Melinda Tanzola

ATLANTA — Obese children are at risk for developing nonalcoholic fatty liver disease and nonalcoholic steatohepatitis, which can lead to fibrosis and cirrhosis, speakers said at a meeting sponsored by the American Association for the Study of Liver Diseases.

A significant number of children are probably affected by nonalcoholic fatty liver disease (NAFLD), according to Dr. Jeffrey B. Schwimmer, a pediatrician at the University of California, San Diego. Various studies have indicated that between 10% and 77% of obese children in China, Italy, Japan, and the United States have NAFLD. An estimated 5%–10% of those children have advanced fibrosis at the time of diagnosis. Demographic factors influence prevalence: boys and Hispanic children are more likely to have NAFLD than are girls and black children.

The first detectable sign of NAFLD is often an elevated serum alanine aminotransferase level. However, diagnosis can be challenging, because children often are asymptomatic, but may have NAFLD and even nonalcoholic steatohepatitis (NASH), despite having normal alanine aminotransferase levels. No single blood test can indicate NAFLD; biopsy is the definitive diagnostic tool for both NAFLD and NASH.

Dr. Philip Rosenthal, professor of pediatrics at the University of California, San Francisco, emphasized the importance of a histologic examination for determining the extent of disease and for distinguishing between simple steatosis and steatohepatitis. Steatohepatitis and fibrosis are commonly observed in children with NASH who are undergoing biopsy, and cirrhosis with rapid progression has been observed.

Dr. Rosenthal also recommended that clinicians look for signs of portal hypertension, including gastrointestinal bleeding and ascites.

Treatments for pediatric NASH have not been evaluated in controlled trials with long follow-up periods. Current treatments primarily aim to reduce steatosis and associated disorders. Prevention and treatment of metabolic syndrome through diet and exercise, insulin-sensitizing agents, and lipid-lowering drugs are central treatment strategies. Metformin may be beneficial in these patients, as it appears to improve NASH in nondiabetic pediatric patients.

Treatment of Nonalcoholic Fatty Liver Disease (TONIC), a randomized, phase III trial sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases, will be evaluating metformin and vitamin E in children with NAFLD/NASH.

Reducing body weight also remains a primary goal in treating pediatric NAFLD, according to Dr. Paul B. Pencharz, professor of pediatrics at the University of Toronto in Ontario.

“With rare exception,” he noted, “NAFLD is associated with excess body fat. In combination with diet, exercise increases loss of weight and excess body fat. As body weight decreases, glucose tolerance improves and, hence, NAFLD would be expected to be improved as well.”

Dr. Pencharz emphasized family involvement as the primary factor for changing behaviors, because “If the family won't buy in, you cannot change the lifestyle.”

In addition to diet and exercise, indirect approaches to weight control may be useful. Two drugs are available for children, although they have only been evaluated in adolescents. They are orlistat, the pancreatic lipase inhibitor; and sibutramine, which alters appetite control by inhibiting uptake of 5-hydroxytryptamine (serotonin) and norepinephrine.

Gastric reduction also is beginning to be evaluated in adolescents. This surgical approach may be beneficial in certain patients; compliance is crucial, particularly in the few months after surgery.

ATLANTA — Obese children are at risk for developing nonalcoholic fatty liver disease and nonalcoholic steatohepatitis, which can lead to fibrosis and cirrhosis, speakers said at a meeting sponsored by the American Association for the Study of Liver Diseases.

A significant number of children are probably affected by nonalcoholic fatty liver disease (NAFLD), according to Dr. Jeffrey B. Schwimmer, a pediatrician at the University of California, San Diego. Various studies have indicated that between 10% and 77% of obese children in China, Italy, Japan, and the United States have NAFLD. An estimated 5%–10% of those children have advanced fibrosis at the time of diagnosis. Demographic factors influence prevalence: boys and Hispanic children are more likely to have NAFLD than are girls and black children.

The first detectable sign of NAFLD is often an elevated serum alanine aminotransferase level. However, diagnosis can be challenging, because children often are asymptomatic, but may have NAFLD and even nonalcoholic steatohepatitis (NASH), despite having normal alanine aminotransferase levels. No single blood test can indicate NAFLD; biopsy is the definitive diagnostic tool for both NAFLD and NASH.

Dr. Philip Rosenthal, professor of pediatrics at the University of California, San Francisco, emphasized the importance of a histologic examination for determining the extent of disease and for distinguishing between simple steatosis and steatohepatitis. Steatohepatitis and fibrosis are commonly observed in children with NASH who are undergoing biopsy, and cirrhosis with rapid progression has been observed.

Dr. Rosenthal also recommended that clinicians look for signs of portal hypertension, including gastrointestinal bleeding and ascites.

Treatments for pediatric NASH have not been evaluated in controlled trials with long follow-up periods. Current treatments primarily aim to reduce steatosis and associated disorders. Prevention and treatment of metabolic syndrome through diet and exercise, insulin-sensitizing agents, and lipid-lowering drugs are central treatment strategies. Metformin may be beneficial in these patients, as it appears to improve NASH in nondiabetic pediatric patients.

Treatment of Nonalcoholic Fatty Liver Disease (TONIC), a randomized, phase III trial sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases, will be evaluating metformin and vitamin E in children with NAFLD/NASH.

Reducing body weight also remains a primary goal in treating pediatric NAFLD, according to Dr. Paul B. Pencharz, professor of pediatrics at the University of Toronto in Ontario.

“With rare exception,” he noted, “NAFLD is associated with excess body fat. In combination with diet, exercise increases loss of weight and excess body fat. As body weight decreases, glucose tolerance improves and, hence, NAFLD would be expected to be improved as well.”

Dr. Pencharz emphasized family involvement as the primary factor for changing behaviors, because “If the family won't buy in, you cannot change the lifestyle.”

In addition to diet and exercise, indirect approaches to weight control may be useful. Two drugs are available for children, although they have only been evaluated in adolescents. They are orlistat, the pancreatic lipase inhibitor; and sibutramine, which alters appetite control by inhibiting uptake of 5-hydroxytryptamine (serotonin) and norepinephrine.

Gastric reduction also is beginning to be evaluated in adolescents. This surgical approach may be beneficial in certain patients; compliance is crucial, particularly in the few months after surgery.

ATLANTA — Obese children are at risk for developing nonalcoholic fatty liver disease and nonalcoholic steatohepatitis, which can lead to fibrosis and cirrhosis, speakers said at a meeting sponsored by the American Association for the Study of Liver Diseases.

A significant number of children are probably affected by nonalcoholic fatty liver disease (NAFLD), according to Dr. Jeffrey B. Schwimmer, a pediatrician at the University of California, San Diego. Various studies have indicated that between 10% and 77% of obese children in China, Italy, Japan, and the United States have NAFLD. An estimated 5%–10% of those children have advanced fibrosis at the time of diagnosis. Demographic factors influence prevalence: boys and Hispanic children are more likely to have NAFLD than are girls and black children.

The first detectable sign of NAFLD is often an elevated serum alanine aminotransferase level. However, diagnosis can be challenging, because children often are asymptomatic, but may have NAFLD and even nonalcoholic steatohepatitis (NASH), despite having normal alanine aminotransferase levels. No single blood test can indicate NAFLD; biopsy is the definitive diagnostic tool for both NAFLD and NASH.

Dr. Philip Rosenthal, professor of pediatrics at the University of California, San Francisco, emphasized the importance of a histologic examination for determining the extent of disease and for distinguishing between simple steatosis and steatohepatitis. Steatohepatitis and fibrosis are commonly observed in children with NASH who are undergoing biopsy, and cirrhosis with rapid progression has been observed.

Dr. Rosenthal also recommended that clinicians look for signs of portal hypertension, including gastrointestinal bleeding and ascites.

Treatments for pediatric NASH have not been evaluated in controlled trials with long follow-up periods. Current treatments primarily aim to reduce steatosis and associated disorders. Prevention and treatment of metabolic syndrome through diet and exercise, insulin-sensitizing agents, and lipid-lowering drugs are central treatment strategies. Metformin may be beneficial in these patients, as it appears to improve NASH in nondiabetic pediatric patients.

Treatment of Nonalcoholic Fatty Liver Disease (TONIC), a randomized, phase III trial sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases, will be evaluating metformin and vitamin E in children with NAFLD/NASH.

Reducing body weight also remains a primary goal in treating pediatric NAFLD, according to Dr. Paul B. Pencharz, professor of pediatrics at the University of Toronto in Ontario.

“With rare exception,” he noted, “NAFLD is associated with excess body fat. In combination with diet, exercise increases loss of weight and excess body fat. As body weight decreases, glucose tolerance improves and, hence, NAFLD would be expected to be improved as well.”

Dr. Pencharz emphasized family involvement as the primary factor for changing behaviors, because “If the family won't buy in, you cannot change the lifestyle.”

In addition to diet and exercise, indirect approaches to weight control may be useful. Two drugs are available for children, although they have only been evaluated in adolescents. They are orlistat, the pancreatic lipase inhibitor; and sibutramine, which alters appetite control by inhibiting uptake of 5-hydroxytryptamine (serotonin) and norepinephrine.

Gastric reduction also is beginning to be evaluated in adolescents. This surgical approach may be beneficial in certain patients; compliance is crucial, particularly in the few months after surgery.

ATLANTA — Automated external defibrillators can be a lifesaver in sudden cardiac arrest, the No. 1 cause of death in young athletes, but planning, preparation, and education are essential.

“The single most important determinant of survival is the time from cardiac arrest to defibrillation,” Dr. Jonathan A. Drezner said at a press conference held during a meeting of the National Athletic Trainers' Association.

Without CPR, survival decreases by 10% with every minute that passes without defibrillation, according to Dr. Drezner of the University of Washington in Seattle.

Between 40% and 70% of people with sudden cardiac arrest (SCA) survive if treated with CPR and an automated external defibrillator (AED). In contrast, survival rates after SCA in young athletes are much lower, around 10%–15%. Possible explanations for this discrepancy include a delayed recognition of SCA and delayed defibrillation; only 25%–50% of schools have an AED.

To improve these outcomes, an interassociation task force, cochaired by Dr. Drezner and Ron Courson, director of sports medicine at the University of Georgia, Athens, has developed formal guidelines to help schools and other organizations prepare for SCA and to manage it should it occur.

The guidelines suggest that all collapsed and unresponsive athletes should be treated as if they have SCA until they demonstrate otherwise. The collapsed person should receive CPR until the AED arrives, though this wait should be as short as possible. The first shock from an AED should be applied within 3–5 minutes of the collapse.

This rapid response requires that the AED is easily accessible from every venue; that individuals know where it is and can retrieve it quickly; and that someone is trained in using the device.

“Our recommendation, consistent with the American Heart Association, supports an AED program in any school where the time from activating the emergency response system to the delivery of a shock will be greater than 5 minutes,” Dr. Drezner said.

The guidelines state that all schools and institutions that sponsor athletic activities should have a written and structured emergency action plan specific to each venue. Components of the plan should include communication, personnel, equipment, and transportation to an emergency facility.

Education is another component of the plan; all first responders should be trained in AED and CPR.

It is important that EMS personnel, school officials, and first responders are involved in the development of the plan, and that, just as with fire drills, these procedures are practiced by the individuals who would be involved in an actual incident.

The first responder should resume chest compressions immediately after the first shock. The guidelines recommend repeat rhythm analysis after 2 minutes or five cycles of CPR until advanced life support arrives or until the person begins moving.

SCA is relatively uncommon in the United States, with incidence rates between 1:50,000 and 1:200,000. However, when a child dies from SCA the impact can be catastrophic, affecting not only the child's family, but the entire school and community.

Complete prevention is difficult because in many cases, occult heart disease goes undetected with no signs or symptoms until the SCA occurs. Preparticipation screening is not likely to detect hypertrophic cardiomyopathy, the abnormality usually associated with SCA.

Moreover, SCA also can occur after a blow to the chest above the heart (commotio cordis). Although proper equipment can minimize the chance of this developing, a small risk remains. Since 1998, 70 children aged 4–18 years have died from commotio cordis, according to a national registry.

ATLANTA — Automated external defibrillators can be a lifesaver in sudden cardiac arrest, the No. 1 cause of death in young athletes, but planning, preparation, and education are essential.

“The single most important determinant of survival is the time from cardiac arrest to defibrillation,” Dr. Jonathan A. Drezner said at a press conference held during a meeting of the National Athletic Trainers' Association.

Without CPR, survival decreases by 10% with every minute that passes without defibrillation, according to Dr. Drezner of the University of Washington in Seattle.

Between 40% and 70% of people with sudden cardiac arrest (SCA) survive if treated with CPR and an automated external defibrillator (AED). In contrast, survival rates after SCA in young athletes are much lower, around 10%–15%. Possible explanations for this discrepancy include a delayed recognition of SCA and delayed defibrillation; only 25%–50% of schools have an AED.

To improve these outcomes, an interassociation task force, cochaired by Dr. Drezner and Ron Courson, director of sports medicine at the University of Georgia, Athens, has developed formal guidelines to help schools and other organizations prepare for SCA and to manage it should it occur.

The guidelines suggest that all collapsed and unresponsive athletes should be treated as if they have SCA until they demonstrate otherwise. The collapsed person should receive CPR until the AED arrives, though this wait should be as short as possible. The first shock from an AED should be applied within 3–5 minutes of the collapse.

This rapid response requires that the AED is easily accessible from every venue; that individuals know where it is and can retrieve it quickly; and that someone is trained in using the device.

“Our recommendation, consistent with the American Heart Association, supports an AED program in any school where the time from activating the emergency response system to the delivery of a shock will be greater than 5 minutes,” Dr. Drezner said.

The guidelines state that all schools and institutions that sponsor athletic activities should have a written and structured emergency action plan specific to each venue. Components of the plan should include communication, personnel, equipment, and transportation to an emergency facility.

Education is another component of the plan; all first responders should be trained in AED and CPR.

It is important that EMS personnel, school officials, and first responders are involved in the development of the plan, and that, just as with fire drills, these procedures are practiced by the individuals who would be involved in an actual incident.

The first responder should resume chest compressions immediately after the first shock. The guidelines recommend repeat rhythm analysis after 2 minutes or five cycles of CPR until advanced life support arrives or until the person begins moving.

SCA is relatively uncommon in the United States, with incidence rates between 1:50,000 and 1:200,000. However, when a child dies from SCA the impact can be catastrophic, affecting not only the child's family, but the entire school and community.

Complete prevention is difficult because in many cases, occult heart disease goes undetected with no signs or symptoms until the SCA occurs. Preparticipation screening is not likely to detect hypertrophic cardiomyopathy, the abnormality usually associated with SCA.

Moreover, SCA also can occur after a blow to the chest above the heart (commotio cordis). Although proper equipment can minimize the chance of this developing, a small risk remains. Since 1998, 70 children aged 4–18 years have died from commotio cordis, according to a national registry.

ATLANTA — Automated external defibrillators can be a lifesaver in sudden cardiac arrest, the No. 1 cause of death in young athletes, but planning, preparation, and education are essential.

“The single most important determinant of survival is the time from cardiac arrest to defibrillation,” Dr. Jonathan A. Drezner said at a press conference held during a meeting of the National Athletic Trainers' Association.

Without CPR, survival decreases by 10% with every minute that passes without defibrillation, according to Dr. Drezner of the University of Washington in Seattle.

Between 40% and 70% of people with sudden cardiac arrest (SCA) survive if treated with CPR and an automated external defibrillator (AED). In contrast, survival rates after SCA in young athletes are much lower, around 10%–15%. Possible explanations for this discrepancy include a delayed recognition of SCA and delayed defibrillation; only 25%–50% of schools have an AED.

To improve these outcomes, an interassociation task force, cochaired by Dr. Drezner and Ron Courson, director of sports medicine at the University of Georgia, Athens, has developed formal guidelines to help schools and other organizations prepare for SCA and to manage it should it occur.

The guidelines suggest that all collapsed and unresponsive athletes should be treated as if they have SCA until they demonstrate otherwise. The collapsed person should receive CPR until the AED arrives, though this wait should be as short as possible. The first shock from an AED should be applied within 3–5 minutes of the collapse.

This rapid response requires that the AED is easily accessible from every venue; that individuals know where it is and can retrieve it quickly; and that someone is trained in using the device.

“Our recommendation, consistent with the American Heart Association, supports an AED program in any school where the time from activating the emergency response system to the delivery of a shock will be greater than 5 minutes,” Dr. Drezner said.

The guidelines state that all schools and institutions that sponsor athletic activities should have a written and structured emergency action plan specific to each venue. Components of the plan should include communication, personnel, equipment, and transportation to an emergency facility.

Education is another component of the plan; all first responders should be trained in AED and CPR.

It is important that EMS personnel, school officials, and first responders are involved in the development of the plan, and that, just as with fire drills, these procedures are practiced by the individuals who would be involved in an actual incident.

The first responder should resume chest compressions immediately after the first shock. The guidelines recommend repeat rhythm analysis after 2 minutes or five cycles of CPR until advanced life support arrives or until the person begins moving.

SCA is relatively uncommon in the United States, with incidence rates between 1:50,000 and 1:200,000. However, when a child dies from SCA the impact can be catastrophic, affecting not only the child's family, but the entire school and community.

Complete prevention is difficult because in many cases, occult heart disease goes undetected with no signs or symptoms until the SCA occurs. Preparticipation screening is not likely to detect hypertrophic cardiomyopathy, the abnormality usually associated with SCA.

Moreover, SCA also can occur after a blow to the chest above the heart (commotio cordis). Although proper equipment can minimize the chance of this developing, a small risk remains. Since 1998, 70 children aged 4–18 years have died from commotio cordis, according to a national registry.

ATLANTA — In postmenopausal women, an active lifestyle provided about a 10% reduction in the risk of developing breast cancer over a 17-year period in over 36,000 women, according to findings from a prospective cohort study presented at the annual meeting of the American Society of Clinical Oncology.

The protective effect of physical activity was most significant against the risk of developing the more aggressive estrogen receptor (ER)-positive, progesterone receptor (PR)-negative form of breast cancer, providing a 34% risk reduction, said Dr. Aditya Bardia, who was pursuing a degree at the University of Iowa, Iowa City, at the time of the study.

Dr. Bardia and colleagues from the Iowa Women's Health Study mailed questionnaires addressing leisure time physical activity and breast cancer risk factors to postmenopausal women living in Iowa in 1986; 41,837 women (43%) responded.

The participants' levels of physical activity were classified as low, medium, or high based on the frequency and intensity of their exercise.

The investigators determined cancer incidence between 1986 and 2003 using the Iowa Surveillance, Epidemiology, and End Results (SEER) Cancer Registry and mortality information from state and national resources. Periodic follow-up surveys confirmed continued residence in Iowa in greater than 99% of the women each year.

After exclusion of women with cancer, a full or partial mastectomy, and those with incomplete data, the cohort included 36,363 women. During the 17-year follow-up period, 2,548 women were diagnosed with breast cancer at an average age of 71 years.

Overall, 47% of women reported low physical activity, 28% reported medium physical activity, and 25% were highly active. In addition to having a lower body mass index (BMI), active women were more likely to have received education beyond high school and reached menopause at an older age.

A high level of physical activity was associated with a 13% reduction in the risk of developing ER-positive breast cancer and an 8% reduction in ER-negative breast cancer, compared with low physical activity. The risk reduction for PR-positive and PR-negative breast cancer was 5% and 27%, respectively.

After the 34% risk reduction for ER-positive/PR-negative breast cancer, the next greatest benefit was a 20% reduction in the risk of developing ER-negative/PR-negative cancer.

The risk of ER-negative/PR-positive breast cancer was increased by 42% with a high activity level, but Dr. Bardia said the confidence intervals were high on this association due to a small number of women in this group.

Modifiable risk factors such as obesity and a sedentary lifestyle may be contributing to the increasing incidence of breast cancer. However, previous prospective studies have yielded mixed results on the correlation between physical activity and breast cancer risk. Furthermore, such prospective cohort studies have until now evaluated only the link between physical activity and breast cancer risk as a whole. Associations between physical activity and certain types of breast cancer would not have been detected.

Dr. Bardia commented that future studies should investigate the association between physical activity and breast cancer incidence in premenopausal women.

Dr. Banu Arun, of the department of breast medical oncology at the M.D. Anderson Cancer Center, Houston, noted that future studies should evaluate other factors including the use of hormone therapy and genetic risks. “There may be many other differences in lifestyle between women who exercise and who do not which could be a confounding factor as well.”

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA — In postmenopausal women, an active lifestyle provided about a 10% reduction in the risk of developing breast cancer over a 17-year period in over 36,000 women, according to findings from a prospective cohort study presented at the annual meeting of the American Society of Clinical Oncology.

The protective effect of physical activity was most significant against the risk of developing the more aggressive estrogen receptor (ER)-positive, progesterone receptor (PR)-negative form of breast cancer, providing a 34% risk reduction, said Dr. Aditya Bardia, who was pursuing a degree at the University of Iowa, Iowa City, at the time of the study.

Dr. Bardia and colleagues from the Iowa Women's Health Study mailed questionnaires addressing leisure time physical activity and breast cancer risk factors to postmenopausal women living in Iowa in 1986; 41,837 women (43%) responded.

The participants' levels of physical activity were classified as low, medium, or high based on the frequency and intensity of their exercise.

The investigators determined cancer incidence between 1986 and 2003 using the Iowa Surveillance, Epidemiology, and End Results (SEER) Cancer Registry and mortality information from state and national resources. Periodic follow-up surveys confirmed continued residence in Iowa in greater than 99% of the women each year.

After exclusion of women with cancer, a full or partial mastectomy, and those with incomplete data, the cohort included 36,363 women. During the 17-year follow-up period, 2,548 women were diagnosed with breast cancer at an average age of 71 years.

Overall, 47% of women reported low physical activity, 28% reported medium physical activity, and 25% were highly active. In addition to having a lower body mass index (BMI), active women were more likely to have received education beyond high school and reached menopause at an older age.

A high level of physical activity was associated with a 13% reduction in the risk of developing ER-positive breast cancer and an 8% reduction in ER-negative breast cancer, compared with low physical activity. The risk reduction for PR-positive and PR-negative breast cancer was 5% and 27%, respectively.

After the 34% risk reduction for ER-positive/PR-negative breast cancer, the next greatest benefit was a 20% reduction in the risk of developing ER-negative/PR-negative cancer.

The risk of ER-negative/PR-positive breast cancer was increased by 42% with a high activity level, but Dr. Bardia said the confidence intervals were high on this association due to a small number of women in this group.

Modifiable risk factors such as obesity and a sedentary lifestyle may be contributing to the increasing incidence of breast cancer. However, previous prospective studies have yielded mixed results on the correlation between physical activity and breast cancer risk. Furthermore, such prospective cohort studies have until now evaluated only the link between physical activity and breast cancer risk as a whole. Associations between physical activity and certain types of breast cancer would not have been detected.

Dr. Bardia commented that future studies should investigate the association between physical activity and breast cancer incidence in premenopausal women.

Dr. Banu Arun, of the department of breast medical oncology at the M.D. Anderson Cancer Center, Houston, noted that future studies should evaluate other factors including the use of hormone therapy and genetic risks. “There may be many other differences in lifestyle between women who exercise and who do not which could be a confounding factor as well.”

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA — In postmenopausal women, an active lifestyle provided about a 10% reduction in the risk of developing breast cancer over a 17-year period in over 36,000 women, according to findings from a prospective cohort study presented at the annual meeting of the American Society of Clinical Oncology.

The protective effect of physical activity was most significant against the risk of developing the more aggressive estrogen receptor (ER)-positive, progesterone receptor (PR)-negative form of breast cancer, providing a 34% risk reduction, said Dr. Aditya Bardia, who was pursuing a degree at the University of Iowa, Iowa City, at the time of the study.

Dr. Bardia and colleagues from the Iowa Women's Health Study mailed questionnaires addressing leisure time physical activity and breast cancer risk factors to postmenopausal women living in Iowa in 1986; 41,837 women (43%) responded.

The participants' levels of physical activity were classified as low, medium, or high based on the frequency and intensity of their exercise.

The investigators determined cancer incidence between 1986 and 2003 using the Iowa Surveillance, Epidemiology, and End Results (SEER) Cancer Registry and mortality information from state and national resources. Periodic follow-up surveys confirmed continued residence in Iowa in greater than 99% of the women each year.

After exclusion of women with cancer, a full or partial mastectomy, and those with incomplete data, the cohort included 36,363 women. During the 17-year follow-up period, 2,548 women were diagnosed with breast cancer at an average age of 71 years.

Overall, 47% of women reported low physical activity, 28% reported medium physical activity, and 25% were highly active. In addition to having a lower body mass index (BMI), active women were more likely to have received education beyond high school and reached menopause at an older age.

A high level of physical activity was associated with a 13% reduction in the risk of developing ER-positive breast cancer and an 8% reduction in ER-negative breast cancer, compared with low physical activity. The risk reduction for PR-positive and PR-negative breast cancer was 5% and 27%, respectively.

After the 34% risk reduction for ER-positive/PR-negative breast cancer, the next greatest benefit was a 20% reduction in the risk of developing ER-negative/PR-negative cancer.

The risk of ER-negative/PR-positive breast cancer was increased by 42% with a high activity level, but Dr. Bardia said the confidence intervals were high on this association due to a small number of women in this group.

Modifiable risk factors such as obesity and a sedentary lifestyle may be contributing to the increasing incidence of breast cancer. However, previous prospective studies have yielded mixed results on the correlation between physical activity and breast cancer risk. Furthermore, such prospective cohort studies have until now evaluated only the link between physical activity and breast cancer risk as a whole. Associations between physical activity and certain types of breast cancer would not have been detected.

Dr. Bardia commented that future studies should investigate the association between physical activity and breast cancer incidence in premenopausal women.

Dr. Banu Arun, of the department of breast medical oncology at the M.D. Anderson Cancer Center, Houston, noted that future studies should evaluate other factors including the use of hormone therapy and genetic risks. “There may be many other differences in lifestyle between women who exercise and who do not which could be a confounding factor as well.”

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA —Transdermal testosterone was no better than placebo for improving libido in female cancer survivors after 4 weeks, according to results of a randomized, blinded, crossover study presented at the annual meeting of the American Society of Clinical Oncology.

In the 131 women who completed the study, both testosterone and placebo provided similar significant improvements in libido.

The North Central Cancer Treatment Group's N02C3 study randomized 150 women to 10 mg/day transdermal testosterone in Vanicream (Pharmaceutical Specialties, Inc.) or placebo (vehicle alone) for 4 weeks, followed by a crossover to the opposite treatment arm for 4 weeks.

All women were postmenopausal with no active disease, and all had reported decreased sexual desire. The investigators excluded women with comorbidities that might confound results. Women were an average of 52 years old; 31% were receiving aromatase inhibitors during the study, and 47% were receiving tamoxifen. Most women (72%) had at least one intact ovary, 80% had received prior chemotherapy, and only 7% had received pelvic radiotherapy.

Efficacy was measured using the Changes in Sexual Functioning Questionnaire (CSFQ) after each 4-week period. The average CSFQ score was 5.5 with testosterone and 4.4 with placebo after the first period and 8.8 and 8.1 after the second period.

“These results might seem very surprising, given the plethora of evidence that shows that transdermal testosterone is effective,” said study author Debra L. Barton, Ph.D., in her presentation. She suggested that the exclusion of women on supplemental estradiol in this trial and its relatively short duration might account for these differences. She also noted that previous studies had reported modest benefits with testosterone.

Low libido is a common issue in female cancer survivors. This clinical impression is validated by the speed with which the trial reached, and actually exceeded, its predicted accrual, according to Dr. Barton, of the Mayo Clinic College of Medicine, Rochester, Minn.

Testosterone treatment significantly increased the levels of free testosterone and bioavailable testosterone in the serum. A safety analysis of self-reported symptoms revealed no differences in side effects associated with virilization.

ATLANTA —Transdermal testosterone was no better than placebo for improving libido in female cancer survivors after 4 weeks, according to results of a randomized, blinded, crossover study presented at the annual meeting of the American Society of Clinical Oncology.

In the 131 women who completed the study, both testosterone and placebo provided similar significant improvements in libido.

The North Central Cancer Treatment Group's N02C3 study randomized 150 women to 10 mg/day transdermal testosterone in Vanicream (Pharmaceutical Specialties, Inc.) or placebo (vehicle alone) for 4 weeks, followed by a crossover to the opposite treatment arm for 4 weeks.

All women were postmenopausal with no active disease, and all had reported decreased sexual desire. The investigators excluded women with comorbidities that might confound results. Women were an average of 52 years old; 31% were receiving aromatase inhibitors during the study, and 47% were receiving tamoxifen. Most women (72%) had at least one intact ovary, 80% had received prior chemotherapy, and only 7% had received pelvic radiotherapy.

Efficacy was measured using the Changes in Sexual Functioning Questionnaire (CSFQ) after each 4-week period. The average CSFQ score was 5.5 with testosterone and 4.4 with placebo after the first period and 8.8 and 8.1 after the second period.

“These results might seem very surprising, given the plethora of evidence that shows that transdermal testosterone is effective,” said study author Debra L. Barton, Ph.D., in her presentation. She suggested that the exclusion of women on supplemental estradiol in this trial and its relatively short duration might account for these differences. She also noted that previous studies had reported modest benefits with testosterone.

Low libido is a common issue in female cancer survivors. This clinical impression is validated by the speed with which the trial reached, and actually exceeded, its predicted accrual, according to Dr. Barton, of the Mayo Clinic College of Medicine, Rochester, Minn.

Testosterone treatment significantly increased the levels of free testosterone and bioavailable testosterone in the serum. A safety analysis of self-reported symptoms revealed no differences in side effects associated with virilization.

ATLANTA —Transdermal testosterone was no better than placebo for improving libido in female cancer survivors after 4 weeks, according to results of a randomized, blinded, crossover study presented at the annual meeting of the American Society of Clinical Oncology.

In the 131 women who completed the study, both testosterone and placebo provided similar significant improvements in libido.

The North Central Cancer Treatment Group's N02C3 study randomized 150 women to 10 mg/day transdermal testosterone in Vanicream (Pharmaceutical Specialties, Inc.) or placebo (vehicle alone) for 4 weeks, followed by a crossover to the opposite treatment arm for 4 weeks.

All women were postmenopausal with no active disease, and all had reported decreased sexual desire. The investigators excluded women with comorbidities that might confound results. Women were an average of 52 years old; 31% were receiving aromatase inhibitors during the study, and 47% were receiving tamoxifen. Most women (72%) had at least one intact ovary, 80% had received prior chemotherapy, and only 7% had received pelvic radiotherapy.

Efficacy was measured using the Changes in Sexual Functioning Questionnaire (CSFQ) after each 4-week period. The average CSFQ score was 5.5 with testosterone and 4.4 with placebo after the first period and 8.8 and 8.1 after the second period.

“These results might seem very surprising, given the plethora of evidence that shows that transdermal testosterone is effective,” said study author Debra L. Barton, Ph.D., in her presentation. She suggested that the exclusion of women on supplemental estradiol in this trial and its relatively short duration might account for these differences. She also noted that previous studies had reported modest benefits with testosterone.

Low libido is a common issue in female cancer survivors. This clinical impression is validated by the speed with which the trial reached, and actually exceeded, its predicted accrual, according to Dr. Barton, of the Mayo Clinic College of Medicine, Rochester, Minn.

Testosterone treatment significantly increased the levels of free testosterone and bioavailable testosterone in the serum. A safety analysis of self-reported symptoms revealed no differences in side effects associated with virilization.

ATLANTA — Salpingo-oophorectomy appears to significantly reduce the incidence of gynecologic cancers in all women with BRCA mutations and the incidence of breast cancer in women with BRCA2 mutations.

This conclusion is based on the results of a multicenter, prospective study presented at the annual meeting of the American Society of Clinical Oncology.

After about 3 years of follow-up, the 546 women who elected to receive risk-reducing salpingo-oophorectomy had a 90% reduction in gynecologic cancers and a 47% reduction in breast cancer incidence compared with the 325 women who chose not receive surgery. However, the risk reduction in breast cancer was limited to women with BRCA2 mutations.

“BRCA1 and BRCA2 cause related but distinct cancer susceptibility syndromes,” explained Dr. Noah D. Kauff in his presentation. He therefore thought it was important to examine the benefit of risk-reducing salpingo-oophorectomy in each population.

In all, 597 women with breast tissue at risk at the start of follow-up were included in the breast cancer risk analysis. Among women carrying the BRCA1 mutation, 15 of 190 patients treated with risk-reducing salpingo-oophorectomy developed breast cancer, compared with 19 of 178 patients not treated with surgery, a 39% risk reduction that was not statistically significant.

Among BRCA2 carriers, the incidence with surgery vs. surveillance was 4 of 113 patients and 9 of 116 patients, respectively, resulting in a significant 72% reduction in cancer risk.

The study, led by Dr. Kauff, of the Memorial Sloan-Kettering Cancer Center in New York, evaluated two prospective cohorts of women carrying a BRCA mutation. Compared with women who chose not to receive risk-reducing salpingo-oophorectomy, those treated with surgery were significantly older (mean age, 47 vs. 43 years), were more likely to have had breast cancer in the past (59% vs. 46%), were more likely to have taken hormone therapy (11% vs. 7%), and were significantly more likely to have given birth (83% vs. 74%).

An exploratory analysis showed an overall 78% risk reduction in estrogen receptor-positive cancer, compared with no significant change in the incidence of ER-negative breast cancer.

“Since most breast cancers related to BRCA1 mutations are ER-negative, it could be postulated that hormonal manipulation—in this case, risk-reducing salpingo-oophorectomy—might not be effective in this population,” said Dr. Banu Arun in her discussion of the study.

Dr. Arun, of the department of breast medical oncology at the University of Texas M.D. Anderson Cancer Center, Houston, suggested that future prospective studies should evaluate risk-reducing salpingo-oophorectomy plus a nonhormonal preventive agent, such as cyclooxygenase-2 inhibitors, retinoids, statins, or other agents, for women with BRCA1 mutations.

ATLANTA — Salpingo-oophorectomy appears to significantly reduce the incidence of gynecologic cancers in all women with BRCA mutations and the incidence of breast cancer in women with BRCA2 mutations.

This conclusion is based on the results of a multicenter, prospective study presented at the annual meeting of the American Society of Clinical Oncology.

After about 3 years of follow-up, the 546 women who elected to receive risk-reducing salpingo-oophorectomy had a 90% reduction in gynecologic cancers and a 47% reduction in breast cancer incidence compared with the 325 women who chose not receive surgery. However, the risk reduction in breast cancer was limited to women with BRCA2 mutations.

“BRCA1 and BRCA2 cause related but distinct cancer susceptibility syndromes,” explained Dr. Noah D. Kauff in his presentation. He therefore thought it was important to examine the benefit of risk-reducing salpingo-oophorectomy in each population.

In all, 597 women with breast tissue at risk at the start of follow-up were included in the breast cancer risk analysis. Among women carrying the BRCA1 mutation, 15 of 190 patients treated with risk-reducing salpingo-oophorectomy developed breast cancer, compared with 19 of 178 patients not treated with surgery, a 39% risk reduction that was not statistically significant.

Among BRCA2 carriers, the incidence with surgery vs. surveillance was 4 of 113 patients and 9 of 116 patients, respectively, resulting in a significant 72% reduction in cancer risk.

The study, led by Dr. Kauff, of the Memorial Sloan-Kettering Cancer Center in New York, evaluated two prospective cohorts of women carrying a BRCA mutation. Compared with women who chose not to receive risk-reducing salpingo-oophorectomy, those treated with surgery were significantly older (mean age, 47 vs. 43 years), were more likely to have had breast cancer in the past (59% vs. 46%), were more likely to have taken hormone therapy (11% vs. 7%), and were significantly more likely to have given birth (83% vs. 74%).

An exploratory analysis showed an overall 78% risk reduction in estrogen receptor-positive cancer, compared with no significant change in the incidence of ER-negative breast cancer.

“Since most breast cancers related to BRCA1 mutations are ER-negative, it could be postulated that hormonal manipulation—in this case, risk-reducing salpingo-oophorectomy—might not be effective in this population,” said Dr. Banu Arun in her discussion of the study.

Dr. Arun, of the department of breast medical oncology at the University of Texas M.D. Anderson Cancer Center, Houston, suggested that future prospective studies should evaluate risk-reducing salpingo-oophorectomy plus a nonhormonal preventive agent, such as cyclooxygenase-2 inhibitors, retinoids, statins, or other agents, for women with BRCA1 mutations.

ATLANTA — Salpingo-oophorectomy appears to significantly reduce the incidence of gynecologic cancers in all women with BRCA mutations and the incidence of breast cancer in women with BRCA2 mutations.

This conclusion is based on the results of a multicenter, prospective study presented at the annual meeting of the American Society of Clinical Oncology.

After about 3 years of follow-up, the 546 women who elected to receive risk-reducing salpingo-oophorectomy had a 90% reduction in gynecologic cancers and a 47% reduction in breast cancer incidence compared with the 325 women who chose not receive surgery. However, the risk reduction in breast cancer was limited to women with BRCA2 mutations.

“BRCA1 and BRCA2 cause related but distinct cancer susceptibility syndromes,” explained Dr. Noah D. Kauff in his presentation. He therefore thought it was important to examine the benefit of risk-reducing salpingo-oophorectomy in each population.

In all, 597 women with breast tissue at risk at the start of follow-up were included in the breast cancer risk analysis. Among women carrying the BRCA1 mutation, 15 of 190 patients treated with risk-reducing salpingo-oophorectomy developed breast cancer, compared with 19 of 178 patients not treated with surgery, a 39% risk reduction that was not statistically significant.

Among BRCA2 carriers, the incidence with surgery vs. surveillance was 4 of 113 patients and 9 of 116 patients, respectively, resulting in a significant 72% reduction in cancer risk.

The study, led by Dr. Kauff, of the Memorial Sloan-Kettering Cancer Center in New York, evaluated two prospective cohorts of women carrying a BRCA mutation. Compared with women who chose not to receive risk-reducing salpingo-oophorectomy, those treated with surgery were significantly older (mean age, 47 vs. 43 years), were more likely to have had breast cancer in the past (59% vs. 46%), were more likely to have taken hormone therapy (11% vs. 7%), and were significantly more likely to have given birth (83% vs. 74%).

An exploratory analysis showed an overall 78% risk reduction in estrogen receptor-positive cancer, compared with no significant change in the incidence of ER-negative breast cancer.

“Since most breast cancers related to BRCA1 mutations are ER-negative, it could be postulated that hormonal manipulation—in this case, risk-reducing salpingo-oophorectomy—might not be effective in this population,” said Dr. Banu Arun in her discussion of the study.

Dr. Arun, of the department of breast medical oncology at the University of Texas M.D. Anderson Cancer Center, Houston, suggested that future prospective studies should evaluate risk-reducing salpingo-oophorectomy plus a nonhormonal preventive agent, such as cyclooxygenase-2 inhibitors, retinoids, statins, or other agents, for women with BRCA1 mutations.

ATLANTA — In postmenopausal women, an active lifestyle provided about a 10% reduction in the risk of developing breast cancer over a 17-year period in over 36,000 women, according to findings from a prospective cohort study presented at the annual meeting of the American Society of Clinical Oncology.

The protective effect of physical activity was most significant against the risk of developing the more aggressive estrogen receptor (ER)-positive, progesterone receptor (PR)-negative form of breast cancer, providing a 34% risk reduction, said Dr. Aditya Bardia, who was pursuing a degree at the University of Iowa, Iowa City, at the time of the study.

Dr. Bardia and colleagues from the Iowa Women's Health Study mailed questionnaires addressing leisure time physical activity and breast cancer risk factors to postmenopausal women living in Iowa in 1986; 41,837 women (43%) responded.

The participants' levels of physical activity were classified as low, medium, or high based on the frequency and intensity of their exercise.

The investigators determined cancer incidence between 1986 and 2003 using the Iowa Surveillance, Epidemiology, and End Results (SEER) Cancer Registry and mortality information from state and national resources. Periodic follow-up surveys confirmed continued residence in Iowa in greater than 99% of the women each year.

After excluding women with cancer, a full or partial mastectomy, and those with incomplete data, the cohort included 36,363 women. During the 17-year follow-up period, 2,548 women were diagnosed with breast cancer at an average age of 71 years.

Overall, 47% of women reported low physical activity, 28% reported medium physical activity, and 25% were highly active. In addition to having a lower body mass index (BMI), active women were more likely to have received education beyond high school and reached menopause at an older age.

A high level of physical activity was associated with a 13% reduction in the risk of developing ER-positive breast cancer and an 8% reduction in ER-negative breast cancer, compared with low physical activity. The risk reduction for PR-positive and PR-negative breast cancer was 5% and 27%, respectively. After the 34% risk reduction for ER-positive/PR-negative breast cancer, the next greatest benefit was a 20% risk reduction in developing ER-negative/PR-negative cancer.

Previous prospective studies have yielded mixed results on the correlation between physical activity and breast cancer risk. Furthermore, such prospective cohort studies have until now evaluated only the link between physical activity and breast cancer risk as a whole. Associations between physical activity and certain types of breast cancer would not have been detected.

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA — In postmenopausal women, an active lifestyle provided about a 10% reduction in the risk of developing breast cancer over a 17-year period in over 36,000 women, according to findings from a prospective cohort study presented at the annual meeting of the American Society of Clinical Oncology.

The protective effect of physical activity was most significant against the risk of developing the more aggressive estrogen receptor (ER)-positive, progesterone receptor (PR)-negative form of breast cancer, providing a 34% risk reduction, said Dr. Aditya Bardia, who was pursuing a degree at the University of Iowa, Iowa City, at the time of the study.

Dr. Bardia and colleagues from the Iowa Women's Health Study mailed questionnaires addressing leisure time physical activity and breast cancer risk factors to postmenopausal women living in Iowa in 1986; 41,837 women (43%) responded.

The participants' levels of physical activity were classified as low, medium, or high based on the frequency and intensity of their exercise.

The investigators determined cancer incidence between 1986 and 2003 using the Iowa Surveillance, Epidemiology, and End Results (SEER) Cancer Registry and mortality information from state and national resources. Periodic follow-up surveys confirmed continued residence in Iowa in greater than 99% of the women each year.

After excluding women with cancer, a full or partial mastectomy, and those with incomplete data, the cohort included 36,363 women. During the 17-year follow-up period, 2,548 women were diagnosed with breast cancer at an average age of 71 years.

Overall, 47% of women reported low physical activity, 28% reported medium physical activity, and 25% were highly active. In addition to having a lower body mass index (BMI), active women were more likely to have received education beyond high school and reached menopause at an older age.

A high level of physical activity was associated with a 13% reduction in the risk of developing ER-positive breast cancer and an 8% reduction in ER-negative breast cancer, compared with low physical activity. The risk reduction for PR-positive and PR-negative breast cancer was 5% and 27%, respectively. After the 34% risk reduction for ER-positive/PR-negative breast cancer, the next greatest benefit was a 20% risk reduction in developing ER-negative/PR-negative cancer.

Previous prospective studies have yielded mixed results on the correlation between physical activity and breast cancer risk. Furthermore, such prospective cohort studies have until now evaluated only the link between physical activity and breast cancer risk as a whole. Associations between physical activity and certain types of breast cancer would not have been detected.

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA — In postmenopausal women, an active lifestyle provided about a 10% reduction in the risk of developing breast cancer over a 17-year period in over 36,000 women, according to findings from a prospective cohort study presented at the annual meeting of the American Society of Clinical Oncology.

The protective effect of physical activity was most significant against the risk of developing the more aggressive estrogen receptor (ER)-positive, progesterone receptor (PR)-negative form of breast cancer, providing a 34% risk reduction, said Dr. Aditya Bardia, who was pursuing a degree at the University of Iowa, Iowa City, at the time of the study.

Dr. Bardia and colleagues from the Iowa Women's Health Study mailed questionnaires addressing leisure time physical activity and breast cancer risk factors to postmenopausal women living in Iowa in 1986; 41,837 women (43%) responded.

The participants' levels of physical activity were classified as low, medium, or high based on the frequency and intensity of their exercise.

The investigators determined cancer incidence between 1986 and 2003 using the Iowa Surveillance, Epidemiology, and End Results (SEER) Cancer Registry and mortality information from state and national resources. Periodic follow-up surveys confirmed continued residence in Iowa in greater than 99% of the women each year.

After excluding women with cancer, a full or partial mastectomy, and those with incomplete data, the cohort included 36,363 women. During the 17-year follow-up period, 2,548 women were diagnosed with breast cancer at an average age of 71 years.

Overall, 47% of women reported low physical activity, 28% reported medium physical activity, and 25% were highly active. In addition to having a lower body mass index (BMI), active women were more likely to have received education beyond high school and reached menopause at an older age.

A high level of physical activity was associated with a 13% reduction in the risk of developing ER-positive breast cancer and an 8% reduction in ER-negative breast cancer, compared with low physical activity. The risk reduction for PR-positive and PR-negative breast cancer was 5% and 27%, respectively. After the 34% risk reduction for ER-positive/PR-negative breast cancer, the next greatest benefit was a 20% risk reduction in developing ER-negative/PR-negative cancer.

Previous prospective studies have yielded mixed results on the correlation between physical activity and breast cancer risk. Furthermore, such prospective cohort studies have until now evaluated only the link between physical activity and breast cancer risk as a whole. Associations between physical activity and certain types of breast cancer would not have been detected.

ELSEVIER GLOBAL MEDICAL NEWS

All rheumatologists should aim to incorporate ultrasonography into their daily practice, according to the European League Against Rheumatism's Working Party on Imaging in Rheumatology.

Ultrasound provides a convenient, quick method of confirming diagnostic suspicions. “If you have a patient with hip pain that you think may have arthritis, if you put the ultrasound machine on the patient, you will see the arthritis immediately,” said Dr. Nanno Swen, a rheumatologist at the Medical Center Alkmaar (the Netherlands) and a member of the ultrasonography working party.

Experts in ultrasonography discussed the practical applications of sonography and reviewed its advantages and challenges at the annual European Congress of Rheumatology in Amsterdam.

One challenge lies in standardizing the interpretation of ultrasonographic images. Interoperator variability exists even among experts, said Dr. Wolfgang A. Schmidt, also a member of the working party.

In his studies of ultrasonography experts, Dr. Schmidt of the Medical Center for Rheumatology in Berlin-Buch, Germany, found that interpretations were most variable at the feet and most consistent at the knee.

Dr. Swen noted, “I can assure you that if you do the same experiment on radiologists, you will have the same problem. … [A]ll of these imaging modalities have interobserver variability.”

Cardiologists and gynecologists do their own sonography, and rheumatologists need to learn the technique. The ultrasonography working party offers 3-day training courses once or twice each year for interested rheumatologists, said Dr. Swen.

Ultrasonography is less expensive than magnetic resonance imaging or bone scans, and it can be quite sensitive, according to Dr. Walter Grassi, chairman of the sonography working party and director of the department of rheumatology at the Università Politecnica delle Marche, Ancona, Italy.

All rheumatologists should aim to incorporate ultrasonography into their daily practice, according to the European League Against Rheumatism's Working Party on Imaging in Rheumatology.

Ultrasound provides a convenient, quick method of confirming diagnostic suspicions. “If you have a patient with hip pain that you think may have arthritis, if you put the ultrasound machine on the patient, you will see the arthritis immediately,” said Dr. Nanno Swen, a rheumatologist at the Medical Center Alkmaar (the Netherlands) and a member of the ultrasonography working party.

Experts in ultrasonography discussed the practical applications of sonography and reviewed its advantages and challenges at the annual European Congress of Rheumatology in Amsterdam.

One challenge lies in standardizing the interpretation of ultrasonographic images. Interoperator variability exists even among experts, said Dr. Wolfgang A. Schmidt, also a member of the working party.

In his studies of ultrasonography experts, Dr. Schmidt of the Medical Center for Rheumatology in Berlin-Buch, Germany, found that interpretations were most variable at the feet and most consistent at the knee.

Dr. Swen noted, “I can assure you that if you do the same experiment on radiologists, you will have the same problem. … [A]ll of these imaging modalities have interobserver variability.”

Cardiologists and gynecologists do their own sonography, and rheumatologists need to learn the technique. The ultrasonography working party offers 3-day training courses once or twice each year for interested rheumatologists, said Dr. Swen.

Ultrasonography is less expensive than magnetic resonance imaging or bone scans, and it can be quite sensitive, according to Dr. Walter Grassi, chairman of the sonography working party and director of the department of rheumatology at the Università Politecnica delle Marche, Ancona, Italy.

All rheumatologists should aim to incorporate ultrasonography into their daily practice, according to the European League Against Rheumatism's Working Party on Imaging in Rheumatology.

Ultrasound provides a convenient, quick method of confirming diagnostic suspicions. “If you have a patient with hip pain that you think may have arthritis, if you put the ultrasound machine on the patient, you will see the arthritis immediately,” said Dr. Nanno Swen, a rheumatologist at the Medical Center Alkmaar (the Netherlands) and a member of the ultrasonography working party.

Experts in ultrasonography discussed the practical applications of sonography and reviewed its advantages and challenges at the annual European Congress of Rheumatology in Amsterdam.

One challenge lies in standardizing the interpretation of ultrasonographic images. Interoperator variability exists even among experts, said Dr. Wolfgang A. Schmidt, also a member of the working party.

In his studies of ultrasonography experts, Dr. Schmidt of the Medical Center for Rheumatology in Berlin-Buch, Germany, found that interpretations were most variable at the feet and most consistent at the knee.

Dr. Swen noted, “I can assure you that if you do the same experiment on radiologists, you will have the same problem. … [A]ll of these imaging modalities have interobserver variability.”

Cardiologists and gynecologists do their own sonography, and rheumatologists need to learn the technique. The ultrasonography working party offers 3-day training courses once or twice each year for interested rheumatologists, said Dr. Swen.

Ultrasonography is less expensive than magnetic resonance imaging or bone scans, and it can be quite sensitive, according to Dr. Walter Grassi, chairman of the sonography working party and director of the department of rheumatology at the Università Politecnica delle Marche, Ancona, Italy.

Childhood Arthritis Means More Breaks

Patients with childhood-onset arthritis are at an increased risk of suffering broken bones during adolescence and after age 45 years, according to a broad analysis of patient records in the United Kingdom.

Between the ages of 10 and 15 years, patients with juvenile idiopathic arthritis were more than three times as likely as control patients to suffer a fracture (Ann. Rheum. Dis. 2006 April 20 [doi:10.1136/ard.2005.048835]).

From ages 15 to 20 years, those patients were 75% more likely to suffer a fracture, and after age 45 years, patients with a history of childhood arthritis were nearly four times as likely as control patients to suffer a fracture, as bone mass begins declining.

The researchers, from the Children's Hospital of Philadelphia and the University of Pennsylvania, examined records from the United Kingdom General Practice Research Database, containing 8.9 million anonymous patient records with data covering 35 million patient-years.

They analyzed the records of 1,939 patients with juvenile idiopathic arthritis and 207,072 sex- and age-matched controls in the same physician practices.

Patients with arthritis were followed either from first diagnosis or from the first point their records met quality-control standards.

Control patients were followed from their registration with the practice or from the first point their records were compliant with quality-control standards.

The patients were then followed until their first fracture, their records were no longer compliant with quality-control standards, the patient left the practice, or death. The median follow-up period was 3.9 years for patients in the arthritis group and 3.95 years for those in the control group.

“Aggressive control of the underlying disease is undoubtedly necessary,” said Dr. Jon M. Burnham, of the Children's Hospital of Philadelphia's division of rheumatology, and the lead author.

“The question is whether it will be sufficient to prevent low bone mass and fractures in children with arthritis.”

Physicians need to be sure children are receiving the recommended amount of calcium and vitamin D, said Dr. Burnham. “There is accumulating evidence that vitamin D insufficiency is extremely common, and it would be reasonable to follow 25-hydroxyvitamin D levels in children with arthritis and prescribe supplements if vitamin D levels are suboptimal.”

Reducing Tension Neck Begins Early

Good flexibility in boys and high endurance strength in girls are associated with a reduced risk of tension neck in adulthood, results of a 25-year study indicate.

High endurance strength in boys, however, nearly doubled the risk of future knee injuries, according to the study.

To evaluate the impact of physical fitness on incidence of musculoskeletal problems in adulthood, Lasse O. Mikkelsson of the Pajulahti Sports Centre in Nastola, Finland, and associates assessed flexibility, endurance strength, and physical activity in 1,687 Finnish adolescents in 1976.

Twenty-five years later, 522 male and 611 female participants completed follow-up questionnaires (Br. J. Sports Med. 2006;40:107–13). Tension neck—a pain syndrome related to tightened neck musculature—in adulthood was 50% less likely in men who ranked in the highest flexibility tertile as adolescents (measured by a sit-and-reach test), compared with men in the lowest tertile.

In women, flexibility during adolescence was not significantly predictive of tension neck across the tertiles.

However, high endurance strength during their adolescence, measured by a sit-up test, was significantly associated with a 34% reduced risk of future tension neck in women. The investigators also noted that in adults “the risk of tension neck increased with each unit increase in [body mass index] by 9% in men and 5% in women.”

For men, regular physical activity during adolescence reduced the likelihood of future recurrent low back pain by 40%. Physical activity during adolescence was not, however, predictive of knee injury, tension neck, or recurrent low back pain in women.

Knee injuries were twice as common among men with high endurance strength as adolescents, compared with those with low endurance strength. A similar trend was noted in women, but the association was not statistically significant.

Regardless of fitness characteristics, the investigators observed gender differences in the incidence of tension neck, back pain, and knee injuries. Women were 2.5 times more likely than were men to experience tension neck (37% vs. 15%), whereas men were 1.5 times more likely than were women to have recurrent low back pain (23% vs. 15%) and twice as likely to have meniscal or ligamentous knee injury (14% vs. 7%).

Childhood Arthritis Means More Breaks

Patients with childhood-onset arthritis are at an increased risk of suffering broken bones during adolescence and after age 45 years, according to a broad analysis of patient records in the United Kingdom.

Between the ages of 10 and 15 years, patients with juvenile idiopathic arthritis were more than three times as likely as control patients to suffer a fracture (Ann. Rheum. Dis. 2006 April 20 [doi:10.1136/ard.2005.048835]).

From ages 15 to 20 years, those patients were 75% more likely to suffer a fracture, and after age 45 years, patients with a history of childhood arthritis were nearly four times as likely as control patients to suffer a fracture, as bone mass begins declining.

The researchers, from the Children's Hospital of Philadelphia and the University of Pennsylvania, examined records from the United Kingdom General Practice Research Database, containing 8.9 million anonymous patient records with data covering 35 million patient-years.

They analyzed the records of 1,939 patients with juvenile idiopathic arthritis and 207,072 sex- and age-matched controls in the same physician practices.

Patients with arthritis were followed either from first diagnosis or from the first point their records met quality-control standards.

Control patients were followed from their registration with the practice or from the first point their records were compliant with quality-control standards.

The patients were then followed until their first fracture, their records were no longer compliant with quality-control standards, the patient left the practice, or death. The median follow-up period was 3.9 years for patients in the arthritis group and 3.95 years for those in the control group.

“Aggressive control of the underlying disease is undoubtedly necessary,” said Dr. Jon M. Burnham, of the Children's Hospital of Philadelphia's division of rheumatology, and the lead author.

“The question is whether it will be sufficient to prevent low bone mass and fractures in children with arthritis.”

Physicians need to be sure children are receiving the recommended amount of calcium and vitamin D, said Dr. Burnham. “There is accumulating evidence that vitamin D insufficiency is extremely common, and it would be reasonable to follow 25-hydroxyvitamin D levels in children with arthritis and prescribe supplements if vitamin D levels are suboptimal.”

Reducing Tension Neck Begins Early

Good flexibility in boys and high endurance strength in girls are associated with a reduced risk of tension neck in adulthood, results of a 25-year study indicate.

High endurance strength in boys, however, nearly doubled the risk of future knee injuries, according to the study.

To evaluate the impact of physical fitness on incidence of musculoskeletal problems in adulthood, Lasse O. Mikkelsson of the Pajulahti Sports Centre in Nastola, Finland, and associates assessed flexibility, endurance strength, and physical activity in 1,687 Finnish adolescents in 1976.

Twenty-five years later, 522 male and 611 female participants completed follow-up questionnaires (Br. J. Sports Med. 2006;40:107–13). Tension neck—a pain syndrome related to tightened neck musculature—in adulthood was 50% less likely in men who ranked in the highest flexibility tertile as adolescents (measured by a sit-and-reach test), compared with men in the lowest tertile.

In women, flexibility during adolescence was not significantly predictive of tension neck across the tertiles.

However, high endurance strength during their adolescence, measured by a sit-up test, was significantly associated with a 34% reduced risk of future tension neck in women. The investigators also noted that in adults “the risk of tension neck increased with each unit increase in [body mass index] by 9% in men and 5% in women.”

For men, regular physical activity during adolescence reduced the likelihood of future recurrent low back pain by 40%. Physical activity during adolescence was not, however, predictive of knee injury, tension neck, or recurrent low back pain in women.

Knee injuries were twice as common among men with high endurance strength as adolescents, compared with those with low endurance strength. A similar trend was noted in women, but the association was not statistically significant.

Regardless of fitness characteristics, the investigators observed gender differences in the incidence of tension neck, back pain, and knee injuries. Women were 2.5 times more likely than were men to experience tension neck (37% vs. 15%), whereas men were 1.5 times more likely than were women to have recurrent low back pain (23% vs. 15%) and twice as likely to have meniscal or ligamentous knee injury (14% vs. 7%).

Childhood Arthritis Means More Breaks

Patients with childhood-onset arthritis are at an increased risk of suffering broken bones during adolescence and after age 45 years, according to a broad analysis of patient records in the United Kingdom.

Between the ages of 10 and 15 years, patients with juvenile idiopathic arthritis were more than three times as likely as control patients to suffer a fracture (Ann. Rheum. Dis. 2006 April 20 [doi:10.1136/ard.2005.048835]).

From ages 15 to 20 years, those patients were 75% more likely to suffer a fracture, and after age 45 years, patients with a history of childhood arthritis were nearly four times as likely as control patients to suffer a fracture, as bone mass begins declining.

The researchers, from the Children's Hospital of Philadelphia and the University of Pennsylvania, examined records from the United Kingdom General Practice Research Database, containing 8.9 million anonymous patient records with data covering 35 million patient-years.

They analyzed the records of 1,939 patients with juvenile idiopathic arthritis and 207,072 sex- and age-matched controls in the same physician practices.

Patients with arthritis were followed either from first diagnosis or from the first point their records met quality-control standards.

Control patients were followed from their registration with the practice or from the first point their records were compliant with quality-control standards.

The patients were then followed until their first fracture, their records were no longer compliant with quality-control standards, the patient left the practice, or death. The median follow-up period was 3.9 years for patients in the arthritis group and 3.95 years for those in the control group.

“Aggressive control of the underlying disease is undoubtedly necessary,” said Dr. Jon M. Burnham, of the Children's Hospital of Philadelphia's division of rheumatology, and the lead author.

“The question is whether it will be sufficient to prevent low bone mass and fractures in children with arthritis.”

Physicians need to be sure children are receiving the recommended amount of calcium and vitamin D, said Dr. Burnham. “There is accumulating evidence that vitamin D insufficiency is extremely common, and it would be reasonable to follow 25-hydroxyvitamin D levels in children with arthritis and prescribe supplements if vitamin D levels are suboptimal.”

Reducing Tension Neck Begins Early

Good flexibility in boys and high endurance strength in girls are associated with a reduced risk of tension neck in adulthood, results of a 25-year study indicate.

High endurance strength in boys, however, nearly doubled the risk of future knee injuries, according to the study.

To evaluate the impact of physical fitness on incidence of musculoskeletal problems in adulthood, Lasse O. Mikkelsson of the Pajulahti Sports Centre in Nastola, Finland, and associates assessed flexibility, endurance strength, and physical activity in 1,687 Finnish adolescents in 1976.

Twenty-five years later, 522 male and 611 female participants completed follow-up questionnaires (Br. J. Sports Med. 2006;40:107–13). Tension neck—a pain syndrome related to tightened neck musculature—in adulthood was 50% less likely in men who ranked in the highest flexibility tertile as adolescents (measured by a sit-and-reach test), compared with men in the lowest tertile.

In women, flexibility during adolescence was not significantly predictive of tension neck across the tertiles.

However, high endurance strength during their adolescence, measured by a sit-up test, was significantly associated with a 34% reduced risk of future tension neck in women. The investigators also noted that in adults “the risk of tension neck increased with each unit increase in [body mass index] by 9% in men and 5% in women.”

For men, regular physical activity during adolescence reduced the likelihood of future recurrent low back pain by 40%. Physical activity during adolescence was not, however, predictive of knee injury, tension neck, or recurrent low back pain in women.

Knee injuries were twice as common among men with high endurance strength as adolescents, compared with those with low endurance strength. A similar trend was noted in women, but the association was not statistically significant.

Regardless of fitness characteristics, the investigators observed gender differences in the incidence of tension neck, back pain, and knee injuries. Women were 2.5 times more likely than were men to experience tension neck (37% vs. 15%), whereas men were 1.5 times more likely than were women to have recurrent low back pain (23% vs. 15%) and twice as likely to have meniscal or ligamentous knee injury (14% vs. 7%).

ATLANTA — A blood test can predict nonalcoholic steatohepatitis in patients with nonalcoholic fatty liver disease, according to results of a study presented at a meeting sponsored by the American Association for the Study of Liver Diseases.

Hepatocyte apoptosis is known to mediate liver injury in nonalcoholic fatty liver disease (NAFLD). The activation of caspases that mediate apoptosis can be measured in the plasma, thus allowing an indirect evaluation of liver damage.

Caspase activation was detected in the plasma using an enzyme-linked immunosorbent assay for cytokeratin-18 fragments, which are a byproduct of caspase activation. In the study, caspase activation was strongly associated with disease severity; a cutoff value of 395 U/L was 99.9% sensitive and 85.7% specific in predicting nonalcoholic steatohepatitis (NASH).

“A liver biopsy is the only reliable method to differentiate simple steatosis from NASH and stage disease severity,” noted study author Dr. Anna Wieckowska of the Cleveland Clinic. However, biopsy has inherent risks and is not practical to perform multiple times. Her group thus evaluated a caspase activity blood test in 44 consecutive patients with suspected NAFLD. They measured caspase activity in plasma samples obtained at liver biopsy and then correlated the blood test results with histopathologic features. Five patients were excluded due to a hemolyzed blood sample, two were excluded because they had borderline NASH, and two had alternative diagnoses, which left 39 evaluable patients.

Caspase activation was significantly elevated in patients with definitive NASH, with median cytokeratin-18 levels of 767 U/L, compared with 202 U/L in patients with simple steatosis. After adjustment for confounding variables, including AST/ALT ratio and body mass index, cytokeratin-18 levels were independently predictive of NASH, with a positive predictive value of 99.9% and a negative predictive value of 85.7%.

Dr. Keith D. Lindor of the Mayo Clinic in Rochester, Minn., noted that “a noninvasive way to accurately predict mild degrees of fibrosis would allow us to select patients for treatment trials.”

ATLANTA — A blood test can predict nonalcoholic steatohepatitis in patients with nonalcoholic fatty liver disease, according to results of a study presented at a meeting sponsored by the American Association for the Study of Liver Diseases.

Hepatocyte apoptosis is known to mediate liver injury in nonalcoholic fatty liver disease (NAFLD). The activation of caspases that mediate apoptosis can be measured in the plasma, thus allowing an indirect evaluation of liver damage.

Caspase activation was detected in the plasma using an enzyme-linked immunosorbent assay for cytokeratin-18 fragments, which are a byproduct of caspase activation. In the study, caspase activation was strongly associated with disease severity; a cutoff value of 395 U/L was 99.9% sensitive and 85.7% specific in predicting nonalcoholic steatohepatitis (NASH).

“A liver biopsy is the only reliable method to differentiate simple steatosis from NASH and stage disease severity,” noted study author Dr. Anna Wieckowska of the Cleveland Clinic. However, biopsy has inherent risks and is not practical to perform multiple times. Her group thus evaluated a caspase activity blood test in 44 consecutive patients with suspected NAFLD. They measured caspase activity in plasma samples obtained at liver biopsy and then correlated the blood test results with histopathologic features. Five patients were excluded due to a hemolyzed blood sample, two were excluded because they had borderline NASH, and two had alternative diagnoses, which left 39 evaluable patients.

Caspase activation was significantly elevated in patients with definitive NASH, with median cytokeratin-18 levels of 767 U/L, compared with 202 U/L in patients with simple steatosis. After adjustment for confounding variables, including AST/ALT ratio and body mass index, cytokeratin-18 levels were independently predictive of NASH, with a positive predictive value of 99.9% and a negative predictive value of 85.7%.

Dr. Keith D. Lindor of the Mayo Clinic in Rochester, Minn., noted that “a noninvasive way to accurately predict mild degrees of fibrosis would allow us to select patients for treatment trials.”

ATLANTA — A blood test can predict nonalcoholic steatohepatitis in patients with nonalcoholic fatty liver disease, according to results of a study presented at a meeting sponsored by the American Association for the Study of Liver Diseases.

Hepatocyte apoptosis is known to mediate liver injury in nonalcoholic fatty liver disease (NAFLD). The activation of caspases that mediate apoptosis can be measured in the plasma, thus allowing an indirect evaluation of liver damage.

Caspase activation was detected in the plasma using an enzyme-linked immunosorbent assay for cytokeratin-18 fragments, which are a byproduct of caspase activation. In the study, caspase activation was strongly associated with disease severity; a cutoff value of 395 U/L was 99.9% sensitive and 85.7% specific in predicting nonalcoholic steatohepatitis (NASH).

“A liver biopsy is the only reliable method to differentiate simple steatosis from NASH and stage disease severity,” noted study author Dr. Anna Wieckowska of the Cleveland Clinic. However, biopsy has inherent risks and is not practical to perform multiple times. Her group thus evaluated a caspase activity blood test in 44 consecutive patients with suspected NAFLD. They measured caspase activity in plasma samples obtained at liver biopsy and then correlated the blood test results with histopathologic features. Five patients were excluded due to a hemolyzed blood sample, two were excluded because they had borderline NASH, and two had alternative diagnoses, which left 39 evaluable patients.

Caspase activation was significantly elevated in patients with definitive NASH, with median cytokeratin-18 levels of 767 U/L, compared with 202 U/L in patients with simple steatosis. After adjustment for confounding variables, including AST/ALT ratio and body mass index, cytokeratin-18 levels were independently predictive of NASH, with a positive predictive value of 99.9% and a negative predictive value of 85.7%.

Dr. Keith D. Lindor of the Mayo Clinic in Rochester, Minn., noted that “a noninvasive way to accurately predict mild degrees of fibrosis would allow us to select patients for treatment trials.”

ATLANTA — Not one more life should be taken unnecessarily by asthma and lung disease, and not one more individual should go without the proper medical attention needed to gain control of his or her health, says pediatric pulmonologist LeRoy Graham.

Experts have grappled for years with the increased asthma morbidity and mortality in minorities, particularly in urban African Americans. Whereas many have suggested various guidelines and strategies to solve the problem, Dr. Graham took to the streets of Atlanta to address the issue head on.

First seeking out a venue through which he could connect with people, Dr. Graham and his colleagues identified African American churches as a viable community resource with which they could partner.

“Black churches have a validated reputation and place within the black community,” Dr. Graham explained. Providing health information and services within this environment can increase people's willingness not only to receive information, but to actively engage and participate in the health care process. When individuals see that their pastors are supportive of the program, they are significantly more likely to become involved.

This community-based combination of education and participation is the crux of the “Not One More Life” program, and the results of the approach thus far have been very encouraging.

Multifaceted Approach

A Not One More Life visit to a church begins with the initial contact, logistics, and setup arranged by the program director, Melvin Butler. A team of one or two physicians (usually a pulmonologist or allergist) and two or three respiratory therapists, in addition to asthma educators and other volunteers, then visits the church.

The program opens with a presentation on asthma and lung disease, with an emphasis on what attendees should expect from good health care—and, in particular, from good asthma control.

Participants then fill out a symptom-based questionnaire drawn from the Juniper model, undergo spirometry to assess lung function, and discuss with a physician the meaning of the results of the questionnaire and spirometry reading.

In contrast with a health fair, in which about half of attendees may allow themselves to undergo some type of testing, 82%–85% of participants at the Not One More Life sessions will submit to testing.

“We think that's because of the unique trust relationship that is fostered in this setting,” Dr. Graham explained. “We are invited in and endorsed by the churches, who participate by helping set up and encouraging people to participate.”

After undergoing testing, individuals with signs of asthma or other lung disease are then provided with a report to give to their primary care providers. Those without a primary care physician, or those requiring a specialist, are referred to a network of providers. Although most participants have some insurance coverage, pro bono care is available.

“We know we're capturing an important population, because 60% of the people who attend our sessions have either abnormal symptoms and/or abnormal lung function, while only 20% of them have self-reported asthma,” Dr. Graham said.

The program also has revealed a disconnect in some individuals between reported symptoms and lung function test results. Between 15% and 18% of participants report no symptoms, despite having measurable abnormal lung function. Through these sessions, individuals gain an understanding of what normal lung function should be.

During the last 3 years, more than 1,500 participants have attended more than 40 sessions, resulting in detection of abnormal lung function and/or symptoms in 1,200 people.

Although the program was originally intended for children, it has since expanded to encompass people at all stages of life, and has served participants from age 4 to 86 years. Dr. Graham said he has noticed a bimodal age distribution of participants, with peaks in childhood and at age 50–60 years.

Long-Term Follow-Up

Unlike other programs or health fairs that have only single encounters with people, Not One More Life has a nurse outcome manager who places serial follow-up phone calls at 1, 3, and 6 months after the sessions to find out whether participants have visited a physician and are receiving treatment. The outcome manager also readministers the questionnaire.

According to these follow-ups, 97% of individuals identified at the sessions as having abnormal lung function go on to visit a physician for further evaluation and treatment. This high success rate shows how effective a comprehensive community-based program can be, program leaders say.

“We've had some astounding success stories—people calling us up, saying, 'I didn't know I could feel this good!'” Dr. Graham added. In addition to asthma, Not One More Life screening has detected emphysema, sarcoidosis, chronic bronchitis, and pulmonary complications of HIV.

As the final, and most expensive, portion of the program, Not One More Life provides Internet-ready computers to small- and medium-sized churches. In Atlanta, only 30% of African American homes have Internet access, compared with 70% of white homes, Dr. Graham said.

By providing these computers, the program enables churches to set up a health kiosk where individuals can learn about different health topics. The program Web site,

www.notonemorelife.org

Funding the Mission

When Not One More Life was first proposed in mid-2000, Dr. Graham and associates lacked the funds necessary to put their concept into action. So they began to pursue funding through industry sponsors. They have since received financial support from pharmaceutical companies to carry out their mission.

Until recently, these funds were distributed through a fiduciary of the American Lung Association of Georgia. However, in December 2005, Not One More Life gained nonprofit 501(c)(3) status, which allowed the program to receive contributions directly. The organization has submitted several grant applications currently under consideration, and it has received a small number of individual contributions.

It is largely volunteer based, with all clinicians giving their time without compensation. Currently, the only paid individuals are the program coordinator, the nurse outcome manager, a grant writer, and a director of development.

Dr. Graham said he hopes to expand the reach of Not One More Life beyond asthma screening in African American churches in Atlanta. Not One More Life has visited other faith-based communities, such as mosques, Southern Baptist churches, and synagogues.

Outside Atlanta, Dr. Graham has made contact with interested persons in other major U.S. cities, and he hopes to be able to spread the concept to these other areas. For those interested in starting a community-based health education and screening program, Dr. Graham has provided some perspectives based on lessons learned over the 5-year history of Not One More Life. (See box.)

Michael Stader, RRT, is part of the respiratory team that conducts education and screening events at Atlanta churches for the Not One More Life program. Courtesy Rick Lockridge

Organizing a Health Education Program

▸ Learn about the community. Be willing to listen and learn from the community leaders rather than having a “missionary” approach. A transactional approach, in which there is a partnership with the community, is much more likely to succeed, Dr. Graham said. “People don't want to be saved—people want to be empowered,” he explained.

▸ Show respect for the community. In working with churches, realize that pastors know what works in their communities. The members of the church place their trust in pastors, and if the pastor trusts you, that trust of the people from the community will be carried over to you as well.

▸ Be flexible in your scheduling. Timing can be an important determinant of a session's success. It is important to identify when a session would be most beneficial. For churches, Saturday or Sunday after services often works, and can result in a spillover effect from other activities going on. In fact, some churches may have a luncheon or dinner in conjunction with the event.

▸ Engage the participants. Many participants say that they have never had a chance to sit down and talk with a doctor one on one. This individual attention can make a difference for many people.

▸ Address the whole needs of the people. In many cases, health care encompasses social and cultural issues as well. People may have a “crisis view” of health care, in which they only attend to their health when a problem arises. In these situations, it is important to explain the importance of preventive care.

ATLANTA — Not one more life should be taken unnecessarily by asthma and lung disease, and not one more individual should go without the proper medical attention needed to gain control of his or her health, says pediatric pulmonologist LeRoy Graham.

Experts have grappled for years with the increased asthma morbidity and mortality in minorities, particularly in urban African Americans. Whereas many have suggested various guidelines and strategies to solve the problem, Dr. Graham took to the streets of Atlanta to address the issue head on.

First seeking out a venue through which he could connect with people, Dr. Graham and his colleagues identified African American churches as a viable community resource with which they could partner.

“Black churches have a validated reputation and place within the black community,” Dr. Graham explained. Providing health information and services within this environment can increase people's willingness not only to receive information, but to actively engage and participate in the health care process. When individuals see that their pastors are supportive of the program, they are significantly more likely to become involved.

This community-based combination of education and participation is the crux of the “Not One More Life” program, and the results of the approach thus far have been very encouraging.

Multifaceted Approach

A Not One More Life visit to a church begins with the initial contact, logistics, and setup arranged by the program director, Melvin Butler. A team of one or two physicians (usually a pulmonologist or allergist) and two or three respiratory therapists, in addition to asthma educators and other volunteers, then visits the church.

The program opens with a presentation on asthma and lung disease, with an emphasis on what attendees should expect from good health care—and, in particular, from good asthma control.

Participants then fill out a symptom-based questionnaire drawn from the Juniper model, undergo spirometry to assess lung function, and discuss with a physician the meaning of the results of the questionnaire and spirometry reading.

In contrast with a health fair, in which about half of attendees may allow themselves to undergo some type of testing, 82%–85% of participants at the Not One More Life sessions will submit to testing.

“We think that's because of the unique trust relationship that is fostered in this setting,” Dr. Graham explained. “We are invited in and endorsed by the churches, who participate by helping set up and encouraging people to participate.”

After undergoing testing, individuals with signs of asthma or other lung disease are then provided with a report to give to their primary care providers. Those without a primary care physician, or those requiring a specialist, are referred to a network of providers. Although most participants have some insurance coverage, pro bono care is available.

“We know we're capturing an important population, because 60% of the people who attend our sessions have either abnormal symptoms and/or abnormal lung function, while only 20% of them have self-reported asthma,” Dr. Graham said.

The program also has revealed a disconnect in some individuals between reported symptoms and lung function test results. Between 15% and 18% of participants report no symptoms, despite having measurable abnormal lung function. Through these sessions, individuals gain an understanding of what normal lung function should be.

During the last 3 years, more than 1,500 participants have attended more than 40 sessions, resulting in detection of abnormal lung function and/or symptoms in 1,200 people.

Although the program was originally intended for children, it has since expanded to encompass people at all stages of life, and has served participants from age 4 to 86 years. Dr. Graham said he has noticed a bimodal age distribution of participants, with peaks in childhood and at age 50–60 years.

Long-Term Follow-Up

Unlike other programs or health fairs that have only single encounters with people, Not One More Life has a nurse outcome manager who places serial follow-up phone calls at 1, 3, and 6 months after the sessions to find out whether participants have visited a physician and are receiving treatment. The outcome manager also readministers the questionnaire.

According to these follow-ups, 97% of individuals identified at the sessions as having abnormal lung function go on to visit a physician for further evaluation and treatment. This high success rate shows how effective a comprehensive community-based program can be, program leaders say.

“We've had some astounding success stories—people calling us up, saying, 'I didn't know I could feel this good!'” Dr. Graham added. In addition to asthma, Not One More Life screening has detected emphysema, sarcoidosis, chronic bronchitis, and pulmonary complications of HIV.

As the final, and most expensive, portion of the program, Not One More Life provides Internet-ready computers to small- and medium-sized churches. In Atlanta, only 30% of African American homes have Internet access, compared with 70% of white homes, Dr. Graham said.

By providing these computers, the program enables churches to set up a health kiosk where individuals can learn about different health topics. The program Web site,

www.notonemorelife.org

Funding the Mission

When Not One More Life was first proposed in mid-2000, Dr. Graham and associates lacked the funds necessary to put their concept into action. So they began to pursue funding through industry sponsors. They have since received financial support from pharmaceutical companies to carry out their mission.

Until recently, these funds were distributed through a fiduciary of the American Lung Association of Georgia. However, in December 2005, Not One More Life gained nonprofit 501(c)(3) status, which allowed the program to receive contributions directly. The organization has submitted several grant applications currently under consideration, and it has received a small number of individual contributions.

It is largely volunteer based, with all clinicians giving their time without compensation. Currently, the only paid individuals are the program coordinator, the nurse outcome manager, a grant writer, and a director of development.

Dr. Graham said he hopes to expand the reach of Not One More Life beyond asthma screening in African American churches in Atlanta. Not One More Life has visited other faith-based communities, such as mosques, Southern Baptist churches, and synagogues.

Outside Atlanta, Dr. Graham has made contact with interested persons in other major U.S. cities, and he hopes to be able to spread the concept to these other areas. For those interested in starting a community-based health education and screening program, Dr. Graham has provided some perspectives based on lessons learned over the 5-year history of Not One More Life. (See box.)

Michael Stader, RRT, is part of the respiratory team that conducts education and screening events at Atlanta churches for the Not One More Life program. Courtesy Rick Lockridge

Organizing a Health Education Program

▸ Learn about the community. Be willing to listen and learn from the community leaders rather than having a “missionary” approach. A transactional approach, in which there is a partnership with the community, is much more likely to succeed, Dr. Graham said. “People don't want to be saved—people want to be empowered,” he explained.

▸ Show respect for the community. In working with churches, realize that pastors know what works in their communities. The members of the church place their trust in pastors, and if the pastor trusts you, that trust of the people from the community will be carried over to you as well.

▸ Be flexible in your scheduling. Timing can be an important determinant of a session's success. It is important to identify when a session would be most beneficial. For churches, Saturday or Sunday after services often works, and can result in a spillover effect from other activities going on. In fact, some churches may have a luncheon or dinner in conjunction with the event.

▸ Engage the participants. Many participants say that they have never had a chance to sit down and talk with a doctor one on one. This individual attention can make a difference for many people.

▸ Address the whole needs of the people. In many cases, health care encompasses social and cultural issues as well. People may have a “crisis view” of health care, in which they only attend to their health when a problem arises. In these situations, it is important to explain the importance of preventive care.

ATLANTA — Not one more life should be taken unnecessarily by asthma and lung disease, and not one more individual should go without the proper medical attention needed to gain control of his or her health, says pediatric pulmonologist LeRoy Graham.

Experts have grappled for years with the increased asthma morbidity and mortality in minorities, particularly in urban African Americans. Whereas many have suggested various guidelines and strategies to solve the problem, Dr. Graham took to the streets of Atlanta to address the issue head on.

First seeking out a venue through which he could connect with people, Dr. Graham and his colleagues identified African American churches as a viable community resource with which they could partner.

“Black churches have a validated reputation and place within the black community,” Dr. Graham explained. Providing health information and services within this environment can increase people's willingness not only to receive information, but to actively engage and participate in the health care process. When individuals see that their pastors are supportive of the program, they are significantly more likely to become involved.

This community-based combination of education and participation is the crux of the “Not One More Life” program, and the results of the approach thus far have been very encouraging.

Multifaceted Approach

A Not One More Life visit to a church begins with the initial contact, logistics, and setup arranged by the program director, Melvin Butler. A team of one or two physicians (usually a pulmonologist or allergist) and two or three respiratory therapists, in addition to asthma educators and other volunteers, then visits the church.

The program opens with a presentation on asthma and lung disease, with an emphasis on what attendees should expect from good health care—and, in particular, from good asthma control.

Participants then fill out a symptom-based questionnaire drawn from the Juniper model, undergo spirometry to assess lung function, and discuss with a physician the meaning of the results of the questionnaire and spirometry reading.

In contrast with a health fair, in which about half of attendees may allow themselves to undergo some type of testing, 82%–85% of participants at the Not One More Life sessions will submit to testing.

“We think that's because of the unique trust relationship that is fostered in this setting,” Dr. Graham explained. “We are invited in and endorsed by the churches, who participate by helping set up and encouraging people to participate.”

After undergoing testing, individuals with signs of asthma or other lung disease are then provided with a report to give to their primary care providers. Those without a primary care physician, or those requiring a specialist, are referred to a network of providers. Although most participants have some insurance coverage, pro bono care is available.

“We know we're capturing an important population, because 60% of the people who attend our sessions have either abnormal symptoms and/or abnormal lung function, while only 20% of them have self-reported asthma,” Dr. Graham said.

The program also has revealed a disconnect in some individuals between reported symptoms and lung function test results. Between 15% and 18% of participants report no symptoms, despite having measurable abnormal lung function. Through these sessions, individuals gain an understanding of what normal lung function should be.

During the last 3 years, more than 1,500 participants have attended more than 40 sessions, resulting in detection of abnormal lung function and/or symptoms in 1,200 people.

Although the program was originally intended for children, it has since expanded to encompass people at all stages of life, and has served participants from age 4 to 86 years. Dr. Graham said he has noticed a bimodal age distribution of participants, with peaks in childhood and at age 50–60 years.

Long-Term Follow-Up

Unlike other programs or health fairs that have only single encounters with people, Not One More Life has a nurse outcome manager who places serial follow-up phone calls at 1, 3, and 6 months after the sessions to find out whether participants have visited a physician and are receiving treatment. The outcome manager also readministers the questionnaire.

According to these follow-ups, 97% of individuals identified at the sessions as having abnormal lung function go on to visit a physician for further evaluation and treatment. This high success rate shows how effective a comprehensive community-based program can be, program leaders say.

“We've had some astounding success stories—people calling us up, saying, 'I didn't know I could feel this good!'” Dr. Graham added. In addition to asthma, Not One More Life screening has detected emphysema, sarcoidosis, chronic bronchitis, and pulmonary complications of HIV.

As the final, and most expensive, portion of the program, Not One More Life provides Internet-ready computers to small- and medium-sized churches. In Atlanta, only 30% of African American homes have Internet access, compared with 70% of white homes, Dr. Graham said.

By providing these computers, the program enables churches to set up a health kiosk where individuals can learn about different health topics. The program Web site,

www.notonemorelife.org

Funding the Mission

When Not One More Life was first proposed in mid-2000, Dr. Graham and associates lacked the funds necessary to put their concept into action. So they began to pursue funding through industry sponsors. They have since received financial support from pharmaceutical companies to carry out their mission.

Until recently, these funds were distributed through a fiduciary of the American Lung Association of Georgia. However, in December 2005, Not One More Life gained nonprofit 501(c)(3) status, which allowed the program to receive contributions directly. The organization has submitted several grant applications currently under consideration, and it has received a small number of individual contributions.

It is largely volunteer based, with all clinicians giving their time without compensation. Currently, the only paid individuals are the program coordinator, the nurse outcome manager, a grant writer, and a director of development.

Dr. Graham said he hopes to expand the reach of Not One More Life beyond asthma screening in African American churches in Atlanta. Not One More Life has visited other faith-based communities, such as mosques, Southern Baptist churches, and synagogues.

Outside Atlanta, Dr. Graham has made contact with interested persons in other major U.S. cities, and he hopes to be able to spread the concept to these other areas. For those interested in starting a community-based health education and screening program, Dr. Graham has provided some perspectives based on lessons learned over the 5-year history of Not One More Life. (See box.)

Michael Stader, RRT, is part of the respiratory team that conducts education and screening events at Atlanta churches for the Not One More Life program. Courtesy Rick Lockridge

Organizing a Health Education Program

▸ Learn about the community. Be willing to listen and learn from the community leaders rather than having a “missionary” approach. A transactional approach, in which there is a partnership with the community, is much more likely to succeed, Dr. Graham said. “People don't want to be saved—people want to be empowered,” he explained.

▸ Show respect for the community. In working with churches, realize that pastors know what works in their communities. The members of the church place their trust in pastors, and if the pastor trusts you, that trust of the people from the community will be carried over to you as well.

▸ Be flexible in your scheduling. Timing can be an important determinant of a session's success. It is important to identify when a session would be most beneficial. For churches, Saturday or Sunday after services often works, and can result in a spillover effect from other activities going on. In fact, some churches may have a luncheon or dinner in conjunction with the event.

▸ Engage the participants. Many participants say that they have never had a chance to sit down and talk with a doctor one on one. This individual attention can make a difference for many people.

▸ Address the whole needs of the people. In many cases, health care encompasses social and cultural issues as well. People may have a “crisis view” of health care, in which they only attend to their health when a problem arises. In these situations, it is important to explain the importance of preventive care.