We present brief summaries of key proceedings from several of the most important medical conferences held in the first half of 2005, focusing, when appropriate, on news of particular interest to...
We present brief summaries of key proceedings from several of the most important medical conferences held in the first half of 2005, focusing, when appropriate, on news of particular interest to primary care physicians. Where possible, we also provide links to additional online conference coverage and news.
Pri-Med Current Clinical Issues in Primary Care (Southwest)
Date: January 20-22
Location: Houston, TX
Nationally recognized faculty from Harvard Medical School and Baylor College of Medicine combined to develop and present the core of this three-day program, which offered more than 50 clinical lectures addressing challenges faced by primary care practitioners. “Practice Solutions,” two days of “cutting edge education,” focused on professionals’ needs to receive information, resources, and education in the areas of technology and practice-based approaches and solutions.
Among the popular topics discussed at this conference were neurology, cardiology, women’s health, pediatrics, office practice, geriatrics, and the latest technology. We’ve chosen topics that, where applicable, focus on the Internet and technology.
Clinical Data at the Touch of a Button
Presenter(s): Rosemarie Nelson, MS
Recap: Ways in which doctors can automate their practice and take advantage of the wealth of clinical information available online were the focus of this presentation. Ms. Nelson explained that many physicians currently have access to online hospital data, lab results, transcribed visit notes, consultant reports, and medicine lists that are generated by e-prescribers. Doctors are also now able to easily access all papers produced in or passing through their office by scanning documents into a document management program. The speaker also compared the potential cost savings that come with the use of clinical information systems to the costs of setting one up.
Communicating With Your Patients Electronically—The Benefits of E-mail
Presenter(s): Lynne C. Columbus, DO
Recap: “More and more plans are reimbursing doctors for e-mailing with patients as they discover that it can save them money,” explained Dr. Columbus, who added that, at the same time, patients are requesting more online access to their doctors. Her presentation discussed the security, time, and reimbursement issues associated with e-mail communications, along with how various secure messaging services differ and their advantages over regular e-mail.
EMR 101: A Novice Approach to Electronic Medical Records
Presenter(s): Jeffrey Hertzberg, MD
Recap: This “crash course” in electronic medical records (EMRs) was meant for those with little knowledge in this area and explored what EMRs do, how they affect office workflow, the various components of EMRs, and the potential benefits to those physicians who use them. Dr. Hertzberg explained how to go about shopping for an EMR system, specifically whether to purchase one that is integrated with a practice management system. He also discussed the new Continuity of Care Record, “which makes it possible for different EMR systems to both import and export key clinical data.”
Functional Imaging of Human Social Cognition (Keynote Address)
Presenter(s): P. Read Montague, PhD
Recap: According to Dr. Montague, “Humans are interactive social creatures with a capacity to maintain, remember, and process information about an enormous number of complex social interactions,” a notion that served as the basis of his talk. He explained that functional neuroimaging experiments have recently started to study the parts of “our mental lives that touch upon those social cognitive capabilities that we most treasure.” Using brain imaging and computational modeling, researchers have begun to analyze the human brain’s ability to detect and respond to many social messages. The emphasis of Dr. Montague’s presentation was on the current state of these efforts and their implications for future study.
HIPAA’s Silver Lining: Transaction Rules That Lower Costs of Working With Managed Care
Presenter(s): Ronald B. Sterling, CPA
Recap: Although many physicians have seen payment delays as a result of the new HIPAA transaction rules, significant savings are available to those who take advantage of a slew of new online transactions that come with fully complying with the rules, said Mr. Sterling. The speaker explained how the cost of working with health plans can be cut in half through online eligibility and benefit information, referral authorizations, and remittance advice. Also discussed were the latest online claims attachments.
New Vaccines and New Uses of Old Vaccines in 2005
Presenter(s): Carol J. Baker, MD
Recap: While meningococcemia and meningococcal meningitis are two very frightening and newsworthy bacterial infections, according to Dr. Baker, a new quadrivalent meningococcal conjugate vaccine (MCV-A, C, Y, W 135) has been licensed for persons age 11-15 that protects two-thirds of infections in the US. Further, in light of rising pertussis cases—from lack of immunity in adolescents and adults who spread the infection—despite good infant vaccine coverage, licensure of an acellular pertussis vaccine for use in adults and adolescents is expected in 2005. Dr. Baker added that “[i]nfluenza vaccine is now recommended for routine use in 6-23 month olds and in all pregnant women anytime during pregnancy when vaccine is available.”
The New World of E-prescribing
Presenter(s): Salvatore S. Volpe, MD
Recap: This presentation discussed what is needed to get started with e-prescribing, as well as the plusses and minuses of various programs and services. More than ever before, e-prescribing is attractive due to several major developments, said Dr. Volpe. As an example, he explained that obtaining dispensing histories for many patients and checking the drugs for interactions with others that may want to be prescribed is now possible, adding that drug—drug checks include allergy checks. Further, prescriptions can be sent to pharmacists electronically in many states.
You will note that there are no additional online resources available for the Pri-Med Southwest presentations summarized here. Find news from Pri-Med Southwest, and information on upcoming 2005 and 2006 Pri-Med conferences (held in Boston, MD, Chicago, IL, Fort Lauderdale, FL, Anaheim, CA, Baltimore, MD, and Houston, TX).
American College of Cardiology 54th Annual Scientific SessionDate: March 6-9, 2005
Location: Orlando, FL
Over the course of four days, hundreds of presentations large and small were offered by cardiovascular experts from across the country, presentations that described the most important clinical and theoretical advances and innovations of the year gone by. Visit the American College of Cardiology (ACC) website dedicated to the meeting, to view on-demand lectures, late-breaking clinical trials, press releases, and other conference highlights.
This year’s event featured full-day sessions in clinical cardiology, CT/MRI, echocardiography, electrophysiology, interventional cardiology, nuclear cardiology, vascular disease, and other topics. Visitors could also attend sessions that covered smoking cessation and fitness, complicated imaging cases, ethnic disparities in cardiovascular disease, genetics and atherosclerosis, stenting, long-term oral antithrombin therapy, and much more. Results from a number of late-breaking clinical trials were presented.
ARMYDA-2: Antiplatelet Therapy for Reduction of Myocardial Damage during Angioplasty 2
Presenter(s): Germano Di Sciascio, MD
Recap: “We can improve the outcome [of angioplasty] by doubling the dose of clopidogrel,” said Dr. Di Sciascio, professor and chairman of cardiology at Campus Biomedico University of Rome, by way of introducing the results of his study. “Thus, our traditional therapy associated with angioplasty will probably need to be changed.” Traditionally, Dr. Di Sciascio noted, patients slated to undergo angioplasty receive 300mg of the antiplatelet agent clopidogrel prior to the procedure; this study randomized 255 patients to receive either this usual dose or 600mg. Thirty days after the procedure, 12% of those receiving the usual dose of 300mg had died, suffered a heart attack, or required an additional procedure to reopen clogged arteries; only 4% of patients receiving 600mg of clopidogrel preoperatively experienced one of these outcomes at 30 days. Patients receiving the higher dose of clopidogrel who were also undergoing treatment with a statin experienced an even more significant risk reduction, Dr. Di Sciascio reported. Elevated levels of creatine kinase MB found in patients receiving 300mg compared to patients receiving 600mg of clopidogrel indicate that the observed ischemic complication risk reduction is attributable to the prevention of coronary injury. Investigators plan to follow this patient group for a full year following the procedure in an effort to determine whether observed risk reduction continues in the long term.
Clopidogrel as Adjunctive Reperfusion Therapy (CLARITY): Thrombolysis in MI
Presenter(s): Mark S. Sabatine, MD, MPH
Recap: A total of 3,491 patients with STEMI (aged 18-75 years) formed the study cohort for this clinical trial, in which all subjects received standard fibrinolytic therapy (including aspirin, heparin, LMWH, beta-blockers, and other medications as required). Subjects were also randomized to receive either clopidogrel or a placebo; those in the former group received a loading dose of the drug (300mg) and then received 30mg clopidogrel daily for 75 days. Within eight days of randomization, all subjects underwent coronary angiography. Clinical follow-up continued for approximately one month. The incidence of occluded artery/death/MI through angiography was higher in the placebo group (21.7%) than in the clopidogrel group (15.0%), and these results held true across every major patient subgroup. All angiographic parameters were also improved with clopidogrel use, and the risk of a composite overall endpoint including CV death, MI, and need for urgent revascularization reduced by 20% compared to placebo. Rates of major bleeding were 1.9% and 1.7% in the clopidogrel and placebo groups, respectively, a non-statistically significant difference. Clopidogrel use does not appear to substantially increase the risk of bleeding events.
COMMIT/CCS-2: Clopidogrel and Metoprolol in Myocardial Infarction Trial
Presenter(s): Zhengming Chen, MD, PhD; and Rory Collins, MBBS, MSc, FRCP, BHF
Recap: With more than 45,000 patients enrolled to date, the COMMIT/CCS-2 study is the largest Chinese clinical trial ever conducted. The purpose of the study was to determine the effect of adding either metoprolol or clopidogrel to conventional therapy among patients with acute MI; results from the metoprolol and clopidogrel arms of the study were presented separately by Drs. Collins and Chen, respectively. Subjects were randomized to receive either clopidogrel 75mg/day or placebo. Incidence of death, reinfarction, and stroke were all lower among patients treated with clopidogrel (a 9% risk reduction overall, including a 13% reduction in risk of reinfarction). As in the previously cited study involving clopidogrel, the drug was not associated with an increased risk of major bleeding. All subjects were also randomized to three doses of metoprolol 5mg IV over the course of 15 minutes, followed by 200mg/day, or placebo. In this population, metoprolol effected an 18% reduction in risk of reinfarction and a 17% reduction in the risk of ventricular fibrillation. However, metoprolol had no effect on risk of in-hospital death; while the drug did cause a substantial reduction in the rate of arrhythmic deaths, it also led to increased risk of cardiogenic shock and associated mortality, balancing out its positive impact on mortality overall.
ENDEAVOR: Comparison of the Endeavor Drug-Eluting Stent With a Bare Metal Stent for Coronary Revascularization Lowering ArmPresenter(s): William Wijns, MD
Recap: Drug-eluting stents have come to play an increasingly prominent role in the physician’s armamentarium against restenosis associated with coronary artery lesions. The variation on the Endeavor stent tested here releases ABT-578, an analogue of the antiproliferative sirolimus that has been in use for some time. Dr. Wijns described the study procedure, in which some 1,200 patients with single de novo lesions were randomized to receive either the Endeavor stent or a bare metal stent, the Driver model. At nine months, the Endeavor and Driver groups were compared with one another in terms of a primary endpoint (“total vessel failure,” or TVF, comprising cardiac death, myocardial infarction, and target vessel revascularization), as well as in terms of major adverse cardiac events. Of the patients receiving the Driver stent, 15.4% experienced an incident of TVF, compared to only 8.1% of patients receiving the Endeavor; much of this difference was attributed to a less frequent need for target vessel or target lesion revascularization observed among Endeavor-treated patients. Stent thrombosis was extremely rare and actually more common in the control group; no cases of thrombosis were observed after 30 days post- implantation.
Pros and Cons of Aggressive Lipid Lowering TherapyPresenter(s): Gregory G. Schwartz, MD; and Stephen D. Wiviott, MD
Recap: This joint presentation began with a lecture by Dr. Schwartz, representing both the VA Medical Center and the University of Colorado Health Sciences Center, Denver, CO. Dr. Schwartz began by noting that many patients and primary care physicians are unaware of the ACS event risk following successful percutaneous coronary intervention, instead believing that the procedure “abrogates the high risk of recurrent coronary syndrome events.” Dr. Schwartz reviewed several trials of moderate-to-high dose statin therapy among patients with ACS, including MIRACL, PROVE-IT, and A-to-Z. In the last of these studies, moderate-dose simvastatin was associated with reduced levels of LDL-cholesterol but not with reduced ACS event risk. MIRACL and PROVE-IT, however, both demonstrated a risk reduction of roughly 15% over four months and two years, respectively, associated with aggressive statin therapy. Substantial reduction in markers of inflammation (specifically C-reactive protein) was associated with high-dose statin treatment in both MIRACL and PROVE-IT, Dr. Schwartz noted, with a reduction of 35% compared to placebo in the former. This suggests that “the benefit of high intensive treatment is likely due to anti- inflammatory effects,” Dr. Schwartz concluded. The relative safety of high-dose statin therapy was addressed by Dr. Wiviott. The speaker observed that in both PROVE-IT and other published studies, creatine kinase elevation associated with statin therapy is generally rare; more importantly, no difference between intensive and moderate therapy in terms of incidence of creatine kinase elevation has been demonstrated. Similarly, rates of muscle complaints were comparable with high-dose statin treatment and moderate-dose statin treatment. These results “reaffirm the safety of both [high-dose and moderate-dose] treatment regimens, Dr. Wiviott stated in his presentation.
REALITY: Comparison of Taxus and Cypher Drug-Eluting Stent SystemsPresenter(s): Marie-Claude Morice, MD, FACC
Recap: A second key presentation focusing on the subject of drug-eluting stents reported the results of a large clinical trial comparing Cypher, a sirolimus-eluting stent, and Taxus, a paclitaxel-eluting stent. Investigators recruited 1,353 patients with no more than two de novo coronary artery lesions and randomized the group to receive implantation of either stent. At baseline, the Taxus and Cypher groups had nearly identical clinical characteristics. After eight months, quantitative coronary angiography was performed on all subjects; parameters from this evaluation significantly favored patients receiving the Cypher stent. However, there was no difference between the groups in rates of in-stent or in-lesion binary restenosis (the primary endpoint identified by authors) and no difference in rates of death, myocardial infarction, and need for revascularization. Significantly more patients receiving Taxus stents were treated for in-stent thrombosis.
TNT: Lipid Reduction in Stable CHD Reduces Risk of Major CV EventsPresenter(s): John LaRosa, MD
Recap: This late-breaking clinical trials session reported on an investigation designed to further quantify the impact of high-intensity lipid reduction (in this case using atorvastatin) on clinical outcome in coronary heart disease (CHD). The traditional dosage of low-dose atorvastatin used for this indication is 10mg/day. In the TNT (Treating to New Targets) study, approximately half of the 10,001 enrolled patients were randomized to receive this dose; the remaining subjects received atorvastatin at 80mg/day, with the goal of reducing LDL cholesterol as significantly as possible (all patients underwent a preliminary eight-week period of atorvastatin 10mg/day treatment before baseline, designed to reduce LDL cholesterol to 130mg/dL or less). After nearly five years of follow-up, patients receiving the larger dose of atorvastatin had significantly lower levels of LDL cholesterol (mean 77mg/dL) than patients receiving the smaller dose (mean 101mg/dL). This difference translated directly into clinical benefit for the high-dose group; risk of myocardial infarction was reduced by 22% in this group, risk of stroke by 25%, and risk of death deriving from CHD by an impressive 20%. According to the authors, in practical terms, approximately 30 patients would have to be treated with this more aggressive regimen (which turned out to be well tolerated) in order to prevent one cardiovascular event.
Scientific Session News
Access archived versions of Scientific Session News, the newsletter published each day during the conference that featured recaps and summaries of the day’s top presentations and announcements. The Preview and Highlights issues are also available.
57th Annual Meeting of the American Academy of NeurologyDate: April 9-16
Location: Miami Beach, FL
This year’s Annual Meeting of the American Academy of Neurology offered a wide variety of full- and half-day educational sessions; breakfast and dinner seminars and symposia; intensive workshops; and case study programs. In all, the curriculum-based Education Program featured more than 160 programs and courses covering 23 key topic areas. The Scientific Program, designed to complement the Education Program, covered the spectrum of neurology, from “updates on the latest diagnostic and treatment techniques to prevention strategies.” Attendees had the opportunity to view more than 1,300 poster and scientific platform presentations.
The Scientific Program closely followed the topic areas covered by the Education Program and featured cutting-edge research in the causes, diagnosis, and treatment of diseases and conditions in a variety of categories, including neurogenetics, epilepsy, movement disorders, multiple sclerosis, aging and dementia, headache, cerebrovascular disease, sleep disorders, and more.
Neurology of Sleep
Presenter(s): Clifford Saper, MD, PhD, FAAN; Michael Thorpy, MD; Mark Mahowald, MD; and Phyllis Zee, MD, PhD
Recap: This session featured a series of presentations that provide a comprehensive review of the neurobiology of sleep and an update on new developments in therapeutic approaches for insomnia, hypersomnia, parasomnia, and other sleep disorders. Dr. Saper explored the “Neurobiology of Sleep;” Dr. Thorpy discussed “Advances in Narcolepsy and Other Hypersomnias;” Dr. Mahowald examined “Parasomnias;” and Dr. Zee presented “New Therapies for Insomnia.” Dr. Saper explained that “patients who have pathological insomnia are demonstrating the effects of damage to the ventral lateral preoptic nucleus,” a switch in the brain that can cause a loss of more than 50% of sleep behaviors. He also explored the process by which the pontine flip-flop switch regulates REM sleep and discussed the process by which sedative drugs can affect the neuronal system that maintains stability of sleep states. Dr. Thorpy explored narcolepsy, an underdiagnosed and undertreated condition that can present itself in a gradual or abrupt manner. “The goal of treatment,” according to Dr. Thorpy, “is to keep the patient as alert as possible during the day and reduce episodes of cataplexy while also minimizing the incidence of undesirable side effects and adverse effects.” In his discussion of parasomnias, Dr. Mahowald discussed the discovery of REM sleep—a finding that enabled researchers to identify and categorize the sleep phenomena—and reviewed the crucial concept that “wakefulness, REM sleep and NREM sleep are not mutually exclusive states, and may occur simultaneously, oscillate rapidly, or appear in dissociated form to produce primary sleep parasomnias.” Finally, Dr. Zee examined the primary management principles of insomnia, which include: treating the underlying cause(s); promoting normal sleep habits; implementing behavioral strategies such as sleep restriction, stimulus control, and relaxation techniques; and prescribing sedatives and hypnotics in combination with behavioral management.
Practical Management of Movement Disorders
Presenter(s): Paul Greene, MD; Cynthia L. Comella, MD; Susan B. Bressman, MD; and Kathleen M. Shannon, MD
Recap: The diagnosis and management of early and late Parkinson’s disease, dystonia, and chorea were the subjects of this series of lectures, with an emphasis on the examination of clinically relevant aspects of these common movement disorders to help provide a practical approach to evaluation and treatment. The four presentations were “Diagnosis of Idiopathic Parkinson’s Disease” by Paul Greene, MD, “Clinical Problems & Management of Advancing Parkinson’s Disease” by Cynthia L. Comella, MD, “Dystonia: Evaluation, Counseling, and Approaches to Treatment” by Susan B. Bressman, MD, and “Chorea: Differential Diagnosis, Evaluation & Treatment” by Kathleen M. Shannon, MD. In the opening lecture, Dr. Greene described the diagnostic process of idiopathic Parkinson’s disease; outlined treatment options including exercise therapy and neuroprotective strategies; and explained how to treat patients with the combination of levodopa and cardidopa, dopamine agonists, apomorphine, and COMT inhibitors. The patient’s response to levodopa, said Dr. Greene, is critical. “In addition to identifying most patients with Parkinson-plus syndromes and pseudo-Parkinson states by their lack of response to levodopa, response to levodopa has considerable prognostic significance.” Dr. Comella discussed the effects of treatment with levodopa; addressed the more frequent occurrence of dyskinesia in the younger age onset; reviewed the treatment concepts for motor complications; examined use of COMT inhibitors in combination with carbidopa/levodopa; and discussed surgical therapies in PD, including ablative, deep brain stimulation, and restorative procedures. Dystonia, according to Dr. Bressman, is characterized by a repetitive, “directional” twisting movement that helps to distinguish it from other similar movement disorders. Common types include primary dystonia, often seen in writer’s cramp or leg dystonia, and dopa-responsive dystonia, which typically presents in mid-childhood with dystonia affecting the gait. Therapy for most patients is symptomatic and “directed at lessening the intensity of the dystonic contractions.” In the final presentation, Dr. Shannon discussed chorea, a disorder that is slower than dystonia but faster than myoclonus and tics and is caused by neurometabolic diseases, infections, or drug use. Most commonly presented in Huntington’s disease, chorea is treated with antidopminergic agents, anticonvulsants, and glutamate antagonists and can also be corrected through surgery.
Neurological Disorders in Pregnancy
Presenter(s): Page B. Pennell, MD; Emma Ciafaloni, MD; Cheryl Bushnell, MD; and Annette Langer-Gould, MD
Recap: Neurological symptoms that affect pregnancy were discussed in detail in the four presentations comprised in this program. Specifically, the four speakers reviewed differential diagnoses and diagnostic evaluation and treatment options for women who are pregnant or postpartum; discussed the careful attention that is required regarding preconception planning and interdisciplinary management during pregnancy; and explained how to go about delivering optimal care to women during preconception planning, pregnancy, labor and delivery, and lactation in order to minimize maternal and fetal risks. In the four lectures, Dr. Pennel focused on “Epilepsy & Eclampsia;” Dr. Ciafaloni discussed “Neuromuscular Disorders and Pregnancy;” Dr. Bushnell covered “Headache & Stroke;” and Dr. Langer-Gould examined “Multiple Sclerosis.” Dr. Pennell examined pre-eclampsia—a condition that affects both young and older pregnant women, diabetics, and those with renal failure and a family history of the condition—and eclampsia, which is characterized by seizures that occur before edema and proteinuera. Dr. Pennell emphasized the importance of planning pregnancies for women who are taking AEDs, so that physicians can “optimize medications prior to conception.” She also urged physicians to discuss with patients the potential effects of AED use on the fetus; strongly advised use of folic acid; and discussed the feasibility of breastfeeding. Dr. Ciafaloni discussed the effects of myasthenia gravis (MG) on pregnancy, which can be very sporadic, and cautioned that women with muscular dystrophy who hope to become pregnant should be made aware of the risks, including hypotinia weakness, mental retardation, and respiratory problems. She also delved into the common neuropathies in pregnant women, such as idiopathic facial palsy, carpal tunnel syndrome, and meralgia parasthesia, and stressed the importance of counseling prior to pregnancy. According to Dr. Bushnell, migraines in pregnancy can be treated with physical therapy and relaxation treatments or with pharmaceuticals including antiemetics, acetaminophen, caffeine, aspirin, and others. The key comes in treating the headache and the dehydration, which can be prevented using magnesium sulfate or corticosteroids. She also discussed stroke in pregnancy, an event that is characterized by large hormonal fluctuations, a reduction in blood volume at delivery, and dehydration, and that can lead to pregnancy-related hypertension. Dr. Langer-Gould reported that women with multiple sclerosis experience a significant immunodulatory effect during pregnancy; can experience a decrease in disease activity; run an increased risk of postpartum exacerbation during first four months; and likely suffer no long-term disabling effects. To help prevent postpartum relapses—which occur more frequently in patients who experience relapses prior to and during pregnancy—physicians can prescribe intravenous immunoglobins, glucocorticosteroids, or beta-interferon, prescribe copolymer-1, and encourage patients to breastfeed.
Presenter(s): Victor W. Henderson, MD, FAAN; Lawrence M. Brass, MD; Robert Cowan, MD; Christian Guilleminault, MD; and Andrew G. Herzog, MD, MSc, FAAN
Recap: The changes that occur during menopause that affect the body have been well-
documented; a substantially less amount of literature has been devoted to the potential influence these changes in the internal hormonal milieu have on functions of the brain. This course focused on recent research on the effects of postmenopausal hormone therapy and risk of Alzheimer’s disease; hormone therapy and the primary and secondary prevention of stroke; endogenous ovarian steroids, menopause, and hormone therapy on headache incidence and management; the influence of menopause and ovarian steroids on sleep fragmentation and sleep-related respiratory disturbances; and hormonal effects on seizure threshold and epilepsy. The presentations were “Alzheimer’s Disease” by Dr. Henderson, “Stroke” by Dr. Brass, “Migraine Headache” by Dr. Cowan, “Sleep Disorders” by Dr. Guilleminault, and “Epilepsy” by Dr. Herzog. Dr. Henderson discussed several studies focusing on the effects of estrogen on the brain as well as the steroid hormone’s possible role in the rate of decline in Alzheimer’s disease and dementia in postmenopausal women. According to Dr. Henderson, several small-scale studies have demonstrated a “beneficial effect of estrogen on certain cognitive skills,” yet global trials have failed to confirm this benefit. Data from the Women’s Health Initiative (WHI) study indicate that the benefits of estrogen don’t exceed the risks, and the results of the Women’s Health Initiative Memory Study suggest that the likelihood of developing dementia was twice as high in women who took estrogen plus progestin compared to those who were administered estrogen alone. Another study, the Multi-Institutional Research on Alzheimer Genetic Epidemiology, suggested that hormone therapy might only be protective for younger women. Dr. Brass examined the vascular effects of estrogen and the feasibility of hormone replacement therapy (HRT) in the prevention of stroke vascular disease. Treatment with estrogen has been reported to offer a number of positive effects. However, recent studies have shown that estrogen plus progesterone therapy is linked with breast cancer; HRT offers no overall benefit to menopausal women with myocardial infarction; and women who take estradiol are more prone to suffer recurrent strokes. The most feasible options, according to Dr. Brass, involve blocking the adverse events of HRT with antithrombotic therapy; stimulating estrogen receptors using the estrogen-agonistic effects of therapeutic agents; and utilizing selective estrogen receptor modulators. Dr. Cowan examined the prevalence, diagnosis, and treatment of headache and migraine in menopausal women, citing a significant increase in headache frequency and severity among women in the perimenopausal years. Because “menstrually related migraine is associated with abrupt change in estrogen levels rather than any absolute value,” said Dr. Cowan, “worsening migraine can often be managed through manipulation of estrogen from cycling to daily continuous release formations.” Strategies for the manipulation of estrogen in menopausal migraine include reducing the dosage, changing the formulation, adjusting the route of administration, and considering short-term addition of androgen. In his review of sleep disorders in menopause, Dr. Guilleminault identified the three main causes of sleep disruption as hot flashes, mood disorder, and sleep disordered breathing (SDB). Dr. Guilleminault introduced new criteria, such as the cyclic alternating pattern, that have been developed by experts to score breathing and sleep and have helped to decode sleep-related complaints seen in menopausal women. He also explored the idea that disruption in sleep is associated with complaint of insomnia and that insomnia can indicate a high frequency of SDB that fails to respond to hormonal treatment. Finally, Dr. Herzog explained that epilepsy promotes changes in hormonal secretion that further the development of reproductive endocrine disorders, menstrual disorders, infertility and premature menopause, and can lead to increases in seizures, migraine, emotional disorders, and possibly female malignancies in menopausal women.
The 2005 Annual Meeting Plenary Sessions and Stroke Therapy Program will be available for viewing after July 15, 2005.
Digestive Disease Week 2005Date: May 14-19, 2005
Location: Chicago, IL
Digestive Disease Week, the largest international gathering of physicians, researchers, and academic thought leaders in the fields of gastroenterology, hepatology, endoscopy, and gastrointestinal surgery, showcased approximately 5,000 presentations on the latest advances in GI research, medicine, and technology. The event was jointly sponsored by the American Association for the Study of Liver Diseases, the American Gastroenterological Association, the American Society for Gastrointestinal Endoscopy, and the Society for Surgery of the Alimentary Tract. Each year, Digestive Disease Week (www.ddw.org) attracts approximately 14,000 physicians; this year’s event boasted more than 16,000 attendees.
The latest technological advances in colonoscopy, the role of race and ethnicity in research, OTC medications versus prescribed medications in treating GERD, and the newest therapies for pancreatic and gastric cancer were among the numerous topics of discussion at this year’s DDW.
Aer-O-Scope: Self-Propelling Self-Navigating Skill-Independent Colonoscopy; a New Era in Screening Colonoscopy
Presenter(s): Pfeffer J, Arber N, Halpern Z
Recap: In this study, researchers at the Tel-Aviv Sourasky Medical Center evaluated the safety, efficacy, average advancement, mucosal damage inflicted, and success at achieving major endpoints of a miniature colon screening device in the colons of 10 young female pigs (based on similarities in size and dimension of and representation of the worst-case scenario of a human colon). Following two Aer-O-Scope procedures in each pig, detection of perforation, erosion, and mucosal damage via colonoscopy was performed by a GI specialist. With a duration of 11-29 minutes, the procedure included an average advancement of 10 minutes and pull back of 3.4 minutes. At 24 hours and seven days following the procedure, all subject animals were in good condition. “Preliminary studies, which supplied the proof of concept in humans, as well as the study presented here suggest that this technology could provide a reliable, less invasive, sedation-free and more easily administered screening option for colon cancer,” concluded Nadir Arber, MD, lead author of the study. “Although we have more work to do before this device is widely utilized in humans, it is an exciting prospect for patients and physicians alike.”
Additional Online Resource(s): www.ddw.org/user-assets/documents/PDF/media/NewColonTechnologies Release.pdf and www.ddw.org/user-assets/documents/PDF/media/ColonTuesday1PM.pdf
How Effective Are OTC Medications and Prescribed Medication in Controlling Symptoms of Gastroesophageal Reflux Disease (GERD)? Results from a Multinational Survey
Presenter(s): Jones R, Liker H, DuCrotte P
Recap: Roger Jones, MD, Guy’s King’s and St. Thomas’ School of Medicine, London, England, and colleagues presented results of an analysis based on results from a phone survey aimed at determining how effective OTC medicines—often taken by sufferers of GERD before a formal diagnosis—are in improving the symptoms of GERD. Of 1908 persons from the US, UK, Germany, and France who agreed to take part in a 100-item questionnaire, 984 were diagnosed with GERD, and 924 were not. Improvement in symptoms since first taking medication was seen in “65% of 787 undiagnosed sufferers taking OTC medicines, 80% of 727 diagnosed patients receiving prescription drugs, 87% of 537 diagnosed patients receiving proton pump inhibitors (PPI), alone or in combination with other drugs, and 91% of 246 diagnosed patients taking PPIs only.” Symptoms did persist, however, in 68% of diagnosed individuals receiving prescription drugs, 69% of diagnosed persons on PPIs, and 81% of undiagnosed persons taking OTC drugs. “Our study indicates that proton pump inhibitors and other prescription medicines for GERD are more effective than over-the-counter remedies in relieving symptoms of the disease,” concluded Dr. Jones.
Additional Online Resource(s): www.ddw.org/user-assets/documents/PDF/media/TherapiesMonday1PM.pdf and www.ddw.org/user-assets/documents/PDF/media/OTCRelease.pdf
Race and Ethnicity in Genetic Research
Presenter(s): Petersen GM
Recap: This presentation focused on the implications of both current and future advancements in genetics research that incorporates race and ethnicity. Gloria M. Petersen, PhD, Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, stated that main issues in this field have come about through research of single nucleotide polymorphisms (SNPs), “which are specific sites in DNA where a simple base change has become frequent enough to be measurably variable among groups of individuals.” With SNPs that occur near one another on the same gene or chromosome likely transmitted together through generations, sets of SNPs (SNP haplotypes) are being mapped in humans in the search for differences by a variety of criteria, particularly by race/ethnicity. Dr. Petersen explained that pitfalls “can occur when investigators inappropriately apply genetic variation or SNPs at the individual level to define population groups, or to link disease-related SNP to phenotype.” The presenter concluded that genetic variations should not be denied but acknowledged and understood, using genetic research to improve health.
Serum Proteomic Fingerprints for Diagnosis of Gastric Cancer
Presenter(s): Leung WK, Poon TC, Ng EK, et al.
Recap: With the lack of a reliable serum tumor marker for the second leading cause of cancer-related death on Earth, Wai K. Leung, MD, and co-researchers at the Chinese University of Hong Kong “attempted to identify potential diagnostic markers for gastric cancer using high-throughput protein profiling technology, the surface-enhanced laser desorption/ionization (SELDI) ProteinChip technology,” and presented their results at this year’s DDW. The SELDI Protein Chip creates a “fingerprint” that represent a series of protein masses that can aid in differentiating normal from diseased patient samples. With a 73% sensitivity for diagnosing gastric cancer in the study, Dr. Leung concluded “[t]his type of proteomic profiling may have the capacity to identify novel biomarkers for the screening and early detection of gastric cancer.”
Additional Online Resource(s): www.ddw.org/user-assets/documents/PDF/media/AdvancesDiagnosticsandProcedures
American Psychiatric Association 2005 Annual Meeting Date: May 21-26, 2005
Location: Atlanta, GA
Continuing a long tradition of showcasing the best in the psychiatric profession, the 158th Annual Meeting of the American Psychiatric Association highlighted the latest scientific developments and traditional humane values in psychiatry and their integration into state-of-the-art patient care. The theme of this year’s Annual Meeting was “Psychosomatic Medicine: Integrating Psychiatry and Medicine,” with many sessions highlighting key aspects of this timely theme.
Sessions for the scientific program at this year’s event were organized into more than 60 topic areas, themselves arranged under five main headings: “Disorders,” of which 13 were covered, including anxiety, attention spectrum, eating, personality, mood, sleep, and somatoform disorders; “Practice Areas/Settings,” which covered psychiatric administration and services in the public, private, and university settings; “Treatments,” including behavior and cognitive therapies, combined pharmacotherapy and psychotherapy, treatment techniques and outcome studies, psychopharmacology, and other somatic therapies; “Subspecialty Areas or Special Interests,” a wide-ranging category that included sessions on addiction psychiatry, cross-cultural and minority issues, epidemiology, genetics, geriatric psychiatry, pain management, and research issues; and the cagily titled “Other Issues,” a catch-all category that featured programs that took for their subject matter all manner of interests and topics, including gender issues in psychiatry, information technology and its uses in practice and diagnosis, managed care and healthcare funding, patient safety, resident and medical student concerns, and telepsychiatry.
Presenter(s): Michelle B. Riba, MD
Recap: Dr. Riba touched on the APA’s five key initiatives for improving patient care: 1) mental health on college campuses; 2) education in psychiatry; 3) government relations; 4) psychosomatic medicine; and 5) communications. She announced an upcoming initiative spearheaded by the APA Presidential Task Force on Mental Health on College Campuses, aimed at providing better services to college students and offering them information and resources for getting help and assistance when they need it. The second initiative Dr. Riba discussed, psychiatric education, has been brought to bear largely through the efforts of last April’s APA Presidential summit. This meeting provided a forum for leading educators to develop strategic undergraduate medical education curricula in psychiatry that will incorporate the latest developments in psychiatry content and teaching methods. With regard to advocacy and government relations, she underscored the defeat of the 2005 Hawaii psychologist prescribing legislation largely through the efforts of Jeffrey Akaka, MD, and Joan Anzia, MD, President of the Illinois Psychiatric Society, and the defeat of formulary expansion legislation as major successes in this area.
The efforts of the new APA Council on Psychosomatic Medicine are directed to support the fourth key initiative of the APA: advancing the new field of psychosomatic medicine. This council will address such issues as clinical care, reimbursement, education of psychiatrists and non-psychiatrists, and research. Dr. Riba concluded with a discussion on the priority of communicating with the public to educate and reduce stigma. The APA’s public awareness campaign, Healthy Minds, Healthy Lives, is aimed at focusing on the benefits for psychiatric care, addressing stigma, and highlighting the importance of seeking treatment from psychiatric physicians.
Adjunctive Eszopiclone With Fluoxetine for Major Depressive Disorder and Insomnia: Depression Effects
Presenter(s): Daniel J. Buysse, MD
Recap: Dr. Buysse presented results of a study in which he and colleagues sought to evaluate the coadministration of eszopiclone and fluoxetine in depressed patients with comorbid insomnia. Patients who met the DSM-IV criteria for new major depressive disorder and insomnia received morning doses of 20mg fluoxetine plus either eszopiclone 3mg or placebo nightly for a period of eight weeks. Using the 17-item Hamilton Depression Rating Scale (HAMD17) and the Global Impression Improvement (CGI-I) and Severity (CGI-S) to assess efficacy, the researchers found that eszopiclone coadministration resulted in greater changes in HAMD17 scores at week four with progressive improvement at week eight. Additionally, by week eight, significantly more eszopiclone patients were responders and remitters. HAMD17 differences were greater in patients with more severe depression. CG-I and CG-S scores were also greater with eszopiclone coadministration. Patients who received the eszopiclone coadministration were also less likely to require fluoxetine dose increases. The researchers concluded that eszopiclone/fluoxetine coadministration “significantly augmented the antidepressant response in patients with MDD and insomnia” and produced an immediate sleep response.
A Workplace Simulation: Performance in ADHD Vs. Control Subjects
Presenter(s): Joseph Biederman, MD
Recap: With the objective of assessing adults with and without ADHD in a full work-day simulation experience, Dr. Biederman and colleagues compared study participants on measures of self-reported ADHD symptoms, objective observations, using a structured instrument, and a variety of written tasks. Dr. Biederman and his team hypothesized that adults with ADHD would show impairments on work-simulated tasks, demonstrate more off-task behavior, and relate more feelings of ADHD symptoms than matched controls. Analyzing the participants using Pearson’s chi-square test, Dr. Biederman and his research team confirmed their hypothesis: subjects with ADHD demonstrated impaired performance on reading comprehension and math fluency. While there was a significant difference in the observer-rated and self-report for deportment, no difference was seen for attention. On the majority of tasks they were asked to complete, ADHD subjects reported difficulty with hyperactivity. Dr. Biederman and colleagues concluded “that ADHD in adults is associated with significant deficits in performance on structured work-related tasks as well as on internal experiences and external observations of core symptoms of ADHD”.
American Urological Association 2005 Annual MeetingDate: May 21-26, 2005
Location: San Antonio, TX
More than 15,000 urologists, healthcare professionals, and exhibitors gathered at the Henry B. Gonzalez Convention Center this May for the American Urological Association (AUA) 100th Annual Scientific Meeting. Poster, plenary, and podium sessions offered in-depth coverage of the latest developments in urology, while more than 300 companies with urological products or services participated in the AUA’s annual exposition—the largest assembly of urological devices, equipment, pharmaceutical products, and practice management systems in the world.
New techniques and developments in the screening and management of urologic disorders, diseases, and malignancies; the expanding use of Botox in urology; and improving upon informed consent were among the research highlights presented at the American Urological Association’s Annual Meeting, presentations on which are outlined in more detail below. We’ve chosen topics that are especially pertinent to primary care with a focus, where applicable, on the Internet and technology.
Presidential Address: A Century of Progress
Presenter(s): Brendan M. Fox, MD
Recap: Among the developments that AUA President Dr. Brendan Fox highlighted in his address include the recent consolidation of the American Foundation for Urologic Disease and the AUA, which became official at the meeting. “Patient education, research, and advocacy will continue to be major efforts on the part of the Foundation,” President Fox stated. “We have also taken steps to coordinate the State and Federal agencies of AUA with those of our sister organizations,” he continued. The organization’s first graduating leadership class of 15 outstanding urologists, its advancement of the advocacy of women in neurology through a partnership with the Society of Urologic Nurses and Associates, and the resignation of AUA executive director Jim Gallagher this July and the appointment of Mike Sheppard to proceed him, were also among Dr. Fox’s announcements about the AUA. Dr. Fox gave a historical account of the development of urology as a practice, pioneers in research and practice, the growth of the AUA and its programs, and monumental highlights from past AUA Annual Meetings over the past century. “Let us continue to nurture our innate sense of compassion as we blaze new trails in the ongoing quest for excellence in helping our fellow man,” Dr. Fox stated in his closing remarks.
Plenary Session: The Challenge of Successful New Drug Development in the 21st Century
Presenter(s): Kenneth Watson, MD, MBA
Recap: Dr. Watson urged conference goers to question whether the common criticisms of the pharmaceutical industry are really valid or whether they signal a lack of understanding about the industry and its business practices. While global sales have tripled over the last 15 years, R&D costs have grown proportionally due to an increasingly stringent clinical trials process. In addition, according to the presenter, drug discovery costs are high. New targets for innovative medicines involve a more complex pharmacology, and their physiology is often unknown, making it hard for industry to define indications for these drugs. This obstacle, coupled with the glut of excellent products already available, has made it extremely difficult for new molecular entities to penetrate the market over the last five years. According to Dr. Watson, only one out of 10,000 compounds that go through the clinical trials process actually proceeds to market. With the out-of-pocket cost for approved drugs at roughly $800 million to develop one successful compound now, the current 7% annual growth rate will increase the cost to $1.5 billion by the year 2015. With R&D costs consistently rising and R&D output consistently decreasing, the pharmaceutical industry is facing a major challenge. “Output needs to be improved, and the best way to do that is to improve the success rates,” Dr. Watson stated. He believes that cooperation with universities and contract research organizations to encourage better innovation, and the development of clinical guidelines and lists of essential medicines may boost healthcare efficiency and may also in the long run serve industry to focus on providing better drugs.
Plenary Session: Use of Botox in Urology
Presenter(s): Jeffrey Thavaseelan, MD
Recap: Bacillus botulinum toxin, since its approval by the FDA for strabismus in 1989, has been researched at length for use in patients with overactive bladder. If injected into the bladder, Dr. Thavaseelan explained, it is believed that botulinum toxin can decrease bladder contractility, sensory urgency, urinary frequency, and bladder pain. If injected into the outflow tract, botulinum toxin might also improve bladder emptying. Literature of the clinical use of botulinum toxin provides mostly category III evidence, with described indications appearing in more than 90 journals covering use in both neurogenic and non-neurogenic overactive bladder groups. Level I evidence, collected this year by Schurch, et al. is to be published over the next few months. This research is the first prospective, randomized, double-blind, placebo-controlled study aimed to evaluate the safety and efficacy of each of two doses of Botox (200 U and 300 U) for the treatment of urinary incontinence caused by neurogenic detrusor overactivity. Dr. Schurch and colleagues reported improvement in incontinence episodes in groups that had Botox compared to those receiving placebo. There was also an increase in maximum cystometric capacity in the Botox group and a significant reduction in mean maximum detrusor pressure. Further, Botox seems to have a promising safety profile. Before Botox can be approved, however, Dr. Thavaseelan points out that the protocol for injection needs to be further defined, especially regarding dosage, dilution, depth of injection, and ideal injection site. There is also a great need to address cost-effectiveness of this treatment and to conduct prospective, randomized trials for each proposed indication, Dr. Thavaseelan said.
Additional Online ResourcePoster: Informed Consent: Are We Deluding Ourselves?
Presenter(s): Junaid Masood
Recap: Mr. Masood and colleagues studied the effectiveness of written standardized consent in addition to routine standardized verbal consent in improving patient understanding of the nature of and risks associated with routine endoscopic urological surgery. They randomized 80 patients undergoing transurethral resection of the prostate or transurethral resection of bladder tumor to receive either routine standardized verbal consent only or in addition to written standardized consent as produced by The British Association of Urological Surgeons. Upon discharge, patients completed a questionnaire assessing their knowledge of their medical condition and their understanding of the surgical and anesthetic risks involved in its treatment. Beyond 14% of those receiving verbal and 23% of those receiving verbal and written consent not knowing what operation was performed, 35% of patients in the verbal consent group and 30% of patients in the verbal and written group could not explain how the surgery was performed. The research team concluded that “additional written consent did not improve patients’ understanding of the nature of the surgery or the risks and complications of the procedure.” At present, they are conducting a study using audiovisual material for consent and assessing its efficacy in improving patient understanding of routine endoscopic urological surgery.