites should be inspected regularly for skin necrosis in diabetic patients who have peripheral vascular disease, said Olivier Giannini, M.D., and Michael Mayr, M.D., of the University Hospitals of Basel (Switzerland).

The physicians reported the case of a 59-year-old diabetic man who was hospitalized for amputation of the lower right leg because of severe arterial occlusive disease. While recovering from the surgery, the patient took fingerprick blood samples to monitor his blood sugar. Within a few days, multiple small, well-circumscribed areas of skin necrosis around the fingerprick sites quickly progressed to full necrosis of the distal phalange, despite treatment with iloprost infusions, the investigators said (Lancet 2004;364:980).

Regular inspection of these sites may prevent such deterioration. If it does develop, capillary blood samples could be drawn from the thenar eminence, rather than the fingertips, they added.

WASHINGTON — A paradoxical benefit of cigarette smoking during pregnancy finally may have been explained.

Smoking has long been linked to a decreased rate of preeclampsia. But rather than protecting against the disorder, smoking may mask the true incidence of preeclampsia by indirectly inducing preterm delivery, so that smokers' infants are simply born before preeclampsia can be manifested, Ahmad O. Hammoud, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

A 1999 study published in the New England Journal of Medicine found that the risk of developing preeclampsia was 32% lower in women who smoked than in nonsmokers. And most studies—a total of 99—cited in a review of the literature since 1959 also showed that smoking was associated with decreased risk. But this link “has always been questioned,” because it is counterintuitive that smoking could benefit pregnancy and because many of these studies had relatively small sample sizes, said Dr. Hammoud, a fourth-year resident in the department of ob.gyn. at Wayne State University, Detroit.

He and his associates examined the issue using a large German database of 170,254 singleton deliveries that took place at 29 hospitals across Germany during the late 1990s. Mean maternal age was 29 years. Overall, 23% of the women were smokers, and the overall rate of preeclampsia was 3.5%.

The incidence of preeclampsia was 2.5% among nonsmokers, compared with only 1.9% among smokers. Moreover, the incidence of preeclampsia showed a clear inverse correlation with the number of cigarettes smoked per day. Nonsmokers had the highest rate of preeclampsia, followed by women who smoked 1-5 cigarettes per day, then by women who smoked 6-10 cigarettes per day, and finally, by women who smoked more than 10 cigarettes per day.

“The new finding in our study was that the incidence of preeclampsia was not uniformly low in all smokers. It increased with advancing gestational age and was especially high in smokers who made it to 40 weeks or more,” Dr. Hammoud said.

“We postulate that placental damage from smoking leads to severe complications, such as placental abruption and restricted fetal growth, which in turn lead to preterm delivery before preeclampsia is manifested. So what smokers actually have is just an apparent decrease in preeclampsia,” he said.

This hypothesis is supported by the finding that smokers had a higher rate of placental abruption than nonsmokers and that fetal weight was adversely affected by smoking in a dose-response fashion, he noted.

WASHINGTON — A paradoxical benefit of cigarette smoking during pregnancy finally may have been explained.

Smoking has long been linked to a decreased rate of preeclampsia. But rather than protecting against the disorder, smoking may mask the true incidence of preeclampsia by indirectly inducing preterm delivery, so that smokers' infants are simply born before preeclampsia can be manifested, Ahmad O. Hammoud, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

A 1999 study published in the New England Journal of Medicine found that the risk of developing preeclampsia was 32% lower in women who smoked than in nonsmokers. And most studies—a total of 99—cited in a review of the literature since 1959 also showed that smoking was associated with decreased risk. But this link “has always been questioned,” because it is counterintuitive that smoking could benefit pregnancy and because many of these studies had relatively small sample sizes, said Dr. Hammoud, a fourth-year resident in the department of ob.gyn. at Wayne State University, Detroit.

He and his associates examined the issue using a large German database of 170,254 singleton deliveries that took place at 29 hospitals across Germany during the late 1990s. Mean maternal age was 29 years. Overall, 23% of the women were smokers, and the overall rate of preeclampsia was 3.5%.

The incidence of preeclampsia was 2.5% among nonsmokers, compared with only 1.9% among smokers. Moreover, the incidence of preeclampsia showed a clear inverse correlation with the number of cigarettes smoked per day. Nonsmokers had the highest rate of preeclampsia, followed by women who smoked 1-5 cigarettes per day, then by women who smoked 6-10 cigarettes per day, and finally, by women who smoked more than 10 cigarettes per day.

“The new finding in our study was that the incidence of preeclampsia was not uniformly low in all smokers. It increased with advancing gestational age and was especially high in smokers who made it to 40 weeks or more,” Dr. Hammoud said.

“We postulate that placental damage from smoking leads to severe complications, such as placental abruption and restricted fetal growth, which in turn lead to preterm delivery before preeclampsia is manifested. So what smokers actually have is just an apparent decrease in preeclampsia,” he said.

This hypothesis is supported by the finding that smokers had a higher rate of placental abruption than nonsmokers and that fetal weight was adversely affected by smoking in a dose-response fashion, he noted.

WASHINGTON — A paradoxical benefit of cigarette smoking during pregnancy finally may have been explained.

Smoking has long been linked to a decreased rate of preeclampsia. But rather than protecting against the disorder, smoking may mask the true incidence of preeclampsia by indirectly inducing preterm delivery, so that smokers' infants are simply born before preeclampsia can be manifested, Ahmad O. Hammoud, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

A 1999 study published in the New England Journal of Medicine found that the risk of developing preeclampsia was 32% lower in women who smoked than in nonsmokers. And most studies—a total of 99—cited in a review of the literature since 1959 also showed that smoking was associated with decreased risk. But this link “has always been questioned,” because it is counterintuitive that smoking could benefit pregnancy and because many of these studies had relatively small sample sizes, said Dr. Hammoud, a fourth-year resident in the department of ob.gyn. at Wayne State University, Detroit.

He and his associates examined the issue using a large German database of 170,254 singleton deliveries that took place at 29 hospitals across Germany during the late 1990s. Mean maternal age was 29 years. Overall, 23% of the women were smokers, and the overall rate of preeclampsia was 3.5%.

The incidence of preeclampsia was 2.5% among nonsmokers, compared with only 1.9% among smokers. Moreover, the incidence of preeclampsia showed a clear inverse correlation with the number of cigarettes smoked per day. Nonsmokers had the highest rate of preeclampsia, followed by women who smoked 1-5 cigarettes per day, then by women who smoked 6-10 cigarettes per day, and finally, by women who smoked more than 10 cigarettes per day.

“The new finding in our study was that the incidence of preeclampsia was not uniformly low in all smokers. It increased with advancing gestational age and was especially high in smokers who made it to 40 weeks or more,” Dr. Hammoud said.

“We postulate that placental damage from smoking leads to severe complications, such as placental abruption and restricted fetal growth, which in turn lead to preterm delivery before preeclampsia is manifested. So what smokers actually have is just an apparent decrease in preeclampsia,” he said.

This hypothesis is supported by the finding that smokers had a higher rate of placental abruption than nonsmokers and that fetal weight was adversely affected by smoking in a dose-response fashion, he noted.

WASHINGTON — Endometrial ablation is safe and effective in adolescents who have intractable menorrhagia and for whom future fertility is not a concern, Jon I. Einarsson, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Endometrial ablation for menorrhagia is usually reserved for women who do not desire pregnancy and is used in younger women only when their bleeding is life-threatening, said Dr. Einarsson of Baylor College of Medicine, Houston.

He reviewed the experience at his institution in six adolescents with concomitant severe disorders that ruled out future fertility. These included severe mental retardation, vasculitis, paraplegia, cerebral palsy, and seizure disorder. All patients had failed to respond to nonsurgical therapy.

The patients' mean age at the time of the procedure was 15.6 years. The initial success rate was 66.7% (four out of six).

One patient in whom ablation failed was found to have an arcuate uterus and subsequently underwent hysterectomy. The second patient, found to have a septate uterus, was successfully treated with a second ablation procedure when the uterine horns were more completely accessed.

After treatment, the patients' use of menstrual pads decreased from a mean of 7.7 per day to 1.3 per day. Mean duration of menses decreased from 7.2 days to 1.5 days. When contacted an average of 32 months after the ablation, “all patients and/or guardians were satisfied with the treatment outcome and would recommend the procedure to others,” Dr. Einarsson said in a poster presentation at the meeting.

“The use of uterine balloon therapy is especially attractive in teenagers, because the 5-mm device requires minimal cervical dilatation, a procedure that can be challenging in an adolescent nulliparous cervix,” he noted.

In addition, the approach is particularly useful because patients typically undergo preablation diagnostic hysteroscopy that allows “identification of possible uterine anomalies that might interfere with the performance of the thermal balloon.”

WASHINGTON — Endometrial ablation is safe and effective in adolescents who have intractable menorrhagia and for whom future fertility is not a concern, Jon I. Einarsson, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Endometrial ablation for menorrhagia is usually reserved for women who do not desire pregnancy and is used in younger women only when their bleeding is life-threatening, said Dr. Einarsson of Baylor College of Medicine, Houston.

He reviewed the experience at his institution in six adolescents with concomitant severe disorders that ruled out future fertility. These included severe mental retardation, vasculitis, paraplegia, cerebral palsy, and seizure disorder. All patients had failed to respond to nonsurgical therapy.

The patients' mean age at the time of the procedure was 15.6 years. The initial success rate was 66.7% (four out of six).

One patient in whom ablation failed was found to have an arcuate uterus and subsequently underwent hysterectomy. The second patient, found to have a septate uterus, was successfully treated with a second ablation procedure when the uterine horns were more completely accessed.

After treatment, the patients' use of menstrual pads decreased from a mean of 7.7 per day to 1.3 per day. Mean duration of menses decreased from 7.2 days to 1.5 days. When contacted an average of 32 months after the ablation, “all patients and/or guardians were satisfied with the treatment outcome and would recommend the procedure to others,” Dr. Einarsson said in a poster presentation at the meeting.

“The use of uterine balloon therapy is especially attractive in teenagers, because the 5-mm device requires minimal cervical dilatation, a procedure that can be challenging in an adolescent nulliparous cervix,” he noted.

In addition, the approach is particularly useful because patients typically undergo preablation diagnostic hysteroscopy that allows “identification of possible uterine anomalies that might interfere with the performance of the thermal balloon.”

WASHINGTON — Endometrial ablation is safe and effective in adolescents who have intractable menorrhagia and for whom future fertility is not a concern, Jon I. Einarsson, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Endometrial ablation for menorrhagia is usually reserved for women who do not desire pregnancy and is used in younger women only when their bleeding is life-threatening, said Dr. Einarsson of Baylor College of Medicine, Houston.

He reviewed the experience at his institution in six adolescents with concomitant severe disorders that ruled out future fertility. These included severe mental retardation, vasculitis, paraplegia, cerebral palsy, and seizure disorder. All patients had failed to respond to nonsurgical therapy.

The patients' mean age at the time of the procedure was 15.6 years. The initial success rate was 66.7% (four out of six).

One patient in whom ablation failed was found to have an arcuate uterus and subsequently underwent hysterectomy. The second patient, found to have a septate uterus, was successfully treated with a second ablation procedure when the uterine horns were more completely accessed.

After treatment, the patients' use of menstrual pads decreased from a mean of 7.7 per day to 1.3 per day. Mean duration of menses decreased from 7.2 days to 1.5 days. When contacted an average of 32 months after the ablation, “all patients and/or guardians were satisfied with the treatment outcome and would recommend the procedure to others,” Dr. Einarsson said in a poster presentation at the meeting.

“The use of uterine balloon therapy is especially attractive in teenagers, because the 5-mm device requires minimal cervical dilatation, a procedure that can be challenging in an adolescent nulliparous cervix,” he noted.

In addition, the approach is particularly useful because patients typically undergo preablation diagnostic hysteroscopy that allows “identification of possible uterine anomalies that might interfere with the performance of the thermal balloon.”