Jeffrey S. Eisenberg

Central retinal venular diameter may help predict the progression of retinal disease in black patients with type 1 diabetes, especially those with less-severe baseline diabetic retinopathy, according to research published in the January 2011 issue of the Archives of Ophthalmology.

These results may lead to another early clinical indicator for progression to more severe forms.

Dilation of the retinal venules has been associated with diabetic retinopathy (DR), but cross-sectional studies have not indicated whether these changes simply reflect disease severity or may help predict progression of DR.

Dr. Monique S. Roy of the New Jersey Medical School, Newark, and her colleagues examined 725 black patients with type 1 diabetes who participated in the New Jersey 725 study in 1993-1998, and reexamined a cohort of 468 of these patients 6 years later (Arch. Ophthalmol. 2011;129:8-15). The exams included seven-field retinal photographs that were evaluated in a masked fashion. Also, graders used a computer-assisted technique to measure retinal vessel diameters.

In the 468 follow-up patients, the mean central retinal arteriolar equivalent (CRAE) and central retinal venular equivalent (CRVE) were 168.8 mcm and 254.2 mcm, respectively. The study found no association between CRAE and incident DR outcomes, even after adjustment for other risk factors. However, increasing CRVE at baseline was associated with triple the risk of progression to proliferative diabetic retinopathy, or to PDR with high-risk characteristics, even when researchers adjusted for other risk factors.

"The relative dilation of the retinal veins seen in DR and other retinopathies associated with ischemia has been variously interpreted," the researchers said. "Wider retinal venules may reflect metabolic changes associated with [diabetes mellitus], such as increased lactic acidosis."

Strengths of the study include its prospective design with high rates of follow-up for a large cohort of well-characterized black patients with type 1 diabetes, the use of standardized protocols to document potential confounding variables, the masked grading of DR using stereoscopic seven-field retinal photographs, and measurements of the retinal vascular diameters with a validated computerized program, the researchers said.

However, they cautioned that measurement of retinal vessel diameter from color retinal photographs may underestimate the true vascular width because only the red blood cell column is being measured. Also, the increased retinal pigmentation that is present in blacks may lead to an overestimation of retinal diameter sizes.

"It remains to be seen whether such a measure may be used in the future to monitor treatments for [diabetes] and other vascular diseases that specifically target the microvasculature," the researchers noted.

The researchers had no financial disclosures. The research was supported by grants from the National Eye Institute and by a Lew Wasserman Merit Award from Research to Prevent Blindness Inc.

Central retinal venular diameter may help predict the progression of retinal disease in black patients with type 1 diabetes, especially those with less-severe baseline diabetic retinopathy, according to research published in the January 2011 issue of the Archives of Ophthalmology.

These results may lead to another early clinical indicator for progression to more severe forms.

Dilation of the retinal venules has been associated with diabetic retinopathy (DR), but cross-sectional studies have not indicated whether these changes simply reflect disease severity or may help predict progression of DR.

Dr. Monique S. Roy of the New Jersey Medical School, Newark, and her colleagues examined 725 black patients with type 1 diabetes who participated in the New Jersey 725 study in 1993-1998, and reexamined a cohort of 468 of these patients 6 years later (Arch. Ophthalmol. 2011;129:8-15). The exams included seven-field retinal photographs that were evaluated in a masked fashion. Also, graders used a computer-assisted technique to measure retinal vessel diameters.

In the 468 follow-up patients, the mean central retinal arteriolar equivalent (CRAE) and central retinal venular equivalent (CRVE) were 168.8 mcm and 254.2 mcm, respectively. The study found no association between CRAE and incident DR outcomes, even after adjustment for other risk factors. However, increasing CRVE at baseline was associated with triple the risk of progression to proliferative diabetic retinopathy, or to PDR with high-risk characteristics, even when researchers adjusted for other risk factors.

"The relative dilation of the retinal veins seen in DR and other retinopathies associated with ischemia has been variously interpreted," the researchers said. "Wider retinal venules may reflect metabolic changes associated with [diabetes mellitus], such as increased lactic acidosis."

Strengths of the study include its prospective design with high rates of follow-up for a large cohort of well-characterized black patients with type 1 diabetes, the use of standardized protocols to document potential confounding variables, the masked grading of DR using stereoscopic seven-field retinal photographs, and measurements of the retinal vascular diameters with a validated computerized program, the researchers said.

However, they cautioned that measurement of retinal vessel diameter from color retinal photographs may underestimate the true vascular width because only the red blood cell column is being measured. Also, the increased retinal pigmentation that is present in blacks may lead to an overestimation of retinal diameter sizes.

"It remains to be seen whether such a measure may be used in the future to monitor treatments for [diabetes] and other vascular diseases that specifically target the microvasculature," the researchers noted.

The researchers had no financial disclosures. The research was supported by grants from the National Eye Institute and by a Lew Wasserman Merit Award from Research to Prevent Blindness Inc.

Central retinal venular diameter may help predict the progression of retinal disease in black patients with type 1 diabetes, especially those with less-severe baseline diabetic retinopathy, according to research published in the January 2011 issue of the Archives of Ophthalmology.

These results may lead to another early clinical indicator for progression to more severe forms.

Dilation of the retinal venules has been associated with diabetic retinopathy (DR), but cross-sectional studies have not indicated whether these changes simply reflect disease severity or may help predict progression of DR.

Dr. Monique S. Roy of the New Jersey Medical School, Newark, and her colleagues examined 725 black patients with type 1 diabetes who participated in the New Jersey 725 study in 1993-1998, and reexamined a cohort of 468 of these patients 6 years later (Arch. Ophthalmol. 2011;129:8-15). The exams included seven-field retinal photographs that were evaluated in a masked fashion. Also, graders used a computer-assisted technique to measure retinal vessel diameters.

In the 468 follow-up patients, the mean central retinal arteriolar equivalent (CRAE) and central retinal venular equivalent (CRVE) were 168.8 mcm and 254.2 mcm, respectively. The study found no association between CRAE and incident DR outcomes, even after adjustment for other risk factors. However, increasing CRVE at baseline was associated with triple the risk of progression to proliferative diabetic retinopathy, or to PDR with high-risk characteristics, even when researchers adjusted for other risk factors.

"The relative dilation of the retinal veins seen in DR and other retinopathies associated with ischemia has been variously interpreted," the researchers said. "Wider retinal venules may reflect metabolic changes associated with [diabetes mellitus], such as increased lactic acidosis."

Strengths of the study include its prospective design with high rates of follow-up for a large cohort of well-characterized black patients with type 1 diabetes, the use of standardized protocols to document potential confounding variables, the masked grading of DR using stereoscopic seven-field retinal photographs, and measurements of the retinal vascular diameters with a validated computerized program, the researchers said.

However, they cautioned that measurement of retinal vessel diameter from color retinal photographs may underestimate the true vascular width because only the red blood cell column is being measured. Also, the increased retinal pigmentation that is present in blacks may lead to an overestimation of retinal diameter sizes.

"It remains to be seen whether such a measure may be used in the future to monitor treatments for [diabetes] and other vascular diseases that specifically target the microvasculature," the researchers noted.

The researchers had no financial disclosures. The research was supported by grants from the National Eye Institute and by a Lew Wasserman Merit Award from Research to Prevent Blindness Inc.

An estimated 6.5% of Americans aged 40 and older have age-related macular degeneration, according to data from the 2005-2008 National Health and Nutrition Evaluation Survey, or NHANES, reported in the January issue of Archives of Ophthalmology. This represented a decrease from the 9.4% reported in the 1988-1994 Third National Health and Nutrition Examination Survey (NHANES III) – the last nationally representative estimates of the prevalence of AMD.

In the latest research, Dr. Ronald Klein of University of Wisconsin, Madison, and colleagues analyzed data from 6,797 participants who had full medical exams at a NHANES unit. They also analyzed digital images for signs of AMD, including drusen, increased retinal pigment, retinal pigment epithelial depigmentation, geographic atrophy, and signs of exudative AMD (Arch. Ophthalmol. 2011;129:75-80).

After excluding 1,244 individuals who were not photographed or who had ungradable fundus images, the researchers estimated the total prevalence of AMD in the U.S. civilian noninstitutionalized population to be 6.5%, which is 30.8% lower than reported in the 1988-1994 cohort. The estimated prevalence of late (more advanced) AMD was 0.8%. Non-Hispanic black individuals aged 60 and older had a statistically significant lower prevalence of any AMD than did non-Hispanic white individuals of the same age – a finding consistent with NHANES III.

"These estimates are consistent with a decreasing incidence of AMD reported in another population-based study and have important public health implications," the authors said. "The decreasing prevalence of AMD may reflect recent change in the frequency of smoking and other exposures such as diet, physical activity, and blood pressure associated with AMD. It remains to be seen whether public health programs designed to increase awareness of the relationships of these exposures to AMD in patients at risk and their physicians and eye care providers will continue to result in further decline of the prevalence of AMD in the population."

Also, Mexican-American individuals appeared to have similar frequencies of early AMD but lower frequencies of late AMD, the researchers found. "The reasons for racial/ethnic differences may reflect differences in environmental or host exposures (e.g., smoking, physical activity, diet) and genetic differences in distributions of protective and high-risk genes associated with AMD among the different racial/ethnic groups.

The researchers say this study has several strengths, namely its nationwide, multiracial, population-based sample, and objective system for grading fundus photographs. Still, they urge caution when interpreting results because several factors may have led them to underestimate the prevalence of AMD. Specifically, the study did not include an institutionalized population, such as nursing home patients; significant numbers of eligible patients did not have photographs; and researchers excluded patients who had no light perception or only light perception in both eyes.

The researchers reported no disclosures. This research was supported by a National Health and Nutrition Examination Survey contract, which provided funding for the entire study, including collection and analysis of data. Additional support was provided by Senior Scientific Investigator Awards from Research to Prevent Blindness.

An estimated 6.5% of Americans aged 40 and older have age-related macular degeneration, according to data from the 2005-2008 National Health and Nutrition Evaluation Survey, or NHANES, reported in the January issue of Archives of Ophthalmology. This represented a decrease from the 9.4% reported in the 1988-1994 Third National Health and Nutrition Examination Survey (NHANES III) – the last nationally representative estimates of the prevalence of AMD.

In the latest research, Dr. Ronald Klein of University of Wisconsin, Madison, and colleagues analyzed data from 6,797 participants who had full medical exams at a NHANES unit. They also analyzed digital images for signs of AMD, including drusen, increased retinal pigment, retinal pigment epithelial depigmentation, geographic atrophy, and signs of exudative AMD (Arch. Ophthalmol. 2011;129:75-80).

After excluding 1,244 individuals who were not photographed or who had ungradable fundus images, the researchers estimated the total prevalence of AMD in the U.S. civilian noninstitutionalized population to be 6.5%, which is 30.8% lower than reported in the 1988-1994 cohort. The estimated prevalence of late (more advanced) AMD was 0.8%. Non-Hispanic black individuals aged 60 and older had a statistically significant lower prevalence of any AMD than did non-Hispanic white individuals of the same age – a finding consistent with NHANES III.

"These estimates are consistent with a decreasing incidence of AMD reported in another population-based study and have important public health implications," the authors said. "The decreasing prevalence of AMD may reflect recent change in the frequency of smoking and other exposures such as diet, physical activity, and blood pressure associated with AMD. It remains to be seen whether public health programs designed to increase awareness of the relationships of these exposures to AMD in patients at risk and their physicians and eye care providers will continue to result in further decline of the prevalence of AMD in the population."

Also, Mexican-American individuals appeared to have similar frequencies of early AMD but lower frequencies of late AMD, the researchers found. "The reasons for racial/ethnic differences may reflect differences in environmental or host exposures (e.g., smoking, physical activity, diet) and genetic differences in distributions of protective and high-risk genes associated with AMD among the different racial/ethnic groups.

The researchers say this study has several strengths, namely its nationwide, multiracial, population-based sample, and objective system for grading fundus photographs. Still, they urge caution when interpreting results because several factors may have led them to underestimate the prevalence of AMD. Specifically, the study did not include an institutionalized population, such as nursing home patients; significant numbers of eligible patients did not have photographs; and researchers excluded patients who had no light perception or only light perception in both eyes.

The researchers reported no disclosures. This research was supported by a National Health and Nutrition Examination Survey contract, which provided funding for the entire study, including collection and analysis of data. Additional support was provided by Senior Scientific Investigator Awards from Research to Prevent Blindness.

An estimated 6.5% of Americans aged 40 and older have age-related macular degeneration, according to data from the 2005-2008 National Health and Nutrition Evaluation Survey, or NHANES, reported in the January issue of Archives of Ophthalmology. This represented a decrease from the 9.4% reported in the 1988-1994 Third National Health and Nutrition Examination Survey (NHANES III) – the last nationally representative estimates of the prevalence of AMD.

In the latest research, Dr. Ronald Klein of University of Wisconsin, Madison, and colleagues analyzed data from 6,797 participants who had full medical exams at a NHANES unit. They also analyzed digital images for signs of AMD, including drusen, increased retinal pigment, retinal pigment epithelial depigmentation, geographic atrophy, and signs of exudative AMD (Arch. Ophthalmol. 2011;129:75-80).

After excluding 1,244 individuals who were not photographed or who had ungradable fundus images, the researchers estimated the total prevalence of AMD in the U.S. civilian noninstitutionalized population to be 6.5%, which is 30.8% lower than reported in the 1988-1994 cohort. The estimated prevalence of late (more advanced) AMD was 0.8%. Non-Hispanic black individuals aged 60 and older had a statistically significant lower prevalence of any AMD than did non-Hispanic white individuals of the same age – a finding consistent with NHANES III.

"These estimates are consistent with a decreasing incidence of AMD reported in another population-based study and have important public health implications," the authors said. "The decreasing prevalence of AMD may reflect recent change in the frequency of smoking and other exposures such as diet, physical activity, and blood pressure associated with AMD. It remains to be seen whether public health programs designed to increase awareness of the relationships of these exposures to AMD in patients at risk and their physicians and eye care providers will continue to result in further decline of the prevalence of AMD in the population."

Also, Mexican-American individuals appeared to have similar frequencies of early AMD but lower frequencies of late AMD, the researchers found. "The reasons for racial/ethnic differences may reflect differences in environmental or host exposures (e.g., smoking, physical activity, diet) and genetic differences in distributions of protective and high-risk genes associated with AMD among the different racial/ethnic groups.

The researchers say this study has several strengths, namely its nationwide, multiracial, population-based sample, and objective system for grading fundus photographs. Still, they urge caution when interpreting results because several factors may have led them to underestimate the prevalence of AMD. Specifically, the study did not include an institutionalized population, such as nursing home patients; significant numbers of eligible patients did not have photographs; and researchers excluded patients who had no light perception or only light perception in both eyes.

The researchers reported no disclosures. This research was supported by a National Health and Nutrition Examination Survey contract, which provided funding for the entire study, including collection and analysis of data. Additional support was provided by Senior Scientific Investigator Awards from Research to Prevent Blindness.

ST. LOUIS — Focused cardiac ultrasonography, or FOCUS, can expedite the diagnostic evaluation of cardiac symptoms at the patient's bedside – allowing for earlier, possibly life-saving interventions – and has become a fundamental tool in the emergency department, according to a joint consensus statement of the American Society of Echocardiography and American College of Emergency Physicians.

FOCUS enables clinicians to determine whether pericardial effusion is present, assess global cardiac systolic function, identify marked right and left ventricular enlargement, and assess intravascular volume, according to the statement (J. Am. Soc. Echocardiogr. 2010;23:1225-30). It can provide guidance for pericardiocentesis and confirm the placement of transvenous pacing wire.

The statement outlines specific clinical scenarios in which FOCUS can affect clinical decision making and patient care:

▸ Cardiac trauma. Performed as part of the FAST (focused assessment with sonography in trauma) exam, FOCUS can help identify possible cardiac injury, such as cardiac hemorrhage, that requires surgical intervention by looking for the presence of pericardial effusion as well as the presence or absence of organized ventricular contractility. FOCUS also can help diagnose cardiac contusions by looking for depressed wall motion and decreased myocardial contractility.

▸ Cardiac arrest. Clinicians can improve the outcome of cardiopulmonary resuscitation by using FOCUS to distinguish among asystole, pulseless electrical activity (PEA), and pseudo-PEA. FOCUS also can help identify causes of PEA, allowing for earlier treatment and the return of spontaneous circulation.

FOCUS can improve outcomes by determining a cardiac cause of the cardiac arrest and by guiding lifesaving procedures at the patient's bedside.

▸ Hypotension/shock. FOCUS can help the clinician determine if the shock is cardiogenic, thus allowing for aggressive early intervention to prevent organ dysfunction. In this case, the exam looks for the presence of pericardial effusion and evaluates global cardiac function, right ventricular size, and inferior vena cava size/collapsibility as a marker of central venous pressure.

FOCUS can determine the presence, size, and functional relevance of a pericardial effusion as a cause of hemodynamic instability. Also, it can expedite pericardiocentesis while reducing complications and increasing the success rate.

▸ Dyspnea/shortness of breath. FOCUS can help rule out pericardial effusion, identify global left ventricular systolic dysfunction, and assess the size of the right ventricle as a proxy for indicating the presence or absence of a hemodynamically significant pulmonary embolus. Still, a complete evaluation of these patients should include comprehensive echocardiography to evaluate diastolic function and pulmonary artery pressures, and to help diagnose pericardial and valvular heart disease.

▸ Chest pain. FOCUS may be helpful in the evaluation of patients with a hemodynamically significant pulmonary embolus or the screening of patients for aortic dissection. When aortic dissection is suspected, the clinician can use FOCUS to look for pericardial or pleural effusions and to assess the diameter of the aortic root. (An aortic root diameter greater than 4 cm is suspicious for type A dissection.) The authors caution that a negative FOCUS exam does not definitively rule out aortic dissection; additional imaging and diagnostic studies are necessary.

FOCUS training should include the presentation of positive and negative cases of various cardiac pathologies. Any program that uses FOCUS should have a quality assurance program that reviews scan quality by comparing interpretations with pathological and surgical data, clinical outcomes, and final diagnoses.

ST. LOUIS — Focused cardiac ultrasonography, or FOCUS, can expedite the diagnostic evaluation of cardiac symptoms at the patient's bedside – allowing for earlier, possibly life-saving interventions – and has become a fundamental tool in the emergency department, according to a joint consensus statement of the American Society of Echocardiography and American College of Emergency Physicians.

FOCUS enables clinicians to determine whether pericardial effusion is present, assess global cardiac systolic function, identify marked right and left ventricular enlargement, and assess intravascular volume, according to the statement (J. Am. Soc. Echocardiogr. 2010;23:1225-30). It can provide guidance for pericardiocentesis and confirm the placement of transvenous pacing wire.

The statement outlines specific clinical scenarios in which FOCUS can affect clinical decision making and patient care:

▸ Cardiac trauma. Performed as part of the FAST (focused assessment with sonography in trauma) exam, FOCUS can help identify possible cardiac injury, such as cardiac hemorrhage, that requires surgical intervention by looking for the presence of pericardial effusion as well as the presence or absence of organized ventricular contractility. FOCUS also can help diagnose cardiac contusions by looking for depressed wall motion and decreased myocardial contractility.

▸ Cardiac arrest. Clinicians can improve the outcome of cardiopulmonary resuscitation by using FOCUS to distinguish among asystole, pulseless electrical activity (PEA), and pseudo-PEA. FOCUS also can help identify causes of PEA, allowing for earlier treatment and the return of spontaneous circulation.

FOCUS can improve outcomes by determining a cardiac cause of the cardiac arrest and by guiding lifesaving procedures at the patient's bedside.

▸ Hypotension/shock. FOCUS can help the clinician determine if the shock is cardiogenic, thus allowing for aggressive early intervention to prevent organ dysfunction. In this case, the exam looks for the presence of pericardial effusion and evaluates global cardiac function, right ventricular size, and inferior vena cava size/collapsibility as a marker of central venous pressure.

FOCUS can determine the presence, size, and functional relevance of a pericardial effusion as a cause of hemodynamic instability. Also, it can expedite pericardiocentesis while reducing complications and increasing the success rate.

▸ Dyspnea/shortness of breath. FOCUS can help rule out pericardial effusion, identify global left ventricular systolic dysfunction, and assess the size of the right ventricle as a proxy for indicating the presence or absence of a hemodynamically significant pulmonary embolus. Still, a complete evaluation of these patients should include comprehensive echocardiography to evaluate diastolic function and pulmonary artery pressures, and to help diagnose pericardial and valvular heart disease.

▸ Chest pain. FOCUS may be helpful in the evaluation of patients with a hemodynamically significant pulmonary embolus or the screening of patients for aortic dissection. When aortic dissection is suspected, the clinician can use FOCUS to look for pericardial or pleural effusions and to assess the diameter of the aortic root. (An aortic root diameter greater than 4 cm is suspicious for type A dissection.) The authors caution that a negative FOCUS exam does not definitively rule out aortic dissection; additional imaging and diagnostic studies are necessary.

FOCUS training should include the presentation of positive and negative cases of various cardiac pathologies. Any program that uses FOCUS should have a quality assurance program that reviews scan quality by comparing interpretations with pathological and surgical data, clinical outcomes, and final diagnoses.

ST. LOUIS — Focused cardiac ultrasonography, or FOCUS, can expedite the diagnostic evaluation of cardiac symptoms at the patient's bedside – allowing for earlier, possibly life-saving interventions – and has become a fundamental tool in the emergency department, according to a joint consensus statement of the American Society of Echocardiography and American College of Emergency Physicians.

FOCUS enables clinicians to determine whether pericardial effusion is present, assess global cardiac systolic function, identify marked right and left ventricular enlargement, and assess intravascular volume, according to the statement (J. Am. Soc. Echocardiogr. 2010;23:1225-30). It can provide guidance for pericardiocentesis and confirm the placement of transvenous pacing wire.

The statement outlines specific clinical scenarios in which FOCUS can affect clinical decision making and patient care:

▸ Cardiac trauma. Performed as part of the FAST (focused assessment with sonography in trauma) exam, FOCUS can help identify possible cardiac injury, such as cardiac hemorrhage, that requires surgical intervention by looking for the presence of pericardial effusion as well as the presence or absence of organized ventricular contractility. FOCUS also can help diagnose cardiac contusions by looking for depressed wall motion and decreased myocardial contractility.

▸ Cardiac arrest. Clinicians can improve the outcome of cardiopulmonary resuscitation by using FOCUS to distinguish among asystole, pulseless electrical activity (PEA), and pseudo-PEA. FOCUS also can help identify causes of PEA, allowing for earlier treatment and the return of spontaneous circulation.

FOCUS can improve outcomes by determining a cardiac cause of the cardiac arrest and by guiding lifesaving procedures at the patient's bedside.

▸ Hypotension/shock. FOCUS can help the clinician determine if the shock is cardiogenic, thus allowing for aggressive early intervention to prevent organ dysfunction. In this case, the exam looks for the presence of pericardial effusion and evaluates global cardiac function, right ventricular size, and inferior vena cava size/collapsibility as a marker of central venous pressure.

FOCUS can determine the presence, size, and functional relevance of a pericardial effusion as a cause of hemodynamic instability. Also, it can expedite pericardiocentesis while reducing complications and increasing the success rate.

▸ Dyspnea/shortness of breath. FOCUS can help rule out pericardial effusion, identify global left ventricular systolic dysfunction, and assess the size of the right ventricle as a proxy for indicating the presence or absence of a hemodynamically significant pulmonary embolus. Still, a complete evaluation of these patients should include comprehensive echocardiography to evaluate diastolic function and pulmonary artery pressures, and to help diagnose pericardial and valvular heart disease.

▸ Chest pain. FOCUS may be helpful in the evaluation of patients with a hemodynamically significant pulmonary embolus or the screening of patients for aortic dissection. When aortic dissection is suspected, the clinician can use FOCUS to look for pericardial or pleural effusions and to assess the diameter of the aortic root. (An aortic root diameter greater than 4 cm is suspicious for type A dissection.) The authors caution that a negative FOCUS exam does not definitively rule out aortic dissection; additional imaging and diagnostic studies are necessary.

FOCUS training should include the presentation of positive and negative cases of various cardiac pathologies. Any program that uses FOCUS should have a quality assurance program that reviews scan quality by comparing interpretations with pathological and surgical data, clinical outcomes, and final diagnoses.

Obstructive sleep apnea may be an additional risk factor in the pathogenesis of retinal vein occlusion or a frequently associated condition that could be a triggering factor, researchers said in the December 2010 issue of Archives of Ophthalmology.

Dr. Agnès Glacet-Bernard of Intercommunal and Henri Mondor Hospitals/Assistance Publique des Hôpitaux de Paris, and her colleagues reviewed records of 63 consecutive patients with retinal vein occlusion (RVO) and chose 30 patients with two out of three risk factors for obstructive sleep apnea (OSA) – cardiovascular disease, snoring, and daytime sleepiness with an Epworth Sleepiness Scale score of higher than 10 – to receive further evaluation with respiratory polygraphy.

Twenty-three of the 30 patients (77%) selected for further evaluation had OSA, with a mean apnea-hypopnea index (AHI) of 21.3. Only one patient was previously diagnosed as having OSA. Ten patients required treatment with nasal continuous positive airway pressure with a mask during sleep, the researchers say, but because the treatment occurred several weeks or months after the onset of the RVO, it was impossible to determine whether treatment might play a beneficial role in visual outcome, the researchers say (Arch. Ophthalmol. 2010;128:1533-8).

Assuming the patients not evaluated did not have OSA, the estimated prevalence of OSA in this series of patients with RVO would be 37%. This lower estimate remains higher than the 2%-7% prevalence that is expected in the general population, according to the researchers.

Sleep apnea results in hemodynamic changes that contribute to a cascade of events leading to RVO. "These events may directly affect the retinal microcirculation, or they can act in concert with other predisposing conditions to RVO," the researchers say. "The immediate physiologic effects of OSA involve nocturnal hypoxemia, hypercapnia, and inspiratory efforts."

The study was limited in that researchers used historical control subjects and only evaluated a subset of patients with RVO who were at increased risk for OSA. Further studies are needed to determine if a causal relationship between OSA and RVO, and to determine the exact prevalence of OSA among patients with RVO, they stated.

"This study suggests that OSA, by acting on retinal microcirculation, could be an additional risk factor for the occurrence of RVO or, at least in older patients with a vascular profile, an associated condition that could play a determinant role in the development of RVO and that could act as a triggering factor," the researchers indicated.

"It is too early to know whether OSA treatment could modify the course of RVO or at least prevent its recurrence or the involvement of the second eye. Nevertheless, in clinical practice, it seems vital for the physician to be aware of this association because OSA treatment has demonstrated its efficacy in reducing the risk of cardiovascular and cerebrovascular disease in virtually any patient," they concluded.

The authors reported having no financial disclosures.

Obstructive sleep apnea may be an additional risk factor in the pathogenesis of retinal vein occlusion or a frequently associated condition that could be a triggering factor, researchers said in the December 2010 issue of Archives of Ophthalmology.

Dr. Agnès Glacet-Bernard of Intercommunal and Henri Mondor Hospitals/Assistance Publique des Hôpitaux de Paris, and her colleagues reviewed records of 63 consecutive patients with retinal vein occlusion (RVO) and chose 30 patients with two out of three risk factors for obstructive sleep apnea (OSA) – cardiovascular disease, snoring, and daytime sleepiness with an Epworth Sleepiness Scale score of higher than 10 – to receive further evaluation with respiratory polygraphy.

Twenty-three of the 30 patients (77%) selected for further evaluation had OSA, with a mean apnea-hypopnea index (AHI) of 21.3. Only one patient was previously diagnosed as having OSA. Ten patients required treatment with nasal continuous positive airway pressure with a mask during sleep, the researchers say, but because the treatment occurred several weeks or months after the onset of the RVO, it was impossible to determine whether treatment might play a beneficial role in visual outcome, the researchers say (Arch. Ophthalmol. 2010;128:1533-8).

Assuming the patients not evaluated did not have OSA, the estimated prevalence of OSA in this series of patients with RVO would be 37%. This lower estimate remains higher than the 2%-7% prevalence that is expected in the general population, according to the researchers.

Sleep apnea results in hemodynamic changes that contribute to a cascade of events leading to RVO. "These events may directly affect the retinal microcirculation, or they can act in concert with other predisposing conditions to RVO," the researchers say. "The immediate physiologic effects of OSA involve nocturnal hypoxemia, hypercapnia, and inspiratory efforts."

The study was limited in that researchers used historical control subjects and only evaluated a subset of patients with RVO who were at increased risk for OSA. Further studies are needed to determine if a causal relationship between OSA and RVO, and to determine the exact prevalence of OSA among patients with RVO, they stated.

"This study suggests that OSA, by acting on retinal microcirculation, could be an additional risk factor for the occurrence of RVO or, at least in older patients with a vascular profile, an associated condition that could play a determinant role in the development of RVO and that could act as a triggering factor," the researchers indicated.

"It is too early to know whether OSA treatment could modify the course of RVO or at least prevent its recurrence or the involvement of the second eye. Nevertheless, in clinical practice, it seems vital for the physician to be aware of this association because OSA treatment has demonstrated its efficacy in reducing the risk of cardiovascular and cerebrovascular disease in virtually any patient," they concluded.

The authors reported having no financial disclosures.

Obstructive sleep apnea may be an additional risk factor in the pathogenesis of retinal vein occlusion or a frequently associated condition that could be a triggering factor, researchers said in the December 2010 issue of Archives of Ophthalmology.

Dr. Agnès Glacet-Bernard of Intercommunal and Henri Mondor Hospitals/Assistance Publique des Hôpitaux de Paris, and her colleagues reviewed records of 63 consecutive patients with retinal vein occlusion (RVO) and chose 30 patients with two out of three risk factors for obstructive sleep apnea (OSA) – cardiovascular disease, snoring, and daytime sleepiness with an Epworth Sleepiness Scale score of higher than 10 – to receive further evaluation with respiratory polygraphy.

Twenty-three of the 30 patients (77%) selected for further evaluation had OSA, with a mean apnea-hypopnea index (AHI) of 21.3. Only one patient was previously diagnosed as having OSA. Ten patients required treatment with nasal continuous positive airway pressure with a mask during sleep, the researchers say, but because the treatment occurred several weeks or months after the onset of the RVO, it was impossible to determine whether treatment might play a beneficial role in visual outcome, the researchers say (Arch. Ophthalmol. 2010;128:1533-8).

Assuming the patients not evaluated did not have OSA, the estimated prevalence of OSA in this series of patients with RVO would be 37%. This lower estimate remains higher than the 2%-7% prevalence that is expected in the general population, according to the researchers.

Sleep apnea results in hemodynamic changes that contribute to a cascade of events leading to RVO. "These events may directly affect the retinal microcirculation, or they can act in concert with other predisposing conditions to RVO," the researchers say. "The immediate physiologic effects of OSA involve nocturnal hypoxemia, hypercapnia, and inspiratory efforts."

The study was limited in that researchers used historical control subjects and only evaluated a subset of patients with RVO who were at increased risk for OSA. Further studies are needed to determine if a causal relationship between OSA and RVO, and to determine the exact prevalence of OSA among patients with RVO, they stated.

"This study suggests that OSA, by acting on retinal microcirculation, could be an additional risk factor for the occurrence of RVO or, at least in older patients with a vascular profile, an associated condition that could play a determinant role in the development of RVO and that could act as a triggering factor," the researchers indicated.

"It is too early to know whether OSA treatment could modify the course of RVO or at least prevent its recurrence or the involvement of the second eye. Nevertheless, in clinical practice, it seems vital for the physician to be aware of this association because OSA treatment has demonstrated its efficacy in reducing the risk of cardiovascular and cerebrovascular disease in virtually any patient," they concluded.

The authors reported having no financial disclosures.

Acupuncture may be an effective alternate treatment to occlusion therapy when treating children with anisometropic amblyopia, suggests a study in the December 2010 issue of Archives of Ophthalmology.

Between December 2007 and May 2009 , Dr. Jianhao Zhao and colleagues from Shantou University, Guangdong, China, and the Chinese University of Hong Kong conducted a randomized, controlled trial in which they compared acupuncture and patching in 88 children aged 7-12 years who had anisometropic amblyopia and had worn spectacles for at least 16 weeks prior to enrollment (Arch. Ophthalmol. 2010;128:1510-7).

Patients received either 2 continuous hours of patching a day or five acupuncture treatments per week. The researchers instructed the patching group to perform near-vision activities for 1 hour during patching and the acupuncture group to perform 1 hour of near vision activities daily. For the latter group, the researchers chose five acupoints based on theory and recent literature of traditional Chinese medicine

Follow-up visits were scheduled at weeks 5, 10, 15, and 25. Best spectacle-corrected visual acuity (BSCVA) in the amblyopic eye at week 15 was the main outcome measure.

At 15 weeks, the researchers gathered data from 42 participants in the patching group and 41 in the acupuncture group. In the patching group, mean BSCVA improved from 0.49 logMAR (minimum angle of resolution) at baseline to 0.30 logMAR, with a mean improvement of 1.83 lines. In the acupuncture group, mean BSCVA improved from 0.46 logMAR at baseline to 0.23 logMAR, with a mean improvement of 2.27 lines, a significant difference between the groups of (P =. 03). Twenty-eight participants (66.7%) in the patching group and 31 (75.6%) in the acupuncture group experienced at least two lines of improved visual acuity. The amblyopia was considered resolved in 7 participants (16.7%) in the patching group and 17 (41.5%) in the acupuncture group.

By 25 weeks, BSCVA was 0.28 logMAR in the patching group and 0.22 logMAR in the acupuncture group. BSCVA in the amblyopic eye improved significantly every 5 weeks, except for week 25. Between the 15th and 25th weeks, eight patients (19%) in the patching group and seven (17%) in the acupuncture group had at least one additional line of improved visual acuity.

Although acupuncture has been used to treat amblyopia, the researchers believe this is the first randomized, clinical trial to compare its effectiveness to patching. However, they say the reasons for its success in treating amblyopia are unclear.

"Acupuncture at vision-related acupoints may modulate the activity of the visual cortex," they wrote. "Moreover, acupuncture has been shown to be effective in increasing blood flow to the cerebral and ocular vasculatures (including the choroid), stimulating the expression of retinal nerve growth factors and leading to metabolic changes in the central nervous system. In amblyopia, microscopic anatomical and structural abnormalities have been found in the retina, lateral geniculate bodies, and visual cortex."

Although the findings of this study suggest that acupuncture is as effective as patching for treating amblyopia, the researchers caution that additional multicenter studies on different types of amblyopia and with a longer follow-up period are necessary. The five acupuncture points used were located around the eye ridges, the top of the head, by the base of the thumb, and on the side of the upper ankle.

Several of the authors have filed a provisional patent application for the stimulation of specific acupuncture points for the improvement of vision with the U.S. Patent and Trademark Office. This study was supported in part by the Mr. Lai Seung Hung and Mrs. Lai Chan Pui Ngong Eye Fund (Hong Kong) and the Edith C. Blum Foundation (New York).

Acupuncture may be an effective alternate treatment to occlusion therapy when treating children with anisometropic amblyopia, suggests a study in the December 2010 issue of Archives of Ophthalmology.

Between December 2007 and May 2009 , Dr. Jianhao Zhao and colleagues from Shantou University, Guangdong, China, and the Chinese University of Hong Kong conducted a randomized, controlled trial in which they compared acupuncture and patching in 88 children aged 7-12 years who had anisometropic amblyopia and had worn spectacles for at least 16 weeks prior to enrollment (Arch. Ophthalmol. 2010;128:1510-7).

Patients received either 2 continuous hours of patching a day or five acupuncture treatments per week. The researchers instructed the patching group to perform near-vision activities for 1 hour during patching and the acupuncture group to perform 1 hour of near vision activities daily. For the latter group, the researchers chose five acupoints based on theory and recent literature of traditional Chinese medicine

Follow-up visits were scheduled at weeks 5, 10, 15, and 25. Best spectacle-corrected visual acuity (BSCVA) in the amblyopic eye at week 15 was the main outcome measure.

At 15 weeks, the researchers gathered data from 42 participants in the patching group and 41 in the acupuncture group. In the patching group, mean BSCVA improved from 0.49 logMAR (minimum angle of resolution) at baseline to 0.30 logMAR, with a mean improvement of 1.83 lines. In the acupuncture group, mean BSCVA improved from 0.46 logMAR at baseline to 0.23 logMAR, with a mean improvement of 2.27 lines, a significant difference between the groups of (P =. 03). Twenty-eight participants (66.7%) in the patching group and 31 (75.6%) in the acupuncture group experienced at least two lines of improved visual acuity. The amblyopia was considered resolved in 7 participants (16.7%) in the patching group and 17 (41.5%) in the acupuncture group.

By 25 weeks, BSCVA was 0.28 logMAR in the patching group and 0.22 logMAR in the acupuncture group. BSCVA in the amblyopic eye improved significantly every 5 weeks, except for week 25. Between the 15th and 25th weeks, eight patients (19%) in the patching group and seven (17%) in the acupuncture group had at least one additional line of improved visual acuity.

Although acupuncture has been used to treat amblyopia, the researchers believe this is the first randomized, clinical trial to compare its effectiveness to patching. However, they say the reasons for its success in treating amblyopia are unclear.

"Acupuncture at vision-related acupoints may modulate the activity of the visual cortex," they wrote. "Moreover, acupuncture has been shown to be effective in increasing blood flow to the cerebral and ocular vasculatures (including the choroid), stimulating the expression of retinal nerve growth factors and leading to metabolic changes in the central nervous system. In amblyopia, microscopic anatomical and structural abnormalities have been found in the retina, lateral geniculate bodies, and visual cortex."

Although the findings of this study suggest that acupuncture is as effective as patching for treating amblyopia, the researchers caution that additional multicenter studies on different types of amblyopia and with a longer follow-up period are necessary. The five acupuncture points used were located around the eye ridges, the top of the head, by the base of the thumb, and on the side of the upper ankle.

Several of the authors have filed a provisional patent application for the stimulation of specific acupuncture points for the improvement of vision with the U.S. Patent and Trademark Office. This study was supported in part by the Mr. Lai Seung Hung and Mrs. Lai Chan Pui Ngong Eye Fund (Hong Kong) and the Edith C. Blum Foundation (New York).

Acupuncture may be an effective alternate treatment to occlusion therapy when treating children with anisometropic amblyopia, suggests a study in the December 2010 issue of Archives of Ophthalmology.

Between December 2007 and May 2009 , Dr. Jianhao Zhao and colleagues from Shantou University, Guangdong, China, and the Chinese University of Hong Kong conducted a randomized, controlled trial in which they compared acupuncture and patching in 88 children aged 7-12 years who had anisometropic amblyopia and had worn spectacles for at least 16 weeks prior to enrollment (Arch. Ophthalmol. 2010;128:1510-7).

Patients received either 2 continuous hours of patching a day or five acupuncture treatments per week. The researchers instructed the patching group to perform near-vision activities for 1 hour during patching and the acupuncture group to perform 1 hour of near vision activities daily. For the latter group, the researchers chose five acupoints based on theory and recent literature of traditional Chinese medicine

Follow-up visits were scheduled at weeks 5, 10, 15, and 25. Best spectacle-corrected visual acuity (BSCVA) in the amblyopic eye at week 15 was the main outcome measure.

At 15 weeks, the researchers gathered data from 42 participants in the patching group and 41 in the acupuncture group. In the patching group, mean BSCVA improved from 0.49 logMAR (minimum angle of resolution) at baseline to 0.30 logMAR, with a mean improvement of 1.83 lines. In the acupuncture group, mean BSCVA improved from 0.46 logMAR at baseline to 0.23 logMAR, with a mean improvement of 2.27 lines, a significant difference between the groups of (P =. 03). Twenty-eight participants (66.7%) in the patching group and 31 (75.6%) in the acupuncture group experienced at least two lines of improved visual acuity. The amblyopia was considered resolved in 7 participants (16.7%) in the patching group and 17 (41.5%) in the acupuncture group.

By 25 weeks, BSCVA was 0.28 logMAR in the patching group and 0.22 logMAR in the acupuncture group. BSCVA in the amblyopic eye improved significantly every 5 weeks, except for week 25. Between the 15th and 25th weeks, eight patients (19%) in the patching group and seven (17%) in the acupuncture group had at least one additional line of improved visual acuity.

Although acupuncture has been used to treat amblyopia, the researchers believe this is the first randomized, clinical trial to compare its effectiveness to patching. However, they say the reasons for its success in treating amblyopia are unclear.

"Acupuncture at vision-related acupoints may modulate the activity of the visual cortex," they wrote. "Moreover, acupuncture has been shown to be effective in increasing blood flow to the cerebral and ocular vasculatures (including the choroid), stimulating the expression of retinal nerve growth factors and leading to metabolic changes in the central nervous system. In amblyopia, microscopic anatomical and structural abnormalities have been found in the retina, lateral geniculate bodies, and visual cortex."

Although the findings of this study suggest that acupuncture is as effective as patching for treating amblyopia, the researchers caution that additional multicenter studies on different types of amblyopia and with a longer follow-up period are necessary. The five acupuncture points used were located around the eye ridges, the top of the head, by the base of the thumb, and on the side of the upper ankle.

Several of the authors have filed a provisional patent application for the stimulation of specific acupuncture points for the improvement of vision with the U.S. Patent and Trademark Office. This study was supported in part by the Mr. Lai Seung Hung and Mrs. Lai Chan Pui Ngong Eye Fund (Hong Kong) and the Edith C. Blum Foundation (New York).

ST. LOUIS – Focused cardiac ultrasonography, or FOCUS, can expedite the diagnostic evaluation of cardiac symptoms at the patient’s bedside – allowing for earlier, possibly life-saving interventions – and has become a fundamental tool in the emergency department, according to a joint consensus statement of the American Society of Echocardiography and American College of Emergency Physicians in the December 2010 issue of the Journal of the American Society of Echocardiography.

FOCUS enables clinicians to determine whether pericardial effusion is present, assess global cardiac systolic function, identify marked right and left ventricular enlargement, and assess intravascular volume, according to the consensus statement (J. Am. Soc. Echocardiogr. 2010;23:1225-30). FOCUS also can provide guidance for pericardiocentesis and confirm the placement of transvenous pacing wire.

The consensus statement also outlines the following specific clinical scenarios in which FOCUS can affect clinical decision making and patient care:

• Cardiac trauma. Performed as part of the FAST (focused assessment with sonography in trauma) exam, FOCUS can help identify possible cardiac injury, such as cardiac hemorrhage, that requires surgical intervention by looking for the presence of pericardial effusion as well as the presence or absence of organized ventricular contractility. FOCUS also can help diagnose cardiac contusions by looking for depressed wall motion and decreased myocardial contractility.

• Cardiac arrest. Clinicians can improve the outcome of cardiopulmonary resuscitation by using FOCUS to distinguish among asystole, pulseless electrical activity (PEA), and pseudo-PEA. FOCUS also can help identify causes of PEA, allowing for earlier treatment and the return of spontaneous circulation.

FOCUS can improve outcomes by determining a cardiac cause of the cardiac arrest and by guiding lifesaving procedures at the patient’s bedside.

• Hypotension/shock. FOCUS can help the clinician determine if the shock is cardiogenic, thus allowing for aggressive early intervention to prevent organ dysfunction. In this case, the exam looks for the presence of pericardial effusion and evaluates global cardiac function, right ventricular size, and inferior vena cava size/collapsibility as a marker of central venous pressure.

FOCUS can also determine the presence, size, and functional relevance of a pericardial effusion as a cause of hemodynamic instability. In addition, it can expedite pericardiocentesis while reducing complications and increasing the success rate.

• Dyspnea/shortness of breath. In cases of dyspnea, FOCUS can help rule out pericardial effusion, identify global left ventricular systolic dysfunction, and assess the size of the right ventricle as a proxy for indicating the presence or absence of a hemodynamically significant pulmonary embolus. Still, a complete evaluation of these patients should include comprehensive echocardiography to evaluate diastolic function and pulmonary artery pressures, and to help diagnose pericardial and valvular heart disease, according to the statement.

• Chest pain. FOCUS may be helpful in the evaluation of patients with a hemodynamically significant pulmonary embolus or the screening of patients for aortic dissection. When aortic dissection is suspected, the clinician can use FOCUS to look for pericardial or pleural effusions and to assess the diameter of the aortic root. (An aortic root diameter greater than 4 cm is suspicious for type A dissection.) However, the authors caution, a negative FOCUS exam does not definitively rule out aortic dissection; additional imaging and diagnostic studies are necessary.

For FOCUS to be successful, training should include the presentation of positive and negative cases of various cardiac pathologies. Also, any program that uses FOCUS should have a quality assurance program that reviews scan quality by comparing interpretations with pathological and surgical data, clinical outcomes, and final diagnoses.

ST. LOUIS – Focused cardiac ultrasonography, or FOCUS, can expedite the diagnostic evaluation of cardiac symptoms at the patient’s bedside – allowing for earlier, possibly life-saving interventions – and has become a fundamental tool in the emergency department, according to a joint consensus statement of the American Society of Echocardiography and American College of Emergency Physicians in the December 2010 issue of the Journal of the American Society of Echocardiography.

FOCUS enables clinicians to determine whether pericardial effusion is present, assess global cardiac systolic function, identify marked right and left ventricular enlargement, and assess intravascular volume, according to the consensus statement (J. Am. Soc. Echocardiogr. 2010;23:1225-30). FOCUS also can provide guidance for pericardiocentesis and confirm the placement of transvenous pacing wire.

The consensus statement also outlines the following specific clinical scenarios in which FOCUS can affect clinical decision making and patient care:

• Cardiac trauma. Performed as part of the FAST (focused assessment with sonography in trauma) exam, FOCUS can help identify possible cardiac injury, such as cardiac hemorrhage, that requires surgical intervention by looking for the presence of pericardial effusion as well as the presence or absence of organized ventricular contractility. FOCUS also can help diagnose cardiac contusions by looking for depressed wall motion and decreased myocardial contractility.

• Cardiac arrest. Clinicians can improve the outcome of cardiopulmonary resuscitation by using FOCUS to distinguish among asystole, pulseless electrical activity (PEA), and pseudo-PEA. FOCUS also can help identify causes of PEA, allowing for earlier treatment and the return of spontaneous circulation.

FOCUS can improve outcomes by determining a cardiac cause of the cardiac arrest and by guiding lifesaving procedures at the patient’s bedside.

• Hypotension/shock. FOCUS can help the clinician determine if the shock is cardiogenic, thus allowing for aggressive early intervention to prevent organ dysfunction. In this case, the exam looks for the presence of pericardial effusion and evaluates global cardiac function, right ventricular size, and inferior vena cava size/collapsibility as a marker of central venous pressure.

FOCUS can also determine the presence, size, and functional relevance of a pericardial effusion as a cause of hemodynamic instability. In addition, it can expedite pericardiocentesis while reducing complications and increasing the success rate.

• Dyspnea/shortness of breath. In cases of dyspnea, FOCUS can help rule out pericardial effusion, identify global left ventricular systolic dysfunction, and assess the size of the right ventricle as a proxy for indicating the presence or absence of a hemodynamically significant pulmonary embolus. Still, a complete evaluation of these patients should include comprehensive echocardiography to evaluate diastolic function and pulmonary artery pressures, and to help diagnose pericardial and valvular heart disease, according to the statement.

• Chest pain. FOCUS may be helpful in the evaluation of patients with a hemodynamically significant pulmonary embolus or the screening of patients for aortic dissection. When aortic dissection is suspected, the clinician can use FOCUS to look for pericardial or pleural effusions and to assess the diameter of the aortic root. (An aortic root diameter greater than 4 cm is suspicious for type A dissection.) However, the authors caution, a negative FOCUS exam does not definitively rule out aortic dissection; additional imaging and diagnostic studies are necessary.

For FOCUS to be successful, training should include the presentation of positive and negative cases of various cardiac pathologies. Also, any program that uses FOCUS should have a quality assurance program that reviews scan quality by comparing interpretations with pathological and surgical data, clinical outcomes, and final diagnoses.

ST. LOUIS – Focused cardiac ultrasonography, or FOCUS, can expedite the diagnostic evaluation of cardiac symptoms at the patient’s bedside – allowing for earlier, possibly life-saving interventions – and has become a fundamental tool in the emergency department, according to a joint consensus statement of the American Society of Echocardiography and American College of Emergency Physicians in the December 2010 issue of the Journal of the American Society of Echocardiography.

FOCUS enables clinicians to determine whether pericardial effusion is present, assess global cardiac systolic function, identify marked right and left ventricular enlargement, and assess intravascular volume, according to the consensus statement (J. Am. Soc. Echocardiogr. 2010;23:1225-30). FOCUS also can provide guidance for pericardiocentesis and confirm the placement of transvenous pacing wire.

The consensus statement also outlines the following specific clinical scenarios in which FOCUS can affect clinical decision making and patient care:

• Cardiac trauma. Performed as part of the FAST (focused assessment with sonography in trauma) exam, FOCUS can help identify possible cardiac injury, such as cardiac hemorrhage, that requires surgical intervention by looking for the presence of pericardial effusion as well as the presence or absence of organized ventricular contractility. FOCUS also can help diagnose cardiac contusions by looking for depressed wall motion and decreased myocardial contractility.

• Cardiac arrest. Clinicians can improve the outcome of cardiopulmonary resuscitation by using FOCUS to distinguish among asystole, pulseless electrical activity (PEA), and pseudo-PEA. FOCUS also can help identify causes of PEA, allowing for earlier treatment and the return of spontaneous circulation.

FOCUS can improve outcomes by determining a cardiac cause of the cardiac arrest and by guiding lifesaving procedures at the patient’s bedside.

• Hypotension/shock. FOCUS can help the clinician determine if the shock is cardiogenic, thus allowing for aggressive early intervention to prevent organ dysfunction. In this case, the exam looks for the presence of pericardial effusion and evaluates global cardiac function, right ventricular size, and inferior vena cava size/collapsibility as a marker of central venous pressure.

FOCUS can also determine the presence, size, and functional relevance of a pericardial effusion as a cause of hemodynamic instability. In addition, it can expedite pericardiocentesis while reducing complications and increasing the success rate.

• Dyspnea/shortness of breath. In cases of dyspnea, FOCUS can help rule out pericardial effusion, identify global left ventricular systolic dysfunction, and assess the size of the right ventricle as a proxy for indicating the presence or absence of a hemodynamically significant pulmonary embolus. Still, a complete evaluation of these patients should include comprehensive echocardiography to evaluate diastolic function and pulmonary artery pressures, and to help diagnose pericardial and valvular heart disease, according to the statement.

• Chest pain. FOCUS may be helpful in the evaluation of patients with a hemodynamically significant pulmonary embolus or the screening of patients for aortic dissection. When aortic dissection is suspected, the clinician can use FOCUS to look for pericardial or pleural effusions and to assess the diameter of the aortic root. (An aortic root diameter greater than 4 cm is suspicious for type A dissection.) However, the authors caution, a negative FOCUS exam does not definitively rule out aortic dissection; additional imaging and diagnostic studies are necessary.

For FOCUS to be successful, training should include the presentation of positive and negative cases of various cardiac pathologies. Also, any program that uses FOCUS should have a quality assurance program that reviews scan quality by comparing interpretations with pathological and surgical data, clinical outcomes, and final diagnoses.

ST. LOUIS – Focused cardiac ultrasonography, or FOCUS, can expedite the diagnostic evaluation of cardiac symptoms at the patient’s bedside – allowing for earlier, possibly life-saving interventions – and has become a fundamental tool in the emergency department, according to a joint consensus statement of the American Society of Echocardiography and American College of Emergency Physicians in the December 2010 issue of the Journal of the American Society of Echocardiography.

FOCUS enables clinicians to determine whether pericardial effusion is present, assess global cardiac systolic function, identify marked right and left ventricular enlargement, and assess intravascular volume, according to the consensus statement (J. Am. Soc. Echocardiogr. 2010;23:1225-30). FOCUS also can provide guidance for pericardiocentesis and confirm the placement of transvenous pacing wire.

The consensus statement also outlines the following specific clinical scenarios in which FOCUS can affect clinical decision making and patient care:

• Cardiac trauma. Performed as part of the FAST (focused assessment with sonography in trauma) exam, FOCUS can help identify possible cardiac injury, such as cardiac hemorrhage, that requires surgical intervention by looking for the presence of pericardial effusion as well as the presence or absence of organized ventricular contractility. FOCUS also can help diagnose cardiac contusions by looking for depressed wall motion and decreased myocardial contractility.

• Cardiac arrest. Clinicians can improve the outcome of cardiopulmonary resuscitation by using FOCUS to distinguish among asystole, pulseless electrical activity (PEA), and pseudo-PEA. FOCUS also can help identify causes of PEA, allowing for earlier treatment and the return of spontaneous circulation.

FOCUS can improve outcomes by determining a cardiac cause of the cardiac arrest and by guiding lifesaving procedures at the patient’s bedside.

• Hypotension/shock. FOCUS can help the clinician determine if the shock is cardiogenic, thus allowing for aggressive early intervention to prevent organ dysfunction. In this case, the exam looks for the presence of pericardial effusion and evaluates global cardiac function, right ventricular size, and inferior vena cava size/collapsibility as a marker of central venous pressure.

FOCUS can also determine the presence, size, and functional relevance of a pericardial effusion as a cause of hemodynamic instability. In addition, it can expedite pericardiocentesis while reducing complications and increasing the success rate.

• Dyspnea/shortness of breath. In cases of dyspnea, FOCUS can help rule out pericardial effusion, identify global left ventricular systolic dysfunction, and assess the size of the right ventricle as a proxy for indicating the presence or absence of a hemodynamically significant pulmonary embolus. Still, a complete evaluation of these patients should include comprehensive echocardiography to evaluate diastolic function and pulmonary artery pressures, and to help diagnose pericardial and valvular heart disease, according to the statement.

• Chest pain. FOCUS may be helpful in the evaluation of patients with a hemodynamically significant pulmonary embolus or the screening of patients for aortic dissection. When aortic dissection is suspected, the clinician can use FOCUS to look for pericardial or pleural effusions and to assess the diameter of the aortic root. (An aortic root diameter greater than 4 cm is suspicious for type A dissection.) However, the authors caution, a negative FOCUS exam does not definitively rule out aortic dissection; additional imaging and diagnostic studies are necessary.

For FOCUS to be successful, training should include the presentation of positive and negative cases of various cardiac pathologies. Also, any program that uses FOCUS should have a quality assurance program that reviews scan quality by comparing interpretations with pathological and surgical data, clinical outcomes, and final diagnoses.

ST. LOUIS – Focused cardiac ultrasonography, or FOCUS, can expedite the diagnostic evaluation of cardiac symptoms at the patient’s bedside – allowing for earlier, possibly life-saving interventions – and has become a fundamental tool in the emergency department, according to a joint consensus statement of the American Society of Echocardiography and American College of Emergency Physicians in the December 2010 issue of the Journal of the American Society of Echocardiography.

FOCUS enables clinicians to determine whether pericardial effusion is present, assess global cardiac systolic function, identify marked right and left ventricular enlargement, and assess intravascular volume, according to the consensus statement (J. Am. Soc. Echocardiogr. 2010;23:1225-30). FOCUS also can provide guidance for pericardiocentesis and confirm the placement of transvenous pacing wire.

The consensus statement also outlines the following specific clinical scenarios in which FOCUS can affect clinical decision making and patient care:

• Cardiac trauma. Performed as part of the FAST (focused assessment with sonography in trauma) exam, FOCUS can help identify possible cardiac injury, such as cardiac hemorrhage, that requires surgical intervention by looking for the presence of pericardial effusion as well as the presence or absence of organized ventricular contractility. FOCUS also can help diagnose cardiac contusions by looking for depressed wall motion and decreased myocardial contractility.

• Cardiac arrest. Clinicians can improve the outcome of cardiopulmonary resuscitation by using FOCUS to distinguish among asystole, pulseless electrical activity (PEA), and pseudo-PEA. FOCUS also can help identify causes of PEA, allowing for earlier treatment and the return of spontaneous circulation.

FOCUS can improve outcomes by determining a cardiac cause of the cardiac arrest and by guiding lifesaving procedures at the patient’s bedside.

• Hypotension/shock. FOCUS can help the clinician determine if the shock is cardiogenic, thus allowing for aggressive early intervention to prevent organ dysfunction. In this case, the exam looks for the presence of pericardial effusion and evaluates global cardiac function, right ventricular size, and inferior vena cava size/collapsibility as a marker of central venous pressure.

FOCUS can also determine the presence, size, and functional relevance of a pericardial effusion as a cause of hemodynamic instability. In addition, it can expedite pericardiocentesis while reducing complications and increasing the success rate.

• Dyspnea/shortness of breath. In cases of dyspnea, FOCUS can help rule out pericardial effusion, identify global left ventricular systolic dysfunction, and assess the size of the right ventricle as a proxy for indicating the presence or absence of a hemodynamically significant pulmonary embolus. Still, a complete evaluation of these patients should include comprehensive echocardiography to evaluate diastolic function and pulmonary artery pressures, and to help diagnose pericardial and valvular heart disease, according to the statement.

• Chest pain. FOCUS may be helpful in the evaluation of patients with a hemodynamically significant pulmonary embolus or the screening of patients for aortic dissection. When aortic dissection is suspected, the clinician can use FOCUS to look for pericardial or pleural effusions and to assess the diameter of the aortic root. (An aortic root diameter greater than 4 cm is suspicious for type A dissection.) However, the authors caution, a negative FOCUS exam does not definitively rule out aortic dissection; additional imaging and diagnostic studies are necessary.

For FOCUS to be successful, training should include the presentation of positive and negative cases of various cardiac pathologies. Also, any program that uses FOCUS should have a quality assurance program that reviews scan quality by comparing interpretations with pathological and surgical data, clinical outcomes, and final diagnoses.

ST. LOUIS – Focused cardiac ultrasonography, or FOCUS, can expedite the diagnostic evaluation of cardiac symptoms at the patient’s bedside – allowing for earlier, possibly life-saving interventions – and has become a fundamental tool in the emergency department, according to a joint consensus statement of the American Society of Echocardiography and American College of Emergency Physicians in the December 2010 issue of the Journal of the American Society of Echocardiography.

FOCUS enables clinicians to determine whether pericardial effusion is present, assess global cardiac systolic function, identify marked right and left ventricular enlargement, and assess intravascular volume, according to the consensus statement (J. Am. Soc. Echocardiogr. 2010;23:1225-30). FOCUS also can provide guidance for pericardiocentesis and confirm the placement of transvenous pacing wire.

The consensus statement also outlines the following specific clinical scenarios in which FOCUS can affect clinical decision making and patient care:

• Cardiac trauma. Performed as part of the FAST (focused assessment with sonography in trauma) exam, FOCUS can help identify possible cardiac injury, such as cardiac hemorrhage, that requires surgical intervention by looking for the presence of pericardial effusion as well as the presence or absence of organized ventricular contractility. FOCUS also can help diagnose cardiac contusions by looking for depressed wall motion and decreased myocardial contractility.

• Cardiac arrest. Clinicians can improve the outcome of cardiopulmonary resuscitation by using FOCUS to distinguish among asystole, pulseless electrical activity (PEA), and pseudo-PEA. FOCUS also can help identify causes of PEA, allowing for earlier treatment and the return of spontaneous circulation.

FOCUS can improve outcomes by determining a cardiac cause of the cardiac arrest and by guiding lifesaving procedures at the patient’s bedside.

• Hypotension/shock. FOCUS can help the clinician determine if the shock is cardiogenic, thus allowing for aggressive early intervention to prevent organ dysfunction. In this case, the exam looks for the presence of pericardial effusion and evaluates global cardiac function, right ventricular size, and inferior vena cava size/collapsibility as a marker of central venous pressure.

FOCUS can also determine the presence, size, and functional relevance of a pericardial effusion as a cause of hemodynamic instability. In addition, it can expedite pericardiocentesis while reducing complications and increasing the success rate.

• Dyspnea/shortness of breath. In cases of dyspnea, FOCUS can help rule out pericardial effusion, identify global left ventricular systolic dysfunction, and assess the size of the right ventricle as a proxy for indicating the presence or absence of a hemodynamically significant pulmonary embolus. Still, a complete evaluation of these patients should include comprehensive echocardiography to evaluate diastolic function and pulmonary artery pressures, and to help diagnose pericardial and valvular heart disease, according to the statement.

• Chest pain. FOCUS may be helpful in the evaluation of patients with a hemodynamically significant pulmonary embolus or the screening of patients for aortic dissection. When aortic dissection is suspected, the clinician can use FOCUS to look for pericardial or pleural effusions and to assess the diameter of the aortic root. (An aortic root diameter greater than 4 cm is suspicious for type A dissection.) However, the authors caution, a negative FOCUS exam does not definitively rule out aortic dissection; additional imaging and diagnostic studies are necessary.

For FOCUS to be successful, training should include the presentation of positive and negative cases of various cardiac pathologies. Also, any program that uses FOCUS should have a quality assurance program that reviews scan quality by comparing interpretations with pathological and surgical data, clinical outcomes, and final diagnoses.

Long-term use of high-dose vitamins E and C, alone or combined, has no effect in preventing the development of cataracts in men, according to the latest findings of the Physicians’ Health Study II reported in the November issue of Archives of Ophthalmology.

The PHS II, a randomized, double-masked, placebo-controlled trial, studied the effectiveness of vitamins E and C and a multivitamin in preventing cancer and cardiovascular disease among 14,641 apparently healthy U.S. male physicians aged 50 years or older. Incident cataract was a secondary end point.

Prospective observational studies have suggested that intake of vitamins E and C helps prevent the oxidative damage to the lens that leads to cataract. However, completed randomized trials have shown little beneficial effect of either vitamin, whether used alone or in combination with other supplements – even with as many as 10 years of treatment.

For this study, Dr. William G. Christen from Brigham and Women’s Hospital and Harvard Medical School, Boston, and his colleagues randomized 11,545 subjects as follows: 5,771 to receive 400 IU of vitamin E every other day, 5,774 to receive a vitamin E placebo every other day, 5,779 to receive 500 mg of vitamin C daily, and 5,746 to receive a vitamin C placebo daily (Arch. Ophthalmol. 2010;128:1397-1405). The researchers distributed baseline characteristics, including risk factors, evenly among the groups.

During a mean follow-up of 8 years, there were 579 cataracts in the vitamin E group, 595 in the vitamin E placebo group, 593 in the vitamin C group, and 581 in the vitamin C placebo group. There appeared little difference among patients with known or possible risk factors. There were 801 cataract extractions during this period.

Supplementation with vitamins E and C had no significant effect on diagnosed cataract or extraction, or on cataract subtype (nuclear, cortical, or posterior subcapsular). In the vitamin C group, there was a possible, but statistically nonsignificant, trend toward increased risk in those with a reported history of cardiovascular disease.

When interpreting these results, the researchers caution that several factors must be considered. For example, participants were generally well nourished, so findings might not apply to less well nourished populations. Also, the doses of both vitamins used were higher than normal dietary levels and levels used in observational studies, so even higher doses would probably yield no benefits. Although follow-up lasted 8 years, cataracts develop slowly over many years and may require longer periods of treatment, and possibly treatment at younger ages.

Finally, the PHS II excluded participants with known cataract. Many previous trials included patients with lens opacities at baseline, so intervention in those trials may have occurred too late in the disease process to have a material effect on rates of cataract, the researchers said.

The authors reported no financial disclosures. Support for the study came from grants funded by the National Eye Institute, the National Institute on Aging, the National Institutes of Health, and BASF Corp. The study was sponsored by BASF, Wyeth Pharmaceuticals, and DSM Nutritional Products, which had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, and approval of the manuscript.

Long-term use of high-dose vitamins E and C, alone or combined, has no effect in preventing the development of cataracts in men, according to the latest findings of the Physicians’ Health Study II reported in the November issue of Archives of Ophthalmology.

The PHS II, a randomized, double-masked, placebo-controlled trial, studied the effectiveness of vitamins E and C and a multivitamin in preventing cancer and cardiovascular disease among 14,641 apparently healthy U.S. male physicians aged 50 years or older. Incident cataract was a secondary end point.

Prospective observational studies have suggested that intake of vitamins E and C helps prevent the oxidative damage to the lens that leads to cataract. However, completed randomized trials have shown little beneficial effect of either vitamin, whether used alone or in combination with other supplements – even with as many as 10 years of treatment.

For this study, Dr. William G. Christen from Brigham and Women’s Hospital and Harvard Medical School, Boston, and his colleagues randomized 11,545 subjects as follows: 5,771 to receive 400 IU of vitamin E every other day, 5,774 to receive a vitamin E placebo every other day, 5,779 to receive 500 mg of vitamin C daily, and 5,746 to receive a vitamin C placebo daily (Arch. Ophthalmol. 2010;128:1397-1405). The researchers distributed baseline characteristics, including risk factors, evenly among the groups.

During a mean follow-up of 8 years, there were 579 cataracts in the vitamin E group, 595 in the vitamin E placebo group, 593 in the vitamin C group, and 581 in the vitamin C placebo group. There appeared little difference among patients with known or possible risk factors. There were 801 cataract extractions during this period.

Supplementation with vitamins E and C had no significant effect on diagnosed cataract or extraction, or on cataract subtype (nuclear, cortical, or posterior subcapsular). In the vitamin C group, there was a possible, but statistically nonsignificant, trend toward increased risk in those with a reported history of cardiovascular disease.

When interpreting these results, the researchers caution that several factors must be considered. For example, participants were generally well nourished, so findings might not apply to less well nourished populations. Also, the doses of both vitamins used were higher than normal dietary levels and levels used in observational studies, so even higher doses would probably yield no benefits. Although follow-up lasted 8 years, cataracts develop slowly over many years and may require longer periods of treatment, and possibly treatment at younger ages.

Finally, the PHS II excluded participants with known cataract. Many previous trials included patients with lens opacities at baseline, so intervention in those trials may have occurred too late in the disease process to have a material effect on rates of cataract, the researchers said.

The authors reported no financial disclosures. Support for the study came from grants funded by the National Eye Institute, the National Institute on Aging, the National Institutes of Health, and BASF Corp. The study was sponsored by BASF, Wyeth Pharmaceuticals, and DSM Nutritional Products, which had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, and approval of the manuscript.

Long-term use of high-dose vitamins E and C, alone or combined, has no effect in preventing the development of cataracts in men, according to the latest findings of the Physicians’ Health Study II reported in the November issue of Archives of Ophthalmology.

The PHS II, a randomized, double-masked, placebo-controlled trial, studied the effectiveness of vitamins E and C and a multivitamin in preventing cancer and cardiovascular disease among 14,641 apparently healthy U.S. male physicians aged 50 years or older. Incident cataract was a secondary end point.

Prospective observational studies have suggested that intake of vitamins E and C helps prevent the oxidative damage to the lens that leads to cataract. However, completed randomized trials have shown little beneficial effect of either vitamin, whether used alone or in combination with other supplements – even with as many as 10 years of treatment.

For this study, Dr. William G. Christen from Brigham and Women’s Hospital and Harvard Medical School, Boston, and his colleagues randomized 11,545 subjects as follows: 5,771 to receive 400 IU of vitamin E every other day, 5,774 to receive a vitamin E placebo every other day, 5,779 to receive 500 mg of vitamin C daily, and 5,746 to receive a vitamin C placebo daily (Arch. Ophthalmol. 2010;128:1397-1405). The researchers distributed baseline characteristics, including risk factors, evenly among the groups.

During a mean follow-up of 8 years, there were 579 cataracts in the vitamin E group, 595 in the vitamin E placebo group, 593 in the vitamin C group, and 581 in the vitamin C placebo group. There appeared little difference among patients with known or possible risk factors. There were 801 cataract extractions during this period.

Supplementation with vitamins E and C had no significant effect on diagnosed cataract or extraction, or on cataract subtype (nuclear, cortical, or posterior subcapsular). In the vitamin C group, there was a possible, but statistically nonsignificant, trend toward increased risk in those with a reported history of cardiovascular disease.

When interpreting these results, the researchers caution that several factors must be considered. For example, participants were generally well nourished, so findings might not apply to less well nourished populations. Also, the doses of both vitamins used were higher than normal dietary levels and levels used in observational studies, so even higher doses would probably yield no benefits. Although follow-up lasted 8 years, cataracts develop slowly over many years and may require longer periods of treatment, and possibly treatment at younger ages.

Finally, the PHS II excluded participants with known cataract. Many previous trials included patients with lens opacities at baseline, so intervention in those trials may have occurred too late in the disease process to have a material effect on rates of cataract, the researchers said.

The authors reported no financial disclosures. Support for the study came from grants funded by the National Eye Institute, the National Institute on Aging, the National Institutes of Health, and BASF Corp. The study was sponsored by BASF, Wyeth Pharmaceuticals, and DSM Nutritional Products, which had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, and approval of the manuscript.

Major Finding: Familial liability to psychosis appears to be partly expressed as a tendency to develop psychotic experiences after cannabis use.

Data Source: Genetic Risk and Outcome in Psychosis (GROUP), an ongoing longitudinal study in the Netherlands and Belgium.

Disclosures: The authors had no financial disclosures. The infrastructure for the GROUP study received funding from the Geestkracht program of the Netherlands Organisation for Health Research and Development, and from numerous universities and mental health care organizations in the Netherlands and Belgium. The analyses were supported by unrestricted grants from Janssen-Cilag, Eli Lilly & Co., AstraZeneca, and Lundbeck.

Genetic risk for psychotic disorder might be expressed in part as sensitivity to the psychotomimetic effect of cannabis. And, cannabis use, combined with this preexisting risk, might cause positive and negative symptoms of psychosis, according to new research published online.

Studies have suggested that exposure to delta-9-tetrahydrocannabinol, the main psychotropic component of Cannabis sativa, induces psychotic symptoms in a substantial proportion of healthy controls. Also, prospective epidemiologic studies indicate that cannabis use not only predicts onset of psychotic disorder but also is linked with subthreshold expression of psychosis in the form of schizotypy or subclinical psychotic experiences.

Data for this study come from Genetic Risk and Outcome in Psychosis (GROUP), an ongoing longitudinal study in selected areas of the Netherlands and Belgium (Arch. Gen. Psychiatry 2010 Oct. 4 [doi:10.1001/archgenpsychiatry.2010.132]). The GROUP sample consists of 1,120 patients with nonaffective psychotic disorder, 1,057 siblings of these patients, 919 parents of patients and their siblings, and 590 unrelated controls.

Researchers used urinalysis to measure current substance abuse, sections of the Composite International Diagnostic Interview to assess long-term substance abuse, and an interview-based measure of schizotypy for the sibling–healthy control comparison. They performed sibling-control and cross-sibling comparisons using samples of patients with a psychotic disorder and community controls.

The main outcome measures were positive and negative schizotypy using the Structured Interview for Schizotypy–Revised for siblings and controls and self-reported positive and negative psychotic experiences using the Community Assessment of Psychic Experiences (CAPE) for siblings and patients. Patients and their siblings more often used cannabis than did control subjects, and more often were male and nonwhite, the researchers found. Additional results showed that:

▸ Siblings of patients displayed more than 15 times greater sensitivity to positive schizotypy associated with particularly current cannabis use by urinalysis, and a similar difference in sensitivity to its effect on negative schizotypy.

▸ Siblings exposed to cannabis resembled their patient relative nearly 10 times more closely in the positive psychotic dimension of CAPE vs. nonexposed siblings.

▸ No significant effect was apparent for the negative domain of CAPE, although the association was directionally similar (two times more resemblance; P interaction = .17).

▸ Cross-sibling, cross-trait analyses suggested that the mechanism underlying these findings was moderation (familial risk increasing sensitivity to cannabis) rather than mediation (familial risk increasing use of cannabis).

“An important issue revealed by this study is that while the relative effect sizes of differential sensitivity were high, absolute effect sizes, for example, of cannabis on schizotypy in unaffected siblings, were small,” the researchers wrote. “It therefore follows that any study examining differential sensitivity will require a very large sample to demonstrate differences in sensitivity for an environmental risk factor between groups.”

Major Finding: Familial liability to psychosis appears to be partly expressed as a tendency to develop psychotic experiences after cannabis use.

Data Source: Genetic Risk and Outcome in Psychosis (GROUP), an ongoing longitudinal study in the Netherlands and Belgium.

Disclosures: The authors had no financial disclosures. The infrastructure for the GROUP study received funding from the Geestkracht program of the Netherlands Organisation for Health Research and Development, and from numerous universities and mental health care organizations in the Netherlands and Belgium. The analyses were supported by unrestricted grants from Janssen-Cilag, Eli Lilly & Co., AstraZeneca, and Lundbeck.

Genetic risk for psychotic disorder might be expressed in part as sensitivity to the psychotomimetic effect of cannabis. And, cannabis use, combined with this preexisting risk, might cause positive and negative symptoms of psychosis, according to new research published online.

Studies have suggested that exposure to delta-9-tetrahydrocannabinol, the main psychotropic component of Cannabis sativa, induces psychotic symptoms in a substantial proportion of healthy controls. Also, prospective epidemiologic studies indicate that cannabis use not only predicts onset of psychotic disorder but also is linked with subthreshold expression of psychosis in the form of schizotypy or subclinical psychotic experiences.

Data for this study come from Genetic Risk and Outcome in Psychosis (GROUP), an ongoing longitudinal study in selected areas of the Netherlands and Belgium (Arch. Gen. Psychiatry 2010 Oct. 4 [doi:10.1001/archgenpsychiatry.2010.132]). The GROUP sample consists of 1,120 patients with nonaffective psychotic disorder, 1,057 siblings of these patients, 919 parents of patients and their siblings, and 590 unrelated controls.

Researchers used urinalysis to measure current substance abuse, sections of the Composite International Diagnostic Interview to assess long-term substance abuse, and an interview-based measure of schizotypy for the sibling–healthy control comparison. They performed sibling-control and cross-sibling comparisons using samples of patients with a psychotic disorder and community controls.

The main outcome measures were positive and negative schizotypy using the Structured Interview for Schizotypy–Revised for siblings and controls and self-reported positive and negative psychotic experiences using the Community Assessment of Psychic Experiences (CAPE) for siblings and patients. Patients and their siblings more often used cannabis than did control subjects, and more often were male and nonwhite, the researchers found. Additional results showed that:

▸ Siblings of patients displayed more than 15 times greater sensitivity to positive schizotypy associated with particularly current cannabis use by urinalysis, and a similar difference in sensitivity to its effect on negative schizotypy.

▸ Siblings exposed to cannabis resembled their patient relative nearly 10 times more closely in the positive psychotic dimension of CAPE vs. nonexposed siblings.

▸ No significant effect was apparent for the negative domain of CAPE, although the association was directionally similar (two times more resemblance; P interaction = .17).

▸ Cross-sibling, cross-trait analyses suggested that the mechanism underlying these findings was moderation (familial risk increasing sensitivity to cannabis) rather than mediation (familial risk increasing use of cannabis).

“An important issue revealed by this study is that while the relative effect sizes of differential sensitivity were high, absolute effect sizes, for example, of cannabis on schizotypy in unaffected siblings, were small,” the researchers wrote. “It therefore follows that any study examining differential sensitivity will require a very large sample to demonstrate differences in sensitivity for an environmental risk factor between groups.”

Major Finding: Familial liability to psychosis appears to be partly expressed as a tendency to develop psychotic experiences after cannabis use.

Data Source: Genetic Risk and Outcome in Psychosis (GROUP), an ongoing longitudinal study in the Netherlands and Belgium.

Disclosures: The authors had no financial disclosures. The infrastructure for the GROUP study received funding from the Geestkracht program of the Netherlands Organisation for Health Research and Development, and from numerous universities and mental health care organizations in the Netherlands and Belgium. The analyses were supported by unrestricted grants from Janssen-Cilag, Eli Lilly & Co., AstraZeneca, and Lundbeck.

Genetic risk for psychotic disorder might be expressed in part as sensitivity to the psychotomimetic effect of cannabis. And, cannabis use, combined with this preexisting risk, might cause positive and negative symptoms of psychosis, according to new research published online.

Studies have suggested that exposure to delta-9-tetrahydrocannabinol, the main psychotropic component of Cannabis sativa, induces psychotic symptoms in a substantial proportion of healthy controls. Also, prospective epidemiologic studies indicate that cannabis use not only predicts onset of psychotic disorder but also is linked with subthreshold expression of psychosis in the form of schizotypy or subclinical psychotic experiences.

Data for this study come from Genetic Risk and Outcome in Psychosis (GROUP), an ongoing longitudinal study in selected areas of the Netherlands and Belgium (Arch. Gen. Psychiatry 2010 Oct. 4 [doi:10.1001/archgenpsychiatry.2010.132]). The GROUP sample consists of 1,120 patients with nonaffective psychotic disorder, 1,057 siblings of these patients, 919 parents of patients and their siblings, and 590 unrelated controls.

Researchers used urinalysis to measure current substance abuse, sections of the Composite International Diagnostic Interview to assess long-term substance abuse, and an interview-based measure of schizotypy for the sibling–healthy control comparison. They performed sibling-control and cross-sibling comparisons using samples of patients with a psychotic disorder and community controls.

The main outcome measures were positive and negative schizotypy using the Structured Interview for Schizotypy–Revised for siblings and controls and self-reported positive and negative psychotic experiences using the Community Assessment of Psychic Experiences (CAPE) for siblings and patients. Patients and their siblings more often used cannabis than did control subjects, and more often were male and nonwhite, the researchers found. Additional results showed that:

▸ Siblings of patients displayed more than 15 times greater sensitivity to positive schizotypy associated with particularly current cannabis use by urinalysis, and a similar difference in sensitivity to its effect on negative schizotypy.

▸ Siblings exposed to cannabis resembled their patient relative nearly 10 times more closely in the positive psychotic dimension of CAPE vs. nonexposed siblings.

▸ No significant effect was apparent for the negative domain of CAPE, although the association was directionally similar (two times more resemblance; P interaction = .17).

▸ Cross-sibling, cross-trait analyses suggested that the mechanism underlying these findings was moderation (familial risk increasing sensitivity to cannabis) rather than mediation (familial risk increasing use of cannabis).

“An important issue revealed by this study is that while the relative effect sizes of differential sensitivity were high, absolute effect sizes, for example, of cannabis on schizotypy in unaffected siblings, were small,” the researchers wrote. “It therefore follows that any study examining differential sensitivity will require a very large sample to demonstrate differences in sensitivity for an environmental risk factor between groups.”

The frequency of surgical complications involving a wrong site or wrong patient remains high, even in the era of the Universal Protocol.

The Joint Commission introduced the Universal Protocol to ensure the correct patient, site, and procedure. Although it became effective July 1, 2004, there still exists a lack of data about the true incidence of wrong-patient and wrong-site operations, called "never events," according to new research reported in the October issue of Archives of Surgery.

To determine the frequency, root causes, and outcomes of these never events, Dr. Philip F. Stahel of Denver Health Medical Center and the University of Colorado School of Medicine, and colleagues performed a retrospective analysis of the Colorado Physician Insurance Company's (COPIC's) comprehensive database (Arch. Surg. 2010;145:978-84).

Dr. Stahel and his colleagues screened 27,370 physician self-reported adverse occurrences between Jan. 1, 2002, and June 1, 2008. The researchers initially found 119 wrong-site and 29 wrong-patient procedures, but eliminated cases they could not classify as being a factual wrong site or wrong patient. The final analysis consisted of 107 wrong-site and 25 wrong-patient procedures.

Analysis of root causes found errors in:

Diagnosis, a root cause for 14 (56.0%) wrong-patient and 13 (12.1%) wrong-site procedures.

Communication, 25 (100%) wrong-patient and 52 (48.6%) wrong-site procedures.

Judgment, 2 (8.0%) wrong-patient and 91 (85.0%) wrong-site procedures.

Treatment, 22 (88.0%) wrong-patient and 9 (92.5%) wrong-site procedures.

In addition, system issues were a root cause in 21 (84.0%) wrong-patient procedures and 78 (72.9%) wrong-site procedures. This category included time-out not being performed in 77 (72%) wrong-site cases.

Wrong-patient cases often were due to a mix-up of patients’ medical records, radiographs, and laboratory or biopsy samples, as well as errors in communication.

Next, the researchers looked at outcomes, namely:

Death, which occurred in 1 patient (0.9%) secondary to a wrong-site procedure.

Significant harm, which occurred in 5 (20%) wrong-patient and 38 (35.5%) wrong-site cases.

Minimal harm or functional impairment, which occurred in 8 (32%) wrong-patient and 65 (60.7%) wrong-site cases.

No-harm event, which occurred in 9 (36%) wrong-patient and 3 (2.8%) wrong-site cases.

The most frequent specialties involved in wrong-patient procedures were internal medicine (24.0% of cases) as well as family or general practice, pathology, urology, obstetrics-gynecology, and pediatrics (8.0% each). The most frequent specialties involved in wrong-site occurrences were orthopedic surgery (22.4% of cases), general surgery (16.8%), and anesthesiology (12.1%).

Overall, nonsurgical specialties were involved in 14 (48.3%) wrong-patient and 29 (27.1%) wrong-site cases.

"The findings from the present study emphasize a continuing and concerning occurrence of wrong-site and wrong-patient procedures in the current era of the Universal Protocol, leading to frequent patient harm and, rarely, patient death," the researchers said. "Shockingly, nonsurgical disciplines equally contribute to patient injuries related to wrong-site procedures."

The researchers believe these findings warrant expansion of the Universal Protocol to nonsurgical specialties.

Limitations of the study include the restricted coverage of the COPIC database to about 6,000 physicians in Colorado; the potential for subjective bias in determining root causes; and the designation of inadequate planning for the procedure, which represents a generic category.

Coauthors on the research analysis reported the following conflicts: Dr.Ted J. Clarke is the chief executive officer of Colorado Physician Insurance Company (COPIC); Dr. Jeffrey Varnell and Dr. Alan Lembitz are employed by COPIC; and Dr. Michael S. Victoroff and Dr. Dennis J. Boyle are consultants for COPIC.

The frequency of surgical complications involving a wrong site or wrong patient remains high, even in the era of the Universal Protocol.

The Joint Commission introduced the Universal Protocol to ensure the correct patient, site, and procedure. Although it became effective July 1, 2004, there still exists a lack of data about the true incidence of wrong-patient and wrong-site operations, called "never events," according to new research reported in the October issue of Archives of Surgery.

To determine the frequency, root causes, and outcomes of these never events, Dr. Philip F. Stahel of Denver Health Medical Center and the University of Colorado School of Medicine, and colleagues performed a retrospective analysis of the Colorado Physician Insurance Company's (COPIC's) comprehensive database (Arch. Surg. 2010;145:978-84).

Dr. Stahel and his colleagues screened 27,370 physician self-reported adverse occurrences between Jan. 1, 2002, and June 1, 2008. The researchers initially found 119 wrong-site and 29 wrong-patient procedures, but eliminated cases they could not classify as being a factual wrong site or wrong patient. The final analysis consisted of 107 wrong-site and 25 wrong-patient procedures.

Analysis of root causes found errors in:

Diagnosis, a root cause for 14 (56.0%) wrong-patient and 13 (12.1%) wrong-site procedures.

Communication, 25 (100%) wrong-patient and 52 (48.6%) wrong-site procedures.

Judgment, 2 (8.0%) wrong-patient and 91 (85.0%) wrong-site procedures.

Treatment, 22 (88.0%) wrong-patient and 9 (92.5%) wrong-site procedures.

In addition, system issues were a root cause in 21 (84.0%) wrong-patient procedures and 78 (72.9%) wrong-site procedures. This category included time-out not being performed in 77 (72%) wrong-site cases.

Wrong-patient cases often were due to a mix-up of patients’ medical records, radiographs, and laboratory or biopsy samples, as well as errors in communication.

Next, the researchers looked at outcomes, namely:

Death, which occurred in 1 patient (0.9%) secondary to a wrong-site procedure.

Significant harm, which occurred in 5 (20%) wrong-patient and 38 (35.5%) wrong-site cases.

Minimal harm or functional impairment, which occurred in 8 (32%) wrong-patient and 65 (60.7%) wrong-site cases.

No-harm event, which occurred in 9 (36%) wrong-patient and 3 (2.8%) wrong-site cases.

The most frequent specialties involved in wrong-patient procedures were internal medicine (24.0% of cases) as well as family or general practice, pathology, urology, obstetrics-gynecology, and pediatrics (8.0% each). The most frequent specialties involved in wrong-site occurrences were orthopedic surgery (22.4% of cases), general surgery (16.8%), and anesthesiology (12.1%).

Overall, nonsurgical specialties were involved in 14 (48.3%) wrong-patient and 29 (27.1%) wrong-site cases.

"The findings from the present study emphasize a continuing and concerning occurrence of wrong-site and wrong-patient procedures in the current era of the Universal Protocol, leading to frequent patient harm and, rarely, patient death," the researchers said. "Shockingly, nonsurgical disciplines equally contribute to patient injuries related to wrong-site procedures."

The researchers believe these findings warrant expansion of the Universal Protocol to nonsurgical specialties.

Limitations of the study include the restricted coverage of the COPIC database to about 6,000 physicians in Colorado; the potential for subjective bias in determining root causes; and the designation of inadequate planning for the procedure, which represents a generic category.

Coauthors on the research analysis reported the following conflicts: Dr.Ted J. Clarke is the chief executive officer of Colorado Physician Insurance Company (COPIC); Dr. Jeffrey Varnell and Dr. Alan Lembitz are employed by COPIC; and Dr. Michael S. Victoroff and Dr. Dennis J. Boyle are consultants for COPIC.

The frequency of surgical complications involving a wrong site or wrong patient remains high, even in the era of the Universal Protocol.

The Joint Commission introduced the Universal Protocol to ensure the correct patient, site, and procedure. Although it became effective July 1, 2004, there still exists a lack of data about the true incidence of wrong-patient and wrong-site operations, called "never events," according to new research reported in the October issue of Archives of Surgery.

To determine the frequency, root causes, and outcomes of these never events, Dr. Philip F. Stahel of Denver Health Medical Center and the University of Colorado School of Medicine, and colleagues performed a retrospective analysis of the Colorado Physician Insurance Company's (COPIC's) comprehensive database (Arch. Surg. 2010;145:978-84).

Dr. Stahel and his colleagues screened 27,370 physician self-reported adverse occurrences between Jan. 1, 2002, and June 1, 2008. The researchers initially found 119 wrong-site and 29 wrong-patient procedures, but eliminated cases they could not classify as being a factual wrong site or wrong patient. The final analysis consisted of 107 wrong-site and 25 wrong-patient procedures.

Analysis of root causes found errors in:

Diagnosis, a root cause for 14 (56.0%) wrong-patient and 13 (12.1%) wrong-site procedures.

Communication, 25 (100%) wrong-patient and 52 (48.6%) wrong-site procedures.

Judgment, 2 (8.0%) wrong-patient and 91 (85.0%) wrong-site procedures.

Treatment, 22 (88.0%) wrong-patient and 9 (92.5%) wrong-site procedures.

In addition, system issues were a root cause in 21 (84.0%) wrong-patient procedures and 78 (72.9%) wrong-site procedures. This category included time-out not being performed in 77 (72%) wrong-site cases.

Wrong-patient cases often were due to a mix-up of patients’ medical records, radiographs, and laboratory or biopsy samples, as well as errors in communication.

Next, the researchers looked at outcomes, namely:

Death, which occurred in 1 patient (0.9%) secondary to a wrong-site procedure.

Significant harm, which occurred in 5 (20%) wrong-patient and 38 (35.5%) wrong-site cases.

Minimal harm or functional impairment, which occurred in 8 (32%) wrong-patient and 65 (60.7%) wrong-site cases.

No-harm event, which occurred in 9 (36%) wrong-patient and 3 (2.8%) wrong-site cases.

The most frequent specialties involved in wrong-patient procedures were internal medicine (24.0% of cases) as well as family or general practice, pathology, urology, obstetrics-gynecology, and pediatrics (8.0% each). The most frequent specialties involved in wrong-site occurrences were orthopedic surgery (22.4% of cases), general surgery (16.8%), and anesthesiology (12.1%).

Overall, nonsurgical specialties were involved in 14 (48.3%) wrong-patient and 29 (27.1%) wrong-site cases.

"The findings from the present study emphasize a continuing and concerning occurrence of wrong-site and wrong-patient procedures in the current era of the Universal Protocol, leading to frequent patient harm and, rarely, patient death," the researchers said. "Shockingly, nonsurgical disciplines equally contribute to patient injuries related to wrong-site procedures."

The researchers believe these findings warrant expansion of the Universal Protocol to nonsurgical specialties.

Limitations of the study include the restricted coverage of the COPIC database to about 6,000 physicians in Colorado; the potential for subjective bias in determining root causes; and the designation of inadequate planning for the procedure, which represents a generic category.

Coauthors on the research analysis reported the following conflicts: Dr.Ted J. Clarke is the chief executive officer of Colorado Physician Insurance Company (COPIC); Dr. Jeffrey Varnell and Dr. Alan Lembitz are employed by COPIC; and Dr. Michael S. Victoroff and Dr. Dennis J. Boyle are consultants for COPIC.