Robert Finn

ATLANTA — African Americans are less likely than members of other races to persist in combination antihypertensive therapy, according to a retrospective analysis of medical and pharmacy claims for Medicaid patients in Maryland who were prescribed the combination of an ACE inhibitor and a calcium channel blocker or an ACE inhibitor and a hydrochlorothiazide diuretic during 2002–2004.

Of the 1,701 total patients, 17.5% were persistent in their use of the medication and 82.5% discontinued. Of the 1,137 African Americans, 15.5% were persistent, compared with 21.2% of the 448 whites and 23.3% of the 116 members of other races, said Fadia T. Shaya, Ph.D., in a poster presentation at a meeting sponsored by the International Society on Hypertension in Blacks and cosponsored by the American Society of Hypertension.

After adjustment for age, gender, and comorbidities, African Americans were 21% more likely to discontinue their therapy than were members of other races. The relationship was statistically significant when patients used a fixed-dose combination in a single pill and when they used a free combination regimen with two concurrent pills, said Dr. Shaya of the University of Maryland, Baltimore. After adjustment for all other covariates, other factors that were significant predictors of nonpersistent behav- ior included patients under age 40 years and those with a higher comorbidity index.

ATLANTA — African Americans are less likely than members of other races to persist in combination antihypertensive therapy, according to a retrospective analysis of medical and pharmacy claims for Medicaid patients in Maryland who were prescribed the combination of an ACE inhibitor and a calcium channel blocker or an ACE inhibitor and a hydrochlorothiazide diuretic during 2002–2004.

Of the 1,701 total patients, 17.5% were persistent in their use of the medication and 82.5% discontinued. Of the 1,137 African Americans, 15.5% were persistent, compared with 21.2% of the 448 whites and 23.3% of the 116 members of other races, said Fadia T. Shaya, Ph.D., in a poster presentation at a meeting sponsored by the International Society on Hypertension in Blacks and cosponsored by the American Society of Hypertension.

After adjustment for age, gender, and comorbidities, African Americans were 21% more likely to discontinue their therapy than were members of other races. The relationship was statistically significant when patients used a fixed-dose combination in a single pill and when they used a free combination regimen with two concurrent pills, said Dr. Shaya of the University of Maryland, Baltimore. After adjustment for all other covariates, other factors that were significant predictors of nonpersistent behav- ior included patients under age 40 years and those with a higher comorbidity index.

ATLANTA — African Americans are less likely than members of other races to persist in combination antihypertensive therapy, according to a retrospective analysis of medical and pharmacy claims for Medicaid patients in Maryland who were prescribed the combination of an ACE inhibitor and a calcium channel blocker or an ACE inhibitor and a hydrochlorothiazide diuretic during 2002–2004.

Of the 1,701 total patients, 17.5% were persistent in their use of the medication and 82.5% discontinued. Of the 1,137 African Americans, 15.5% were persistent, compared with 21.2% of the 448 whites and 23.3% of the 116 members of other races, said Fadia T. Shaya, Ph.D., in a poster presentation at a meeting sponsored by the International Society on Hypertension in Blacks and cosponsored by the American Society of Hypertension.

After adjustment for age, gender, and comorbidities, African Americans were 21% more likely to discontinue their therapy than were members of other races. The relationship was statistically significant when patients used a fixed-dose combination in a single pill and when they used a free combination regimen with two concurrent pills, said Dr. Shaya of the University of Maryland, Baltimore. After adjustment for all other covariates, other factors that were significant predictors of nonpersistent behav- ior included patients under age 40 years and those with a higher comorbidity index.

DENVER — Adults with Down syndrome seem to be protected against atherosclerosis, despite having elevated risk factors, Christopher C. Draheim, Ph.D., and Donald R. Dengel, Ph.D., reported in a poster presentation at the annual meeting of the American College of Sports Medicine.

Such adults have significantly elevated total body fat, higher levels of triglycerides and C-reactive protein, and lower levels of moderate to vigorous physical activity, but they also have significantly lower intima media thickness (IMT) than do age-, gender-, and race-matched controls without Down syndrome or mental retardation, the researchers noted.

Dr. Draheim, of Oregon State University, Corvallis, and Dr. Dengel, of the University of Minnesota, Minneapolis, compared 52 community-dwelling adults with Down syndrome and mild to moderate mental retardation, aged 35–60 years, with 52 controls. They used a high-resolution ultrasound scanner and electronic wall-tracking software to measure IMT on the far wall of the left common carotid artery.

The investigators obtained fasting blood chemistries from all of the participants, they measured total body fat with dual-energy x-ray absorptiometry, and they administered a questionnaire to assess the participants' regular physical activity habits.

As expected, a number of risk factors predicted IMT in the control group. Six of these factors—fasting plasma insulin, age, the amount of fruit and vegetables consumed, LDL cholesterol, and smoking status—accounted for 70% of the variance in IMT. In contrast, only two factors—male gender and the level of moderate to vigorous physical activity—predicted IMT in the adults with Down syndrome. Those factors accounted for only 33% of the variance in IMT.

The results confirm earlier study findings that suggest people with Down syndrome who reside in large institutional settings have less atherosclerotic plaque than do others with and without mental retardation. However, most adults with Down syndrome now live in community settings and are more likely to be exposed to a lifestyle in which low levels of physical activity and high-fat and high-cholesterol diets are more prevalent, and that may put them at a higher risk of cardiovascular disease.

However, adults with Down syndrome typically have low blood pressure, which is associated with a lower risk of cardiovascular disease. The average blood pressure in participants in the study was 116/59 mm Hg, which was significantly lower than the 125/73 mm Hg in the control group.

“The significant reduction in the IMT values of adults with Down syndrome, along with differing predictors of IMT in persons with DS, indicate that [they] possess a unique atherogenic model that differs from individuals without DS,” the investigators wrote. Additional research is needed to determine which mechanisms protect people with Down syndrome from atherosclerosis, they noted.

DENVER — Adults with Down syndrome seem to be protected against atherosclerosis, despite having elevated risk factors, Christopher C. Draheim, Ph.D., and Donald R. Dengel, Ph.D., reported in a poster presentation at the annual meeting of the American College of Sports Medicine.

Such adults have significantly elevated total body fat, higher levels of triglycerides and C-reactive protein, and lower levels of moderate to vigorous physical activity, but they also have significantly lower intima media thickness (IMT) than do age-, gender-, and race-matched controls without Down syndrome or mental retardation, the researchers noted.

Dr. Draheim, of Oregon State University, Corvallis, and Dr. Dengel, of the University of Minnesota, Minneapolis, compared 52 community-dwelling adults with Down syndrome and mild to moderate mental retardation, aged 35–60 years, with 52 controls. They used a high-resolution ultrasound scanner and electronic wall-tracking software to measure IMT on the far wall of the left common carotid artery.

The investigators obtained fasting blood chemistries from all of the participants, they measured total body fat with dual-energy x-ray absorptiometry, and they administered a questionnaire to assess the participants' regular physical activity habits.

As expected, a number of risk factors predicted IMT in the control group. Six of these factors—fasting plasma insulin, age, the amount of fruit and vegetables consumed, LDL cholesterol, and smoking status—accounted for 70% of the variance in IMT. In contrast, only two factors—male gender and the level of moderate to vigorous physical activity—predicted IMT in the adults with Down syndrome. Those factors accounted for only 33% of the variance in IMT.

The results confirm earlier study findings that suggest people with Down syndrome who reside in large institutional settings have less atherosclerotic plaque than do others with and without mental retardation. However, most adults with Down syndrome now live in community settings and are more likely to be exposed to a lifestyle in which low levels of physical activity and high-fat and high-cholesterol diets are more prevalent, and that may put them at a higher risk of cardiovascular disease.

However, adults with Down syndrome typically have low blood pressure, which is associated with a lower risk of cardiovascular disease. The average blood pressure in participants in the study was 116/59 mm Hg, which was significantly lower than the 125/73 mm Hg in the control group.

“The significant reduction in the IMT values of adults with Down syndrome, along with differing predictors of IMT in persons with DS, indicate that [they] possess a unique atherogenic model that differs from individuals without DS,” the investigators wrote. Additional research is needed to determine which mechanisms protect people with Down syndrome from atherosclerosis, they noted.

DENVER — Adults with Down syndrome seem to be protected against atherosclerosis, despite having elevated risk factors, Christopher C. Draheim, Ph.D., and Donald R. Dengel, Ph.D., reported in a poster presentation at the annual meeting of the American College of Sports Medicine.

Such adults have significantly elevated total body fat, higher levels of triglycerides and C-reactive protein, and lower levels of moderate to vigorous physical activity, but they also have significantly lower intima media thickness (IMT) than do age-, gender-, and race-matched controls without Down syndrome or mental retardation, the researchers noted.

Dr. Draheim, of Oregon State University, Corvallis, and Dr. Dengel, of the University of Minnesota, Minneapolis, compared 52 community-dwelling adults with Down syndrome and mild to moderate mental retardation, aged 35–60 years, with 52 controls. They used a high-resolution ultrasound scanner and electronic wall-tracking software to measure IMT on the far wall of the left common carotid artery.

The investigators obtained fasting blood chemistries from all of the participants, they measured total body fat with dual-energy x-ray absorptiometry, and they administered a questionnaire to assess the participants' regular physical activity habits.

As expected, a number of risk factors predicted IMT in the control group. Six of these factors—fasting plasma insulin, age, the amount of fruit and vegetables consumed, LDL cholesterol, and smoking status—accounted for 70% of the variance in IMT. In contrast, only two factors—male gender and the level of moderate to vigorous physical activity—predicted IMT in the adults with Down syndrome. Those factors accounted for only 33% of the variance in IMT.

The results confirm earlier study findings that suggest people with Down syndrome who reside in large institutional settings have less atherosclerotic plaque than do others with and without mental retardation. However, most adults with Down syndrome now live in community settings and are more likely to be exposed to a lifestyle in which low levels of physical activity and high-fat and high-cholesterol diets are more prevalent, and that may put them at a higher risk of cardiovascular disease.

However, adults with Down syndrome typically have low blood pressure, which is associated with a lower risk of cardiovascular disease. The average blood pressure in participants in the study was 116/59 mm Hg, which was significantly lower than the 125/73 mm Hg in the control group.

“The significant reduction in the IMT values of adults with Down syndrome, along with differing predictors of IMT in persons with DS, indicate that [they] possess a unique atherogenic model that differs from individuals without DS,” the investigators wrote. Additional research is needed to determine which mechanisms protect people with Down syndrome from atherosclerosis, they noted.

ATLANTA — African Americans are less likely than members of other races to persist in combination antihypertensive therapy, according to a retrospective analysis of medical and pharmacy claims for Medicaid patients in Maryland.

After adjustment for age, gender, and comorbidities, African Americans were 21% more likely to discontinue their therapy than were members of other races. This relationship was significant when the patients were using a fixed-dose combination in a single pill and also when they were using a free combination regimen with two concurrent pills, according to a poster presentation by Fadia T. Shaya, Ph.D., at a meeting sponsored by the International Society on Hypertension in Blacks.

After adjustment for all other covariates, several other factors proved to be significant predictors of nonpersistent behavior. Patients under age 40 years were 26% more likely to discontinue than were older patients, and those with a higher comorbidity index were 4% more likely to do so.

On the other hand, patients on a fixed-dose combination regimen were 18% less likely to discontinue than were patients taking a combination of two pills, wrote Dr. Shaya of the University of Maryland, Baltimore, at the meeting, cosponsored by the American Society of Hypertension.

The analysis involved all Medicaid patients in Maryland who were prescribed the combination of an ACE inhibitor and a calcium channel blocker or an ACE inhibitor and a hydrochlorothiazide diuretic during 2002–2004.

Of the 1,701 total patients, 17.5% were persistent in their use of the medication and 82.5% discontinued. Of the 1,137 African Americans, 15.5% were persistent, compared with 21.2% of the 448 whites and 23.3% of the 116 members of other races.

ATLANTA — African Americans are less likely than members of other races to persist in combination antihypertensive therapy, according to a retrospective analysis of medical and pharmacy claims for Medicaid patients in Maryland.

After adjustment for age, gender, and comorbidities, African Americans were 21% more likely to discontinue their therapy than were members of other races. This relationship was significant when the patients were using a fixed-dose combination in a single pill and also when they were using a free combination regimen with two concurrent pills, according to a poster presentation by Fadia T. Shaya, Ph.D., at a meeting sponsored by the International Society on Hypertension in Blacks.

After adjustment for all other covariates, several other factors proved to be significant predictors of nonpersistent behavior. Patients under age 40 years were 26% more likely to discontinue than were older patients, and those with a higher comorbidity index were 4% more likely to do so.

On the other hand, patients on a fixed-dose combination regimen were 18% less likely to discontinue than were patients taking a combination of two pills, wrote Dr. Shaya of the University of Maryland, Baltimore, at the meeting, cosponsored by the American Society of Hypertension.

The analysis involved all Medicaid patients in Maryland who were prescribed the combination of an ACE inhibitor and a calcium channel blocker or an ACE inhibitor and a hydrochlorothiazide diuretic during 2002–2004.

Of the 1,701 total patients, 17.5% were persistent in their use of the medication and 82.5% discontinued. Of the 1,137 African Americans, 15.5% were persistent, compared with 21.2% of the 448 whites and 23.3% of the 116 members of other races.

ATLANTA — African Americans are less likely than members of other races to persist in combination antihypertensive therapy, according to a retrospective analysis of medical and pharmacy claims for Medicaid patients in Maryland.

After adjustment for age, gender, and comorbidities, African Americans were 21% more likely to discontinue their therapy than were members of other races. This relationship was significant when the patients were using a fixed-dose combination in a single pill and also when they were using a free combination regimen with two concurrent pills, according to a poster presentation by Fadia T. Shaya, Ph.D., at a meeting sponsored by the International Society on Hypertension in Blacks.

After adjustment for all other covariates, several other factors proved to be significant predictors of nonpersistent behavior. Patients under age 40 years were 26% more likely to discontinue than were older patients, and those with a higher comorbidity index were 4% more likely to do so.

On the other hand, patients on a fixed-dose combination regimen were 18% less likely to discontinue than were patients taking a combination of two pills, wrote Dr. Shaya of the University of Maryland, Baltimore, at the meeting, cosponsored by the American Society of Hypertension.

The analysis involved all Medicaid patients in Maryland who were prescribed the combination of an ACE inhibitor and a calcium channel blocker or an ACE inhibitor and a hydrochlorothiazide diuretic during 2002–2004.

Of the 1,701 total patients, 17.5% were persistent in their use of the medication and 82.5% discontinued. Of the 1,137 African Americans, 15.5% were persistent, compared with 21.2% of the 448 whites and 23.3% of the 116 members of other races.

SAN FRANCISCO — Evidence-based osteoporosis guidelines now being developed by the World Health Organization will evaluate treatment cost-effectiveness and help individual nations tailor management of the disease based on their resources, Dr. Douglas C. Bauer said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Several speakers at the UCSF conference said that they expect these guidelines to appear later in 2006 or sometime in 2007. Dr. Bauer, of UCSF, said he hopes that the WHO guidelines can be adapted for use on a personal digital assistant or a Web-based program. The clinician would plug in the patient's bone mineral density (BMD) and other risk factors, and the software would calculate the patient's probability of suffering a fracture within the next 10 years.

Until the WHO guidelines are finished, however, “clinicians are sort of left out dangling by themselves” with currently available guidelines, which contain many gaps, said Dr. Bauer. “There are absolutely no good evidence-based guidelines for nonpostmenopausal women populations,” or for men and ethnic minorities. “There are no good evidence-based guidelines to help you decide how long you should treat people.”

The five available guidelines are:

▸ The 1994 WHO guidelines. These were highly influential because they defined osteoporosis and osteopenia based on T-scores, resulting in the widespread use of densitometry. “This was never meant to be a treatment guideline or to identify treatment thresholds, although in the medical community they were largely identified as such,” Dr. Bauer said.

▸ The American Association of Clinical Endocrinologists (AACE) guidelines. Although AACE conducted a review of the literature, the AACE guidelines ultimately were based on a consensus of experts rather than a quantitative, evidence-based review (Endocr. Pract. 2003;9:544–64), Dr. Bauer noted.

These guidelines state that women with postmenopausal osteoporosis should be treated if they've experienced a fracture and have a low BMD, or if their T-score is less than −2.5. Women with osteopenia should also be treated if they have risk factors, and the list of risk factors is longer than in the National Osteoporosis Foundation (NOF) guidelines. Patients should also be treated if nonpharmacologic therapy—vitamin D and calcium supplementation—proves ineffective as evidenced by bone loss or fracture.

▸ U.S. Preventive Services Task Force guidelines. These guidelines, published in 2002, addressed only screening for osteoporosis, not treatment, Dr. Bauer said.

▸ Canadian Task Force on Preventive Health Care guidelines. Issued in 2004 (CMAJ 2004;170:1665–7), these guidelines were developed using a rigorous evidence-based approach and state that patients who are classified as normal under WHO guidelines should receive no treatment. Those classified as having WHO osteopenia should be considered for a bisphosphonate or raloxifene if they are older than 65 years and have a T-score below −2.0. Patients classified as having WHO osteoporosis should be treated with a bisphosphonate and raloxifene, and parathyroid hormone should also be considered.

▸ National Osteoporosis Foundation guidelines. Dr. Bauer reserved his greatest praise for these guidelines, first published in 1999, revised in 2003, and available through the foundation's Web site (www.nof.org

Centered on an unbiased, evidence-based review of the literature, the NOF guidelines state that patients should be treated if their T-scores are less than −2.0 without any additional risk factors or less than −1.5 in the presence of certain risk factors. Treatment was also indicated even in the absence of a BMD score for patients with previous vertebral or hip fractures.

A drawback is that the NOF guidelines don't apply to ethnic minorities, premenopausal women, or men.

SAN FRANCISCO — Evidence-based osteoporosis guidelines now being developed by the World Health Organization will evaluate treatment cost-effectiveness and help individual nations tailor management of the disease based on their resources, Dr. Douglas C. Bauer said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Several speakers at the UCSF conference said that they expect these guidelines to appear later in 2006 or sometime in 2007. Dr. Bauer, of UCSF, said he hopes that the WHO guidelines can be adapted for use on a personal digital assistant or a Web-based program. The clinician would plug in the patient's bone mineral density (BMD) and other risk factors, and the software would calculate the patient's probability of suffering a fracture within the next 10 years.

Until the WHO guidelines are finished, however, “clinicians are sort of left out dangling by themselves” with currently available guidelines, which contain many gaps, said Dr. Bauer. “There are absolutely no good evidence-based guidelines for nonpostmenopausal women populations,” or for men and ethnic minorities. “There are no good evidence-based guidelines to help you decide how long you should treat people.”

The five available guidelines are:

▸ The 1994 WHO guidelines. These were highly influential because they defined osteoporosis and osteopenia based on T-scores, resulting in the widespread use of densitometry. “This was never meant to be a treatment guideline or to identify treatment thresholds, although in the medical community they were largely identified as such,” Dr. Bauer said.

▸ The American Association of Clinical Endocrinologists (AACE) guidelines. Although AACE conducted a review of the literature, the AACE guidelines ultimately were based on a consensus of experts rather than a quantitative, evidence-based review (Endocr. Pract. 2003;9:544–64), Dr. Bauer noted.

These guidelines state that women with postmenopausal osteoporosis should be treated if they've experienced a fracture and have a low BMD, or if their T-score is less than −2.5. Women with osteopenia should also be treated if they have risk factors, and the list of risk factors is longer than in the National Osteoporosis Foundation (NOF) guidelines. Patients should also be treated if nonpharmacologic therapy—vitamin D and calcium supplementation—proves ineffective as evidenced by bone loss or fracture.

▸ U.S. Preventive Services Task Force guidelines. These guidelines, published in 2002, addressed only screening for osteoporosis, not treatment, Dr. Bauer said.

▸ Canadian Task Force on Preventive Health Care guidelines. Issued in 2004 (CMAJ 2004;170:1665–7), these guidelines were developed using a rigorous evidence-based approach and state that patients who are classified as normal under WHO guidelines should receive no treatment. Those classified as having WHO osteopenia should be considered for a bisphosphonate or raloxifene if they are older than 65 years and have a T-score below −2.0. Patients classified as having WHO osteoporosis should be treated with a bisphosphonate and raloxifene, and parathyroid hormone should also be considered.

▸ National Osteoporosis Foundation guidelines. Dr. Bauer reserved his greatest praise for these guidelines, first published in 1999, revised in 2003, and available through the foundation's Web site (www.nof.org

Centered on an unbiased, evidence-based review of the literature, the NOF guidelines state that patients should be treated if their T-scores are less than −2.0 without any additional risk factors or less than −1.5 in the presence of certain risk factors. Treatment was also indicated even in the absence of a BMD score for patients with previous vertebral or hip fractures.

A drawback is that the NOF guidelines don't apply to ethnic minorities, premenopausal women, or men.

SAN FRANCISCO — Evidence-based osteoporosis guidelines now being developed by the World Health Organization will evaluate treatment cost-effectiveness and help individual nations tailor management of the disease based on their resources, Dr. Douglas C. Bauer said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Several speakers at the UCSF conference said that they expect these guidelines to appear later in 2006 or sometime in 2007. Dr. Bauer, of UCSF, said he hopes that the WHO guidelines can be adapted for use on a personal digital assistant or a Web-based program. The clinician would plug in the patient's bone mineral density (BMD) and other risk factors, and the software would calculate the patient's probability of suffering a fracture within the next 10 years.

Until the WHO guidelines are finished, however, “clinicians are sort of left out dangling by themselves” with currently available guidelines, which contain many gaps, said Dr. Bauer. “There are absolutely no good evidence-based guidelines for nonpostmenopausal women populations,” or for men and ethnic minorities. “There are no good evidence-based guidelines to help you decide how long you should treat people.”

The five available guidelines are:

▸ The 1994 WHO guidelines. These were highly influential because they defined osteoporosis and osteopenia based on T-scores, resulting in the widespread use of densitometry. “This was never meant to be a treatment guideline or to identify treatment thresholds, although in the medical community they were largely identified as such,” Dr. Bauer said.

▸ The American Association of Clinical Endocrinologists (AACE) guidelines. Although AACE conducted a review of the literature, the AACE guidelines ultimately were based on a consensus of experts rather than a quantitative, evidence-based review (Endocr. Pract. 2003;9:544–64), Dr. Bauer noted.

These guidelines state that women with postmenopausal osteoporosis should be treated if they've experienced a fracture and have a low BMD, or if their T-score is less than −2.5. Women with osteopenia should also be treated if they have risk factors, and the list of risk factors is longer than in the National Osteoporosis Foundation (NOF) guidelines. Patients should also be treated if nonpharmacologic therapy—vitamin D and calcium supplementation—proves ineffective as evidenced by bone loss or fracture.

▸ U.S. Preventive Services Task Force guidelines. These guidelines, published in 2002, addressed only screening for osteoporosis, not treatment, Dr. Bauer said.

▸ Canadian Task Force on Preventive Health Care guidelines. Issued in 2004 (CMAJ 2004;170:1665–7), these guidelines were developed using a rigorous evidence-based approach and state that patients who are classified as normal under WHO guidelines should receive no treatment. Those classified as having WHO osteopenia should be considered for a bisphosphonate or raloxifene if they are older than 65 years and have a T-score below −2.0. Patients classified as having WHO osteoporosis should be treated with a bisphosphonate and raloxifene, and parathyroid hormone should also be considered.

▸ National Osteoporosis Foundation guidelines. Dr. Bauer reserved his greatest praise for these guidelines, first published in 1999, revised in 2003, and available through the foundation's Web site (www.nof.org

Centered on an unbiased, evidence-based review of the literature, the NOF guidelines state that patients should be treated if their T-scores are less than −2.0 without any additional risk factors or less than −1.5 in the presence of certain risk factors. Treatment was also indicated even in the absence of a BMD score for patients with previous vertebral or hip fractures.

A drawback is that the NOF guidelines don't apply to ethnic minorities, premenopausal women, or men.

SAN FRANCISCO — Antiresorptive therapy should be continued even in patients showing no apparent response, Dr. Douglas C. Bauer said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Monitoring response with periodic bone mineral density (BMD) testing may be misleading, said Dr. Bauer, of UCSF. Furthermore, studies show that antiresorptive therapy decreases fracture risk even when BMD declines. And a patient whose BMD declines in the first year of therapy will often see an improvement in subsequent years.

Those advocating periodic monitoring cite several potential advantages of the practice, including increases in patient satisfaction, improvements in adherence, and the ability to change to more effective therapy in the presence of a nonresponse.

But Dr. Bauer pointed out that there are no studies demonstrating that monitoring improves patient satisfaction or adherence. While it's true that many patients stop taking drugs to prevent osteoporosis, more than half of those who discontinue do so within 6 months of beginning therapy, he said. Measuring BMD 1–2 years following diagnosis is therefore unlikely to encourage adherence in the majority of patients.

In addition, changes in BMD on subsequent measurements may be misleading. Although BMD is usually considered a very precise measurement, with precision errors in the neighborhood of 1%–2%, some apparent changes in BMD may be due to noise or to small differences in patient position, Dr. Bauer said.

To figure out what changes in BMD measurements are due to chance, Dr. Bauer recommended using the “least significant change” formula. The least significant change in any measurement is defined as three times the measurement's long-term reproducibility. For example, if a dual-energy x-ray absorptiometry (DXA) instrument has a long-term coefficient of variation of 1.5%, its least significant change would be 4.5%, meaning that changes of less than 4.5% from measurement to measurement may well be due to chance.

But even if a patient's BMD truly is declining, that does not necessarily mean that the patient is failing to respond to treatment, since he or she may well have lost more bone without treatment, he added.

And an initial loss of bone during treatment doesn't mean that this loss will continue. Dr. Bauer quoted one study that showed that of patients who lost more than 4% of their BMD during the first year of treatment, 92% gained BMD in the second year, and the average increase during the second year was 4.8%. On the other hand, of patients who gained more than 8% in BMD during the first year, only 36% continue to gain BMD in the second year, and as a whole that group lost 1% of their BMD during that second-year.

An analysis of a clinical trial of alendronate versus placebo compared the patients who lost most BMD while taking alendronate with those who lost most BMD while taking placebo. Fracture risk was reduced by about 50% in those taking alendronate despite their loss of BMD.

Clinicians should consider secondary causes of osteoporosis in patients who are losing BMD despite antiresorptive therapy, Dr. Bauer said. Among the common secondary causes of bone loss are weight loss; medications such as corticosteroids, aromatase inhibitors, and glitazones; inflammatory diseases or myeloma; or malabsorption.

SAN FRANCISCO — Antiresorptive therapy should be continued even in patients showing no apparent response, Dr. Douglas C. Bauer said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Monitoring response with periodic bone mineral density (BMD) testing may be misleading, said Dr. Bauer, of UCSF. Furthermore, studies show that antiresorptive therapy decreases fracture risk even when BMD declines. And a patient whose BMD declines in the first year of therapy will often see an improvement in subsequent years.

Those advocating periodic monitoring cite several potential advantages of the practice, including increases in patient satisfaction, improvements in adherence, and the ability to change to more effective therapy in the presence of a nonresponse.

But Dr. Bauer pointed out that there are no studies demonstrating that monitoring improves patient satisfaction or adherence. While it's true that many patients stop taking drugs to prevent osteoporosis, more than half of those who discontinue do so within 6 months of beginning therapy, he said. Measuring BMD 1–2 years following diagnosis is therefore unlikely to encourage adherence in the majority of patients.

In addition, changes in BMD on subsequent measurements may be misleading. Although BMD is usually considered a very precise measurement, with precision errors in the neighborhood of 1%–2%, some apparent changes in BMD may be due to noise or to small differences in patient position, Dr. Bauer said.

To figure out what changes in BMD measurements are due to chance, Dr. Bauer recommended using the “least significant change” formula. The least significant change in any measurement is defined as three times the measurement's long-term reproducibility. For example, if a dual-energy x-ray absorptiometry (DXA) instrument has a long-term coefficient of variation of 1.5%, its least significant change would be 4.5%, meaning that changes of less than 4.5% from measurement to measurement may well be due to chance.

But even if a patient's BMD truly is declining, that does not necessarily mean that the patient is failing to respond to treatment, since he or she may well have lost more bone without treatment, he added.

And an initial loss of bone during treatment doesn't mean that this loss will continue. Dr. Bauer quoted one study that showed that of patients who lost more than 4% of their BMD during the first year of treatment, 92% gained BMD in the second year, and the average increase during the second year was 4.8%. On the other hand, of patients who gained more than 8% in BMD during the first year, only 36% continue to gain BMD in the second year, and as a whole that group lost 1% of their BMD during that second-year.

An analysis of a clinical trial of alendronate versus placebo compared the patients who lost most BMD while taking alendronate with those who lost most BMD while taking placebo. Fracture risk was reduced by about 50% in those taking alendronate despite their loss of BMD.

Clinicians should consider secondary causes of osteoporosis in patients who are losing BMD despite antiresorptive therapy, Dr. Bauer said. Among the common secondary causes of bone loss are weight loss; medications such as corticosteroids, aromatase inhibitors, and glitazones; inflammatory diseases or myeloma; or malabsorption.

SAN FRANCISCO — Antiresorptive therapy should be continued even in patients showing no apparent response, Dr. Douglas C. Bauer said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Monitoring response with periodic bone mineral density (BMD) testing may be misleading, said Dr. Bauer, of UCSF. Furthermore, studies show that antiresorptive therapy decreases fracture risk even when BMD declines. And a patient whose BMD declines in the first year of therapy will often see an improvement in subsequent years.

Those advocating periodic monitoring cite several potential advantages of the practice, including increases in patient satisfaction, improvements in adherence, and the ability to change to more effective therapy in the presence of a nonresponse.

But Dr. Bauer pointed out that there are no studies demonstrating that monitoring improves patient satisfaction or adherence. While it's true that many patients stop taking drugs to prevent osteoporosis, more than half of those who discontinue do so within 6 months of beginning therapy, he said. Measuring BMD 1–2 years following diagnosis is therefore unlikely to encourage adherence in the majority of patients.

In addition, changes in BMD on subsequent measurements may be misleading. Although BMD is usually considered a very precise measurement, with precision errors in the neighborhood of 1%–2%, some apparent changes in BMD may be due to noise or to small differences in patient position, Dr. Bauer said.

To figure out what changes in BMD measurements are due to chance, Dr. Bauer recommended using the “least significant change” formula. The least significant change in any measurement is defined as three times the measurement's long-term reproducibility. For example, if a dual-energy x-ray absorptiometry (DXA) instrument has a long-term coefficient of variation of 1.5%, its least significant change would be 4.5%, meaning that changes of less than 4.5% from measurement to measurement may well be due to chance.

But even if a patient's BMD truly is declining, that does not necessarily mean that the patient is failing to respond to treatment, since he or she may well have lost more bone without treatment, he added.

And an initial loss of bone during treatment doesn't mean that this loss will continue. Dr. Bauer quoted one study that showed that of patients who lost more than 4% of their BMD during the first year of treatment, 92% gained BMD in the second year, and the average increase during the second year was 4.8%. On the other hand, of patients who gained more than 8% in BMD during the first year, only 36% continue to gain BMD in the second year, and as a whole that group lost 1% of their BMD during that second-year.

An analysis of a clinical trial of alendronate versus placebo compared the patients who lost most BMD while taking alendronate with those who lost most BMD while taking placebo. Fracture risk was reduced by about 50% in those taking alendronate despite their loss of BMD.

Clinicians should consider secondary causes of osteoporosis in patients who are losing BMD despite antiresorptive therapy, Dr. Bauer said. Among the common secondary causes of bone loss are weight loss; medications such as corticosteroids, aromatase inhibitors, and glitazones; inflammatory diseases or myeloma; or malabsorption.

SAN FRANCISCO — Finding one possible cause of secondary osteoporosis does not mean there aren't other causes as well, Dr. Diana Antoniucci reported at a meeting on osteoporosis sponsored by the University of California, San Francisco.

“Having one secondary cause of osteoporosis does not preclude you from having another, so even if one contributor is obvious from the history, you can still consider laboratory testing,” said Dr. Antoniucci, of UCSF. (See sidebar for suggestions on which tests to order.) She listed four frequent causes of secondary osteoporosis for physicians to consider.

Glucocorticoid Use

This is the most common cause of drug-induced osteoporosis. In these patients, prevention is clearly the best strategy. All patients should be taking supplemental calcium and vitamin D, Dr. Antoniucci said, and if the patient has already been diagnosed with osteoporosis or is otherwise at high risk, the physician should measure bone mineral density (BMD) with dual-energy x-ray absorptiometry (DXA). Clinical trials have shown that bisphosphonates halt bone loss and reduce fractures in patients taking glucocorticoids, and alendronate and risedronate are both approved for this indication. They should be considered for any patient on glucocorticoids with low BMD.

Vitamin D Deficiency

This deficiency is very common in the general population. Depending on the study population, the prevalence appears to range between 9% and 50%.

When severe, vitamin D deficiency is associated with osteomalacia, which is indistinguishable from low bone density on DXA. Less-severe vitamin D deficiency is associated with secondary hyperparathyroidism.

One difficulty in the assessment and treatment of vitamin D deficiency is that there is no general agreement as to what constitutes a sufficient level of 25-hydroxyvitamin D, Dr. Antoniucci noted. A level of 20 ng/mL appears to be necessary for normal parathyroid dynamics, 32–36 ng/mL appears to be necessary for maximal intestinal calcium transport, and 30–40 ng/mL is the level that several randomized controlled trials have determined is necessary for fracture reduction.

“The good news is that vitamin D insufficiency is treatable,” Dr. Antoniucci said. “Replacement reestablishes vitamin D stores, and it improves bone mineral density because it allows optimal calcification of preexisting osteoid.”

Celiac Disease

Somewhere between 9% and 12% of patients with osteoporosis also have celiac disease. Conversely, about 50% of patients with celiac disease have a BMD that is two standard deviations or more under the mean. Among patients with celiac disease, those with a low BMD are more likely to have villous atrophy, an indication of more severe disease. The pathogenesis of bone disease in these patients is likely multifactorial, according to Dr. Antoniucci. They tend to have worse calcium absorption from the gut, especially before their disease is diagnosed, which can be many years in some patients. They also can have vitamin D deficiency from secondary hyperparathyroidism. Some women with celiac disease also have infertility and amenorrhea, both of which can lead to poor bone health.

At least one study has demonstrated that among patients with celiac disease, a strict gluten-free diet over the period of a year can improve bone mass in both men and women (Arch. Intern. Med. 2005;165:393–9). The authors of that study concluded that it's worth screening patients with unexplained osteoporosis for celiac disease. Dr. Antoniucci is not so sure that that's a good idea. “First of all, what exactly is 'unexplained osteoporosis'? And secondly, it might be a very expensive way to be treating the disease,” she said.

Androgen Deprivation Therapy

The longer a man is on this common therapy forprostate cancer, the greater his BMD loss and the greater his chance of fracture. After 10 years on androgen deprivation therapy, about 20% of men will have experienced a fracture, a risk fivefold greater than in age-matched controls. Slender white men appear to be at greatest risk, she said, noting that both pamidronate and zoledronate have been shown to prevent bone loss caused by androgen deprivation therapy.

Labs to Detect Secondary Osteoporosis

There is no consensus on whom to evaluate for secondary osteoporosis, said Dr. Antoniucci. However, “most people would agree that we should evaluate virtually all men with low T-scores, premenopausal women with low Z-scores or fragility fractures, and postmenopausal women,” she said.

Dr. Antoniucci said a standard laboratory work-up should include:

▸ Electrolyte levels.

▸ Renal and hepatic function.

▸ Complete blood count.

▸ 24-hour urine calcium excretion (which can provide important information if the result is very high or very low).

▸ 25-hydroxyvitamin D levels.

▸ Testosterone levels.

▸ Thyroid-stimulating hormone levels (in patients on thyroid hormone replacement).

Additional tests are dictated by the patient's history and physical exam and the physician's clinical judgment.

SAN FRANCISCO — Finding one possible cause of secondary osteoporosis does not mean there aren't other causes as well, Dr. Diana Antoniucci reported at a meeting on osteoporosis sponsored by the University of California, San Francisco.

“Having one secondary cause of osteoporosis does not preclude you from having another, so even if one contributor is obvious from the history, you can still consider laboratory testing,” said Dr. Antoniucci, of UCSF. (See sidebar for suggestions on which tests to order.) She listed four frequent causes of secondary osteoporosis for physicians to consider.

Glucocorticoid Use

This is the most common cause of drug-induced osteoporosis. In these patients, prevention is clearly the best strategy. All patients should be taking supplemental calcium and vitamin D, Dr. Antoniucci said, and if the patient has already been diagnosed with osteoporosis or is otherwise at high risk, the physician should measure bone mineral density (BMD) with dual-energy x-ray absorptiometry (DXA). Clinical trials have shown that bisphosphonates halt bone loss and reduce fractures in patients taking glucocorticoids, and alendronate and risedronate are both approved for this indication. They should be considered for any patient on glucocorticoids with low BMD.

Vitamin D Deficiency

This deficiency is very common in the general population. Depending on the study population, the prevalence appears to range between 9% and 50%.

When severe, vitamin D deficiency is associated with osteomalacia, which is indistinguishable from low bone density on DXA. Less-severe vitamin D deficiency is associated with secondary hyperparathyroidism.

One difficulty in the assessment and treatment of vitamin D deficiency is that there is no general agreement as to what constitutes a sufficient level of 25-hydroxyvitamin D, Dr. Antoniucci noted. A level of 20 ng/mL appears to be necessary for normal parathyroid dynamics, 32–36 ng/mL appears to be necessary for maximal intestinal calcium transport, and 30–40 ng/mL is the level that several randomized controlled trials have determined is necessary for fracture reduction.

“The good news is that vitamin D insufficiency is treatable,” Dr. Antoniucci said. “Replacement reestablishes vitamin D stores, and it improves bone mineral density because it allows optimal calcification of preexisting osteoid.”

Celiac Disease

Somewhere between 9% and 12% of patients with osteoporosis also have celiac disease. Conversely, about 50% of patients with celiac disease have a BMD that is two standard deviations or more under the mean. Among patients with celiac disease, those with a low BMD are more likely to have villous atrophy, an indication of more severe disease. The pathogenesis of bone disease in these patients is likely multifactorial, according to Dr. Antoniucci. They tend to have worse calcium absorption from the gut, especially before their disease is diagnosed, which can be many years in some patients. They also can have vitamin D deficiency from secondary hyperparathyroidism. Some women with celiac disease also have infertility and amenorrhea, both of which can lead to poor bone health.

At least one study has demonstrated that among patients with celiac disease, a strict gluten-free diet over the period of a year can improve bone mass in both men and women (Arch. Intern. Med. 2005;165:393–9). The authors of that study concluded that it's worth screening patients with unexplained osteoporosis for celiac disease. Dr. Antoniucci is not so sure that that's a good idea. “First of all, what exactly is 'unexplained osteoporosis'? And secondly, it might be a very expensive way to be treating the disease,” she said.

Androgen Deprivation Therapy

The longer a man is on this common therapy forprostate cancer, the greater his BMD loss and the greater his chance of fracture. After 10 years on androgen deprivation therapy, about 20% of men will have experienced a fracture, a risk fivefold greater than in age-matched controls. Slender white men appear to be at greatest risk, she said, noting that both pamidronate and zoledronate have been shown to prevent bone loss caused by androgen deprivation therapy.

Labs to Detect Secondary Osteoporosis

There is no consensus on whom to evaluate for secondary osteoporosis, said Dr. Antoniucci. However, “most people would agree that we should evaluate virtually all men with low T-scores, premenopausal women with low Z-scores or fragility fractures, and postmenopausal women,” she said.

Dr. Antoniucci said a standard laboratory work-up should include:

▸ Electrolyte levels.

▸ Renal and hepatic function.

▸ Complete blood count.

▸ 24-hour urine calcium excretion (which can provide important information if the result is very high or very low).

▸ 25-hydroxyvitamin D levels.

▸ Testosterone levels.

▸ Thyroid-stimulating hormone levels (in patients on thyroid hormone replacement).

Additional tests are dictated by the patient's history and physical exam and the physician's clinical judgment.

SAN FRANCISCO — Finding one possible cause of secondary osteoporosis does not mean there aren't other causes as well, Dr. Diana Antoniucci reported at a meeting on osteoporosis sponsored by the University of California, San Francisco.

“Having one secondary cause of osteoporosis does not preclude you from having another, so even if one contributor is obvious from the history, you can still consider laboratory testing,” said Dr. Antoniucci, of UCSF. (See sidebar for suggestions on which tests to order.) She listed four frequent causes of secondary osteoporosis for physicians to consider.

Glucocorticoid Use

This is the most common cause of drug-induced osteoporosis. In these patients, prevention is clearly the best strategy. All patients should be taking supplemental calcium and vitamin D, Dr. Antoniucci said, and if the patient has already been diagnosed with osteoporosis or is otherwise at high risk, the physician should measure bone mineral density (BMD) with dual-energy x-ray absorptiometry (DXA). Clinical trials have shown that bisphosphonates halt bone loss and reduce fractures in patients taking glucocorticoids, and alendronate and risedronate are both approved for this indication. They should be considered for any patient on glucocorticoids with low BMD.

Vitamin D Deficiency

This deficiency is very common in the general population. Depending on the study population, the prevalence appears to range between 9% and 50%.

When severe, vitamin D deficiency is associated with osteomalacia, which is indistinguishable from low bone density on DXA. Less-severe vitamin D deficiency is associated with secondary hyperparathyroidism.

One difficulty in the assessment and treatment of vitamin D deficiency is that there is no general agreement as to what constitutes a sufficient level of 25-hydroxyvitamin D, Dr. Antoniucci noted. A level of 20 ng/mL appears to be necessary for normal parathyroid dynamics, 32–36 ng/mL appears to be necessary for maximal intestinal calcium transport, and 30–40 ng/mL is the level that several randomized controlled trials have determined is necessary for fracture reduction.

“The good news is that vitamin D insufficiency is treatable,” Dr. Antoniucci said. “Replacement reestablishes vitamin D stores, and it improves bone mineral density because it allows optimal calcification of preexisting osteoid.”

Celiac Disease

Somewhere between 9% and 12% of patients with osteoporosis also have celiac disease. Conversely, about 50% of patients with celiac disease have a BMD that is two standard deviations or more under the mean. Among patients with celiac disease, those with a low BMD are more likely to have villous atrophy, an indication of more severe disease. The pathogenesis of bone disease in these patients is likely multifactorial, according to Dr. Antoniucci. They tend to have worse calcium absorption from the gut, especially before their disease is diagnosed, which can be many years in some patients. They also can have vitamin D deficiency from secondary hyperparathyroidism. Some women with celiac disease also have infertility and amenorrhea, both of which can lead to poor bone health.

At least one study has demonstrated that among patients with celiac disease, a strict gluten-free diet over the period of a year can improve bone mass in both men and women (Arch. Intern. Med. 2005;165:393–9). The authors of that study concluded that it's worth screening patients with unexplained osteoporosis for celiac disease. Dr. Antoniucci is not so sure that that's a good idea. “First of all, what exactly is 'unexplained osteoporosis'? And secondly, it might be a very expensive way to be treating the disease,” she said.

Androgen Deprivation Therapy

The longer a man is on this common therapy forprostate cancer, the greater his BMD loss and the greater his chance of fracture. After 10 years on androgen deprivation therapy, about 20% of men will have experienced a fracture, a risk fivefold greater than in age-matched controls. Slender white men appear to be at greatest risk, she said, noting that both pamidronate and zoledronate have been shown to prevent bone loss caused by androgen deprivation therapy.

Labs to Detect Secondary Osteoporosis

There is no consensus on whom to evaluate for secondary osteoporosis, said Dr. Antoniucci. However, “most people would agree that we should evaluate virtually all men with low T-scores, premenopausal women with low Z-scores or fragility fractures, and postmenopausal women,” she said.

Dr. Antoniucci said a standard laboratory work-up should include:

▸ Electrolyte levels.

▸ Renal and hepatic function.

▸ Complete blood count.

▸ 24-hour urine calcium excretion (which can provide important information if the result is very high or very low).

▸ 25-hydroxyvitamin D levels.

▸ Testosterone levels.

▸ Thyroid-stimulating hormone levels (in patients on thyroid hormone replacement).

Additional tests are dictated by the patient's history and physical exam and the physician's clinical judgment.

ATLANTA — Elevated blood pressure is associated with increased body mass index in children as young as 2 years old, according to results of a large study reported by Dr. Elizabeth B. Rappaport at the annual meeting of the International Society on Hypertension in Blacks.

Among boys 2- to 5-years-old with BMIs above the 95th percentile, 7.8% have systolic or diastolic blood pressures at the 95th percentile or above. This increases to 10.8% in boys 6- to 10-years-old, 20.0% in boys 11- to 15-years-old, and 18.5% in boys 16- to 19-years-old. The results are similar in girls (see chart).

The retrospective study involved 18,618 pediatric primary care patients seen during well-child visits in 2002 at a network of clinics in Delaware (J. Pediatr. 2006;148:195–200). “This is a fairly efficient practice that has a routine of measuring blood pressure in nearly all the children down to age 2 as they come through the door,” said Dr. Rappaport of Thomas Jefferson University, Philadelphia. “In most cases they do it by auscultation, and they have the proper cuff sizes and so forth, so we felt these would be reasonably reliable blood pressures.”

Blood pressure information was entered into electronic medical records at the time of the visit along with data on the child's height, weight, and insurance status. Insurance status was used as a surrogate for socioeconomic status; children with commercial or private insurance were considered to be better off than children with government or public insurance. While data on the child's race were included in the electronic medical record, the investigators regarded this information as unreliable because the child's race was assigned by the registering clerk rather than by self-assignment.

In agreement with other studies, the prevalence of overweight among the children was quite high. Overall, only 63.1% of the children had a BMI under the 85th percentile, which is considered normal weight. The prevalence of overweight—BMI at or above the 95th percentile—was 20.2%. The prevalence of children with BMIs between the 85th and 94th percentile, considered to be at risk for overweight, was 16.7%.

Although many of the children appeared to have elevated blood pressures, the fact that there was only a single blood pressure measurement prevented the investigators from making formal assessments of hypertension. The definition of hypertension in children and adolescents requires systolic or diastolic pressures to be at or above the 95th percentile on at least three separate visits.

Based on that single blood pressure measurement, more than 7.5% of the 2- to 5-year-old children and 10%–20% of the older children and adolescents would require follow-up measurements, Dr. Rappaport said.

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA — Elevated blood pressure is associated with increased body mass index in children as young as 2 years old, according to results of a large study reported by Dr. Elizabeth B. Rappaport at the annual meeting of the International Society on Hypertension in Blacks.

Among boys 2- to 5-years-old with BMIs above the 95th percentile, 7.8% have systolic or diastolic blood pressures at the 95th percentile or above. This increases to 10.8% in boys 6- to 10-years-old, 20.0% in boys 11- to 15-years-old, and 18.5% in boys 16- to 19-years-old. The results are similar in girls (see chart).

The retrospective study involved 18,618 pediatric primary care patients seen during well-child visits in 2002 at a network of clinics in Delaware (J. Pediatr. 2006;148:195–200). “This is a fairly efficient practice that has a routine of measuring blood pressure in nearly all the children down to age 2 as they come through the door,” said Dr. Rappaport of Thomas Jefferson University, Philadelphia. “In most cases they do it by auscultation, and they have the proper cuff sizes and so forth, so we felt these would be reasonably reliable blood pressures.”

Blood pressure information was entered into electronic medical records at the time of the visit along with data on the child's height, weight, and insurance status. Insurance status was used as a surrogate for socioeconomic status; children with commercial or private insurance were considered to be better off than children with government or public insurance. While data on the child's race were included in the electronic medical record, the investigators regarded this information as unreliable because the child's race was assigned by the registering clerk rather than by self-assignment.

In agreement with other studies, the prevalence of overweight among the children was quite high. Overall, only 63.1% of the children had a BMI under the 85th percentile, which is considered normal weight. The prevalence of overweight—BMI at or above the 95th percentile—was 20.2%. The prevalence of children with BMIs between the 85th and 94th percentile, considered to be at risk for overweight, was 16.7%.

Although many of the children appeared to have elevated blood pressures, the fact that there was only a single blood pressure measurement prevented the investigators from making formal assessments of hypertension. The definition of hypertension in children and adolescents requires systolic or diastolic pressures to be at or above the 95th percentile on at least three separate visits.

Based on that single blood pressure measurement, more than 7.5% of the 2- to 5-year-old children and 10%–20% of the older children and adolescents would require follow-up measurements, Dr. Rappaport said.

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA — Elevated blood pressure is associated with increased body mass index in children as young as 2 years old, according to results of a large study reported by Dr. Elizabeth B. Rappaport at the annual meeting of the International Society on Hypertension in Blacks.

Among boys 2- to 5-years-old with BMIs above the 95th percentile, 7.8% have systolic or diastolic blood pressures at the 95th percentile or above. This increases to 10.8% in boys 6- to 10-years-old, 20.0% in boys 11- to 15-years-old, and 18.5% in boys 16- to 19-years-old. The results are similar in girls (see chart).

The retrospective study involved 18,618 pediatric primary care patients seen during well-child visits in 2002 at a network of clinics in Delaware (J. Pediatr. 2006;148:195–200). “This is a fairly efficient practice that has a routine of measuring blood pressure in nearly all the children down to age 2 as they come through the door,” said Dr. Rappaport of Thomas Jefferson University, Philadelphia. “In most cases they do it by auscultation, and they have the proper cuff sizes and so forth, so we felt these would be reasonably reliable blood pressures.”

Blood pressure information was entered into electronic medical records at the time of the visit along with data on the child's height, weight, and insurance status. Insurance status was used as a surrogate for socioeconomic status; children with commercial or private insurance were considered to be better off than children with government or public insurance. While data on the child's race were included in the electronic medical record, the investigators regarded this information as unreliable because the child's race was assigned by the registering clerk rather than by self-assignment.

In agreement with other studies, the prevalence of overweight among the children was quite high. Overall, only 63.1% of the children had a BMI under the 85th percentile, which is considered normal weight. The prevalence of overweight—BMI at or above the 95th percentile—was 20.2%. The prevalence of children with BMIs between the 85th and 94th percentile, considered to be at risk for overweight, was 16.7%.

Although many of the children appeared to have elevated blood pressures, the fact that there was only a single blood pressure measurement prevented the investigators from making formal assessments of hypertension. The definition of hypertension in children and adolescents requires systolic or diastolic pressures to be at or above the 95th percentile on at least three separate visits.

Based on that single blood pressure measurement, more than 7.5% of the 2- to 5-year-old children and 10%–20% of the older children and adolescents would require follow-up measurements, Dr. Rappaport said.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Using a simple system of reading back medical orders reduced the error rate from 9.1% to zero in an inpatient pediatric unit, according to a poster presentation at the annual meeting of the Pediatric Academic Societies.

“Although this was a small study, these results are very encouraging,” Dr. Michael Vossmeyer of Cincinnati Children's Hospital Medical Center said in a statement.

At Cincinnati Children's Hospital, rounds are conducted inside patients' rooms. The attending physician or chief resident communicates the order orally, and the resident physician enters it into the computer system.

For the study, baseline data were gathered on 5 consecutive days. Each day, all orders entered during rounds were audited after rounds by an attending physician without the knowledge of the residents. Of 77 consecutive orders, 7 were found to contain errors. Most of the errors were in dosages that would not have affected patient safety, but in two instances, the resident wrote down the wrong drug.

Then Dr. Vossmeyer instituted the new process. Before leaving the patient's room, the resident would read back the orders to the attending physician, and the attending would sign the orders only if they were correct. The procedure added less than 90 seconds to each patient visit, and it was well accepted by the staff. Once again, data were collected on 5 consecutive days without the knowledge of the residents. Of 75 orders, there was not a single error.

“We're doing a follow-up study to determine if the results are sustainable and the process is reliable, but they appear to be very generalizable,” Dr. Vossmeyer said in the statement. “That's particularly important for tertiary patients, such as children with organ transplants, where proper doses mean so much.”

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — Using a simple system of reading back medical orders reduced the error rate from 9.1% to zero in an inpatient pediatric unit, according to a poster presentation at the annual meeting of the Pediatric Academic Societies.

“Although this was a small study, these results are very encouraging,” Dr. Michael Vossmeyer of Cincinnati Children's Hospital Medical Center said in a statement.

At Cincinnati Children's Hospital, rounds are conducted inside patients' rooms. The attending physician or chief resident communicates the order orally, and the resident physician enters it into the computer system.

For the study, baseline data were gathered on 5 consecutive days. Each day, all orders entered during rounds were audited after rounds by an attending physician without the knowledge of the residents. Of 77 consecutive orders, 7 were found to contain errors. Most of the errors were in dosages that would not have affected patient safety, but in two instances, the resident wrote down the wrong drug.

Then Dr. Vossmeyer instituted the new process. Before leaving the patient's room, the resident would read back the orders to the attending physician, and the attending would sign the orders only if they were correct. The procedure added less than 90 seconds to each patient visit, and it was well accepted by the staff. Once again, data were collected on 5 consecutive days without the knowledge of the residents. Of 75 orders, there was not a single error.

“We're doing a follow-up study to determine if the results are sustainable and the process is reliable, but they appear to be very generalizable,” Dr. Vossmeyer said in the statement. “That's particularly important for tertiary patients, such as children with organ transplants, where proper doses mean so much.”

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — Using a simple system of reading back medical orders reduced the error rate from 9.1% to zero in an inpatient pediatric unit, according to a poster presentation at the annual meeting of the Pediatric Academic Societies.

“Although this was a small study, these results are very encouraging,” Dr. Michael Vossmeyer of Cincinnati Children's Hospital Medical Center said in a statement.

At Cincinnati Children's Hospital, rounds are conducted inside patients' rooms. The attending physician or chief resident communicates the order orally, and the resident physician enters it into the computer system.

For the study, baseline data were gathered on 5 consecutive days. Each day, all orders entered during rounds were audited after rounds by an attending physician without the knowledge of the residents. Of 77 consecutive orders, 7 were found to contain errors. Most of the errors were in dosages that would not have affected patient safety, but in two instances, the resident wrote down the wrong drug.

Then Dr. Vossmeyer instituted the new process. Before leaving the patient's room, the resident would read back the orders to the attending physician, and the attending would sign the orders only if they were correct. The procedure added less than 90 seconds to each patient visit, and it was well accepted by the staff. Once again, data were collected on 5 consecutive days without the knowledge of the residents. Of 75 orders, there was not a single error.

“We're doing a follow-up study to determine if the results are sustainable and the process is reliable, but they appear to be very generalizable,” Dr. Vossmeyer said in the statement. “That's particularly important for tertiary patients, such as children with organ transplants, where proper doses mean so much.”

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — Records for most vaccines from most countries of origin for children adopted internationally are trustworthy, Dr. Bindy Crouch said in a poster presentation at the annual meeting of the Pediatric Academic Societies.

For this reason, Dr. Crouch of the State University of New York at Stony Brook and her colleagues recommend that antibody titers should be tested before revaccinating adopted children who have documentation of vaccines that were given in their countries of origin.

The study involved a retrospective chart review of 219 internationally adopted children seen between January 2003 and December 2004.

Of those children, 72 came from China, 87 from Russia, 28 from Korea, 19 from Guatemala, 4 from Ethiopia, 2 each from Belarus, Colombia, and the Philippines, and 1 each from India, Kazakhstan, and Romania.

At the time of adoption, 73% were under the age of 2 years.

With the exception of hepatitis B among children adopted from Korea and mumps among all children, the percentages of positive antibody titers were similar to rates that have been reported in U.S. vaccine studies.

For example, of the children with records of DTP vaccine, 99% were titer positive for diphtheria antibody and 88% were titer positive for tetanus. Children with records of polio vaccine were 95% titer positive, those with records of measles vaccine were 92% titer positive, and those with reported rubella vaccine were 92% titer positive.

On the other hand, of children adopted from Asian countries other than China (28 of 31 of these children came from Korea), only 63% of those who had records of hepatitis B vaccine were titer positive. This was a significantly lower percentage of positive titers than that seen in children from all other areas.

The investigators suggested that the lower percentage of positive hepatitis B titers in children from Korea may be due to the manufacturing, storage, or administration of vaccine, but it is also plausible that Korean children have poorer responses to the vaccine.

Only 67% of all the adopted children with records of mumps vaccine had positive titers, which the investigators said was significantly lower than the percentage reported in U.S. vaccine studies. Investigators said that this may be attributable to issues with vaccine handling and storage, inaccurate record keeping, or an impaired immune response to the mumps vaccines used.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — Records for most vaccines from most countries of origin for children adopted internationally are trustworthy, Dr. Bindy Crouch said in a poster presentation at the annual meeting of the Pediatric Academic Societies.

For this reason, Dr. Crouch of the State University of New York at Stony Brook and her colleagues recommend that antibody titers should be tested before revaccinating adopted children who have documentation of vaccines that were given in their countries of origin.

The study involved a retrospective chart review of 219 internationally adopted children seen between January 2003 and December 2004.

Of those children, 72 came from China, 87 from Russia, 28 from Korea, 19 from Guatemala, 4 from Ethiopia, 2 each from Belarus, Colombia, and the Philippines, and 1 each from India, Kazakhstan, and Romania.

At the time of adoption, 73% were under the age of 2 years.

With the exception of hepatitis B among children adopted from Korea and mumps among all children, the percentages of positive antibody titers were similar to rates that have been reported in U.S. vaccine studies.

For example, of the children with records of DTP vaccine, 99% were titer positive for diphtheria antibody and 88% were titer positive for tetanus. Children with records of polio vaccine were 95% titer positive, those with records of measles vaccine were 92% titer positive, and those with reported rubella vaccine were 92% titer positive.

On the other hand, of children adopted from Asian countries other than China (28 of 31 of these children came from Korea), only 63% of those who had records of hepatitis B vaccine were titer positive. This was a significantly lower percentage of positive titers than that seen in children from all other areas.

The investigators suggested that the lower percentage of positive hepatitis B titers in children from Korea may be due to the manufacturing, storage, or administration of vaccine, but it is also plausible that Korean children have poorer responses to the vaccine.

Only 67% of all the adopted children with records of mumps vaccine had positive titers, which the investigators said was significantly lower than the percentage reported in U.S. vaccine studies. Investigators said that this may be attributable to issues with vaccine handling and storage, inaccurate record keeping, or an impaired immune response to the mumps vaccines used.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — Records for most vaccines from most countries of origin for children adopted internationally are trustworthy, Dr. Bindy Crouch said in a poster presentation at the annual meeting of the Pediatric Academic Societies.

For this reason, Dr. Crouch of the State University of New York at Stony Brook and her colleagues recommend that antibody titers should be tested before revaccinating adopted children who have documentation of vaccines that were given in their countries of origin.

The study involved a retrospective chart review of 219 internationally adopted children seen between January 2003 and December 2004.

Of those children, 72 came from China, 87 from Russia, 28 from Korea, 19 from Guatemala, 4 from Ethiopia, 2 each from Belarus, Colombia, and the Philippines, and 1 each from India, Kazakhstan, and Romania.

At the time of adoption, 73% were under the age of 2 years.

With the exception of hepatitis B among children adopted from Korea and mumps among all children, the percentages of positive antibody titers were similar to rates that have been reported in U.S. vaccine studies.

For example, of the children with records of DTP vaccine, 99% were titer positive for diphtheria antibody and 88% were titer positive for tetanus. Children with records of polio vaccine were 95% titer positive, those with records of measles vaccine were 92% titer positive, and those with reported rubella vaccine were 92% titer positive.

On the other hand, of children adopted from Asian countries other than China (28 of 31 of these children came from Korea), only 63% of those who had records of hepatitis B vaccine were titer positive. This was a significantly lower percentage of positive titers than that seen in children from all other areas.

The investigators suggested that the lower percentage of positive hepatitis B titers in children from Korea may be due to the manufacturing, storage, or administration of vaccine, but it is also plausible that Korean children have poorer responses to the vaccine.

Only 67% of all the adopted children with records of mumps vaccine had positive titers, which the investigators said was significantly lower than the percentage reported in U.S. vaccine studies. Investigators said that this may be attributable to issues with vaccine handling and storage, inaccurate record keeping, or an impaired immune response to the mumps vaccines used.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — Although it may seem logical that corticosteroids, antihistamines, and/or decongestants may be good adjunctive treatments of acute otitis media, the evidence does not bear this out, Dr. Tasnee Chonmaitree said at the annual meeting of the Pediatric Academic Societies.

The rationale for using corticosteroids and antihistamines is clear: Drugs that can inhibit the synthesis or counteract the actions of inflammatory mediators should help improve the outcome—or at least provide some symptom relief—in acute otitis media (AOM), said Dr. Chonmaitree of the University of Texas, Galveston.

Corticosteroids, for example, inhibit the recruitment of leukocytes and monocytes to the affected area, reduce vascular permeability, and inhibit the synthesis or release of numerous inflammatory mediators and cytokines. Moreover, there is evidence that corticosteroids improve outcomes in otorrhea in children and AOM in animal models.

But two randomized controlled trials conducted by Dr. Chonmaitree and her colleagues demonstrated no clear benefit for corticosteroids and antihistamines alone or in combination in patients taking antibiotics.

Both studies had four arms. Some patients received two placebos, some received one placebo plus corticosteroid, some received one placebo plus antihistamine, and some received corticosteroid plus antihistamine.

The first study involved 80 patients, aged 3 months to 6 years, who were followed for 3 months. There were no differences in laboratory values, including levels of histamine and leukotriene B4 that could be attributed to either of the drugs.

However, corticosteroid treatment was associated with a lower rate of treatment failure within the first 2 weeks and a shorter duration of middle ear effusion.

A second trial followed 180 high-risk children with at least two previous episodes of AOM for 6 months. There were no statistically significant differences in the percentage of patients experiencing treatment failure in the first 2 weeks. But there was a significant difference in the duration of middle ear effusion. This difference favored placebo.

Patients receiving placebo alone experienced a median of 25 days of middle ear effusion.

Patients receiving antihistamine alone experienced middle ear effusion for a median of 73 days, almost three times longer.

Patients taking corticosteroid alone had about the same duration of effusion as did the placebo patients, and patients taking antihistamine and corticosteroid experienced a median of 36 days of effusion.

The conclusion was that antihistamines actually prolong middle ear effusion in patients with AOM and thus should not be used.

The Cochrane Collaboration conducted a detailed metaanalysis on the use of antihistamines and/or decongestants in AOM and came to similar conclusions (Cochrane Database Syst. Rev. 2004;3:CD001727).

Reviewing 15 randomized controlled trials involving a total of 2,695 cases, the investigators found that the combined evidence favored neither antihistamines nor decongestants on their primary outcome measure, which was persistent AOM at 2 weeks.

There was at least one significant difference, however—patients taking antihistamines and/or decongestants experienced significantly more side effects than did patients taking placebo.

“I conclude that for decongestants and antihistamines in acute otitis media [there is] no benefit for early cure rate, no benefit for symptom reduction, no benefit for prevention of complications, and increased risk for side effects,” Dr. Chonmaitree said at the meeting, which was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

Corticosteroids have similar evidence of inefficacy, and the bottom line is that the symptomatic treatment of AOM should include only an analgesic/antipyretic, she said.

Regarding the use of steroids, decongestants, or antihistamines in AOM, Dr. Richard M. Rosenfeld of Long Island College Hospital, New York, said in an interview that he largely agrees with Dr. Chonmaitree. “I would say the evidence [for their use] is quite weak. Occasionally you'll find a little statistically significant benefit pop out on one of the outcomes… but looked at as a whole the benefits are quite small if not trivial or absent. And when you then factor in the issue of potential side effects, it's a real tough case to recommend adding these adjuvant therapies. … In the child who's a frequent-flier and manages every couple of weeks to get a new episode of acute otitis, I think that it becomes even more ludicrous to repeatedly expose them to therapies of questionable benefit but significant adverse effects.” Dr. Rosenfeld is cochair of the American Academy of Pediatrics Subcommittee on Otitis Media With Effusion.

SAN FRANCISCO — Although it may seem logical that corticosteroids, antihistamines, and/or decongestants may be good adjunctive treatments of acute otitis media, the evidence does not bear this out, Dr. Tasnee Chonmaitree said at the annual meeting of the Pediatric Academic Societies.

The rationale for using corticosteroids and antihistamines is clear: Drugs that can inhibit the synthesis or counteract the actions of inflammatory mediators should help improve the outcome—or at least provide some symptom relief—in acute otitis media (AOM), said Dr. Chonmaitree of the University of Texas, Galveston.

Corticosteroids, for example, inhibit the recruitment of leukocytes and monocytes to the affected area, reduce vascular permeability, and inhibit the synthesis or release of numerous inflammatory mediators and cytokines. Moreover, there is evidence that corticosteroids improve outcomes in otorrhea in children and AOM in animal models.

But two randomized controlled trials conducted by Dr. Chonmaitree and her colleagues demonstrated no clear benefit for corticosteroids and antihistamines alone or in combination in patients taking antibiotics.

Both studies had four arms. Some patients received two placebos, some received one placebo plus corticosteroid, some received one placebo plus antihistamine, and some received corticosteroid plus antihistamine.

The first study involved 80 patients, aged 3 months to 6 years, who were followed for 3 months. There were no differences in laboratory values, including levels of histamine and leukotriene B4 that could be attributed to either of the drugs.

However, corticosteroid treatment was associated with a lower rate of treatment failure within the first 2 weeks and a shorter duration of middle ear effusion.

A second trial followed 180 high-risk children with at least two previous episodes of AOM for 6 months. There were no statistically significant differences in the percentage of patients experiencing treatment failure in the first 2 weeks. But there was a significant difference in the duration of middle ear effusion. This difference favored placebo.

Patients receiving placebo alone experienced a median of 25 days of middle ear effusion.

Patients receiving antihistamine alone experienced middle ear effusion for a median of 73 days, almost three times longer.

Patients taking corticosteroid alone had about the same duration of effusion as did the placebo patients, and patients taking antihistamine and corticosteroid experienced a median of 36 days of effusion.

The conclusion was that antihistamines actually prolong middle ear effusion in patients with AOM and thus should not be used.

The Cochrane Collaboration conducted a detailed metaanalysis on the use of antihistamines and/or decongestants in AOM and came to similar conclusions (Cochrane Database Syst. Rev. 2004;3:CD001727).

Reviewing 15 randomized controlled trials involving a total of 2,695 cases, the investigators found that the combined evidence favored neither antihistamines nor decongestants on their primary outcome measure, which was persistent AOM at 2 weeks.

There was at least one significant difference, however—patients taking antihistamines and/or decongestants experienced significantly more side effects than did patients taking placebo.

“I conclude that for decongestants and antihistamines in acute otitis media [there is] no benefit for early cure rate, no benefit for symptom reduction, no benefit for prevention of complications, and increased risk for side effects,” Dr. Chonmaitree said at the meeting, which was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

Corticosteroids have similar evidence of inefficacy, and the bottom line is that the symptomatic treatment of AOM should include only an analgesic/antipyretic, she said.

Regarding the use of steroids, decongestants, or antihistamines in AOM, Dr. Richard M. Rosenfeld of Long Island College Hospital, New York, said in an interview that he largely agrees with Dr. Chonmaitree. “I would say the evidence [for their use] is quite weak. Occasionally you'll find a little statistically significant benefit pop out on one of the outcomes… but looked at as a whole the benefits are quite small if not trivial or absent. And when you then factor in the issue of potential side effects, it's a real tough case to recommend adding these adjuvant therapies. … In the child who's a frequent-flier and manages every couple of weeks to get a new episode of acute otitis, I think that it becomes even more ludicrous to repeatedly expose them to therapies of questionable benefit but significant adverse effects.” Dr. Rosenfeld is cochair of the American Academy of Pediatrics Subcommittee on Otitis Media With Effusion.

SAN FRANCISCO — Although it may seem logical that corticosteroids, antihistamines, and/or decongestants may be good adjunctive treatments of acute otitis media, the evidence does not bear this out, Dr. Tasnee Chonmaitree said at the annual meeting of the Pediatric Academic Societies.

The rationale for using corticosteroids and antihistamines is clear: Drugs that can inhibit the synthesis or counteract the actions of inflammatory mediators should help improve the outcome—or at least provide some symptom relief—in acute otitis media (AOM), said Dr. Chonmaitree of the University of Texas, Galveston.

Corticosteroids, for example, inhibit the recruitment of leukocytes and monocytes to the affected area, reduce vascular permeability, and inhibit the synthesis or release of numerous inflammatory mediators and cytokines. Moreover, there is evidence that corticosteroids improve outcomes in otorrhea in children and AOM in animal models.

But two randomized controlled trials conducted by Dr. Chonmaitree and her colleagues demonstrated no clear benefit for corticosteroids and antihistamines alone or in combination in patients taking antibiotics.

Both studies had four arms. Some patients received two placebos, some received one placebo plus corticosteroid, some received one placebo plus antihistamine, and some received corticosteroid plus antihistamine.

The first study involved 80 patients, aged 3 months to 6 years, who were followed for 3 months. There were no differences in laboratory values, including levels of histamine and leukotriene B4 that could be attributed to either of the drugs.

However, corticosteroid treatment was associated with a lower rate of treatment failure within the first 2 weeks and a shorter duration of middle ear effusion.

A second trial followed 180 high-risk children with at least two previous episodes of AOM for 6 months. There were no statistically significant differences in the percentage of patients experiencing treatment failure in the first 2 weeks. But there was a significant difference in the duration of middle ear effusion. This difference favored placebo.

Patients receiving placebo alone experienced a median of 25 days of middle ear effusion.

Patients receiving antihistamine alone experienced middle ear effusion for a median of 73 days, almost three times longer.

Patients taking corticosteroid alone had about the same duration of effusion as did the placebo patients, and patients taking antihistamine and corticosteroid experienced a median of 36 days of effusion.

The conclusion was that antihistamines actually prolong middle ear effusion in patients with AOM and thus should not be used.

The Cochrane Collaboration conducted a detailed metaanalysis on the use of antihistamines and/or decongestants in AOM and came to similar conclusions (Cochrane Database Syst. Rev. 2004;3:CD001727).

Reviewing 15 randomized controlled trials involving a total of 2,695 cases, the investigators found that the combined evidence favored neither antihistamines nor decongestants on their primary outcome measure, which was persistent AOM at 2 weeks.

There was at least one significant difference, however—patients taking antihistamines and/or decongestants experienced significantly more side effects than did patients taking placebo.

“I conclude that for decongestants and antihistamines in acute otitis media [there is] no benefit for early cure rate, no benefit for symptom reduction, no benefit for prevention of complications, and increased risk for side effects,” Dr. Chonmaitree said at the meeting, which was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

Corticosteroids have similar evidence of inefficacy, and the bottom line is that the symptomatic treatment of AOM should include only an analgesic/antipyretic, she said.

Regarding the use of steroids, decongestants, or antihistamines in AOM, Dr. Richard M. Rosenfeld of Long Island College Hospital, New York, said in an interview that he largely agrees with Dr. Chonmaitree. “I would say the evidence [for their use] is quite weak. Occasionally you'll find a little statistically significant benefit pop out on one of the outcomes… but looked at as a whole the benefits are quite small if not trivial or absent. And when you then factor in the issue of potential side effects, it's a real tough case to recommend adding these adjuvant therapies. … In the child who's a frequent-flier and manages every couple of weeks to get a new episode of acute otitis, I think that it becomes even more ludicrous to repeatedly expose them to therapies of questionable benefit but significant adverse effects.” Dr. Rosenfeld is cochair of the American Academy of Pediatrics Subcommittee on Otitis Media With Effusion.