Kate Johnson

Children who lose sleep may have an increased risk of gaining weight, according to findings of a new study.

This points to the importance of sleep in the fight against obesity and further fuels the argument for later starts to the school day, reported Emily K. Snell and colleagues in Child Development.

“Encouraging parents to put their younger children to bed earlier at night and allowing both younger and older children to sleep longer in the morning, as well as urging school districts to avoid very early school start times for later elementary and middle school aged children, might represent an important and relatively low cost strategy to reduce childhood weight problems,” wrote Ms. Snell of the Department of Human Development and Social Policy and the Institute for Policy Research at Northwestern University, Chicago (Child Development 2007;78:309–23).

In a study of 2,281 children from a nationally representative survey called the Child Development Supplement of the Panel Survey of Income Dynamics, the children were aged 3–12 years at baseline and 8–17 years at follow-up. Time diaries were used on a randomly selected weekday and weekend to record sleep behavior, and then a subsample of 1,441 children were examined to see whether sleep behavior at baseline influenced weight at follow-up.

The study found “a large decline in weekday sleep across middle childhood and adolescence, driven largely by later weekday bedtimes,” a finding that the researchers described as “troubling.” While they recommend a minimum of 10–11 hours of sleep per night for younger children, a goal which the study subjects usually achieved on weekends, children as young as 7 years old were already falling short on weeknight sleep. “The fact that a substantial portion of American children achieve such small amounts of sleep should be of concern in light of findings from prior studies suggesting associations between poor sleep hygiene and decreased cognitive and social functioning,” they wrote.

The investigators also noted that “the shift towards later weekday bedtimes might begin earlier than some researchers have suspected,” occurring in preadolescence, as early as age 8 or 9 years. “There is clear evidence for the appropriateness of later bedtimes for adolescents, as these changes … may be biologically driven. … For younger children, however, the change to later bedtimes may be driven more by social factors rather than changes in biology,” they suggested.

The study also found that lost sleep shows up on the scales 5 years later—with later bedtimes for younger children (aged 3–7.9 years) having the most impact on subsequent body mass index (BMI), while later wake times were more important for older children (aged 8–12.9 years) and subsequent BMI. “Even 1 additional hour of sleep may have a significant and meaningful effect on BMI and overweight status,” they wrote, noting that at baseline, 1 extra hour of sleep above average lowered a child's risk of being overweight 5 years later—from 36% to 30%, even after controlling for baseline BMI, family socioeconomics, and race. The study found no evidence that gender or physical activity influenced the effect of sleep on BMI.

The mediating pathway between inadequate sleep and weight gain may be the disruption of hormones that regulate appetite and metabolism, suggested the authors, “with insufficient sleep hours causing reduced levels of leptin and increased levels of ghrelin, a hormonal profile associated with increased hunger and appetite for carbohydrate-rich foods.”

The investigators suggested that a combination of strategies geared toward earlier bedtimes and later wake times depending on a child's age “might well improve multiple aspects of children's health, emotional well-being, and academic performance.”

Children who lose sleep may have an increased risk of gaining weight, according to findings of a new study.

This points to the importance of sleep in the fight against obesity and further fuels the argument for later starts to the school day, reported Emily K. Snell and colleagues in Child Development.

“Encouraging parents to put their younger children to bed earlier at night and allowing both younger and older children to sleep longer in the morning, as well as urging school districts to avoid very early school start times for later elementary and middle school aged children, might represent an important and relatively low cost strategy to reduce childhood weight problems,” wrote Ms. Snell of the Department of Human Development and Social Policy and the Institute for Policy Research at Northwestern University, Chicago (Child Development 2007;78:309–23).

In a study of 2,281 children from a nationally representative survey called the Child Development Supplement of the Panel Survey of Income Dynamics, the children were aged 3–12 years at baseline and 8–17 years at follow-up. Time diaries were used on a randomly selected weekday and weekend to record sleep behavior, and then a subsample of 1,441 children were examined to see whether sleep behavior at baseline influenced weight at follow-up.

The study found “a large decline in weekday sleep across middle childhood and adolescence, driven largely by later weekday bedtimes,” a finding that the researchers described as “troubling.” While they recommend a minimum of 10–11 hours of sleep per night for younger children, a goal which the study subjects usually achieved on weekends, children as young as 7 years old were already falling short on weeknight sleep. “The fact that a substantial portion of American children achieve such small amounts of sleep should be of concern in light of findings from prior studies suggesting associations between poor sleep hygiene and decreased cognitive and social functioning,” they wrote.

The investigators also noted that “the shift towards later weekday bedtimes might begin earlier than some researchers have suspected,” occurring in preadolescence, as early as age 8 or 9 years. “There is clear evidence for the appropriateness of later bedtimes for adolescents, as these changes … may be biologically driven. … For younger children, however, the change to later bedtimes may be driven more by social factors rather than changes in biology,” they suggested.

The study also found that lost sleep shows up on the scales 5 years later—with later bedtimes for younger children (aged 3–7.9 years) having the most impact on subsequent body mass index (BMI), while later wake times were more important for older children (aged 8–12.9 years) and subsequent BMI. “Even 1 additional hour of sleep may have a significant and meaningful effect on BMI and overweight status,” they wrote, noting that at baseline, 1 extra hour of sleep above average lowered a child's risk of being overweight 5 years later—from 36% to 30%, even after controlling for baseline BMI, family socioeconomics, and race. The study found no evidence that gender or physical activity influenced the effect of sleep on BMI.

The mediating pathway between inadequate sleep and weight gain may be the disruption of hormones that regulate appetite and metabolism, suggested the authors, “with insufficient sleep hours causing reduced levels of leptin and increased levels of ghrelin, a hormonal profile associated with increased hunger and appetite for carbohydrate-rich foods.”

The investigators suggested that a combination of strategies geared toward earlier bedtimes and later wake times depending on a child's age “might well improve multiple aspects of children's health, emotional well-being, and academic performance.”

Children who lose sleep may have an increased risk of gaining weight, according to findings of a new study.

This points to the importance of sleep in the fight against obesity and further fuels the argument for later starts to the school day, reported Emily K. Snell and colleagues in Child Development.

“Encouraging parents to put their younger children to bed earlier at night and allowing both younger and older children to sleep longer in the morning, as well as urging school districts to avoid very early school start times for later elementary and middle school aged children, might represent an important and relatively low cost strategy to reduce childhood weight problems,” wrote Ms. Snell of the Department of Human Development and Social Policy and the Institute for Policy Research at Northwestern University, Chicago (Child Development 2007;78:309–23).

In a study of 2,281 children from a nationally representative survey called the Child Development Supplement of the Panel Survey of Income Dynamics, the children were aged 3–12 years at baseline and 8–17 years at follow-up. Time diaries were used on a randomly selected weekday and weekend to record sleep behavior, and then a subsample of 1,441 children were examined to see whether sleep behavior at baseline influenced weight at follow-up.

The study found “a large decline in weekday sleep across middle childhood and adolescence, driven largely by later weekday bedtimes,” a finding that the researchers described as “troubling.” While they recommend a minimum of 10–11 hours of sleep per night for younger children, a goal which the study subjects usually achieved on weekends, children as young as 7 years old were already falling short on weeknight sleep. “The fact that a substantial portion of American children achieve such small amounts of sleep should be of concern in light of findings from prior studies suggesting associations between poor sleep hygiene and decreased cognitive and social functioning,” they wrote.

The investigators also noted that “the shift towards later weekday bedtimes might begin earlier than some researchers have suspected,” occurring in preadolescence, as early as age 8 or 9 years. “There is clear evidence for the appropriateness of later bedtimes for adolescents, as these changes … may be biologically driven. … For younger children, however, the change to later bedtimes may be driven more by social factors rather than changes in biology,” they suggested.

The study also found that lost sleep shows up on the scales 5 years later—with later bedtimes for younger children (aged 3–7.9 years) having the most impact on subsequent body mass index (BMI), while later wake times were more important for older children (aged 8–12.9 years) and subsequent BMI. “Even 1 additional hour of sleep may have a significant and meaningful effect on BMI and overweight status,” they wrote, noting that at baseline, 1 extra hour of sleep above average lowered a child's risk of being overweight 5 years later—from 36% to 30%, even after controlling for baseline BMI, family socioeconomics, and race. The study found no evidence that gender or physical activity influenced the effect of sleep on BMI.

The mediating pathway between inadequate sleep and weight gain may be the disruption of hormones that regulate appetite and metabolism, suggested the authors, “with insufficient sleep hours causing reduced levels of leptin and increased levels of ghrelin, a hormonal profile associated with increased hunger and appetite for carbohydrate-rich foods.”

The investigators suggested that a combination of strategies geared toward earlier bedtimes and later wake times depending on a child's age “might well improve multiple aspects of children's health, emotional well-being, and academic performance.”

BOSTON — Interim results from a large military study comparing virtual and optical colonoscopy for colorectal cancer screening suggest the two methods are comparable in sensitivity and specificity, said Maj. Richard P. Moser III, MC, USA.

If final results of the 8-year screening virtual colonoscopy (VC) trial confirm this, they will be seen as validating the 2003 trial (N. Engl. J. Med. 2003;349: 2191–200) that put VC on the map for colorectal cancer screening, said Dr. Moser of Walter Reed Army Medical Center in Washington.

Speaking at an international symposium sponsored by Boston University, Dr. Moser said the trial includes 3,000 average-risk subjects.

Its goals are to validate the 2003 trial, to evaluate the effectiveness and cost-effectiveness of VC screening, and to gather data on the short-term natural history of 6- to 9-mm polyps.

Patients undergoing VC screening are sent to same-day optical colonoscopy (OC) if they have a polyp measuring 10 mm or more, or three polyps measuring at least 6 mm, Dr. Moser said. Patients with fewer than three medium-sized polyps are randomized to either same-day colonoscopy or 1-year VC follow-up. Patients with no polyps are randomized to either same-day OC or 5-year VC follow-up.

Interim results suggest that for polyps measuring at least 6 mm, VC has a sensitivity of about 90% vs. about 97% for OC. The specificity of VC was 73% vs. 80% specificity found in the 2003 trial, indicating a tendency to identify too many polyps.

BOSTON — Interim results from a large military study comparing virtual and optical colonoscopy for colorectal cancer screening suggest the two methods are comparable in sensitivity and specificity, said Maj. Richard P. Moser III, MC, USA.

If final results of the 8-year screening virtual colonoscopy (VC) trial confirm this, they will be seen as validating the 2003 trial (N. Engl. J. Med. 2003;349: 2191–200) that put VC on the map for colorectal cancer screening, said Dr. Moser of Walter Reed Army Medical Center in Washington.

Speaking at an international symposium sponsored by Boston University, Dr. Moser said the trial includes 3,000 average-risk subjects.

Its goals are to validate the 2003 trial, to evaluate the effectiveness and cost-effectiveness of VC screening, and to gather data on the short-term natural history of 6- to 9-mm polyps.

Patients undergoing VC screening are sent to same-day optical colonoscopy (OC) if they have a polyp measuring 10 mm or more, or three polyps measuring at least 6 mm, Dr. Moser said. Patients with fewer than three medium-sized polyps are randomized to either same-day colonoscopy or 1-year VC follow-up. Patients with no polyps are randomized to either same-day OC or 5-year VC follow-up.

Interim results suggest that for polyps measuring at least 6 mm, VC has a sensitivity of about 90% vs. about 97% for OC. The specificity of VC was 73% vs. 80% specificity found in the 2003 trial, indicating a tendency to identify too many polyps.

BOSTON — Interim results from a large military study comparing virtual and optical colonoscopy for colorectal cancer screening suggest the two methods are comparable in sensitivity and specificity, said Maj. Richard P. Moser III, MC, USA.

If final results of the 8-year screening virtual colonoscopy (VC) trial confirm this, they will be seen as validating the 2003 trial (N. Engl. J. Med. 2003;349: 2191–200) that put VC on the map for colorectal cancer screening, said Dr. Moser of Walter Reed Army Medical Center in Washington.

Speaking at an international symposium sponsored by Boston University, Dr. Moser said the trial includes 3,000 average-risk subjects.

Its goals are to validate the 2003 trial, to evaluate the effectiveness and cost-effectiveness of VC screening, and to gather data on the short-term natural history of 6- to 9-mm polyps.

Patients undergoing VC screening are sent to same-day optical colonoscopy (OC) if they have a polyp measuring 10 mm or more, or three polyps measuring at least 6 mm, Dr. Moser said. Patients with fewer than three medium-sized polyps are randomized to either same-day colonoscopy or 1-year VC follow-up. Patients with no polyps are randomized to either same-day OC or 5-year VC follow-up.

Interim results suggest that for polyps measuring at least 6 mm, VC has a sensitivity of about 90% vs. about 97% for OC. The specificity of VC was 73% vs. 80% specificity found in the 2003 trial, indicating a tendency to identify too many polyps.

MONTREAL – Oral appliances are equally effective as continuous positive airway pressure therapy in patients with mild to moderate obstructive sleep apnea, but not in those with severe disease, according to a randomized trial.

“We've now shown clearly that oral appliances are a viable option that can be considered alongside CPAP [continuous positive airway pressure] therapy in mild to moderate cases,” Dr. Aarnoud Hoekema said in an interview. “Oral appliances are still a subject of much debate. In some clinics, they are used as secondary therapy only when CPAP therapy fails. Other clinics might use them only in patients with mild sleep apnea.”

His study, which he presented at the Eighth World Congress on Sleep Apnea, randomized 103 patients with obstructive sleep apnea to either CPAP (52) or oral appliance therapy (51).

Treatment effectiveness was evaluated by polysomnography after 8 weeks, and was defined as either a reduction in the apnea-hypopnea index (AHI) to below 5, or an AHI reduction to below 20 if this represented at least a 50% reduction in AHI and also rendered the patient symptom free.

A total of 50 patients were classified as having mild to moderate sleep apnea, defined as an AHI of between 5 and 30, while the remaining 53 patients had severe disease, with an AHI of more than 30, reported Dr. Hoekema, who is a dentist and research associate in the department of oral and maxillofacial surgery and maxillofacial prosthetics at Groningen University Hospital in Groningen, the Netherlands.

Overall, the study found that treatment was effective for most patients in both the oral appliance (76.5%) and the CPAP (82.7%) groups. In this comparison of the groups, oral appliance therapy met the predefined criterion for noninferiority, Dr. Hoekema said. But when the results were subanalyzed based on the severity of sleep apnea, oral appliance therapy was inferior in patients with severe disease, resulting in a 69% success rate, compared with 85% for CPAP. In the subgroup of patients with mild to moderate disease, oral appliance therapy was not inferior, with an 84% success rate, compared with an 80% success rate among patients using CPAP.

In mild to moderate patients, it might make sense to consider oral appliances first, he said.

MONTREAL – Oral appliances are equally effective as continuous positive airway pressure therapy in patients with mild to moderate obstructive sleep apnea, but not in those with severe disease, according to a randomized trial.

“We've now shown clearly that oral appliances are a viable option that can be considered alongside CPAP [continuous positive airway pressure] therapy in mild to moderate cases,” Dr. Aarnoud Hoekema said in an interview. “Oral appliances are still a subject of much debate. In some clinics, they are used as secondary therapy only when CPAP therapy fails. Other clinics might use them only in patients with mild sleep apnea.”

His study, which he presented at the Eighth World Congress on Sleep Apnea, randomized 103 patients with obstructive sleep apnea to either CPAP (52) or oral appliance therapy (51).

Treatment effectiveness was evaluated by polysomnography after 8 weeks, and was defined as either a reduction in the apnea-hypopnea index (AHI) to below 5, or an AHI reduction to below 20 if this represented at least a 50% reduction in AHI and also rendered the patient symptom free.

A total of 50 patients were classified as having mild to moderate sleep apnea, defined as an AHI of between 5 and 30, while the remaining 53 patients had severe disease, with an AHI of more than 30, reported Dr. Hoekema, who is a dentist and research associate in the department of oral and maxillofacial surgery and maxillofacial prosthetics at Groningen University Hospital in Groningen, the Netherlands.

Overall, the study found that treatment was effective for most patients in both the oral appliance (76.5%) and the CPAP (82.7%) groups. In this comparison of the groups, oral appliance therapy met the predefined criterion for noninferiority, Dr. Hoekema said. But when the results were subanalyzed based on the severity of sleep apnea, oral appliance therapy was inferior in patients with severe disease, resulting in a 69% success rate, compared with 85% for CPAP. In the subgroup of patients with mild to moderate disease, oral appliance therapy was not inferior, with an 84% success rate, compared with an 80% success rate among patients using CPAP.

In mild to moderate patients, it might make sense to consider oral appliances first, he said.

MONTREAL – Oral appliances are equally effective as continuous positive airway pressure therapy in patients with mild to moderate obstructive sleep apnea, but not in those with severe disease, according to a randomized trial.

“We've now shown clearly that oral appliances are a viable option that can be considered alongside CPAP [continuous positive airway pressure] therapy in mild to moderate cases,” Dr. Aarnoud Hoekema said in an interview. “Oral appliances are still a subject of much debate. In some clinics, they are used as secondary therapy only when CPAP therapy fails. Other clinics might use them only in patients with mild sleep apnea.”

His study, which he presented at the Eighth World Congress on Sleep Apnea, randomized 103 patients with obstructive sleep apnea to either CPAP (52) or oral appliance therapy (51).

Treatment effectiveness was evaluated by polysomnography after 8 weeks, and was defined as either a reduction in the apnea-hypopnea index (AHI) to below 5, or an AHI reduction to below 20 if this represented at least a 50% reduction in AHI and also rendered the patient symptom free.

A total of 50 patients were classified as having mild to moderate sleep apnea, defined as an AHI of between 5 and 30, while the remaining 53 patients had severe disease, with an AHI of more than 30, reported Dr. Hoekema, who is a dentist and research associate in the department of oral and maxillofacial surgery and maxillofacial prosthetics at Groningen University Hospital in Groningen, the Netherlands.

Overall, the study found that treatment was effective for most patients in both the oral appliance (76.5%) and the CPAP (82.7%) groups. In this comparison of the groups, oral appliance therapy met the predefined criterion for noninferiority, Dr. Hoekema said. But when the results were subanalyzed based on the severity of sleep apnea, oral appliance therapy was inferior in patients with severe disease, resulting in a 69% success rate, compared with 85% for CPAP. In the subgroup of patients with mild to moderate disease, oral appliance therapy was not inferior, with an 84% success rate, compared with an 80% success rate among patients using CPAP.

In mild to moderate patients, it might make sense to consider oral appliances first, he said.

PHOENIX — Large, depressed abdominal scars that complicate liposuction can be safely removed using "a novel technique" involving standard laparoscopic scissors, Dr. Marco A. Pelosi II said at the annual meeting of the American Academy of Cosmetic Surgery.

The technique has no laparoscopic component, he said in an interview, and following his success with standard laparoscopic scissors in this study, he has since designed the Pelosi Liposcar scissors, which are specifically intended for this purpose.

Surgical scars that do not involve direct adherence of the dermis to the muscle fascia are relatively simple to manage at the time of liposuction using either small-diameter liposuction cannulas or V-tip dissector cannulas, Dr. Pelosi said. However, more complicated scars that involve the aponeurosis cannot be eliminated using these tools.

In a study of 20 consecutive patients who required release of such depressed abdominal scars prior to office liposuction, standard laparoscopic scissors were safe and effective, reported Dr. Pelosi, who is a gynecologist in Bayonne, N.J.

Computed axial tomography scans of all scars were performed preoperatively to rule out incisional hernias, and all surgeries were performed under tumescent anesthesia.

The laparoscopic scissors were introduced through a 3- to 4-mm incision parallel to the skin surface in the superficial subcutaneous layer and advanced toward the scar. As soon as fibrotic resistance was encountered, the operator's free hand was used to stabilize the area while the other hand moved the scissors in "a lancing and fanning motion" to cut the subcutaneous fibrotic strands, Dr. Pelosi explained.

The scissors were then directed into the deep dermis to cut the fibrotic strands attached to the muscle fascia. Finally, the scissors were used to feel and release any remnants of fibrotic tissue holding the scar. After full release of the scar, standard liposuction was performed.

Complete release of the scar was achieved in all of the study subjects without any intraoperative or postoperative complications.

At 12 months post procedure there was no evidence of recurring subcutaneous fibrotic strands, he said.

JULIE KELLER/ELSEVIER GLOBAL MEDICAL NEWS

This depressed scar, caused by three previous laparotomies, can be released with standard laparoscopic scissors.

The scar has been safely and fully released in preparation for liposuction. Photos courtesy Dr. Marco A. Pelosi II

PHOENIX — Large, depressed abdominal scars that complicate liposuction can be safely removed using "a novel technique" involving standard laparoscopic scissors, Dr. Marco A. Pelosi II said at the annual meeting of the American Academy of Cosmetic Surgery.

The technique has no laparoscopic component, he said in an interview, and following his success with standard laparoscopic scissors in this study, he has since designed the Pelosi Liposcar scissors, which are specifically intended for this purpose.

Surgical scars that do not involve direct adherence of the dermis to the muscle fascia are relatively simple to manage at the time of liposuction using either small-diameter liposuction cannulas or V-tip dissector cannulas, Dr. Pelosi said. However, more complicated scars that involve the aponeurosis cannot be eliminated using these tools.

In a study of 20 consecutive patients who required release of such depressed abdominal scars prior to office liposuction, standard laparoscopic scissors were safe and effective, reported Dr. Pelosi, who is a gynecologist in Bayonne, N.J.

Computed axial tomography scans of all scars were performed preoperatively to rule out incisional hernias, and all surgeries were performed under tumescent anesthesia.

The laparoscopic scissors were introduced through a 3- to 4-mm incision parallel to the skin surface in the superficial subcutaneous layer and advanced toward the scar. As soon as fibrotic resistance was encountered, the operator's free hand was used to stabilize the area while the other hand moved the scissors in "a lancing and fanning motion" to cut the subcutaneous fibrotic strands, Dr. Pelosi explained.

The scissors were then directed into the deep dermis to cut the fibrotic strands attached to the muscle fascia. Finally, the scissors were used to feel and release any remnants of fibrotic tissue holding the scar. After full release of the scar, standard liposuction was performed.

Complete release of the scar was achieved in all of the study subjects without any intraoperative or postoperative complications.

At 12 months post procedure there was no evidence of recurring subcutaneous fibrotic strands, he said.

JULIE KELLER/ELSEVIER GLOBAL MEDICAL NEWS

This depressed scar, caused by three previous laparotomies, can be released with standard laparoscopic scissors.

The scar has been safely and fully released in preparation for liposuction. Photos courtesy Dr. Marco A. Pelosi II

PHOENIX — Large, depressed abdominal scars that complicate liposuction can be safely removed using "a novel technique" involving standard laparoscopic scissors, Dr. Marco A. Pelosi II said at the annual meeting of the American Academy of Cosmetic Surgery.

The technique has no laparoscopic component, he said in an interview, and following his success with standard laparoscopic scissors in this study, he has since designed the Pelosi Liposcar scissors, which are specifically intended for this purpose.

Surgical scars that do not involve direct adherence of the dermis to the muscle fascia are relatively simple to manage at the time of liposuction using either small-diameter liposuction cannulas or V-tip dissector cannulas, Dr. Pelosi said. However, more complicated scars that involve the aponeurosis cannot be eliminated using these tools.

In a study of 20 consecutive patients who required release of such depressed abdominal scars prior to office liposuction, standard laparoscopic scissors were safe and effective, reported Dr. Pelosi, who is a gynecologist in Bayonne, N.J.

Computed axial tomography scans of all scars were performed preoperatively to rule out incisional hernias, and all surgeries were performed under tumescent anesthesia.

The laparoscopic scissors were introduced through a 3- to 4-mm incision parallel to the skin surface in the superficial subcutaneous layer and advanced toward the scar. As soon as fibrotic resistance was encountered, the operator's free hand was used to stabilize the area while the other hand moved the scissors in "a lancing and fanning motion" to cut the subcutaneous fibrotic strands, Dr. Pelosi explained.

The scissors were then directed into the deep dermis to cut the fibrotic strands attached to the muscle fascia. Finally, the scissors were used to feel and release any remnants of fibrotic tissue holding the scar. After full release of the scar, standard liposuction was performed.

Complete release of the scar was achieved in all of the study subjects without any intraoperative or postoperative complications.

At 12 months post procedure there was no evidence of recurring subcutaneous fibrotic strands, he said.

JULIE KELLER/ELSEVIER GLOBAL MEDICAL NEWS

This depressed scar, caused by three previous laparotomies, can be released with standard laparoscopic scissors.

The scar has been safely and fully released in preparation for liposuction. Photos courtesy Dr. Marco A. Pelosi II

PHOENIX — In the face of myriad short-scar rhytidectomy techniques, suture extrusion rates and efficacy of lift are two variables that can help surgeons identify their preferred approach, Dr. Neil Tanna said at the annual meeting of the American Academy of Cosmetic Surgery.

Although secure suspension of the superficial musculoaponeurotic system (SMAS) is indispensable for effective results, there are numerous SMAS suspension techniques and no consensus on which is superior, said Dr. Tanna, who is a resident in otolaryngology and head and neck surgery at George Washington University in Washington.

"Surgeon preference is usually based on the efficacy of the achieved lift and the rate of suture extrusion," he said in an interview, explaining that suture extrusion disrupts the biomechanical properties of the manipulated tissue.

"With the loss of deep tissue support, there is an increase in wound tension and an increased risk of necrosis, scarring, trophic changes, and contour defect," Dr. Tanna said.

His retrospective study compared 1,850 short-scar rhytidectomies performed by one surgeon between January 2002 and January 2006, with the primary outcome being the rate of suture extrusion. All patients also received cervicofacial liposuction at the time of the surgery and were divided into six groups based on the type of SMAS plication they underwent.

In group A, 100 patients received O-shaped purse-string sutures (2–0 Ethibond). For the 100 patients in group B, both O-shaped and U-shaped purse-string sutures (2–0 Ethibond) were used. Interrupted horizontal mattress sutures were used for the 50 patients in group C (2–0 Ethibond), 50 patients in group D (2–0 Vicryl), and 50 patients in group E (2–0 Mersilene). Group F included 1,500 patients in whom a two-layer running locked plication stitch was used with a braided, nonabsorbable suture (2–0 Mersilene).

After at least 6 months of follow-up, the patients were compared in terms of rate, type, and location of suture extrusion.

Group A had a 5% rate of suture extrusion, compared with 8% for group B, 6% for group C, and 1.2% for group F, reported Dr. Tanna. Although groups D and E had no suture extrusions, he concluded that patients in group F had achieved the best overall outcome in terms of both lift and a low rate of suture extrusion.

Although the study didn't formally "evaluate the efficacy of the achieved lift while looking at suture extrusion … anecdotal experience suggests that the two-layer plication stitch employing a braided nonabsorbable suture allows an effective SMAS suspension with a tolerable rate of suture extrusion," he said.

This patient is undergoing the two-layer running locked superficial musculoaponeurotic system plication with a braided, nonabsorbable suture. Courtesy Dr. Neil Tanna

PHOENIX — In the face of myriad short-scar rhytidectomy techniques, suture extrusion rates and efficacy of lift are two variables that can help surgeons identify their preferred approach, Dr. Neil Tanna said at the annual meeting of the American Academy of Cosmetic Surgery.

Although secure suspension of the superficial musculoaponeurotic system (SMAS) is indispensable for effective results, there are numerous SMAS suspension techniques and no consensus on which is superior, said Dr. Tanna, who is a resident in otolaryngology and head and neck surgery at George Washington University in Washington.

"Surgeon preference is usually based on the efficacy of the achieved lift and the rate of suture extrusion," he said in an interview, explaining that suture extrusion disrupts the biomechanical properties of the manipulated tissue.

"With the loss of deep tissue support, there is an increase in wound tension and an increased risk of necrosis, scarring, trophic changes, and contour defect," Dr. Tanna said.

His retrospective study compared 1,850 short-scar rhytidectomies performed by one surgeon between January 2002 and January 2006, with the primary outcome being the rate of suture extrusion. All patients also received cervicofacial liposuction at the time of the surgery and were divided into six groups based on the type of SMAS plication they underwent.

In group A, 100 patients received O-shaped purse-string sutures (2–0 Ethibond). For the 100 patients in group B, both O-shaped and U-shaped purse-string sutures (2–0 Ethibond) were used. Interrupted horizontal mattress sutures were used for the 50 patients in group C (2–0 Ethibond), 50 patients in group D (2–0 Vicryl), and 50 patients in group E (2–0 Mersilene). Group F included 1,500 patients in whom a two-layer running locked plication stitch was used with a braided, nonabsorbable suture (2–0 Mersilene).

After at least 6 months of follow-up, the patients were compared in terms of rate, type, and location of suture extrusion.

Group A had a 5% rate of suture extrusion, compared with 8% for group B, 6% for group C, and 1.2% for group F, reported Dr. Tanna. Although groups D and E had no suture extrusions, he concluded that patients in group F had achieved the best overall outcome in terms of both lift and a low rate of suture extrusion.

Although the study didn't formally "evaluate the efficacy of the achieved lift while looking at suture extrusion … anecdotal experience suggests that the two-layer plication stitch employing a braided nonabsorbable suture allows an effective SMAS suspension with a tolerable rate of suture extrusion," he said.

This patient is undergoing the two-layer running locked superficial musculoaponeurotic system plication with a braided, nonabsorbable suture. Courtesy Dr. Neil Tanna

PHOENIX — In the face of myriad short-scar rhytidectomy techniques, suture extrusion rates and efficacy of lift are two variables that can help surgeons identify their preferred approach, Dr. Neil Tanna said at the annual meeting of the American Academy of Cosmetic Surgery.

Although secure suspension of the superficial musculoaponeurotic system (SMAS) is indispensable for effective results, there are numerous SMAS suspension techniques and no consensus on which is superior, said Dr. Tanna, who is a resident in otolaryngology and head and neck surgery at George Washington University in Washington.

"Surgeon preference is usually based on the efficacy of the achieved lift and the rate of suture extrusion," he said in an interview, explaining that suture extrusion disrupts the biomechanical properties of the manipulated tissue.

"With the loss of deep tissue support, there is an increase in wound tension and an increased risk of necrosis, scarring, trophic changes, and contour defect," Dr. Tanna said.

His retrospective study compared 1,850 short-scar rhytidectomies performed by one surgeon between January 2002 and January 2006, with the primary outcome being the rate of suture extrusion. All patients also received cervicofacial liposuction at the time of the surgery and were divided into six groups based on the type of SMAS plication they underwent.

In group A, 100 patients received O-shaped purse-string sutures (2–0 Ethibond). For the 100 patients in group B, both O-shaped and U-shaped purse-string sutures (2–0 Ethibond) were used. Interrupted horizontal mattress sutures were used for the 50 patients in group C (2–0 Ethibond), 50 patients in group D (2–0 Vicryl), and 50 patients in group E (2–0 Mersilene). Group F included 1,500 patients in whom a two-layer running locked plication stitch was used with a braided, nonabsorbable suture (2–0 Mersilene).

After at least 6 months of follow-up, the patients were compared in terms of rate, type, and location of suture extrusion.

Group A had a 5% rate of suture extrusion, compared with 8% for group B, 6% for group C, and 1.2% for group F, reported Dr. Tanna. Although groups D and E had no suture extrusions, he concluded that patients in group F had achieved the best overall outcome in terms of both lift and a low rate of suture extrusion.

Although the study didn't formally "evaluate the efficacy of the achieved lift while looking at suture extrusion … anecdotal experience suggests that the two-layer plication stitch employing a braided nonabsorbable suture allows an effective SMAS suspension with a tolerable rate of suture extrusion," he said.

This patient is undergoing the two-layer running locked superficial musculoaponeurotic system plication with a braided, nonabsorbable suture. Courtesy Dr. Neil Tanna

PRAGUE — Nonpharmacologic therapies remain less commonly prescribed than are pharmacologic therapies for the treatment of knee and hand osteoarthritis—and this trend has been noted both for primary care physicians and rheumatologists, according to two studies presented at the 2006 World Congress on Osteoarthritis.

When it comes to primary care physicians (PCPs) treating knee osteoarthritis (OA), nonpharmacologic treatments are “insufficiently prescribed and, when initiated, are rarely continued over the long term,” reported Dr. Bernard Mazières of Rangueil University Hospital, in Toulouse, France.

However, first-line pharmacologic treatment with acetaminophen was initiated in 96% of patients and was well followed, Dr. Mazières said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Recommendations recently approved by the European League Against Rheumatism (EULAR) suggest that the optimal treatment of both knee and hand OA involves a combination of pharmacologic and nonpharmacologic therapy (Ann. Rheum. Dis. 2006 [Epub doi:10.1136/ard.2006.062091] and Ann. Rheum. Dis. 2003;62:1145–55).

Dr. Mazières' observational, prospective, multicenter, 1-year cohort study included a total of 933 knee OA patients from 383 randomly selected PCPs in France and Spain. Information on the EULAR recommendations for treating knee OA was provided to the PCPs at the start of the study.

Although 99% of the patients were prescribed acetaminophen during the study period, only 47% (437) were prescribed a treatment strictly following the EULAR recommendations—namely acetaminophen in conjunction with nonpharmacologic therapy. Among those who received nonpharmacologic therapy, the most common prescription was rehabilitation (40%), followed by weight loss (24%), and education (20%).

The study concluded that under these therapeutic conditions patients were satisfied with their OA treatment and “improvement in pain, stiffness, and clinical signs of inflammation was clinically relevant.”

In a separate oral presentation at the meeting, Dr. Emmanuel Maheu reported that, when compared with PCPs, rheumatologists are no better at prescribing nonpharmacologic therapy—at least when it comes to the treatment of hand osteoarthritis.

His prospective cross-sectional study included 169 French rheumatologists and PCPs treating 316 hand OA patients. The study found that, when compared with rheumatologists, PCPs prescribed more analgesics (93% vs. 73%), more nonsteroidal anti-inflammatories (62% vs. 43%), and “surprisingly” more physical therapy (19% vs. 3%), said Dr. Maheu, of St. Antoine Hospital, Paris. Rheumatologists prescribed more splints (30% vs. 13%) and more intra-articular steroid injections (16% vs. 5%).

PRAGUE — Nonpharmacologic therapies remain less commonly prescribed than are pharmacologic therapies for the treatment of knee and hand osteoarthritis—and this trend has been noted both for primary care physicians and rheumatologists, according to two studies presented at the 2006 World Congress on Osteoarthritis.

When it comes to primary care physicians (PCPs) treating knee osteoarthritis (OA), nonpharmacologic treatments are “insufficiently prescribed and, when initiated, are rarely continued over the long term,” reported Dr. Bernard Mazières of Rangueil University Hospital, in Toulouse, France.

However, first-line pharmacologic treatment with acetaminophen was initiated in 96% of patients and was well followed, Dr. Mazières said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Recommendations recently approved by the European League Against Rheumatism (EULAR) suggest that the optimal treatment of both knee and hand OA involves a combination of pharmacologic and nonpharmacologic therapy (Ann. Rheum. Dis. 2006 [Epub doi:10.1136/ard.2006.062091] and Ann. Rheum. Dis. 2003;62:1145–55).

Dr. Mazières' observational, prospective, multicenter, 1-year cohort study included a total of 933 knee OA patients from 383 randomly selected PCPs in France and Spain. Information on the EULAR recommendations for treating knee OA was provided to the PCPs at the start of the study.

Although 99% of the patients were prescribed acetaminophen during the study period, only 47% (437) were prescribed a treatment strictly following the EULAR recommendations—namely acetaminophen in conjunction with nonpharmacologic therapy. Among those who received nonpharmacologic therapy, the most common prescription was rehabilitation (40%), followed by weight loss (24%), and education (20%).

The study concluded that under these therapeutic conditions patients were satisfied with their OA treatment and “improvement in pain, stiffness, and clinical signs of inflammation was clinically relevant.”

In a separate oral presentation at the meeting, Dr. Emmanuel Maheu reported that, when compared with PCPs, rheumatologists are no better at prescribing nonpharmacologic therapy—at least when it comes to the treatment of hand osteoarthritis.

His prospective cross-sectional study included 169 French rheumatologists and PCPs treating 316 hand OA patients. The study found that, when compared with rheumatologists, PCPs prescribed more analgesics (93% vs. 73%), more nonsteroidal anti-inflammatories (62% vs. 43%), and “surprisingly” more physical therapy (19% vs. 3%), said Dr. Maheu, of St. Antoine Hospital, Paris. Rheumatologists prescribed more splints (30% vs. 13%) and more intra-articular steroid injections (16% vs. 5%).

PRAGUE — Nonpharmacologic therapies remain less commonly prescribed than are pharmacologic therapies for the treatment of knee and hand osteoarthritis—and this trend has been noted both for primary care physicians and rheumatologists, according to two studies presented at the 2006 World Congress on Osteoarthritis.

When it comes to primary care physicians (PCPs) treating knee osteoarthritis (OA), nonpharmacologic treatments are “insufficiently prescribed and, when initiated, are rarely continued over the long term,” reported Dr. Bernard Mazières of Rangueil University Hospital, in Toulouse, France.

However, first-line pharmacologic treatment with acetaminophen was initiated in 96% of patients and was well followed, Dr. Mazières said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Recommendations recently approved by the European League Against Rheumatism (EULAR) suggest that the optimal treatment of both knee and hand OA involves a combination of pharmacologic and nonpharmacologic therapy (Ann. Rheum. Dis. 2006 [Epub doi:10.1136/ard.2006.062091] and Ann. Rheum. Dis. 2003;62:1145–55).

Dr. Mazières' observational, prospective, multicenter, 1-year cohort study included a total of 933 knee OA patients from 383 randomly selected PCPs in France and Spain. Information on the EULAR recommendations for treating knee OA was provided to the PCPs at the start of the study.

Although 99% of the patients were prescribed acetaminophen during the study period, only 47% (437) were prescribed a treatment strictly following the EULAR recommendations—namely acetaminophen in conjunction with nonpharmacologic therapy. Among those who received nonpharmacologic therapy, the most common prescription was rehabilitation (40%), followed by weight loss (24%), and education (20%).

The study concluded that under these therapeutic conditions patients were satisfied with their OA treatment and “improvement in pain, stiffness, and clinical signs of inflammation was clinically relevant.”

In a separate oral presentation at the meeting, Dr. Emmanuel Maheu reported that, when compared with PCPs, rheumatologists are no better at prescribing nonpharmacologic therapy—at least when it comes to the treatment of hand osteoarthritis.

His prospective cross-sectional study included 169 French rheumatologists and PCPs treating 316 hand OA patients. The study found that, when compared with rheumatologists, PCPs prescribed more analgesics (93% vs. 73%), more nonsteroidal anti-inflammatories (62% vs. 43%), and “surprisingly” more physical therapy (19% vs. 3%), said Dr. Maheu, of St. Antoine Hospital, Paris. Rheumatologists prescribed more splints (30% vs. 13%) and more intra-articular steroid injections (16% vs. 5%).

PRAGUE — Intra-articular injections of autologous conditioned serum reduced the symptoms of knee osteoarthritis significantly more than did either saline or hyaluronan injections in the first controlled clinical trial of the therapy, Dr. Carsten Moser reported at the 2006 World Congress on Osteoarthritis.

“This is a completely different approach to the treatment of osteoarthritis,” said Dr. Moser, a physician at University Hospital Düsseldorf, Germany, and also an advisor to the company that markets Orthokine, the product used to condition the serum.

The therapy, originally marketed as IRAP to treat lameness in racehorses, is used by more than 400 physicians in Europe to enhance muscle healing in humans, he said at the meeting, which was sponsored by the Osteoarthritis Research Society International. “It does not require approval in Europe because it involves autologous serum, which is drawn and prepared by the physician,” he said in an interview. The company is currently facing distribution problems in the United States, and it is unclear if the therapy will require FDA approval, he added.

Serum conditioning involves incubation of patients' venous blood with medical grade glass beads, Dr. Moser said. Previously published work has shown that this incubation procedure elicits a rapid increase in the serum's synthesis of several anti-inflammatory cytokines (Inflamm. Res. 2003;52:404–7).

“Peripheral blood leukocytes produce elevated amounts of endogenous anti-inflammatory cytokines such as interleukin-1 receptor antagonist,” he said. The conditioned serum is then injected into the affected joint.

The trial involved 345 patients, average age 57 years, with radiological evidence of knee osteoarthritis and pain greater than 50 points on a 100-point visual analog scale. After blood was drawn from all patients, they were randomized, to ensure blinding, to intra-articular injections of either autologous conditioned serum (ACS), hyaluronan (HA), or saline twice a week for 3 weeks.

The outcomes were assessed at 7, 13, and 26 weeks after the last injection, using patient-administered outcome instruments of pain measurement including the Western Ontario and McMaster Osteoarthritis index (WOMAC), the Visual Analog Scale (VAS), and a health-related quality-of-life measure (SF-8).

“Pain was significantly reduced in all three groups and quality of life was increased. However, the positive therapeutic responses to ACS were stronger, compared to the other treatment modalities,” he said. “The magnitude of improvement in the ACS group was significantly higher and persisted for months after the last injection. Compared with ACS, the mean reduction in pain was half in the other treatment groups.”

Adverse events were minor in all groups and were confined to localized pain and swelling from the injection. This occurred in 23% of the ACS group, compared with 28% of the saline group and 38% of the HA group, Dr. Moser noted.

PRAGUE — Intra-articular injections of autologous conditioned serum reduced the symptoms of knee osteoarthritis significantly more than did either saline or hyaluronan injections in the first controlled clinical trial of the therapy, Dr. Carsten Moser reported at the 2006 World Congress on Osteoarthritis.

“This is a completely different approach to the treatment of osteoarthritis,” said Dr. Moser, a physician at University Hospital Düsseldorf, Germany, and also an advisor to the company that markets Orthokine, the product used to condition the serum.

The therapy, originally marketed as IRAP to treat lameness in racehorses, is used by more than 400 physicians in Europe to enhance muscle healing in humans, he said at the meeting, which was sponsored by the Osteoarthritis Research Society International. “It does not require approval in Europe because it involves autologous serum, which is drawn and prepared by the physician,” he said in an interview. The company is currently facing distribution problems in the United States, and it is unclear if the therapy will require FDA approval, he added.

Serum conditioning involves incubation of patients' venous blood with medical grade glass beads, Dr. Moser said. Previously published work has shown that this incubation procedure elicits a rapid increase in the serum's synthesis of several anti-inflammatory cytokines (Inflamm. Res. 2003;52:404–7).

“Peripheral blood leukocytes produce elevated amounts of endogenous anti-inflammatory cytokines such as interleukin-1 receptor antagonist,” he said. The conditioned serum is then injected into the affected joint.

The trial involved 345 patients, average age 57 years, with radiological evidence of knee osteoarthritis and pain greater than 50 points on a 100-point visual analog scale. After blood was drawn from all patients, they were randomized, to ensure blinding, to intra-articular injections of either autologous conditioned serum (ACS), hyaluronan (HA), or saline twice a week for 3 weeks.

The outcomes were assessed at 7, 13, and 26 weeks after the last injection, using patient-administered outcome instruments of pain measurement including the Western Ontario and McMaster Osteoarthritis index (WOMAC), the Visual Analog Scale (VAS), and a health-related quality-of-life measure (SF-8).

“Pain was significantly reduced in all three groups and quality of life was increased. However, the positive therapeutic responses to ACS were stronger, compared to the other treatment modalities,” he said. “The magnitude of improvement in the ACS group was significantly higher and persisted for months after the last injection. Compared with ACS, the mean reduction in pain was half in the other treatment groups.”

Adverse events were minor in all groups and were confined to localized pain and swelling from the injection. This occurred in 23% of the ACS group, compared with 28% of the saline group and 38% of the HA group, Dr. Moser noted.

PRAGUE — Intra-articular injections of autologous conditioned serum reduced the symptoms of knee osteoarthritis significantly more than did either saline or hyaluronan injections in the first controlled clinical trial of the therapy, Dr. Carsten Moser reported at the 2006 World Congress on Osteoarthritis.

“This is a completely different approach to the treatment of osteoarthritis,” said Dr. Moser, a physician at University Hospital Düsseldorf, Germany, and also an advisor to the company that markets Orthokine, the product used to condition the serum.

The therapy, originally marketed as IRAP to treat lameness in racehorses, is used by more than 400 physicians in Europe to enhance muscle healing in humans, he said at the meeting, which was sponsored by the Osteoarthritis Research Society International. “It does not require approval in Europe because it involves autologous serum, which is drawn and prepared by the physician,” he said in an interview. The company is currently facing distribution problems in the United States, and it is unclear if the therapy will require FDA approval, he added.

Serum conditioning involves incubation of patients' venous blood with medical grade glass beads, Dr. Moser said. Previously published work has shown that this incubation procedure elicits a rapid increase in the serum's synthesis of several anti-inflammatory cytokines (Inflamm. Res. 2003;52:404–7).

“Peripheral blood leukocytes produce elevated amounts of endogenous anti-inflammatory cytokines such as interleukin-1 receptor antagonist,” he said. The conditioned serum is then injected into the affected joint.

The trial involved 345 patients, average age 57 years, with radiological evidence of knee osteoarthritis and pain greater than 50 points on a 100-point visual analog scale. After blood was drawn from all patients, they were randomized, to ensure blinding, to intra-articular injections of either autologous conditioned serum (ACS), hyaluronan (HA), or saline twice a week for 3 weeks.

The outcomes were assessed at 7, 13, and 26 weeks after the last injection, using patient-administered outcome instruments of pain measurement including the Western Ontario and McMaster Osteoarthritis index (WOMAC), the Visual Analog Scale (VAS), and a health-related quality-of-life measure (SF-8).

“Pain was significantly reduced in all three groups and quality of life was increased. However, the positive therapeutic responses to ACS were stronger, compared to the other treatment modalities,” he said. “The magnitude of improvement in the ACS group was significantly higher and persisted for months after the last injection. Compared with ACS, the mean reduction in pain was half in the other treatment groups.”

Adverse events were minor in all groups and were confined to localized pain and swelling from the injection. This occurred in 23% of the ACS group, compared with 28% of the saline group and 38% of the HA group, Dr. Moser noted.

Diabetologists and cardiologists are joining forces to address the issue of cardiovascular disease in patients with diabetes.

In North America, new joint guidelines from the American Heart Association (AHA) and the American Diabetes Association (ADA) focus on the primary prevention of cardiovascular disease in patients with diabetes (Circulation 2007;115:114–26; Diabetes Care 2007;30:162–72).

“People with … diabetes are at increased risk for [cardiovascular disease] and have worse outcomes after surviving a CVD event,” wrote coauthor Dr. John Buse, director of the diabetes care center at the University of North Carolina at Chapel Hill, and his colleagues.

And in Europe, the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC) have issued guidelines on diabetes, prediabetes and cardiovascular diseases (Eur. Heart J. 2007;28:88–136).

Although both the North American and European documents recognize the importance of harmonizing the approaches of cardiologists and diabetologists, they both also focus on specific and different aspects of the diabetes-cardiovascular disease dyad, making them potentially complementary documents. In both documents, special attention is placed on the early stages of disease development, but the European document focuses on the role of prediabetes in early cardiovascular dysfunction, whereas the North American document emphasizes primary prevention of cardiovascular disease in patients with overt diabetes.

The importance of the ADA/AHA document is not so much its content, but rather its existence, suggested Dr. Daniel Einhorn, medical director of the Scripps Whittier Institute for Diabetes, an endocrinologist at the University of California, San Diego, and a spokesperson for the American Association of Clinical Endocrinologists (AACE). “What is new here is that these two organizations are agreeing to a joint statement on primary prevention of cardiovascular disease in diabetes.”

Cooperation between the ADA and AHA is, for both organizations, a hurdle crossed after some much publicized disagreement last year, acknowledged Dr. Buse in an interview. “This paper was an effort to get together and hammer out where the common ground is in the few areas where there were fairly nuanced differences in approach.”

The main issue of contention between the ADA and AHA has been the debate over whether or not metabolic syndrome exists. In the joint statement, they have agreed to disagree: “The AHA and the [National Heart, Lung, and Blood Institute] have issued a statement on management of the metabolic syndrome and maintain that with regard to risk for CVD, the metabolic syndrome and type 2 diabetes can coexist in one person. The ADA, in contrast, contends that once type 2 diabetes is present, the metabolic syndrome no longer pertains because CVD risk factors characteristic of the metabolic syndrome are largely subsumed in the type 2 diabetes syndrome,” they wrote.

Dr. Einhorn said that even with some opposing viewpoints, a single set of guidelines shared by cardiologists and endocrinologists serves not only to clarify clinical practice, but to justify a preventive approach.

“It is important for people in managed care environments to have some validation that it is important to do testing, to prescribe medications, and to follow up on these patients from a cardiovascular standpoint, even when they don't have any known cardiovascular disease yet. It offers some impetus in large medical group settings,” he said.

It was an effort to hammer out the common ground in the few areas in which there were fairly nuanced differences. DR. BUSE

More Aggressive Tactics Recommended

The new joint ADA/AHA guidelines “encourage more aggressive prevention and treatment of risk factors that lead to heart disease” in people with diabetes, according to a press release from the two organizations. “Patients with diabetes have twice the risk of incident myocardial infarction and stroke as that of the general population,” they say. “Furthermore, large numbers of people with diabetes do not survive their first event, and if they do survive, their [mortality] over the subsequent months to years is generally greater than that of the general population. As many as 80% of patients with type 2 diabetes will develop and possibly die of macrovascular disease.”

While continuing to encourage lifestyle changes—such as weight loss, improved nutrition, and physical activity—the joint statement also emphasizes the importance of medical interventions to manage lipids, blood pressure, and blood glucose in this population. The full text of the guidelines can be viewed at

http://care.diabetesjournals.org/cgi/content/full/30/1/162

Diabetologists and cardiologists are joining forces to address the issue of cardiovascular disease in patients with diabetes.

In North America, new joint guidelines from the American Heart Association (AHA) and the American Diabetes Association (ADA) focus on the primary prevention of cardiovascular disease in patients with diabetes (Circulation 2007;115:114–26; Diabetes Care 2007;30:162–72).

“People with … diabetes are at increased risk for [cardiovascular disease] and have worse outcomes after surviving a CVD event,” wrote coauthor Dr. John Buse, director of the diabetes care center at the University of North Carolina at Chapel Hill, and his colleagues.

And in Europe, the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC) have issued guidelines on diabetes, prediabetes and cardiovascular diseases (Eur. Heart J. 2007;28:88–136).

Although both the North American and European documents recognize the importance of harmonizing the approaches of cardiologists and diabetologists, they both also focus on specific and different aspects of the diabetes-cardiovascular disease dyad, making them potentially complementary documents. In both documents, special attention is placed on the early stages of disease development, but the European document focuses on the role of prediabetes in early cardiovascular dysfunction, whereas the North American document emphasizes primary prevention of cardiovascular disease in patients with overt diabetes.

The importance of the ADA/AHA document is not so much its content, but rather its existence, suggested Dr. Daniel Einhorn, medical director of the Scripps Whittier Institute for Diabetes, an endocrinologist at the University of California, San Diego, and a spokesperson for the American Association of Clinical Endocrinologists (AACE). “What is new here is that these two organizations are agreeing to a joint statement on primary prevention of cardiovascular disease in diabetes.”

Cooperation between the ADA and AHA is, for both organizations, a hurdle crossed after some much publicized disagreement last year, acknowledged Dr. Buse in an interview. “This paper was an effort to get together and hammer out where the common ground is in the few areas where there were fairly nuanced differences in approach.”

The main issue of contention between the ADA and AHA has been the debate over whether or not metabolic syndrome exists. In the joint statement, they have agreed to disagree: “The AHA and the [National Heart, Lung, and Blood Institute] have issued a statement on management of the metabolic syndrome and maintain that with regard to risk for CVD, the metabolic syndrome and type 2 diabetes can coexist in one person. The ADA, in contrast, contends that once type 2 diabetes is present, the metabolic syndrome no longer pertains because CVD risk factors characteristic of the metabolic syndrome are largely subsumed in the type 2 diabetes syndrome,” they wrote.

Dr. Einhorn said that even with some opposing viewpoints, a single set of guidelines shared by cardiologists and endocrinologists serves not only to clarify clinical practice, but to justify a preventive approach.

“It is important for people in managed care environments to have some validation that it is important to do testing, to prescribe medications, and to follow up on these patients from a cardiovascular standpoint, even when they don't have any known cardiovascular disease yet. It offers some impetus in large medical group settings,” he said.

It was an effort to hammer out the common ground in the few areas in which there were fairly nuanced differences. DR. BUSE

More Aggressive Tactics Recommended

The new joint ADA/AHA guidelines “encourage more aggressive prevention and treatment of risk factors that lead to heart disease” in people with diabetes, according to a press release from the two organizations. “Patients with diabetes have twice the risk of incident myocardial infarction and stroke as that of the general population,” they say. “Furthermore, large numbers of people with diabetes do not survive their first event, and if they do survive, their [mortality] over the subsequent months to years is generally greater than that of the general population. As many as 80% of patients with type 2 diabetes will develop and possibly die of macrovascular disease.”

While continuing to encourage lifestyle changes—such as weight loss, improved nutrition, and physical activity—the joint statement also emphasizes the importance of medical interventions to manage lipids, blood pressure, and blood glucose in this population. The full text of the guidelines can be viewed at

http://care.diabetesjournals.org/cgi/content/full/30/1/162

Diabetologists and cardiologists are joining forces to address the issue of cardiovascular disease in patients with diabetes.

In North America, new joint guidelines from the American Heart Association (AHA) and the American Diabetes Association (ADA) focus on the primary prevention of cardiovascular disease in patients with diabetes (Circulation 2007;115:114–26; Diabetes Care 2007;30:162–72).

“People with … diabetes are at increased risk for [cardiovascular disease] and have worse outcomes after surviving a CVD event,” wrote coauthor Dr. John Buse, director of the diabetes care center at the University of North Carolina at Chapel Hill, and his colleagues.

And in Europe, the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC) have issued guidelines on diabetes, prediabetes and cardiovascular diseases (Eur. Heart J. 2007;28:88–136).

Although both the North American and European documents recognize the importance of harmonizing the approaches of cardiologists and diabetologists, they both also focus on specific and different aspects of the diabetes-cardiovascular disease dyad, making them potentially complementary documents. In both documents, special attention is placed on the early stages of disease development, but the European document focuses on the role of prediabetes in early cardiovascular dysfunction, whereas the North American document emphasizes primary prevention of cardiovascular disease in patients with overt diabetes.

The importance of the ADA/AHA document is not so much its content, but rather its existence, suggested Dr. Daniel Einhorn, medical director of the Scripps Whittier Institute for Diabetes, an endocrinologist at the University of California, San Diego, and a spokesperson for the American Association of Clinical Endocrinologists (AACE). “What is new here is that these two organizations are agreeing to a joint statement on primary prevention of cardiovascular disease in diabetes.”

Cooperation between the ADA and AHA is, for both organizations, a hurdle crossed after some much publicized disagreement last year, acknowledged Dr. Buse in an interview. “This paper was an effort to get together and hammer out where the common ground is in the few areas where there were fairly nuanced differences in approach.”

The main issue of contention between the ADA and AHA has been the debate over whether or not metabolic syndrome exists. In the joint statement, they have agreed to disagree: “The AHA and the [National Heart, Lung, and Blood Institute] have issued a statement on management of the metabolic syndrome and maintain that with regard to risk for CVD, the metabolic syndrome and type 2 diabetes can coexist in one person. The ADA, in contrast, contends that once type 2 diabetes is present, the metabolic syndrome no longer pertains because CVD risk factors characteristic of the metabolic syndrome are largely subsumed in the type 2 diabetes syndrome,” they wrote.

Dr. Einhorn said that even with some opposing viewpoints, a single set of guidelines shared by cardiologists and endocrinologists serves not only to clarify clinical practice, but to justify a preventive approach.

“It is important for people in managed care environments to have some validation that it is important to do testing, to prescribe medications, and to follow up on these patients from a cardiovascular standpoint, even when they don't have any known cardiovascular disease yet. It offers some impetus in large medical group settings,” he said.

It was an effort to hammer out the common ground in the few areas in which there were fairly nuanced differences. DR. BUSE

More Aggressive Tactics Recommended

The new joint ADA/AHA guidelines “encourage more aggressive prevention and treatment of risk factors that lead to heart disease” in people with diabetes, according to a press release from the two organizations. “Patients with diabetes have twice the risk of incident myocardial infarction and stroke as that of the general population,” they say. “Furthermore, large numbers of people with diabetes do not survive their first event, and if they do survive, their [mortality] over the subsequent months to years is generally greater than that of the general population. As many as 80% of patients with type 2 diabetes will develop and possibly die of macrovascular disease.”

While continuing to encourage lifestyle changes—such as weight loss, improved nutrition, and physical activity—the joint statement also emphasizes the importance of medical interventions to manage lipids, blood pressure, and blood glucose in this population. The full text of the guidelines can be viewed at

http://care.diabetesjournals.org/cgi/content/full/30/1/162

PRAGUE — Nonpharmacologic therapies remain less commonly prescribed than are pharmacologic therapies for the treatment of knee and hand osteoarthritis—and this trend has been noted both for primary care physicians and rheumatologists, according to two studies presented at the 2006 World Congress on Osteoarthritis.

When it comes to primary care physicians (PCPs) treating knee osteoarthritis (OA), nonpharmacologic treatments are “insufficiently prescribed and, when initiated, are rarely continued over the long term,” reported Dr. Bernard Mazières of Rangueil University Hospital, in Toulouse, France. However, first-line pharmacologic treatment with acetaminophen was initiated in 96% of patients, Dr. Mazières reported at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Dr. Mazières' observational, prospective, multicenter, 1-year cohort study included a total of 933 knee OA patients from 383 randomly selected PCPs in France and Spain. Information on the EULAR recommendations for treating knee OA was provided to the PCPs at the start of the study.

While 99% of the patients were prescribed acetaminophen during the study period, only 47% (437) were prescribed a treatment strictly following the EULAR recommendations. Among those who received nonpharmacologic therapy, the most common prescription was rehabilitation (40%), followed by weight loss (24%), and education (20%). The study concluded that under these therapeutic conditions patients were satisfied with their OA treatment and “improvement in pain, stiffness, and clinical signs of inflammation was clinically relevant.”

In a separate oral presentation at the meeting, Dr. Emmanuel Maheu reported that, when compared with PCPs, rheumatologists are no better at prescribing nonpharmacologic therapy—at least when it comes to the treatment of hand osteoarthritis.

His prospective cross-sectional study included 169 French rheumatologists and PCPs treating 316 hand OA patients. The study found that, when compared with rheumatologists, PCPs prescribed more analgesics (93% vs. 73%), more nonsteroidal anti-inflammatories (62% vs. 43%), and “surprisingly” more physical therapy (19% vs. 3%), said Dr. Maheu, of St. Antoine Hospital, Paris.

Rheumatologists prescribed more splints (30% vs. 13%) and more intra-articular steroid injections (16% vs. 5%).

PRAGUE — Nonpharmacologic therapies remain less commonly prescribed than are pharmacologic therapies for the treatment of knee and hand osteoarthritis—and this trend has been noted both for primary care physicians and rheumatologists, according to two studies presented at the 2006 World Congress on Osteoarthritis.

When it comes to primary care physicians (PCPs) treating knee osteoarthritis (OA), nonpharmacologic treatments are “insufficiently prescribed and, when initiated, are rarely continued over the long term,” reported Dr. Bernard Mazières of Rangueil University Hospital, in Toulouse, France. However, first-line pharmacologic treatment with acetaminophen was initiated in 96% of patients, Dr. Mazières reported at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Dr. Mazières' observational, prospective, multicenter, 1-year cohort study included a total of 933 knee OA patients from 383 randomly selected PCPs in France and Spain. Information on the EULAR recommendations for treating knee OA was provided to the PCPs at the start of the study.

While 99% of the patients were prescribed acetaminophen during the study period, only 47% (437) were prescribed a treatment strictly following the EULAR recommendations. Among those who received nonpharmacologic therapy, the most common prescription was rehabilitation (40%), followed by weight loss (24%), and education (20%). The study concluded that under these therapeutic conditions patients were satisfied with their OA treatment and “improvement in pain, stiffness, and clinical signs of inflammation was clinically relevant.”

In a separate oral presentation at the meeting, Dr. Emmanuel Maheu reported that, when compared with PCPs, rheumatologists are no better at prescribing nonpharmacologic therapy—at least when it comes to the treatment of hand osteoarthritis.

His prospective cross-sectional study included 169 French rheumatologists and PCPs treating 316 hand OA patients. The study found that, when compared with rheumatologists, PCPs prescribed more analgesics (93% vs. 73%), more nonsteroidal anti-inflammatories (62% vs. 43%), and “surprisingly” more physical therapy (19% vs. 3%), said Dr. Maheu, of St. Antoine Hospital, Paris.

Rheumatologists prescribed more splints (30% vs. 13%) and more intra-articular steroid injections (16% vs. 5%).

PRAGUE — Nonpharmacologic therapies remain less commonly prescribed than are pharmacologic therapies for the treatment of knee and hand osteoarthritis—and this trend has been noted both for primary care physicians and rheumatologists, according to two studies presented at the 2006 World Congress on Osteoarthritis.

When it comes to primary care physicians (PCPs) treating knee osteoarthritis (OA), nonpharmacologic treatments are “insufficiently prescribed and, when initiated, are rarely continued over the long term,” reported Dr. Bernard Mazières of Rangueil University Hospital, in Toulouse, France. However, first-line pharmacologic treatment with acetaminophen was initiated in 96% of patients, Dr. Mazières reported at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Dr. Mazières' observational, prospective, multicenter, 1-year cohort study included a total of 933 knee OA patients from 383 randomly selected PCPs in France and Spain. Information on the EULAR recommendations for treating knee OA was provided to the PCPs at the start of the study.

While 99% of the patients were prescribed acetaminophen during the study period, only 47% (437) were prescribed a treatment strictly following the EULAR recommendations. Among those who received nonpharmacologic therapy, the most common prescription was rehabilitation (40%), followed by weight loss (24%), and education (20%). The study concluded that under these therapeutic conditions patients were satisfied with their OA treatment and “improvement in pain, stiffness, and clinical signs of inflammation was clinically relevant.”

In a separate oral presentation at the meeting, Dr. Emmanuel Maheu reported that, when compared with PCPs, rheumatologists are no better at prescribing nonpharmacologic therapy—at least when it comes to the treatment of hand osteoarthritis.

His prospective cross-sectional study included 169 French rheumatologists and PCPs treating 316 hand OA patients. The study found that, when compared with rheumatologists, PCPs prescribed more analgesics (93% vs. 73%), more nonsteroidal anti-inflammatories (62% vs. 43%), and “surprisingly” more physical therapy (19% vs. 3%), said Dr. Maheu, of St. Antoine Hospital, Paris.

Rheumatologists prescribed more splints (30% vs. 13%) and more intra-articular steroid injections (16% vs. 5%).

More than 80% of pediatricians surveyed in January and February 2006 said they would recommend the rotavirus vaccine, reported Dr. Allison Kempe from the University of Colorado, Denver, and colleagues in the January 2007 issue of Pediatrics.

The vaccine in question is RotaTeq (Merck & Co.) and was approved by the Food and Drug Administration on Feb. 3, 2006—in the middle of the survey period. It is not clear what percentage of the survey's 305 mail and Internet respondents answered before or after the approval (Pediatrics 2007;119;1–10).

The FDA approval subsequently was followed by a recommendation from the Centers for Disease Control's Advisory Committee on Immunization Practices (ACIP) for routine use of the vaccine in infants in August 2006 (dose one at 12 weeks of age and all three vaccinations by 32 weeks of age, with at least a 4- to 10-week interval between doses), and a similar recommendation from the American Academy of Pediatrics shortly afterward, in November.

“The findings of this nationally representative survey demonstrate that pediatricians recognize the burden of rotavirus disease and the value of a rotavirus vaccine for children in this country,” wrote the authors. Of the respondents, 51% strongly agreed that the burden of rotavirus disease was sufficient in the United States to justify the need for a vaccine, while 83% agreed the burden in developing countries was sufficient to justify a global need.

When asked what they would recommend in the event that ACIP recommended routine use of the vaccine, 50% of the respondents said they would strongly recommend the vaccine and 34% said they would recommend it but not strongly.

Additionally, 52% said they would begin using the vaccine within 6 months of the recommendation, 27% from 6 months to 1 year, 7% from 1 to 2 years, and 1% more than 2 years after the recommendation. A total of 0.3% said they would never use the vaccine, and 13% were unsure. The most common reasons given for delaying for more than 6 months from the recommendation were as follows: determining that insurers would cover the vaccine; waiting to see if there were adverse effects reported; and ensuring that vaccine supplies were adequate.

Respondents indicated that the three most commonly perceived barriers to implementing rotavirus vaccine recommendations were their concerns about uneven coverage by insurers, concerns about lack of adequate reimbursement, and parents' safety concerns in light of the withdrawal of the previous RotaShield (Wyeth Laboratories) vaccine from the market in 1999 because of its association with intussusception, wrote the authors.

“Implementation in this country will be greatly facilitated if lessons learned from the implementation of other recent new vaccines such as PCV7 [the heptavalent pneumococcal conjugate] vaccine are heeded,” Dr. Kempe and her associates suggested.

“Some of the problems faced by pediatricians in the initial stages of implementation, including substantial delays in being able to bill for vaccines to insurers who have not yet changed their billing procedures to accommodate a new vaccine and unsynchronized timing of coverage between the public and private sectors, might well be ameliorated by an increased coordination between ACIP, vaccine manufacturers, and health plans before recommendation of a new vaccine,” they concluded.

The surveyed physicians are representative of pediatricians in the AAP nationally in regards to practice characteristics, demographics, and location throughout the United States, they said. The response rate to the survey was high.

Dr. Kempe and associates indicated they have no conflicts of interest to disclose. The study was funded by a CDC grant.

More than 80% of pediatricians surveyed in January and February 2006 said they would recommend the rotavirus vaccine, reported Dr. Allison Kempe from the University of Colorado, Denver, and colleagues in the January 2007 issue of Pediatrics.

The vaccine in question is RotaTeq (Merck & Co.) and was approved by the Food and Drug Administration on Feb. 3, 2006—in the middle of the survey period. It is not clear what percentage of the survey's 305 mail and Internet respondents answered before or after the approval (Pediatrics 2007;119;1–10).

The FDA approval subsequently was followed by a recommendation from the Centers for Disease Control's Advisory Committee on Immunization Practices (ACIP) for routine use of the vaccine in infants in August 2006 (dose one at 12 weeks of age and all three vaccinations by 32 weeks of age, with at least a 4- to 10-week interval between doses), and a similar recommendation from the American Academy of Pediatrics shortly afterward, in November.

“The findings of this nationally representative survey demonstrate that pediatricians recognize the burden of rotavirus disease and the value of a rotavirus vaccine for children in this country,” wrote the authors. Of the respondents, 51% strongly agreed that the burden of rotavirus disease was sufficient in the United States to justify the need for a vaccine, while 83% agreed the burden in developing countries was sufficient to justify a global need.

When asked what they would recommend in the event that ACIP recommended routine use of the vaccine, 50% of the respondents said they would strongly recommend the vaccine and 34% said they would recommend it but not strongly.

Additionally, 52% said they would begin using the vaccine within 6 months of the recommendation, 27% from 6 months to 1 year, 7% from 1 to 2 years, and 1% more than 2 years after the recommendation. A total of 0.3% said they would never use the vaccine, and 13% were unsure. The most common reasons given for delaying for more than 6 months from the recommendation were as follows: determining that insurers would cover the vaccine; waiting to see if there were adverse effects reported; and ensuring that vaccine supplies were adequate.

Respondents indicated that the three most commonly perceived barriers to implementing rotavirus vaccine recommendations were their concerns about uneven coverage by insurers, concerns about lack of adequate reimbursement, and parents' safety concerns in light of the withdrawal of the previous RotaShield (Wyeth Laboratories) vaccine from the market in 1999 because of its association with intussusception, wrote the authors.

“Implementation in this country will be greatly facilitated if lessons learned from the implementation of other recent new vaccines such as PCV7 [the heptavalent pneumococcal conjugate] vaccine are heeded,” Dr. Kempe and her associates suggested.

“Some of the problems faced by pediatricians in the initial stages of implementation, including substantial delays in being able to bill for vaccines to insurers who have not yet changed their billing procedures to accommodate a new vaccine and unsynchronized timing of coverage between the public and private sectors, might well be ameliorated by an increased coordination between ACIP, vaccine manufacturers, and health plans before recommendation of a new vaccine,” they concluded.

The surveyed physicians are representative of pediatricians in the AAP nationally in regards to practice characteristics, demographics, and location throughout the United States, they said. The response rate to the survey was high.

Dr. Kempe and associates indicated they have no conflicts of interest to disclose. The study was funded by a CDC grant.

More than 80% of pediatricians surveyed in January and February 2006 said they would recommend the rotavirus vaccine, reported Dr. Allison Kempe from the University of Colorado, Denver, and colleagues in the January 2007 issue of Pediatrics.

The vaccine in question is RotaTeq (Merck & Co.) and was approved by the Food and Drug Administration on Feb. 3, 2006—in the middle of the survey period. It is not clear what percentage of the survey's 305 mail and Internet respondents answered before or after the approval (Pediatrics 2007;119;1–10).

The FDA approval subsequently was followed by a recommendation from the Centers for Disease Control's Advisory Committee on Immunization Practices (ACIP) for routine use of the vaccine in infants in August 2006 (dose one at 12 weeks of age and all three vaccinations by 32 weeks of age, with at least a 4- to 10-week interval between doses), and a similar recommendation from the American Academy of Pediatrics shortly afterward, in November.

“The findings of this nationally representative survey demonstrate that pediatricians recognize the burden of rotavirus disease and the value of a rotavirus vaccine for children in this country,” wrote the authors. Of the respondents, 51% strongly agreed that the burden of rotavirus disease was sufficient in the United States to justify the need for a vaccine, while 83% agreed the burden in developing countries was sufficient to justify a global need.

When asked what they would recommend in the event that ACIP recommended routine use of the vaccine, 50% of the respondents said they would strongly recommend the vaccine and 34% said they would recommend it but not strongly.

Additionally, 52% said they would begin using the vaccine within 6 months of the recommendation, 27% from 6 months to 1 year, 7% from 1 to 2 years, and 1% more than 2 years after the recommendation. A total of 0.3% said they would never use the vaccine, and 13% were unsure. The most common reasons given for delaying for more than 6 months from the recommendation were as follows: determining that insurers would cover the vaccine; waiting to see if there were adverse effects reported; and ensuring that vaccine supplies were adequate.

Respondents indicated that the three most commonly perceived barriers to implementing rotavirus vaccine recommendations were their concerns about uneven coverage by insurers, concerns about lack of adequate reimbursement, and parents' safety concerns in light of the withdrawal of the previous RotaShield (Wyeth Laboratories) vaccine from the market in 1999 because of its association with intussusception, wrote the authors.

“Implementation in this country will be greatly facilitated if lessons learned from the implementation of other recent new vaccines such as PCV7 [the heptavalent pneumococcal conjugate] vaccine are heeded,” Dr. Kempe and her associates suggested.

“Some of the problems faced by pediatricians in the initial stages of implementation, including substantial delays in being able to bill for vaccines to insurers who have not yet changed their billing procedures to accommodate a new vaccine and unsynchronized timing of coverage between the public and private sectors, might well be ameliorated by an increased coordination between ACIP, vaccine manufacturers, and health plans before recommendation of a new vaccine,” they concluded.

The surveyed physicians are representative of pediatricians in the AAP nationally in regards to practice characteristics, demographics, and location throughout the United States, they said. The response rate to the survey was high.

Dr. Kempe and associates indicated they have no conflicts of interest to disclose. The study was funded by a CDC grant.