M. Alexander Otto

LAS VEGAS – If patients don’t respond to an antidepressant within 2 weeks, it’s probably time to switch them to another antidepressant or think about add-on therapy. If symptoms have gotten worse, however, it’s time to stop the antidepressant altogether, according to Dr. Charles Raison, professor of psychiatry at the University of Arizona in Tucson.

It doesn’t take 6-8 weeks for antidepressants to work; that commonly held notion is “100% wrong,” he said.

Imaging studies show brain activity changes within 2 hours of a single dose, and in trials where antidepressants separate from placebo, they do so in a week or 2 (Arch. Gen. Psychiatry 2006;63:1217-23). “Most of the action is early on,” Dr. Raison said at the annual Perspectives in Rheumatic Diseases conference held by the Global Academy for Medical Education.

“Monitoring response in the first 2 weeks is essential, because it’s going to tell you whether you’ve got the right” treatment. With any given antidepressant, about 75% of patients will respond, but about 25% will get “much, much worse. If a patient gets worse, stop. You should take that extremely seriously,” he said (Arch. Gen. Psychiatry 2011;68:1227-37).

In general, anxious people and suicidal people don’t do as well on antidepressants. Also, people with a history of childhood neglect, abuse, or trauma respond better to psychotherapy, so it’s worth asking about such issues. It’s also worth asking patients what they want to do, be it pharmaceuticals, psychotherapy, or both. Success is more likely if patients get what they want, Dr. Raison said.

“Pain is a powerful predictor of not doing well,” especially with SSRIs, so “unfortunately, [rheumatologists] deal with populations that are less likely to have a robust response.” Even so, “if you can help people with their pain, you’ll probably help” relieve their depression and help their antidepressant work, he said.

When patients don’t respond after a few weeks, “the first thing most of us do is increase the dose; for SSRIs, the data” indicate it doesn’t work. In one study, for instance, people did just as well on a lower dose as on a higher one, he said (Br. J. Psychiatry 2006;189:309-16).

Up to a quarter of patients, however, will do better if switched to another antidepressant. Some studies suggest staying in the same class of drugs; others suggest trying a different class. For now, which one to pick “depends [mostly] on side effects. There isn’t a best antidepressant; the best one is the one that works in any given patient,” Dr. Raison said (Eur. Neuropsychopharmacol. 2012;22:453-68).

Augmentation is another option, with atypical antipsychotics currently the most popular choice. There’s convincing evidence that they help, but they also have well-known and serious side effects, including extrapyramidal syndromes, metabolic derangements, and weight gain.

There’s also strong evidence for psychotherapy as an adjunct, and good data for lithium and a range of other agents. Whole-body hyperthermia is emerging as a possible depression treatment, as well.

Dr. Raison recommended actively treating nausea, jitteriness, diarrhea, and other short-term SSRI side effects; it makes it more likely that patients will stay on their treatment. Also, anxious patients and those with somatic complaints are more likely to tolerate antidepressants if they are started on subtherapeutic doses, then are titrated slowly up to a recommended dose.

Of all the SSRIs, paroxetine (Paxil) “is the one I most highly recommend you do not use. There’s no evidence it’s better than any of the others,” and it’s the one most likely to cause weight gain, sexual dysfunction, and cardiac issues, he said.

“We don’t know how long you should treat” with antidepressants; “probably at least 6-9 months,” he noted.

Dr. Raison is a consultant for Pamlab, Lilly, and Lundbeck. He is on the speakers bureaus of Pamlab and Sunovion. Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

LAS VEGAS – If patients don’t respond to an antidepressant within 2 weeks, it’s probably time to switch them to another antidepressant or think about add-on therapy. If symptoms have gotten worse, however, it’s time to stop the antidepressant altogether, according to Dr. Charles Raison, professor of psychiatry at the University of Arizona in Tucson.

It doesn’t take 6-8 weeks for antidepressants to work; that commonly held notion is “100% wrong,” he said.

Imaging studies show brain activity changes within 2 hours of a single dose, and in trials where antidepressants separate from placebo, they do so in a week or 2 (Arch. Gen. Psychiatry 2006;63:1217-23). “Most of the action is early on,” Dr. Raison said at the annual Perspectives in Rheumatic Diseases conference held by the Global Academy for Medical Education.

“Monitoring response in the first 2 weeks is essential, because it’s going to tell you whether you’ve got the right” treatment. With any given antidepressant, about 75% of patients will respond, but about 25% will get “much, much worse. If a patient gets worse, stop. You should take that extremely seriously,” he said (Arch. Gen. Psychiatry 2011;68:1227-37).

In general, anxious people and suicidal people don’t do as well on antidepressants. Also, people with a history of childhood neglect, abuse, or trauma respond better to psychotherapy, so it’s worth asking about such issues. It’s also worth asking patients what they want to do, be it pharmaceuticals, psychotherapy, or both. Success is more likely if patients get what they want, Dr. Raison said.

“Pain is a powerful predictor of not doing well,” especially with SSRIs, so “unfortunately, [rheumatologists] deal with populations that are less likely to have a robust response.” Even so, “if you can help people with their pain, you’ll probably help” relieve their depression and help their antidepressant work, he said.

When patients don’t respond after a few weeks, “the first thing most of us do is increase the dose; for SSRIs, the data” indicate it doesn’t work. In one study, for instance, people did just as well on a lower dose as on a higher one, he said (Br. J. Psychiatry 2006;189:309-16).

Up to a quarter of patients, however, will do better if switched to another antidepressant. Some studies suggest staying in the same class of drugs; others suggest trying a different class. For now, which one to pick “depends [mostly] on side effects. There isn’t a best antidepressant; the best one is the one that works in any given patient,” Dr. Raison said (Eur. Neuropsychopharmacol. 2012;22:453-68).

Augmentation is another option, with atypical antipsychotics currently the most popular choice. There’s convincing evidence that they help, but they also have well-known and serious side effects, including extrapyramidal syndromes, metabolic derangements, and weight gain.

There’s also strong evidence for psychotherapy as an adjunct, and good data for lithium and a range of other agents. Whole-body hyperthermia is emerging as a possible depression treatment, as well.

Dr. Raison recommended actively treating nausea, jitteriness, diarrhea, and other short-term SSRI side effects; it makes it more likely that patients will stay on their treatment. Also, anxious patients and those with somatic complaints are more likely to tolerate antidepressants if they are started on subtherapeutic doses, then are titrated slowly up to a recommended dose.

Of all the SSRIs, paroxetine (Paxil) “is the one I most highly recommend you do not use. There’s no evidence it’s better than any of the others,” and it’s the one most likely to cause weight gain, sexual dysfunction, and cardiac issues, he said.

“We don’t know how long you should treat” with antidepressants; “probably at least 6-9 months,” he noted.

Dr. Raison is a consultant for Pamlab, Lilly, and Lundbeck. He is on the speakers bureaus of Pamlab and Sunovion. Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

LAS VEGAS – If patients don’t respond to an antidepressant within 2 weeks, it’s probably time to switch them to another antidepressant or think about add-on therapy. If symptoms have gotten worse, however, it’s time to stop the antidepressant altogether, according to Dr. Charles Raison, professor of psychiatry at the University of Arizona in Tucson.

It doesn’t take 6-8 weeks for antidepressants to work; that commonly held notion is “100% wrong,” he said.

Imaging studies show brain activity changes within 2 hours of a single dose, and in trials where antidepressants separate from placebo, they do so in a week or 2 (Arch. Gen. Psychiatry 2006;63:1217-23). “Most of the action is early on,” Dr. Raison said at the annual Perspectives in Rheumatic Diseases conference held by the Global Academy for Medical Education.

“Monitoring response in the first 2 weeks is essential, because it’s going to tell you whether you’ve got the right” treatment. With any given antidepressant, about 75% of patients will respond, but about 25% will get “much, much worse. If a patient gets worse, stop. You should take that extremely seriously,” he said (Arch. Gen. Psychiatry 2011;68:1227-37).

In general, anxious people and suicidal people don’t do as well on antidepressants. Also, people with a history of childhood neglect, abuse, or trauma respond better to psychotherapy, so it’s worth asking about such issues. It’s also worth asking patients what they want to do, be it pharmaceuticals, psychotherapy, or both. Success is more likely if patients get what they want, Dr. Raison said.

“Pain is a powerful predictor of not doing well,” especially with SSRIs, so “unfortunately, [rheumatologists] deal with populations that are less likely to have a robust response.” Even so, “if you can help people with their pain, you’ll probably help” relieve their depression and help their antidepressant work, he said.

When patients don’t respond after a few weeks, “the first thing most of us do is increase the dose; for SSRIs, the data” indicate it doesn’t work. In one study, for instance, people did just as well on a lower dose as on a higher one, he said (Br. J. Psychiatry 2006;189:309-16).

Up to a quarter of patients, however, will do better if switched to another antidepressant. Some studies suggest staying in the same class of drugs; others suggest trying a different class. For now, which one to pick “depends [mostly] on side effects. There isn’t a best antidepressant; the best one is the one that works in any given patient,” Dr. Raison said (Eur. Neuropsychopharmacol. 2012;22:453-68).

Augmentation is another option, with atypical antipsychotics currently the most popular choice. There’s convincing evidence that they help, but they also have well-known and serious side effects, including extrapyramidal syndromes, metabolic derangements, and weight gain.

There’s also strong evidence for psychotherapy as an adjunct, and good data for lithium and a range of other agents. Whole-body hyperthermia is emerging as a possible depression treatment, as well.

Dr. Raison recommended actively treating nausea, jitteriness, diarrhea, and other short-term SSRI side effects; it makes it more likely that patients will stay on their treatment. Also, anxious patients and those with somatic complaints are more likely to tolerate antidepressants if they are started on subtherapeutic doses, then are titrated slowly up to a recommended dose.

Of all the SSRIs, paroxetine (Paxil) “is the one I most highly recommend you do not use. There’s no evidence it’s better than any of the others,” and it’s the one most likely to cause weight gain, sexual dysfunction, and cardiac issues, he said.

“We don’t know how long you should treat” with antidepressants; “probably at least 6-9 months,” he noted.

Dr. Raison is a consultant for Pamlab, Lilly, and Lundbeck. He is on the speakers bureaus of Pamlab and Sunovion. Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

LAS VEGAS – New diagnostic criteria from the Systemic Lupus International Collaborating Clinics make the difficult task of diagnosing systemic lupus easier.

SLICC’s criteria are meant to supplant years-old criteria from the American College of Rheumatology. The SLICC criteria cast a wider net, without sacrificing specificity (Arthritis Rheum. 2012;64:2677-86).

SLICC coauthor Dr. Susan Manzi, chair of the department of medicine in the Allegheny Health Network and director of the Lupus Center of Excellence, both in Pittsburgh, explained how the new criteria work, and why they are an improvement.

At the conference held by Global Academy for Medical Education, she also explained why antinuclear antibody – “the lupus test” – isn’t completely reliable when diagnosing the disease.

Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

LAS VEGAS – New diagnostic criteria from the Systemic Lupus International Collaborating Clinics make the difficult task of diagnosing systemic lupus easier.

SLICC’s criteria are meant to supplant years-old criteria from the American College of Rheumatology. The SLICC criteria cast a wider net, without sacrificing specificity (Arthritis Rheum. 2012;64:2677-86).

SLICC coauthor Dr. Susan Manzi, chair of the department of medicine in the Allegheny Health Network and director of the Lupus Center of Excellence, both in Pittsburgh, explained how the new criteria work, and why they are an improvement.

At the conference held by Global Academy for Medical Education, she also explained why antinuclear antibody – “the lupus test” – isn’t completely reliable when diagnosing the disease.

Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

LAS VEGAS – New diagnostic criteria from the Systemic Lupus International Collaborating Clinics make the difficult task of diagnosing systemic lupus easier.

SLICC’s criteria are meant to supplant years-old criteria from the American College of Rheumatology. The SLICC criteria cast a wider net, without sacrificing specificity (Arthritis Rheum. 2012;64:2677-86).

SLICC coauthor Dr. Susan Manzi, chair of the department of medicine in the Allegheny Health Network and director of the Lupus Center of Excellence, both in Pittsburgh, explained how the new criteria work, and why they are an improvement.

At the conference held by Global Academy for Medical Education, she also explained why antinuclear antibody – “the lupus test” – isn’t completely reliable when diagnosing the disease.

Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

LAS VEGAS – After 3-6 months of remission induction therapy with high-dose steroids and cyclophosphamide, it’s time to switch ANCA-associated vasculitis patients to maintenance therapy.

Recent studies have shown it’s not necessary to go beyond that point with induction treatment; patients do well by then with less toxic maintenance agents.

Dr. Brian Mandell explained how he and his colleagues at the Cleveland Clinic handle the matter and what they use for maintenance therapy, at the conference held by Global Academy for Medical Education. Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

LAS VEGAS – After 3-6 months of remission induction therapy with high-dose steroids and cyclophosphamide, it’s time to switch ANCA-associated vasculitis patients to maintenance therapy.

Recent studies have shown it’s not necessary to go beyond that point with induction treatment; patients do well by then with less toxic maintenance agents.

Dr. Brian Mandell explained how he and his colleagues at the Cleveland Clinic handle the matter and what they use for maintenance therapy, at the conference held by Global Academy for Medical Education. Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

LAS VEGAS – After 3-6 months of remission induction therapy with high-dose steroids and cyclophosphamide, it’s time to switch ANCA-associated vasculitis patients to maintenance therapy.

Recent studies have shown it’s not necessary to go beyond that point with induction treatment; patients do well by then with less toxic maintenance agents.

Dr. Brian Mandell explained how he and his colleagues at the Cleveland Clinic handle the matter and what they use for maintenance therapy, at the conference held by Global Academy for Medical Education. Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

LAS VEGAS – Scleroderma patients should be screened every year for pulmonary hypertension even if they are recently diagnosed and have no respiratory symptoms.

Noninvasive tests can catch pulmonary problems early, and treatments are available to slow the progression of scleroderma. Dr. Dinesh Khanna, director of the University of Michigan’s Scleroderma Program in Ann Arbor, discussed how to perform scleroderma screening at a conference held by Global Academy for Medical Education. Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

LAS VEGAS – Scleroderma patients should be screened every year for pulmonary hypertension even if they are recently diagnosed and have no respiratory symptoms.

Noninvasive tests can catch pulmonary problems early, and treatments are available to slow the progression of scleroderma. Dr. Dinesh Khanna, director of the University of Michigan’s Scleroderma Program in Ann Arbor, discussed how to perform scleroderma screening at a conference held by Global Academy for Medical Education. Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

LAS VEGAS – Scleroderma patients should be screened every year for pulmonary hypertension even if they are recently diagnosed and have no respiratory symptoms.

Noninvasive tests can catch pulmonary problems early, and treatments are available to slow the progression of scleroderma. Dr. Dinesh Khanna, director of the University of Michigan’s Scleroderma Program in Ann Arbor, discussed how to perform scleroderma screening at a conference held by Global Academy for Medical Education. Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

aotto@frontlinemedcom.com

CHICAGO – In very short children, the slight increase in adult height from growth hormone treatment comes at the cost of psychological well-being, at least at first, according to a prospective cohort study.

So far in the ongoing investigation, the parents of 12 children with growth hormone (GH) deficiency, defined as peak stimulated GH of less than 5 ng/mL, and 7 children with idiopathic short stature (ISS) filled out the Behavior Assessment System for Children, Second Edition (BASC-2) at baseline and after 9-12 months of GH treatment. The results were compared to what the parents of nine ISS children who were not treated reported on the assessment.

GH-deficient children grew a bit, moving from –2.3 to –1.9 standard deviations below growth chart means, and ISS children grew from –2.6 to –2.2 standard deviations. Untreated children remained about 2.5 standard deviations behind their peers.

There were no statistically significant differences in baseline BASC-2 scores. However, while untreated children improved from a mean baseline depression score of 63 to 55 points, depression scores in treated children rose from 59 to 63 points. Similarly, social withdrawal in untreated children improved from 52 to 47 points, but rose from 54 to 60 points in treated children, lead investigator Dr. Emily Walvoord reported at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

Scores below 60 are considered nonclinical, scores of 60-65 indicate risk, and scores above 65 indicate pathology, explained Dr. Walvoord, a pediatric endocrinologist at Indiana University in Indianapolis.

"For short, otherwise healthy children, ... daily injections, visits to the endocrinologist every 4-6 months, and repeated discussion [of] their height might exacerbate instead of improve psychosocial concerns about being different. This [study] raises concerns that psychosocial benefits may not be achieved despite improvements in height," she and her colleagues concluded.

"I worry that we are medicalizing these kids. The message we send them is, ‘You’re not okay; there’s something wrong with you because you are too short. So you have to get a shot every day, you have to go see the doctor, and we have to talk about your height all the time.’ That’s the message I worry they internalize," Dr. Walvoord said.

"Are we really helping them? We have to be very careful about what we think is the most important outcome. Is it making the kid an inch or two taller as an adult, or is it that they have better self-esteem and psychological functioning?" she said.

If nothing else, the findings highlight the need to remind children that they are more than a number on a growth curve, and that other things matter in life.

There were no between-group differences in parent-reported cognitive functioning at baseline or follow-up. Anxiety scores improved in both cohorts, falling from 58 to 54 points in treated children, and 52 to 47 in untreated children; the meaning of that finding is uncertain. In addition, "it is possible that there was a bias toward treatment of ISS children who had underlying emotional issues," the investigators noted.

The children in the study were about 11 years old on average, with no significant differences in age, sex, or initial height standard deviations between the two groups.

Dr. Walvoord is gathering results for 13 additional children; of the total 41 subjects, 25 are boys. She hopes to follow the children for more than a year, and split out results for GH-deficient and ISS patients.

Dr. Walvoord and her colleagues had no disclosures. She initiated the work, and Eli Lilly funded it at her request.

aotto@frontlinemedcom.com

CHICAGO – In very short children, the slight increase in adult height from growth hormone treatment comes at the cost of psychological well-being, at least at first, according to a prospective cohort study.

So far in the ongoing investigation, the parents of 12 children with growth hormone (GH) deficiency, defined as peak stimulated GH of less than 5 ng/mL, and 7 children with idiopathic short stature (ISS) filled out the Behavior Assessment System for Children, Second Edition (BASC-2) at baseline and after 9-12 months of GH treatment. The results were compared to what the parents of nine ISS children who were not treated reported on the assessment.

GH-deficient children grew a bit, moving from –2.3 to –1.9 standard deviations below growth chart means, and ISS children grew from –2.6 to –2.2 standard deviations. Untreated children remained about 2.5 standard deviations behind their peers.

There were no statistically significant differences in baseline BASC-2 scores. However, while untreated children improved from a mean baseline depression score of 63 to 55 points, depression scores in treated children rose from 59 to 63 points. Similarly, social withdrawal in untreated children improved from 52 to 47 points, but rose from 54 to 60 points in treated children, lead investigator Dr. Emily Walvoord reported at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

Scores below 60 are considered nonclinical, scores of 60-65 indicate risk, and scores above 65 indicate pathology, explained Dr. Walvoord, a pediatric endocrinologist at Indiana University in Indianapolis.

"For short, otherwise healthy children, ... daily injections, visits to the endocrinologist every 4-6 months, and repeated discussion [of] their height might exacerbate instead of improve psychosocial concerns about being different. This [study] raises concerns that psychosocial benefits may not be achieved despite improvements in height," she and her colleagues concluded.

"I worry that we are medicalizing these kids. The message we send them is, ‘You’re not okay; there’s something wrong with you because you are too short. So you have to get a shot every day, you have to go see the doctor, and we have to talk about your height all the time.’ That’s the message I worry they internalize," Dr. Walvoord said.

"Are we really helping them? We have to be very careful about what we think is the most important outcome. Is it making the kid an inch or two taller as an adult, or is it that they have better self-esteem and psychological functioning?" she said.

If nothing else, the findings highlight the need to remind children that they are more than a number on a growth curve, and that other things matter in life.

There were no between-group differences in parent-reported cognitive functioning at baseline or follow-up. Anxiety scores improved in both cohorts, falling from 58 to 54 points in treated children, and 52 to 47 in untreated children; the meaning of that finding is uncertain. In addition, "it is possible that there was a bias toward treatment of ISS children who had underlying emotional issues," the investigators noted.

The children in the study were about 11 years old on average, with no significant differences in age, sex, or initial height standard deviations between the two groups.

Dr. Walvoord is gathering results for 13 additional children; of the total 41 subjects, 25 are boys. She hopes to follow the children for more than a year, and split out results for GH-deficient and ISS patients.

Dr. Walvoord and her colleagues had no disclosures. She initiated the work, and Eli Lilly funded it at her request.

aotto@frontlinemedcom.com

CHICAGO – In very short children, the slight increase in adult height from growth hormone treatment comes at the cost of psychological well-being, at least at first, according to a prospective cohort study.

So far in the ongoing investigation, the parents of 12 children with growth hormone (GH) deficiency, defined as peak stimulated GH of less than 5 ng/mL, and 7 children with idiopathic short stature (ISS) filled out the Behavior Assessment System for Children, Second Edition (BASC-2) at baseline and after 9-12 months of GH treatment. The results were compared to what the parents of nine ISS children who were not treated reported on the assessment.

GH-deficient children grew a bit, moving from –2.3 to –1.9 standard deviations below growth chart means, and ISS children grew from –2.6 to –2.2 standard deviations. Untreated children remained about 2.5 standard deviations behind their peers.

There were no statistically significant differences in baseline BASC-2 scores. However, while untreated children improved from a mean baseline depression score of 63 to 55 points, depression scores in treated children rose from 59 to 63 points. Similarly, social withdrawal in untreated children improved from 52 to 47 points, but rose from 54 to 60 points in treated children, lead investigator Dr. Emily Walvoord reported at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

Scores below 60 are considered nonclinical, scores of 60-65 indicate risk, and scores above 65 indicate pathology, explained Dr. Walvoord, a pediatric endocrinologist at Indiana University in Indianapolis.

"For short, otherwise healthy children, ... daily injections, visits to the endocrinologist every 4-6 months, and repeated discussion [of] their height might exacerbate instead of improve psychosocial concerns about being different. This [study] raises concerns that psychosocial benefits may not be achieved despite improvements in height," she and her colleagues concluded.

"I worry that we are medicalizing these kids. The message we send them is, ‘You’re not okay; there’s something wrong with you because you are too short. So you have to get a shot every day, you have to go see the doctor, and we have to talk about your height all the time.’ That’s the message I worry they internalize," Dr. Walvoord said.

"Are we really helping them? We have to be very careful about what we think is the most important outcome. Is it making the kid an inch or two taller as an adult, or is it that they have better self-esteem and psychological functioning?" she said.

If nothing else, the findings highlight the need to remind children that they are more than a number on a growth curve, and that other things matter in life.

There were no between-group differences in parent-reported cognitive functioning at baseline or follow-up. Anxiety scores improved in both cohorts, falling from 58 to 54 points in treated children, and 52 to 47 in untreated children; the meaning of that finding is uncertain. In addition, "it is possible that there was a bias toward treatment of ISS children who had underlying emotional issues," the investigators noted.

The children in the study were about 11 years old on average, with no significant differences in age, sex, or initial height standard deviations between the two groups.

Dr. Walvoord is gathering results for 13 additional children; of the total 41 subjects, 25 are boys. She hopes to follow the children for more than a year, and split out results for GH-deficient and ISS patients.

Dr. Walvoord and her colleagues had no disclosures. She initiated the work, and Eli Lilly funded it at her request.

aotto@frontlinemedcom.com

CHICAGO – More liberal lipid targets in elderly patients and lower statin doses might offset the risk of memory decline associated with statin use in these patients, Australian investigators suggested.

Dr. Katherine Samaras and her associates did neuropsychometric testing on 377 subjects 70-90 years old who had been on statins for 2-22 years, and 301 controls who had not taken the drugs. They then repeated the assessments at 2 and 4 years, and calculated composite, normalized z scores for various cognitive functions.

The team found a significantly greater decline in memory z score from baseline among statin users at both 2 and 4 years (4-year z score –0.27 vs. –0.07).

However, statin use was not associated with greater 4-year declines in language, processing speed, or visuospatial or executive functions. Also, metabolic syndrome was not associated with accelerated cognitive decline, Dr. Samaras reported at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

The analysis controlled for age, sex, education, smoking, the presence of hypertension, diabetes, heart disease, stroke, obesity, and the presence of apolipoprotein E e4 genotype (APOEe4), which increases the risk for Alzheimer’s disease.

Previous stroke was significantly associated with an even greater memory decline among statin users. Smoking and APOEe4 seemed to be, as well, but the trends were not significant.

The subjects were part of the Sydney Memory and Ageing Study, a longitudinal cohort of community-dwelling, well elderly from the affluent part of Sydney. None had dementia.

The findings add weight to the Food and Drug Administration's warning about statin use and memory loss in 2012.

This has "made me look very closely at who I prescribe statins for. People do report cognitive changes" if asked, said Dr. Samaras of the Garvan Institute of Medical Research and the University of New South Wales in Sydney.

To forestall memory loss, "I wonder if we should have a greater range of appropriate lipid targets for the elderly, just as we have for hemoglobin A_1c," she said. For now, if an elderly person is "really tightly controlled and well under the benchmark we are trying to reach [with statins], then I reduce the dose," with appropriate follow-up, Dr. Samaras said.

Trials of lipid-lowering therapy should include formal cognitive measurements, as well. "As a prescriber, I’d like to know that data," she said.

The subjects in the study were about 80 years old on average, and about equally split between men and women. The average body mass index was 27.1 kg/m², and the average fasting glucose level was 5.6 mmol/L. Sixty percent of statin users and 45.9% of nonusers had metabolic syndrome; 15.2% of statin users and 5.5% of nonusers had diabetes.

Australia’s National Health and Medical Research Council funded the work. Dr. Samaras and her colleagues said they had no disclosures.

aotto@frontlinemedcom.com

CHICAGO – More liberal lipid targets in elderly patients and lower statin doses might offset the risk of memory decline associated with statin use in these patients, Australian investigators suggested.

Dr. Katherine Samaras and her associates did neuropsychometric testing on 377 subjects 70-90 years old who had been on statins for 2-22 years, and 301 controls who had not taken the drugs. They then repeated the assessments at 2 and 4 years, and calculated composite, normalized z scores for various cognitive functions.

The team found a significantly greater decline in memory z score from baseline among statin users at both 2 and 4 years (4-year z score –0.27 vs. –0.07).

However, statin use was not associated with greater 4-year declines in language, processing speed, or visuospatial or executive functions. Also, metabolic syndrome was not associated with accelerated cognitive decline, Dr. Samaras reported at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

The analysis controlled for age, sex, education, smoking, the presence of hypertension, diabetes, heart disease, stroke, obesity, and the presence of apolipoprotein E e4 genotype (APOEe4), which increases the risk for Alzheimer’s disease.

Previous stroke was significantly associated with an even greater memory decline among statin users. Smoking and APOEe4 seemed to be, as well, but the trends were not significant.

The subjects were part of the Sydney Memory and Ageing Study, a longitudinal cohort of community-dwelling, well elderly from the affluent part of Sydney. None had dementia.

The findings add weight to the Food and Drug Administration's warning about statin use and memory loss in 2012.

This has "made me look very closely at who I prescribe statins for. People do report cognitive changes" if asked, said Dr. Samaras of the Garvan Institute of Medical Research and the University of New South Wales in Sydney.

To forestall memory loss, "I wonder if we should have a greater range of appropriate lipid targets for the elderly, just as we have for hemoglobin A_1c," she said. For now, if an elderly person is "really tightly controlled and well under the benchmark we are trying to reach [with statins], then I reduce the dose," with appropriate follow-up, Dr. Samaras said.

Trials of lipid-lowering therapy should include formal cognitive measurements, as well. "As a prescriber, I’d like to know that data," she said.

The subjects in the study were about 80 years old on average, and about equally split between men and women. The average body mass index was 27.1 kg/m², and the average fasting glucose level was 5.6 mmol/L. Sixty percent of statin users and 45.9% of nonusers had metabolic syndrome; 15.2% of statin users and 5.5% of nonusers had diabetes.

Australia’s National Health and Medical Research Council funded the work. Dr. Samaras and her colleagues said they had no disclosures.

aotto@frontlinemedcom.com

CHICAGO – More liberal lipid targets in elderly patients and lower statin doses might offset the risk of memory decline associated with statin use in these patients, Australian investigators suggested.

Dr. Katherine Samaras and her associates did neuropsychometric testing on 377 subjects 70-90 years old who had been on statins for 2-22 years, and 301 controls who had not taken the drugs. They then repeated the assessments at 2 and 4 years, and calculated composite, normalized z scores for various cognitive functions.

The team found a significantly greater decline in memory z score from baseline among statin users at both 2 and 4 years (4-year z score –0.27 vs. –0.07).

However, statin use was not associated with greater 4-year declines in language, processing speed, or visuospatial or executive functions. Also, metabolic syndrome was not associated with accelerated cognitive decline, Dr. Samaras reported at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

The analysis controlled for age, sex, education, smoking, the presence of hypertension, diabetes, heart disease, stroke, obesity, and the presence of apolipoprotein E e4 genotype (APOEe4), which increases the risk for Alzheimer’s disease.

Previous stroke was significantly associated with an even greater memory decline among statin users. Smoking and APOEe4 seemed to be, as well, but the trends were not significant.

The subjects were part of the Sydney Memory and Ageing Study, a longitudinal cohort of community-dwelling, well elderly from the affluent part of Sydney. None had dementia.

The findings add weight to the Food and Drug Administration's warning about statin use and memory loss in 2012.

This has "made me look very closely at who I prescribe statins for. People do report cognitive changes" if asked, said Dr. Samaras of the Garvan Institute of Medical Research and the University of New South Wales in Sydney.

To forestall memory loss, "I wonder if we should have a greater range of appropriate lipid targets for the elderly, just as we have for hemoglobin A_1c," she said. For now, if an elderly person is "really tightly controlled and well under the benchmark we are trying to reach [with statins], then I reduce the dose," with appropriate follow-up, Dr. Samaras said.

Trials of lipid-lowering therapy should include formal cognitive measurements, as well. "As a prescriber, I’d like to know that data," she said.

The subjects in the study were about 80 years old on average, and about equally split between men and women. The average body mass index was 27.1 kg/m², and the average fasting glucose level was 5.6 mmol/L. Sixty percent of statin users and 45.9% of nonusers had metabolic syndrome; 15.2% of statin users and 5.5% of nonusers had diabetes.

Australia’s National Health and Medical Research Council funded the work. Dr. Samaras and her colleagues said they had no disclosures.

aotto@frontlinemedcom.com

CHICAGO – Older adults who undergo Roux-en-Y gastric bypass are at risk for lessened bone mineral density for at least 2 years after their surgery and should be monitored appropriately for osteoporosis or fragility fractures, according to investigators from Massachusetts General Hospital in Boston.

Two years postoperatively, vertebral bone mineral density (BMD) in 30 patients was about 7% lower on quantitative computed tomography (QCT) and 6% lower on dual-energy x-ray absorptiometry (DXA) – both methods were used to ensure accuracy – when compared with 20 well-matched, morbidly obese controls. Total hip BMD was 6% lower on QCT and 10% lower on DXA. Femoral neck BMD was about 6% lower by both measures.

Biomarkers of bone turnover remained markedly elevated in surgery patients, as well, but unchanged in controls (C-telopeptide 0.65 ng/mL vs. 0.3 ng/mL; amino-terminal propeptide of type I collagen 65 ng/mL vs. 40 ng/mL). The findings were all statistically significant.

The groups started to separate early on BMD, and there’s concern that bone loss will continue for more than 2 years after surgery. Preoperatively, most Roux-en-Y gastric bypass patients have a higher than normal BMD, "so even a loss of 10% over 2 years is not going to put most of them in the osteopenic or osteoporotic range. The caveat now is that we are [offering surgery] to older patients and adolescents. Elderly patients are starting with lower bone mass, so there are concerns about [post-op] skeletal fragility. The oldest patient in our study was 72. She became osteoporotic after surgery because her bone density was low to begin with," said lead investigator Dr. Elaine W. Yu, an endocrinologist at Massachusetts General.

"In adolescents, there are implications for achieving peak bone mass. Even if you have a normal bone density 2 years after surgery, what’s going to happen in 10 years, 20 years?" she asked.

In short, "people should pay attention to bone density and bone loss and discuss this as one of the potential negative effects of bariatric surgery. For patients at risk, you should definitely consider serial bone density monitoring and osteoporosis therapy if needed," she said at the joint meeting of the International Society of Endocrinology and the Endocrine Society.

At baseline, both subjects and controls were about 47 years old and 270 pounds, with a mean a mean body mass index of 45 kg/m². About 85% were women. The study excluded patients with histories of bone disorders or use of bone-affecting medications.

Surgery patients lost a mean of about 85 pounds in the first 6 months; their weight loss then stabilized, but they continued to lose bone. Controls stayed about the same weight.

The findings can’t be explained by post-op calcium or vitamin D depletion. "These subjects were aggressively supplemented with both," and both groups maintained normal levels throughout the study. Also, there were no statistical differences in parathyroid hormone levels between the groups.

"Our theory is that there are changes in gut hormones after gastric bypass that have direct effects on bone, like ghrelin," Dr. Yu said.

The National Institutes of Health funded the work. Dr. Yu is a consultant for Amgen.

aotto@frontlinemedcom.com

CHICAGO – Older adults who undergo Roux-en-Y gastric bypass are at risk for lessened bone mineral density for at least 2 years after their surgery and should be monitored appropriately for osteoporosis or fragility fractures, according to investigators from Massachusetts General Hospital in Boston.

Two years postoperatively, vertebral bone mineral density (BMD) in 30 patients was about 7% lower on quantitative computed tomography (QCT) and 6% lower on dual-energy x-ray absorptiometry (DXA) – both methods were used to ensure accuracy – when compared with 20 well-matched, morbidly obese controls. Total hip BMD was 6% lower on QCT and 10% lower on DXA. Femoral neck BMD was about 6% lower by both measures.

Biomarkers of bone turnover remained markedly elevated in surgery patients, as well, but unchanged in controls (C-telopeptide 0.65 ng/mL vs. 0.3 ng/mL; amino-terminal propeptide of type I collagen 65 ng/mL vs. 40 ng/mL). The findings were all statistically significant.

The groups started to separate early on BMD, and there’s concern that bone loss will continue for more than 2 years after surgery. Preoperatively, most Roux-en-Y gastric bypass patients have a higher than normal BMD, "so even a loss of 10% over 2 years is not going to put most of them in the osteopenic or osteoporotic range. The caveat now is that we are [offering surgery] to older patients and adolescents. Elderly patients are starting with lower bone mass, so there are concerns about [post-op] skeletal fragility. The oldest patient in our study was 72. She became osteoporotic after surgery because her bone density was low to begin with," said lead investigator Dr. Elaine W. Yu, an endocrinologist at Massachusetts General.

"In adolescents, there are implications for achieving peak bone mass. Even if you have a normal bone density 2 years after surgery, what’s going to happen in 10 years, 20 years?" she asked.

In short, "people should pay attention to bone density and bone loss and discuss this as one of the potential negative effects of bariatric surgery. For patients at risk, you should definitely consider serial bone density monitoring and osteoporosis therapy if needed," she said at the joint meeting of the International Society of Endocrinology and the Endocrine Society.

At baseline, both subjects and controls were about 47 years old and 270 pounds, with a mean a mean body mass index of 45 kg/m². About 85% were women. The study excluded patients with histories of bone disorders or use of bone-affecting medications.

Surgery patients lost a mean of about 85 pounds in the first 6 months; their weight loss then stabilized, but they continued to lose bone. Controls stayed about the same weight.

The findings can’t be explained by post-op calcium or vitamin D depletion. "These subjects were aggressively supplemented with both," and both groups maintained normal levels throughout the study. Also, there were no statistical differences in parathyroid hormone levels between the groups.

"Our theory is that there are changes in gut hormones after gastric bypass that have direct effects on bone, like ghrelin," Dr. Yu said.

The National Institutes of Health funded the work. Dr. Yu is a consultant for Amgen.

aotto@frontlinemedcom.com

CHICAGO – Older adults who undergo Roux-en-Y gastric bypass are at risk for lessened bone mineral density for at least 2 years after their surgery and should be monitored appropriately for osteoporosis or fragility fractures, according to investigators from Massachusetts General Hospital in Boston.

Two years postoperatively, vertebral bone mineral density (BMD) in 30 patients was about 7% lower on quantitative computed tomography (QCT) and 6% lower on dual-energy x-ray absorptiometry (DXA) – both methods were used to ensure accuracy – when compared with 20 well-matched, morbidly obese controls. Total hip BMD was 6% lower on QCT and 10% lower on DXA. Femoral neck BMD was about 6% lower by both measures.

Biomarkers of bone turnover remained markedly elevated in surgery patients, as well, but unchanged in controls (C-telopeptide 0.65 ng/mL vs. 0.3 ng/mL; amino-terminal propeptide of type I collagen 65 ng/mL vs. 40 ng/mL). The findings were all statistically significant.

The groups started to separate early on BMD, and there’s concern that bone loss will continue for more than 2 years after surgery. Preoperatively, most Roux-en-Y gastric bypass patients have a higher than normal BMD, "so even a loss of 10% over 2 years is not going to put most of them in the osteopenic or osteoporotic range. The caveat now is that we are [offering surgery] to older patients and adolescents. Elderly patients are starting with lower bone mass, so there are concerns about [post-op] skeletal fragility. The oldest patient in our study was 72. She became osteoporotic after surgery because her bone density was low to begin with," said lead investigator Dr. Elaine W. Yu, an endocrinologist at Massachusetts General.

"In adolescents, there are implications for achieving peak bone mass. Even if you have a normal bone density 2 years after surgery, what’s going to happen in 10 years, 20 years?" she asked.

In short, "people should pay attention to bone density and bone loss and discuss this as one of the potential negative effects of bariatric surgery. For patients at risk, you should definitely consider serial bone density monitoring and osteoporosis therapy if needed," she said at the joint meeting of the International Society of Endocrinology and the Endocrine Society.

At baseline, both subjects and controls were about 47 years old and 270 pounds, with a mean a mean body mass index of 45 kg/m². About 85% were women. The study excluded patients with histories of bone disorders or use of bone-affecting medications.

Surgery patients lost a mean of about 85 pounds in the first 6 months; their weight loss then stabilized, but they continued to lose bone. Controls stayed about the same weight.

The findings can’t be explained by post-op calcium or vitamin D depletion. "These subjects were aggressively supplemented with both," and both groups maintained normal levels throughout the study. Also, there were no statistical differences in parathyroid hormone levels between the groups.

"Our theory is that there are changes in gut hormones after gastric bypass that have direct effects on bone, like ghrelin," Dr. Yu said.

The National Institutes of Health funded the work. Dr. Yu is a consultant for Amgen.

aotto@frontlinemedcom.com

CHICAGO – More than half of patients who discontinue thiazide diuretics due to hypercalcemia will remain hypercalcemic even after stopping the drugs, and will eventually be diagnosed with primary hyperparathyroidism, according to a retrospective review from the Mayo Clinic in Rochester, Minn.

Those patients probably have subclinical primary hyperparathyroidism (PHP) disease before starting thiazides, and it may have contributed to their hypertension. In the study, PHP was likely unmasked by thiazide treatment, which reduces calcium excretion. "In our clinical practice, it’s not uncommon for us to stop thiazides, and then find calcium levels don’t normalize. Now we have data to confirm our clinical impression," said senior investigator Dr. Robert Wermers, an endocrinologist in the departments of endocrinology, diabetes, metabolism and nutrition at Mayo.

The finding is something to keep in mind when prescribing thiazides. In almost all patients, they were prescribed for hypertension. Hypercalcemia was an incidental finding in the study; none of the patients were symptomatic. Older women were most at risk for PHP, and surgery was the usual treatment, he said at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

In all, the team reviewed 220 patients diagnosed with thiazide-associated hypercalcemia between 1992 and 2010. They were a median of 68 years old; 190 (86%) were women.

Eighty-one (37%) of those patients were taken off the drug; hypercalcemia persisted in 49 (60%) patients, of whom 43 (88%) were subsequently diagnosed with PHP.

The findings suggest that "primary hyperparathyroidism is common in patients who develop hypercalcemia while taking thiazide diuretics," the investigators said.

Compared with the overall patient population of 220, those who were diagnosed with PHP had a slightly higher maximum serum calcium while on thiazides (mean 10.9 vs. 10.7 mg/dL) and had been on thiazides a shorter period of time when hypercalcemia was detected (median 2.9 vs. 3.9 years). More than 80% of the patients in both groups were women, and the mean age at onset of hypercalcemia was about 67 years. Serum calcium was normal in both groups before thiazide treatment (median 9.7 mg/dL for both groups).

Of the 139 (63%) patients who stayed on thiazides despite hypercalcemia, 71 (51%) remained hypercalcemic, seven (5%) were eventually diagnosed with PHP, and calcium normalized in 68 (48.9%).

The overall incidence of thiazide associated hypercalcemia was 17 cases per 100,000 person-years. The highest rate was 314.3/100,000 person-years in women 65-74 years old. The incidence started climbing in the mid-1990s and peaked in 1999 at 31.7 cases per 100,000 person-years, perhaps because the guidelines released at the time that called for increased osteoporosis screening. In 2010, the incidence was about 20 cases per 100,000 person-years.

The investigators have no disclosures, and had no outside funding for the project.

aotto@frontlinemedcom.com

CHICAGO – More than half of patients who discontinue thiazide diuretics due to hypercalcemia will remain hypercalcemic even after stopping the drugs, and will eventually be diagnosed with primary hyperparathyroidism, according to a retrospective review from the Mayo Clinic in Rochester, Minn.

Those patients probably have subclinical primary hyperparathyroidism (PHP) disease before starting thiazides, and it may have contributed to their hypertension. In the study, PHP was likely unmasked by thiazide treatment, which reduces calcium excretion. "In our clinical practice, it’s not uncommon for us to stop thiazides, and then find calcium levels don’t normalize. Now we have data to confirm our clinical impression," said senior investigator Dr. Robert Wermers, an endocrinologist in the departments of endocrinology, diabetes, metabolism and nutrition at Mayo.

The finding is something to keep in mind when prescribing thiazides. In almost all patients, they were prescribed for hypertension. Hypercalcemia was an incidental finding in the study; none of the patients were symptomatic. Older women were most at risk for PHP, and surgery was the usual treatment, he said at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

In all, the team reviewed 220 patients diagnosed with thiazide-associated hypercalcemia between 1992 and 2010. They were a median of 68 years old; 190 (86%) were women.

Eighty-one (37%) of those patients were taken off the drug; hypercalcemia persisted in 49 (60%) patients, of whom 43 (88%) were subsequently diagnosed with PHP.

The findings suggest that "primary hyperparathyroidism is common in patients who develop hypercalcemia while taking thiazide diuretics," the investigators said.

Compared with the overall patient population of 220, those who were diagnosed with PHP had a slightly higher maximum serum calcium while on thiazides (mean 10.9 vs. 10.7 mg/dL) and had been on thiazides a shorter period of time when hypercalcemia was detected (median 2.9 vs. 3.9 years). More than 80% of the patients in both groups were women, and the mean age at onset of hypercalcemia was about 67 years. Serum calcium was normal in both groups before thiazide treatment (median 9.7 mg/dL for both groups).

Of the 139 (63%) patients who stayed on thiazides despite hypercalcemia, 71 (51%) remained hypercalcemic, seven (5%) were eventually diagnosed with PHP, and calcium normalized in 68 (48.9%).

The overall incidence of thiazide associated hypercalcemia was 17 cases per 100,000 person-years. The highest rate was 314.3/100,000 person-years in women 65-74 years old. The incidence started climbing in the mid-1990s and peaked in 1999 at 31.7 cases per 100,000 person-years, perhaps because the guidelines released at the time that called for increased osteoporosis screening. In 2010, the incidence was about 20 cases per 100,000 person-years.

The investigators have no disclosures, and had no outside funding for the project.

aotto@frontlinemedcom.com

CHICAGO – More than half of patients who discontinue thiazide diuretics due to hypercalcemia will remain hypercalcemic even after stopping the drugs, and will eventually be diagnosed with primary hyperparathyroidism, according to a retrospective review from the Mayo Clinic in Rochester, Minn.

Those patients probably have subclinical primary hyperparathyroidism (PHP) disease before starting thiazides, and it may have contributed to their hypertension. In the study, PHP was likely unmasked by thiazide treatment, which reduces calcium excretion. "In our clinical practice, it’s not uncommon for us to stop thiazides, and then find calcium levels don’t normalize. Now we have data to confirm our clinical impression," said senior investigator Dr. Robert Wermers, an endocrinologist in the departments of endocrinology, diabetes, metabolism and nutrition at Mayo.

The finding is something to keep in mind when prescribing thiazides. In almost all patients, they were prescribed for hypertension. Hypercalcemia was an incidental finding in the study; none of the patients were symptomatic. Older women were most at risk for PHP, and surgery was the usual treatment, he said at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

In all, the team reviewed 220 patients diagnosed with thiazide-associated hypercalcemia between 1992 and 2010. They were a median of 68 years old; 190 (86%) were women.

Eighty-one (37%) of those patients were taken off the drug; hypercalcemia persisted in 49 (60%) patients, of whom 43 (88%) were subsequently diagnosed with PHP.

The findings suggest that "primary hyperparathyroidism is common in patients who develop hypercalcemia while taking thiazide diuretics," the investigators said.

Compared with the overall patient population of 220, those who were diagnosed with PHP had a slightly higher maximum serum calcium while on thiazides (mean 10.9 vs. 10.7 mg/dL) and had been on thiazides a shorter period of time when hypercalcemia was detected (median 2.9 vs. 3.9 years). More than 80% of the patients in both groups were women, and the mean age at onset of hypercalcemia was about 67 years. Serum calcium was normal in both groups before thiazide treatment (median 9.7 mg/dL for both groups).

Of the 139 (63%) patients who stayed on thiazides despite hypercalcemia, 71 (51%) remained hypercalcemic, seven (5%) were eventually diagnosed with PHP, and calcium normalized in 68 (48.9%).

The overall incidence of thiazide associated hypercalcemia was 17 cases per 100,000 person-years. The highest rate was 314.3/100,000 person-years in women 65-74 years old. The incidence started climbing in the mid-1990s and peaked in 1999 at 31.7 cases per 100,000 person-years, perhaps because the guidelines released at the time that called for increased osteoporosis screening. In 2010, the incidence was about 20 cases per 100,000 person-years.

The investigators have no disclosures, and had no outside funding for the project.

aotto@frontlinemedcom.com

SEATTLE – Correcting jumping and landing techniques may prevent lower-limb stress fractures in active young people, based on the results of a prospective study of 1,772 cadets at the United States Military Academy in West Point, N.Y.

Scores on the Landing Error Scoring System (LESS), which assesses 17 components of jumping and landing, were predictive of lower extremity stress fractures in the study, which was reported at the annual meeting of the American Orthopaedic Society for Sports Medicine.

Based on the results, freshman at West Point are now being screened for movement problems that are corrected when necessary. "We’ve seen a pretty impressive reduction – on average 30%-40% – in stress fractures, said lead investigator Kenneth Cameron, Ph.D., director of orthopedic research at Keller Army Community Hospital in West Point.

The reductions have not yet reached statistical significance because the program is fairly new, said Dr. Cameron, who added that the findings might prove useful for preventing post-traumatic osteoarthritis, anterior cruciate ligament tears, and other injuries.

For the study, cadets were instructed to jump off a 30-cm high box, then to leap as high as they could. Subjects were about 19 years old, on average, and had a body mass index of about 24 kg/m² in men and 23 kg/m² in women. The investigators videotaped the cadets and graded their movements using the LESS criteria.

Overall, there were 94 first-time fractures in the cohort, giving a cumulative incidence of 5.3%. Stress fractures were three times more likely in women, about one-third of the study population (incidence rate ratio = 2.86; 95% confidence interval, 1.88-4.34; P less than .001).

Controlling for sex and year of entry into the cohort, cadets who consistently landed flat footed or heel to toe were more than twice as likely (IRR = 2.32; 95% CI, 1.35-3.97; P = .002) to have a lower-extremity stress fracture during 4 years of follow-up. Similarly, a higher rate of stress fractures was noted in those who consistently landed asymmetrically (IRR = 2.53; 95% CI, 1.35-4.77; P = .004). Each additional movement error increased the incidence rate of lower-extremity stress fracture by 15% (IRR = 1.15; 95% CI, 1.02-1.31; P = .025).

"Typically, we don’t focus on changing movement patterns" when people have stress fractures, so most "move just as badly if not worse" and are at risk for another injury, he said. "Strength training isn’t enough; there’s a neuromuscular control issue, as well."

In stress fracture, "we see excessive motion in the frontal plane and transverse plane, and not much [side] plane motion. We also see hamstring and quadriceps weakness. Instead of flexing [the hip, knee, and ankle] to absorb force, [subjects] focus on compensatory movements," like internal rotation and abduction.

Hitting the floor with abnormal ankle flexion, stance width, and trunk flexion also increases the stress fracture risk.

The work was funded by the Department of Defense and National Institutes of Health, among others. Dr. Cameron had no relevant disclosures.

aotto@frontlinemedcom.com

SEATTLE – Correcting jumping and landing techniques may prevent lower-limb stress fractures in active young people, based on the results of a prospective study of 1,772 cadets at the United States Military Academy in West Point, N.Y.

Scores on the Landing Error Scoring System (LESS), which assesses 17 components of jumping and landing, were predictive of lower extremity stress fractures in the study, which was reported at the annual meeting of the American Orthopaedic Society for Sports Medicine.

Based on the results, freshman at West Point are now being screened for movement problems that are corrected when necessary. "We’ve seen a pretty impressive reduction – on average 30%-40% – in stress fractures, said lead investigator Kenneth Cameron, Ph.D., director of orthopedic research at Keller Army Community Hospital in West Point.

The reductions have not yet reached statistical significance because the program is fairly new, said Dr. Cameron, who added that the findings might prove useful for preventing post-traumatic osteoarthritis, anterior cruciate ligament tears, and other injuries.

For the study, cadets were instructed to jump off a 30-cm high box, then to leap as high as they could. Subjects were about 19 years old, on average, and had a body mass index of about 24 kg/m² in men and 23 kg/m² in women. The investigators videotaped the cadets and graded their movements using the LESS criteria.

Overall, there were 94 first-time fractures in the cohort, giving a cumulative incidence of 5.3%. Stress fractures were three times more likely in women, about one-third of the study population (incidence rate ratio = 2.86; 95% confidence interval, 1.88-4.34; P less than .001).

Controlling for sex and year of entry into the cohort, cadets who consistently landed flat footed or heel to toe were more than twice as likely (IRR = 2.32; 95% CI, 1.35-3.97; P = .002) to have a lower-extremity stress fracture during 4 years of follow-up. Similarly, a higher rate of stress fractures was noted in those who consistently landed asymmetrically (IRR = 2.53; 95% CI, 1.35-4.77; P = .004). Each additional movement error increased the incidence rate of lower-extremity stress fracture by 15% (IRR = 1.15; 95% CI, 1.02-1.31; P = .025).

"Typically, we don’t focus on changing movement patterns" when people have stress fractures, so most "move just as badly if not worse" and are at risk for another injury, he said. "Strength training isn’t enough; there’s a neuromuscular control issue, as well."

In stress fracture, "we see excessive motion in the frontal plane and transverse plane, and not much [side] plane motion. We also see hamstring and quadriceps weakness. Instead of flexing [the hip, knee, and ankle] to absorb force, [subjects] focus on compensatory movements," like internal rotation and abduction.

Hitting the floor with abnormal ankle flexion, stance width, and trunk flexion also increases the stress fracture risk.

The work was funded by the Department of Defense and National Institutes of Health, among others. Dr. Cameron had no relevant disclosures.

aotto@frontlinemedcom.com

SEATTLE – Correcting jumping and landing techniques may prevent lower-limb stress fractures in active young people, based on the results of a prospective study of 1,772 cadets at the United States Military Academy in West Point, N.Y.

Scores on the Landing Error Scoring System (LESS), which assesses 17 components of jumping and landing, were predictive of lower extremity stress fractures in the study, which was reported at the annual meeting of the American Orthopaedic Society for Sports Medicine.

Based on the results, freshman at West Point are now being screened for movement problems that are corrected when necessary. "We’ve seen a pretty impressive reduction – on average 30%-40% – in stress fractures, said lead investigator Kenneth Cameron, Ph.D., director of orthopedic research at Keller Army Community Hospital in West Point.

The reductions have not yet reached statistical significance because the program is fairly new, said Dr. Cameron, who added that the findings might prove useful for preventing post-traumatic osteoarthritis, anterior cruciate ligament tears, and other injuries.

For the study, cadets were instructed to jump off a 30-cm high box, then to leap as high as they could. Subjects were about 19 years old, on average, and had a body mass index of about 24 kg/m² in men and 23 kg/m² in women. The investigators videotaped the cadets and graded their movements using the LESS criteria.

Overall, there were 94 first-time fractures in the cohort, giving a cumulative incidence of 5.3%. Stress fractures were three times more likely in women, about one-third of the study population (incidence rate ratio = 2.86; 95% confidence interval, 1.88-4.34; P less than .001).

Controlling for sex and year of entry into the cohort, cadets who consistently landed flat footed or heel to toe were more than twice as likely (IRR = 2.32; 95% CI, 1.35-3.97; P = .002) to have a lower-extremity stress fracture during 4 years of follow-up. Similarly, a higher rate of stress fractures was noted in those who consistently landed asymmetrically (IRR = 2.53; 95% CI, 1.35-4.77; P = .004). Each additional movement error increased the incidence rate of lower-extremity stress fracture by 15% (IRR = 1.15; 95% CI, 1.02-1.31; P = .025).

"Typically, we don’t focus on changing movement patterns" when people have stress fractures, so most "move just as badly if not worse" and are at risk for another injury, he said. "Strength training isn’t enough; there’s a neuromuscular control issue, as well."

In stress fracture, "we see excessive motion in the frontal plane and transverse plane, and not much [side] plane motion. We also see hamstring and quadriceps weakness. Instead of flexing [the hip, knee, and ankle] to absorb force, [subjects] focus on compensatory movements," like internal rotation and abduction.

Hitting the floor with abnormal ankle flexion, stance width, and trunk flexion also increases the stress fracture risk.

The work was funded by the Department of Defense and National Institutes of Health, among others. Dr. Cameron had no relevant disclosures.

aotto@frontlinemedcom.com

CHICAGO – At least in some institutions, about a third of follicular thyroid lesions of undetermined significance are malignant, reported researchers from the University of Wisconsin, Madison.

That rate is a higher proportion than the 5%-15% rate estimated by the Bethesda System, a national standard for reporting thyroid cytopathology, said Dr. Juan Carlos Jaume at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

"The message here is to be aware of your local institutional rates for cancer in FLUS, because following [the Bethesda System] may mislead you and your patient" when deciding on a course of action, be it surgery, repeat biopsy, or observation, he said. "Other institutions [should be encouraged to] do similar analyses to generate more accurate local guidelines for management of FLUS," noted Dr. Jaume, senior author of the study.

Of 1,420 nodules assessed over 2 years at the thyroid clinic at the University of Wisconsin, Madison, 134 (9.4%) were reported as follicular lesions of undetermined significance (FLUS) on fine-needle aspiration. Eighty patients opted for surgery; pathology revealed that 27 (34%) actually had differentiated thyroid cancer. Cancer also was found in four more patients, but at sites different from the original fine-needle aspiration. Most of the cancers (27) were papillary, 3 were follicular, and 1 was a Hurthle cell tumor, the investigators reported.

It’s unlikely the findings were due to selection bias, with patients who were more likely to have cancer opting for surgery. More than half of the patients chose surgery after discussing risks and benefits with their providers, not because of tumor progression. Almost all the others opted for surgery because of compression symptoms or because they had a nodule larger than 4 cm.

Even if there was a bias, "the highest expectation [with Bethesda] is 15%; our rate was 34%," a large difference, Dr. Jaume said. "As soon as we had the rate available, we conveyed the information" to providers so they could more accurately counsel patients. "I think eventually we will see an increase in the number of patients deciding on surgery."

The team performed the study because providers at the university had been relying on the Bethesda estimate to guide patients, but had a hunch that their local FLUS cancer rates were higher.

The majority of the 134 FLUS patients who opted against surgery chose ultrasound monitoring. Among the 22 who chose repeat fine-needle aspiration, half were rediagnosed with benign cytology, 5 were again diagnosed with FLUS, and most of the rest were lost to follow-up.

Among the 80 surgical patients, pathology was benign in 47 and parathyroid tissue was present in 1 biopsy. Records were unavailable for the final patient.

Some cytopathologists tend to call thyroid lesions FLUS more frequently than others; possibly, that predilection has something to do with the discordance in reported cancer rates, Dr. Jaume said.

Ultimately, the solution will be genetic analysis of fine-needle aspiration samples. There is a commercial product on the market, but "we are not using [it] in our institution because the negative predictive value is high, but the positive predictive value is low," he said.

The investigators had no relevant disclosures and had no outside funding for their work.

aotto@frontlinemedcom.com

*Correction, 8/25/2014: An earlier version of this article misspelled Dr. Jaume's name.

CHICAGO – At least in some institutions, about a third of follicular thyroid lesions of undetermined significance are malignant, reported researchers from the University of Wisconsin, Madison.

That rate is a higher proportion than the 5%-15% rate estimated by the Bethesda System, a national standard for reporting thyroid cytopathology, said Dr. Juan Carlos Jaume at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

"The message here is to be aware of your local institutional rates for cancer in FLUS, because following [the Bethesda System] may mislead you and your patient" when deciding on a course of action, be it surgery, repeat biopsy, or observation, he said. "Other institutions [should be encouraged to] do similar analyses to generate more accurate local guidelines for management of FLUS," noted Dr. Jaume, senior author of the study.

Of 1,420 nodules assessed over 2 years at the thyroid clinic at the University of Wisconsin, Madison, 134 (9.4%) were reported as follicular lesions of undetermined significance (FLUS) on fine-needle aspiration. Eighty patients opted for surgery; pathology revealed that 27 (34%) actually had differentiated thyroid cancer. Cancer also was found in four more patients, but at sites different from the original fine-needle aspiration. Most of the cancers (27) were papillary, 3 were follicular, and 1 was a Hurthle cell tumor, the investigators reported.

It’s unlikely the findings were due to selection bias, with patients who were more likely to have cancer opting for surgery. More than half of the patients chose surgery after discussing risks and benefits with their providers, not because of tumor progression. Almost all the others opted for surgery because of compression symptoms or because they had a nodule larger than 4 cm.

Even if there was a bias, "the highest expectation [with Bethesda] is 15%; our rate was 34%," a large difference, Dr. Jaume said. "As soon as we had the rate available, we conveyed the information" to providers so they could more accurately counsel patients. "I think eventually we will see an increase in the number of patients deciding on surgery."

The team performed the study because providers at the university had been relying on the Bethesda estimate to guide patients, but had a hunch that their local FLUS cancer rates were higher.

The majority of the 134 FLUS patients who opted against surgery chose ultrasound monitoring. Among the 22 who chose repeat fine-needle aspiration, half were rediagnosed with benign cytology, 5 were again diagnosed with FLUS, and most of the rest were lost to follow-up.

Among the 80 surgical patients, pathology was benign in 47 and parathyroid tissue was present in 1 biopsy. Records were unavailable for the final patient.

Some cytopathologists tend to call thyroid lesions FLUS more frequently than others; possibly, that predilection has something to do with the discordance in reported cancer rates, Dr. Jaume said.

Ultimately, the solution will be genetic analysis of fine-needle aspiration samples. There is a commercial product on the market, but "we are not using [it] in our institution because the negative predictive value is high, but the positive predictive value is low," he said.

The investigators had no relevant disclosures and had no outside funding for their work.

aotto@frontlinemedcom.com

*Correction, 8/25/2014: An earlier version of this article misspelled Dr. Jaume's name.

CHICAGO – At least in some institutions, about a third of follicular thyroid lesions of undetermined significance are malignant, reported researchers from the University of Wisconsin, Madison.

That rate is a higher proportion than the 5%-15% rate estimated by the Bethesda System, a national standard for reporting thyroid cytopathology, said Dr. Juan Carlos Jaume at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

"The message here is to be aware of your local institutional rates for cancer in FLUS, because following [the Bethesda System] may mislead you and your patient" when deciding on a course of action, be it surgery, repeat biopsy, or observation, he said. "Other institutions [should be encouraged to] do similar analyses to generate more accurate local guidelines for management of FLUS," noted Dr. Jaume, senior author of the study.

Of 1,420 nodules assessed over 2 years at the thyroid clinic at the University of Wisconsin, Madison, 134 (9.4%) were reported as follicular lesions of undetermined significance (FLUS) on fine-needle aspiration. Eighty patients opted for surgery; pathology revealed that 27 (34%) actually had differentiated thyroid cancer. Cancer also was found in four more patients, but at sites different from the original fine-needle aspiration. Most of the cancers (27) were papillary, 3 were follicular, and 1 was a Hurthle cell tumor, the investigators reported.

It’s unlikely the findings were due to selection bias, with patients who were more likely to have cancer opting for surgery. More than half of the patients chose surgery after discussing risks and benefits with their providers, not because of tumor progression. Almost all the others opted for surgery because of compression symptoms or because they had a nodule larger than 4 cm.

Even if there was a bias, "the highest expectation [with Bethesda] is 15%; our rate was 34%," a large difference, Dr. Jaume said. "As soon as we had the rate available, we conveyed the information" to providers so they could more accurately counsel patients. "I think eventually we will see an increase in the number of patients deciding on surgery."

The team performed the study because providers at the university had been relying on the Bethesda estimate to guide patients, but had a hunch that their local FLUS cancer rates were higher.

The majority of the 134 FLUS patients who opted against surgery chose ultrasound monitoring. Among the 22 who chose repeat fine-needle aspiration, half were rediagnosed with benign cytology, 5 were again diagnosed with FLUS, and most of the rest were lost to follow-up.

Among the 80 surgical patients, pathology was benign in 47 and parathyroid tissue was present in 1 biopsy. Records were unavailable for the final patient.

Some cytopathologists tend to call thyroid lesions FLUS more frequently than others; possibly, that predilection has something to do with the discordance in reported cancer rates, Dr. Jaume said.

Ultimately, the solution will be genetic analysis of fine-needle aspiration samples. There is a commercial product on the market, but "we are not using [it] in our institution because the negative predictive value is high, but the positive predictive value is low," he said.

The investigators had no relevant disclosures and had no outside funding for their work.

aotto@frontlinemedcom.com

*Correction, 8/25/2014: An earlier version of this article misspelled Dr. Jaume's name.