Robert Finn

SAN FRANCISCO – Eighteen-month-old children who scored above the threshold for autism spectrum disorders on the Autism Diagnostic Observation Schedule were more than six times as likely to have a clinical diagnosis of autism spectrum disorder at the age of 3 years than those who scored lower, Dr. Lonnie Zwaigenbaum reported in a poster presentation at the annual meeting of the Pediatric Academic Societies.

Nevertheless, scores on the Autism Diagnostic Observation Schedule (ADOS) must be interpreted with caution in children who are 18 months old, wrote Dr. Zwaigenbaum of McMaster University, Hamilton, Ontario, and his colleagues. ADOS scores should be interpreted in the context of an overall clinical assessment, because the test has a high sensitivity but a relatively low specificity, missing more than 50% of the children with diagnoses at 3 years.

The study involved 101 children who were at increased risk of autism by virtue of having an older sibling with autism. Also included in the trial were 42 control children with no increased risk of autism.

The children were assessed with ADOS and the MacArthur Communicative Development Inventory at the average age of 18 months, and they received a blinded diagnosis by an expert clinician at an average age of 39 months.

This diagnosis was based on the clinician's best judgment after a comprehensive assessment that included the ADOS, the DSM-IV, and the Autism Diagnostic Interview-Revised. The ADOS scoring algorithm includes one cutoff score for autism spectrum disorders (ASDs) and a higher cutoff score for autism. Only one of the control children scored in the ASD range at 18 months, but that child was not in the ASD range at 24 months and did not have a diagnosis of ASD at 3 years.

Using the autism cutoff, the 18-month assessment identified 9 of 20 children who ended up with a clinical diagnosis at 3 years (sensitivity of 45%) and 6 of 81 children who did not receive a diagnosis at age 3 (specificity of 93%).

With the less-stringent ASD cutoff, the 18-month assessment identified 16 of 20 children who ended up with a clinical diagnosis at 3 years (sensitivity of 80%) and 23 of 81 children who did not (specificity of 72%). The relative risk of a clinical diagnosis at 3 years given a score above the ASD cutoff at 18 months was 6.4, which was statistically significant.

There were four false negatives: children with clinical diagnoses at 3 years who scored below the ASD cutoff at 18 months. Two of these children had very low scores–0 and 1 on the ADOS, in which the ASD cutoff is a score of 7. One of those children deteriorated markedly by 24 months and was diagnosed with autism. The second child had more slowly progressing impairments between 18 and 36 months, and his ADOS score at 24 months was still below the ASD cutoff.

More longitudinal research is needed to better understand the sources of disagreement between the diagnostic assessments, the investigators said.

SAN FRANCISCO – Eighteen-month-old children who scored above the threshold for autism spectrum disorders on the Autism Diagnostic Observation Schedule were more than six times as likely to have a clinical diagnosis of autism spectrum disorder at the age of 3 years than those who scored lower, Dr. Lonnie Zwaigenbaum reported in a poster presentation at the annual meeting of the Pediatric Academic Societies.

Nevertheless, scores on the Autism Diagnostic Observation Schedule (ADOS) must be interpreted with caution in children who are 18 months old, wrote Dr. Zwaigenbaum of McMaster University, Hamilton, Ontario, and his colleagues. ADOS scores should be interpreted in the context of an overall clinical assessment, because the test has a high sensitivity but a relatively low specificity, missing more than 50% of the children with diagnoses at 3 years.

The study involved 101 children who were at increased risk of autism by virtue of having an older sibling with autism. Also included in the trial were 42 control children with no increased risk of autism.

The children were assessed with ADOS and the MacArthur Communicative Development Inventory at the average age of 18 months, and they received a blinded diagnosis by an expert clinician at an average age of 39 months.

This diagnosis was based on the clinician's best judgment after a comprehensive assessment that included the ADOS, the DSM-IV, and the Autism Diagnostic Interview-Revised. The ADOS scoring algorithm includes one cutoff score for autism spectrum disorders (ASDs) and a higher cutoff score for autism. Only one of the control children scored in the ASD range at 18 months, but that child was not in the ASD range at 24 months and did not have a diagnosis of ASD at 3 years.

Using the autism cutoff, the 18-month assessment identified 9 of 20 children who ended up with a clinical diagnosis at 3 years (sensitivity of 45%) and 6 of 81 children who did not receive a diagnosis at age 3 (specificity of 93%).

With the less-stringent ASD cutoff, the 18-month assessment identified 16 of 20 children who ended up with a clinical diagnosis at 3 years (sensitivity of 80%) and 23 of 81 children who did not (specificity of 72%). The relative risk of a clinical diagnosis at 3 years given a score above the ASD cutoff at 18 months was 6.4, which was statistically significant.

There were four false negatives: children with clinical diagnoses at 3 years who scored below the ASD cutoff at 18 months. Two of these children had very low scores–0 and 1 on the ADOS, in which the ASD cutoff is a score of 7. One of those children deteriorated markedly by 24 months and was diagnosed with autism. The second child had more slowly progressing impairments between 18 and 36 months, and his ADOS score at 24 months was still below the ASD cutoff.

More longitudinal research is needed to better understand the sources of disagreement between the diagnostic assessments, the investigators said.

SAN FRANCISCO – Eighteen-month-old children who scored above the threshold for autism spectrum disorders on the Autism Diagnostic Observation Schedule were more than six times as likely to have a clinical diagnosis of autism spectrum disorder at the age of 3 years than those who scored lower, Dr. Lonnie Zwaigenbaum reported in a poster presentation at the annual meeting of the Pediatric Academic Societies.

Nevertheless, scores on the Autism Diagnostic Observation Schedule (ADOS) must be interpreted with caution in children who are 18 months old, wrote Dr. Zwaigenbaum of McMaster University, Hamilton, Ontario, and his colleagues. ADOS scores should be interpreted in the context of an overall clinical assessment, because the test has a high sensitivity but a relatively low specificity, missing more than 50% of the children with diagnoses at 3 years.

The study involved 101 children who were at increased risk of autism by virtue of having an older sibling with autism. Also included in the trial were 42 control children with no increased risk of autism.

The children were assessed with ADOS and the MacArthur Communicative Development Inventory at the average age of 18 months, and they received a blinded diagnosis by an expert clinician at an average age of 39 months.

This diagnosis was based on the clinician's best judgment after a comprehensive assessment that included the ADOS, the DSM-IV, and the Autism Diagnostic Interview-Revised. The ADOS scoring algorithm includes one cutoff score for autism spectrum disorders (ASDs) and a higher cutoff score for autism. Only one of the control children scored in the ASD range at 18 months, but that child was not in the ASD range at 24 months and did not have a diagnosis of ASD at 3 years.

Using the autism cutoff, the 18-month assessment identified 9 of 20 children who ended up with a clinical diagnosis at 3 years (sensitivity of 45%) and 6 of 81 children who did not receive a diagnosis at age 3 (specificity of 93%).

With the less-stringent ASD cutoff, the 18-month assessment identified 16 of 20 children who ended up with a clinical diagnosis at 3 years (sensitivity of 80%) and 23 of 81 children who did not (specificity of 72%). The relative risk of a clinical diagnosis at 3 years given a score above the ASD cutoff at 18 months was 6.4, which was statistically significant.

There were four false negatives: children with clinical diagnoses at 3 years who scored below the ASD cutoff at 18 months. Two of these children had very low scores–0 and 1 on the ADOS, in which the ASD cutoff is a score of 7. One of those children deteriorated markedly by 24 months and was diagnosed with autism. The second child had more slowly progressing impairments between 18 and 36 months, and his ADOS score at 24 months was still below the ASD cutoff.

More longitudinal research is needed to better understand the sources of disagreement between the diagnostic assessments, the investigators said.

DENVER — Brisk walking appears to place significant stress on knee joints, especially in obese individuals, and that may contribute to musculoskeletal injuries, Ray Browning, Ph.D., reported at the annual meeting of the American College of Sports Medicine.

Walking at 1.5 m/sec (3.4 mph), obese people have about 50% more torque at the knee joint than normal-weight individuals. That increased torque disappears when obese people walk at 1 m/sec (2.2 mph).

Dr. Browning, a physiology researcher at the University of Colorado, Boulder, cited data from the Centers for Disease Control and Prevention indicating that about one in four obese patients suffer a musculoskeletal injury when they first start walking for exercise, and that 25% of those injured patients never return to exercise. Prescribing slower walking speeds to obese patients may, in part, alleviate this problem.

The study involved 10 obese patients with a mean BMI of 35.5 kg/m

DENVER — Brisk walking appears to place significant stress on knee joints, especially in obese individuals, and that may contribute to musculoskeletal injuries, Ray Browning, Ph.D., reported at the annual meeting of the American College of Sports Medicine.

Walking at 1.5 m/sec (3.4 mph), obese people have about 50% more torque at the knee joint than normal-weight individuals. That increased torque disappears when obese people walk at 1 m/sec (2.2 mph).

Dr. Browning, a physiology researcher at the University of Colorado, Boulder, cited data from the Centers for Disease Control and Prevention indicating that about one in four obese patients suffer a musculoskeletal injury when they first start walking for exercise, and that 25% of those injured patients never return to exercise. Prescribing slower walking speeds to obese patients may, in part, alleviate this problem.

The study involved 10 obese patients with a mean BMI of 35.5 kg/m

DENVER — Brisk walking appears to place significant stress on knee joints, especially in obese individuals, and that may contribute to musculoskeletal injuries, Ray Browning, Ph.D., reported at the annual meeting of the American College of Sports Medicine.

Walking at 1.5 m/sec (3.4 mph), obese people have about 50% more torque at the knee joint than normal-weight individuals. That increased torque disappears when obese people walk at 1 m/sec (2.2 mph).

Dr. Browning, a physiology researcher at the University of Colorado, Boulder, cited data from the Centers for Disease Control and Prevention indicating that about one in four obese patients suffer a musculoskeletal injury when they first start walking for exercise, and that 25% of those injured patients never return to exercise. Prescribing slower walking speeds to obese patients may, in part, alleviate this problem.

The study involved 10 obese patients with a mean BMI of 35.5 kg/m

SAN FRANCISCO — A high risk for sleep apnea was common in women with polycystic ovary syndrome and was linked to high fasting insulin levels, Dr. Esra Tasali reported at a conference sponsored by the American Diabetes Association.

Among the women with normal glucose tolerance, insulin levels in response to oral glucose were twice as high in the women at high risk for sleep apnea, compared with those who were at low risk.

This finding suggests that sleep apnea might worsen the metabolic consequences of insulin resistance, accelerating the conversion from normal to impaired glucose tolerance, Dr. Tasali said.

Although the study does not establish causation, Dr. Tasali recommended that women with polycystic ovary syndrome (PCOS) be systematically evaluated for sleep apnea because treatment of existing sleep apnea might improve glucose metabolism.

A high risk for sleep apnea was observed in 30 of 40 women with PCOS, and 92% of the women had sleep problems, according to Dr. Tasali and her colleagues at the University of Chicago (J. Clin. Endocrinol. Metab. 2006;91:36–42).

Of the 40 women, 32 had previously been given an oral glucose tolerance test. Glucose tolerance was normal in 19 women.

In 22 women at high risk of sleep apnea, average fasting insulin levels were significantly higher (168 pmol/L) than they were in the 10 women at low risk of apnea (97 pmol/L), Dr. Tasali said.

Among the 13 women who had impaired glucose tolerance, glucose and insulin levels did not differ depending on the their level of risk for sleep apnea.

Another cohort of eight women with PCOS underwent overnight polysomnography for symptoms suggestive of obstructive sleep apnea.

Mean sleep efficiency was 80% in the women with PCOS, compared with 92% in a control group of age-matched, nonobese women.

The women with PCOS also had significantly longer mean sleep latency (41 minutes compared with 10 minutes), and significantly shorter total sleep time (323 minutes compared with 442 minutes, a difference of almost 2 hours).

“Sleep apnea might be an intrinsic component of the metabolic disturbances that appear with polycystic ovary syndrome,” Dr. Tasali said.

Furthermore, severity of sleep apnea as measured by the apnea-hypopnea index, and the degree of oxygen desaturations during rapid-eye-movement sleep, accounted for more than 90% of the variability in measures of glucose tolerance including hemoglobin A_1c levels.

Together, these findings could mean that both glucose tolerance and sleep apnea are strongly influenced by a common mechanism in women with PCOS.

Dr. Tasali disclosed that she had no conflict of interest related to her presentation.

SAN FRANCISCO — A high risk for sleep apnea was common in women with polycystic ovary syndrome and was linked to high fasting insulin levels, Dr. Esra Tasali reported at a conference sponsored by the American Diabetes Association.

Among the women with normal glucose tolerance, insulin levels in response to oral glucose were twice as high in the women at high risk for sleep apnea, compared with those who were at low risk.

This finding suggests that sleep apnea might worsen the metabolic consequences of insulin resistance, accelerating the conversion from normal to impaired glucose tolerance, Dr. Tasali said.

Although the study does not establish causation, Dr. Tasali recommended that women with polycystic ovary syndrome (PCOS) be systematically evaluated for sleep apnea because treatment of existing sleep apnea might improve glucose metabolism.

A high risk for sleep apnea was observed in 30 of 40 women with PCOS, and 92% of the women had sleep problems, according to Dr. Tasali and her colleagues at the University of Chicago (J. Clin. Endocrinol. Metab. 2006;91:36–42).

Of the 40 women, 32 had previously been given an oral glucose tolerance test. Glucose tolerance was normal in 19 women.

In 22 women at high risk of sleep apnea, average fasting insulin levels were significantly higher (168 pmol/L) than they were in the 10 women at low risk of apnea (97 pmol/L), Dr. Tasali said.

Among the 13 women who had impaired glucose tolerance, glucose and insulin levels did not differ depending on the their level of risk for sleep apnea.

Another cohort of eight women with PCOS underwent overnight polysomnography for symptoms suggestive of obstructive sleep apnea.

Mean sleep efficiency was 80% in the women with PCOS, compared with 92% in a control group of age-matched, nonobese women.

The women with PCOS also had significantly longer mean sleep latency (41 minutes compared with 10 minutes), and significantly shorter total sleep time (323 minutes compared with 442 minutes, a difference of almost 2 hours).

“Sleep apnea might be an intrinsic component of the metabolic disturbances that appear with polycystic ovary syndrome,” Dr. Tasali said.

Furthermore, severity of sleep apnea as measured by the apnea-hypopnea index, and the degree of oxygen desaturations during rapid-eye-movement sleep, accounted for more than 90% of the variability in measures of glucose tolerance including hemoglobin A_1c levels.

Together, these findings could mean that both glucose tolerance and sleep apnea are strongly influenced by a common mechanism in women with PCOS.

Dr. Tasali disclosed that she had no conflict of interest related to her presentation.

SAN FRANCISCO — A high risk for sleep apnea was common in women with polycystic ovary syndrome and was linked to high fasting insulin levels, Dr. Esra Tasali reported at a conference sponsored by the American Diabetes Association.

Among the women with normal glucose tolerance, insulin levels in response to oral glucose were twice as high in the women at high risk for sleep apnea, compared with those who were at low risk.

This finding suggests that sleep apnea might worsen the metabolic consequences of insulin resistance, accelerating the conversion from normal to impaired glucose tolerance, Dr. Tasali said.

Although the study does not establish causation, Dr. Tasali recommended that women with polycystic ovary syndrome (PCOS) be systematically evaluated for sleep apnea because treatment of existing sleep apnea might improve glucose metabolism.

A high risk for sleep apnea was observed in 30 of 40 women with PCOS, and 92% of the women had sleep problems, according to Dr. Tasali and her colleagues at the University of Chicago (J. Clin. Endocrinol. Metab. 2006;91:36–42).

Of the 40 women, 32 had previously been given an oral glucose tolerance test. Glucose tolerance was normal in 19 women.

In 22 women at high risk of sleep apnea, average fasting insulin levels were significantly higher (168 pmol/L) than they were in the 10 women at low risk of apnea (97 pmol/L), Dr. Tasali said.

Among the 13 women who had impaired glucose tolerance, glucose and insulin levels did not differ depending on the their level of risk for sleep apnea.

Another cohort of eight women with PCOS underwent overnight polysomnography for symptoms suggestive of obstructive sleep apnea.

Mean sleep efficiency was 80% in the women with PCOS, compared with 92% in a control group of age-matched, nonobese women.

The women with PCOS also had significantly longer mean sleep latency (41 minutes compared with 10 minutes), and significantly shorter total sleep time (323 minutes compared with 442 minutes, a difference of almost 2 hours).

“Sleep apnea might be an intrinsic component of the metabolic disturbances that appear with polycystic ovary syndrome,” Dr. Tasali said.

Furthermore, severity of sleep apnea as measured by the apnea-hypopnea index, and the degree of oxygen desaturations during rapid-eye-movement sleep, accounted for more than 90% of the variability in measures of glucose tolerance including hemoglobin A_1c levels.

Together, these findings could mean that both glucose tolerance and sleep apnea are strongly influenced by a common mechanism in women with PCOS.

Dr. Tasali disclosed that she had no conflict of interest related to her presentation.

SAN FRANCISCO — Azithromycin had no influence on the clinical course of pityriasis rosea, according to a poster presentation of a small randomized controlled trial at the annual meeting of the Pediatric Academic Societies.

The etiologic agent for pityriasis rosea, an acute inflammatory skin disease common in children and adolescents, is unknown. A study published in 2000 reported complete resolution of symptoms in 73% of patients treated with erythromycin (J. Am. Acad. Dermatol. 2000;42:241–4).

Dr. Ahdi Amer and Dr. Howard Fischer, of the Wayne State University, Detroit, treated 49 children an average of 1.5 weeks after a diagnosis of pityriasis rosea. The children, aged 2–18 years, were randomly assigned to get a 5-day course of azithromycin or placebo, the researchers said at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics. Fifteen patients in the azithromycin group (60%) and 10 in the placebo group (42%) had complete resolution of symptoms within 2 weeks. Seven patients in each group had partial resolution. There were three treatment failures in the azithromycin group and seven in the placebo group. These differences weren't statistically significant.

SAN FRANCISCO — Azithromycin had no influence on the clinical course of pityriasis rosea, according to a poster presentation of a small randomized controlled trial at the annual meeting of the Pediatric Academic Societies.

The etiologic agent for pityriasis rosea, an acute inflammatory skin disease common in children and adolescents, is unknown. A study published in 2000 reported complete resolution of symptoms in 73% of patients treated with erythromycin (J. Am. Acad. Dermatol. 2000;42:241–4).

Dr. Ahdi Amer and Dr. Howard Fischer, of the Wayne State University, Detroit, treated 49 children an average of 1.5 weeks after a diagnosis of pityriasis rosea. The children, aged 2–18 years, were randomly assigned to get a 5-day course of azithromycin or placebo, the researchers said at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics. Fifteen patients in the azithromycin group (60%) and 10 in the placebo group (42%) had complete resolution of symptoms within 2 weeks. Seven patients in each group had partial resolution. There were three treatment failures in the azithromycin group and seven in the placebo group. These differences weren't statistically significant.

SAN FRANCISCO — Azithromycin had no influence on the clinical course of pityriasis rosea, according to a poster presentation of a small randomized controlled trial at the annual meeting of the Pediatric Academic Societies.

The etiologic agent for pityriasis rosea, an acute inflammatory skin disease common in children and adolescents, is unknown. A study published in 2000 reported complete resolution of symptoms in 73% of patients treated with erythromycin (J. Am. Acad. Dermatol. 2000;42:241–4).

Dr. Ahdi Amer and Dr. Howard Fischer, of the Wayne State University, Detroit, treated 49 children an average of 1.5 weeks after a diagnosis of pityriasis rosea. The children, aged 2–18 years, were randomly assigned to get a 5-day course of azithromycin or placebo, the researchers said at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics. Fifteen patients in the azithromycin group (60%) and 10 in the placebo group (42%) had complete resolution of symptoms within 2 weeks. Seven patients in each group had partial resolution. There were three treatment failures in the azithromycin group and seven in the placebo group. These differences weren't statistically significant.

ATLANTA — People with metabolic syndrome have blood pressures that are more sensitive to salt intake than do people without metabolic syndrome, according to a poster presentation by Dr. Luigi X. Cubeddu at a meeting sponsored by the International Society on Hypertension in Blacks.

His study, involving 301 subjects with and without metabolic syndrome, showed that normal dietary salt intake induces large increases in blood pressure in people with metabolic syndrome, rendering them “exquisitely sensitive to dietary salt.

“Salt restriction, in addition to exercise and caloric restriction, must be a fundamental part of the treatment plan for patients with the metabolic syndrome,” wrote Dr. Cubeddu of Nova Southeastern University, Fort Lauderdale, Fla. The subjects had a mean age of 42 years, and 109 of them were diagnosed as having metabolic syndrome in accordance with guidelines from the National Cholesterol Education Program. Those with metabolic syndrome had significantly higher baseline blood pressure did than those without: 127/83 mm Hg, compared with 114/75 mm Hg.

The investigators measured blood pressure and several other physiologic signs during a week-long baseline period in which salt intake was normal (8 g/day), and also during a week of high salt intake (about 18 g/day) and a week of low salt intake (2.3 g/day).

The high-salt condition resulted in increases in blood pressure in both groups of subjects, but those with metabolic syndrome had significantly larger increases in both systolic and diastolic pressures. While the patients without metabolic syndrome increased their systolic blood pressure an average of 5.0 mm Hg and their diastolic pressure an average of 3.0 mm Hg, those with metabolic syndrome experienced systolic and diastolic increases of 9.6 and 4.5 mm Hg, respectively.

The degree of salt sensitivity was also associated with the severity of metabolic syndrome. The more components of metabolic syndrome a subject had, the larger was his or her decrease in blood pressure associated with salt restriction.

Subjects with four or five components of metabolic syndrome saw decreases of 8.7 mm Hg systolic and 5.0 mm Hg diastolic in response to salt restriction, while those with just two of the traits saw decreases of 3.4 and 2.1, respectively.

The investigators noted that salt sensitivity is a gradual condition that worsens in parallel with metabolic syndrome. Dietary salt is a major determinant of the increased prevalence of prehypertension and hypertension in those with metabolic syndrome.

The meeting was cosponsored by the American Society of Hypertension.

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA — People with metabolic syndrome have blood pressures that are more sensitive to salt intake than do people without metabolic syndrome, according to a poster presentation by Dr. Luigi X. Cubeddu at a meeting sponsored by the International Society on Hypertension in Blacks.

His study, involving 301 subjects with and without metabolic syndrome, showed that normal dietary salt intake induces large increases in blood pressure in people with metabolic syndrome, rendering them “exquisitely sensitive to dietary salt.

“Salt restriction, in addition to exercise and caloric restriction, must be a fundamental part of the treatment plan for patients with the metabolic syndrome,” wrote Dr. Cubeddu of Nova Southeastern University, Fort Lauderdale, Fla. The subjects had a mean age of 42 years, and 109 of them were diagnosed as having metabolic syndrome in accordance with guidelines from the National Cholesterol Education Program. Those with metabolic syndrome had significantly higher baseline blood pressure did than those without: 127/83 mm Hg, compared with 114/75 mm Hg.

The investigators measured blood pressure and several other physiologic signs during a week-long baseline period in which salt intake was normal (8 g/day), and also during a week of high salt intake (about 18 g/day) and a week of low salt intake (2.3 g/day).

The high-salt condition resulted in increases in blood pressure in both groups of subjects, but those with metabolic syndrome had significantly larger increases in both systolic and diastolic pressures. While the patients without metabolic syndrome increased their systolic blood pressure an average of 5.0 mm Hg and their diastolic pressure an average of 3.0 mm Hg, those with metabolic syndrome experienced systolic and diastolic increases of 9.6 and 4.5 mm Hg, respectively.

The degree of salt sensitivity was also associated with the severity of metabolic syndrome. The more components of metabolic syndrome a subject had, the larger was his or her decrease in blood pressure associated with salt restriction.

Subjects with four or five components of metabolic syndrome saw decreases of 8.7 mm Hg systolic and 5.0 mm Hg diastolic in response to salt restriction, while those with just two of the traits saw decreases of 3.4 and 2.1, respectively.

The investigators noted that salt sensitivity is a gradual condition that worsens in parallel with metabolic syndrome. Dietary salt is a major determinant of the increased prevalence of prehypertension and hypertension in those with metabolic syndrome.

The meeting was cosponsored by the American Society of Hypertension.

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA — People with metabolic syndrome have blood pressures that are more sensitive to salt intake than do people without metabolic syndrome, according to a poster presentation by Dr. Luigi X. Cubeddu at a meeting sponsored by the International Society on Hypertension in Blacks.

His study, involving 301 subjects with and without metabolic syndrome, showed that normal dietary salt intake induces large increases in blood pressure in people with metabolic syndrome, rendering them “exquisitely sensitive to dietary salt.

“Salt restriction, in addition to exercise and caloric restriction, must be a fundamental part of the treatment plan for patients with the metabolic syndrome,” wrote Dr. Cubeddu of Nova Southeastern University, Fort Lauderdale, Fla. The subjects had a mean age of 42 years, and 109 of them were diagnosed as having metabolic syndrome in accordance with guidelines from the National Cholesterol Education Program. Those with metabolic syndrome had significantly higher baseline blood pressure did than those without: 127/83 mm Hg, compared with 114/75 mm Hg.

The investigators measured blood pressure and several other physiologic signs during a week-long baseline period in which salt intake was normal (8 g/day), and also during a week of high salt intake (about 18 g/day) and a week of low salt intake (2.3 g/day).

The high-salt condition resulted in increases in blood pressure in both groups of subjects, but those with metabolic syndrome had significantly larger increases in both systolic and diastolic pressures. While the patients without metabolic syndrome increased their systolic blood pressure an average of 5.0 mm Hg and their diastolic pressure an average of 3.0 mm Hg, those with metabolic syndrome experienced systolic and diastolic increases of 9.6 and 4.5 mm Hg, respectively.

The degree of salt sensitivity was also associated with the severity of metabolic syndrome. The more components of metabolic syndrome a subject had, the larger was his or her decrease in blood pressure associated with salt restriction.

Subjects with four or five components of metabolic syndrome saw decreases of 8.7 mm Hg systolic and 5.0 mm Hg diastolic in response to salt restriction, while those with just two of the traits saw decreases of 3.4 and 2.1, respectively.

The investigators noted that salt sensitivity is a gradual condition that worsens in parallel with metabolic syndrome. Dietary salt is a major determinant of the increased prevalence of prehypertension and hypertension in those with metabolic syndrome.

The meeting was cosponsored by the American Society of Hypertension.

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA — Current criteria for diagnosing metabolic syndrome fail to identify many African American patients at increased risk of cardiovascular disease and diabetes, so the criteria should be changed for those patients, said Dr. Anne E. Sumner at a meeting sponsored by the International Society on Hypertension in Blacks.

Of the three sets of diagnostic criteria currently in use, all list triglyceride levels in excess of 150 mg/dL as one sign that a patient has the metabolic syndrome. But studies show that even obese and insulin-resistant African Americans can have low triglyceride levels, said Dr. Sumner, a clinical investigator at the National Institute of Diabetes and Digestive and Kidney Diseases branch of the National Institutes of Health.

“The inclusion of triglyceride [levels] in the metabolic syndrome leads to the exclusion of a significant proportion of insulin-resistant African Americans,” Dr. Sumner said at the meeting, cosponsored by the American Society of Hypertension. On the other hand, “the exclusion of triglyceride from the metabolic syndrome criteria [would] lead to the inclusion of the significant proportion of insulin-resistant African Americans.”

Dr. Sumner relied on several clinical studies to support her conclusion. Data from the National Health and Nutrition Examination Survey (NHANES) show that both African American men and women have a significantly higher prevalence of cardiovascular disease and diabetes than do whites. Despite that, NHANES data show that African American men and women at all body-mass index levels have lower rates of metabolic syndrome than do whites.

Preliminary results from the Triglyceride and Cardiovascular Risk in African Americans study, for which Dr. Sumner is a principal investigator, show that even African Americans with very high BMIs and very high levels of insulin resistance can have very low levels of triglycerides.

She pointed in particular to 2 women among the 210 African Americans so far enrolled in the study. One has a BMI of 55 kg/m

Thirty percent of the African Americans in the study are insulin resistant, but only 2% have elevated triglycerides. In comparison, data from other studies show that about 60% of whites with insulin resistance have elevated triglycerides.

Dr. Sumner obtained similar results from her as-yet-unpublished analysis of NHANES data. She examined data from a cohort of 2,804 persons, aged 20–70, composed of 569 non-Hispanic blacks, 1,485 non-Hispanic whites, and 750 Mexican Americans. She divided the entire cohort into thirds based on their homeostasis model assessment (HOMA) scores, a surrogate for insulin resistance. Of the patients with the highest HOMA scores, the blacks had significantly lower triglyceride levels than either the whites or the Mexican Americans. This held true for both men and women as well as for individuals who were obese, overweight, and of normal weight.

Although triglyceride levels do have a direct relationship with insulin resistance, the absence of high triglyceride levels in African Americans does not mean the absence of insulin resistance. Therefore, any system that relies on triglyceride levels as a marker for insulin resistance risks underdiagnosis in African Americans. “In blacks, the danger of underdiagnosis is the lost opportunity for the prevention of diseases related to insulin resistance, particularly diabetes and heart disease,” Dr. Sumner said.

She suggested the solution is to develop criteria for “triglyceride-absent metabolic syndrome” to be used in African Americans and to test prospectively whether requiring just two of the four remaining criteria (waist circumference, hypertension, low HDL cholesterol, and high fasting glucose) for the diagnosis of metabolic syndrome would accurately predict the onset of diabetes or cardiovascular disease.

For the those in Dr. Sumner's study, the definition of metabolic syndrome developed by the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) results in a prevalence of 11%, a sensitivity of 21%, and a specificity of 97%. With the triglyceride-absent definition, the prevalence would be 30%, the sensitivity would be 53%, and the specificity would be 81%. “I felt this [triglyceride-absent definition] was a minimalist approach to the changing of the metabolic syndrome with the smallest perturbation,” she said.

ATLANTA — Current criteria for diagnosing metabolic syndrome fail to identify many African American patients at increased risk of cardiovascular disease and diabetes, so the criteria should be changed for those patients, said Dr. Anne E. Sumner at a meeting sponsored by the International Society on Hypertension in Blacks.

Of the three sets of diagnostic criteria currently in use, all list triglyceride levels in excess of 150 mg/dL as one sign that a patient has the metabolic syndrome. But studies show that even obese and insulin-resistant African Americans can have low triglyceride levels, said Dr. Sumner, a clinical investigator at the National Institute of Diabetes and Digestive and Kidney Diseases branch of the National Institutes of Health.

“The inclusion of triglyceride [levels] in the metabolic syndrome leads to the exclusion of a significant proportion of insulin-resistant African Americans,” Dr. Sumner said at the meeting, cosponsored by the American Society of Hypertension. On the other hand, “the exclusion of triglyceride from the metabolic syndrome criteria [would] lead to the inclusion of the significant proportion of insulin-resistant African Americans.”

Dr. Sumner relied on several clinical studies to support her conclusion. Data from the National Health and Nutrition Examination Survey (NHANES) show that both African American men and women have a significantly higher prevalence of cardiovascular disease and diabetes than do whites. Despite that, NHANES data show that African American men and women at all body-mass index levels have lower rates of metabolic syndrome than do whites.

Preliminary results from the Triglyceride and Cardiovascular Risk in African Americans study, for which Dr. Sumner is a principal investigator, show that even African Americans with very high BMIs and very high levels of insulin resistance can have very low levels of triglycerides.

She pointed in particular to 2 women among the 210 African Americans so far enrolled in the study. One has a BMI of 55 kg/m

Thirty percent of the African Americans in the study are insulin resistant, but only 2% have elevated triglycerides. In comparison, data from other studies show that about 60% of whites with insulin resistance have elevated triglycerides.

Dr. Sumner obtained similar results from her as-yet-unpublished analysis of NHANES data. She examined data from a cohort of 2,804 persons, aged 20–70, composed of 569 non-Hispanic blacks, 1,485 non-Hispanic whites, and 750 Mexican Americans. She divided the entire cohort into thirds based on their homeostasis model assessment (HOMA) scores, a surrogate for insulin resistance. Of the patients with the highest HOMA scores, the blacks had significantly lower triglyceride levels than either the whites or the Mexican Americans. This held true for both men and women as well as for individuals who were obese, overweight, and of normal weight.

Although triglyceride levels do have a direct relationship with insulin resistance, the absence of high triglyceride levels in African Americans does not mean the absence of insulin resistance. Therefore, any system that relies on triglyceride levels as a marker for insulin resistance risks underdiagnosis in African Americans. “In blacks, the danger of underdiagnosis is the lost opportunity for the prevention of diseases related to insulin resistance, particularly diabetes and heart disease,” Dr. Sumner said.

She suggested the solution is to develop criteria for “triglyceride-absent metabolic syndrome” to be used in African Americans and to test prospectively whether requiring just two of the four remaining criteria (waist circumference, hypertension, low HDL cholesterol, and high fasting glucose) for the diagnosis of metabolic syndrome would accurately predict the onset of diabetes or cardiovascular disease.

For the those in Dr. Sumner's study, the definition of metabolic syndrome developed by the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) results in a prevalence of 11%, a sensitivity of 21%, and a specificity of 97%. With the triglyceride-absent definition, the prevalence would be 30%, the sensitivity would be 53%, and the specificity would be 81%. “I felt this [triglyceride-absent definition] was a minimalist approach to the changing of the metabolic syndrome with the smallest perturbation,” she said.

ATLANTA — Current criteria for diagnosing metabolic syndrome fail to identify many African American patients at increased risk of cardiovascular disease and diabetes, so the criteria should be changed for those patients, said Dr. Anne E. Sumner at a meeting sponsored by the International Society on Hypertension in Blacks.

Of the three sets of diagnostic criteria currently in use, all list triglyceride levels in excess of 150 mg/dL as one sign that a patient has the metabolic syndrome. But studies show that even obese and insulin-resistant African Americans can have low triglyceride levels, said Dr. Sumner, a clinical investigator at the National Institute of Diabetes and Digestive and Kidney Diseases branch of the National Institutes of Health.

“The inclusion of triglyceride [levels] in the metabolic syndrome leads to the exclusion of a significant proportion of insulin-resistant African Americans,” Dr. Sumner said at the meeting, cosponsored by the American Society of Hypertension. On the other hand, “the exclusion of triglyceride from the metabolic syndrome criteria [would] lead to the inclusion of the significant proportion of insulin-resistant African Americans.”

Dr. Sumner relied on several clinical studies to support her conclusion. Data from the National Health and Nutrition Examination Survey (NHANES) show that both African American men and women have a significantly higher prevalence of cardiovascular disease and diabetes than do whites. Despite that, NHANES data show that African American men and women at all body-mass index levels have lower rates of metabolic syndrome than do whites.

Preliminary results from the Triglyceride and Cardiovascular Risk in African Americans study, for which Dr. Sumner is a principal investigator, show that even African Americans with very high BMIs and very high levels of insulin resistance can have very low levels of triglycerides.

She pointed in particular to 2 women among the 210 African Americans so far enrolled in the study. One has a BMI of 55 kg/m

Thirty percent of the African Americans in the study are insulin resistant, but only 2% have elevated triglycerides. In comparison, data from other studies show that about 60% of whites with insulin resistance have elevated triglycerides.

Dr. Sumner obtained similar results from her as-yet-unpublished analysis of NHANES data. She examined data from a cohort of 2,804 persons, aged 20–70, composed of 569 non-Hispanic blacks, 1,485 non-Hispanic whites, and 750 Mexican Americans. She divided the entire cohort into thirds based on their homeostasis model assessment (HOMA) scores, a surrogate for insulin resistance. Of the patients with the highest HOMA scores, the blacks had significantly lower triglyceride levels than either the whites or the Mexican Americans. This held true for both men and women as well as for individuals who were obese, overweight, and of normal weight.

Although triglyceride levels do have a direct relationship with insulin resistance, the absence of high triglyceride levels in African Americans does not mean the absence of insulin resistance. Therefore, any system that relies on triglyceride levels as a marker for insulin resistance risks underdiagnosis in African Americans. “In blacks, the danger of underdiagnosis is the lost opportunity for the prevention of diseases related to insulin resistance, particularly diabetes and heart disease,” Dr. Sumner said.

She suggested the solution is to develop criteria for “triglyceride-absent metabolic syndrome” to be used in African Americans and to test prospectively whether requiring just two of the four remaining criteria (waist circumference, hypertension, low HDL cholesterol, and high fasting glucose) for the diagnosis of metabolic syndrome would accurately predict the onset of diabetes or cardiovascular disease.

For the those in Dr. Sumner's study, the definition of metabolic syndrome developed by the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) results in a prevalence of 11%, a sensitivity of 21%, and a specificity of 97%. With the triglyceride-absent definition, the prevalence would be 30%, the sensitivity would be 53%, and the specificity would be 81%. “I felt this [triglyceride-absent definition] was a minimalist approach to the changing of the metabolic syndrome with the smallest perturbation,” she said.

ATLANTA — Stubbornly refractory hypertension can be approached with a number of drug combinations and other novel treatments, Dr. Angela L. Brown said at a meeting sponsored by the International Society on Hypertension in Blacks.

The combination of a diuretic and an inhibitor of the renin-angiotensin-aldosterone system (RAAS) is probably the most popular choice, said Dr. Brown of Washington University, St. Louis. This combination makes physiological sense because the two classes of drugs have complementary modes of action—as the diuretic decreases fluid volume, the RAAS inhibitor decreases pulmonary vascular resistance. RAAS inhibitors also counteract the relative increase in blood pressure from diuretic-induced renin secretion. The combination is well tolerated and effective in low-renin populations and African Americans.

Another popular combination is an ACE inhibitor with a calcium channel blocker (CCB). The ACE inhibitor blocks the renin-angiotensin system, is effective in high-renin hypertension, works in all populations—especially whites, Hispanics, and young patients—and produces arterial and venous vasodilation. The CCB blocks the sympathetic nervous system, provides excellent efficacy, produces arterial vasodilation, is effective in low-renin hypertension, and works in all populations, particularly African Americans and the elderly.

Theoretical considerations suggest that an ACE inhibitor along with an angiotensin II receptor blocker (ARB) should also work, but studies have not shown enhanced blood pressure reduction, although the combination does result in significant reduction in proteinuria.

The combination of a dihydropyridine CCB (such as amlodipine, nifedipine, or isradipine) with a nondihydropyridine CCB, such as verapamil or diltiazem, may be more effective. The dihydropyridines are less likely to decrease cardiac output and may cause an acute reflux tachycardia. The nondihydropyridines lower the pulse rate and may have a negative inotropic affect. The nondihydropyridines also inhibit the cytochrome P450 system and slow metabolism of the dihydropyridine CCBs. There's good evidence that this combination decreases blood pressure, Dr. Brown said.

Two other treatments for refractory hypertension—insulin sensitizers or statins—take into account common comorbidities such as dyslipidemia and obesity.

Thiazolidinedione insulin sensitizers can bind to peroxisome proliferator-activated receptor gamma (PPARγ) in fat and muscle to lower insulin resistance. Studies have shown such receptors are also plentiful in the kidney, and that two mutations in the PPARγ gene are associated with severe hypertension in humans. Pioglitazone seems to result in significant decreases in systolic blood pressure in clinical trials.

The statins reduce cholesterol, are atheroprotective and stabilize atherosclerotic plaques, have antioxidative effects, reduce inflammation and thrombus formation, and improve endothelial function. A small study has now shown that statins can reduce the magnitude of angiotensin-induced increases in blood pressure.

Nitrates are effective for the acute treatment of severe hypertension and aortic dissection, but long-term use is hampered by tachyphylaxis and tolerance. Some studies have suggesed intermittent dosing of long-acting nitrates led to a decrease in the augmentation index of the reflected pulse wave, thus lowering systolic blood pressure.

Dr. Brown has received research support from GlaxoSmithKline and Novartis, is a consultant for Pfizer, and is on speakers' bureaus for five pharmaceutical companies. The meeting was cosponsored by the American Society of Hypertension.

ATLANTA — Stubbornly refractory hypertension can be approached with a number of drug combinations and other novel treatments, Dr. Angela L. Brown said at a meeting sponsored by the International Society on Hypertension in Blacks.

The combination of a diuretic and an inhibitor of the renin-angiotensin-aldosterone system (RAAS) is probably the most popular choice, said Dr. Brown of Washington University, St. Louis. This combination makes physiological sense because the two classes of drugs have complementary modes of action—as the diuretic decreases fluid volume, the RAAS inhibitor decreases pulmonary vascular resistance. RAAS inhibitors also counteract the relative increase in blood pressure from diuretic-induced renin secretion. The combination is well tolerated and effective in low-renin populations and African Americans.

Another popular combination is an ACE inhibitor with a calcium channel blocker (CCB). The ACE inhibitor blocks the renin-angiotensin system, is effective in high-renin hypertension, works in all populations—especially whites, Hispanics, and young patients—and produces arterial and venous vasodilation. The CCB blocks the sympathetic nervous system, provides excellent efficacy, produces arterial vasodilation, is effective in low-renin hypertension, and works in all populations, particularly African Americans and the elderly.

Theoretical considerations suggest that an ACE inhibitor along with an angiotensin II receptor blocker (ARB) should also work, but studies have not shown enhanced blood pressure reduction, although the combination does result in significant reduction in proteinuria.

The combination of a dihydropyridine CCB (such as amlodipine, nifedipine, or isradipine) with a nondihydropyridine CCB, such as verapamil or diltiazem, may be more effective. The dihydropyridines are less likely to decrease cardiac output and may cause an acute reflux tachycardia. The nondihydropyridines lower the pulse rate and may have a negative inotropic affect. The nondihydropyridines also inhibit the cytochrome P450 system and slow metabolism of the dihydropyridine CCBs. There's good evidence that this combination decreases blood pressure, Dr. Brown said.

Two other treatments for refractory hypertension—insulin sensitizers or statins—take into account common comorbidities such as dyslipidemia and obesity.

Thiazolidinedione insulin sensitizers can bind to peroxisome proliferator-activated receptor gamma (PPARγ) in fat and muscle to lower insulin resistance. Studies have shown such receptors are also plentiful in the kidney, and that two mutations in the PPARγ gene are associated with severe hypertension in humans. Pioglitazone seems to result in significant decreases in systolic blood pressure in clinical trials.

The statins reduce cholesterol, are atheroprotective and stabilize atherosclerotic plaques, have antioxidative effects, reduce inflammation and thrombus formation, and improve endothelial function. A small study has now shown that statins can reduce the magnitude of angiotensin-induced increases in blood pressure.

Nitrates are effective for the acute treatment of severe hypertension and aortic dissection, but long-term use is hampered by tachyphylaxis and tolerance. Some studies have suggesed intermittent dosing of long-acting nitrates led to a decrease in the augmentation index of the reflected pulse wave, thus lowering systolic blood pressure.

Dr. Brown has received research support from GlaxoSmithKline and Novartis, is a consultant for Pfizer, and is on speakers' bureaus for five pharmaceutical companies. The meeting was cosponsored by the American Society of Hypertension.

ATLANTA — Stubbornly refractory hypertension can be approached with a number of drug combinations and other novel treatments, Dr. Angela L. Brown said at a meeting sponsored by the International Society on Hypertension in Blacks.

The combination of a diuretic and an inhibitor of the renin-angiotensin-aldosterone system (RAAS) is probably the most popular choice, said Dr. Brown of Washington University, St. Louis. This combination makes physiological sense because the two classes of drugs have complementary modes of action—as the diuretic decreases fluid volume, the RAAS inhibitor decreases pulmonary vascular resistance. RAAS inhibitors also counteract the relative increase in blood pressure from diuretic-induced renin secretion. The combination is well tolerated and effective in low-renin populations and African Americans.

Another popular combination is an ACE inhibitor with a calcium channel blocker (CCB). The ACE inhibitor blocks the renin-angiotensin system, is effective in high-renin hypertension, works in all populations—especially whites, Hispanics, and young patients—and produces arterial and venous vasodilation. The CCB blocks the sympathetic nervous system, provides excellent efficacy, produces arterial vasodilation, is effective in low-renin hypertension, and works in all populations, particularly African Americans and the elderly.

Theoretical considerations suggest that an ACE inhibitor along with an angiotensin II receptor blocker (ARB) should also work, but studies have not shown enhanced blood pressure reduction, although the combination does result in significant reduction in proteinuria.

The combination of a dihydropyridine CCB (such as amlodipine, nifedipine, or isradipine) with a nondihydropyridine CCB, such as verapamil or diltiazem, may be more effective. The dihydropyridines are less likely to decrease cardiac output and may cause an acute reflux tachycardia. The nondihydropyridines lower the pulse rate and may have a negative inotropic affect. The nondihydropyridines also inhibit the cytochrome P450 system and slow metabolism of the dihydropyridine CCBs. There's good evidence that this combination decreases blood pressure, Dr. Brown said.

Two other treatments for refractory hypertension—insulin sensitizers or statins—take into account common comorbidities such as dyslipidemia and obesity.

Thiazolidinedione insulin sensitizers can bind to peroxisome proliferator-activated receptor gamma (PPARγ) in fat and muscle to lower insulin resistance. Studies have shown such receptors are also plentiful in the kidney, and that two mutations in the PPARγ gene are associated with severe hypertension in humans. Pioglitazone seems to result in significant decreases in systolic blood pressure in clinical trials.

The statins reduce cholesterol, are atheroprotective and stabilize atherosclerotic plaques, have antioxidative effects, reduce inflammation and thrombus formation, and improve endothelial function. A small study has now shown that statins can reduce the magnitude of angiotensin-induced increases in blood pressure.

Nitrates are effective for the acute treatment of severe hypertension and aortic dissection, but long-term use is hampered by tachyphylaxis and tolerance. Some studies have suggesed intermittent dosing of long-acting nitrates led to a decrease in the augmentation index of the reflected pulse wave, thus lowering systolic blood pressure.

Dr. Brown has received research support from GlaxoSmithKline and Novartis, is a consultant for Pfizer, and is on speakers' bureaus for five pharmaceutical companies. The meeting was cosponsored by the American Society of Hypertension.

ATLANTA — Elevated blood pressure is associated with elevated body mass index in children as young as 2 years, 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 who are aged 2–5 years 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 who are aged 6–10 years, 20.0% in boys aged 11–15 years, and 18.5% in those aged 16–19 years. 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.

Although data on the child's race were included in the electronic medical record, the investigators regarded the information as being unreliable because the child's race was assigned by the registering clerk rather than by self-assignment.

In a finding that was 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.

One unexpected result of the study was that government and public insurance was associated with lower blood pressure. This was surprising because a frequent finding in other studies is that lower socioeconomic status is associated with higher blood pressure, she said.

The results of the study suggest that effective strategies for preventing childhood obesity must be applied at very young ages to stem the tide of increasing cardiovascular risk, Dr. Rappaport said.

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA — Elevated blood pressure is associated with elevated body mass index in children as young as 2 years, 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 who are aged 2–5 years 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 who are aged 6–10 years, 20.0% in boys aged 11–15 years, and 18.5% in those aged 16–19 years. 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.

Although data on the child's race were included in the electronic medical record, the investigators regarded the information as being unreliable because the child's race was assigned by the registering clerk rather than by self-assignment.

In a finding that was 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.

One unexpected result of the study was that government and public insurance was associated with lower blood pressure. This was surprising because a frequent finding in other studies is that lower socioeconomic status is associated with higher blood pressure, she said.

The results of the study suggest that effective strategies for preventing childhood obesity must be applied at very young ages to stem the tide of increasing cardiovascular risk, Dr. Rappaport said.

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA — Elevated blood pressure is associated with elevated body mass index in children as young as 2 years, 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 who are aged 2–5 years 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 who are aged 6–10 years, 20.0% in boys aged 11–15 years, and 18.5% in those aged 16–19 years. 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.

Although data on the child's race were included in the electronic medical record, the investigators regarded the information as being unreliable because the child's race was assigned by the registering clerk rather than by self-assignment.

In a finding that was 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.

One unexpected result of the study was that government and public insurance was associated with lower blood pressure. This was surprising because a frequent finding in other studies is that lower socioeconomic status is associated with higher blood pressure, she said.

The results of the study suggest that effective strategies for preventing childhood obesity must be applied at very young ages to stem the tide of increasing cardiovascular risk, Dr. Rappaport said.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Acute myocarditis and dilated cardiomyopathy should be in the differential diagnosis of any child who presents with difficulty breathing or respiratory symptoms, according to a poster presentation by Dr. Yamini Durani at the annual meeting of the Pediatric Academic Societies.

In a retrospective study of 49 children eventually diagnosed with myocarditis or dilated cardiomyopathy (DCM), Dr. Durani, of Thomas Jefferson University, Philadelphia, and colleagues determined that only 20% were suspected of having one of these disorders at the first visit. The most common initial diagnoses by a physician were respiratory illness (29%) and cardiac disease (29%), followed by viral illness (8%) and other illnesses (33%). The most common primary complaints were difficulty breathing (69%), vomiting (43%), upper respiratory infection (43%), fever (37%), poor feeding (35%), and lethargy (33%).

The investigators acknowledged that respiratory symptoms are extremely common in children, and they don't recommend a cardiac work-up for every child who walks into the office with a cough. They do suggest that physicians keep myocarditis and dilated cardiomyopathy in the differential diagnosis of these children, and that certain subtleties such as hepatomegaly on physical exam or cardiomegaly on chest x-ray may help distinguish these diagnoses from more common respiratory and viral illnesses.

Tachypnea was the most common finding on physical exam, seen in 59% of the patients. Other abnormal signs included hepatomegaly (47%), respiratory distress (43%), and abnormal lung exams (29%).

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

SAN FRANCISCO — Acute myocarditis and dilated cardiomyopathy should be in the differential diagnosis of any child who presents with difficulty breathing or respiratory symptoms, according to a poster presentation by Dr. Yamini Durani at the annual meeting of the Pediatric Academic Societies.

In a retrospective study of 49 children eventually diagnosed with myocarditis or dilated cardiomyopathy (DCM), Dr. Durani, of Thomas Jefferson University, Philadelphia, and colleagues determined that only 20% were suspected of having one of these disorders at the first visit. The most common initial diagnoses by a physician were respiratory illness (29%) and cardiac disease (29%), followed by viral illness (8%) and other illnesses (33%). The most common primary complaints were difficulty breathing (69%), vomiting (43%), upper respiratory infection (43%), fever (37%), poor feeding (35%), and lethargy (33%).

The investigators acknowledged that respiratory symptoms are extremely common in children, and they don't recommend a cardiac work-up for every child who walks into the office with a cough. They do suggest that physicians keep myocarditis and dilated cardiomyopathy in the differential diagnosis of these children, and that certain subtleties such as hepatomegaly on physical exam or cardiomegaly on chest x-ray may help distinguish these diagnoses from more common respiratory and viral illnesses.

Tachypnea was the most common finding on physical exam, seen in 59% of the patients. Other abnormal signs included hepatomegaly (47%), respiratory distress (43%), and abnormal lung exams (29%).

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

SAN FRANCISCO — Acute myocarditis and dilated cardiomyopathy should be in the differential diagnosis of any child who presents with difficulty breathing or respiratory symptoms, according to a poster presentation by Dr. Yamini Durani at the annual meeting of the Pediatric Academic Societies.

In a retrospective study of 49 children eventually diagnosed with myocarditis or dilated cardiomyopathy (DCM), Dr. Durani, of Thomas Jefferson University, Philadelphia, and colleagues determined that only 20% were suspected of having one of these disorders at the first visit. The most common initial diagnoses by a physician were respiratory illness (29%) and cardiac disease (29%), followed by viral illness (8%) and other illnesses (33%). The most common primary complaints were difficulty breathing (69%), vomiting (43%), upper respiratory infection (43%), fever (37%), poor feeding (35%), and lethargy (33%).

The investigators acknowledged that respiratory symptoms are extremely common in children, and they don't recommend a cardiac work-up for every child who walks into the office with a cough. They do suggest that physicians keep myocarditis and dilated cardiomyopathy in the differential diagnosis of these children, and that certain subtleties such as hepatomegaly on physical exam or cardiomegaly on chest x-ray may help distinguish these diagnoses from more common respiratory and viral illnesses.

Tachypnea was the most common finding on physical exam, seen in 59% of the patients. Other abnormal signs included hepatomegaly (47%), respiratory distress (43%), and abnormal lung exams (29%).

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

ATLANTA — People with metabolic syndrome have blood pressures that are more sensitive to salt than do people without the syndrome, according to a poster presentation by Dr. Luigi X. Cubeddu at a meeting sponsored by the International Society on Hypertension in Blacks.

His study, in 301 subjects with and without metabolic syndrome, showed that normal dietary salt intake induces large BP increases in people with the condition, making them “exquisitely sensitive to dietary salt.

“Salt restriction, in addition to exercise and caloric restriction, must be a fundamental part of the treatment plan for patients with the metabolic syndrome,” wrote Dr. Cubeddu of Nova Southeastern University, Fort Lauderdale, Fla.

The subjects' average age was 42 years; 109 of them were diagnosed with metabolic syndrome in accordance with guidelines from the National Cholesterol Education Program. As expected, subjects with metabolic syndrome had significantly higher baseline BP than those without: 127/83 mm Hg, compared with 114/75 mm Hg.

The investigators measured blood pressure and several other physiologic signs during a week-long baseline period in which salt intake was normal (8 g/day), and also during a week of high salt intake (about 18 g/day) and a week of low salt intake (2.3 g/day).

The high-salt condition resulted in increases in BP in both groups of subjects, but those with metabolic syndrome had significantly larger increases in both systolic and diastolic pressures. While the patients without metabolic syndrome increased their systolic BP an average of 5.0 mm Hg and their diastolic pressure an average of 3.0 mm Hg, those with metabolic syndrome experienced systolic and diastolic increases of 9.6 and 4.5 mm Hg, respectively.

The degree of salt sensitivity was also associated with the severity of metabolic syndrome. The more components of metabolic syndrome a subject had, the larger was his or her decrease in blood pressure associated with salt restriction.

Subjects with four or five components of metabolic syndrome saw decreases of 8.7 mm Hg systolic and 5.0 mm Hg diastolic in response to salt restriction, while those with just two of the traits saw decreases of 3.4 and 2.1.

The investigators noted that salt sensitivity is a gradual condition that worsens in parallel with metabolic syndrome, and that dietary salt is a major determinant of the increased prevalence of prehypertension and hypertension in such patients.

The meeting was cosponsored by the American Society of Hypertension.

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA — People with metabolic syndrome have blood pressures that are more sensitive to salt than do people without the syndrome, according to a poster presentation by Dr. Luigi X. Cubeddu at a meeting sponsored by the International Society on Hypertension in Blacks.

His study, in 301 subjects with and without metabolic syndrome, showed that normal dietary salt intake induces large BP increases in people with the condition, making them “exquisitely sensitive to dietary salt.

“Salt restriction, in addition to exercise and caloric restriction, must be a fundamental part of the treatment plan for patients with the metabolic syndrome,” wrote Dr. Cubeddu of Nova Southeastern University, Fort Lauderdale, Fla.

The subjects' average age was 42 years; 109 of them were diagnosed with metabolic syndrome in accordance with guidelines from the National Cholesterol Education Program. As expected, subjects with metabolic syndrome had significantly higher baseline BP than those without: 127/83 mm Hg, compared with 114/75 mm Hg.

The investigators measured blood pressure and several other physiologic signs during a week-long baseline period in which salt intake was normal (8 g/day), and also during a week of high salt intake (about 18 g/day) and a week of low salt intake (2.3 g/day).

The high-salt condition resulted in increases in BP in both groups of subjects, but those with metabolic syndrome had significantly larger increases in both systolic and diastolic pressures. While the patients without metabolic syndrome increased their systolic BP an average of 5.0 mm Hg and their diastolic pressure an average of 3.0 mm Hg, those with metabolic syndrome experienced systolic and diastolic increases of 9.6 and 4.5 mm Hg, respectively.

The degree of salt sensitivity was also associated with the severity of metabolic syndrome. The more components of metabolic syndrome a subject had, the larger was his or her decrease in blood pressure associated with salt restriction.

Subjects with four or five components of metabolic syndrome saw decreases of 8.7 mm Hg systolic and 5.0 mm Hg diastolic in response to salt restriction, while those with just two of the traits saw decreases of 3.4 and 2.1.

The investigators noted that salt sensitivity is a gradual condition that worsens in parallel with metabolic syndrome, and that dietary salt is a major determinant of the increased prevalence of prehypertension and hypertension in such patients.

The meeting was cosponsored by the American Society of Hypertension.

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA — People with metabolic syndrome have blood pressures that are more sensitive to salt than do people without the syndrome, according to a poster presentation by Dr. Luigi X. Cubeddu at a meeting sponsored by the International Society on Hypertension in Blacks.

His study, in 301 subjects with and without metabolic syndrome, showed that normal dietary salt intake induces large BP increases in people with the condition, making them “exquisitely sensitive to dietary salt.

“Salt restriction, in addition to exercise and caloric restriction, must be a fundamental part of the treatment plan for patients with the metabolic syndrome,” wrote Dr. Cubeddu of Nova Southeastern University, Fort Lauderdale, Fla.

The subjects' average age was 42 years; 109 of them were diagnosed with metabolic syndrome in accordance with guidelines from the National Cholesterol Education Program. As expected, subjects with metabolic syndrome had significantly higher baseline BP than those without: 127/83 mm Hg, compared with 114/75 mm Hg.

The investigators measured blood pressure and several other physiologic signs during a week-long baseline period in which salt intake was normal (8 g/day), and also during a week of high salt intake (about 18 g/day) and a week of low salt intake (2.3 g/day).

The high-salt condition resulted in increases in BP in both groups of subjects, but those with metabolic syndrome had significantly larger increases in both systolic and diastolic pressures. While the patients without metabolic syndrome increased their systolic BP an average of 5.0 mm Hg and their diastolic pressure an average of 3.0 mm Hg, those with metabolic syndrome experienced systolic and diastolic increases of 9.6 and 4.5 mm Hg, respectively.

The degree of salt sensitivity was also associated with the severity of metabolic syndrome. The more components of metabolic syndrome a subject had, the larger was his or her decrease in blood pressure associated with salt restriction.

Subjects with four or five components of metabolic syndrome saw decreases of 8.7 mm Hg systolic and 5.0 mm Hg diastolic in response to salt restriction, while those with just two of the traits saw decreases of 3.4 and 2.1.

The investigators noted that salt sensitivity is a gradual condition that worsens in parallel with metabolic syndrome, and that dietary salt is a major determinant of the increased prevalence of prehypertension and hypertension in such patients.

The meeting was cosponsored by the American Society of Hypertension.

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