Kate Johnson

PRAGUE — Individually calibrated shoes that provide dynamic wedging can significantly improve pain and function in patients with knee osteoarthritis—sometimes immediately, according to a study reported Dr. Yuval Ran 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 the APOS system footwear from Atlantic Prosthetic Orthotic Services Ltd. in Kilcolgan, Ireland, 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 knee OA patients, mean age 66 years, 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.

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.

The wedging implants are designed to reduce age-related stress on the knee.

Couple with OA demonstrate the footwear with wedging. Photos 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, according to a study reported Dr. Yuval Ran 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 the APOS system footwear from Atlantic Prosthetic Orthotic Services Ltd. in Kilcolgan, Ireland, 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 knee OA patients, mean age 66 years, 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.

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.

The wedging implants are designed to reduce age-related stress on the knee.

Couple with OA demonstrate the footwear with wedging. Photos 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, according to a study reported Dr. Yuval Ran 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 the APOS system footwear from Atlantic Prosthetic Orthotic Services Ltd. in Kilcolgan, Ireland, 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 knee OA patients, mean age 66 years, 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.

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.

The wedging implants are designed to reduce age-related stress on the knee.

Couple with OA demonstrate the footwear with wedging. Photos courtesy Dr. Yuval Ran/Dr. Avi Elbaz/Dr. Amit Mor

NEW ORLEANS — Premenopausal vasomotor symptoms, particularly night sweats, are a previously unrecognized risk factor for low bone mineral density and enhanced bone turnover in infertile women—and probably in fertile women as well, although this has not yet been confirmed, according to Dr. Lubna Pal of the Albert Einstein College of Medicine, N.Y.

Her study won the prize paper from the Society for Reproductive Endocrinology and Infertility at the annual meeting of the American Society for Reproductive Medicine. Based on these data, “I would advise providers to specifically ask about vasomotor symptoms in premenopausal women and, for those who are symptomatic, to focus on unmasking additional factors that may enhance their fracture risk, such as low body mass; family or personal history of fractures; or smoking,” she said in an interview. “I don't think we are there yet in terms of recommending bone density screening for this population … but these women need to be advised that a further deterioration in their bone density parameters is likely to occur in the postmenopausal period, and measures to optimize skeletal health should be addressed now rather than later.”

The cross-sectional study included 86 premenopausal infertile women aged 42 years or younger without premature ovarian failure or oophorectomy. A questionnaire was used to ask about the presence and frequency of vasomotor symptoms, including hot flashes and night sweats.

The study also measured subjects' bone mineral density (BMD) and levels of serum N-telopeptide (NTx), a marker of bone turnover. A total of 12% of respondents reported one or both vasomotor symptoms, and 21% of respondents had evidence of low BMD, Dr. Pal reported.

There was a highly significant correlation between vasomotor symptoms and low BMD, with 62.5% of symptomatic women showing evidence of low BMD, compared with 14% of asymptomatic women (odds ratio 10.18). Similarly, 36% of women with low BMD reported vasomotor symptoms, compared with 5% of those with normal BMD.

After controlling for age, body mass index, menstrual regularity, race, and smoking, the study found that vasomotor symptoms (night sweats and/or hot flashes) were independent predictors of low bone density in the study population. The magnitude of this association was most robust for night sweats, with an adjusted odds ratio (AOR) of 52.47, followed by both symptoms combined (AOR 24.10), and then hot flashes alone (AOR 15.10).

The presence of night sweats was also an independent predictor of bone turnover, with higher levels of serum NTx seen in symptomatic compared with asymptomatic women, she said.

Levels of inhibin B, a marker of ovarian reserve, were also significantly lower in women with night sweats compared with asymptomatic women, she said.

NEW ORLEANS — Premenopausal vasomotor symptoms, particularly night sweats, are a previously unrecognized risk factor for low bone mineral density and enhanced bone turnover in infertile women—and probably in fertile women as well, although this has not yet been confirmed, according to Dr. Lubna Pal of the Albert Einstein College of Medicine, N.Y.

Her study won the prize paper from the Society for Reproductive Endocrinology and Infertility at the annual meeting of the American Society for Reproductive Medicine. Based on these data, “I would advise providers to specifically ask about vasomotor symptoms in premenopausal women and, for those who are symptomatic, to focus on unmasking additional factors that may enhance their fracture risk, such as low body mass; family or personal history of fractures; or smoking,” she said in an interview. “I don't think we are there yet in terms of recommending bone density screening for this population … but these women need to be advised that a further deterioration in their bone density parameters is likely to occur in the postmenopausal period, and measures to optimize skeletal health should be addressed now rather than later.”

The cross-sectional study included 86 premenopausal infertile women aged 42 years or younger without premature ovarian failure or oophorectomy. A questionnaire was used to ask about the presence and frequency of vasomotor symptoms, including hot flashes and night sweats.

The study also measured subjects' bone mineral density (BMD) and levels of serum N-telopeptide (NTx), a marker of bone turnover. A total of 12% of respondents reported one or both vasomotor symptoms, and 21% of respondents had evidence of low BMD, Dr. Pal reported.

There was a highly significant correlation between vasomotor symptoms and low BMD, with 62.5% of symptomatic women showing evidence of low BMD, compared with 14% of asymptomatic women (odds ratio 10.18). Similarly, 36% of women with low BMD reported vasomotor symptoms, compared with 5% of those with normal BMD.

After controlling for age, body mass index, menstrual regularity, race, and smoking, the study found that vasomotor symptoms (night sweats and/or hot flashes) were independent predictors of low bone density in the study population. The magnitude of this association was most robust for night sweats, with an adjusted odds ratio (AOR) of 52.47, followed by both symptoms combined (AOR 24.10), and then hot flashes alone (AOR 15.10).

The presence of night sweats was also an independent predictor of bone turnover, with higher levels of serum NTx seen in symptomatic compared with asymptomatic women, she said.

Levels of inhibin B, a marker of ovarian reserve, were also significantly lower in women with night sweats compared with asymptomatic women, she said.

NEW ORLEANS — Premenopausal vasomotor symptoms, particularly night sweats, are a previously unrecognized risk factor for low bone mineral density and enhanced bone turnover in infertile women—and probably in fertile women as well, although this has not yet been confirmed, according to Dr. Lubna Pal of the Albert Einstein College of Medicine, N.Y.

Her study won the prize paper from the Society for Reproductive Endocrinology and Infertility at the annual meeting of the American Society for Reproductive Medicine. Based on these data, “I would advise providers to specifically ask about vasomotor symptoms in premenopausal women and, for those who are symptomatic, to focus on unmasking additional factors that may enhance their fracture risk, such as low body mass; family or personal history of fractures; or smoking,” she said in an interview. “I don't think we are there yet in terms of recommending bone density screening for this population … but these women need to be advised that a further deterioration in their bone density parameters is likely to occur in the postmenopausal period, and measures to optimize skeletal health should be addressed now rather than later.”

The cross-sectional study included 86 premenopausal infertile women aged 42 years or younger without premature ovarian failure or oophorectomy. A questionnaire was used to ask about the presence and frequency of vasomotor symptoms, including hot flashes and night sweats.

The study also measured subjects' bone mineral density (BMD) and levels of serum N-telopeptide (NTx), a marker of bone turnover. A total of 12% of respondents reported one or both vasomotor symptoms, and 21% of respondents had evidence of low BMD, Dr. Pal reported.

There was a highly significant correlation between vasomotor symptoms and low BMD, with 62.5% of symptomatic women showing evidence of low BMD, compared with 14% of asymptomatic women (odds ratio 10.18). Similarly, 36% of women with low BMD reported vasomotor symptoms, compared with 5% of those with normal BMD.

After controlling for age, body mass index, menstrual regularity, race, and smoking, the study found that vasomotor symptoms (night sweats and/or hot flashes) were independent predictors of low bone density in the study population. The magnitude of this association was most robust for night sweats, with an adjusted odds ratio (AOR) of 52.47, followed by both symptoms combined (AOR 24.10), and then hot flashes alone (AOR 15.10).

The presence of night sweats was also an independent predictor of bone turnover, with higher levels of serum NTx seen in symptomatic compared with asymptomatic women, she said.

Levels of inhibin B, a marker of ovarian reserve, were also significantly lower in women with night sweats compared with asymptomatic women, she said.

MONTREAL – Pediatric obstructive sleep apnea may have lifelong physiologic and cognitive consequences even after it is successfully treated, according to Dr. David Gozal, professor of pediatrics at the University of Louisville (Ky.).

“Children have a plastic system, and as such, they can be conditioned to develop differently than they would otherwise if they were not perturbed by sleep-disordered breathing during their childhood,” he said at the Eighth World Congress on Sleep Apnea. “It is our duty to start identifying this condition very early and to identify those children at risk for consequences later in life.”

Dr. Gozal suggests that sleep apnea may be a childhood antecedent of adult cardiovascular disease in genetically susceptible individuals.

His study in 26 nonobese children with obstructive sleep apnea demonstrated the presence of endothelial dysfunction, compared with controls in response to cuff occlusion applied for 30 seconds to the brachial artery and then released.

“Reperfusion was slow and sluggish in those with sleep apnea, compared to control children,” he said. With effective treatment of their sleep apnea, 18 of the 26 children normalized to the reperfusion rate of controls.

However, in eight children there was no change in reperfusion rate despite complete resolution of obstructive sleep apnea for 6 months.

“These eight children had a special burden–they had very strong family histories of cardiovascular disease. It might be that, if you have sleep apnea and you have a genetic susceptibility to another disease, the sleep apnea could trigger the onset of a disease to which you are predisposed genetically or it could accelerate the process,” he suggested.

Other research by Dr. Gozal and his colleagues has shown that even with treatment, sleep-disordered breathing in early childhood is associated with behavioral and academic problems in middle school. His study of more than 1,500 middle school students found that those in the bottom 25th percentile of academic performance were three times more likely to have received adenotonsillectomy in early childhood for snoring, compared with students in the top 25th percentile. The rate of adenotonsillectomy for recurrent infection was the same in both groups (Pediatrics 2001;107:1394–9).

“This tells us that sleep-disordered breathing is associated with neurocognitive morbidity, which is partially irreversible,” he said.

“If you lose some IQ points and you are male, you may run the risk of never recovering. Given the theory that estrogen provides neural protection, there is some biological plausibility for these findings,” he said in an interview.

Despite his studies showing evidence of residual consequences even after treatment of childhood apnea, other research by Dr. Gozal suggests that early treatment may have the potential to completely reverse such consequences.

“The problem with studies showing residual issues [after treatment] is that we do not know how long the disease was there before it was treated. Therefore, in the current context of late referral, it is likely that residual deficits will remain. However, it is also likely that with early diagnosis and intervention these residual deficits can be prevented,” he said.

Dr. Gozal disclosed that he has various speaking, consultancy, or grant arrangements with Merck & Co., AstraZeneca Pharmaceuticals, and Itamar Medical Ltd.

MONTREAL – Pediatric obstructive sleep apnea may have lifelong physiologic and cognitive consequences even after it is successfully treated, according to Dr. David Gozal, professor of pediatrics at the University of Louisville (Ky.).

“Children have a plastic system, and as such, they can be conditioned to develop differently than they would otherwise if they were not perturbed by sleep-disordered breathing during their childhood,” he said at the Eighth World Congress on Sleep Apnea. “It is our duty to start identifying this condition very early and to identify those children at risk for consequences later in life.”

Dr. Gozal suggests that sleep apnea may be a childhood antecedent of adult cardiovascular disease in genetically susceptible individuals.

His study in 26 nonobese children with obstructive sleep apnea demonstrated the presence of endothelial dysfunction, compared with controls in response to cuff occlusion applied for 30 seconds to the brachial artery and then released.

“Reperfusion was slow and sluggish in those with sleep apnea, compared to control children,” he said. With effective treatment of their sleep apnea, 18 of the 26 children normalized to the reperfusion rate of controls.

However, in eight children there was no change in reperfusion rate despite complete resolution of obstructive sleep apnea for 6 months.

“These eight children had a special burden–they had very strong family histories of cardiovascular disease. It might be that, if you have sleep apnea and you have a genetic susceptibility to another disease, the sleep apnea could trigger the onset of a disease to which you are predisposed genetically or it could accelerate the process,” he suggested.

Other research by Dr. Gozal and his colleagues has shown that even with treatment, sleep-disordered breathing in early childhood is associated with behavioral and academic problems in middle school. His study of more than 1,500 middle school students found that those in the bottom 25th percentile of academic performance were three times more likely to have received adenotonsillectomy in early childhood for snoring, compared with students in the top 25th percentile. The rate of adenotonsillectomy for recurrent infection was the same in both groups (Pediatrics 2001;107:1394–9).

“This tells us that sleep-disordered breathing is associated with neurocognitive morbidity, which is partially irreversible,” he said.

“If you lose some IQ points and you are male, you may run the risk of never recovering. Given the theory that estrogen provides neural protection, there is some biological plausibility for these findings,” he said in an interview.

Despite his studies showing evidence of residual consequences even after treatment of childhood apnea, other research by Dr. Gozal suggests that early treatment may have the potential to completely reverse such consequences.

“The problem with studies showing residual issues [after treatment] is that we do not know how long the disease was there before it was treated. Therefore, in the current context of late referral, it is likely that residual deficits will remain. However, it is also likely that with early diagnosis and intervention these residual deficits can be prevented,” he said.

Dr. Gozal disclosed that he has various speaking, consultancy, or grant arrangements with Merck & Co., AstraZeneca Pharmaceuticals, and Itamar Medical Ltd.

MONTREAL – Pediatric obstructive sleep apnea may have lifelong physiologic and cognitive consequences even after it is successfully treated, according to Dr. David Gozal, professor of pediatrics at the University of Louisville (Ky.).

“Children have a plastic system, and as such, they can be conditioned to develop differently than they would otherwise if they were not perturbed by sleep-disordered breathing during their childhood,” he said at the Eighth World Congress on Sleep Apnea. “It is our duty to start identifying this condition very early and to identify those children at risk for consequences later in life.”

Dr. Gozal suggests that sleep apnea may be a childhood antecedent of adult cardiovascular disease in genetically susceptible individuals.

His study in 26 nonobese children with obstructive sleep apnea demonstrated the presence of endothelial dysfunction, compared with controls in response to cuff occlusion applied for 30 seconds to the brachial artery and then released.

“Reperfusion was slow and sluggish in those with sleep apnea, compared to control children,” he said. With effective treatment of their sleep apnea, 18 of the 26 children normalized to the reperfusion rate of controls.

However, in eight children there was no change in reperfusion rate despite complete resolution of obstructive sleep apnea for 6 months.

“These eight children had a special burden–they had very strong family histories of cardiovascular disease. It might be that, if you have sleep apnea and you have a genetic susceptibility to another disease, the sleep apnea could trigger the onset of a disease to which you are predisposed genetically or it could accelerate the process,” he suggested.

Other research by Dr. Gozal and his colleagues has shown that even with treatment, sleep-disordered breathing in early childhood is associated with behavioral and academic problems in middle school. His study of more than 1,500 middle school students found that those in the bottom 25th percentile of academic performance were three times more likely to have received adenotonsillectomy in early childhood for snoring, compared with students in the top 25th percentile. The rate of adenotonsillectomy for recurrent infection was the same in both groups (Pediatrics 2001;107:1394–9).

“This tells us that sleep-disordered breathing is associated with neurocognitive morbidity, which is partially irreversible,” he said.

“If you lose some IQ points and you are male, you may run the risk of never recovering. Given the theory that estrogen provides neural protection, there is some biological plausibility for these findings,” he said in an interview.

Despite his studies showing evidence of residual consequences even after treatment of childhood apnea, other research by Dr. Gozal suggests that early treatment may have the potential to completely reverse such consequences.

“The problem with studies showing residual issues [after treatment] is that we do not know how long the disease was there before it was treated. Therefore, in the current context of late referral, it is likely that residual deficits will remain. However, it is also likely that with early diagnosis and intervention these residual deficits can be prevented,” he said.

Dr. Gozal disclosed that he has various speaking, consultancy, or grant arrangements with Merck & Co., AstraZeneca Pharmaceuticals, and Itamar Medical Ltd.

BOSTON — New data from two studies are putting virtual colonoscopy in a good light compared with optical colonoscopy.

Interim results from a large military study comparing virtual and optical colonoscopy for colorectal cancer screening suggest that the two methods are comparable in terms of sensitivity and specificity, said Maj. Richard P. Moser III, MC, USA.

If final results of the 8-year screening virtual colonoscopy (VC) trial confirm this trend, they will be seen as a validation of the landmark 2003 trial (N. Engl. J. Med. 2003;349:2191–200) that put VC on the map for colorectal cancer screening, suggested Dr. Moser of Walter Reed Army Medical Center in Washington.

Speaking at an international symposium on virtual colonoscopy sponsored by Boston University, Dr. Moser outlined the trial, which includes 3,000 subjects considered to be at average risk in terms of colorectal cancer screening.

The study's primary goals are to validate the 2003 trial, to evaluate the effectiveness and cost-effectiveness of VC screening in routine clinical practice, and to gather data on the short-term natural history of medium-sized (6–9 mm) polyps.

Patients undergoing VC screening are sent to same-day optical colonoscopy (OC) if they have a polyp measuring 10 mm or more, or if they have three polyps measuring at least 6 mm (medium size), Dr. Moser said. Patients with fewer than three medium-sized polyps are randomized to either same-day colonoscopy or 1-year VC follow-up. And patients with no polyps are randomized to either same-day OC or 5-year VC follow-up.

The interim results suggest that for polyps measuring at least 6 mm, VC has a sensitivity of about 90%, compared with about 97% for OC. The specificity of VC was 73%, slightly less than the 80% specificity found in the 2003 trial, indicating some tendency to identify too many polyps, Dr. Moser suggested.

In a separate presentation, Dr. Joel G. Fletcher of the Mayo Clinic in Rochester, Minn., reported that the miss rate for large advanced neoplasia during optical colonoscopy may be “higher than previously anticipated.”

He based his conclusion on comparisons of virtual colonoscopy findings and optical colonoscopy results in a prospective trial of 452 asymptomatic patients who underwent both procedures on the same day.

Dr. Fletcher's team noted 43 lesions measuring 1 cm or larger, including 5 cancers and 21 large adenomatous lesions. Seven of these lesions were missed on optical colonoscopy but were seen on virtual colonoscopy. Four of these lesions were cancers measuring 1.3–3.2 cm. There was also 1 tubulovillous adenoma measuring 3 cm, 1 hyperplastic polyp measuring 1.3 cm, and 1 probable leiomyoma measuring 4.4 cm.

Four patients were referred for a repeat colonoscopy, two were recommended for close interval surveillance, and one was observed for new symptoms.

Dr. Fletcher said that the lesions missed on index optical colonoscopy were not confined to any particular colonic segment. Two were located on the proximal aspect of a fold, three were flat, and four were polypoid.

BOSTON — New data from two studies are putting virtual colonoscopy in a good light compared with optical colonoscopy.

Interim results from a large military study comparing virtual and optical colonoscopy for colorectal cancer screening suggest that the two methods are comparable in terms of sensitivity and specificity, said Maj. Richard P. Moser III, MC, USA.

If final results of the 8-year screening virtual colonoscopy (VC) trial confirm this trend, they will be seen as a validation of the landmark 2003 trial (N. Engl. J. Med. 2003;349:2191–200) that put VC on the map for colorectal cancer screening, suggested Dr. Moser of Walter Reed Army Medical Center in Washington.

Speaking at an international symposium on virtual colonoscopy sponsored by Boston University, Dr. Moser outlined the trial, which includes 3,000 subjects considered to be at average risk in terms of colorectal cancer screening.

The study's primary goals are to validate the 2003 trial, to evaluate the effectiveness and cost-effectiveness of VC screening in routine clinical practice, and to gather data on the short-term natural history of medium-sized (6–9 mm) polyps.

Patients undergoing VC screening are sent to same-day optical colonoscopy (OC) if they have a polyp measuring 10 mm or more, or if they have three polyps measuring at least 6 mm (medium size), Dr. Moser said. Patients with fewer than three medium-sized polyps are randomized to either same-day colonoscopy or 1-year VC follow-up. And patients with no polyps are randomized to either same-day OC or 5-year VC follow-up.

The interim results suggest that for polyps measuring at least 6 mm, VC has a sensitivity of about 90%, compared with about 97% for OC. The specificity of VC was 73%, slightly less than the 80% specificity found in the 2003 trial, indicating some tendency to identify too many polyps, Dr. Moser suggested.

In a separate presentation, Dr. Joel G. Fletcher of the Mayo Clinic in Rochester, Minn., reported that the miss rate for large advanced neoplasia during optical colonoscopy may be “higher than previously anticipated.”

He based his conclusion on comparisons of virtual colonoscopy findings and optical colonoscopy results in a prospective trial of 452 asymptomatic patients who underwent both procedures on the same day.

Dr. Fletcher's team noted 43 lesions measuring 1 cm or larger, including 5 cancers and 21 large adenomatous lesions. Seven of these lesions were missed on optical colonoscopy but were seen on virtual colonoscopy. Four of these lesions were cancers measuring 1.3–3.2 cm. There was also 1 tubulovillous adenoma measuring 3 cm, 1 hyperplastic polyp measuring 1.3 cm, and 1 probable leiomyoma measuring 4.4 cm.

Four patients were referred for a repeat colonoscopy, two were recommended for close interval surveillance, and one was observed for new symptoms.

Dr. Fletcher said that the lesions missed on index optical colonoscopy were not confined to any particular colonic segment. Two were located on the proximal aspect of a fold, three were flat, and four were polypoid.

BOSTON — New data from two studies are putting virtual colonoscopy in a good light compared with optical colonoscopy.

Interim results from a large military study comparing virtual and optical colonoscopy for colorectal cancer screening suggest that the two methods are comparable in terms of sensitivity and specificity, said Maj. Richard P. Moser III, MC, USA.

If final results of the 8-year screening virtual colonoscopy (VC) trial confirm this trend, they will be seen as a validation of the landmark 2003 trial (N. Engl. J. Med. 2003;349:2191–200) that put VC on the map for colorectal cancer screening, suggested Dr. Moser of Walter Reed Army Medical Center in Washington.

Speaking at an international symposium on virtual colonoscopy sponsored by Boston University, Dr. Moser outlined the trial, which includes 3,000 subjects considered to be at average risk in terms of colorectal cancer screening.

The study's primary goals are to validate the 2003 trial, to evaluate the effectiveness and cost-effectiveness of VC screening in routine clinical practice, and to gather data on the short-term natural history of medium-sized (6–9 mm) polyps.

Patients undergoing VC screening are sent to same-day optical colonoscopy (OC) if they have a polyp measuring 10 mm or more, or if they have three polyps measuring at least 6 mm (medium size), Dr. Moser said. Patients with fewer than three medium-sized polyps are randomized to either same-day colonoscopy or 1-year VC follow-up. And patients with no polyps are randomized to either same-day OC or 5-year VC follow-up.

The interim results suggest that for polyps measuring at least 6 mm, VC has a sensitivity of about 90%, compared with about 97% for OC. The specificity of VC was 73%, slightly less than the 80% specificity found in the 2003 trial, indicating some tendency to identify too many polyps, Dr. Moser suggested.

In a separate presentation, Dr. Joel G. Fletcher of the Mayo Clinic in Rochester, Minn., reported that the miss rate for large advanced neoplasia during optical colonoscopy may be “higher than previously anticipated.”

He based his conclusion on comparisons of virtual colonoscopy findings and optical colonoscopy results in a prospective trial of 452 asymptomatic patients who underwent both procedures on the same day.

Dr. Fletcher's team noted 43 lesions measuring 1 cm or larger, including 5 cancers and 21 large adenomatous lesions. Seven of these lesions were missed on optical colonoscopy but were seen on virtual colonoscopy. Four of these lesions were cancers measuring 1.3–3.2 cm. There was also 1 tubulovillous adenoma measuring 3 cm, 1 hyperplastic polyp measuring 1.3 cm, and 1 probable leiomyoma measuring 4.4 cm.

Four patients were referred for a repeat colonoscopy, two were recommended for close interval surveillance, and one was observed for new symptoms.

Dr. Fletcher said that the lesions missed on index optical colonoscopy were not confined to any particular colonic segment. Two were located on the proximal aspect of a fold, three were flat, and four were polypoid.

BOSTON — Computed tomographic colonography using a fecal-tagging bowel preparation performed well, showing high sensitivity, specificity, and negative predictive value for polyps measuring 8 mm or more, Dr. Didier Bielen reported at an international symposium on virtual colonoscopy sponsored by Boston University.

Although patients prefer the noninvasive nature of computed tomographic colonography (CTC) as compared to optical colonoscopy, both procedures require purgative bowel preparation. But a nonlaxative preparation may be an adequate alternative that proves to yield good results.

In a study of 75 patients undergoing CTC because of family or personal history of colorectal carcinoma or suspicion of colonic pathology, a nonlaxative fecal-tagging bowel preparation allowed sufficient visualization of polyps measuring 8 mm or larger, said Dr. Bielen of University Hospital Gasthuisberg and Katholieke Universiteit Leuven, both in Leuven, Belgium.

The patients (mean age 61) consumed a low-fiber diet for 2 days before the exam. Fecal tagging was achieved with 100 mL water-soluble, iodinated contrast medium given the day prior to the exam. After the CTC was completed, additional bowel preparation was performed with 4–5 L of an electrolyte solution to allow for a same-day comparison to optical colonoscopy.

CTC detected 14 of 20 polyps measuring 6 mm or more in 12 patients and one tumor in another patient. Specifically, CTC detected three of eight polyps measuring 6–7 mm, four of five polyps that were 8–9 mm, all seven polyps measuring 10 mm or more, and the single tumor.

The sensitivity and specificity of CTC per patient for polyps measuring 6–9 mm were 50% and 98.6%, respectively. The negative predictive value for the same polyp size was 95.8%. For polyps of 10 mm or more, the sensitivity, specificity, and negative predictive value were 100%.

With the fecal-tagging preparation, residual fluid was present, but it covered less than 20% of the colonic surface and tagging was homogeneous in most patients. Residual stool was present in some patients, and although its tagging was insufficient in most cases, the stool could be easily recognized because it was floating in tagged fluid, Dr. Bielen reported.

Preliminary results from a screening population study also looked promising, reported Maj. Richard P. Moser III, MC, USA, of Walter Reed Army Medical Center in Washington. Subjects consume a low-fiber diet for 2 days, and stool tagging is achieved with 800 cc of 40% barium solution in six divided doses over the 2 days. Gastrografin (60 cc) is also given the night before the CTC. In the 50 subjects enrolled to date, 30 polyps measuring 6 mm or more have been identified, he said.

Deflation Maneuver Reduces Pain in Virtual Colonoscopy

Dr. Abraham H. Dachman described another innovation in virtual colonoscopy in a separate presentation at the meeting.

A deflation maneuver that lasts only 4 seconds can alleviate roughly 6 minutes of pain during virtual colonoscopy, he reported.

“This maneuver works for every patient and should now become routine,” said Dr. Dachman of the University of Chicago. “It makes virtual colonoscopy more tolerable and theoretically should reduce the risk of colonic perforation.”

Insufflation of the colon with carbon dioxide is necessary during virtual colonoscopy (VC) to allow adequate visualization, he said. But the resulting abdominal distension, required for the full duration of the 7- to 15-minute exam, causes pain, which is sometimes severe.

In his study of 38 patients, partial deflation between the supine and prone portions of the exam reduced perceived pain in all patients without compromising quality or significantly prolonging the duration of the procedure.

“We turn off the CO2 flow and disconnect the rectal tubing for about 4 seconds after completion of the supine scan. This deflates the rectum but not the colon,” he explained.

After the deflation maneuver, the patients' average visual analog pain scores dropped from 3.4 to 1.6 and the average colonic pressure dropped by 14 mm Hg. Patients then turned over, and the scanner was prepared and initialized for the prone scan. Reinflation to adequate colonic distension in the prone position took between 5 and 20 seconds.

Although the entire deflation maneuver prolonged the virtual colonoscopy procedure by only 15–30 seconds, it reduced pain for 6 minutes, said Dr. Dachman, adding that the improvement was so significant in all patients that he did not feel it was ethical to include a control group.

“Theoretically, this reduction in colonic pressure should also reduce the risk of colonic perforation, although we have not studied that,” he noted.

BOSTON — Computed tomographic colonography using a fecal-tagging bowel preparation performed well, showing high sensitivity, specificity, and negative predictive value for polyps measuring 8 mm or more, Dr. Didier Bielen reported at an international symposium on virtual colonoscopy sponsored by Boston University.

Although patients prefer the noninvasive nature of computed tomographic colonography (CTC) as compared to optical colonoscopy, both procedures require purgative bowel preparation. But a nonlaxative preparation may be an adequate alternative that proves to yield good results.

In a study of 75 patients undergoing CTC because of family or personal history of colorectal carcinoma or suspicion of colonic pathology, a nonlaxative fecal-tagging bowel preparation allowed sufficient visualization of polyps measuring 8 mm or larger, said Dr. Bielen of University Hospital Gasthuisberg and Katholieke Universiteit Leuven, both in Leuven, Belgium.

The patients (mean age 61) consumed a low-fiber diet for 2 days before the exam. Fecal tagging was achieved with 100 mL water-soluble, iodinated contrast medium given the day prior to the exam. After the CTC was completed, additional bowel preparation was performed with 4–5 L of an electrolyte solution to allow for a same-day comparison to optical colonoscopy.

CTC detected 14 of 20 polyps measuring 6 mm or more in 12 patients and one tumor in another patient. Specifically, CTC detected three of eight polyps measuring 6–7 mm, four of five polyps that were 8–9 mm, all seven polyps measuring 10 mm or more, and the single tumor.

The sensitivity and specificity of CTC per patient for polyps measuring 6–9 mm were 50% and 98.6%, respectively. The negative predictive value for the same polyp size was 95.8%. For polyps of 10 mm or more, the sensitivity, specificity, and negative predictive value were 100%.

With the fecal-tagging preparation, residual fluid was present, but it covered less than 20% of the colonic surface and tagging was homogeneous in most patients. Residual stool was present in some patients, and although its tagging was insufficient in most cases, the stool could be easily recognized because it was floating in tagged fluid, Dr. Bielen reported.

Preliminary results from a screening population study also looked promising, reported Maj. Richard P. Moser III, MC, USA, of Walter Reed Army Medical Center in Washington. Subjects consume a low-fiber diet for 2 days, and stool tagging is achieved with 800 cc of 40% barium solution in six divided doses over the 2 days. Gastrografin (60 cc) is also given the night before the CTC. In the 50 subjects enrolled to date, 30 polyps measuring 6 mm or more have been identified, he said.

Deflation Maneuver Reduces Pain in Virtual Colonoscopy

Dr. Abraham H. Dachman described another innovation in virtual colonoscopy in a separate presentation at the meeting.

A deflation maneuver that lasts only 4 seconds can alleviate roughly 6 minutes of pain during virtual colonoscopy, he reported.

“This maneuver works for every patient and should now become routine,” said Dr. Dachman of the University of Chicago. “It makes virtual colonoscopy more tolerable and theoretically should reduce the risk of colonic perforation.”

Insufflation of the colon with carbon dioxide is necessary during virtual colonoscopy (VC) to allow adequate visualization, he said. But the resulting abdominal distension, required for the full duration of the 7- to 15-minute exam, causes pain, which is sometimes severe.

In his study of 38 patients, partial deflation between the supine and prone portions of the exam reduced perceived pain in all patients without compromising quality or significantly prolonging the duration of the procedure.

“We turn off the CO2 flow and disconnect the rectal tubing for about 4 seconds after completion of the supine scan. This deflates the rectum but not the colon,” he explained.

After the deflation maneuver, the patients' average visual analog pain scores dropped from 3.4 to 1.6 and the average colonic pressure dropped by 14 mm Hg. Patients then turned over, and the scanner was prepared and initialized for the prone scan. Reinflation to adequate colonic distension in the prone position took between 5 and 20 seconds.

Although the entire deflation maneuver prolonged the virtual colonoscopy procedure by only 15–30 seconds, it reduced pain for 6 minutes, said Dr. Dachman, adding that the improvement was so significant in all patients that he did not feel it was ethical to include a control group.

“Theoretically, this reduction in colonic pressure should also reduce the risk of colonic perforation, although we have not studied that,” he noted.

BOSTON — Computed tomographic colonography using a fecal-tagging bowel preparation performed well, showing high sensitivity, specificity, and negative predictive value for polyps measuring 8 mm or more, Dr. Didier Bielen reported at an international symposium on virtual colonoscopy sponsored by Boston University.

Although patients prefer the noninvasive nature of computed tomographic colonography (CTC) as compared to optical colonoscopy, both procedures require purgative bowel preparation. But a nonlaxative preparation may be an adequate alternative that proves to yield good results.

In a study of 75 patients undergoing CTC because of family or personal history of colorectal carcinoma or suspicion of colonic pathology, a nonlaxative fecal-tagging bowel preparation allowed sufficient visualization of polyps measuring 8 mm or larger, said Dr. Bielen of University Hospital Gasthuisberg and Katholieke Universiteit Leuven, both in Leuven, Belgium.

The patients (mean age 61) consumed a low-fiber diet for 2 days before the exam. Fecal tagging was achieved with 100 mL water-soluble, iodinated contrast medium given the day prior to the exam. After the CTC was completed, additional bowel preparation was performed with 4–5 L of an electrolyte solution to allow for a same-day comparison to optical colonoscopy.

CTC detected 14 of 20 polyps measuring 6 mm or more in 12 patients and one tumor in another patient. Specifically, CTC detected three of eight polyps measuring 6–7 mm, four of five polyps that were 8–9 mm, all seven polyps measuring 10 mm or more, and the single tumor.

The sensitivity and specificity of CTC per patient for polyps measuring 6–9 mm were 50% and 98.6%, respectively. The negative predictive value for the same polyp size was 95.8%. For polyps of 10 mm or more, the sensitivity, specificity, and negative predictive value were 100%.

With the fecal-tagging preparation, residual fluid was present, but it covered less than 20% of the colonic surface and tagging was homogeneous in most patients. Residual stool was present in some patients, and although its tagging was insufficient in most cases, the stool could be easily recognized because it was floating in tagged fluid, Dr. Bielen reported.

Preliminary results from a screening population study also looked promising, reported Maj. Richard P. Moser III, MC, USA, of Walter Reed Army Medical Center in Washington. Subjects consume a low-fiber diet for 2 days, and stool tagging is achieved with 800 cc of 40% barium solution in six divided doses over the 2 days. Gastrografin (60 cc) is also given the night before the CTC. In the 50 subjects enrolled to date, 30 polyps measuring 6 mm or more have been identified, he said.

Deflation Maneuver Reduces Pain in Virtual Colonoscopy

Dr. Abraham H. Dachman described another innovation in virtual colonoscopy in a separate presentation at the meeting.

A deflation maneuver that lasts only 4 seconds can alleviate roughly 6 minutes of pain during virtual colonoscopy, he reported.

“This maneuver works for every patient and should now become routine,” said Dr. Dachman of the University of Chicago. “It makes virtual colonoscopy more tolerable and theoretically should reduce the risk of colonic perforation.”

Insufflation of the colon with carbon dioxide is necessary during virtual colonoscopy (VC) to allow adequate visualization, he said. But the resulting abdominal distension, required for the full duration of the 7- to 15-minute exam, causes pain, which is sometimes severe.

In his study of 38 patients, partial deflation between the supine and prone portions of the exam reduced perceived pain in all patients without compromising quality or significantly prolonging the duration of the procedure.

“We turn off the CO2 flow and disconnect the rectal tubing for about 4 seconds after completion of the supine scan. This deflates the rectum but not the colon,” he explained.

After the deflation maneuver, the patients' average visual analog pain scores dropped from 3.4 to 1.6 and the average colonic pressure dropped by 14 mm Hg. Patients then turned over, and the scanner was prepared and initialized for the prone scan. Reinflation to adequate colonic distension in the prone position took between 5 and 20 seconds.

Although the entire deflation maneuver prolonged the virtual colonoscopy procedure by only 15–30 seconds, it reduced pain for 6 minutes, said Dr. Dachman, adding that the improvement was so significant in all patients that he did not feel it was ethical to include a control group.

“Theoretically, this reduction in colonic pressure should also reduce the risk of colonic perforation, although we have not studied that,” he noted.

NEW YORK — Serology tests for suspected celiac disease are often inappropriately ordered or managed, increasing the chance of missed diagnosis, according to a study presented at an international symposium on celiac disease.

An analysis of 349 positive antiendomysial antibody (EMA) tests over a 17-month period showed that 51% of patients had not received a concurrent serum IgA test to evaluate for IgA deficiency, and 10% of patients were overlooked for a follow-up intestinal biopsy, reported Kelly McGowan of the University of Calgary (Alta.).

IgA deficiency is more common in patients with celiac disease than in the general population, and its presence negates the results of EMA tests, according to Ms. McGowan. “The EMA tests were inappropriately ordered in the absence of IgA tests, because if a patient with IgA deficiency undergoes screening for celiac disease, their test result will always be negative.”

Of the positive serology tests, 69% were appropriately managed with a follow-up intestinal biopsy. A total of 194 biopsies were diagnostic of celiac disease, yielding a positive predictive value of 91% and a disease prevalence of 2%, based on the total sample of 9,533 patients tested.

Another 8% of positive serology tests did not include a follow-up biopsy but were considered to be appropriately managed because a biopsy had been done previously or was contraindicated, she said.

A further 3% of patients refused a biopsy, and 5% of tests were not followed up because of an administrative error.

But 10% of tests were classified as inappropriately managed because physicians failed to order a biopsy. For another 5% of tests, the physicians did not respond to the investigator's query about why they did not order a biopsy, possibly representing more mismanaged tests, she said.

NEW YORK — Serology tests for suspected celiac disease are often inappropriately ordered or managed, increasing the chance of missed diagnosis, according to a study presented at an international symposium on celiac disease.

An analysis of 349 positive antiendomysial antibody (EMA) tests over a 17-month period showed that 51% of patients had not received a concurrent serum IgA test to evaluate for IgA deficiency, and 10% of patients were overlooked for a follow-up intestinal biopsy, reported Kelly McGowan of the University of Calgary (Alta.).

IgA deficiency is more common in patients with celiac disease than in the general population, and its presence negates the results of EMA tests, according to Ms. McGowan. “The EMA tests were inappropriately ordered in the absence of IgA tests, because if a patient with IgA deficiency undergoes screening for celiac disease, their test result will always be negative.”

Of the positive serology tests, 69% were appropriately managed with a follow-up intestinal biopsy. A total of 194 biopsies were diagnostic of celiac disease, yielding a positive predictive value of 91% and a disease prevalence of 2%, based on the total sample of 9,533 patients tested.

Another 8% of positive serology tests did not include a follow-up biopsy but were considered to be appropriately managed because a biopsy had been done previously or was contraindicated, she said.

A further 3% of patients refused a biopsy, and 5% of tests were not followed up because of an administrative error.

But 10% of tests were classified as inappropriately managed because physicians failed to order a biopsy. For another 5% of tests, the physicians did not respond to the investigator's query about why they did not order a biopsy, possibly representing more mismanaged tests, she said.

NEW YORK — Serology tests for suspected celiac disease are often inappropriately ordered or managed, increasing the chance of missed diagnosis, according to a study presented at an international symposium on celiac disease.

An analysis of 349 positive antiendomysial antibody (EMA) tests over a 17-month period showed that 51% of patients had not received a concurrent serum IgA test to evaluate for IgA deficiency, and 10% of patients were overlooked for a follow-up intestinal biopsy, reported Kelly McGowan of the University of Calgary (Alta.).

IgA deficiency is more common in patients with celiac disease than in the general population, and its presence negates the results of EMA tests, according to Ms. McGowan. “The EMA tests were inappropriately ordered in the absence of IgA tests, because if a patient with IgA deficiency undergoes screening for celiac disease, their test result will always be negative.”

Of the positive serology tests, 69% were appropriately managed with a follow-up intestinal biopsy. A total of 194 biopsies were diagnostic of celiac disease, yielding a positive predictive value of 91% and a disease prevalence of 2%, based on the total sample of 9,533 patients tested.

Another 8% of positive serology tests did not include a follow-up biopsy but were considered to be appropriately managed because a biopsy had been done previously or was contraindicated, she said.

A further 3% of patients refused a biopsy, and 5% of tests were not followed up because of an administrative error.

But 10% of tests were classified as inappropriately managed because physicians failed to order a biopsy. For another 5% of tests, the physicians did not respond to the investigator's query about why they did not order a biopsy, possibly representing more mismanaged tests, she said.

NEW YORK — Dental enamel defects and aphthous ulcers are both strongly associated with celiac disease, and should be followed up with a full investigation for the disorder in undiagnosed people, Theologos Malahias, D.D.S., said at an international symposium on celiac disease.

Dental enamel defects that are seen in permanent teeth form when the teeth first develop, and thus will not reverse when celiac patients are treated with a gluten-free diet, said Dr. Malahias, a dentist from Groton, Conn.

“For example, the 6-year molars—also known as adult permanent first molars—start forming enamel when a baby is 3–4 months old,” he said in an interview. “So if celiac disease is present at that time, it can affect the enamel, but you won't see the defect until the tooth erupts at 6 years old.”

Patients with these problems also may experience a delay in the eruption of permanent teeth, he added.

The bilateral, symmetrical markings are most commonly seen on central incisors and molars and are evident in all four quadrants of the mouth, Dr. Malahias explained. They are opaque and can be white, yellow, or brown, causing the enamel to look mottled, and not shiny. “There are other causes for this type of dental appearance, so I always stress that celiac disease should be considered in the context of the rest of the patient's medical history,” he said.

His study of 136 patients, 67 with celiac disease and 69 without, found dental enamel defects in 51% of the celiac cohort and in 30% of the nonceliac group. Among the pediatric subgroup of 47 children aged 6–16 years, 87% of the 23 celiac patients had enamel defects, compared with 33% of the 24 who did not have celiac disease. In children younger than age 12 with mixed dentition, the enamel defect rate was 90% among those with celiac disease and 44% among the others.

The rate of dental decay was similar for children with and without celiac disease, but was higher in the 44 adult celiac patients than in the 45 adults without celiac disease, he reported.

Dr. John Zone, a dermatologist from the University of Utah, Salt Lake City, said at the meeting that about 5% of people with unexplained aphthous ulcers have occult celiac disease. “They are presumably due to chronic stimulation of the immune system by gluten,” he suggested.

The ulcers continue to occur, but less frequently, after celiac patients start a gluten-free diet, Dr. Malahias said.

Celiac disease can cause tooth enamel defects while the adult teeth are forming.

Aphthous ulcers occur less often after the introduction of a gluten-free diet. Photos courtesy Dr. Theologos Malahias

NEW YORK — Dental enamel defects and aphthous ulcers are both strongly associated with celiac disease, and should be followed up with a full investigation for the disorder in undiagnosed people, Theologos Malahias, D.D.S., said at an international symposium on celiac disease.

Dental enamel defects that are seen in permanent teeth form when the teeth first develop, and thus will not reverse when celiac patients are treated with a gluten-free diet, said Dr. Malahias, a dentist from Groton, Conn.

“For example, the 6-year molars—also known as adult permanent first molars—start forming enamel when a baby is 3–4 months old,” he said in an interview. “So if celiac disease is present at that time, it can affect the enamel, but you won't see the defect until the tooth erupts at 6 years old.”

Patients with these problems also may experience a delay in the eruption of permanent teeth, he added.

The bilateral, symmetrical markings are most commonly seen on central incisors and molars and are evident in all four quadrants of the mouth, Dr. Malahias explained. They are opaque and can be white, yellow, or brown, causing the enamel to look mottled, and not shiny. “There are other causes for this type of dental appearance, so I always stress that celiac disease should be considered in the context of the rest of the patient's medical history,” he said.

His study of 136 patients, 67 with celiac disease and 69 without, found dental enamel defects in 51% of the celiac cohort and in 30% of the nonceliac group. Among the pediatric subgroup of 47 children aged 6–16 years, 87% of the 23 celiac patients had enamel defects, compared with 33% of the 24 who did not have celiac disease. In children younger than age 12 with mixed dentition, the enamel defect rate was 90% among those with celiac disease and 44% among the others.

The rate of dental decay was similar for children with and without celiac disease, but was higher in the 44 adult celiac patients than in the 45 adults without celiac disease, he reported.

Dr. John Zone, a dermatologist from the University of Utah, Salt Lake City, said at the meeting that about 5% of people with unexplained aphthous ulcers have occult celiac disease. “They are presumably due to chronic stimulation of the immune system by gluten,” he suggested.

The ulcers continue to occur, but less frequently, after celiac patients start a gluten-free diet, Dr. Malahias said.

Celiac disease can cause tooth enamel defects while the adult teeth are forming.

Aphthous ulcers occur less often after the introduction of a gluten-free diet. Photos courtesy Dr. Theologos Malahias

NEW YORK — Dental enamel defects and aphthous ulcers are both strongly associated with celiac disease, and should be followed up with a full investigation for the disorder in undiagnosed people, Theologos Malahias, D.D.S., said at an international symposium on celiac disease.

Dental enamel defects that are seen in permanent teeth form when the teeth first develop, and thus will not reverse when celiac patients are treated with a gluten-free diet, said Dr. Malahias, a dentist from Groton, Conn.

“For example, the 6-year molars—also known as adult permanent first molars—start forming enamel when a baby is 3–4 months old,” he said in an interview. “So if celiac disease is present at that time, it can affect the enamel, but you won't see the defect until the tooth erupts at 6 years old.”

Patients with these problems also may experience a delay in the eruption of permanent teeth, he added.

The bilateral, symmetrical markings are most commonly seen on central incisors and molars and are evident in all four quadrants of the mouth, Dr. Malahias explained. They are opaque and can be white, yellow, or brown, causing the enamel to look mottled, and not shiny. “There are other causes for this type of dental appearance, so I always stress that celiac disease should be considered in the context of the rest of the patient's medical history,” he said.

His study of 136 patients, 67 with celiac disease and 69 without, found dental enamel defects in 51% of the celiac cohort and in 30% of the nonceliac group. Among the pediatric subgroup of 47 children aged 6–16 years, 87% of the 23 celiac patients had enamel defects, compared with 33% of the 24 who did not have celiac disease. In children younger than age 12 with mixed dentition, the enamel defect rate was 90% among those with celiac disease and 44% among the others.

The rate of dental decay was similar for children with and without celiac disease, but was higher in the 44 adult celiac patients than in the 45 adults without celiac disease, he reported.

Dr. John Zone, a dermatologist from the University of Utah, Salt Lake City, said at the meeting that about 5% of people with unexplained aphthous ulcers have occult celiac disease. “They are presumably due to chronic stimulation of the immune system by gluten,” he suggested.

The ulcers continue to occur, but less frequently, after celiac patients start a gluten-free diet, Dr. Malahias said.

Celiac disease can cause tooth enamel defects while the adult teeth are forming.

Aphthous ulcers occur less often after the introduction of a gluten-free diet. Photos courtesy Dr. Theologos Malahias

NEW ORLEANS — Women who become mothers in their 50s with egg donation are no less able to handle the physical and mental demands of parenting compared with their younger counterparts, according to a study presented at the annual meeting of the American Society for Reproductive Medicine.

“We jumped to some conclusions in the past that weren't necessarily correct about older women's reduced parenting capabilities,” said the study's lead investigator, Dr. Anne Z. Steiner of the University of North Carolina in Chapel Hill.

Her study surveyed women in their 50s who had conceived and delivered after egg donation and matched them to an equal number of women in their 40s and 30s who also had conceived and delivered following in vitro fertilization. The 64 respondents (18 in their 50s, 24 in their 40s, and 22 in their 30s) had children aged 3 or 4 years old at the time of the study.

The surveys covered issues of parenting stress, using the Parenting Stress Index/Short Form questionnaire. Physical and mental function also were assessed, along with information on demographics, family structure, and child care, to determine a measure of “total parenting stress.”

Overall, the study found no significant difference in physical or mental function or parental stress between the older women and their younger counterparts. Women in their 50s had a nonsignificantly lower physical function score compared with women in their 30s (55 vs. 57), but all scores were higher than the average national female score (49), said Dr. Steiner. Mental function scores were slightly higher for women in their 50s compared with women in their 30s (54 vs. 50), but again, this difference was not significant. Adjustments for race, employment status, use of child care services, age and health of the child, gestational order, and family income did not alter the findings.

“To our knowledge this is the first study to evaluate parenting in women who conceive after age 50,” wrote the study's authors. “Our data do not support the hypothesis that mothers of advanced maternal age have reduced parenting capacity.”

NEW ORLEANS — Women who become mothers in their 50s with egg donation are no less able to handle the physical and mental demands of parenting compared with their younger counterparts, according to a study presented at the annual meeting of the American Society for Reproductive Medicine.

“We jumped to some conclusions in the past that weren't necessarily correct about older women's reduced parenting capabilities,” said the study's lead investigator, Dr. Anne Z. Steiner of the University of North Carolina in Chapel Hill.

Her study surveyed women in their 50s who had conceived and delivered after egg donation and matched them to an equal number of women in their 40s and 30s who also had conceived and delivered following in vitro fertilization. The 64 respondents (18 in their 50s, 24 in their 40s, and 22 in their 30s) had children aged 3 or 4 years old at the time of the study.

The surveys covered issues of parenting stress, using the Parenting Stress Index/Short Form questionnaire. Physical and mental function also were assessed, along with information on demographics, family structure, and child care, to determine a measure of “total parenting stress.”

Overall, the study found no significant difference in physical or mental function or parental stress between the older women and their younger counterparts. Women in their 50s had a nonsignificantly lower physical function score compared with women in their 30s (55 vs. 57), but all scores were higher than the average national female score (49), said Dr. Steiner. Mental function scores were slightly higher for women in their 50s compared with women in their 30s (54 vs. 50), but again, this difference was not significant. Adjustments for race, employment status, use of child care services, age and health of the child, gestational order, and family income did not alter the findings.

“To our knowledge this is the first study to evaluate parenting in women who conceive after age 50,” wrote the study's authors. “Our data do not support the hypothesis that mothers of advanced maternal age have reduced parenting capacity.”

NEW ORLEANS — Women who become mothers in their 50s with egg donation are no less able to handle the physical and mental demands of parenting compared with their younger counterparts, according to a study presented at the annual meeting of the American Society for Reproductive Medicine.

“We jumped to some conclusions in the past that weren't necessarily correct about older women's reduced parenting capabilities,” said the study's lead investigator, Dr. Anne Z. Steiner of the University of North Carolina in Chapel Hill.

Her study surveyed women in their 50s who had conceived and delivered after egg donation and matched them to an equal number of women in their 40s and 30s who also had conceived and delivered following in vitro fertilization. The 64 respondents (18 in their 50s, 24 in their 40s, and 22 in their 30s) had children aged 3 or 4 years old at the time of the study.

The surveys covered issues of parenting stress, using the Parenting Stress Index/Short Form questionnaire. Physical and mental function also were assessed, along with information on demographics, family structure, and child care, to determine a measure of “total parenting stress.”

Overall, the study found no significant difference in physical or mental function or parental stress between the older women and their younger counterparts. Women in their 50s had a nonsignificantly lower physical function score compared with women in their 30s (55 vs. 57), but all scores were higher than the average national female score (49), said Dr. Steiner. Mental function scores were slightly higher for women in their 50s compared with women in their 30s (54 vs. 50), but again, this difference was not significant. Adjustments for race, employment status, use of child care services, age and health of the child, gestational order, and family income did not alter the findings.

“To our knowledge this is the first study to evaluate parenting in women who conceive after age 50,” wrote the study's authors. “Our data do not support the hypothesis that mothers of advanced maternal age have reduced parenting capacity.”

NEW ORLEANS — Women seeking infertility treatment should be warned about the increased risks associated with pregnancy at older ages, according to Barbara Luke, Sc.D., professor at the School of Nursing & Health Studies, University of Miami at Coral Gables in Florida.

In an analysis of more than 8 million singleton live births to women aged 30–54 years, her study found significantly increased risks of pregnancy complications and adverse outcomes as women aged.

The study used the U.S. Birth Cohort Linked Birth/Infant Death data set of singleton live births of 20 weeks' gestation or more between 1995 and 2000. Births to women aged 30–34 years were the reference, and the study controlled for maternal race, smoking, macrosomia, and breech or malpresentation. The highest risks were seen in women aged 45 years and older, but “many risks are significantly elevated by age 35–39 years,” Dr. Luke said in an interview.

Looking at the overall population, the study found that two of the greatest health risks for older pregnant women—chronic hypertension and diabetes—may be present even before pregnancy. Chronic hypertension (hypertension developing before pregnancy or up to 20 weeks' gestation) was highest in women aged 45 or older (adjusted odds ratio of 3.7 for primiparas and 4.89 for multiparas), as was diabetes (AOR of 2.19 for primiparas and 2.58 for multiparas). Pregnancy-associated hypertension, defined as developing after 20 weeks' gestation, was another important risk in this age group (AOR 1.55 for primiparas and 2.13 for multiparas), Dr. Luke said.

Similarly, premature rupture of membranes (PROM), premature birth (less than 32 weeks' gestation), and infant death were markedly increased by age 35–39 years, with the greatest risk in women 45 years and older (AOR 1.02, 2.11, and 2.68, respectively, for primiparas and AOR 1.38, 1.77, and 1.92, respectively, for multiparas).

The risk of precipitous labor and stimulation of labor decreased with age, but the risk of excessive bleeding, dysfunctional labor, induction of labor, and prolonged labor all increased as women got older.

Primary cesarean section increased with age in both primiparas and multiparas (AOR 3.15 and 2.65 in the oldest age group), while forceps, vacuum, and vaginal deliveries actually decreased with age in the primiparous group (AOR 0.90, 0.73, and 0.32, respectively), said Dr. Luke. In the oldest multiparous group the risk of repeat section increased (AOR 1.56), forceps and vacuum deliveries increased (AOR 1.29 and 1.08), and vaginal births after cesarean section decreased (AOR 0.64).

“This is particularly worrisome since with C-section there is a doubling of the neonatal mortality rate and an increased risk of stillborn and placental complications in subsequent pregnancies,” she noted.

There is also evidence of long-term health implications for women who develop pregnancy complications such as preeclampsia and preterm birth, Dr. Luke concluded.

NEW ORLEANS — Women seeking infertility treatment should be warned about the increased risks associated with pregnancy at older ages, according to Barbara Luke, Sc.D., professor at the School of Nursing & Health Studies, University of Miami at Coral Gables in Florida.

In an analysis of more than 8 million singleton live births to women aged 30–54 years, her study found significantly increased risks of pregnancy complications and adverse outcomes as women aged.

The study used the U.S. Birth Cohort Linked Birth/Infant Death data set of singleton live births of 20 weeks' gestation or more between 1995 and 2000. Births to women aged 30–34 years were the reference, and the study controlled for maternal race, smoking, macrosomia, and breech or malpresentation. The highest risks were seen in women aged 45 years and older, but “many risks are significantly elevated by age 35–39 years,” Dr. Luke said in an interview.

Looking at the overall population, the study found that two of the greatest health risks for older pregnant women—chronic hypertension and diabetes—may be present even before pregnancy. Chronic hypertension (hypertension developing before pregnancy or up to 20 weeks' gestation) was highest in women aged 45 or older (adjusted odds ratio of 3.7 for primiparas and 4.89 for multiparas), as was diabetes (AOR of 2.19 for primiparas and 2.58 for multiparas). Pregnancy-associated hypertension, defined as developing after 20 weeks' gestation, was another important risk in this age group (AOR 1.55 for primiparas and 2.13 for multiparas), Dr. Luke said.

Similarly, premature rupture of membranes (PROM), premature birth (less than 32 weeks' gestation), and infant death were markedly increased by age 35–39 years, with the greatest risk in women 45 years and older (AOR 1.02, 2.11, and 2.68, respectively, for primiparas and AOR 1.38, 1.77, and 1.92, respectively, for multiparas).

The risk of precipitous labor and stimulation of labor decreased with age, but the risk of excessive bleeding, dysfunctional labor, induction of labor, and prolonged labor all increased as women got older.

Primary cesarean section increased with age in both primiparas and multiparas (AOR 3.15 and 2.65 in the oldest age group), while forceps, vacuum, and vaginal deliveries actually decreased with age in the primiparous group (AOR 0.90, 0.73, and 0.32, respectively), said Dr. Luke. In the oldest multiparous group the risk of repeat section increased (AOR 1.56), forceps and vacuum deliveries increased (AOR 1.29 and 1.08), and vaginal births after cesarean section decreased (AOR 0.64).

“This is particularly worrisome since with C-section there is a doubling of the neonatal mortality rate and an increased risk of stillborn and placental complications in subsequent pregnancies,” she noted.

There is also evidence of long-term health implications for women who develop pregnancy complications such as preeclampsia and preterm birth, Dr. Luke concluded.

NEW ORLEANS — Women seeking infertility treatment should be warned about the increased risks associated with pregnancy at older ages, according to Barbara Luke, Sc.D., professor at the School of Nursing & Health Studies, University of Miami at Coral Gables in Florida.

In an analysis of more than 8 million singleton live births to women aged 30–54 years, her study found significantly increased risks of pregnancy complications and adverse outcomes as women aged.

The study used the U.S. Birth Cohort Linked Birth/Infant Death data set of singleton live births of 20 weeks' gestation or more between 1995 and 2000. Births to women aged 30–34 years were the reference, and the study controlled for maternal race, smoking, macrosomia, and breech or malpresentation. The highest risks were seen in women aged 45 years and older, but “many risks are significantly elevated by age 35–39 years,” Dr. Luke said in an interview.

Looking at the overall population, the study found that two of the greatest health risks for older pregnant women—chronic hypertension and diabetes—may be present even before pregnancy. Chronic hypertension (hypertension developing before pregnancy or up to 20 weeks' gestation) was highest in women aged 45 or older (adjusted odds ratio of 3.7 for primiparas and 4.89 for multiparas), as was diabetes (AOR of 2.19 for primiparas and 2.58 for multiparas). Pregnancy-associated hypertension, defined as developing after 20 weeks' gestation, was another important risk in this age group (AOR 1.55 for primiparas and 2.13 for multiparas), Dr. Luke said.

Similarly, premature rupture of membranes (PROM), premature birth (less than 32 weeks' gestation), and infant death were markedly increased by age 35–39 years, with the greatest risk in women 45 years and older (AOR 1.02, 2.11, and 2.68, respectively, for primiparas and AOR 1.38, 1.77, and 1.92, respectively, for multiparas).

The risk of precipitous labor and stimulation of labor decreased with age, but the risk of excessive bleeding, dysfunctional labor, induction of labor, and prolonged labor all increased as women got older.

Primary cesarean section increased with age in both primiparas and multiparas (AOR 3.15 and 2.65 in the oldest age group), while forceps, vacuum, and vaginal deliveries actually decreased with age in the primiparous group (AOR 0.90, 0.73, and 0.32, respectively), said Dr. Luke. In the oldest multiparous group the risk of repeat section increased (AOR 1.56), forceps and vacuum deliveries increased (AOR 1.29 and 1.08), and vaginal births after cesarean section decreased (AOR 0.64).

“This is particularly worrisome since with C-section there is a doubling of the neonatal mortality rate and an increased risk of stillborn and placental complications in subsequent pregnancies,” she noted.

There is also evidence of long-term health implications for women who develop pregnancy complications such as preeclampsia and preterm birth, Dr. Luke concluded.

NEW ORLEANS — Postmenopausal women are more than twice as likely to experience sexual dysfunction as are younger women, and their risk also is doubled if they have low levels of dehydroepiandrosterone (DHEA), according to new data from the Penn Ovarian Aging Study.

“Higher levels of DHEA appear to be protective in this population,” said Dr. Clarisa R. Gracia, who presented the findings at the annual meeting of the American Society for Reproductive Medicine. “This raises the question about whether supplementation is an option—although there is no evidence to support this at this time,” she commented at a press conference during the meeting.

The Penn Ovarian Aging Study, which included more than 400 healthy women aged 35–47 years, aimed to examine the natural progression of ovarian function during the transition to menopause.

Women were followed for 3 years with questionnaires, including the Female Sexual Function Index, and annual measurement of reproductive hormones including follicle-stimulating hormone, luteinizing hormone, sex hormone-binding globulin, total testosterone, and DHEA.

This analysis of the study included 311 women—102 with sexual dysfunction and 209 without. Women with sexual dysfunction were twice as likely to have DHEA levels in the lowest quartile, with an average measurement of 66.5 mcg/dL compared with an average measurement of 81.1 mcg/dL in those without sexual dysfunction. No significant associations were noted between the other measured hormones and sexual dysfunction, according to Dr. Gracia of the University of Pennsylvania in Philadelphia.

Multivariate analysis revealed that high DHEA levels were protective against sexual dysfunction, while factors associated with sexual dysfunction included absence of a sexual partner (OR 11.2), high anxiety (OR 3.8), and children under age of 18 living at home (OR 1.6), she said.

NEW ORLEANS — Postmenopausal women are more than twice as likely to experience sexual dysfunction as are younger women, and their risk also is doubled if they have low levels of dehydroepiandrosterone (DHEA), according to new data from the Penn Ovarian Aging Study.

“Higher levels of DHEA appear to be protective in this population,” said Dr. Clarisa R. Gracia, who presented the findings at the annual meeting of the American Society for Reproductive Medicine. “This raises the question about whether supplementation is an option—although there is no evidence to support this at this time,” she commented at a press conference during the meeting.

The Penn Ovarian Aging Study, which included more than 400 healthy women aged 35–47 years, aimed to examine the natural progression of ovarian function during the transition to menopause.

Women were followed for 3 years with questionnaires, including the Female Sexual Function Index, and annual measurement of reproductive hormones including follicle-stimulating hormone, luteinizing hormone, sex hormone-binding globulin, total testosterone, and DHEA.

This analysis of the study included 311 women—102 with sexual dysfunction and 209 without. Women with sexual dysfunction were twice as likely to have DHEA levels in the lowest quartile, with an average measurement of 66.5 mcg/dL compared with an average measurement of 81.1 mcg/dL in those without sexual dysfunction. No significant associations were noted between the other measured hormones and sexual dysfunction, according to Dr. Gracia of the University of Pennsylvania in Philadelphia.

Multivariate analysis revealed that high DHEA levels were protective against sexual dysfunction, while factors associated with sexual dysfunction included absence of a sexual partner (OR 11.2), high anxiety (OR 3.8), and children under age of 18 living at home (OR 1.6), she said.

NEW ORLEANS — Postmenopausal women are more than twice as likely to experience sexual dysfunction as are younger women, and their risk also is doubled if they have low levels of dehydroepiandrosterone (DHEA), according to new data from the Penn Ovarian Aging Study.

“Higher levels of DHEA appear to be protective in this population,” said Dr. Clarisa R. Gracia, who presented the findings at the annual meeting of the American Society for Reproductive Medicine. “This raises the question about whether supplementation is an option—although there is no evidence to support this at this time,” she commented at a press conference during the meeting.

The Penn Ovarian Aging Study, which included more than 400 healthy women aged 35–47 years, aimed to examine the natural progression of ovarian function during the transition to menopause.

Women were followed for 3 years with questionnaires, including the Female Sexual Function Index, and annual measurement of reproductive hormones including follicle-stimulating hormone, luteinizing hormone, sex hormone-binding globulin, total testosterone, and DHEA.

This analysis of the study included 311 women—102 with sexual dysfunction and 209 without. Women with sexual dysfunction were twice as likely to have DHEA levels in the lowest quartile, with an average measurement of 66.5 mcg/dL compared with an average measurement of 81.1 mcg/dL in those without sexual dysfunction. No significant associations were noted between the other measured hormones and sexual dysfunction, according to Dr. Gracia of the University of Pennsylvania in Philadelphia.

Multivariate analysis revealed that high DHEA levels were protective against sexual dysfunction, while factors associated with sexual dysfunction included absence of a sexual partner (OR 11.2), high anxiety (OR 3.8), and children under age of 18 living at home (OR 1.6), she said.