Doug Brunk

SAN DIEGO — About half of postmenopausal women who take bisphosphonates for osteoporosis take at least three concomitant medications and 15% take six or more, researchers led by Dr. Sydney Lou Bonnick reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“Patients receiving bisphosphonate therapy for postmenopausal osteoporosis have a substantial pill burden,” the researchers wrote in their poster. “Adherence to therapy may be improved if physicians consider prescribing more convenient, less frequently dosed medications.”

Dr. Bonnick, medical director of the Clinical Research Center of North Texas in Denton, and her associates obtained patient prescription information from November 1999 to June 2004 from NDCHealth, a database that contains records from 14,000 retail pharmacies in the United States. They identified women aged 50 years and older who were receiving alendronate or risedronate, which were the bisphosphonates approved for osteoporosis treatment during the study period.

Concomitant medications were defined as a minimum of a 2-week supply of medications that are prescribed in the same month as are a minimum of a 2-week supply of bisphosphonates.

Between November 1999 and June 2004 the number of women in the database using bisphosphonates rose from 78,909 to 250,286. Of the women prescribed concomitant medications, 74% were on two or more additional medications, 52% were on three or more, and 15% were on six or more.

The percentage of women taking six or more concomitant medications increased from 12% to 19% during the study period.

The most common concomitant drugs taken were cholesterol reducers, synthetic thyroid hormones, calcium channel blockers, β-blockers, ACE inhibitors, and systemic antiarthritis medications.

Dr. Bonnick and her associates observed that by the end of the study, women on daily bisphosphonate therapy were on a higher mean number of concomitant medications, compared with those on weekly bisphosphonate therapy (4.16 vs. 3.77, respectively). In addition, women aged 75 years and older were on a higher mean number of concomitant medications, compared with those aged 50–64 years (3.97 vs. 3.09, respectively).

GlaxoSmithKline supported the study.

SAN DIEGO — About half of postmenopausal women who take bisphosphonates for osteoporosis take at least three concomitant medications and 15% take six or more, researchers led by Dr. Sydney Lou Bonnick reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“Patients receiving bisphosphonate therapy for postmenopausal osteoporosis have a substantial pill burden,” the researchers wrote in their poster. “Adherence to therapy may be improved if physicians consider prescribing more convenient, less frequently dosed medications.”

Dr. Bonnick, medical director of the Clinical Research Center of North Texas in Denton, and her associates obtained patient prescription information from November 1999 to June 2004 from NDCHealth, a database that contains records from 14,000 retail pharmacies in the United States. They identified women aged 50 years and older who were receiving alendronate or risedronate, which were the bisphosphonates approved for osteoporosis treatment during the study period.

Concomitant medications were defined as a minimum of a 2-week supply of medications that are prescribed in the same month as are a minimum of a 2-week supply of bisphosphonates.

Between November 1999 and June 2004 the number of women in the database using bisphosphonates rose from 78,909 to 250,286. Of the women prescribed concomitant medications, 74% were on two or more additional medications, 52% were on three or more, and 15% were on six or more.

The percentage of women taking six or more concomitant medications increased from 12% to 19% during the study period.

The most common concomitant drugs taken were cholesterol reducers, synthetic thyroid hormones, calcium channel blockers, β-blockers, ACE inhibitors, and systemic antiarthritis medications.

Dr. Bonnick and her associates observed that by the end of the study, women on daily bisphosphonate therapy were on a higher mean number of concomitant medications, compared with those on weekly bisphosphonate therapy (4.16 vs. 3.77, respectively). In addition, women aged 75 years and older were on a higher mean number of concomitant medications, compared with those aged 50–64 years (3.97 vs. 3.09, respectively).

GlaxoSmithKline supported the study.

SAN DIEGO — About half of postmenopausal women who take bisphosphonates for osteoporosis take at least three concomitant medications and 15% take six or more, researchers led by Dr. Sydney Lou Bonnick reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“Patients receiving bisphosphonate therapy for postmenopausal osteoporosis have a substantial pill burden,” the researchers wrote in their poster. “Adherence to therapy may be improved if physicians consider prescribing more convenient, less frequently dosed medications.”

Dr. Bonnick, medical director of the Clinical Research Center of North Texas in Denton, and her associates obtained patient prescription information from November 1999 to June 2004 from NDCHealth, a database that contains records from 14,000 retail pharmacies in the United States. They identified women aged 50 years and older who were receiving alendronate or risedronate, which were the bisphosphonates approved for osteoporosis treatment during the study period.

Concomitant medications were defined as a minimum of a 2-week supply of medications that are prescribed in the same month as are a minimum of a 2-week supply of bisphosphonates.

Between November 1999 and June 2004 the number of women in the database using bisphosphonates rose from 78,909 to 250,286. Of the women prescribed concomitant medications, 74% were on two or more additional medications, 52% were on three or more, and 15% were on six or more.

The percentage of women taking six or more concomitant medications increased from 12% to 19% during the study period.

The most common concomitant drugs taken were cholesterol reducers, synthetic thyroid hormones, calcium channel blockers, β-blockers, ACE inhibitors, and systemic antiarthritis medications.

Dr. Bonnick and her associates observed that by the end of the study, women on daily bisphosphonate therapy were on a higher mean number of concomitant medications, compared with those on weekly bisphosphonate therapy (4.16 vs. 3.77, respectively). In addition, women aged 75 years and older were on a higher mean number of concomitant medications, compared with those aged 50–64 years (3.97 vs. 3.09, respectively).

GlaxoSmithKline supported the study.

SAN DIEGO — Postmenopausal women with low bone density who received once-weekly alendronate 70 mg had significantly greater increases in bone mineral density and reductions in markers of bone turnover over a 2-year period, compared with those who received once-weekly risedronate 35 mg, results from a randomized, double-blind trial demonstrated.

In addition, there were no differences between the two treatment groups in terms of upper-gastrointestinal adverse events or overall safety and tolerability, Dr. Anne E. de Papp reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“There has always been a perception that risedronate is better tolerated,” Dr. de Papp, senior medical director of clinical development for Merck & Co., said in an interview. “This is nice evidence that at least in a clinical trial setting, there is no difference [between risedronate and alendronate] in upper GI tolerability.”

However, she quickly cautioned that this head-to-head study only compared surrogate end points for bone fracture risk, not the actual rate of clinical fractures. “To do a head-to-head fracture trial between two agents that are active therapies for osteoporosis would require huge numbers of patients for many years,” she said. “I think when you're comparing two drugs that work by the same mechanism of action, it's reasonable to compare them using surrogate markers of efficacy.

“We saw greater gains in BMD and greater reductions in [markers of] bone turnover [with alendronate treatment], but the contention is, what does that mean in terms of fracture outcomes? We don't know, but … there is evidence to support that drugs causing greater gains in BMD and greater reductions in bone turnover are associated with greater fracture reduction.”

In the study, led by Dr. Sydney Bonnick of the Denton, Tex.-based Clinical Research Center of North Texas, researchers performed a 1-year extension of the original 1-year, randomized, double-blind Fosamax Actonel Comparison Trial (J. Bone Miner. Res. 2005;20:141–51).

Of the 833 patients, 419 received once-weekly risedronate 35 mg and 414 received once-weekly alendronate 70 mg. Their mean age was 64 years, and all had low bone density. This was defined as greater than or equal to 2.0 standard deviations below young normal mean bone mass in at least one of four sites: total hip, hip trochanter, femoral neck, or lumbar spine (L1-L4).

All patients underwent a DXA and lab analyses of biochemical markers at baseline and at 2 years.

Patients in the alendronate group had significantly greater increases in bone mineral density (BMD) at 2 years, compared with their counterparts in the risedronate group at the following sites: hip trochanter (4.6% vs. 2.5%), total hip (3.0% vs. 1.3%), femoral neck (2.8% vs. 1.0%), and lumbar spine (5.2% vs. 3.4%).

Significantly greater reductions of serum bone-specific alkaline phosphatase and other bone markers were seen in the alendronate group, compared with the risedronate group.

No significant differences between the two treatment groups were seen in terms of overall safety and tolerability, including gastrointestinal adverse events.

Merck & Co. funded the study.

In addition, there were no differences between the two treatment groups in terms of GI adverse events. DR. DE PAPP

Elsevier Global Medical News

SAN DIEGO — Postmenopausal women with low bone density who received once-weekly alendronate 70 mg had significantly greater increases in bone mineral density and reductions in markers of bone turnover over a 2-year period, compared with those who received once-weekly risedronate 35 mg, results from a randomized, double-blind trial demonstrated.

In addition, there were no differences between the two treatment groups in terms of upper-gastrointestinal adverse events or overall safety and tolerability, Dr. Anne E. de Papp reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“There has always been a perception that risedronate is better tolerated,” Dr. de Papp, senior medical director of clinical development for Merck & Co., said in an interview. “This is nice evidence that at least in a clinical trial setting, there is no difference [between risedronate and alendronate] in upper GI tolerability.”

However, she quickly cautioned that this head-to-head study only compared surrogate end points for bone fracture risk, not the actual rate of clinical fractures. “To do a head-to-head fracture trial between two agents that are active therapies for osteoporosis would require huge numbers of patients for many years,” she said. “I think when you're comparing two drugs that work by the same mechanism of action, it's reasonable to compare them using surrogate markers of efficacy.

“We saw greater gains in BMD and greater reductions in [markers of] bone turnover [with alendronate treatment], but the contention is, what does that mean in terms of fracture outcomes? We don't know, but … there is evidence to support that drugs causing greater gains in BMD and greater reductions in bone turnover are associated with greater fracture reduction.”

In the study, led by Dr. Sydney Bonnick of the Denton, Tex.-based Clinical Research Center of North Texas, researchers performed a 1-year extension of the original 1-year, randomized, double-blind Fosamax Actonel Comparison Trial (J. Bone Miner. Res. 2005;20:141–51).

Of the 833 patients, 419 received once-weekly risedronate 35 mg and 414 received once-weekly alendronate 70 mg. Their mean age was 64 years, and all had low bone density. This was defined as greater than or equal to 2.0 standard deviations below young normal mean bone mass in at least one of four sites: total hip, hip trochanter, femoral neck, or lumbar spine (L1-L4).

All patients underwent a DXA and lab analyses of biochemical markers at baseline and at 2 years.

Patients in the alendronate group had significantly greater increases in bone mineral density (BMD) at 2 years, compared with their counterparts in the risedronate group at the following sites: hip trochanter (4.6% vs. 2.5%), total hip (3.0% vs. 1.3%), femoral neck (2.8% vs. 1.0%), and lumbar spine (5.2% vs. 3.4%).

Significantly greater reductions of serum bone-specific alkaline phosphatase and other bone markers were seen in the alendronate group, compared with the risedronate group.

No significant differences between the two treatment groups were seen in terms of overall safety and tolerability, including gastrointestinal adverse events.

Merck & Co. funded the study.

In addition, there were no differences between the two treatment groups in terms of GI adverse events. DR. DE PAPP

Elsevier Global Medical News

SAN DIEGO — Postmenopausal women with low bone density who received once-weekly alendronate 70 mg had significantly greater increases in bone mineral density and reductions in markers of bone turnover over a 2-year period, compared with those who received once-weekly risedronate 35 mg, results from a randomized, double-blind trial demonstrated.

In addition, there were no differences between the two treatment groups in terms of upper-gastrointestinal adverse events or overall safety and tolerability, Dr. Anne E. de Papp reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“There has always been a perception that risedronate is better tolerated,” Dr. de Papp, senior medical director of clinical development for Merck & Co., said in an interview. “This is nice evidence that at least in a clinical trial setting, there is no difference [between risedronate and alendronate] in upper GI tolerability.”

However, she quickly cautioned that this head-to-head study only compared surrogate end points for bone fracture risk, not the actual rate of clinical fractures. “To do a head-to-head fracture trial between two agents that are active therapies for osteoporosis would require huge numbers of patients for many years,” she said. “I think when you're comparing two drugs that work by the same mechanism of action, it's reasonable to compare them using surrogate markers of efficacy.

“We saw greater gains in BMD and greater reductions in [markers of] bone turnover [with alendronate treatment], but the contention is, what does that mean in terms of fracture outcomes? We don't know, but … there is evidence to support that drugs causing greater gains in BMD and greater reductions in bone turnover are associated with greater fracture reduction.”

In the study, led by Dr. Sydney Bonnick of the Denton, Tex.-based Clinical Research Center of North Texas, researchers performed a 1-year extension of the original 1-year, randomized, double-blind Fosamax Actonel Comparison Trial (J. Bone Miner. Res. 2005;20:141–51).

Of the 833 patients, 419 received once-weekly risedronate 35 mg and 414 received once-weekly alendronate 70 mg. Their mean age was 64 years, and all had low bone density. This was defined as greater than or equal to 2.0 standard deviations below young normal mean bone mass in at least one of four sites: total hip, hip trochanter, femoral neck, or lumbar spine (L1-L4).

All patients underwent a DXA and lab analyses of biochemical markers at baseline and at 2 years.

Patients in the alendronate group had significantly greater increases in bone mineral density (BMD) at 2 years, compared with their counterparts in the risedronate group at the following sites: hip trochanter (4.6% vs. 2.5%), total hip (3.0% vs. 1.3%), femoral neck (2.8% vs. 1.0%), and lumbar spine (5.2% vs. 3.4%).

Significantly greater reductions of serum bone-specific alkaline phosphatase and other bone markers were seen in the alendronate group, compared with the risedronate group.

No significant differences between the two treatment groups were seen in terms of overall safety and tolerability, including gastrointestinal adverse events.

Merck & Co. funded the study.

In addition, there were no differences between the two treatment groups in terms of GI adverse events. DR. DE PAPP

Elsevier Global Medical News

SAN DIEGO — Female gender in extremely-low-birth-weight infants has a positive influence on the neurodevelopmental outcome at 18–22 months, increasing the Bayley-II Mental Developmental Index scores by 8–10 points, Dr. Regina A. Gargus reported at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

“The persistence of this effect over time will need to be reassessed in longer-term studies,” said Dr. Gargus, medical director of the Dennis Developmental Center at Arkansas Children's Hospital, Little Rock.

The finding is important because the influence of gender alone on the outcome of extremely-low-birth-weight (ELBW) infants has not been described.

In a study Dr. Gargus conducted during her fellowship at Brown University, Providence, R.I., she and her associates reviewed prospectively collected data from the neonatal intensive care unit (NICU) course and follow-up visits of 71 female and 53 male ELBW infant survivors who were admitted to Women and Infants Hospital of Rhode Island in Providence from January 1, 2000 to December 31, 2001. The infants had a gestational age of less than 32 weeks and a birth weight of less than 1,000 g, and they participated in developmental assessments at 18–22 months. Infants who were born with chromosomal or major congenital anomalies were excluded from the study.

The investigators analyzed the data for demographic characteristics, Score for Neonatal Acute Physiology-Perinatal Extension II (SNAP-PE II) scores, neonatal course, perinatal morbidities, and 18-month outcome.

Most of the medical characteristics did not differ between the two groups, but the mean number of days on oxygen was significantly greater in the male population (65.9 days vs. 50.6 days). The incidence of chronic lung disease was 1.5 times greater in males compared with females, but other comorbidities were not different between the two groups.

Bivariate analysis revealed that female gender was associated with decreased neurodevelopmental impairment and increased Bayley-II Mental Developmental Index scores.

Multivariate regression analysis, adjusted for gestation, chronic lung disease, SNAP-PE II, and level of maternal education, revealed that Bayley-II MDI scores were associated with female gender. Overall, the MDI scores of females were 8–10 points higher than the scores of their male counterparts.

SAN DIEGO — Female gender in extremely-low-birth-weight infants has a positive influence on the neurodevelopmental outcome at 18–22 months, increasing the Bayley-II Mental Developmental Index scores by 8–10 points, Dr. Regina A. Gargus reported at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

“The persistence of this effect over time will need to be reassessed in longer-term studies,” said Dr. Gargus, medical director of the Dennis Developmental Center at Arkansas Children's Hospital, Little Rock.

The finding is important because the influence of gender alone on the outcome of extremely-low-birth-weight (ELBW) infants has not been described.

In a study Dr. Gargus conducted during her fellowship at Brown University, Providence, R.I., she and her associates reviewed prospectively collected data from the neonatal intensive care unit (NICU) course and follow-up visits of 71 female and 53 male ELBW infant survivors who were admitted to Women and Infants Hospital of Rhode Island in Providence from January 1, 2000 to December 31, 2001. The infants had a gestational age of less than 32 weeks and a birth weight of less than 1,000 g, and they participated in developmental assessments at 18–22 months. Infants who were born with chromosomal or major congenital anomalies were excluded from the study.

The investigators analyzed the data for demographic characteristics, Score for Neonatal Acute Physiology-Perinatal Extension II (SNAP-PE II) scores, neonatal course, perinatal morbidities, and 18-month outcome.

Most of the medical characteristics did not differ between the two groups, but the mean number of days on oxygen was significantly greater in the male population (65.9 days vs. 50.6 days). The incidence of chronic lung disease was 1.5 times greater in males compared with females, but other comorbidities were not different between the two groups.

Bivariate analysis revealed that female gender was associated with decreased neurodevelopmental impairment and increased Bayley-II Mental Developmental Index scores.

Multivariate regression analysis, adjusted for gestation, chronic lung disease, SNAP-PE II, and level of maternal education, revealed that Bayley-II MDI scores were associated with female gender. Overall, the MDI scores of females were 8–10 points higher than the scores of their male counterparts.

SAN DIEGO — Female gender in extremely-low-birth-weight infants has a positive influence on the neurodevelopmental outcome at 18–22 months, increasing the Bayley-II Mental Developmental Index scores by 8–10 points, Dr. Regina A. Gargus reported at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

“The persistence of this effect over time will need to be reassessed in longer-term studies,” said Dr. Gargus, medical director of the Dennis Developmental Center at Arkansas Children's Hospital, Little Rock.

The finding is important because the influence of gender alone on the outcome of extremely-low-birth-weight (ELBW) infants has not been described.

In a study Dr. Gargus conducted during her fellowship at Brown University, Providence, R.I., she and her associates reviewed prospectively collected data from the neonatal intensive care unit (NICU) course and follow-up visits of 71 female and 53 male ELBW infant survivors who were admitted to Women and Infants Hospital of Rhode Island in Providence from January 1, 2000 to December 31, 2001. The infants had a gestational age of less than 32 weeks and a birth weight of less than 1,000 g, and they participated in developmental assessments at 18–22 months. Infants who were born with chromosomal or major congenital anomalies were excluded from the study.

The investigators analyzed the data for demographic characteristics, Score for Neonatal Acute Physiology-Perinatal Extension II (SNAP-PE II) scores, neonatal course, perinatal morbidities, and 18-month outcome.

Most of the medical characteristics did not differ between the two groups, but the mean number of days on oxygen was significantly greater in the male population (65.9 days vs. 50.6 days). The incidence of chronic lung disease was 1.5 times greater in males compared with females, but other comorbidities were not different between the two groups.

Bivariate analysis revealed that female gender was associated with decreased neurodevelopmental impairment and increased Bayley-II Mental Developmental Index scores.

Multivariate regression analysis, adjusted for gestation, chronic lung disease, SNAP-PE II, and level of maternal education, revealed that Bayley-II MDI scores were associated with female gender. Overall, the MDI scores of females were 8–10 points higher than the scores of their male counterparts.

LA JOLLA, CALIF. — Children and adults with chronic tic disorders who were treated with levodopa did not experience a worsening of tics, Dr. Mollie Gordon reported during a poster session at the annual meeting of the American Neuropsychiatric Association.

Treated patients did experience significant improvements in attention and hyperactivity symptoms.

“I think this challenges the way we think about the dopamine pathways in the brain,” Dr. Gordon, of the department of psychiatry at Washington University School of Medicine, St. Louis, said in an interview. “We've always thought of Tourette as being in a sense an excess of and when we block the dopamine, these patients do better.” But their tics do not worsen when given exogenous dopamine. In an 8-week pilot study, Dr. Gordon and her associates randomly assigned 12 children and 18 adults with Tourette syndrome or chronic tic disorder to receive 12.5 mg of carbidopa, 50 mg of levodopa, or matched placebo capsules.

The researchers found that tic severity did not increase in patients who took levodopa; instead levodopa improved attention and hyperreactivity symptoms (a 17% improvement vs. no improvement for those on placebo), and the drug was not associated with any significant side effects.

“We know that these patients have a dopamine abnormality in the brain,” Dr. Gordon said. “If it's not a matter of being too much or too little [dopamine], the question is, how do we figure out what's wrong? Is it a dopamine dysregulation? Do these drugs affect auto inhibitory receptors? Is there something going on in the brain that has to do with the dopamine dysregulation? If we [have] more information about the pathophysiology of these diseases, then we can figure out the best management.” The study was funded in part by the Tourette Syndrome Association.

LA JOLLA, CALIF. — Children and adults with chronic tic disorders who were treated with levodopa did not experience a worsening of tics, Dr. Mollie Gordon reported during a poster session at the annual meeting of the American Neuropsychiatric Association.

Treated patients did experience significant improvements in attention and hyperactivity symptoms.

“I think this challenges the way we think about the dopamine pathways in the brain,” Dr. Gordon, of the department of psychiatry at Washington University School of Medicine, St. Louis, said in an interview. “We've always thought of Tourette as being in a sense an excess of and when we block the dopamine, these patients do better.” But their tics do not worsen when given exogenous dopamine. In an 8-week pilot study, Dr. Gordon and her associates randomly assigned 12 children and 18 adults with Tourette syndrome or chronic tic disorder to receive 12.5 mg of carbidopa, 50 mg of levodopa, or matched placebo capsules.

The researchers found that tic severity did not increase in patients who took levodopa; instead levodopa improved attention and hyperreactivity symptoms (a 17% improvement vs. no improvement for those on placebo), and the drug was not associated with any significant side effects.

“We know that these patients have a dopamine abnormality in the brain,” Dr. Gordon said. “If it's not a matter of being too much or too little [dopamine], the question is, how do we figure out what's wrong? Is it a dopamine dysregulation? Do these drugs affect auto inhibitory receptors? Is there something going on in the brain that has to do with the dopamine dysregulation? If we [have] more information about the pathophysiology of these diseases, then we can figure out the best management.” The study was funded in part by the Tourette Syndrome Association.

LA JOLLA, CALIF. — Children and adults with chronic tic disorders who were treated with levodopa did not experience a worsening of tics, Dr. Mollie Gordon reported during a poster session at the annual meeting of the American Neuropsychiatric Association.

Treated patients did experience significant improvements in attention and hyperactivity symptoms.

“I think this challenges the way we think about the dopamine pathways in the brain,” Dr. Gordon, of the department of psychiatry at Washington University School of Medicine, St. Louis, said in an interview. “We've always thought of Tourette as being in a sense an excess of and when we block the dopamine, these patients do better.” But their tics do not worsen when given exogenous dopamine. In an 8-week pilot study, Dr. Gordon and her associates randomly assigned 12 children and 18 adults with Tourette syndrome or chronic tic disorder to receive 12.5 mg of carbidopa, 50 mg of levodopa, or matched placebo capsules.

The researchers found that tic severity did not increase in patients who took levodopa; instead levodopa improved attention and hyperreactivity symptoms (a 17% improvement vs. no improvement for those on placebo), and the drug was not associated with any significant side effects.

“We know that these patients have a dopamine abnormality in the brain,” Dr. Gordon said. “If it's not a matter of being too much or too little [dopamine], the question is, how do we figure out what's wrong? Is it a dopamine dysregulation? Do these drugs affect auto inhibitory receptors? Is there something going on in the brain that has to do with the dopamine dysregulation? If we [have] more information about the pathophysiology of these diseases, then we can figure out the best management.” The study was funded in part by the Tourette Syndrome Association.

SAN DIEGO — Microfracture as a treatment for full thickness chondral lesions provided functional improvement in a group of professional and recreational athletes at 6-year follow-up, but the level of postoperative sports participation declined with time, Dr. Alberto Gobbi reported at a symposium sponsored by the International Cartilage Repair Society.

The finding suggests that while microfracture can be performed as a simple, minimally invasive method to promote cartilage healing, it “may not be the definitive treatment for the athletes' knee, as further procedures may be indicated in the future,” said Dr. Gobbi, an orthopedic surgeon with the Orthopedic Arthroscopic Surgery International Research Center in Milan. “However, it can relieve symptoms and delay the need for further treatment.”

Dr. Gobbi and his associate Dr. Ramces Francisco followed 53 professional and recreational athletes who underwent microfracture surgery for unilateral knee articular cartilage injury at their center. Mean patient age was 38 years. Of the patients, 33 were male, and 26 were professional athletes. Mean follow-up was 6 years.

Outcomes were assessed using the Lysholm score, Tegner activity level score, the International Knee Documentation Committee (IKDC) scoring system, and a subjective evaluation based on a 100-point scale. Roentgenograms, MRI, or CT scans were done pre- and postoperatively.

Dr. Gobbi reported that the cause of most injuries was related to sports microtrauma (38%) and macrotrauma (21%), although 38% of patients did not report any traumatic etiology and 4% showed patellar malalignment. The most common location of injury was the medial femoral condyle (61%), and the mean defect size among study participants was 4 cm

Between baseline and final follow-up the mean Lysholm scores improved from 57 to 87; the Tegner scores improved from 3 to 5; and the subjective evaluation improved from 40/100 to 70/100. At baseline, only three patients scored an A or B on the IKDC, but by final follow-up, 70% of patients scored an A or B.

Also by final follow-up, activities of daily living improved in 65% of patients while imaging studies revealed increased degenerative changes in 30% of patients.

“When we analyzed the [return to] strenuous sports activities, we found they increased to 80% in the first 2 years but then gradually decreased to 55% at final follow-up,” Dr. Gobbi added. Changing to a low-risk sport, advancing age of the study participants, work and family obligations, and the influence of degenerative joint disease may have contributed to the decline in postsurgical sports activity.

Second-look arthroscopy performed in 10 patients showed that the articular defects were covered with fibrocartilaginous tissue at a level adjacent with normal articular surface and were firm when palpated with a probe. Biopsies from these same 10 patients showed areas of fibromyxoid tissue with differentiation, a transition zone with cartilage tissue, and initial hyaline transformation tissue.

Candidates should be evaluated by age, activity level, type of sport, type of injury, expectations, associated pathologies, likelihood of rehabilitation compliance, and the articular depth of the defect.

SAN DIEGO — Microfracture as a treatment for full thickness chondral lesions provided functional improvement in a group of professional and recreational athletes at 6-year follow-up, but the level of postoperative sports participation declined with time, Dr. Alberto Gobbi reported at a symposium sponsored by the International Cartilage Repair Society.

The finding suggests that while microfracture can be performed as a simple, minimally invasive method to promote cartilage healing, it “may not be the definitive treatment for the athletes' knee, as further procedures may be indicated in the future,” said Dr. Gobbi, an orthopedic surgeon with the Orthopedic Arthroscopic Surgery International Research Center in Milan. “However, it can relieve symptoms and delay the need for further treatment.”

Dr. Gobbi and his associate Dr. Ramces Francisco followed 53 professional and recreational athletes who underwent microfracture surgery for unilateral knee articular cartilage injury at their center. Mean patient age was 38 years. Of the patients, 33 were male, and 26 were professional athletes. Mean follow-up was 6 years.

Outcomes were assessed using the Lysholm score, Tegner activity level score, the International Knee Documentation Committee (IKDC) scoring system, and a subjective evaluation based on a 100-point scale. Roentgenograms, MRI, or CT scans were done pre- and postoperatively.

Dr. Gobbi reported that the cause of most injuries was related to sports microtrauma (38%) and macrotrauma (21%), although 38% of patients did not report any traumatic etiology and 4% showed patellar malalignment. The most common location of injury was the medial femoral condyle (61%), and the mean defect size among study participants was 4 cm

Between baseline and final follow-up the mean Lysholm scores improved from 57 to 87; the Tegner scores improved from 3 to 5; and the subjective evaluation improved from 40/100 to 70/100. At baseline, only three patients scored an A or B on the IKDC, but by final follow-up, 70% of patients scored an A or B.

Also by final follow-up, activities of daily living improved in 65% of patients while imaging studies revealed increased degenerative changes in 30% of patients.

“When we analyzed the [return to] strenuous sports activities, we found they increased to 80% in the first 2 years but then gradually decreased to 55% at final follow-up,” Dr. Gobbi added. Changing to a low-risk sport, advancing age of the study participants, work and family obligations, and the influence of degenerative joint disease may have contributed to the decline in postsurgical sports activity.

Second-look arthroscopy performed in 10 patients showed that the articular defects were covered with fibrocartilaginous tissue at a level adjacent with normal articular surface and were firm when palpated with a probe. Biopsies from these same 10 patients showed areas of fibromyxoid tissue with differentiation, a transition zone with cartilage tissue, and initial hyaline transformation tissue.

Candidates should be evaluated by age, activity level, type of sport, type of injury, expectations, associated pathologies, likelihood of rehabilitation compliance, and the articular depth of the defect.

SAN DIEGO — Microfracture as a treatment for full thickness chondral lesions provided functional improvement in a group of professional and recreational athletes at 6-year follow-up, but the level of postoperative sports participation declined with time, Dr. Alberto Gobbi reported at a symposium sponsored by the International Cartilage Repair Society.

The finding suggests that while microfracture can be performed as a simple, minimally invasive method to promote cartilage healing, it “may not be the definitive treatment for the athletes' knee, as further procedures may be indicated in the future,” said Dr. Gobbi, an orthopedic surgeon with the Orthopedic Arthroscopic Surgery International Research Center in Milan. “However, it can relieve symptoms and delay the need for further treatment.”

Dr. Gobbi and his associate Dr. Ramces Francisco followed 53 professional and recreational athletes who underwent microfracture surgery for unilateral knee articular cartilage injury at their center. Mean patient age was 38 years. Of the patients, 33 were male, and 26 were professional athletes. Mean follow-up was 6 years.

Outcomes were assessed using the Lysholm score, Tegner activity level score, the International Knee Documentation Committee (IKDC) scoring system, and a subjective evaluation based on a 100-point scale. Roentgenograms, MRI, or CT scans were done pre- and postoperatively.

Dr. Gobbi reported that the cause of most injuries was related to sports microtrauma (38%) and macrotrauma (21%), although 38% of patients did not report any traumatic etiology and 4% showed patellar malalignment. The most common location of injury was the medial femoral condyle (61%), and the mean defect size among study participants was 4 cm

Between baseline and final follow-up the mean Lysholm scores improved from 57 to 87; the Tegner scores improved from 3 to 5; and the subjective evaluation improved from 40/100 to 70/100. At baseline, only three patients scored an A or B on the IKDC, but by final follow-up, 70% of patients scored an A or B.

Also by final follow-up, activities of daily living improved in 65% of patients while imaging studies revealed increased degenerative changes in 30% of patients.

“When we analyzed the [return to] strenuous sports activities, we found they increased to 80% in the first 2 years but then gradually decreased to 55% at final follow-up,” Dr. Gobbi added. Changing to a low-risk sport, advancing age of the study participants, work and family obligations, and the influence of degenerative joint disease may have contributed to the decline in postsurgical sports activity.

Second-look arthroscopy performed in 10 patients showed that the articular defects were covered with fibrocartilaginous tissue at a level adjacent with normal articular surface and were firm when palpated with a probe. Biopsies from these same 10 patients showed areas of fibromyxoid tissue with differentiation, a transition zone with cartilage tissue, and initial hyaline transformation tissue.

Candidates should be evaluated by age, activity level, type of sport, type of injury, expectations, associated pathologies, likelihood of rehabilitation compliance, and the articular depth of the defect.

SAN DIEGO — Moderate to severe vertebral compression deformities are uncommon among postmenopausal women with osteopenia who lack a clinical history of fragility fracture, Dr. Angela M. Cheung reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

In what she described as the first study to describe the prevalence of vertebral deformities in healthy postmenopausal women with osteopenia, Dr. Cheung and her associates conducted a cross-sectional analysis of 439 women participating in the ongoing 2-year Evaluation of the Clinical Use of Vitamin K Supplementation in Postmenopausal Women with Osteopenia trial (ECKO).

Of the 48 deformities detected in the study, 45 (94%) were grade 1.

“The unknown is, how does that mild, grade 1 vertebral compression deformity translate to future fracture risk?” Dr. Cheung, director of the osteoporosis program for the University Health Network, Toronto, said in an interview. “We'll take a look at that. It's an ongoing study.”

Exclusion criteria included being on an osteoporosis medication, having a clinical fragility fracture, or having a T score of less than −2.0 at the lumbar spine, total hip, or femoral neck. Researchers used densitometry to measure bone mineral density and to perform a vertebral fracture assessment.

The mean patient age at baseline was 58 years, and mean body mass index was 26 kg/m

Baseline mean T scores were −1.2 for L1-L4, −0.6 for total hip, and −1.2 for femoral neck.

Baseline vertebral fracture assessment revealed that about 1 in 10 women had at least one vertebral compression deformity. Specifically, 8.7% had a single deformity, and 1.1% had two deformities.

Dr. Cheung said she was surprised to see the presence of vertebral compression deformities in women from all age groups. The age of study participants ranged from 40 to 82 years.

“While we do see a higher percentage of [older] people [with] vertebral compression deformities, we see it in [more] young people, too,” she said. “The gradient is from about 10% in the lowest age group to about 15% in the older age group.”

Two women (aged 56 and 60) had grade 2 deformities while one 74-year-old had a grade 3 deformity.

Limitations acknowledged by the researchers in their poster included the cross-sectional study design and a lack of lateral spine x-rays on the women for comparison.

However, they wrote that vertebral fracture assessment “has been validated by different groups, and the performance of the test is excellent for grades 2–4 deformities.”

While we see more vertebral deformities in older people, we see more in the young, too. DR. CHEUNG

A densitometer image shows a grade 1 L1 vertebral compression deformity. Courtesy Dr. Angela M. Cheung

SAN DIEGO — Moderate to severe vertebral compression deformities are uncommon among postmenopausal women with osteopenia who lack a clinical history of fragility fracture, Dr. Angela M. Cheung reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

In what she described as the first study to describe the prevalence of vertebral deformities in healthy postmenopausal women with osteopenia, Dr. Cheung and her associates conducted a cross-sectional analysis of 439 women participating in the ongoing 2-year Evaluation of the Clinical Use of Vitamin K Supplementation in Postmenopausal Women with Osteopenia trial (ECKO).

Of the 48 deformities detected in the study, 45 (94%) were grade 1.

“The unknown is, how does that mild, grade 1 vertebral compression deformity translate to future fracture risk?” Dr. Cheung, director of the osteoporosis program for the University Health Network, Toronto, said in an interview. “We'll take a look at that. It's an ongoing study.”

Exclusion criteria included being on an osteoporosis medication, having a clinical fragility fracture, or having a T score of less than −2.0 at the lumbar spine, total hip, or femoral neck. Researchers used densitometry to measure bone mineral density and to perform a vertebral fracture assessment.

The mean patient age at baseline was 58 years, and mean body mass index was 26 kg/m

Baseline mean T scores were −1.2 for L1-L4, −0.6 for total hip, and −1.2 for femoral neck.

Baseline vertebral fracture assessment revealed that about 1 in 10 women had at least one vertebral compression deformity. Specifically, 8.7% had a single deformity, and 1.1% had two deformities.

Dr. Cheung said she was surprised to see the presence of vertebral compression deformities in women from all age groups. The age of study participants ranged from 40 to 82 years.

“While we do see a higher percentage of [older] people [with] vertebral compression deformities, we see it in [more] young people, too,” she said. “The gradient is from about 10% in the lowest age group to about 15% in the older age group.”

Two women (aged 56 and 60) had grade 2 deformities while one 74-year-old had a grade 3 deformity.

Limitations acknowledged by the researchers in their poster included the cross-sectional study design and a lack of lateral spine x-rays on the women for comparison.

However, they wrote that vertebral fracture assessment “has been validated by different groups, and the performance of the test is excellent for grades 2–4 deformities.”

While we see more vertebral deformities in older people, we see more in the young, too. DR. CHEUNG

A densitometer image shows a grade 1 L1 vertebral compression deformity. Courtesy Dr. Angela M. Cheung

SAN DIEGO — Moderate to severe vertebral compression deformities are uncommon among postmenopausal women with osteopenia who lack a clinical history of fragility fracture, Dr. Angela M. Cheung reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

In what she described as the first study to describe the prevalence of vertebral deformities in healthy postmenopausal women with osteopenia, Dr. Cheung and her associates conducted a cross-sectional analysis of 439 women participating in the ongoing 2-year Evaluation of the Clinical Use of Vitamin K Supplementation in Postmenopausal Women with Osteopenia trial (ECKO).

Of the 48 deformities detected in the study, 45 (94%) were grade 1.

“The unknown is, how does that mild, grade 1 vertebral compression deformity translate to future fracture risk?” Dr. Cheung, director of the osteoporosis program for the University Health Network, Toronto, said in an interview. “We'll take a look at that. It's an ongoing study.”

Exclusion criteria included being on an osteoporosis medication, having a clinical fragility fracture, or having a T score of less than −2.0 at the lumbar spine, total hip, or femoral neck. Researchers used densitometry to measure bone mineral density and to perform a vertebral fracture assessment.

The mean patient age at baseline was 58 years, and mean body mass index was 26 kg/m

Baseline mean T scores were −1.2 for L1-L4, −0.6 for total hip, and −1.2 for femoral neck.

Baseline vertebral fracture assessment revealed that about 1 in 10 women had at least one vertebral compression deformity. Specifically, 8.7% had a single deformity, and 1.1% had two deformities.

Dr. Cheung said she was surprised to see the presence of vertebral compression deformities in women from all age groups. The age of study participants ranged from 40 to 82 years.

“While we do see a higher percentage of [older] people [with] vertebral compression deformities, we see it in [more] young people, too,” she said. “The gradient is from about 10% in the lowest age group to about 15% in the older age group.”

Two women (aged 56 and 60) had grade 2 deformities while one 74-year-old had a grade 3 deformity.

Limitations acknowledged by the researchers in their poster included the cross-sectional study design and a lack of lateral spine x-rays on the women for comparison.

However, they wrote that vertebral fracture assessment “has been validated by different groups, and the performance of the test is excellent for grades 2–4 deformities.”

While we see more vertebral deformities in older people, we see more in the young, too. DR. CHEUNG

A densitometer image shows a grade 1 L1 vertebral compression deformity. Courtesy Dr. Angela M. Cheung

LAS VEGAS — A medical student approaches you for some advice. She is seeking a career choice in pediatrics and has been thinking about becoming a pediatric gastroenterologist, but she's heard rumors that interest in training in the pediatric subspecialties has declined.

What should you tell her?

“This young lady needs to understand that she can get a job,” Dr. James Stockman III said at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP. Factors that influence the work force, he said, include the supply of trainees, the number of international medical school graduates, the increasing number of women coming into pediatrics, the impact of managed care, the increasing number of children that need to be cared for, and the “delicate interface between what a generalist does and what a subspecialist does.”

According to data from the American Board of Pediatrics, the bulk of pediatric subspecialists certified through January 2005 were in neonatal-perinatal medicine (4,136) followed by hematology/oncology (1,884) and cardiology (1,870).

“There are some subspecialties such as sports medicine where there are just a [few] people certified in the discipline,” said Dr. Stockman, who is president of the ABP. “We tend to see what looks like large numbers of neonatal/perinatal people, but these numbers actually are not huge. In fact, if you added up [all pediatric subspecialists] in the United States they would equal about half the number of adult cardiologists. So there are relatively few pediatric subspecialists in the United States.”

He noted that the percentage of pediatric residents going into subspecialties dropped to 18% by the late 1980s, largely as a result of the emphasis on gatekeeping in primary care. “Fortunately these numbers have turned around,” Dr. Stockman said. For example, 664 residents chose a subspecialty fellowship in 1997–1998, compared with 1,121 in 2004–2005.

To ensure enough people are being trained in specific subspecialties, the ABP tracks their average age. “We look at the people who are currently in the field who are age 50 or older, add up those numbers and [infer that] in 10–15 years they're not likely to be seeing patients,” he said.

Using pediatric gastroenterology as an example, he explained that almost half of diplomates in that subspecialty are aged 50 and older, “so this whole cohort needs to be replaced in the next 15 years,” said Dr. Stockman, also of the pediatrics departments at the University of North Carolina and at Duke University.

LAS VEGAS — A medical student approaches you for some advice. She is seeking a career choice in pediatrics and has been thinking about becoming a pediatric gastroenterologist, but she's heard rumors that interest in training in the pediatric subspecialties has declined.

What should you tell her?

“This young lady needs to understand that she can get a job,” Dr. James Stockman III said at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP. Factors that influence the work force, he said, include the supply of trainees, the number of international medical school graduates, the increasing number of women coming into pediatrics, the impact of managed care, the increasing number of children that need to be cared for, and the “delicate interface between what a generalist does and what a subspecialist does.”

According to data from the American Board of Pediatrics, the bulk of pediatric subspecialists certified through January 2005 were in neonatal-perinatal medicine (4,136) followed by hematology/oncology (1,884) and cardiology (1,870).

“There are some subspecialties such as sports medicine where there are just a [few] people certified in the discipline,” said Dr. Stockman, who is president of the ABP. “We tend to see what looks like large numbers of neonatal/perinatal people, but these numbers actually are not huge. In fact, if you added up [all pediatric subspecialists] in the United States they would equal about half the number of adult cardiologists. So there are relatively few pediatric subspecialists in the United States.”

He noted that the percentage of pediatric residents going into subspecialties dropped to 18% by the late 1980s, largely as a result of the emphasis on gatekeeping in primary care. “Fortunately these numbers have turned around,” Dr. Stockman said. For example, 664 residents chose a subspecialty fellowship in 1997–1998, compared with 1,121 in 2004–2005.

To ensure enough people are being trained in specific subspecialties, the ABP tracks their average age. “We look at the people who are currently in the field who are age 50 or older, add up those numbers and [infer that] in 10–15 years they're not likely to be seeing patients,” he said.

Using pediatric gastroenterology as an example, he explained that almost half of diplomates in that subspecialty are aged 50 and older, “so this whole cohort needs to be replaced in the next 15 years,” said Dr. Stockman, also of the pediatrics departments at the University of North Carolina and at Duke University.

LAS VEGAS — A medical student approaches you for some advice. She is seeking a career choice in pediatrics and has been thinking about becoming a pediatric gastroenterologist, but she's heard rumors that interest in training in the pediatric subspecialties has declined.

What should you tell her?

“This young lady needs to understand that she can get a job,” Dr. James Stockman III said at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP. Factors that influence the work force, he said, include the supply of trainees, the number of international medical school graduates, the increasing number of women coming into pediatrics, the impact of managed care, the increasing number of children that need to be cared for, and the “delicate interface between what a generalist does and what a subspecialist does.”

According to data from the American Board of Pediatrics, the bulk of pediatric subspecialists certified through January 2005 were in neonatal-perinatal medicine (4,136) followed by hematology/oncology (1,884) and cardiology (1,870).

“There are some subspecialties such as sports medicine where there are just a [few] people certified in the discipline,” said Dr. Stockman, who is president of the ABP. “We tend to see what looks like large numbers of neonatal/perinatal people, but these numbers actually are not huge. In fact, if you added up [all pediatric subspecialists] in the United States they would equal about half the number of adult cardiologists. So there are relatively few pediatric subspecialists in the United States.”

He noted that the percentage of pediatric residents going into subspecialties dropped to 18% by the late 1980s, largely as a result of the emphasis on gatekeeping in primary care. “Fortunately these numbers have turned around,” Dr. Stockman said. For example, 664 residents chose a subspecialty fellowship in 1997–1998, compared with 1,121 in 2004–2005.

To ensure enough people are being trained in specific subspecialties, the ABP tracks their average age. “We look at the people who are currently in the field who are age 50 or older, add up those numbers and [infer that] in 10–15 years they're not likely to be seeing patients,” he said.

Using pediatric gastroenterology as an example, he explained that almost half of diplomates in that subspecialty are aged 50 and older, “so this whole cohort needs to be replaced in the next 15 years,” said Dr. Stockman, also of the pediatrics departments at the University of North Carolina and at Duke University.

LAS VEGAS — Respiratory syncytial virus infection is a clinical diagnosis based on patient history, physical exam, and the season of the year, Dr. Veda L. Ackerman said at a meeting sponsored by the American Academy of Pediatrics and its California Chapters 1, 2, 3, and 4.

“So if you try to tell me that you have a baby who is RSV positive on July 4th in your practice, I'm going to tell you that your RSV test has cross-reacted with another virus,” said Dr. Ackerman, of the section of pulmonology and critical care in the department of pediatrics at the James Whitcomb Riley Hospital for Children, Indianapolis. “We do not see RSV in the summer in the United States. It peaks in midwinter and early spring.”

You can use RSV rapid tests to make a diagnosis, but these “have both a high degree of false-negatives and a high degree of false-positives,” she said. “You have to take that into consideration.”

Even with viral cultures—which are traditionally the preferred method—there is a high false-negative rate due to the lability of the virus.

“So you can't take RSV positive or negative as a very good guideline for what you do,” she explained. “As therapy is largely supportive, proving that the baby has RSV really shouldn't matter to you, except for potential infection control.”

By age 2 years, 99% of children have been infected with RSV at least once and 36% have had a least 2 infections. This makes RSV “as contagious as varicella, and it has significant impact on missed days of school and missed days of work.”

Factors that increase one's risk of acquiring RSV infection include maternal education of grade 12 or less, day care attendance, school-age siblings, lack of breast-feeding, two or more people sharing a bedroom, multiple births, passive smoke exposure, and birth within 6 months before onset of RSV infection.

“Obviously you're much better delivering your baby in March or April than you are in December,” Dr. Ackerman said. “You're less likely to have that baby acquire RSV.”

Clinical features of RSV infection include nasal flaring, chest wall retractions, tachypnea with apneic episodes, expiratory wheezing, prolonged expiration, rales and rhonchi, croupy cough, and hypoxemia and cyanosis. Tiny babies infected with RSV may present only with apnea.

In a study of 213 infants younger than 13 months who had bronchiolitis, the best predictor of more severe disease was an oxygen saturation level of less than 95% oximetry (Am. J. Dis. Child. 1991;145:151–5). “If you happen to not have [pulse] oximetry in your office, I urge you that it is one of the things that will help you tremendously, both in figuring out what to do with the child with asthma and what to do with the child with bronchiolitis,” Dr. Ackerman said.

Treatment for RSV infection is mainly supportive and includes supplemental humidified oxygen, IV hydration if needed, proper nutrition, and ventilatory assistance for respiratory failure.

A trial of bronchodilators is appropriate, “but to continue them if there's no response is not appropriate,” she warned.

Corticosteroids are not currently indicated for RSV infection but Dr. Ackerman said she would use them in a 9-month-old infant with a second or third episode of wheezing who happens to have RSV. “That's an asthmatic and that's a baby [in which] I would use corticosteroids.”

She also would use them in a baby with RSV and congestive heart failure.

Efforts to delay RSV spread include limiting contact with infected people, enrolling your child in a day care facility with few children, and washing hands frequently.

The James Whitcomb Riley Hospital for Children is in the midst of a handwashing campaign. Parents are given a brochure on admission which urges them to ask, “Doctor, have you washed your hands?” every time they see a physician touch their child. “My answer is supposed to be, 'Yes, I have. Thank you for asking,'” Dr. Ackerman said.

Other efforts to prevent spread include disinfecting surfaces exposed to infectious secretions, grouping hospitalized patients with RSV, and promotion of breast-feeding.

One strategy to help prevent infection in high-risk premature infants is to administer palivizumab (Synagis), which has been shown to reduce RSV-related hospitalizations in this patient population by more than 50%. “The down side of Synagis is you have to give it before exposure and you have to give it every 30 days,” Dr. Ackerman commented. “This is really a problem because you have to give it before you're ever exposed and you have to give it frequently.”

She also noted that there are no data to address the use of palivizumab in children over 2 years of age or in those with cerebral palsy, neurologic disease, metabolic disease, or immunodeficiency.

Dr. Ackerman disclosed that she is on the speakers' bureau for GlaxoSmithKline Inc., maker of Zovirax (generic name acyclovir) and for AstraZeneca.

LAS VEGAS — Respiratory syncytial virus infection is a clinical diagnosis based on patient history, physical exam, and the season of the year, Dr. Veda L. Ackerman said at a meeting sponsored by the American Academy of Pediatrics and its California Chapters 1, 2, 3, and 4.

“So if you try to tell me that you have a baby who is RSV positive on July 4th in your practice, I'm going to tell you that your RSV test has cross-reacted with another virus,” said Dr. Ackerman, of the section of pulmonology and critical care in the department of pediatrics at the James Whitcomb Riley Hospital for Children, Indianapolis. “We do not see RSV in the summer in the United States. It peaks in midwinter and early spring.”

You can use RSV rapid tests to make a diagnosis, but these “have both a high degree of false-negatives and a high degree of false-positives,” she said. “You have to take that into consideration.”

Even with viral cultures—which are traditionally the preferred method—there is a high false-negative rate due to the lability of the virus.

“So you can't take RSV positive or negative as a very good guideline for what you do,” she explained. “As therapy is largely supportive, proving that the baby has RSV really shouldn't matter to you, except for potential infection control.”

By age 2 years, 99% of children have been infected with RSV at least once and 36% have had a least 2 infections. This makes RSV “as contagious as varicella, and it has significant impact on missed days of school and missed days of work.”

Factors that increase one's risk of acquiring RSV infection include maternal education of grade 12 or less, day care attendance, school-age siblings, lack of breast-feeding, two or more people sharing a bedroom, multiple births, passive smoke exposure, and birth within 6 months before onset of RSV infection.

“Obviously you're much better delivering your baby in March or April than you are in December,” Dr. Ackerman said. “You're less likely to have that baby acquire RSV.”

Clinical features of RSV infection include nasal flaring, chest wall retractions, tachypnea with apneic episodes, expiratory wheezing, prolonged expiration, rales and rhonchi, croupy cough, and hypoxemia and cyanosis. Tiny babies infected with RSV may present only with apnea.

In a study of 213 infants younger than 13 months who had bronchiolitis, the best predictor of more severe disease was an oxygen saturation level of less than 95% oximetry (Am. J. Dis. Child. 1991;145:151–5). “If you happen to not have [pulse] oximetry in your office, I urge you that it is one of the things that will help you tremendously, both in figuring out what to do with the child with asthma and what to do with the child with bronchiolitis,” Dr. Ackerman said.

Treatment for RSV infection is mainly supportive and includes supplemental humidified oxygen, IV hydration if needed, proper nutrition, and ventilatory assistance for respiratory failure.

A trial of bronchodilators is appropriate, “but to continue them if there's no response is not appropriate,” she warned.

Corticosteroids are not currently indicated for RSV infection but Dr. Ackerman said she would use them in a 9-month-old infant with a second or third episode of wheezing who happens to have RSV. “That's an asthmatic and that's a baby [in which] I would use corticosteroids.”

She also would use them in a baby with RSV and congestive heart failure.

Efforts to delay RSV spread include limiting contact with infected people, enrolling your child in a day care facility with few children, and washing hands frequently.

The James Whitcomb Riley Hospital for Children is in the midst of a handwashing campaign. Parents are given a brochure on admission which urges them to ask, “Doctor, have you washed your hands?” every time they see a physician touch their child. “My answer is supposed to be, 'Yes, I have. Thank you for asking,'” Dr. Ackerman said.

Other efforts to prevent spread include disinfecting surfaces exposed to infectious secretions, grouping hospitalized patients with RSV, and promotion of breast-feeding.

One strategy to help prevent infection in high-risk premature infants is to administer palivizumab (Synagis), which has been shown to reduce RSV-related hospitalizations in this patient population by more than 50%. “The down side of Synagis is you have to give it before exposure and you have to give it every 30 days,” Dr. Ackerman commented. “This is really a problem because you have to give it before you're ever exposed and you have to give it frequently.”

She also noted that there are no data to address the use of palivizumab in children over 2 years of age or in those with cerebral palsy, neurologic disease, metabolic disease, or immunodeficiency.

Dr. Ackerman disclosed that she is on the speakers' bureau for GlaxoSmithKline Inc., maker of Zovirax (generic name acyclovir) and for AstraZeneca.

LAS VEGAS — Respiratory syncytial virus infection is a clinical diagnosis based on patient history, physical exam, and the season of the year, Dr. Veda L. Ackerman said at a meeting sponsored by the American Academy of Pediatrics and its California Chapters 1, 2, 3, and 4.

“So if you try to tell me that you have a baby who is RSV positive on July 4th in your practice, I'm going to tell you that your RSV test has cross-reacted with another virus,” said Dr. Ackerman, of the section of pulmonology and critical care in the department of pediatrics at the James Whitcomb Riley Hospital for Children, Indianapolis. “We do not see RSV in the summer in the United States. It peaks in midwinter and early spring.”

You can use RSV rapid tests to make a diagnosis, but these “have both a high degree of false-negatives and a high degree of false-positives,” she said. “You have to take that into consideration.”

Even with viral cultures—which are traditionally the preferred method—there is a high false-negative rate due to the lability of the virus.

“So you can't take RSV positive or negative as a very good guideline for what you do,” she explained. “As therapy is largely supportive, proving that the baby has RSV really shouldn't matter to you, except for potential infection control.”

By age 2 years, 99% of children have been infected with RSV at least once and 36% have had a least 2 infections. This makes RSV “as contagious as varicella, and it has significant impact on missed days of school and missed days of work.”

Factors that increase one's risk of acquiring RSV infection include maternal education of grade 12 or less, day care attendance, school-age siblings, lack of breast-feeding, two or more people sharing a bedroom, multiple births, passive smoke exposure, and birth within 6 months before onset of RSV infection.

“Obviously you're much better delivering your baby in March or April than you are in December,” Dr. Ackerman said. “You're less likely to have that baby acquire RSV.”

Clinical features of RSV infection include nasal flaring, chest wall retractions, tachypnea with apneic episodes, expiratory wheezing, prolonged expiration, rales and rhonchi, croupy cough, and hypoxemia and cyanosis. Tiny babies infected with RSV may present only with apnea.

In a study of 213 infants younger than 13 months who had bronchiolitis, the best predictor of more severe disease was an oxygen saturation level of less than 95% oximetry (Am. J. Dis. Child. 1991;145:151–5). “If you happen to not have [pulse] oximetry in your office, I urge you that it is one of the things that will help you tremendously, both in figuring out what to do with the child with asthma and what to do with the child with bronchiolitis,” Dr. Ackerman said.

Treatment for RSV infection is mainly supportive and includes supplemental humidified oxygen, IV hydration if needed, proper nutrition, and ventilatory assistance for respiratory failure.

A trial of bronchodilators is appropriate, “but to continue them if there's no response is not appropriate,” she warned.

Corticosteroids are not currently indicated for RSV infection but Dr. Ackerman said she would use them in a 9-month-old infant with a second or third episode of wheezing who happens to have RSV. “That's an asthmatic and that's a baby [in which] I would use corticosteroids.”

She also would use them in a baby with RSV and congestive heart failure.

Efforts to delay RSV spread include limiting contact with infected people, enrolling your child in a day care facility with few children, and washing hands frequently.

The James Whitcomb Riley Hospital for Children is in the midst of a handwashing campaign. Parents are given a brochure on admission which urges them to ask, “Doctor, have you washed your hands?” every time they see a physician touch their child. “My answer is supposed to be, 'Yes, I have. Thank you for asking,'” Dr. Ackerman said.

Other efforts to prevent spread include disinfecting surfaces exposed to infectious secretions, grouping hospitalized patients with RSV, and promotion of breast-feeding.

One strategy to help prevent infection in high-risk premature infants is to administer palivizumab (Synagis), which has been shown to reduce RSV-related hospitalizations in this patient population by more than 50%. “The down side of Synagis is you have to give it before exposure and you have to give it every 30 days,” Dr. Ackerman commented. “This is really a problem because you have to give it before you're ever exposed and you have to give it frequently.”

She also noted that there are no data to address the use of palivizumab in children over 2 years of age or in those with cerebral palsy, neurologic disease, metabolic disease, or immunodeficiency.

Dr. Ackerman disclosed that she is on the speakers' bureau for GlaxoSmithKline Inc., maker of Zovirax (generic name acyclovir) and for AstraZeneca.

LAS VEGAS — Posing an open-ended question is the best way to approach the topic of treatment options when talking with an obese child or adolescent and the patient's family, Dr. William H. Dietz advised at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

Such questions help you zero in on how the patient and family view his or her weight, said Dr. Dietz, who directs the division of nutrition and physical activity at the Centers for Disease Control and Prevention, Atlanta. Useful questions include:

▸ “Are you concerned about your weight?”

▸ “Has your weight caused you any difficulties?”

▸ “What things in your life do you value most? Does your weight influence your ability to pursue those values?”

Tying weight to a child's values “is an important strategic step,” he said. “Rather than rely on external motivation, we need to focus on internally motivating patients and families. The key to success is successful self-management.”

One way to gauge the patient's readiness to make a behavior change to lose weight is by asking, “On a scale of 1–10, with 10 being very interested, how interested are you in changing your behavior?”

Follow this by asking, “On a scale of 1–10, with 10 being very confident, how confident are you that you can change your behavior?”

If the patient expresses a readiness to change, consider these questions:

▸ “What might you want to do about this?”

▸ “What is likely to get in the way?”

▸ “Where do we go from here?”

If the patient is not ready to change, say something like, “It sounds like you are not yet ready to make a change. Perhaps we can think about what we have discussed and we can talk about it again.”

Dr. Dietz said that the majority of focus for overweight and obese youngsters should involve altering diet, increasing activity, and decreasing inactivity.

The current pediatric recommendations for physical activity are 60 minutes daily of moderate physical activity most or all days of the week, he said. That recommendation is derived from the impact of physical activity on cardiovascular disease, not on obesity.

Nearly everything known about successful strategies for weight maintenance comes from studies of adults. These strategies include low fat intake, eating breakfast, expending at least 400 kcal per day on physical activity, and monitoring weight at least once a week.

Reducing the amount of television viewing at home is another important strategy. Dr. Dietz estimated that about half of families in the United States watch television during meals. “Changing the perspective on meals as the potential family time may be an important strategy,” he said. “Families are much more concerned about the time their children spend watching television during the week because it interferes with homework. They're not concerned about weekend TV, which is when children are exposed to food advertisements.”

Some parents worry that if they control their child's television viewing time, they'll have to entertain them. But when asked what they would do if they didn't watch television, children “provide a whole list of activities, almost none of which involve parents,” he said.

LAS VEGAS — Posing an open-ended question is the best way to approach the topic of treatment options when talking with an obese child or adolescent and the patient's family, Dr. William H. Dietz advised at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

Such questions help you zero in on how the patient and family view his or her weight, said Dr. Dietz, who directs the division of nutrition and physical activity at the Centers for Disease Control and Prevention, Atlanta. Useful questions include:

▸ “Are you concerned about your weight?”

▸ “Has your weight caused you any difficulties?”

▸ “What things in your life do you value most? Does your weight influence your ability to pursue those values?”

Tying weight to a child's values “is an important strategic step,” he said. “Rather than rely on external motivation, we need to focus on internally motivating patients and families. The key to success is successful self-management.”

One way to gauge the patient's readiness to make a behavior change to lose weight is by asking, “On a scale of 1–10, with 10 being very interested, how interested are you in changing your behavior?”

Follow this by asking, “On a scale of 1–10, with 10 being very confident, how confident are you that you can change your behavior?”

If the patient expresses a readiness to change, consider these questions:

▸ “What might you want to do about this?”

▸ “What is likely to get in the way?”

▸ “Where do we go from here?”

If the patient is not ready to change, say something like, “It sounds like you are not yet ready to make a change. Perhaps we can think about what we have discussed and we can talk about it again.”

Dr. Dietz said that the majority of focus for overweight and obese youngsters should involve altering diet, increasing activity, and decreasing inactivity.

The current pediatric recommendations for physical activity are 60 minutes daily of moderate physical activity most or all days of the week, he said. That recommendation is derived from the impact of physical activity on cardiovascular disease, not on obesity.

Nearly everything known about successful strategies for weight maintenance comes from studies of adults. These strategies include low fat intake, eating breakfast, expending at least 400 kcal per day on physical activity, and monitoring weight at least once a week.

Reducing the amount of television viewing at home is another important strategy. Dr. Dietz estimated that about half of families in the United States watch television during meals. “Changing the perspective on meals as the potential family time may be an important strategy,” he said. “Families are much more concerned about the time their children spend watching television during the week because it interferes with homework. They're not concerned about weekend TV, which is when children are exposed to food advertisements.”

Some parents worry that if they control their child's television viewing time, they'll have to entertain them. But when asked what they would do if they didn't watch television, children “provide a whole list of activities, almost none of which involve parents,” he said.

LAS VEGAS — Posing an open-ended question is the best way to approach the topic of treatment options when talking with an obese child or adolescent and the patient's family, Dr. William H. Dietz advised at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

Such questions help you zero in on how the patient and family view his or her weight, said Dr. Dietz, who directs the division of nutrition and physical activity at the Centers for Disease Control and Prevention, Atlanta. Useful questions include:

▸ “Are you concerned about your weight?”

▸ “Has your weight caused you any difficulties?”

▸ “What things in your life do you value most? Does your weight influence your ability to pursue those values?”

Tying weight to a child's values “is an important strategic step,” he said. “Rather than rely on external motivation, we need to focus on internally motivating patients and families. The key to success is successful self-management.”

One way to gauge the patient's readiness to make a behavior change to lose weight is by asking, “On a scale of 1–10, with 10 being very interested, how interested are you in changing your behavior?”

Follow this by asking, “On a scale of 1–10, with 10 being very confident, how confident are you that you can change your behavior?”

If the patient expresses a readiness to change, consider these questions:

▸ “What might you want to do about this?”

▸ “What is likely to get in the way?”

▸ “Where do we go from here?”

If the patient is not ready to change, say something like, “It sounds like you are not yet ready to make a change. Perhaps we can think about what we have discussed and we can talk about it again.”

Dr. Dietz said that the majority of focus for overweight and obese youngsters should involve altering diet, increasing activity, and decreasing inactivity.

The current pediatric recommendations for physical activity are 60 minutes daily of moderate physical activity most or all days of the week, he said. That recommendation is derived from the impact of physical activity on cardiovascular disease, not on obesity.

Nearly everything known about successful strategies for weight maintenance comes from studies of adults. These strategies include low fat intake, eating breakfast, expending at least 400 kcal per day on physical activity, and monitoring weight at least once a week.

Reducing the amount of television viewing at home is another important strategy. Dr. Dietz estimated that about half of families in the United States watch television during meals. “Changing the perspective on meals as the potential family time may be an important strategy,” he said. “Families are much more concerned about the time their children spend watching television during the week because it interferes with homework. They're not concerned about weekend TV, which is when children are exposed to food advertisements.”

Some parents worry that if they control their child's television viewing time, they'll have to entertain them. But when asked what they would do if they didn't watch television, children “provide a whole list of activities, almost none of which involve parents,” he said.

LAS VEGAS — There are at least six behavior change strategies physicians can recommend to prevent child and adolescent obesity, Dr. William H. Dietz said at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

“Reasonable scientific certainty” exists for three of the six strategies, said Dr. Dietz, who directs the division of nutrition and physical activity at the Centers for Disease Control and Prevention, Atlanta. These “reasonable” strategies are:

▸ Increase physical activity. There is emerging evidence in the pediatric population that physical activity appears to reduce obesity-associated comorbidity, particularly glucose intolerance and hyperlipidemia. “So if you are obese, inactive, and have elevated triglycerides, increased physical activity will improve your triglyceride level,” he said. “It can also raise your HDL and lower your LDL.”

He added that about 10 years ago, 20% of children walked to school. Today that figure is less than 12%.

▸ Reduce television viewing time. According the Kaiser Family Foundation, 17% of children and adolescents are watching 5 or more hours of television a day. “Even in the heaviest adolescent computer users, computer time pales by comparison to sedentary [television viewing] time,” Dr. Dietz said. “We have [found] a linear relationship between the amount of television a child watches and the prevalence of overweight. One of the most concerning statistics is that 25% of 2-year-old children have a television in their own room and 65% of all children have a television in their room.”

▸ Promote breast-feeding. Three metaanalyses in the medical literature demonstrate that breast-feeding appears to reduce early childhood overweight.

Dr. Dietz defined the next three interventions as “promising. Characteristic of these strategies is that there's no absolute impact for any of them,” he said.

These three strategies are:

▸ Increase fruit and vegetable consumption. This “appears to have an impact on satiety by virtue of the volume of foods that you consume,” he explained. “Satiety does not appear to be regulated by calories. It appears to be regulated by the volume of food. Therefore, food of low caloric density that is high [in] water content is more filling. However, data is still lacking for the evidence that increasing [intake of] fruits and vegetables helps reduce weight or that people who have an increased fruit and vegetable intake have a lower risk of being obese.”

▸ Reduce soft drink consumption. A number of studies have linked soft drink consumption to increased weight gain. However, “we don't yet have studies which demonstrate that reduced soft drink intake is a good way to control weight,” he noted.

▸ Reduce portion size. This strategy “has a very robust impact on food intake,” Dr. Dietz said. “The larger the portion an individual is exposed to, the more likely they are to overeat. We don't have good data that control of portion size is an effective way to reduce weight, but it is a logical potential strategy.”

“One of the problems is a lack of consistent messages.” Young people need to hear a message from their physician, and then have that same message reinforced by what they hear in school, in the community, and from their parents, he said.

Dr. Dietz said that awareness of the problem of obesity among children and adolescents in the United States is beginning to plateau. “I don't think we yet have strategies as effective as those which have been employed against tobacco [use]. Per capita cigarette consumption didn't decline because of a single intervention but because of multiple overlapping interventions. I think interventions with respect to obesity are going to be found in the clinical arena as well as in the schools and communities. We need more communication strategies and advocacy on your part.”

LAS VEGAS — There are at least six behavior change strategies physicians can recommend to prevent child and adolescent obesity, Dr. William H. Dietz said at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

“Reasonable scientific certainty” exists for three of the six strategies, said Dr. Dietz, who directs the division of nutrition and physical activity at the Centers for Disease Control and Prevention, Atlanta. These “reasonable” strategies are:

▸ Increase physical activity. There is emerging evidence in the pediatric population that physical activity appears to reduce obesity-associated comorbidity, particularly glucose intolerance and hyperlipidemia. “So if you are obese, inactive, and have elevated triglycerides, increased physical activity will improve your triglyceride level,” he said. “It can also raise your HDL and lower your LDL.”

He added that about 10 years ago, 20% of children walked to school. Today that figure is less than 12%.

▸ Reduce television viewing time. According the Kaiser Family Foundation, 17% of children and adolescents are watching 5 or more hours of television a day. “Even in the heaviest adolescent computer users, computer time pales by comparison to sedentary [television viewing] time,” Dr. Dietz said. “We have [found] a linear relationship between the amount of television a child watches and the prevalence of overweight. One of the most concerning statistics is that 25% of 2-year-old children have a television in their own room and 65% of all children have a television in their room.”

▸ Promote breast-feeding. Three metaanalyses in the medical literature demonstrate that breast-feeding appears to reduce early childhood overweight.

Dr. Dietz defined the next three interventions as “promising. Characteristic of these strategies is that there's no absolute impact for any of them,” he said.

These three strategies are:

▸ Increase fruit and vegetable consumption. This “appears to have an impact on satiety by virtue of the volume of foods that you consume,” he explained. “Satiety does not appear to be regulated by calories. It appears to be regulated by the volume of food. Therefore, food of low caloric density that is high [in] water content is more filling. However, data is still lacking for the evidence that increasing [intake of] fruits and vegetables helps reduce weight or that people who have an increased fruit and vegetable intake have a lower risk of being obese.”

▸ Reduce soft drink consumption. A number of studies have linked soft drink consumption to increased weight gain. However, “we don't yet have studies which demonstrate that reduced soft drink intake is a good way to control weight,” he noted.

▸ Reduce portion size. This strategy “has a very robust impact on food intake,” Dr. Dietz said. “The larger the portion an individual is exposed to, the more likely they are to overeat. We don't have good data that control of portion size is an effective way to reduce weight, but it is a logical potential strategy.”

“One of the problems is a lack of consistent messages.” Young people need to hear a message from their physician, and then have that same message reinforced by what they hear in school, in the community, and from their parents, he said.

Dr. Dietz said that awareness of the problem of obesity among children and adolescents in the United States is beginning to plateau. “I don't think we yet have strategies as effective as those which have been employed against tobacco [use]. Per capita cigarette consumption didn't decline because of a single intervention but because of multiple overlapping interventions. I think interventions with respect to obesity are going to be found in the clinical arena as well as in the schools and communities. We need more communication strategies and advocacy on your part.”

LAS VEGAS — There are at least six behavior change strategies physicians can recommend to prevent child and adolescent obesity, Dr. William H. Dietz said at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

“Reasonable scientific certainty” exists for three of the six strategies, said Dr. Dietz, who directs the division of nutrition and physical activity at the Centers for Disease Control and Prevention, Atlanta. These “reasonable” strategies are:

▸ Increase physical activity. There is emerging evidence in the pediatric population that physical activity appears to reduce obesity-associated comorbidity, particularly glucose intolerance and hyperlipidemia. “So if you are obese, inactive, and have elevated triglycerides, increased physical activity will improve your triglyceride level,” he said. “It can also raise your HDL and lower your LDL.”

He added that about 10 years ago, 20% of children walked to school. Today that figure is less than 12%.

▸ Reduce television viewing time. According the Kaiser Family Foundation, 17% of children and adolescents are watching 5 or more hours of television a day. “Even in the heaviest adolescent computer users, computer time pales by comparison to sedentary [television viewing] time,” Dr. Dietz said. “We have [found] a linear relationship between the amount of television a child watches and the prevalence of overweight. One of the most concerning statistics is that 25% of 2-year-old children have a television in their own room and 65% of all children have a television in their room.”

▸ Promote breast-feeding. Three metaanalyses in the medical literature demonstrate that breast-feeding appears to reduce early childhood overweight.

Dr. Dietz defined the next three interventions as “promising. Characteristic of these strategies is that there's no absolute impact for any of them,” he said.

These three strategies are:

▸ Increase fruit and vegetable consumption. This “appears to have an impact on satiety by virtue of the volume of foods that you consume,” he explained. “Satiety does not appear to be regulated by calories. It appears to be regulated by the volume of food. Therefore, food of low caloric density that is high [in] water content is more filling. However, data is still lacking for the evidence that increasing [intake of] fruits and vegetables helps reduce weight or that people who have an increased fruit and vegetable intake have a lower risk of being obese.”

▸ Reduce soft drink consumption. A number of studies have linked soft drink consumption to increased weight gain. However, “we don't yet have studies which demonstrate that reduced soft drink intake is a good way to control weight,” he noted.

▸ Reduce portion size. This strategy “has a very robust impact on food intake,” Dr. Dietz said. “The larger the portion an individual is exposed to, the more likely they are to overeat. We don't have good data that control of portion size is an effective way to reduce weight, but it is a logical potential strategy.”

“One of the problems is a lack of consistent messages.” Young people need to hear a message from their physician, and then have that same message reinforced by what they hear in school, in the community, and from their parents, he said.

Dr. Dietz said that awareness of the problem of obesity among children and adolescents in the United States is beginning to plateau. “I don't think we yet have strategies as effective as those which have been employed against tobacco [use]. Per capita cigarette consumption didn't decline because of a single intervention but because of multiple overlapping interventions. I think interventions with respect to obesity are going to be found in the clinical arena as well as in the schools and communities. We need more communication strategies and advocacy on your part.”