April 7, 2006 -- A vasectomy can take months to take full effect, but many men skip follow-up tests that check the vasectomy's success, a new study shows.

A vasectomy is a permanent sterilization procedure for men. Doctors cut the vas deferens, which are tubes in the male reproductive system that carry sperm. A vasectomy prevents sperm from being transported out of the testes, but it doesn't affect a man's orgasm or ejaculation. It also doesn't prevent sexually transmitted diseases.

While vasectomy almost always works, success isn't necessarily instant. That's why doctors ask men to get follow-up tests. Until those tests show success, patients and their female partners need to use another form of birth control to avoid pregnancy.

No Clue About Success

The new study, published in BJU International, included 436 men who got vasectomies at The Cleveland Clinic.

The men were told to submit two semen samples two months after vasectomy and again a month later. If those samples contained sperm, the men were to submit semen samples monthly until they had gotten two consecutive negative tests.

A quarter of the men didn't do their two-month test, and only 21% followed the full instructions to get two back-to-back negative tests, the study shows.

The no-shows for the two-month test "had no idea whether the procedure was successful or if their partner could still become pregnant," researcher Nivedita Dhar, MD, says in a news release. Dhar is the chief urology resident of The Cleveland Clinic's Glickman Urological Institute.

Patients' Results

In patients who followed the testing rules, vasectomy was eventually judged successful in all but one man, the study shows.

Two months after vasectomy, sperm were found in a quarter of the semen samples that were submitted. Most of those sperm were rare and nonmotile, meaning they were few in number and couldn't move on their own.

But three samples showed rare motile sperm, which can move. A man who submitted one of those samples later got a second vasectomy, which worked.

Three months after vasectomy, half of all patients submitted semen samples, 9% of which contained sperm. Three patients whose semen samples showed no sperm at two months showed rare, nonmotile sperm in the three-month check. Those three men all had sperm-free semen samples four and five months after vasectomy.

It's "impossible," Dhar says, to know if and when the vasectomies succeeded in the patients who didn't submit semen samples.

Fewer Tests, Better Compliance?

Dhar and colleagues suggest simplifying the follow-up process to encourage more men to get follow-up tests after vasectomy.

"Provided patients have been adequately counseled, we think that one negative semen analysis at three months or one with rare, nonmotile sperm at two months may be adequate to determine the success of vasectomy," the researchers write.

SOURCES: Dhar, N. BJU International, April 2006; vol 97: pp 773-76. WebMD Medical Reference provided in collaboration with The Cleveland Clinic: "Sexual Health: Your Guide to Birth Control: Sterilization." News release, The Cleveland Clinic.

Reviewed by Louise Chang

News Author: Laurie Barclay, MD

April 10, 2006 — Both active and passive smoking increase the risk of developing glucose intolerance, according to the results of a prospective cohort study reported in the April 6 Online First issue of the BMJ.

"Smoking has been linked to impaired response to glucose tolerance tests and insulin resistance," write Thomas K. Houston, MD, from the Birmingham Veterans Affairs Medical Center in Alabama, and colleagues. "Although smoking cessation can result in modest weight gain, smoking is related to a more unhealthy distribution of upper body weight and greater waist:hip ratio. Smoking has also been associated with risk of chronic pancreatitis and pancreatic cancer, suggesting that tobacco smoke may be directly toxic to the pancreas."

The Coronary Artery Risk Development In young Adults (CARDIA) study began in 1985 to 1986 with recruitment of black and white men and women aged 18 to 30 years with no glucose intolerance at baseline. Participants were 1386 current smokers, 621 previous smokers, 1452 never smokers with reported exposure to secondhand smoke (validated by serum cotinine concentrations, 1 - 15 ng/mL), and 1113 never smokers with no exposure to secondhand smoke. The primary endpoint was time to development of glucose intolerance (glucose, >/= 100 mg/dL or taking antidiabetic drugs) during 15 years of follow-up.

At baseline, median age was 25 years, 55% of participants were women, and 50% were African American. During follow-up, glucose intolerance developed in 16.7% of participants. There was a graded association between smoking exposure and the incidence of glucose intolerance during the 15-year follow-up, which was 21.8% for smokers, 17.2% for never smokers with passive smoke exposure, 14.4% for previous smokers, and 11.5% for never smokers with no passive smoke exposure.

After adjustment for multiple baseline sociodemographic, biological, and behavioral factors, risk was still higher in current smokers (hazard ratio [HR], 1.65, 95% confidence interval [CI], 1.27 - 2.13) and never smokers with passive smoke exposure (HR, 1.35; 95% CI, 1.06 - 1.71) than in never smokers without passive smoke exposure. However, risk in previous smokers was similar to that in never smokers without passive smoke exposure.

"We found that tobacco exposure is associated with the development of glucose intolerance over a 15 year period, with a dose-response effect apparent," the authors write. "These findings support a role of both active and passive smoking in the development of glucose intolerance in young adulthood."

Study limitations include potential residual confounding, observational nature, and recruitment of African Americans and white people from 4 US urban areas, limiting generalizability.

"Importantly, we identified passive tobacco exposure in never smokers as a new risk factor for glucose intolerance," the authors conclude. "If confirmed by further research, these findings provide further documentation of the deleterious effects of tobacco smoking, and policy makers may use them as additional justification to reduce exposure to passive smoke."

News Author: Laurie Barclay, MD

April 10, 2006 — Omega-3 fatty acid supplements may be effective for relieving neck and low back pain, according to the results of a short-term trial reported in the April issue of Surgical Neurology.

"The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is a well-established effective therapy for both acute and chronic nonspecific neck and back pain," write Joseph Charles Maroon, MD, and Jeffrey W. Bost, PAC, from the University of Pittsburgh Medical Center in Pennsylvania. "Extreme complications, including gastric ulcers, bleeding, myocardial infarction, and even deaths, are associated with their use. An alternative treatment with fewer side effects that also reduces the inflammatory response and thereby reduces pain is believed to be omega-3 essential fatty acids (EFAs) found in fish oil."

From March to June 2004, 250 patients evaluated by a neurosurgeon and found to have nonsurgical neck or back pain were asked to take a total of 1200 mg/day of omega-3 EFAs (eicosapentaenoic acid [EPA] and decosahexaenoic acid [DHA]) found in fish oil supplements. Approximately 1 month after starting the supplement, these patients were sent a questionnaire.

Of the 250 patients, 125 returned the questionnaire. Average duration of fish oil therapy at the time of returning the questionnaire was 75 days. Dosage of EFAs was 1200 mg in 78% and 2400 mg in 22%. Reported benefits were discontinuation of prescription NSAIDs in 59% of patients, improvement in overall pain in 60%, improvement in joint pain in 60%, and satisfaction with the level of improvement in 80%. There were no significant adverse effects reported, and 88% stated they would continue to take the fish oil supplements.

"Our results mirror other controlled studies that compared ibuprofen and omega-3 EFAs demonstrating equivalent effect in reducing arthritic pain," the authors write. "Omega-3 EFA fish oil supplements appear to be a safer alternative to NSAIDs for treatment of nonsurgical neck or back pain in this selective group."

Study limitations include retrospective, non–placebo-controlled survey design; variability in underlying patient pathology; and lack of long-term follow-up.

"That close to two thirds of patients could discontinue NSAIDs is certainly provocative, especially given the recent FDA [Food and Drug Administration] warnings regarding their complications," the authors write. "The effectiveness of omega-3 EFAs in rheumatoid and some cases of osteoarthritis has been demonstrated. Appropriately designed studies are needed to confirm the effectiveness of omega-3 EFA for pain relief in discogenic pain."

News Author: Laurie Barclay, MD

April 3, 2006 — Frequent tanning is addictive, according to the results of a small, randomized study reported in the April issue of the Journal of the American Academy of Dermatology.

"We had previously shown that ultraviolet light has an effect on mood that tanners value," lead author Mandeep Kaur, MD, from Wake Forest University School of Medicine in Winston-Salem, North Carolina, said in a news release. "Now, in this small study, we've shown that some tanners actually experience withdrawal symptoms when the 'feel-good' chemicals are blocked."

The authors note that frequent tanners overwhelmingly prefer UV-emitting beds to non–UV-emitting tanning beds, even when their choice is blinded. Frequent tanning has features of an addictive behavior, which may be mediated by induction of cutaneous endorphins by UV light.

The investigators tested whether opioid antagonism blocks the potential reinforcing effect of indoor tanning in 8 frequent tanners, defined as those who tan 8 to 15 times a month or more than necessary to maintain a tan; and in 8 infrequent tanner control subjects who used tanning beds no more than 12 times a year.

Opioid blockade reduced UV preference in frequent tanners. With naltrexone administration, 4 of 8 frequent tanners, but no infrequent tanners, had withdrawal-like symptoms.

The major study limitation is the small sample size, leading the authors to recommend further studies.

"The finding was unexpected and is consistent with the hypothesis that frequent tanning may be driven in part by a mild dependence on opioids, most likely endorphins," says senior author Steven Feldman, MD, PhD, also from Wake Forest. "The nausea and jitteriness induced by the medication are consistent with symptoms of mild opiate withdrawal."

The National Institutes of Health partly funded this study, along with Galderma Laboratories, LP, and the Wake Forest University Women's Health Center of Excellence. The authors have disclosed no relevant financial disclosures.

NEW YORK (Reuters Health) Apr 04 - Women with high intakes of vitamin D and calcium appear to have a lower risk of type 2 diabetes, according to Boston-based researchers.

Dr. Anastassios G. Pittas, of Tufts-New England Medical Center and colleagues evaluated data for 83,779 women enrolled in the Nurses' Health Study. The women had no history of diabetes, cardiovascular disease or cancer at baseline. Vitamin D and calcium intake from foods and from supplements were evaluated every 2 to 4 years. The results of the study are published in the March issue of Diabetes Care.

A total of 4843 incident cases of diabetes were documented over 20 years of follow-up. The mean daily cumulative intakes of vitamin D and calcium in these women were 309 IU and 867 mg, respectively.

"Based on the latest guidelines set by the Institute of Medicine, only 3% of women in our cohort had adequate vitamin D intake, and only 24% had adequate calcium intake," Dr. Pittas's group reports.

Total vitamin D intake was not significantly associated with type 2 diabetes after adjusting for multiple potential confounders, but there was a 13% lower risk of diabetes among women in the highest versus the lowest category of vitamin D intake from supplements (p = 0.04).

Women with the highest versus total calcium had a 21% lower risk of diabetes than those with the lowest intakes (p < 0.01). The risk was 18% lower among women in the highest versus the lowest category of calcium intake from supplements (p < 0.001).

The lowest risk of diabetes was observed among women with the highest combined intakes of calcium and vitamin D compared with those with the lowest.

The mechanism by which vitamin D affects diabetes risk is unclear. Insulin resistance and impaired pancreatic beta-cell function have been linked with vitamin D insufficiency. "These observations together with the finding of vitamin D receptors in beta-cells and the finding of impaired insulin secretory capacity in mice lacking a functional vitamin D receptor indicate an important role for vitamin D in regulating beta-cell function," the researchers report.

The mechanism by which calcium may affect the risk of diabetes is also unclear. "Abnormal regulation of intracellular calcium affecting both insulin sensitivity and insulin release has been suggested as a potential mechanism to explain the putative association between calcium insufficiency and risk of diabetes."

April 11, 2006 -- After hysterectomy, estrogen-only hormone therapy does not increase a woman's risk of breast cancer.

That's the word from the final analysis of the estrogen-only arm of the Women's Health Initiative (WHI) study. The trial was stopped early because it linked hormone therapy to increased risk of stroke, with no reduction in heart-disease risk.

The study had two arms. Menopausal women with an intact uterus received estrogen plus progestin or an inactive placebo. That's because estrogen alone increases a woman's risk of uterine cancer. Women who had undergone hysterectomy, however, received estrogen-only hormone therapy or placebo.

The average five-year breast cancer risk estimates were similar between the estrogen-plus-progestin group and the estrogen-only group.

Could this be true? Stanford researcher Marcia L. Stefanick, PhD, chairwoman of the WHI steering committee, led a team that took a detailed look at the estrogen-only data. Stefanick's report appears in the April 12 issue of The Journal of the American Medical Association.

"The major finding is no increased risk of breast cancer in women taking just estrogen," Stefanick tells WebMD. "There is a tendency for decreased risk of breast cancer, but it is not statistically significant. This means it would be inappropriate simply to say estrogen alone decreases breast cancer."

Stefanick says estrogen may be safer for some women than for others.

"Women at lower initial risk of breast cancer seem to be the ones who have even lower risk if they go on estrogen," she says. "Women with a higher risk of breast cancer seem to have even higher risk with estrogen."

HRT Risk Overblown?

Stefanick says there are big differences between treating women who have had a hysterectomy and women with an intact uterus. And there are big differences between estrogen-only hormone therapy and estrogen-plus-progestin therapy.

"The media always talk about 'hormones do this' or 'hormones do that,'" Stefanick says. "What we are clear on is estrogen plus progestin does one thing in one group, and estrogen alone does something very different in a different group. We cannot say it is all about progestin. But we can say progestin plus estrogen gives a really different outcome than just estrogen."

The study results are very reassuring to Hugh Taylor, MD, associate chief for research in the obstetrics, gynecology, and reproductive sciences department at Yale University. Taylor spoke at a news conference organized by Wyeth, which makes Premarin and Prempro, the hormones tested in the WHI study. Taylor has received speakers' fees from Wyeth, but has no financial interest in the company. Wyeth is a WebMD sponsor.

Controversy Continues

"Women have been on a roller coaster ride. That ride is over," Taylor says. "For women with hysterectomy, the evidence is clear: Estrogen is safe for them. There is no breast cancer risk for estrogen alone. This has been the No. 1 fear keeping women from using estrogen for their menopausal symptoms."

While the study did not consistently find an overall reduction in breast cancer, the women on estrogen-only therapy did have significantly fewer cases of the most common kind of breast cancer -- ductal cancer.

"What was significantly decreased was ductal cancer, the most common form, a real reduction by almost 30% in the most common kind of breast cancer," Taylor says.

What about women who have not had a hysterectomy?

"As we see more detailed results from the WHI, we see there are some reassuring findings for women without hysterectomy," Taylor says. "In terms of heart disease, in younger women there is no increased risk. Ongoing studies with newly menopausal women are suggesting a benefit even with combined estrogen/progestin treatment. There was increased risk of breast cancer, but this number was very small. On balance, the risks of estrogen plus progestin are very low."

That's a controversial opinion. Boston University epidemiologist Lynn Rosenberg, ScD, recently analyzed data from a study of more than 23,000 black women. Reporting in the April 10 issue of the Archives of Internal Medicine, she finds that women who used hormone therapy -- even estrogen alone -- had a higher risk of breast cancer than women who never used hormone therapy.

"In my view, the weight of evidence would make me very suspicious of estrogen alone," Rosenberg tells WebMD. "It seems absolutely certain that estrogen plus progestin increases the risk of breast cancer, particularly if you take if for a long time."

Doctors currently prescribe hormone therapy for women who need help with the symptoms of menopause. Taylor says every woman with these symptoms is a candidate for this treatment, unless they have a high risk of breast cancer or a clotting disorder.

"The paradigm of treating menopause symptoms with the lowest effective dose of hormone therapy, for the shortest period necessary, is very sensible," Taylor says.

SOURCES: Stefanick, M.L. The Journal of the American Medical Association, April 12, 2006; vol 295: pp 1647-1657. Marcia L. Stefanick, PhD, professor of medicine, Stanford University School of Medicine; chairwoman, Women's Health Initiative steering committee. Wyeth news conference with Hugh Taylor, MD, associate professor and associate chief for research, department of obstetrics, gynecology & reproductive sciences, Yale University; and William T. Creasman, MD, professor of obstetrics and gynecology, Medical University of South Carolina. Lynn Rosenberg, ScD, professor epidemiology, Boston University.

Reviewed by Louise Chang

News Author: Laurie Barclay, MD

Jan. 4, 2006 — A low-fat eating pattern emphasizing fruits, vegetables, and grains does not result in weight gain in postmenopausal women, according to an interim report from the Women's Health Initiative (WHI) Dietary Modification Trial reported in the January 4 issue of JAMA.

"Obesity in the United States has increased dramatically during the past several decades," write Barbara V. Howard, PhD, from MedStar Research Institute in Washington, DC, and colleagues. "There is debate about optimum calorie balance for prevention of weight gain, and proponents of some low-carbohydrate diet regimens have suggested that the increasing obesity may be attributed, in part, to low-fat, high-carbohydrate diets."

In this long-term, low-fat diet trial for which the primary end points were breast and colorectal cancer, 48,835 postmenopausal US women of diverse backgrounds and ethnicities were enrolled between 1993 and 1998 and randomized to a dietary intervention (40%) or control group (60%).

The dietary intervention included group and individual sessions to promote decreased fat intake and increased consumption of vegetables, fruits, and grains, but it did not include weight loss or caloric restriction goals. The control group received diet-related educational materials. The primary endpoint was change in body weight from baseline to follow-up. This analysis includes data from a mean follow-up of 7.5 years, through August 31, 2004.

Compared with the control group, women in the intervention group lost weight in the first year (mean, 2.2 kg; P < .001) and maintained lower weight (difference, 1.9 kg; P < .001 at 1 year and 0.4 kg; P = .01 at 7.5 years). Even when stratified by age, ethnicity, or body mass index (BMI), women in the intervention group showed no tendency toward weight gain. In either group, weight loss was greatest among women who decreased their percentage of energy from fat. A similar but lesser trend was seen with increases in vegetable and fruit servings. There was a nonsignificant trend toward weight loss with increasing intake of fiber.

"A low-fat eating pattern does not result in weight gain in postmenopausal women," the authors write. "This large randomized trial demonstrates that dietary recommendations for reducing fat and replacing it with vegetables, fruits, and grains do not increase body weight, which implies that guidelines that restrict fat intake and advocate increases in complex carbohydrates have not been a contributing factor to the weight gain that has been occurring in the United States throughout the past several decades."

Study limitations include low representation of nonwhites; inclusion only of postmenopausal women aged 50 to 79 years, although the researchers purport that the data are likely generalizable to younger persons and to both sexes; exclusion of women reporting less than 32% fat intake at baseline; biased nature of self-reported food intake; inability to separate carbohydrate intake into the percentage of sugar or simple vs complex carbohydrate; inability to evaluate the potential effects of changes in caloric intake; and possible overestimate of the baseline percentage of energy from fat.

The National Heart, Lung, and Blood Institute funded this study. Dr. Howard has disclosed various relevant financial relationships with Merck, the Egg Nutrition Council, General Mills, Pfizer, and Schering-Plough.

In an accompanying editorial, Michael L. Dansinger, MD, MS, and Ernst J. Schaefer, MD, from Tufts University Human Nutrition Research Center in Boston, Massachusetts, call this a "landmark study... [because the] trial provide[d] a unique opportunity to examine long-term effects of an ad libitum low-fat dietary pattern on body weight and the relationship between weight changes and specific changes in dietary components." However, they continue to describe that the findings on long-term weight change are "somewhat underwhelming." Again, total weight loss at 1 year for the intervention group was only 2.2 kg with a 1.9-kg difference between the intervention and control groups at 1 year and only a 0.4-kg difference after 7.5 years of follow-up.

The editorialists suggest that the dietary intervention should have included the goal of weight reduction. They also stress that weight loss for an individual will not occur without physical activity and belief (by physician and patient) in lifestyle change, regardless of the dietary intervention applied. Citing their own study, published in the January 5, 2005, issue of JAMA, they explain that better adherence leads to better results.

"Much more work needs to be done on the obesity front, including a concerted collective effort focused on developing reliable methods of facilitating high long-term adherence levels to substantial lifestyle efforts — specifically calorie-reduced eating patterns and much more exercise," Drs. Dansinger and Schaefer write. "That is something on which health advocates and popular diet proponents can agree."

NEW YORK (Reuters Health) Apr 11 - Since the introduction of a heptavalent pneumococcal conjugate vaccine (PCV7) in 2000 and its recommendation for all children 2-23 months old, rates of invasive pneumococcal disease among young infants have declined, new research suggests.

Previous reports have linked PCV7 use with a drop in IPD rates among children younger than 2 years of age. However, it was unclear if childhood PCV7 immunization reduced disease rates among infants who were too young to receive PCV7 themselves, namely those who were just a few months old.

In the present study, reported in the Journal of the American Medical Association for April 12, Dr. Katherine A. Poehling, from Vanderbilt University School of Medicine in Nashville, and colleagues assessed IPD rates among infants, 0 to 90 days of age, before and after the introduction of PC7V.

In the eight states studied, 89 cases of IPD occurred before PCV7 introduction and 57 occurred afterward. The bulk of these cases - 64% -- involved isolated bacteremia.

With the introduction of PCV7, the average rate of IPD among young infants fell 40% from 11.8 to 7.2 cases per 100,000 live births. The reduction was most pronounced for black infants, falling from 17.1 to 5.3 cases per 100,000 live births (p = 0.001). By contrast, the decline seen among white infants was not statistically significant.

Use of PCV7 was associated with a drop in rates of PCV7-serotype isolates, but seemed to have no effect on rates of non-PCV7 serotypes.

"Our data provide further evidence that PCV7 has resulted in herd immunity because neonates and young infants have had a significant decrease in IPD rates, although they are too young to receive a full series of PCV7," the authors conclude.

Reuters Health Information 2006. © 2006 Reuters Ltd.
Republication or redistribution of Reuters content, including by framing or similar means, is expressly prohibited without the prior written consent of Reuters. Reuters shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon. Reuters and the Reuters sphere logo are registered trademarks and trademarks of the Reuters group of companies around the world.

NEW YORK (Reuters Health) Apr 12 - Adolescents with abnormal cervical cytology screening results should be treated less aggressively than adult women, the American College of Obstetricians and Gynecologists (ACOG) recommends.

ACOG issued its committee opinion on evaluating and treating abnormal cervical cytology in adolescents, in the April issue of Obstetrics & Gynecology. In many cases, the authors write, monitoring is more appropriate than more invasive treatment, given that cervical intraepithelial neoplasia (CIN) grades 1 and 2 typically regress in adolescents, and that "surgical excision or destruction of cervical tissue in a nulliparous adolescent may be detrimental to future fertility and cervical competency."

Although treatment for atypical squamous cells of undetermined significance with high-risk human papillomavirus warrants immediate colposcopy in adult women, according to ACOG, the college recommends a repeat Pap at six and 12 months or a high-risk HPV test only, for adolescents. If test results remain abnormal, colposcopy should be performed.

For low-grade squamous epithelial lesions in adolescents, ACOG also recommends a repeat Pap test at six and 12 months or a high-risk HPV test at 12 months rather than immediate colposcopy. And for CIN 2, the committee recommends close follow-up at four to six month intervals with cytology or colposcopy, while noting that follow-up without treatment is not recommended for noncompliant patients.

All other recommendations for adolescents are the same as for adult women.

ACOG also recommends that cervical cancer screening be initiated in adolescents three years after sexual activity begins, but before age 21, while a patient's risk of future non-compliance and of contracting HPV infection should also be considered. "Obtaining a complete and accurate sexual history, therefore, is critical," the committee, states.

They add that clinicians also should consider issues of confidentiality and parental consent when colposcopy or other more invasive treatment is required for adolescents.

Reuters Health Information 2006. © 2006 Reuters Ltd.
Republication or redistribution of Reuters content, including by framing or similar means, is expressly prohibited without the prior written consent of Reuters. Reuters shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon. Reuters and the Reuters sphere logo are registered trademarks and trademarks of the Reuters group of companies around the world.

By Will Boggs, MD

NEW YORK (Reuters Health) Apr 12 - Functional MRI can be used to predict which patients with unipolar depression will respond to cognitive behavior therapy (CBT), according to a report in the April issue of the American Journal of Psychiatry.

"By examining brain function before treatment," Dr. Greg J. Siegle from the University of Pittsburgh School of Medicine told Reuters Health, "it may be possible to give cognitive therapy to just those patients for whom it is most likely to be effective, thereby improving treatment rates and decreasing patient burden."

Dr. Siegle and colleagues performed functional MRI on 14 unmedicated depressed patients and 21 comparison subjects who had never been depressed. This was done during performance of a task sensitive to sustained emotional information processing. The investigators repeated testing of the depressed patients after 16 sessions of CBT.

The team found that low sustained reactivity in the subgenual cingulate cortex to negative words was strongly associated with a reduction in depression after CBT. High sustained reactivity to negative words in a region of the right amygdala was also associated with improved treatment response.

"Depression," continued Dr. Siegle, "often involves increased automatic reactions to emotional situations and decreased regulation of emotional responses, This study suggests that cognitive therapy, which helps people to react differently to emotional situations and thoughts, may be particularly useful for depressed people who have brain correlates of these characteristics."

Dr. Siegle went on to say that he and his colleagues are conducting a larger study to investigate "whether the same mechanisms which predict response to CBT change upon recovery. In addition, we are looking forward to performing similar studies with patients who are receiving medications."

Reuters Health Information 2006. © 2006 Reuters Ltd.
Republication or redistribution of Reuters content, including by framing or similar means, is expressly prohibited without the prior written consent of Reuters. Reuters shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon. Reuters and the Reuters sphere logo are registered trademarks and trademarks of the Reuters group of companies around the world.

News Author: Laurie Barclay, MD

April 11, 2006 — Human papillomavirus (HPV) vaccine is highly immunogenic and safe and offers protection for up to 4.5 years, according to follow-up results of a randomized study published in the April 6 Early Online Publication issue of The Lancet.

"These findings set the stage for the widescale adoption of HPV vaccination for prevention of cervical cancer," lead author Diane M. Harper, MD, from Dartmouth Medical School in Lebanon, NH, said in a news release.

The authors note that effective vaccination against HPV 16 and HPV 18 to prevent cervical cancer requires a high degree of sustained protection against infection and precancerous lesions.

To evaluate the long-term efficacy, immunogenicity, and safety of a bivalent HPV-16/18 L1 virus-like particle AS04 vaccine, the investigators did a follow-up study of their multicenter, double-blind, randomized, placebo-controlled trial reported in 2004. The sample included 393 women who originally received all three 0.5-mL doses of bivalent HPV-16/18 virus-like particle AS04 vaccine, and 383 women who received placebo.

During the extended follow-up phase, more than 98% seropositivity was maintained for HPV-16/18 antibodies. The vaccine had significant efficacy against HPV-16 and HPV-18 endpoints, including incident infection (96.9%; 95% confidence interval [CI], 81.3 - 99.9); persistent infection: 6-month definition, 94.3% (95% CI, 63.2 - 99.9); 12-month definition, 100% (95% CI, 33.6 - 100).

Combined analysis of the initial efficacy and extended follow-up showed a vaccine efficacy of 100% (95% CI, 42.4 - 100) against cervical intraepithelial neoplasia lesions associated with vaccine types. However, there was also broad protection against cytohistologic outcomes beyond that anticipated for HPV-16/18, and protection against incident infection with HPV 45 and HPV 31. Safety profile was good over the long term.

"Up to 4.5 years, the HPV-16/18 L1 virus-like particle AS04 vaccine is highly immunogenic and safe, and induces a high degree of protection against HPV-16/18 infection and associated cervical lesions," the authors write. "There is also evidence of cross protection."

The main study limitation is the few observations of cervical intraepithelial neoplasia in the extended follow-up phase, which may reflect the time required to develop true persistent high-grade cervical dysplasia.

GlaxoSmithKline Biologicals funded and coordinated this study, and employs 4 of its authors. Several other authors have disclosed various financial relationships with GlaxoSmithKline Biologicals, Merck & Co, 3M, Pfizer, Roche, and/or Schering.

News Author: Laurie Barclay, MD

April 7, 2006 — Long-term, biannual dietary intervention reduces risk for insulin resistance in 9-year-old children, according to the results of a randomized study reported in the April issue of Diabetes Care.

"Insulin resistance, defined as an inadequate metabolic response to plasma insulin at normal concentrations, is promoted by obesity and high intake of saturated fat, and up to 30% of overweight or obese individuals develop insulin resistance," write Tuuli Kaitosaari, MD, from the University of Turku in Finland, and colleagues from the Special Turku Coronary Risk Factor Intervention Project for Children (STRIP) study. "Preventing obesity and sedentary lifestyle and supporting a healthy lifestyle are important preventive measures, particularly if started in childhood."

In this study, healthy 7-month-old infants (n = 1062) were randomized to the intervention (n = 540) and control groups (n = 522). The intervention consisted of biannual individualized counseling sessions for each child's family, aimed at minimizing children's exposure to known environmental risk factors for atherosclerosis. At 9 years of age in a random subgroup of 78 intervention children and 89 control children, a homeostasis model assessment of insulin resistance (HOMA-IR) index, serum lipids, blood pressure, and weight for height were determined.

Compared with the control children, the intervention children consumed less total fat (P = .002) and saturated fat (P < .0001) and had a lower HOMA-IR index (P = .02). Saturated fat intake was significantly correlated with HOMA-IR. Multivariate analyses revealed that the study group, but not saturated fat intake or other determinants of HOMA-IR (serum triglyceride concentration, weight for height, and systolic blood pressure), was significantly associated with HOMA-IR.

"This suggests that the beneficial effect of intervention on insulin sensitivity was largely, but not fully, explained by the decrease in saturated fat intake," the authors write. "The long-term biannual dietary intervention decreases the intake of total and saturated fat and has a positive effect on insulin resistance index in 9-year-old children."

The authors suggest that development of insulin resistance and possibly also atherosclerosis may be delayed or prevented by introducing relevant dietary and lifestyle habits in early childhood.

"Further follow-up studies with continuing counseling sessions in our trial will show whether the observed beneficial effects of intervention will continue over puberty into early adulthood," the authors conclude.

The Juho Vainio Foundation; the Yrjö Jahnsson Foundation; the Finnish Cardiac Research Foundation; the Foundation for Pediatric Research, Finland; the Academy of Finland; the Sigrid Juselius Foundation; the Turku University Foundation; the Finnish Cultural Foundation, City of Turku; EVO funds of Turku University Central Hospital; and the Raisio Group Research Foundation supported this study.

The costs of publication of this article were defrayed in part by the payment of page charges, mandating that the article must therefore be marked "advertisement."

By Karla Gale

NEW YORK (Reuters Health) Apr 07 - For patients at high risk of Alzheimer's disease, taking a combination of vitamins E and C plus ibuprofen significantly reduces their risk, results of a longitudinal study suggest.

"We found that for people at low risk, taking vitamin C and E alone is sufficient to further reduce their risk. But for those with apolipoprotein epsilon-4 (APOE-epsilon-4) alleles, the combination exerts a synergistic benefit," Dr. Majid Fotuhi told Reuters Health.

Dr. Fotuhi, from Johns Hopkins University in Baltimore, and his associates prospectively followed nearly 5000 elderly residents of Cache County in Utah for 8 years, taking into account their regular consumption of vitamins C and E, ibuprofen, or a combination of the three. Dr. Fotuhi reported the findings at the American Academy of Neurology's 58th Annual Meeting here in San Diego.

They identified 127 subjects who regularly consumed all three agents. Results showed that this group exhibited significantly less decline in Modified Mini-Mental State Exam scores. After adjusting for age, gender, APOE genotype, hypertension, cholesterol, stroke, coronary artery bypass surgery, and MI, those who used all three agents performed better than non-users by approximately 1 point every 2 years.

"With this approach, we've advanced a 2-point attack on the cascade of events that leads to Alzheimer's disease pathology," Dr. Fotuhi said. "On the one hand, we reduce inflammation (with vitamins E and C), and on the other hand, we reduce the amount of amyloid in the brain (with ibuprofen), the substrate that causes inflammation."

As noted, APOE-epsilon-4 carriers experienced the greatest benefit from the triple-combination treatment. According to the researchers' presentation, this subset of patients in their late 60s or 70s exhibited no decline in cognitive function during the 8-year follow-up when they took all three agents. Subjects who took just one of these agents had worsening memory over time.

"So if patients seem to be at high risk, such as having several family members with Alzheimer's disease or with early memory loss, they are likely to benefit the most from the triple-combination therapy," the researcher said.

As to what dose of ibuprofen to use, Dr. Fotuhi urges caution, since the drug is associated with gastric ulcers. He recommends a dose no higher than 100 mg/day.

He is so encouraged by these findings that he has patented a combination pill containing vitamins A and E, ibuprofen, and "a small amount of omega-3 fatty acid."

April 6, 2006 -- For the first time, researchers report a possible link between secondhand smoke and glucose intolerance.

The study, published in BMJ Online First, doesn't prove that secondhand smoke causes glucose intolerance. But it does show an association between tobacco exposure -- including nonsmokers exposed to secondhand smoke -- and glucose intolerance.

Thomas Houston, MD, MPH, of Alabama's Birmingham Veterans Affairs Medical Center, helped conduct the study. He and his colleagues studied more than 4,600 young blacks and whites for 15 years.

Current cigarette smokers were most likely to develop glucose intolerance, which was defined as having diabetes or impaired fasting glucose (blood sugar). Having impaired fasting glucose is also referred to as prediabetes. Nonsmokers reporting secondhand-smoke exposure came in second, followed by former smokers. Nonsmokers without secondhand-smoke exposure were least likely to develop glucose intolerance, the study shows.

About the Participants

The group was equally split between blacks and whites. Fifty-five percent were women.

Participants had enrolled in a larger study on heart health. They lived in four cities: Chicago; Minneapolis; Birmingham, Ala.; and Oakland, Calif.

When the study started, participants were 18-30 years old and didn't have glucose intolerance. They got an initial checkup lasting four or five hours and were interviewed about smoking.

The group included 1,386 current smokers, 621 former smokers, 1,452 smokers who reported secondhand-smoke exposure, and 1,113 nonsmokers who reported no secondhand-smoke exposure. To try to make sure that nonsmokers really weren't smokers, the researchers checked participants' blood for a marker of nicotine.

Participants got follow-up interviews by telephone every year. They were also scheduled for in-person checkups two, five, seven, 10, and 15 years into the study.

Other Influences

The researchers gathered lots of other information about participants, including diet habits, waist-to-hip ratio, blood pressure, alcohol use, physical activity, income, and education.

Those factors might affect a person's risk of developing glucose intolerance and varied among participants. For instance, current smokers had lower education and consumed more fat and alcohol than nonsmokers with no secondhand-smoke exposure.

The researchers took those and other factors into account. The study's main findings didn't change, but Houston's team doesn't rule out other possible influences, since observational studies can't prove cause and effect.

The findings should be checked in other groups of people, write Houston and colleagues. They note mixed results in other studies on tobacco exposure and diabetes risk.

SOURCES: Houston, T. BMJ Online First, April 7, 2006. News release, BMJ.

Reviewed by Louise Chang

NEW YORK (Reuters Health) Apr 06 - Obese patients with coronary artery disease (CAD) who have normal myocardial perfusion on single-photon emission computed tomography (MPS) have a lower risk of death from cardiac causes that their leaner counterparts.

A prospective study of 4720 patients with known CAD and 10,019 patients with suspected CAD, conducted by Dr. Daniel S. Berman, of Cedars-Sinai Medical Center in Los Angeles, and colleagues assessed the relationship between body mass index and the prognostic value of MPS.

Obese, overweight and normal weight patients with or without known CAD and a normal MPS had similar rates of cardiac deaths, less than 1% annually.

Obese and overweight patients with known CAD and an abnormal MPS had a lower risk of cardiac death than their normal-weight counterparts. Normal-weight patients with low ejection fractions also had the highest rate of cardiac death.

Dr. Berman's team found that body mass index was not predictive of cardiac death in patients with suspected CAD, but it was an independent inverse predictor of cardiac death in patients with known CAD. This relationship was especially strong in women, those with a low ejection fraction, abnormal MPS and adenosine stress.

The results are published in the April 4th issue of the Journal of the American College of Cardiology.

Reuters Health Information 2006. © 2006 Reuters Ltd.
Republication or redistribution of Reuters content, including by framing or similar means, is expressly prohibited without the prior written consent of Reuters. Reuters shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon. Reuters and the Reuters sphere logo are registered trademarks and trademarks of the Reuters group of companies around the world.

News Author: Laurie Barclay, MD

April 6, 2006 — Sleeping less than 6 hours per night increases the risk for hypertension, according to the results of a longitudinal study reported in the April 3 Online First issue of Hypertension.

"Depriving healthy subjects of sleep has been shown to acutely increase blood pressure and sympathetic nervous system activity," write James E. Gangwisch, MD, from the College of Physicians and Surgeons at Columbia University in New York, NY, and colleagues. "Prolonged short sleep durations could lead to hypertension through extended exposure to raised 24-hour blood pressure and heart rate, elevated sympathetic nervous system activity, and increased salt retention. Such forces could lead to structural adaptations and the entrainment of the cardiovascular system to operate at an elevated pressure equilibrium."

The investigators conducted longitudinal analyses of the first National Health and Nutrition Examination Survey (n = 4810), using Cox proportional hazards models and controlling for covariates. During the 8- to 10-year follow-up period between 1982 and 1992, there were 647 cases of hypertension, determined by physician diagnosis, hospital record, or cause of death.

In subjects between the ages of 32 and 59 years, sleep durations of less than 6 hours per night were associated with more than double the risk for hypertension (hazard ratio, 2.10; 95% confidence interval [CI], 1.58 - 2.79). Controlling for potential confounding variables only partially reduced this relationship. The increased risk continued to be significant after controlling for obesity and diabetes, consistent with the hypothesis that these variables would act as partial mediators.

"Short sleep duration could, therefore, be a significant risk factor for hypertension," the authors write. "Further research is needed to investigate the biological mechanisms that link short sleep duration and high blood pressure. If short sleep duration functions to increase blood pressure, then interventions that increase the amount and quality of sleep could potentially serve as treatments and as primary preventative measures for hypertension."

Study limitations include relatively low sample size for older subjects; inability to determine whether short self-reported sleep durations indicated sleep deprivation or normal variability between individuals in required sleep durations; inability to rule out reverse causation or uncontrolled confounders; use of self-reported sleep durations; lack of repeated measures of sleep duration; possible underdiagnosis of hypertension; possible bias arising from loss to follow-up; and missing data on baseline risk variables.

"In results from the National Sleep Foundation 2002 Sleep in America Poll, not getting enough sleep was associated with irritability, impatience, pessimism, and feeling tired and stressed," the authors point out. "It would seem that these feelings and emotional states would function to lessen one's resolve and willpower to follow dietary or exercise regimens that would be protective against hypertension."

April 5, 2006 -- A vaccine targeting the sexually-transmitted virus that can cause cervical cancer was still protecting women who got it after more than four years, researchers reported Wednesday.

The findings represent the longest follow-up yet of an experimental human papillomavirus (HPV) vaccine, which has the potential to dramatically lower deaths from cervical cancer.

Two such vaccines are poised to hit the market in the U.S. pending approval by the FDA. The agency is expected to rule on Merck's vaccine -- called Gardasil -- early in June.

A spokesman for GlaxoSmithKline tells WebMD that the company plans to seek FDA approval for its HPV vaccine -- Cervarix -- by the end of the year.

"With fast-track status, if all goes well, we could have [approval] within six months," says Phillippe Monteyne, who heads global vaccine development for the company.

100% Protection

The study included 800 women who were vaccinated with either three doses of Cervarix or a placebo.

In November 2004, researchers reported that the vaccine was 100% effective in preventing persistent infection with the two HPV strains that cause about 70% of cervical cancers -- HPV-16 and HPV-18.

In a follow-up, published in the latest issue of The Lancet, they reported that the women given the vaccine continued to be protected four and a half years after receiving the last dose of the vaccine.

The women were also protected against two other HPV strains that have also been associated with cervical cancer -- HPV 45 and HPV 31. This cross-protection occurred even though the vaccine was not designed to target these strains.

About half a million cases of cervical cancer are diagnosed worldwide each year, and an estimated 280,000 women -- mostly in developing countries -- die from the disease.

Researchers estimate that if all eligible women got the vaccine, it would reduce the worldwide incidence of cervical cancer by almost 70%.

"This is a very exciting time," says Diane M. Harper, MD, MPH, who led the study team. "We haven't had an advance like this in cancer care or in women's health for 50 years. This has tremendous potential."

Unanswered Questions

There are still many unanswered questions, most notably who will get the vaccine, when they will be vaccinated, and which vaccine they will get.

The GlaxoSmithKline vaccine protects against cervical cancer alone, while the Merck vaccine also targets two HPV viruses that cause genital warts.

But Harper says her findings suggest that the GlaxoSmithKline vaccine may protect women against cervical cancer longer than its competitor.

Harper directs the Gynecologic Cancer Prevention Research Group at Dartmouth Medical School's Norris Cotton Cancer Center. The study was funded by GlaxoSmithKline, but she says she has also done research on the Merck vaccine. GlaxoSmithKline and Merck are WebMD sponsors.

"I'm not trying to pick a fight and say one vaccine is better than the other," she says. "These are both good vaccines, but it is clear that there are real differences between them."

If, as expected, the FDA approves the Merck vaccine in early June, the CDC's Advisory Committee on Immunization Practices is expected to weigh in on who should be vaccinated at its meeting later that month.

It may recommend that preteen girls be given the vaccine, or it may recommend the vaccine for girls in their teens.

HPV infection rates peak among women in their late teens and very early 20s, Harper says.

"Stay tuned for June," American Cancer Society Director of Breast and Gynecological Cancer Debbie Saslow, PhD, tells WebMD. "There are a lot of groups interested in having a voice in how this vaccine is used."

Some conservative groups have been vocally opposed to the vaccine, arguing that it could undermine efforts to discourage sex among teens.

Saslow says other conservative groups have expressed support for the vaccine, although they don't want it to be among the immunizations that schools require.

The Developing World

Immunization strategies for nonindustrialized countries, where 80% of cervical cancer deaths occur, remain to be determined.

In the U.S, the vaccine is expected to cost between $200 and $300 for a three-dose series, although the companies have not said how much they will charge, according to Saslow.

Projections are that without the vaccine, cervical cancer deaths in the developing world will rise dramatically in the coming decades.

The Bill and Melinda Gates Foundation has pledged $50 million for the prevention of cervical cancer in the coming decades, but it is not clear how big a role vaccination will play in its efforts.

SOURCES: Harper, D.M. The Lancet, April 6, 2006; vol 367: online edition. Diane M. Harper, MD, MPH, director, gynecologic cancer prevention research group, Norris Cotton Cancer Center, Dartmouth Medical School, Lebanon, N.H. Debbie Saslow, PhD, director of breast and gynecological cancer, American Cancer Society. Phillippe Monteyne, head of global vaccine development, GlaxoSmithKline. WebMD: "Vaccine May Prevent Cervical Cancer."

NEW YORK (Reuters Health) Apr 06 - Obese patients with coronary artery disease (CAD) who have normal myocardial perfusion on single-photon emission computed tomography (MPS) have a lower risk of death from cardiac causes that their leaner counterparts.

A prospective study of 4720 patients with known CAD and 10,019 patients with suspected CAD, conducted by Dr. Daniel S. Berman, of Cedars-Sinai Medical Center in Los Angeles, and colleagues assessed the relationship between body mass index and the prognostic value of MPS.

Obese, overweight and normal weight patients with or without known CAD and a normal MPS had similar rates of cardiac deaths, less than 1% annually.

Obese and overweight patients with known CAD and an abnormal MPS had a lower risk of cardiac death than their normal-weight counterparts. Normal-weight patients with low ejection fractions also had the highest rate of cardiac death.

Dr. Berman's team found that body mass index was not predictive of cardiac death in patients with suspected CAD, but it was an independent inverse predictor of cardiac death in patients with known CAD. This relationship was especially strong in women, those with a low ejection fraction, abnormal MPS and adenosine stress.

The results are published in the April 4th issue of the Journal of the American College of Cardiology.

Reuters Health Information 2006. © 2006 Reuters Ltd.
Republication or redistribution of Reuters content, including by framing or similar means, is expressly prohibited without the prior written consent of Reuters. Reuters shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon. Reuters and the Reuters sphere logo are registered trademarks and trademarks of the Reuters group of companies around the world.

News Author: Laurie Barclay, MD

April 6, 2006 — Sleeping less than 6 hours per night increases the risk for hypertension, according to the results of a longitudinal study reported in the April 3 Online First issue of Hypertension.

"Depriving healthy subjects of sleep has been shown to acutely increase blood pressure and sympathetic nervous system activity," write James E. Gangwisch, MD, from the College of Physicians and Surgeons at Columbia University in New York, NY, and colleagues. "Prolonged short sleep durations could lead to hypertension through extended exposure to raised 24-hour blood pressure and heart rate, elevated sympathetic nervous system activity, and increased salt retention. Such forces could lead to structural adaptations and the entrainment of the cardiovascular system to operate at an elevated pressure equilibrium."

The investigators conducted longitudinal analyses of the first National Health and Nutrition Examination Survey (n = 4810), using Cox proportional hazards models and controlling for covariates. During the 8- to 10-year follow-up period between 1982 and 1992, there were 647 cases of hypertension, determined by physician diagnosis, hospital record, or cause of death.

In subjects between the ages of 32 and 59 years, sleep durations of less than 6 hours per night were associated with more than double the risk for hypertension (hazard ratio, 2.10; 95% confidence interval [CI], 1.58 - 2.79). Controlling for potential confounding variables only partially reduced this relationship. The increased risk continued to be significant after controlling for obesity and diabetes, consistent with the hypothesis that these variables would act as partial mediators.

"Short sleep duration could, therefore, be a significant risk factor for hypertension," the authors write. "Further research is needed to investigate the biological mechanisms that link short sleep duration and high blood pressure. If short sleep duration functions to increase blood pressure, then interventions that increase the amount and quality of sleep could potentially serve as treatments and as primary preventative measures for hypertension."

Study limitations include relatively low sample size for older subjects; inability to determine whether short self-reported sleep durations indicated sleep deprivation or normal variability between individuals in required sleep durations; inability to rule out reverse causation or uncontrolled confounders; use of self-reported sleep durations; lack of repeated measures of sleep duration; possible underdiagnosis of hypertension; possible bias arising from loss to follow-up; and missing data on baseline risk variables.

"In results from the National Sleep Foundation 2002 Sleep in America Poll, not getting enough sleep was associated with irritability, impatience, pessimism, and feeling tired and stressed," the authors point out. "It would seem that these feelings and emotional states would function to lessen one's resolve and willpower to follow dietary or exercise regimens that would be protective against hypertension."

April 5, 2006 -- A vaccine targeting the sexually-transmitted virus that can cause cervical cancer was still protecting women who got it after more than four years, researchers reported Wednesday.

The findings represent the longest follow-up yet of an experimental human papillomavirus (HPV) vaccine, which has the potential to dramatically lower deaths from cervical cancer.

Two such vaccines are poised to hit the market in the U.S. pending approval by the FDA. The agency is expected to rule on Merck's vaccine -- called Gardasil -- early in June.

A spokesman for GlaxoSmithKline tells WebMD that the company plans to seek FDA approval for its HPV vaccine -- Cervarix -- by the end of the year.

"With fast-track status, if all goes well, we could have [approval] within six months," says Phillippe Monteyne, who heads global vaccine development for the company.

100% Protection

The study included 800 women who were vaccinated with either three doses of Cervarix or a placebo.

In November 2004, researchers reported that the vaccine was 100% effective in preventing persistent infection with the two HPV strains that cause about 70% of cervical cancers -- HPV-16 and HPV-18.

In a follow-up, published in the latest issue of The Lancet, they reported that the women given the vaccine continued to be protected four and a half years after receiving the last dose of the vaccine.

The women were also protected against two other HPV strains that have also been associated with cervical cancer -- HPV 45 and HPV 31. This cross-protection occurred even though the vaccine was not designed to target these strains.

About half a million cases of cervical cancer are diagnosed worldwide each year, and an estimated 280,000 women -- mostly in developing countries -- die from the disease.

Researchers estimate that if all eligible women got the vaccine, it would reduce the worldwide incidence of cervical cancer by almost 70%.

"This is a very exciting time," says Diane M. Harper, MD, MPH, who led the study team. "We haven't had an advance like this in cancer care or in women's health for 50 years. This has tremendous potential."

Unanswered Questions

There are still many unanswered questions, most notably who will get the vaccine, when they will be vaccinated, and which vaccine they will get.

The GlaxoSmithKline vaccine protects against cervical cancer alone, while the Merck vaccine also targets two HPV viruses that cause genital warts.

But Harper says her findings suggest that the GlaxoSmithKline vaccine may protect women against cervical cancer longer than its competitor.

Harper directs the Gynecologic Cancer Prevention Research Group at Dartmouth Medical School's Norris Cotton Cancer Center. The study was funded by GlaxoSmithKline, but she says she has also done research on the Merck vaccine. GlaxoSmithKline and Merck are WebMD sponsors.

"I'm not trying to pick a fight and say one vaccine is better than the other," she says. "These are both good vaccines, but it is clear that there are real differences between them."

If, as expected, the FDA approves the Merck vaccine in early June, the CDC's Advisory Committee on Immunization Practices is expected to weigh in on who should be vaccinated at its meeting later that month.

It may recommend that preteen girls be given the vaccine, or it may recommend the vaccine for girls in their teens.

HPV infection rates peak among women in their late teens and very early 20s, Harper says.

"Stay tuned for June," American Cancer Society Director of Breast and Gynecological Cancer Debbie Saslow, PhD, tells WebMD. "There are a lot of groups interested in having a voice in how this vaccine is used."

Some conservative groups have been vocally opposed to the vaccine, arguing that it could undermine efforts to discourage sex among teens.

Saslow says other conservative groups have expressed support for the vaccine, although they don't want it to be among the immunizations that schools require.

The Developing World

Immunization strategies for nonindustrialized countries, where 80% of cervical cancer deaths occur, remain to be determined.

In the U.S, the vaccine is expected to cost between $200 and $300 for a three-dose series, although the companies have not said how much they will charge, according to Saslow.

Projections are that without the vaccine, cervical cancer deaths in the developing world will rise dramatically in the coming decades.

The Bill and Melinda Gates Foundation has pledged $50 million for the prevention of cervical cancer in the coming decades, but it is not clear how big a role vaccination will play in its efforts.

SOURCES: Harper, D.M. The Lancet, April 6, 2006; vol 367: online edition. Diane M. Harper, MD, MPH, director, gynecologic cancer prevention research group, Norris Cotton Cancer Center, Dartmouth Medical School, Lebanon, N.H. Debbie Saslow, PhD, director of breast and gynecological cancer, American Cancer Society. Phillippe Monteyne, head of global vaccine development, GlaxoSmithKline. WebMD: "Vaccine May Prevent Cervical Cancer."

NEW YORK (Reuters Health) Apr 04 - Clinical history and the use of computer models are not helpful in distinguishing organic from functional dyspepsia, according to a report in the Journal of the American Medical Association for April 5th.

"Current data suggest that a patient's dyspeptic symptoms appear inefficient for diagnosing the presence or absence of disease, even when the symptoms are modeled in a computer analysis or assessed by a gastroenterologist," lead author Dr. Paul Moayyedi, from McMaster University in Hamilton, Ontario, and colleagues note.

The findings are based on an analysis of data from 15 studies, published between 1983 and 2003, which included 11,366 patients evaluated for dyspepsia. Of these subjects, 4817 were classified as having organic dyspepsia.

When the clinician or computer model suggested an organic etiology for dyspepsia, the likelihood ratio of this being the actual diagnosis was 1.6. Conversely, when they suggested the absence of organic dyspepsia, the likelihood ratio was 0.46.

The clinician and computer model had a likelihood ratio of 2.2 when suggesting the presence of peptic ulcer disease and a ratio of 0.46 when suggesting its absence. Similarly, the corresponding ratios for esophagitis were 2.4 and 0.50.

"These results point to the diagnostic difficulty of identifying functional dyspepsia, peptic ulcer disease, and esophagitis," the researchers note.

"Future research should evaluate whether adding response to interventions, such as acid suppression to the clinical history, improves diagnostic accuracy across a broad spectrum of patients," they add.

News Author: Laurie Barclay, MD

Adults with prehypertension can maintain changes in lifestyle that reduce progression to hypertension for 18 months, according to the results of a randomized study by Patricia J. Elmer, PhD, and colleagues from the PREMIER Collaborative Research Group, reported in the April 4 issue of the Annals of Internal Medicine.

"This study underscores the value of lifestyle changes — namely improving diet and increasing physical activity — in reducing high blood pressure, an important public health problem," National Heart, Lung and Blood Institute of Health (NHLBI) director Elizabeth G. Nabel, MD, said in a news release. "For the millions of Americans with prehypertension and hypertension, this shows that individuals can make healthy lifestyle changes to keep blood pressure under control without the use of medications."

From January 2000 through November 2002, 810 men and women aged 25 and older with either prehypertension (120 - 139 mm Hg/80 - 89 mm Hg) or stage 1 hypertension (140 - 159 mm Hg/90 - 95 mm Hg) but who were not taking antihypertensive medications were randomized to 3 groups. Two of the groups (established groups) were prescribed goals for weight loss and physical activity and were given sodium and alcohol intake limits, and they received 18 counseling sessions during the first 6 months, including 14 group meetings and 4 individual sessions. During the last 12 months, participants in these 2 groups received 12 group meetings and 3 individual sessions.

One of these groups also received guidance on following the Dietary Approaches to Stop Hypertension diet (DASH), which is high in fruits and vegetables and low-fat dairy products and low in saturated, total fat, and dietary cholesterol. The US Dietary Guidelines for Americans recommend DASH as an example of a healthy eating plan, and previous NHLBI studies have shown that DASH lowers blood pressure.

The third group served as a control. Participants in this group received only two 30-minute counseling sessions regarding standard recommendations for blood pressure control; one at study enrollment and one 6 months later, as well as a third session if desired at the end of the trial after 18-month measurements were completed. Follow-up for blood pressure measurement at 18 months was 94%.

Compared with advice only, both behavioral interventions were associated with statistically significant reductions in weight, fat intake, and sodium intake. The DASH group also had statistically significant increases in fruit, vegetable, dairy, fiber, and mineral intakes.

Compared with the control group, the odds ratios for hypertension at 18 months were 0.83 (95% confidence interval [CI], 0.67 - 1.04) for the established group and 0.77 (95% CI, 0.62 - 0.97) for the established plus DASH group. Reductions in absolute blood pressure at 18 months were greater for participants in the established and the established plus DASH groups than in the control group, but these differences did not reach statistical significance.

"These rates of hypertension control produced by the two interventions are even better than the 50% control rates typically found when single drug therapy is used to control high blood pressure," says study investigator William M. Vollmer, PhD, from Kaiser Permanente Center for Health Research.

Study limitations include limited generalizability because of the exclusion criteria and the volunteer nature of the cohort; and duration was too short and sample size too small to assess intervention effects on clinical cardiovascular events.

"Participants in the two intervention groups made greater changes than those in the control group and saw the greatest benefit in blood pressure status," says coauthor Eva Obarzanek, PhD. "This shows that people at risk for heart disease can successfully and simultaneously make multiple changes in lifestyle, for a substantial benefit."

News Author: Laurie Barclay, MD

April 3, 2006 — Vitamin C and vitamin E supplementation are not helpful for woman with preeclampsia and may be harmful to the fetus, according to the results of a randomized trial published the March 30 Early Online Publication issue of The Lancet.

"Oxidative stress could play a part in pre-eclampsia, and there is some evidence to suggest that vitamin C and vitamin E supplements could reduce the risk of the disorder," write L. Poston, MD, from St. Thomas' Hospital in London, United Kingdom, and colleagues from the Vitamins in Pre-eclampsia (VIP) Trial Consortium. "Our aim was to investigate the potential benefit of these antioxidants in a cohort of women with a range of clinical risk factors."

At 25 hospitals, 2410 women at increased risk for preeclampsia were randomized to receive 1000 mg of vitamin C and 400 IU vitamin E (RRR alpha-tocopherol; n = 1199) or matched placebo (n = 1205) daily from the second trimester of pregnancy until delivery. The main outcome was preeclampsia, and secondary outcomes were low birth weight (<2.5 kg) and small size for gestational age (less than fifth customized birth weight percentile). Analyses were by intent-to-treat.

Data were analyzed for 2395 (99.6%) of 2404 patients treated. The incidence of preeclampsia was 15% (n = 181) in the treatment group and 16% (n = 187) in the placebo group (relative risk [RR], 0.97; 95% confidence interval [CI], 0.80 - 1.17). More low birth weight babies were born to women in the treatment group than in the placebo group (28% [n = 387] vs 24% [n = 335]; RR, 1.15; 95% CI, 1.02 - 1.30]). Small size for gestational age was similar in both groups (21% [n = 294] vs 19% [n = 259]; RR, 1.12; 95% CI, 0.96 - 1.31]).

"Concomitant supplementation with vitamin C and vitamin E does not prevent pre-eclampsia in women at risk, but does increase the rate of babies born with a low birth weight," the authors write. "As such, use of these high-dose antioxidants is not justified in pregnancy."

The authors note that the daily doses of vitamin C and vitamin E given were below the maximum recommended intake in pregnant women (2000 mg/day and 1000 mg [1600 IU] daily, respectively).

"The absence of benefit and evidence of unfavorable outcomes in this study cannot be extrapolated to other antioxidants, including the same vitamins at lower doses," the authors conclude. "Additionally, our findings should not detract from the potential importance of oxidative stress in pre-eclampsia."

Some of the authors have disclosed being principal investigators on the World Health Organization trial of vitamin C and vitamin E supplementation for the prevention of preeclampsia; patents regarding diagnosis of preeclampsia; and/or holding shares in CORRA Life Sciences, a biotech company that develops biomarker tests to predict abnormal pregnancy outcomes.

This trial was funded by the Wellcome Trust, with additional support from Tommy's the baby charity.

In an accompanying editorial, Marshall D. Lindheimer, MD, and Baha M. Sibai, MD, from the University of Chicago in Illinois, note that vitamin C levels were obtained in less than half of the participants and longitudinally in only about 10%. Other potential limitations are possible confounding variables, and a heterogeneous population of high-risk patients limiting generalizability.

"Our limited resources should focus more on basic research, with human studies stressing prediction markers combined with ancillary studies to help define mechanisms (and, of course, the safety and efficacy of therapy)," Drs Lindheimer and Sibai write. "It appears surprising that administration of vitamins in amounts that did not exceed maximum daily tolerable allowances should be associated with adverse effects, but the VIP data are not the first time that vitamin or nutrient supplements administered to populations already consuming considerable amounts of the supplement's content in their diets have had adverse effects.... It would not be surprising if two ongoing trials involving antioxidant supplementation in areas of developing nations where nutrient deficiencies are rampant produced results differing from those here."

Laurie Barclay, MD

April 3, 2006 — Investigators successfully grew and implanted tissue-engineered autologous bladders into 7 patients needing cystoplasty, according to a report in the April 4 issue of The Lancet. However, more study is required before use of the procedure becomes widespread.

"Patients with end-stage bladder disease can be treated with cystoplasty using gastrointestinal segments," write Anthony Atala, from Wake Forest University School of Medicine in Winston-Salem, North Carolina, and colleagues. "Engineering bladder tissue with selective cell transplantation might provide a means to create functional new tissues. Cell-based approaches to engineering bladder tissue have been reported, and bioengineering has allowed creation of functional neo-bladder tissues in several animal models."

Seven patients aged 4 to 19 years, with myelomeningocele and high-pressure or poorly compliant bladders, were identified as candidates for cystoplasty. Each patient underwent bladder biopsy, and urothelial and muscle cells were grown in culture and seeded on a biodegradable bladder-shaped scaffold made of collagen, or on a composite of collagen and polyglycolic acid. About 7 weeks later, the autologous engineered bladder constructs were used for reconstruction, and implanted either with or without an omental wrap. After implantation, patients underwent serial urodynamics, cystograms, ultrasounds, bladder biopsies, and serum analyses.

Mean follow-up time was 46 months (range, 22-61 months). The composite engineered bladders with an omental wrap had the greatest postoperative mean bladder leak point pressure decrease (56%), volume increase (1.58-fold) and compliance increase (2.79-fold). Bowel function returned promptly after surgery. There were no metabolic consequences or urinary calculi detected; mucus production was normal; and renal function was preserved. Biopsies of the engineered bladders showed an adequate structural architecture and phenotype.

"Engineered bladder tissues, created with autologous cells seeded on collagen-polyglycolic acid scaffolds, and wrapped in omentum after implantation, can be used in patients who need cystoplasty," the authors write. "The urodynamic results were similar to those that would be expected with the use of gastrointestinal tissue. However, the patients did not experience any of the ill effects associated with gastrointestinal tissues."

As in patients undergoing cystoplasty with bowel segments, these patients continued to need intermittent catheterization.

"The implanted composite engineered bladders showed improved functional parameters that were durable over a period of years," the authors conclude. "Although follow-up of longer than 5 years is reported, additional studies will be needed before this procedure can be used widely."

The authors note that several patents relating to the technology described in this article were assigned to Children's Hospital and were licensed to Tengion in 2003. Five authors report various financial relationships with Tengion.

In an accompanying editorial, Steve Y. Chung, from the Advanced Urology Institute of Illinois in Spring Valley, notes that vascular supply and neural restoration of the engineered bladders needs further study.

"Atala and colleagues should be praised for the milestone they have reached, but further multi-institutional studies are needed with longer follow-up," Dr. Chung writes. "Until then, intestinal cystoplasty remains the gold standard."

Dr. Chung reports no relevant financial relationships.

Lancet. Published online April 4, 2006.

Reviewed by Gary D. Vogin, MD

NEW YORK (Reuters Health) Apr 03 - Elevated B-type natriuretic peptide (BNP) levels are a sign of potentially reversible myocardial ischemia in stroke survivors without chest pain, past MI, or left ventricular systolic impairment, a study shows.

For the patient who survives the first six months following a stroke, the most common cause of death in later years is cardiac-related, Dr. Kenneth Y. K. Wong and colleagues point out in the April issue of Heart. "Stroke survivors with a high BNP deserve further investigations to rule out significant reversible myocardial ischemia, in order to reduce their risk of cardiac death," they conclude.

Dr. Wong's group studied the value of BNP concentrations in 56 stroke patients who "made a good recovery" and were at least 1 month from a recently documented stroke or transient ischemic attack.

"The key finding of the study," Dr. Wong told Reuters Health, was that BNP correlated significantly with the degree of reversible myocardial ischaemia demonstrated on stress myocardial perfusion scanning in subjects who did not have chest pain or a history of MI or evidence of left ventricular systolic dysfunction.

"Thus, BNP might be used to risk stratify stroke survivors for myocardial perfusion scanning to look for evidence of reversible ischaemia," he said.

In the large number of stroke survivors who are not candidates for revascularization, an abnormal BNP level and myocardial perfusion scan may prompt efforts to achieve tighter control of risk factors, such as blood pressure, than usual, Dr. Wong and colleagues suggest in their report.

Asymptomatic stroke survivors with reversible myocardial ischemia might also benefit from intensified statin therapy, they add.

Future research is needed to determine whether a strategy of obtaining BNP levels and myocardial perfusion scans "would ultimately reduce the high incidence of cardiac death in stroke survivors," Dr. Wong said.

Reuters Health Information 2006. © 2006 Reuters Ltd.

NEW YORK (Reuters Health) Apr 03 - Short sleep durations over a prolonged period appears to be an important and potentially modifiable risk factor for hypertension, according to a report in the May issue of Hypertension.

"People who sleep for only short durations raise their average 24-hour blood pressure and heart rate," lead author Dr. James E. Gangwisch, from Columbia University in New York, said in a statement. "This may set up the cardiovascular system to operate at an elevated pressure."

Previous reports have linked sleep disorders with cardiovascular disease, but it was unclear if sleep deprivation, in subjects who did not have a sleep disorder, affected the risk of hypertension.

The findings are based on an analysis of data for 4810 subjects, between 32 and 86 years old, who participated in the first National Health and Nutrition Examination Survey. Hypertension was diagnosed in 647 subjects during the follow-up period from 1982 to 1992.

Among the subjects between 32 and 59 years of age, sleeping less than 6 hours per night raised the risk of hypertension by 2.10-fold, the report indicates. Moreover, this association remained significant after adjusting for obesity and diabetes, which were both hypothesized to be partial mediators of the relationship.

Further studies are needed to better understand the mechanisms linking sleep deprivation with high blood pressure, the authors note. "If short sleep duration functions to increase blood pressure, then interventions that increase the amount and quality of sleep could potentially serve as treatments and as primary preventative measures for hypertension."

Miranda Hitti

April 3, 2006 -- Diabetes care in the U.S. is improving, but not as much as experts would like.

"Overall, quality of care for people with diabetes has improved in the past 10 years, but important opportunities remain for further improvement," write the CDC's Jinan Saadine, MD, and colleagues in the Annals of Internal Medicine.

Saadine's team studied data collected from two national surveys. The surveys included U.S. adults aged 18-75 with diabetes in 1988-2002.

The researchers checked whether diabetes care changed during that time. Benchmarks included blood sugar and cholesterol control, blood pressure control, eye and foot exams, flu vaccination, and aspirin use to lower heart risks.

Study's Findings

The surveys showed improvements in diabetes care including:

• Better cholesterol control
• Increased use of eye and foot exams
• Rise in flu vaccinations
• Better self-monitoring of blood sugar level
• Increased aspirin use

Those changes are "encouraging," write Saadine and colleagues. But they note that the findings weren't totally rosy. For instance, blood pressure didn't improve, and no major shift was seen in blood sugar control.

The researchers report that:

• 2 in 5 diabetes patients still have poor LDL 'bad' cholesterol control.
• 1 in 3 still has poor blood pressure control.
• 1 in 5 still has poor blood sugar control.

The statistics don't include women with gestational diabetes, which can occur during pregnancy.

Diabetes Rising

Nearly 21 million people in the U.S. have diabetes. That number is projected to reach 39 million by 2050, the researchers note.

"Ensuring access to and delivering high-quality care for all people with diabetes should be a national priority," write Saadine and colleagues.

A journal editorial states that the study's main finding is that "millions of Americans remain at high risk for the complications of diabetes despite the new evidence and campaigns to educate the public and the medical profession."

The editorialists agree with Saadine's team that America needs to step up its diabetes care.

"If we succeed, we will improve the prospect of healthier lives for tens of millions of Americans," write the editorialists. They included Jonathan Perlin, MD, PhD, MSHA, of the U.S. Department of Veterans Affairs.

SOURCES: Saadine, J. Annals of Internal Medicine, April 4, 2006; vol 144: pp 465-474. Perlin, J. Annals of Internal Medicine, April 4, 2006; vol 144: pp 525-527. News release, American College of Physicians.

Reviewed by Louise Chang

Miranda Hitti

March 30, 2006 -- The hormone cortisol may help defuse phobias, new research shows.

A phobia is a persistent, excessive fear of a specific object or situation. Scientists recently studied two small groups of people with phobias. One group feared public speaking; the others were extremely afraid of spiders.

Participants faced their fears in the experiment. They were less fearful if they had taken the corticosteroids cortisol or cortisone an hour earlier.

Those steroids may make it harder to recall fearful memories, thus helping to calm phobias, write Leila Soravia, DrPhil, and colleagues.

Soravia works at the Institute of Psychology at Switzerland's University of Zurich. Her study appears in Proceedings of the National Academy of Sciences.

Public Speaking Phobia

Twenty-one participants feared public speaking. Nine took a dose of cortisone by mouth. The others took a placebo treatment containing no cortisone.

An hour later, participants were given 10 minutes' notice to prepare a speech pitching themselves for a job. They were also told that after the speech, they would take a mental math test in front of an audience.

Participants wore heart rate monitors and self-rated their fear. After hearing about the speech and math test, heart rates jumped up for the placebo group but only increased slightly for the cortisone group. The cortisone group also reported less fear than the placebo group, the study shows.

Slaying Spider Fears

The spider test included 20 people with spider phobias. Half got oral cortisol; half got a placebo.

An hour after treatment, participants were shown a color photo of a large black spider with long legs. The photo included a ruler showing that the spider's longest legs spanned nearly four inches.

Participants rated their fear and desire to get away from the photo. They saw the photo six times. For comparison, no one got cortisol in the first and last sessions.

Fear fell for the cortisol group with each session. Those benefits remained in the last session -- held two days after cortisol treatment stopped. The placebo group didn't make as much progress in taming its phobias.

Cortisol and cortisone showed "potentially beneficial effects in phobia" but didn't seem to calm general anxiety unrelated to phobias, Soravia's team writes.

Steroids aren't typically used to treat phobias or anxiety. They can have side effects including osteoporosis (thinning of bones) and diabetes, especially with long-term use.

SOURCES: Soravia, L. Proceedings of the National Academy of Sciences, April 4, 2006; vol 103: pp 5585-5590. News release, Proceedings of the National Academy of Sciences.

Reviewed by Louise Chang

By Carol Sorgen
Reviewed By Kathleen Zelman

Summertime. Long, sunny days. Warmer temperatures. That's the good news. The bad news? If you have any intention of cooling off in the pool or at the beach, you're going to have to slip into that dreaded bathing suit. Unless you're 8 years old, that thought is enough to bring anyone to their knees.

"Those fluorescent lights have just got to go!" says Deborah Klinger, MA, LMFT, staff psychotherapist and certified eating disorder specialist at Structure House, a residential weight loss facility in Durham, N.C.

That would certainly help -- as anyone who's ever cringed in front of a dressing room's full-length mirror can attest. But what if your fear of swimsuit shopping goes beyond the glaring lights that magnify every bump and bulge? What if you can't even bear the thought of appearing in public because you're ashamed of your body?

Why Our Bodies Bother Us

Well, you're certainly not alone. Take a quick survey among your friends, family, and co-workers, and chances are you'll find that there's nary a person among the group who's actually happy with their body.

How has it come to pass that so many of us spend so much time obsessing over our body? It starts at home, says Alexander Sackeyfio, MD, coordinator of the Eating Disorder Program at Beaumont Hospital in suburban Detroit. "How well we think we fit in depends on how our family sees us," Sackeyfio says. "It's the family that serves as the buffer between us and the world out there, and if we've been teased or criticized at home, we're left with all sorts of questions about our body image."

Needless to say, the constant barrage of seemingly perfect men and women on TV, in the movies, and in magazines doesn't help. "The media portrays women's -- and now men's -- bodies as never being good enough," says Rebecca Cook, PhD, a postdoctoral psychology resident at the University of Dayton and a dietitian with 10 years of experience treating eating disorders. "The messages we're receiving need to change so that we're appreciating our body rather than hating it."

"Most of us are incapable of looking like the models in the magazines," adds Denise Lensky, PhD, director of the Eating Disorders Program at the Belmont Center for Comprehensive Treatment in Philadelphia. "That's not the norm and it can't -- and never will -- be."

Your Body: Love It or Loathe It?

If anything you've read so far strikes a chord, take heed -- and take heart. You're not condemned to a lifetime of body loathing. You can take steps on your own to improve your body image.

For starters, address the fact that there is more to each of us than our weight. "Concentrate on your personality, your smile, the way you carry yourself, the way you relate to other people," Sackeyfio says. "Enhance the other aspects of yourself."

Become more in touch with your body. "Practice body mindfulness," says Klinger. "Touch your body; get an idea of its shape, its contours."

"Too often our body is regarded as something 'other' or apart from ourselves," Klinger says. When you're walking on a treadmill, headphones in place, or eyes glued to the TV, it's easy to ignore the fact that you're doing something for your body. "Take up yoga instead (or in addition)," says Klinger. "That's a good way to connect with your body."

Stop the negative self-talk, Klinger continues. "Pay attention to what your brain is saying. Become aware of it and how much it rules you." Perhaps easier said than done, but Klinger suggests that when those bad body thoughts come flitting through your mind, "consciously think about something else -- it doesn't matter what, just change the channel."

When you've quieted the mind 'chatter,' give yourself positive reinforcement, says Cook. "Look in the mirror and find parts of your body that you like. Then every morning focus on those parts and give yourself a positive message."

If you can't actually get from "I hate my thighs" to "I love my thighs" (and how many of us really can?!), you can at least get to the more neutral, "My thighs are important to my ability to walk," says Cook.

It wouldn't hurt to "just say no" either, says White. Not to food, but to the steady stream of messages from both the media and your friends. Throw away the fashion magazines, White suggests, and start hanging out with people who share your interests.

Finally, think about what you really value in life. Your family? Your friends? Your creativity? "Chances are, when you think about what's really important to you, it's not going to be your body." White says. "Take the energy that you spend on your body image and put it into what you value most."

All great advice, but are you any closer to wanting to shop for a swimsuit? Maybe not. So why not try to make it a positive, fun experience, says Klinger. Take a friend (just make sure it's a supportive friend!), then go out to lunch afterward or go see a movie. And just remember, your body is not that big a deal.

"It's who you are that's important," Klinger says. "It's really not about your body."

Originally Published June 6, 2004
Medically Updated May 12, 2005

News Author: Laurie Barclay, MD

March 29, 2006 — Matching therapy to type of low back pain (LBP) improves outcome, according to the results of a randomized trial reported in the March 15 issue of Spine.

"Despite concentrated research efforts, few interventions have been identified as effective for patients with acute LBP," write Gerard P. Brennan, PhD, PT, from the Rehab Agency Intermountain Health Care in Salt Lake City, Utah, and colleagues. "One explanation offered for the failure to identify effective treatments is the lack of methods for subgrouping, or classifying, patients with 'nonspecific' LBP in a manner that would help direct treatment decision-making."

Before starting treatment, the investigators examined 123 patients with LBP of less than 90 days' duration who were referred to physical therapy. They classified the patients into 3 subgroups based on the type of treatment thought most likely to benefit the patient (manipulation, stabilization exercise, or specific exercise) and then randomized them to receive one of these treatments for 4 weeks. Using the Oswestry, the investigators assessed short-term (4 weeks) and long-term (1 year) disability. Patients receiving treatment matched to their subgroup were compared with those receiving unmatched treatment.

Mean age was 37.7 ± 10.7 years, and 45% were female. Patients receiving matched treatments had greater short- and long-term reductions in disability than did those receiving unmatched treatments. After 4 weeks, the difference favoring the matched treatment group was 6.6 Oswestry points (95% confidence interval [CI], 0.70 - 12.5). At long-term follow-up, this difference was 8.3 points (95% CI, 2.5 - 14.1). Analysis of long-term outcomes for only those patients who complied with therapy yielded a similar result.

"Nonspecific low back pain should not be viewed as a homogenous condition," the authors write. "Outcomes can be improved when subgrouping is used to guide treatment decision-making."

Study limitations include incomplete long-term follow-up; more female patients receiving unmatched treatment; and lack of generalizability to patients with more mild disability, more chronic symptoms, or signs of nerve root compression.

"Given the increasing likelihood of persistent disability among patients who fail to recover quickly, the initial treatment phase may be the 'window of opportunity" for clinicians," the authors write. "Improved decision-making through subgrouping during the initial treatment phase may therefore have important long-term consequences."

The Deseret Foundation supported this study. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this article.