Robert Finn

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.

Furthermore, RAAS inhibitors counteract the relative increase in blood pressure resulting from diuretic-induced renin secretion. The combination is well tolerated, and it's effective in low-renin populations and African Americans.

Another popular combination is an ACE inhibitor along 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.

Theoretically, an ACE inhibitor along with an angiotensin II receptor blocker (ARB) should also work, since they would provide intervention at two points in the RAAS cascade, and the use of an ARB may block angiotensin II formed through the non-ACE-dependent pathway. But in reality, studies have not shown enhanced blood pressure reduction, although the combination does significantly reduce proteinuria levels.

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

Two other novel treatments for refractory hypertension—insulin sensitizers or statins—take common comorbidities into account. “Most of the patients I see don't just come in with hypertension,” Dr. Brown said. “Maybe it's the blood pressure that gets them in the door, but when you get there and inspect them, they have dyslipidemia, they're obese, they have insulin resistance, [or] they have other cardiovascular risk factors that we have to treat.”

Thiazolidinedione insulin sensitizers bind to peroxisome proliferator-activated receptor gamma (PPARγ) in muscle and fat to decrease insulin resistance. Studies have shown that such receptors are also plentiful in the kidney and that two mutations in the PPARγ gene are associated with severe hypertension in humans. Pioglitazone appears 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 known to be effective for the acute treatment of severe hypertension and aortic dissection, but long-term use is hampered by tachyphylaxis and tolerance. Some studies have suggested, however, that intermittent dosing of long-acting nitrates resulted in a decrease in the augmentation index of the reflected pulse wave, thereby decreasing systolic blood pressure.

In addition to pharmacotherapy, there's at least one medical device that shows promise in treating refractory hypertension. The CVRx Rheos Baroreflex Hypertension Therapy System is an investigational implantable device that stimulates baroreceptors in the arterial walls of the carotid sinus. This simulates a rise in blood pressure that the brain works to counteract.

Studies have shown that the device causes a decrease in heart rate, a relaxation of blood vessels, and fluid release from the kidneys. Blood pressure in one patient was reduced from 186/98 mm Hg to 153/80 mm Hg in seconds by the use of the device. Dr. Brown, who disclosed that she has no ties to the manufacturer, said the device is well tolerated and causes no discomfort in patients.

She did disclose that she has received research support from GlaxoSmithKline and Novartis, is a consultant for Pfizer, and serves 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.

Furthermore, RAAS inhibitors counteract the relative increase in blood pressure resulting from diuretic-induced renin secretion. The combination is well tolerated, and it's effective in low-renin populations and African Americans.

Another popular combination is an ACE inhibitor along 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.

Theoretically, an ACE inhibitor along with an angiotensin II receptor blocker (ARB) should also work, since they would provide intervention at two points in the RAAS cascade, and the use of an ARB may block angiotensin II formed through the non-ACE-dependent pathway. But in reality, studies have not shown enhanced blood pressure reduction, although the combination does significantly reduce proteinuria levels.

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

Two other novel treatments for refractory hypertension—insulin sensitizers or statins—take common comorbidities into account. “Most of the patients I see don't just come in with hypertension,” Dr. Brown said. “Maybe it's the blood pressure that gets them in the door, but when you get there and inspect them, they have dyslipidemia, they're obese, they have insulin resistance, [or] they have other cardiovascular risk factors that we have to treat.”

Thiazolidinedione insulin sensitizers bind to peroxisome proliferator-activated receptor gamma (PPARγ) in muscle and fat to decrease insulin resistance. Studies have shown that such receptors are also plentiful in the kidney and that two mutations in the PPARγ gene are associated with severe hypertension in humans. Pioglitazone appears 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 known to be effective for the acute treatment of severe hypertension and aortic dissection, but long-term use is hampered by tachyphylaxis and tolerance. Some studies have suggested, however, that intermittent dosing of long-acting nitrates resulted in a decrease in the augmentation index of the reflected pulse wave, thereby decreasing systolic blood pressure.

In addition to pharmacotherapy, there's at least one medical device that shows promise in treating refractory hypertension. The CVRx Rheos Baroreflex Hypertension Therapy System is an investigational implantable device that stimulates baroreceptors in the arterial walls of the carotid sinus. This simulates a rise in blood pressure that the brain works to counteract.

Studies have shown that the device causes a decrease in heart rate, a relaxation of blood vessels, and fluid release from the kidneys. Blood pressure in one patient was reduced from 186/98 mm Hg to 153/80 mm Hg in seconds by the use of the device. Dr. Brown, who disclosed that she has no ties to the manufacturer, said the device is well tolerated and causes no discomfort in patients.

She did disclose that she has received research support from GlaxoSmithKline and Novartis, is a consultant for Pfizer, and serves 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.

Furthermore, RAAS inhibitors counteract the relative increase in blood pressure resulting from diuretic-induced renin secretion. The combination is well tolerated, and it's effective in low-renin populations and African Americans.

Another popular combination is an ACE inhibitor along 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.

Theoretically, an ACE inhibitor along with an angiotensin II receptor blocker (ARB) should also work, since they would provide intervention at two points in the RAAS cascade, and the use of an ARB may block angiotensin II formed through the non-ACE-dependent pathway. But in reality, studies have not shown enhanced blood pressure reduction, although the combination does significantly reduce proteinuria levels.

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

Two other novel treatments for refractory hypertension—insulin sensitizers or statins—take common comorbidities into account. “Most of the patients I see don't just come in with hypertension,” Dr. Brown said. “Maybe it's the blood pressure that gets them in the door, but when you get there and inspect them, they have dyslipidemia, they're obese, they have insulin resistance, [or] they have other cardiovascular risk factors that we have to treat.”

Thiazolidinedione insulin sensitizers bind to peroxisome proliferator-activated receptor gamma (PPARγ) in muscle and fat to decrease insulin resistance. Studies have shown that such receptors are also plentiful in the kidney and that two mutations in the PPARγ gene are associated with severe hypertension in humans. Pioglitazone appears 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 known to be effective for the acute treatment of severe hypertension and aortic dissection, but long-term use is hampered by tachyphylaxis and tolerance. Some studies have suggested, however, that intermittent dosing of long-acting nitrates resulted in a decrease in the augmentation index of the reflected pulse wave, thereby decreasing systolic blood pressure.

In addition to pharmacotherapy, there's at least one medical device that shows promise in treating refractory hypertension. The CVRx Rheos Baroreflex Hypertension Therapy System is an investigational implantable device that stimulates baroreceptors in the arterial walls of the carotid sinus. This simulates a rise in blood pressure that the brain works to counteract.

Studies have shown that the device causes a decrease in heart rate, a relaxation of blood vessels, and fluid release from the kidneys. Blood pressure in one patient was reduced from 186/98 mm Hg to 153/80 mm Hg in seconds by the use of the device. Dr. Brown, who disclosed that she has no ties to the manufacturer, said the device is well tolerated and causes no discomfort in patients.

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

SAN FRANCISCO — Maternal smoking, maternal asthma, or both are independent risk factors for the development of bronchiolitis in infants, according to findings of a large retrospective study.

After controlling for maternal race, region of residence, infant sex, infant birth weight, and whether the child has one or more living siblings, children of women who had a history of asthma and who smoked during pregnancy were 47% more likely to develop bronchiolitis during their first year of life than children whose mothers had neither risk factor, Dr. Kecia Carroll reported at the annual meeting of the Pediatric Academic Societies.

Children of mothers who had asthma alone had a 39% increased risk of bronchiolitis, and children of mothers who smoked but did not have asthma had a 14% increased risk. All of these adjusted hazard ratios were statistically significant.

Dr. Carroll and her colleagues from Vanderbilt University, Nashville, Tenn., combined records from the state of Tennessee's Medicaid program with public records data from 1995 through 2003, and isolated 101,459 mother-infant dyads that met certain criteria: All mothers were enrolled in Medicaid continuously beginning at least a year before the birth through a year after the birth, and the infants were all healthy, full-term, singleton babies without chronic lung or heart disease.

Overall, about 20% of the infants developed bronchiolitis during their first year of life. Before adjustment for the potential confounders mentioned above, about one-third of infants with both maternal asthma and maternal smoking had at least one clinic, emergency department, or hospital visit for bronchiolitis, compared with 24% of infants with maternal asthma, 24% of infants with maternal smoking, and 18% of infants with neither risk factor.

Maternal smoking, asthma, or both also increased the risk for severe bronchiolitis, defined as disease requiring 3 or more days of hospitalization. The risk increased a statistically significant 19% for maternal smoking, 52% for maternal asthma, and 39% for both smoking and asthma. The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — Maternal smoking, maternal asthma, or both are independent risk factors for the development of bronchiolitis in infants, according to findings of a large retrospective study.

After controlling for maternal race, region of residence, infant sex, infant birth weight, and whether the child has one or more living siblings, children of women who had a history of asthma and who smoked during pregnancy were 47% more likely to develop bronchiolitis during their first year of life than children whose mothers had neither risk factor, Dr. Kecia Carroll reported at the annual meeting of the Pediatric Academic Societies.

Children of mothers who had asthma alone had a 39% increased risk of bronchiolitis, and children of mothers who smoked but did not have asthma had a 14% increased risk. All of these adjusted hazard ratios were statistically significant.

Dr. Carroll and her colleagues from Vanderbilt University, Nashville, Tenn., combined records from the state of Tennessee's Medicaid program with public records data from 1995 through 2003, and isolated 101,459 mother-infant dyads that met certain criteria: All mothers were enrolled in Medicaid continuously beginning at least a year before the birth through a year after the birth, and the infants were all healthy, full-term, singleton babies without chronic lung or heart disease.

Overall, about 20% of the infants developed bronchiolitis during their first year of life. Before adjustment for the potential confounders mentioned above, about one-third of infants with both maternal asthma and maternal smoking had at least one clinic, emergency department, or hospital visit for bronchiolitis, compared with 24% of infants with maternal asthma, 24% of infants with maternal smoking, and 18% of infants with neither risk factor.

Maternal smoking, asthma, or both also increased the risk for severe bronchiolitis, defined as disease requiring 3 or more days of hospitalization. The risk increased a statistically significant 19% for maternal smoking, 52% for maternal asthma, and 39% for both smoking and asthma. The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — Maternal smoking, maternal asthma, or both are independent risk factors for the development of bronchiolitis in infants, according to findings of a large retrospective study.

After controlling for maternal race, region of residence, infant sex, infant birth weight, and whether the child has one or more living siblings, children of women who had a history of asthma and who smoked during pregnancy were 47% more likely to develop bronchiolitis during their first year of life than children whose mothers had neither risk factor, Dr. Kecia Carroll reported at the annual meeting of the Pediatric Academic Societies.

Children of mothers who had asthma alone had a 39% increased risk of bronchiolitis, and children of mothers who smoked but did not have asthma had a 14% increased risk. All of these adjusted hazard ratios were statistically significant.

Dr. Carroll and her colleagues from Vanderbilt University, Nashville, Tenn., combined records from the state of Tennessee's Medicaid program with public records data from 1995 through 2003, and isolated 101,459 mother-infant dyads that met certain criteria: All mothers were enrolled in Medicaid continuously beginning at least a year before the birth through a year after the birth, and the infants were all healthy, full-term, singleton babies without chronic lung or heart disease.

Overall, about 20% of the infants developed bronchiolitis during their first year of life. Before adjustment for the potential confounders mentioned above, about one-third of infants with both maternal asthma and maternal smoking had at least one clinic, emergency department, or hospital visit for bronchiolitis, compared with 24% of infants with maternal asthma, 24% of infants with maternal smoking, and 18% of infants with neither risk factor.

Maternal smoking, asthma, or both also increased the risk for severe bronchiolitis, defined as disease requiring 3 or more days of hospitalization. The risk increased a statistically significant 19% for maternal smoking, 52% for maternal asthma, and 39% for both smoking and asthma. The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — The diagnosis of appendicitis is notoriously difficult in children, with estimates of misdiagnosis rates ranging from 28% to 57% for children over the age of 12 and up to 100% for children under 2 years of age.

But the diagnosis may be made with high specificity using a combination of C-reactive protein and white blood cell levels, suggest the findings of a poster presented by Dr. Karen Y. Kwan and Dr. Alan L. Nager at the annual meeting of the Pediatric Academic Societies.

In particular, a C-reactive protein (CRP) level of 1.0 mg/dL or greater combined with a WBC count of 15,000 cells/mm

The study, conducted at the University of Southern California, Los Angeles, involved 209 patients aged 1–18 years presenting at a tertiary urban children's hospital with abdominal pain suspicious for acute appendicitis. In addition to history, physical exam, x-ray studies, and histopathology, the investigators conducted blood tests for CRP, WBC, D-lactate, and procalcitonin. Two to 6 weeks following discharge from the emergency department, investigators followed up with the patients to determine the ultimate diagnosis.

Of the 209 patients, 115 (55%) had confirmed appendicitis and 94 (45%) were negative. Among the diagnoses for children negative for appendicitis were constipation, gastroenteritis, pyelonephritis, ovarian torsion, and neoplasm.

The mean D-lactate values did not differ between patients who were positive and negative for appendicitis. The values of the other three lab markers did differ significantly; in each case patients with appendicitis had a significantly higher level than patients without.

Using a cutoff value of 1.0 mg/dL of CRP alone would yield a sensitivity of 84% and a specificity of 70%. A combination of that CRP cutoff with a WBC cutoff greater than 15,000 cells/mm

The investigators advised interpreting their findings with caution as 85% of the patients were Hispanic and largely indigent, and acute or chronic diseases may skew the laboratory values.

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

SAN FRANCISCO — The diagnosis of appendicitis is notoriously difficult in children, with estimates of misdiagnosis rates ranging from 28% to 57% for children over the age of 12 and up to 100% for children under 2 years of age.

But the diagnosis may be made with high specificity using a combination of C-reactive protein and white blood cell levels, suggest the findings of a poster presented by Dr. Karen Y. Kwan and Dr. Alan L. Nager at the annual meeting of the Pediatric Academic Societies.

In particular, a C-reactive protein (CRP) level of 1.0 mg/dL or greater combined with a WBC count of 15,000 cells/mm

The study, conducted at the University of Southern California, Los Angeles, involved 209 patients aged 1–18 years presenting at a tertiary urban children's hospital with abdominal pain suspicious for acute appendicitis. In addition to history, physical exam, x-ray studies, and histopathology, the investigators conducted blood tests for CRP, WBC, D-lactate, and procalcitonin. Two to 6 weeks following discharge from the emergency department, investigators followed up with the patients to determine the ultimate diagnosis.

Of the 209 patients, 115 (55%) had confirmed appendicitis and 94 (45%) were negative. Among the diagnoses for children negative for appendicitis were constipation, gastroenteritis, pyelonephritis, ovarian torsion, and neoplasm.

The mean D-lactate values did not differ between patients who were positive and negative for appendicitis. The values of the other three lab markers did differ significantly; in each case patients with appendicitis had a significantly higher level than patients without.

Using a cutoff value of 1.0 mg/dL of CRP alone would yield a sensitivity of 84% and a specificity of 70%. A combination of that CRP cutoff with a WBC cutoff greater than 15,000 cells/mm

The investigators advised interpreting their findings with caution as 85% of the patients were Hispanic and largely indigent, and acute or chronic diseases may skew the laboratory values.

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

SAN FRANCISCO — The diagnosis of appendicitis is notoriously difficult in children, with estimates of misdiagnosis rates ranging from 28% to 57% for children over the age of 12 and up to 100% for children under 2 years of age.

But the diagnosis may be made with high specificity using a combination of C-reactive protein and white blood cell levels, suggest the findings of a poster presented by Dr. Karen Y. Kwan and Dr. Alan L. Nager at the annual meeting of the Pediatric Academic Societies.

In particular, a C-reactive protein (CRP) level of 1.0 mg/dL or greater combined with a WBC count of 15,000 cells/mm

The study, conducted at the University of Southern California, Los Angeles, involved 209 patients aged 1–18 years presenting at a tertiary urban children's hospital with abdominal pain suspicious for acute appendicitis. In addition to history, physical exam, x-ray studies, and histopathology, the investigators conducted blood tests for CRP, WBC, D-lactate, and procalcitonin. Two to 6 weeks following discharge from the emergency department, investigators followed up with the patients to determine the ultimate diagnosis.

Of the 209 patients, 115 (55%) had confirmed appendicitis and 94 (45%) were negative. Among the diagnoses for children negative for appendicitis were constipation, gastroenteritis, pyelonephritis, ovarian torsion, and neoplasm.

The mean D-lactate values did not differ between patients who were positive and negative for appendicitis. The values of the other three lab markers did differ significantly; in each case patients with appendicitis had a significantly higher level than patients without.

Using a cutoff value of 1.0 mg/dL of CRP alone would yield a sensitivity of 84% and a specificity of 70%. A combination of that CRP cutoff with a WBC cutoff greater than 15,000 cells/mm

The investigators advised interpreting their findings with caution as 85% of the patients were Hispanic and largely indigent, and acute or chronic diseases may skew the laboratory values.

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

DENVER — A simple device seems to ease nighttime shoulder pain, according to study findings presented at the annual meeting of the American College of Sports Medicine.

Dr. Michael Carroll, a Traverse City, Mich.-based family physician in private practice, presented independent research on the device, called the NyteTyme Shoulder Immobilizer. The data showed improvement in all of the patients who used the device for 28 days, whereas more than half of the patients who did not use it reported worsening or no improvement in their shoulder pain.

The device consists of a thigh sleeve and a wrist sleeve connected by an elastic strap. Its design is aimed at keeping the arm adducted, limiting abduction to 5 degrees and providing a variable amount of traction.

The controlled study involved 24 patients diagnosed by their primary care physicians with rotator cuff tendinopathy. A randomly selected group of 11 patients wore the device nightly for 28 days, and the remaining 13 patients did not. All patients continued their regular treatments during the study. Most were taking nonsteroidal anti-inflammatories, and several were also doing physical therapy.

Patients were excluded from the study if they had a recent history of shoulder or neck trauma, a history of deep vein thrombosis, or a history of cancer except for nonmelanoma skin cancer. None of the patients received steroid injections during the course of the study.

Investigators administered the standardized Simple Shoulder Test (SST), a 12-item test that assesses shoulder symptoms, at day 0, day 7, and day 28.

Of the patients using the device, 100% reported improvements on the SST, compared with only 47% of the patients in the control group, a statistically significant difference.

Dr. Carroll owns a patent on the device, as well as the company that manufactures it, but the study was conducted by an independent clinical research organization after approval by an institutional review board based at Munson Medical Center, Traverse City, and the patients were referred by primary care physicians with no financial interest in the device.

Shoulder pain is extremely common, ranking third behind back and neck pain as a cause of dysfunction in the working population, Dr. Carroll noted. One study showed that 30% of the population experiences shoulder pain during any given 12-month period. Another study showed that partial rotator-cuff tears can be found in autopsy in 32%–37% of individuals above the age of 40.

Rotator cuff tendinopathy is typically treated with nonsteroidal anti-inflammatory drugs and physical therapy, but even compliant patients can experience a worsening of their pain and eventually require surgery.

Two nighttime factors contribute to supraspinatus tendon impingement and can therefore lead to further injury of the rotator cuff.

The first factor is that when patients lie down, they lose the traction of the weight of the arm that gravity normally provides when upright. The second factor is that abduction of the arms away from the body can cause the humeral head to move closer to the coracoacromial ligament, further impinging the supraspinatus tendon. Keeping the arm adducted, prevents additional injury and promotes healing.

Dr. Carroll said the device is available through a single supplier, Teter Orthotics and Prosthetics Inc. (www.teterop.com

DENVER — A simple device seems to ease nighttime shoulder pain, according to study findings presented at the annual meeting of the American College of Sports Medicine.

Dr. Michael Carroll, a Traverse City, Mich.-based family physician in private practice, presented independent research on the device, called the NyteTyme Shoulder Immobilizer. The data showed improvement in all of the patients who used the device for 28 days, whereas more than half of the patients who did not use it reported worsening or no improvement in their shoulder pain.

The device consists of a thigh sleeve and a wrist sleeve connected by an elastic strap. Its design is aimed at keeping the arm adducted, limiting abduction to 5 degrees and providing a variable amount of traction.

The controlled study involved 24 patients diagnosed by their primary care physicians with rotator cuff tendinopathy. A randomly selected group of 11 patients wore the device nightly for 28 days, and the remaining 13 patients did not. All patients continued their regular treatments during the study. Most were taking nonsteroidal anti-inflammatories, and several were also doing physical therapy.

Patients were excluded from the study if they had a recent history of shoulder or neck trauma, a history of deep vein thrombosis, or a history of cancer except for nonmelanoma skin cancer. None of the patients received steroid injections during the course of the study.

Investigators administered the standardized Simple Shoulder Test (SST), a 12-item test that assesses shoulder symptoms, at day 0, day 7, and day 28.

Of the patients using the device, 100% reported improvements on the SST, compared with only 47% of the patients in the control group, a statistically significant difference.

Dr. Carroll owns a patent on the device, as well as the company that manufactures it, but the study was conducted by an independent clinical research organization after approval by an institutional review board based at Munson Medical Center, Traverse City, and the patients were referred by primary care physicians with no financial interest in the device.

Shoulder pain is extremely common, ranking third behind back and neck pain as a cause of dysfunction in the working population, Dr. Carroll noted. One study showed that 30% of the population experiences shoulder pain during any given 12-month period. Another study showed that partial rotator-cuff tears can be found in autopsy in 32%–37% of individuals above the age of 40.

Rotator cuff tendinopathy is typically treated with nonsteroidal anti-inflammatory drugs and physical therapy, but even compliant patients can experience a worsening of their pain and eventually require surgery.

Two nighttime factors contribute to supraspinatus tendon impingement and can therefore lead to further injury of the rotator cuff.

The first factor is that when patients lie down, they lose the traction of the weight of the arm that gravity normally provides when upright. The second factor is that abduction of the arms away from the body can cause the humeral head to move closer to the coracoacromial ligament, further impinging the supraspinatus tendon. Keeping the arm adducted, prevents additional injury and promotes healing.

Dr. Carroll said the device is available through a single supplier, Teter Orthotics and Prosthetics Inc. (www.teterop.com

DENVER — A simple device seems to ease nighttime shoulder pain, according to study findings presented at the annual meeting of the American College of Sports Medicine.

Dr. Michael Carroll, a Traverse City, Mich.-based family physician in private practice, presented independent research on the device, called the NyteTyme Shoulder Immobilizer. The data showed improvement in all of the patients who used the device for 28 days, whereas more than half of the patients who did not use it reported worsening or no improvement in their shoulder pain.

The device consists of a thigh sleeve and a wrist sleeve connected by an elastic strap. Its design is aimed at keeping the arm adducted, limiting abduction to 5 degrees and providing a variable amount of traction.

The controlled study involved 24 patients diagnosed by their primary care physicians with rotator cuff tendinopathy. A randomly selected group of 11 patients wore the device nightly for 28 days, and the remaining 13 patients did not. All patients continued their regular treatments during the study. Most were taking nonsteroidal anti-inflammatories, and several were also doing physical therapy.

Patients were excluded from the study if they had a recent history of shoulder or neck trauma, a history of deep vein thrombosis, or a history of cancer except for nonmelanoma skin cancer. None of the patients received steroid injections during the course of the study.

Investigators administered the standardized Simple Shoulder Test (SST), a 12-item test that assesses shoulder symptoms, at day 0, day 7, and day 28.

Of the patients using the device, 100% reported improvements on the SST, compared with only 47% of the patients in the control group, a statistically significant difference.

Dr. Carroll owns a patent on the device, as well as the company that manufactures it, but the study was conducted by an independent clinical research organization after approval by an institutional review board based at Munson Medical Center, Traverse City, and the patients were referred by primary care physicians with no financial interest in the device.

Shoulder pain is extremely common, ranking third behind back and neck pain as a cause of dysfunction in the working population, Dr. Carroll noted. One study showed that 30% of the population experiences shoulder pain during any given 12-month period. Another study showed that partial rotator-cuff tears can be found in autopsy in 32%–37% of individuals above the age of 40.

Rotator cuff tendinopathy is typically treated with nonsteroidal anti-inflammatory drugs and physical therapy, but even compliant patients can experience a worsening of their pain and eventually require surgery.

Two nighttime factors contribute to supraspinatus tendon impingement and can therefore lead to further injury of the rotator cuff.

The first factor is that when patients lie down, they lose the traction of the weight of the arm that gravity normally provides when upright. The second factor is that abduction of the arms away from the body can cause the humeral head to move closer to the coracoacromial ligament, further impinging the supraspinatus tendon. Keeping the arm adducted, prevents additional injury and promotes healing.

Dr. Carroll said the device is available through a single supplier, Teter Orthotics and Prosthetics Inc. (www.teterop.com

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 women at high risk for sleep apnea, compared with those 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, as its treatment 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 sleep apnea risk, average fasting insulin levels were significantly higher (168 pmol/L) than they were in the 10 women at low apnea risk (97 pmol/L). Among the 13 women with impaired glucose tolerance, glucose and insulin levels did not differ depending on the level of apnea risk.

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 vs. 10 minutes), and significantly shorter total sleep time (323 minutes vs. 442 minutes, a difference of almost 2 hours).

“Sleep apnea might be an intrinsic component of the metabolic disturbances that appear with” PCOS, 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.

Dr. Tasali had no conflict of interest to report regarding her presentation.

Women withPCOS should be evaluated for sleep apnea, as its treatment might improve glucose metabolism. DR. TASALI

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 women at high risk for sleep apnea, compared with those 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, as its treatment 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 sleep apnea risk, average fasting insulin levels were significantly higher (168 pmol/L) than they were in the 10 women at low apnea risk (97 pmol/L). Among the 13 women with impaired glucose tolerance, glucose and insulin levels did not differ depending on the level of apnea risk.

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 vs. 10 minutes), and significantly shorter total sleep time (323 minutes vs. 442 minutes, a difference of almost 2 hours).

“Sleep apnea might be an intrinsic component of the metabolic disturbances that appear with” PCOS, 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.

Dr. Tasali had no conflict of interest to report regarding her presentation.

Women withPCOS should be evaluated for sleep apnea, as its treatment might improve glucose metabolism. DR. TASALI

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 women at high risk for sleep apnea, compared with those 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, as its treatment 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 sleep apnea risk, average fasting insulin levels were significantly higher (168 pmol/L) than they were in the 10 women at low apnea risk (97 pmol/L). Among the 13 women with impaired glucose tolerance, glucose and insulin levels did not differ depending on the level of apnea risk.

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 vs. 10 minutes), and significantly shorter total sleep time (323 minutes vs. 442 minutes, a difference of almost 2 hours).

“Sleep apnea might be an intrinsic component of the metabolic disturbances that appear with” PCOS, 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.

Dr. Tasali had no conflict of interest to report regarding her presentation.

Women withPCOS should be evaluated for sleep apnea, as its treatment might improve glucose metabolism. DR. TASALI

SAN FRANCISCO – The question of whether stimulant therapy for attention-deficit hyperactivity disorder inhibits a child's growth has long been controversial, with well-designed studies providing conflicting results.

Now, a metaanalysis has indicated that stimulant therapy inhibits both weight gain and expected height gain. Dr. Omar Khwaja reported the results of this metaanalysis in a poster presentation at the annual meeting of the Pediatric Academic Societies.

Twenty-two studies including 2,383 patients were selected for the metaanalysis. The children, aged 0–18 years, were treated with either dextroamphetamine or methylphenidate for a mean duration of 1.5 years.

The metaanalysis included clinical trials, observational cohort studies, and case-control studies.

The effect sizes, as measured by a statistic called Cohen's d, were statistically significant for both weight and height, but greater for weight. However, the metaanalysis found that the effect size favoring weight gain restriction was −0.63, and the effect size favoring restriction in expected height gain was −0.41.

Standard interpretations of the Cohen's d statistic describe an effect size of −0.41 as small to medium, and an effect size of −0.63 as medium to large.

The effect was more pronounced for dextroamphetamine than for methylphenidate, wrote Dr. Khwaja, of Children's Hospital, Boston, and his colleagues.

Their meta-regression analysis evaluated the relative effects of the study's duration, medication type, the study's outcome metric, and the child's age at treatment.

The authors found that medication type proved to be the only statistically significant variable.

“Physicians should continue to be vigilant in monitoring growth parameters in stimulant-treated children,” the authors wrote.

SAN FRANCISCO – The question of whether stimulant therapy for attention-deficit hyperactivity disorder inhibits a child's growth has long been controversial, with well-designed studies providing conflicting results.

Now, a metaanalysis has indicated that stimulant therapy inhibits both weight gain and expected height gain. Dr. Omar Khwaja reported the results of this metaanalysis in a poster presentation at the annual meeting of the Pediatric Academic Societies.

Twenty-two studies including 2,383 patients were selected for the metaanalysis. The children, aged 0–18 years, were treated with either dextroamphetamine or methylphenidate for a mean duration of 1.5 years.

The metaanalysis included clinical trials, observational cohort studies, and case-control studies.

The effect sizes, as measured by a statistic called Cohen's d, were statistically significant for both weight and height, but greater for weight. However, the metaanalysis found that the effect size favoring weight gain restriction was −0.63, and the effect size favoring restriction in expected height gain was −0.41.

Standard interpretations of the Cohen's d statistic describe an effect size of −0.41 as small to medium, and an effect size of −0.63 as medium to large.

The effect was more pronounced for dextroamphetamine than for methylphenidate, wrote Dr. Khwaja, of Children's Hospital, Boston, and his colleagues.

Their meta-regression analysis evaluated the relative effects of the study's duration, medication type, the study's outcome metric, and the child's age at treatment.

The authors found that medication type proved to be the only statistically significant variable.

“Physicians should continue to be vigilant in monitoring growth parameters in stimulant-treated children,” the authors wrote.

SAN FRANCISCO – The question of whether stimulant therapy for attention-deficit hyperactivity disorder inhibits a child's growth has long been controversial, with well-designed studies providing conflicting results.

Now, a metaanalysis has indicated that stimulant therapy inhibits both weight gain and expected height gain. Dr. Omar Khwaja reported the results of this metaanalysis in a poster presentation at the annual meeting of the Pediatric Academic Societies.

Twenty-two studies including 2,383 patients were selected for the metaanalysis. The children, aged 0–18 years, were treated with either dextroamphetamine or methylphenidate for a mean duration of 1.5 years.

The metaanalysis included clinical trials, observational cohort studies, and case-control studies.

The effect sizes, as measured by a statistic called Cohen's d, were statistically significant for both weight and height, but greater for weight. However, the metaanalysis found that the effect size favoring weight gain restriction was −0.63, and the effect size favoring restriction in expected height gain was −0.41.

Standard interpretations of the Cohen's d statistic describe an effect size of −0.41 as small to medium, and an effect size of −0.63 as medium to large.

The effect was more pronounced for dextroamphetamine than for methylphenidate, wrote Dr. Khwaja, of Children's Hospital, Boston, and his colleagues.

Their meta-regression analysis evaluated the relative effects of the study's duration, medication type, the study's outcome metric, and the child's age at treatment.

The authors found that medication type proved to be the only statistically significant variable.

“Physicians should continue to be vigilant in monitoring growth parameters in stimulant-treated children,” the authors wrote.

SAN FRANCISCO — A diagnosis of bipolar disorder can be missed in any patient, but this appears to be a particular problem in the elderly population, Dr. Josepha A. Cheong said at the annual meeting of the American Academy of Clinical Psychiatrists.

According to clinical lore passed down through generations of psychiatrists, bipolar disorder is rare in the geriatric population, because these patients all burn out while they're still young. Dr. Cheong, of the University of Florida, Gainesville, recalled being taught that during her training. But studies show that bipolar disorder accounts for 5%–19% of mood disorder presentations in the elderly. In one study, about 10% of chronically institutionalized elderly patients were diagnosed with bipolar disorder, and in another study, 17% of people over the age of 60 presenting to a psychiatric emergency room were diagnosed with bipolar disorder.

The diagnosis can be difficult, because bipolar disorder shares features of both unipolar depression and Alzheimer's disease or other types of dementia (see box).

But it's critical to make the right diagnosis. If bipolar disorder is misdiagnosed as dementia, the misdiagnosis can lead to ineffective treatment, early nursing home placement, continued disability, and an increased risk of suicide. If bipolar disorder is misdiagnosed as agitated depression, the symptoms might worsen and antidepressant use could precipitate rapid cycling or a switch to mania. Some of the DSM-IV criteria for mania might present differently in the elderly. For example, “impaired function” can be hard to demonstrate, because many elderly patients don't have a regular occupational environment or routine.

Mania might present with less of the grandiosity often seen in younger patients and more irritability. “There's more of a dysphoric quality to geriatric mania,” Dr. Cheong said. Additionally, disorientation and distractibility might be mistaken for symptoms of dementia instead of mania.

Elderly patients with bipolar disorder also have some special issues with common drug treatments. Lithium in particular has a very narrow therapeutic index in all patients, but this problem is exacerbated in the elderly, who might be taking other medications that can increase or decrease serum lithium levels.

Although therapeutic plasma concentrations of lithium are generally quoted as 0.8–1.2 mEq/L for acute mania and 0.6–1.0 mEq/L for maintenance, these ranges are much too high for most geriatric patients. “With geriatrics, I would definitely recommend keeping the range somewhere between 0.3 and 0.6 [mEq/L],” Dr. Cheong said. “Higher than that in the geriatric patient [and you can run into] a lot of trouble with things like tremor, metallic taste, gait ataxia, blurred vision…You really need to titrate according to the symptoms as well as the side effects.”

SAN FRANCISCO — A diagnosis of bipolar disorder can be missed in any patient, but this appears to be a particular problem in the elderly population, Dr. Josepha A. Cheong said at the annual meeting of the American Academy of Clinical Psychiatrists.

According to clinical lore passed down through generations of psychiatrists, bipolar disorder is rare in the geriatric population, because these patients all burn out while they're still young. Dr. Cheong, of the University of Florida, Gainesville, recalled being taught that during her training. But studies show that bipolar disorder accounts for 5%–19% of mood disorder presentations in the elderly. In one study, about 10% of chronically institutionalized elderly patients were diagnosed with bipolar disorder, and in another study, 17% of people over the age of 60 presenting to a psychiatric emergency room were diagnosed with bipolar disorder.

The diagnosis can be difficult, because bipolar disorder shares features of both unipolar depression and Alzheimer's disease or other types of dementia (see box).

But it's critical to make the right diagnosis. If bipolar disorder is misdiagnosed as dementia, the misdiagnosis can lead to ineffective treatment, early nursing home placement, continued disability, and an increased risk of suicide. If bipolar disorder is misdiagnosed as agitated depression, the symptoms might worsen and antidepressant use could precipitate rapid cycling or a switch to mania. Some of the DSM-IV criteria for mania might present differently in the elderly. For example, “impaired function” can be hard to demonstrate, because many elderly patients don't have a regular occupational environment or routine.

Mania might present with less of the grandiosity often seen in younger patients and more irritability. “There's more of a dysphoric quality to geriatric mania,” Dr. Cheong said. Additionally, disorientation and distractibility might be mistaken for symptoms of dementia instead of mania.

Elderly patients with bipolar disorder also have some special issues with common drug treatments. Lithium in particular has a very narrow therapeutic index in all patients, but this problem is exacerbated in the elderly, who might be taking other medications that can increase or decrease serum lithium levels.

Although therapeutic plasma concentrations of lithium are generally quoted as 0.8–1.2 mEq/L for acute mania and 0.6–1.0 mEq/L for maintenance, these ranges are much too high for most geriatric patients. “With geriatrics, I would definitely recommend keeping the range somewhere between 0.3 and 0.6 [mEq/L],” Dr. Cheong said. “Higher than that in the geriatric patient [and you can run into] a lot of trouble with things like tremor, metallic taste, gait ataxia, blurred vision…You really need to titrate according to the symptoms as well as the side effects.”

SAN FRANCISCO — A diagnosis of bipolar disorder can be missed in any patient, but this appears to be a particular problem in the elderly population, Dr. Josepha A. Cheong said at the annual meeting of the American Academy of Clinical Psychiatrists.

According to clinical lore passed down through generations of psychiatrists, bipolar disorder is rare in the geriatric population, because these patients all burn out while they're still young. Dr. Cheong, of the University of Florida, Gainesville, recalled being taught that during her training. But studies show that bipolar disorder accounts for 5%–19% of mood disorder presentations in the elderly. In one study, about 10% of chronically institutionalized elderly patients were diagnosed with bipolar disorder, and in another study, 17% of people over the age of 60 presenting to a psychiatric emergency room were diagnosed with bipolar disorder.

The diagnosis can be difficult, because bipolar disorder shares features of both unipolar depression and Alzheimer's disease or other types of dementia (see box).

But it's critical to make the right diagnosis. If bipolar disorder is misdiagnosed as dementia, the misdiagnosis can lead to ineffective treatment, early nursing home placement, continued disability, and an increased risk of suicide. If bipolar disorder is misdiagnosed as agitated depression, the symptoms might worsen and antidepressant use could precipitate rapid cycling or a switch to mania. Some of the DSM-IV criteria for mania might present differently in the elderly. For example, “impaired function” can be hard to demonstrate, because many elderly patients don't have a regular occupational environment or routine.

Mania might present with less of the grandiosity often seen in younger patients and more irritability. “There's more of a dysphoric quality to geriatric mania,” Dr. Cheong said. Additionally, disorientation and distractibility might be mistaken for symptoms of dementia instead of mania.

Elderly patients with bipolar disorder also have some special issues with common drug treatments. Lithium in particular has a very narrow therapeutic index in all patients, but this problem is exacerbated in the elderly, who might be taking other medications that can increase or decrease serum lithium levels.

Although therapeutic plasma concentrations of lithium are generally quoted as 0.8–1.2 mEq/L for acute mania and 0.6–1.0 mEq/L for maintenance, these ranges are much too high for most geriatric patients. “With geriatrics, I would definitely recommend keeping the range somewhere between 0.3 and 0.6 [mEq/L],” Dr. Cheong said. “Higher than that in the geriatric patient [and you can run into] a lot of trouble with things like tremor, metallic taste, gait ataxia, blurred vision…You really need to titrate according to the symptoms as well as the side effects.”

SAN FRANCISCO — Glucocorticoids and retinoids are important treatment mainstays for a variety of dermatologic conditions in children, but their adverse effects on bone health should make clinicians think twice before prescribing them, Dr. Laura K. Bachrach said at a meeting of the Society for Pediatric Dermatology.

“It's astounding how often this isn't done,” said Dr. Bachrach of Stanford (Calif.) University. “Specialists tend to have tunnel vision on their organ of interest. If you're a cystic fibrosis doctor, you watch the lungs and you don't think about vitamin D. If you're a rheumatologist, you may hone in on renal function and forget about other factors.”

The first thing to do when a child is prescribed steroids or retinoids is to optimize the child's nutrition. Make sure they're receiving adequate calories, protein, calcium, and vitamin D. In terms of vitamin D, children should have an annual measurement of their 25-hydroxyvitamin D concentration. The current consensus is that an adequate concentration is at least 20 ng/mL.

A multivitamin supplement is simply inadequate for children who have low vitamin D concentrations, Dr. Bachrach said.

Megadoses of oral ergocalciferol (10,000 U/wk for children under the age of 6 and 50,000 U/wk for older children) for 6–8 weeks are usually necessary to restore a child's vitamin D levels.

Prescribing physical activity is also important. This activity should be titrated to the patient. It's especially important to navigate between the twin hazards of immobilization and overuse.

Even children who need wheelchairs should be encouraged to at least stand. At the same time, you don't want children to exercise so much that they greatly increase their risk of fracture. Overexercise can also lead to slow weight gain.

It's also important to address any underlying endocrine disorders in these children. Deficits in sex steroids should be addressed, and in cases of delayed puberty, an endocrinology consult may be in order.

Most drugs for adult osteoporosis are contraindicated or have been inadequately tested in children, Dr. Bachrach said.

Parathyroid hormone can't be used in children because of the risk of osteosarcoma. And while bisphosphonates have been shown to be highly effective in adults, most studies in children have been observational, except in the case of osteogenesis imperfecta. There have been no studies in children with chronic disease and no consensus on duration or dose.

Furthermore, bisphosphonates have both minor and major adverse effects. They can cause fever, myalgia, bone pain, and GI pain or distension. More rarely, they can cause esophageal or oral erosion, delayed bone healing, or osteopetrosis, and there's also a risk of teratogenicity.

Bisphosphonates should be restricted to cases of osteogenesis imperfecta, children with fragility fractures, and randomized, controlled trials. They should not be used for low bone density only, and they definitely shouldn't be used as prophylaxis in children who are getting steroid therapy, she concluded.

SAN FRANCISCO — Glucocorticoids and retinoids are important treatment mainstays for a variety of dermatologic conditions in children, but their adverse effects on bone health should make clinicians think twice before prescribing them, Dr. Laura K. Bachrach said at a meeting of the Society for Pediatric Dermatology.

“It's astounding how often this isn't done,” said Dr. Bachrach of Stanford (Calif.) University. “Specialists tend to have tunnel vision on their organ of interest. If you're a cystic fibrosis doctor, you watch the lungs and you don't think about vitamin D. If you're a rheumatologist, you may hone in on renal function and forget about other factors.”

The first thing to do when a child is prescribed steroids or retinoids is to optimize the child's nutrition. Make sure they're receiving adequate calories, protein, calcium, and vitamin D. In terms of vitamin D, children should have an annual measurement of their 25-hydroxyvitamin D concentration. The current consensus is that an adequate concentration is at least 20 ng/mL.

A multivitamin supplement is simply inadequate for children who have low vitamin D concentrations, Dr. Bachrach said.

Megadoses of oral ergocalciferol (10,000 U/wk for children under the age of 6 and 50,000 U/wk for older children) for 6–8 weeks are usually necessary to restore a child's vitamin D levels.

Prescribing physical activity is also important. This activity should be titrated to the patient. It's especially important to navigate between the twin hazards of immobilization and overuse.

Even children who need wheelchairs should be encouraged to at least stand. At the same time, you don't want children to exercise so much that they greatly increase their risk of fracture. Overexercise can also lead to slow weight gain.

It's also important to address any underlying endocrine disorders in these children. Deficits in sex steroids should be addressed, and in cases of delayed puberty, an endocrinology consult may be in order.

Most drugs for adult osteoporosis are contraindicated or have been inadequately tested in children, Dr. Bachrach said.

Parathyroid hormone can't be used in children because of the risk of osteosarcoma. And while bisphosphonates have been shown to be highly effective in adults, most studies in children have been observational, except in the case of osteogenesis imperfecta. There have been no studies in children with chronic disease and no consensus on duration or dose.

Furthermore, bisphosphonates have both minor and major adverse effects. They can cause fever, myalgia, bone pain, and GI pain or distension. More rarely, they can cause esophageal or oral erosion, delayed bone healing, or osteopetrosis, and there's also a risk of teratogenicity.

Bisphosphonates should be restricted to cases of osteogenesis imperfecta, children with fragility fractures, and randomized, controlled trials. They should not be used for low bone density only, and they definitely shouldn't be used as prophylaxis in children who are getting steroid therapy, she concluded.

SAN FRANCISCO — Glucocorticoids and retinoids are important treatment mainstays for a variety of dermatologic conditions in children, but their adverse effects on bone health should make clinicians think twice before prescribing them, Dr. Laura K. Bachrach said at a meeting of the Society for Pediatric Dermatology.

“It's astounding how often this isn't done,” said Dr. Bachrach of Stanford (Calif.) University. “Specialists tend to have tunnel vision on their organ of interest. If you're a cystic fibrosis doctor, you watch the lungs and you don't think about vitamin D. If you're a rheumatologist, you may hone in on renal function and forget about other factors.”

The first thing to do when a child is prescribed steroids or retinoids is to optimize the child's nutrition. Make sure they're receiving adequate calories, protein, calcium, and vitamin D. In terms of vitamin D, children should have an annual measurement of their 25-hydroxyvitamin D concentration. The current consensus is that an adequate concentration is at least 20 ng/mL.

A multivitamin supplement is simply inadequate for children who have low vitamin D concentrations, Dr. Bachrach said.

Megadoses of oral ergocalciferol (10,000 U/wk for children under the age of 6 and 50,000 U/wk for older children) for 6–8 weeks are usually necessary to restore a child's vitamin D levels.

Prescribing physical activity is also important. This activity should be titrated to the patient. It's especially important to navigate between the twin hazards of immobilization and overuse.

Even children who need wheelchairs should be encouraged to at least stand. At the same time, you don't want children to exercise so much that they greatly increase their risk of fracture. Overexercise can also lead to slow weight gain.

It's also important to address any underlying endocrine disorders in these children. Deficits in sex steroids should be addressed, and in cases of delayed puberty, an endocrinology consult may be in order.

Most drugs for adult osteoporosis are contraindicated or have been inadequately tested in children, Dr. Bachrach said.

Parathyroid hormone can't be used in children because of the risk of osteosarcoma. And while bisphosphonates have been shown to be highly effective in adults, most studies in children have been observational, except in the case of osteogenesis imperfecta. There have been no studies in children with chronic disease and no consensus on duration or dose.

Furthermore, bisphosphonates have both minor and major adverse effects. They can cause fever, myalgia, bone pain, and GI pain or distension. More rarely, they can cause esophageal or oral erosion, delayed bone healing, or osteopetrosis, and there's also a risk of teratogenicity.

Bisphosphonates should be restricted to cases of osteogenesis imperfecta, children with fragility fractures, and randomized, controlled trials. They should not be used for low bone density only, and they definitely shouldn't be used as prophylaxis in children who are getting steroid therapy, she concluded.

SAN FRANCISCO — Plain x-rays are insufficiently quantitative to assess a child's bone mineral density, and dual-energy x-ray absorptiometry is usually the best choice, said Dr. Laura K. Bachrach at a meeting of the Society for Pediatric Dermatology.

Dual-energy x-ray absorptiometry (DXA) is fast, precise, safe, and readily available. But interpreting the results can present some challenges to the nonspecialist, said Dr. Bachrach of Stanford (Calif.) University.

“There's often a very inadequate response from the DXA center or nuclear medicine department or the radiologist who prepares the report,” Dr. Bachrach said. “[Often they] produce some numbers and throw up their hands and say 'Here, you ordered it, you interpret it.'”

The results will be in units of bone mineral content (BMC) in grams or bone mineral density (BMD) in g/cm

Some clinicians make the mistake of relying on the standard deviation T score, but this is particularly inappropriate in children. A T score compares a patient's bone mineral density to that of a healthy young adult. Children with normal bone mineral density will often appear to have abnormally low BMD by that standard.

The z score, on the other hand, compares the child's result to children of the same age and sex.

It's also important to pay attention to both the make and the model number of the DXA machine. Normative data for one machine should not be used to analyze results from another.

But even a z score is not enough, Dr. Bachrach said. “Usually the children you're ordering the DXA scan on have a chronic illness, and often these illnesses have affected their growth, maturation, and have really slowed things down. These can affect the results. And this is where you may want to get on the phone and talk to your friendly bone-density colleague. There's definitely a tendency to overdiagnose low bone mass, most commonly because of the T score error, but also potentially if you don't take bone size into account.”

Dr. Bachrach said that patients frequently call, saying, “My doctor says my child's losing bone.” But it's simply not possible to determine that with a single DXA scan. More likely, the child is not losing bone, but he or she is failing to accrue bone.

Additionally, because it's unknown what a given child's fracture threshold is, it's impossible to diagnose osteoporosis on the basis of the DXA scan alone. “We don't want to label children as having osteoporosis just on the basis of a bone density. That's really a clinical diagnosis based upon fractures,” Dr. Bachrach said.

SAN FRANCISCO — Plain x-rays are insufficiently quantitative to assess a child's bone mineral density, and dual-energy x-ray absorptiometry is usually the best choice, said Dr. Laura K. Bachrach at a meeting of the Society for Pediatric Dermatology.

Dual-energy x-ray absorptiometry (DXA) is fast, precise, safe, and readily available. But interpreting the results can present some challenges to the nonspecialist, said Dr. Bachrach of Stanford (Calif.) University.

“There's often a very inadequate response from the DXA center or nuclear medicine department or the radiologist who prepares the report,” Dr. Bachrach said. “[Often they] produce some numbers and throw up their hands and say 'Here, you ordered it, you interpret it.'”

The results will be in units of bone mineral content (BMC) in grams or bone mineral density (BMD) in g/cm

Some clinicians make the mistake of relying on the standard deviation T score, but this is particularly inappropriate in children. A T score compares a patient's bone mineral density to that of a healthy young adult. Children with normal bone mineral density will often appear to have abnormally low BMD by that standard.

The z score, on the other hand, compares the child's result to children of the same age and sex.

It's also important to pay attention to both the make and the model number of the DXA machine. Normative data for one machine should not be used to analyze results from another.

But even a z score is not enough, Dr. Bachrach said. “Usually the children you're ordering the DXA scan on have a chronic illness, and often these illnesses have affected their growth, maturation, and have really slowed things down. These can affect the results. And this is where you may want to get on the phone and talk to your friendly bone-density colleague. There's definitely a tendency to overdiagnose low bone mass, most commonly because of the T score error, but also potentially if you don't take bone size into account.”

Dr. Bachrach said that patients frequently call, saying, “My doctor says my child's losing bone.” But it's simply not possible to determine that with a single DXA scan. More likely, the child is not losing bone, but he or she is failing to accrue bone.

Additionally, because it's unknown what a given child's fracture threshold is, it's impossible to diagnose osteoporosis on the basis of the DXA scan alone. “We don't want to label children as having osteoporosis just on the basis of a bone density. That's really a clinical diagnosis based upon fractures,” Dr. Bachrach said.

SAN FRANCISCO — Plain x-rays are insufficiently quantitative to assess a child's bone mineral density, and dual-energy x-ray absorptiometry is usually the best choice, said Dr. Laura K. Bachrach at a meeting of the Society for Pediatric Dermatology.

Dual-energy x-ray absorptiometry (DXA) is fast, precise, safe, and readily available. But interpreting the results can present some challenges to the nonspecialist, said Dr. Bachrach of Stanford (Calif.) University.

“There's often a very inadequate response from the DXA center or nuclear medicine department or the radiologist who prepares the report,” Dr. Bachrach said. “[Often they] produce some numbers and throw up their hands and say 'Here, you ordered it, you interpret it.'”

The results will be in units of bone mineral content (BMC) in grams or bone mineral density (BMD) in g/cm

Some clinicians make the mistake of relying on the standard deviation T score, but this is particularly inappropriate in children. A T score compares a patient's bone mineral density to that of a healthy young adult. Children with normal bone mineral density will often appear to have abnormally low BMD by that standard.

The z score, on the other hand, compares the child's result to children of the same age and sex.

It's also important to pay attention to both the make and the model number of the DXA machine. Normative data for one machine should not be used to analyze results from another.

But even a z score is not enough, Dr. Bachrach said. “Usually the children you're ordering the DXA scan on have a chronic illness, and often these illnesses have affected their growth, maturation, and have really slowed things down. These can affect the results. And this is where you may want to get on the phone and talk to your friendly bone-density colleague. There's definitely a tendency to overdiagnose low bone mass, most commonly because of the T score error, but also potentially if you don't take bone size into account.”

Dr. Bachrach said that patients frequently call, saying, “My doctor says my child's losing bone.” But it's simply not possible to determine that with a single DXA scan. More likely, the child is not losing bone, but he or she is failing to accrue bone.

Additionally, because it's unknown what a given child's fracture threshold is, it's impossible to diagnose osteoporosis on the basis of the DXA scan alone. “We don't want to label children as having osteoporosis just on the basis of a bone density. That's really a clinical diagnosis based upon fractures,” Dr. Bachrach said.

A large, randomized, placebo-controlled trial has confirmed that calcium supplementation in women above the age of 70 can reduce osteoporotic fractures, but the investigators concluded that it would be ineffective as a public health measure since almost half the women were not compliant.

The study's intent-to-treat analysis demonstrated no overall benefit from calcium supplementation of 1,200 mg per day. But when the analysis was restricted to women who took at least 80% of their tablets, calcium supplementation resulted in a statistically significant 34% decrease in fracture incidence, compared with placebo, Dr. Richard L. Prince of the University of Western Australia, Nedlands, and his colleagues reported (Arch. Intern. Med. 2006;166:869–75).

This figure corresponds to an absolute risk reduction of 10.2% in the calcium group vs. 15.4% in the placebo group.

The 5-year study involved 1,460 women with an average age of 75 years who were randomized to receive 600 mg calcium carbonate twice per day or an identical placebo.

Investigators collected data on incident osteoporotic fractures, vertebral deformity, dual x-ray absorptiometry of the hip and whole body, quantitative ultrasonography of the heel, peripheral quantitative computed tomography of the distal radius, and adverse events.

A total of 236 individuals (16%) sustained 297 incident osteoporotic fractures. After adjustment for age, body mass index, and prevalent baseline fractures, the intent-to-treat analysis revealed that calcium supplementation did not significantly reduce fracture risk.

Medication compliance was checked by counting returned tablets in each 12-month review, and average yearly compliance of less than 80% was classified as noncompliant. By this measure, 630 participants (43%) were noncompliant.

When the analysis was restricted to the 830 participants who were compliant, the investigators demonstrated a reduction in all-site clinical fractures (hazard ratio 0.66), appendicular fractures (hazard ratio 0.65), and upper-limb fractures (hazard ratio 0.44).

The investigators recorded 92,000 adverse events, but only constipation was significantly higher in the calcium group (13%), compared with the placebo group (9%).

The investigators concluded that individuals who are compliant, especially if they are under the care of a clinician, can benefit from calcium supplementation. However, they also concluded, “These data should give pause to those who consider that public health policy in this area should be based on epidemiological or surrogate end point data.”

A large, randomized, placebo-controlled trial has confirmed that calcium supplementation in women above the age of 70 can reduce osteoporotic fractures, but the investigators concluded that it would be ineffective as a public health measure since almost half the women were not compliant.

The study's intent-to-treat analysis demonstrated no overall benefit from calcium supplementation of 1,200 mg per day. But when the analysis was restricted to women who took at least 80% of their tablets, calcium supplementation resulted in a statistically significant 34% decrease in fracture incidence, compared with placebo, Dr. Richard L. Prince of the University of Western Australia, Nedlands, and his colleagues reported (Arch. Intern. Med. 2006;166:869–75).

This figure corresponds to an absolute risk reduction of 10.2% in the calcium group vs. 15.4% in the placebo group.

The 5-year study involved 1,460 women with an average age of 75 years who were randomized to receive 600 mg calcium carbonate twice per day or an identical placebo.

Investigators collected data on incident osteoporotic fractures, vertebral deformity, dual x-ray absorptiometry of the hip and whole body, quantitative ultrasonography of the heel, peripheral quantitative computed tomography of the distal radius, and adverse events.

A total of 236 individuals (16%) sustained 297 incident osteoporotic fractures. After adjustment for age, body mass index, and prevalent baseline fractures, the intent-to-treat analysis revealed that calcium supplementation did not significantly reduce fracture risk.

Medication compliance was checked by counting returned tablets in each 12-month review, and average yearly compliance of less than 80% was classified as noncompliant. By this measure, 630 participants (43%) were noncompliant.

When the analysis was restricted to the 830 participants who were compliant, the investigators demonstrated a reduction in all-site clinical fractures (hazard ratio 0.66), appendicular fractures (hazard ratio 0.65), and upper-limb fractures (hazard ratio 0.44).

The investigators recorded 92,000 adverse events, but only constipation was significantly higher in the calcium group (13%), compared with the placebo group (9%).

The investigators concluded that individuals who are compliant, especially if they are under the care of a clinician, can benefit from calcium supplementation. However, they also concluded, “These data should give pause to those who consider that public health policy in this area should be based on epidemiological or surrogate end point data.”

A large, randomized, placebo-controlled trial has confirmed that calcium supplementation in women above the age of 70 can reduce osteoporotic fractures, but the investigators concluded that it would be ineffective as a public health measure since almost half the women were not compliant.

The study's intent-to-treat analysis demonstrated no overall benefit from calcium supplementation of 1,200 mg per day. But when the analysis was restricted to women who took at least 80% of their tablets, calcium supplementation resulted in a statistically significant 34% decrease in fracture incidence, compared with placebo, Dr. Richard L. Prince of the University of Western Australia, Nedlands, and his colleagues reported (Arch. Intern. Med. 2006;166:869–75).

This figure corresponds to an absolute risk reduction of 10.2% in the calcium group vs. 15.4% in the placebo group.

The 5-year study involved 1,460 women with an average age of 75 years who were randomized to receive 600 mg calcium carbonate twice per day or an identical placebo.

Investigators collected data on incident osteoporotic fractures, vertebral deformity, dual x-ray absorptiometry of the hip and whole body, quantitative ultrasonography of the heel, peripheral quantitative computed tomography of the distal radius, and adverse events.

A total of 236 individuals (16%) sustained 297 incident osteoporotic fractures. After adjustment for age, body mass index, and prevalent baseline fractures, the intent-to-treat analysis revealed that calcium supplementation did not significantly reduce fracture risk.

Medication compliance was checked by counting returned tablets in each 12-month review, and average yearly compliance of less than 80% was classified as noncompliant. By this measure, 630 participants (43%) were noncompliant.

When the analysis was restricted to the 830 participants who were compliant, the investigators demonstrated a reduction in all-site clinical fractures (hazard ratio 0.66), appendicular fractures (hazard ratio 0.65), and upper-limb fractures (hazard ratio 0.44).

The investigators recorded 92,000 adverse events, but only constipation was significantly higher in the calcium group (13%), compared with the placebo group (9%).

The investigators concluded that individuals who are compliant, especially if they are under the care of a clinician, can benefit from calcium supplementation. However, they also concluded, “These data should give pause to those who consider that public health policy in this area should be based on epidemiological or surrogate end point data.”