M. Alexander Otto

SEATTLE – Postoperative femoral nerve blocks prolong quadricep and hamstring weakness after anterior cruciate ligament reconstruction in young athletes, and delay recovery, according to investigators from the Mayo Clinic in Rochester, Minn.

Because of that, "I’ve stopped using them," said investigator Dr. Amy McIntosh, a pediatric orthopedic surgeon in Rochester.

M. Alexander Otto/Frontline Medical News

In a retrospective study of patients no older than 18 years, her team found that 68% (42 of 62 patients) who got the block – weight-based bupivacaine HCl in all cases – were cleared for sports at 6 months, meaning that their operated knee was at least 85% as strong as their uninjured knee, and at least 90% as functional. Among children who didn’t get the blocks after anterior cruciate ligament reconstruction (ACL), 90% (56 of 62) were ready to return to sports, a significant difference. Overall, unblocked kids were 4.4 times more likely to be cleared at 6 months.

"Kids who didn’t clear at 6 months usually took another 3-4 months. At a year, everybody looked about the same," Dr. McIntosh said at the American Orthopaedic Society for Sports Medicine annual meeting.

Also at 6 months, kids who got the nerve block had significantly greater mean deficits in fast isokinetic knee extensions, a measure of quadricep strength (17.6% in the operated knee vs. 11.2% in the uninjured knee), and fast (9.9% vs. 5.7%) and slow (13.0% vs. 8.5%) isokinetic flexion, a measure of hamstring strength. It didn’t seem to matter if they got a one-shot femoral nerve block or a continuous pump infusion.

Dr. McIntosh initially lobbied Mayo anesthesiologists to use femoral blocks in kids, opting first for the pump. "Then I saw that those kids had a lot of quad atrophy and were taking a longer time to get off their crutches, so I started going to the one-shot block, but they still had quad atrophy, and took a little longer to get off their crutches and get their normal gait back. Now, after seeing this data, I’m done with it," she said.

She’s not alone. Long considered a benign and effective method for short-term pain control, surgeons have been reconsidering the blocks because of similar findings in adults.

"I tell patients [and parents] that they have to decide if they want great pain control up front, or a little more pain in the first few days after surgery," but a quicker return to sports. When offered the choice, young athletes opt against the block because it will likely mean missing an entire season. "That’s what matters to these kids," Dr. McIntosh said.

The nerve block group and control groups were evenly matched; children in both were about 16 years old, on average, with a mean body mass index of about 24 kg/m². There were slightly more girls in the study than boys.

Most of the kids in both groups had patellar tendon autografts, and the rest had hamstring autografts. Those who got nerve blocks had shorter tourniquet (82 vs. 93 minutes), operative (134 vs. 155 minutes.), and anesthesia times (177 vs. 200 minutes).

Dr. McIntosh said he had no relevant financial disclosures. The project was funded internally.

aotto@frontlinemedcom.com

SEATTLE – Postoperative femoral nerve blocks prolong quadricep and hamstring weakness after anterior cruciate ligament reconstruction in young athletes, and delay recovery, according to investigators from the Mayo Clinic in Rochester, Minn.

Because of that, "I’ve stopped using them," said investigator Dr. Amy McIntosh, a pediatric orthopedic surgeon in Rochester.

M. Alexander Otto/Frontline Medical News

In a retrospective study of patients no older than 18 years, her team found that 68% (42 of 62 patients) who got the block – weight-based bupivacaine HCl in all cases – were cleared for sports at 6 months, meaning that their operated knee was at least 85% as strong as their uninjured knee, and at least 90% as functional. Among children who didn’t get the blocks after anterior cruciate ligament reconstruction (ACL), 90% (56 of 62) were ready to return to sports, a significant difference. Overall, unblocked kids were 4.4 times more likely to be cleared at 6 months.

"Kids who didn’t clear at 6 months usually took another 3-4 months. At a year, everybody looked about the same," Dr. McIntosh said at the American Orthopaedic Society for Sports Medicine annual meeting.

Also at 6 months, kids who got the nerve block had significantly greater mean deficits in fast isokinetic knee extensions, a measure of quadricep strength (17.6% in the operated knee vs. 11.2% in the uninjured knee), and fast (9.9% vs. 5.7%) and slow (13.0% vs. 8.5%) isokinetic flexion, a measure of hamstring strength. It didn’t seem to matter if they got a one-shot femoral nerve block or a continuous pump infusion.

Dr. McIntosh initially lobbied Mayo anesthesiologists to use femoral blocks in kids, opting first for the pump. "Then I saw that those kids had a lot of quad atrophy and were taking a longer time to get off their crutches, so I started going to the one-shot block, but they still had quad atrophy, and took a little longer to get off their crutches and get their normal gait back. Now, after seeing this data, I’m done with it," she said.

She’s not alone. Long considered a benign and effective method for short-term pain control, surgeons have been reconsidering the blocks because of similar findings in adults.

"I tell patients [and parents] that they have to decide if they want great pain control up front, or a little more pain in the first few days after surgery," but a quicker return to sports. When offered the choice, young athletes opt against the block because it will likely mean missing an entire season. "That’s what matters to these kids," Dr. McIntosh said.

The nerve block group and control groups were evenly matched; children in both were about 16 years old, on average, with a mean body mass index of about 24 kg/m². There were slightly more girls in the study than boys.

Most of the kids in both groups had patellar tendon autografts, and the rest had hamstring autografts. Those who got nerve blocks had shorter tourniquet (82 vs. 93 minutes), operative (134 vs. 155 minutes.), and anesthesia times (177 vs. 200 minutes).

Dr. McIntosh said he had no relevant financial disclosures. The project was funded internally.

aotto@frontlinemedcom.com

SEATTLE – Postoperative femoral nerve blocks prolong quadricep and hamstring weakness after anterior cruciate ligament reconstruction in young athletes, and delay recovery, according to investigators from the Mayo Clinic in Rochester, Minn.

Because of that, "I’ve stopped using them," said investigator Dr. Amy McIntosh, a pediatric orthopedic surgeon in Rochester.

M. Alexander Otto/Frontline Medical News

In a retrospective study of patients no older than 18 years, her team found that 68% (42 of 62 patients) who got the block – weight-based bupivacaine HCl in all cases – were cleared for sports at 6 months, meaning that their operated knee was at least 85% as strong as their uninjured knee, and at least 90% as functional. Among children who didn’t get the blocks after anterior cruciate ligament reconstruction (ACL), 90% (56 of 62) were ready to return to sports, a significant difference. Overall, unblocked kids were 4.4 times more likely to be cleared at 6 months.

"Kids who didn’t clear at 6 months usually took another 3-4 months. At a year, everybody looked about the same," Dr. McIntosh said at the American Orthopaedic Society for Sports Medicine annual meeting.

Also at 6 months, kids who got the nerve block had significantly greater mean deficits in fast isokinetic knee extensions, a measure of quadricep strength (17.6% in the operated knee vs. 11.2% in the uninjured knee), and fast (9.9% vs. 5.7%) and slow (13.0% vs. 8.5%) isokinetic flexion, a measure of hamstring strength. It didn’t seem to matter if they got a one-shot femoral nerve block or a continuous pump infusion.

Dr. McIntosh initially lobbied Mayo anesthesiologists to use femoral blocks in kids, opting first for the pump. "Then I saw that those kids had a lot of quad atrophy and were taking a longer time to get off their crutches, so I started going to the one-shot block, but they still had quad atrophy, and took a little longer to get off their crutches and get their normal gait back. Now, after seeing this data, I’m done with it," she said.

She’s not alone. Long considered a benign and effective method for short-term pain control, surgeons have been reconsidering the blocks because of similar findings in adults.

"I tell patients [and parents] that they have to decide if they want great pain control up front, or a little more pain in the first few days after surgery," but a quicker return to sports. When offered the choice, young athletes opt against the block because it will likely mean missing an entire season. "That’s what matters to these kids," Dr. McIntosh said.

The nerve block group and control groups were evenly matched; children in both were about 16 years old, on average, with a mean body mass index of about 24 kg/m². There were slightly more girls in the study than boys.

Most of the kids in both groups had patellar tendon autografts, and the rest had hamstring autografts. Those who got nerve blocks had shorter tourniquet (82 vs. 93 minutes), operative (134 vs. 155 minutes.), and anesthesia times (177 vs. 200 minutes).

Dr. McIntosh said he had no relevant financial disclosures. The project was funded internally.

aotto@frontlinemedcom.com

SEATTLE – Arthroscopic Bankart lesion repairs don’t seem to work well in patients who have lost more than 13.5% of their glenoid fossa after dislocating their shoulders; an open inferior capsular shift or Latarjet procedure is likely to be a better bet, according to a review of 72 consecutive soldiers at Tripler Army Medical Center in Honolulu, who had an arthroscopic Bankart repair after shoulder dislocation.

Seven of the 29 patients (24%) who went into the operation with greater levels of bone loss redislocated over an average of about 4 years of follow-up, versus 2 of 37 (5%) who had less than 13.5% of their glenoid fossa missing. When patients who redislocated were excluded, the mean Western Ontario Shoulder Instability (WOSI) score was 43% of normal in the 13.5% or more bone loss group, but about 80% of normal in those who had lost less bone.

In short, bone loss of 13.5% led to "unacceptable clinical outcomes. Patients with bone loss beyond this threshold should be counseled accordingly with consideration for alternative surgical procedures," the investigators concluded.

Surgeons "have to pay a lot more attention to how much bone loss is there. We have traditionally defined the level of bone loss" that triggers an open procedure at 20%. "In today’s world, everybody agrees that 20% is too high, but the" question has been by how much. At 13.5% – judged by preoperative MRI or CT – "two things become clear. They redislocate at too high a level, and they" report too much instability on the WOSI," said lead investigator Dr. John Tokish, now an orthopedic surgeon at the Greenville (S.C.) Health System.

"If you are just evaluating your results based on whether or not the person redislocates, you missed the point. When we evaluate function in these patients with well below 20% bone loss, they have pain and apprehension. Even if their shoulders don’t come out again, these patients are self-limiting," he said.

When arthroscopic Bankart repair is ruled out, Dr. Tokish cautioned, it "doesn’t necessarily mean we should jump right away to a Latarjet," in which the tip of the coracoid process is repositioned to increase glenoid surface area. "Some would argue that a Latarjet is too big a step. An open inferior capsular shift" may be enough, or even superior.

There were 73 operated shoulders in the 72 patients, 68 of whom were men. The average age at surgery was 26.3 years. Glenoid bone loss was calculated by overlaying a circle onto preop images of the fossa. Patients were excluded if they had a previous shoulder operation.

Dr. Tokish had no disclosures. The work was funded internally.

aotto@frontlinemedcom.com

SEATTLE – Arthroscopic Bankart lesion repairs don’t seem to work well in patients who have lost more than 13.5% of their glenoid fossa after dislocating their shoulders; an open inferior capsular shift or Latarjet procedure is likely to be a better bet, according to a review of 72 consecutive soldiers at Tripler Army Medical Center in Honolulu, who had an arthroscopic Bankart repair after shoulder dislocation.

Seven of the 29 patients (24%) who went into the operation with greater levels of bone loss redislocated over an average of about 4 years of follow-up, versus 2 of 37 (5%) who had less than 13.5% of their glenoid fossa missing. When patients who redislocated were excluded, the mean Western Ontario Shoulder Instability (WOSI) score was 43% of normal in the 13.5% or more bone loss group, but about 80% of normal in those who had lost less bone.

In short, bone loss of 13.5% led to "unacceptable clinical outcomes. Patients with bone loss beyond this threshold should be counseled accordingly with consideration for alternative surgical procedures," the investigators concluded.

Surgeons "have to pay a lot more attention to how much bone loss is there. We have traditionally defined the level of bone loss" that triggers an open procedure at 20%. "In today’s world, everybody agrees that 20% is too high, but the" question has been by how much. At 13.5% – judged by preoperative MRI or CT – "two things become clear. They redislocate at too high a level, and they" report too much instability on the WOSI," said lead investigator Dr. John Tokish, now an orthopedic surgeon at the Greenville (S.C.) Health System.

"If you are just evaluating your results based on whether or not the person redislocates, you missed the point. When we evaluate function in these patients with well below 20% bone loss, they have pain and apprehension. Even if their shoulders don’t come out again, these patients are self-limiting," he said.

When arthroscopic Bankart repair is ruled out, Dr. Tokish cautioned, it "doesn’t necessarily mean we should jump right away to a Latarjet," in which the tip of the coracoid process is repositioned to increase glenoid surface area. "Some would argue that a Latarjet is too big a step. An open inferior capsular shift" may be enough, or even superior.

There were 73 operated shoulders in the 72 patients, 68 of whom were men. The average age at surgery was 26.3 years. Glenoid bone loss was calculated by overlaying a circle onto preop images of the fossa. Patients were excluded if they had a previous shoulder operation.

Dr. Tokish had no disclosures. The work was funded internally.

aotto@frontlinemedcom.com

SEATTLE – Arthroscopic Bankart lesion repairs don’t seem to work well in patients who have lost more than 13.5% of their glenoid fossa after dislocating their shoulders; an open inferior capsular shift or Latarjet procedure is likely to be a better bet, according to a review of 72 consecutive soldiers at Tripler Army Medical Center in Honolulu, who had an arthroscopic Bankart repair after shoulder dislocation.

Seven of the 29 patients (24%) who went into the operation with greater levels of bone loss redislocated over an average of about 4 years of follow-up, versus 2 of 37 (5%) who had less than 13.5% of their glenoid fossa missing. When patients who redislocated were excluded, the mean Western Ontario Shoulder Instability (WOSI) score was 43% of normal in the 13.5% or more bone loss group, but about 80% of normal in those who had lost less bone.

In short, bone loss of 13.5% led to "unacceptable clinical outcomes. Patients with bone loss beyond this threshold should be counseled accordingly with consideration for alternative surgical procedures," the investigators concluded.

Surgeons "have to pay a lot more attention to how much bone loss is there. We have traditionally defined the level of bone loss" that triggers an open procedure at 20%. "In today’s world, everybody agrees that 20% is too high, but the" question has been by how much. At 13.5% – judged by preoperative MRI or CT – "two things become clear. They redislocate at too high a level, and they" report too much instability on the WOSI," said lead investigator Dr. John Tokish, now an orthopedic surgeon at the Greenville (S.C.) Health System.

"If you are just evaluating your results based on whether or not the person redislocates, you missed the point. When we evaluate function in these patients with well below 20% bone loss, they have pain and apprehension. Even if their shoulders don’t come out again, these patients are self-limiting," he said.

When arthroscopic Bankart repair is ruled out, Dr. Tokish cautioned, it "doesn’t necessarily mean we should jump right away to a Latarjet," in which the tip of the coracoid process is repositioned to increase glenoid surface area. "Some would argue that a Latarjet is too big a step. An open inferior capsular shift" may be enough, or even superior.

There were 73 operated shoulders in the 72 patients, 68 of whom were men. The average age at surgery was 26.3 years. Glenoid bone loss was calculated by overlaying a circle onto preop images of the fossa. Patients were excluded if they had a previous shoulder operation.

Dr. Tokish had no disclosures. The work was funded internally.

aotto@frontlinemedcom.com

SEATTLE – A total of 57% of girls and 35% of boys aged 13-17 years has received at least one dose of human papillomavirus vaccine as of 2013, according to national estimates released by the Centers for Disease Control and Prevention.

That’s an increase from 2012 data that found only 54% of girls and 21% of boys in that age group had received at least one dose of the vaccine.

The reason for the uptick is that clinicians are increasingly recommending vaccination against human papillomavirus (HPV). In 2013, 64% of girls’ parents and 42% of boys’ parents reported a provider recommendation for the vaccine, up from 61% and 28%, respectively, in 2012. The data were published July 25 in the Morbidity and Mortality Weekly Report (2014;63:620-4).

Even so, "it is concerning that approximately one-third of parents of girls and more than half of parents of boys reported that their child’s clinician had not recommended that their child receive an HPV vaccination. The lack of a clinician recommendation among parents of boys might reflect knowledge limitations among clinicians, because the recommendation for routine HPV vaccination for boys has been in place only since December 2011," wrote the investigators, led by Shannon Stokley of the Immunization Services Division at the CDC’s National Center for Immunization and Respiratory Diseases.

To increase uptake, the agency asked clinicians to recommend the vaccine when kids come in for other shots, such as tetanus, diphtheria, and pertussis (Tdap). If HPV shots were piggybacked onto those visits, CDC estimated that 91% of girls born in 2000 would have gotten at least one dose of the vaccine.

Meanwhile, about 86% of adolescents had received at least one Tdap shot in the 2013 survey. "The high coverage rate of Tdap vaccine shows us that it is certainly possible to reach our goal of vaccinating 80% of adolescents against cancers caused by HPV," NCIRD director Dr. Anne Schuchat said in a statement.

The findings come from a random-digit–dialed phone survey of the parents and guardians of 18,000 adolescents aged 13-17 years old; investigators checked medical records to verify what they were told.

Safety concerns also caused parents to shy away from the vaccine, but data do not bear out these concerns. "In the 8 years of post-licensure vaccine safety monitoring and evaluation conducted independently by federal agencies and vaccine manufacturers, and after 67 million doses of HPV vaccine have been distributed, no serious safety concerns have been linked" to the vaccine, the CDC noted.

As in 2012, about one-third of adolescent girls had all three doses recommend by the CDC’s Advisory Committee on Immunization Practices.

The agency has put together several resources to promote the vaccine, including an HPV website for clinicians, a tip sheet for talking to parents, and continuing medical education programs about the impact of persistent HPV infection.

The investigators are employees of the CDC.

aotto@frontlinemedcom.com 

SEATTLE – A total of 57% of girls and 35% of boys aged 13-17 years has received at least one dose of human papillomavirus vaccine as of 2013, according to national estimates released by the Centers for Disease Control and Prevention.

That’s an increase from 2012 data that found only 54% of girls and 21% of boys in that age group had received at least one dose of the vaccine.

The reason for the uptick is that clinicians are increasingly recommending vaccination against human papillomavirus (HPV). In 2013, 64% of girls’ parents and 42% of boys’ parents reported a provider recommendation for the vaccine, up from 61% and 28%, respectively, in 2012. The data were published July 25 in the Morbidity and Mortality Weekly Report (2014;63:620-4).

Even so, "it is concerning that approximately one-third of parents of girls and more than half of parents of boys reported that their child’s clinician had not recommended that their child receive an HPV vaccination. The lack of a clinician recommendation among parents of boys might reflect knowledge limitations among clinicians, because the recommendation for routine HPV vaccination for boys has been in place only since December 2011," wrote the investigators, led by Shannon Stokley of the Immunization Services Division at the CDC’s National Center for Immunization and Respiratory Diseases.

To increase uptake, the agency asked clinicians to recommend the vaccine when kids come in for other shots, such as tetanus, diphtheria, and pertussis (Tdap). If HPV shots were piggybacked onto those visits, CDC estimated that 91% of girls born in 2000 would have gotten at least one dose of the vaccine.

Meanwhile, about 86% of adolescents had received at least one Tdap shot in the 2013 survey. "The high coverage rate of Tdap vaccine shows us that it is certainly possible to reach our goal of vaccinating 80% of adolescents against cancers caused by HPV," NCIRD director Dr. Anne Schuchat said in a statement.

The findings come from a random-digit–dialed phone survey of the parents and guardians of 18,000 adolescents aged 13-17 years old; investigators checked medical records to verify what they were told.

Safety concerns also caused parents to shy away from the vaccine, but data do not bear out these concerns. "In the 8 years of post-licensure vaccine safety monitoring and evaluation conducted independently by federal agencies and vaccine manufacturers, and after 67 million doses of HPV vaccine have been distributed, no serious safety concerns have been linked" to the vaccine, the CDC noted.

As in 2012, about one-third of adolescent girls had all three doses recommend by the CDC’s Advisory Committee on Immunization Practices.

The agency has put together several resources to promote the vaccine, including an HPV website for clinicians, a tip sheet for talking to parents, and continuing medical education programs about the impact of persistent HPV infection.

The investigators are employees of the CDC.

aotto@frontlinemedcom.com 

SEATTLE – A total of 57% of girls and 35% of boys aged 13-17 years has received at least one dose of human papillomavirus vaccine as of 2013, according to national estimates released by the Centers for Disease Control and Prevention.

That’s an increase from 2012 data that found only 54% of girls and 21% of boys in that age group had received at least one dose of the vaccine.

The reason for the uptick is that clinicians are increasingly recommending vaccination against human papillomavirus (HPV). In 2013, 64% of girls’ parents and 42% of boys’ parents reported a provider recommendation for the vaccine, up from 61% and 28%, respectively, in 2012. The data were published July 25 in the Morbidity and Mortality Weekly Report (2014;63:620-4).

Even so, "it is concerning that approximately one-third of parents of girls and more than half of parents of boys reported that their child’s clinician had not recommended that their child receive an HPV vaccination. The lack of a clinician recommendation among parents of boys might reflect knowledge limitations among clinicians, because the recommendation for routine HPV vaccination for boys has been in place only since December 2011," wrote the investigators, led by Shannon Stokley of the Immunization Services Division at the CDC’s National Center for Immunization and Respiratory Diseases.

To increase uptake, the agency asked clinicians to recommend the vaccine when kids come in for other shots, such as tetanus, diphtheria, and pertussis (Tdap). If HPV shots were piggybacked onto those visits, CDC estimated that 91% of girls born in 2000 would have gotten at least one dose of the vaccine.

Meanwhile, about 86% of adolescents had received at least one Tdap shot in the 2013 survey. "The high coverage rate of Tdap vaccine shows us that it is certainly possible to reach our goal of vaccinating 80% of adolescents against cancers caused by HPV," NCIRD director Dr. Anne Schuchat said in a statement.

The findings come from a random-digit–dialed phone survey of the parents and guardians of 18,000 adolescents aged 13-17 years old; investigators checked medical records to verify what they were told.

Safety concerns also caused parents to shy away from the vaccine, but data do not bear out these concerns. "In the 8 years of post-licensure vaccine safety monitoring and evaluation conducted independently by federal agencies and vaccine manufacturers, and after 67 million doses of HPV vaccine have been distributed, no serious safety concerns have been linked" to the vaccine, the CDC noted.

As in 2012, about one-third of adolescent girls had all three doses recommend by the CDC’s Advisory Committee on Immunization Practices.

The agency has put together several resources to promote the vaccine, including an HPV website for clinicians, a tip sheet for talking to parents, and continuing medical education programs about the impact of persistent HPV infection.

The investigators are employees of the CDC.

aotto@frontlinemedcom.com 

SEATTLE – A total of 57% of girls and 35% of boys aged 13-17 years has received at least one dose of human papillomavirus vaccine as of 2013, according to national estimates released by the Centers for Disease Control and Prevention.

That’s an increase from 2012 data that found only 54% of girls and 21% of boys in that age group had received at least one dose of the vaccine.

The reason for the uptick is that clinicians are increasingly recommending vaccination against human papillomavirus (HPV). In 2013, 64% of girls’ parents and 42% of boys’ parents reported a provider recommendation for the vaccine, up from 61% and 28%, respectively, in 2012. The data were published July 25 in the Morbidity and Mortality Weekly Report (2014;63:620-4).

Even so, "it is concerning that approximately one-third of parents of girls and more than half of parents of boys reported that their child’s clinician had not recommended that their child receive an HPV vaccination. The lack of a clinician recommendation among parents of boys might reflect knowledge limitations among clinicians, because the recommendation for routine HPV vaccination for boys has been in place only since December 2011," wrote the investigators, led by Shannon Stokley of the Immunization Services Division at the CDC’s National Center for Immunization and Respiratory Diseases.

To increase uptake, the agency asked clinicians to recommend the vaccine when kids come in for other shots, such as tetanus, diphtheria, and pertussis (Tdap). If HPV shots were piggybacked onto those visits, CDC estimated that 91% of girls born in 2000 would have gotten at least one dose of the vaccine.

Meanwhile, about 86% of adolescents had received at least one Tdap shot in the 2013 survey. "The high coverage rate of Tdap vaccine shows us that it is certainly possible to reach our goal of vaccinating 80% of adolescents against cancers caused by HPV," NCIRD director Dr. Anne Schuchat said in a statement.

The findings come from a random-digit–dialed phone survey of the parents and guardians of 18,000 adolescents aged 13-17 years old; investigators checked medical records to verify what they were told.

Safety concerns also caused parents to shy away from the vaccine, but data do not bear out these concerns. "In the 8 years of post-licensure vaccine safety monitoring and evaluation conducted independently by federal agencies and vaccine manufacturers, and after 67 million doses of HPV vaccine have been distributed, no serious safety concerns have been linked" to the vaccine, the CDC noted.

As in 2012, about one-third of adolescent girls had all three doses recommend by the CDC’s Advisory Committee on Immunization Practices.

The agency has put together several resources to promote the vaccine, including an HPV website for clinicians, a tip sheet for talking to parents, and continuing medical education programs about the impact of persistent HPV infection.

The investigators are employees of the CDC.

aotto@frontlinemedcom.com

SEATTLE – A total of 57% of girls and 35% of boys aged 13-17 years has received at least one dose of human papillomavirus vaccine as of 2013, according to national estimates released by the Centers for Disease Control and Prevention.

That’s an increase from 2012 data that found only 54% of girls and 21% of boys in that age group had received at least one dose of the vaccine.

The reason for the uptick is that clinicians are increasingly recommending vaccination against human papillomavirus (HPV). In 2013, 64% of girls’ parents and 42% of boys’ parents reported a provider recommendation for the vaccine, up from 61% and 28%, respectively, in 2012. The data were published July 25 in the Morbidity and Mortality Weekly Report (2014;63:620-4).

Even so, "it is concerning that approximately one-third of parents of girls and more than half of parents of boys reported that their child’s clinician had not recommended that their child receive an HPV vaccination. The lack of a clinician recommendation among parents of boys might reflect knowledge limitations among clinicians, because the recommendation for routine HPV vaccination for boys has been in place only since December 2011," wrote the investigators, led by Shannon Stokley of the Immunization Services Division at the CDC’s National Center for Immunization and Respiratory Diseases.

To increase uptake, the agency asked clinicians to recommend the vaccine when kids come in for other shots, such as tetanus, diphtheria, and pertussis (Tdap). If HPV shots were piggybacked onto those visits, CDC estimated that 91% of girls born in 2000 would have gotten at least one dose of the vaccine.

Meanwhile, about 86% of adolescents had received at least one Tdap shot in the 2013 survey. "The high coverage rate of Tdap vaccine shows us that it is certainly possible to reach our goal of vaccinating 80% of adolescents against cancers caused by HPV," NCIRD director Dr. Anne Schuchat said in a statement.

The findings come from a random-digit–dialed phone survey of the parents and guardians of 18,000 adolescents aged 13-17 years old; investigators checked medical records to verify what they were told.

Safety concerns also caused parents to shy away from the vaccine, but data do not bear out these concerns. "In the 8 years of post-licensure vaccine safety monitoring and evaluation conducted independently by federal agencies and vaccine manufacturers, and after 67 million doses of HPV vaccine have been distributed, no serious safety concerns have been linked" to the vaccine, the CDC noted.

As in 2012, about one-third of adolescent girls had all three doses recommend by the CDC’s Advisory Committee on Immunization Practices.

The agency has put together several resources to promote the vaccine, including an HPV website for clinicians, a tip sheet for talking to parents, and continuing medical education programs about the impact of persistent HPV infection.

The investigators are employees of the CDC.

aotto@frontlinemedcom.com

SEATTLE – A total of 57% of girls and 35% of boys aged 13-17 years has received at least one dose of human papillomavirus vaccine as of 2013, according to national estimates released by the Centers for Disease Control and Prevention.

That’s an increase from 2012 data that found only 54% of girls and 21% of boys in that age group had received at least one dose of the vaccine.

The reason for the uptick is that clinicians are increasingly recommending vaccination against human papillomavirus (HPV). In 2013, 64% of girls’ parents and 42% of boys’ parents reported a provider recommendation for the vaccine, up from 61% and 28%, respectively, in 2012. The data were published July 25 in the Morbidity and Mortality Weekly Report (2014;63:620-4).

Even so, "it is concerning that approximately one-third of parents of girls and more than half of parents of boys reported that their child’s clinician had not recommended that their child receive an HPV vaccination. The lack of a clinician recommendation among parents of boys might reflect knowledge limitations among clinicians, because the recommendation for routine HPV vaccination for boys has been in place only since December 2011," wrote the investigators, led by Shannon Stokley of the Immunization Services Division at the CDC’s National Center for Immunization and Respiratory Diseases.

To increase uptake, the agency asked clinicians to recommend the vaccine when kids come in for other shots, such as tetanus, diphtheria, and pertussis (Tdap). If HPV shots were piggybacked onto those visits, CDC estimated that 91% of girls born in 2000 would have gotten at least one dose of the vaccine.

Meanwhile, about 86% of adolescents had received at least one Tdap shot in the 2013 survey. "The high coverage rate of Tdap vaccine shows us that it is certainly possible to reach our goal of vaccinating 80% of adolescents against cancers caused by HPV," NCIRD director Dr. Anne Schuchat said in a statement.

The findings come from a random-digit–dialed phone survey of the parents and guardians of 18,000 adolescents aged 13-17 years old; investigators checked medical records to verify what they were told.

Safety concerns also caused parents to shy away from the vaccine, but data do not bear out these concerns. "In the 8 years of post-licensure vaccine safety monitoring and evaluation conducted independently by federal agencies and vaccine manufacturers, and after 67 million doses of HPV vaccine have been distributed, no serious safety concerns have been linked" to the vaccine, the CDC noted.

As in 2012, about one-third of adolescent girls had all three doses recommend by the CDC’s Advisory Committee on Immunization Practices.

The agency has put together several resources to promote the vaccine, including an HPV website for clinicians, a tip sheet for talking to parents, and continuing medical education programs about the impact of persistent HPV infection.

The investigators are employees of the CDC.

aotto@frontlinemedcom.com

SEATTLE – In about 80% of patients, patellofemoral knee pain is due to muscular dysfunction and often responds to strengthening and other conservative measures, according to Dr. Christian Lattermann of the department of orthopedic surgery at the University of Kentucky, Lexington.

Surgery should be the last option, and "only if you have identified a structural or functional pathology that you can correct." When surgery is indicated, lateral releases should be avoided; lateral retinacular lengthening is the better option because it preserves the anatomical bridle that keeps the knee cap tracking properly. "Surgically, you can lengthen it by about 2 cm, and that’s usually enough," Dr. Lattermann said at the annual meeting of the American Orthopaedic Society for Sports Medicine.

Patellofemoral pain is common but also frustrating to treat. Finding the cause is difficult; whether it’s subluxation, instability, plica, tendinitis, or simply a noisy knee, "all of it will be described to you as pain. You need to figure it out," he said.

Injections might help. "If you inject them, and they have absolutely no pain," it suggests extraarticular issues. In those cases, "rehab is probably your first bet." Meanwhile, effusions hint at intraarticular pathology, he said.

"McConnell taping is an excellent tool, and will help make the surgical decision. If it’s truly effective," soft tissue realignment might be enough, he said.

"If you have a patient who tells you they have pain all the time everywhere, then think about deconditioning." After perhaps years of compensating for chronic knee problems, the musculature is weak – perhaps in both knees – and gait alterations are also likely. Patients "are basically slamming into their knee cap with every step. You have to start the process of getting them out of that," and it doesn’t involve surgery, at least at first, he said.

"Many of these patients are difficult to manage because as soon as you want to look at their knee, they start becoming apprehensive. It’s not because they are crazy, but because they’ve had experiences that were hard to deal with. You can often help them by talking and identifying those for them, and putting them into perspective," he said.

If they only have pain, "we essentially start with physical therapy," including strengthening and stretching the core, hip, and leg muscles. Even in patients with apprehension or instability, "I’d be very careful to try to identify muscular dysfunction. You always need to treat that," Dr. Lattermann said.

Runners and other athletes might get into problems by overdoing it, which can lead to chronic muscle fatigue and patella overload. For some, the root of the problem might be an odd gait or an odd way or running. "You need to basically teach these people how to move properly," he said.

In addition to MRI and CT to assess anatomy and biomechanics, bone scans might demonstrate a "hot spot that will help guide you." Also, when it’s an issue, weight is a "discussion that happens almost every time with every patient," he said.

Dr. Lattermann is a consultant for Ceterix, Icartilage, and Sanofi/Genzyme.

aotto@frontlinemedcom.com

SEATTLE – In about 80% of patients, patellofemoral knee pain is due to muscular dysfunction and often responds to strengthening and other conservative measures, according to Dr. Christian Lattermann of the department of orthopedic surgery at the University of Kentucky, Lexington.

Surgery should be the last option, and "only if you have identified a structural or functional pathology that you can correct." When surgery is indicated, lateral releases should be avoided; lateral retinacular lengthening is the better option because it preserves the anatomical bridle that keeps the knee cap tracking properly. "Surgically, you can lengthen it by about 2 cm, and that’s usually enough," Dr. Lattermann said at the annual meeting of the American Orthopaedic Society for Sports Medicine.

Patellofemoral pain is common but also frustrating to treat. Finding the cause is difficult; whether it’s subluxation, instability, plica, tendinitis, or simply a noisy knee, "all of it will be described to you as pain. You need to figure it out," he said.

Injections might help. "If you inject them, and they have absolutely no pain," it suggests extraarticular issues. In those cases, "rehab is probably your first bet." Meanwhile, effusions hint at intraarticular pathology, he said.

"McConnell taping is an excellent tool, and will help make the surgical decision. If it’s truly effective," soft tissue realignment might be enough, he said.

"If you have a patient who tells you they have pain all the time everywhere, then think about deconditioning." After perhaps years of compensating for chronic knee problems, the musculature is weak – perhaps in both knees – and gait alterations are also likely. Patients "are basically slamming into their knee cap with every step. You have to start the process of getting them out of that," and it doesn’t involve surgery, at least at first, he said.

"Many of these patients are difficult to manage because as soon as you want to look at their knee, they start becoming apprehensive. It’s not because they are crazy, but because they’ve had experiences that were hard to deal with. You can often help them by talking and identifying those for them, and putting them into perspective," he said.

If they only have pain, "we essentially start with physical therapy," including strengthening and stretching the core, hip, and leg muscles. Even in patients with apprehension or instability, "I’d be very careful to try to identify muscular dysfunction. You always need to treat that," Dr. Lattermann said.

Runners and other athletes might get into problems by overdoing it, which can lead to chronic muscle fatigue and patella overload. For some, the root of the problem might be an odd gait or an odd way or running. "You need to basically teach these people how to move properly," he said.

In addition to MRI and CT to assess anatomy and biomechanics, bone scans might demonstrate a "hot spot that will help guide you." Also, when it’s an issue, weight is a "discussion that happens almost every time with every patient," he said.

Dr. Lattermann is a consultant for Ceterix, Icartilage, and Sanofi/Genzyme.

aotto@frontlinemedcom.com

SEATTLE – In about 80% of patients, patellofemoral knee pain is due to muscular dysfunction and often responds to strengthening and other conservative measures, according to Dr. Christian Lattermann of the department of orthopedic surgery at the University of Kentucky, Lexington.

Surgery should be the last option, and "only if you have identified a structural or functional pathology that you can correct." When surgery is indicated, lateral releases should be avoided; lateral retinacular lengthening is the better option because it preserves the anatomical bridle that keeps the knee cap tracking properly. "Surgically, you can lengthen it by about 2 cm, and that’s usually enough," Dr. Lattermann said at the annual meeting of the American Orthopaedic Society for Sports Medicine.

Patellofemoral pain is common but also frustrating to treat. Finding the cause is difficult; whether it’s subluxation, instability, plica, tendinitis, or simply a noisy knee, "all of it will be described to you as pain. You need to figure it out," he said.

Injections might help. "If you inject them, and they have absolutely no pain," it suggests extraarticular issues. In those cases, "rehab is probably your first bet." Meanwhile, effusions hint at intraarticular pathology, he said.

"McConnell taping is an excellent tool, and will help make the surgical decision. If it’s truly effective," soft tissue realignment might be enough, he said.

"If you have a patient who tells you they have pain all the time everywhere, then think about deconditioning." After perhaps years of compensating for chronic knee problems, the musculature is weak – perhaps in both knees – and gait alterations are also likely. Patients "are basically slamming into their knee cap with every step. You have to start the process of getting them out of that," and it doesn’t involve surgery, at least at first, he said.

"Many of these patients are difficult to manage because as soon as you want to look at their knee, they start becoming apprehensive. It’s not because they are crazy, but because they’ve had experiences that were hard to deal with. You can often help them by talking and identifying those for them, and putting them into perspective," he said.

If they only have pain, "we essentially start with physical therapy," including strengthening and stretching the core, hip, and leg muscles. Even in patients with apprehension or instability, "I’d be very careful to try to identify muscular dysfunction. You always need to treat that," Dr. Lattermann said.

Runners and other athletes might get into problems by overdoing it, which can lead to chronic muscle fatigue and patella overload. For some, the root of the problem might be an odd gait or an odd way or running. "You need to basically teach these people how to move properly," he said.

In addition to MRI and CT to assess anatomy and biomechanics, bone scans might demonstrate a "hot spot that will help guide you." Also, when it’s an issue, weight is a "discussion that happens almost every time with every patient," he said.

Dr. Lattermann is a consultant for Ceterix, Icartilage, and Sanofi/Genzyme.

aotto@frontlinemedcom.com

SAN DIEGO – Three days of acetaminophen seemed to lower creatinine levels in severely septic patients, suggesting a renoprotective effect, according to results from a phase II study out of Vanderbilt University in Nashville, Tenn.

Investigators there randomized 18 septic ICU patients to acetaminophen 1 g every 6 hours for 3 days and 22 patients to placebo, both delivered by mouth or feeding tube. The patients had all been in the ICU for less than 24 hours, and had detectable levels of plasma cell-free hemoglobin (CFH).

The findings were presented at an international conference of the American Thoracic Society.

©Ingram Publishing/thinkstockphotos.com

CFH has been associated with death in a number of conditions. The iron separates, radicalizes, and causes oxidative injury, especially to the kidneys. Acetaminophen chemically reduces the iron, and has been shown to counter the harm.

In an earlier observational study, the Vanderbilt team found that detectible CFH is common in ICU sepsis patients, as well as elevated plasma levels of F₂-isoprostanes, an indicator of oxidative injury. They also observed that CFH was associated with death, and that exposure to acetaminophen seemed to reduce F₂-isoprostanes levels and improve survival (Crit Care Med. 2013;41:784-90).

The findings prompted the phase II investigation. The team found that the acetaminophen group had lower levels of F₂-isoprostanes on study day 2 (mean 24.9 pg/mL vs. 41.2 pg/mL) and lower levels of serum creatinine on study day 3 (mean 1.0 mg/dL vs. 1.3 mg/dL). These differences were significant and the renal benefit persisted throughout hospitalization.

Acetaminophen patients overall started with a lower mean baseline creatinine level (1.63 mg/dL vs. 2.06 mg/dL), so the investigators reran their analysis, excluding patients on renal replacement therapy. "The baseline imbalance went away, and the story remained the same: There was still a significant decrease in serum creatinine in the acetaminophen group," said lead investigator Dr. David Janz, a critical care fellow at Vanderbilt.

Despite a favorable trend, acetaminophen did not significantly improve survival, a secondary outcome; one (5.6%) acetaminophen and four (18.2%) placebo patients died.

Still, the results are strong enough to suggest that acetaminophen might one day prove to be "a potent intervention to improve sepsis outcomes. Even small creatinine changes are associated with increased length of stay and mortality," Dr. Janz said.

"Our trial contains some negative results" – most notably no significant effect on day 3 F₂-isoprostanes levels – but "the consistent reduction in creatinine across a number of different analyses and the biologic plausibility underlying this signal prompt further investigation. We need larger studies that focus on length of stay and mortality," he said.

Acetaminophen patients were slightly younger (50 vs. 58 years), but besides that and the baseline creatinine difference, the groups were well matched. Both had mean Apache II scores in the low 20s. Nine acetaminophen patients (50%) and seven placebo patients (32%) were intubated.

Both groups received a median of 12 study doses. There was no statistical between-group difference in the number of patients whose AST/ALT topped 400 U/L, a stop-point hit by two acetaminophen patients and one placebo patient. No one in the acetaminophen group developed a rash.

Patients who had liver disease or who had gotten acetaminophen within 48 hours were among those excluded from the study.

The work was funded by the National Institutes of Health and the American Heart Association. Dr. Janz had no disclosures.

aotto@frontlinemedcom.com

SAN DIEGO – Three days of acetaminophen seemed to lower creatinine levels in severely septic patients, suggesting a renoprotective effect, according to results from a phase II study out of Vanderbilt University in Nashville, Tenn.

Investigators there randomized 18 septic ICU patients to acetaminophen 1 g every 6 hours for 3 days and 22 patients to placebo, both delivered by mouth or feeding tube. The patients had all been in the ICU for less than 24 hours, and had detectable levels of plasma cell-free hemoglobin (CFH).

The findings were presented at an international conference of the American Thoracic Society.

©Ingram Publishing/thinkstockphotos.com

CFH has been associated with death in a number of conditions. The iron separates, radicalizes, and causes oxidative injury, especially to the kidneys. Acetaminophen chemically reduces the iron, and has been shown to counter the harm.

In an earlier observational study, the Vanderbilt team found that detectible CFH is common in ICU sepsis patients, as well as elevated plasma levels of F₂-isoprostanes, an indicator of oxidative injury. They also observed that CFH was associated with death, and that exposure to acetaminophen seemed to reduce F₂-isoprostanes levels and improve survival (Crit Care Med. 2013;41:784-90).

The findings prompted the phase II investigation. The team found that the acetaminophen group had lower levels of F₂-isoprostanes on study day 2 (mean 24.9 pg/mL vs. 41.2 pg/mL) and lower levels of serum creatinine on study day 3 (mean 1.0 mg/dL vs. 1.3 mg/dL). These differences were significant and the renal benefit persisted throughout hospitalization.

Acetaminophen patients overall started with a lower mean baseline creatinine level (1.63 mg/dL vs. 2.06 mg/dL), so the investigators reran their analysis, excluding patients on renal replacement therapy. "The baseline imbalance went away, and the story remained the same: There was still a significant decrease in serum creatinine in the acetaminophen group," said lead investigator Dr. David Janz, a critical care fellow at Vanderbilt.

Despite a favorable trend, acetaminophen did not significantly improve survival, a secondary outcome; one (5.6%) acetaminophen and four (18.2%) placebo patients died.

Still, the results are strong enough to suggest that acetaminophen might one day prove to be "a potent intervention to improve sepsis outcomes. Even small creatinine changes are associated with increased length of stay and mortality," Dr. Janz said.

"Our trial contains some negative results" – most notably no significant effect on day 3 F₂-isoprostanes levels – but "the consistent reduction in creatinine across a number of different analyses and the biologic plausibility underlying this signal prompt further investigation. We need larger studies that focus on length of stay and mortality," he said.

Acetaminophen patients were slightly younger (50 vs. 58 years), but besides that and the baseline creatinine difference, the groups were well matched. Both had mean Apache II scores in the low 20s. Nine acetaminophen patients (50%) and seven placebo patients (32%) were intubated.

Both groups received a median of 12 study doses. There was no statistical between-group difference in the number of patients whose AST/ALT topped 400 U/L, a stop-point hit by two acetaminophen patients and one placebo patient. No one in the acetaminophen group developed a rash.

Patients who had liver disease or who had gotten acetaminophen within 48 hours were among those excluded from the study.

The work was funded by the National Institutes of Health and the American Heart Association. Dr. Janz had no disclosures.

aotto@frontlinemedcom.com

SAN DIEGO – Three days of acetaminophen seemed to lower creatinine levels in severely septic patients, suggesting a renoprotective effect, according to results from a phase II study out of Vanderbilt University in Nashville, Tenn.

Investigators there randomized 18 septic ICU patients to acetaminophen 1 g every 6 hours for 3 days and 22 patients to placebo, both delivered by mouth or feeding tube. The patients had all been in the ICU for less than 24 hours, and had detectable levels of plasma cell-free hemoglobin (CFH).

The findings were presented at an international conference of the American Thoracic Society.

©Ingram Publishing/thinkstockphotos.com

CFH has been associated with death in a number of conditions. The iron separates, radicalizes, and causes oxidative injury, especially to the kidneys. Acetaminophen chemically reduces the iron, and has been shown to counter the harm.

In an earlier observational study, the Vanderbilt team found that detectible CFH is common in ICU sepsis patients, as well as elevated plasma levels of F₂-isoprostanes, an indicator of oxidative injury. They also observed that CFH was associated with death, and that exposure to acetaminophen seemed to reduce F₂-isoprostanes levels and improve survival (Crit Care Med. 2013;41:784-90).

The findings prompted the phase II investigation. The team found that the acetaminophen group had lower levels of F₂-isoprostanes on study day 2 (mean 24.9 pg/mL vs. 41.2 pg/mL) and lower levels of serum creatinine on study day 3 (mean 1.0 mg/dL vs. 1.3 mg/dL). These differences were significant and the renal benefit persisted throughout hospitalization.

Acetaminophen patients overall started with a lower mean baseline creatinine level (1.63 mg/dL vs. 2.06 mg/dL), so the investigators reran their analysis, excluding patients on renal replacement therapy. "The baseline imbalance went away, and the story remained the same: There was still a significant decrease in serum creatinine in the acetaminophen group," said lead investigator Dr. David Janz, a critical care fellow at Vanderbilt.

Despite a favorable trend, acetaminophen did not significantly improve survival, a secondary outcome; one (5.6%) acetaminophen and four (18.2%) placebo patients died.

Still, the results are strong enough to suggest that acetaminophen might one day prove to be "a potent intervention to improve sepsis outcomes. Even small creatinine changes are associated with increased length of stay and mortality," Dr. Janz said.

"Our trial contains some negative results" – most notably no significant effect on day 3 F₂-isoprostanes levels – but "the consistent reduction in creatinine across a number of different analyses and the biologic plausibility underlying this signal prompt further investigation. We need larger studies that focus on length of stay and mortality," he said.

Acetaminophen patients were slightly younger (50 vs. 58 years), but besides that and the baseline creatinine difference, the groups were well matched. Both had mean Apache II scores in the low 20s. Nine acetaminophen patients (50%) and seven placebo patients (32%) were intubated.

Both groups received a median of 12 study doses. There was no statistical between-group difference in the number of patients whose AST/ALT topped 400 U/L, a stop-point hit by two acetaminophen patients and one placebo patient. No one in the acetaminophen group developed a rash.

Patients who had liver disease or who had gotten acetaminophen within 48 hours were among those excluded from the study.

The work was funded by the National Institutes of Health and the American Heart Association. Dr. Janz had no disclosures.

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

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 – Hyponatremia quadruples the risk of osteoporosis and fragility fractures, according to a retrospective database study presented at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

A team from Georgetown University in Washington matched 30,517 patients diagnosed with osteoporosis to 30,517 controls for age, race, sex, and how long they had been in the database of the MedStar Health System, which serves Baltimore and Washington.

The investigators found that patients with chronic hyponatremia – at least two sodium values below 135 mmol/L at least 1 year apart – were far more likely to be later diagnosed with osteoporosis (adjusted odds ratio, 3.99). Recent hyponatremia – at least one value below 135 mmol/L in the previous 30 days – also increased the risk (aOR, 3.08). In contrast, glucocorticoid use, a known osteoporosis risk factor, was associated with a far lower risk (aOR, 1.4), the team reported in a poster session at the meeting.

The researchers had similar results when they matched 46,256 patients with fragility fractures to 46,256 without: The fracture risk was substantially increased in patients with chronic hyponatremia (aOR, 4.71) and recent hyponatremia (aOR, 3.08). A previous diagnosis of osteoporosis – again, a known risk factor – increased the risk only moderately (aOR, 1.8).

The severity of hyponatremia played a role, too; patients with at least one value below 125 mmol/L had the highest risk for osteoporosis and fragility fractures.

The findings were all statistically significant.

"The results of this study support the hypothesis that hyponatremia is a significant and clinically important risk factor for both osteoporosis and bone fractures in inpatients and outpatients," the team concluded.

"We were surprised by the odds ratios and how strong a factor this was. Right now, hyponatremia is not an indication for bone mineral density [testing] because it’s never been considered to be a risk factor. It ought to be added as an indication. Patients with hyponatremia beyond an isolated single event should be evaluated for their bone density and fracture risk" no matter their age or sex, said senior investigator Dr. Joseph Verbalis, chief of the division on endocrinology and metabolism at Georgetown.

Based on the findings, "we [speculate] that early treatment of hyponatremia will prevent progression of bone disease and decrease fracture risk," and perhaps even obviate the need for bisphosphonates. "It’s an implication that needs to be followed up with definitive studies," he said.

Chronic hyponatremia increases osteoclast proliferation and activity, while recent hyponatremia reduces reaction time and makes it less likely people will catch themselves if they stumble. Elderly people are most at risk, either from overzealous salt restriction, sodium-depleting drugs like thiazide diuretics, or the syndrome of inappropriate antidiuretic hormone secretion (Indian J. Endocrinol. Metab. 2011;15(Suppl3):S208-S215).

The mean age of subjects in the osteoporosis analysis was about 75 years, and almost 90% were women. In the fragility fracture analysis, the mean age was about 60 years, and just over half the subjects were women.

Among the roughly 3 million patients the team initially sampled at the start of their work, there was a more than twofold increase in the prevalence of osteoporosis in hyponatremic (4.6%) vs. nonhyponatremic (1.8%) subjects, and a similar increase in vertebral or long-bone fractures (9.5% vs. 3.7%).

Dr. Verbalis is a consultant, investigator, speaker, and adviser for Otsuka, the maker of the hyponatremia drug tolvaptan. He is also a consultant for Cornerstone Therapeutics and Ferring Pharmaceuticals. The study had no outside funding.

aotto@frontlinemedcom.com

CHICAGO – Hyponatremia quadruples the risk of osteoporosis and fragility fractures, according to a retrospective database study presented at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

A team from Georgetown University in Washington matched 30,517 patients diagnosed with osteoporosis to 30,517 controls for age, race, sex, and how long they had been in the database of the MedStar Health System, which serves Baltimore and Washington.

The investigators found that patients with chronic hyponatremia – at least two sodium values below 135 mmol/L at least 1 year apart – were far more likely to be later diagnosed with osteoporosis (adjusted odds ratio, 3.99). Recent hyponatremia – at least one value below 135 mmol/L in the previous 30 days – also increased the risk (aOR, 3.08). In contrast, glucocorticoid use, a known osteoporosis risk factor, was associated with a far lower risk (aOR, 1.4), the team reported in a poster session at the meeting.

The researchers had similar results when they matched 46,256 patients with fragility fractures to 46,256 without: The fracture risk was substantially increased in patients with chronic hyponatremia (aOR, 4.71) and recent hyponatremia (aOR, 3.08). A previous diagnosis of osteoporosis – again, a known risk factor – increased the risk only moderately (aOR, 1.8).

The severity of hyponatremia played a role, too; patients with at least one value below 125 mmol/L had the highest risk for osteoporosis and fragility fractures.

The findings were all statistically significant.

"The results of this study support the hypothesis that hyponatremia is a significant and clinically important risk factor for both osteoporosis and bone fractures in inpatients and outpatients," the team concluded.

"We were surprised by the odds ratios and how strong a factor this was. Right now, hyponatremia is not an indication for bone mineral density [testing] because it’s never been considered to be a risk factor. It ought to be added as an indication. Patients with hyponatremia beyond an isolated single event should be evaluated for their bone density and fracture risk" no matter their age or sex, said senior investigator Dr. Joseph Verbalis, chief of the division on endocrinology and metabolism at Georgetown.

Based on the findings, "we [speculate] that early treatment of hyponatremia will prevent progression of bone disease and decrease fracture risk," and perhaps even obviate the need for bisphosphonates. "It’s an implication that needs to be followed up with definitive studies," he said.

Chronic hyponatremia increases osteoclast proliferation and activity, while recent hyponatremia reduces reaction time and makes it less likely people will catch themselves if they stumble. Elderly people are most at risk, either from overzealous salt restriction, sodium-depleting drugs like thiazide diuretics, or the syndrome of inappropriate antidiuretic hormone secretion (Indian J. Endocrinol. Metab. 2011;15(Suppl3):S208-S215).

The mean age of subjects in the osteoporosis analysis was about 75 years, and almost 90% were women. In the fragility fracture analysis, the mean age was about 60 years, and just over half the subjects were women.

Among the roughly 3 million patients the team initially sampled at the start of their work, there was a more than twofold increase in the prevalence of osteoporosis in hyponatremic (4.6%) vs. nonhyponatremic (1.8%) subjects, and a similar increase in vertebral or long-bone fractures (9.5% vs. 3.7%).

Dr. Verbalis is a consultant, investigator, speaker, and adviser for Otsuka, the maker of the hyponatremia drug tolvaptan. He is also a consultant for Cornerstone Therapeutics and Ferring Pharmaceuticals. The study had no outside funding.

aotto@frontlinemedcom.com

CHICAGO – Hyponatremia quadruples the risk of osteoporosis and fragility fractures, according to a retrospective database study presented at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

A team from Georgetown University in Washington matched 30,517 patients diagnosed with osteoporosis to 30,517 controls for age, race, sex, and how long they had been in the database of the MedStar Health System, which serves Baltimore and Washington.

The investigators found that patients with chronic hyponatremia – at least two sodium values below 135 mmol/L at least 1 year apart – were far more likely to be later diagnosed with osteoporosis (adjusted odds ratio, 3.99). Recent hyponatremia – at least one value below 135 mmol/L in the previous 30 days – also increased the risk (aOR, 3.08). In contrast, glucocorticoid use, a known osteoporosis risk factor, was associated with a far lower risk (aOR, 1.4), the team reported in a poster session at the meeting.

The researchers had similar results when they matched 46,256 patients with fragility fractures to 46,256 without: The fracture risk was substantially increased in patients with chronic hyponatremia (aOR, 4.71) and recent hyponatremia (aOR, 3.08). A previous diagnosis of osteoporosis – again, a known risk factor – increased the risk only moderately (aOR, 1.8).

The severity of hyponatremia played a role, too; patients with at least one value below 125 mmol/L had the highest risk for osteoporosis and fragility fractures.

The findings were all statistically significant.

"The results of this study support the hypothesis that hyponatremia is a significant and clinically important risk factor for both osteoporosis and bone fractures in inpatients and outpatients," the team concluded.

"We were surprised by the odds ratios and how strong a factor this was. Right now, hyponatremia is not an indication for bone mineral density [testing] because it’s never been considered to be a risk factor. It ought to be added as an indication. Patients with hyponatremia beyond an isolated single event should be evaluated for their bone density and fracture risk" no matter their age or sex, said senior investigator Dr. Joseph Verbalis, chief of the division on endocrinology and metabolism at Georgetown.

Based on the findings, "we [speculate] that early treatment of hyponatremia will prevent progression of bone disease and decrease fracture risk," and perhaps even obviate the need for bisphosphonates. "It’s an implication that needs to be followed up with definitive studies," he said.

Chronic hyponatremia increases osteoclast proliferation and activity, while recent hyponatremia reduces reaction time and makes it less likely people will catch themselves if they stumble. Elderly people are most at risk, either from overzealous salt restriction, sodium-depleting drugs like thiazide diuretics, or the syndrome of inappropriate antidiuretic hormone secretion (Indian J. Endocrinol. Metab. 2011;15(Suppl3):S208-S215).

The mean age of subjects in the osteoporosis analysis was about 75 years, and almost 90% were women. In the fragility fracture analysis, the mean age was about 60 years, and just over half the subjects were women.

Among the roughly 3 million patients the team initially sampled at the start of their work, there was a more than twofold increase in the prevalence of osteoporosis in hyponatremic (4.6%) vs. nonhyponatremic (1.8%) subjects, and a similar increase in vertebral or long-bone fractures (9.5% vs. 3.7%).

Dr. Verbalis is a consultant, investigator, speaker, and adviser for Otsuka, the maker of the hyponatremia drug tolvaptan. He is also a consultant for Cornerstone Therapeutics and Ferring Pharmaceuticals. The study had no outside funding.

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