Mary Ann Moon

Among African Americans with type 1 diabetes, high-caloric and high-sodium intakes were significantly and independently associated with progression of retinopathy, a longitudinal study has shown.

Restricting one's diet might be key to the preservation of vision in this patient population, wrote Dr. Monique S. Roy of the Institute of Ophthalmology and Visual Science at the New Jersey Medical School, Newark, and associates.

They noted that the role of diet as an important determinant of retinopathy progression had been assessed in only a few previous studies that did not include black populations.

Dr. Roy and associates analyzed data from a larger study of 725 African Americans with type 1 diabetes. Their analysis comprised 469 people (280 women and 189 men) who had participated in the 6-year follow-up study from 1999 through 2004. At baseline, the women had a mean age of 28 years, the men 27 years; they had completed a detailed food-frequency questionnaire; and they had undergone complete eye examinations, which were then repeated at follow-up. Baseline caloric intake was analyzed by quartiles. Total mean daily caloric intake was 2,310 and 1,706 kcal for men and women, respectively.

After adjustment for diabetic retinopathy clinical risk factors, high caloric intake was significantly associated with progression to proliferative diabetic retinopathy, macular edema, and severe retinal hard exudates (Arch. Ophthalmol. 2010;128:33-9).

These findings are consistent with those of a large clinical trial of predominantly white patients that total caloric intake is one of the strongest risk factors for retinopathy progression (MedGenMed. 2005;7:3). “As in our study, total caloric intake was also significantly and positively associated with higher glycated hemoglobin levels, one of the strongest risk factors for progression of diabetic retinopathy,” the authors wrote.

“The increased metabolic burden and oxidative stress associated with hyperglycemia and dyslipidemia present in diabetes may be mechanisms underlying” this association. “The retina is particularly susceptible to oxidative stress because of its high lipid content,” they wrote, adding that high sodium intake also was significantly and independently associated with the progression of diabetic retinopathy. The study subjects had a mean sodium intake of 3,235 mg daily compared with the 2,400 mg recommended by the American Diabetes Association.

The study was supported by the National Eye Institute, Bethesda, Md., and Research to Prevent Blindness Inc., New York. No financial conflicts of interest were reported.

Among African Americans with type 1 diabetes, high-caloric and high-sodium intakes were significantly and independently associated with progression of retinopathy, a longitudinal study has shown.

Restricting one's diet might be key to the preservation of vision in this patient population, wrote Dr. Monique S. Roy of the Institute of Ophthalmology and Visual Science at the New Jersey Medical School, Newark, and associates.

They noted that the role of diet as an important determinant of retinopathy progression had been assessed in only a few previous studies that did not include black populations.

Dr. Roy and associates analyzed data from a larger study of 725 African Americans with type 1 diabetes. Their analysis comprised 469 people (280 women and 189 men) who had participated in the 6-year follow-up study from 1999 through 2004. At baseline, the women had a mean age of 28 years, the men 27 years; they had completed a detailed food-frequency questionnaire; and they had undergone complete eye examinations, which were then repeated at follow-up. Baseline caloric intake was analyzed by quartiles. Total mean daily caloric intake was 2,310 and 1,706 kcal for men and women, respectively.

After adjustment for diabetic retinopathy clinical risk factors, high caloric intake was significantly associated with progression to proliferative diabetic retinopathy, macular edema, and severe retinal hard exudates (Arch. Ophthalmol. 2010;128:33-9).

These findings are consistent with those of a large clinical trial of predominantly white patients that total caloric intake is one of the strongest risk factors for retinopathy progression (MedGenMed. 2005;7:3). “As in our study, total caloric intake was also significantly and positively associated with higher glycated hemoglobin levels, one of the strongest risk factors for progression of diabetic retinopathy,” the authors wrote.

“The increased metabolic burden and oxidative stress associated with hyperglycemia and dyslipidemia present in diabetes may be mechanisms underlying” this association. “The retina is particularly susceptible to oxidative stress because of its high lipid content,” they wrote, adding that high sodium intake also was significantly and independently associated with the progression of diabetic retinopathy. The study subjects had a mean sodium intake of 3,235 mg daily compared with the 2,400 mg recommended by the American Diabetes Association.

The study was supported by the National Eye Institute, Bethesda, Md., and Research to Prevent Blindness Inc., New York. No financial conflicts of interest were reported.

Among African Americans with type 1 diabetes, high-caloric and high-sodium intakes were significantly and independently associated with progression of retinopathy, a longitudinal study has shown.

Restricting one's diet might be key to the preservation of vision in this patient population, wrote Dr. Monique S. Roy of the Institute of Ophthalmology and Visual Science at the New Jersey Medical School, Newark, and associates.

They noted that the role of diet as an important determinant of retinopathy progression had been assessed in only a few previous studies that did not include black populations.

Dr. Roy and associates analyzed data from a larger study of 725 African Americans with type 1 diabetes. Their analysis comprised 469 people (280 women and 189 men) who had participated in the 6-year follow-up study from 1999 through 2004. At baseline, the women had a mean age of 28 years, the men 27 years; they had completed a detailed food-frequency questionnaire; and they had undergone complete eye examinations, which were then repeated at follow-up. Baseline caloric intake was analyzed by quartiles. Total mean daily caloric intake was 2,310 and 1,706 kcal for men and women, respectively.

After adjustment for diabetic retinopathy clinical risk factors, high caloric intake was significantly associated with progression to proliferative diabetic retinopathy, macular edema, and severe retinal hard exudates (Arch. Ophthalmol. 2010;128:33-9).

These findings are consistent with those of a large clinical trial of predominantly white patients that total caloric intake is one of the strongest risk factors for retinopathy progression (MedGenMed. 2005;7:3). “As in our study, total caloric intake was also significantly and positively associated with higher glycated hemoglobin levels, one of the strongest risk factors for progression of diabetic retinopathy,” the authors wrote.

“The increased metabolic burden and oxidative stress associated with hyperglycemia and dyslipidemia present in diabetes may be mechanisms underlying” this association. “The retina is particularly susceptible to oxidative stress because of its high lipid content,” they wrote, adding that high sodium intake also was significantly and independently associated with the progression of diabetic retinopathy. The study subjects had a mean sodium intake of 3,235 mg daily compared with the 2,400 mg recommended by the American Diabetes Association.

The study was supported by the National Eye Institute, Bethesda, Md., and Research to Prevent Blindness Inc., New York. No financial conflicts of interest were reported.

Major Finding: Exercisers showed beneficial changes in MMP-9 levels and MMP9/TIMP ratios, compared with controls. Neither group improved in MMP-2 and TIMP-1 levels.

Data Source: Fifty overweight, sedentary type 2 diabetes patients randomized to exercise or no-exercise groups for 4 months.

Disclosures: The lead author reported receiving a grant from the Alexander S. Onassis Public Benefit Foundation. No other conflicts of interest were reported.

A 4-month exercise program of moderate intensity improved the inflammatory milieu, including markers of atherosclerosis, in overweight, sedentary diabetic patients.

The exercise did not alter body weight or insulin resistance, but it significantly improved glycemic, lipid, and cardiorespiratory factors, reported Dr. Nikolaos P.E. Kadoglou of Hippokratio General Hospital of Thessaloniki (Greece) and his associates (Diabetes Metab. 2010 Feb. 9 [doi:10.1016/j.diabet.2009.11.004]).

They compared outcomes in 50 sedentary, overweight, white patients with type 2 diabetes who were aged 50–65 years and whose glycemic control had failed to improve after they had followed a diet and taken oral antidiabetic drugs for at least 4 months.

The participants were randomly assigned to an exercise program or a control group. Subjects were instructed to perform 30–60 minutes of brisk walking at least 4 days per week, with no more than 2 consecutive days of inactivity. They also were encouraged to increase daily activities by taking walking breaks during the work day, gardening, and doing household work. They were asked to meet with a personal trainer once a week for a 1-hour supervised session of aerobic activity.

A total of 87% of the patients in the exercise group said they achieved their target of 150 minutes per week of moderate-intensity exercise.

After 4 months, the exercise group had significantly increased exercise capacity, reduced hemoglobin A_1c levels, decreased BP, and lower levels of total and LDL cholesterol, whereas the control group did not. But there was no improvement in either group in body mass index, waist-to-hip ratio, insulin resistance, and MMP-2 and TIMP-1 levels, Dr. Kadoglou and colleagues wrote.

Major Finding: Exercisers showed beneficial changes in MMP-9 levels and MMP9/TIMP ratios, compared with controls. Neither group improved in MMP-2 and TIMP-1 levels.

Data Source: Fifty overweight, sedentary type 2 diabetes patients randomized to exercise or no-exercise groups for 4 months.

Disclosures: The lead author reported receiving a grant from the Alexander S. Onassis Public Benefit Foundation. No other conflicts of interest were reported.

A 4-month exercise program of moderate intensity improved the inflammatory milieu, including markers of atherosclerosis, in overweight, sedentary diabetic patients.

The exercise did not alter body weight or insulin resistance, but it significantly improved glycemic, lipid, and cardiorespiratory factors, reported Dr. Nikolaos P.E. Kadoglou of Hippokratio General Hospital of Thessaloniki (Greece) and his associates (Diabetes Metab. 2010 Feb. 9 [doi:10.1016/j.diabet.2009.11.004]).

They compared outcomes in 50 sedentary, overweight, white patients with type 2 diabetes who were aged 50–65 years and whose glycemic control had failed to improve after they had followed a diet and taken oral antidiabetic drugs for at least 4 months.

The participants were randomly assigned to an exercise program or a control group. Subjects were instructed to perform 30–60 minutes of brisk walking at least 4 days per week, with no more than 2 consecutive days of inactivity. They also were encouraged to increase daily activities by taking walking breaks during the work day, gardening, and doing household work. They were asked to meet with a personal trainer once a week for a 1-hour supervised session of aerobic activity.

A total of 87% of the patients in the exercise group said they achieved their target of 150 minutes per week of moderate-intensity exercise.

After 4 months, the exercise group had significantly increased exercise capacity, reduced hemoglobin A_1c levels, decreased BP, and lower levels of total and LDL cholesterol, whereas the control group did not. But there was no improvement in either group in body mass index, waist-to-hip ratio, insulin resistance, and MMP-2 and TIMP-1 levels, Dr. Kadoglou and colleagues wrote.

Major Finding: Exercisers showed beneficial changes in MMP-9 levels and MMP9/TIMP ratios, compared with controls. Neither group improved in MMP-2 and TIMP-1 levels.

Data Source: Fifty overweight, sedentary type 2 diabetes patients randomized to exercise or no-exercise groups for 4 months.

Disclosures: The lead author reported receiving a grant from the Alexander S. Onassis Public Benefit Foundation. No other conflicts of interest were reported.

A 4-month exercise program of moderate intensity improved the inflammatory milieu, including markers of atherosclerosis, in overweight, sedentary diabetic patients.

The exercise did not alter body weight or insulin resistance, but it significantly improved glycemic, lipid, and cardiorespiratory factors, reported Dr. Nikolaos P.E. Kadoglou of Hippokratio General Hospital of Thessaloniki (Greece) and his associates (Diabetes Metab. 2010 Feb. 9 [doi:10.1016/j.diabet.2009.11.004]).

They compared outcomes in 50 sedentary, overweight, white patients with type 2 diabetes who were aged 50–65 years and whose glycemic control had failed to improve after they had followed a diet and taken oral antidiabetic drugs for at least 4 months.

The participants were randomly assigned to an exercise program or a control group. Subjects were instructed to perform 30–60 minutes of brisk walking at least 4 days per week, with no more than 2 consecutive days of inactivity. They also were encouraged to increase daily activities by taking walking breaks during the work day, gardening, and doing household work. They were asked to meet with a personal trainer once a week for a 1-hour supervised session of aerobic activity.

A total of 87% of the patients in the exercise group said they achieved their target of 150 minutes per week of moderate-intensity exercise.

After 4 months, the exercise group had significantly increased exercise capacity, reduced hemoglobin A_1c levels, decreased BP, and lower levels of total and LDL cholesterol, whereas the control group did not. But there was no improvement in either group in body mass index, waist-to-hip ratio, insulin resistance, and MMP-2 and TIMP-1 levels, Dr. Kadoglou and colleagues wrote.

Major Finding: Shorter fetal crown-to-rump length in the first trimester is associated with several maternal factors, including higher than average diastolic blood pressure.

Data Source: A population-based prospective study involving 1,631 pregnant women.

Disclosures: Funding sources included Erasmus Medical Center and the Netherlands Organization for Health Research. Dr. Mook-Kanamori reported no relevant conflicts of interest. Dr. Smith reported being a member of GlaxoSmithKline's preterm labor advisory boards.

Pregnant women who smoke, don't take folic acid supplements, or have higher than average blood pressure or hematocrit levels are at greater risk than others for fetal growth restriction during the first trimester, according to a report.

In turn, such growth restriction is associated with a greater risk of poor outcomes such as preterm birth, small size for gestational age (SGA) at birth, and a compensatory accelerated rate of postnatal growth that persists until age 2 years, said Dr. Dennis O. Mook-Kanamori and his associates at Erasmus Medical Center, Rotterdam, the Netherlands.

These findings from a population-based prospective study involving 1,631 pregnant women suggest that growth patterns as early as the first trimester have a far-reaching influence, perhaps affecting disease risk in adulthood as well as in childhood, the investigators said.

They assessed fetal crown-to-rump length via ultrasound during the first trimester among women participating in a larger study in the Netherlands concerning fetal life.

Higher than average diastolic blood pressure and hematocrit levels, smoking, and nonuse of folic acid supplements significantly correlated with shorter crown-to-rump length.

There was even a dose-response relation between the number of cigarettes smoked and the degree of growth restriction.

Maternal weight and height showed no relation to the development of fetal growth restriction, which indicates that the researchers were indeed measuring true in utero growth restriction rather than small stature.

Fetuses in the lowest 20% of crown-to-rump length had a 7% risk of preterm birth, an 11% risk of SGA, and an 8% risk of low birth weight (LBW). In contrast, these rates were 4%, 4%, and 3.5%, respectively, among fetuses that did not show growth restriction.

This indicates a two- to threefold increase in risk for these complications, Dr. Mook-Kanamori and his colleagues said (JAMA 2010;303:527-34).

First-trimester fetal crown-to-rump length also correlated with head circumference, femur length, and weight not only throughout pregnancy and at birth, but also at 1-year and 14-month assessments.

This correlation had disappeared by the time the study subjects were evaluated at age 2 years.

“Increased postnatal growth rate is a well-established risk factor for metabolic and cardiovascular disease in later life,” the researchers noted.

In an editorial comment accompanying this report, Dr. Gordon C.S. Smith of the University of Cambridge (England) said these findings suggest that “complications of late pregnancy may, at least for some women, already be determined in the first 3 months post conception, even before a woman has sought prenatal care.”

It is possible that combined ultrasound and laboratory screening in the first trimester may help identify fetuses with growth restriction who are thus at risk of later complications.

“The challenges for future research are to produce robust screening tests with acceptable levels of detection and prediction, and to identify interventions that are effective in improving outcome when a pregnancy has been identified as high risk,” Dr. Smith wrote (JAMA 2010;303:561-2).

Major Finding: Shorter fetal crown-to-rump length in the first trimester is associated with several maternal factors, including higher than average diastolic blood pressure.

Data Source: A population-based prospective study involving 1,631 pregnant women.

Disclosures: Funding sources included Erasmus Medical Center and the Netherlands Organization for Health Research. Dr. Mook-Kanamori reported no relevant conflicts of interest. Dr. Smith reported being a member of GlaxoSmithKline's preterm labor advisory boards.

Pregnant women who smoke, don't take folic acid supplements, or have higher than average blood pressure or hematocrit levels are at greater risk than others for fetal growth restriction during the first trimester, according to a report.

In turn, such growth restriction is associated with a greater risk of poor outcomes such as preterm birth, small size for gestational age (SGA) at birth, and a compensatory accelerated rate of postnatal growth that persists until age 2 years, said Dr. Dennis O. Mook-Kanamori and his associates at Erasmus Medical Center, Rotterdam, the Netherlands.

These findings from a population-based prospective study involving 1,631 pregnant women suggest that growth patterns as early as the first trimester have a far-reaching influence, perhaps affecting disease risk in adulthood as well as in childhood, the investigators said.

They assessed fetal crown-to-rump length via ultrasound during the first trimester among women participating in a larger study in the Netherlands concerning fetal life.

Higher than average diastolic blood pressure and hematocrit levels, smoking, and nonuse of folic acid supplements significantly correlated with shorter crown-to-rump length.

There was even a dose-response relation between the number of cigarettes smoked and the degree of growth restriction.

Maternal weight and height showed no relation to the development of fetal growth restriction, which indicates that the researchers were indeed measuring true in utero growth restriction rather than small stature.

Fetuses in the lowest 20% of crown-to-rump length had a 7% risk of preterm birth, an 11% risk of SGA, and an 8% risk of low birth weight (LBW). In contrast, these rates were 4%, 4%, and 3.5%, respectively, among fetuses that did not show growth restriction.

This indicates a two- to threefold increase in risk for these complications, Dr. Mook-Kanamori and his colleagues said (JAMA 2010;303:527-34).

First-trimester fetal crown-to-rump length also correlated with head circumference, femur length, and weight not only throughout pregnancy and at birth, but also at 1-year and 14-month assessments.

This correlation had disappeared by the time the study subjects were evaluated at age 2 years.

“Increased postnatal growth rate is a well-established risk factor for metabolic and cardiovascular disease in later life,” the researchers noted.

In an editorial comment accompanying this report, Dr. Gordon C.S. Smith of the University of Cambridge (England) said these findings suggest that “complications of late pregnancy may, at least for some women, already be determined in the first 3 months post conception, even before a woman has sought prenatal care.”

It is possible that combined ultrasound and laboratory screening in the first trimester may help identify fetuses with growth restriction who are thus at risk of later complications.

“The challenges for future research are to produce robust screening tests with acceptable levels of detection and prediction, and to identify interventions that are effective in improving outcome when a pregnancy has been identified as high risk,” Dr. Smith wrote (JAMA 2010;303:561-2).

Major Finding: Shorter fetal crown-to-rump length in the first trimester is associated with several maternal factors, including higher than average diastolic blood pressure.

Data Source: A population-based prospective study involving 1,631 pregnant women.

Disclosures: Funding sources included Erasmus Medical Center and the Netherlands Organization for Health Research. Dr. Mook-Kanamori reported no relevant conflicts of interest. Dr. Smith reported being a member of GlaxoSmithKline's preterm labor advisory boards.

Pregnant women who smoke, don't take folic acid supplements, or have higher than average blood pressure or hematocrit levels are at greater risk than others for fetal growth restriction during the first trimester, according to a report.

In turn, such growth restriction is associated with a greater risk of poor outcomes such as preterm birth, small size for gestational age (SGA) at birth, and a compensatory accelerated rate of postnatal growth that persists until age 2 years, said Dr. Dennis O. Mook-Kanamori and his associates at Erasmus Medical Center, Rotterdam, the Netherlands.

These findings from a population-based prospective study involving 1,631 pregnant women suggest that growth patterns as early as the first trimester have a far-reaching influence, perhaps affecting disease risk in adulthood as well as in childhood, the investigators said.

They assessed fetal crown-to-rump length via ultrasound during the first trimester among women participating in a larger study in the Netherlands concerning fetal life.

Higher than average diastolic blood pressure and hematocrit levels, smoking, and nonuse of folic acid supplements significantly correlated with shorter crown-to-rump length.

There was even a dose-response relation between the number of cigarettes smoked and the degree of growth restriction.

Maternal weight and height showed no relation to the development of fetal growth restriction, which indicates that the researchers were indeed measuring true in utero growth restriction rather than small stature.

Fetuses in the lowest 20% of crown-to-rump length had a 7% risk of preterm birth, an 11% risk of SGA, and an 8% risk of low birth weight (LBW). In contrast, these rates were 4%, 4%, and 3.5%, respectively, among fetuses that did not show growth restriction.

This indicates a two- to threefold increase in risk for these complications, Dr. Mook-Kanamori and his colleagues said (JAMA 2010;303:527-34).

First-trimester fetal crown-to-rump length also correlated with head circumference, femur length, and weight not only throughout pregnancy and at birth, but also at 1-year and 14-month assessments.

This correlation had disappeared by the time the study subjects were evaluated at age 2 years.

“Increased postnatal growth rate is a well-established risk factor for metabolic and cardiovascular disease in later life,” the researchers noted.

In an editorial comment accompanying this report, Dr. Gordon C.S. Smith of the University of Cambridge (England) said these findings suggest that “complications of late pregnancy may, at least for some women, already be determined in the first 3 months post conception, even before a woman has sought prenatal care.”

It is possible that combined ultrasound and laboratory screening in the first trimester may help identify fetuses with growth restriction who are thus at risk of later complications.

“The challenges for future research are to produce robust screening tests with acceptable levels of detection and prediction, and to identify interventions that are effective in improving outcome when a pregnancy has been identified as high risk,” Dr. Smith wrote (JAMA 2010;303:561-2).

Major Finding: Thirty-one percent of women in the internal-tocodynamometry group and thirty percent in the external-monitoring group required operative delivery, a nonsignificant difference.

Data Source: A multicenter trial of 1,456 women.

Disclosures: None reported.

Internal tocodynamometry during induced or augmented labor failed to reduce the rate of operative deliveries compared with external monitoring of uterine contractions, according to a report.

Nor did internal tocodynamometry improve the rate of adverse neonatal outcomes, the use of analgesia, the use of antibiotics, or duration of labor in a multicenter trial comparing the two approaches, according to Jannet J.H. Bakker of the Academic Medical Center, Amsterdam, and her associates.

Internal tocodynamometry is advocated by professional obstetric societies because it “is thought to quantify the frequency, duration, and magnitude of uterine activity more accurately” than external monitoring. This in turn is assumed to allow better adjustment of oxytocin infusion and improved interpretation of fetal heart-rate patterns.

“However, clinical data to support such hypotheses are limited, and recommendations are based on expert opinion” in the absence of definitive data, the investigators noted.

Only three small clinical trials have compared the two techniques, and “the small samples in these trials resulted in limited power to detect differences and in wide confidence intervals around estimated risk reductions,” they said.

Ms. Bakker and her colleagues assessed 1,456 women who delivered at six hospitals in the Netherlands over a 4-year period. All the women had singleton, term pregnancies and received oxytocin for induction or augmentation of labor. They were randomized to internal tocodynamometry (734 patients) or external monitoring (722 patients).

The primary outcome was the rate of operative delivery. In all, 230 women (31%) in the internal-tocodynamometry group and 214 (30%) in the external-monitoring group required operative delivery, a nonsignificant difference, the researchers said (N. Engl. J. Med. 2010;362:306-13).

The rates of secondary outcomes also were similar between the two groups. These included adverse neonatal outcomes, use of antibiotics during labor, use of analgesia, and total amount of oxytocin used.

Internal tocodynamometry carries serious risks, “including placental or fetal-vessel damage, infection, and anaphylactic reaction. We did not observe any complications of internal monitoring in our study, but it was not powered to detect these events,” which are estimated to occur in up to 1 in 300 deliveries.

Major Finding: Thirty-one percent of women in the internal-tocodynamometry group and thirty percent in the external-monitoring group required operative delivery, a nonsignificant difference.

Data Source: A multicenter trial of 1,456 women.

Disclosures: None reported.

Internal tocodynamometry during induced or augmented labor failed to reduce the rate of operative deliveries compared with external monitoring of uterine contractions, according to a report.

Nor did internal tocodynamometry improve the rate of adverse neonatal outcomes, the use of analgesia, the use of antibiotics, or duration of labor in a multicenter trial comparing the two approaches, according to Jannet J.H. Bakker of the Academic Medical Center, Amsterdam, and her associates.

Internal tocodynamometry is advocated by professional obstetric societies because it “is thought to quantify the frequency, duration, and magnitude of uterine activity more accurately” than external monitoring. This in turn is assumed to allow better adjustment of oxytocin infusion and improved interpretation of fetal heart-rate patterns.

“However, clinical data to support such hypotheses are limited, and recommendations are based on expert opinion” in the absence of definitive data, the investigators noted.

Only three small clinical trials have compared the two techniques, and “the small samples in these trials resulted in limited power to detect differences and in wide confidence intervals around estimated risk reductions,” they said.

Ms. Bakker and her colleagues assessed 1,456 women who delivered at six hospitals in the Netherlands over a 4-year period. All the women had singleton, term pregnancies and received oxytocin for induction or augmentation of labor. They were randomized to internal tocodynamometry (734 patients) or external monitoring (722 patients).

The primary outcome was the rate of operative delivery. In all, 230 women (31%) in the internal-tocodynamometry group and 214 (30%) in the external-monitoring group required operative delivery, a nonsignificant difference, the researchers said (N. Engl. J. Med. 2010;362:306-13).

The rates of secondary outcomes also were similar between the two groups. These included adverse neonatal outcomes, use of antibiotics during labor, use of analgesia, and total amount of oxytocin used.

Internal tocodynamometry carries serious risks, “including placental or fetal-vessel damage, infection, and anaphylactic reaction. We did not observe any complications of internal monitoring in our study, but it was not powered to detect these events,” which are estimated to occur in up to 1 in 300 deliveries.

Major Finding: Thirty-one percent of women in the internal-tocodynamometry group and thirty percent in the external-monitoring group required operative delivery, a nonsignificant difference.

Data Source: A multicenter trial of 1,456 women.

Disclosures: None reported.

Internal tocodynamometry during induced or augmented labor failed to reduce the rate of operative deliveries compared with external monitoring of uterine contractions, according to a report.

Nor did internal tocodynamometry improve the rate of adverse neonatal outcomes, the use of analgesia, the use of antibiotics, or duration of labor in a multicenter trial comparing the two approaches, according to Jannet J.H. Bakker of the Academic Medical Center, Amsterdam, and her associates.

Internal tocodynamometry is advocated by professional obstetric societies because it “is thought to quantify the frequency, duration, and magnitude of uterine activity more accurately” than external monitoring. This in turn is assumed to allow better adjustment of oxytocin infusion and improved interpretation of fetal heart-rate patterns.

“However, clinical data to support such hypotheses are limited, and recommendations are based on expert opinion” in the absence of definitive data, the investigators noted.

Only three small clinical trials have compared the two techniques, and “the small samples in these trials resulted in limited power to detect differences and in wide confidence intervals around estimated risk reductions,” they said.

Ms. Bakker and her colleagues assessed 1,456 women who delivered at six hospitals in the Netherlands over a 4-year period. All the women had singleton, term pregnancies and received oxytocin for induction or augmentation of labor. They were randomized to internal tocodynamometry (734 patients) or external monitoring (722 patients).

The primary outcome was the rate of operative delivery. In all, 230 women (31%) in the internal-tocodynamometry group and 214 (30%) in the external-monitoring group required operative delivery, a nonsignificant difference, the researchers said (N. Engl. J. Med. 2010;362:306-13).

The rates of secondary outcomes also were similar between the two groups. These included adverse neonatal outcomes, use of antibiotics during labor, use of analgesia, and total amount of oxytocin used.

Internal tocodynamometry carries serious risks, “including placental or fetal-vessel damage, infection, and anaphylactic reaction. We did not observe any complications of internal monitoring in our study, but it was not powered to detect these events,” which are estimated to occur in up to 1 in 300 deliveries.

Neutralizing antibodies to interferon beta not only persist in some multiple sclerosis patients who discontinue the recombinant-DNA treatment, they also appear to worsen the disease course.

In patients with relapsing-remitting MS who had been treated with interferon beta in the past, the relapse rate was higher and progression of disability faster in those who had neutralizing antibodies in their circulation than in those who did not have the antibodies, said Dr. Laura F. van der Voort of Vrije University Medical Center, Amsterdam, and associates.

They reviewed the medical records of 71 MS patients treated with interferon beta between 1994 and 2006. A median of 25 months after discontinuing therapy, 17 patients (24%) still had circulating neutralizing antibodies to interferon beta.

Patients with persistent antibodies were no different from those without them, even when considering potential predisposing factors such as age at MS onset, sex, MS subtype, disease duration, duration of interferon-beta therapy, and degree of disability at the start of treatment. The relapse rate was nearly 5 times higher in antibody-positive patients than in antibody-negative patients (Arch. Neurol. 2010; Feb. 8 [doi:10.1001/archneurol.2010.21

Patients with persistent neutralizing antibodies also showed faster progression of disability when evaluated using the Expanded Disability Status Scale.

“Most patients who discontinued interferon beta treatment because of perceived efficacy failure were not neutralizing-antibody positive,” the authors wrote. It is not yet clear why neutralizing antibodies to interferon beta can persist months or years after exposure to the antigen has ceased or how persisting antibodies exert their effect on MS activity.

It is possible that the antibodies affect endogenous interferon pathways, causing “a more proinflammatory modification of the immune system. Alternatively, the tendency to develop and sustain anti–interferon beta antibodies might be a reflection of a more active immune system.”

The retrospective nature and the small sample of the study did not allow for definitive conclusions to be drawn, and causality could not be proven, they added.

This study was supported in part by a targeted research project on neutralizing antibodies funded by the European Commission. Dr. van der Voort reported being involved in clinical trials of companies that market drugs for MS, and working with some that have development programs for future drugs for the disease.

Neutralizing antibodies to interferon beta not only persist in some multiple sclerosis patients who discontinue the recombinant-DNA treatment, they also appear to worsen the disease course.

In patients with relapsing-remitting MS who had been treated with interferon beta in the past, the relapse rate was higher and progression of disability faster in those who had neutralizing antibodies in their circulation than in those who did not have the antibodies, said Dr. Laura F. van der Voort of Vrije University Medical Center, Amsterdam, and associates.

They reviewed the medical records of 71 MS patients treated with interferon beta between 1994 and 2006. A median of 25 months after discontinuing therapy, 17 patients (24%) still had circulating neutralizing antibodies to interferon beta.

Patients with persistent antibodies were no different from those without them, even when considering potential predisposing factors such as age at MS onset, sex, MS subtype, disease duration, duration of interferon-beta therapy, and degree of disability at the start of treatment. The relapse rate was nearly 5 times higher in antibody-positive patients than in antibody-negative patients (Arch. Neurol. 2010; Feb. 8 [doi:10.1001/archneurol.2010.21

Patients with persistent neutralizing antibodies also showed faster progression of disability when evaluated using the Expanded Disability Status Scale.

“Most patients who discontinued interferon beta treatment because of perceived efficacy failure were not neutralizing-antibody positive,” the authors wrote. It is not yet clear why neutralizing antibodies to interferon beta can persist months or years after exposure to the antigen has ceased or how persisting antibodies exert their effect on MS activity.

It is possible that the antibodies affect endogenous interferon pathways, causing “a more proinflammatory modification of the immune system. Alternatively, the tendency to develop and sustain anti–interferon beta antibodies might be a reflection of a more active immune system.”

The retrospective nature and the small sample of the study did not allow for definitive conclusions to be drawn, and causality could not be proven, they added.

This study was supported in part by a targeted research project on neutralizing antibodies funded by the European Commission. Dr. van der Voort reported being involved in clinical trials of companies that market drugs for MS, and working with some that have development programs for future drugs for the disease.

Neutralizing antibodies to interferon beta not only persist in some multiple sclerosis patients who discontinue the recombinant-DNA treatment, they also appear to worsen the disease course.

In patients with relapsing-remitting MS who had been treated with interferon beta in the past, the relapse rate was higher and progression of disability faster in those who had neutralizing antibodies in their circulation than in those who did not have the antibodies, said Dr. Laura F. van der Voort of Vrije University Medical Center, Amsterdam, and associates.

They reviewed the medical records of 71 MS patients treated with interferon beta between 1994 and 2006. A median of 25 months after discontinuing therapy, 17 patients (24%) still had circulating neutralizing antibodies to interferon beta.

Patients with persistent antibodies were no different from those without them, even when considering potential predisposing factors such as age at MS onset, sex, MS subtype, disease duration, duration of interferon-beta therapy, and degree of disability at the start of treatment. The relapse rate was nearly 5 times higher in antibody-positive patients than in antibody-negative patients (Arch. Neurol. 2010; Feb. 8 [doi:10.1001/archneurol.2010.21

Patients with persistent neutralizing antibodies also showed faster progression of disability when evaluated using the Expanded Disability Status Scale.

“Most patients who discontinued interferon beta treatment because of perceived efficacy failure were not neutralizing-antibody positive,” the authors wrote. It is not yet clear why neutralizing antibodies to interferon beta can persist months or years after exposure to the antigen has ceased or how persisting antibodies exert their effect on MS activity.

It is possible that the antibodies affect endogenous interferon pathways, causing “a more proinflammatory modification of the immune system. Alternatively, the tendency to develop and sustain anti–interferon beta antibodies might be a reflection of a more active immune system.”

The retrospective nature and the small sample of the study did not allow for definitive conclusions to be drawn, and causality could not be proven, they added.

This study was supported in part by a targeted research project on neutralizing antibodies funded by the European Commission. Dr. van der Voort reported being involved in clinical trials of companies that market drugs for MS, and working with some that have development programs for future drugs for the disease.

The use of medical technology has grown dramatically over the last decade, according to the federal government's annual health report.

That's just one finding in the massive “Health, United States, 2009,” a snapshot of Americans' health, which the Centers for Disease Control and Prevention compiles yearly as “an essential step in making sound health policy and setting research and program priorities.”

This year's edition, the 33rd, includes a special section on medical technology, which includes procedures, tests, drugs, devices, and support systems such as computerized records. The principal findings in this section include:

▸ The use of MRI, CT, and PET imaging soared during the past decade. The number of such imaging studies either ordered or provided by physician offices and hospital outpatient departments more than tripled; those ordered or provided by emergency departments quadrupled.

▸ The rate of angioplasty without stent placement declined by 80% during the past decade. Drug-eluting stents have rapidly replaced bare-metal stents and were used in 75% of angioplasties in 2006.

▸ The use of antidiabetic drugs among patients aged 45 and older increased approximately 50%, and that of statins soared tenfold in the past decade.

▸ The percentage of people taking at least 1 prescription drug during the preceding month rose from 38% in the 1980s and 1990s to 47% in recent years. The percentage taking 3 or more prescription drugs also increased, from 11% to 21%, during that time.

▸ The rate of outpatient upper endoscopies rose by 90% and the rate of outpatient colonoscopy tripled during the same interval.

The report also detailed trends in mortality. Both life expectancy and infant mortality have been improving but continue to lag behind levels found in most developed countries. Infant mortality in the United States is now 27% lower than it was in 1990.

American men now can expect to live 3.5 years longer, and women can expect to live 1.6 years longer, than they did in 1990. Overall life expectancy in the U.S. was 77.9 years in 2007, a record high.

Life expectancy increased more among blacks than among whites, but a gap between the races still persists. In 1990, life expectancy for whites was 7 years longer than that for blacks; by 2007, that gap narrowed to 4.6 years.

Mortality from heart disease, stroke, and cancer continues to decline, while mortality from chronic respiratory diseases and unintentional injuries has remained stable. The leading cause of death for people aged 1–44 years is unintentional injuries, for people aged 45–64 years is cancer, and for people aged 65 and older is heart disease.

With regard to chronic physical, mental, or emotional conditions, the report noted that the proportion of working-age adults who reported that a chronic condition limited their activity has remained steady at approximately 10%. Arthritis and other musculoskeletal disorders were the most frequent causes of such limitations in adults, while learning disabilities, ADD, and ADHD were among school-aged children.

Mental illness was the second-leading cause of limitation due to chronic conditions in adults aged 18–44 years; heart and circulatory disorders were the second-leading cause in older adults, but mental illness was frequently cited in this age group as well.

Among younger children, speech impairment and asthma were commonly cited chronic conditions that limited activity. In older children and adolescents, mental, emotional, or behavioral problems were frequently cited.

The full report is available at www.cdc.gov/nchs/hus.htm

The use of medical technology has grown dramatically over the last decade, according to the federal government's annual health report.

That's just one finding in the massive “Health, United States, 2009,” a snapshot of Americans' health, which the Centers for Disease Control and Prevention compiles yearly as “an essential step in making sound health policy and setting research and program priorities.”

This year's edition, the 33rd, includes a special section on medical technology, which includes procedures, tests, drugs, devices, and support systems such as computerized records. The principal findings in this section include:

▸ The use of MRI, CT, and PET imaging soared during the past decade. The number of such imaging studies either ordered or provided by physician offices and hospital outpatient departments more than tripled; those ordered or provided by emergency departments quadrupled.

▸ The rate of angioplasty without stent placement declined by 80% during the past decade. Drug-eluting stents have rapidly replaced bare-metal stents and were used in 75% of angioplasties in 2006.

▸ The use of antidiabetic drugs among patients aged 45 and older increased approximately 50%, and that of statins soared tenfold in the past decade.

▸ The percentage of people taking at least 1 prescription drug during the preceding month rose from 38% in the 1980s and 1990s to 47% in recent years. The percentage taking 3 or more prescription drugs also increased, from 11% to 21%, during that time.

▸ The rate of outpatient upper endoscopies rose by 90% and the rate of outpatient colonoscopy tripled during the same interval.

The report also detailed trends in mortality. Both life expectancy and infant mortality have been improving but continue to lag behind levels found in most developed countries. Infant mortality in the United States is now 27% lower than it was in 1990.

American men now can expect to live 3.5 years longer, and women can expect to live 1.6 years longer, than they did in 1990. Overall life expectancy in the U.S. was 77.9 years in 2007, a record high.

Life expectancy increased more among blacks than among whites, but a gap between the races still persists. In 1990, life expectancy for whites was 7 years longer than that for blacks; by 2007, that gap narrowed to 4.6 years.

Mortality from heart disease, stroke, and cancer continues to decline, while mortality from chronic respiratory diseases and unintentional injuries has remained stable. The leading cause of death for people aged 1–44 years is unintentional injuries, for people aged 45–64 years is cancer, and for people aged 65 and older is heart disease.

With regard to chronic physical, mental, or emotional conditions, the report noted that the proportion of working-age adults who reported that a chronic condition limited their activity has remained steady at approximately 10%. Arthritis and other musculoskeletal disorders were the most frequent causes of such limitations in adults, while learning disabilities, ADD, and ADHD were among school-aged children.

Mental illness was the second-leading cause of limitation due to chronic conditions in adults aged 18–44 years; heart and circulatory disorders were the second-leading cause in older adults, but mental illness was frequently cited in this age group as well.

Among younger children, speech impairment and asthma were commonly cited chronic conditions that limited activity. In older children and adolescents, mental, emotional, or behavioral problems were frequently cited.

The full report is available at www.cdc.gov/nchs/hus.htm

The use of medical technology has grown dramatically over the last decade, according to the federal government's annual health report.

That's just one finding in the massive “Health, United States, 2009,” a snapshot of Americans' health, which the Centers for Disease Control and Prevention compiles yearly as “an essential step in making sound health policy and setting research and program priorities.”

This year's edition, the 33rd, includes a special section on medical technology, which includes procedures, tests, drugs, devices, and support systems such as computerized records. The principal findings in this section include:

▸ The use of MRI, CT, and PET imaging soared during the past decade. The number of such imaging studies either ordered or provided by physician offices and hospital outpatient departments more than tripled; those ordered or provided by emergency departments quadrupled.

▸ The rate of angioplasty without stent placement declined by 80% during the past decade. Drug-eluting stents have rapidly replaced bare-metal stents and were used in 75% of angioplasties in 2006.

▸ The use of antidiabetic drugs among patients aged 45 and older increased approximately 50%, and that of statins soared tenfold in the past decade.

▸ The percentage of people taking at least 1 prescription drug during the preceding month rose from 38% in the 1980s and 1990s to 47% in recent years. The percentage taking 3 or more prescription drugs also increased, from 11% to 21%, during that time.

▸ The rate of outpatient upper endoscopies rose by 90% and the rate of outpatient colonoscopy tripled during the same interval.

The report also detailed trends in mortality. Both life expectancy and infant mortality have been improving but continue to lag behind levels found in most developed countries. Infant mortality in the United States is now 27% lower than it was in 1990.

American men now can expect to live 3.5 years longer, and women can expect to live 1.6 years longer, than they did in 1990. Overall life expectancy in the U.S. was 77.9 years in 2007, a record high.

Life expectancy increased more among blacks than among whites, but a gap between the races still persists. In 1990, life expectancy for whites was 7 years longer than that for blacks; by 2007, that gap narrowed to 4.6 years.

Mortality from heart disease, stroke, and cancer continues to decline, while mortality from chronic respiratory diseases and unintentional injuries has remained stable. The leading cause of death for people aged 1–44 years is unintentional injuries, for people aged 45–64 years is cancer, and for people aged 65 and older is heart disease.

With regard to chronic physical, mental, or emotional conditions, the report noted that the proportion of working-age adults who reported that a chronic condition limited their activity has remained steady at approximately 10%. Arthritis and other musculoskeletal disorders were the most frequent causes of such limitations in adults, while learning disabilities, ADD, and ADHD were among school-aged children.

Mental illness was the second-leading cause of limitation due to chronic conditions in adults aged 18–44 years; heart and circulatory disorders were the second-leading cause in older adults, but mental illness was frequently cited in this age group as well.

Among younger children, speech impairment and asthma were commonly cited chronic conditions that limited activity. In older children and adolescents, mental, emotional, or behavioral problems were frequently cited.

The full report is available at www.cdc.gov/nchs/hus.htm

The number of hours U.S. physicians work each week has markedly and steadily decreased during the past decade, after having remained stable during the 2 preceding decades, according to a report.

While the study was not designed to identify why such changes have occurred, investigators did find a striking correlation between physicians' decreasing hours and decreasing fees for their services.

Inflation-adjusted physician fees changed little until the mid-1990s, when they began a steady 10-year decline. “By 2006, physician fees were 25% lower than their inflation-adjusted 1995 levels,” Douglas O. Staiger, Ph.D., of Dartmouth College, Hanover, N.H., and his colleagues noted.

The decrease in hours worked per week “was broad-based and not concentrated among physicians with particular demographic characteristics or working in particular settings.” Physicians from all demographic areas have shortened their typical work weeks from the approximately 55 hours that prevailed since 1977 to 51 hours, the investigators said.

In contrast, mean weekly hours worked by other professionals such as lawyers, engineers, and registered nurses “changed very little during the past 30 years, which is consistent with national trends in mean weekly hours among all workers published by the Bureau of Labor Statistics,” they said.

The researchers said they examined this issue because most studies concerning the medical work force, as well as the policy decisions based on those studies, have assumed that hours worked by physicians have remained constant.

A few recent studies have suggested that this assumption may no longer be warranted.

Dr. Staiger and his colleagues analyzed data from the Census Bureau's Current Population Survey, an annual report that obtains detailed information about employment from a nationally representative sample of adults. They examined data from the late 1970s through 2008 on all 116,733 survey subjects listed as physicians or surgeons.

Physician weekly work hours were stable during 1977-1997, ranging only from a low of 54.6 hours to a high of 55.9. Since then, however, work hours have declined steadily, and they currently total 51 hours per week.

During the same interval, mean physician fees, adjusted for inflation, decreased by 25%.

“It is likely that a third factor that was associated with lower fees, such as growing managed care penetration or market competition, may have contributed to the decrease in physician hours,” Dr. Staiger and his colleagues noted (JAMA 2010;303:747-53).

“Whatever the underlying cause, the decrease … raises implications for physician workforce supply and overall health care policy. A 5.7% decrease in hours worked by nonresident physicians in patient care, out of a workforce of approximately 630,000 in 2007, is equivalent to a loss of approximately 36,000 physicians from the workforce.

“Although the number of physicians has nearly doubled during the last 30 years, many workforce analysts and professional organizations are concerned about the adequacy of the size of the future physician workforce.

This trend toward lower hours, if it continues, will make expanding or maintaining current levels of physician supply more difficult,” they noted.

The trend also “could frustrate stated goals of health reform, which may require an expanded physician workforce to take on new roles and enhanced functions in a reformed delivery system.”

Disclosures: This study was supported by the National Institutes of Health. No financial conflicts of interest were reported.

My Take

These Findings Are Limited

This study is flawed, as it fails to take into account more part-time physicians and more women physicians, especially in pediatrics.

I believe that for male, head-of-household, sole provider physicians, hours spent weekly likely have risen, and incomes are up or steady as well.

I wouldn't intuit anything at all from this study, other than to say it will be most difficult for us to assess workforce needs of the future, given the change in physician demographics and the needs of the newer generation, and given the possibilities of increased access to care someday with health care reform. We likely will need more providers, but we cannot just tie it in to the conclusions of this study.

The number of hours U.S. physicians work each week has markedly and steadily decreased during the past decade, after having remained stable during the 2 preceding decades, according to a report.

While the study was not designed to identify why such changes have occurred, investigators did find a striking correlation between physicians' decreasing hours and decreasing fees for their services.

Inflation-adjusted physician fees changed little until the mid-1990s, when they began a steady 10-year decline. “By 2006, physician fees were 25% lower than their inflation-adjusted 1995 levels,” Douglas O. Staiger, Ph.D., of Dartmouth College, Hanover, N.H., and his colleagues noted.

The decrease in hours worked per week “was broad-based and not concentrated among physicians with particular demographic characteristics or working in particular settings.” Physicians from all demographic areas have shortened their typical work weeks from the approximately 55 hours that prevailed since 1977 to 51 hours, the investigators said.

In contrast, mean weekly hours worked by other professionals such as lawyers, engineers, and registered nurses “changed very little during the past 30 years, which is consistent with national trends in mean weekly hours among all workers published by the Bureau of Labor Statistics,” they said.

The researchers said they examined this issue because most studies concerning the medical work force, as well as the policy decisions based on those studies, have assumed that hours worked by physicians have remained constant.

A few recent studies have suggested that this assumption may no longer be warranted.

Dr. Staiger and his colleagues analyzed data from the Census Bureau's Current Population Survey, an annual report that obtains detailed information about employment from a nationally representative sample of adults. They examined data from the late 1970s through 2008 on all 116,733 survey subjects listed as physicians or surgeons.

Physician weekly work hours were stable during 1977-1997, ranging only from a low of 54.6 hours to a high of 55.9. Since then, however, work hours have declined steadily, and they currently total 51 hours per week.

During the same interval, mean physician fees, adjusted for inflation, decreased by 25%.

“It is likely that a third factor that was associated with lower fees, such as growing managed care penetration or market competition, may have contributed to the decrease in physician hours,” Dr. Staiger and his colleagues noted (JAMA 2010;303:747-53).

“Whatever the underlying cause, the decrease … raises implications for physician workforce supply and overall health care policy. A 5.7% decrease in hours worked by nonresident physicians in patient care, out of a workforce of approximately 630,000 in 2007, is equivalent to a loss of approximately 36,000 physicians from the workforce.

“Although the number of physicians has nearly doubled during the last 30 years, many workforce analysts and professional organizations are concerned about the adequacy of the size of the future physician workforce.

This trend toward lower hours, if it continues, will make expanding or maintaining current levels of physician supply more difficult,” they noted.

The trend also “could frustrate stated goals of health reform, which may require an expanded physician workforce to take on new roles and enhanced functions in a reformed delivery system.”

Disclosures: This study was supported by the National Institutes of Health. No financial conflicts of interest were reported.

My Take

These Findings Are Limited

This study is flawed, as it fails to take into account more part-time physicians and more women physicians, especially in pediatrics.

I believe that for male, head-of-household, sole provider physicians, hours spent weekly likely have risen, and incomes are up or steady as well.

I wouldn't intuit anything at all from this study, other than to say it will be most difficult for us to assess workforce needs of the future, given the change in physician demographics and the needs of the newer generation, and given the possibilities of increased access to care someday with health care reform. We likely will need more providers, but we cannot just tie it in to the conclusions of this study.

The number of hours U.S. physicians work each week has markedly and steadily decreased during the past decade, after having remained stable during the 2 preceding decades, according to a report.

While the study was not designed to identify why such changes have occurred, investigators did find a striking correlation between physicians' decreasing hours and decreasing fees for their services.

Inflation-adjusted physician fees changed little until the mid-1990s, when they began a steady 10-year decline. “By 2006, physician fees were 25% lower than their inflation-adjusted 1995 levels,” Douglas O. Staiger, Ph.D., of Dartmouth College, Hanover, N.H., and his colleagues noted.

The decrease in hours worked per week “was broad-based and not concentrated among physicians with particular demographic characteristics or working in particular settings.” Physicians from all demographic areas have shortened their typical work weeks from the approximately 55 hours that prevailed since 1977 to 51 hours, the investigators said.

In contrast, mean weekly hours worked by other professionals such as lawyers, engineers, and registered nurses “changed very little during the past 30 years, which is consistent with national trends in mean weekly hours among all workers published by the Bureau of Labor Statistics,” they said.

The researchers said they examined this issue because most studies concerning the medical work force, as well as the policy decisions based on those studies, have assumed that hours worked by physicians have remained constant.

A few recent studies have suggested that this assumption may no longer be warranted.

Dr. Staiger and his colleagues analyzed data from the Census Bureau's Current Population Survey, an annual report that obtains detailed information about employment from a nationally representative sample of adults. They examined data from the late 1970s through 2008 on all 116,733 survey subjects listed as physicians or surgeons.

Physician weekly work hours were stable during 1977-1997, ranging only from a low of 54.6 hours to a high of 55.9. Since then, however, work hours have declined steadily, and they currently total 51 hours per week.

During the same interval, mean physician fees, adjusted for inflation, decreased by 25%.

“It is likely that a third factor that was associated with lower fees, such as growing managed care penetration or market competition, may have contributed to the decrease in physician hours,” Dr. Staiger and his colleagues noted (JAMA 2010;303:747-53).

“Whatever the underlying cause, the decrease … raises implications for physician workforce supply and overall health care policy. A 5.7% decrease in hours worked by nonresident physicians in patient care, out of a workforce of approximately 630,000 in 2007, is equivalent to a loss of approximately 36,000 physicians from the workforce.

“Although the number of physicians has nearly doubled during the last 30 years, many workforce analysts and professional organizations are concerned about the adequacy of the size of the future physician workforce.

This trend toward lower hours, if it continues, will make expanding or maintaining current levels of physician supply more difficult,” they noted.

The trend also “could frustrate stated goals of health reform, which may require an expanded physician workforce to take on new roles and enhanced functions in a reformed delivery system.”

Disclosures: This study was supported by the National Institutes of Health. No financial conflicts of interest were reported.

My Take

These Findings Are Limited

This study is flawed, as it fails to take into account more part-time physicians and more women physicians, especially in pediatrics.

I believe that for male, head-of-household, sole provider physicians, hours spent weekly likely have risen, and incomes are up or steady as well.

I wouldn't intuit anything at all from this study, other than to say it will be most difficult for us to assess workforce needs of the future, given the change in physician demographics and the needs of the newer generation, and given the possibilities of increased access to care someday with health care reform. We likely will need more providers, but we cannot just tie it in to the conclusions of this study.

The use of medical technology has grown dramatically over the last decade, according to the federal government's annual health report.

That's just one finding in the massive “Health, United States, 2009,” a snapshot of Americans' health, which the Centers for Disease Control and Prevention compiles yearly as “an essential step in making sound health policy and setting research and program priorities.”

This year's edition, the 33rd, includes a special section on medical technology, which includes procedures, tests, drugs, devices, and support systems such as computerized records. The principal findings include:

▸ The use of MRI, CT, and PET imaging soared during the past decade. The number of such imaging studies either ordered or provided by physician offices and hospital outpatient departments more than tripled; those ordered or provided by emergency departments quadrupled.

▸ The rate of knee replacement surgery performed in patients aged 45 years and older rose 70% during the same interval, from 26 to 45 per 10,000 population. The rate of total hip replacement surgery increased by 33%, and that of partial hip replacements increased by 60%.

▸ The rate of angioplasty without stent placement declined by 80% during the past decade. Drug-eluting stents have rapidly replaced bare-metal stents and were used in 75% of angioplasties in 2006.

▸ The number of assisted reproductive technology cycles doubled during the past decade, with the fastest rate of growth occurring in women older than 40 (11% per year).

▸ The rate of outpatient upper endoscopies rose by 90% and the rate of outpatient colonoscopy tripled during the same interval.

▸ The use of antidiabetic drugs among patients aged 45 and older increased approximately 50%, and that of statins soared tenfold in the past decade.

▸ The percentage of people taking at least one prescription drug during the preceding month rose from 38% in the 1980s and 1990s to 47% in recent years. The percentage taking three or more prescription drugs also increased, from 11% to 21%, during that time.

The full report is available at www.cdc.gov/nchs/hus.htm

The use of medical technology has grown dramatically over the last decade, according to the federal government's annual health report.

That's just one finding in the massive “Health, United States, 2009,” a snapshot of Americans' health, which the Centers for Disease Control and Prevention compiles yearly as “an essential step in making sound health policy and setting research and program priorities.”

This year's edition, the 33rd, includes a special section on medical technology, which includes procedures, tests, drugs, devices, and support systems such as computerized records. The principal findings include:

▸ The use of MRI, CT, and PET imaging soared during the past decade. The number of such imaging studies either ordered or provided by physician offices and hospital outpatient departments more than tripled; those ordered or provided by emergency departments quadrupled.

▸ The rate of knee replacement surgery performed in patients aged 45 years and older rose 70% during the same interval, from 26 to 45 per 10,000 population. The rate of total hip replacement surgery increased by 33%, and that of partial hip replacements increased by 60%.

▸ The rate of angioplasty without stent placement declined by 80% during the past decade. Drug-eluting stents have rapidly replaced bare-metal stents and were used in 75% of angioplasties in 2006.

▸ The number of assisted reproductive technology cycles doubled during the past decade, with the fastest rate of growth occurring in women older than 40 (11% per year).

▸ The rate of outpatient upper endoscopies rose by 90% and the rate of outpatient colonoscopy tripled during the same interval.

▸ The use of antidiabetic drugs among patients aged 45 and older increased approximately 50%, and that of statins soared tenfold in the past decade.

▸ The percentage of people taking at least one prescription drug during the preceding month rose from 38% in the 1980s and 1990s to 47% in recent years. The percentage taking three or more prescription drugs also increased, from 11% to 21%, during that time.

The full report is available at www.cdc.gov/nchs/hus.htm

The use of medical technology has grown dramatically over the last decade, according to the federal government's annual health report.

That's just one finding in the massive “Health, United States, 2009,” a snapshot of Americans' health, which the Centers for Disease Control and Prevention compiles yearly as “an essential step in making sound health policy and setting research and program priorities.”

This year's edition, the 33rd, includes a special section on medical technology, which includes procedures, tests, drugs, devices, and support systems such as computerized records. The principal findings include:

▸ The use of MRI, CT, and PET imaging soared during the past decade. The number of such imaging studies either ordered or provided by physician offices and hospital outpatient departments more than tripled; those ordered or provided by emergency departments quadrupled.

▸ The rate of knee replacement surgery performed in patients aged 45 years and older rose 70% during the same interval, from 26 to 45 per 10,000 population. The rate of total hip replacement surgery increased by 33%, and that of partial hip replacements increased by 60%.

▸ The rate of angioplasty without stent placement declined by 80% during the past decade. Drug-eluting stents have rapidly replaced bare-metal stents and were used in 75% of angioplasties in 2006.

▸ The number of assisted reproductive technology cycles doubled during the past decade, with the fastest rate of growth occurring in women older than 40 (11% per year).

▸ The rate of outpatient upper endoscopies rose by 90% and the rate of outpatient colonoscopy tripled during the same interval.

▸ The use of antidiabetic drugs among patients aged 45 and older increased approximately 50%, and that of statins soared tenfold in the past decade.

▸ The percentage of people taking at least one prescription drug during the preceding month rose from 38% in the 1980s and 1990s to 47% in recent years. The percentage taking three or more prescription drugs also increased, from 11% to 21%, during that time.

The full report is available at www.cdc.gov/nchs/hus.htm

Major Finding: Childhood obesity raised the risk of premature death in adulthood by 50%, hypertension did so by 57%, and a high glucose level did so by 73%.

Data Source: A study of 4,857 Native American children through adulthood or death.

Disclosures: The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases' intramural research program. Dr. Franks reported no conflicts of interest.

Obesity, hypertension, and glucose intolerance in childhood are strongly associated with premature death from endogenous causes, according to an analysis of data from a longitudinal study.

Failure to reverse the current population trends in childhood obesity thus could have far-reaching consequences for longevity, said Paul W. Franks, Ph.D., of the National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, and his associates.

The investigators noted that “little is known about the way in which cardiovascular risk factors that are present during childhood affect the life span,” and examined the issue using data from a longitudinal study of diabetes among Native Americans who were born between 1945 and 1984. The 4,857 study subjects were children and adolescents (aged 5-20 years) when first enrolled between 1966 and 2003.

The study subjects had at least 4/8 Pima or Tohono O'odham Indian heritage and lived in the Gila River Indian Community.

This is a population with high rates of obesity and diabetes, and 1,394 (29%) of the children in this study were obese. However, “this prevalence is similar to that observed in contemporary Hispanic and African American children.

“Thus … our findings may reflect the future burden of premature death among contemporary children from other ethnic groups and may be more generalizable than the findings in previous studies,” Dr. Franks and his colleagues noted (N. Engl. J. Med. 2010;362;485-93).

The study subjects were followed until death, their 55th birthday, or the end of 2003, whichever came first. Deaths due to endogenous causes were defined as those with a proximate cause of disease or self-inflicted injury such as acute alcohol intoxication or drug use.

A total of 559 (11.5%) study subjects died before they reached 55 years of age, and 166 of these deaths were due to endogenous causes. Most deaths (59) were attributed to alcoholic liver disease, 22 to cardiovascular disease, 21 to infection, 12 to cancer, 10 to diabetes or diabetic nephropathy, 9 to acute alcohol poisoning or drug overdose, and 33 to miscellaneous causes.

Obesity was strongly related to risk of premature death. Adult mortality was more than twice as high among children in the highest quartile of body mass index than among those in the lowest quartile.

Similarly, hypertension and glucose intolerance in childhood were strongly related to premature death. Hypertension raised the risk by 57%, and children in the highest quartile of glucose level had a 73% higher risk of premature death than did those in the lowest quartile.

In contrast, childhood hypercholesterolemia was not associated with premature death. That may be due in part to the fact that the proportion of deaths from cardiovascular disease was quite low in this young cohort (13%).

In addition, cholesterol levels are lower in most Native Americans than in other ethnic groups, which may have affected this outcome, the investigators said.

Dr. Franks was supported in part by grants from the Swedish Diabetes Association, the Swedish Heart Lung Foundation, the Swedish Research Council, Umeå University, and Västerbotten regional health authority.

Major Finding: Childhood obesity raised the risk of premature death in adulthood by 50%, hypertension did so by 57%, and a high glucose level did so by 73%.

Data Source: A study of 4,857 Native American children through adulthood or death.

Disclosures: The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases' intramural research program. Dr. Franks reported no conflicts of interest.

Obesity, hypertension, and glucose intolerance in childhood are strongly associated with premature death from endogenous causes, according to an analysis of data from a longitudinal study.

Failure to reverse the current population trends in childhood obesity thus could have far-reaching consequences for longevity, said Paul W. Franks, Ph.D., of the National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, and his associates.

The investigators noted that “little is known about the way in which cardiovascular risk factors that are present during childhood affect the life span,” and examined the issue using data from a longitudinal study of diabetes among Native Americans who were born between 1945 and 1984. The 4,857 study subjects were children and adolescents (aged 5-20 years) when first enrolled between 1966 and 2003.

The study subjects had at least 4/8 Pima or Tohono O'odham Indian heritage and lived in the Gila River Indian Community.

This is a population with high rates of obesity and diabetes, and 1,394 (29%) of the children in this study were obese. However, “this prevalence is similar to that observed in contemporary Hispanic and African American children.

“Thus … our findings may reflect the future burden of premature death among contemporary children from other ethnic groups and may be more generalizable than the findings in previous studies,” Dr. Franks and his colleagues noted (N. Engl. J. Med. 2010;362;485-93).

The study subjects were followed until death, their 55th birthday, or the end of 2003, whichever came first. Deaths due to endogenous causes were defined as those with a proximate cause of disease or self-inflicted injury such as acute alcohol intoxication or drug use.

A total of 559 (11.5%) study subjects died before they reached 55 years of age, and 166 of these deaths were due to endogenous causes. Most deaths (59) were attributed to alcoholic liver disease, 22 to cardiovascular disease, 21 to infection, 12 to cancer, 10 to diabetes or diabetic nephropathy, 9 to acute alcohol poisoning or drug overdose, and 33 to miscellaneous causes.

Obesity was strongly related to risk of premature death. Adult mortality was more than twice as high among children in the highest quartile of body mass index than among those in the lowest quartile.

Similarly, hypertension and glucose intolerance in childhood were strongly related to premature death. Hypertension raised the risk by 57%, and children in the highest quartile of glucose level had a 73% higher risk of premature death than did those in the lowest quartile.

In contrast, childhood hypercholesterolemia was not associated with premature death. That may be due in part to the fact that the proportion of deaths from cardiovascular disease was quite low in this young cohort (13%).

In addition, cholesterol levels are lower in most Native Americans than in other ethnic groups, which may have affected this outcome, the investigators said.

Dr. Franks was supported in part by grants from the Swedish Diabetes Association, the Swedish Heart Lung Foundation, the Swedish Research Council, Umeå University, and Västerbotten regional health authority.

Major Finding: Childhood obesity raised the risk of premature death in adulthood by 50%, hypertension did so by 57%, and a high glucose level did so by 73%.

Data Source: A study of 4,857 Native American children through adulthood or death.

Disclosures: The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases' intramural research program. Dr. Franks reported no conflicts of interest.

Obesity, hypertension, and glucose intolerance in childhood are strongly associated with premature death from endogenous causes, according to an analysis of data from a longitudinal study.

Failure to reverse the current population trends in childhood obesity thus could have far-reaching consequences for longevity, said Paul W. Franks, Ph.D., of the National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, and his associates.

The investigators noted that “little is known about the way in which cardiovascular risk factors that are present during childhood affect the life span,” and examined the issue using data from a longitudinal study of diabetes among Native Americans who were born between 1945 and 1984. The 4,857 study subjects were children and adolescents (aged 5-20 years) when first enrolled between 1966 and 2003.

The study subjects had at least 4/8 Pima or Tohono O'odham Indian heritage and lived in the Gila River Indian Community.

This is a population with high rates of obesity and diabetes, and 1,394 (29%) of the children in this study were obese. However, “this prevalence is similar to that observed in contemporary Hispanic and African American children.

“Thus … our findings may reflect the future burden of premature death among contemporary children from other ethnic groups and may be more generalizable than the findings in previous studies,” Dr. Franks and his colleagues noted (N. Engl. J. Med. 2010;362;485-93).

The study subjects were followed until death, their 55th birthday, or the end of 2003, whichever came first. Deaths due to endogenous causes were defined as those with a proximate cause of disease or self-inflicted injury such as acute alcohol intoxication or drug use.

A total of 559 (11.5%) study subjects died before they reached 55 years of age, and 166 of these deaths were due to endogenous causes. Most deaths (59) were attributed to alcoholic liver disease, 22 to cardiovascular disease, 21 to infection, 12 to cancer, 10 to diabetes or diabetic nephropathy, 9 to acute alcohol poisoning or drug overdose, and 33 to miscellaneous causes.

Obesity was strongly related to risk of premature death. Adult mortality was more than twice as high among children in the highest quartile of body mass index than among those in the lowest quartile.

Similarly, hypertension and glucose intolerance in childhood were strongly related to premature death. Hypertension raised the risk by 57%, and children in the highest quartile of glucose level had a 73% higher risk of premature death than did those in the lowest quartile.

In contrast, childhood hypercholesterolemia was not associated with premature death. That may be due in part to the fact that the proportion of deaths from cardiovascular disease was quite low in this young cohort (13%).

In addition, cholesterol levels are lower in most Native Americans than in other ethnic groups, which may have affected this outcome, the investigators said.

Dr. Franks was supported in part by grants from the Swedish Diabetes Association, the Swedish Heart Lung Foundation, the Swedish Research Council, Umeå University, and Västerbotten regional health authority.

Gastric banding allowed extremely obese adolescents to achieve a more substantial and durable weight loss than did an intensive lifestyle modification program, based on results of a prospective clinical trial with 50 adolescents.

The bariatric procedure improved overall health better than the lifestyle intervention did, resolving all cases of metabolic syndrome and insulin resistance. It also improved the adolescents' quality of life to a greater degree, according to the findings of a randomized controlled trial.

Dr. Paul E. O'Brien of the Centre for Obesity Research and Education at Monash University, Melbourne, and his associates compared the two approaches in adolescents aged 14-18 years with a body mass index of greater than 35. All study subjects had related medical complications, including hypertension, metabolic syndrome, asthma, and back pain, as well as physical limitations such as the inability to play sports and problems performing activities of daily living. They also reported psychosocial problems including isolation, low self-esteem, and victimization by bullies.

The subjects were randomly assigned to undergo laparoscopic adjustable gastric binding with follow-up education and guidance or to participate in an intensive nonsurgical intervention program.

The program focused on reduced energy intake (800-2,000 kcal per day, depending on age and weight); increased physical activity (more than 10,000 steps/day as measured by pedometry), which included structured exercise for at least 30 minutes per day; and behavior modification. The subjects were advised to limit time spent on sedentary pursuits such as computer or television to 2 hours per day, and to participate in bike rides, hiking trips, kickboxing events, and bowling parties with other patients. They received 6 weeks of instruction from a personal trainer and met with a physician, a dietitian, or an exercise consultant every 6 weeks.

Twenty-four of the 25 subjects in the surgery group (96%) completed the full 2 years of follow-up, compared with 18 of the 25 in the lifestyle group (72%).

Twenty-one subjects in the surgery group (84%) but only three subjects in the lifestyle group (12%) achieved the primary outcome measure of a loss of at least 50% of excess weight.

At 2 years, surgery group subjects had lost a mean of 35 kg, which represents a mean loss of 28% of total body weight. In comparison, subjects in the lifestyle group lost a mean of 3 kg, which represents a mean loss of 3% of total body weight, according to Dr. O'Brien and his colleagues (JAMA 2010;303:519-26).

At the inception of the study, 9 subjects in the surgery group and 10 in the lifestyle group had metabolic syndrome. By the end of the study, this had resolved in all surgery subjects and in six of the lifestyle subjects.

Similarly, insulin resistance was abnormally high in more than half of the subjects at baseline. The problem resolved in all subjects in the surgery group but persisted in three subjects in the lifestyle group.

Those who underwent gastric banding also showed significant improvements in quality of life in the domains of physical functioning, general health, self-esteem, and family activities, whereas those who participated in the nonsurgical intervention did not.

There were no operative or postoperative complications, and the rates of adverse events were similar between the two groups.

Two girls in each group became pregnant during follow-up, an unexpectedly high rate that “suggests sexual counseling may be appropriate in association with weight-loss programs” in adolescents, the researchers said.

Since “the need for revisional procedures for enlargement of the stomach above the band or injury to the tubing is intrinsic to the gastric banding procedure,” it was not surprising that seven patients in the surgery group (28%) required such revisions, they noted. “The need for a revisional procedure did not compromise the weight loss outcome or lead to additional adverse events,” the investigators stated.

However, compared with adults, adolescents may have more difficulty understanding and complying with instructions to eat only small meals and to eat very slowly in order to avoid the need for revisional procedures. Therefore, additional education and supervision of eating may be helpful for this age group, they added.

In an editorial comment accompanying the article, Dr. Edward H. Livingston of the University of Texas Southwestern Medical Center, Dallas, said that the study provides another randomized controlled trial comparing bariatric surgery with nonsurgical treatments, culminating in more level 1 evidence. This is crucial because the quality of the current evidence in support of bariatric surgery is “poor,” he said (JAMA 2010;303:559-60).

Dr. Livingston added that the 28% rate of revisional procedures in this study is particularly important “because O'Brien et al. are among the most experienced group in the world with these operations, suggesting that these complication rates will probably be higher in actual community practice.”

This study was supported in part by Allergan Inc., which provided the gastric bands. Dr. O'Brien reported no potential conflicts of interest, but one of his associates is a consultant for Allergan, Bariatric Advantage, Scientific Intake Ltd., SP Health Co., Optifast, Abbott Australasia, Eli Lilly Australia, Merck Sharp & Dohme Australia, Nestle Australia, and Roche Products Australia. Dr. Livingston reported no potential conflicts of interest.

Gastric banding allowed extremely obese adolescents to achieve a more substantial and durable weight loss than did an intensive lifestyle modification program, based on results of a prospective clinical trial with 50 adolescents.

The bariatric procedure improved overall health better than the lifestyle intervention did, resolving all cases of metabolic syndrome and insulin resistance. It also improved the adolescents' quality of life to a greater degree, according to the findings of a randomized controlled trial.

Dr. Paul E. O'Brien of the Centre for Obesity Research and Education at Monash University, Melbourne, and his associates compared the two approaches in adolescents aged 14-18 years with a body mass index of greater than 35. All study subjects had related medical complications, including hypertension, metabolic syndrome, asthma, and back pain, as well as physical limitations such as the inability to play sports and problems performing activities of daily living. They also reported psychosocial problems including isolation, low self-esteem, and victimization by bullies.

The subjects were randomly assigned to undergo laparoscopic adjustable gastric binding with follow-up education and guidance or to participate in an intensive nonsurgical intervention program.

The program focused on reduced energy intake (800-2,000 kcal per day, depending on age and weight); increased physical activity (more than 10,000 steps/day as measured by pedometry), which included structured exercise for at least 30 minutes per day; and behavior modification. The subjects were advised to limit time spent on sedentary pursuits such as computer or television to 2 hours per day, and to participate in bike rides, hiking trips, kickboxing events, and bowling parties with other patients. They received 6 weeks of instruction from a personal trainer and met with a physician, a dietitian, or an exercise consultant every 6 weeks.

Twenty-four of the 25 subjects in the surgery group (96%) completed the full 2 years of follow-up, compared with 18 of the 25 in the lifestyle group (72%).

Twenty-one subjects in the surgery group (84%) but only three subjects in the lifestyle group (12%) achieved the primary outcome measure of a loss of at least 50% of excess weight.

At 2 years, surgery group subjects had lost a mean of 35 kg, which represents a mean loss of 28% of total body weight. In comparison, subjects in the lifestyle group lost a mean of 3 kg, which represents a mean loss of 3% of total body weight, according to Dr. O'Brien and his colleagues (JAMA 2010;303:519-26).

At the inception of the study, 9 subjects in the surgery group and 10 in the lifestyle group had metabolic syndrome. By the end of the study, this had resolved in all surgery subjects and in six of the lifestyle subjects.

Similarly, insulin resistance was abnormally high in more than half of the subjects at baseline. The problem resolved in all subjects in the surgery group but persisted in three subjects in the lifestyle group.

Those who underwent gastric banding also showed significant improvements in quality of life in the domains of physical functioning, general health, self-esteem, and family activities, whereas those who participated in the nonsurgical intervention did not.

There were no operative or postoperative complications, and the rates of adverse events were similar between the two groups.

Two girls in each group became pregnant during follow-up, an unexpectedly high rate that “suggests sexual counseling may be appropriate in association with weight-loss programs” in adolescents, the researchers said.

Since “the need for revisional procedures for enlargement of the stomach above the band or injury to the tubing is intrinsic to the gastric banding procedure,” it was not surprising that seven patients in the surgery group (28%) required such revisions, they noted. “The need for a revisional procedure did not compromise the weight loss outcome or lead to additional adverse events,” the investigators stated.

However, compared with adults, adolescents may have more difficulty understanding and complying with instructions to eat only small meals and to eat very slowly in order to avoid the need for revisional procedures. Therefore, additional education and supervision of eating may be helpful for this age group, they added.

In an editorial comment accompanying the article, Dr. Edward H. Livingston of the University of Texas Southwestern Medical Center, Dallas, said that the study provides another randomized controlled trial comparing bariatric surgery with nonsurgical treatments, culminating in more level 1 evidence. This is crucial because the quality of the current evidence in support of bariatric surgery is “poor,” he said (JAMA 2010;303:559-60).

Dr. Livingston added that the 28% rate of revisional procedures in this study is particularly important “because O'Brien et al. are among the most experienced group in the world with these operations, suggesting that these complication rates will probably be higher in actual community practice.”

This study was supported in part by Allergan Inc., which provided the gastric bands. Dr. O'Brien reported no potential conflicts of interest, but one of his associates is a consultant for Allergan, Bariatric Advantage, Scientific Intake Ltd., SP Health Co., Optifast, Abbott Australasia, Eli Lilly Australia, Merck Sharp & Dohme Australia, Nestle Australia, and Roche Products Australia. Dr. Livingston reported no potential conflicts of interest.

Gastric banding allowed extremely obese adolescents to achieve a more substantial and durable weight loss than did an intensive lifestyle modification program, based on results of a prospective clinical trial with 50 adolescents.

The bariatric procedure improved overall health better than the lifestyle intervention did, resolving all cases of metabolic syndrome and insulin resistance. It also improved the adolescents' quality of life to a greater degree, according to the findings of a randomized controlled trial.

Dr. Paul E. O'Brien of the Centre for Obesity Research and Education at Monash University, Melbourne, and his associates compared the two approaches in adolescents aged 14-18 years with a body mass index of greater than 35. All study subjects had related medical complications, including hypertension, metabolic syndrome, asthma, and back pain, as well as physical limitations such as the inability to play sports and problems performing activities of daily living. They also reported psychosocial problems including isolation, low self-esteem, and victimization by bullies.

The subjects were randomly assigned to undergo laparoscopic adjustable gastric binding with follow-up education and guidance or to participate in an intensive nonsurgical intervention program.

The program focused on reduced energy intake (800-2,000 kcal per day, depending on age and weight); increased physical activity (more than 10,000 steps/day as measured by pedometry), which included structured exercise for at least 30 minutes per day; and behavior modification. The subjects were advised to limit time spent on sedentary pursuits such as computer or television to 2 hours per day, and to participate in bike rides, hiking trips, kickboxing events, and bowling parties with other patients. They received 6 weeks of instruction from a personal trainer and met with a physician, a dietitian, or an exercise consultant every 6 weeks.

Twenty-four of the 25 subjects in the surgery group (96%) completed the full 2 years of follow-up, compared with 18 of the 25 in the lifestyle group (72%).

Twenty-one subjects in the surgery group (84%) but only three subjects in the lifestyle group (12%) achieved the primary outcome measure of a loss of at least 50% of excess weight.

At 2 years, surgery group subjects had lost a mean of 35 kg, which represents a mean loss of 28% of total body weight. In comparison, subjects in the lifestyle group lost a mean of 3 kg, which represents a mean loss of 3% of total body weight, according to Dr. O'Brien and his colleagues (JAMA 2010;303:519-26).

At the inception of the study, 9 subjects in the surgery group and 10 in the lifestyle group had metabolic syndrome. By the end of the study, this had resolved in all surgery subjects and in six of the lifestyle subjects.

Similarly, insulin resistance was abnormally high in more than half of the subjects at baseline. The problem resolved in all subjects in the surgery group but persisted in three subjects in the lifestyle group.

Those who underwent gastric banding also showed significant improvements in quality of life in the domains of physical functioning, general health, self-esteem, and family activities, whereas those who participated in the nonsurgical intervention did not.

There were no operative or postoperative complications, and the rates of adverse events were similar between the two groups.

Two girls in each group became pregnant during follow-up, an unexpectedly high rate that “suggests sexual counseling may be appropriate in association with weight-loss programs” in adolescents, the researchers said.

Since “the need for revisional procedures for enlargement of the stomach above the band or injury to the tubing is intrinsic to the gastric banding procedure,” it was not surprising that seven patients in the surgery group (28%) required such revisions, they noted. “The need for a revisional procedure did not compromise the weight loss outcome or lead to additional adverse events,” the investigators stated.

However, compared with adults, adolescents may have more difficulty understanding and complying with instructions to eat only small meals and to eat very slowly in order to avoid the need for revisional procedures. Therefore, additional education and supervision of eating may be helpful for this age group, they added.

In an editorial comment accompanying the article, Dr. Edward H. Livingston of the University of Texas Southwestern Medical Center, Dallas, said that the study provides another randomized controlled trial comparing bariatric surgery with nonsurgical treatments, culminating in more level 1 evidence. This is crucial because the quality of the current evidence in support of bariatric surgery is “poor,” he said (JAMA 2010;303:559-60).

Dr. Livingston added that the 28% rate of revisional procedures in this study is particularly important “because O'Brien et al. are among the most experienced group in the world with these operations, suggesting that these complication rates will probably be higher in actual community practice.”

This study was supported in part by Allergan Inc., which provided the gastric bands. Dr. O'Brien reported no potential conflicts of interest, but one of his associates is a consultant for Allergan, Bariatric Advantage, Scientific Intake Ltd., SP Health Co., Optifast, Abbott Australasia, Eli Lilly Australia, Merck Sharp & Dohme Australia, Nestle Australia, and Roche Products Australia. Dr. Livingston reported no potential conflicts of interest.