Mary Ann Moon

Major Finding: The use of disease-modifying antirheumatic drugs varies widely according to patient age, sex, and race; income; location; and health plan.

Data Source: An analysis of Healthcare Effectiveness Data and Information Set data on medication use in a nationally representative sample of 93,134 RA patients enrolled in Medicare managed care plans.

Disclosures: This study was supported by the American College of Rheumatology, National Center for Research Resources, Rosalind Russell Medical Research Centers for Arthritis, National Institutes of Health, State of California Lupus Fund, Arthritis Foundation, Agency for Healthcare Research and Quality, and National Institute of Arthritis and Musculoskeletal and Skin Diseases. An associate of Dr. Schmajuk reported financial ties to Merck and the Pfizer Foundation.

Whether patients with rheumatoid arthritis receive appropriate antirheumatic medications varies widely and depends on their age, sex, race, income, the neighborhood and area of the country where they reside, and their health care plan, judging from recent study findings.

“Although RA was once an inevitably deforming and disabling condition, the development of new DMARDs [disease-modifying antirheumatic drugs] and support for their early use has dramatically improved clinical outcomes for many patients.

“This study suggests that one mechanism for the sociodemographic disparities in RA outcomes in the United States may relate to differences in DMARD receipt,” according to Dr. Gabriela Schmajuk of Stanford (Calif.) University and her associates.

Recent population-based studies have shown consistently low rates of DMARD use, even though evidence-based guidelines recommend early and aggressive treatment.

Dr. Schmajuk and her colleagues assessed medication use in a cohort of 93,143 RA patients enrolled in Medicare managed care plans during a recent 4-year period.

The cohort comprises a nationally representative sample of the managed care population aged 65 years and older.

Overall, 37% of patients were not receiving DMARDs.

These include abatacept, adalimumab, anakinra, azathioprine, cyclophosphamide, cyclosporine, etanercept, gold, hydroxychloroquine, infliximab, leflunomide, methotrexate, minocycline, penicillamine, rituximab, staphylococcal protein A, and sulfasalazine.

In some cases, patients may have declined DMARD treatment, may have had quiescent disease that didn't require treatment, or may have had contraindications to all 17 of these drugs.

The greatest variation in the rate of DMARD use occurred by patient ag.

Only 42% of patients aged 85 years or older received DMARDs, compared with 72%, of those aged 65-69 years.

It is possible that older patients had more comorbidities limiting their ability to use these drugs.

It also is possible that age bias played a role in this result, according to the investigators.

Men had slightly lower rates of use than women, and patients self-identified as black or “other” had lower rates of use (57% and 58%, respectively) than white patients (64%).

The rate of DMARD use was 55% among patients with a low personal income, compared with 64% among those with higher incomes.

Similarly, patients who lived in neighborhoods of low socioeconomic status were less likely to be taking DMARDs than patients living in neighborhoods with higher socioeconomic status.

It is possible that some of these patients don't get DMARDs because they are unable to afford copayments or other forms of cost sharing, the investigators said.

Patients living in the South Atlantic and Middle Atlantic regions of the country had rates of use that were 10% lower than those living in other regions.

The use of DMARDs was 6% lower among patients who were enrolled in for-profit health plans than among those who were enrolled in not-for-profit plans, a difference that was small but statistically significant.

However, variability by health plan was much greater than that statistic alone would convey.

Rates of use of DMARDs varied from a low of 16% in one health plan to a high of 87% in another. This findings held true even after the data had been adjusted to account for differences in case mix.

This finding is “concerning,” Dr. Schmajuk and her associates said (JAMA 2011;305:480-6).

It is unknown whether this 70-point difference in DMARD use is due to differences in the availability or accessibility of specialty care within some health plans or differences in allowances on prescription drug benefits between health plans.

It may even reflect in part inaccurate reporting on the forms used to collect the data, they added.

Whatever the explanations, the large variations in DMARD use are “unacceptable,” the researchers said.

“Targeting educational and quality improvement interventions to patients who are underusing DMARDs and their clinicians will be important to eliminate these disparities,” they said.

Major Finding: The use of disease-modifying antirheumatic drugs varies widely according to patient age, sex, and race; income; location; and health plan.

Data Source: An analysis of Healthcare Effectiveness Data and Information Set data on medication use in a nationally representative sample of 93,134 RA patients enrolled in Medicare managed care plans.

Disclosures: This study was supported by the American College of Rheumatology, National Center for Research Resources, Rosalind Russell Medical Research Centers for Arthritis, National Institutes of Health, State of California Lupus Fund, Arthritis Foundation, Agency for Healthcare Research and Quality, and National Institute of Arthritis and Musculoskeletal and Skin Diseases. An associate of Dr. Schmajuk reported financial ties to Merck and the Pfizer Foundation.

Whether patients with rheumatoid arthritis receive appropriate antirheumatic medications varies widely and depends on their age, sex, race, income, the neighborhood and area of the country where they reside, and their health care plan, judging from recent study findings.

“Although RA was once an inevitably deforming and disabling condition, the development of new DMARDs [disease-modifying antirheumatic drugs] and support for their early use has dramatically improved clinical outcomes for many patients.

“This study suggests that one mechanism for the sociodemographic disparities in RA outcomes in the United States may relate to differences in DMARD receipt,” according to Dr. Gabriela Schmajuk of Stanford (Calif.) University and her associates.

Recent population-based studies have shown consistently low rates of DMARD use, even though evidence-based guidelines recommend early and aggressive treatment.

Dr. Schmajuk and her colleagues assessed medication use in a cohort of 93,143 RA patients enrolled in Medicare managed care plans during a recent 4-year period.

The cohort comprises a nationally representative sample of the managed care population aged 65 years and older.

Overall, 37% of patients were not receiving DMARDs.

These include abatacept, adalimumab, anakinra, azathioprine, cyclophosphamide, cyclosporine, etanercept, gold, hydroxychloroquine, infliximab, leflunomide, methotrexate, minocycline, penicillamine, rituximab, staphylococcal protein A, and sulfasalazine.

In some cases, patients may have declined DMARD treatment, may have had quiescent disease that didn't require treatment, or may have had contraindications to all 17 of these drugs.

The greatest variation in the rate of DMARD use occurred by patient ag.

Only 42% of patients aged 85 years or older received DMARDs, compared with 72%, of those aged 65-69 years.

It is possible that older patients had more comorbidities limiting their ability to use these drugs.

It also is possible that age bias played a role in this result, according to the investigators.

Men had slightly lower rates of use than women, and patients self-identified as black or “other” had lower rates of use (57% and 58%, respectively) than white patients (64%).

The rate of DMARD use was 55% among patients with a low personal income, compared with 64% among those with higher incomes.

Similarly, patients who lived in neighborhoods of low socioeconomic status were less likely to be taking DMARDs than patients living in neighborhoods with higher socioeconomic status.

It is possible that some of these patients don't get DMARDs because they are unable to afford copayments or other forms of cost sharing, the investigators said.

Patients living in the South Atlantic and Middle Atlantic regions of the country had rates of use that were 10% lower than those living in other regions.

The use of DMARDs was 6% lower among patients who were enrolled in for-profit health plans than among those who were enrolled in not-for-profit plans, a difference that was small but statistically significant.

However, variability by health plan was much greater than that statistic alone would convey.

Rates of use of DMARDs varied from a low of 16% in one health plan to a high of 87% in another. This findings held true even after the data had been adjusted to account for differences in case mix.

This finding is “concerning,” Dr. Schmajuk and her associates said (JAMA 2011;305:480-6).

It is unknown whether this 70-point difference in DMARD use is due to differences in the availability or accessibility of specialty care within some health plans or differences in allowances on prescription drug benefits between health plans.

It may even reflect in part inaccurate reporting on the forms used to collect the data, they added.

Whatever the explanations, the large variations in DMARD use are “unacceptable,” the researchers said.

“Targeting educational and quality improvement interventions to patients who are underusing DMARDs and their clinicians will be important to eliminate these disparities,” they said.

Major Finding: The use of disease-modifying antirheumatic drugs varies widely according to patient age, sex, and race; income; location; and health plan.

Data Source: An analysis of Healthcare Effectiveness Data and Information Set data on medication use in a nationally representative sample of 93,134 RA patients enrolled in Medicare managed care plans.

Disclosures: This study was supported by the American College of Rheumatology, National Center for Research Resources, Rosalind Russell Medical Research Centers for Arthritis, National Institutes of Health, State of California Lupus Fund, Arthritis Foundation, Agency for Healthcare Research and Quality, and National Institute of Arthritis and Musculoskeletal and Skin Diseases. An associate of Dr. Schmajuk reported financial ties to Merck and the Pfizer Foundation.

Whether patients with rheumatoid arthritis receive appropriate antirheumatic medications varies widely and depends on their age, sex, race, income, the neighborhood and area of the country where they reside, and their health care plan, judging from recent study findings.

“Although RA was once an inevitably deforming and disabling condition, the development of new DMARDs [disease-modifying antirheumatic drugs] and support for their early use has dramatically improved clinical outcomes for many patients.

“This study suggests that one mechanism for the sociodemographic disparities in RA outcomes in the United States may relate to differences in DMARD receipt,” according to Dr. Gabriela Schmajuk of Stanford (Calif.) University and her associates.

Recent population-based studies have shown consistently low rates of DMARD use, even though evidence-based guidelines recommend early and aggressive treatment.

Dr. Schmajuk and her colleagues assessed medication use in a cohort of 93,143 RA patients enrolled in Medicare managed care plans during a recent 4-year period.

The cohort comprises a nationally representative sample of the managed care population aged 65 years and older.

Overall, 37% of patients were not receiving DMARDs.

These include abatacept, adalimumab, anakinra, azathioprine, cyclophosphamide, cyclosporine, etanercept, gold, hydroxychloroquine, infliximab, leflunomide, methotrexate, minocycline, penicillamine, rituximab, staphylococcal protein A, and sulfasalazine.

In some cases, patients may have declined DMARD treatment, may have had quiescent disease that didn't require treatment, or may have had contraindications to all 17 of these drugs.

The greatest variation in the rate of DMARD use occurred by patient ag.

Only 42% of patients aged 85 years or older received DMARDs, compared with 72%, of those aged 65-69 years.

It is possible that older patients had more comorbidities limiting their ability to use these drugs.

It also is possible that age bias played a role in this result, according to the investigators.

Men had slightly lower rates of use than women, and patients self-identified as black or “other” had lower rates of use (57% and 58%, respectively) than white patients (64%).

The rate of DMARD use was 55% among patients with a low personal income, compared with 64% among those with higher incomes.

Similarly, patients who lived in neighborhoods of low socioeconomic status were less likely to be taking DMARDs than patients living in neighborhoods with higher socioeconomic status.

It is possible that some of these patients don't get DMARDs because they are unable to afford copayments or other forms of cost sharing, the investigators said.

Patients living in the South Atlantic and Middle Atlantic regions of the country had rates of use that were 10% lower than those living in other regions.

The use of DMARDs was 6% lower among patients who were enrolled in for-profit health plans than among those who were enrolled in not-for-profit plans, a difference that was small but statistically significant.

However, variability by health plan was much greater than that statistic alone would convey.

Rates of use of DMARDs varied from a low of 16% in one health plan to a high of 87% in another. This findings held true even after the data had been adjusted to account for differences in case mix.

This finding is “concerning,” Dr. Schmajuk and her associates said (JAMA 2011;305:480-6).

It is unknown whether this 70-point difference in DMARD use is due to differences in the availability or accessibility of specialty care within some health plans or differences in allowances on prescription drug benefits between health plans.

It may even reflect in part inaccurate reporting on the forms used to collect the data, they added.

Whatever the explanations, the large variations in DMARD use are “unacceptable,” the researchers said.

“Targeting educational and quality improvement interventions to patients who are underusing DMARDs and their clinicians will be important to eliminate these disparities,” they said.

A subtype of hemoglobin H disease distinguished by life-threatening anemia during infectious illnesses should be recognized as a clinical entity distinct from other thalassemias, all of which are becoming more common in the United States, according to a single-center study.

Hemoglobin H Constant Spring (hemoglobin HCS) causes significant growth delay, causes repeated plunges in hemoglobin levels requiring urgent blood transfusions as early as infancy, and can lead to iron overload in early childhood, with its attendant sequelae. Most important, patients with HCS show acute, life-threatening worsening of anemia during common illnesses caused by viral or bacterial infections such as strep throat.

In contrast, other hemoglobin H disease does not cause growth deficits or iron overload during childhood, and it rarely causes severe anemia, said Dr. Ashutosh Lal of the department of hematology/oncology at Children's Hospital and Research Center Oakland (Calif.), and his associates.

The investigators were able to characterize the natural history of hemoglobin H disease and the subtype hemoglobin HCS among children in the United States for the first time largely because of newborn screening for the disorders, which has been done in California since 1998. They identified and followed 86 cases of hemoglobin H disease.

In the past, hemoglobin H disease has been prevalent in Asian and Mediterranean populations but rare in others. Now, however, it appears to be making inroads into the United States. In this study, many patients were of mixed ethnic backgrounds, including African Americans, who historically have a very low rate of alpha-thalassemias.

This finding supports the usefulness of universal newborn screening for hemoglobin H syndromes. “Life-threatening anemia may develop in infants before the diagnosis can be made through conventional means in the absence of newborn screening,” Dr. Lal and his colleagues noted (N. Engl. J. Med. 2011;364:710-8).

Among the 86 cases, 60 patients (70%) had hemoglobin H, 23 (27%) had the more severe HCS, and 3 (3.5%) had other, nondeletional hemoglobin H illness.

All of the episodes of acute worsening of anemia requiring blood transfusions occurred in the HCS group, while the children with hemoglobin H disease “had a predictably benign course.” In HCS, the probability of requiring at least one transfusion before 1 year of age was 13%; this increased to 39% by the age of 5 years, 75% by the age of 10 years, and 80% by the age of 20 years. Thirty-seven transfusions (82%) were precipitated by infections.

Growth was significantly delayed in children with HCS but not in the other children. “This finding suggests that close attention to growth is required and that nutritional and hematologic associations with growth delay should be evaluated,” the investigators said.

Patients with HCS required nearly twice as many clinic visits each year and nearly four times as many hospital admissions. In addition, “substantial fatigue was observed in a subgroup of older patients with HCS, a finding that raises concern that the quality of life of patients may deteriorate with age,” Dr. Lal and his associates said.

Five patients with HCS underwent splenectomy between the ages of 3.9 and 13 years because of their need for frequent blood transfusions, while no children with hemoglobin H disease did. Splenectomy reduced or eliminated acute hemolytic episodes in four of the five children.

“We suggest that HCS be recognized as a thalassemia syndrome that is distinct from hemoglobin H disease, so that the appropriate treatment approach can be devised for each group,” they noted.

This study was supported in part by the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services. The authors reported no relevant financial disclosures.

A subtype of hemoglobin H disease distinguished by life-threatening anemia during infectious illnesses should be recognized as a clinical entity distinct from other thalassemias, all of which are becoming more common in the United States, according to a single-center study.

Hemoglobin H Constant Spring (hemoglobin HCS) causes significant growth delay, causes repeated plunges in hemoglobin levels requiring urgent blood transfusions as early as infancy, and can lead to iron overload in early childhood, with its attendant sequelae. Most important, patients with HCS show acute, life-threatening worsening of anemia during common illnesses caused by viral or bacterial infections such as strep throat.

In contrast, other hemoglobin H disease does not cause growth deficits or iron overload during childhood, and it rarely causes severe anemia, said Dr. Ashutosh Lal of the department of hematology/oncology at Children's Hospital and Research Center Oakland (Calif.), and his associates.

The investigators were able to characterize the natural history of hemoglobin H disease and the subtype hemoglobin HCS among children in the United States for the first time largely because of newborn screening for the disorders, which has been done in California since 1998. They identified and followed 86 cases of hemoglobin H disease.

In the past, hemoglobin H disease has been prevalent in Asian and Mediterranean populations but rare in others. Now, however, it appears to be making inroads into the United States. In this study, many patients were of mixed ethnic backgrounds, including African Americans, who historically have a very low rate of alpha-thalassemias.

This finding supports the usefulness of universal newborn screening for hemoglobin H syndromes. “Life-threatening anemia may develop in infants before the diagnosis can be made through conventional means in the absence of newborn screening,” Dr. Lal and his colleagues noted (N. Engl. J. Med. 2011;364:710-8).

Among the 86 cases, 60 patients (70%) had hemoglobin H, 23 (27%) had the more severe HCS, and 3 (3.5%) had other, nondeletional hemoglobin H illness.

All of the episodes of acute worsening of anemia requiring blood transfusions occurred in the HCS group, while the children with hemoglobin H disease “had a predictably benign course.” In HCS, the probability of requiring at least one transfusion before 1 year of age was 13%; this increased to 39% by the age of 5 years, 75% by the age of 10 years, and 80% by the age of 20 years. Thirty-seven transfusions (82%) were precipitated by infections.

Growth was significantly delayed in children with HCS but not in the other children. “This finding suggests that close attention to growth is required and that nutritional and hematologic associations with growth delay should be evaluated,” the investigators said.

Patients with HCS required nearly twice as many clinic visits each year and nearly four times as many hospital admissions. In addition, “substantial fatigue was observed in a subgroup of older patients with HCS, a finding that raises concern that the quality of life of patients may deteriorate with age,” Dr. Lal and his associates said.

Five patients with HCS underwent splenectomy between the ages of 3.9 and 13 years because of their need for frequent blood transfusions, while no children with hemoglobin H disease did. Splenectomy reduced or eliminated acute hemolytic episodes in four of the five children.

“We suggest that HCS be recognized as a thalassemia syndrome that is distinct from hemoglobin H disease, so that the appropriate treatment approach can be devised for each group,” they noted.

This study was supported in part by the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services. The authors reported no relevant financial disclosures.

A subtype of hemoglobin H disease distinguished by life-threatening anemia during infectious illnesses should be recognized as a clinical entity distinct from other thalassemias, all of which are becoming more common in the United States, according to a single-center study.

Hemoglobin H Constant Spring (hemoglobin HCS) causes significant growth delay, causes repeated plunges in hemoglobin levels requiring urgent blood transfusions as early as infancy, and can lead to iron overload in early childhood, with its attendant sequelae. Most important, patients with HCS show acute, life-threatening worsening of anemia during common illnesses caused by viral or bacterial infections such as strep throat.

In contrast, other hemoglobin H disease does not cause growth deficits or iron overload during childhood, and it rarely causes severe anemia, said Dr. Ashutosh Lal of the department of hematology/oncology at Children's Hospital and Research Center Oakland (Calif.), and his associates.

The investigators were able to characterize the natural history of hemoglobin H disease and the subtype hemoglobin HCS among children in the United States for the first time largely because of newborn screening for the disorders, which has been done in California since 1998. They identified and followed 86 cases of hemoglobin H disease.

In the past, hemoglobin H disease has been prevalent in Asian and Mediterranean populations but rare in others. Now, however, it appears to be making inroads into the United States. In this study, many patients were of mixed ethnic backgrounds, including African Americans, who historically have a very low rate of alpha-thalassemias.

This finding supports the usefulness of universal newborn screening for hemoglobin H syndromes. “Life-threatening anemia may develop in infants before the diagnosis can be made through conventional means in the absence of newborn screening,” Dr. Lal and his colleagues noted (N. Engl. J. Med. 2011;364:710-8).

Among the 86 cases, 60 patients (70%) had hemoglobin H, 23 (27%) had the more severe HCS, and 3 (3.5%) had other, nondeletional hemoglobin H illness.

All of the episodes of acute worsening of anemia requiring blood transfusions occurred in the HCS group, while the children with hemoglobin H disease “had a predictably benign course.” In HCS, the probability of requiring at least one transfusion before 1 year of age was 13%; this increased to 39% by the age of 5 years, 75% by the age of 10 years, and 80% by the age of 20 years. Thirty-seven transfusions (82%) were precipitated by infections.

Growth was significantly delayed in children with HCS but not in the other children. “This finding suggests that close attention to growth is required and that nutritional and hematologic associations with growth delay should be evaluated,” the investigators said.

Patients with HCS required nearly twice as many clinic visits each year and nearly four times as many hospital admissions. In addition, “substantial fatigue was observed in a subgroup of older patients with HCS, a finding that raises concern that the quality of life of patients may deteriorate with age,” Dr. Lal and his associates said.

Five patients with HCS underwent splenectomy between the ages of 3.9 and 13 years because of their need for frequent blood transfusions, while no children with hemoglobin H disease did. Splenectomy reduced or eliminated acute hemolytic episodes in four of the five children.

“We suggest that HCS be recognized as a thalassemia syndrome that is distinct from hemoglobin H disease, so that the appropriate treatment approach can be devised for each group,” they noted.

This study was supported in part by the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services. The authors reported no relevant financial disclosures.

Findings from a systematic review of the literature published through July 2010 will support the new acute otitis media practice guidelines now being prepared by the American Academy of Pediatrics, according to a report.

Experts looked to the latest results on AOM diagnosis, the changing microbial epidemiology associated with introduction of the heptavalent pneumococcal conjugate vaccine (PCV7) vaccine, the decision about whether to treat with antibiotics, and the comparative effectiveness of various antibiotics to inform the upcoming AAP practice guideline – an update of their 2001 study that was the basis of the 2004 AAP–American Academy of Family Physicians joint practice guideline on AOM, said Dr. Tumaini R. Coker of the University of California, Los Angeles, and the RAND Corp., Los Angeles, and her associates.

They included 80 articles used in the previous systematic review and 55 published since that time, reviewing both randomized controlled trials and observational studies (JAMA 2010;304:2161-9). Among their findings were the following:

▸ Otoscopic signs of inflammation (redness) and effusion (bulging or immobile tympanic membrane) are strongly associated with accurate diagnosis of AOM, while the importance of clinical symptoms is “less convincing.”

“Perhaps the most important way to improve diagnosis is to increase clinicians' ability to recognize and rely on key otoscopic findings,” Dr. Coker and her colleagues said.

▸ AOM microbiology has shifted significantly since the introduction of PCV7, with Haemophilus influenzae becoming more prevalent and Streptococcus pneumoniae becoming less so. However, a recent study indicates that this balance may be shifting back again “because of an increase in the proportion of AOM with nonvaccine S. pneumoniae serotypes.” Clinicians must stay current with microbial trends, especially given the recent approval of PCV13, the researchers said.

▸ Immediate ampicillin/amoxicillin treatment has a modest advantage over delayed antibiotic therapy or placebo, but also is more likely to cause diarrhea and rash. “Of 100 average-risk children with AOM, approximately 80 would likely get better within 3 days without antibiotics. If all were treated with immediate ampicillin/amoxicillin, an additional 12 would likely improve, but 3–10 children would develop rash and 5–10 would develop diarrhea. Clinicians need to weigh these risks (including possible long-term effects on antibiotic resistance) before prescribing immediate antibiotics for uncomplicated AOM,” the investigators said.

▸ Most antibiotics have similar clinical efficacy in children at average risk who have uncomplicated AOM. “We found no evidence of the superiority of any other antibiotic over amoxicillin,” they noted.

In particular, there is no evidence to support first-line use of more expensive antibiotics such as cefdinir or cefixime. In a given year, cefdinir is prescribed at 14% of the estimated 8 million physician visits for AOM, according to an analysis of data from the National Ambulatory Medical Care Survey. If such prescription is appropriate in approximately half of these cases because of a penicillin allergy, and if physicians prescribed amoxicillin instead of cefdinir in the other half of cases, annual savings would exceed $34 million, Dr. Coker and her associates said.

This study was supported by the Agency for Healthcare Research and Quality. One of Dr. Coker's associates reported selling Pfizer stock at the start of the study.

Findings from a systematic review of the literature published through July 2010 will support the new acute otitis media practice guidelines now being prepared by the American Academy of Pediatrics, according to a report.

Experts looked to the latest results on AOM diagnosis, the changing microbial epidemiology associated with introduction of the heptavalent pneumococcal conjugate vaccine (PCV7) vaccine, the decision about whether to treat with antibiotics, and the comparative effectiveness of various antibiotics to inform the upcoming AAP practice guideline – an update of their 2001 study that was the basis of the 2004 AAP–American Academy of Family Physicians joint practice guideline on AOM, said Dr. Tumaini R. Coker of the University of California, Los Angeles, and the RAND Corp., Los Angeles, and her associates.

They included 80 articles used in the previous systematic review and 55 published since that time, reviewing both randomized controlled trials and observational studies (JAMA 2010;304:2161-9). Among their findings were the following:

▸ Otoscopic signs of inflammation (redness) and effusion (bulging or immobile tympanic membrane) are strongly associated with accurate diagnosis of AOM, while the importance of clinical symptoms is “less convincing.”

“Perhaps the most important way to improve diagnosis is to increase clinicians' ability to recognize and rely on key otoscopic findings,” Dr. Coker and her colleagues said.

▸ AOM microbiology has shifted significantly since the introduction of PCV7, with Haemophilus influenzae becoming more prevalent and Streptococcus pneumoniae becoming less so. However, a recent study indicates that this balance may be shifting back again “because of an increase in the proportion of AOM with nonvaccine S. pneumoniae serotypes.” Clinicians must stay current with microbial trends, especially given the recent approval of PCV13, the researchers said.

▸ Immediate ampicillin/amoxicillin treatment has a modest advantage over delayed antibiotic therapy or placebo, but also is more likely to cause diarrhea and rash. “Of 100 average-risk children with AOM, approximately 80 would likely get better within 3 days without antibiotics. If all were treated with immediate ampicillin/amoxicillin, an additional 12 would likely improve, but 3–10 children would develop rash and 5–10 would develop diarrhea. Clinicians need to weigh these risks (including possible long-term effects on antibiotic resistance) before prescribing immediate antibiotics for uncomplicated AOM,” the investigators said.

▸ Most antibiotics have similar clinical efficacy in children at average risk who have uncomplicated AOM. “We found no evidence of the superiority of any other antibiotic over amoxicillin,” they noted.

In particular, there is no evidence to support first-line use of more expensive antibiotics such as cefdinir or cefixime. In a given year, cefdinir is prescribed at 14% of the estimated 8 million physician visits for AOM, according to an analysis of data from the National Ambulatory Medical Care Survey. If such prescription is appropriate in approximately half of these cases because of a penicillin allergy, and if physicians prescribed amoxicillin instead of cefdinir in the other half of cases, annual savings would exceed $34 million, Dr. Coker and her associates said.

This study was supported by the Agency for Healthcare Research and Quality. One of Dr. Coker's associates reported selling Pfizer stock at the start of the study.

Findings from a systematic review of the literature published through July 2010 will support the new acute otitis media practice guidelines now being prepared by the American Academy of Pediatrics, according to a report.

Experts looked to the latest results on AOM diagnosis, the changing microbial epidemiology associated with introduction of the heptavalent pneumococcal conjugate vaccine (PCV7) vaccine, the decision about whether to treat with antibiotics, and the comparative effectiveness of various antibiotics to inform the upcoming AAP practice guideline – an update of their 2001 study that was the basis of the 2004 AAP–American Academy of Family Physicians joint practice guideline on AOM, said Dr. Tumaini R. Coker of the University of California, Los Angeles, and the RAND Corp., Los Angeles, and her associates.

They included 80 articles used in the previous systematic review and 55 published since that time, reviewing both randomized controlled trials and observational studies (JAMA 2010;304:2161-9). Among their findings were the following:

▸ Otoscopic signs of inflammation (redness) and effusion (bulging or immobile tympanic membrane) are strongly associated with accurate diagnosis of AOM, while the importance of clinical symptoms is “less convincing.”

“Perhaps the most important way to improve diagnosis is to increase clinicians' ability to recognize and rely on key otoscopic findings,” Dr. Coker and her colleagues said.

▸ AOM microbiology has shifted significantly since the introduction of PCV7, with Haemophilus influenzae becoming more prevalent and Streptococcus pneumoniae becoming less so. However, a recent study indicates that this balance may be shifting back again “because of an increase in the proportion of AOM with nonvaccine S. pneumoniae serotypes.” Clinicians must stay current with microbial trends, especially given the recent approval of PCV13, the researchers said.

▸ Immediate ampicillin/amoxicillin treatment has a modest advantage over delayed antibiotic therapy or placebo, but also is more likely to cause diarrhea and rash. “Of 100 average-risk children with AOM, approximately 80 would likely get better within 3 days without antibiotics. If all were treated with immediate ampicillin/amoxicillin, an additional 12 would likely improve, but 3–10 children would develop rash and 5–10 would develop diarrhea. Clinicians need to weigh these risks (including possible long-term effects on antibiotic resistance) before prescribing immediate antibiotics for uncomplicated AOM,” the investigators said.

▸ Most antibiotics have similar clinical efficacy in children at average risk who have uncomplicated AOM. “We found no evidence of the superiority of any other antibiotic over amoxicillin,” they noted.

In particular, there is no evidence to support first-line use of more expensive antibiotics such as cefdinir or cefixime. In a given year, cefdinir is prescribed at 14% of the estimated 8 million physician visits for AOM, according to an analysis of data from the National Ambulatory Medical Care Survey. If such prescription is appropriate in approximately half of these cases because of a penicillin allergy, and if physicians prescribed amoxicillin instead of cefdinir in the other half of cases, annual savings would exceed $34 million, Dr. Coker and her associates said.

This study was supported by the Agency for Healthcare Research and Quality. One of Dr. Coker's associates reported selling Pfizer stock at the start of the study.

Children who attend large day-care programs before age 2 1/2 years show a short-term increase in the number of infections they acquire but are protected against infections during the elementary school years.

“This study provides reassuring evidence for parents that their choices regarding child care (group size and age at enrollment) should not have a major effect on the health of their children from a long-term perspective, at least regarding respiratory tract infections, gastrointestinal tract infections, and ear infections,” said Sylvana M. Côté, Ph.D., of the department of social and preventive medicine, Ste-Justine Hospital, Montreal, and her associates.

“Physicians may reassure parents whose children initiate large group child care early that their child's experiencing infections is temporary and is likely to provide them with greater immunity during the elementary school years,” they noted.

Dr. Côté and her colleagues performed what they described as the first prospective, population-based study to examine the associations between different day-care experiences and three types of infections from early preschool age through mid-elementary school age. They used data from the Quebec Longitudinal Study of Child Development to follow a representative sample of 1,238 study subjects every year from 5 months of age in 1998 through 8 years of age in 2006.

The researchers statistically controlled for potentially confounding variables such as maternal education level, maternal health status, low birth weight, breastfeeding status, ethnicity, and family size.

In all, 244 children (approximately 20%) were cared for at home and did not attend day care of any size before enrolling in school. An additional 402 children (32%) attended a small, home-based day-care program for 3–8 children younger than age 2 1/2, while 249 (20%) attended a large day-care program (up to 10 groups of 8–12 children per “class”) before age 2 1/2. The remaining children attended either small or large day-care programs after age 2 1/2.

Compared with home-cared children, those who started large day-care programs early in their preschool years had higher rates of respiratory and ear infections around the time they enrolled. However, they did not have higher rates of respiratory and ear infections at ages 3–4. More important, they had lower rates of such infections during the elementary school years, a time “when absenteeism carries more important consequences,” the investigators said (Arch. Pediatr. Adolesc. Med. 2010;164:1132-7).

Children who started large day-care programs later in their preschool years had higher rates of respiratory and ear infections at that time, but did not differ from home-cared children at any other time.

Children who started small day-care programs in either their early preschool years or late preschool years did not differ from home-cared children at any time. It thus appears that large day-care programs protect against future infections while small programs do not, perhaps because the large programs “provide exposure to a larger number of serotypes (and infectious agents) and … this wider exposure is necessary for preschoolers to acquire immunity,” Dr. Côté and her associates said.

Day care was not associated with gastrointestinal infections at any developmental period.

When the data were analyzed across the entire study period up to age 8 years, there was no difference in the overall number of infections between children who attended only home care before elementary school and children who attended either type of day care before elementary school.

This study was supported by the government of Quebec, Fondation Chagnon, Fond Québécois de la Recherche sur la Société et la Culture, Fonds pour la Recherche en Santé du Québec, Social Science and Humanities Research Council of Canada, Canadian Institutes for Health Research, Ste-Justine Hospital's Research Center, and the University of Montreal. No financial conflicts of interest were reported.

Children who attend large day-care programs before age 2 1/2 years show a short-term increase in the number of infections they acquire but are protected against infections during the elementary school years.

“This study provides reassuring evidence for parents that their choices regarding child care (group size and age at enrollment) should not have a major effect on the health of their children from a long-term perspective, at least regarding respiratory tract infections, gastrointestinal tract infections, and ear infections,” said Sylvana M. Côté, Ph.D., of the department of social and preventive medicine, Ste-Justine Hospital, Montreal, and her associates.

“Physicians may reassure parents whose children initiate large group child care early that their child's experiencing infections is temporary and is likely to provide them with greater immunity during the elementary school years,” they noted.

Dr. Côté and her colleagues performed what they described as the first prospective, population-based study to examine the associations between different day-care experiences and three types of infections from early preschool age through mid-elementary school age. They used data from the Quebec Longitudinal Study of Child Development to follow a representative sample of 1,238 study subjects every year from 5 months of age in 1998 through 8 years of age in 2006.

The researchers statistically controlled for potentially confounding variables such as maternal education level, maternal health status, low birth weight, breastfeeding status, ethnicity, and family size.

In all, 244 children (approximately 20%) were cared for at home and did not attend day care of any size before enrolling in school. An additional 402 children (32%) attended a small, home-based day-care program for 3–8 children younger than age 2 1/2, while 249 (20%) attended a large day-care program (up to 10 groups of 8–12 children per “class”) before age 2 1/2. The remaining children attended either small or large day-care programs after age 2 1/2.

Compared with home-cared children, those who started large day-care programs early in their preschool years had higher rates of respiratory and ear infections around the time they enrolled. However, they did not have higher rates of respiratory and ear infections at ages 3–4. More important, they had lower rates of such infections during the elementary school years, a time “when absenteeism carries more important consequences,” the investigators said (Arch. Pediatr. Adolesc. Med. 2010;164:1132-7).

Children who started large day-care programs later in their preschool years had higher rates of respiratory and ear infections at that time, but did not differ from home-cared children at any other time.

Children who started small day-care programs in either their early preschool years or late preschool years did not differ from home-cared children at any time. It thus appears that large day-care programs protect against future infections while small programs do not, perhaps because the large programs “provide exposure to a larger number of serotypes (and infectious agents) and … this wider exposure is necessary for preschoolers to acquire immunity,” Dr. Côté and her associates said.

Day care was not associated with gastrointestinal infections at any developmental period.

When the data were analyzed across the entire study period up to age 8 years, there was no difference in the overall number of infections between children who attended only home care before elementary school and children who attended either type of day care before elementary school.

This study was supported by the government of Quebec, Fondation Chagnon, Fond Québécois de la Recherche sur la Société et la Culture, Fonds pour la Recherche en Santé du Québec, Social Science and Humanities Research Council of Canada, Canadian Institutes for Health Research, Ste-Justine Hospital's Research Center, and the University of Montreal. No financial conflicts of interest were reported.

Children who attend large day-care programs before age 2 1/2 years show a short-term increase in the number of infections they acquire but are protected against infections during the elementary school years.

“This study provides reassuring evidence for parents that their choices regarding child care (group size and age at enrollment) should not have a major effect on the health of their children from a long-term perspective, at least regarding respiratory tract infections, gastrointestinal tract infections, and ear infections,” said Sylvana M. Côté, Ph.D., of the department of social and preventive medicine, Ste-Justine Hospital, Montreal, and her associates.

“Physicians may reassure parents whose children initiate large group child care early that their child's experiencing infections is temporary and is likely to provide them with greater immunity during the elementary school years,” they noted.

Dr. Côté and her colleagues performed what they described as the first prospective, population-based study to examine the associations between different day-care experiences and three types of infections from early preschool age through mid-elementary school age. They used data from the Quebec Longitudinal Study of Child Development to follow a representative sample of 1,238 study subjects every year from 5 months of age in 1998 through 8 years of age in 2006.

The researchers statistically controlled for potentially confounding variables such as maternal education level, maternal health status, low birth weight, breastfeeding status, ethnicity, and family size.

In all, 244 children (approximately 20%) were cared for at home and did not attend day care of any size before enrolling in school. An additional 402 children (32%) attended a small, home-based day-care program for 3–8 children younger than age 2 1/2, while 249 (20%) attended a large day-care program (up to 10 groups of 8–12 children per “class”) before age 2 1/2. The remaining children attended either small or large day-care programs after age 2 1/2.

Compared with home-cared children, those who started large day-care programs early in their preschool years had higher rates of respiratory and ear infections around the time they enrolled. However, they did not have higher rates of respiratory and ear infections at ages 3–4. More important, they had lower rates of such infections during the elementary school years, a time “when absenteeism carries more important consequences,” the investigators said (Arch. Pediatr. Adolesc. Med. 2010;164:1132-7).

Children who started large day-care programs later in their preschool years had higher rates of respiratory and ear infections at that time, but did not differ from home-cared children at any other time.

Children who started small day-care programs in either their early preschool years or late preschool years did not differ from home-cared children at any time. It thus appears that large day-care programs protect against future infections while small programs do not, perhaps because the large programs “provide exposure to a larger number of serotypes (and infectious agents) and … this wider exposure is necessary for preschoolers to acquire immunity,” Dr. Côté and her associates said.

Day care was not associated with gastrointestinal infections at any developmental period.

When the data were analyzed across the entire study period up to age 8 years, there was no difference in the overall number of infections between children who attended only home care before elementary school and children who attended either type of day care before elementary school.

This study was supported by the government of Quebec, Fondation Chagnon, Fond Québécois de la Recherche sur la Société et la Culture, Fonds pour la Recherche en Santé du Québec, Social Science and Humanities Research Council of Canada, Canadian Institutes for Health Research, Ste-Justine Hospital's Research Center, and the University of Montreal. No financial conflicts of interest were reported.

Approximately half of men of all ages were infected with genital human papillomavirus, according to a prospective study of three urban areas in the United States, Brazil, and Mexico.

In addition, men’s risk for acquiring HPV did not decline with age as it does in women, but appeared to remain stable throughout their lifetimes, said Dr. Anna R. Giuliano of the risk assessment, detection, and intervention program at H. Lee Moffitt Cancer Center and Research Institute, Tampa, and her associates.

The Lancet published the study online March 1.

The researchers examined the incidence and clearance of genital HPV among men because little is known about the subject. Optimal strategies for preventing the disease both in men and in their sexual partners cannot be devised until more is known about its epidemiology in men, they said.

The prospective HPV in Men (HIM) study involved 1,427 men in Tampa, 1,443 in Sao Paulo, Brazil, and 1,429 in Cuernavaca, Mexico, who were examined for HPV infection at 6-month intervals for a median of 27.5 months. The men were aged 18-70 years at baseline, with a median age of 32 years. All subjects were HIV negative and had no history of cancer.

At each visit, three specimens of penile and scrotal cells were obtained from the coronal sulcus, glans penis, penile shaft, and scrotum for the detection of HPV DNA and for HPV genotyping. Sociodemographic and sexual behavior data were obtained using a questionnaire.

Dr. Giuliano and her colleagues reported findings for a subgroup of the first 1,159 study subjects they assessed. The overall rate of infection with any HPV type was 50%. The overall prevalence of oncogenic HPV subtypes was 30% and that of nononcogenic subtypes was 38%, they said (Lancet 2011 March 1:[doi:10.106/S0140-6736(10)62342-2]).

The incidence of acquisition of a new HPV infection was 38.4/1,000 person-months and did not change appreciably according to subject age. The reason for the lack of an age association such as that seen among women is not yet known. In the study cohort, men in three age groups – 18-30 years, 31-44 years, and 45-70 years – reported having similar numbers of sexual partners and of new sexual partners. Thus, it is possible that they have continued exposure to HPV as they age, the researchers noted.

"Another possible explanation is sex differences in the HPV immune response," Dr. Giuliano and her associates said. "HPV infection of keratinized epithelium, such as the penile skin, might generate lower and weaker immune responses than infection of mucosal epithelium such as the cervix or anal canal."

If men remain at high risk of developing new HPV infections throughout their lives, "then vaccination of older men might be warranted," they noted.

Acquisition of a new HPV infection strongly correlated with the patients’ reported number of sexual partners, male or female. Compared with men who reported no more than 1 lifetime female sexual partner, men who reported they had 10-49 lifetime female sexual partners were 2.7 times as likely to be infected. Those who reported at least three male anal-sex partners in the past 3 months were 2.3 times as likely to develop an infection as those reporting no partners.

Similarly, acquisition of a new infection with an oncogenic HPV subtype correlated with the number of female sexual partners and of male partners who engaged in anal sex. Again, the risk was more than two times greater among men who reported 10 or more such partners than among those who reported no more than 1 partner. Those who reported at least three male anal-sex partners in the past 3 months were 2.6 times as likely to develop an oncogenic HPV infection as those reporting no partners.

The odds of clearing an existing HPV infection also showed a strong association with number of sexual partners. And, as has been reported among women, the odds of clearing an HPV infection in men varied according to HPV subtype. The median time to clearance for oncogenic HPV was 7.2 months, while the median time to clearance of nononcogenic HPV was 7.6 months. Infection clearance times shortened with increasing age.

"The results from this study provide much-needed data about the incidence and clearance of HPV infection in men; these data are essential for the development of realistic cost-effectiveness models for male HPV vaccination internationally," the investigators said.

The National Cancer Institute supported the study. Dr. Giuliano reported ties to Merck, the manufacturer of the HPV vaccine.

Approximately half of men of all ages were infected with genital human papillomavirus, according to a prospective study of three urban areas in the United States, Brazil, and Mexico.

In addition, men’s risk for acquiring HPV did not decline with age as it does in women, but appeared to remain stable throughout their lifetimes, said Dr. Anna R. Giuliano of the risk assessment, detection, and intervention program at H. Lee Moffitt Cancer Center and Research Institute, Tampa, and her associates.

The Lancet published the study online March 1.

The researchers examined the incidence and clearance of genital HPV among men because little is known about the subject. Optimal strategies for preventing the disease both in men and in their sexual partners cannot be devised until more is known about its epidemiology in men, they said.

The prospective HPV in Men (HIM) study involved 1,427 men in Tampa, 1,443 in Sao Paulo, Brazil, and 1,429 in Cuernavaca, Mexico, who were examined for HPV infection at 6-month intervals for a median of 27.5 months. The men were aged 18-70 years at baseline, with a median age of 32 years. All subjects were HIV negative and had no history of cancer.

At each visit, three specimens of penile and scrotal cells were obtained from the coronal sulcus, glans penis, penile shaft, and scrotum for the detection of HPV DNA and for HPV genotyping. Sociodemographic and sexual behavior data were obtained using a questionnaire.

Dr. Giuliano and her colleagues reported findings for a subgroup of the first 1,159 study subjects they assessed. The overall rate of infection with any HPV type was 50%. The overall prevalence of oncogenic HPV subtypes was 30% and that of nononcogenic subtypes was 38%, they said (Lancet 2011 March 1:[doi:10.106/S0140-6736(10)62342-2]).

The incidence of acquisition of a new HPV infection was 38.4/1,000 person-months and did not change appreciably according to subject age. The reason for the lack of an age association such as that seen among women is not yet known. In the study cohort, men in three age groups – 18-30 years, 31-44 years, and 45-70 years – reported having similar numbers of sexual partners and of new sexual partners. Thus, it is possible that they have continued exposure to HPV as they age, the researchers noted.

"Another possible explanation is sex differences in the HPV immune response," Dr. Giuliano and her associates said. "HPV infection of keratinized epithelium, such as the penile skin, might generate lower and weaker immune responses than infection of mucosal epithelium such as the cervix or anal canal."

If men remain at high risk of developing new HPV infections throughout their lives, "then vaccination of older men might be warranted," they noted.

Acquisition of a new HPV infection strongly correlated with the patients’ reported number of sexual partners, male or female. Compared with men who reported no more than 1 lifetime female sexual partner, men who reported they had 10-49 lifetime female sexual partners were 2.7 times as likely to be infected. Those who reported at least three male anal-sex partners in the past 3 months were 2.3 times as likely to develop an infection as those reporting no partners.

Similarly, acquisition of a new infection with an oncogenic HPV subtype correlated with the number of female sexual partners and of male partners who engaged in anal sex. Again, the risk was more than two times greater among men who reported 10 or more such partners than among those who reported no more than 1 partner. Those who reported at least three male anal-sex partners in the past 3 months were 2.6 times as likely to develop an oncogenic HPV infection as those reporting no partners.

The odds of clearing an existing HPV infection also showed a strong association with number of sexual partners. And, as has been reported among women, the odds of clearing an HPV infection in men varied according to HPV subtype. The median time to clearance for oncogenic HPV was 7.2 months, while the median time to clearance of nononcogenic HPV was 7.6 months. Infection clearance times shortened with increasing age.

"The results from this study provide much-needed data about the incidence and clearance of HPV infection in men; these data are essential for the development of realistic cost-effectiveness models for male HPV vaccination internationally," the investigators said.

The National Cancer Institute supported the study. Dr. Giuliano reported ties to Merck, the manufacturer of the HPV vaccine.

Approximately half of men of all ages were infected with genital human papillomavirus, according to a prospective study of three urban areas in the United States, Brazil, and Mexico.

In addition, men’s risk for acquiring HPV did not decline with age as it does in women, but appeared to remain stable throughout their lifetimes, said Dr. Anna R. Giuliano of the risk assessment, detection, and intervention program at H. Lee Moffitt Cancer Center and Research Institute, Tampa, and her associates.

The Lancet published the study online March 1.

The researchers examined the incidence and clearance of genital HPV among men because little is known about the subject. Optimal strategies for preventing the disease both in men and in their sexual partners cannot be devised until more is known about its epidemiology in men, they said.

The prospective HPV in Men (HIM) study involved 1,427 men in Tampa, 1,443 in Sao Paulo, Brazil, and 1,429 in Cuernavaca, Mexico, who were examined for HPV infection at 6-month intervals for a median of 27.5 months. The men were aged 18-70 years at baseline, with a median age of 32 years. All subjects were HIV negative and had no history of cancer.

At each visit, three specimens of penile and scrotal cells were obtained from the coronal sulcus, glans penis, penile shaft, and scrotum for the detection of HPV DNA and for HPV genotyping. Sociodemographic and sexual behavior data were obtained using a questionnaire.

Dr. Giuliano and her colleagues reported findings for a subgroup of the first 1,159 study subjects they assessed. The overall rate of infection with any HPV type was 50%. The overall prevalence of oncogenic HPV subtypes was 30% and that of nononcogenic subtypes was 38%, they said (Lancet 2011 March 1:[doi:10.106/S0140-6736(10)62342-2]).

The incidence of acquisition of a new HPV infection was 38.4/1,000 person-months and did not change appreciably according to subject age. The reason for the lack of an age association such as that seen among women is not yet known. In the study cohort, men in three age groups – 18-30 years, 31-44 years, and 45-70 years – reported having similar numbers of sexual partners and of new sexual partners. Thus, it is possible that they have continued exposure to HPV as they age, the researchers noted.

"Another possible explanation is sex differences in the HPV immune response," Dr. Giuliano and her associates said. "HPV infection of keratinized epithelium, such as the penile skin, might generate lower and weaker immune responses than infection of mucosal epithelium such as the cervix or anal canal."

If men remain at high risk of developing new HPV infections throughout their lives, "then vaccination of older men might be warranted," they noted.

Acquisition of a new HPV infection strongly correlated with the patients’ reported number of sexual partners, male or female. Compared with men who reported no more than 1 lifetime female sexual partner, men who reported they had 10-49 lifetime female sexual partners were 2.7 times as likely to be infected. Those who reported at least three male anal-sex partners in the past 3 months were 2.3 times as likely to develop an infection as those reporting no partners.

Similarly, acquisition of a new infection with an oncogenic HPV subtype correlated with the number of female sexual partners and of male partners who engaged in anal sex. Again, the risk was more than two times greater among men who reported 10 or more such partners than among those who reported no more than 1 partner. Those who reported at least three male anal-sex partners in the past 3 months were 2.6 times as likely to develop an oncogenic HPV infection as those reporting no partners.

The odds of clearing an existing HPV infection also showed a strong association with number of sexual partners. And, as has been reported among women, the odds of clearing an HPV infection in men varied according to HPV subtype. The median time to clearance for oncogenic HPV was 7.2 months, while the median time to clearance of nononcogenic HPV was 7.6 months. Infection clearance times shortened with increasing age.

"The results from this study provide much-needed data about the incidence and clearance of HPV infection in men; these data are essential for the development of realistic cost-effectiveness models for male HPV vaccination internationally," the investigators said.

The National Cancer Institute supported the study. Dr. Giuliano reported ties to Merck, the manufacturer of the HPV vaccine.

Approximately half of men of all ages were infected with genital human papillomavirus, according to a prospective study of three urban areas in the United States, Brazil, and Mexico.

In addition, men’s risk for acquiring HPV did not decline with age as it does in women, but appeared to remain stable throughout their lifetimes, said Dr. Anna R. Giuliano of the risk assessment, detection, and intervention program at H. Lee Moffitt Cancer Center and Research Institute, Tampa, and her associates.

The Lancet published the study online March 1.

The researchers examined the incidence and clearance of genital HPV among men because little is known about the subject. Optimal strategies for preventing the disease both in men and in their sexual partners cannot be devised until more is known about its epidemiology in men, they said.

The prospective HPV in Men (HIM) study involved 1,427 men in Tampa, 1,443 in Sao Paulo, Brazil, and 1,429 in Cuernavaca, Mexico, who were examined for HPV infection at 6-month intervals for a median of 27.5 months. The men were aged 18-70 years at baseline, with a median age of 32 years. All subjects were HIV negative and had no history of cancer.

At each visit, three specimens of penile and scrotal cells were obtained from the coronal sulcus, glans penis, penile shaft, and scrotum for the detection of HPV DNA and for HPV genotyping. Sociodemographic and sexual behavior data were obtained using a questionnaire.

Dr. Giuliano and her colleagues reported findings for a subgroup of the first 1,159 study subjects they assessed. The overall rate of infection with any HPV type was 50%. The overall prevalence of oncogenic HPV subtypes was 30% and that of nononcogenic subtypes was 38%, they said (Lancet 2011 March 1:[doi:10.106/S0140-6736(10)62342-2]).

The incidence of acquisition of a new HPV infection was 38.4/1,000 person-months and did not change appreciably according to subject age. The reason for the lack of an age association such as that seen among women is not yet known. In the study cohort, men in three age groups – 18-30 years, 31-44 years, and 45-70 years – reported having similar numbers of sexual partners and of new sexual partners. Thus, it is possible that they have continued exposure to HPV as they age, the researchers noted.

"Another possible explanation is sex differences in the HPV immune response," Dr. Giuliano and her associates said. "HPV infection of keratinized epithelium, such as the penile skin, might generate lower and weaker immune responses than infection of mucosal epithelium such as the cervix or anal canal."

If men remain at high risk of developing new HPV infections throughout their lives, "then vaccination of older men might be warranted," they noted.

Acquisition of a new HPV infection strongly correlated with the patients’ reported number of sexual partners, male or female. Compared with men who reported no more than 1 lifetime female sexual partner, men who reported they had 10-49 lifetime female sexual partners were 2.7 times as likely to be infected. Those who reported at least three male anal-sex partners in the past 3 months were 2.3 times as likely to develop an infection as those reporting no partners.

Similarly, acquisition of a new infection with an oncogenic HPV subtype correlated with the number of female sexual partners and of male partners who engaged in anal sex. Again, the risk was more than two times greater among men who reported 10 or more such partners than among those who reported no more than 1 partner. Those who reported at least three male anal-sex partners in the past 3 months were 2.6 times as likely to develop an oncogenic HPV infection as those reporting no partners.

The odds of clearing an existing HPV infection also showed a strong association with number of sexual partners. And, as has been reported among women, the odds of clearing an HPV infection in men varied according to HPV subtype. The median time to clearance for oncogenic HPV was 7.2 months, while the median time to clearance of nononcogenic HPV was 7.6 months. Infection clearance times shortened with increasing age.

"The results from this study provide much-needed data about the incidence and clearance of HPV infection in men; these data are essential for the development of realistic cost-effectiveness models for male HPV vaccination internationally," the investigators said.

The National Cancer Institute supported the study. Dr. Giuliano reported ties to Merck, the manufacturer of the HPV vaccine.

Approximately half of men of all ages were infected with genital human papillomavirus, according to a prospective study of three urban areas in the United States, Brazil, and Mexico.

In addition, men’s risk for acquiring HPV did not decline with age as it does in women, but appeared to remain stable throughout their lifetimes, said Dr. Anna R. Giuliano of the risk assessment, detection, and intervention program at H. Lee Moffitt Cancer Center and Research Institute, Tampa, and her associates.

The Lancet published the study online March 1.

The researchers examined the incidence and clearance of genital HPV among men because little is known about the subject. Optimal strategies for preventing the disease both in men and in their sexual partners cannot be devised until more is known about its epidemiology in men, they said.

The prospective HPV in Men (HIM) study involved 1,427 men in Tampa, 1,443 in Sao Paulo, Brazil, and 1,429 in Cuernavaca, Mexico, who were examined for HPV infection at 6-month intervals for a median of 27.5 months. The men were aged 18-70 years at baseline, with a median age of 32 years. All subjects were HIV negative and had no history of cancer.

At each visit, three specimens of penile and scrotal cells were obtained from the coronal sulcus, glans penis, penile shaft, and scrotum for the detection of HPV DNA and for HPV genotyping. Sociodemographic and sexual behavior data were obtained using a questionnaire.

Dr. Giuliano and her colleagues reported findings for a subgroup of the first 1,159 study subjects they assessed. The overall rate of infection with any HPV type was 50%. The overall prevalence of oncogenic HPV subtypes was 30% and that of nononcogenic subtypes was 38%, they said (Lancet 2011 March 1:[doi:10.106/S0140-6736(10)62342-2]).

The incidence of acquisition of a new HPV infection was 38.4/1,000 person-months and did not change appreciably according to subject age. The reason for the lack of an age association such as that seen among women is not yet known. In the study cohort, men in three age groups – 18-30 years, 31-44 years, and 45-70 years – reported having similar numbers of sexual partners and of new sexual partners. Thus, it is possible that they have continued exposure to HPV as they age, the researchers noted.

"Another possible explanation is sex differences in the HPV immune response," Dr. Giuliano and her associates said. "HPV infection of keratinized epithelium, such as the penile skin, might generate lower and weaker immune responses than infection of mucosal epithelium such as the cervix or anal canal."

If men remain at high risk of developing new HPV infections throughout their lives, "then vaccination of older men might be warranted," they noted.

Acquisition of a new HPV infection strongly correlated with the patients’ reported number of sexual partners, male or female. Compared with men who reported no more than 1 lifetime female sexual partner, men who reported they had 10-49 lifetime female sexual partners were 2.7 times as likely to be infected. Those who reported at least three male anal-sex partners in the past 3 months were 2.3 times as likely to develop an infection as those reporting no partners.

Similarly, acquisition of a new infection with an oncogenic HPV subtype correlated with the number of female sexual partners and of male partners who engaged in anal sex. Again, the risk was more than two times greater among men who reported 10 or more such partners than among those who reported no more than 1 partner. Those who reported at least three male anal-sex partners in the past 3 months were 2.6 times as likely to develop an oncogenic HPV infection as those reporting no partners.

The odds of clearing an existing HPV infection also showed a strong association with number of sexual partners. And, as has been reported among women, the odds of clearing an HPV infection in men varied according to HPV subtype. The median time to clearance for oncogenic HPV was 7.2 months, while the median time to clearance of nononcogenic HPV was 7.6 months. Infection clearance times shortened with increasing age.

"The results from this study provide much-needed data about the incidence and clearance of HPV infection in men; these data are essential for the development of realistic cost-effectiveness models for male HPV vaccination internationally," the investigators said.

The National Cancer Institute supported the study. Dr. Giuliano reported ties to Merck, the manufacturer of the HPV vaccine.

Approximately half of men of all ages were infected with genital human papillomavirus, according to a prospective study of three urban areas in the United States, Brazil, and Mexico.

In addition, men’s risk for acquiring HPV did not decline with age as it does in women, but appeared to remain stable throughout their lifetimes, said Dr. Anna R. Giuliano of the risk assessment, detection, and intervention program at H. Lee Moffitt Cancer Center and Research Institute, Tampa, and her associates.

The Lancet published the study online March 1.

The researchers examined the incidence and clearance of genital HPV among men because little is known about the subject. Optimal strategies for preventing the disease both in men and in their sexual partners cannot be devised until more is known about its epidemiology in men, they said.

The prospective HPV in Men (HIM) study involved 1,427 men in Tampa, 1,443 in Sao Paulo, Brazil, and 1,429 in Cuernavaca, Mexico, who were examined for HPV infection at 6-month intervals for a median of 27.5 months. The men were aged 18-70 years at baseline, with a median age of 32 years. All subjects were HIV negative and had no history of cancer.

At each visit, three specimens of penile and scrotal cells were obtained from the coronal sulcus, glans penis, penile shaft, and scrotum for the detection of HPV DNA and for HPV genotyping. Sociodemographic and sexual behavior data were obtained using a questionnaire.

Dr. Giuliano and her colleagues reported findings for a subgroup of the first 1,159 study subjects they assessed. The overall rate of infection with any HPV type was 50%. The overall prevalence of oncogenic HPV subtypes was 30% and that of nononcogenic subtypes was 38%, they said (Lancet 2011 March 1:[doi:10.106/S0140-6736(10)62342-2]).

The incidence of acquisition of a new HPV infection was 38.4/1,000 person-months and did not change appreciably according to subject age. The reason for the lack of an age association such as that seen among women is not yet known. In the study cohort, men in three age groups – 18-30 years, 31-44 years, and 45-70 years – reported having similar numbers of sexual partners and of new sexual partners. Thus, it is possible that they have continued exposure to HPV as they age, the researchers noted.

"Another possible explanation is sex differences in the HPV immune response," Dr. Giuliano and her associates said. "HPV infection of keratinized epithelium, such as the penile skin, might generate lower and weaker immune responses than infection of mucosal epithelium such as the cervix or anal canal."

If men remain at high risk of developing new HPV infections throughout their lives, "then vaccination of older men might be warranted," they noted.

Acquisition of a new HPV infection strongly correlated with the patients’ reported number of sexual partners, male or female. Compared with men who reported no more than 1 lifetime female sexual partner, men who reported they had 10-49 lifetime female sexual partners were 2.7 times as likely to be infected. Those who reported at least three male anal-sex partners in the past 3 months were 2.3 times as likely to develop an infection as those reporting no partners.

Similarly, acquisition of a new infection with an oncogenic HPV subtype correlated with the number of female sexual partners and of male partners who engaged in anal sex. Again, the risk was more than two times greater among men who reported 10 or more such partners than among those who reported no more than 1 partner. Those who reported at least three male anal-sex partners in the past 3 months were 2.6 times as likely to develop an oncogenic HPV infection as those reporting no partners.

The odds of clearing an existing HPV infection also showed a strong association with number of sexual partners. And, as has been reported among women, the odds of clearing an HPV infection in men varied according to HPV subtype. The median time to clearance for oncogenic HPV was 7.2 months, while the median time to clearance of nononcogenic HPV was 7.6 months. Infection clearance times shortened with increasing age.

"The results from this study provide much-needed data about the incidence and clearance of HPV infection in men; these data are essential for the development of realistic cost-effectiveness models for male HPV vaccination internationally," the investigators said.

The National Cancer Institute supported the study. Dr. Giuliano reported ties to Merck, the manufacturer of the HPV vaccine.

Lifestyle counseling from specially trained nurse-practitioners in a primary-care setting was no better at preventing weight gain in a 3-year study than was usual care delivered by the primary-care physician, according to a report in the Feb. 28 issue of the Archives of Internal Medicine.

Researchers in the Groningen Overweight and Lifestyle (GOAL) study compared the effects of two different approaches to preventing weight gain in the primary-care setting: structured lifestyle counseling provided by nurse-practitioners versus usual care.

The study subjects were 457 men and women aged 40-70 years who attended 11 primary-care practices in the Netherlands. They had a body mass index between 25 kg/m² and 40 kg/m² and concomitant hypertension or dyslipidemia, said Nancy C.W. ter Bogt of University Medical Center Groningen, the Netherlands, and her associates.

These subjects were randomly assigned to usual care with the primary physician (232 patients) or to an intervention in which nurse-practitioners counseled them in four in-person 30-minute individual sessions and one telephone "feedback" session during the first year, followed by one individual and two feedback sessions during the next 2 years.

The nurse-practitioner sessions incorporated several elements of behavioral counseling such as individual goal-setting, keeping food diaries, using pedometers to track physical activity, and addressing barriers to lifestyle change. The primary aim of the intervention was to prevent weight gain and, in those patients who were motivated to do so, to promote the loss of 5%-10% of body weight.

After 1 year, 80% of the subjects in the nurse-practitioner group had not gained any weight, compared with only 64% in the physician group. However, in this follow-up at 3 years, that difference had disappeared. An equal proportion of both groups – approximately 60% – had maintained or lost weight, Ms. ter Bogt and her colleagues said (Arch. Intern. Med. 2011;171:306-13).

Subjects counseled by nurse-practitioners showed a slight advantage in fasting glucose level at 3 years, and there were no differences between the two groups in serum lipid levels or blood pressure levels.

The researchers hypothesized that two visits with the nurse-practitioner after the first year of the intervention may not have been sufficient to help patients sustain weight loss. However, analysis showed that maintaining weight was not related to the number of visits in either study group.

Analysis of data in subgroups of patients showed that those who had attempted to lose weight four or more times in the years preceding the study had less success in preventing weight gain than did those who had not. "This means that our intervention is not suitable for experienced dieters," Ms. ter Bogt and her associates wrote.

Lifestyle counseling from specially trained nurse-practitioners in a primary-care setting was no better at preventing weight gain in a 3-year study than was usual care delivered by the primary-care physician, according to a report in the Feb. 28 issue of the Archives of Internal Medicine.

Researchers in the Groningen Overweight and Lifestyle (GOAL) study compared the effects of two different approaches to preventing weight gain in the primary-care setting: structured lifestyle counseling provided by nurse-practitioners versus usual care.

The study subjects were 457 men and women aged 40-70 years who attended 11 primary-care practices in the Netherlands. They had a body mass index between 25 kg/m² and 40 kg/m² and concomitant hypertension or dyslipidemia, said Nancy C.W. ter Bogt of University Medical Center Groningen, the Netherlands, and her associates.

These subjects were randomly assigned to usual care with the primary physician (232 patients) or to an intervention in which nurse-practitioners counseled them in four in-person 30-minute individual sessions and one telephone "feedback" session during the first year, followed by one individual and two feedback sessions during the next 2 years.

The nurse-practitioner sessions incorporated several elements of behavioral counseling such as individual goal-setting, keeping food diaries, using pedometers to track physical activity, and addressing barriers to lifestyle change. The primary aim of the intervention was to prevent weight gain and, in those patients who were motivated to do so, to promote the loss of 5%-10% of body weight.

After 1 year, 80% of the subjects in the nurse-practitioner group had not gained any weight, compared with only 64% in the physician group. However, in this follow-up at 3 years, that difference had disappeared. An equal proportion of both groups – approximately 60% – had maintained or lost weight, Ms. ter Bogt and her colleagues said (Arch. Intern. Med. 2011;171:306-13).

Subjects counseled by nurse-practitioners showed a slight advantage in fasting glucose level at 3 years, and there were no differences between the two groups in serum lipid levels or blood pressure levels.

The researchers hypothesized that two visits with the nurse-practitioner after the first year of the intervention may not have been sufficient to help patients sustain weight loss. However, analysis showed that maintaining weight was not related to the number of visits in either study group.

Analysis of data in subgroups of patients showed that those who had attempted to lose weight four or more times in the years preceding the study had less success in preventing weight gain than did those who had not. "This means that our intervention is not suitable for experienced dieters," Ms. ter Bogt and her associates wrote.

Lifestyle counseling from specially trained nurse-practitioners in a primary-care setting was no better at preventing weight gain in a 3-year study than was usual care delivered by the primary-care physician, according to a report in the Feb. 28 issue of the Archives of Internal Medicine.

Researchers in the Groningen Overweight and Lifestyle (GOAL) study compared the effects of two different approaches to preventing weight gain in the primary-care setting: structured lifestyle counseling provided by nurse-practitioners versus usual care.

The study subjects were 457 men and women aged 40-70 years who attended 11 primary-care practices in the Netherlands. They had a body mass index between 25 kg/m² and 40 kg/m² and concomitant hypertension or dyslipidemia, said Nancy C.W. ter Bogt of University Medical Center Groningen, the Netherlands, and her associates.

These subjects were randomly assigned to usual care with the primary physician (232 patients) or to an intervention in which nurse-practitioners counseled them in four in-person 30-minute individual sessions and one telephone "feedback" session during the first year, followed by one individual and two feedback sessions during the next 2 years.

The nurse-practitioner sessions incorporated several elements of behavioral counseling such as individual goal-setting, keeping food diaries, using pedometers to track physical activity, and addressing barriers to lifestyle change. The primary aim of the intervention was to prevent weight gain and, in those patients who were motivated to do so, to promote the loss of 5%-10% of body weight.

After 1 year, 80% of the subjects in the nurse-practitioner group had not gained any weight, compared with only 64% in the physician group. However, in this follow-up at 3 years, that difference had disappeared. An equal proportion of both groups – approximately 60% – had maintained or lost weight, Ms. ter Bogt and her colleagues said (Arch. Intern. Med. 2011;171:306-13).

Subjects counseled by nurse-practitioners showed a slight advantage in fasting glucose level at 3 years, and there were no differences between the two groups in serum lipid levels or blood pressure levels.

The researchers hypothesized that two visits with the nurse-practitioner after the first year of the intervention may not have been sufficient to help patients sustain weight loss. However, analysis showed that maintaining weight was not related to the number of visits in either study group.

Analysis of data in subgroups of patients showed that those who had attempted to lose weight four or more times in the years preceding the study had less success in preventing weight gain than did those who had not. "This means that our intervention is not suitable for experienced dieters," Ms. ter Bogt and her associates wrote.

Lifestyle counseling from specially trained nurse-practitioners in a primary-care setting was no better at preventing weight gain in a 3-year study than was usual care delivered by the primary-care physician, according to a report in the Feb. 28 issue of the Archives of Internal Medicine.

Researchers in the Groningen Overweight and Lifestyle (GOAL) study compared the effects of two different approaches to preventing weight gain in the primary-care setting: structured lifestyle counseling provided by nurse-practitioners versus usual care.

The study subjects were 457 men and women aged 40-70 years who attended 11 primary-care practices in the Netherlands. They had a body mass index between 25 kg/m² and 40 kg/m² and concomitant hypertension or dyslipidemia, said Nancy C.W. ter Bogt of University Medical Center Groningen, the Netherlands, and her associates.

These subjects were randomly assigned to usual care with the primary physician (232 patients) or to an intervention in which nurse-practitioners counseled them in four in-person 30-minute individual sessions and one telephone "feedback" session during the first year, followed by one individual and two feedback sessions during the next 2 years.

The nurse-practitioner sessions incorporated several elements of behavioral counseling such as individual goal-setting, keeping food diaries, using pedometers to track physical activity, and addressing barriers to lifestyle change. The primary aim of the intervention was to prevent weight gain and, in those patients who were motivated to do so, to promote the loss of 5%-10% of body weight.

After 1 year, 80% of the subjects in the nurse-practitioner group had not gained any weight, compared with only 64% in the physician group. However, in this follow-up at 3 years, that difference had disappeared. An equal proportion of both groups – approximately 60% – had maintained or lost weight, Ms. ter Bogt and her colleagues said (Arch. Intern. Med. 2011;171:306-13).

Subjects counseled by nurse-practitioners showed a slight advantage in fasting glucose level at 3 years, and there were no differences between the two groups in serum lipid levels or blood pressure levels.

The researchers hypothesized that two visits with the nurse-practitioner after the first year of the intervention may not have been sufficient to help patients sustain weight loss. However, analysis showed that maintaining weight was not related to the number of visits in either study group.

Analysis of data in subgroups of patients showed that those who had attempted to lose weight four or more times in the years preceding the study had less success in preventing weight gain than did those who had not. "This means that our intervention is not suitable for experienced dieters," Ms. ter Bogt and her associates wrote.

Lifestyle counseling from specially trained nurse-practitioners in a primary-care setting was no better at preventing weight gain in a 3-year study than was usual care delivered by the primary-care physician, according to a report in the Feb. 28 issue of the Archives of Internal Medicine.

Researchers in the Groningen Overweight and Lifestyle (GOAL) study compared the effects of two different approaches to preventing weight gain in the primary-care setting: structured lifestyle counseling provided by nurse-practitioners versus usual care.

The study subjects were 457 men and women aged 40-70 years who attended 11 primary-care practices in the Netherlands. They had a body mass index between 25 kg/m² and 40 kg/m² and concomitant hypertension or dyslipidemia, said Nancy C.W. ter Bogt of University Medical Center Groningen, the Netherlands, and her associates.

These subjects were randomly assigned to usual care with the primary physician (232 patients) or to an intervention in which nurse-practitioners counseled them in four in-person 30-minute individual sessions and one telephone "feedback" session during the first year, followed by one individual and two feedback sessions during the next 2 years.

The nurse-practitioner sessions incorporated several elements of behavioral counseling such as individual goal-setting, keeping food diaries, using pedometers to track physical activity, and addressing barriers to lifestyle change. The primary aim of the intervention was to prevent weight gain and, in those patients who were motivated to do so, to promote the loss of 5%-10% of body weight.

After 1 year, 80% of the subjects in the nurse-practitioner group had not gained any weight, compared with only 64% in the physician group. However, in this follow-up at 3 years, that difference had disappeared. An equal proportion of both groups – approximately 60% – had maintained or lost weight, Ms. ter Bogt and her colleagues said (Arch. Intern. Med. 2011;171:306-13).

Subjects counseled by nurse-practitioners showed a slight advantage in fasting glucose level at 3 years, and there were no differences between the two groups in serum lipid levels or blood pressure levels.

The researchers hypothesized that two visits with the nurse-practitioner after the first year of the intervention may not have been sufficient to help patients sustain weight loss. However, analysis showed that maintaining weight was not related to the number of visits in either study group.

Analysis of data in subgroups of patients showed that those who had attempted to lose weight four or more times in the years preceding the study had less success in preventing weight gain than did those who had not. "This means that our intervention is not suitable for experienced dieters," Ms. ter Bogt and her associates wrote.

Lifestyle counseling from specially trained nurse-practitioners in a primary-care setting was no better at preventing weight gain in a 3-year study than was usual care delivered by the primary-care physician, according to a report in the Feb. 28 issue of the Archives of Internal Medicine.

Researchers in the Groningen Overweight and Lifestyle (GOAL) study compared the effects of two different approaches to preventing weight gain in the primary-care setting: structured lifestyle counseling provided by nurse-practitioners versus usual care.

The study subjects were 457 men and women aged 40-70 years who attended 11 primary-care practices in the Netherlands. They had a body mass index between 25 kg/m² and 40 kg/m² and concomitant hypertension or dyslipidemia, said Nancy C.W. ter Bogt of University Medical Center Groningen, the Netherlands, and her associates.

These subjects were randomly assigned to usual care with the primary physician (232 patients) or to an intervention in which nurse-practitioners counseled them in four in-person 30-minute individual sessions and one telephone "feedback" session during the first year, followed by one individual and two feedback sessions during the next 2 years.

The nurse-practitioner sessions incorporated several elements of behavioral counseling such as individual goal-setting, keeping food diaries, using pedometers to track physical activity, and addressing barriers to lifestyle change. The primary aim of the intervention was to prevent weight gain and, in those patients who were motivated to do so, to promote the loss of 5%-10% of body weight.

After 1 year, 80% of the subjects in the nurse-practitioner group had not gained any weight, compared with only 64% in the physician group. However, in this follow-up at 3 years, that difference had disappeared. An equal proportion of both groups – approximately 60% – had maintained or lost weight, Ms. ter Bogt and her colleagues said (Arch. Intern. Med. 2011;171:306-13).

Subjects counseled by nurse-practitioners showed a slight advantage in fasting glucose level at 3 years, and there were no differences between the two groups in serum lipid levels or blood pressure levels.

The researchers hypothesized that two visits with the nurse-practitioner after the first year of the intervention may not have been sufficient to help patients sustain weight loss. However, analysis showed that maintaining weight was not related to the number of visits in either study group.

Analysis of data in subgroups of patients showed that those who had attempted to lose weight four or more times in the years preceding the study had less success in preventing weight gain than did those who had not. "This means that our intervention is not suitable for experienced dieters," Ms. ter Bogt and her associates wrote.

Lifestyle counseling from specially trained nurse-practitioners in a primary-care setting was no better at preventing weight gain in a 3-year study than was usual care delivered by the primary-care physician, according to a report in the Feb. 28 issue of the Archives of Internal Medicine.

Researchers in the Groningen Overweight and Lifestyle (GOAL) study compared the effects of two different approaches to preventing weight gain in the primary-care setting: structured lifestyle counseling provided by nurse-practitioners versus usual care.

The study subjects were 457 men and women aged 40-70 years who attended 11 primary-care practices in the Netherlands. They had a body mass index between 25 kg/m² and 40 kg/m² and concomitant hypertension or dyslipidemia, said Nancy C.W. ter Bogt of University Medical Center Groningen, the Netherlands, and her associates.

These subjects were randomly assigned to usual care with the primary physician (232 patients) or to an intervention in which nurse-practitioners counseled them in four in-person 30-minute individual sessions and one telephone "feedback" session during the first year, followed by one individual and two feedback sessions during the next 2 years.

The nurse-practitioner sessions incorporated several elements of behavioral counseling such as individual goal-setting, keeping food diaries, using pedometers to track physical activity, and addressing barriers to lifestyle change. The primary aim of the intervention was to prevent weight gain and, in those patients who were motivated to do so, to promote the loss of 5%-10% of body weight.

After 1 year, 80% of the subjects in the nurse-practitioner group had not gained any weight, compared with only 64% in the physician group. However, in this follow-up at 3 years, that difference had disappeared. An equal proportion of both groups – approximately 60% – had maintained or lost weight, Ms. ter Bogt and her colleagues said (Arch. Intern. Med. 2011;171:306-13).

Subjects counseled by nurse-practitioners showed a slight advantage in fasting glucose level at 3 years, and there were no differences between the two groups in serum lipid levels or blood pressure levels.

The researchers hypothesized that two visits with the nurse-practitioner after the first year of the intervention may not have been sufficient to help patients sustain weight loss. However, analysis showed that maintaining weight was not related to the number of visits in either study group.

Analysis of data in subgroups of patients showed that those who had attempted to lose weight four or more times in the years preceding the study had less success in preventing weight gain than did those who had not. "This means that our intervention is not suitable for experienced dieters," Ms. ter Bogt and her associates wrote.

Lifestyle counseling from specially trained nurse-practitioners in a primary-care setting was no better at preventing weight gain in a 3-year study than was usual care delivered by the primary-care physician, according to a report in the Feb. 28 issue of the Archives of Internal Medicine.

Researchers in the Groningen Overweight and Lifestyle (GOAL) study compared the effects of two different approaches to preventing weight gain in the primary-care setting: structured lifestyle counseling provided by nurse-practitioners versus usual care.

The study subjects were 457 men and women aged 40-70 years who attended 11 primary-care practices in the Netherlands. They had a body mass index between 25 kg/m² and 40 kg/m² and concomitant hypertension or dyslipidemia, said Nancy C.W. ter Bogt of University Medical Center Groningen, the Netherlands, and her associates.

These subjects were randomly assigned to usual care with the primary physician (232 patients) or to an intervention in which nurse-practitioners counseled them in four in-person 30-minute individual sessions and one telephone "feedback" session during the first year, followed by one individual and two feedback sessions during the next 2 years.

The nurse-practitioner sessions incorporated several elements of behavioral counseling such as individual goal-setting, keeping food diaries, using pedometers to track physical activity, and addressing barriers to lifestyle change. The primary aim of the intervention was to prevent weight gain and, in those patients who were motivated to do so, to promote the loss of 5%-10% of body weight.

After 1 year, 80% of the subjects in the nurse-practitioner group had not gained any weight, compared with only 64% in the physician group. However, in this follow-up at 3 years, that difference had disappeared. An equal proportion of both groups – approximately 60% – had maintained or lost weight, Ms. ter Bogt and her colleagues said (Arch. Intern. Med. 2011;171:306-13).

Subjects counseled by nurse-practitioners showed a slight advantage in fasting glucose level at 3 years, and there were no differences between the two groups in serum lipid levels or blood pressure levels.

The researchers hypothesized that two visits with the nurse-practitioner after the first year of the intervention may not have been sufficient to help patients sustain weight loss. However, analysis showed that maintaining weight was not related to the number of visits in either study group.

Analysis of data in subgroups of patients showed that those who had attempted to lose weight four or more times in the years preceding the study had less success in preventing weight gain than did those who had not. "This means that our intervention is not suitable for experienced dieters," Ms. ter Bogt and her associates wrote.

Lifestyle counseling from specially trained nurse-practitioners in a primary-care setting was no better at preventing weight gain in a 3-year study than was usual care delivered by the primary-care physician, according to a report in the Feb. 28 issue of the Archives of Internal Medicine.

Researchers in the Groningen Overweight and Lifestyle (GOAL) study compared the effects of two different approaches to preventing weight gain in the primary-care setting: structured lifestyle counseling provided by nurse-practitioners versus usual care.

The study subjects were 457 men and women aged 40-70 years who attended 11 primary-care practices in the Netherlands. They had a body mass index between 25 kg/m² and 40 kg/m² and concomitant hypertension or dyslipidemia, said Nancy C.W. ter Bogt of University Medical Center Groningen, the Netherlands, and her associates.

These subjects were randomly assigned to usual care with the primary physician (232 patients) or to an intervention in which nurse-practitioners counseled them in four in-person 30-minute individual sessions and one telephone "feedback" session during the first year, followed by one individual and two feedback sessions during the next 2 years.

The nurse-practitioner sessions incorporated several elements of behavioral counseling such as individual goal-setting, keeping food diaries, using pedometers to track physical activity, and addressing barriers to lifestyle change. The primary aim of the intervention was to prevent weight gain and, in those patients who were motivated to do so, to promote the loss of 5%-10% of body weight.

After 1 year, 80% of the subjects in the nurse-practitioner group had not gained any weight, compared with only 64% in the physician group. However, in this follow-up at 3 years, that difference had disappeared. An equal proportion of both groups – approximately 60% – had maintained or lost weight, Ms. ter Bogt and her colleagues said (Arch. Intern. Med. 2011;171:306-13).

Subjects counseled by nurse-practitioners showed a slight advantage in fasting glucose level at 3 years, and there were no differences between the two groups in serum lipid levels or blood pressure levels.

The researchers hypothesized that two visits with the nurse-practitioner after the first year of the intervention may not have been sufficient to help patients sustain weight loss. However, analysis showed that maintaining weight was not related to the number of visits in either study group.

Analysis of data in subgroups of patients showed that those who had attempted to lose weight four or more times in the years preceding the study had less success in preventing weight gain than did those who had not. "This means that our intervention is not suitable for experienced dieters," Ms. ter Bogt and her associates wrote.

When physicians tell patients directly that they are overweight, it raises the odds that the patients will perceive their weight realistically, will want to lose weight, and will try to lose weight, according to a report in the Feb. 28 issue of Archives of Internal Medicine.

However, fewer than half of overweight patients and fewer than two-thirds of obese patients say they have been told by their physicians that they are overweight.

"This is an important intervention point that is being missed by many physicians. Physicians need to tell more overweight and obese patients that they are overweight because this may help encourage them to change their behavior to lose weight and lower their risk for many diseases," said Dr. Robert E. Post of the department of family medicine, Medical University of South Carolina, Charleston, and his associates.

Today’s overweight and obese patients are more likely to consider themselves to be of normal weight than their counterparts of 20 years ago were, in part because the current obesity epidemic has made higher weights and larger sizes seem more normal. Patients who don’t perceive their weight accurately won’t recognize their health risks and won’t work to reduce them, the investigators said.

They analyzed data from the 2005-2008 National Health and Nutrition Examination Survey in a cross-sectional study to assess the effect of physician acknowledgment of weight status on patient behavior. The study included data for 7,790 men and women aged 20-64 years who constituted a nationally representative sample of the U.S. population.

A total of 5,474 of these subjects qualified as overweight, with a BMI of 25 kg/m² or greater, including 2,874 who qualified as obese, with a BMI of 30 or greater.

Of the overweight subjects, 45% reported that their physicians had told them they were overweight, as did 66% of the obese subjects. These subjects were much more likely to identify themselves as overweight (94%) or obese (97%) than were overweight subjects whose physicians had not so informed them (63% and 81%, respectively). They also were much more likely to report that they wanted to lose weight and had attempted to lose weight during the preceding year.

However, about 37% of overweight and 19% of obese subjects had not been told they were overweight by their physicians and did not consider themselves to be. In comparison, only 6% of overweight and 3% of obese subjects who had been told by their physicians that they were overweight continued to consider themselves to be of normal weight.

"This speaks strongly to the influence that physicians’ words have on their patients," Dr. Post and his colleagues said (Arch. Intern. Med. 2011;171:316-21).

Extrapolating this finding to the general U.S. adult population, "this equates to more than 74 million overweight individuals, including nearly 23 million obese individuals, who have never been told that they are overweight," they added.

Telling patients that they are overweight was associated with an eightfold increase in the odds that they would accurately see themselves as overweight and a sixfold increase in the odds that they would accurately see themselves as obese. This recognition is essential because being aware of the problem is the first step in changing behavior to overcome it, the investigators noted.

This study could not assess why physicians fail to identify patients as overweight. It is possible that some patients didn’t "hear" this even though their physicians did tell them.

Alternatively, some physicians may not bother to inform patients of weight status because they see patients as lacking in self-control or motivation to change. Some may feel that labeling patients as overweight or obese is simply stating the obvious and won’t make much difference. Still others may cite time constraints, feeling that if they don’t have the time, they should "avoid starting a potentially long conversation" during a patient visit.

The strong association found in this study between physicians’ remarks and patients’ beliefs "should help to change these negative perceptions among physicians and encourage incorporating extra time into visits to discuss weight management with their patients," Dr. Post and his associates said.

No financial conflicts of interest were reported.

When physicians tell patients directly that they are overweight, it raises the odds that the patients will perceive their weight realistically, will want to lose weight, and will try to lose weight, according to a report in the Feb. 28 issue of Archives of Internal Medicine.

However, fewer than half of overweight patients and fewer than two-thirds of obese patients say they have been told by their physicians that they are overweight.

"This is an important intervention point that is being missed by many physicians. Physicians need to tell more overweight and obese patients that they are overweight because this may help encourage them to change their behavior to lose weight and lower their risk for many diseases," said Dr. Robert E. Post of the department of family medicine, Medical University of South Carolina, Charleston, and his associates.

Today’s overweight and obese patients are more likely to consider themselves to be of normal weight than their counterparts of 20 years ago were, in part because the current obesity epidemic has made higher weights and larger sizes seem more normal. Patients who don’t perceive their weight accurately won’t recognize their health risks and won’t work to reduce them, the investigators said.

They analyzed data from the 2005-2008 National Health and Nutrition Examination Survey in a cross-sectional study to assess the effect of physician acknowledgment of weight status on patient behavior. The study included data for 7,790 men and women aged 20-64 years who constituted a nationally representative sample of the U.S. population.

A total of 5,474 of these subjects qualified as overweight, with a BMI of 25 kg/m² or greater, including 2,874 who qualified as obese, with a BMI of 30 or greater.

Of the overweight subjects, 45% reported that their physicians had told them they were overweight, as did 66% of the obese subjects. These subjects were much more likely to identify themselves as overweight (94%) or obese (97%) than were overweight subjects whose physicians had not so informed them (63% and 81%, respectively). They also were much more likely to report that they wanted to lose weight and had attempted to lose weight during the preceding year.

However, about 37% of overweight and 19% of obese subjects had not been told they were overweight by their physicians and did not consider themselves to be. In comparison, only 6% of overweight and 3% of obese subjects who had been told by their physicians that they were overweight continued to consider themselves to be of normal weight.

"This speaks strongly to the influence that physicians’ words have on their patients," Dr. Post and his colleagues said (Arch. Intern. Med. 2011;171:316-21).

Extrapolating this finding to the general U.S. adult population, "this equates to more than 74 million overweight individuals, including nearly 23 million obese individuals, who have never been told that they are overweight," they added.

Telling patients that they are overweight was associated with an eightfold increase in the odds that they would accurately see themselves as overweight and a sixfold increase in the odds that they would accurately see themselves as obese. This recognition is essential because being aware of the problem is the first step in changing behavior to overcome it, the investigators noted.

This study could not assess why physicians fail to identify patients as overweight. It is possible that some patients didn’t "hear" this even though their physicians did tell them.

Alternatively, some physicians may not bother to inform patients of weight status because they see patients as lacking in self-control or motivation to change. Some may feel that labeling patients as overweight or obese is simply stating the obvious and won’t make much difference. Still others may cite time constraints, feeling that if they don’t have the time, they should "avoid starting a potentially long conversation" during a patient visit.

The strong association found in this study between physicians’ remarks and patients’ beliefs "should help to change these negative perceptions among physicians and encourage incorporating extra time into visits to discuss weight management with their patients," Dr. Post and his associates said.

No financial conflicts of interest were reported.

When physicians tell patients directly that they are overweight, it raises the odds that the patients will perceive their weight realistically, will want to lose weight, and will try to lose weight, according to a report in the Feb. 28 issue of Archives of Internal Medicine.

However, fewer than half of overweight patients and fewer than two-thirds of obese patients say they have been told by their physicians that they are overweight.

"This is an important intervention point that is being missed by many physicians. Physicians need to tell more overweight and obese patients that they are overweight because this may help encourage them to change their behavior to lose weight and lower their risk for many diseases," said Dr. Robert E. Post of the department of family medicine, Medical University of South Carolina, Charleston, and his associates.

Today’s overweight and obese patients are more likely to consider themselves to be of normal weight than their counterparts of 20 years ago were, in part because the current obesity epidemic has made higher weights and larger sizes seem more normal. Patients who don’t perceive their weight accurately won’t recognize their health risks and won’t work to reduce them, the investigators said.

They analyzed data from the 2005-2008 National Health and Nutrition Examination Survey in a cross-sectional study to assess the effect of physician acknowledgment of weight status on patient behavior. The study included data for 7,790 men and women aged 20-64 years who constituted a nationally representative sample of the U.S. population.

A total of 5,474 of these subjects qualified as overweight, with a BMI of 25 kg/m² or greater, including 2,874 who qualified as obese, with a BMI of 30 or greater.

Of the overweight subjects, 45% reported that their physicians had told them they were overweight, as did 66% of the obese subjects. These subjects were much more likely to identify themselves as overweight (94%) or obese (97%) than were overweight subjects whose physicians had not so informed them (63% and 81%, respectively). They also were much more likely to report that they wanted to lose weight and had attempted to lose weight during the preceding year.

However, about 37% of overweight and 19% of obese subjects had not been told they were overweight by their physicians and did not consider themselves to be. In comparison, only 6% of overweight and 3% of obese subjects who had been told by their physicians that they were overweight continued to consider themselves to be of normal weight.

"This speaks strongly to the influence that physicians’ words have on their patients," Dr. Post and his colleagues said (Arch. Intern. Med. 2011;171:316-21).

Extrapolating this finding to the general U.S. adult population, "this equates to more than 74 million overweight individuals, including nearly 23 million obese individuals, who have never been told that they are overweight," they added.

Telling patients that they are overweight was associated with an eightfold increase in the odds that they would accurately see themselves as overweight and a sixfold increase in the odds that they would accurately see themselves as obese. This recognition is essential because being aware of the problem is the first step in changing behavior to overcome it, the investigators noted.

This study could not assess why physicians fail to identify patients as overweight. It is possible that some patients didn’t "hear" this even though their physicians did tell them.

Alternatively, some physicians may not bother to inform patients of weight status because they see patients as lacking in self-control or motivation to change. Some may feel that labeling patients as overweight or obese is simply stating the obvious and won’t make much difference. Still others may cite time constraints, feeling that if they don’t have the time, they should "avoid starting a potentially long conversation" during a patient visit.

The strong association found in this study between physicians’ remarks and patients’ beliefs "should help to change these negative perceptions among physicians and encourage incorporating extra time into visits to discuss weight management with their patients," Dr. Post and his associates said.

No financial conflicts of interest were reported.