Sharon Worcester

ATLANTA – Low-level laser therapy produced a significant and durable reduction in upper arm circumference in a randomized, double-blind, sham-controlled study of 62 patients.

An overall reduction in upper arm circumference of at least 1.25 cm was achieved in 58% of 31 patients randomized to receive three, 20-minute treatments each week for 2 weeks, compared with 3% of 31 patients randomized to receive sham treatments, Dr. Mark S. Nestor reported at the annual meeting of the American Society for Dermatologic Surgery.

The mean combined reductions in arm circumference were 2.0 cm after three treatments and 3.7 cm after six active treatments in the intervention group patients, compared with a gain of 0.1 cm and a reduction of 0.3 cm after 3 and 6 treatments, respectively, in the sham-treated control group, said Dr. Nestor, a dermatologist in private practice in Aventura, Fla.

The differences between the intervention and control group were statistically significant, he said.

The results were unchanged at the 2-week follow up. In 14 intervention group patients available for follow-up at 5-10 months post treatment, the decrease in upper arm circumference persisted at 3.25 cm, which was "essentially unchanged from the 4-week result," he noted.

The low-level laser therapy device used for this study (Zerona) consists of five independent diodes emitting 17 mW of red 635-nm laser light in overlapping patterns. A total of 3.94 J/cm² of energy was delivered during each treatment.

The device has been cleared as a noninvasive body contouring therapy for reducing hip, waist, and thigh circumference, but potential effects of confounding variables when it comes to measuring results have created confusion about the extent of the effects, Dr. Nestor said.

For example, abdominal measures from one day to the next can easily be affected by diet and other factors, he explained.

Upper arm circumference provides a more objective measure.

"I think that this model for body contouring is really wonderful, because [with the upper arm] you don’t see a lot of change from exercise or diet in the short term," he said.

Subjects in this study, who agreed to abstain from changes in diet or exercise during the study period, were treated at one of three participating centers. Arm circumference was measured at three equidistant points between the elbow and shoulder.

There were no reports of pain or discomfort, and no adverse events occurred.

Patient satisfaction was high, Dr. Nestor said. More subjects in the treatment group than in the control group reported satisfaction with the results (65% vs. 22%), improved appearance (81% vs. 26%), and results that exceeded expectations (45% vs. 17%).

Dr. Nestor reported that he has served as a consultant for and received research funding from Erchonia, maker of the Zerona laser therapy device used in this study.

ATLANTA – Low-level laser therapy produced a significant and durable reduction in upper arm circumference in a randomized, double-blind, sham-controlled study of 62 patients.

An overall reduction in upper arm circumference of at least 1.25 cm was achieved in 58% of 31 patients randomized to receive three, 20-minute treatments each week for 2 weeks, compared with 3% of 31 patients randomized to receive sham treatments, Dr. Mark S. Nestor reported at the annual meeting of the American Society for Dermatologic Surgery.

The mean combined reductions in arm circumference were 2.0 cm after three treatments and 3.7 cm after six active treatments in the intervention group patients, compared with a gain of 0.1 cm and a reduction of 0.3 cm after 3 and 6 treatments, respectively, in the sham-treated control group, said Dr. Nestor, a dermatologist in private practice in Aventura, Fla.

The differences between the intervention and control group were statistically significant, he said.

The results were unchanged at the 2-week follow up. In 14 intervention group patients available for follow-up at 5-10 months post treatment, the decrease in upper arm circumference persisted at 3.25 cm, which was "essentially unchanged from the 4-week result," he noted.

The low-level laser therapy device used for this study (Zerona) consists of five independent diodes emitting 17 mW of red 635-nm laser light in overlapping patterns. A total of 3.94 J/cm² of energy was delivered during each treatment.

The device has been cleared as a noninvasive body contouring therapy for reducing hip, waist, and thigh circumference, but potential effects of confounding variables when it comes to measuring results have created confusion about the extent of the effects, Dr. Nestor said.

For example, abdominal measures from one day to the next can easily be affected by diet and other factors, he explained.

Upper arm circumference provides a more objective measure.

"I think that this model for body contouring is really wonderful, because [with the upper arm] you don’t see a lot of change from exercise or diet in the short term," he said.

Subjects in this study, who agreed to abstain from changes in diet or exercise during the study period, were treated at one of three participating centers. Arm circumference was measured at three equidistant points between the elbow and shoulder.

There were no reports of pain or discomfort, and no adverse events occurred.

Patient satisfaction was high, Dr. Nestor said. More subjects in the treatment group than in the control group reported satisfaction with the results (65% vs. 22%), improved appearance (81% vs. 26%), and results that exceeded expectations (45% vs. 17%).

Dr. Nestor reported that he has served as a consultant for and received research funding from Erchonia, maker of the Zerona laser therapy device used in this study.

ATLANTA – Low-level laser therapy produced a significant and durable reduction in upper arm circumference in a randomized, double-blind, sham-controlled study of 62 patients.

An overall reduction in upper arm circumference of at least 1.25 cm was achieved in 58% of 31 patients randomized to receive three, 20-minute treatments each week for 2 weeks, compared with 3% of 31 patients randomized to receive sham treatments, Dr. Mark S. Nestor reported at the annual meeting of the American Society for Dermatologic Surgery.

The mean combined reductions in arm circumference were 2.0 cm after three treatments and 3.7 cm after six active treatments in the intervention group patients, compared with a gain of 0.1 cm and a reduction of 0.3 cm after 3 and 6 treatments, respectively, in the sham-treated control group, said Dr. Nestor, a dermatologist in private practice in Aventura, Fla.

The differences between the intervention and control group were statistically significant, he said.

The results were unchanged at the 2-week follow up. In 14 intervention group patients available for follow-up at 5-10 months post treatment, the decrease in upper arm circumference persisted at 3.25 cm, which was "essentially unchanged from the 4-week result," he noted.

The low-level laser therapy device used for this study (Zerona) consists of five independent diodes emitting 17 mW of red 635-nm laser light in overlapping patterns. A total of 3.94 J/cm² of energy was delivered during each treatment.

The device has been cleared as a noninvasive body contouring therapy for reducing hip, waist, and thigh circumference, but potential effects of confounding variables when it comes to measuring results have created confusion about the extent of the effects, Dr. Nestor said.

For example, abdominal measures from one day to the next can easily be affected by diet and other factors, he explained.

Upper arm circumference provides a more objective measure.

"I think that this model for body contouring is really wonderful, because [with the upper arm] you don’t see a lot of change from exercise or diet in the short term," he said.

Subjects in this study, who agreed to abstain from changes in diet or exercise during the study period, were treated at one of three participating centers. Arm circumference was measured at three equidistant points between the elbow and shoulder.

There were no reports of pain or discomfort, and no adverse events occurred.

Patient satisfaction was high, Dr. Nestor said. More subjects in the treatment group than in the control group reported satisfaction with the results (65% vs. 22%), improved appearance (81% vs. 26%), and results that exceeded expectations (45% vs. 17%).

Dr. Nestor reported that he has served as a consultant for and received research funding from Erchonia, maker of the Zerona laser therapy device used in this study.

Women younger than age 40 years who undergo uterine artery embolization for the treatment of uterine fibroids have a good chance of maintaining fertility and of having a good pregnancy outcome, even years following the procedure, according to findings from a retrospective chart review.

The findings suggest that for women who desire a future pregnancy, uterine artery embolization may offer advantages over myomectomy, Dr. Bruce McLucas reported at ISET 2013, an international symposium on endovascular therapy.

Of 44 women aged 26-40 years who desired a future pregnancy and who underwent uterine artery embolization between 1996 and 2010, 22 reported a total of 28 pregnancies. One patient had three pregnancies, 4 had two pregnancies, and 17 had one pregnancy.

The pregnancies occurred at a mean of 41 months following treatment (range of 13 to 108 months from treatment to delivery). Only one patient required the use of "additional reproductive techniques," said Dr. McLucas of the University of California, Los Angeles.

Of the 28 pregnancies, 3 resulted in miscarriage, 3 involved preterm labor followed by cesarean delivery, 18 involved cesarean delivery at term, and 4 involved vaginal delivery at term – something that is not possible following myomectomy, he said.

The average birth weight of the babies was a healthy 3 kg, and mean total uterine volume prior to uterine artery embolization was also healthy at 400.6 cm. The average fibroid size prior to the treatment was 8.46 cm.

No perfusion problems occurred during pregnancy or labor, and there were no reports of any intrauterine growth restriction, fetal distress during labor, or problems related to uterine integrity. Also, none of the patients experienced premature menopause as a result of uterine artery embolization.

In fact, only two patients reported problems during pregnancy, and these included borderline oligohydramnios and low-lying placenta.

The pregnancy rate in this study compares favorably with the rate seen in previous studies of women who underwent myomectomy. Because about 10% of myomectomies result in conversion to hysterectomy and because vaginal delivery is not possible following myomectomy, these findings suggest that uterine artery embolization is a viable alternative, Dr. McLucas said.

This is particularly true for those who wish to wait longer than 1 year after the procedure to become pregnant, which is the case for many younger patients, he said. It takes about 6 months for the uterus to heal following myomectomy, and the chances of becoming pregnant are best between and 7 and 12 months following myomectomy. After 12 months, fibroids begin to recur, hindering the chances of conception.

Women should be advised of the small chance of premature ovarian failure (which occurs in about 10 in 1,000 cases) and of hysterectomy (which occurs in about 5 in 1,000 cases) with uterine artery embolization. Nonetheless, the treatment is a good option in those who desire to maintain fertility and to postpone childbearing, he concluded.

Dr. McLucas reported having no financial disclosures.

Women younger than age 40 years who undergo uterine artery embolization for the treatment of uterine fibroids have a good chance of maintaining fertility and of having a good pregnancy outcome, even years following the procedure, according to findings from a retrospective chart review.

The findings suggest that for women who desire a future pregnancy, uterine artery embolization may offer advantages over myomectomy, Dr. Bruce McLucas reported at ISET 2013, an international symposium on endovascular therapy.

Of 44 women aged 26-40 years who desired a future pregnancy and who underwent uterine artery embolization between 1996 and 2010, 22 reported a total of 28 pregnancies. One patient had three pregnancies, 4 had two pregnancies, and 17 had one pregnancy.

The pregnancies occurred at a mean of 41 months following treatment (range of 13 to 108 months from treatment to delivery). Only one patient required the use of "additional reproductive techniques," said Dr. McLucas of the University of California, Los Angeles.

Of the 28 pregnancies, 3 resulted in miscarriage, 3 involved preterm labor followed by cesarean delivery, 18 involved cesarean delivery at term, and 4 involved vaginal delivery at term – something that is not possible following myomectomy, he said.

The average birth weight of the babies was a healthy 3 kg, and mean total uterine volume prior to uterine artery embolization was also healthy at 400.6 cm. The average fibroid size prior to the treatment was 8.46 cm.

No perfusion problems occurred during pregnancy or labor, and there were no reports of any intrauterine growth restriction, fetal distress during labor, or problems related to uterine integrity. Also, none of the patients experienced premature menopause as a result of uterine artery embolization.

In fact, only two patients reported problems during pregnancy, and these included borderline oligohydramnios and low-lying placenta.

The pregnancy rate in this study compares favorably with the rate seen in previous studies of women who underwent myomectomy. Because about 10% of myomectomies result in conversion to hysterectomy and because vaginal delivery is not possible following myomectomy, these findings suggest that uterine artery embolization is a viable alternative, Dr. McLucas said.

This is particularly true for those who wish to wait longer than 1 year after the procedure to become pregnant, which is the case for many younger patients, he said. It takes about 6 months for the uterus to heal following myomectomy, and the chances of becoming pregnant are best between and 7 and 12 months following myomectomy. After 12 months, fibroids begin to recur, hindering the chances of conception.

Women should be advised of the small chance of premature ovarian failure (which occurs in about 10 in 1,000 cases) and of hysterectomy (which occurs in about 5 in 1,000 cases) with uterine artery embolization. Nonetheless, the treatment is a good option in those who desire to maintain fertility and to postpone childbearing, he concluded.

Dr. McLucas reported having no financial disclosures.

Women younger than age 40 years who undergo uterine artery embolization for the treatment of uterine fibroids have a good chance of maintaining fertility and of having a good pregnancy outcome, even years following the procedure, according to findings from a retrospective chart review.

The findings suggest that for women who desire a future pregnancy, uterine artery embolization may offer advantages over myomectomy, Dr. Bruce McLucas reported at ISET 2013, an international symposium on endovascular therapy.

Of 44 women aged 26-40 years who desired a future pregnancy and who underwent uterine artery embolization between 1996 and 2010, 22 reported a total of 28 pregnancies. One patient had three pregnancies, 4 had two pregnancies, and 17 had one pregnancy.

The pregnancies occurred at a mean of 41 months following treatment (range of 13 to 108 months from treatment to delivery). Only one patient required the use of "additional reproductive techniques," said Dr. McLucas of the University of California, Los Angeles.

Of the 28 pregnancies, 3 resulted in miscarriage, 3 involved preterm labor followed by cesarean delivery, 18 involved cesarean delivery at term, and 4 involved vaginal delivery at term – something that is not possible following myomectomy, he said.

The average birth weight of the babies was a healthy 3 kg, and mean total uterine volume prior to uterine artery embolization was also healthy at 400.6 cm. The average fibroid size prior to the treatment was 8.46 cm.

No perfusion problems occurred during pregnancy or labor, and there were no reports of any intrauterine growth restriction, fetal distress during labor, or problems related to uterine integrity. Also, none of the patients experienced premature menopause as a result of uterine artery embolization.

In fact, only two patients reported problems during pregnancy, and these included borderline oligohydramnios and low-lying placenta.

The pregnancy rate in this study compares favorably with the rate seen in previous studies of women who underwent myomectomy. Because about 10% of myomectomies result in conversion to hysterectomy and because vaginal delivery is not possible following myomectomy, these findings suggest that uterine artery embolization is a viable alternative, Dr. McLucas said.

This is particularly true for those who wish to wait longer than 1 year after the procedure to become pregnant, which is the case for many younger patients, he said. It takes about 6 months for the uterus to heal following myomectomy, and the chances of becoming pregnant are best between and 7 and 12 months following myomectomy. After 12 months, fibroids begin to recur, hindering the chances of conception.

Women should be advised of the small chance of premature ovarian failure (which occurs in about 10 in 1,000 cases) and of hysterectomy (which occurs in about 5 in 1,000 cases) with uterine artery embolization. Nonetheless, the treatment is a good option in those who desire to maintain fertility and to postpone childbearing, he concluded.

Dr. McLucas reported having no financial disclosures.

A relative decline in verbal ability between the ages of 13 and 18 years is associated with an increased risk of schizophrenia and other psychoses in adulthood, according to findings from a Swedish longitudinal cohort study involving nearly 11,000 adolescent boys and young men.

For example, compared with the unaffected population, each increase of 1 standard deviation in verbal ability in the 10,717 study subjects was associated with an adjusted hazard ratio for schizophrenia and schizoaffective disorder of 0.59 after adjustment for urbanicity, parental educational level, and family history of psychosis, Dr. James H. MacCabe of King’s College London, and his colleagues reported online Jan. 16 in JAMA Psychiatry, formerly Archives of General Psychiatry.

Similarly, a relative decline in verbal ability between ages 13 and 18 was the strongest predictor (other than family history of psychosis) of other affective and nonaffective psychoses (hazard ratios of 0.45 and 0.67, respectively, in the fully adjusted model), the investigators found. (JAMA Psychiatry 2013 Jan. 16 [doi:10.1001/2013.jamapsychiatry.43]).

"In all diagnostic groups, a clear relative decline was observed in verbal ability, compared with the male general population between ages 13 and 18 years," they said, noting that this was a stronger predictor of later psychosis than poor verbal ability at age 18 years alone, and that verbal decline was "by far the strongest and most consistent finding."

Also, the associations between verbal decline and psychosis persisted – and in fact, were strengthened – even when cases with onset before age 25 years were excluded from the analysis, thereby ruling out the possibility that the findings were confounded by prodromal effects, the investigators said.

"This suggests that relative verbal decline in adolescence and young adulthood reflects a neurodevelopmental process that occurs at fixed age and puts the individual at an increased lifetime risk for psychosis, as opposed to a prodromal process that occurs shortly before the onset of symptoms," the investigators said.

To assess the influence of cognitive developmental trajectories during adolescence and young adulthood on the risk for later affective and nonaffective psychoses, the investigators studied four population-based cohorts of boys and young men born in Sweden in 1953, 1967, 1972, and 1977 and followed through 2006.

Standardized timed verbal, spatial, and inductive ability test scores at baseline and age 18 years were compared, and associations between premorbid cognitive functioning and the risk of schizophrenia and schizoaffective disorder, other nonaffective psychoses, bipolar disorder, and other affective psychoses were assessed.

The declines in verbal ability noted in this study are relative to the general population. They are not likely a reflection of actual deterioration in verbal ability, but probably are an indication that individuals who will develop psychosis do not progress as quickly as their peers, the investigators noted.

"The consistency of the results across all four diagnostic groups and the statistical significance in three diagnostic groups provide a strong indication that these are not chance findings," they added.

Nonetheless, replication in another sample would "add further weight," they said.

Additional large-scale longitudinal studies that examine brain structural and cognitive changes in order to clarify the potential role of reduction in gray matter density in a region of the left motor cortex that is activated by the articulation of speech also are needed, they said, explaining that recent studies have demonstrated a correlation between change in verbal IQ and changes in gray matter density in that brain region.

This study was supported by funding from numerous organizations, including the Swedish Research Council for Working Life and Social Research, the Swedish Council for Research in the Humanities and Social Sciences, and the Swedish Council for Planning and Coordination of Research. The authors reported having no conflicts of interest.

A relative decline in verbal ability between the ages of 13 and 18 years is associated with an increased risk of schizophrenia and other psychoses in adulthood, according to findings from a Swedish longitudinal cohort study involving nearly 11,000 adolescent boys and young men.

For example, compared with the unaffected population, each increase of 1 standard deviation in verbal ability in the 10,717 study subjects was associated with an adjusted hazard ratio for schizophrenia and schizoaffective disorder of 0.59 after adjustment for urbanicity, parental educational level, and family history of psychosis, Dr. James H. MacCabe of King’s College London, and his colleagues reported online Jan. 16 in JAMA Psychiatry, formerly Archives of General Psychiatry.

Similarly, a relative decline in verbal ability between ages 13 and 18 was the strongest predictor (other than family history of psychosis) of other affective and nonaffective psychoses (hazard ratios of 0.45 and 0.67, respectively, in the fully adjusted model), the investigators found. (JAMA Psychiatry 2013 Jan. 16 [doi:10.1001/2013.jamapsychiatry.43]).

"In all diagnostic groups, a clear relative decline was observed in verbal ability, compared with the male general population between ages 13 and 18 years," they said, noting that this was a stronger predictor of later psychosis than poor verbal ability at age 18 years alone, and that verbal decline was "by far the strongest and most consistent finding."

Also, the associations between verbal decline and psychosis persisted – and in fact, were strengthened – even when cases with onset before age 25 years were excluded from the analysis, thereby ruling out the possibility that the findings were confounded by prodromal effects, the investigators said.

"This suggests that relative verbal decline in adolescence and young adulthood reflects a neurodevelopmental process that occurs at fixed age and puts the individual at an increased lifetime risk for psychosis, as opposed to a prodromal process that occurs shortly before the onset of symptoms," the investigators said.

To assess the influence of cognitive developmental trajectories during adolescence and young adulthood on the risk for later affective and nonaffective psychoses, the investigators studied four population-based cohorts of boys and young men born in Sweden in 1953, 1967, 1972, and 1977 and followed through 2006.

Standardized timed verbal, spatial, and inductive ability test scores at baseline and age 18 years were compared, and associations between premorbid cognitive functioning and the risk of schizophrenia and schizoaffective disorder, other nonaffective psychoses, bipolar disorder, and other affective psychoses were assessed.

The declines in verbal ability noted in this study are relative to the general population. They are not likely a reflection of actual deterioration in verbal ability, but probably are an indication that individuals who will develop psychosis do not progress as quickly as their peers, the investigators noted.

"The consistency of the results across all four diagnostic groups and the statistical significance in three diagnostic groups provide a strong indication that these are not chance findings," they added.

Nonetheless, replication in another sample would "add further weight," they said.

Additional large-scale longitudinal studies that examine brain structural and cognitive changes in order to clarify the potential role of reduction in gray matter density in a region of the left motor cortex that is activated by the articulation of speech also are needed, they said, explaining that recent studies have demonstrated a correlation between change in verbal IQ and changes in gray matter density in that brain region.

This study was supported by funding from numerous organizations, including the Swedish Research Council for Working Life and Social Research, the Swedish Council for Research in the Humanities and Social Sciences, and the Swedish Council for Planning and Coordination of Research. The authors reported having no conflicts of interest.

A relative decline in verbal ability between the ages of 13 and 18 years is associated with an increased risk of schizophrenia and other psychoses in adulthood, according to findings from a Swedish longitudinal cohort study involving nearly 11,000 adolescent boys and young men.

For example, compared with the unaffected population, each increase of 1 standard deviation in verbal ability in the 10,717 study subjects was associated with an adjusted hazard ratio for schizophrenia and schizoaffective disorder of 0.59 after adjustment for urbanicity, parental educational level, and family history of psychosis, Dr. James H. MacCabe of King’s College London, and his colleagues reported online Jan. 16 in JAMA Psychiatry, formerly Archives of General Psychiatry.

Similarly, a relative decline in verbal ability between ages 13 and 18 was the strongest predictor (other than family history of psychosis) of other affective and nonaffective psychoses (hazard ratios of 0.45 and 0.67, respectively, in the fully adjusted model), the investigators found. (JAMA Psychiatry 2013 Jan. 16 [doi:10.1001/2013.jamapsychiatry.43]).

"In all diagnostic groups, a clear relative decline was observed in verbal ability, compared with the male general population between ages 13 and 18 years," they said, noting that this was a stronger predictor of later psychosis than poor verbal ability at age 18 years alone, and that verbal decline was "by far the strongest and most consistent finding."

Also, the associations between verbal decline and psychosis persisted – and in fact, were strengthened – even when cases with onset before age 25 years were excluded from the analysis, thereby ruling out the possibility that the findings were confounded by prodromal effects, the investigators said.

"This suggests that relative verbal decline in adolescence and young adulthood reflects a neurodevelopmental process that occurs at fixed age and puts the individual at an increased lifetime risk for psychosis, as opposed to a prodromal process that occurs shortly before the onset of symptoms," the investigators said.

To assess the influence of cognitive developmental trajectories during adolescence and young adulthood on the risk for later affective and nonaffective psychoses, the investigators studied four population-based cohorts of boys and young men born in Sweden in 1953, 1967, 1972, and 1977 and followed through 2006.

Standardized timed verbal, spatial, and inductive ability test scores at baseline and age 18 years were compared, and associations between premorbid cognitive functioning and the risk of schizophrenia and schizoaffective disorder, other nonaffective psychoses, bipolar disorder, and other affective psychoses were assessed.

The declines in verbal ability noted in this study are relative to the general population. They are not likely a reflection of actual deterioration in verbal ability, but probably are an indication that individuals who will develop psychosis do not progress as quickly as their peers, the investigators noted.

"The consistency of the results across all four diagnostic groups and the statistical significance in three diagnostic groups provide a strong indication that these are not chance findings," they added.

Nonetheless, replication in another sample would "add further weight," they said.

Additional large-scale longitudinal studies that examine brain structural and cognitive changes in order to clarify the potential role of reduction in gray matter density in a region of the left motor cortex that is activated by the articulation of speech also are needed, they said, explaining that recent studies have demonstrated a correlation between change in verbal IQ and changes in gray matter density in that brain region.

This study was supported by funding from numerous organizations, including the Swedish Research Council for Working Life and Social Research, the Swedish Council for Research in the Humanities and Social Sciences, and the Swedish Council for Planning and Coordination of Research. The authors reported having no conflicts of interest.

Three out of four smartphone applications designed to assess melanoma risk misclassified at least 30% of melanomas as benign in a case-control diagnostic accuracy study.

Although these applications are intended for educational purposes rather than diagnostic purposes, they pose a potential risk to consumers, according to medical student Joel A. Wolf and his colleagues at the University of Pittsburgh.

"These applications are not subject to any sort of validation or regulatory oversight. Despite disclaimers that these applications are intended for educational purposes, they have the potential to harm users who may believe mistakenly that the evaluation given by such an application is a substitute for medical advice," the investigators wrote. The study was published online Jan. 16 in JAMA Dermatology.

The investigators used the four smartphone applications to evaluate digital images of pigmented cutaneous lesions, including 60 histologically confirmed melanomas and 128 benign control lesions. The applications deemed 85%-98% of the images evaluable.

Based only on the images considered evaluable, the overall sensitivity of the applications ranged from 7% to 98% and the overall specificity ranged from 30% to 94%. Positive predictive value ranged from 33% to 42% and negative predictive value ranged from 65% to 97%.

The highest sensitivity occurred with the only application that sent images to a board-certified dermatologist for analysis within 24 hours; the other three applications relied on automated algorithms for image analysis (JAMA Dermatol. 2013 Jan. 16 [doi:10.1001/jamadermatol.2013.3282]).

"Even the best of these three applications (that used automated algorithms) classified 18 of 60 melanomas (30%) in our study as benign," the investigators said.

The images used for this study were selected from a database of images captured routinely from patients before skin lesion removal. Only close-up images without identifiable features and without equivocal histology were used. The smartphone applications evaluated as part of the study were selected based on their ability to use existing images and on claims or suggestions of "an ability to assist users in determining whether a skin lesion may be malignant," Mr. Wolf and his associates said.

The applications were not identified because the purpose of the study was to determine the accuracy of such applications in general, rather than to make a statement about any particular application, the investigators noted.

Given the ubiquity of smartphone health care applications that are marketed to consumers (13,000 are available in the largest online application store alone, the investigators said), and given that the Food and Drug Administration has announced plans to regulate certain health-related smartphone applications, the findings underscore the need for physicians to be aware of the types of applications available to "aid us in protecting and educating our patients," the investigators noted.

These types of technologies have the potential to improve mortality from melanoma, but extreme care must be taken to prevent potential harm, they added.

"Despite disclaimers presented by each of these applications that they were designed for educational purposes rather than actual diagnosis and that they should not substitute for standard medical care, releasing a tool to the public requires some thought as to how it could be misused. This potential is of particular concern in times of economic hardship, when uninsured and even insured patients, deterred by the cost of copayments for medical visits, may turn to these applications as alternatives to physician evaluation," Mr. Wolf and his associates said.

This study was supported by grants from the National Institutes of Health. Study author Dr. Laura K. Ferris disclosed having served as an investigator and consultant for MELA Sciences Inc. The remaining authors had no disclosures to report.

Three out of four smartphone applications designed to assess melanoma risk misclassified at least 30% of melanomas as benign in a case-control diagnostic accuracy study.

Although these applications are intended for educational purposes rather than diagnostic purposes, they pose a potential risk to consumers, according to medical student Joel A. Wolf and his colleagues at the University of Pittsburgh.

"These applications are not subject to any sort of validation or regulatory oversight. Despite disclaimers that these applications are intended for educational purposes, they have the potential to harm users who may believe mistakenly that the evaluation given by such an application is a substitute for medical advice," the investigators wrote. The study was published online Jan. 16 in JAMA Dermatology.

The investigators used the four smartphone applications to evaluate digital images of pigmented cutaneous lesions, including 60 histologically confirmed melanomas and 128 benign control lesions. The applications deemed 85%-98% of the images evaluable.

Based only on the images considered evaluable, the overall sensitivity of the applications ranged from 7% to 98% and the overall specificity ranged from 30% to 94%. Positive predictive value ranged from 33% to 42% and negative predictive value ranged from 65% to 97%.

The highest sensitivity occurred with the only application that sent images to a board-certified dermatologist for analysis within 24 hours; the other three applications relied on automated algorithms for image analysis (JAMA Dermatol. 2013 Jan. 16 [doi:10.1001/jamadermatol.2013.3282]).

"Even the best of these three applications (that used automated algorithms) classified 18 of 60 melanomas (30%) in our study as benign," the investigators said.

The images used for this study were selected from a database of images captured routinely from patients before skin lesion removal. Only close-up images without identifiable features and without equivocal histology were used. The smartphone applications evaluated as part of the study were selected based on their ability to use existing images and on claims or suggestions of "an ability to assist users in determining whether a skin lesion may be malignant," Mr. Wolf and his associates said.

The applications were not identified because the purpose of the study was to determine the accuracy of such applications in general, rather than to make a statement about any particular application, the investigators noted.

Given the ubiquity of smartphone health care applications that are marketed to consumers (13,000 are available in the largest online application store alone, the investigators said), and given that the Food and Drug Administration has announced plans to regulate certain health-related smartphone applications, the findings underscore the need for physicians to be aware of the types of applications available to "aid us in protecting and educating our patients," the investigators noted.

These types of technologies have the potential to improve mortality from melanoma, but extreme care must be taken to prevent potential harm, they added.

"Despite disclaimers presented by each of these applications that they were designed for educational purposes rather than actual diagnosis and that they should not substitute for standard medical care, releasing a tool to the public requires some thought as to how it could be misused. This potential is of particular concern in times of economic hardship, when uninsured and even insured patients, deterred by the cost of copayments for medical visits, may turn to these applications as alternatives to physician evaluation," Mr. Wolf and his associates said.

This study was supported by grants from the National Institutes of Health. Study author Dr. Laura K. Ferris disclosed having served as an investigator and consultant for MELA Sciences Inc. The remaining authors had no disclosures to report.

Three out of four smartphone applications designed to assess melanoma risk misclassified at least 30% of melanomas as benign in a case-control diagnostic accuracy study.

Although these applications are intended for educational purposes rather than diagnostic purposes, they pose a potential risk to consumers, according to medical student Joel A. Wolf and his colleagues at the University of Pittsburgh.

"These applications are not subject to any sort of validation or regulatory oversight. Despite disclaimers that these applications are intended for educational purposes, they have the potential to harm users who may believe mistakenly that the evaluation given by such an application is a substitute for medical advice," the investigators wrote. The study was published online Jan. 16 in JAMA Dermatology.

The investigators used the four smartphone applications to evaluate digital images of pigmented cutaneous lesions, including 60 histologically confirmed melanomas and 128 benign control lesions. The applications deemed 85%-98% of the images evaluable.

Based only on the images considered evaluable, the overall sensitivity of the applications ranged from 7% to 98% and the overall specificity ranged from 30% to 94%. Positive predictive value ranged from 33% to 42% and negative predictive value ranged from 65% to 97%.

The highest sensitivity occurred with the only application that sent images to a board-certified dermatologist for analysis within 24 hours; the other three applications relied on automated algorithms for image analysis (JAMA Dermatol. 2013 Jan. 16 [doi:10.1001/jamadermatol.2013.3282]).

"Even the best of these three applications (that used automated algorithms) classified 18 of 60 melanomas (30%) in our study as benign," the investigators said.

The images used for this study were selected from a database of images captured routinely from patients before skin lesion removal. Only close-up images without identifiable features and without equivocal histology were used. The smartphone applications evaluated as part of the study were selected based on their ability to use existing images and on claims or suggestions of "an ability to assist users in determining whether a skin lesion may be malignant," Mr. Wolf and his associates said.

The applications were not identified because the purpose of the study was to determine the accuracy of such applications in general, rather than to make a statement about any particular application, the investigators noted.

Given the ubiquity of smartphone health care applications that are marketed to consumers (13,000 are available in the largest online application store alone, the investigators said), and given that the Food and Drug Administration has announced plans to regulate certain health-related smartphone applications, the findings underscore the need for physicians to be aware of the types of applications available to "aid us in protecting and educating our patients," the investigators noted.

These types of technologies have the potential to improve mortality from melanoma, but extreme care must be taken to prevent potential harm, they added.

"Despite disclaimers presented by each of these applications that they were designed for educational purposes rather than actual diagnosis and that they should not substitute for standard medical care, releasing a tool to the public requires some thought as to how it could be misused. This potential is of particular concern in times of economic hardship, when uninsured and even insured patients, deterred by the cost of copayments for medical visits, may turn to these applications as alternatives to physician evaluation," Mr. Wolf and his associates said.

This study was supported by grants from the National Institutes of Health. Study author Dr. Laura K. Ferris disclosed having served as an investigator and consultant for MELA Sciences Inc. The remaining authors had no disclosures to report.

High-resolution manometry with esophageal pressure topography is known to improve the accuracy of manometry for detecting achalasia and defined clinically relevant subtypes prior to treatment, but new data demonstrate that the procedure also is useful for evaluating treatment efficacy.

In a study of 31 men and 19 women aged 20-79 years, resolution of the achalasia pattern on high-resolution manometry with esophageal pressure topography (HRM-EPT) after treatment was associated with symptom improvement and reduced bolus retention, reported Dr. Frédéric Nicodème of Northwestern University, Chicago, and his colleagues.

Video source: American Gastroenterological Association's YouTube Channel

Study participants included one cohort of 25 patients who underwent endoscopy, HRM, timed barium esophagram (TBE) following a 200-mL barium swallow, and symptom assessment before treatment, and a second cohort of 25 treated patients who had pretreatment type 1 or 2 achalasia and who were undergoing a posttreatment study protocol including HRM, TBE, endoscopy, and symptom assessment. The investigators assessed dysphagia, regurgitation, retrosternal pain, and weight loss and used them to calculate an Eckardt score (ES) for both cohorts.

In the untreated cohort, which included 10 patients with type 1 achalasia and 15 with type 2 achalasia, the key EPT metric of integrated relaxation pressure (IRP) was significantly greater in the type 2 patients, as was the nadir-relaxation pressure. No differences were seen based on disease type with respect to resting esophagogastric junction (EGJ) pressure, barium column height, barium column width, or ES (Clin. Gastroenterol. Hepatol. 2012 Oct. 12 [doi: 10.1016/j.cgh.2012.10.015]).

No correlation was found between TBE column height at 5 minutes and IRP, resting EGJ pressure, nadir-EGJ relaxation pressure, or ES, and no correlation was seen between ES and IRP, resting EGJ pressure, or nadir-EGJ relaxation pressure.

In the posttreatment cohort, 10 patients, including 6 with type 1 disease and 4 with type 2 disease, had EPT findings of persistent achalasia pattern, and 15 had resolution of the achalasia pattern. Of these 15 patients, 8 converted to absent peristalsis and 7 to weak peristalsis.

"The IRP, resting EGJ pressure, and nadir-EGJ were all significantly correlated with posttreatment ES," the investigators noted.

Furthermore, TBE column height at 5 minutes, IRP, and ES were significantly lower in patients with resolved achalasia patterns on HRM than in those with a persistent achalasia pattern; the subgroup of 7 patients with weak peristalsis appeared to have the best outcome.

"The median TBE column height at 5 minutes was significantly lower [in those with weak peristalsis] than the three other groups, and ES showed a trend toward a lower value compared to the other 3 groups," they explained.

No significant correlations between TBE column height at 5 minutes and resting EGJ pressure or nadir-EGJ relaxation pressure were noted in the posttreatment patients. Only the IRP showed a weak correlation.

"The correlation between TBE column height at 5 minutes and ES after treatment was also not significant. However, the median TBE column height at 5 minutes for patients with an ES of 3 or greater was significantly greater than that for patients with an ES less than 3," they wrote.

"Our findings suggest that resolution of the achalasia pattern on EPT after treatment was associated with an improvement in symptoms and reduced bolus retention. Although the IRP was not strongly linearly correlated with symptom severity, when analyzed dichotomously patients with an IRP greater than or equal to 15 mm Hg had worse symptom scores and greater bolus retention on TBE compared to those with normal IRP values," the investigators wrote.

In contrast, no EPT pattern or metric, and no TBE variable predicted symptom severity in the untreated cohort, and barium height on TBE did not distinguish achalasia EPT subtypes, they noted.

"These findings suggest that in addition to its proven utility in detecting pretreatment achalasia, EPT also has utility in the management of posttreatment achalasia that can complement TBE," they said.

Although TBE did not distinguish disease subtypes, it does complement EPT, especially when the disease has progressed to an anatomic-dominant disorder, they said. Additional studies in larger series of patients are needed before and after therapy to confidently establish the relative merits of each evaluation with respect to the prediction of long-term outcomes and cost-effectiveness, they said.

This study was supported by the Public Health Service. The authors reported having no disclosures.

High-resolution manometry with esophageal pressure topography is known to improve the accuracy of manometry for detecting achalasia and defined clinically relevant subtypes prior to treatment, but new data demonstrate that the procedure also is useful for evaluating treatment efficacy.

In a study of 31 men and 19 women aged 20-79 years, resolution of the achalasia pattern on high-resolution manometry with esophageal pressure topography (HRM-EPT) after treatment was associated with symptom improvement and reduced bolus retention, reported Dr. Frédéric Nicodème of Northwestern University, Chicago, and his colleagues.

Video source: American Gastroenterological Association's YouTube Channel

Study participants included one cohort of 25 patients who underwent endoscopy, HRM, timed barium esophagram (TBE) following a 200-mL barium swallow, and symptom assessment before treatment, and a second cohort of 25 treated patients who had pretreatment type 1 or 2 achalasia and who were undergoing a posttreatment study protocol including HRM, TBE, endoscopy, and symptom assessment. The investigators assessed dysphagia, regurgitation, retrosternal pain, and weight loss and used them to calculate an Eckardt score (ES) for both cohorts.

In the untreated cohort, which included 10 patients with type 1 achalasia and 15 with type 2 achalasia, the key EPT metric of integrated relaxation pressure (IRP) was significantly greater in the type 2 patients, as was the nadir-relaxation pressure. No differences were seen based on disease type with respect to resting esophagogastric junction (EGJ) pressure, barium column height, barium column width, or ES (Clin. Gastroenterol. Hepatol. 2012 Oct. 12 [doi: 10.1016/j.cgh.2012.10.015]).

No correlation was found between TBE column height at 5 minutes and IRP, resting EGJ pressure, nadir-EGJ relaxation pressure, or ES, and no correlation was seen between ES and IRP, resting EGJ pressure, or nadir-EGJ relaxation pressure.

In the posttreatment cohort, 10 patients, including 6 with type 1 disease and 4 with type 2 disease, had EPT findings of persistent achalasia pattern, and 15 had resolution of the achalasia pattern. Of these 15 patients, 8 converted to absent peristalsis and 7 to weak peristalsis.

"The IRP, resting EGJ pressure, and nadir-EGJ were all significantly correlated with posttreatment ES," the investigators noted.

Furthermore, TBE column height at 5 minutes, IRP, and ES were significantly lower in patients with resolved achalasia patterns on HRM than in those with a persistent achalasia pattern; the subgroup of 7 patients with weak peristalsis appeared to have the best outcome.

"The median TBE column height at 5 minutes was significantly lower [in those with weak peristalsis] than the three other groups, and ES showed a trend toward a lower value compared to the other 3 groups," they explained.

No significant correlations between TBE column height at 5 minutes and resting EGJ pressure or nadir-EGJ relaxation pressure were noted in the posttreatment patients. Only the IRP showed a weak correlation.

"The correlation between TBE column height at 5 minutes and ES after treatment was also not significant. However, the median TBE column height at 5 minutes for patients with an ES of 3 or greater was significantly greater than that for patients with an ES less than 3," they wrote.

"Our findings suggest that resolution of the achalasia pattern on EPT after treatment was associated with an improvement in symptoms and reduced bolus retention. Although the IRP was not strongly linearly correlated with symptom severity, when analyzed dichotomously patients with an IRP greater than or equal to 15 mm Hg had worse symptom scores and greater bolus retention on TBE compared to those with normal IRP values," the investigators wrote.

In contrast, no EPT pattern or metric, and no TBE variable predicted symptom severity in the untreated cohort, and barium height on TBE did not distinguish achalasia EPT subtypes, they noted.

"These findings suggest that in addition to its proven utility in detecting pretreatment achalasia, EPT also has utility in the management of posttreatment achalasia that can complement TBE," they said.

Although TBE did not distinguish disease subtypes, it does complement EPT, especially when the disease has progressed to an anatomic-dominant disorder, they said. Additional studies in larger series of patients are needed before and after therapy to confidently establish the relative merits of each evaluation with respect to the prediction of long-term outcomes and cost-effectiveness, they said.

This study was supported by the Public Health Service. The authors reported having no disclosures.

High-resolution manometry with esophageal pressure topography is known to improve the accuracy of manometry for detecting achalasia and defined clinically relevant subtypes prior to treatment, but new data demonstrate that the procedure also is useful for evaluating treatment efficacy.

In a study of 31 men and 19 women aged 20-79 years, resolution of the achalasia pattern on high-resolution manometry with esophageal pressure topography (HRM-EPT) after treatment was associated with symptom improvement and reduced bolus retention, reported Dr. Frédéric Nicodème of Northwestern University, Chicago, and his colleagues.

Video source: American Gastroenterological Association's YouTube Channel

Study participants included one cohort of 25 patients who underwent endoscopy, HRM, timed barium esophagram (TBE) following a 200-mL barium swallow, and symptom assessment before treatment, and a second cohort of 25 treated patients who had pretreatment type 1 or 2 achalasia and who were undergoing a posttreatment study protocol including HRM, TBE, endoscopy, and symptom assessment. The investigators assessed dysphagia, regurgitation, retrosternal pain, and weight loss and used them to calculate an Eckardt score (ES) for both cohorts.

In the untreated cohort, which included 10 patients with type 1 achalasia and 15 with type 2 achalasia, the key EPT metric of integrated relaxation pressure (IRP) was significantly greater in the type 2 patients, as was the nadir-relaxation pressure. No differences were seen based on disease type with respect to resting esophagogastric junction (EGJ) pressure, barium column height, barium column width, or ES (Clin. Gastroenterol. Hepatol. 2012 Oct. 12 [doi: 10.1016/j.cgh.2012.10.015]).

No correlation was found between TBE column height at 5 minutes and IRP, resting EGJ pressure, nadir-EGJ relaxation pressure, or ES, and no correlation was seen between ES and IRP, resting EGJ pressure, or nadir-EGJ relaxation pressure.

In the posttreatment cohort, 10 patients, including 6 with type 1 disease and 4 with type 2 disease, had EPT findings of persistent achalasia pattern, and 15 had resolution of the achalasia pattern. Of these 15 patients, 8 converted to absent peristalsis and 7 to weak peristalsis.

"The IRP, resting EGJ pressure, and nadir-EGJ were all significantly correlated with posttreatment ES," the investigators noted.

Furthermore, TBE column height at 5 minutes, IRP, and ES were significantly lower in patients with resolved achalasia patterns on HRM than in those with a persistent achalasia pattern; the subgroup of 7 patients with weak peristalsis appeared to have the best outcome.

"The median TBE column height at 5 minutes was significantly lower [in those with weak peristalsis] than the three other groups, and ES showed a trend toward a lower value compared to the other 3 groups," they explained.

No significant correlations between TBE column height at 5 minutes and resting EGJ pressure or nadir-EGJ relaxation pressure were noted in the posttreatment patients. Only the IRP showed a weak correlation.

"The correlation between TBE column height at 5 minutes and ES after treatment was also not significant. However, the median TBE column height at 5 minutes for patients with an ES of 3 or greater was significantly greater than that for patients with an ES less than 3," they wrote.

"Our findings suggest that resolution of the achalasia pattern on EPT after treatment was associated with an improvement in symptoms and reduced bolus retention. Although the IRP was not strongly linearly correlated with symptom severity, when analyzed dichotomously patients with an IRP greater than or equal to 15 mm Hg had worse symptom scores and greater bolus retention on TBE compared to those with normal IRP values," the investigators wrote.

In contrast, no EPT pattern or metric, and no TBE variable predicted symptom severity in the untreated cohort, and barium height on TBE did not distinguish achalasia EPT subtypes, they noted.

"These findings suggest that in addition to its proven utility in detecting pretreatment achalasia, EPT also has utility in the management of posttreatment achalasia that can complement TBE," they said.

Although TBE did not distinguish disease subtypes, it does complement EPT, especially when the disease has progressed to an anatomic-dominant disorder, they said. Additional studies in larger series of patients are needed before and after therapy to confidently establish the relative merits of each evaluation with respect to the prediction of long-term outcomes and cost-effectiveness, they said.

This study was supported by the Public Health Service. The authors reported having no disclosures.

Perceived support from adult family members was negatively associated with depressive symptoms, and negative interactions with police were positively associated with depressive symptoms in a study of 707 adolescents from an urban high school.

However, these relationships varied based on sex, race, and social class, Pratyusha Tummala-Narra, Ph.D., and Nina Sathasivam-Rueckert of Boston College, Chestnut Hill, Mass., reported in the February issue of the Journal of Adolescence.

For example, multiracial adolescents reported significantly higher levels of depressive symptoms than did African American and white adolescents, and a significantly higher level of depressive symptoms was reported by girls than boys. Also, boys were more likely than girls to turn to family members for help, as were adolescents from higher socioeconomic backgrounds.

Those from lower socioeconomic backgrounds were more likely to turn to adults at school for help, the investigators said (J. Adolescence 2013;36:209-19).

With respect to interactions with police, boys reported significantly more negative interactions than girls, and multiracial adolescents reported significantly more negative interactions than Asian adolescents.

As for the relationship between perceived adult support and depressive symptoms, perceived support from adult family members was a significant predictor of adolescents’ depressive symptoms, but perceived support from adults at school was not. Higher levels of perceived support from adult family members were a significant predictor of lower levels of depressive symptomology for girls.

This wasn’t true for boys, but lower levels of perceived support from adult family members was negatively correlated with higher levels of depressive symptoms for both boys and girls. This association was stronger for girls, the investigators said.

Perceived support from adults at school was not significantly related to depressive symptoms for boys or girls.

Additional analyses demonstrated that perceived support from adult family members was negatively associated with depressive symptomology in Latino, Asian, and multiracial adolescents.

Specifically, the investigators found that higher levels of perceived support from adult family members was a significant predictor of lower levels of depressive symptoms for Latino, Asian, and multiracial participants.

In the overall sample, negative interactions with police were associated with higher levels of depressive symptomology. Adolescent girls who reported higher levels of negative interactions with police were more likely to report more depressive symptoms, but negative contact with police was not a significant predictor of depressive symptoms for boys.

With respect to race, however, negative interactions with police were a predictor of higher levels of depressive symptoms only for Asian adolescents, and with respect to socioeconomic status, a greater degree of negative interactions with police was a significant predictor of higher levels of depressive symptoms for those from lower socioeconomic backgrounds.

Study participants were 9th and 10th graders aged 12-18 years (80% aged 14-15 years) from a diverse high school in a large urban center in the northeastern United States. They were surveyed using components of the Polling for Justice Survey to assess aspects of perceived adult support, and also completed the Center for Epidemiologic Studies Depression Scale for Children to measure signs and symptoms of depression.

The findings raise important questions about how different subgroups of adolescents negotiate interactions with adults in their lives, and about their decisions to seek support from adults. An example is that although boys were more likely than girls to turn to family member for help, girls who sought help from family members reported lower depressive symptoms.

"While family support is important for both boys and girls, girls may be less likely to seek the support from family members that may be needed to cope with stress," they said.

Additionally, the findings indicate that youth from lower social class backgrounds might be especially vulnerable to depressive symptoms after negative encounters with police.

This study was limited by the focus on adolescents from just one urban high school and on the reliance on self-report measures. Still, the findings suggest that researchers and practitioners should consider the "unique ecological context" of adolescents, as well as their social locations, when addressing mental health needs, the investigators said.

"Our findings warrant further research on the experiences of vulnerable groups of adolescents ... and on how youth cope with stress and negotiate seeking help from adults," they added, noting that ecologically focused mental health interventions for adolescents dealing with issues such as depression should be tailored to the specific needs of subgroups, and clinicians should attend to adolescents’ experiences with adults in a variety of contexts.

The research was supported by the Collaborative Fellows Grant at Boston College. The authors reported having no conflicts or disclosures.

Perceived support from adult family members was negatively associated with depressive symptoms, and negative interactions with police were positively associated with depressive symptoms in a study of 707 adolescents from an urban high school.

However, these relationships varied based on sex, race, and social class, Pratyusha Tummala-Narra, Ph.D., and Nina Sathasivam-Rueckert of Boston College, Chestnut Hill, Mass., reported in the February issue of the Journal of Adolescence.

For example, multiracial adolescents reported significantly higher levels of depressive symptoms than did African American and white adolescents, and a significantly higher level of depressive symptoms was reported by girls than boys. Also, boys were more likely than girls to turn to family members for help, as were adolescents from higher socioeconomic backgrounds.

Those from lower socioeconomic backgrounds were more likely to turn to adults at school for help, the investigators said (J. Adolescence 2013;36:209-19).

With respect to interactions with police, boys reported significantly more negative interactions than girls, and multiracial adolescents reported significantly more negative interactions than Asian adolescents.

As for the relationship between perceived adult support and depressive symptoms, perceived support from adult family members was a significant predictor of adolescents’ depressive symptoms, but perceived support from adults at school was not. Higher levels of perceived support from adult family members were a significant predictor of lower levels of depressive symptomology for girls.

This wasn’t true for boys, but lower levels of perceived support from adult family members was negatively correlated with higher levels of depressive symptoms for both boys and girls. This association was stronger for girls, the investigators said.

Perceived support from adults at school was not significantly related to depressive symptoms for boys or girls.

Additional analyses demonstrated that perceived support from adult family members was negatively associated with depressive symptomology in Latino, Asian, and multiracial adolescents.

Specifically, the investigators found that higher levels of perceived support from adult family members was a significant predictor of lower levels of depressive symptoms for Latino, Asian, and multiracial participants.

In the overall sample, negative interactions with police were associated with higher levels of depressive symptomology. Adolescent girls who reported higher levels of negative interactions with police were more likely to report more depressive symptoms, but negative contact with police was not a significant predictor of depressive symptoms for boys.

With respect to race, however, negative interactions with police were a predictor of higher levels of depressive symptoms only for Asian adolescents, and with respect to socioeconomic status, a greater degree of negative interactions with police was a significant predictor of higher levels of depressive symptoms for those from lower socioeconomic backgrounds.

Study participants were 9th and 10th graders aged 12-18 years (80% aged 14-15 years) from a diverse high school in a large urban center in the northeastern United States. They were surveyed using components of the Polling for Justice Survey to assess aspects of perceived adult support, and also completed the Center for Epidemiologic Studies Depression Scale for Children to measure signs and symptoms of depression.

The findings raise important questions about how different subgroups of adolescents negotiate interactions with adults in their lives, and about their decisions to seek support from adults. An example is that although boys were more likely than girls to turn to family member for help, girls who sought help from family members reported lower depressive symptoms.

"While family support is important for both boys and girls, girls may be less likely to seek the support from family members that may be needed to cope with stress," they said.

Additionally, the findings indicate that youth from lower social class backgrounds might be especially vulnerable to depressive symptoms after negative encounters with police.

This study was limited by the focus on adolescents from just one urban high school and on the reliance on self-report measures. Still, the findings suggest that researchers and practitioners should consider the "unique ecological context" of adolescents, as well as their social locations, when addressing mental health needs, the investigators said.

"Our findings warrant further research on the experiences of vulnerable groups of adolescents ... and on how youth cope with stress and negotiate seeking help from adults," they added, noting that ecologically focused mental health interventions for adolescents dealing with issues such as depression should be tailored to the specific needs of subgroups, and clinicians should attend to adolescents’ experiences with adults in a variety of contexts.

The research was supported by the Collaborative Fellows Grant at Boston College. The authors reported having no conflicts or disclosures.

Perceived support from adult family members was negatively associated with depressive symptoms, and negative interactions with police were positively associated with depressive symptoms in a study of 707 adolescents from an urban high school.

However, these relationships varied based on sex, race, and social class, Pratyusha Tummala-Narra, Ph.D., and Nina Sathasivam-Rueckert of Boston College, Chestnut Hill, Mass., reported in the February issue of the Journal of Adolescence.

For example, multiracial adolescents reported significantly higher levels of depressive symptoms than did African American and white adolescents, and a significantly higher level of depressive symptoms was reported by girls than boys. Also, boys were more likely than girls to turn to family members for help, as were adolescents from higher socioeconomic backgrounds.

Those from lower socioeconomic backgrounds were more likely to turn to adults at school for help, the investigators said (J. Adolescence 2013;36:209-19).

With respect to interactions with police, boys reported significantly more negative interactions than girls, and multiracial adolescents reported significantly more negative interactions than Asian adolescents.

As for the relationship between perceived adult support and depressive symptoms, perceived support from adult family members was a significant predictor of adolescents’ depressive symptoms, but perceived support from adults at school was not. Higher levels of perceived support from adult family members were a significant predictor of lower levels of depressive symptomology for girls.

This wasn’t true for boys, but lower levels of perceived support from adult family members was negatively correlated with higher levels of depressive symptoms for both boys and girls. This association was stronger for girls, the investigators said.

Perceived support from adults at school was not significantly related to depressive symptoms for boys or girls.

Additional analyses demonstrated that perceived support from adult family members was negatively associated with depressive symptomology in Latino, Asian, and multiracial adolescents.

Specifically, the investigators found that higher levels of perceived support from adult family members was a significant predictor of lower levels of depressive symptoms for Latino, Asian, and multiracial participants.

In the overall sample, negative interactions with police were associated with higher levels of depressive symptomology. Adolescent girls who reported higher levels of negative interactions with police were more likely to report more depressive symptoms, but negative contact with police was not a significant predictor of depressive symptoms for boys.

With respect to race, however, negative interactions with police were a predictor of higher levels of depressive symptoms only for Asian adolescents, and with respect to socioeconomic status, a greater degree of negative interactions with police was a significant predictor of higher levels of depressive symptoms for those from lower socioeconomic backgrounds.

Study participants were 9th and 10th graders aged 12-18 years (80% aged 14-15 years) from a diverse high school in a large urban center in the northeastern United States. They were surveyed using components of the Polling for Justice Survey to assess aspects of perceived adult support, and also completed the Center for Epidemiologic Studies Depression Scale for Children to measure signs and symptoms of depression.

The findings raise important questions about how different subgroups of adolescents negotiate interactions with adults in their lives, and about their decisions to seek support from adults. An example is that although boys were more likely than girls to turn to family member for help, girls who sought help from family members reported lower depressive symptoms.

"While family support is important for both boys and girls, girls may be less likely to seek the support from family members that may be needed to cope with stress," they said.

Additionally, the findings indicate that youth from lower social class backgrounds might be especially vulnerable to depressive symptoms after negative encounters with police.

This study was limited by the focus on adolescents from just one urban high school and on the reliance on self-report measures. Still, the findings suggest that researchers and practitioners should consider the "unique ecological context" of adolescents, as well as their social locations, when addressing mental health needs, the investigators said.

"Our findings warrant further research on the experiences of vulnerable groups of adolescents ... and on how youth cope with stress and negotiate seeking help from adults," they added, noting that ecologically focused mental health interventions for adolescents dealing with issues such as depression should be tailored to the specific needs of subgroups, and clinicians should attend to adolescents’ experiences with adults in a variety of contexts.

The research was supported by the Collaborative Fellows Grant at Boston College. The authors reported having no conflicts or disclosures.

A low level of social skills in early adolescence predicts depression in both girls and boys during later adolescence, and a lack of friend support in middle adolescence mediates this relationship for girls but not for boys, according to findings from a longitudinal population-based study.

The findings underscore a need for social skills training in programs aimed at preventing the development of depression in both genders, and for training for girls on how to cope with interpersonal difficulties, Wendy Nilsen, Ph.D., of the Norwegian Institute of Public Health, Oslo, and her colleagues reported in the February issue of the Journal of Adolescence.

The investigators studied 566 adolescents involved in TOPP (Norwegian Tracking Opportunities and Problems Project) who completed a questionnaire at age 12.5 years. Of these, 456 also completed a questionnaire at age 14.5 years and 375 also completed a questionnaire at age 16.5 years.

At ages 12.5 and 16.5 years, girls reported significantly higher levels of depressive symptoms than boys, and at age 12.5 they reported significantly more social skills than boys. For both boys and girls, social skills at age 12.5 years correlated positively with social support at age 14.5 and correlated negatively with depressive symptoms at age 16.5. Social support at age 14.5 correlated negatively with depressive symptoms at age 16.5, but only for girls, the investigators said (J. Adolesc. 2013;36:11-20).

A significant increase in depressive symptoms from age 12.5 years to age 16.5 was noted for the total sample, but gender-based analysis demonstrated that the increase was significant only in girls.

Thus, female gender predicted increases in depressive symptoms, Dr. Nilsen and her associates said, noting that a low level of social support from friends at age 14.5, but not a low level of parent or teacher support, was associated with the increases.

The findings confirm those of previous studies showing that a lack of social skills and social support are risk factors for future depressive symptoms. The findings also support those from other studies indicating that gender-specific mechanisms for these relationships exist. Few studies, however, have examined the interaction between social skills, support, and depressive symptoms.

Indeed, more knowledge about the gender-specific mechanisms behind the prospective association between these factors and depressive symptoms throughout adolescence is needed to improve preventive programs, the investigators said.

Participants in this study were part of TOPP, which includes 90% of all Norwegian families with children. Adolescents, who were invited to participate via a letter sent to their mothers, were assessed using the 13-item Short Mood and Feelings questionnaire; the 24-item self-reported version of the Social Skills Rating System; and self-reported 3-, 3-, and 10-item measures aimed at assessing friend, teacher, and parent support, respectively.

Though limited by the self-reported nature of the data and by a pattern of dropouts that might limit generalization of the results to the general adolescent population, the findings are from a large population-based sample of adolescents at three time points using validated measures, noted Dr. Nilsen and her associates.

"In sum, the current study indicated that there are both gender-specific and source-specific mechanisms underlying the relationship between social skills and depressive symptoms – specifically related to friend support as a mediator for girls," the investigators wrote, adding that the results highlight the "universal importance" of social skills in early adolescence both for preventing increased depressive symptoms and for obtaining social support.

TOPP is primarily funded by the Norwegian Research Council. Dr. Nilsen and coauthor Evalill Karevold, Ph.D., also are supported by the Norwegian Research Council and the Norwegian Extra Foundation for Health and Rehabilitation for their doctoral and postdoctoral positions, respectively. The authors had no other disclosures to report.

A low level of social skills in early adolescence predicts depression in both girls and boys during later adolescence, and a lack of friend support in middle adolescence mediates this relationship for girls but not for boys, according to findings from a longitudinal population-based study.

The findings underscore a need for social skills training in programs aimed at preventing the development of depression in both genders, and for training for girls on how to cope with interpersonal difficulties, Wendy Nilsen, Ph.D., of the Norwegian Institute of Public Health, Oslo, and her colleagues reported in the February issue of the Journal of Adolescence.

The investigators studied 566 adolescents involved in TOPP (Norwegian Tracking Opportunities and Problems Project) who completed a questionnaire at age 12.5 years. Of these, 456 also completed a questionnaire at age 14.5 years and 375 also completed a questionnaire at age 16.5 years.

At ages 12.5 and 16.5 years, girls reported significantly higher levels of depressive symptoms than boys, and at age 12.5 they reported significantly more social skills than boys. For both boys and girls, social skills at age 12.5 years correlated positively with social support at age 14.5 and correlated negatively with depressive symptoms at age 16.5. Social support at age 14.5 correlated negatively with depressive symptoms at age 16.5, but only for girls, the investigators said (J. Adolesc. 2013;36:11-20).

A significant increase in depressive symptoms from age 12.5 years to age 16.5 was noted for the total sample, but gender-based analysis demonstrated that the increase was significant only in girls.

Thus, female gender predicted increases in depressive symptoms, Dr. Nilsen and her associates said, noting that a low level of social support from friends at age 14.5, but not a low level of parent or teacher support, was associated with the increases.

The findings confirm those of previous studies showing that a lack of social skills and social support are risk factors for future depressive symptoms. The findings also support those from other studies indicating that gender-specific mechanisms for these relationships exist. Few studies, however, have examined the interaction between social skills, support, and depressive symptoms.

Indeed, more knowledge about the gender-specific mechanisms behind the prospective association between these factors and depressive symptoms throughout adolescence is needed to improve preventive programs, the investigators said.

Participants in this study were part of TOPP, which includes 90% of all Norwegian families with children. Adolescents, who were invited to participate via a letter sent to their mothers, were assessed using the 13-item Short Mood and Feelings questionnaire; the 24-item self-reported version of the Social Skills Rating System; and self-reported 3-, 3-, and 10-item measures aimed at assessing friend, teacher, and parent support, respectively.

Though limited by the self-reported nature of the data and by a pattern of dropouts that might limit generalization of the results to the general adolescent population, the findings are from a large population-based sample of adolescents at three time points using validated measures, noted Dr. Nilsen and her associates.

"In sum, the current study indicated that there are both gender-specific and source-specific mechanisms underlying the relationship between social skills and depressive symptoms – specifically related to friend support as a mediator for girls," the investigators wrote, adding that the results highlight the "universal importance" of social skills in early adolescence both for preventing increased depressive symptoms and for obtaining social support.

TOPP is primarily funded by the Norwegian Research Council. Dr. Nilsen and coauthor Evalill Karevold, Ph.D., also are supported by the Norwegian Research Council and the Norwegian Extra Foundation for Health and Rehabilitation for their doctoral and postdoctoral positions, respectively. The authors had no other disclosures to report.

A low level of social skills in early adolescence predicts depression in both girls and boys during later adolescence, and a lack of friend support in middle adolescence mediates this relationship for girls but not for boys, according to findings from a longitudinal population-based study.

The findings underscore a need for social skills training in programs aimed at preventing the development of depression in both genders, and for training for girls on how to cope with interpersonal difficulties, Wendy Nilsen, Ph.D., of the Norwegian Institute of Public Health, Oslo, and her colleagues reported in the February issue of the Journal of Adolescence.

The investigators studied 566 adolescents involved in TOPP (Norwegian Tracking Opportunities and Problems Project) who completed a questionnaire at age 12.5 years. Of these, 456 also completed a questionnaire at age 14.5 years and 375 also completed a questionnaire at age 16.5 years.

At ages 12.5 and 16.5 years, girls reported significantly higher levels of depressive symptoms than boys, and at age 12.5 they reported significantly more social skills than boys. For both boys and girls, social skills at age 12.5 years correlated positively with social support at age 14.5 and correlated negatively with depressive symptoms at age 16.5. Social support at age 14.5 correlated negatively with depressive symptoms at age 16.5, but only for girls, the investigators said (J. Adolesc. 2013;36:11-20).

A significant increase in depressive symptoms from age 12.5 years to age 16.5 was noted for the total sample, but gender-based analysis demonstrated that the increase was significant only in girls.

Thus, female gender predicted increases in depressive symptoms, Dr. Nilsen and her associates said, noting that a low level of social support from friends at age 14.5, but not a low level of parent or teacher support, was associated with the increases.

The findings confirm those of previous studies showing that a lack of social skills and social support are risk factors for future depressive symptoms. The findings also support those from other studies indicating that gender-specific mechanisms for these relationships exist. Few studies, however, have examined the interaction between social skills, support, and depressive symptoms.

Indeed, more knowledge about the gender-specific mechanisms behind the prospective association between these factors and depressive symptoms throughout adolescence is needed to improve preventive programs, the investigators said.

Participants in this study were part of TOPP, which includes 90% of all Norwegian families with children. Adolescents, who were invited to participate via a letter sent to their mothers, were assessed using the 13-item Short Mood and Feelings questionnaire; the 24-item self-reported version of the Social Skills Rating System; and self-reported 3-, 3-, and 10-item measures aimed at assessing friend, teacher, and parent support, respectively.

Though limited by the self-reported nature of the data and by a pattern of dropouts that might limit generalization of the results to the general adolescent population, the findings are from a large population-based sample of adolescents at three time points using validated measures, noted Dr. Nilsen and her associates.

"In sum, the current study indicated that there are both gender-specific and source-specific mechanisms underlying the relationship between social skills and depressive symptoms – specifically related to friend support as a mediator for girls," the investigators wrote, adding that the results highlight the "universal importance" of social skills in early adolescence both for preventing increased depressive symptoms and for obtaining social support.

TOPP is primarily funded by the Norwegian Research Council. Dr. Nilsen and coauthor Evalill Karevold, Ph.D., also are supported by the Norwegian Research Council and the Norwegian Extra Foundation for Health and Rehabilitation for their doctoral and postdoctoral positions, respectively. The authors had no other disclosures to report.

The target range for serum thyrotropin levels in nonpregnant adults should be the normal range of a third-generation assay, and if an upper limit of normal for the assay is unspecified, the limit should be considered 4.12 mIU/L in iodine-sufficient areas, according to new clinical practice guidelines issued jointly by the American Association of Clinical Endocrinologists and the American Thyroid Association.

Thus, the new guidelines "take the middle ground" with respect to the controversy over what the upper limit of normal is for serum thyrotropin (TSH) levels, Dr. Hossein Gharib of the Mayo Clinic, Rochester, Minn., said in an interview.

The reference range is generally considered to be between 2.5 and 5 mIU/L by laboratories that perform the tests, he noted.

Naseem S. Miller/IMNG Medical Media

The recommendation (#17) is one of 34 main recommendations and 18 subrecommendations included in the new guidelines. It is a Grade B recommendation with a Best Evidence Level (BEL) of 2, indicating that the evidence is limited but based on prospective controlled trials with or without randomization.

The evidence-based guidelines, developed by a task force of expert clinicians appointed by the American Association of Clinical Endocrinologists (AACE) and the American Thyroid Association (ATA), represent a joint effort by these organizations to address the etiology and epidemiology of hypothyroidism, as well as clinical and laboratory evaluation, management, and consequences of hypothyroidism.

Topics addressed by the guidelines include everything from screening to treatment of subclinical disease to pregnancy-related concerns, according to lead author Dr. Jeffrey R. Garber, the task force chair, and his colleagues (Endocr. Pract. 2012;18:988-s4).

"We covered a wide range of issues important to clinical endocrinologists," said Dr. Gharib, a task force member as well as past president of the AACE and president-elect of the ATA.

Other recommendations within the guidelines that Dr. Gharib highlighted address the use of thyroxin monotherapy, management of subclinical disease, and management of hypothyroidism in pregnancy.

Thyroxin monotherapy

Thyroxin monotherapy, rather than combination therapy, is preferred in patients with hypothyroidism, according to the guidelines.

This represents an endorsement of current practice, Dr. Gharib said.

Specifically, recommendations 22.1 and 22.2 state that patients with hypothyroidism should be treated with L-thyroxine monotherapy and that the evidence does not support using L-thyroxine and L-triiodothyronine combinations to treat hypothyroidism (Grade A, BEL 1 [indicating the evidence is based on large, randomized controlled prospective trials] and Grade B, BEL 1, respectively).

Subclinical hypothyroidism

Subclinical hypothyroidism, defined by TSH above normal when T3 and T4 are normal, usually involves mildly elevated TSH at between 5 and 10 mIU/L. Controversy has existed over whether treatment or observation is best in these patients, Dr. Gharib explained.

Recommendation 16 of the guidelines states that treatment should definitely be considered in those with TSH above 10 mIU/L, particularly if the patient has symptoms suggestive of hypothyroidism; positive anti-microsomal/anti-thyroid peroxidase antibodies (TPOAb); or evidence of atherosclerotic cardiovascular disease, heart failure, or associated risk factors for these diseases (Grade B, BEL 1).

Pregnancy

With respect to pregnancy, the new recommendations underscore the fact that TSH levels differ between pregnant and nonpregnant women, Dr. Gharib said.

Recommendation 18 states that reference levels should be adjusted based on trimester-specific TSH values. If trimester-specific reference ranges are not available from a given laboratory, the following upper-normal reference limits should be used: 2.5 mIU/L for the first trimester, 3.0 mIU/L for the second trimester, and 3.5 mIU/L for the third trimester (Grade C, BEL 2).

"These guidelines are a document that reflects the current state of the field and are intended to provide a working document for guideline updates since rapid changes in this field are expected in the future. We encourage medical professionals to use this information in conjunction with their best clinical judgment," the authors wrote, noting that the recommendations may not be appropriate in all situations.

"Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances," they added.

Areas for future research include the evaluation of possible cardiac and cognitive benefit from treating subclinical hypothyroidism, combination therapy for hypothyroidism, monotherapy with L-triiodothyronine, the use of thyroid hormone antagonists in therapy, screening for hypothyroidism in pregnancy, and agents and conditions impacting therapy and interpretation of thyroid tests, they noted.

These guidelines were cosponsored by the AACE and the ATA. One task force member, Dr. Jeffrey I. Mechanick, reported receiving speaker and program development honoraria from Abbott Nutrition. The remaining task force members reported having no disclosures.

The target range for serum thyrotropin levels in nonpregnant adults should be the normal range of a third-generation assay, and if an upper limit of normal for the assay is unspecified, the limit should be considered 4.12 mIU/L in iodine-sufficient areas, according to new clinical practice guidelines issued jointly by the American Association of Clinical Endocrinologists and the American Thyroid Association.

Thus, the new guidelines "take the middle ground" with respect to the controversy over what the upper limit of normal is for serum thyrotropin (TSH) levels, Dr. Hossein Gharib of the Mayo Clinic, Rochester, Minn., said in an interview.

The reference range is generally considered to be between 2.5 and 5 mIU/L by laboratories that perform the tests, he noted.

Naseem S. Miller/IMNG Medical Media

The recommendation (#17) is one of 34 main recommendations and 18 subrecommendations included in the new guidelines. It is a Grade B recommendation with a Best Evidence Level (BEL) of 2, indicating that the evidence is limited but based on prospective controlled trials with or without randomization.

The evidence-based guidelines, developed by a task force of expert clinicians appointed by the American Association of Clinical Endocrinologists (AACE) and the American Thyroid Association (ATA), represent a joint effort by these organizations to address the etiology and epidemiology of hypothyroidism, as well as clinical and laboratory evaluation, management, and consequences of hypothyroidism.

Topics addressed by the guidelines include everything from screening to treatment of subclinical disease to pregnancy-related concerns, according to lead author Dr. Jeffrey R. Garber, the task force chair, and his colleagues (Endocr. Pract. 2012;18:988-s4).

"We covered a wide range of issues important to clinical endocrinologists," said Dr. Gharib, a task force member as well as past president of the AACE and president-elect of the ATA.

Other recommendations within the guidelines that Dr. Gharib highlighted address the use of thyroxin monotherapy, management of subclinical disease, and management of hypothyroidism in pregnancy.

Thyroxin monotherapy

Thyroxin monotherapy, rather than combination therapy, is preferred in patients with hypothyroidism, according to the guidelines.

This represents an endorsement of current practice, Dr. Gharib said.

Specifically, recommendations 22.1 and 22.2 state that patients with hypothyroidism should be treated with L-thyroxine monotherapy and that the evidence does not support using L-thyroxine and L-triiodothyronine combinations to treat hypothyroidism (Grade A, BEL 1 [indicating the evidence is based on large, randomized controlled prospective trials] and Grade B, BEL 1, respectively).

Subclinical hypothyroidism

Subclinical hypothyroidism, defined by TSH above normal when T3 and T4 are normal, usually involves mildly elevated TSH at between 5 and 10 mIU/L. Controversy has existed over whether treatment or observation is best in these patients, Dr. Gharib explained.

Recommendation 16 of the guidelines states that treatment should definitely be considered in those with TSH above 10 mIU/L, particularly if the patient has symptoms suggestive of hypothyroidism; positive anti-microsomal/anti-thyroid peroxidase antibodies (TPOAb); or evidence of atherosclerotic cardiovascular disease, heart failure, or associated risk factors for these diseases (Grade B, BEL 1).

Pregnancy

With respect to pregnancy, the new recommendations underscore the fact that TSH levels differ between pregnant and nonpregnant women, Dr. Gharib said.

Recommendation 18 states that reference levels should be adjusted based on trimester-specific TSH values. If trimester-specific reference ranges are not available from a given laboratory, the following upper-normal reference limits should be used: 2.5 mIU/L for the first trimester, 3.0 mIU/L for the second trimester, and 3.5 mIU/L for the third trimester (Grade C, BEL 2).

"These guidelines are a document that reflects the current state of the field and are intended to provide a working document for guideline updates since rapid changes in this field are expected in the future. We encourage medical professionals to use this information in conjunction with their best clinical judgment," the authors wrote, noting that the recommendations may not be appropriate in all situations.

"Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances," they added.

Areas for future research include the evaluation of possible cardiac and cognitive benefit from treating subclinical hypothyroidism, combination therapy for hypothyroidism, monotherapy with L-triiodothyronine, the use of thyroid hormone antagonists in therapy, screening for hypothyroidism in pregnancy, and agents and conditions impacting therapy and interpretation of thyroid tests, they noted.

These guidelines were cosponsored by the AACE and the ATA. One task force member, Dr. Jeffrey I. Mechanick, reported receiving speaker and program development honoraria from Abbott Nutrition. The remaining task force members reported having no disclosures.

The target range for serum thyrotropin levels in nonpregnant adults should be the normal range of a third-generation assay, and if an upper limit of normal for the assay is unspecified, the limit should be considered 4.12 mIU/L in iodine-sufficient areas, according to new clinical practice guidelines issued jointly by the American Association of Clinical Endocrinologists and the American Thyroid Association.

Thus, the new guidelines "take the middle ground" with respect to the controversy over what the upper limit of normal is for serum thyrotropin (TSH) levels, Dr. Hossein Gharib of the Mayo Clinic, Rochester, Minn., said in an interview.

The reference range is generally considered to be between 2.5 and 5 mIU/L by laboratories that perform the tests, he noted.

Naseem S. Miller/IMNG Medical Media

The recommendation (#17) is one of 34 main recommendations and 18 subrecommendations included in the new guidelines. It is a Grade B recommendation with a Best Evidence Level (BEL) of 2, indicating that the evidence is limited but based on prospective controlled trials with or without randomization.

The evidence-based guidelines, developed by a task force of expert clinicians appointed by the American Association of Clinical Endocrinologists (AACE) and the American Thyroid Association (ATA), represent a joint effort by these organizations to address the etiology and epidemiology of hypothyroidism, as well as clinical and laboratory evaluation, management, and consequences of hypothyroidism.

Topics addressed by the guidelines include everything from screening to treatment of subclinical disease to pregnancy-related concerns, according to lead author Dr. Jeffrey R. Garber, the task force chair, and his colleagues (Endocr. Pract. 2012;18:988-s4).

"We covered a wide range of issues important to clinical endocrinologists," said Dr. Gharib, a task force member as well as past president of the AACE and president-elect of the ATA.

Other recommendations within the guidelines that Dr. Gharib highlighted address the use of thyroxin monotherapy, management of subclinical disease, and management of hypothyroidism in pregnancy.

Thyroxin monotherapy

Thyroxin monotherapy, rather than combination therapy, is preferred in patients with hypothyroidism, according to the guidelines.

This represents an endorsement of current practice, Dr. Gharib said.

Specifically, recommendations 22.1 and 22.2 state that patients with hypothyroidism should be treated with L-thyroxine monotherapy and that the evidence does not support using L-thyroxine and L-triiodothyronine combinations to treat hypothyroidism (Grade A, BEL 1 [indicating the evidence is based on large, randomized controlled prospective trials] and Grade B, BEL 1, respectively).

Subclinical hypothyroidism

Subclinical hypothyroidism, defined by TSH above normal when T3 and T4 are normal, usually involves mildly elevated TSH at between 5 and 10 mIU/L. Controversy has existed over whether treatment or observation is best in these patients, Dr. Gharib explained.

Recommendation 16 of the guidelines states that treatment should definitely be considered in those with TSH above 10 mIU/L, particularly if the patient has symptoms suggestive of hypothyroidism; positive anti-microsomal/anti-thyroid peroxidase antibodies (TPOAb); or evidence of atherosclerotic cardiovascular disease, heart failure, or associated risk factors for these diseases (Grade B, BEL 1).

Pregnancy

With respect to pregnancy, the new recommendations underscore the fact that TSH levels differ between pregnant and nonpregnant women, Dr. Gharib said.

Recommendation 18 states that reference levels should be adjusted based on trimester-specific TSH values. If trimester-specific reference ranges are not available from a given laboratory, the following upper-normal reference limits should be used: 2.5 mIU/L for the first trimester, 3.0 mIU/L for the second trimester, and 3.5 mIU/L for the third trimester (Grade C, BEL 2).

"These guidelines are a document that reflects the current state of the field and are intended to provide a working document for guideline updates since rapid changes in this field are expected in the future. We encourage medical professionals to use this information in conjunction with their best clinical judgment," the authors wrote, noting that the recommendations may not be appropriate in all situations.

"Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances," they added.

Areas for future research include the evaluation of possible cardiac and cognitive benefit from treating subclinical hypothyroidism, combination therapy for hypothyroidism, monotherapy with L-triiodothyronine, the use of thyroid hormone antagonists in therapy, screening for hypothyroidism in pregnancy, and agents and conditions impacting therapy and interpretation of thyroid tests, they noted.

These guidelines were cosponsored by the AACE and the ATA. One task force member, Dr. Jeffrey I. Mechanick, reported receiving speaker and program development honoraria from Abbott Nutrition. The remaining task force members reported having no disclosures.