Heidi Splete

WASHINGTON — The key to motivational interviewing is raising a subject without generating resistance, Sam Weir, M.D., explained at the annual meeting of the American College of Preventive Medicine.

"People are more likely to change when there is a discrepancy between their current behavior and their goals," said Dr. Weir of the department of family medicine at the University of North Carolina, Chapel Hill.

Once the physical exam and behavioral assessment are completed, summarize the results of the visit for the patient, and consider adding some motivational interviewing strategies, Dr. Weir suggested.

The FRAMES acronym is a quick and easy way to summarize and address preventive medicine issues, Dr. Weir said:

▸ Feedback. Feedback means being nonjudgmental, and saying with a straight face, "You know Mrs. Jones, drinking a six-pack of beer every night is more than most of my patients drink, and it's more than is recommended for your health." The doctor states a discrepancy in the behavior, compared with what is considered healthy, but makes no judgment. Ideally, the doctor would then ask the patient, "What do you think about that?" But when time is at a premium, move on to the next point.

▸ Responsibility. Make a statement that reasserts that problematic behavior, and the patient's reaction is up to the patient—for example, "What you do about your drinking is up to you."

▸ Advice. Doctors who avoid the use of the words "should" and "need," when offering advice are less likely to generate resistance in patients. "I encourage you to consider reducing your drinking" is better; the doctor communicates respect for the patient by the way he or she phrases the advice.

▸ Menu. Choices often provide motivation for behavior change. Remind patients that there are many ways to change their behavior, and offer to help them explore their options for doing so.

▸ Empathy. Tell patients that, "It might be hard for you to make this change," because sometimes it is. However, Dr. Weir said that he avoids saying that "it is hard" to change, because for some people it is not, once they make up their minds.

▸ Self-Efficacy. A statement such as, "But I'm confident that when you make up your mind to change, you will be able to do it," reinforces the fact that behavior change starts with the patients, but the doctor believes in their ability to change and will support their efforts when they are ready.

"This FRAMES moniker is a way to give advice about a lot of things in a short period of time," Dr. Weir noted, encouraging physicians to incorporate these principles in written materials, or in other communications with patients.

In his work with medical students, Dr. Weir teaches a 30-second version of FRAMES—a short statement to use with patients that touches all the FRAMES elements, not necessarily in the same order, that can be tweaked to specific behaviors. For example:

"Mrs. Jones, I strongly encourage you to consider quitting smoking. For most people, quitting is the single most important thing they can do to improve their health. The decision to quit is yours, and yours alone. There are many different ways that people can quit, and if you do decide that you want to quit, I'm confident that you can do it. If you decide at some point that you're interested, I'd be very willing to help you look at the options."

Dr. Weir said that he encourages medical students to take the FRAMES approach and write their own 30-second versions that they feel comfortable using, as long as they include all the FRAMES elements. "It's like a rosary chain; you need to touch all the beads," he said.

Dr. Weir also explained what motivational interviewing is not. "It is not arguing that a person has a problem and needs to change, it is not giving a solution without the patient's permission, and it is not taking an 'expert' stance," he said.

"Knowledge is not as much of a deficit as ambivalence," he added. Patients usually have feelings about their behavior, and it can be important to let them hear themselves talk about these feelings and have the opportunity to reflect on them.

Dr. Weir recalled that as a younger physician, he sometimes felt that his own value was negatively affected if a patient persisted in an unhealthy behavior.

WASHINGTON — The key to motivational interviewing is raising a subject without generating resistance, Sam Weir, M.D., explained at the annual meeting of the American College of Preventive Medicine.

"People are more likely to change when there is a discrepancy between their current behavior and their goals," said Dr. Weir of the department of family medicine at the University of North Carolina, Chapel Hill.

Once the physical exam and behavioral assessment are completed, summarize the results of the visit for the patient, and consider adding some motivational interviewing strategies, Dr. Weir suggested.

The FRAMES acronym is a quick and easy way to summarize and address preventive medicine issues, Dr. Weir said:

▸ Feedback. Feedback means being nonjudgmental, and saying with a straight face, "You know Mrs. Jones, drinking a six-pack of beer every night is more than most of my patients drink, and it's more than is recommended for your health." The doctor states a discrepancy in the behavior, compared with what is considered healthy, but makes no judgment. Ideally, the doctor would then ask the patient, "What do you think about that?" But when time is at a premium, move on to the next point.

▸ Responsibility. Make a statement that reasserts that problematic behavior, and the patient's reaction is up to the patient—for example, "What you do about your drinking is up to you."

▸ Advice. Doctors who avoid the use of the words "should" and "need," when offering advice are less likely to generate resistance in patients. "I encourage you to consider reducing your drinking" is better; the doctor communicates respect for the patient by the way he or she phrases the advice.

▸ Menu. Choices often provide motivation for behavior change. Remind patients that there are many ways to change their behavior, and offer to help them explore their options for doing so.

▸ Empathy. Tell patients that, "It might be hard for you to make this change," because sometimes it is. However, Dr. Weir said that he avoids saying that "it is hard" to change, because for some people it is not, once they make up their minds.

▸ Self-Efficacy. A statement such as, "But I'm confident that when you make up your mind to change, you will be able to do it," reinforces the fact that behavior change starts with the patients, but the doctor believes in their ability to change and will support their efforts when they are ready.

"This FRAMES moniker is a way to give advice about a lot of things in a short period of time," Dr. Weir noted, encouraging physicians to incorporate these principles in written materials, or in other communications with patients.

In his work with medical students, Dr. Weir teaches a 30-second version of FRAMES—a short statement to use with patients that touches all the FRAMES elements, not necessarily in the same order, that can be tweaked to specific behaviors. For example:

"Mrs. Jones, I strongly encourage you to consider quitting smoking. For most people, quitting is the single most important thing they can do to improve their health. The decision to quit is yours, and yours alone. There are many different ways that people can quit, and if you do decide that you want to quit, I'm confident that you can do it. If you decide at some point that you're interested, I'd be very willing to help you look at the options."

Dr. Weir said that he encourages medical students to take the FRAMES approach and write their own 30-second versions that they feel comfortable using, as long as they include all the FRAMES elements. "It's like a rosary chain; you need to touch all the beads," he said.

Dr. Weir also explained what motivational interviewing is not. "It is not arguing that a person has a problem and needs to change, it is not giving a solution without the patient's permission, and it is not taking an 'expert' stance," he said.

"Knowledge is not as much of a deficit as ambivalence," he added. Patients usually have feelings about their behavior, and it can be important to let them hear themselves talk about these feelings and have the opportunity to reflect on them.

Dr. Weir recalled that as a younger physician, he sometimes felt that his own value was negatively affected if a patient persisted in an unhealthy behavior.

WASHINGTON — The key to motivational interviewing is raising a subject without generating resistance, Sam Weir, M.D., explained at the annual meeting of the American College of Preventive Medicine.

"People are more likely to change when there is a discrepancy between their current behavior and their goals," said Dr. Weir of the department of family medicine at the University of North Carolina, Chapel Hill.

Once the physical exam and behavioral assessment are completed, summarize the results of the visit for the patient, and consider adding some motivational interviewing strategies, Dr. Weir suggested.

The FRAMES acronym is a quick and easy way to summarize and address preventive medicine issues, Dr. Weir said:

▸ Feedback. Feedback means being nonjudgmental, and saying with a straight face, "You know Mrs. Jones, drinking a six-pack of beer every night is more than most of my patients drink, and it's more than is recommended for your health." The doctor states a discrepancy in the behavior, compared with what is considered healthy, but makes no judgment. Ideally, the doctor would then ask the patient, "What do you think about that?" But when time is at a premium, move on to the next point.

▸ Responsibility. Make a statement that reasserts that problematic behavior, and the patient's reaction is up to the patient—for example, "What you do about your drinking is up to you."

▸ Advice. Doctors who avoid the use of the words "should" and "need," when offering advice are less likely to generate resistance in patients. "I encourage you to consider reducing your drinking" is better; the doctor communicates respect for the patient by the way he or she phrases the advice.

▸ Menu. Choices often provide motivation for behavior change. Remind patients that there are many ways to change their behavior, and offer to help them explore their options for doing so.

▸ Empathy. Tell patients that, "It might be hard for you to make this change," because sometimes it is. However, Dr. Weir said that he avoids saying that "it is hard" to change, because for some people it is not, once they make up their minds.

▸ Self-Efficacy. A statement such as, "But I'm confident that when you make up your mind to change, you will be able to do it," reinforces the fact that behavior change starts with the patients, but the doctor believes in their ability to change and will support their efforts when they are ready.

"This FRAMES moniker is a way to give advice about a lot of things in a short period of time," Dr. Weir noted, encouraging physicians to incorporate these principles in written materials, or in other communications with patients.

In his work with medical students, Dr. Weir teaches a 30-second version of FRAMES—a short statement to use with patients that touches all the FRAMES elements, not necessarily in the same order, that can be tweaked to specific behaviors. For example:

"Mrs. Jones, I strongly encourage you to consider quitting smoking. For most people, quitting is the single most important thing they can do to improve their health. The decision to quit is yours, and yours alone. There are many different ways that people can quit, and if you do decide that you want to quit, I'm confident that you can do it. If you decide at some point that you're interested, I'd be very willing to help you look at the options."

Dr. Weir said that he encourages medical students to take the FRAMES approach and write their own 30-second versions that they feel comfortable using, as long as they include all the FRAMES elements. "It's like a rosary chain; you need to touch all the beads," he said.

Dr. Weir also explained what motivational interviewing is not. "It is not arguing that a person has a problem and needs to change, it is not giving a solution without the patient's permission, and it is not taking an 'expert' stance," he said.

"Knowledge is not as much of a deficit as ambivalence," he added. Patients usually have feelings about their behavior, and it can be important to let them hear themselves talk about these feelings and have the opportunity to reflect on them.

Dr. Weir recalled that as a younger physician, he sometimes felt that his own value was negatively affected if a patient persisted in an unhealthy behavior.

WASHINGTON — Pulse wave analysis is an investigational noninvasive technique that might help doctors identify women at increased risk for preeclampsia, results of a pilot study suggest.

A distinctive peak on the augmentation index, which is a measure of aortic stiffness, distinguishes preeclampsia from other hypertensive disorders in pregnancy, according to a poster presented by Brendan J. Smyth, M.D., at the Clinical Research 2005 meeting sponsored by the American Federation for Medical Research.

In a normal pregnancy, the augmentation index (AIx) decreases, but in this study it stayed elevated with preeclampsia, said Dr. Smyth of Georgetown University, Washington. The AIx is the ratio of augmented systolic pressure to pulse pressure, and represents factors related to arterial function.

Dr. Smyth and his colleagues presented data on 17 preeclampsia patients from their prospective, ongoing pilot study. Pulse wave analysis was used to assess women at prepartum and postpartum sessions or within 24 hours of antihypertensive therapy. They said those with preeclampsia had a distinctive peak in the waveform.

The mean percentage for the AIx peak in preeclampsia patients was 35%, compared with 15% for an additional 16 women with chronic hypertension, 15% for 15 women with gestational diabetes, and −6% for 8 normally healthy women.

The mean percentage was 31% for five women with preeclampsia superimposed on chronic hypertension and 30% among three with preeclampsia superimposed on chronic hypertension plus diabetes mellitus.

The AIx measurement could be used to identify women at increased risk and to prevent unnecessary hospitalization.

The pilot study was supported in part by the National Center for Research Resources.

WASHINGTON — Pulse wave analysis is an investigational noninvasive technique that might help doctors identify women at increased risk for preeclampsia, results of a pilot study suggest.

A distinctive peak on the augmentation index, which is a measure of aortic stiffness, distinguishes preeclampsia from other hypertensive disorders in pregnancy, according to a poster presented by Brendan J. Smyth, M.D., at the Clinical Research 2005 meeting sponsored by the American Federation for Medical Research.

In a normal pregnancy, the augmentation index (AIx) decreases, but in this study it stayed elevated with preeclampsia, said Dr. Smyth of Georgetown University, Washington. The AIx is the ratio of augmented systolic pressure to pulse pressure, and represents factors related to arterial function.

Dr. Smyth and his colleagues presented data on 17 preeclampsia patients from their prospective, ongoing pilot study. Pulse wave analysis was used to assess women at prepartum and postpartum sessions or within 24 hours of antihypertensive therapy. They said those with preeclampsia had a distinctive peak in the waveform.

The mean percentage for the AIx peak in preeclampsia patients was 35%, compared with 15% for an additional 16 women with chronic hypertension, 15% for 15 women with gestational diabetes, and −6% for 8 normally healthy women.

The mean percentage was 31% for five women with preeclampsia superimposed on chronic hypertension and 30% among three with preeclampsia superimposed on chronic hypertension plus diabetes mellitus.

The AIx measurement could be used to identify women at increased risk and to prevent unnecessary hospitalization.

The pilot study was supported in part by the National Center for Research Resources.

WASHINGTON — Pulse wave analysis is an investigational noninvasive technique that might help doctors identify women at increased risk for preeclampsia, results of a pilot study suggest.

A distinctive peak on the augmentation index, which is a measure of aortic stiffness, distinguishes preeclampsia from other hypertensive disorders in pregnancy, according to a poster presented by Brendan J. Smyth, M.D., at the Clinical Research 2005 meeting sponsored by the American Federation for Medical Research.

In a normal pregnancy, the augmentation index (AIx) decreases, but in this study it stayed elevated with preeclampsia, said Dr. Smyth of Georgetown University, Washington. The AIx is the ratio of augmented systolic pressure to pulse pressure, and represents factors related to arterial function.

Dr. Smyth and his colleagues presented data on 17 preeclampsia patients from their prospective, ongoing pilot study. Pulse wave analysis was used to assess women at prepartum and postpartum sessions or within 24 hours of antihypertensive therapy. They said those with preeclampsia had a distinctive peak in the waveform.

The mean percentage for the AIx peak in preeclampsia patients was 35%, compared with 15% for an additional 16 women with chronic hypertension, 15% for 15 women with gestational diabetes, and −6% for 8 normally healthy women.

The mean percentage was 31% for five women with preeclampsia superimposed on chronic hypertension and 30% among three with preeclampsia superimposed on chronic hypertension plus diabetes mellitus.

The AIx measurement could be used to identify women at increased risk and to prevent unnecessary hospitalization.

The pilot study was supported in part by the National Center for Research Resources.

Acetaminophen might be detrimental to the lungs, reported Tricia M. McKeever, Ph.D., of the University of Nottingham (England) and her colleagues.

An analysis of data from the third National Health and Nutrition Examination Survey (NHANES III) confirmed previous findings suggesting links between consistent acetaminophen use and asthma risk, chronic obstructive pulmonary disease (COPD) risk, and poor lung function. The study included 13,492 adults, 53% of whom were women, with a mean age of 45 years. About 41% were white, 30% were black, and 29% were Mexican American (Am. J. Respir. Crit. Care Med. 2005;171:966–71). The participants completed questionnaires and underwent physicals and lung function tests.

Overall, the prevalence of asthma was 6.9%, the prevalence of COPD was 11.8%, and the prevalence of both conditions together was 2.8%. About 4% of the participants reported taking acetaminophen daily, compared with 8.2% and 2.5% of those who reported taking daily aspirin and ibuprofen, respectively.

A dose-dependent relationship surfaced between increased acetaminophen use and increased asthma prevalence, with an odds ratio of 1.20 for each increasing category of medication intake. The categories were: never, occasional (1–5 times per month), regular (6–29 times per month), and daily (at least 30 times per month).

Regular or daily acetaminophen use also was associated with an increased prevalence of COPD (odds ratio 1.16 for each increasing category of use), independent of asthma risk.

Acetaminophen might be detrimental to the lungs, reported Tricia M. McKeever, Ph.D., of the University of Nottingham (England) and her colleagues.

An analysis of data from the third National Health and Nutrition Examination Survey (NHANES III) confirmed previous findings suggesting links between consistent acetaminophen use and asthma risk, chronic obstructive pulmonary disease (COPD) risk, and poor lung function. The study included 13,492 adults, 53% of whom were women, with a mean age of 45 years. About 41% were white, 30% were black, and 29% were Mexican American (Am. J. Respir. Crit. Care Med. 2005;171:966–71). The participants completed questionnaires and underwent physicals and lung function tests.

Overall, the prevalence of asthma was 6.9%, the prevalence of COPD was 11.8%, and the prevalence of both conditions together was 2.8%. About 4% of the participants reported taking acetaminophen daily, compared with 8.2% and 2.5% of those who reported taking daily aspirin and ibuprofen, respectively.

A dose-dependent relationship surfaced between increased acetaminophen use and increased asthma prevalence, with an odds ratio of 1.20 for each increasing category of medication intake. The categories were: never, occasional (1–5 times per month), regular (6–29 times per month), and daily (at least 30 times per month).

Regular or daily acetaminophen use also was associated with an increased prevalence of COPD (odds ratio 1.16 for each increasing category of use), independent of asthma risk.

Acetaminophen might be detrimental to the lungs, reported Tricia M. McKeever, Ph.D., of the University of Nottingham (England) and her colleagues.

An analysis of data from the third National Health and Nutrition Examination Survey (NHANES III) confirmed previous findings suggesting links between consistent acetaminophen use and asthma risk, chronic obstructive pulmonary disease (COPD) risk, and poor lung function. The study included 13,492 adults, 53% of whom were women, with a mean age of 45 years. About 41% were white, 30% were black, and 29% were Mexican American (Am. J. Respir. Crit. Care Med. 2005;171:966–71). The participants completed questionnaires and underwent physicals and lung function tests.

Overall, the prevalence of asthma was 6.9%, the prevalence of COPD was 11.8%, and the prevalence of both conditions together was 2.8%. About 4% of the participants reported taking acetaminophen daily, compared with 8.2% and 2.5% of those who reported taking daily aspirin and ibuprofen, respectively.

A dose-dependent relationship surfaced between increased acetaminophen use and increased asthma prevalence, with an odds ratio of 1.20 for each increasing category of medication intake. The categories were: never, occasional (1–5 times per month), regular (6–29 times per month), and daily (at least 30 times per month).

Regular or daily acetaminophen use also was associated with an increased prevalence of COPD (odds ratio 1.16 for each increasing category of use), independent of asthma risk.

Hormone therapy is associated with a significantly increased risk of stroke, based on studies involving nearly 40,000 patients.

A review of 28 studies ranging in size from 59 to 16,608 adults and with follow-up times of 0.7–6.8 years showed a significant association between HT use and an increased risk of total stroke, with an odds ratio of 1.29. The review supports previous studies that showed an association between increased risk of stroke and hormone therapy, reported Philip Bath, M.D., and Laura Gray of the University of Nottingham, (England) (BMJ [Epub ahead of print], January 2005. Article DOI number: 10.1136/bmj.38331.655347.8F. Available from: www.bmj.com

Twelve studies included women taking estrogen only; 16 included women taking estrogen plus progesterone. The average ages ranged from 55 to 71 years, and three studies of estrogen combined with progesterone included men. All but 5 studies were placebo-controlled, and 11 small trials recorded no stroke events.

Overall, 2% of patients randomized to no HT suffered strokes, but the risk of stroke among women randomized to HT increased 29%, primarily because of the increase in ischemic stroke. In addition, severity of stroke increased with HT use; the chance of a poor functional outcome, defined as either death or disability and dependency, was 56% higher among women randomized to HT. In particular, HT use was associated with a significant increase in the risk of ischemic stroke in 16 studies (OR 1.29). HT use also was significantly associated with an increased risk of nonfatal stroke in 21 studies (OR 1.23), and with an increased risk of stroke leading to death or dependency in 14 studies (OR 1.56).

Hormone therapy is associated with a significantly increased risk of stroke, based on studies involving nearly 40,000 patients.

A review of 28 studies ranging in size from 59 to 16,608 adults and with follow-up times of 0.7–6.8 years showed a significant association between HT use and an increased risk of total stroke, with an odds ratio of 1.29. The review supports previous studies that showed an association between increased risk of stroke and hormone therapy, reported Philip Bath, M.D., and Laura Gray of the University of Nottingham, (England) (BMJ [Epub ahead of print], January 2005. Article DOI number: 10.1136/bmj.38331.655347.8F. Available from: www.bmj.com

Twelve studies included women taking estrogen only; 16 included women taking estrogen plus progesterone. The average ages ranged from 55 to 71 years, and three studies of estrogen combined with progesterone included men. All but 5 studies were placebo-controlled, and 11 small trials recorded no stroke events.

Overall, 2% of patients randomized to no HT suffered strokes, but the risk of stroke among women randomized to HT increased 29%, primarily because of the increase in ischemic stroke. In addition, severity of stroke increased with HT use; the chance of a poor functional outcome, defined as either death or disability and dependency, was 56% higher among women randomized to HT. In particular, HT use was associated with a significant increase in the risk of ischemic stroke in 16 studies (OR 1.29). HT use also was significantly associated with an increased risk of nonfatal stroke in 21 studies (OR 1.23), and with an increased risk of stroke leading to death or dependency in 14 studies (OR 1.56).

Hormone therapy is associated with a significantly increased risk of stroke, based on studies involving nearly 40,000 patients.

A review of 28 studies ranging in size from 59 to 16,608 adults and with follow-up times of 0.7–6.8 years showed a significant association between HT use and an increased risk of total stroke, with an odds ratio of 1.29. The review supports previous studies that showed an association between increased risk of stroke and hormone therapy, reported Philip Bath, M.D., and Laura Gray of the University of Nottingham, (England) (BMJ [Epub ahead of print], January 2005. Article DOI number: 10.1136/bmj.38331.655347.8F. Available from: www.bmj.com

Twelve studies included women taking estrogen only; 16 included women taking estrogen plus progesterone. The average ages ranged from 55 to 71 years, and three studies of estrogen combined with progesterone included men. All but 5 studies were placebo-controlled, and 11 small trials recorded no stroke events.

Overall, 2% of patients randomized to no HT suffered strokes, but the risk of stroke among women randomized to HT increased 29%, primarily because of the increase in ischemic stroke. In addition, severity of stroke increased with HT use; the chance of a poor functional outcome, defined as either death or disability and dependency, was 56% higher among women randomized to HT. In particular, HT use was associated with a significant increase in the risk of ischemic stroke in 16 studies (OR 1.29). HT use also was significantly associated with an increased risk of nonfatal stroke in 21 studies (OR 1.23), and with an increased risk of stroke leading to death or dependency in 14 studies (OR 1.56).

HOUSTON — In the age of 24-hour technology, bullying no longer stops at the edge of the playground.

Cyber bullying is a form of harassment using text messages, e-mail, and Web sites. This high-technology approach allows children and adolescents to engage in bullying not only at school, but at home, at all hours of the day and night.

A bully can post a disparaging comment on the Internet or in an e-mail message and send it to 3 people, 30 people, or 300 people, said Richard Sarles, M.D., at the annual meeting of the American Society for Adolescent Psychiatry.

In addition, the insult is there for the victim and recipients of the message to read over and over again—which makes this kind of aggression even more insidious, said Dr. Sarles, professor of psychiatry and pediatrics at the University of Maryland, Baltimore.

The anonymous nature of cyberspace creates additional problems, because the bully need not face the victim and may be unknown.

Any sort of bullying is a significant clinical problem, Dr. Sarles said at the meeting, cosponsored by the University of Texas Southwestern Medical Center at Dallas. In fact, bullying, the most common form of aggression experienced by children and teens, is more problematic for this population than is racism or pressure to use drugs or alcohol or to have sex, he said.

Traditional bullying can be either physical or verbal. Dr. Sarles said boys tend to be more direct—and aggressive—than girls.

Boys are more likely to intimidate their victims by engaging in name-calling, malicious teasing, and obnoxious gestures.

Girls who bully tend to use more passive approaches. They are more likely to employ rumor spreading, malicious gossip, and sexual innuendo. In addition, girls are less likely to use physical bullying. Instead, they are more drawn to relational bullying, which is meant to cause social isolation. Their goals are to damage reputations and relationships.

Cyber bullying in the hands of girls can be particularly devastating. After all, they are coming at a time when peer group acceptance and the need for belonging are highly sought, Dr. Sarles said.

“Girls share so much information when they are friends that they never run out of ammunition if they turn on one another,” he noted.

Several theories exist about the etiology of bullying, Dr. Sarles said.

The person-centered theory involves the characteristics of the bully, victim, and onlookers, and the way in which they predispose children to bullying or being bullied.

“We know that bullies are impulsive; they often have characteristics of oppositional defiant disorder, often have a hard time following school rules, and derive satisfaction from inflicting harm and intimidating others,” Dr. Sarles said. They tend to be nonempathetic and domineering. These children or teens may have conduct disorder and antisocial personality disorder as well.

In some cases, parents encourage bullying behavior and model it for the children at home, Dr. Sarles noted.

The victims of bullies tend to be shy, quiet, socially awkward, and sometimes labeled “nerds,” or “weirdos.” They tend to be nonassertive and have few friends and low self-esteem, and have poor social skills.

In other words, victims tend “not to fit in,” which is a stronger predictor of being the victim of a bully than other physical characteristics such as height and weight, Dr. Sarles noted. Bullies are more likely to pick on socially awkward children than those with obvious physical abnormalities or disabilities, he said.

“Bully-victims are a group that we don't know much about,” Dr. Sarles said. These children or adolescents are usually victims first, and then they become bullies, and they are overrepresented as perpetrators in instances of school shootings.

The onlookers represent the largest group of adolescents. This group doesn't present with symptoms, so are not treated for anything from a clinical psychiatrist's point of view.

However, they are extremely important in discussions of intervention, because they provide an audience and tacit approval for the behavior to continue. “Bullies like a crowd,” Dr. Sarles said. The onlookers could stop the bullying, but they may fear retaliation from the bully if they interfere, or they fear being labeled a snitch or tattletale.

The dominance theory of bullying involves a hierarchy based on access to and control of resources.

When transitioning from elementary school to middle school, children need to reassert their dominance.

Research has shown that the most common time for bullying behavior is in middle school, when children both redefine their identities and adjust to the onset of puberty, Dr. Sarles said.

Their surging hormones allow for variation in size and development that can foster bullying behavior.

The ecologic theory goes beyond the bully-victim dyad. This theory includes all factors that allow bullying to develop and persist, with interplay among the family, victim, bully, onlookers, school personnel, and community.

This theory suggests that school and playground designs may foster unsupervised spaces where children and adolescents are vulnerable to bullies, and that inaction on the part of parents, teachers, principals, and other school personnel and members of the community allow bullying to continue.

“If you can't change community attitudes and the school environment, you won't be able to prevent bullying,” Dr. Sarles said. A successful intervention involves parents and school personnel recognizing that bullying exists and developing a consensus on prevention programs. (See sidebar.)

Physicians may recognize bullying before the parents do.

“As clinicians, you know that someone doesn't walk into your office and say, 'I need help; I'm a bully,'” Dr Sarles said.

However, there are clear links between bullying and other antisocial behaviors later in life. Dr. Sarles cited one study in which 40% of people who reported being bullies as children or adolescents had been convicted of a crime by the age of 24 years.

Children and adolescents who are victims, on the other hand, may present to clinicians with symptoms of anxiety. These children often do not want to go to school, feign illness, and have unexplained cuts and bruises. Belongings, such as hats, jackets, books, or backpacks, often end up missing for bullying victims.

After the bullying stops, the symptoms tend to disappear in the absence of a genuine comorbid condition, Dr. Sarles explained.

How Do You Stop a Bully?

Most bullying, even cyber bullying, begins at school—where children meet and spend much of their time. Many interventions against bullying start at school as well.

“You have to get people to agree that bullying is not for kids,” by encouraging parents to go to their children's schools and advocate for a no-tolerance policy, Dr. Sarles said.

School-based strategies include:

▸ Increasing adult supervision of children in public spaces during lunch and recess.

▸ Elimination of unsupervised places where children might be bullied.

▸ Use of classroom-based antibullying programs in an effort to teach that bullying is wrong and should be reported.

▸ Use of a “bully box” near the school counselor's office that allows children to anonymously report bullying episodes.

▸ Role playing and assertiveness training.

▸ Use of video cameras on school buses, on school property, and in buildings to record instances of bullying and to act as a deterrent.

▸ Establishment and enforcement of a zero-tolerance bullying policy that includes all school personnel, from teachers to cafeteria workers, coaches, and janitors.

▸ Switching schools. If the school and community fail to cooperate, the child must simply change schools to get out of an abusive environment.

The federal government has jumped on the bully bandwagon. Its Web site,

http://stopbullyingnow.hrsa.gov

The bottom line is to create a safe environment for the child, because children who feel intimidated in school can't learn, Dr. Sarles said.

HOUSTON — In the age of 24-hour technology, bullying no longer stops at the edge of the playground.

Cyber bullying is a form of harassment using text messages, e-mail, and Web sites. This high-technology approach allows children and adolescents to engage in bullying not only at school, but at home, at all hours of the day and night.

A bully can post a disparaging comment on the Internet or in an e-mail message and send it to 3 people, 30 people, or 300 people, said Richard Sarles, M.D., at the annual meeting of the American Society for Adolescent Psychiatry.

In addition, the insult is there for the victim and recipients of the message to read over and over again—which makes this kind of aggression even more insidious, said Dr. Sarles, professor of psychiatry and pediatrics at the University of Maryland, Baltimore.

The anonymous nature of cyberspace creates additional problems, because the bully need not face the victim and may be unknown.

Any sort of bullying is a significant clinical problem, Dr. Sarles said at the meeting, cosponsored by the University of Texas Southwestern Medical Center at Dallas. In fact, bullying, the most common form of aggression experienced by children and teens, is more problematic for this population than is racism or pressure to use drugs or alcohol or to have sex, he said.

Traditional bullying can be either physical or verbal. Dr. Sarles said boys tend to be more direct—and aggressive—than girls.

Boys are more likely to intimidate their victims by engaging in name-calling, malicious teasing, and obnoxious gestures.

Girls who bully tend to use more passive approaches. They are more likely to employ rumor spreading, malicious gossip, and sexual innuendo. In addition, girls are less likely to use physical bullying. Instead, they are more drawn to relational bullying, which is meant to cause social isolation. Their goals are to damage reputations and relationships.

Cyber bullying in the hands of girls can be particularly devastating. After all, they are coming at a time when peer group acceptance and the need for belonging are highly sought, Dr. Sarles said.

“Girls share so much information when they are friends that they never run out of ammunition if they turn on one another,” he noted.

Several theories exist about the etiology of bullying, Dr. Sarles said.

The person-centered theory involves the characteristics of the bully, victim, and onlookers, and the way in which they predispose children to bullying or being bullied.

“We know that bullies are impulsive; they often have characteristics of oppositional defiant disorder, often have a hard time following school rules, and derive satisfaction from inflicting harm and intimidating others,” Dr. Sarles said. They tend to be nonempathetic and domineering. These children or teens may have conduct disorder and antisocial personality disorder as well.

In some cases, parents encourage bullying behavior and model it for the children at home, Dr. Sarles noted.

The victims of bullies tend to be shy, quiet, socially awkward, and sometimes labeled “nerds,” or “weirdos.” They tend to be nonassertive and have few friends and low self-esteem, and have poor social skills.

In other words, victims tend “not to fit in,” which is a stronger predictor of being the victim of a bully than other physical characteristics such as height and weight, Dr. Sarles noted. Bullies are more likely to pick on socially awkward children than those with obvious physical abnormalities or disabilities, he said.

“Bully-victims are a group that we don't know much about,” Dr. Sarles said. These children or adolescents are usually victims first, and then they become bullies, and they are overrepresented as perpetrators in instances of school shootings.

The onlookers represent the largest group of adolescents. This group doesn't present with symptoms, so are not treated for anything from a clinical psychiatrist's point of view.

However, they are extremely important in discussions of intervention, because they provide an audience and tacit approval for the behavior to continue. “Bullies like a crowd,” Dr. Sarles said. The onlookers could stop the bullying, but they may fear retaliation from the bully if they interfere, or they fear being labeled a snitch or tattletale.

The dominance theory of bullying involves a hierarchy based on access to and control of resources.

When transitioning from elementary school to middle school, children need to reassert their dominance.

Research has shown that the most common time for bullying behavior is in middle school, when children both redefine their identities and adjust to the onset of puberty, Dr. Sarles said.

Their surging hormones allow for variation in size and development that can foster bullying behavior.

The ecologic theory goes beyond the bully-victim dyad. This theory includes all factors that allow bullying to develop and persist, with interplay among the family, victim, bully, onlookers, school personnel, and community.

This theory suggests that school and playground designs may foster unsupervised spaces where children and adolescents are vulnerable to bullies, and that inaction on the part of parents, teachers, principals, and other school personnel and members of the community allow bullying to continue.

“If you can't change community attitudes and the school environment, you won't be able to prevent bullying,” Dr. Sarles said. A successful intervention involves parents and school personnel recognizing that bullying exists and developing a consensus on prevention programs. (See sidebar.)

Physicians may recognize bullying before the parents do.

“As clinicians, you know that someone doesn't walk into your office and say, 'I need help; I'm a bully,'” Dr Sarles said.

However, there are clear links between bullying and other antisocial behaviors later in life. Dr. Sarles cited one study in which 40% of people who reported being bullies as children or adolescents had been convicted of a crime by the age of 24 years.

Children and adolescents who are victims, on the other hand, may present to clinicians with symptoms of anxiety. These children often do not want to go to school, feign illness, and have unexplained cuts and bruises. Belongings, such as hats, jackets, books, or backpacks, often end up missing for bullying victims.

After the bullying stops, the symptoms tend to disappear in the absence of a genuine comorbid condition, Dr. Sarles explained.

How Do You Stop a Bully?

Most bullying, even cyber bullying, begins at school—where children meet and spend much of their time. Many interventions against bullying start at school as well.

“You have to get people to agree that bullying is not for kids,” by encouraging parents to go to their children's schools and advocate for a no-tolerance policy, Dr. Sarles said.

School-based strategies include:

▸ Increasing adult supervision of children in public spaces during lunch and recess.

▸ Elimination of unsupervised places where children might be bullied.

▸ Use of classroom-based antibullying programs in an effort to teach that bullying is wrong and should be reported.

▸ Use of a “bully box” near the school counselor's office that allows children to anonymously report bullying episodes.

▸ Role playing and assertiveness training.

▸ Use of video cameras on school buses, on school property, and in buildings to record instances of bullying and to act as a deterrent.

▸ Establishment and enforcement of a zero-tolerance bullying policy that includes all school personnel, from teachers to cafeteria workers, coaches, and janitors.

▸ Switching schools. If the school and community fail to cooperate, the child must simply change schools to get out of an abusive environment.

The federal government has jumped on the bully bandwagon. Its Web site,

http://stopbullyingnow.hrsa.gov

The bottom line is to create a safe environment for the child, because children who feel intimidated in school can't learn, Dr. Sarles said.

HOUSTON — In the age of 24-hour technology, bullying no longer stops at the edge of the playground.

Cyber bullying is a form of harassment using text messages, e-mail, and Web sites. This high-technology approach allows children and adolescents to engage in bullying not only at school, but at home, at all hours of the day and night.

A bully can post a disparaging comment on the Internet or in an e-mail message and send it to 3 people, 30 people, or 300 people, said Richard Sarles, M.D., at the annual meeting of the American Society for Adolescent Psychiatry.

In addition, the insult is there for the victim and recipients of the message to read over and over again—which makes this kind of aggression even more insidious, said Dr. Sarles, professor of psychiatry and pediatrics at the University of Maryland, Baltimore.

The anonymous nature of cyberspace creates additional problems, because the bully need not face the victim and may be unknown.

Any sort of bullying is a significant clinical problem, Dr. Sarles said at the meeting, cosponsored by the University of Texas Southwestern Medical Center at Dallas. In fact, bullying, the most common form of aggression experienced by children and teens, is more problematic for this population than is racism or pressure to use drugs or alcohol or to have sex, he said.

Traditional bullying can be either physical or verbal. Dr. Sarles said boys tend to be more direct—and aggressive—than girls.

Boys are more likely to intimidate their victims by engaging in name-calling, malicious teasing, and obnoxious gestures.

Girls who bully tend to use more passive approaches. They are more likely to employ rumor spreading, malicious gossip, and sexual innuendo. In addition, girls are less likely to use physical bullying. Instead, they are more drawn to relational bullying, which is meant to cause social isolation. Their goals are to damage reputations and relationships.

Cyber bullying in the hands of girls can be particularly devastating. After all, they are coming at a time when peer group acceptance and the need for belonging are highly sought, Dr. Sarles said.

“Girls share so much information when they are friends that they never run out of ammunition if they turn on one another,” he noted.

Several theories exist about the etiology of bullying, Dr. Sarles said.

The person-centered theory involves the characteristics of the bully, victim, and onlookers, and the way in which they predispose children to bullying or being bullied.

“We know that bullies are impulsive; they often have characteristics of oppositional defiant disorder, often have a hard time following school rules, and derive satisfaction from inflicting harm and intimidating others,” Dr. Sarles said. They tend to be nonempathetic and domineering. These children or teens may have conduct disorder and antisocial personality disorder as well.

In some cases, parents encourage bullying behavior and model it for the children at home, Dr. Sarles noted.

The victims of bullies tend to be shy, quiet, socially awkward, and sometimes labeled “nerds,” or “weirdos.” They tend to be nonassertive and have few friends and low self-esteem, and have poor social skills.

In other words, victims tend “not to fit in,” which is a stronger predictor of being the victim of a bully than other physical characteristics such as height and weight, Dr. Sarles noted. Bullies are more likely to pick on socially awkward children than those with obvious physical abnormalities or disabilities, he said.

“Bully-victims are a group that we don't know much about,” Dr. Sarles said. These children or adolescents are usually victims first, and then they become bullies, and they are overrepresented as perpetrators in instances of school shootings.

The onlookers represent the largest group of adolescents. This group doesn't present with symptoms, so are not treated for anything from a clinical psychiatrist's point of view.

However, they are extremely important in discussions of intervention, because they provide an audience and tacit approval for the behavior to continue. “Bullies like a crowd,” Dr. Sarles said. The onlookers could stop the bullying, but they may fear retaliation from the bully if they interfere, or they fear being labeled a snitch or tattletale.

The dominance theory of bullying involves a hierarchy based on access to and control of resources.

When transitioning from elementary school to middle school, children need to reassert their dominance.

Research has shown that the most common time for bullying behavior is in middle school, when children both redefine their identities and adjust to the onset of puberty, Dr. Sarles said.

Their surging hormones allow for variation in size and development that can foster bullying behavior.

The ecologic theory goes beyond the bully-victim dyad. This theory includes all factors that allow bullying to develop and persist, with interplay among the family, victim, bully, onlookers, school personnel, and community.

This theory suggests that school and playground designs may foster unsupervised spaces where children and adolescents are vulnerable to bullies, and that inaction on the part of parents, teachers, principals, and other school personnel and members of the community allow bullying to continue.

“If you can't change community attitudes and the school environment, you won't be able to prevent bullying,” Dr. Sarles said. A successful intervention involves parents and school personnel recognizing that bullying exists and developing a consensus on prevention programs. (See sidebar.)

Physicians may recognize bullying before the parents do.

“As clinicians, you know that someone doesn't walk into your office and say, 'I need help; I'm a bully,'” Dr Sarles said.

However, there are clear links between bullying and other antisocial behaviors later in life. Dr. Sarles cited one study in which 40% of people who reported being bullies as children or adolescents had been convicted of a crime by the age of 24 years.

Children and adolescents who are victims, on the other hand, may present to clinicians with symptoms of anxiety. These children often do not want to go to school, feign illness, and have unexplained cuts and bruises. Belongings, such as hats, jackets, books, or backpacks, often end up missing for bullying victims.

After the bullying stops, the symptoms tend to disappear in the absence of a genuine comorbid condition, Dr. Sarles explained.

How Do You Stop a Bully?

Most bullying, even cyber bullying, begins at school—where children meet and spend much of their time. Many interventions against bullying start at school as well.

“You have to get people to agree that bullying is not for kids,” by encouraging parents to go to their children's schools and advocate for a no-tolerance policy, Dr. Sarles said.

School-based strategies include:

▸ Increasing adult supervision of children in public spaces during lunch and recess.

▸ Elimination of unsupervised places where children might be bullied.

▸ Use of classroom-based antibullying programs in an effort to teach that bullying is wrong and should be reported.

▸ Use of a “bully box” near the school counselor's office that allows children to anonymously report bullying episodes.

▸ Role playing and assertiveness training.

▸ Use of video cameras on school buses, on school property, and in buildings to record instances of bullying and to act as a deterrent.

▸ Establishment and enforcement of a zero-tolerance bullying policy that includes all school personnel, from teachers to cafeteria workers, coaches, and janitors.

▸ Switching schools. If the school and community fail to cooperate, the child must simply change schools to get out of an abusive environment.

The federal government has jumped on the bully bandwagon. Its Web site,

http://stopbullyingnow.hrsa.gov

The bottom line is to create a safe environment for the child, because children who feel intimidated in school can't learn, Dr. Sarles said.

Reasons for Vaccine Refusal

Approximately 69% of 277 parents of nonvaccinated children cited concerns that vaccines might cause harm, said Daniel A. Salmon, Ph.D., of Johns Hopkins University, and his colleagues (Arch. Pediatr. Adolesc. Med. 2005;159:470–6). In a case-control study, the investigators reviewed data from surveys of 976 parents of vaccinated children and 277 parents of children who received nonmedical exemptions to school vaccination requirements.

Varicella was the most often refused vaccine and was not given to 147 (53%) of the 277 exempt children. Polio was the least often refused vaccine and was not given to 45 (16%) children.

Other reasons for refusing vaccination included concerns that the vaccines might overload the immune system (49%), belief that the child was not at risk for the disease (37%), that the disease was not dangerous (20%), and that that vaccines might not work (13%).

Parents of exempt children were less likely to report that their child's primary health provider was a physician, compared with parents of vaccinated children (76% vs. 94%). In general, parents of exempt children were more likely to be older than the median age of 36–40 years and to have a higher level of education compared with parents of vaccinated children. The parents of exempt and vaccinated children were similar in terms of family income and race.

One Swab Is Enough

Use of two throat swabs did not significantly improve the sensitivity of the OIA MAX test for group A streptococcus in a randomized study of 363 children aged 5–18 years with acute pharyngitis, said Elias N. Ezike, M.D., of the Children's Hospital of Michigan, Detroit, and his associates (Arch. Pediatr. Adolesc. Med. 2005;159:486–90).

One throat swab was obtained from a group of 117 children (group 1), and two swabs were obtained from a group of 186 children (group 2). The sensitivity was 94.7% and 100% for groups 1 and 2, respectively, and the specificity was 92.4% and 96.3% for groups 1 and 2, respectively. Overall, the OIA MAX test identified group A streptococcus in 148 of the 363 (40.8%) patients, including 71 in group 1 (40.1%) and 77 in group 2 (41.4%). Clinical presentations were not significantly different between children with and without group A streptococcus, and there was no association between the severity of pharyngitis and the sensitivity of the OIA MAX test.

Group B Strep Poorly Diagnosed

A differential diagnosis in adolescents with purulent vaginal discharge should include group B streptococci, said Liana R. Clark, M.D., and Marisa Atendido of the Children's Hospital of Philadelphia (J. Adolesc. Health 2005;36:437–40).

The investigators conducted a retrospective analysis of 13 adolescents (mean age 16 years) who demonstrated clinical signs of infection and tested positive for group B streptococci. Of these, 12 of 13 had a purulent cervicovaginal discharge. Of the 12, 3 had cervicitis, 3 had inflamed vaginal mucosa, 2 had vaginal erythema, and 1 had vaginal bleeding. Only one girl was accurately diagnosed with group B streptococci at the time of her visit, and she was treated with cefuroxime. Three were misdiagnosed with STDs. Small numbers and lack of asymptomatic controls limited the study.

Pocket Pets May Pack Salmonella

The Centers for Disease Control and Prevention identified 28 cases of Salmonella enteritidis serotype typhimurium associated with pet rodents including hamsters, mice, and rats between December 2003 and October 2004 (MMWR 2005;54:429–32). The mean age of those affected was 16 years, and seven cases occurred in children younger than 7 years.

Particularly severe cases occurred in two 5-year-old boys. The first of these occurred in June 2004 in Minnesota, when the boy became ill 4 days after he received a pet mouse. The second case occurred in August 2004 in South Carolina, when the boy became ill 9 days after he received a pet hamster. In both cases, the children developed fevers, diarrhea, and abdominal cramping, and stool cultures yielded S. typhimurium. Both pet rodents died within a week of their purchase, and a culture from the mouse also yielded S. typhimurium. Rodents linked to all 28 cases were purchased from multiple retail pet store chains and distributors, and S. typhimurium was recovered from pet transport containers and from bins containing rodent droppings.

Reasons for Vaccine Refusal

Approximately 69% of 277 parents of nonvaccinated children cited concerns that vaccines might cause harm, said Daniel A. Salmon, Ph.D., of Johns Hopkins University, and his colleagues (Arch. Pediatr. Adolesc. Med. 2005;159:470–6). In a case-control study, the investigators reviewed data from surveys of 976 parents of vaccinated children and 277 parents of children who received nonmedical exemptions to school vaccination requirements.

Varicella was the most often refused vaccine and was not given to 147 (53%) of the 277 exempt children. Polio was the least often refused vaccine and was not given to 45 (16%) children.

Other reasons for refusing vaccination included concerns that the vaccines might overload the immune system (49%), belief that the child was not at risk for the disease (37%), that the disease was not dangerous (20%), and that that vaccines might not work (13%).

Parents of exempt children were less likely to report that their child's primary health provider was a physician, compared with parents of vaccinated children (76% vs. 94%). In general, parents of exempt children were more likely to be older than the median age of 36–40 years and to have a higher level of education compared with parents of vaccinated children. The parents of exempt and vaccinated children were similar in terms of family income and race.

One Swab Is Enough

Use of two throat swabs did not significantly improve the sensitivity of the OIA MAX test for group A streptococcus in a randomized study of 363 children aged 5–18 years with acute pharyngitis, said Elias N. Ezike, M.D., of the Children's Hospital of Michigan, Detroit, and his associates (Arch. Pediatr. Adolesc. Med. 2005;159:486–90).

One throat swab was obtained from a group of 117 children (group 1), and two swabs were obtained from a group of 186 children (group 2). The sensitivity was 94.7% and 100% for groups 1 and 2, respectively, and the specificity was 92.4% and 96.3% for groups 1 and 2, respectively. Overall, the OIA MAX test identified group A streptococcus in 148 of the 363 (40.8%) patients, including 71 in group 1 (40.1%) and 77 in group 2 (41.4%). Clinical presentations were not significantly different between children with and without group A streptococcus, and there was no association between the severity of pharyngitis and the sensitivity of the OIA MAX test.

Group B Strep Poorly Diagnosed

A differential diagnosis in adolescents with purulent vaginal discharge should include group B streptococci, said Liana R. Clark, M.D., and Marisa Atendido of the Children's Hospital of Philadelphia (J. Adolesc. Health 2005;36:437–40).

The investigators conducted a retrospective analysis of 13 adolescents (mean age 16 years) who demonstrated clinical signs of infection and tested positive for group B streptococci. Of these, 12 of 13 had a purulent cervicovaginal discharge. Of the 12, 3 had cervicitis, 3 had inflamed vaginal mucosa, 2 had vaginal erythema, and 1 had vaginal bleeding. Only one girl was accurately diagnosed with group B streptococci at the time of her visit, and she was treated with cefuroxime. Three were misdiagnosed with STDs. Small numbers and lack of asymptomatic controls limited the study.

Pocket Pets May Pack Salmonella

The Centers for Disease Control and Prevention identified 28 cases of Salmonella enteritidis serotype typhimurium associated with pet rodents including hamsters, mice, and rats between December 2003 and October 2004 (MMWR 2005;54:429–32). The mean age of those affected was 16 years, and seven cases occurred in children younger than 7 years.

Particularly severe cases occurred in two 5-year-old boys. The first of these occurred in June 2004 in Minnesota, when the boy became ill 4 days after he received a pet mouse. The second case occurred in August 2004 in South Carolina, when the boy became ill 9 days after he received a pet hamster. In both cases, the children developed fevers, diarrhea, and abdominal cramping, and stool cultures yielded S. typhimurium. Both pet rodents died within a week of their purchase, and a culture from the mouse also yielded S. typhimurium. Rodents linked to all 28 cases were purchased from multiple retail pet store chains and distributors, and S. typhimurium was recovered from pet transport containers and from bins containing rodent droppings.

Reasons for Vaccine Refusal

Approximately 69% of 277 parents of nonvaccinated children cited concerns that vaccines might cause harm, said Daniel A. Salmon, Ph.D., of Johns Hopkins University, and his colleagues (Arch. Pediatr. Adolesc. Med. 2005;159:470–6). In a case-control study, the investigators reviewed data from surveys of 976 parents of vaccinated children and 277 parents of children who received nonmedical exemptions to school vaccination requirements.

Varicella was the most often refused vaccine and was not given to 147 (53%) of the 277 exempt children. Polio was the least often refused vaccine and was not given to 45 (16%) children.

Other reasons for refusing vaccination included concerns that the vaccines might overload the immune system (49%), belief that the child was not at risk for the disease (37%), that the disease was not dangerous (20%), and that that vaccines might not work (13%).

Parents of exempt children were less likely to report that their child's primary health provider was a physician, compared with parents of vaccinated children (76% vs. 94%). In general, parents of exempt children were more likely to be older than the median age of 36–40 years and to have a higher level of education compared with parents of vaccinated children. The parents of exempt and vaccinated children were similar in terms of family income and race.

One Swab Is Enough

Use of two throat swabs did not significantly improve the sensitivity of the OIA MAX test for group A streptococcus in a randomized study of 363 children aged 5–18 years with acute pharyngitis, said Elias N. Ezike, M.D., of the Children's Hospital of Michigan, Detroit, and his associates (Arch. Pediatr. Adolesc. Med. 2005;159:486–90).

One throat swab was obtained from a group of 117 children (group 1), and two swabs were obtained from a group of 186 children (group 2). The sensitivity was 94.7% and 100% for groups 1 and 2, respectively, and the specificity was 92.4% and 96.3% for groups 1 and 2, respectively. Overall, the OIA MAX test identified group A streptococcus in 148 of the 363 (40.8%) patients, including 71 in group 1 (40.1%) and 77 in group 2 (41.4%). Clinical presentations were not significantly different between children with and without group A streptococcus, and there was no association between the severity of pharyngitis and the sensitivity of the OIA MAX test.

Group B Strep Poorly Diagnosed

A differential diagnosis in adolescents with purulent vaginal discharge should include group B streptococci, said Liana R. Clark, M.D., and Marisa Atendido of the Children's Hospital of Philadelphia (J. Adolesc. Health 2005;36:437–40).

The investigators conducted a retrospective analysis of 13 adolescents (mean age 16 years) who demonstrated clinical signs of infection and tested positive for group B streptococci. Of these, 12 of 13 had a purulent cervicovaginal discharge. Of the 12, 3 had cervicitis, 3 had inflamed vaginal mucosa, 2 had vaginal erythema, and 1 had vaginal bleeding. Only one girl was accurately diagnosed with group B streptococci at the time of her visit, and she was treated with cefuroxime. Three were misdiagnosed with STDs. Small numbers and lack of asymptomatic controls limited the study.

Pocket Pets May Pack Salmonella

The Centers for Disease Control and Prevention identified 28 cases of Salmonella enteritidis serotype typhimurium associated with pet rodents including hamsters, mice, and rats between December 2003 and October 2004 (MMWR 2005;54:429–32). The mean age of those affected was 16 years, and seven cases occurred in children younger than 7 years.

Particularly severe cases occurred in two 5-year-old boys. The first of these occurred in June 2004 in Minnesota, when the boy became ill 4 days after he received a pet mouse. The second case occurred in August 2004 in South Carolina, when the boy became ill 9 days after he received a pet hamster. In both cases, the children developed fevers, diarrhea, and abdominal cramping, and stool cultures yielded S. typhimurium. Both pet rodents died within a week of their purchase, and a culture from the mouse also yielded S. typhimurium. Rodents linked to all 28 cases were purchased from multiple retail pet store chains and distributors, and S. typhimurium was recovered from pet transport containers and from bins containing rodent droppings.

WASHINGTON — Endoscopy is an invasive procedure that patients don't like, and it may not be necessary for the evaluation of ulcerative colitis, Peter Higgins, M.D., said at the Clinical Research 2005 meeting.

In a study of 66 consecutive adult ulcerative colitis (UC) patients, results from two noninvasive indices overlapped significantly with results from invasive indices, said Dr. Higgins of the University of Michigan, Ann Arbor, and his colleagues. Regular use of noninvasive indices to assess UC could lower costs and encourage more patients to participate in clinical trials, he noted.

The investigators compared invasive and noninvasive indices in terms of how well each measured disease remission and other clinically important outcomes. The invasive indices used were the St. Mark's Index and the Ulcerative Colitis Disease Activity Index (UCDAI), and the noninvasive indices were the Simple Clinical Colitis Activity Index (SCCAI) and the Seo index. In addition, the doctors simply asked patients whether their disease was in remission.

Other indices are available in addition to those used in this study, Dr. Higgins said. “The problem is that none of them are validated, and none of them work that well.”

The investigators measured the correlations between the various indices to determine whether the noninvasive tests could provide similar information to that provided by the invasive tests. The two noninvasive indices, SCCAI and Seo, correlated well with the invasive St. Mark's index, with correlations of 0.86 for the SCCAI and 0.70 for Seo.

When the two invasive indices were compared with each other, the UCDAI endoscopy item predicted only 0.04% of the variance in the St. Mark's index after adjustment for the three noninvasive items on the UCDAI index.

Overall, endoscopy contributed very little to the assessment—significantly less than the 10% that Dr. Higgins expected. “We may not need endoscopy” to evaluate UC patients, he said. One explanation for endoscopy's minor role might be that other items on the same scale have measured the same factors, which would make endoscopy redundant.

Dr. Higgins concluded that noninvasive indices could effectively predict remission. “We're not losing much by leaving out endoscopy,” he said. The clinical practice of treating patients based on their reported symptoms is appropriate, and clinicians are correct to avoid rushing to scope.

“If the patient tells you they have 10 bloody stools, they are having a flare,” he said at the meeting, sponsored by the American Federation for Medical Research.

WASHINGTON — Endoscopy is an invasive procedure that patients don't like, and it may not be necessary for the evaluation of ulcerative colitis, Peter Higgins, M.D., said at the Clinical Research 2005 meeting.

In a study of 66 consecutive adult ulcerative colitis (UC) patients, results from two noninvasive indices overlapped significantly with results from invasive indices, said Dr. Higgins of the University of Michigan, Ann Arbor, and his colleagues. Regular use of noninvasive indices to assess UC could lower costs and encourage more patients to participate in clinical trials, he noted.

The investigators compared invasive and noninvasive indices in terms of how well each measured disease remission and other clinically important outcomes. The invasive indices used were the St. Mark's Index and the Ulcerative Colitis Disease Activity Index (UCDAI), and the noninvasive indices were the Simple Clinical Colitis Activity Index (SCCAI) and the Seo index. In addition, the doctors simply asked patients whether their disease was in remission.

Other indices are available in addition to those used in this study, Dr. Higgins said. “The problem is that none of them are validated, and none of them work that well.”

The investigators measured the correlations between the various indices to determine whether the noninvasive tests could provide similar information to that provided by the invasive tests. The two noninvasive indices, SCCAI and Seo, correlated well with the invasive St. Mark's index, with correlations of 0.86 for the SCCAI and 0.70 for Seo.

When the two invasive indices were compared with each other, the UCDAI endoscopy item predicted only 0.04% of the variance in the St. Mark's index after adjustment for the three noninvasive items on the UCDAI index.

Overall, endoscopy contributed very little to the assessment—significantly less than the 10% that Dr. Higgins expected. “We may not need endoscopy” to evaluate UC patients, he said. One explanation for endoscopy's minor role might be that other items on the same scale have measured the same factors, which would make endoscopy redundant.

Dr. Higgins concluded that noninvasive indices could effectively predict remission. “We're not losing much by leaving out endoscopy,” he said. The clinical practice of treating patients based on their reported symptoms is appropriate, and clinicians are correct to avoid rushing to scope.

“If the patient tells you they have 10 bloody stools, they are having a flare,” he said at the meeting, sponsored by the American Federation for Medical Research.

WASHINGTON — Endoscopy is an invasive procedure that patients don't like, and it may not be necessary for the evaluation of ulcerative colitis, Peter Higgins, M.D., said at the Clinical Research 2005 meeting.

In a study of 66 consecutive adult ulcerative colitis (UC) patients, results from two noninvasive indices overlapped significantly with results from invasive indices, said Dr. Higgins of the University of Michigan, Ann Arbor, and his colleagues. Regular use of noninvasive indices to assess UC could lower costs and encourage more patients to participate in clinical trials, he noted.

The investigators compared invasive and noninvasive indices in terms of how well each measured disease remission and other clinically important outcomes. The invasive indices used were the St. Mark's Index and the Ulcerative Colitis Disease Activity Index (UCDAI), and the noninvasive indices were the Simple Clinical Colitis Activity Index (SCCAI) and the Seo index. In addition, the doctors simply asked patients whether their disease was in remission.

Other indices are available in addition to those used in this study, Dr. Higgins said. “The problem is that none of them are validated, and none of them work that well.”

The investigators measured the correlations between the various indices to determine whether the noninvasive tests could provide similar information to that provided by the invasive tests. The two noninvasive indices, SCCAI and Seo, correlated well with the invasive St. Mark's index, with correlations of 0.86 for the SCCAI and 0.70 for Seo.

When the two invasive indices were compared with each other, the UCDAI endoscopy item predicted only 0.04% of the variance in the St. Mark's index after adjustment for the three noninvasive items on the UCDAI index.

Overall, endoscopy contributed very little to the assessment—significantly less than the 10% that Dr. Higgins expected. “We may not need endoscopy” to evaluate UC patients, he said. One explanation for endoscopy's minor role might be that other items on the same scale have measured the same factors, which would make endoscopy redundant.

Dr. Higgins concluded that noninvasive indices could effectively predict remission. “We're not losing much by leaving out endoscopy,” he said. The clinical practice of treating patients based on their reported symptoms is appropriate, and clinicians are correct to avoid rushing to scope.

“If the patient tells you they have 10 bloody stools, they are having a flare,” he said at the meeting, sponsored by the American Federation for Medical Research.

WASHINGTON — Vitamin D levels are inadequate in up to half of postmenopausal women who receive treatment for osteoporosis, Ethel Siris, M.D., reported during an international symposium sponsored by the National Osteoporosis Foundation.

Vitamin D inadequacy was significantly worse among women who took less than 400 IU of vitamin D supplementation daily, compared with women who took at least 400 IU of vitamin D daily (63% vs. 45%).

Previous study findings suggest that serum 25-hydroxyvitamin D concentrations of at least 30 ng/mL are needed to stabilize serum parathyroid hormone levels, Dr. Siris, director of the metabolic bone diseases program at Columbia University, New York, and her colleagues, wrote in a poster presentation.

In a cross-sectional, observational study conducted between November 2003 and March 2004, the investigators collected blood samples from 1,536 postmenopausal women, mean age 71 years, at 61 sites throughout North America.

They used several cut points of serum 25-hydroxyvitamin D to define inadequacy—less than 9 ng/mL, less than 20 ng/mL, less than 25 ng/mL, and less than 30 ng/mL.

Parathyroid hormone values stabilized among patients with serum 25-hydroxyvitamin D concentrations of at least 29.8 ng/mL, which suggests that concentrations of approximately 30 ng/mL are important for healthy parathyroid levels.

Additional factors significantly related to vitamin D inadequacy in a multivariate analysis included age older than 80 years, BMI greater than 30, lack of exercise, and lack of physician counseling about the importance of vitamin D.

More than half (59%) of the women reported that they had not discussed vitamin D with a doctor.

Dr. Siris is a paid consultant for Eli Lilly & Co., Merck & Co., Sanofi Aventis, Procter and Gamble Pharmaceuticals, and Novartis.

WASHINGTON — Vitamin D levels are inadequate in up to half of postmenopausal women who receive treatment for osteoporosis, Ethel Siris, M.D., reported during an international symposium sponsored by the National Osteoporosis Foundation.

Vitamin D inadequacy was significantly worse among women who took less than 400 IU of vitamin D supplementation daily, compared with women who took at least 400 IU of vitamin D daily (63% vs. 45%).

Previous study findings suggest that serum 25-hydroxyvitamin D concentrations of at least 30 ng/mL are needed to stabilize serum parathyroid hormone levels, Dr. Siris, director of the metabolic bone diseases program at Columbia University, New York, and her colleagues, wrote in a poster presentation.

In a cross-sectional, observational study conducted between November 2003 and March 2004, the investigators collected blood samples from 1,536 postmenopausal women, mean age 71 years, at 61 sites throughout North America.

They used several cut points of serum 25-hydroxyvitamin D to define inadequacy—less than 9 ng/mL, less than 20 ng/mL, less than 25 ng/mL, and less than 30 ng/mL.

Parathyroid hormone values stabilized among patients with serum 25-hydroxyvitamin D concentrations of at least 29.8 ng/mL, which suggests that concentrations of approximately 30 ng/mL are important for healthy parathyroid levels.

Additional factors significantly related to vitamin D inadequacy in a multivariate analysis included age older than 80 years, BMI greater than 30, lack of exercise, and lack of physician counseling about the importance of vitamin D.

More than half (59%) of the women reported that they had not discussed vitamin D with a doctor.

Dr. Siris is a paid consultant for Eli Lilly & Co., Merck & Co., Sanofi Aventis, Procter and Gamble Pharmaceuticals, and Novartis.

WASHINGTON — Vitamin D levels are inadequate in up to half of postmenopausal women who receive treatment for osteoporosis, Ethel Siris, M.D., reported during an international symposium sponsored by the National Osteoporosis Foundation.

Vitamin D inadequacy was significantly worse among women who took less than 400 IU of vitamin D supplementation daily, compared with women who took at least 400 IU of vitamin D daily (63% vs. 45%).

Previous study findings suggest that serum 25-hydroxyvitamin D concentrations of at least 30 ng/mL are needed to stabilize serum parathyroid hormone levels, Dr. Siris, director of the metabolic bone diseases program at Columbia University, New York, and her colleagues, wrote in a poster presentation.

In a cross-sectional, observational study conducted between November 2003 and March 2004, the investigators collected blood samples from 1,536 postmenopausal women, mean age 71 years, at 61 sites throughout North America.

They used several cut points of serum 25-hydroxyvitamin D to define inadequacy—less than 9 ng/mL, less than 20 ng/mL, less than 25 ng/mL, and less than 30 ng/mL.

Parathyroid hormone values stabilized among patients with serum 25-hydroxyvitamin D concentrations of at least 29.8 ng/mL, which suggests that concentrations of approximately 30 ng/mL are important for healthy parathyroid levels.

Additional factors significantly related to vitamin D inadequacy in a multivariate analysis included age older than 80 years, BMI greater than 30, lack of exercise, and lack of physician counseling about the importance of vitamin D.

More than half (59%) of the women reported that they had not discussed vitamin D with a doctor.

Dr. Siris is a paid consultant for Eli Lilly & Co., Merck & Co., Sanofi Aventis, Procter and Gamble Pharmaceuticals, and Novartis.

WASHINGTON — A monthly dose of oral ibandronate is at least as safe and as effective at increasing bone mineral density as a daily dose, according to data from a study of more than 1,200 postmenopausal women with osteoporosis.

The Monthly Oral Ibandronate in Ladies (MOBILE) study, a multinational randomized, double-blind, phase III study of women aged 55–80 years, will continue for 2 years, Michael Bolognese, M.D., explained in a poster presented at an international symposium sponsored by the National Osteoporosis Foundation. Dr. Bolognese and his colleagues presented their 1-year results at the meeting.

A total of 318 women received a 2.5-mg dose of oral ibandronate (Boniva) daily; another 328 women received a 50/50 mg dose (two 50-mg single doses on 2 consecutive days) monthly; 311 received one 100-mg dose monthly; and 320 received one 150-mg dose monthly.

After 1 year, the increase in BMD at the lumbar spine was 3.9% in the daily group, compared with 4.3%, 4.1%, and 4.9% in the groups receiving, respectively, 50/50 mg, 100 mg, and 150 mg monthly.

Increases in the total hip BMD were 2.2% in the daily group, compared with 2.2%, 2.7%, and 3.1% in the 50/50 mg, and monthly groups, respectively.

Similar increases occurred at the femoral neck and hip trochanter.

In addition, all treatment groups demonstrated significant decreases in serum C-terminal cross-linking telopeptide of type I collagen (CTX), a bone resorption marker that's used to measure the effectiveness of treatment. The 150-mg group showed the most robust response.

“The once-monthly oral ibandronate has a comparable safety profile with the daily, and therefore seems like it should provide an effective, well-tolerated, and practical alternative to daily and weekly oral bisphosphonate,” Dr. Bolognese said in his oral presentation of the data.

The dosage of the newly approved monthly formulation of ibandronate (Boniva) is 150 mg, and it has been shown to have maximal effectiveness when taken 60 minutes before eating meals, said Dr. Bolognese, of Bethesda (Md.) Health Research.

The incidence of adverse events and withdrawal rates were comparable across all treatment groups.

Approximately 70%–80% of the adverse events were gastrointestinal, which remains a concern with bisphosphonate therapy, but the incidence was relatively low and comparable across all treatment groups. In fact, the rate of discontinuation due to upper GI events was lower among patients in the 150-mg group (3.3%), 100-mg group (4.0%), and 50/50-mg group (4.0%), compared with the daily group (5.3%).

Dr. Bolognese is a consultant for Eli Lilly & Co. and Procter & Gamble, and he has received grants or research support from Sanofi-Aventis, Pfizer, Lilly, and Wyeth Pharmaceuticals.

WASHINGTON — A monthly dose of oral ibandronate is at least as safe and as effective at increasing bone mineral density as a daily dose, according to data from a study of more than 1,200 postmenopausal women with osteoporosis.

The Monthly Oral Ibandronate in Ladies (MOBILE) study, a multinational randomized, double-blind, phase III study of women aged 55–80 years, will continue for 2 years, Michael Bolognese, M.D., explained in a poster presented at an international symposium sponsored by the National Osteoporosis Foundation. Dr. Bolognese and his colleagues presented their 1-year results at the meeting.

A total of 318 women received a 2.5-mg dose of oral ibandronate (Boniva) daily; another 328 women received a 50/50 mg dose (two 50-mg single doses on 2 consecutive days) monthly; 311 received one 100-mg dose monthly; and 320 received one 150-mg dose monthly.

After 1 year, the increase in BMD at the lumbar spine was 3.9% in the daily group, compared with 4.3%, 4.1%, and 4.9% in the groups receiving, respectively, 50/50 mg, 100 mg, and 150 mg monthly.

Increases in the total hip BMD were 2.2% in the daily group, compared with 2.2%, 2.7%, and 3.1% in the 50/50 mg, and monthly groups, respectively.

Similar increases occurred at the femoral neck and hip trochanter.

In addition, all treatment groups demonstrated significant decreases in serum C-terminal cross-linking telopeptide of type I collagen (CTX), a bone resorption marker that's used to measure the effectiveness of treatment. The 150-mg group showed the most robust response.

“The once-monthly oral ibandronate has a comparable safety profile with the daily, and therefore seems like it should provide an effective, well-tolerated, and practical alternative to daily and weekly oral bisphosphonate,” Dr. Bolognese said in his oral presentation of the data.

The dosage of the newly approved monthly formulation of ibandronate (Boniva) is 150 mg, and it has been shown to have maximal effectiveness when taken 60 minutes before eating meals, said Dr. Bolognese, of Bethesda (Md.) Health Research.

The incidence of adverse events and withdrawal rates were comparable across all treatment groups.

Approximately 70%–80% of the adverse events were gastrointestinal, which remains a concern with bisphosphonate therapy, but the incidence was relatively low and comparable across all treatment groups. In fact, the rate of discontinuation due to upper GI events was lower among patients in the 150-mg group (3.3%), 100-mg group (4.0%), and 50/50-mg group (4.0%), compared with the daily group (5.3%).

Dr. Bolognese is a consultant for Eli Lilly & Co. and Procter & Gamble, and he has received grants or research support from Sanofi-Aventis, Pfizer, Lilly, and Wyeth Pharmaceuticals.

WASHINGTON — A monthly dose of oral ibandronate is at least as safe and as effective at increasing bone mineral density as a daily dose, according to data from a study of more than 1,200 postmenopausal women with osteoporosis.

The Monthly Oral Ibandronate in Ladies (MOBILE) study, a multinational randomized, double-blind, phase III study of women aged 55–80 years, will continue for 2 years, Michael Bolognese, M.D., explained in a poster presented at an international symposium sponsored by the National Osteoporosis Foundation. Dr. Bolognese and his colleagues presented their 1-year results at the meeting.

A total of 318 women received a 2.5-mg dose of oral ibandronate (Boniva) daily; another 328 women received a 50/50 mg dose (two 50-mg single doses on 2 consecutive days) monthly; 311 received one 100-mg dose monthly; and 320 received one 150-mg dose monthly.

After 1 year, the increase in BMD at the lumbar spine was 3.9% in the daily group, compared with 4.3%, 4.1%, and 4.9% in the groups receiving, respectively, 50/50 mg, 100 mg, and 150 mg monthly.

Increases in the total hip BMD were 2.2% in the daily group, compared with 2.2%, 2.7%, and 3.1% in the 50/50 mg, and monthly groups, respectively.

Similar increases occurred at the femoral neck and hip trochanter.

In addition, all treatment groups demonstrated significant decreases in serum C-terminal cross-linking telopeptide of type I collagen (CTX), a bone resorption marker that's used to measure the effectiveness of treatment. The 150-mg group showed the most robust response.

“The once-monthly oral ibandronate has a comparable safety profile with the daily, and therefore seems like it should provide an effective, well-tolerated, and practical alternative to daily and weekly oral bisphosphonate,” Dr. Bolognese said in his oral presentation of the data.

The dosage of the newly approved monthly formulation of ibandronate (Boniva) is 150 mg, and it has been shown to have maximal effectiveness when taken 60 minutes before eating meals, said Dr. Bolognese, of Bethesda (Md.) Health Research.

The incidence of adverse events and withdrawal rates were comparable across all treatment groups.

Approximately 70%–80% of the adverse events were gastrointestinal, which remains a concern with bisphosphonate therapy, but the incidence was relatively low and comparable across all treatment groups. In fact, the rate of discontinuation due to upper GI events was lower among patients in the 150-mg group (3.3%), 100-mg group (4.0%), and 50/50-mg group (4.0%), compared with the daily group (5.3%).

Dr. Bolognese is a consultant for Eli Lilly & Co. and Procter & Gamble, and he has received grants or research support from Sanofi-Aventis, Pfizer, Lilly, and Wyeth Pharmaceuticals.

WASHINGTON — The severity of vertebral fractures increases significantly in patients whose trabecular bone volume falls below the critical value of 15%, Harry K. Genant, M.D., said in his oral presentation of a poster at an international symposium sponsored by the National Osteoporosis Foundation.

Dr. Genant, a member of the Osteoporosis and Arthritis Research Group at the University of California, San Francisco, and his colleagues assessed the bone quality of 190 postmenopausal women, mean age 69 years, using radiographic data from 2-D histomorphometry and 3-D microCT.

The women were categorized into four groups based on varying severity of vertebral fractures, with 0 meaning “no fracture,” and 1, 2, and 3, relating to mild, moderate, and severe fracture levels, respectively.

Based on the radiographic data, patients in the moderate and severe fracture groups had significantly reduced 2-dimensional trabecular bone volumes (0.15 and 0.13, respectively), compared with patients who had no fractures (0.20). On further analysis of the radiographs, the researchers found that as the severity of vertebral fractures grew worse, patients had progressively worse bone quality based on measurements including trabecular separation, trabecular number, and 3-dimensional trabecular bone volume.

These results are consistent with earlier findings that patients are at significantly increased risk of fracture when the trabecular bone volume falls below approximately 15%. Dr. Genant has received grants and research support, as well as an honorarium, from Eli Lilly & Co.

WASHINGTON — The severity of vertebral fractures increases significantly in patients whose trabecular bone volume falls below the critical value of 15%, Harry K. Genant, M.D., said in his oral presentation of a poster at an international symposium sponsored by the National Osteoporosis Foundation.

Dr. Genant, a member of the Osteoporosis and Arthritis Research Group at the University of California, San Francisco, and his colleagues assessed the bone quality of 190 postmenopausal women, mean age 69 years, using radiographic data from 2-D histomorphometry and 3-D microCT.

The women were categorized into four groups based on varying severity of vertebral fractures, with 0 meaning “no fracture,” and 1, 2, and 3, relating to mild, moderate, and severe fracture levels, respectively.

Based on the radiographic data, patients in the moderate and severe fracture groups had significantly reduced 2-dimensional trabecular bone volumes (0.15 and 0.13, respectively), compared with patients who had no fractures (0.20). On further analysis of the radiographs, the researchers found that as the severity of vertebral fractures grew worse, patients had progressively worse bone quality based on measurements including trabecular separation, trabecular number, and 3-dimensional trabecular bone volume.

These results are consistent with earlier findings that patients are at significantly increased risk of fracture when the trabecular bone volume falls below approximately 15%. Dr. Genant has received grants and research support, as well as an honorarium, from Eli Lilly & Co.

WASHINGTON — The severity of vertebral fractures increases significantly in patients whose trabecular bone volume falls below the critical value of 15%, Harry K. Genant, M.D., said in his oral presentation of a poster at an international symposium sponsored by the National Osteoporosis Foundation.

Dr. Genant, a member of the Osteoporosis and Arthritis Research Group at the University of California, San Francisco, and his colleagues assessed the bone quality of 190 postmenopausal women, mean age 69 years, using radiographic data from 2-D histomorphometry and 3-D microCT.

The women were categorized into four groups based on varying severity of vertebral fractures, with 0 meaning “no fracture,” and 1, 2, and 3, relating to mild, moderate, and severe fracture levels, respectively.

Based on the radiographic data, patients in the moderate and severe fracture groups had significantly reduced 2-dimensional trabecular bone volumes (0.15 and 0.13, respectively), compared with patients who had no fractures (0.20). On further analysis of the radiographs, the researchers found that as the severity of vertebral fractures grew worse, patients had progressively worse bone quality based on measurements including trabecular separation, trabecular number, and 3-dimensional trabecular bone volume.

These results are consistent with earlier findings that patients are at significantly increased risk of fracture when the trabecular bone volume falls below approximately 15%. Dr. Genant has received grants and research support, as well as an honorarium, from Eli Lilly & Co.