Kate Johnson

SAN ANTONIO – Physicians may be able to quickly and accurately assess and stratify an adolescent's 1-year risk of developing new-onset major depression using a 20-item checklist, Dr. Benjamin W. Van Voorhees said at the annual meeting of the Society for Prevention Research.

The information could then help physicians guide patients and parents toward reducing the risk using a variety of therapeutic interventions, including a Web-based approach that he has developed and is now testing, according to Dr. Van Voorhees, who is both a pediatrician and an internist at the University of Chicago.

Dr. Voorhees said primary care physicians use a brief list of questions to stratify a person's 10-year risk of cardiovascular disease and to guide their interventions. “So we wanted to make this depression risk model just as easy to use in the primary care setting,” Dr. Voorhees said in an interview.

He said primary care providers now have no alternative to medications or psychotherapy referrals for patients with mild to moderate depression symptoms. “We are trying to create an alternative–to reshape the current paradigm,” Dr. Van Voorhees said.

He and his colleagues developed their depression risk prediction model using data from the National Longitudinal Study of Adolescent Health, which involved 6,504 adolescents in grades 7–12. Baseline data on the subjects, collected in 1995, included home, school, and parent surveys. Follow-up data were collected 1 year later on 4,791 subjects.

Using a subsample of 3,814 subjects, none of whom had major depression at baseline and for whom 1-year follow-up data were available, Dr. Van Voorhees identified gender, ethnicity, weight, height, and age as well as 15 independent variables that could be used to predict the patient's development of major depression in the coming year. The model, which has a sensitivity of 74% and a specificity of 87%, includes information on the adolescent's social connectedness, quality of life, mood, and other factors.

His research group plans to formally test the prediction model in a prospective study of youth at risk for developing major depression.

In a separate analysis of the same subset, Dr. Van Voorhees also identified a list of factors that appeared to protect against the development of depression. For example, on a personal level, an adolescent's self-rated health, adequate sleep, and self-efficacy seemed protective. On a family and community level, participation, attachment, and competence seemed protective.

“My idea is that if we have a good risk prediction model, we can basically calculate an adolescent's risk at a well-child visit and then give that information to the child and parent,” he said. “Then they can choose whether they want to be involved in a preventive intervention. We believe that such interventions could be done at low cost and, if designed well, could be efficacious and very acceptable to patients and physicians in community settings.”

He suggests patients identified as having moderate risk might consider improving the protective factors in their lives, although whether this could actually reduce risk must be explored in a randomized, controlled trial, he added.

For patients identified as having higher depression risk, he suggests a more structured intervention such as Project CATCH-IT, a combined primary care/Web-based intervention that he has developed.

Project CATCH-IT, designed for adolescents who are at moderate to high risk for depression, involves an initial “motivational interview” with a primary care physician aimed at helping the adolescent identify personal goals and understand how depression could jeopardize those goals.

During this session, the primary care physician also focuses on boosting the adolescent's motivation to change and increasing his or her interest in the Web-based intervention (a demonstration can be seen at www.animateband.com/siteX/Untitled-1.html

The intervention concludes with a follow-up visit with the primary care physician. If no benefit is observed at this stage, Dr. Van Voorhees advises face-to-face sessions with a mental health professional.

In a pilot test of Project CATCH-IT, Dr. Van Voorhees' group observed benefits of the intervention among 14 late adolescents who were at high risk for depression (Can. Child Adolesc. Psychiatry Rev. 2005;14:40–3).

“Completers experienced favorable changes in known risk factors with effect sizes similar to those of other preventive interventions for depression,” they wrote. However, with no control group in the study, “we cannot know to what degree these changes would have occurred without an intervention,” they added.

Dr. Van Voorhees is now enrolling primary care practices to test the intervention in a larger study.

The aim of depression risk prediction and early intervention is to prevent the development of more serious mental illness, but Dr. Van Voorhees cautions about the potential adverse effects of this approach. “When you are dealing with young people who may be vulnerable and somewhat pessimistic, telling them that they are at risk for depression may make them feel stigmatized,” he said. “So the way we approach this is to talk in terms of resiliency.

“We tell them they have high, medium, or low resiliency. High resiliency would mean almost no risk of depression, whereas low would mean they need to take care of themselves.”

SAN ANTONIO – Physicians may be able to quickly and accurately assess and stratify an adolescent's 1-year risk of developing new-onset major depression using a 20-item checklist, Dr. Benjamin W. Van Voorhees said at the annual meeting of the Society for Prevention Research.

The information could then help physicians guide patients and parents toward reducing the risk using a variety of therapeutic interventions, including a Web-based approach that he has developed and is now testing, according to Dr. Van Voorhees, who is both a pediatrician and an internist at the University of Chicago.

Dr. Voorhees said primary care physicians use a brief list of questions to stratify a person's 10-year risk of cardiovascular disease and to guide their interventions. “So we wanted to make this depression risk model just as easy to use in the primary care setting,” Dr. Voorhees said in an interview.

He said primary care providers now have no alternative to medications or psychotherapy referrals for patients with mild to moderate depression symptoms. “We are trying to create an alternative–to reshape the current paradigm,” Dr. Van Voorhees said.

He and his colleagues developed their depression risk prediction model using data from the National Longitudinal Study of Adolescent Health, which involved 6,504 adolescents in grades 7–12. Baseline data on the subjects, collected in 1995, included home, school, and parent surveys. Follow-up data were collected 1 year later on 4,791 subjects.

Using a subsample of 3,814 subjects, none of whom had major depression at baseline and for whom 1-year follow-up data were available, Dr. Van Voorhees identified gender, ethnicity, weight, height, and age as well as 15 independent variables that could be used to predict the patient's development of major depression in the coming year. The model, which has a sensitivity of 74% and a specificity of 87%, includes information on the adolescent's social connectedness, quality of life, mood, and other factors.

His research group plans to formally test the prediction model in a prospective study of youth at risk for developing major depression.

In a separate analysis of the same subset, Dr. Van Voorhees also identified a list of factors that appeared to protect against the development of depression. For example, on a personal level, an adolescent's self-rated health, adequate sleep, and self-efficacy seemed protective. On a family and community level, participation, attachment, and competence seemed protective.

“My idea is that if we have a good risk prediction model, we can basically calculate an adolescent's risk at a well-child visit and then give that information to the child and parent,” he said. “Then they can choose whether they want to be involved in a preventive intervention. We believe that such interventions could be done at low cost and, if designed well, could be efficacious and very acceptable to patients and physicians in community settings.”

He suggests patients identified as having moderate risk might consider improving the protective factors in their lives, although whether this could actually reduce risk must be explored in a randomized, controlled trial, he added.

For patients identified as having higher depression risk, he suggests a more structured intervention such as Project CATCH-IT, a combined primary care/Web-based intervention that he has developed.

Project CATCH-IT, designed for adolescents who are at moderate to high risk for depression, involves an initial “motivational interview” with a primary care physician aimed at helping the adolescent identify personal goals and understand how depression could jeopardize those goals.

During this session, the primary care physician also focuses on boosting the adolescent's motivation to change and increasing his or her interest in the Web-based intervention (a demonstration can be seen at www.animateband.com/siteX/Untitled-1.html

The intervention concludes with a follow-up visit with the primary care physician. If no benefit is observed at this stage, Dr. Van Voorhees advises face-to-face sessions with a mental health professional.

In a pilot test of Project CATCH-IT, Dr. Van Voorhees' group observed benefits of the intervention among 14 late adolescents who were at high risk for depression (Can. Child Adolesc. Psychiatry Rev. 2005;14:40–3).

“Completers experienced favorable changes in known risk factors with effect sizes similar to those of other preventive interventions for depression,” they wrote. However, with no control group in the study, “we cannot know to what degree these changes would have occurred without an intervention,” they added.

Dr. Van Voorhees is now enrolling primary care practices to test the intervention in a larger study.

The aim of depression risk prediction and early intervention is to prevent the development of more serious mental illness, but Dr. Van Voorhees cautions about the potential adverse effects of this approach. “When you are dealing with young people who may be vulnerable and somewhat pessimistic, telling them that they are at risk for depression may make them feel stigmatized,” he said. “So the way we approach this is to talk in terms of resiliency.

“We tell them they have high, medium, or low resiliency. High resiliency would mean almost no risk of depression, whereas low would mean they need to take care of themselves.”

SAN ANTONIO – Physicians may be able to quickly and accurately assess and stratify an adolescent's 1-year risk of developing new-onset major depression using a 20-item checklist, Dr. Benjamin W. Van Voorhees said at the annual meeting of the Society for Prevention Research.

The information could then help physicians guide patients and parents toward reducing the risk using a variety of therapeutic interventions, including a Web-based approach that he has developed and is now testing, according to Dr. Van Voorhees, who is both a pediatrician and an internist at the University of Chicago.

Dr. Voorhees said primary care physicians use a brief list of questions to stratify a person's 10-year risk of cardiovascular disease and to guide their interventions. “So we wanted to make this depression risk model just as easy to use in the primary care setting,” Dr. Voorhees said in an interview.

He said primary care providers now have no alternative to medications or psychotherapy referrals for patients with mild to moderate depression symptoms. “We are trying to create an alternative–to reshape the current paradigm,” Dr. Van Voorhees said.

He and his colleagues developed their depression risk prediction model using data from the National Longitudinal Study of Adolescent Health, which involved 6,504 adolescents in grades 7–12. Baseline data on the subjects, collected in 1995, included home, school, and parent surveys. Follow-up data were collected 1 year later on 4,791 subjects.

Using a subsample of 3,814 subjects, none of whom had major depression at baseline and for whom 1-year follow-up data were available, Dr. Van Voorhees identified gender, ethnicity, weight, height, and age as well as 15 independent variables that could be used to predict the patient's development of major depression in the coming year. The model, which has a sensitivity of 74% and a specificity of 87%, includes information on the adolescent's social connectedness, quality of life, mood, and other factors.

His research group plans to formally test the prediction model in a prospective study of youth at risk for developing major depression.

In a separate analysis of the same subset, Dr. Van Voorhees also identified a list of factors that appeared to protect against the development of depression. For example, on a personal level, an adolescent's self-rated health, adequate sleep, and self-efficacy seemed protective. On a family and community level, participation, attachment, and competence seemed protective.

“My idea is that if we have a good risk prediction model, we can basically calculate an adolescent's risk at a well-child visit and then give that information to the child and parent,” he said. “Then they can choose whether they want to be involved in a preventive intervention. We believe that such interventions could be done at low cost and, if designed well, could be efficacious and very acceptable to patients and physicians in community settings.”

He suggests patients identified as having moderate risk might consider improving the protective factors in their lives, although whether this could actually reduce risk must be explored in a randomized, controlled trial, he added.

For patients identified as having higher depression risk, he suggests a more structured intervention such as Project CATCH-IT, a combined primary care/Web-based intervention that he has developed.

Project CATCH-IT, designed for adolescents who are at moderate to high risk for depression, involves an initial “motivational interview” with a primary care physician aimed at helping the adolescent identify personal goals and understand how depression could jeopardize those goals.

During this session, the primary care physician also focuses on boosting the adolescent's motivation to change and increasing his or her interest in the Web-based intervention (a demonstration can be seen at www.animateband.com/siteX/Untitled-1.html

The intervention concludes with a follow-up visit with the primary care physician. If no benefit is observed at this stage, Dr. Van Voorhees advises face-to-face sessions with a mental health professional.

In a pilot test of Project CATCH-IT, Dr. Van Voorhees' group observed benefits of the intervention among 14 late adolescents who were at high risk for depression (Can. Child Adolesc. Psychiatry Rev. 2005;14:40–3).

“Completers experienced favorable changes in known risk factors with effect sizes similar to those of other preventive interventions for depression,” they wrote. However, with no control group in the study, “we cannot know to what degree these changes would have occurred without an intervention,” they added.

Dr. Van Voorhees is now enrolling primary care practices to test the intervention in a larger study.

The aim of depression risk prediction and early intervention is to prevent the development of more serious mental illness, but Dr. Van Voorhees cautions about the potential adverse effects of this approach. “When you are dealing with young people who may be vulnerable and somewhat pessimistic, telling them that they are at risk for depression may make them feel stigmatized,” he said. “So the way we approach this is to talk in terms of resiliency.

“We tell them they have high, medium, or low resiliency. High resiliency would mean almost no risk of depression, whereas low would mean they need to take care of themselves.”

COPENHAGEN – Parents of children with type 1 diabetes intensely experience the psychological impact of the disease, according to new study findings.

“Both parents and children may need counseling to help them cope with worries associated with the disease,” Douglas C.A. Taylor said at the annual meeting of the European Society for the Study of Diabetes.

The study, supported by Sanofi-Aventis U.S., was part of a baseline assessment of participants who were enrolled in a 24-week randomized clinical trial comparing insulin glargine to twice-daily intermediate-acting insulin, said Mr. Taylor, who is director of health economics and outcomes research for i3 Innovus, in Medford, Mass.

A total of 175 children and adolescents (aged 9–17 years), and one parent of each, answered either the youth or the caregiver modified versions of the Diabetes Quality-of-Life Measure, a self-administered questionnaire gauging life satisfaction, diabetes worry, and diabetes impact.

Life satisfaction questions assessed issues such as disease management, checkups, treatment, flexibility, and family burden of diabetes. Disease impact questions asked about embarrassment related to the disease, interference of the disease on family, school, and leisure. And diabetes worry questions addressed future concerns about the disease impact on education, marriage, job prospects, and future health.

The female parent was the respondent in 86% of the parental surveys.

Overall, parents scored worse (higher) than their children in all domains of the questionnaire. In the domain of life satisfaction, the parents' mean score was 28, compared with a mean score of 27 for the children; however, this difference was not statistically significant. For both the disease impact and the disease worry, the parents' score was 23, compared with 21 for the children, a difference that in both cases was statistically significant.

When the responses were divided by the gender of the children, boys reported better quality of life than girls; yet in the domains of disease impact and disease worry, parents of sons scored worse than those of daughters.

“My personal opinion is that the boys are less worried about the diabetes than the girls, because the boys aren't really thinking in the long term,” he said.

COPENHAGEN – Parents of children with type 1 diabetes intensely experience the psychological impact of the disease, according to new study findings.

“Both parents and children may need counseling to help them cope with worries associated with the disease,” Douglas C.A. Taylor said at the annual meeting of the European Society for the Study of Diabetes.

The study, supported by Sanofi-Aventis U.S., was part of a baseline assessment of participants who were enrolled in a 24-week randomized clinical trial comparing insulin glargine to twice-daily intermediate-acting insulin, said Mr. Taylor, who is director of health economics and outcomes research for i3 Innovus, in Medford, Mass.

A total of 175 children and adolescents (aged 9–17 years), and one parent of each, answered either the youth or the caregiver modified versions of the Diabetes Quality-of-Life Measure, a self-administered questionnaire gauging life satisfaction, diabetes worry, and diabetes impact.

Life satisfaction questions assessed issues such as disease management, checkups, treatment, flexibility, and family burden of diabetes. Disease impact questions asked about embarrassment related to the disease, interference of the disease on family, school, and leisure. And diabetes worry questions addressed future concerns about the disease impact on education, marriage, job prospects, and future health.

The female parent was the respondent in 86% of the parental surveys.

Overall, parents scored worse (higher) than their children in all domains of the questionnaire. In the domain of life satisfaction, the parents' mean score was 28, compared with a mean score of 27 for the children; however, this difference was not statistically significant. For both the disease impact and the disease worry, the parents' score was 23, compared with 21 for the children, a difference that in both cases was statistically significant.

When the responses were divided by the gender of the children, boys reported better quality of life than girls; yet in the domains of disease impact and disease worry, parents of sons scored worse than those of daughters.

“My personal opinion is that the boys are less worried about the diabetes than the girls, because the boys aren't really thinking in the long term,” he said.

COPENHAGEN – Parents of children with type 1 diabetes intensely experience the psychological impact of the disease, according to new study findings.

“Both parents and children may need counseling to help them cope with worries associated with the disease,” Douglas C.A. Taylor said at the annual meeting of the European Society for the Study of Diabetes.

The study, supported by Sanofi-Aventis U.S., was part of a baseline assessment of participants who were enrolled in a 24-week randomized clinical trial comparing insulin glargine to twice-daily intermediate-acting insulin, said Mr. Taylor, who is director of health economics and outcomes research for i3 Innovus, in Medford, Mass.

A total of 175 children and adolescents (aged 9–17 years), and one parent of each, answered either the youth or the caregiver modified versions of the Diabetes Quality-of-Life Measure, a self-administered questionnaire gauging life satisfaction, diabetes worry, and diabetes impact.

Life satisfaction questions assessed issues such as disease management, checkups, treatment, flexibility, and family burden of diabetes. Disease impact questions asked about embarrassment related to the disease, interference of the disease on family, school, and leisure. And diabetes worry questions addressed future concerns about the disease impact on education, marriage, job prospects, and future health.

The female parent was the respondent in 86% of the parental surveys.

Overall, parents scored worse (higher) than their children in all domains of the questionnaire. In the domain of life satisfaction, the parents' mean score was 28, compared with a mean score of 27 for the children; however, this difference was not statistically significant. For both the disease impact and the disease worry, the parents' score was 23, compared with 21 for the children, a difference that in both cases was statistically significant.

When the responses were divided by the gender of the children, boys reported better quality of life than girls; yet in the domains of disease impact and disease worry, parents of sons scored worse than those of daughters.

“My personal opinion is that the boys are less worried about the diabetes than the girls, because the boys aren't really thinking in the long term,” he said.

PRAGUE — Individually calibrated shoes that provide dynamic wedging can significantly improve pain and function in patients with knee osteoarthritis—sometimes immediately, Dr. Yuval Ran reported at the 2006 World Congress on Osteoarthritis.

“We have clearly demonstrated clinical efficacy. Immediate relief of pain in some patients enabled them to walk painlessly during real-life activity thus reacquiring neuromuscular skills and balance,” he said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Dr. Ran, from the Assaf Harofeh Medical Center in Tel Aviv, has been treating patients with footwarefrom APOS Medical and Sports Technologies Ltd. (Herzliya, Israel) for about 2 years, he said, adding that he has no conflict of interest to disclose.

Unlike other active osteoarthritis (OA) interventions, which usually require intensive physical therapy programs and result in low compliance, the APOS system, which involves semispherical, individually calibrated implants in special footwear, often relieves pain immediately and thus results in extraordinary compliance, he said. “Many patients wear the shoes all the time because we can't instruct them not to wear something that relieves pain,” he said, noting that the implants are designed to improve age-related loss in neuromuscular control and resulting muscle-weakness and stress on the knee joint.

The semispherical rubber devices that are placed on the soles of the shoes at the hindfoot and midfoot can move medially and laterally and may be individually adjusted in order to balance loading, he explained.

In a randomized trial of 61 patients who had knee osteoarthritis (mean age, 66 years) who were treated for 8 weeks with the APOS implants or placebo, Dr. Ran and his colleagues noted a “highly significant” 70% decrease in pain in the treated group, measured with the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and a 33% improvement in function according to the Aggregated Locomotor Function (ALF) scale, compared with no improvements in the control group.

Patients were advised to start the treatment with 10 minutes of indoor wear, building up to 30 minutes of outdoor walking—however, he said the majority of patients chose to wear the shoes most of the time because of the pain relief provided. Evaluation was performed at baseline, 4 weeks, and 8 weeks.

The patients also were supervised four times during the study to make adjustments to the shoes, if necessary. Patients in the placebo arm wore shoes that looked identical except without the spheres on the soles.

Semispherical rubber devices at the hindfoot and midfoot can be adjusted to balance loading. Courtesy Dr. Yuval Ran/Dr. Avi Elbaz/Dr. Amit Mor

PRAGUE — Individually calibrated shoes that provide dynamic wedging can significantly improve pain and function in patients with knee osteoarthritis—sometimes immediately, Dr. Yuval Ran reported at the 2006 World Congress on Osteoarthritis.

“We have clearly demonstrated clinical efficacy. Immediate relief of pain in some patients enabled them to walk painlessly during real-life activity thus reacquiring neuromuscular skills and balance,” he said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Dr. Ran, from the Assaf Harofeh Medical Center in Tel Aviv, has been treating patients with footwarefrom APOS Medical and Sports Technologies Ltd. (Herzliya, Israel) for about 2 years, he said, adding that he has no conflict of interest to disclose.

Unlike other active osteoarthritis (OA) interventions, which usually require intensive physical therapy programs and result in low compliance, the APOS system, which involves semispherical, individually calibrated implants in special footwear, often relieves pain immediately and thus results in extraordinary compliance, he said. “Many patients wear the shoes all the time because we can't instruct them not to wear something that relieves pain,” he said, noting that the implants are designed to improve age-related loss in neuromuscular control and resulting muscle-weakness and stress on the knee joint.

The semispherical rubber devices that are placed on the soles of the shoes at the hindfoot and midfoot can move medially and laterally and may be individually adjusted in order to balance loading, he explained.

In a randomized trial of 61 patients who had knee osteoarthritis (mean age, 66 years) who were treated for 8 weeks with the APOS implants or placebo, Dr. Ran and his colleagues noted a “highly significant” 70% decrease in pain in the treated group, measured with the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and a 33% improvement in function according to the Aggregated Locomotor Function (ALF) scale, compared with no improvements in the control group.

Patients were advised to start the treatment with 10 minutes of indoor wear, building up to 30 minutes of outdoor walking—however, he said the majority of patients chose to wear the shoes most of the time because of the pain relief provided. Evaluation was performed at baseline, 4 weeks, and 8 weeks.

The patients also were supervised four times during the study to make adjustments to the shoes, if necessary. Patients in the placebo arm wore shoes that looked identical except without the spheres on the soles.

Semispherical rubber devices at the hindfoot and midfoot can be adjusted to balance loading. Courtesy Dr. Yuval Ran/Dr. Avi Elbaz/Dr. Amit Mor

PRAGUE — Individually calibrated shoes that provide dynamic wedging can significantly improve pain and function in patients with knee osteoarthritis—sometimes immediately, Dr. Yuval Ran reported at the 2006 World Congress on Osteoarthritis.

“We have clearly demonstrated clinical efficacy. Immediate relief of pain in some patients enabled them to walk painlessly during real-life activity thus reacquiring neuromuscular skills and balance,” he said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Dr. Ran, from the Assaf Harofeh Medical Center in Tel Aviv, has been treating patients with footwarefrom APOS Medical and Sports Technologies Ltd. (Herzliya, Israel) for about 2 years, he said, adding that he has no conflict of interest to disclose.

Unlike other active osteoarthritis (OA) interventions, which usually require intensive physical therapy programs and result in low compliance, the APOS system, which involves semispherical, individually calibrated implants in special footwear, often relieves pain immediately and thus results in extraordinary compliance, he said. “Many patients wear the shoes all the time because we can't instruct them not to wear something that relieves pain,” he said, noting that the implants are designed to improve age-related loss in neuromuscular control and resulting muscle-weakness and stress on the knee joint.

The semispherical rubber devices that are placed on the soles of the shoes at the hindfoot and midfoot can move medially and laterally and may be individually adjusted in order to balance loading, he explained.

In a randomized trial of 61 patients who had knee osteoarthritis (mean age, 66 years) who were treated for 8 weeks with the APOS implants or placebo, Dr. Ran and his colleagues noted a “highly significant” 70% decrease in pain in the treated group, measured with the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and a 33% improvement in function according to the Aggregated Locomotor Function (ALF) scale, compared with no improvements in the control group.

Patients were advised to start the treatment with 10 minutes of indoor wear, building up to 30 minutes of outdoor walking—however, he said the majority of patients chose to wear the shoes most of the time because of the pain relief provided. Evaluation was performed at baseline, 4 weeks, and 8 weeks.

The patients also were supervised four times during the study to make adjustments to the shoes, if necessary. Patients in the placebo arm wore shoes that looked identical except without the spheres on the soles.

Semispherical rubber devices at the hindfoot and midfoot can be adjusted to balance loading. Courtesy Dr. Yuval Ran/Dr. Avi Elbaz/Dr. Amit Mor

NEW YORK — Capsule endoscopy, a promising alternative to upper endoscopy for the investigation and diagnosis of celiac disease, may one day negate the need for endoscopically obtained intestinal biopsies, Dr. Ernest Seidman said at an international conference on celiac disease.

“I don't think that we can yet say that the capsule should replace the biopsy in every case,” said Dr. Seidman, professor of medicine and pediatrics at McGill University, Montreal, and also a consultant for Given Imaging, which makes the only FDA-approved capsule endoscope. “The consensus opinion is that capsule endoscopy is equivalent to histology [for celiac disease], but only in those with severe villous atrophy. More data is required to prove diagnostic equivalence for those with partial atrophy.”

Usually, patients with serologic evidence of celiac disease undergo intestinal biopsy to verify the presence of villous atrophy, which is currently the definitive diagnostic finding. But a consensus of expert opinion from the International Conference on Capsule Endoscopy in Paris last June suggested that the tool may be an alternative for patients who are unwilling or unable to undergo biopsy, for those whose initial biopsy is equivocal, and for patients with confirmed celiac disease who develop alarming symptoms despite adherence to a gluten-free diet (Endoscopy 2005;37:1055–9).

One advantage of capsule endoscopy in the investigation of celiac disease is that it offers unprecedented views of the small bowel in its entirety.

“So much of the small bowel has been a black box for us, and with capsule endoscopy, we can see areas that are not accessible with the upper endoscope,” Dr. Seidman said.

Capsule endoscopy is also state-of-the-art technology for examining the intestinal lining for other small bowel disorders. “We can see target lesions that would not otherwise be detectable by other imaging methods. Moreover, villous appearance can be seen extremely well—the resolution of the camera is extraordinary. We see villi routinely without doing magnification, and when the villi are atrophic or edematous, it's very apparent,” he added.

Capsule findings of the intestinal lining that are suggestive of celiac disease include fissuring, scalloping, a mosaic pattern, nodularity, and delayed appearance of villi with a loss of circular folds, he said.

Although the avoidance of endoscopy and sedation may be particularly attractive when dealing with pediatric patients, children under the age of 8 years are rarely able to swallow the jelly bean-size capsule, he said, adding that getting them to demonstrate with a real jelly bean is a wise idea.

“Otherwise, you run into a situation where you have opened the blister pack, which activates the camera, and you have the child holding it and saying they can't do it. It's an expensive way to get pictures of their face,” he said.

There is a delivery device that allows the introduction of the capsule into the small bowel with an endoscope, but this negates much of the advantage of the capsule, he said.

Even after starting a gluten-free diet, patients with celiac disease might face up to a 40-fold increased risk of developing small bowel lymphomas, compared with people who do not have celiac disease.

Consequently, recurrent or persistent bowel symptoms in diagnosed patients following a strict gluten-free diet are to be carefully evaluated and investigated. Capsule endoscopy often reveals abnormalities in such patients, Dr. Seidman said.

“Small bowel tumors are notoriously silent until it's too late—and finding them is extremely difficult. Needless to say, capsule endoscopy is the most proficient way to look for these tumors,” he said.

A recent study of capsule endoscopy in 47 celiac patients with abdominal pain or other symptoms suggestive of malignancy found cancer in 5%, ulcerations in 50%, and villous atrophy in 68% (indicating noncompliance with the gluten-free diet), he said (Gastrointest. Endosc. 2005;62:55–61).

NEW YORK — Capsule endoscopy, a promising alternative to upper endoscopy for the investigation and diagnosis of celiac disease, may one day negate the need for endoscopically obtained intestinal biopsies, Dr. Ernest Seidman said at an international conference on celiac disease.

“I don't think that we can yet say that the capsule should replace the biopsy in every case,” said Dr. Seidman, professor of medicine and pediatrics at McGill University, Montreal, and also a consultant for Given Imaging, which makes the only FDA-approved capsule endoscope. “The consensus opinion is that capsule endoscopy is equivalent to histology [for celiac disease], but only in those with severe villous atrophy. More data is required to prove diagnostic equivalence for those with partial atrophy.”

Usually, patients with serologic evidence of celiac disease undergo intestinal biopsy to verify the presence of villous atrophy, which is currently the definitive diagnostic finding. But a consensus of expert opinion from the International Conference on Capsule Endoscopy in Paris last June suggested that the tool may be an alternative for patients who are unwilling or unable to undergo biopsy, for those whose initial biopsy is equivocal, and for patients with confirmed celiac disease who develop alarming symptoms despite adherence to a gluten-free diet (Endoscopy 2005;37:1055–9).

One advantage of capsule endoscopy in the investigation of celiac disease is that it offers unprecedented views of the small bowel in its entirety.

“So much of the small bowel has been a black box for us, and with capsule endoscopy, we can see areas that are not accessible with the upper endoscope,” Dr. Seidman said.

Capsule endoscopy is also state-of-the-art technology for examining the intestinal lining for other small bowel disorders. “We can see target lesions that would not otherwise be detectable by other imaging methods. Moreover, villous appearance can be seen extremely well—the resolution of the camera is extraordinary. We see villi routinely without doing magnification, and when the villi are atrophic or edematous, it's very apparent,” he added.

Capsule findings of the intestinal lining that are suggestive of celiac disease include fissuring, scalloping, a mosaic pattern, nodularity, and delayed appearance of villi with a loss of circular folds, he said.

Although the avoidance of endoscopy and sedation may be particularly attractive when dealing with pediatric patients, children under the age of 8 years are rarely able to swallow the jelly bean-size capsule, he said, adding that getting them to demonstrate with a real jelly bean is a wise idea.

“Otherwise, you run into a situation where you have opened the blister pack, which activates the camera, and you have the child holding it and saying they can't do it. It's an expensive way to get pictures of their face,” he said.

There is a delivery device that allows the introduction of the capsule into the small bowel with an endoscope, but this negates much of the advantage of the capsule, he said.

Even after starting a gluten-free diet, patients with celiac disease might face up to a 40-fold increased risk of developing small bowel lymphomas, compared with people who do not have celiac disease.

Consequently, recurrent or persistent bowel symptoms in diagnosed patients following a strict gluten-free diet are to be carefully evaluated and investigated. Capsule endoscopy often reveals abnormalities in such patients, Dr. Seidman said.

“Small bowel tumors are notoriously silent until it's too late—and finding them is extremely difficult. Needless to say, capsule endoscopy is the most proficient way to look for these tumors,” he said.

A recent study of capsule endoscopy in 47 celiac patients with abdominal pain or other symptoms suggestive of malignancy found cancer in 5%, ulcerations in 50%, and villous atrophy in 68% (indicating noncompliance with the gluten-free diet), he said (Gastrointest. Endosc. 2005;62:55–61).

NEW YORK — Capsule endoscopy, a promising alternative to upper endoscopy for the investigation and diagnosis of celiac disease, may one day negate the need for endoscopically obtained intestinal biopsies, Dr. Ernest Seidman said at an international conference on celiac disease.

“I don't think that we can yet say that the capsule should replace the biopsy in every case,” said Dr. Seidman, professor of medicine and pediatrics at McGill University, Montreal, and also a consultant for Given Imaging, which makes the only FDA-approved capsule endoscope. “The consensus opinion is that capsule endoscopy is equivalent to histology [for celiac disease], but only in those with severe villous atrophy. More data is required to prove diagnostic equivalence for those with partial atrophy.”

Usually, patients with serologic evidence of celiac disease undergo intestinal biopsy to verify the presence of villous atrophy, which is currently the definitive diagnostic finding. But a consensus of expert opinion from the International Conference on Capsule Endoscopy in Paris last June suggested that the tool may be an alternative for patients who are unwilling or unable to undergo biopsy, for those whose initial biopsy is equivocal, and for patients with confirmed celiac disease who develop alarming symptoms despite adherence to a gluten-free diet (Endoscopy 2005;37:1055–9).

One advantage of capsule endoscopy in the investigation of celiac disease is that it offers unprecedented views of the small bowel in its entirety.

“So much of the small bowel has been a black box for us, and with capsule endoscopy, we can see areas that are not accessible with the upper endoscope,” Dr. Seidman said.

Capsule endoscopy is also state-of-the-art technology for examining the intestinal lining for other small bowel disorders. “We can see target lesions that would not otherwise be detectable by other imaging methods. Moreover, villous appearance can be seen extremely well—the resolution of the camera is extraordinary. We see villi routinely without doing magnification, and when the villi are atrophic or edematous, it's very apparent,” he added.

Capsule findings of the intestinal lining that are suggestive of celiac disease include fissuring, scalloping, a mosaic pattern, nodularity, and delayed appearance of villi with a loss of circular folds, he said.

Although the avoidance of endoscopy and sedation may be particularly attractive when dealing with pediatric patients, children under the age of 8 years are rarely able to swallow the jelly bean-size capsule, he said, adding that getting them to demonstrate with a real jelly bean is a wise idea.

“Otherwise, you run into a situation where you have opened the blister pack, which activates the camera, and you have the child holding it and saying they can't do it. It's an expensive way to get pictures of their face,” he said.

There is a delivery device that allows the introduction of the capsule into the small bowel with an endoscope, but this negates much of the advantage of the capsule, he said.

Even after starting a gluten-free diet, patients with celiac disease might face up to a 40-fold increased risk of developing small bowel lymphomas, compared with people who do not have celiac disease.

Consequently, recurrent or persistent bowel symptoms in diagnosed patients following a strict gluten-free diet are to be carefully evaluated and investigated. Capsule endoscopy often reveals abnormalities in such patients, Dr. Seidman said.

“Small bowel tumors are notoriously silent until it's too late—and finding them is extremely difficult. Needless to say, capsule endoscopy is the most proficient way to look for these tumors,” he said.

A recent study of capsule endoscopy in 47 celiac patients with abdominal pain or other symptoms suggestive of malignancy found cancer in 5%, ulcerations in 50%, and villous atrophy in 68% (indicating noncompliance with the gluten-free diet), he said (Gastrointest. Endosc. 2005;62:55–61).

NEW YORK — Skin biopsies to confirm dermatitis herpetiformis should be taken from normal-looking skin adjacent to a lesion, and not from within the lesion, Dr. John Zone said at an international symposium on celiac disease. “Twenty percent of skin biopsies from within lesions are negative because the inflammatory infiltrate destroys the antibody,” he said.

The hallmark of dermatitis herpetiformis (DH) is granular IgA in the dermal papillae. “On routine histology, this can be confused with some other diseases of the skin, including linear IgA disease and bullous lupus erythematosus, so it really is essential to do direct immunofluorescence to confirm the diagnosis,” advised Dr. Zone, professor and chairman of dermatology at the University of Utah, Salt Lake City.

Dermatitis herpetiformis, the skin manifestation of celiac disease, is characterized by intensely pruritic papulovesicles and excoriations on the elbows, knees, buttocks and scalp. It occurs in about 20% of celiac patients, and, like celiac disease, responds to a gluten-free diet. About 10% of first-degree relatives of DH patients will have either DH or another form of celiac disease. “DH does not segregate in celiac families, so one person may have DH and the other may have celiac disease,” he explained.

Up to one-third of DH patients will have negative serum antiendomysial antibodies even before starting a gluten-free diet, but such patients will frequently show abnormalities on intestinal biopsy.

“Negative serology does not rule out DH,” Dr. Zone stressed, adding that 30%–40% of DH patients will have intestinal villous atrophy or villous blunting; 20%–30% will have intestinal intraepithelial lymphocytes; and only 10%–20% will have normal intestinal findings. But in keeping with other manifestations of celiac disease, gastrointestinal symptoms in DH patients do not necessarily correlate with the presence or severity of intestinal abnormalities. Improvement of DH with the elimination of dietary gluten occurs within weeks to months of the initiation of the diet. “In my experience, the time to response correlates with the duration of the disease.”

Patients can expect a recurrence of symptoms with the reintroduction of gluten, but this can take place within hours or weeks of ingestion, and the amount of gluten required to produce symptoms varies widely from individual to individual. Treatment with dapsone can suppress the skin inflammation of DH and allow patients to eat gluten without symptoms, but this treatment does not suppress intestinal inflammation.

“DH patients, like other people with celiac [disease], have an increased risk of intestinal lymphoma, which can be reduced with a gluten-free diet,” Dr. Zone said. About 10% of DH patients will have a spontaneous remission.

Unlike celiac disease, which is commonly diagnosed in childhood, DH usually presents in patients who are 20–30 years old. The mean age of Dr. Zone's patient population is 38 years. “I have … examined about a thousand DH patients, and I have only seen about 10 kids. It seems that chronic, low-grade, smoldering celiac disease is important in the development of DH.”

Dermatitis herpetiformis (shown here) is characterized by pruritic papulovesicles and excoriations on the elbows, knees, buttocks, and scalp. Courtesy Dr. John Zone

NEW YORK — Skin biopsies to confirm dermatitis herpetiformis should be taken from normal-looking skin adjacent to a lesion, and not from within the lesion, Dr. John Zone said at an international symposium on celiac disease. “Twenty percent of skin biopsies from within lesions are negative because the inflammatory infiltrate destroys the antibody,” he said.

The hallmark of dermatitis herpetiformis (DH) is granular IgA in the dermal papillae. “On routine histology, this can be confused with some other diseases of the skin, including linear IgA disease and bullous lupus erythematosus, so it really is essential to do direct immunofluorescence to confirm the diagnosis,” advised Dr. Zone, professor and chairman of dermatology at the University of Utah, Salt Lake City.

Dermatitis herpetiformis, the skin manifestation of celiac disease, is characterized by intensely pruritic papulovesicles and excoriations on the elbows, knees, buttocks and scalp. It occurs in about 20% of celiac patients, and, like celiac disease, responds to a gluten-free diet. About 10% of first-degree relatives of DH patients will have either DH or another form of celiac disease. “DH does not segregate in celiac families, so one person may have DH and the other may have celiac disease,” he explained.

Up to one-third of DH patients will have negative serum antiendomysial antibodies even before starting a gluten-free diet, but such patients will frequently show abnormalities on intestinal biopsy.

“Negative serology does not rule out DH,” Dr. Zone stressed, adding that 30%–40% of DH patients will have intestinal villous atrophy or villous blunting; 20%–30% will have intestinal intraepithelial lymphocytes; and only 10%–20% will have normal intestinal findings. But in keeping with other manifestations of celiac disease, gastrointestinal symptoms in DH patients do not necessarily correlate with the presence or severity of intestinal abnormalities. Improvement of DH with the elimination of dietary gluten occurs within weeks to months of the initiation of the diet. “In my experience, the time to response correlates with the duration of the disease.”

Patients can expect a recurrence of symptoms with the reintroduction of gluten, but this can take place within hours or weeks of ingestion, and the amount of gluten required to produce symptoms varies widely from individual to individual. Treatment with dapsone can suppress the skin inflammation of DH and allow patients to eat gluten without symptoms, but this treatment does not suppress intestinal inflammation.

“DH patients, like other people with celiac [disease], have an increased risk of intestinal lymphoma, which can be reduced with a gluten-free diet,” Dr. Zone said. About 10% of DH patients will have a spontaneous remission.

Unlike celiac disease, which is commonly diagnosed in childhood, DH usually presents in patients who are 20–30 years old. The mean age of Dr. Zone's patient population is 38 years. “I have … examined about a thousand DH patients, and I have only seen about 10 kids. It seems that chronic, low-grade, smoldering celiac disease is important in the development of DH.”

Dermatitis herpetiformis (shown here) is characterized by pruritic papulovesicles and excoriations on the elbows, knees, buttocks, and scalp. Courtesy Dr. John Zone

NEW YORK — Skin biopsies to confirm dermatitis herpetiformis should be taken from normal-looking skin adjacent to a lesion, and not from within the lesion, Dr. John Zone said at an international symposium on celiac disease. “Twenty percent of skin biopsies from within lesions are negative because the inflammatory infiltrate destroys the antibody,” he said.

The hallmark of dermatitis herpetiformis (DH) is granular IgA in the dermal papillae. “On routine histology, this can be confused with some other diseases of the skin, including linear IgA disease and bullous lupus erythematosus, so it really is essential to do direct immunofluorescence to confirm the diagnosis,” advised Dr. Zone, professor and chairman of dermatology at the University of Utah, Salt Lake City.

Dermatitis herpetiformis, the skin manifestation of celiac disease, is characterized by intensely pruritic papulovesicles and excoriations on the elbows, knees, buttocks and scalp. It occurs in about 20% of celiac patients, and, like celiac disease, responds to a gluten-free diet. About 10% of first-degree relatives of DH patients will have either DH or another form of celiac disease. “DH does not segregate in celiac families, so one person may have DH and the other may have celiac disease,” he explained.

Up to one-third of DH patients will have negative serum antiendomysial antibodies even before starting a gluten-free diet, but such patients will frequently show abnormalities on intestinal biopsy.

“Negative serology does not rule out DH,” Dr. Zone stressed, adding that 30%–40% of DH patients will have intestinal villous atrophy or villous blunting; 20%–30% will have intestinal intraepithelial lymphocytes; and only 10%–20% will have normal intestinal findings. But in keeping with other manifestations of celiac disease, gastrointestinal symptoms in DH patients do not necessarily correlate with the presence or severity of intestinal abnormalities. Improvement of DH with the elimination of dietary gluten occurs within weeks to months of the initiation of the diet. “In my experience, the time to response correlates with the duration of the disease.”

Patients can expect a recurrence of symptoms with the reintroduction of gluten, but this can take place within hours or weeks of ingestion, and the amount of gluten required to produce symptoms varies widely from individual to individual. Treatment with dapsone can suppress the skin inflammation of DH and allow patients to eat gluten without symptoms, but this treatment does not suppress intestinal inflammation.

“DH patients, like other people with celiac [disease], have an increased risk of intestinal lymphoma, which can be reduced with a gluten-free diet,” Dr. Zone said. About 10% of DH patients will have a spontaneous remission.

Unlike celiac disease, which is commonly diagnosed in childhood, DH usually presents in patients who are 20–30 years old. The mean age of Dr. Zone's patient population is 38 years. “I have … examined about a thousand DH patients, and I have only seen about 10 kids. It seems that chronic, low-grade, smoldering celiac disease is important in the development of DH.”

Dermatitis herpetiformis (shown here) is characterized by pruritic papulovesicles and excoriations on the elbows, knees, buttocks, and scalp. Courtesy Dr. John Zone

NEW YORK — Capsule endoscopy, a promising alternative to upper endoscopy for the investigation and diagnosis of celiac disease, may one day negate the need for endoscopically obtained intestinal biopsies, Dr. Ernest Seidman said at an international conference on celiac disease.

“I don't think that we can yet say that the capsule should replace the biopsy in every case,” said Dr. Seidman, who is professor of medicine and pediatrics at McGill University, Montreal, and also a consultant for Given Imaging, which manufactures the only capsule endoscope that has been approved by the Food and Drug Administration.

“The consensus opinion is that capsule endoscopy is equivalent to histology [for the detection of celiac disease], but only in those with severe villous atrophy. More data is required to prove diagnostic equivalence for those with partial atrophy,” he said.

Usually, patients with serologic evidence of celiac disease undergo intestinal biopsy to verify the presence of villous atrophy, which is currently the definitive diagnostic finding.

But a consensus of expert opinion from the International Conference on Capsule Endoscopy in Paris last June suggested that the tool may be an alternative for patients who are unwilling or unable to undergo biopsy, for those whose initial biopsy is equivocal, and for patients with confirmed celiac disease who develop alarming symptoms despite adherence to a gluten-free diet (Endoscopy 2005;37: 1055–9).

One advantage of capsule endoscopy in the investigation of celiac disease is that it offers unprecedented views of the small bowel in its entirety. “So much of the small bowel has been a black box for us, and with capsule endoscopy, we can see areas that are not accessible with the upper endoscope,” Dr. Seidman said.

Capsule endoscopy is also state-of-the-art technology for examining the intestinal lining for other small bowel disorders. “We can see target lesions that would not otherwise be detectable by other imaging methods. Moreover, villous appearance can be seen extremely well—the resolution of the camera is extraordinary. We see villi routinely without doing magnification, and when the villi are atrophic or edematous, it's very apparent,” he added.

Capsule findings of the intestinal lining that are suggestive of celiac disease include fissuring, scalloping, a mosaic pattern, nodularity, and delayed appearance of villi with a loss of circular folds, Dr. Seidman said.

Although the avoidance of endoscopy and sedation may be particularly attractive when dealing with pediatric patients, children under the age of 8 years are rarely able to swallow the jelly bean-size capsule, he said, adding that getting them to demonstrate with a real jelly bean is a wise idea.

“Otherwise, you run into a situation where you have opened the blister pack, which activates the camera, and you have the child holding it and saying they can't do it. It's an expensive way to get pictures of their face,” he said.

There is a delivery device that allows the introduction of the capsule into the small bowel with an endoscope, but this approach negates much of the advantage of the capsule, he said.

Even after they have started a gluten-free diet, patients with celiac disease might face up to a 40-fold increased risk of developing small bowel lymphomas, compared with the risk in people who don't have celiac disease. Consequently, any recurrent or persistent bowel symptoms that occur in diagnosed patients following the adoption of a strict gluten-free diet are to be carefully evaluated and investigated. Capsule endoscopy often reveals abnormalities in such patients, Dr. Seidman said.

“Small bowel tumors are notoriously silent until it's too late—and finding them is extremely difficult. Needless to say, capsule endoscopy is the most proficient way to look for these tumors,” he said.

A recent study of capsule endoscopy in 47 celiac patients with abdominal pain or other symptoms suggestive of malignancy found cancer in 5%, ulcerations in 50%, and villous atrophy in 68% (indicating noncompliance with the gluten-free diet), he said (Gastrointest. Endosc. 2005;62: 55–61).

NEW YORK — Capsule endoscopy, a promising alternative to upper endoscopy for the investigation and diagnosis of celiac disease, may one day negate the need for endoscopically obtained intestinal biopsies, Dr. Ernest Seidman said at an international conference on celiac disease.

“I don't think that we can yet say that the capsule should replace the biopsy in every case,” said Dr. Seidman, who is professor of medicine and pediatrics at McGill University, Montreal, and also a consultant for Given Imaging, which manufactures the only capsule endoscope that has been approved by the Food and Drug Administration.

“The consensus opinion is that capsule endoscopy is equivalent to histology [for the detection of celiac disease], but only in those with severe villous atrophy. More data is required to prove diagnostic equivalence for those with partial atrophy,” he said.

Usually, patients with serologic evidence of celiac disease undergo intestinal biopsy to verify the presence of villous atrophy, which is currently the definitive diagnostic finding.

But a consensus of expert opinion from the International Conference on Capsule Endoscopy in Paris last June suggested that the tool may be an alternative for patients who are unwilling or unable to undergo biopsy, for those whose initial biopsy is equivocal, and for patients with confirmed celiac disease who develop alarming symptoms despite adherence to a gluten-free diet (Endoscopy 2005;37: 1055–9).

One advantage of capsule endoscopy in the investigation of celiac disease is that it offers unprecedented views of the small bowel in its entirety. “So much of the small bowel has been a black box for us, and with capsule endoscopy, we can see areas that are not accessible with the upper endoscope,” Dr. Seidman said.

Capsule endoscopy is also state-of-the-art technology for examining the intestinal lining for other small bowel disorders. “We can see target lesions that would not otherwise be detectable by other imaging methods. Moreover, villous appearance can be seen extremely well—the resolution of the camera is extraordinary. We see villi routinely without doing magnification, and when the villi are atrophic or edematous, it's very apparent,” he added.

Capsule findings of the intestinal lining that are suggestive of celiac disease include fissuring, scalloping, a mosaic pattern, nodularity, and delayed appearance of villi with a loss of circular folds, Dr. Seidman said.

Although the avoidance of endoscopy and sedation may be particularly attractive when dealing with pediatric patients, children under the age of 8 years are rarely able to swallow the jelly bean-size capsule, he said, adding that getting them to demonstrate with a real jelly bean is a wise idea.

“Otherwise, you run into a situation where you have opened the blister pack, which activates the camera, and you have the child holding it and saying they can't do it. It's an expensive way to get pictures of their face,” he said.

There is a delivery device that allows the introduction of the capsule into the small bowel with an endoscope, but this approach negates much of the advantage of the capsule, he said.

Even after they have started a gluten-free diet, patients with celiac disease might face up to a 40-fold increased risk of developing small bowel lymphomas, compared with the risk in people who don't have celiac disease. Consequently, any recurrent or persistent bowel symptoms that occur in diagnosed patients following the adoption of a strict gluten-free diet are to be carefully evaluated and investigated. Capsule endoscopy often reveals abnormalities in such patients, Dr. Seidman said.

“Small bowel tumors are notoriously silent until it's too late—and finding them is extremely difficult. Needless to say, capsule endoscopy is the most proficient way to look for these tumors,” he said.

A recent study of capsule endoscopy in 47 celiac patients with abdominal pain or other symptoms suggestive of malignancy found cancer in 5%, ulcerations in 50%, and villous atrophy in 68% (indicating noncompliance with the gluten-free diet), he said (Gastrointest. Endosc. 2005;62: 55–61).

NEW YORK — Capsule endoscopy, a promising alternative to upper endoscopy for the investigation and diagnosis of celiac disease, may one day negate the need for endoscopically obtained intestinal biopsies, Dr. Ernest Seidman said at an international conference on celiac disease.

“I don't think that we can yet say that the capsule should replace the biopsy in every case,” said Dr. Seidman, who is professor of medicine and pediatrics at McGill University, Montreal, and also a consultant for Given Imaging, which manufactures the only capsule endoscope that has been approved by the Food and Drug Administration.

“The consensus opinion is that capsule endoscopy is equivalent to histology [for the detection of celiac disease], but only in those with severe villous atrophy. More data is required to prove diagnostic equivalence for those with partial atrophy,” he said.

Usually, patients with serologic evidence of celiac disease undergo intestinal biopsy to verify the presence of villous atrophy, which is currently the definitive diagnostic finding.

But a consensus of expert opinion from the International Conference on Capsule Endoscopy in Paris last June suggested that the tool may be an alternative for patients who are unwilling or unable to undergo biopsy, for those whose initial biopsy is equivocal, and for patients with confirmed celiac disease who develop alarming symptoms despite adherence to a gluten-free diet (Endoscopy 2005;37: 1055–9).

One advantage of capsule endoscopy in the investigation of celiac disease is that it offers unprecedented views of the small bowel in its entirety. “So much of the small bowel has been a black box for us, and with capsule endoscopy, we can see areas that are not accessible with the upper endoscope,” Dr. Seidman said.

Capsule endoscopy is also state-of-the-art technology for examining the intestinal lining for other small bowel disorders. “We can see target lesions that would not otherwise be detectable by other imaging methods. Moreover, villous appearance can be seen extremely well—the resolution of the camera is extraordinary. We see villi routinely without doing magnification, and when the villi are atrophic or edematous, it's very apparent,” he added.

Capsule findings of the intestinal lining that are suggestive of celiac disease include fissuring, scalloping, a mosaic pattern, nodularity, and delayed appearance of villi with a loss of circular folds, Dr. Seidman said.

Although the avoidance of endoscopy and sedation may be particularly attractive when dealing with pediatric patients, children under the age of 8 years are rarely able to swallow the jelly bean-size capsule, he said, adding that getting them to demonstrate with a real jelly bean is a wise idea.

“Otherwise, you run into a situation where you have opened the blister pack, which activates the camera, and you have the child holding it and saying they can't do it. It's an expensive way to get pictures of their face,” he said.

There is a delivery device that allows the introduction of the capsule into the small bowel with an endoscope, but this approach negates much of the advantage of the capsule, he said.

Even after they have started a gluten-free diet, patients with celiac disease might face up to a 40-fold increased risk of developing small bowel lymphomas, compared with the risk in people who don't have celiac disease. Consequently, any recurrent or persistent bowel symptoms that occur in diagnosed patients following the adoption of a strict gluten-free diet are to be carefully evaluated and investigated. Capsule endoscopy often reveals abnormalities in such patients, Dr. Seidman said.

“Small bowel tumors are notoriously silent until it's too late—and finding them is extremely difficult. Needless to say, capsule endoscopy is the most proficient way to look for these tumors,” he said.

A recent study of capsule endoscopy in 47 celiac patients with abdominal pain or other symptoms suggestive of malignancy found cancer in 5%, ulcerations in 50%, and villous atrophy in 68% (indicating noncompliance with the gluten-free diet), he said (Gastrointest. Endosc. 2005;62: 55–61).

NEW YORK — Neurologic dysfunction may be the sole presenting symptom of celiac disease, according to Dr. Marios Hadjivassiliou, a neurologist at the Royal Hallamshire Hospital in Sheffield, England.

Speaking at an international symposium on celiac disease, Dr. Hadjivassiliou reported that his neurology clinic has followed 312 patients with gluten sensitivity who presented with various types of neurologic dysfunction. The majority of the patients had gluten ataxia (n = 147), while others had peripheral neuropathy (n = 116), gluten encephalopathy (n = 31), and gluten myopathies (n = 13).

His previous research has found that gluten ataxia is the single most common cause of sporadic, idiopathic ataxia—accounting for 40% of sporadic, idiopathic ataxias and 21% of all ataxias (Brain 2003;126:685–91). “These patients have limb and gait ataxia, and one-third will also have an enteropathy,” he said.

He has also shown that patients with gluten ataxia improve or stabilize within a year of starting a strict gluten-free diet, even in the absence of enteropathy (J. Neurol. Neurosurg. Psychiatry 2003;74:1221–4). “However, the sooner you intervene, the better,” he said. “About 60% of these patients will have atrophy of the cerebellum shown on MRI, and there is loss of Purkinje cells, which is not reversible.”

With regard to gluten neuropathy, new research by Dr. Hadjivassiliou has shown that it accounts for 26% of all axonal neuropathies and 34% of idiopathic, sporadic axonal neuropathies (J. Neurol. Neurosurg. Psychiatry 2006;77:1262–6). “The prevalence of gluten-sensitive enteropathy is 10 times higher in patients with axonal neuropathy compared to healthy individuals,” he said.

He has also recently published evidence showing that patients with gluten-sensitive neuropathy show improvement on a gluten-free diet, while patients who continue to ingest gluten deteriorate further (Muscle Nerve 2006;34:762–6).

However, neuropathies are still common in treated celiac patients, he added. “If you screen adults with established celiac disease, one-quarter of them will have evidence of neuropathy despite a gluten-free diet.”

Gluten encephalopathy—episodic headache often associated with confusion and focal neurologic dysfunction, requiring hospital admission—is also a neurologic manifestation of celiac disease, Dr. Hadjivassiliou reported.

Magnetic resonance imaging shows white matter abnormalities associated with focal neurologic deficits, and these are not always reversible even after the patient starts a gluten-free diet. However, the headaches respond well to the elimination of gluten, he said.

Dr. Hadjivassiliou believes that nutritional deficiencies resulting from malabsorption in the small intestine can now be ruled out as a cause of gluten-sensitive neuropathies.

“The overwhelming evidence is for an immune-mediated mechanism,” he said, adding that pathological data mainly from postmortem examinations show evidence of MRI inflammatory changes with perivascular emphasis primarily affecting the cerebellum and brainstem, but also other parts of the brain.

He urged physicians to recognize that celiac disease is a systemic disorder that has diverse manifestations in the body beyond the gastrointestinal system. “There is a historical misconception that gluten sensitivity is solely a disease of the gut,” he said. “To recognize the neurologic impact, you have to appreciate it is a systemic disorder.”

His experience is that many gluten-sensitive neurologic disorders have an age of onset in the mid-50s. Many patients have no gastrointestinal symptoms, but serologic tests for IgG and IgA antigliadin antibodies are positive.

Endomysial antibodies or tissue transglutaminase antibodies can help identify those patients who may also have an enteropathy; however, only one-third of these patients will have histologic confirmation of this on biopsy.

MRI scans taken over 7 years show progressive cerebellar degeneration in a patient with gluten ataxia who refused to go on a gluten-free diet (earliest scan at upper left to most recent at lower right). Courtesy Dr. Marios Hadjivassiliou

NEW YORK — Neurologic dysfunction may be the sole presenting symptom of celiac disease, according to Dr. Marios Hadjivassiliou, a neurologist at the Royal Hallamshire Hospital in Sheffield, England.

Speaking at an international symposium on celiac disease, Dr. Hadjivassiliou reported that his neurology clinic has followed 312 patients with gluten sensitivity who presented with various types of neurologic dysfunction. The majority of the patients had gluten ataxia (n = 147), while others had peripheral neuropathy (n = 116), gluten encephalopathy (n = 31), and gluten myopathies (n = 13).

His previous research has found that gluten ataxia is the single most common cause of sporadic, idiopathic ataxia—accounting for 40% of sporadic, idiopathic ataxias and 21% of all ataxias (Brain 2003;126:685–91). “These patients have limb and gait ataxia, and one-third will also have an enteropathy,” he said.

He has also shown that patients with gluten ataxia improve or stabilize within a year of starting a strict gluten-free diet, even in the absence of enteropathy (J. Neurol. Neurosurg. Psychiatry 2003;74:1221–4). “However, the sooner you intervene, the better,” he said. “About 60% of these patients will have atrophy of the cerebellum shown on MRI, and there is loss of Purkinje cells, which is not reversible.”

With regard to gluten neuropathy, new research by Dr. Hadjivassiliou has shown that it accounts for 26% of all axonal neuropathies and 34% of idiopathic, sporadic axonal neuropathies (J. Neurol. Neurosurg. Psychiatry 2006;77:1262–6). “The prevalence of gluten-sensitive enteropathy is 10 times higher in patients with axonal neuropathy compared to healthy individuals,” he said.

He has also recently published evidence showing that patients with gluten-sensitive neuropathy show improvement on a gluten-free diet, while patients who continue to ingest gluten deteriorate further (Muscle Nerve 2006;34:762–6).

However, neuropathies are still common in treated celiac patients, he added. “If you screen adults with established celiac disease, one-quarter of them will have evidence of neuropathy despite a gluten-free diet.”

Gluten encephalopathy—episodic headache often associated with confusion and focal neurologic dysfunction, requiring hospital admission—is also a neurologic manifestation of celiac disease, Dr. Hadjivassiliou reported.

Magnetic resonance imaging shows white matter abnormalities associated with focal neurologic deficits, and these are not always reversible even after the patient starts a gluten-free diet. However, the headaches respond well to the elimination of gluten, he said.

Dr. Hadjivassiliou believes that nutritional deficiencies resulting from malabsorption in the small intestine can now be ruled out as a cause of gluten-sensitive neuropathies.

“The overwhelming evidence is for an immune-mediated mechanism,” he said, adding that pathological data mainly from postmortem examinations show evidence of MRI inflammatory changes with perivascular emphasis primarily affecting the cerebellum and brainstem, but also other parts of the brain.

He urged physicians to recognize that celiac disease is a systemic disorder that has diverse manifestations in the body beyond the gastrointestinal system. “There is a historical misconception that gluten sensitivity is solely a disease of the gut,” he said. “To recognize the neurologic impact, you have to appreciate it is a systemic disorder.”

His experience is that many gluten-sensitive neurologic disorders have an age of onset in the mid-50s. Many patients have no gastrointestinal symptoms, but serologic tests for IgG and IgA antigliadin antibodies are positive.

Endomysial antibodies or tissue transglutaminase antibodies can help identify those patients who may also have an enteropathy; however, only one-third of these patients will have histologic confirmation of this on biopsy.

MRI scans taken over 7 years show progressive cerebellar degeneration in a patient with gluten ataxia who refused to go on a gluten-free diet (earliest scan at upper left to most recent at lower right). Courtesy Dr. Marios Hadjivassiliou

NEW YORK — Neurologic dysfunction may be the sole presenting symptom of celiac disease, according to Dr. Marios Hadjivassiliou, a neurologist at the Royal Hallamshire Hospital in Sheffield, England.

Speaking at an international symposium on celiac disease, Dr. Hadjivassiliou reported that his neurology clinic has followed 312 patients with gluten sensitivity who presented with various types of neurologic dysfunction. The majority of the patients had gluten ataxia (n = 147), while others had peripheral neuropathy (n = 116), gluten encephalopathy (n = 31), and gluten myopathies (n = 13).

His previous research has found that gluten ataxia is the single most common cause of sporadic, idiopathic ataxia—accounting for 40% of sporadic, idiopathic ataxias and 21% of all ataxias (Brain 2003;126:685–91). “These patients have limb and gait ataxia, and one-third will also have an enteropathy,” he said.

He has also shown that patients with gluten ataxia improve or stabilize within a year of starting a strict gluten-free diet, even in the absence of enteropathy (J. Neurol. Neurosurg. Psychiatry 2003;74:1221–4). “However, the sooner you intervene, the better,” he said. “About 60% of these patients will have atrophy of the cerebellum shown on MRI, and there is loss of Purkinje cells, which is not reversible.”

With regard to gluten neuropathy, new research by Dr. Hadjivassiliou has shown that it accounts for 26% of all axonal neuropathies and 34% of idiopathic, sporadic axonal neuropathies (J. Neurol. Neurosurg. Psychiatry 2006;77:1262–6). “The prevalence of gluten-sensitive enteropathy is 10 times higher in patients with axonal neuropathy compared to healthy individuals,” he said.

He has also recently published evidence showing that patients with gluten-sensitive neuropathy show improvement on a gluten-free diet, while patients who continue to ingest gluten deteriorate further (Muscle Nerve 2006;34:762–6).

However, neuropathies are still common in treated celiac patients, he added. “If you screen adults with established celiac disease, one-quarter of them will have evidence of neuropathy despite a gluten-free diet.”

Gluten encephalopathy—episodic headache often associated with confusion and focal neurologic dysfunction, requiring hospital admission—is also a neurologic manifestation of celiac disease, Dr. Hadjivassiliou reported.

Magnetic resonance imaging shows white matter abnormalities associated with focal neurologic deficits, and these are not always reversible even after the patient starts a gluten-free diet. However, the headaches respond well to the elimination of gluten, he said.

Dr. Hadjivassiliou believes that nutritional deficiencies resulting from malabsorption in the small intestine can now be ruled out as a cause of gluten-sensitive neuropathies.

“The overwhelming evidence is for an immune-mediated mechanism,” he said, adding that pathological data mainly from postmortem examinations show evidence of MRI inflammatory changes with perivascular emphasis primarily affecting the cerebellum and brainstem, but also other parts of the brain.

He urged physicians to recognize that celiac disease is a systemic disorder that has diverse manifestations in the body beyond the gastrointestinal system. “There is a historical misconception that gluten sensitivity is solely a disease of the gut,” he said. “To recognize the neurologic impact, you have to appreciate it is a systemic disorder.”

His experience is that many gluten-sensitive neurologic disorders have an age of onset in the mid-50s. Many patients have no gastrointestinal symptoms, but serologic tests for IgG and IgA antigliadin antibodies are positive.

Endomysial antibodies or tissue transglutaminase antibodies can help identify those patients who may also have an enteropathy; however, only one-third of these patients will have histologic confirmation of this on biopsy.

MRI scans taken over 7 years show progressive cerebellar degeneration in a patient with gluten ataxia who refused to go on a gluten-free diet (earliest scan at upper left to most recent at lower right). Courtesy Dr. Marios Hadjivassiliou

NEW YORK — Celiac disease doesn't look like it used to, and consequently the diagnosis is frequently missed by physicians who think of it as a disease of wasting, reported experts at an international symposium on celiac disease.

Traditionally, textbook pictures of celiac patients have shown the wasted limbs and swollen abdomens characteristic of malnutrition—but today, up to 40% of patients are overweight and 13% are obese at presentation, according to Dr. William Dickey of Altnagelvin Hospital, Londonderry, Northern Ireland.

Dr. Dickey's study of body mass index at presentation in 371 celiac patients over a 10-year period found that only 5% were underweight, and few presented with the classic symptoms of diarrhea and anemia (Am. J. Gastroenterol. 2006;101:2356–9). The well-documented problem of missed or delayed diagnosis of celiac disease may be partially explained by failure to recognize its modern presentation, he suggested.

In response to “significant lack of awareness and very substantial underdiagnosis of patients,” the National Institutes of Health has embarked on an awareness campaign aimed at primary care providers, said Dr. Stephen James, director of the digestive diseases and nutrition division of the NIH, who also spoke at the meeting.

“Physicians do not perceive the underdiagnosis of celiac to be problematic,” he said, citing findings from the recent NIH Consensus Development Conference on Celiac Disease (www.consensus.nih.gov/2004/2004CeliacDisease118html.htm

Recent evidence suggests that the prevalence of celiac disease—about 1%–-is the same in both Europe and North America (Arch. Intern. Med. 2003;163:286–92). Higher prevalence rates are seen in first-degree relatives (5%–15%), monozygotic twins (70%–75%), and patients with other autoimmune disorders.

The prevalence of celiac disease is slightly higher than that of either type 1 diabetes or Crohn's disease, but many physicians still have the misperception that celiac disease is a rare disorder, Dr. James said. Although many primary care physicians surveyed said they had never seen a case of celiac disease, they probably had several undiagnosed patients in their practice, he said.

Extragastrointestinal signs and symptoms of celiac disease—such as dermatitis herpetiformis, neurologic disorders, more than one miscarriage, osteoporosis, and dental and oral problems—often go unrecognized, he noted.

The ambiguity of diagnostic tests contributes to the elusiveness of celiac disease, once called a “clinical chameleon” by Dr. Alessio Fasano, a leading expert from the University of Maryland Medical Center, Baltimore. In addition to the nonspecific spectrum of clinical symptoms, diagnostic criteria have hinged on positive serum antibodies and small bowel biopsies, but equivocal serologic and histologic results are frequently found, experts agreed.

The combination of positive serology followed by a positive bowel biopsy and response to a gluten-free diet confirms the disease with roughly 95% accuracy, said Dr. Edward J. Hoffenberg, of the University of Colorado Health Sciences Center in Denver. But his work, and that of others, has shown that an individual's degree of immune response can fluctuate, especially if they are not ingesting gluten at the time of testing, and the characteristic villous atrophy seen on bowel biopsies is not always present.

A diagnosis of celiac disease within a family should alert physicians to the increased risk for other family members, said Dr. Chris Mulder of Vrije Universiteit Medical Center, Amsterdam. Genetic testing can rule out celiac for such risk groups, because 99% of celiac patients express the DQ2 or DQ8 haplotype.

However, 30% of those with genetic susceptibility may not develop celiac, he said. Genetic testing is part of the celiac work-up in the Netherlands, but it is less available in North America, making family history a more realistic genetic marker.

NEW YORK — Celiac disease doesn't look like it used to, and consequently the diagnosis is frequently missed by physicians who think of it as a disease of wasting, reported experts at an international symposium on celiac disease.

Traditionally, textbook pictures of celiac patients have shown the wasted limbs and swollen abdomens characteristic of malnutrition—but today, up to 40% of patients are overweight and 13% are obese at presentation, according to Dr. William Dickey of Altnagelvin Hospital, Londonderry, Northern Ireland.

Dr. Dickey's study of body mass index at presentation in 371 celiac patients over a 10-year period found that only 5% were underweight, and few presented with the classic symptoms of diarrhea and anemia (Am. J. Gastroenterol. 2006;101:2356–9). The well-documented problem of missed or delayed diagnosis of celiac disease may be partially explained by failure to recognize its modern presentation, he suggested.

In response to “significant lack of awareness and very substantial underdiagnosis of patients,” the National Institutes of Health has embarked on an awareness campaign aimed at primary care providers, said Dr. Stephen James, director of the digestive diseases and nutrition division of the NIH, who also spoke at the meeting.

“Physicians do not perceive the underdiagnosis of celiac to be problematic,” he said, citing findings from the recent NIH Consensus Development Conference on Celiac Disease (www.consensus.nih.gov/2004/2004CeliacDisease118html.htm

Recent evidence suggests that the prevalence of celiac disease—about 1%–-is the same in both Europe and North America (Arch. Intern. Med. 2003;163:286–92). Higher prevalence rates are seen in first-degree relatives (5%–15%), monozygotic twins (70%–75%), and patients with other autoimmune disorders.

The prevalence of celiac disease is slightly higher than that of either type 1 diabetes or Crohn's disease, but many physicians still have the misperception that celiac disease is a rare disorder, Dr. James said. Although many primary care physicians surveyed said they had never seen a case of celiac disease, they probably had several undiagnosed patients in their practice, he said.

Extragastrointestinal signs and symptoms of celiac disease—such as dermatitis herpetiformis, neurologic disorders, more than one miscarriage, osteoporosis, and dental and oral problems—often go unrecognized, he noted.

The ambiguity of diagnostic tests contributes to the elusiveness of celiac disease, once called a “clinical chameleon” by Dr. Alessio Fasano, a leading expert from the University of Maryland Medical Center, Baltimore. In addition to the nonspecific spectrum of clinical symptoms, diagnostic criteria have hinged on positive serum antibodies and small bowel biopsies, but equivocal serologic and histologic results are frequently found, experts agreed.

The combination of positive serology followed by a positive bowel biopsy and response to a gluten-free diet confirms the disease with roughly 95% accuracy, said Dr. Edward J. Hoffenberg, of the University of Colorado Health Sciences Center in Denver. But his work, and that of others, has shown that an individual's degree of immune response can fluctuate, especially if they are not ingesting gluten at the time of testing, and the characteristic villous atrophy seen on bowel biopsies is not always present.

A diagnosis of celiac disease within a family should alert physicians to the increased risk for other family members, said Dr. Chris Mulder of Vrije Universiteit Medical Center, Amsterdam. Genetic testing can rule out celiac for such risk groups, because 99% of celiac patients express the DQ2 or DQ8 haplotype.

However, 30% of those with genetic susceptibility may not develop celiac, he said. Genetic testing is part of the celiac work-up in the Netherlands, but it is less available in North America, making family history a more realistic genetic marker.

NEW YORK — Celiac disease doesn't look like it used to, and consequently the diagnosis is frequently missed by physicians who think of it as a disease of wasting, reported experts at an international symposium on celiac disease.

Traditionally, textbook pictures of celiac patients have shown the wasted limbs and swollen abdomens characteristic of malnutrition—but today, up to 40% of patients are overweight and 13% are obese at presentation, according to Dr. William Dickey of Altnagelvin Hospital, Londonderry, Northern Ireland.

Dr. Dickey's study of body mass index at presentation in 371 celiac patients over a 10-year period found that only 5% were underweight, and few presented with the classic symptoms of diarrhea and anemia (Am. J. Gastroenterol. 2006;101:2356–9). The well-documented problem of missed or delayed diagnosis of celiac disease may be partially explained by failure to recognize its modern presentation, he suggested.

In response to “significant lack of awareness and very substantial underdiagnosis of patients,” the National Institutes of Health has embarked on an awareness campaign aimed at primary care providers, said Dr. Stephen James, director of the digestive diseases and nutrition division of the NIH, who also spoke at the meeting.

“Physicians do not perceive the underdiagnosis of celiac to be problematic,” he said, citing findings from the recent NIH Consensus Development Conference on Celiac Disease (www.consensus.nih.gov/2004/2004CeliacDisease118html.htm

Recent evidence suggests that the prevalence of celiac disease—about 1%–-is the same in both Europe and North America (Arch. Intern. Med. 2003;163:286–92). Higher prevalence rates are seen in first-degree relatives (5%–15%), monozygotic twins (70%–75%), and patients with other autoimmune disorders.

The prevalence of celiac disease is slightly higher than that of either type 1 diabetes or Crohn's disease, but many physicians still have the misperception that celiac disease is a rare disorder, Dr. James said. Although many primary care physicians surveyed said they had never seen a case of celiac disease, they probably had several undiagnosed patients in their practice, he said.

Extragastrointestinal signs and symptoms of celiac disease—such as dermatitis herpetiformis, neurologic disorders, more than one miscarriage, osteoporosis, and dental and oral problems—often go unrecognized, he noted.

The ambiguity of diagnostic tests contributes to the elusiveness of celiac disease, once called a “clinical chameleon” by Dr. Alessio Fasano, a leading expert from the University of Maryland Medical Center, Baltimore. In addition to the nonspecific spectrum of clinical symptoms, diagnostic criteria have hinged on positive serum antibodies and small bowel biopsies, but equivocal serologic and histologic results are frequently found, experts agreed.

The combination of positive serology followed by a positive bowel biopsy and response to a gluten-free diet confirms the disease with roughly 95% accuracy, said Dr. Edward J. Hoffenberg, of the University of Colorado Health Sciences Center in Denver. But his work, and that of others, has shown that an individual's degree of immune response can fluctuate, especially if they are not ingesting gluten at the time of testing, and the characteristic villous atrophy seen on bowel biopsies is not always present.

A diagnosis of celiac disease within a family should alert physicians to the increased risk for other family members, said Dr. Chris Mulder of Vrije Universiteit Medical Center, Amsterdam. Genetic testing can rule out celiac for such risk groups, because 99% of celiac patients express the DQ2 or DQ8 haplotype.

However, 30% of those with genetic susceptibility may not develop celiac, he said. Genetic testing is part of the celiac work-up in the Netherlands, but it is less available in North America, making family history a more realistic genetic marker.

COPENHAGEN — Nondiabetic and diabetic patients benefit equally from the hypertension-lowering effects of an amlodipine/perindopril regimen, according to a subanalysis of a large cardiac outcomes trial reported at the annual meeting of the European Association for the Study of Diabetes.

The Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA) was stopped early because of the distinct advantages of the calcium channel blocker/ACE inhibitor combination over a traditional β-blocker (atenolol)/thiazide diuretic (bendroflumethiazide) combination (Lancet 2005;366:895–90).

The benefits were seen in reduced fatal and nonfatal stroke, cardiovascular events and procedures, and all-cause mortality. In the overall ASCOT-BPLA cohort of more than 19,000 hypertensive patients, the amlodipine-based regimen also resulted in a significant reduction in new-onset diabetes.

The current analysis included a subset of 5,137 trial participants who had pre-existing diabetes and found similar benefits for the amlodipine-based therapy, reported Dr. Jan Östergren from Karolinska University Hospital in Stockholm.

At the end of 5 years, total cardiovascular events and procedures were reduced by 14% in the amlodipine-treated group compared with the atenolol-treated group.

“This is almost exactly the same reduction as what we found in the larger study of nondiabetic subjects, where we saw a 16% reduction,” said Dr. Östergren. Specifically, the incidence of fatal and nonfatal stroke was 25% lower, peripheral arterial disease was 48% lower, and noncoronary revascularization procedures were 57% lower.

COPENHAGEN — Nondiabetic and diabetic patients benefit equally from the hypertension-lowering effects of an amlodipine/perindopril regimen, according to a subanalysis of a large cardiac outcomes trial reported at the annual meeting of the European Association for the Study of Diabetes.

The Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA) was stopped early because of the distinct advantages of the calcium channel blocker/ACE inhibitor combination over a traditional β-blocker (atenolol)/thiazide diuretic (bendroflumethiazide) combination (Lancet 2005;366:895–90).

The benefits were seen in reduced fatal and nonfatal stroke, cardiovascular events and procedures, and all-cause mortality. In the overall ASCOT-BPLA cohort of more than 19,000 hypertensive patients, the amlodipine-based regimen also resulted in a significant reduction in new-onset diabetes.

The current analysis included a subset of 5,137 trial participants who had pre-existing diabetes and found similar benefits for the amlodipine-based therapy, reported Dr. Jan Östergren from Karolinska University Hospital in Stockholm.

At the end of 5 years, total cardiovascular events and procedures were reduced by 14% in the amlodipine-treated group compared with the atenolol-treated group.

“This is almost exactly the same reduction as what we found in the larger study of nondiabetic subjects, where we saw a 16% reduction,” said Dr. Östergren. Specifically, the incidence of fatal and nonfatal stroke was 25% lower, peripheral arterial disease was 48% lower, and noncoronary revascularization procedures were 57% lower.

COPENHAGEN — Nondiabetic and diabetic patients benefit equally from the hypertension-lowering effects of an amlodipine/perindopril regimen, according to a subanalysis of a large cardiac outcomes trial reported at the annual meeting of the European Association for the Study of Diabetes.

The Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA) was stopped early because of the distinct advantages of the calcium channel blocker/ACE inhibitor combination over a traditional β-blocker (atenolol)/thiazide diuretic (bendroflumethiazide) combination (Lancet 2005;366:895–90).

The benefits were seen in reduced fatal and nonfatal stroke, cardiovascular events and procedures, and all-cause mortality. In the overall ASCOT-BPLA cohort of more than 19,000 hypertensive patients, the amlodipine-based regimen also resulted in a significant reduction in new-onset diabetes.

The current analysis included a subset of 5,137 trial participants who had pre-existing diabetes and found similar benefits for the amlodipine-based therapy, reported Dr. Jan Östergren from Karolinska University Hospital in Stockholm.

At the end of 5 years, total cardiovascular events and procedures were reduced by 14% in the amlodipine-treated group compared with the atenolol-treated group.

“This is almost exactly the same reduction as what we found in the larger study of nondiabetic subjects, where we saw a 16% reduction,” said Dr. Östergren. Specifically, the incidence of fatal and nonfatal stroke was 25% lower, peripheral arterial disease was 48% lower, and noncoronary revascularization procedures were 57% lower.

PRAGUE — In patients with osteoarthritis—and even in healthy subjects—standard walking shoes result in significantly more knee adduction compared with barefoot walking or walking with a specially designed “unloading” shoe, reported Dr. Najia Shakoor in a poster at the 2006 World Congress on Osteoarthritis.

“High [dynamic] loading has been associated with both the presence and progression of OA,” Dr. Shakoor commented in an interview, noting that increased loading results in increased adduction.

In a previous study, Dr. Shakoor and colleagues from Rush Medical College, Chicago, demonstrated that in subjects with knee OA, walking barefoot significantly decreases peak external knee adduction compared with walking in standard walking shoes (Arthritis Rheum. 2006;54:2923–7).

The group subsequently designed a shoe to mimic the unloading characteristics of barefoot walking and tested it in a cohort of 26 healthy subjects.

The 18 females and 8 males, with a mean age of 42 years, received gait evaluations while wearing their self-selected normal walking shoes.

All subjects also had a gait analysis while walking barefoot, and 19 were analyzed while they wore the specially designed unloading shoes. “The shoes are very flat and thin-soled, with a soft upper that wraps around the foot like a glove,” said Dr. Shakoor.

“There are slit lines in the sole to conform to the major natural flexion points of the foot.”

Although a provisional patent has been filed and the group hopes the shoes will one day be marketed as a therapeutic intervention, they do not currently have any company affiliations.

Overall, a significant 13% reduction in subjects' external knee adduction was noted during their walking while barefoot and with the unloading shoes, compared with walking in their normal walking shoes.

The researchers also have data showing similar unloading effects of the shoes in patients with OA, according to Dr. Shakoor, speaking at the conference, which was sponsored by the Osteoarthritis Research Society International.

A man undergoes gait analysis in his normal walking shoes. Courtesy Dr. Najia Shakoor

PRAGUE — In patients with osteoarthritis—and even in healthy subjects—standard walking shoes result in significantly more knee adduction compared with barefoot walking or walking with a specially designed “unloading” shoe, reported Dr. Najia Shakoor in a poster at the 2006 World Congress on Osteoarthritis.

“High [dynamic] loading has been associated with both the presence and progression of OA,” Dr. Shakoor commented in an interview, noting that increased loading results in increased adduction.

In a previous study, Dr. Shakoor and colleagues from Rush Medical College, Chicago, demonstrated that in subjects with knee OA, walking barefoot significantly decreases peak external knee adduction compared with walking in standard walking shoes (Arthritis Rheum. 2006;54:2923–7).

The group subsequently designed a shoe to mimic the unloading characteristics of barefoot walking and tested it in a cohort of 26 healthy subjects.

The 18 females and 8 males, with a mean age of 42 years, received gait evaluations while wearing their self-selected normal walking shoes.

All subjects also had a gait analysis while walking barefoot, and 19 were analyzed while they wore the specially designed unloading shoes. “The shoes are very flat and thin-soled, with a soft upper that wraps around the foot like a glove,” said Dr. Shakoor.

“There are slit lines in the sole to conform to the major natural flexion points of the foot.”

Although a provisional patent has been filed and the group hopes the shoes will one day be marketed as a therapeutic intervention, they do not currently have any company affiliations.

Overall, a significant 13% reduction in subjects' external knee adduction was noted during their walking while barefoot and with the unloading shoes, compared with walking in their normal walking shoes.

The researchers also have data showing similar unloading effects of the shoes in patients with OA, according to Dr. Shakoor, speaking at the conference, which was sponsored by the Osteoarthritis Research Society International.

A man undergoes gait analysis in his normal walking shoes. Courtesy Dr. Najia Shakoor

PRAGUE — In patients with osteoarthritis—and even in healthy subjects—standard walking shoes result in significantly more knee adduction compared with barefoot walking or walking with a specially designed “unloading” shoe, reported Dr. Najia Shakoor in a poster at the 2006 World Congress on Osteoarthritis.

“High [dynamic] loading has been associated with both the presence and progression of OA,” Dr. Shakoor commented in an interview, noting that increased loading results in increased adduction.

In a previous study, Dr. Shakoor and colleagues from Rush Medical College, Chicago, demonstrated that in subjects with knee OA, walking barefoot significantly decreases peak external knee adduction compared with walking in standard walking shoes (Arthritis Rheum. 2006;54:2923–7).

The group subsequently designed a shoe to mimic the unloading characteristics of barefoot walking and tested it in a cohort of 26 healthy subjects.

The 18 females and 8 males, with a mean age of 42 years, received gait evaluations while wearing their self-selected normal walking shoes.

All subjects also had a gait analysis while walking barefoot, and 19 were analyzed while they wore the specially designed unloading shoes. “The shoes are very flat and thin-soled, with a soft upper that wraps around the foot like a glove,” said Dr. Shakoor.

“There are slit lines in the sole to conform to the major natural flexion points of the foot.”

Although a provisional patent has been filed and the group hopes the shoes will one day be marketed as a therapeutic intervention, they do not currently have any company affiliations.

Overall, a significant 13% reduction in subjects' external knee adduction was noted during their walking while barefoot and with the unloading shoes, compared with walking in their normal walking shoes.

The researchers also have data showing similar unloading effects of the shoes in patients with OA, according to Dr. Shakoor, speaking at the conference, which was sponsored by the Osteoarthritis Research Society International.

A man undergoes gait analysis in his normal walking shoes. Courtesy Dr. Najia Shakoor