Robert Finn

Stimulation of the P6 acupuncture point on the wrist significantly reduced the risk of postoperative nausea and vomiting, according to a new meta-analysis of 40 randomized, controlled trials involving 4,856 participants.

Compared with sham treatment, several forms of P6 stimulation reduced the risk of nausea by 29%, the risk of vomiting by 30%, and the need for rescue antiemetics by 31%, wrote Dr. Anna Lee and Dr. Lawrence T.Y. Fan for the Cochrane Collaboration (Cochrane Database Syst. Rev. 2009 [doi:10.1002/14651858.CD003281.pub3

Those relative risks were statistically significant. In direct comparisons with antiemetic drugs, P6 stimulation proved to be equally effective in reducing nausea, vomiting, and the need for rescue antiemetics.

The side effects of P6 stimulation were minor, whether the stimulation was performed with traditional acupuncture needles, electroacupuncture, laser acupuncture, transcutaneous electrical stimulation, an acustimulation device, acupressure, or capsicum plaster.

Acupuncture needles produced hematomas on rare occasions, and some patients reported pain, irritation, redness, fatigue, or sleepiness. Patients receiving acupressure with wrist bands occasionally complained of discomfort, red indentations, blisters, and swelling. One patient complained of mild irritation at the site of the capsicum plaster.

“Drugs only partially prevent postoperative nausea and vomiting, and they, of course, have a lot of adverse side effects,” said Dr. Geno J. Merli in an interview. Dr. Merli, chief medical officer of Thomas Jefferson University Hospital, Philadelphia, was not involved in the meta-analysis. Patients on antiemetic drugs can have changes in mental status and can develop confusion or disorientation. Some patients become stimulated by the antiemetic agent, while others can experience oculogyric crises, a very rare complication.

Dr. Merli was especially intrigued by the notion that wrist stimulation could be used prophylactically to prevent nausea and vomiting. Antiemetic medications are typically given as needed if postop patients develop symptoms.

Dr. Lee and Dr. Fan, both from the Chinese University of Hong Kong, acknowledged that publication bias is a frequent problem in randomized, controlled trials of traditional Chinese medicine. Negative studies are less likely to be published than are positive ones. But using a statistical technique called “contour enhanced funnel plots,” the investigators found no evidence of publication bias among the studies included in their meta-analysis.

“I was not a believer in acupuncture as a postoperative nausea and vomiting preventative,” Dr. Merli said. “I saw this review and said we should be doing this more often.”

However, hospitals would have to be convinced of the cost-effectiveness of P6 stimulation, Dr. Merli added. He noted that the acupressure wristbands available in drugstores cost about $10. Even if hospitals could get that cost down to $5, they would have to compare that to 5 cents or so for a dose of prochlorperazine. The real savings would come, Dr. Merli noted, if P6 stimulation reduced the average length of hospital stays.

Dr. Merli suggested that P6 stimulation might be reserved for patients for whom postop nausea and vomiting present a particular risk, such as those undergoing abdominal, thoracic, or brain surgery.

P6 stimulation “is a good option,” said Dr. Jessica Zuleta, an internal medicine hospitalist at the University of Miami. But it shouldn't completely replace antiemetics, she added, because the studies are limited. She called for more rigidly controlled, blinded studies comparing P6 stimulation and antiemetic drugs.

Dr. Lee and Dr. Fan said they had no relevant conflicts of interest. The study was supported by the U.S. National Center for Complementary and Alternative Medicine, the Chinese University of Hong Kong's department of anesthesia and intensive care, and the Cochrane Complementary Medicine Field Bursary.

EMILY BRANNAN/ILLUSTRATION

Stimulation of the P6 acupuncture point on the wrist significantly reduced the risk of postoperative nausea and vomiting, according to a new meta-analysis of 40 randomized, controlled trials involving 4,856 participants.

Compared with sham treatment, several forms of P6 stimulation reduced the risk of nausea by 29%, the risk of vomiting by 30%, and the need for rescue antiemetics by 31%, wrote Dr. Anna Lee and Dr. Lawrence T.Y. Fan for the Cochrane Collaboration (Cochrane Database Syst. Rev. 2009 [doi:10.1002/14651858.CD003281.pub3

Those relative risks were statistically significant. In direct comparisons with antiemetic drugs, P6 stimulation proved to be equally effective in reducing nausea, vomiting, and the need for rescue antiemetics.

The side effects of P6 stimulation were minor, whether the stimulation was performed with traditional acupuncture needles, electroacupuncture, laser acupuncture, transcutaneous electrical stimulation, an acustimulation device, acupressure, or capsicum plaster.

Acupuncture needles produced hematomas on rare occasions, and some patients reported pain, irritation, redness, fatigue, or sleepiness. Patients receiving acupressure with wrist bands occasionally complained of discomfort, red indentations, blisters, and swelling. One patient complained of mild irritation at the site of the capsicum plaster.

“Drugs only partially prevent postoperative nausea and vomiting, and they, of course, have a lot of adverse side effects,” said Dr. Geno J. Merli in an interview. Dr. Merli, chief medical officer of Thomas Jefferson University Hospital, Philadelphia, was not involved in the meta-analysis. Patients on antiemetic drugs can have changes in mental status and can develop confusion or disorientation. Some patients become stimulated by the antiemetic agent, while others can experience oculogyric crises, a very rare complication.

Dr. Merli was especially intrigued by the notion that wrist stimulation could be used prophylactically to prevent nausea and vomiting. Antiemetic medications are typically given as needed if postop patients develop symptoms.

Dr. Lee and Dr. Fan, both from the Chinese University of Hong Kong, acknowledged that publication bias is a frequent problem in randomized, controlled trials of traditional Chinese medicine. Negative studies are less likely to be published than are positive ones. But using a statistical technique called “contour enhanced funnel plots,” the investigators found no evidence of publication bias among the studies included in their meta-analysis.

“I was not a believer in acupuncture as a postoperative nausea and vomiting preventative,” Dr. Merli said. “I saw this review and said we should be doing this more often.”

However, hospitals would have to be convinced of the cost-effectiveness of P6 stimulation, Dr. Merli added. He noted that the acupressure wristbands available in drugstores cost about $10. Even if hospitals could get that cost down to $5, they would have to compare that to 5 cents or so for a dose of prochlorperazine. The real savings would come, Dr. Merli noted, if P6 stimulation reduced the average length of hospital stays.

Dr. Merli suggested that P6 stimulation might be reserved for patients for whom postop nausea and vomiting present a particular risk, such as those undergoing abdominal, thoracic, or brain surgery.

P6 stimulation “is a good option,” said Dr. Jessica Zuleta, an internal medicine hospitalist at the University of Miami. But it shouldn't completely replace antiemetics, she added, because the studies are limited. She called for more rigidly controlled, blinded studies comparing P6 stimulation and antiemetic drugs.

Dr. Lee and Dr. Fan said they had no relevant conflicts of interest. The study was supported by the U.S. National Center for Complementary and Alternative Medicine, the Chinese University of Hong Kong's department of anesthesia and intensive care, and the Cochrane Complementary Medicine Field Bursary.

EMILY BRANNAN/ILLUSTRATION

Stimulation of the P6 acupuncture point on the wrist significantly reduced the risk of postoperative nausea and vomiting, according to a new meta-analysis of 40 randomized, controlled trials involving 4,856 participants.

Compared with sham treatment, several forms of P6 stimulation reduced the risk of nausea by 29%, the risk of vomiting by 30%, and the need for rescue antiemetics by 31%, wrote Dr. Anna Lee and Dr. Lawrence T.Y. Fan for the Cochrane Collaboration (Cochrane Database Syst. Rev. 2009 [doi:10.1002/14651858.CD003281.pub3

Those relative risks were statistically significant. In direct comparisons with antiemetic drugs, P6 stimulation proved to be equally effective in reducing nausea, vomiting, and the need for rescue antiemetics.

The side effects of P6 stimulation were minor, whether the stimulation was performed with traditional acupuncture needles, electroacupuncture, laser acupuncture, transcutaneous electrical stimulation, an acustimulation device, acupressure, or capsicum plaster.

Acupuncture needles produced hematomas on rare occasions, and some patients reported pain, irritation, redness, fatigue, or sleepiness. Patients receiving acupressure with wrist bands occasionally complained of discomfort, red indentations, blisters, and swelling. One patient complained of mild irritation at the site of the capsicum plaster.

“Drugs only partially prevent postoperative nausea and vomiting, and they, of course, have a lot of adverse side effects,” said Dr. Geno J. Merli in an interview. Dr. Merli, chief medical officer of Thomas Jefferson University Hospital, Philadelphia, was not involved in the meta-analysis. Patients on antiemetic drugs can have changes in mental status and can develop confusion or disorientation. Some patients become stimulated by the antiemetic agent, while others can experience oculogyric crises, a very rare complication.

Dr. Merli was especially intrigued by the notion that wrist stimulation could be used prophylactically to prevent nausea and vomiting. Antiemetic medications are typically given as needed if postop patients develop symptoms.

Dr. Lee and Dr. Fan, both from the Chinese University of Hong Kong, acknowledged that publication bias is a frequent problem in randomized, controlled trials of traditional Chinese medicine. Negative studies are less likely to be published than are positive ones. But using a statistical technique called “contour enhanced funnel plots,” the investigators found no evidence of publication bias among the studies included in their meta-analysis.

“I was not a believer in acupuncture as a postoperative nausea and vomiting preventative,” Dr. Merli said. “I saw this review and said we should be doing this more often.”

However, hospitals would have to be convinced of the cost-effectiveness of P6 stimulation, Dr. Merli added. He noted that the acupressure wristbands available in drugstores cost about $10. Even if hospitals could get that cost down to $5, they would have to compare that to 5 cents or so for a dose of prochlorperazine. The real savings would come, Dr. Merli noted, if P6 stimulation reduced the average length of hospital stays.

Dr. Merli suggested that P6 stimulation might be reserved for patients for whom postop nausea and vomiting present a particular risk, such as those undergoing abdominal, thoracic, or brain surgery.

P6 stimulation “is a good option,” said Dr. Jessica Zuleta, an internal medicine hospitalist at the University of Miami. But it shouldn't completely replace antiemetics, she added, because the studies are limited. She called for more rigidly controlled, blinded studies comparing P6 stimulation and antiemetic drugs.

Dr. Lee and Dr. Fan said they had no relevant conflicts of interest. The study was supported by the U.S. National Center for Complementary and Alternative Medicine, the Chinese University of Hong Kong's department of anesthesia and intensive care, and the Cochrane Complementary Medicine Field Bursary.

EMILY BRANNAN/ILLUSTRATION

The National Foundation for Infectious Diseases has unveiled a Web site that takes a multipronged approach to increasing the rate of adult vaccination in the United States.

Revealed during a Webcast for reporters, www.adultvaccination.com

Adult immunization rates are far too low, Dr. Rehm said during the Webcast: “Most vaccination rates in adults are below 50%. The highest rates are for influenza and pneumococcal vaccines in people 65 and older, but even in these groups vaccination rates are below 70%.”

Dr. Rehm attributed those higher rates to long-standing, comprehensive educational and awareness efforts aimed both at the public and health care providers. “Our mission here is to focus the same type of concentrated efforts on all adult vaccines, to support increases in vaccination rates across the entire adult spectrum. While we're at it we'll also aim to increase the influenza and pneumococcal vaccination rates to new target levels,” she said.

For patients, the Web site includes basic information on 13 vaccine-preventable diseases along with a short quiz that helps discern which vaccines they need.

It also includes a simple fact sheet and the full schedule of adult immunizations recommended by the Centers for Disease Control and Prevention.

For health care providers, the Web site includes a “Professional Practice Toolkit,” with numerous resources. These include suggested text for reminder postcards, text to be added to the back of appointment reminder cards, and scripts for recorded telephone messages to be played when patients are on hold or when the office is closed. (See box.)

Dr. Rehm has used a number of these resources in her own practice, and has implemented other strategies as well. “We have posters in our waiting room regarding various immunizations, and in each of the individual examination rooms we have posted the adult vaccination recommendations from the CDC. People can take a look at those and then it's also a stimulus for us to talk about them,” she explained.

“We have built in questions about vaccinations into our intake, so that when our assistants ask patients what medicines they're taking and they get their vital signs … they also update their vaccination immunization [records] and cue us to talk with patients about vaccines,” she added.

The Web site is being supported by unrestricted educational grants to the National Foundation for Infectious Diseases from GlaxoSmithKline, Merck & Co., Sanofi Pasteur, and Wyeth Pharmaceuticals.

Vaccination Resources for Physicians

▸ Appointment reminder cards

▸ “Office closed” message script

▸ “On hold” message script

▸ Patient fact sheet

▸ Patient Q&A

▸ Poster

▸ Tabletop tent cards

▸ Article for practice newsletter or physician's Web site

▸ Reminder postcards

▸ Resource list

▸ Sample standing orders

Source:

www.adultvaccination.com

The National Foundation for Infectious Diseases has unveiled a Web site that takes a multipronged approach to increasing the rate of adult vaccination in the United States.

Revealed during a Webcast for reporters, www.adultvaccination.com

Adult immunization rates are far too low, Dr. Rehm said during the Webcast: “Most vaccination rates in adults are below 50%. The highest rates are for influenza and pneumococcal vaccines in people 65 and older, but even in these groups vaccination rates are below 70%.”

Dr. Rehm attributed those higher rates to long-standing, comprehensive educational and awareness efforts aimed both at the public and health care providers. “Our mission here is to focus the same type of concentrated efforts on all adult vaccines, to support increases in vaccination rates across the entire adult spectrum. While we're at it we'll also aim to increase the influenza and pneumococcal vaccination rates to new target levels,” she said.

For patients, the Web site includes basic information on 13 vaccine-preventable diseases along with a short quiz that helps discern which vaccines they need.

It also includes a simple fact sheet and the full schedule of adult immunizations recommended by the Centers for Disease Control and Prevention.

For health care providers, the Web site includes a “Professional Practice Toolkit,” with numerous resources. These include suggested text for reminder postcards, text to be added to the back of appointment reminder cards, and scripts for recorded telephone messages to be played when patients are on hold or when the office is closed. (See box.)

Dr. Rehm has used a number of these resources in her own practice, and has implemented other strategies as well. “We have posters in our waiting room regarding various immunizations, and in each of the individual examination rooms we have posted the adult vaccination recommendations from the CDC. People can take a look at those and then it's also a stimulus for us to talk about them,” she explained.

“We have built in questions about vaccinations into our intake, so that when our assistants ask patients what medicines they're taking and they get their vital signs … they also update their vaccination immunization [records] and cue us to talk with patients about vaccines,” she added.

The Web site is being supported by unrestricted educational grants to the National Foundation for Infectious Diseases from GlaxoSmithKline, Merck & Co., Sanofi Pasteur, and Wyeth Pharmaceuticals.

Vaccination Resources for Physicians

▸ Appointment reminder cards

▸ “Office closed” message script

▸ “On hold” message script

▸ Patient fact sheet

▸ Patient Q&A

▸ Poster

▸ Tabletop tent cards

▸ Article for practice newsletter or physician's Web site

▸ Reminder postcards

▸ Resource list

▸ Sample standing orders

Source:

www.adultvaccination.com

The National Foundation for Infectious Diseases has unveiled a Web site that takes a multipronged approach to increasing the rate of adult vaccination in the United States.

Revealed during a Webcast for reporters, www.adultvaccination.com

Adult immunization rates are far too low, Dr. Rehm said during the Webcast: “Most vaccination rates in adults are below 50%. The highest rates are for influenza and pneumococcal vaccines in people 65 and older, but even in these groups vaccination rates are below 70%.”

Dr. Rehm attributed those higher rates to long-standing, comprehensive educational and awareness efforts aimed both at the public and health care providers. “Our mission here is to focus the same type of concentrated efforts on all adult vaccines, to support increases in vaccination rates across the entire adult spectrum. While we're at it we'll also aim to increase the influenza and pneumococcal vaccination rates to new target levels,” she said.

For patients, the Web site includes basic information on 13 vaccine-preventable diseases along with a short quiz that helps discern which vaccines they need.

It also includes a simple fact sheet and the full schedule of adult immunizations recommended by the Centers for Disease Control and Prevention.

For health care providers, the Web site includes a “Professional Practice Toolkit,” with numerous resources. These include suggested text for reminder postcards, text to be added to the back of appointment reminder cards, and scripts for recorded telephone messages to be played when patients are on hold or when the office is closed. (See box.)

Dr. Rehm has used a number of these resources in her own practice, and has implemented other strategies as well. “We have posters in our waiting room regarding various immunizations, and in each of the individual examination rooms we have posted the adult vaccination recommendations from the CDC. People can take a look at those and then it's also a stimulus for us to talk about them,” she explained.

“We have built in questions about vaccinations into our intake, so that when our assistants ask patients what medicines they're taking and they get their vital signs … they also update their vaccination immunization [records] and cue us to talk with patients about vaccines,” she added.

The Web site is being supported by unrestricted educational grants to the National Foundation for Infectious Diseases from GlaxoSmithKline, Merck & Co., Sanofi Pasteur, and Wyeth Pharmaceuticals.

Vaccination Resources for Physicians

▸ Appointment reminder cards

▸ “Office closed” message script

▸ “On hold” message script

▸ Patient fact sheet

▸ Patient Q&A

▸ Poster

▸ Tabletop tent cards

▸ Article for practice newsletter or physician's Web site

▸ Reminder postcards

▸ Resource list

▸ Sample standing orders

Source:

www.adultvaccination.com

SAN DIEGO — Women who reach menopause before the age of 42 years are twice as likely to suffer a stroke in later life as are women who reach menopause after age 42, according to a new analysis of data from the Framingham Heart Study presented at the International Stroke Conference.

The study involved prospectively collected data from 1,430 women who were followed for an average of 22 years, said Lynda Lisabeth, Ph.D., of the University of Michigan, Ann Arbor. All participants were stroke-free at 60 years of age, experienced natural menopause, and had never taken estrogen before menopause. The use of self-reported data on the age of menopause was a limitation of the study, Dr. Lisabeth acknowledged.

In all, the women suffered 234 ischemic strokes at an average age of 80 years. The unadjusted rate of strokes was 23% among women who reached menopause before the age of 42 years, 16% among women who reached menopause between the ages of 42 and 54 years, and 11% among women who reached menopause at age 55 years or older.

After adjusting for age, systolic blood pressure, atrial fibrillation, diabetes, current smoking, cardiovascular disease, and estrogen use after menopause, the investigators determined that the age of menopause was an independent predictor of ischemic stroke.

Compared with women who reached menopause before age 42 years, those who reached menopause between ages 42 and 54 years were half as likely to experience a stroke, and those who reached menopause at age 55 or older were 69% less likely to have a stroke. In other words, women who reached menopause before age 42 years were 2.03-fold more likely to have a stroke. This difference was statistically significant.

The study showed that 4%–5% of strokes in women can be attributed to menopause before age 42, Dr. Lisabeth said.

About 1%–2% of women reach menopause at or before age 40 years. It is referred to as “premature ovarian failure” and its etiology remains unknown, but investigators are certain that it is different from natural menopause. About 3%–10% of women experience “early” menopause, defined as natural menopause before age 45 years.

Several possible mechanisms could account for the increased rate of stroke, Dr. Lisabeth said. Estrogen may play a role, since estrogen deficiency is thought to promote cardiovascular disease through functional or structural changes in arteries. Androgens and sex hormone-binding globulin also are risk factors for cardiovascular disease.

Additional studies with measures of endogenous hormones would be needed to unravel the relationship between the hormonal changes of menopause and ischemic stroke, she said.

The study was supported by the National Heart, Lung, and Blood Institute and the National Institute of Neurological Disorders and Stroke. Dr. Lisabeth said that she had no conflicts of interest.

SAN DIEGO — Women who reach menopause before the age of 42 years are twice as likely to suffer a stroke in later life as are women who reach menopause after age 42, according to a new analysis of data from the Framingham Heart Study presented at the International Stroke Conference.

The study involved prospectively collected data from 1,430 women who were followed for an average of 22 years, said Lynda Lisabeth, Ph.D., of the University of Michigan, Ann Arbor. All participants were stroke-free at 60 years of age, experienced natural menopause, and had never taken estrogen before menopause. The use of self-reported data on the age of menopause was a limitation of the study, Dr. Lisabeth acknowledged.

In all, the women suffered 234 ischemic strokes at an average age of 80 years. The unadjusted rate of strokes was 23% among women who reached menopause before the age of 42 years, 16% among women who reached menopause between the ages of 42 and 54 years, and 11% among women who reached menopause at age 55 years or older.

After adjusting for age, systolic blood pressure, atrial fibrillation, diabetes, current smoking, cardiovascular disease, and estrogen use after menopause, the investigators determined that the age of menopause was an independent predictor of ischemic stroke.

Compared with women who reached menopause before age 42 years, those who reached menopause between ages 42 and 54 years were half as likely to experience a stroke, and those who reached menopause at age 55 or older were 69% less likely to have a stroke. In other words, women who reached menopause before age 42 years were 2.03-fold more likely to have a stroke. This difference was statistically significant.

The study showed that 4%–5% of strokes in women can be attributed to menopause before age 42, Dr. Lisabeth said.

About 1%–2% of women reach menopause at or before age 40 years. It is referred to as “premature ovarian failure” and its etiology remains unknown, but investigators are certain that it is different from natural menopause. About 3%–10% of women experience “early” menopause, defined as natural menopause before age 45 years.

Several possible mechanisms could account for the increased rate of stroke, Dr. Lisabeth said. Estrogen may play a role, since estrogen deficiency is thought to promote cardiovascular disease through functional or structural changes in arteries. Androgens and sex hormone-binding globulin also are risk factors for cardiovascular disease.

Additional studies with measures of endogenous hormones would be needed to unravel the relationship between the hormonal changes of menopause and ischemic stroke, she said.

The study was supported by the National Heart, Lung, and Blood Institute and the National Institute of Neurological Disorders and Stroke. Dr. Lisabeth said that she had no conflicts of interest.

SAN DIEGO — Women who reach menopause before the age of 42 years are twice as likely to suffer a stroke in later life as are women who reach menopause after age 42, according to a new analysis of data from the Framingham Heart Study presented at the International Stroke Conference.

The study involved prospectively collected data from 1,430 women who were followed for an average of 22 years, said Lynda Lisabeth, Ph.D., of the University of Michigan, Ann Arbor. All participants were stroke-free at 60 years of age, experienced natural menopause, and had never taken estrogen before menopause. The use of self-reported data on the age of menopause was a limitation of the study, Dr. Lisabeth acknowledged.

In all, the women suffered 234 ischemic strokes at an average age of 80 years. The unadjusted rate of strokes was 23% among women who reached menopause before the age of 42 years, 16% among women who reached menopause between the ages of 42 and 54 years, and 11% among women who reached menopause at age 55 years or older.

After adjusting for age, systolic blood pressure, atrial fibrillation, diabetes, current smoking, cardiovascular disease, and estrogen use after menopause, the investigators determined that the age of menopause was an independent predictor of ischemic stroke.

Compared with women who reached menopause before age 42 years, those who reached menopause between ages 42 and 54 years were half as likely to experience a stroke, and those who reached menopause at age 55 or older were 69% less likely to have a stroke. In other words, women who reached menopause before age 42 years were 2.03-fold more likely to have a stroke. This difference was statistically significant.

The study showed that 4%–5% of strokes in women can be attributed to menopause before age 42, Dr. Lisabeth said.

About 1%–2% of women reach menopause at or before age 40 years. It is referred to as “premature ovarian failure” and its etiology remains unknown, but investigators are certain that it is different from natural menopause. About 3%–10% of women experience “early” menopause, defined as natural menopause before age 45 years.

Several possible mechanisms could account for the increased rate of stroke, Dr. Lisabeth said. Estrogen may play a role, since estrogen deficiency is thought to promote cardiovascular disease through functional or structural changes in arteries. Androgens and sex hormone-binding globulin also are risk factors for cardiovascular disease.

Additional studies with measures of endogenous hormones would be needed to unravel the relationship between the hormonal changes of menopause and ischemic stroke, she said.

The study was supported by the National Heart, Lung, and Blood Institute and the National Institute of Neurological Disorders and Stroke. Dr. Lisabeth said that she had no conflicts of interest.

SAN FRANCISCO — People who worked at outdoor summer jobs as teenagers for 3 years or more had twice the risk of developing malignant melanoma later in life as those who did not, according to a case-control study by Dr. Darrell S. Rigel of New York University Medical Center.

The study identified six independent risk factors, each of which increased the risk of malignant melanoma between two- and threefold, Dr. Rigel said in presenting preliminary results at the annual meeting of the American Academy of Dermatology.

Besides an outdoor summer job, the other five risk factors were history of blistering sunburns, red or blonde hair, freckling of the upper back, family history of melanoma, and a history of actinic keratoses.

The study involved 300 consecutive patients with malignant melanoma who were seen at Dr. Rigel's clinic. They were compared with 302 age- and gender-matched controls seen for acne, psoriasis, eczema, or other reasons unrelated to pigmented lesions. The average age of the patients was about 50 years, with a range from 18 years to the mid-70s.

Dr. Rigel and his colleagues evaluated all patients for the presence of 43 potential risk factors. Only six emerged as independent risk factors in a multivariate analysis.

In an interview, Dr. Rigel said there was at least one potential risk factor that was conspicuous by its absence from that list: The study showed no increase in melanoma risk with increasing age. “The model tended to predict early on in life what was going to happen later in life,” he said.

The presence of any one of the six risk factors increased the lifetime risk to 3%–5%. The lifetime risk of melanoma in the U.S. population is about 1.5%, he noted.

The presence of two or more of the risk factors increased the lifetime risk of melanoma 5–10 times over that of the general population. Those with three or more of the risk factors have a 10-fold to 20-fold increase in the risk of melanoma.

“You want to come up with a model that focuses as effectively as possible on those at high risk,” Dr. Rigel said. “Eventually, if you think about it, these are not the models we want. We're using surrogates. We're using factors that are not really the cause. The cause is genetic susceptibility and exposure to UV. … I believe that 5 or 10 years from now we'll have a genetic screen for melanoma.”

According to Dr. Rigel, this study carries an important message for primary care physicians. “There's only 9,000 dermatologists [in the United States]. Only one-third of dermatologic disease is treated by dermatologists. That means two-thirds are going to [primary care physicians]. We want those melanomas to be detected early. So models like this may let the primary care physician also focus on who they should focus their efforts on.”

Dr. Rigel disclosed financial relationships with Graceway, Pharmaderm, Johnson & Johnson, Neutrogena, and LaRoche-Posay. He said that none of those were relevant to his presentation, and that the study was privately funded.

Sun exposure during adolescence is predictive of melanoma later in life. ©

SAN FRANCISCO — People who worked at outdoor summer jobs as teenagers for 3 years or more had twice the risk of developing malignant melanoma later in life as those who did not, according to a case-control study by Dr. Darrell S. Rigel of New York University Medical Center.

The study identified six independent risk factors, each of which increased the risk of malignant melanoma between two- and threefold, Dr. Rigel said in presenting preliminary results at the annual meeting of the American Academy of Dermatology.

Besides an outdoor summer job, the other five risk factors were history of blistering sunburns, red or blonde hair, freckling of the upper back, family history of melanoma, and a history of actinic keratoses.

The study involved 300 consecutive patients with malignant melanoma who were seen at Dr. Rigel's clinic. They were compared with 302 age- and gender-matched controls seen for acne, psoriasis, eczema, or other reasons unrelated to pigmented lesions. The average age of the patients was about 50 years, with a range from 18 years to the mid-70s.

Dr. Rigel and his colleagues evaluated all patients for the presence of 43 potential risk factors. Only six emerged as independent risk factors in a multivariate analysis.

In an interview, Dr. Rigel said there was at least one potential risk factor that was conspicuous by its absence from that list: The study showed no increase in melanoma risk with increasing age. “The model tended to predict early on in life what was going to happen later in life,” he said.

The presence of any one of the six risk factors increased the lifetime risk to 3%–5%. The lifetime risk of melanoma in the U.S. population is about 1.5%, he noted.

The presence of two or more of the risk factors increased the lifetime risk of melanoma 5–10 times over that of the general population. Those with three or more of the risk factors have a 10-fold to 20-fold increase in the risk of melanoma.

“You want to come up with a model that focuses as effectively as possible on those at high risk,” Dr. Rigel said. “Eventually, if you think about it, these are not the models we want. We're using surrogates. We're using factors that are not really the cause. The cause is genetic susceptibility and exposure to UV. … I believe that 5 or 10 years from now we'll have a genetic screen for melanoma.”

According to Dr. Rigel, this study carries an important message for primary care physicians. “There's only 9,000 dermatologists [in the United States]. Only one-third of dermatologic disease is treated by dermatologists. That means two-thirds are going to [primary care physicians]. We want those melanomas to be detected early. So models like this may let the primary care physician also focus on who they should focus their efforts on.”

Dr. Rigel disclosed financial relationships with Graceway, Pharmaderm, Johnson & Johnson, Neutrogena, and LaRoche-Posay. He said that none of those were relevant to his presentation, and that the study was privately funded.

Sun exposure during adolescence is predictive of melanoma later in life. ©

SAN FRANCISCO — People who worked at outdoor summer jobs as teenagers for 3 years or more had twice the risk of developing malignant melanoma later in life as those who did not, according to a case-control study by Dr. Darrell S. Rigel of New York University Medical Center.

The study identified six independent risk factors, each of which increased the risk of malignant melanoma between two- and threefold, Dr. Rigel said in presenting preliminary results at the annual meeting of the American Academy of Dermatology.

Besides an outdoor summer job, the other five risk factors were history of blistering sunburns, red or blonde hair, freckling of the upper back, family history of melanoma, and a history of actinic keratoses.

The study involved 300 consecutive patients with malignant melanoma who were seen at Dr. Rigel's clinic. They were compared with 302 age- and gender-matched controls seen for acne, psoriasis, eczema, or other reasons unrelated to pigmented lesions. The average age of the patients was about 50 years, with a range from 18 years to the mid-70s.

Dr. Rigel and his colleagues evaluated all patients for the presence of 43 potential risk factors. Only six emerged as independent risk factors in a multivariate analysis.

In an interview, Dr. Rigel said there was at least one potential risk factor that was conspicuous by its absence from that list: The study showed no increase in melanoma risk with increasing age. “The model tended to predict early on in life what was going to happen later in life,” he said.

The presence of any one of the six risk factors increased the lifetime risk to 3%–5%. The lifetime risk of melanoma in the U.S. population is about 1.5%, he noted.

The presence of two or more of the risk factors increased the lifetime risk of melanoma 5–10 times over that of the general population. Those with three or more of the risk factors have a 10-fold to 20-fold increase in the risk of melanoma.

“You want to come up with a model that focuses as effectively as possible on those at high risk,” Dr. Rigel said. “Eventually, if you think about it, these are not the models we want. We're using surrogates. We're using factors that are not really the cause. The cause is genetic susceptibility and exposure to UV. … I believe that 5 or 10 years from now we'll have a genetic screen for melanoma.”

According to Dr. Rigel, this study carries an important message for primary care physicians. “There's only 9,000 dermatologists [in the United States]. Only one-third of dermatologic disease is treated by dermatologists. That means two-thirds are going to [primary care physicians]. We want those melanomas to be detected early. So models like this may let the primary care physician also focus on who they should focus their efforts on.”

Dr. Rigel disclosed financial relationships with Graceway, Pharmaderm, Johnson & Johnson, Neutrogena, and LaRoche-Posay. He said that none of those were relevant to his presentation, and that the study was privately funded.

Sun exposure during adolescence is predictive of melanoma later in life. ©

SAN FRANCISCO — Chronic wounds due to scleroderma responded well to a combination of mesenchymal stem cells and bilayer bioengineered skin, in a study of 12 patients followed for up to 6 months.

Four wounds completely healed, and the others decreased in size enough that patients' quality of life was improved, Dr. Vincent Falanga said in a press briefing at the annual meeting of the American Academy of Dermatology.

He and his associates harvested the patients' own stem cells from a small amount of bone marrow taken from the hip. And they applied the stem cells to the wound with an innovative fibrin spray system that had not been used before in humans.

Using a pressurized double-barrel syringe, they placed the cells in fibrinogen in one barrel and in a thrombin solution in the other. This produced a fine spray, spreading the cells evenly over the wound and simultaneously combining the fibrinogen and thrombin to form fibrin, which glued the cells to the exposed wound tissue, said Dr. Falanga of Boston University and Roger Williams Medical Center, Providence, R.I.

In prior studies, Dr. Falanga determined that the spray alone would not be enough to encourage the stem cells to differentiate into skin cells. To teach the stem cells to become skin cells, he covered the spray with living bioengineered skin substitute, specifically a product from Organogenesis Inc. called Apligraf that contains two layers of living cells, one of fibroblasts and one of keratinocytes.

Dr. Falanga gave each patient three treatments, the maximum permitted by the Food and Drug Administration. He said that he thinks the patients would do even better with additional treatments and hopes to receive approval for this as his studies continue.

Dr. Falanga said he found it necessary to use quite a large number of stem cells, 1.5 million to 2 million/cm

He continued, “I think that this is a lesson that's going to be learned when we go into other areas of medicine. Whether it's skin, brain, spinal cord, we have to have some methods whereby we impart upon the stem cells a didactic component, a direction we want them to go to.”

Dr. Falanga disclosed that he is a former consultant to the company Organogenesis.

SAN FRANCISCO — Chronic wounds due to scleroderma responded well to a combination of mesenchymal stem cells and bilayer bioengineered skin, in a study of 12 patients followed for up to 6 months.

Four wounds completely healed, and the others decreased in size enough that patients' quality of life was improved, Dr. Vincent Falanga said in a press briefing at the annual meeting of the American Academy of Dermatology.

He and his associates harvested the patients' own stem cells from a small amount of bone marrow taken from the hip. And they applied the stem cells to the wound with an innovative fibrin spray system that had not been used before in humans.

Using a pressurized double-barrel syringe, they placed the cells in fibrinogen in one barrel and in a thrombin solution in the other. This produced a fine spray, spreading the cells evenly over the wound and simultaneously combining the fibrinogen and thrombin to form fibrin, which glued the cells to the exposed wound tissue, said Dr. Falanga of Boston University and Roger Williams Medical Center, Providence, R.I.

In prior studies, Dr. Falanga determined that the spray alone would not be enough to encourage the stem cells to differentiate into skin cells. To teach the stem cells to become skin cells, he covered the spray with living bioengineered skin substitute, specifically a product from Organogenesis Inc. called Apligraf that contains two layers of living cells, one of fibroblasts and one of keratinocytes.

Dr. Falanga gave each patient three treatments, the maximum permitted by the Food and Drug Administration. He said that he thinks the patients would do even better with additional treatments and hopes to receive approval for this as his studies continue.

Dr. Falanga said he found it necessary to use quite a large number of stem cells, 1.5 million to 2 million/cm

He continued, “I think that this is a lesson that's going to be learned when we go into other areas of medicine. Whether it's skin, brain, spinal cord, we have to have some methods whereby we impart upon the stem cells a didactic component, a direction we want them to go to.”

Dr. Falanga disclosed that he is a former consultant to the company Organogenesis.

SAN FRANCISCO — Chronic wounds due to scleroderma responded well to a combination of mesenchymal stem cells and bilayer bioengineered skin, in a study of 12 patients followed for up to 6 months.

Four wounds completely healed, and the others decreased in size enough that patients' quality of life was improved, Dr. Vincent Falanga said in a press briefing at the annual meeting of the American Academy of Dermatology.

He and his associates harvested the patients' own stem cells from a small amount of bone marrow taken from the hip. And they applied the stem cells to the wound with an innovative fibrin spray system that had not been used before in humans.

Using a pressurized double-barrel syringe, they placed the cells in fibrinogen in one barrel and in a thrombin solution in the other. This produced a fine spray, spreading the cells evenly over the wound and simultaneously combining the fibrinogen and thrombin to form fibrin, which glued the cells to the exposed wound tissue, said Dr. Falanga of Boston University and Roger Williams Medical Center, Providence, R.I.

In prior studies, Dr. Falanga determined that the spray alone would not be enough to encourage the stem cells to differentiate into skin cells. To teach the stem cells to become skin cells, he covered the spray with living bioengineered skin substitute, specifically a product from Organogenesis Inc. called Apligraf that contains two layers of living cells, one of fibroblasts and one of keratinocytes.

Dr. Falanga gave each patient three treatments, the maximum permitted by the Food and Drug Administration. He said that he thinks the patients would do even better with additional treatments and hopes to receive approval for this as his studies continue.

Dr. Falanga said he found it necessary to use quite a large number of stem cells, 1.5 million to 2 million/cm

He continued, “I think that this is a lesson that's going to be learned when we go into other areas of medicine. Whether it's skin, brain, spinal cord, we have to have some methods whereby we impart upon the stem cells a didactic component, a direction we want them to go to.”

Dr. Falanga disclosed that he is a former consultant to the company Organogenesis.

SAN FRANCISCO — As many as 26,500 ischemic strokes occurring in the United States each year may be associated with patient withdrawal from antithrombotic and antiplatelet medications, according to a study presented at the International Stroke Conference.

Among 2,082 patients in the Cincinnati area who had 2,191 ischemic strokes in 2005, 84 (3.8%) of the strokes occurred in patients who had stopped their medications within 60 days. The first 7 days after withdrawal of antiplatelet or antithrombotic medication appeared to be the most dangerous time, Dr. Jordan Bonomo of the University of Cincinnati reported.

A total of 182 strokes occurred in warfarin patients. Of the 58 strokes that occurred in those who went off warfarin, 31 were within 7 days of withdrawal, 12 at 8–14 days, 8 at 15–30 days, and 7 at 31–60 days.

Similarly, 896 patients had been taking aspirin around the time of their stroke. Of these, 44 had discontinued aspirin; 24 of the strokes occurred within 7 days after halting aspirin therapy, 7 at 8–14 days, 11 at 15–30 days, and 2 at 31–60 days.

The investigators found a similar pattern among 228 patients who had been taking clopidogrel around the time of their stroke, 21 of whom had stopped taking the drug—10 strokes occurred within 7 days of discontinuation, 4 at 8–14 days, 5 at 15–30 days, and 2 at 31–60 days.

These results “mandate continued review of guidelines for withdrawal of anticoagulant and antiplatelet medication in the peri-procedural period,” he said.

Dr. Bonomo stated that he had no conflicts of interest. The study was supported by the National Institute of Neurological Disorders and Stroke.

SAN FRANCISCO — As many as 26,500 ischemic strokes occurring in the United States each year may be associated with patient withdrawal from antithrombotic and antiplatelet medications, according to a study presented at the International Stroke Conference.

Among 2,082 patients in the Cincinnati area who had 2,191 ischemic strokes in 2005, 84 (3.8%) of the strokes occurred in patients who had stopped their medications within 60 days. The first 7 days after withdrawal of antiplatelet or antithrombotic medication appeared to be the most dangerous time, Dr. Jordan Bonomo of the University of Cincinnati reported.

A total of 182 strokes occurred in warfarin patients. Of the 58 strokes that occurred in those who went off warfarin, 31 were within 7 days of withdrawal, 12 at 8–14 days, 8 at 15–30 days, and 7 at 31–60 days.

Similarly, 896 patients had been taking aspirin around the time of their stroke. Of these, 44 had discontinued aspirin; 24 of the strokes occurred within 7 days after halting aspirin therapy, 7 at 8–14 days, 11 at 15–30 days, and 2 at 31–60 days.

The investigators found a similar pattern among 228 patients who had been taking clopidogrel around the time of their stroke, 21 of whom had stopped taking the drug—10 strokes occurred within 7 days of discontinuation, 4 at 8–14 days, 5 at 15–30 days, and 2 at 31–60 days.

These results “mandate continued review of guidelines for withdrawal of anticoagulant and antiplatelet medication in the peri-procedural period,” he said.

Dr. Bonomo stated that he had no conflicts of interest. The study was supported by the National Institute of Neurological Disorders and Stroke.

SAN FRANCISCO — As many as 26,500 ischemic strokes occurring in the United States each year may be associated with patient withdrawal from antithrombotic and antiplatelet medications, according to a study presented at the International Stroke Conference.

Among 2,082 patients in the Cincinnati area who had 2,191 ischemic strokes in 2005, 84 (3.8%) of the strokes occurred in patients who had stopped their medications within 60 days. The first 7 days after withdrawal of antiplatelet or antithrombotic medication appeared to be the most dangerous time, Dr. Jordan Bonomo of the University of Cincinnati reported.

A total of 182 strokes occurred in warfarin patients. Of the 58 strokes that occurred in those who went off warfarin, 31 were within 7 days of withdrawal, 12 at 8–14 days, 8 at 15–30 days, and 7 at 31–60 days.

Similarly, 896 patients had been taking aspirin around the time of their stroke. Of these, 44 had discontinued aspirin; 24 of the strokes occurred within 7 days after halting aspirin therapy, 7 at 8–14 days, 11 at 15–30 days, and 2 at 31–60 days.

The investigators found a similar pattern among 228 patients who had been taking clopidogrel around the time of their stroke, 21 of whom had stopped taking the drug—10 strokes occurred within 7 days of discontinuation, 4 at 8–14 days, 5 at 15–30 days, and 2 at 31–60 days.

These results “mandate continued review of guidelines for withdrawal of anticoagulant and antiplatelet medication in the peri-procedural period,” he said.

Dr. Bonomo stated that he had no conflicts of interest. The study was supported by the National Institute of Neurological Disorders and Stroke.

Severe obesity is associated with a loss of 8–10 years of life, and moderate obesity is associated with 2–4 lost years, according to a very large study.

“Excess weight shortens human life span. In countries like Britain and America, weighing a third more than the optimum shortens life span by about 3 years. For most people, a third more than the optimum means carrying 20–30 kg [50–60 pounds] of excess weight. If you are becoming overweight or obese, avoiding further weight gain could well add years to your life,” Dr. Gary Whitlock of the University of Oxford (England), study investigator, said in a statement.

The analysis combined prospectively collected data from 894,576 adults who participated in 57 separate studies, mostly in Europe, Israel, the United States, and Australia. Participants were 46 years old on average when recruited, and were followed for an average of 13 years. The investigators discarded the first 5 years of mortality data to limit the effects of preexisting disease on the analysis. Not counting that 5-year period, the participants were followed for 6.5 million person-years (Lancet 2009 March 18 [doi:10.1016/S0140–6736(09)60318–4]).

The mortality rate was lowest in participants with a body mass index between 22.5 and 25 kg/m

Low BMI also was associated with excess mortality. Men with a BMI between 15 and 17.5 kg/m

Higher BMI was associated with higher rates of virtually all causes of mortality including ischemic heart disease, stroke, other vascular disease, diabetes, kidney disease, liver disease, respiratory disease, and neoplastic disease.

The association between BMI and cancer was much weaker than that between BMI and vascular disease, however. Each 5-kg/m

The investigators emphasized that prevention of excess weight gain would likely be more effective than dieting to lose weight.

They wrote, “In adult life, it may be easier to avoid substantial weight gain than to lose that weight once it has been gained. By avoiding a further increase from 28 kg/m

The many coauthors of this study were part of the Prospective Studies Collaboration of the Clinical Trial Service Unit of the University of Oxford. The collaboration was supported by the UK Medical Research Council, the British Heart Foundation, Cancer Research UK, the EU BIOMED Program, and the National Institute on Aging.

Severe obesity is associated with a loss of 8–10 years of life, and moderate obesity is associated with 2–4 lost years, according to a very large study.

“Excess weight shortens human life span. In countries like Britain and America, weighing a third more than the optimum shortens life span by about 3 years. For most people, a third more than the optimum means carrying 20–30 kg [50–60 pounds] of excess weight. If you are becoming overweight or obese, avoiding further weight gain could well add years to your life,” Dr. Gary Whitlock of the University of Oxford (England), study investigator, said in a statement.

The analysis combined prospectively collected data from 894,576 adults who participated in 57 separate studies, mostly in Europe, Israel, the United States, and Australia. Participants were 46 years old on average when recruited, and were followed for an average of 13 years. The investigators discarded the first 5 years of mortality data to limit the effects of preexisting disease on the analysis. Not counting that 5-year period, the participants were followed for 6.5 million person-years (Lancet 2009 March 18 [doi:10.1016/S0140–6736(09)60318–4]).

The mortality rate was lowest in participants with a body mass index between 22.5 and 25 kg/m

Low BMI also was associated with excess mortality. Men with a BMI between 15 and 17.5 kg/m

Higher BMI was associated with higher rates of virtually all causes of mortality including ischemic heart disease, stroke, other vascular disease, diabetes, kidney disease, liver disease, respiratory disease, and neoplastic disease.

The association between BMI and cancer was much weaker than that between BMI and vascular disease, however. Each 5-kg/m

The investigators emphasized that prevention of excess weight gain would likely be more effective than dieting to lose weight.

They wrote, “In adult life, it may be easier to avoid substantial weight gain than to lose that weight once it has been gained. By avoiding a further increase from 28 kg/m

The many coauthors of this study were part of the Prospective Studies Collaboration of the Clinical Trial Service Unit of the University of Oxford. The collaboration was supported by the UK Medical Research Council, the British Heart Foundation, Cancer Research UK, the EU BIOMED Program, and the National Institute on Aging.

Severe obesity is associated with a loss of 8–10 years of life, and moderate obesity is associated with 2–4 lost years, according to a very large study.

“Excess weight shortens human life span. In countries like Britain and America, weighing a third more than the optimum shortens life span by about 3 years. For most people, a third more than the optimum means carrying 20–30 kg [50–60 pounds] of excess weight. If you are becoming overweight or obese, avoiding further weight gain could well add years to your life,” Dr. Gary Whitlock of the University of Oxford (England), study investigator, said in a statement.

The analysis combined prospectively collected data from 894,576 adults who participated in 57 separate studies, mostly in Europe, Israel, the United States, and Australia. Participants were 46 years old on average when recruited, and were followed for an average of 13 years. The investigators discarded the first 5 years of mortality data to limit the effects of preexisting disease on the analysis. Not counting that 5-year period, the participants were followed for 6.5 million person-years (Lancet 2009 March 18 [doi:10.1016/S0140–6736(09)60318–4]).

The mortality rate was lowest in participants with a body mass index between 22.5 and 25 kg/m

Low BMI also was associated with excess mortality. Men with a BMI between 15 and 17.5 kg/m

Higher BMI was associated with higher rates of virtually all causes of mortality including ischemic heart disease, stroke, other vascular disease, diabetes, kidney disease, liver disease, respiratory disease, and neoplastic disease.

The association between BMI and cancer was much weaker than that between BMI and vascular disease, however. Each 5-kg/m

The investigators emphasized that prevention of excess weight gain would likely be more effective than dieting to lose weight.

They wrote, “In adult life, it may be easier to avoid substantial weight gain than to lose that weight once it has been gained. By avoiding a further increase from 28 kg/m

The many coauthors of this study were part of the Prospective Studies Collaboration of the Clinical Trial Service Unit of the University of Oxford. The collaboration was supported by the UK Medical Research Council, the British Heart Foundation, Cancer Research UK, the EU BIOMED Program, and the National Institute on Aging.

Many patients with Clostridium difficile infection experience repeated bouts of the illness, and a rule has been developed to accurately predict a patient's risk of recurrence.

The prediction rule, which is simple to use, takes into account a patient's age, use of antibiotics, and severity of disease. The investigators demonstrated that the rule has a diagnostic accuracy of 72%.

These factors had been shown previously to be significant independent predictors of recurrent C. difficile diarrhea, wrote Dr. Mary Y. Hu of Harvard Medical School, Boston, and her colleagues. A fourth independent predictor—the serum level of antitoxin A IgG—appeared to reduce the accuracy of the rule.

The investigators derived the rule from a study of 63 patients hospitalized with C. difficile infection between January and May 1998. They validated the tool with data collected prospectively from 64 patients hospitalized between December 2004 and May 2006.

The rule assigns 1 point to each of the following characteristics: age greater than 65 years, disease judged to be severe or fulminant in intensity, and additional antibiotic use after the discontinuation of therapy for C. difficile infection. In the validation group, recurrence occurred in 7 of 19 patients scoring 2 points or higher (37%) but in 6 of 45 patients scoring 0 or 1 (13%).

In the validation cohort, the sensitivity of the rule was 54%, the specificity was 77%, the positive predictive value was 37%, and the negative predictive value was 87%. The diagnostic accuracy was 72%. This compared favorably to the original derivation cohort, in which the rule's diagnostic accuracy was 77%.

If the rule's threshold for assigning patients to the high-risk group was changed to a score of 1 or higher, the sensitivity increased to 100% in the validation cohort, but the specificity decreased to 18%. “This alternative application may be useful in circumstances where high sensitivity is paramount,” they wrote.

They also tested a combined rule that assigned an additional 2 points to a serum antitoxin A IgG level less than 1.29 ELISA units. With a threshold of 4 points or above, this combined rule appeared promising among the derivation cohort. Of these patients, 16 had antitoxin A IgG data available. Of those, all eight patients in the high-risk group had recurrent C. difficile infection, while only one of the eight patients in the low-risk group had recurrence. In this analysis, the sensitivity of the rule was 89%, the specificity was 100%, the positive predictive value was 100%, and the negative predictive value was 87.5%. The diagnostic accuracy was 94%.

Unfortunately, this rule proved to be far less predictive in the validation cohort, in which 26 patients had antitoxin A IgG data available. Infection recurred in 3 of 6 patients in the high-risk group and 5 of 20 patients in the low-risk group. This translates to a sensitivity of 38%, a specificity of 83%, a positive predictive value of 50%, and a negative predictive value of 75%. The diagnostic accuracy was 69%.

The three-factor prediction rule for recurrence was “simple, reliable, and accurate,” according to the investigators. “This rule is valuable in clinical practice as it defines a high-risk population in whom awareness of the risk can facilitate more prompt recognition, diagnosis, and treatment of recurrent [C. difficile infection]. These patients are also most likely to benefit from interventions to prevent recurrence, such as infection control precautions, prudent use of antibiotics, prolongation of metronidazole or vancomycin therapy, and use of probiotics or other prophylactic measures.”

The study was supported by grants from the National Institutes of Health and the Irish Health Research Board. One of the investigators, Dr. Ciarán P. Kelly of Harvard Medical School, acknowledged acting as a scientific consultant for Acambis, Actelion, BioHelix, Genzyme, Replidyne, Salix, and ViroPharm, and receiving research grant funding from Actelion, Genzyme, Massachusetts Biologics Laboratories, Medarex, and Salix Pharmaceuticals, companies that are producing or developing treatments for C. difficile infection.

A new rule can be used to predict recurrence of C. difficile infection, which can cause repeated bouts of diarrhea. CDC/DR. GILDA JONES

Many patients with Clostridium difficile infection experience repeated bouts of the illness, and a rule has been developed to accurately predict a patient's risk of recurrence.

The prediction rule, which is simple to use, takes into account a patient's age, use of antibiotics, and severity of disease. The investigators demonstrated that the rule has a diagnostic accuracy of 72%.

These factors had been shown previously to be significant independent predictors of recurrent C. difficile diarrhea, wrote Dr. Mary Y. Hu of Harvard Medical School, Boston, and her colleagues. A fourth independent predictor—the serum level of antitoxin A IgG—appeared to reduce the accuracy of the rule.

The investigators derived the rule from a study of 63 patients hospitalized with C. difficile infection between January and May 1998. They validated the tool with data collected prospectively from 64 patients hospitalized between December 2004 and May 2006.

The rule assigns 1 point to each of the following characteristics: age greater than 65 years, disease judged to be severe or fulminant in intensity, and additional antibiotic use after the discontinuation of therapy for C. difficile infection. In the validation group, recurrence occurred in 7 of 19 patients scoring 2 points or higher (37%) but in 6 of 45 patients scoring 0 or 1 (13%).

In the validation cohort, the sensitivity of the rule was 54%, the specificity was 77%, the positive predictive value was 37%, and the negative predictive value was 87%. The diagnostic accuracy was 72%. This compared favorably to the original derivation cohort, in which the rule's diagnostic accuracy was 77%.

If the rule's threshold for assigning patients to the high-risk group was changed to a score of 1 or higher, the sensitivity increased to 100% in the validation cohort, but the specificity decreased to 18%. “This alternative application may be useful in circumstances where high sensitivity is paramount,” they wrote.

They also tested a combined rule that assigned an additional 2 points to a serum antitoxin A IgG level less than 1.29 ELISA units. With a threshold of 4 points or above, this combined rule appeared promising among the derivation cohort. Of these patients, 16 had antitoxin A IgG data available. Of those, all eight patients in the high-risk group had recurrent C. difficile infection, while only one of the eight patients in the low-risk group had recurrence. In this analysis, the sensitivity of the rule was 89%, the specificity was 100%, the positive predictive value was 100%, and the negative predictive value was 87.5%. The diagnostic accuracy was 94%.

Unfortunately, this rule proved to be far less predictive in the validation cohort, in which 26 patients had antitoxin A IgG data available. Infection recurred in 3 of 6 patients in the high-risk group and 5 of 20 patients in the low-risk group. This translates to a sensitivity of 38%, a specificity of 83%, a positive predictive value of 50%, and a negative predictive value of 75%. The diagnostic accuracy was 69%.

The three-factor prediction rule for recurrence was “simple, reliable, and accurate,” according to the investigators. “This rule is valuable in clinical practice as it defines a high-risk population in whom awareness of the risk can facilitate more prompt recognition, diagnosis, and treatment of recurrent [C. difficile infection]. These patients are also most likely to benefit from interventions to prevent recurrence, such as infection control precautions, prudent use of antibiotics, prolongation of metronidazole or vancomycin therapy, and use of probiotics or other prophylactic measures.”

The study was supported by grants from the National Institutes of Health and the Irish Health Research Board. One of the investigators, Dr. Ciarán P. Kelly of Harvard Medical School, acknowledged acting as a scientific consultant for Acambis, Actelion, BioHelix, Genzyme, Replidyne, Salix, and ViroPharm, and receiving research grant funding from Actelion, Genzyme, Massachusetts Biologics Laboratories, Medarex, and Salix Pharmaceuticals, companies that are producing or developing treatments for C. difficile infection.

A new rule can be used to predict recurrence of C. difficile infection, which can cause repeated bouts of diarrhea. CDC/DR. GILDA JONES

Many patients with Clostridium difficile infection experience repeated bouts of the illness, and a rule has been developed to accurately predict a patient's risk of recurrence.

The prediction rule, which is simple to use, takes into account a patient's age, use of antibiotics, and severity of disease. The investigators demonstrated that the rule has a diagnostic accuracy of 72%.

These factors had been shown previously to be significant independent predictors of recurrent C. difficile diarrhea, wrote Dr. Mary Y. Hu of Harvard Medical School, Boston, and her colleagues. A fourth independent predictor—the serum level of antitoxin A IgG—appeared to reduce the accuracy of the rule.

The investigators derived the rule from a study of 63 patients hospitalized with C. difficile infection between January and May 1998. They validated the tool with data collected prospectively from 64 patients hospitalized between December 2004 and May 2006.

The rule assigns 1 point to each of the following characteristics: age greater than 65 years, disease judged to be severe or fulminant in intensity, and additional antibiotic use after the discontinuation of therapy for C. difficile infection. In the validation group, recurrence occurred in 7 of 19 patients scoring 2 points or higher (37%) but in 6 of 45 patients scoring 0 or 1 (13%).

In the validation cohort, the sensitivity of the rule was 54%, the specificity was 77%, the positive predictive value was 37%, and the negative predictive value was 87%. The diagnostic accuracy was 72%. This compared favorably to the original derivation cohort, in which the rule's diagnostic accuracy was 77%.

If the rule's threshold for assigning patients to the high-risk group was changed to a score of 1 or higher, the sensitivity increased to 100% in the validation cohort, but the specificity decreased to 18%. “This alternative application may be useful in circumstances where high sensitivity is paramount,” they wrote.

They also tested a combined rule that assigned an additional 2 points to a serum antitoxin A IgG level less than 1.29 ELISA units. With a threshold of 4 points or above, this combined rule appeared promising among the derivation cohort. Of these patients, 16 had antitoxin A IgG data available. Of those, all eight patients in the high-risk group had recurrent C. difficile infection, while only one of the eight patients in the low-risk group had recurrence. In this analysis, the sensitivity of the rule was 89%, the specificity was 100%, the positive predictive value was 100%, and the negative predictive value was 87.5%. The diagnostic accuracy was 94%.

Unfortunately, this rule proved to be far less predictive in the validation cohort, in which 26 patients had antitoxin A IgG data available. Infection recurred in 3 of 6 patients in the high-risk group and 5 of 20 patients in the low-risk group. This translates to a sensitivity of 38%, a specificity of 83%, a positive predictive value of 50%, and a negative predictive value of 75%. The diagnostic accuracy was 69%.

The three-factor prediction rule for recurrence was “simple, reliable, and accurate,” according to the investigators. “This rule is valuable in clinical practice as it defines a high-risk population in whom awareness of the risk can facilitate more prompt recognition, diagnosis, and treatment of recurrent [C. difficile infection]. These patients are also most likely to benefit from interventions to prevent recurrence, such as infection control precautions, prudent use of antibiotics, prolongation of metronidazole or vancomycin therapy, and use of probiotics or other prophylactic measures.”

The study was supported by grants from the National Institutes of Health and the Irish Health Research Board. One of the investigators, Dr. Ciarán P. Kelly of Harvard Medical School, acknowledged acting as a scientific consultant for Acambis, Actelion, BioHelix, Genzyme, Replidyne, Salix, and ViroPharm, and receiving research grant funding from Actelion, Genzyme, Massachusetts Biologics Laboratories, Medarex, and Salix Pharmaceuticals, companies that are producing or developing treatments for C. difficile infection.

A new rule can be used to predict recurrence of C. difficile infection, which can cause repeated bouts of diarrhea. CDC/DR. GILDA JONES

SAN FRANCISCO — People who worked at outdoor summer jobs as teenagers for 3 years or more had twice the risk of developing malignant melanoma later in life as those who did not, according to a case-control study by Dr. Darrell S. Rigel of New York University Medical Center.

Dr. Rigel presented his preliminary results at the annual meeting of the American Academy of Dermatology.

The study identified six independent risk factors, each of which increased the risk of malignant melanoma between two- and threefold. In addition to the outdoor summer job, the other five were history of blistering sunburns, red or blonde hair, marked freckling of the upper back, a family history of melanoma, and a history of actinic keratoses.

The study involved 300 consecutive patients with malignant melanoma who were compared with 302 age- and gender-matched controls. The average age of the patients was about 50 years, with a range from 18 years to the mid-70s.

In an interview, Dr. Rigel said there was at least one potential risk factor that was conspicuous by its absence from that list: The study found no increase in risk with increasing age. “The model tended to predict early on in life what was going to happen later in life,” he said.

The lifetime risk of melanoma in the U.S. population is about 1.5%, Dr. Rigel said. The presence of any one of the six risk factors increased this risk to 3%–5%.

The presence of two or more of the risk factors increases the lifetime risk 5–10 times over that of the general population. Those with three or more have a 10-fold to 20-fold increase in risk.

This study carries an important message to primary care physicians, Dr. Rigel said. “There's only 9,000 [U.S.] dermatologists. Only one-third of dermatologic disease is treated by dermatologists. That means two-thirds are going to [primary care physicians]. We want those melanomas to be detected early. So models like this may let the primary care physician also focus on who they should focus their efforts on.”

Dr. Rigel disclosed financial relationships with Graceway, Pharmaderm, Johnson and Johnson, Neutrogena, and LaRoche-Posay. He said that none of those were relevant to his presentation and the study was privately funded.

SAN FRANCISCO — People who worked at outdoor summer jobs as teenagers for 3 years or more had twice the risk of developing malignant melanoma later in life as those who did not, according to a case-control study by Dr. Darrell S. Rigel of New York University Medical Center.

Dr. Rigel presented his preliminary results at the annual meeting of the American Academy of Dermatology.

The study identified six independent risk factors, each of which increased the risk of malignant melanoma between two- and threefold. In addition to the outdoor summer job, the other five were history of blistering sunburns, red or blonde hair, marked freckling of the upper back, a family history of melanoma, and a history of actinic keratoses.

The study involved 300 consecutive patients with malignant melanoma who were compared with 302 age- and gender-matched controls. The average age of the patients was about 50 years, with a range from 18 years to the mid-70s.

In an interview, Dr. Rigel said there was at least one potential risk factor that was conspicuous by its absence from that list: The study found no increase in risk with increasing age. “The model tended to predict early on in life what was going to happen later in life,” he said.

The lifetime risk of melanoma in the U.S. population is about 1.5%, Dr. Rigel said. The presence of any one of the six risk factors increased this risk to 3%–5%.

The presence of two or more of the risk factors increases the lifetime risk 5–10 times over that of the general population. Those with three or more have a 10-fold to 20-fold increase in risk.

This study carries an important message to primary care physicians, Dr. Rigel said. “There's only 9,000 [U.S.] dermatologists. Only one-third of dermatologic disease is treated by dermatologists. That means two-thirds are going to [primary care physicians]. We want those melanomas to be detected early. So models like this may let the primary care physician also focus on who they should focus their efforts on.”

Dr. Rigel disclosed financial relationships with Graceway, Pharmaderm, Johnson and Johnson, Neutrogena, and LaRoche-Posay. He said that none of those were relevant to his presentation and the study was privately funded.

SAN FRANCISCO — People who worked at outdoor summer jobs as teenagers for 3 years or more had twice the risk of developing malignant melanoma later in life as those who did not, according to a case-control study by Dr. Darrell S. Rigel of New York University Medical Center.

Dr. Rigel presented his preliminary results at the annual meeting of the American Academy of Dermatology.

The study identified six independent risk factors, each of which increased the risk of malignant melanoma between two- and threefold. In addition to the outdoor summer job, the other five were history of blistering sunburns, red or blonde hair, marked freckling of the upper back, a family history of melanoma, and a history of actinic keratoses.

The study involved 300 consecutive patients with malignant melanoma who were compared with 302 age- and gender-matched controls. The average age of the patients was about 50 years, with a range from 18 years to the mid-70s.

In an interview, Dr. Rigel said there was at least one potential risk factor that was conspicuous by its absence from that list: The study found no increase in risk with increasing age. “The model tended to predict early on in life what was going to happen later in life,” he said.

The lifetime risk of melanoma in the U.S. population is about 1.5%, Dr. Rigel said. The presence of any one of the six risk factors increased this risk to 3%–5%.

The presence of two or more of the risk factors increases the lifetime risk 5–10 times over that of the general population. Those with three or more have a 10-fold to 20-fold increase in risk.

This study carries an important message to primary care physicians, Dr. Rigel said. “There's only 9,000 [U.S.] dermatologists. Only one-third of dermatologic disease is treated by dermatologists. That means two-thirds are going to [primary care physicians]. We want those melanomas to be detected early. So models like this may let the primary care physician also focus on who they should focus their efforts on.”

Dr. Rigel disclosed financial relationships with Graceway, Pharmaderm, Johnson and Johnson, Neutrogena, and LaRoche-Posay. He said that none of those were relevant to his presentation and the study was privately funded.

SAN FRANCISCO — As many as 26,500 ischemic strokes occurring in the United States each year may be associated with patient withdrawal from antithrombotic and antiplatelet medications, according to a study presented at the International Stroke Conference.

Among 2,082 patients in the Cincinnati area who had 2,191 ischemic strokes in 2005, 84 (3.8%) of the strokes occurred in patients who had stopped their medications within 60 days. The first 7 days after withdrawal of antiplatelet or antithrombotic medication appeared to be the most dangerous time, Dr. Jordan Bonomo of the University of Cincinnati reported. Some patients had been on more than one medication simultaneously.

A total of 182 strokes occurred in patients who were either on warfarin or recently had stopped taking the drug. Of the 58 strokes that occurred in those who went off warfarin, 31 were within 7 days of withdrawal, 12 between 8 and 14 days, 8 between 15 and 30 days, and 7 between 31 and 60 days.

Similarly, 896 patients had been taking aspirin around the time of their stroke. Of these, 44 had discontinued aspirin; 24 of the strokes occurred within 7 days after halting aspirin therapy; 7 occurred between 8 and 14 days, 11 between 15 and 30 days, and 2 between 31 and 60 days.

The investigators found a similar pattern among 228 patients who had been taking clopidogrel around the time of their stroke, 21 of whom had gotten off the drug—10 strokes occurred within 7 days of discontinuation, 4 between 8 and 14 days, 5 between 15 and 30 days, and 2 between 31 and 60 days.

Dr. Bonomo noted that the greater Cincinnati area is demographically similar to the overall U.S. population. Therefore, of the 692,000 ischemic strokes that occur annually in the United States, an estimated 26,500 occur in patients who have withdrawn from antithrombotic or antiplatelet medications within 60 days.

Of the 84 strokes, 54 (64%) occurred in patients whose medication had been withdrawn on the order of their physicians.

In most cases, physicians ordered withdrawal because of an upcoming medical procedure or because of bleeding. Among the withdrawals that occurred when the patient stopped their medication on their own, noncompliance and financial burden were the most common causes.

These results “mandate continued review of guidelines for withdrawal of anticoagulant and antiplatelet medication in the peri-procedural period,” Dr. Bonomo said. To investigate these matters further, the National Heart, Lung, and Blood Institute is funding a clinical trial called Effectiveness of Bridging Anticoagulation for Surgery (The BRIDGE Study) that will begin in May 2009.

Dr. Bonomo stated that he had no conflicts of interest to disclose. The study was supported by the National Institute of Neurological Disorders and Stroke.

SAN FRANCISCO — As many as 26,500 ischemic strokes occurring in the United States each year may be associated with patient withdrawal from antithrombotic and antiplatelet medications, according to a study presented at the International Stroke Conference.

Among 2,082 patients in the Cincinnati area who had 2,191 ischemic strokes in 2005, 84 (3.8%) of the strokes occurred in patients who had stopped their medications within 60 days. The first 7 days after withdrawal of antiplatelet or antithrombotic medication appeared to be the most dangerous time, Dr. Jordan Bonomo of the University of Cincinnati reported. Some patients had been on more than one medication simultaneously.

A total of 182 strokes occurred in patients who were either on warfarin or recently had stopped taking the drug. Of the 58 strokes that occurred in those who went off warfarin, 31 were within 7 days of withdrawal, 12 between 8 and 14 days, 8 between 15 and 30 days, and 7 between 31 and 60 days.

Similarly, 896 patients had been taking aspirin around the time of their stroke. Of these, 44 had discontinued aspirin; 24 of the strokes occurred within 7 days after halting aspirin therapy; 7 occurred between 8 and 14 days, 11 between 15 and 30 days, and 2 between 31 and 60 days.

The investigators found a similar pattern among 228 patients who had been taking clopidogrel around the time of their stroke, 21 of whom had gotten off the drug—10 strokes occurred within 7 days of discontinuation, 4 between 8 and 14 days, 5 between 15 and 30 days, and 2 between 31 and 60 days.

Dr. Bonomo noted that the greater Cincinnati area is demographically similar to the overall U.S. population. Therefore, of the 692,000 ischemic strokes that occur annually in the United States, an estimated 26,500 occur in patients who have withdrawn from antithrombotic or antiplatelet medications within 60 days.

Of the 84 strokes, 54 (64%) occurred in patients whose medication had been withdrawn on the order of their physicians.

In most cases, physicians ordered withdrawal because of an upcoming medical procedure or because of bleeding. Among the withdrawals that occurred when the patient stopped their medication on their own, noncompliance and financial burden were the most common causes.

These results “mandate continued review of guidelines for withdrawal of anticoagulant and antiplatelet medication in the peri-procedural period,” Dr. Bonomo said. To investigate these matters further, the National Heart, Lung, and Blood Institute is funding a clinical trial called Effectiveness of Bridging Anticoagulation for Surgery (The BRIDGE Study) that will begin in May 2009.

Dr. Bonomo stated that he had no conflicts of interest to disclose. The study was supported by the National Institute of Neurological Disorders and Stroke.

SAN FRANCISCO — As many as 26,500 ischemic strokes occurring in the United States each year may be associated with patient withdrawal from antithrombotic and antiplatelet medications, according to a study presented at the International Stroke Conference.

Among 2,082 patients in the Cincinnati area who had 2,191 ischemic strokes in 2005, 84 (3.8%) of the strokes occurred in patients who had stopped their medications within 60 days. The first 7 days after withdrawal of antiplatelet or antithrombotic medication appeared to be the most dangerous time, Dr. Jordan Bonomo of the University of Cincinnati reported. Some patients had been on more than one medication simultaneously.

A total of 182 strokes occurred in patients who were either on warfarin or recently had stopped taking the drug. Of the 58 strokes that occurred in those who went off warfarin, 31 were within 7 days of withdrawal, 12 between 8 and 14 days, 8 between 15 and 30 days, and 7 between 31 and 60 days.

Similarly, 896 patients had been taking aspirin around the time of their stroke. Of these, 44 had discontinued aspirin; 24 of the strokes occurred within 7 days after halting aspirin therapy; 7 occurred between 8 and 14 days, 11 between 15 and 30 days, and 2 between 31 and 60 days.

The investigators found a similar pattern among 228 patients who had been taking clopidogrel around the time of their stroke, 21 of whom had gotten off the drug—10 strokes occurred within 7 days of discontinuation, 4 between 8 and 14 days, 5 between 15 and 30 days, and 2 between 31 and 60 days.

Dr. Bonomo noted that the greater Cincinnati area is demographically similar to the overall U.S. population. Therefore, of the 692,000 ischemic strokes that occur annually in the United States, an estimated 26,500 occur in patients who have withdrawn from antithrombotic or antiplatelet medications within 60 days.

Of the 84 strokes, 54 (64%) occurred in patients whose medication had been withdrawn on the order of their physicians.

In most cases, physicians ordered withdrawal because of an upcoming medical procedure or because of bleeding. Among the withdrawals that occurred when the patient stopped their medication on their own, noncompliance and financial burden were the most common causes.

These results “mandate continued review of guidelines for withdrawal of anticoagulant and antiplatelet medication in the peri-procedural period,” Dr. Bonomo said. To investigate these matters further, the National Heart, Lung, and Blood Institute is funding a clinical trial called Effectiveness of Bridging Anticoagulation for Surgery (The BRIDGE Study) that will begin in May 2009.

Dr. Bonomo stated that he had no conflicts of interest to disclose. The study was supported by the National Institute of Neurological Disorders and Stroke.