Michele G. Sullivan

BOSTON — Bariatric surgery may resolve symptoms of polycystic ovary syndrome in obese women with the condition, Dr. Héctor Escobar-Morreale reported at the annual meeting of the Androgen Excess Society.

“In some women, the syndrome is so driven by insulin resistance that it may resolve completely with weight loss,” said the endocrinologist, of the Hospital Ramón y Cajal in Madrid.

Among women seeking weight-loss advice at his endocrinology practice, Dr. Escobar-Morreale found a PCOS prevalence of 28%, more than five times the prevalence among lean women in Madrid. He then examined the prevalence of the disorder among 36 obese women referred for bariatric surgery. Of this group, 17 (47%) were diagnosed with PCOS.

Follow-up data at 1 year were available on 12 women. By 12 months, the women had lost an average of 41 kg and their hirsutism had resolved. Significant decreases were noted in their sex steroid levels: Total testosterone dropped from a mean of 69 ng/dL to 19 ng/dL, free testosterone from 1.6 to 0.3 ng/dL, androstenedione from 4.1 to 1.5 ng/dL, and dehydroepiandrosterone sulfate from 2,000 to 795 ng/dL.

Insulin sensitivity returned to normal and regular menstruation was restored. Among 10 women who were tested, all had hormonal evidence of ovulation.

BOSTON — Bariatric surgery may resolve symptoms of polycystic ovary syndrome in obese women with the condition, Dr. Héctor Escobar-Morreale reported at the annual meeting of the Androgen Excess Society.

“In some women, the syndrome is so driven by insulin resistance that it may resolve completely with weight loss,” said the endocrinologist, of the Hospital Ramón y Cajal in Madrid.

Among women seeking weight-loss advice at his endocrinology practice, Dr. Escobar-Morreale found a PCOS prevalence of 28%, more than five times the prevalence among lean women in Madrid. He then examined the prevalence of the disorder among 36 obese women referred for bariatric surgery. Of this group, 17 (47%) were diagnosed with PCOS.

Follow-up data at 1 year were available on 12 women. By 12 months, the women had lost an average of 41 kg and their hirsutism had resolved. Significant decreases were noted in their sex steroid levels: Total testosterone dropped from a mean of 69 ng/dL to 19 ng/dL, free testosterone from 1.6 to 0.3 ng/dL, androstenedione from 4.1 to 1.5 ng/dL, and dehydroepiandrosterone sulfate from 2,000 to 795 ng/dL.

Insulin sensitivity returned to normal and regular menstruation was restored. Among 10 women who were tested, all had hormonal evidence of ovulation.

BOSTON — Bariatric surgery may resolve symptoms of polycystic ovary syndrome in obese women with the condition, Dr. Héctor Escobar-Morreale reported at the annual meeting of the Androgen Excess Society.

“In some women, the syndrome is so driven by insulin resistance that it may resolve completely with weight loss,” said the endocrinologist, of the Hospital Ramón y Cajal in Madrid.

Among women seeking weight-loss advice at his endocrinology practice, Dr. Escobar-Morreale found a PCOS prevalence of 28%, more than five times the prevalence among lean women in Madrid. He then examined the prevalence of the disorder among 36 obese women referred for bariatric surgery. Of this group, 17 (47%) were diagnosed with PCOS.

Follow-up data at 1 year were available on 12 women. By 12 months, the women had lost an average of 41 kg and their hirsutism had resolved. Significant decreases were noted in their sex steroid levels: Total testosterone dropped from a mean of 69 ng/dL to 19 ng/dL, free testosterone from 1.6 to 0.3 ng/dL, androstenedione from 4.1 to 1.5 ng/dL, and dehydroepiandrosterone sulfate from 2,000 to 795 ng/dL.

Insulin sensitivity returned to normal and regular menstruation was restored. Among 10 women who were tested, all had hormonal evidence of ovulation.

BOSTON — The daughters of women with polycystic ovary syndrome have elevated levels of antimüllerian hormone from infancy to the perimenarchal period, suggesting that the underpinnings of PCOS may be present long before clinical symptoms develop.

Folliculogenesis may be altered in these girls, said Dr. Nicolas Crisosto of the University of Chile, Santiago, at the annual meeting of the Androgen Excess Society.

He compared anthropometric, hormonal, and metabolic parameters in 58 daughters of women with PCOS and in 65 daughters of control women at three time points: early infancy (2–3 months), childhood (4–7 years), and the perimenarchal period (8–15 years).

At each of the three time points, the girls received a physical exam that included assessment of weight, height, waist-to-hip ratio, and sexual development. A panel of tests was performed for serum hormone levels (gonadotropins, sex steroids, sex hormone-binding globulin, and antimüllerian hormone). The girls in perimenarchal group also had a transabdominal ultrasound exam of their ovaries.

There were no significant anthropometric differences between the two groups at any of the exams, Dr. Crisosto said. Antimüllerian hormone levels were significantly increased in the PCOS group at all three stages. Free androgen level was elevated in the PCOS group at the perimenarchal exam. Other values were similar for the two groups.

The mean antimüllerian hormone levels in infants were 20.4 pmol/L in the girls born to women with PCOS vs. 9.2 pmol/L in girls born to women without PCOS. In childhood, the values for the two groups were 14.8 pmol/L and 7.7 pmol/L. In the perimenarchal period, the respective values were 25.2 pmol/L vs. 15.0 pmol/L.

The results of the transabdominal ultrasound showed slightly higher ovarian volume (8.8 cm

The findings, recently published in the Journal of Clinical Endocrinology and Metabolism (DOI:10.1210/jc.2005–2693), led Dr. Crisosto and his colleagues to conclude that serum antimüllerian hormone levels seem to be correlated with the development of preantral and small antral follicles, from puberty to the end of reproductive life. Elevated serum antimüllerian hormone concentrations in daughters of PCOS women during childhood, at a time when the gonadal axis is relatively quiescent and other hormonal markers of ovarian function are very low, suggests that antimüllerian hormone may be used as an early marker of ovarian follicular development.

BOSTON — The daughters of women with polycystic ovary syndrome have elevated levels of antimüllerian hormone from infancy to the perimenarchal period, suggesting that the underpinnings of PCOS may be present long before clinical symptoms develop.

Folliculogenesis may be altered in these girls, said Dr. Nicolas Crisosto of the University of Chile, Santiago, at the annual meeting of the Androgen Excess Society.

He compared anthropometric, hormonal, and metabolic parameters in 58 daughters of women with PCOS and in 65 daughters of control women at three time points: early infancy (2–3 months), childhood (4–7 years), and the perimenarchal period (8–15 years).

At each of the three time points, the girls received a physical exam that included assessment of weight, height, waist-to-hip ratio, and sexual development. A panel of tests was performed for serum hormone levels (gonadotropins, sex steroids, sex hormone-binding globulin, and antimüllerian hormone). The girls in perimenarchal group also had a transabdominal ultrasound exam of their ovaries.

There were no significant anthropometric differences between the two groups at any of the exams, Dr. Crisosto said. Antimüllerian hormone levels were significantly increased in the PCOS group at all three stages. Free androgen level was elevated in the PCOS group at the perimenarchal exam. Other values were similar for the two groups.

The mean antimüllerian hormone levels in infants were 20.4 pmol/L in the girls born to women with PCOS vs. 9.2 pmol/L in girls born to women without PCOS. In childhood, the values for the two groups were 14.8 pmol/L and 7.7 pmol/L. In the perimenarchal period, the respective values were 25.2 pmol/L vs. 15.0 pmol/L.

The results of the transabdominal ultrasound showed slightly higher ovarian volume (8.8 cm

The findings, recently published in the Journal of Clinical Endocrinology and Metabolism (DOI:10.1210/jc.2005–2693), led Dr. Crisosto and his colleagues to conclude that serum antimüllerian hormone levels seem to be correlated with the development of preantral and small antral follicles, from puberty to the end of reproductive life. Elevated serum antimüllerian hormone concentrations in daughters of PCOS women during childhood, at a time when the gonadal axis is relatively quiescent and other hormonal markers of ovarian function are very low, suggests that antimüllerian hormone may be used as an early marker of ovarian follicular development.

BOSTON — The daughters of women with polycystic ovary syndrome have elevated levels of antimüllerian hormone from infancy to the perimenarchal period, suggesting that the underpinnings of PCOS may be present long before clinical symptoms develop.

Folliculogenesis may be altered in these girls, said Dr. Nicolas Crisosto of the University of Chile, Santiago, at the annual meeting of the Androgen Excess Society.

He compared anthropometric, hormonal, and metabolic parameters in 58 daughters of women with PCOS and in 65 daughters of control women at three time points: early infancy (2–3 months), childhood (4–7 years), and the perimenarchal period (8–15 years).

At each of the three time points, the girls received a physical exam that included assessment of weight, height, waist-to-hip ratio, and sexual development. A panel of tests was performed for serum hormone levels (gonadotropins, sex steroids, sex hormone-binding globulin, and antimüllerian hormone). The girls in perimenarchal group also had a transabdominal ultrasound exam of their ovaries.

There were no significant anthropometric differences between the two groups at any of the exams, Dr. Crisosto said. Antimüllerian hormone levels were significantly increased in the PCOS group at all three stages. Free androgen level was elevated in the PCOS group at the perimenarchal exam. Other values were similar for the two groups.

The mean antimüllerian hormone levels in infants were 20.4 pmol/L in the girls born to women with PCOS vs. 9.2 pmol/L in girls born to women without PCOS. In childhood, the values for the two groups were 14.8 pmol/L and 7.7 pmol/L. In the perimenarchal period, the respective values were 25.2 pmol/L vs. 15.0 pmol/L.

The results of the transabdominal ultrasound showed slightly higher ovarian volume (8.8 cm

The findings, recently published in the Journal of Clinical Endocrinology and Metabolism (DOI:10.1210/jc.2005–2693), led Dr. Crisosto and his colleagues to conclude that serum antimüllerian hormone levels seem to be correlated with the development of preantral and small antral follicles, from puberty to the end of reproductive life. Elevated serum antimüllerian hormone concentrations in daughters of PCOS women during childhood, at a time when the gonadal axis is relatively quiescent and other hormonal markers of ovarian function are very low, suggests that antimüllerian hormone may be used as an early marker of ovarian follicular development.

BOSTON — Intermittent intravenous ibandronate is at least as effective as daily oral ibandronate for increasing bone mineral density and may be preferable to oral dosing in patients with esophageal disease or compliance problems.

There are no fracture data for the intravenous dosing schedule, but the risk reduction that has been shown with oral ibandronate can probably be extrapolated to the intravenous form of the drug, Dr. Mone Zaidi said at the annual meeting of the Endocrine Society.

Study results have shown that oral ibandronate reduces the risk of new vertebral fractures by up to 60% (Curr. Med. Res. Opin. 2005;21:391–401; J. Bone Miner. Res. 2004;19:1241–9).

“If you can show equivalence or superiority in bone mineral density changes to [the form] with proven fracture data, which we have done, I think everyone would agree that you can extrapolate that data,” said Dr. Zaidi, director of the Mount Sinai Bone Program, Mount Sinai School of Medicine, New York.

Dr. Zaidi presented 2-year bone mineral density (BMD) data from the ibandronate Dosing Intravenous Administration trial, a Roche-sponsored phase III study that compared two doses of intravenous ibandronate (2 mg every 2 months and 3 mg every 3 months) with the approved oral dosing schedule (2.5 mg daily). The study group included 1,400 postmenopausal women with low bone mass (T scores of −3.3 for total spine and −2 for hip).

After 2 years, BMD at the lumbar spine increased significantly more in both intravenous groups than in the oral group (mean increase 6.4% for the 2-mg IV dose, 6.3% for the 3-mg IV dose, and 4.8% for the oral dose). BMD increased similarly at all other sites measured, with consistently greater gains in both intravenous groups than in the oral group, Dr. Zaidi said.

At 2 years, the incidence of adverse events was similar across all groups. Flulike illnesses and gastrointestinal intolerance were seen primarily in the first year, with only slight increases in cumulative numbers during the second year. There was no osteonecrosis of the jaw. Renal and urinary incidents were uncommon and similar across groups.

Fracture incidence was low and similar in all groups, although Dr. Zaidi stressed that the study was not powered to prove fracture risk reduction.

Intravenous ibandronate would be especially useful in patients with contraindications to oral therapy or evidence of noncompliance, Dr Zaidi said. “Use this in patients who are intolerant to the oral form or who have problems like a bleeding ulcer, stricture, or dysmotility. It would also be useful for those who can't sit upright, such as bedridden nursing home patients.”

BOSTON — Intermittent intravenous ibandronate is at least as effective as daily oral ibandronate for increasing bone mineral density and may be preferable to oral dosing in patients with esophageal disease or compliance problems.

There are no fracture data for the intravenous dosing schedule, but the risk reduction that has been shown with oral ibandronate can probably be extrapolated to the intravenous form of the drug, Dr. Mone Zaidi said at the annual meeting of the Endocrine Society.

Study results have shown that oral ibandronate reduces the risk of new vertebral fractures by up to 60% (Curr. Med. Res. Opin. 2005;21:391–401; J. Bone Miner. Res. 2004;19:1241–9).

“If you can show equivalence or superiority in bone mineral density changes to [the form] with proven fracture data, which we have done, I think everyone would agree that you can extrapolate that data,” said Dr. Zaidi, director of the Mount Sinai Bone Program, Mount Sinai School of Medicine, New York.

Dr. Zaidi presented 2-year bone mineral density (BMD) data from the ibandronate Dosing Intravenous Administration trial, a Roche-sponsored phase III study that compared two doses of intravenous ibandronate (2 mg every 2 months and 3 mg every 3 months) with the approved oral dosing schedule (2.5 mg daily). The study group included 1,400 postmenopausal women with low bone mass (T scores of −3.3 for total spine and −2 for hip).

After 2 years, BMD at the lumbar spine increased significantly more in both intravenous groups than in the oral group (mean increase 6.4% for the 2-mg IV dose, 6.3% for the 3-mg IV dose, and 4.8% for the oral dose). BMD increased similarly at all other sites measured, with consistently greater gains in both intravenous groups than in the oral group, Dr. Zaidi said.

At 2 years, the incidence of adverse events was similar across all groups. Flulike illnesses and gastrointestinal intolerance were seen primarily in the first year, with only slight increases in cumulative numbers during the second year. There was no osteonecrosis of the jaw. Renal and urinary incidents were uncommon and similar across groups.

Fracture incidence was low and similar in all groups, although Dr. Zaidi stressed that the study was not powered to prove fracture risk reduction.

Intravenous ibandronate would be especially useful in patients with contraindications to oral therapy or evidence of noncompliance, Dr Zaidi said. “Use this in patients who are intolerant to the oral form or who have problems like a bleeding ulcer, stricture, or dysmotility. It would also be useful for those who can't sit upright, such as bedridden nursing home patients.”

BOSTON — Intermittent intravenous ibandronate is at least as effective as daily oral ibandronate for increasing bone mineral density and may be preferable to oral dosing in patients with esophageal disease or compliance problems.

There are no fracture data for the intravenous dosing schedule, but the risk reduction that has been shown with oral ibandronate can probably be extrapolated to the intravenous form of the drug, Dr. Mone Zaidi said at the annual meeting of the Endocrine Society.

Study results have shown that oral ibandronate reduces the risk of new vertebral fractures by up to 60% (Curr. Med. Res. Opin. 2005;21:391–401; J. Bone Miner. Res. 2004;19:1241–9).

“If you can show equivalence or superiority in bone mineral density changes to [the form] with proven fracture data, which we have done, I think everyone would agree that you can extrapolate that data,” said Dr. Zaidi, director of the Mount Sinai Bone Program, Mount Sinai School of Medicine, New York.

Dr. Zaidi presented 2-year bone mineral density (BMD) data from the ibandronate Dosing Intravenous Administration trial, a Roche-sponsored phase III study that compared two doses of intravenous ibandronate (2 mg every 2 months and 3 mg every 3 months) with the approved oral dosing schedule (2.5 mg daily). The study group included 1,400 postmenopausal women with low bone mass (T scores of −3.3 for total spine and −2 for hip).

After 2 years, BMD at the lumbar spine increased significantly more in both intravenous groups than in the oral group (mean increase 6.4% for the 2-mg IV dose, 6.3% for the 3-mg IV dose, and 4.8% for the oral dose). BMD increased similarly at all other sites measured, with consistently greater gains in both intravenous groups than in the oral group, Dr. Zaidi said.

At 2 years, the incidence of adverse events was similar across all groups. Flulike illnesses and gastrointestinal intolerance were seen primarily in the first year, with only slight increases in cumulative numbers during the second year. There was no osteonecrosis of the jaw. Renal and urinary incidents were uncommon and similar across groups.

Fracture incidence was low and similar in all groups, although Dr. Zaidi stressed that the study was not powered to prove fracture risk reduction.

Intravenous ibandronate would be especially useful in patients with contraindications to oral therapy or evidence of noncompliance, Dr Zaidi said. “Use this in patients who are intolerant to the oral form or who have problems like a bleeding ulcer, stricture, or dysmotility. It would also be useful for those who can't sit upright, such as bedridden nursing home patients.”

BOSTON — To maintain skeletal health and reach optimal bone development, patients with childhood-onset growth hormone deficiency should continue therapy as they approach young adulthood, according to new treatment guidelines that have been issued by The Endocrine Society.

“The mindset in the past has been that you treat these children until they stop growing,” Dr. Mark Molitch said at the society's annual meeting. “But the bones don't mature until the mid-20s, so they may still need the hormone as they transition into adulthood.”

In addition, he said, skeletal maturity may occur more slowly in patients with delayed onset of puberty or decreased gonadotropin secretion, so continuation of treatment is even more important for this population. Bone mineral density testing may provide additional valuable information for the decisions about continuing therapy.

The new guidelines, which were presented for the first time at the meeting, recommend retesting all children with idiopathic growth hormone deficiency as soon as possible after discontinuing the medication.

Although many will have normal values, therapy should be quickly reinstituted for those who remain deficient.

The guidelines are based on 166 published studies examining the prevalence and diagnosis of growth hormone deficiency in adults, as well as treatment strategies and their long-term risks and benefits, said Dr. Molitch, chairman of the guidelines committee and professor of endocrinology at Northwestern University, Chicago.

The recommendations are aimed only at adults with clinically proven deficiency. “There is a lack of evidence for treating for any other reason, including longevity or athletic performance,” he said in a press conference.

In adults, growth hormone deficiencies may result from genetic defects, radiotherapy, structural lesions, or trauma. Only rarely is adult deficiency idiopathic, the guidelines state.

In the past, the insulin tolerance test was the favored diagnostic tool. However, this test carries an increased risk in patients with seizure disorders and cardiovascular disease, and requires close monitoring of even healthy patients. Recently, Dr. Molitch said, stimulation testing with growth hormone releasing hormone-arginine (GRHR-arginine) has gained favor. The test is less affected by age or obesity.

In a recent study of five different tests, including stimulation with GHRH-arginine and insulin tolerance, the stimulation test had 95% sensitivity and 91% specificity at the growth hormone cutoff level of 4.1 mcg/L; insulin testing was 96% sensitive and 92% specific at the cutoff level of 5.1 mcg/L.

Testing is indicated for adults with pituitary disease; surgery, trauma, or radiation in the pituitary area; or other pituitary deficiencies.

Although children with idiopathic growth hormone deficiency should be retested as they approach adulthood, testing may be unnecessary for those with low insulinlike growth factor-1 and known defects, lesions, surgery or radiation of the hypothalamic-pituitary region, or a proven genetic defect of their capacity to secrete growth hormone.

“This [combination] generally suffices to document continuing growth hormone deficiency,” the guidelines state.

The evidence strongly supports individualized growth hormone dosing regimens. Generally, treatment should start low and should be titrated upward based on clinical response, side effects, and IGF-1 levels.

Younger patients are likely to need higher doses, as are women, especially those on oral contraceptives, Dr. Molitch said. Patients aged 30–60 years can usually start at 300 mcg/day; dosing should be increased by 100–200 mcg/day every 1–2 months, with a therapeutic target of an IGF-1 level in the upper half of the normal range.

Older patients should be started on 100–200 mcg/day, while those younger than 30 years may benefit from initially higher doses (400–500 mcg/day).

Although no studies have linked growth hormone therapy with malignancies, the guidelines recommend against using the hormone in anyone with an active cancer. There is no evidence that treatment affects the recurrence of pituitary tumors. Patients with diabetes may need adjustments to their diabetes medications when on growth hormone.

The side effects of growth hormone therapy are usually dose-related and can be alleviated by adjusting the medication. The most common are related to fluid retention. These effects occur in up to 18% of patients and include paresthesias, joint stiffness, peripheral edema, arthralgia, and myalgia. Increased blood pressure is sometimes seen, but can be avoided with appropriate dosing.

Therapy offers significant benefits, including a decrease in fat mass and its attendant risk reductions of improved lipid levels and decreased insulin resistence. The modest increases in muscle mass improve exercise tolerance, which in turn has beneficial effects on blood pressure and cardiac function. Patients with childhood-onset growth hormone deficiency also may experience improvements in left ventricular muscle mass and end diastolic volume, as well as stroke volume. Therapy also benefits bone health with both anabolic and antiresorptive effects.

However, no studies have confirmed a mortality benefit with growth hormone therapy, Dr. Molitch said.

“Some do suggest that mortality is increased in those with hypopituitarism, but it's never been proven that hypopituitarism is the cause of this, or that growth hormone decreases it,” he said.

Bone mineral density testing may facilitate decisions about whether to continue therapy. DR. MOLITCH

BOSTON — To maintain skeletal health and reach optimal bone development, patients with childhood-onset growth hormone deficiency should continue therapy as they approach young adulthood, according to new treatment guidelines that have been issued by The Endocrine Society.

“The mindset in the past has been that you treat these children until they stop growing,” Dr. Mark Molitch said at the society's annual meeting. “But the bones don't mature until the mid-20s, so they may still need the hormone as they transition into adulthood.”

In addition, he said, skeletal maturity may occur more slowly in patients with delayed onset of puberty or decreased gonadotropin secretion, so continuation of treatment is even more important for this population. Bone mineral density testing may provide additional valuable information for the decisions about continuing therapy.

The new guidelines, which were presented for the first time at the meeting, recommend retesting all children with idiopathic growth hormone deficiency as soon as possible after discontinuing the medication.

Although many will have normal values, therapy should be quickly reinstituted for those who remain deficient.

The guidelines are based on 166 published studies examining the prevalence and diagnosis of growth hormone deficiency in adults, as well as treatment strategies and their long-term risks and benefits, said Dr. Molitch, chairman of the guidelines committee and professor of endocrinology at Northwestern University, Chicago.

The recommendations are aimed only at adults with clinically proven deficiency. “There is a lack of evidence for treating for any other reason, including longevity or athletic performance,” he said in a press conference.

In adults, growth hormone deficiencies may result from genetic defects, radiotherapy, structural lesions, or trauma. Only rarely is adult deficiency idiopathic, the guidelines state.

In the past, the insulin tolerance test was the favored diagnostic tool. However, this test carries an increased risk in patients with seizure disorders and cardiovascular disease, and requires close monitoring of even healthy patients. Recently, Dr. Molitch said, stimulation testing with growth hormone releasing hormone-arginine (GRHR-arginine) has gained favor. The test is less affected by age or obesity.

In a recent study of five different tests, including stimulation with GHRH-arginine and insulin tolerance, the stimulation test had 95% sensitivity and 91% specificity at the growth hormone cutoff level of 4.1 mcg/L; insulin testing was 96% sensitive and 92% specific at the cutoff level of 5.1 mcg/L.

Testing is indicated for adults with pituitary disease; surgery, trauma, or radiation in the pituitary area; or other pituitary deficiencies.

Although children with idiopathic growth hormone deficiency should be retested as they approach adulthood, testing may be unnecessary for those with low insulinlike growth factor-1 and known defects, lesions, surgery or radiation of the hypothalamic-pituitary region, or a proven genetic defect of their capacity to secrete growth hormone.

“This [combination] generally suffices to document continuing growth hormone deficiency,” the guidelines state.

The evidence strongly supports individualized growth hormone dosing regimens. Generally, treatment should start low and should be titrated upward based on clinical response, side effects, and IGF-1 levels.

Younger patients are likely to need higher doses, as are women, especially those on oral contraceptives, Dr. Molitch said. Patients aged 30–60 years can usually start at 300 mcg/day; dosing should be increased by 100–200 mcg/day every 1–2 months, with a therapeutic target of an IGF-1 level in the upper half of the normal range.

Older patients should be started on 100–200 mcg/day, while those younger than 30 years may benefit from initially higher doses (400–500 mcg/day).

Although no studies have linked growth hormone therapy with malignancies, the guidelines recommend against using the hormone in anyone with an active cancer. There is no evidence that treatment affects the recurrence of pituitary tumors. Patients with diabetes may need adjustments to their diabetes medications when on growth hormone.

The side effects of growth hormone therapy are usually dose-related and can be alleviated by adjusting the medication. The most common are related to fluid retention. These effects occur in up to 18% of patients and include paresthesias, joint stiffness, peripheral edema, arthralgia, and myalgia. Increased blood pressure is sometimes seen, but can be avoided with appropriate dosing.

Therapy offers significant benefits, including a decrease in fat mass and its attendant risk reductions of improved lipid levels and decreased insulin resistence. The modest increases in muscle mass improve exercise tolerance, which in turn has beneficial effects on blood pressure and cardiac function. Patients with childhood-onset growth hormone deficiency also may experience improvements in left ventricular muscle mass and end diastolic volume, as well as stroke volume. Therapy also benefits bone health with both anabolic and antiresorptive effects.

However, no studies have confirmed a mortality benefit with growth hormone therapy, Dr. Molitch said.

“Some do suggest that mortality is increased in those with hypopituitarism, but it's never been proven that hypopituitarism is the cause of this, or that growth hormone decreases it,” he said.

Bone mineral density testing may facilitate decisions about whether to continue therapy. DR. MOLITCH

BOSTON — To maintain skeletal health and reach optimal bone development, patients with childhood-onset growth hormone deficiency should continue therapy as they approach young adulthood, according to new treatment guidelines that have been issued by The Endocrine Society.

“The mindset in the past has been that you treat these children until they stop growing,” Dr. Mark Molitch said at the society's annual meeting. “But the bones don't mature until the mid-20s, so they may still need the hormone as they transition into adulthood.”

In addition, he said, skeletal maturity may occur more slowly in patients with delayed onset of puberty or decreased gonadotropin secretion, so continuation of treatment is even more important for this population. Bone mineral density testing may provide additional valuable information for the decisions about continuing therapy.

The new guidelines, which were presented for the first time at the meeting, recommend retesting all children with idiopathic growth hormone deficiency as soon as possible after discontinuing the medication.

Although many will have normal values, therapy should be quickly reinstituted for those who remain deficient.

The guidelines are based on 166 published studies examining the prevalence and diagnosis of growth hormone deficiency in adults, as well as treatment strategies and their long-term risks and benefits, said Dr. Molitch, chairman of the guidelines committee and professor of endocrinology at Northwestern University, Chicago.

The recommendations are aimed only at adults with clinically proven deficiency. “There is a lack of evidence for treating for any other reason, including longevity or athletic performance,” he said in a press conference.

In adults, growth hormone deficiencies may result from genetic defects, radiotherapy, structural lesions, or trauma. Only rarely is adult deficiency idiopathic, the guidelines state.

In the past, the insulin tolerance test was the favored diagnostic tool. However, this test carries an increased risk in patients with seizure disorders and cardiovascular disease, and requires close monitoring of even healthy patients. Recently, Dr. Molitch said, stimulation testing with growth hormone releasing hormone-arginine (GRHR-arginine) has gained favor. The test is less affected by age or obesity.

In a recent study of five different tests, including stimulation with GHRH-arginine and insulin tolerance, the stimulation test had 95% sensitivity and 91% specificity at the growth hormone cutoff level of 4.1 mcg/L; insulin testing was 96% sensitive and 92% specific at the cutoff level of 5.1 mcg/L.

Testing is indicated for adults with pituitary disease; surgery, trauma, or radiation in the pituitary area; or other pituitary deficiencies.

Although children with idiopathic growth hormone deficiency should be retested as they approach adulthood, testing may be unnecessary for those with low insulinlike growth factor-1 and known defects, lesions, surgery or radiation of the hypothalamic-pituitary region, or a proven genetic defect of their capacity to secrete growth hormone.

“This [combination] generally suffices to document continuing growth hormone deficiency,” the guidelines state.

The evidence strongly supports individualized growth hormone dosing regimens. Generally, treatment should start low and should be titrated upward based on clinical response, side effects, and IGF-1 levels.

Younger patients are likely to need higher doses, as are women, especially those on oral contraceptives, Dr. Molitch said. Patients aged 30–60 years can usually start at 300 mcg/day; dosing should be increased by 100–200 mcg/day every 1–2 months, with a therapeutic target of an IGF-1 level in the upper half of the normal range.

Older patients should be started on 100–200 mcg/day, while those younger than 30 years may benefit from initially higher doses (400–500 mcg/day).

Although no studies have linked growth hormone therapy with malignancies, the guidelines recommend against using the hormone in anyone with an active cancer. There is no evidence that treatment affects the recurrence of pituitary tumors. Patients with diabetes may need adjustments to their diabetes medications when on growth hormone.

The side effects of growth hormone therapy are usually dose-related and can be alleviated by adjusting the medication. The most common are related to fluid retention. These effects occur in up to 18% of patients and include paresthesias, joint stiffness, peripheral edema, arthralgia, and myalgia. Increased blood pressure is sometimes seen, but can be avoided with appropriate dosing.

Therapy offers significant benefits, including a decrease in fat mass and its attendant risk reductions of improved lipid levels and decreased insulin resistence. The modest increases in muscle mass improve exercise tolerance, which in turn has beneficial effects on blood pressure and cardiac function. Patients with childhood-onset growth hormone deficiency also may experience improvements in left ventricular muscle mass and end diastolic volume, as well as stroke volume. Therapy also benefits bone health with both anabolic and antiresorptive effects.

However, no studies have confirmed a mortality benefit with growth hormone therapy, Dr. Molitch said.

“Some do suggest that mortality is increased in those with hypopituitarism, but it's never been proven that hypopituitarism is the cause of this, or that growth hormone decreases it,” he said.

Bone mineral density testing may facilitate decisions about whether to continue therapy. DR. MOLITCH

BOSTON — Intermittent intravenous ibandronate is at least as effective as daily oral ibandronate for increasing bone mineral density and may be preferable to oral dosing in patients with esophageal disease or compliance problems.

There are no fracture data for the intravenous dosing schedule, but the risk reduction that has been shown with oral ibandronate can probably be extrapolated to the intravenous form of the drug, Dr. Mone Zaidi said at the annual meeting of the Endocrine Society.

Oral ibandronate has been shown to reduce the risk of new vertebral fractures by up to 60% (Curr. Med. Res. Opin. 2005;21:391–401; J. Bone Miner. Res. 2004;19:1241–9).

He presented 2-year bone mineral density (BMD) data from the ibandronate Dosing Intravenous Administration trial, a Roche-sponsored phase III study that compared two doses of intravenous ibandronate (2 mg every 2 months and 3 mg every 3 months) with the approved oral dosing schedule (2.5 mg daily). The study group included 1,400 postmenopausal women with low bone mass (T-scores of −3.3 for total spine and −2 for hip).

After 2 years, BMD at the lumbar spine increased significantly more in both intravenous groups than in the oral group (mean increase 6.4% for the 2-mg IV dose, 6.3% for the 3-mg IV dose, and 4.8% for the oral dose). BMD increased similarly at all sites measured, said Dr. Zaidi, director of the Mount Sinai Bone Program, Mount Sinai School of Medicine, New York.

At 2 years, the incidence of adverse events was similar across all groups. Flulike illnesses and gastrointestinal intolerance were seen primarily in the first year, with only slight increases in cumulative numbers during the second year.

Intravenous ibandronate would be especially useful in patients with contraindications to oral therapy or clinical or biochemical evidence of noncompliance, Dr. Zaidi said. “I would use this in patients who are intolerant to the oral form or who have problems like a bleeding ulcer, stricture, or dysmotility. It would also be useful for those who can't sit upright, such as bedridden nursing home patients.” The intermittent dosing would also be “a great way” to ensure compliance, he added.

BOSTON — Intermittent intravenous ibandronate is at least as effective as daily oral ibandronate for increasing bone mineral density and may be preferable to oral dosing in patients with esophageal disease or compliance problems.

There are no fracture data for the intravenous dosing schedule, but the risk reduction that has been shown with oral ibandronate can probably be extrapolated to the intravenous form of the drug, Dr. Mone Zaidi said at the annual meeting of the Endocrine Society.

Oral ibandronate has been shown to reduce the risk of new vertebral fractures by up to 60% (Curr. Med. Res. Opin. 2005;21:391–401; J. Bone Miner. Res. 2004;19:1241–9).

He presented 2-year bone mineral density (BMD) data from the ibandronate Dosing Intravenous Administration trial, a Roche-sponsored phase III study that compared two doses of intravenous ibandronate (2 mg every 2 months and 3 mg every 3 months) with the approved oral dosing schedule (2.5 mg daily). The study group included 1,400 postmenopausal women with low bone mass (T-scores of −3.3 for total spine and −2 for hip).

After 2 years, BMD at the lumbar spine increased significantly more in both intravenous groups than in the oral group (mean increase 6.4% for the 2-mg IV dose, 6.3% for the 3-mg IV dose, and 4.8% for the oral dose). BMD increased similarly at all sites measured, said Dr. Zaidi, director of the Mount Sinai Bone Program, Mount Sinai School of Medicine, New York.

At 2 years, the incidence of adverse events was similar across all groups. Flulike illnesses and gastrointestinal intolerance were seen primarily in the first year, with only slight increases in cumulative numbers during the second year.

Intravenous ibandronate would be especially useful in patients with contraindications to oral therapy or clinical or biochemical evidence of noncompliance, Dr. Zaidi said. “I would use this in patients who are intolerant to the oral form or who have problems like a bleeding ulcer, stricture, or dysmotility. It would also be useful for those who can't sit upright, such as bedridden nursing home patients.” The intermittent dosing would also be “a great way” to ensure compliance, he added.

BOSTON — Intermittent intravenous ibandronate is at least as effective as daily oral ibandronate for increasing bone mineral density and may be preferable to oral dosing in patients with esophageal disease or compliance problems.

There are no fracture data for the intravenous dosing schedule, but the risk reduction that has been shown with oral ibandronate can probably be extrapolated to the intravenous form of the drug, Dr. Mone Zaidi said at the annual meeting of the Endocrine Society.

Oral ibandronate has been shown to reduce the risk of new vertebral fractures by up to 60% (Curr. Med. Res. Opin. 2005;21:391–401; J. Bone Miner. Res. 2004;19:1241–9).

He presented 2-year bone mineral density (BMD) data from the ibandronate Dosing Intravenous Administration trial, a Roche-sponsored phase III study that compared two doses of intravenous ibandronate (2 mg every 2 months and 3 mg every 3 months) with the approved oral dosing schedule (2.5 mg daily). The study group included 1,400 postmenopausal women with low bone mass (T-scores of −3.3 for total spine and −2 for hip).

After 2 years, BMD at the lumbar spine increased significantly more in both intravenous groups than in the oral group (mean increase 6.4% for the 2-mg IV dose, 6.3% for the 3-mg IV dose, and 4.8% for the oral dose). BMD increased similarly at all sites measured, said Dr. Zaidi, director of the Mount Sinai Bone Program, Mount Sinai School of Medicine, New York.

At 2 years, the incidence of adverse events was similar across all groups. Flulike illnesses and gastrointestinal intolerance were seen primarily in the first year, with only slight increases in cumulative numbers during the second year.

Intravenous ibandronate would be especially useful in patients with contraindications to oral therapy or clinical or biochemical evidence of noncompliance, Dr. Zaidi said. “I would use this in patients who are intolerant to the oral form or who have problems like a bleeding ulcer, stricture, or dysmotility. It would also be useful for those who can't sit upright, such as bedridden nursing home patients.” The intermittent dosing would also be “a great way” to ensure compliance, he added.

DESTIN, FLA. — Patients with rheumatic disease and osteoporosis or low-impact fracture might benefit from early sequential therapy with anabolic and antiresorptive drugs to build and maintain bone, Dr. Nancy Lane reported at a rheumatology meeting sponsored by Virginia Commonwealth University.

“Although the exact treatment recommendation is still unclear, you could use parathyroid hormone for a year or two to change the bone architecture in a positive way and then maintain those gains with an antiresorptive agent—either a bisphosphonate or a selective estrogen receptor modulator,” Dr. Lane said.

The continuous inflammation of diseases like systemic lupus erythematosus and rheumatoid arthritis appears to adversely affect bone health by increasing bone resorption and decreasing formation. Even premenopausal patients with relatively normal bone density are at high risk for skeletal problems, said Dr. Lane, director, the Center for Healthy Aging at the University of California, Davis.

In a study of vertebral fractures in 70 patients with systemic lupus erythematosus who were compared with 22 matched healthy controls, no bone mineral density differences were found between the two groups. However, 21% of the lupus group had at least one thoracic or lumbar spine fracture, compared with no subjects in the control group. The study included premenopausal women with a mean age of 31.5 years (Lupus 2005;14:529–33).

The first step is to address the problem of systemic inflammation, Dr. Lane said. But it's also critical to be aggressive in identifying and treating those who are at risk for fracture. Glucocorticoid therapy can also induce osteoporotic changes. Initiating therapy early is important, Dr Lane said at the meeting, also sponsored by the International Society for Clinical Densitometry and the Alabama Chapter of the Arthritis Foundation.

DESTIN, FLA. — Patients with rheumatic disease and osteoporosis or low-impact fracture might benefit from early sequential therapy with anabolic and antiresorptive drugs to build and maintain bone, Dr. Nancy Lane reported at a rheumatology meeting sponsored by Virginia Commonwealth University.

“Although the exact treatment recommendation is still unclear, you could use parathyroid hormone for a year or two to change the bone architecture in a positive way and then maintain those gains with an antiresorptive agent—either a bisphosphonate or a selective estrogen receptor modulator,” Dr. Lane said.

The continuous inflammation of diseases like systemic lupus erythematosus and rheumatoid arthritis appears to adversely affect bone health by increasing bone resorption and decreasing formation. Even premenopausal patients with relatively normal bone density are at high risk for skeletal problems, said Dr. Lane, director, the Center for Healthy Aging at the University of California, Davis.

In a study of vertebral fractures in 70 patients with systemic lupus erythematosus who were compared with 22 matched healthy controls, no bone mineral density differences were found between the two groups. However, 21% of the lupus group had at least one thoracic or lumbar spine fracture, compared with no subjects in the control group. The study included premenopausal women with a mean age of 31.5 years (Lupus 2005;14:529–33).

The first step is to address the problem of systemic inflammation, Dr. Lane said. But it's also critical to be aggressive in identifying and treating those who are at risk for fracture. Glucocorticoid therapy can also induce osteoporotic changes. Initiating therapy early is important, Dr Lane said at the meeting, also sponsored by the International Society for Clinical Densitometry and the Alabama Chapter of the Arthritis Foundation.

DESTIN, FLA. — Patients with rheumatic disease and osteoporosis or low-impact fracture might benefit from early sequential therapy with anabolic and antiresorptive drugs to build and maintain bone, Dr. Nancy Lane reported at a rheumatology meeting sponsored by Virginia Commonwealth University.

“Although the exact treatment recommendation is still unclear, you could use parathyroid hormone for a year or two to change the bone architecture in a positive way and then maintain those gains with an antiresorptive agent—either a bisphosphonate or a selective estrogen receptor modulator,” Dr. Lane said.

The continuous inflammation of diseases like systemic lupus erythematosus and rheumatoid arthritis appears to adversely affect bone health by increasing bone resorption and decreasing formation. Even premenopausal patients with relatively normal bone density are at high risk for skeletal problems, said Dr. Lane, director, the Center for Healthy Aging at the University of California, Davis.

In a study of vertebral fractures in 70 patients with systemic lupus erythematosus who were compared with 22 matched healthy controls, no bone mineral density differences were found between the two groups. However, 21% of the lupus group had at least one thoracic or lumbar spine fracture, compared with no subjects in the control group. The study included premenopausal women with a mean age of 31.5 years (Lupus 2005;14:529–33).

The first step is to address the problem of systemic inflammation, Dr. Lane said. But it's also critical to be aggressive in identifying and treating those who are at risk for fracture. Glucocorticoid therapy can also induce osteoporotic changes. Initiating therapy early is important, Dr Lane said at the meeting, also sponsored by the International Society for Clinical Densitometry and the Alabama Chapter of the Arthritis Foundation.

SAN FRANCISCO — The first state effort to address childhood obesity through changes in public schools has met with some success, according to researchers who spoke at the annual meeting of the Society of Behavioral Medicine.

Arkansas Act 1220 passed into law in 2003, said James Raczynski, Ph.D. The product of a “remarkable confluence of political, private, and institutional support,” the law requires schools to monitor every student's weight annually, remove vending machines from elementary schools, and disclose all vending contracts. It also mandates the creation of state and local advisory committees to examine nutrition and physical activity programs in schools and to advise legislators on future childhood health policies.

Concerns about the number of obese and overweight children in Arkansas spurred legislators, physicians, and communities to work together on the law, said Dr. Raczynski of the University of Arkansas, Little Rock: 36% of children in the state are either overweight or at risk for being overweight.

Initially, he said, public support for every aspect of the legislation was very high. Concerns arose during the first year, however. “The biggest issue was parental worry about the annual body mass index [BMI] measurement,” he said. “Parents feared that having their child identified as overweight or at risk would stigmatize the child.”

Although spearheaded by a small group of vocal parents, the debate became heated and garnered lots of publicity, he said.

Physicians also expressed concern. The law requires schools to send home letters about the annual BMI measurement; parents whose children were identified as overweight or at risk are advised to take the letter and the child to a physician. “We heard from some physicians that they were concerned they'd be overwhelmed with visits from worried parents,” Dr. Raczynski said.

He and his colleagues presented information from a 1-year evaluation of the law, which included interviews with parents, children, and physicians and visits to schools. Baseline data from spring 2004—when the law went into effect—were compared with data collected during 2005.

The annual BMI measurements appear to be having a positive impact on parents, said Delia West, Ph.D. After the school BMI screening, parents were significantly better at accurately identifying whether their child was overweight, said Dr. West of the University of Arkansas.

The baseline survey asked parents of children in kindergarten through grade 10 to assess their child's weight status. The follow-up survey asked the same after the child had brought an annual BMI report from school. Before the BMI screen, only 40% of parents accurately identified their child as overweight or at risk of becoming overweight. After the screen, that number increased to 50%.

Black parents and parents of children younger than 12 years were most likely to improve. Before the screen, only 35% of parents with young overweight children correctly identified their weight status. After the screen, that number rose to 65%. Black parents also improved their identification of overweight children, increasing from 30% correct before the BMI screen to 44% correct after the screen.

The change is important because family identification of weight problems can be the foundation of behavior change, Dr. West said. “Parents who identify their child as overweight may be more likely to institute or support appropriate health behaviors.”

The parental concern of an increase in stigmatization of overweight children was not an issue, said Nadia Siddiqui of the University of Arkansas. Data from the baseline and 1-year follow-up surveys found no increase in weight-based teasing among any age group after the annual BMI measurement was instituted.

Physicians' concerns about being overwhelmed with unnecessarily worried parents were unfounded as well, said Jada Walker, also of the university. More than half of the 481 physicians surveyed (57%) reported that at least one family had brought in a BMI report to discuss. “They were not as overwhelmed as some had feared, and they also reported being very supportive of the legislation,” Ms. Walker said.

However, added Dr. Raczynski, it is somewhat worrisome that only 57% of physicians had dealt with a BMI concern prompted by the act. “We'd like to see more letters going to physicians.”

SAN FRANCISCO — The first state effort to address childhood obesity through changes in public schools has met with some success, according to researchers who spoke at the annual meeting of the Society of Behavioral Medicine.

Arkansas Act 1220 passed into law in 2003, said James Raczynski, Ph.D. The product of a “remarkable confluence of political, private, and institutional support,” the law requires schools to monitor every student's weight annually, remove vending machines from elementary schools, and disclose all vending contracts. It also mandates the creation of state and local advisory committees to examine nutrition and physical activity programs in schools and to advise legislators on future childhood health policies.

Concerns about the number of obese and overweight children in Arkansas spurred legislators, physicians, and communities to work together on the law, said Dr. Raczynski of the University of Arkansas, Little Rock: 36% of children in the state are either overweight or at risk for being overweight.

Initially, he said, public support for every aspect of the legislation was very high. Concerns arose during the first year, however. “The biggest issue was parental worry about the annual body mass index [BMI] measurement,” he said. “Parents feared that having their child identified as overweight or at risk would stigmatize the child.”

Although spearheaded by a small group of vocal parents, the debate became heated and garnered lots of publicity, he said.

Physicians also expressed concern. The law requires schools to send home letters about the annual BMI measurement; parents whose children were identified as overweight or at risk are advised to take the letter and the child to a physician. “We heard from some physicians that they were concerned they'd be overwhelmed with visits from worried parents,” Dr. Raczynski said.

He and his colleagues presented information from a 1-year evaluation of the law, which included interviews with parents, children, and physicians and visits to schools. Baseline data from spring 2004—when the law went into effect—were compared with data collected during 2005.

The annual BMI measurements appear to be having a positive impact on parents, said Delia West, Ph.D. After the school BMI screening, parents were significantly better at accurately identifying whether their child was overweight, said Dr. West of the University of Arkansas.

The baseline survey asked parents of children in kindergarten through grade 10 to assess their child's weight status. The follow-up survey asked the same after the child had brought an annual BMI report from school. Before the BMI screen, only 40% of parents accurately identified their child as overweight or at risk of becoming overweight. After the screen, that number increased to 50%.

Black parents and parents of children younger than 12 years were most likely to improve. Before the screen, only 35% of parents with young overweight children correctly identified their weight status. After the screen, that number rose to 65%. Black parents also improved their identification of overweight children, increasing from 30% correct before the BMI screen to 44% correct after the screen.

The change is important because family identification of weight problems can be the foundation of behavior change, Dr. West said. “Parents who identify their child as overweight may be more likely to institute or support appropriate health behaviors.”

The parental concern of an increase in stigmatization of overweight children was not an issue, said Nadia Siddiqui of the University of Arkansas. Data from the baseline and 1-year follow-up surveys found no increase in weight-based teasing among any age group after the annual BMI measurement was instituted.

Physicians' concerns about being overwhelmed with unnecessarily worried parents were unfounded as well, said Jada Walker, also of the university. More than half of the 481 physicians surveyed (57%) reported that at least one family had brought in a BMI report to discuss. “They were not as overwhelmed as some had feared, and they also reported being very supportive of the legislation,” Ms. Walker said.

However, added Dr. Raczynski, it is somewhat worrisome that only 57% of physicians had dealt with a BMI concern prompted by the act. “We'd like to see more letters going to physicians.”

SAN FRANCISCO — The first state effort to address childhood obesity through changes in public schools has met with some success, according to researchers who spoke at the annual meeting of the Society of Behavioral Medicine.

Arkansas Act 1220 passed into law in 2003, said James Raczynski, Ph.D. The product of a “remarkable confluence of political, private, and institutional support,” the law requires schools to monitor every student's weight annually, remove vending machines from elementary schools, and disclose all vending contracts. It also mandates the creation of state and local advisory committees to examine nutrition and physical activity programs in schools and to advise legislators on future childhood health policies.

Concerns about the number of obese and overweight children in Arkansas spurred legislators, physicians, and communities to work together on the law, said Dr. Raczynski of the University of Arkansas, Little Rock: 36% of children in the state are either overweight or at risk for being overweight.

Initially, he said, public support for every aspect of the legislation was very high. Concerns arose during the first year, however. “The biggest issue was parental worry about the annual body mass index [BMI] measurement,” he said. “Parents feared that having their child identified as overweight or at risk would stigmatize the child.”

Although spearheaded by a small group of vocal parents, the debate became heated and garnered lots of publicity, he said.

Physicians also expressed concern. The law requires schools to send home letters about the annual BMI measurement; parents whose children were identified as overweight or at risk are advised to take the letter and the child to a physician. “We heard from some physicians that they were concerned they'd be overwhelmed with visits from worried parents,” Dr. Raczynski said.

He and his colleagues presented information from a 1-year evaluation of the law, which included interviews with parents, children, and physicians and visits to schools. Baseline data from spring 2004—when the law went into effect—were compared with data collected during 2005.

The annual BMI measurements appear to be having a positive impact on parents, said Delia West, Ph.D. After the school BMI screening, parents were significantly better at accurately identifying whether their child was overweight, said Dr. West of the University of Arkansas.

The baseline survey asked parents of children in kindergarten through grade 10 to assess their child's weight status. The follow-up survey asked the same after the child had brought an annual BMI report from school. Before the BMI screen, only 40% of parents accurately identified their child as overweight or at risk of becoming overweight. After the screen, that number increased to 50%.

Black parents and parents of children younger than 12 years were most likely to improve. Before the screen, only 35% of parents with young overweight children correctly identified their weight status. After the screen, that number rose to 65%. Black parents also improved their identification of overweight children, increasing from 30% correct before the BMI screen to 44% correct after the screen.

The change is important because family identification of weight problems can be the foundation of behavior change, Dr. West said. “Parents who identify their child as overweight may be more likely to institute or support appropriate health behaviors.”

The parental concern of an increase in stigmatization of overweight children was not an issue, said Nadia Siddiqui of the University of Arkansas. Data from the baseline and 1-year follow-up surveys found no increase in weight-based teasing among any age group after the annual BMI measurement was instituted.

Physicians' concerns about being overwhelmed with unnecessarily worried parents were unfounded as well, said Jada Walker, also of the university. More than half of the 481 physicians surveyed (57%) reported that at least one family had brought in a BMI report to discuss. “They were not as overwhelmed as some had feared, and they also reported being very supportive of the legislation,” Ms. Walker said.

However, added Dr. Raczynski, it is somewhat worrisome that only 57% of physicians had dealt with a BMI concern prompted by the act. “We'd like to see more letters going to physicians.”

HILTON HEAD ISLAND, S.C. — Interval appendectomy may be unnecessary after a bout of medically managed appendicitis in children, Dr. Devin Puapong said at the annual meeting of the American Pediatric Surgical Association.

Surgeons often cite a high risk of recurrence as the primary reason for an elective interval appendectomy. But according to Dr. Puapong of the Kasier Permanente Los Angeles Medical Center, “Recurrence of appendicitis after initial nonoperative treatment is very uncommon and not associated with any major complications. We feel [interval appendectomy] may not be necessary.”

Dr. Puapong conducted a retrospective study of Kaiser's medical records database, which included 6,446 children treated for appendicitis from 1992 to 2002.

Of those, only 72 were initially managed with medical therapy; 11 went on to have an interval appendectomy, and the other 61 were observed. The length of stay in the observed patients was significantly longer (15 days vs. 7 days).

Over a mean follow-up of 7.5 years, there were only five recurrences of appendicitis (a rate of 8%). All recurrences occurred within 1 year and most were within 2–3 months, Dr. Puapong said.

Four of the recurrences were in patients who presented with an initial abscess, but because of the small number, the association was not statistically significant. Nor were age, gender, type of initial appendicitis, and drainage of initial abscess significantly associated with recurrence. No major complications were observed in any of the patients with recurrence, although two were found to have a prolonged ileum.

HILTON HEAD ISLAND, S.C. — Interval appendectomy may be unnecessary after a bout of medically managed appendicitis in children, Dr. Devin Puapong said at the annual meeting of the American Pediatric Surgical Association.

Surgeons often cite a high risk of recurrence as the primary reason for an elective interval appendectomy. But according to Dr. Puapong of the Kasier Permanente Los Angeles Medical Center, “Recurrence of appendicitis after initial nonoperative treatment is very uncommon and not associated with any major complications. We feel [interval appendectomy] may not be necessary.”

Dr. Puapong conducted a retrospective study of Kaiser's medical records database, which included 6,446 children treated for appendicitis from 1992 to 2002.

Of those, only 72 were initially managed with medical therapy; 11 went on to have an interval appendectomy, and the other 61 were observed. The length of stay in the observed patients was significantly longer (15 days vs. 7 days).

Over a mean follow-up of 7.5 years, there were only five recurrences of appendicitis (a rate of 8%). All recurrences occurred within 1 year and most were within 2–3 months, Dr. Puapong said.

Four of the recurrences were in patients who presented with an initial abscess, but because of the small number, the association was not statistically significant. Nor were age, gender, type of initial appendicitis, and drainage of initial abscess significantly associated with recurrence. No major complications were observed in any of the patients with recurrence, although two were found to have a prolonged ileum.

HILTON HEAD ISLAND, S.C. — Interval appendectomy may be unnecessary after a bout of medically managed appendicitis in children, Dr. Devin Puapong said at the annual meeting of the American Pediatric Surgical Association.

Surgeons often cite a high risk of recurrence as the primary reason for an elective interval appendectomy. But according to Dr. Puapong of the Kasier Permanente Los Angeles Medical Center, “Recurrence of appendicitis after initial nonoperative treatment is very uncommon and not associated with any major complications. We feel [interval appendectomy] may not be necessary.”

Dr. Puapong conducted a retrospective study of Kaiser's medical records database, which included 6,446 children treated for appendicitis from 1992 to 2002.

Of those, only 72 were initially managed with medical therapy; 11 went on to have an interval appendectomy, and the other 61 were observed. The length of stay in the observed patients was significantly longer (15 days vs. 7 days).

Over a mean follow-up of 7.5 years, there were only five recurrences of appendicitis (a rate of 8%). All recurrences occurred within 1 year and most were within 2–3 months, Dr. Puapong said.

Four of the recurrences were in patients who presented with an initial abscess, but because of the small number, the association was not statistically significant. Nor were age, gender, type of initial appendicitis, and drainage of initial abscess significantly associated with recurrence. No major complications were observed in any of the patients with recurrence, although two were found to have a prolonged ileum.

SAN FRANCISCO — A behavioral medicine program of play combined with stress reduction and management techniques significantly reduced symptoms of posttraumatic stress disorder in a group of children whose community had been decimated by two consecutive hurricanes.

Play is a natural healing force for children, Carmen Russoniello, Ph.D., said at the annual meeting of the Society of Behavioral Medicine. “We believed that since recreation is inherently healing, we could perhaps meld it into a structured program that would help these kids learn to cope with what had happened to their school and community.”

In 1999, two consecutive hurricanes flooded eastern North Carolina, destroying homes and schools; 51 people died. Dr. Russoniello, director of the psychophysiology and biofeedback lab at East Carolina University, Greenville, N.C., created the program in response to pleas from school administrators in one of the flood-devastated communities. Their elementary school was destroyed; all the students were relocated to trailer classrooms near the federal disaster management site.

“These children had lost their school, and almost 40% had their homes flooded,” he said. Many of the children watched helicopters flying in and out of the community rescuing their families and feared that they would die. “They had experienced a terrifying event,” he said. It was a perfect opportunity not only to try and help the children cope with their experience but also to study posttraumatic stress disorder (PTSD) in children—an area that has received little attention.

“Until rather recently, we thought PTSD didn't occur in children,” he said. “We now know that it does and that the symptoms can have devastating effects on their health and performance, including depression and anxiety, and school and social problems.”

The intervention began with a baseline assessment of PTSD symptoms in the school's fourth-graders, 6 months after the hurricanes hit, said Susan McGhee, Ph.D., also of East Carolina University. In the group of 150 children (mean age 9.5 years), PTSD (as measured by the Posttraumatic Stress Reaction Index, child version) was very severe in 9%, severe in 25%, and moderate in 36%.

Another one-quarter had mild symptoms, while the diagnosis was doubtful in about 5%. All of the children reported symptoms of reexperiencing; 85% reported symptoms of hyperarousal; and 64% reported symptoms of numbing/avoidance. Symptoms were worse in girls and in children whose homes had been flooded.

The intervention consisted of five weekly hour-long sessions. Each session opened with a recreational activity, which was followed by a 20-minute learning session that focused on stress reduction or management, including overview of childhood stress, positive thinking, deep breathing and relaxation, stress-reduction activities, and emotional regulation. Each session closed with more play, during which children were encouraged to use the techniques they had just learned.

Postintervention assessment showed a significant decline in PTSD symptoms. Only 3% had very severe symptoms, while symptoms were severe in 22%, moderate in 30%, mild in 28%, and doubtful in 15%. There were significant reductions in reexperiencing and numbing/avoidance, but hyperarousal symptoms were resistant, especially in boys.

The program also affected the children's coping mechanisms, as measured by the KidCope checklist. Children reported less blaming of themselves, less withdrawal into television watching, less anger and lashing out, and being less likely to try and fix the problem.

Dr. Russoniello and Dr. McGhee designed the behavioral intervention, but it was delivered at the school by students of the university's recreational therapy program. Using college students had unexpected benefits, Dr. Russoniello said. “The children bonded with them instantly, perhaps because they were closer in age or because they could see the possibility of their own future success in them.”

The students also gained experience and proved their worth in times of emergency. “When we are responding to large-scale disasters, there aren't enough professionals to go around,” he said. “This study showed us that trained college students might be able to fill some of these gaps.”

SAN FRANCISCO — A behavioral medicine program of play combined with stress reduction and management techniques significantly reduced symptoms of posttraumatic stress disorder in a group of children whose community had been decimated by two consecutive hurricanes.

Play is a natural healing force for children, Carmen Russoniello, Ph.D., said at the annual meeting of the Society of Behavioral Medicine. “We believed that since recreation is inherently healing, we could perhaps meld it into a structured program that would help these kids learn to cope with what had happened to their school and community.”

In 1999, two consecutive hurricanes flooded eastern North Carolina, destroying homes and schools; 51 people died. Dr. Russoniello, director of the psychophysiology and biofeedback lab at East Carolina University, Greenville, N.C., created the program in response to pleas from school administrators in one of the flood-devastated communities. Their elementary school was destroyed; all the students were relocated to trailer classrooms near the federal disaster management site.

“These children had lost their school, and almost 40% had their homes flooded,” he said. Many of the children watched helicopters flying in and out of the community rescuing their families and feared that they would die. “They had experienced a terrifying event,” he said. It was a perfect opportunity not only to try and help the children cope with their experience but also to study posttraumatic stress disorder (PTSD) in children—an area that has received little attention.

“Until rather recently, we thought PTSD didn't occur in children,” he said. “We now know that it does and that the symptoms can have devastating effects on their health and performance, including depression and anxiety, and school and social problems.”

The intervention began with a baseline assessment of PTSD symptoms in the school's fourth-graders, 6 months after the hurricanes hit, said Susan McGhee, Ph.D., also of East Carolina University. In the group of 150 children (mean age 9.5 years), PTSD (as measured by the Posttraumatic Stress Reaction Index, child version) was very severe in 9%, severe in 25%, and moderate in 36%.

Another one-quarter had mild symptoms, while the diagnosis was doubtful in about 5%. All of the children reported symptoms of reexperiencing; 85% reported symptoms of hyperarousal; and 64% reported symptoms of numbing/avoidance. Symptoms were worse in girls and in children whose homes had been flooded.

The intervention consisted of five weekly hour-long sessions. Each session opened with a recreational activity, which was followed by a 20-minute learning session that focused on stress reduction or management, including overview of childhood stress, positive thinking, deep breathing and relaxation, stress-reduction activities, and emotional regulation. Each session closed with more play, during which children were encouraged to use the techniques they had just learned.

Postintervention assessment showed a significant decline in PTSD symptoms. Only 3% had very severe symptoms, while symptoms were severe in 22%, moderate in 30%, mild in 28%, and doubtful in 15%. There were significant reductions in reexperiencing and numbing/avoidance, but hyperarousal symptoms were resistant, especially in boys.

The program also affected the children's coping mechanisms, as measured by the KidCope checklist. Children reported less blaming of themselves, less withdrawal into television watching, less anger and lashing out, and being less likely to try and fix the problem.

Dr. Russoniello and Dr. McGhee designed the behavioral intervention, but it was delivered at the school by students of the university's recreational therapy program. Using college students had unexpected benefits, Dr. Russoniello said. “The children bonded with them instantly, perhaps because they were closer in age or because they could see the possibility of their own future success in them.”

The students also gained experience and proved their worth in times of emergency. “When we are responding to large-scale disasters, there aren't enough professionals to go around,” he said. “This study showed us that trained college students might be able to fill some of these gaps.”

SAN FRANCISCO — A behavioral medicine program of play combined with stress reduction and management techniques significantly reduced symptoms of posttraumatic stress disorder in a group of children whose community had been decimated by two consecutive hurricanes.

Play is a natural healing force for children, Carmen Russoniello, Ph.D., said at the annual meeting of the Society of Behavioral Medicine. “We believed that since recreation is inherently healing, we could perhaps meld it into a structured program that would help these kids learn to cope with what had happened to their school and community.”

In 1999, two consecutive hurricanes flooded eastern North Carolina, destroying homes and schools; 51 people died. Dr. Russoniello, director of the psychophysiology and biofeedback lab at East Carolina University, Greenville, N.C., created the program in response to pleas from school administrators in one of the flood-devastated communities. Their elementary school was destroyed; all the students were relocated to trailer classrooms near the federal disaster management site.

“These children had lost their school, and almost 40% had their homes flooded,” he said. Many of the children watched helicopters flying in and out of the community rescuing their families and feared that they would die. “They had experienced a terrifying event,” he said. It was a perfect opportunity not only to try and help the children cope with their experience but also to study posttraumatic stress disorder (PTSD) in children—an area that has received little attention.

“Until rather recently, we thought PTSD didn't occur in children,” he said. “We now know that it does and that the symptoms can have devastating effects on their health and performance, including depression and anxiety, and school and social problems.”

The intervention began with a baseline assessment of PTSD symptoms in the school's fourth-graders, 6 months after the hurricanes hit, said Susan McGhee, Ph.D., also of East Carolina University. In the group of 150 children (mean age 9.5 years), PTSD (as measured by the Posttraumatic Stress Reaction Index, child version) was very severe in 9%, severe in 25%, and moderate in 36%.

Another one-quarter had mild symptoms, while the diagnosis was doubtful in about 5%. All of the children reported symptoms of reexperiencing; 85% reported symptoms of hyperarousal; and 64% reported symptoms of numbing/avoidance. Symptoms were worse in girls and in children whose homes had been flooded.

The intervention consisted of five weekly hour-long sessions. Each session opened with a recreational activity, which was followed by a 20-minute learning session that focused on stress reduction or management, including overview of childhood stress, positive thinking, deep breathing and relaxation, stress-reduction activities, and emotional regulation. Each session closed with more play, during which children were encouraged to use the techniques they had just learned.

Postintervention assessment showed a significant decline in PTSD symptoms. Only 3% had very severe symptoms, while symptoms were severe in 22%, moderate in 30%, mild in 28%, and doubtful in 15%. There were significant reductions in reexperiencing and numbing/avoidance, but hyperarousal symptoms were resistant, especially in boys.

The program also affected the children's coping mechanisms, as measured by the KidCope checklist. Children reported less blaming of themselves, less withdrawal into television watching, less anger and lashing out, and being less likely to try and fix the problem.

Dr. Russoniello and Dr. McGhee designed the behavioral intervention, but it was delivered at the school by students of the university's recreational therapy program. Using college students had unexpected benefits, Dr. Russoniello said. “The children bonded with them instantly, perhaps because they were closer in age or because they could see the possibility of their own future success in them.”

The students also gained experience and proved their worth in times of emergency. “When we are responding to large-scale disasters, there aren't enough professionals to go around,” he said. “This study showed us that trained college students might be able to fill some of these gaps.”

DESTIN, FLA. — A lack of increase in bone mineral density does not necessarily indicate a failure of antiresorptive therapy for osteoporosis, and is not a reason to switch a patient's drugs, Dr. Michael McClung said at a rheumatology meeting sponsored by the Virginia Commonwealth University.

A sizeable proportion of patients on antiresorptive therapy do not have an increase in their bone mineral density (BMD), and some actually experience a decrease, he said. “Patients need to be told up front that these are not bone density-building drugs—they are designed to prevent bone loss and preserve what is there.”

Nor do changes in bone density completely predict future fracture risk, according to a study cited by Dr. McClung, director of the Oregon Osteoporosis Center, Portland. Osteoporosis treatments increase BMD and reduce fracture risk, but even those women with no increase in density experience protection from fracture. “This suggests that most of the reduction in fracture risk is due to something else besides increasing bone density,” he said.

Markers of bone turnover are also an imperfect way to predict future fracture risk, Dr. McClung said. Patients who respond usually have quick and observable changes in their markers, but attempting to use markers to monitor treatment response in individual patients is difficult because of the imprecision of current assays.

Nonresponse can only be identified by deterioration of skeletal health while on treatment. This deterioration is usually defined as a true decrease in BMD, but in clinical trials, it's very uncommon. With estrogen or alendronate, nonresponse occurs in less than 3% of patients. In clinical practice however, bone loss may be more common (8%–10%) due to noncompliance, poor bioavailability, and other medical issues that affect bone health.

“Don't overinterpret any changes, or lack of changes, you see when you monitor patients,” said Dr. McClung. “The main reason to follow BMD after starting therapy is to identify those patients who continue to lose bone mass. Seeing no change or even a decrease in bone density is a signal to review dosing and compliance, and to take another look at any other medical circumstances that could be affecting bone health.”

It is not even possible to monitor treatment response with some agents, like calcitonin, which have very small effects on BMD or markers, Dr. McClung said.

DESTIN, FLA. — A lack of increase in bone mineral density does not necessarily indicate a failure of antiresorptive therapy for osteoporosis, and is not a reason to switch a patient's drugs, Dr. Michael McClung said at a rheumatology meeting sponsored by the Virginia Commonwealth University.

A sizeable proportion of patients on antiresorptive therapy do not have an increase in their bone mineral density (BMD), and some actually experience a decrease, he said. “Patients need to be told up front that these are not bone density-building drugs—they are designed to prevent bone loss and preserve what is there.”

Nor do changes in bone density completely predict future fracture risk, according to a study cited by Dr. McClung, director of the Oregon Osteoporosis Center, Portland. Osteoporosis treatments increase BMD and reduce fracture risk, but even those women with no increase in density experience protection from fracture. “This suggests that most of the reduction in fracture risk is due to something else besides increasing bone density,” he said.

Markers of bone turnover are also an imperfect way to predict future fracture risk, Dr. McClung said. Patients who respond usually have quick and observable changes in their markers, but attempting to use markers to monitor treatment response in individual patients is difficult because of the imprecision of current assays.

Nonresponse can only be identified by deterioration of skeletal health while on treatment. This deterioration is usually defined as a true decrease in BMD, but in clinical trials, it's very uncommon. With estrogen or alendronate, nonresponse occurs in less than 3% of patients. In clinical practice however, bone loss may be more common (8%–10%) due to noncompliance, poor bioavailability, and other medical issues that affect bone health.

“Don't overinterpret any changes, or lack of changes, you see when you monitor patients,” said Dr. McClung. “The main reason to follow BMD after starting therapy is to identify those patients who continue to lose bone mass. Seeing no change or even a decrease in bone density is a signal to review dosing and compliance, and to take another look at any other medical circumstances that could be affecting bone health.”

It is not even possible to monitor treatment response with some agents, like calcitonin, which have very small effects on BMD or markers, Dr. McClung said.

DESTIN, FLA. — A lack of increase in bone mineral density does not necessarily indicate a failure of antiresorptive therapy for osteoporosis, and is not a reason to switch a patient's drugs, Dr. Michael McClung said at a rheumatology meeting sponsored by the Virginia Commonwealth University.

A sizeable proportion of patients on antiresorptive therapy do not have an increase in their bone mineral density (BMD), and some actually experience a decrease, he said. “Patients need to be told up front that these are not bone density-building drugs—they are designed to prevent bone loss and preserve what is there.”

Nor do changes in bone density completely predict future fracture risk, according to a study cited by Dr. McClung, director of the Oregon Osteoporosis Center, Portland. Osteoporosis treatments increase BMD and reduce fracture risk, but even those women with no increase in density experience protection from fracture. “This suggests that most of the reduction in fracture risk is due to something else besides increasing bone density,” he said.

Markers of bone turnover are also an imperfect way to predict future fracture risk, Dr. McClung said. Patients who respond usually have quick and observable changes in their markers, but attempting to use markers to monitor treatment response in individual patients is difficult because of the imprecision of current assays.

Nonresponse can only be identified by deterioration of skeletal health while on treatment. This deterioration is usually defined as a true decrease in BMD, but in clinical trials, it's very uncommon. With estrogen or alendronate, nonresponse occurs in less than 3% of patients. In clinical practice however, bone loss may be more common (8%–10%) due to noncompliance, poor bioavailability, and other medical issues that affect bone health.

“Don't overinterpret any changes, or lack of changes, you see when you monitor patients,” said Dr. McClung. “The main reason to follow BMD after starting therapy is to identify those patients who continue to lose bone mass. Seeing no change or even a decrease in bone density is a signal to review dosing and compliance, and to take another look at any other medical circumstances that could be affecting bone health.”

It is not even possible to monitor treatment response with some agents, like calcitonin, which have very small effects on BMD or markers, Dr. McClung said.