Several studies (not to mention common sense) have shown that better communication and coordination of care should reduce preventable adverse outcomes in patients with chronic disease. This approach to disease management has been greatly facilitated by Web-based monitoring and reporting tools, smartphones, and other technologies. The question confronting physicians, patients, and payers as we move ahead is: does any of this work?

“Monitoring of live-feed data from the homes of the elderly or infirm will tell clinicians and family members about medication taking, ambulation, consumption, and other aspects of autonomous daily living. Implantable devices with wireless feeds will report patients’ physiological status to physicians and monitoring centers and will report functional anomalies to the manufacturer and relevant federal agencies. And that is not to mention inputs about weight and reaction times from automobiles, ambient environmental sampling data linked to one’s location by wearable global positioning system (GPS) devices, exercise data from implantable stress monitors, and sensors at one’s desk for other kinds of stress. In short, the future of interoperability is to bind together a wide network of real-time, life-critical data that not only transform health care but become health care.” 

— David J. Brailer, MD, PhD, Former National Health Information Technology Coordinator (

Just five years after Brailer’s Orwellian forecast, most of these predictions are already reality, spawned by our need to control an epidemic of chronic disease.

Chronic illness accounts for most of the disease burden in the United States. The cost, in lives and dollars, is staggering. Almost one out of every two adults has at least one chronic illness, and 70% of deaths are attributable to chronic disease (

). Chronic diseases consume 70% of healthcare expenditures, with a current estimated financial cost of $2 trillion per year and a projected cost of over $4 trillion by 2023 as the population continues to age (

). Most chronic diseases cannot be cured and, given our refractory lifestyle choices, are unlikely to be prevented. Can they at least be better managed?

Disease management (DM) evolved from the rational notion that better communication and coordination of care should reduce preventable adverse outcomes in patients with chronic disease. The concept was enthusiastically embraced, perhaps prematurely, by insurers and large employers eager to find ways to reign in health care costs and improve the health of their beneficiaries.

Early models of DM involved the development of call centers staffed with nurses who routinely contacted at-risk patients to provide follow-up and advice. Interventions were targeted toward those with the most common chronic diseases: asthma, congestive heart failure, depression, diabetes, and hypertension. Poorly controlled diabetics might, for example, be asked to communicate daily blood sugars and symptoms to nurses trained to adjust insulin dosages, with the hope that the need for hospital admissions might be preempted. Such programs were liked by patients and were generally accepted as being of value, although this latter conclusion may have been supported more on the basis of commonsense assumptions rather than rigorous financial analysis. Nonetheless, DM has grown into what is currently a $2.5 billion-per-year industry (

As interventions expanded beyond the call center, a wider concept of what constitutes DM evolved. DM is now broadly defined as “a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant” (

Not surprisingly, technology is extending the reach and scope of DM. Advances in monitoring devices allow for less obtrusive, real-time patient monitoring, while the Internet is replacing the telephone as a means of educating patients and allowing them to communicate with their providers. Adoption has been further accelerated by the availability of devices that work faster, cost less, and are easier to use, coupled with greater access to broadband and wireless pipelines by more segments of the population.

Web-enabled disease management: no longer science fiction

Effective DM depends on frequent, regular monitoring of patients. Devices now exist that can unobtrusively monitor a wide variety of physiologic data with little or no effort on the part of patients. For example, a band-aid like device is currently available that can monitor respirations, oximetry, patient movement, temperature, and electrocardiogram—and display that information on an individual’s cell phone or transmit it via the Internet (

). A sensor wire (the diameter of two human hairs) can be inserted under the skin by a diabetic patient to allow continuous wireless monitoring of blood sugars (

). A “smart-pill” system allows physicians to monitor medication adherence by attaching tiny microchips to patients’ pills; as each pill passes the stomach, the patient’s prescriber is notified by the patient’s smartphone via the Internet (

). For $3,500, one can even purchase an “Intelligence Toilet” system, capable of measuring sugar levels in urine, blood pressure, body fat, and weight (

). The toilet automatically transfers its data to a home network for analysis on a personal computer. Each of these devices is already commercially available. Other wearable innovations, such as a “smart tee shirt” used by the military to monitor vital signs and remotely detect gunshot wounds, will undoubtedly soon find their way into the DM armamentarium (

The biggest current obstacle to smarter DM is not sensor technology, however. According to Steven

Eisenberg, MD, senior vice president and chief science officer at LifeMasters Supported SelfCare Inc, “Physicians are never going to have the time to spend going through volumes and volumes of data, so it is going to be up to the computers themselves to integrate, correlate, and analyze” (

). Currently, device technology leads development of those systems, but the latter will undoubtedly catch up.

Ultimately, however, it is the non-technological factors that will likely determine the face of DM in the 21st century. Continuous transmission of intimate physiologic details over wireless networks and the Internet demands rigorous security and personal privacy protections. Indeed, such technologies may well challenge society to re-examine the definition of “personal space” (

). Furthermore, DM must prove itself cost-effective in an era of dwindling economic resources and competing societal priorities.

Critics and skeptics are quick to point out that DM has not yet convincingly been demonstrated to be an effective strategy. A 2009 Rand report concluded that DM could increase employer and government spending in Massachusetts by $6.7 billion over 10 years with little overall benefit (

). This followed a 2008 analysis of a Medicare pilot project of 200,000 patients, which concluded that DM did not reduce hospitalizations, emergency room visits, or deaths from chronic disease. Proponents of DM argue that the study included patients who were not representative of those most likely to benefit and that Medicare did not extend the study long enough to see benefits. They cite contrasting studies, such as one study of elderly veterans that found a combination of home telemonitoring, video visits, and coordinated care resulted in a 40% reduction in emergency room visits, a 63% reduction in hospital admissions, a 60% reduction in hospital bed days of care, and similar reductions in nursing home care (

Both sides of the debate note that studies of DM to date have been of variable quality, often involved small numbers of patients, and may have used flawed assumptions in their cost-effectiveness analyses. A study published last month in the 

) addressed these methodological concerns (also, see the accompanying editorial at 

). This randomized controlled trial followed 1,653 patients recruited from 33 cardiology practices across the US who were recently discharged following hospitalization for heart failure.

The study demonstrated that telemonitoring did not reduce readmission rates or death over the six month follow-up period. Not surprisingly, the researchers found that by the final week of the study period, only 55% of patients were still using the system at least three times per week; 14% of patients in the telemonitoring group never used the system. (These latter observations are probably not unexpected by physicians; technological solutions alone are unlikely to ever overcome the intrinsic difficulties of motivating and changing human behavior.)

The authors concluded that their results “underscore the need for rigorous, independent evaluation of disease-management systems before their adoption. In an environment in which vendors promote their products to health systems that are under increasing pressure to reduce readmission rates, the knowledge that telemonitoring is ineffective suggests the need to consider alternative approaches to improving care” (

). Studies of DM in other conditions should be forthcoming (http://hcp.lv/dBirb1).

In the meantime, action-oriented business leaders are already convinced; DM programs are currently offered by three-quarters of large companies and most Medicaid programs (

). Given this level of commitment by business and government, the future of DM would seem secure over the near term. The shape it will take, however, is less certain.

Currently, most formal DM is administered by disease management organizations contracted to insurers and employers. But this model has been criticized as being too remote from patients, both physically and personally. In an article in 

), General Electric’s Chief Medical Officer, Robert S. Galvin, MD, expressed skepticism that chronically ill employees would change unhealthy behavior at the direction of unfamiliar nurses calling from remote offices. This seems a salient point; behavior change is the ultimate determinate of effective self care, and most chronic diseases are, at least in part, the result of unhealthy habits. Galvin, a former primary care physician, stated it this way: “If you are going to influence someone, you need a social relationship with them.” He and others thus favor a different model of incentivizing patients’ own physicians to provide DM services from their offices.

Physician-directed DM is a central premise of the “patient-centered medical home,” a concept endorsed in a joint position statement by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association (

). In this model, it is the primary care physician who directs, provides, and coordinates DM within the context of an ongoing patient—physician relationship. Primary care physicians would, of course, expect reimbursement for providing these services, including the time spent reviewing and responding to remotely acquired patient data. There is uniform agreement that without major reimbursement reform, the patient-centered medical home and a shift toward physician-directed DM is unlikely to succeed.

Although the eventual form and ultimate impact of DM over the next decade remains speculative, the epidemic of chronic illness ensures that DM will play an increasing role in healthcare policy and delivery. Evolving technology will undoubtedly overcome remaining barriers, providing us with the capability to broadly scrutinize measures of health, disease, and behavior. These capabilities will continue to challenge our concepts of privacy and prompt us to re-examine fundamental assumptions, such as “What constitutes reasonable care?” “How should we prioritize healthcare funding?” and “What is the ideal patient—physician relationship?” In the end, however, we are still faced with the most daunting obstacle to chronic disease management: human behavior. Technology alone is unlikely to overcome this final fundamental barrier to better health.

editorial board member and program director, Internal Medicine Residency and associate professor of Clinical Medicine, Department of Medicine, University of Illinois College of Medicine, Peoria, IL. 

Articles

Cover Story

Technology is extending the reach and scope of disease management in cardiology and other specialties and enabling less obtrusive, real-time patient monitoring.

Breaking Boundaries with Web-based Disease Management

Are your patients aware of the difference between angina and myocardial infarction? Despite the fact that symptoms of angina will most likely alleviate within a matter of minutes, the experience could be enough to send patients into a panic, thinking that they’re having a heart attack. This guide from HealthierYou.com explains the difference between the two, what causes angina, how it is diagnosed and treated, what types of chest pain are considered angina, what level of exercise is safe, and the definitions of stable and unstable angina, and the two forms of angina pectoris.

Chronic Stable Angina: Disease Progression or Status Quo?

This straightforward activity aims to educate practitioners about “the most up-to-date information regarding management of patients with chronic stable angina, including attention to escalating symptoms, atypical complaints, and the potential for a worsening clinical picture.”

Over the course of an hour you’ll be hearing from Eugene Braunwald, MD, Distinguished Hersey Professor of Medicine, Harvard Medical School; Carl Pepine, MD, Professor of Medicine, Professor and Chief, Division of Cardiovascular Medicine, University of Florida; and Peter Stone, MD, Associate Professor of Medicine, Harvard Medical School. Their three presentations focus on the evolution of “the field of angina” over the past 20 years, specifically dealing with medical interventions “and how this has affected the identification and evaluation of patients.” Further, participants will be asked to “identify treatment gaps” (ie, “what do patients still need in the age of revascularization?”) and “assess new medical approaches and how they differ from traditional agents.”

An Elderly Woman with Unstable Angina/Non-ST-Elevation Myocardial Infarction Presenting for Follow-up

The developers of this activity felt there was a significant opportunity to educate clinicians about three “major practice gaps [that] have been noted in the treatment approaches rendered by healthcare professionals…in the area of acute coronary syndromes.” All focus on the administration of antiplatelet therapy, about which it is recommended clinicians “increase their awareness of the options for dual antiplatelet therapy, including available agents, dosing regimens, and timing of administration, to come closer to achieving equilibrium between safety and efficacy in the context of acute and long-term care of patients with ACS.”

This podcast, which introduced listeners to “CardioExchange, a joint effort by Journal Watch and the New England Journal of Medicine to create an online community of clinicians interested in cardiovascular diseases,” features, among other topics, an interview in which CardioExchange editors Drs. Richard Lange and L. David Hillis discuss the COURAGE study with Dr. Gregg Stone of Columbia University and Dr. William Bowden of the University of Buffalo. In the study, researchers compared medical therapy alone to medical therapy combined with PCI for the initial management of patients with stable coronary artery disease. They found that PCI reduced angina but didn’t reduce hard end points like death, myocardial infarction, and later hospitalizations for coronary disease.

Delay from Symptom Onset to Hospital Presentation for Patients with Non—ST-Segment Elevation Myocardial Infarction

 Though “secular trends and factors associated with delay time from symptom onset to hospital presentation are known for patients with ST-segment elevation myocardial infarction,” they “are less well-described for non-STEMI.”

 The authors “studied 104,622 patients with non-STEMI enrolled at 568 hospitals participating in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines” over a six-year period and found that “lond delay times are common and have not changed over time for patients with non-STEMI” in large part because “patients cannot differentiate whether symptoms are due to STEMI or non-STEMI.” This highlights the importance of “early presentation…in both instances.”

Impact of Therapy with Statins, Beta-blockers and Angiotensin-converting Enzyme Inhibitors on Plasma Myeloperoxidase in Patients with Coronary Artery Disease 

 Ndrepepa G, Braun S, Schömig A, Kastrati A

 The authors analyzed blood samples of a 680-patient cohort “with angiographically confirmed CAD: 382 patients with stable CAD, 107 patients with unstable angina and 191 patients with ST-segment elevation acute myocardial infarction” in order to investigate “whether therapy with statins, beta-blockers and angiotensin-converting enzyme inhibitors on admission affects the plasma level of myeloperoxidase in patients with coronary artery disease.”

 “On admission, 316 patients were receiving statins, 432 patients were receiving beta-blockers and 354 patients were receiving ACE inhibitors.” Though beta-blockers were “independently associated with lower levels of plasma myeloperoxidase,” researchers found that “pre-admission therapy with statins, beta-blockers or ACE inhibitors reduced MPO levels in patients with acute coronary syndromes, but not in patients with stable CAD.”

Incidence and Prognosis of Angina Pectoris in South Asians and Whites 

 Because the causes of “higher coronary mortality in South Asians compared with White populations” are unknown, researchers examined the “cumulative incidence of chest pain…and prognosis of chest pain” in the two groups.

“Over seven phases of 18-year follow-up of the Whitehall-II study…chest pain was assessed using the Rose questionnaire. Coronary death/non-fatal myocardial infarction was examined comparing those with chest pain to those with no chest pain at baseline.” An analysis of the data obtained revealed that “South Asians had higher cumulative frequencies of typical angina by Phase 7…and exertional chest pain…compared with Whites.” Overall, prognosis was worse in South Asians.

The Relationship between Early Left Ventricular Myocardial Alterations and Reduced Coronary Flow Reserve in Non-Insulin-Dependent Diabetic Patients with Microvascular Angina

D’Andrea A, Nistri S, Castaldo F, et al

Researchers selected “a population of 45 normotensive patients with non-insulin dependent diabetes mellitus…with left ventricular ejection fraction > 50% and microvascular angina…[and] thirty-five age-and sex-matched healthy controls” to take part in a study that would help them “evaluate left ventricular systolic and diastolic myocardial function, and their relation to coronary flow reserve…”

“All the patients underwent standard echocardiography, Tissue Doppler (TDI), two-dimensional strain (2DSE) imaging, and coronary flow reserve (CFR) measurement.” The authors found all tests to be “valuable non-invasive and easy-repeatable tools for detecting LV myocardial and coronary function in DM patients with microvascular angina.”

Improvement in Left Ventricular Systolic and Diastolic Performance During Ranolazine Treatment in Patients With Stable Angina

Journal of Cardiovascular Pharmacology and Therapeutics

 Figueredo V, Pressman G, Romero-Corral A, et al

 “By preventing myocyte sodium and calcium overload, ranolazine also have potential beneficial effects on myocardial function.” Because previous research “support[s] this concept,” researchers sought to evaluate “changes in parameters of left ventricular function in stable angina patients treated with oral ranolazine.”

 “Global left ventricular function, as assessed by the myocardial performance index, was significantly improved on drug therapy…due to improvement in both diastolic and systolic parameters.” Out of 21 total patients, “17 reported less angina and 8 patients reported an increase in activity level.”

 Individuals with angina, right ventricular ischemia, and pulmonary arterial hypertension are eligible to participate in this study which will “determine if the medication, ranolazine (study drug), can help improve blood flow to your heart, increase your exercise capacity and improve your quality of life.”

Generic Product News: Enozaparin Sodium Injection

Enoxaparin sodium injection is indicated for the prevention and treatment of deep vein thrombosis, the prevention of ischemic complications of unstable angina and myocardial infarction (MI), and the treatment of acute ST-segment elevation MI, and was the first generic version of Lovenox to receive FDA approval.

Paramedic Defibrillator/Monitors to Transmit Cardiac Data to Physician iPhones/iPads

Medtronic's Physio-Control has partnered with AirStrip Technologies to bring real-time monitoring of cardiac data from the ambulance straight to a physician's iPhone or iPad. Physio-Control's LIFEPAK monitor/defibrillators will transmit ECG data via the firm's LIFENET system to AirStrip's CARDIOLOGY app.

Net Guide

Angina

Clinical Decisions Case-based Lesson: Upper Respiratory Tract Infections

This brief, question-and-answer-based course focuses on the clinical manifestations of upper respiratory tract infections (URIs), appropriate management of URI, and counseling of patients on how to prevent the spread of upper respiratory tract infections.

Although viruses are the most common causes of cases of pharyngitis, group A beta hemolytic 

infection (GABHS) “can be the cause in children (15%-30%) and adults (5%-10%).” This activity will provide physicians with the knowledge to determine which cases of pharyngitis are caused by GABHS. The primary reason to identify and treat GABHS—“to decrease the risk of acute rheumatic fever”&mdash;is discussed, as well as the growing concern about “the indiscriminate use of antibiotics.”

Developing a Computer Delivered, Theory Based Intervention for Guideline Implementation in General Practice

 McDermott L, Yardley L, Little P, et al.

To “develop computer-delivered prompts to promote guideline adherence for antibiotic prescribing in respiratory tract infections, and adherence to recommendations for secondary stroke prevention.”

General practitioners were more likely to use prompts that were perceived as offering support and choice as opposed to those perceived as methods of enforcement. Anticipated patient outcomes, individual prescriber differences, accessibility and presentation of prompts, and acceptability of guidelines also played a role in physician’s attitudes toward use of the prompts. After prompts were modified based on participant feedback, comments regarding them were mostly positive.

Effect of Two Interventions on Reducing Antibiotic Prescription in Pharyngitis in Primary Care

(November 16, 2010; online ahead of print)

Llor C, Maria Cots J, Lopez-Valcarcel B, et al.

 To “evaluate the effect of two interventions”—discussion sessions of the results of a registry of all pharyngitis cases during a three-week period, courses for general practitioners, guidelines,  patient information leaflets, workshops on rapid tests, and use of rapid antigen detection tests (RADTs) in consulting offices versus all of the above minus the workshop and RADTs&mdash;“on reducing antibiotic prescription in pharyngitis,”

Although the prescription of antibiotics was reducing with intervention use, reductions were only statistically significant when RADTs were provided to the general practitioners.

Staphylococcus Aureus Sinus Infections in Children

 International Journal of Pediatric Otorhinolaryngology

(November 12, 2010; online ahead of print)           

“To describe the clinical characteristics of pediatric patients with 

cultured from sinus specimens, treated at Texas Children's Hospital (TCH), and [characterize] their isolates by molecular methods.”

“MSSA was more commonly isolated than MRSA from sinus cultures of children who underwent ESS at TCH. The majority of ESS cultures positive for 

, were mixed with other respiratory pathogens, principally 

. USA300 was the major clone among the MRSA sinusitis isolates, but was not associated with more complications than other 

Effectiveness of the Acute Respiratory Infection Smart Form

 Agency for Healthcare Research and Quality

 “To design and implement an integrated documentation-based clinical decision support and physician feedback system, provided in an electronic health record (EHR), to improve the management of patients with acute medical conditions,” with the hypothesis that such systems “can be designed and implemented to facilitate documentation and physician order-entry, provide individualized, evidence-based recommendations for the management of patients acute respiratory infections (ARIs), and are usable by primary care physicians.”

 To “learn more about the genetics of chronic sinusitis and identify genes involved in chronic sinusitis.”

Vitamin D and Health Advice for the Prevention of Upper Respiratory Tract Infections

To “assess the effectiveness of daily gargling and vitamin D supplementation as preventative measures against incident upper respiratory tract infection,” based on the hypothesis that both vitamin D3 supplementation and gargling will decrease the incidence of symptomatic upper respiratory tract infections.

Medline Plus Medical Encyclopedia: Pharyngitis

Because most cases of pharyngitis can be treated without the need for prescription medications, the “Treatment” section of this website will be useful for patients who are unsure how to take care of pharyngitis. Remedies are described for reducing pain, such as acetaminophen and use of a cool-mist vaporizer. The information on complications and when additional medical attention may be necessary will also be particularly helpful for patients in determining what symptoms constitute a more serious problem.

Upper Respiratory Infection Causes, Symptoms, and Treatment by MedicineNet.com

This physician-authored and -edited site thoroughly covers all the bases when it comes to upper respiratory infections, from risk factors and diagnosis to home remedies and prevention. Site visits can also view slideshows that cover “the superbug,” infectious mononucleosis, and strep or sore throat. Throughout this resource, key terms are hyperliniked to equally comprehensive information on those topics, including laryngitis, whooping cough, Echinacea, and nonsteroidal anti-inflammatory drugs.

Acute Pharyngitis in Adults: Physician Information Sheet

The principles described in this CDC guideline “apply to the diagnosis and treatment of Group A ß-hemolytic streptococcal (GABHS) pharyngitis in otherwise healthy adults.” A description of the multi-step process needed to confirm acute pharyngitis will serve as an instant refresher course for physicians, while the treatment section will provide standard options as well as ways for reducing antibiotic use in patients.

Mom Was Right: Vapor Rub can Help that Cough

A study that put an old, commonly used remedy to the test found that vapor rubs can indeed provide symptomatic relief from nocturnal cold symptoms in children.

Primary Care Doctors Need More, Better Info about Sinusitis

Primary care doctors often don't have the latest information on sinusitis diagnosis and management.

Diclofenac Potassium Versus Acetaminophen in Febrile Children with Acute Upper Respiratory Tract Infections

Upper Respiratory Infection

Unraveling the Complexities of Menopause Management

Though this CME activity is expired, the educational material, of which there is a good amount, remains relevant and fresh. The eight presentations are: Critical Issue of Disentangling Menopause From Aging; Applying an Understanding of the Mechanisms of Action of Estrogen and SERMs to Patient and Treatment Selection in Clinical Practice; Putting the WHI into Clinical Perspective; Are All SERMs the Same?; Selecting Candidates for Fracture Prevention Based on Risk Prediction; Efficacy and Safety Profiles of New and Emerging Menopause Treatments; Future Treatment Strategies for Menopausal Symptom Management; Starting and Stopping Hormone Therapy.

International Menopause Society Educational Slide Kit

Though the impetus behind the IMS Educational Slide Kit was the IMS Workshop in Budapest during February of 2007, only eight of 13 sections are currently available for download. All focus on various aspects of caring for women with menopause and were put together with the

Did you know that menopause could be considered an extremely rare reproductive disorder? Out of the entire animal kingdom, humans and two species of whale are the only ones that share the experience of going through menopause. 

 Online News Editor David Grimm discusses why, in addition to whether parasites can lower your IQ and astrobiologists’ hopes of finding extraterrestrial life.

Created by Kathryn Colas after having survived her own “hormonal anarchy,” Simply Hormones seeks to help guide women through “the pit-falls that can be experienced during ‘the change.” She’s lately been adding podcasts, the fifth in the series being an interview with a woman name Marian Child who discusses the experience of going through menopause at the early age of 43.

Management of Osteoporosis in Postmenopausal Women

The North American Menopause Society has designated their 2010 position statement on the management of osteoporosis in postmenopausal women a CME activity that they intend will educate physicians on “the effect of menopause and aging on bone health…risk factors that contribute to fracture risk…how to rule out secondary causes of osteoporosis…nonpharmacologic and lifestyle approaches to prevent bone loss and fractures…the effects of various therapeutic agents on preventing osteoporotic fracture [and] their effects on bone density and turnover…developing treatment strategies to reduce morbidity and quality of life…and understanding the clinical effects of discontinuing different antiresporptive and anabolic therapies.”

Midlife Menopause Mangement: Assessing Risks and Benefits, Individualizing Strategies

This activity comprises four articles, each of which focus on “assessing benefits and risks of hormone therapy…highlights from the latest WHI publications and the latest North American Menopause Society position statement on use of menopausal hormone therapy…nonhormonal approaches to menopausal management…[and] putting the latest data into practice.”

Determinants of Short-term Memory: Is there a Difference between Young Adults and Postmenopausal Women?

 Di Blasio A, Di Donato F, D’Angelo E, et al

 Researchers were attempting to identify “the main determinants of the short-term memory among anthropometric, dietary and performance variables in a sample of healthy women.” They also examined whether age plays a role. “Participants were analyzed for Digit Span, blood pressure, body composition, aerobic fitness and dietary habits.”

 Of the 45 “healthy overweight women” recruited for the study, “22 were postmenopausal.” The authors found that “in postmenopause, vitamin D daily intake is important not only for skeletal, but also for cognitive health,” though overall the “young adults and post-menopausal women did not differ for health status.”

D’haeseleer E, Depypere H, Claeys S, et al

 Researchers wanted to “describe the effect of menopause on vocal characteristics” and did so “by comparing premenopausal and postmenopausal women (not taking hormone therapy [HT]).”

 Despite “significant differences in aerodynamic parameters…vocal range…and acoustic parameters” between the two groups, the authors concluded that “postmenopausal women not taking HT had a good overall vocal quality. However, in comparison with premenopausal women, they showed a lower habitual fundamental frequency in continuous speech.”

Factors Associated with Non-compliance with Hormone Therapy Cessation before Screening Mammography

 Conducted at “Group Health, a health plan in Washington State,” this study randomized 1704 women to one of three groups (no cessation and 1-month or 2-month cessation) and had them to self-report certain data “before the study mammogram, including symptoms and compliance,” as well as “complete baseline and follow-up questionnaires.”

 While “most participants were using unopposed estrogen (63.3%) and intended to continue HT (90%),” and “9.6% were non-compliant with HT cessation,” participants more likely to be non-compliant were of younger age, lower BMI, symptom severity and use of unopposed estrogen.” The authors insist that “alternatives for menopause symptom management are needed to assist women with HT cessation.”

A “Window of Opportunity:” The Reduction of Coronary Heart Disease and Total Mortality with Menopausal Therapies is Age- and Time-dependent

 The authors analyzed reams of data in order to identify “the ‘window of opportunity’ for reducing coronary heart disease (CHD) and overall mortality” for women undergoing menopausal therapies.

 “The totality of data” indicates that “initiation of hormone therapy within 6 years of menopause and/or before 60 years of age…reduces CHD risk and overall mortality…and substantially increases quality-adjusted life-years (QALYs) by 1.5 QALYs and is highly cost-effective at $2438 per QALY gained.”

The Role of Vitamin D in Menopause: Relationship to Menopausal Symptoms in Body Composition

This study was put together with three specific goals: 1) “To compare effects of Vitamin D supplementation to usual care on symptoms in women transitioning to early postmenopause and determine the associated effect size in order to conduct a power analysis for a future RCT”; 2) “To compare effects of Vitamin D supplementation to usual care on body composition…in overweight/obese women transitioning to early postmenopause and determine the associated effect size for a power analysis for a future RCT”; 3) “To estimate the proportion of overweight/obese middle-aged women who achieve sufficiency by 1 month versus 2 or more months and to determine if achieving sufficiency by 1 month varies by baseline characteristics.”

Over the course of 24 weeks, women with moderate to severe vasomotor symptoms associated with menopause will be randomly assigned a regimen of Mesafem capsules or a placebo control in order to measure the “mean change in frequency & severity of moderate to severe vasomotor symptoms from baseline” and “change from baseline in total number of awakenings due to hot flashes.”

Efficacy and Safety of S-Equol on Vasomotor Symptoms in Menopausal Patients

Participants in this study will be given either a 150mg, 50mg, or 10mg dose of S-equol in order to determine “the efficacy, safety, and acceptability of 3 doses of S equol to placebo in menopausal patients with vasomotor symptoms.”

Equol Improves Menopausal Symptoms in Japanese Women

 To report on a group of studies which tested the hypothesis that “high intake of soy isoflavones in the traditional Japanese diet” explains the “well documented” phenomenon of fewer hot flashes and night sweats among Japanese women than Western women.

 In three randomized clinical trials, it was shown “that a daily dose of 10 mg of natural S-equol improved menopausal symptoms.” A confirmation study demonstrated that “menopausal women who were equol nonproducers who consumed 10 mg/d of natural S-equol for 12 wk had significantly reduced severity and frequency of hot flashes as well as a significant reduction in the severity of neck or shoulder stiffness. The equol-ingesting group also showed trends of improvement in sweating and irritability and a significant improvement in the somatic category symptoms.” Takeshi concludes that this body of data supports “the supplement containing natural S-equol…as an alternative remedy in the management of menopausal symptoms.”

December 2010

Breaking Boundaries with Web-based Disease Management

Angina

Upper Respiratory Infection

Menopause

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