Sherry Boschert

Adolescents with dyslipidemia—especially those who were overweight or obese—were more likely than were adolescents with normal lipid levels to have increased carotid artery intima-media thickness by young adulthood, a study of 1,711 people found.

The study also found the single set of cut points used to identify adolescent dyslipidemia in the National Cholesterol Education Program (NCEP) guidelines worked as well as age- and sex-specific cut points derived from growth curve data in three National Health and Nutrition Examination Surveys (NHANES) to predict increased carotid intima-media thickness in young adulthood (J. Am. Coll. Cardiol. 2009;53:860-9 [doi:10.1016/j.jacc.2008.09.061]). This argues in favor of using the simpler, fixed NCEP approach rather than the percentile-based NHANES approach, reported Costan G. Magnussen of the University of Tasmania (Australia).

Mr. Magnussen and his associates analyzed data from three large population-based, prospective cohort studies: the Finnish Cardiovascular Risk in Young Finns Study, the U.S.-based Bogalusa Heart Study, and the Australian Childhood Determination of Adult Health Study. Lipid and lipoprotein levels were measured in adolescents between the ages of 12 and 18 years and again when they were between the ages of 29 and 30 years, at which time they also had an ultrasound to measure carotid intima-media thickness, a surrogate for the risk of developing atherosclerotic cardiovascular disease.

In a previous analysis of this same data set, Mr. Magnussen and his associates found that adolescents with borderline or high-risk dyslipidemia were significantly more likely than were those with normal lipid levels to have dyslipidemia as adults after a mean follow-up of 20 years (Circulation 2008;117:32-42).

In the current study, adolescent dyslipidemia increased the relative risk for high intima-media thickness in adulthood by 60%-250%, and the higher risk was seen regardless of adult lipid and lipoprotein levels.

Adult carotid intima-media thickness was substantially higher in those who had been overweight or obese adolescents with dyslipidemia. The investigators estimated that overweight or obese 15-year-olds with dyslipidemia would show a difference in intima-media thickness of 0.11 mm in males or 0.08 mm in females by age 35 years, compared with normal-weight 15-year-olds with normal cholesterol levels.

The end point of increased intima-media thickness in young adulthood provides “a more solid end point than we've had before,” said Dr. Roberta Williams, who was not involved in the study.

“Something structurally will happen. If you are both overweight/obese and have abnormal lipid levels, it is highly likely that you are headedfor having real changesin your vascular bed as an adult,” said Dr. Williams, chair of pediatrics at the University of Southern California, Los Angeles. She said she has no conflicts of interest related to this topic.

The positive predictive value of adolescent dyslipidemia was low (ranging from 11% to 37% depending on weight and type of dyslipidemia), a fact that may be explained in part by normal fluctuations during adolescence in levels of lipoproteins, which are “building blocks”' for some hormones, she said. As a result, it's hard to tell which adolescents with dyslipidemia will go on to have increased intima-media thickness.

But the study found a high negative predictive value (ranging from 81% to 90%), meaning that adolescents without dyslipidemia are unlikely to develop cardiovascular disease as young adults. “This does not mean that they should go out and have a double cheeseburger,” she said.

In an editorial commenting on the study, Dr. Stephen R. Daniels noted that the findings do not settle the question of whether all adolescents or targeted populations should be screened for dyslipidemia. Current guidelines recommend screening based on family history or the presence of other risk factors such as obesity, diabetes, or hypertension.

The study addresses neither the morbidity and mortality outcomes after adolescent dyslipidemia is identified, nor the costs or acceptability of screening, noted Dr. Daniels, professor and chairman of pediatrics at the University of Colorado at Denver (J. Am. Coll. Cardiol. 2009;53:870-1 [doi:10.1016/j.jacc.2008.11.037]).

“A substantially greater base of information is needed that will require additional investigation,” he commented.

Dr. Magnussen and his associates reported having no potential conflicts of interest related to this study. Dr. Daniels has been a consultant for Abbott Laboratories and Merck/Schering-Plough Pharmaceuticals, which market anticholesterol medications.

If you are obese and have dyslipidemia, it is likely that you will have changes in your vascular bed as an adult. DR. WILLIAMS

Adolescents with dyslipidemia—especially those who were overweight or obese—were more likely than were adolescents with normal lipid levels to have increased carotid artery intima-media thickness by young adulthood, a study of 1,711 people found.

The study also found the single set of cut points used to identify adolescent dyslipidemia in the National Cholesterol Education Program (NCEP) guidelines worked as well as age- and sex-specific cut points derived from growth curve data in three National Health and Nutrition Examination Surveys (NHANES) to predict increased carotid intima-media thickness in young adulthood (J. Am. Coll. Cardiol. 2009;53:860-9 [doi:10.1016/j.jacc.2008.09.061]). This argues in favor of using the simpler, fixed NCEP approach rather than the percentile-based NHANES approach, reported Costan G. Magnussen of the University of Tasmania (Australia).

Mr. Magnussen and his associates analyzed data from three large population-based, prospective cohort studies: the Finnish Cardiovascular Risk in Young Finns Study, the U.S.-based Bogalusa Heart Study, and the Australian Childhood Determination of Adult Health Study. Lipid and lipoprotein levels were measured in adolescents between the ages of 12 and 18 years and again when they were between the ages of 29 and 30 years, at which time they also had an ultrasound to measure carotid intima-media thickness, a surrogate for the risk of developing atherosclerotic cardiovascular disease.

In a previous analysis of this same data set, Mr. Magnussen and his associates found that adolescents with borderline or high-risk dyslipidemia were significantly more likely than were those with normal lipid levels to have dyslipidemia as adults after a mean follow-up of 20 years (Circulation 2008;117:32-42).

In the current study, adolescent dyslipidemia increased the relative risk for high intima-media thickness in adulthood by 60%-250%, and the higher risk was seen regardless of adult lipid and lipoprotein levels.

Adult carotid intima-media thickness was substantially higher in those who had been overweight or obese adolescents with dyslipidemia. The investigators estimated that overweight or obese 15-year-olds with dyslipidemia would show a difference in intima-media thickness of 0.11 mm in males or 0.08 mm in females by age 35 years, compared with normal-weight 15-year-olds with normal cholesterol levels.

The end point of increased intima-media thickness in young adulthood provides “a more solid end point than we've had before,” said Dr. Roberta Williams, who was not involved in the study.

“Something structurally will happen. If you are both overweight/obese and have abnormal lipid levels, it is highly likely that you are headedfor having real changesin your vascular bed as an adult,” said Dr. Williams, chair of pediatrics at the University of Southern California, Los Angeles. She said she has no conflicts of interest related to this topic.

The positive predictive value of adolescent dyslipidemia was low (ranging from 11% to 37% depending on weight and type of dyslipidemia), a fact that may be explained in part by normal fluctuations during adolescence in levels of lipoproteins, which are “building blocks”' for some hormones, she said. As a result, it's hard to tell which adolescents with dyslipidemia will go on to have increased intima-media thickness.

But the study found a high negative predictive value (ranging from 81% to 90%), meaning that adolescents without dyslipidemia are unlikely to develop cardiovascular disease as young adults. “This does not mean that they should go out and have a double cheeseburger,” she said.

In an editorial commenting on the study, Dr. Stephen R. Daniels noted that the findings do not settle the question of whether all adolescents or targeted populations should be screened for dyslipidemia. Current guidelines recommend screening based on family history or the presence of other risk factors such as obesity, diabetes, or hypertension.

The study addresses neither the morbidity and mortality outcomes after adolescent dyslipidemia is identified, nor the costs or acceptability of screening, noted Dr. Daniels, professor and chairman of pediatrics at the University of Colorado at Denver (J. Am. Coll. Cardiol. 2009;53:870-1 [doi:10.1016/j.jacc.2008.11.037]).

“A substantially greater base of information is needed that will require additional investigation,” he commented.

Dr. Magnussen and his associates reported having no potential conflicts of interest related to this study. Dr. Daniels has been a consultant for Abbott Laboratories and Merck/Schering-Plough Pharmaceuticals, which market anticholesterol medications.

If you are obese and have dyslipidemia, it is likely that you will have changes in your vascular bed as an adult. DR. WILLIAMS

Adolescents with dyslipidemia—especially those who were overweight or obese—were more likely than were adolescents with normal lipid levels to have increased carotid artery intima-media thickness by young adulthood, a study of 1,711 people found.

The study also found the single set of cut points used to identify adolescent dyslipidemia in the National Cholesterol Education Program (NCEP) guidelines worked as well as age- and sex-specific cut points derived from growth curve data in three National Health and Nutrition Examination Surveys (NHANES) to predict increased carotid intima-media thickness in young adulthood (J. Am. Coll. Cardiol. 2009;53:860-9 [doi:10.1016/j.jacc.2008.09.061]). This argues in favor of using the simpler, fixed NCEP approach rather than the percentile-based NHANES approach, reported Costan G. Magnussen of the University of Tasmania (Australia).

Mr. Magnussen and his associates analyzed data from three large population-based, prospective cohort studies: the Finnish Cardiovascular Risk in Young Finns Study, the U.S.-based Bogalusa Heart Study, and the Australian Childhood Determination of Adult Health Study. Lipid and lipoprotein levels were measured in adolescents between the ages of 12 and 18 years and again when they were between the ages of 29 and 30 years, at which time they also had an ultrasound to measure carotid intima-media thickness, a surrogate for the risk of developing atherosclerotic cardiovascular disease.

In a previous analysis of this same data set, Mr. Magnussen and his associates found that adolescents with borderline or high-risk dyslipidemia were significantly more likely than were those with normal lipid levels to have dyslipidemia as adults after a mean follow-up of 20 years (Circulation 2008;117:32-42).

In the current study, adolescent dyslipidemia increased the relative risk for high intima-media thickness in adulthood by 60%-250%, and the higher risk was seen regardless of adult lipid and lipoprotein levels.

Adult carotid intima-media thickness was substantially higher in those who had been overweight or obese adolescents with dyslipidemia. The investigators estimated that overweight or obese 15-year-olds with dyslipidemia would show a difference in intima-media thickness of 0.11 mm in males or 0.08 mm in females by age 35 years, compared with normal-weight 15-year-olds with normal cholesterol levels.

The end point of increased intima-media thickness in young adulthood provides “a more solid end point than we've had before,” said Dr. Roberta Williams, who was not involved in the study.

“Something structurally will happen. If you are both overweight/obese and have abnormal lipid levels, it is highly likely that you are headedfor having real changesin your vascular bed as an adult,” said Dr. Williams, chair of pediatrics at the University of Southern California, Los Angeles. She said she has no conflicts of interest related to this topic.

The positive predictive value of adolescent dyslipidemia was low (ranging from 11% to 37% depending on weight and type of dyslipidemia), a fact that may be explained in part by normal fluctuations during adolescence in levels of lipoproteins, which are “building blocks”' for some hormones, she said. As a result, it's hard to tell which adolescents with dyslipidemia will go on to have increased intima-media thickness.

But the study found a high negative predictive value (ranging from 81% to 90%), meaning that adolescents without dyslipidemia are unlikely to develop cardiovascular disease as young adults. “This does not mean that they should go out and have a double cheeseburger,” she said.

In an editorial commenting on the study, Dr. Stephen R. Daniels noted that the findings do not settle the question of whether all adolescents or targeted populations should be screened for dyslipidemia. Current guidelines recommend screening based on family history or the presence of other risk factors such as obesity, diabetes, or hypertension.

The study addresses neither the morbidity and mortality outcomes after adolescent dyslipidemia is identified, nor the costs or acceptability of screening, noted Dr. Daniels, professor and chairman of pediatrics at the University of Colorado at Denver (J. Am. Coll. Cardiol. 2009;53:870-1 [doi:10.1016/j.jacc.2008.11.037]).

“A substantially greater base of information is needed that will require additional investigation,” he commented.

Dr. Magnussen and his associates reported having no potential conflicts of interest related to this study. Dr. Daniels has been a consultant for Abbott Laboratories and Merck/Schering-Plough Pharmaceuticals, which market anticholesterol medications.

If you are obese and have dyslipidemia, it is likely that you will have changes in your vascular bed as an adult. DR. WILLIAMS

The dominant strain of influenza A during the current flu season is nearly completely resistant to oseltamivir because of a mutation that leaves its virulence intact, according to two studies that upset long-held ideas about oseltamivir-resistant influenza A (H1N1) viruses.

Findings from a third study bolster the rationale for widespread vaccination.

Taken together, the findings from these three studies should motivate more people to get annual influenza vaccinations, especially health care workers, since treatment options are now more limited, said Dr. Gregory A. Poland, who was not a participant in the studies. He is the American College of Physicians liaison to the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP).

In the first study, Dr. Nila J. Dharan of the CDC's influenza division in Atlanta, and associates, tested 268 influenza A (H1N1) isolates from the 2008-2009 season and found that 99% were oseltamivir (Tamiflu) resistant (JAMA 2009 [doi:10.1001/jama.2009.294]).

Such findings shore up concerns raised by a December 2008 CDC health advisory that reported resistance to oseltamivir in 98% of 50 influenza A (H1N1) viruses from 12 states in the early part of the 2008-2009 influenza season. As recently as the 2006-2007 influenza season, oseltamivir-resistant influenza was very uncommon. In the 2007-2008 season, however, influenza A (H1N1) comprised 19% of circulating influenza viruses, and 12% of 1,155 H1N1 viruses tested from 45 states showed oseltamivir resistance, according to Dr. Dharan and associates. About 55% of influenza types isolated so far by the CDC in the 2008-2009 season are oseltamivir-resistant H1N1.

Previously it was thought the mutation conferring oseltamivir resistance weakens the virus' ability to be transmitted from person to person and to sicken or kill, but Dr. Dharan's study and another by Dr. Jairo Gooskens dispel those notions. In Dr. Dharan's study, 3% of 142 patients whose resistant viruses were tested by the CDC died of influenza.

Dr. Gooskens of Leiden (the Netherlands) University, and associates performed gene sequencing analysis on viruses from four patients in a nosocomial outbreak of oseltamivir-resistant influenza A (H1N1) at one hospital. The virus spread from the index patient to three others, two of whom died, and possibly to five health care workers (JAMA 2009 [doi:10.1001/jama.2009.297]).

In neither study did use or overuse of oseltamivir appear to contribute to viral resistance, a fact that “frankly, has caught us with our intellectual pants down. That really did surprise us,” said Dr. William Schaffner, chair of preventive medicine at Vanderbilt University, Nashville, Tenn., and the Infectious Diseases Society of America liaison to the ACIP. He did not participate in the studies.

At an ACIP meeting held in late February, committee members “acknowledged that we are still a little flummoxed about how it is that these viruses could have spread not only within the United States but globally so rapidly,” he said.

The third study analyzed more than a million active-duty members of the U.S. military during three influenza seasons. The trivalent inactivated vaccine (TIV) was more effective than was the live attenuated influenza vaccine (LAIV) or no vaccine in protecting this annually immunized cohort, reported Zhong Wang, Ph.D., of the Armed Forces Health Surveillance Center, Silver Spring, Md., and associates (JAMA 2009;301:945-53).

The study investigators all reported having no conflicts of interest related to the studies. Dr. Schaffner has been a consultant for, or received funding from, GlaxoSmithKline, Novartis, Sanofi Pasteur, and MedImmune, which make influenza vaccines or treatments. Dr. Poland has been a consultant for, or received funding from, Dynavax, Novavax, Merck & Co., GlaxoSmithKline, Novartis Vaccines, CSL Biotherapies, PowerderMed, Avianax, and Protein Sciences.

Updates on CDC influenza antiviral recommendations can be monitored at www.cdc.gov/flu/professionals/antivirals

The dominant strain of influenza A during the current flu season is nearly completely resistant to oseltamivir because of a mutation that leaves its virulence intact, according to two studies that upset long-held ideas about oseltamivir-resistant influenza A (H1N1) viruses.

Findings from a third study bolster the rationale for widespread vaccination.

Taken together, the findings from these three studies should motivate more people to get annual influenza vaccinations, especially health care workers, since treatment options are now more limited, said Dr. Gregory A. Poland, who was not a participant in the studies. He is the American College of Physicians liaison to the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP).

In the first study, Dr. Nila J. Dharan of the CDC's influenza division in Atlanta, and associates, tested 268 influenza A (H1N1) isolates from the 2008-2009 season and found that 99% were oseltamivir (Tamiflu) resistant (JAMA 2009 [doi:10.1001/jama.2009.294]).

Such findings shore up concerns raised by a December 2008 CDC health advisory that reported resistance to oseltamivir in 98% of 50 influenza A (H1N1) viruses from 12 states in the early part of the 2008-2009 influenza season. As recently as the 2006-2007 influenza season, oseltamivir-resistant influenza was very uncommon. In the 2007-2008 season, however, influenza A (H1N1) comprised 19% of circulating influenza viruses, and 12% of 1,155 H1N1 viruses tested from 45 states showed oseltamivir resistance, according to Dr. Dharan and associates. About 55% of influenza types isolated so far by the CDC in the 2008-2009 season are oseltamivir-resistant H1N1.

Previously it was thought the mutation conferring oseltamivir resistance weakens the virus' ability to be transmitted from person to person and to sicken or kill, but Dr. Dharan's study and another by Dr. Jairo Gooskens dispel those notions. In Dr. Dharan's study, 3% of 142 patients whose resistant viruses were tested by the CDC died of influenza.

Dr. Gooskens of Leiden (the Netherlands) University, and associates performed gene sequencing analysis on viruses from four patients in a nosocomial outbreak of oseltamivir-resistant influenza A (H1N1) at one hospital. The virus spread from the index patient to three others, two of whom died, and possibly to five health care workers (JAMA 2009 [doi:10.1001/jama.2009.297]).

In neither study did use or overuse of oseltamivir appear to contribute to viral resistance, a fact that “frankly, has caught us with our intellectual pants down. That really did surprise us,” said Dr. William Schaffner, chair of preventive medicine at Vanderbilt University, Nashville, Tenn., and the Infectious Diseases Society of America liaison to the ACIP. He did not participate in the studies.

At an ACIP meeting held in late February, committee members “acknowledged that we are still a little flummoxed about how it is that these viruses could have spread not only within the United States but globally so rapidly,” he said.

The third study analyzed more than a million active-duty members of the U.S. military during three influenza seasons. The trivalent inactivated vaccine (TIV) was more effective than was the live attenuated influenza vaccine (LAIV) or no vaccine in protecting this annually immunized cohort, reported Zhong Wang, Ph.D., of the Armed Forces Health Surveillance Center, Silver Spring, Md., and associates (JAMA 2009;301:945-53).

The study investigators all reported having no conflicts of interest related to the studies. Dr. Schaffner has been a consultant for, or received funding from, GlaxoSmithKline, Novartis, Sanofi Pasteur, and MedImmune, which make influenza vaccines or treatments. Dr. Poland has been a consultant for, or received funding from, Dynavax, Novavax, Merck & Co., GlaxoSmithKline, Novartis Vaccines, CSL Biotherapies, PowerderMed, Avianax, and Protein Sciences.

Updates on CDC influenza antiviral recommendations can be monitored at www.cdc.gov/flu/professionals/antivirals

The dominant strain of influenza A during the current flu season is nearly completely resistant to oseltamivir because of a mutation that leaves its virulence intact, according to two studies that upset long-held ideas about oseltamivir-resistant influenza A (H1N1) viruses.

Findings from a third study bolster the rationale for widespread vaccination.

Taken together, the findings from these three studies should motivate more people to get annual influenza vaccinations, especially health care workers, since treatment options are now more limited, said Dr. Gregory A. Poland, who was not a participant in the studies. He is the American College of Physicians liaison to the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP).

In the first study, Dr. Nila J. Dharan of the CDC's influenza division in Atlanta, and associates, tested 268 influenza A (H1N1) isolates from the 2008-2009 season and found that 99% were oseltamivir (Tamiflu) resistant (JAMA 2009 [doi:10.1001/jama.2009.294]).

Such findings shore up concerns raised by a December 2008 CDC health advisory that reported resistance to oseltamivir in 98% of 50 influenza A (H1N1) viruses from 12 states in the early part of the 2008-2009 influenza season. As recently as the 2006-2007 influenza season, oseltamivir-resistant influenza was very uncommon. In the 2007-2008 season, however, influenza A (H1N1) comprised 19% of circulating influenza viruses, and 12% of 1,155 H1N1 viruses tested from 45 states showed oseltamivir resistance, according to Dr. Dharan and associates. About 55% of influenza types isolated so far by the CDC in the 2008-2009 season are oseltamivir-resistant H1N1.

Previously it was thought the mutation conferring oseltamivir resistance weakens the virus' ability to be transmitted from person to person and to sicken or kill, but Dr. Dharan's study and another by Dr. Jairo Gooskens dispel those notions. In Dr. Dharan's study, 3% of 142 patients whose resistant viruses were tested by the CDC died of influenza.

Dr. Gooskens of Leiden (the Netherlands) University, and associates performed gene sequencing analysis on viruses from four patients in a nosocomial outbreak of oseltamivir-resistant influenza A (H1N1) at one hospital. The virus spread from the index patient to three others, two of whom died, and possibly to five health care workers (JAMA 2009 [doi:10.1001/jama.2009.297]).

In neither study did use or overuse of oseltamivir appear to contribute to viral resistance, a fact that “frankly, has caught us with our intellectual pants down. That really did surprise us,” said Dr. William Schaffner, chair of preventive medicine at Vanderbilt University, Nashville, Tenn., and the Infectious Diseases Society of America liaison to the ACIP. He did not participate in the studies.

At an ACIP meeting held in late February, committee members “acknowledged that we are still a little flummoxed about how it is that these viruses could have spread not only within the United States but globally so rapidly,” he said.

The third study analyzed more than a million active-duty members of the U.S. military during three influenza seasons. The trivalent inactivated vaccine (TIV) was more effective than was the live attenuated influenza vaccine (LAIV) or no vaccine in protecting this annually immunized cohort, reported Zhong Wang, Ph.D., of the Armed Forces Health Surveillance Center, Silver Spring, Md., and associates (JAMA 2009;301:945-53).

The study investigators all reported having no conflicts of interest related to the studies. Dr. Schaffner has been a consultant for, or received funding from, GlaxoSmithKline, Novartis, Sanofi Pasteur, and MedImmune, which make influenza vaccines or treatments. Dr. Poland has been a consultant for, or received funding from, Dynavax, Novavax, Merck & Co., GlaxoSmithKline, Novartis Vaccines, CSL Biotherapies, PowerderMed, Avianax, and Protein Sciences.

Updates on CDC influenza antiviral recommendations can be monitored at www.cdc.gov/flu/professionals/antivirals

SAN FRANCISCO — The gentle martial art tai chi significantly lessened pain and improved physical function in a randomized, controlled trial in 40 patients with knee osteoarthritis.

Participants were randomly selected to attend hour-long classes twice a week for 12 weeks to learn and practice 10 modified forms of tai chi or to receive wellness education and engage in stretching in a control group. Patient characteristics were similar between groups, with baseline pain scores of 209 in the tai chi group and 220 in the control group on the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index, which was the main outcome measure.

After 12 weeks, scores decreased by 157 points in the tai chi group and 39 points in the control group, a significant difference (P = .004), Dr. Chenchen Wang reported at the annual meeting of the American College of Rheumatology.

Although the WOMAC pain scores remained significantly different between groups at 24 weeks, they did not at 48 weeks, as some patients stopped tai chi once the 12-week intervention had ended. Those who continued, however, showed significant improvements in pain and secondary measures of function, compared with controls, said Dr. Wang of Tufts University, Boston.

The tai chi group also showed significant improvements, compared with the control group, in the WOMAC physical function score; the patient and physician global assessment scores (on visual analog scales); a timed chair-stand test; an assessment of knee proprioception; and in depression scores on the Center for Epidemiologic Studies-Depression scale.

Sessions in the current trial included a warm-up, review of technique, and practice of the meditative movements, some of which were modified for the osteoarthritic cohort by incorporating chairs or other accommodations.

Patients were obese, with a baseline body mass index of 30 kg/m

All patients completed the 12-week trial, with 85% attendance in the tai chi sessions and 89% in the control sessions.

The Arthritis Foundation promotes a tai chi practice based on the Sun style that differs in some respects from the Yang style used in the study, she noted.

Tai chi uses an integrated mind-body approach to enhance muscle function, balance, and flexibility. ©Anne Clark/

SAN FRANCISCO — The gentle martial art tai chi significantly lessened pain and improved physical function in a randomized, controlled trial in 40 patients with knee osteoarthritis.

Participants were randomly selected to attend hour-long classes twice a week for 12 weeks to learn and practice 10 modified forms of tai chi or to receive wellness education and engage in stretching in a control group. Patient characteristics were similar between groups, with baseline pain scores of 209 in the tai chi group and 220 in the control group on the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index, which was the main outcome measure.

After 12 weeks, scores decreased by 157 points in the tai chi group and 39 points in the control group, a significant difference (P = .004), Dr. Chenchen Wang reported at the annual meeting of the American College of Rheumatology.

Although the WOMAC pain scores remained significantly different between groups at 24 weeks, they did not at 48 weeks, as some patients stopped tai chi once the 12-week intervention had ended. Those who continued, however, showed significant improvements in pain and secondary measures of function, compared with controls, said Dr. Wang of Tufts University, Boston.

The tai chi group also showed significant improvements, compared with the control group, in the WOMAC physical function score; the patient and physician global assessment scores (on visual analog scales); a timed chair-stand test; an assessment of knee proprioception; and in depression scores on the Center for Epidemiologic Studies-Depression scale.

Sessions in the current trial included a warm-up, review of technique, and practice of the meditative movements, some of which were modified for the osteoarthritic cohort by incorporating chairs or other accommodations.

Patients were obese, with a baseline body mass index of 30 kg/m

All patients completed the 12-week trial, with 85% attendance in the tai chi sessions and 89% in the control sessions.

The Arthritis Foundation promotes a tai chi practice based on the Sun style that differs in some respects from the Yang style used in the study, she noted.

Tai chi uses an integrated mind-body approach to enhance muscle function, balance, and flexibility. ©Anne Clark/

SAN FRANCISCO — The gentle martial art tai chi significantly lessened pain and improved physical function in a randomized, controlled trial in 40 patients with knee osteoarthritis.

Participants were randomly selected to attend hour-long classes twice a week for 12 weeks to learn and practice 10 modified forms of tai chi or to receive wellness education and engage in stretching in a control group. Patient characteristics were similar between groups, with baseline pain scores of 209 in the tai chi group and 220 in the control group on the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index, which was the main outcome measure.

After 12 weeks, scores decreased by 157 points in the tai chi group and 39 points in the control group, a significant difference (P = .004), Dr. Chenchen Wang reported at the annual meeting of the American College of Rheumatology.

Although the WOMAC pain scores remained significantly different between groups at 24 weeks, they did not at 48 weeks, as some patients stopped tai chi once the 12-week intervention had ended. Those who continued, however, showed significant improvements in pain and secondary measures of function, compared with controls, said Dr. Wang of Tufts University, Boston.

The tai chi group also showed significant improvements, compared with the control group, in the WOMAC physical function score; the patient and physician global assessment scores (on visual analog scales); a timed chair-stand test; an assessment of knee proprioception; and in depression scores on the Center for Epidemiologic Studies-Depression scale.

Sessions in the current trial included a warm-up, review of technique, and practice of the meditative movements, some of which were modified for the osteoarthritic cohort by incorporating chairs or other accommodations.

Patients were obese, with a baseline body mass index of 30 kg/m

All patients completed the 12-week trial, with 85% attendance in the tai chi sessions and 89% in the control sessions.

The Arthritis Foundation promotes a tai chi practice based on the Sun style that differs in some respects from the Yang style used in the study, she noted.

Tai chi uses an integrated mind-body approach to enhance muscle function, balance, and flexibility. ©Anne Clark/

SAN FRANCISCO — A study of 156 patients with systemic sclerosis in two European cities found that vitamin D deficiency was present in 28% of them.

Deficient levels of serum 25-hydroxyvitamin D (25[OH]D)—less than 10 ng/mL—were seen in 29 (32%) of 90 patients in Paris and 15 (23%) of 66 in Cagliari in southern Italy, Dr. Alessandra Vacca and her associates reported in a poster presentation at the annual meeting of the American College of Rheumatology.

In addition, 84% of all patients had insufficient vitamin D levels (less than 30 ng/mL), a result seen in 75 (82%) of the Parisians and 57 (86%) of the Italians.

The mean vitamin D value in the two cohorts was 19 ng/mL, said Dr. Vacca of the University of Cagliari.

The rates of vitamin D deficiency did not differ significantly between cities and so were independent of the different UV radiation levels in the northern and southern cities. Rates of vitamin D deficiency also were independent of usual levels of vitamin D supplementation (800 IU/day), which were taken by 30% of Parisian patients and 45% of Italian patients.

Because conventional doses of vitamin D supplementation did not prevent vitamin D deficiency, higher dose supplementation may be needed in patients with systemic sclerosis, especially those with inflammatory activity, she said.

Low vitamin D levels were associated with pulmonary fibrosis (P = .04), systolic pulmonary arterial hypertension (P = .004), and inflammatory activity indicated by acute phase reactants—erythrocyte sedimentation rate (P = .004) and C-reactive protein values (P = .01).

There was a significant negative correlation between low vitamin D levels and European disease activity scores (P = −0.04). A mild negative association was seen between vitamin D deficiency and anticentromere antibodies.

Low vitamin D levels may be linked to multiple risk factors, Dr. Vacca suggested, including scarce sun exposure due to disability; insufficient intake and malabsorption of vitamin D due to gastroenteric disease involvement; or use of drugs that can alter metabolism of vitamin D, such as steroids.

There was no association between vitamin D deficiency and other markers of impaired malabsorption such as hemoglobin, ferritin, or albuminemia among other.

No associations were found between vitamin D deficiency and acro-osteolysis, calcinosis, or Medsger's disease severity score.

The patients had a mean age of 57 years, and 97% were female.

Vitamin D, which is a steroid hormone, is essential for bone and mineral homeostasis, and is widely thought to play a role in muscles, vasculature, reproduction, cellular growth and differentiation, malignancy, and the immune system.

The investigators reported no conflicts of interest related to this study.

SAN FRANCISCO — A study of 156 patients with systemic sclerosis in two European cities found that vitamin D deficiency was present in 28% of them.

Deficient levels of serum 25-hydroxyvitamin D (25[OH]D)—less than 10 ng/mL—were seen in 29 (32%) of 90 patients in Paris and 15 (23%) of 66 in Cagliari in southern Italy, Dr. Alessandra Vacca and her associates reported in a poster presentation at the annual meeting of the American College of Rheumatology.

In addition, 84% of all patients had insufficient vitamin D levels (less than 30 ng/mL), a result seen in 75 (82%) of the Parisians and 57 (86%) of the Italians.

The mean vitamin D value in the two cohorts was 19 ng/mL, said Dr. Vacca of the University of Cagliari.

The rates of vitamin D deficiency did not differ significantly between cities and so were independent of the different UV radiation levels in the northern and southern cities. Rates of vitamin D deficiency also were independent of usual levels of vitamin D supplementation (800 IU/day), which were taken by 30% of Parisian patients and 45% of Italian patients.

Because conventional doses of vitamin D supplementation did not prevent vitamin D deficiency, higher dose supplementation may be needed in patients with systemic sclerosis, especially those with inflammatory activity, she said.

Low vitamin D levels were associated with pulmonary fibrosis (P = .04), systolic pulmonary arterial hypertension (P = .004), and inflammatory activity indicated by acute phase reactants—erythrocyte sedimentation rate (P = .004) and C-reactive protein values (P = .01).

There was a significant negative correlation between low vitamin D levels and European disease activity scores (P = −0.04). A mild negative association was seen between vitamin D deficiency and anticentromere antibodies.

Low vitamin D levels may be linked to multiple risk factors, Dr. Vacca suggested, including scarce sun exposure due to disability; insufficient intake and malabsorption of vitamin D due to gastroenteric disease involvement; or use of drugs that can alter metabolism of vitamin D, such as steroids.

There was no association between vitamin D deficiency and other markers of impaired malabsorption such as hemoglobin, ferritin, or albuminemia among other.

No associations were found between vitamin D deficiency and acro-osteolysis, calcinosis, or Medsger's disease severity score.

The patients had a mean age of 57 years, and 97% were female.

Vitamin D, which is a steroid hormone, is essential for bone and mineral homeostasis, and is widely thought to play a role in muscles, vasculature, reproduction, cellular growth and differentiation, malignancy, and the immune system.

The investigators reported no conflicts of interest related to this study.

SAN FRANCISCO — A study of 156 patients with systemic sclerosis in two European cities found that vitamin D deficiency was present in 28% of them.

Deficient levels of serum 25-hydroxyvitamin D (25[OH]D)—less than 10 ng/mL—were seen in 29 (32%) of 90 patients in Paris and 15 (23%) of 66 in Cagliari in southern Italy, Dr. Alessandra Vacca and her associates reported in a poster presentation at the annual meeting of the American College of Rheumatology.

In addition, 84% of all patients had insufficient vitamin D levels (less than 30 ng/mL), a result seen in 75 (82%) of the Parisians and 57 (86%) of the Italians.

The mean vitamin D value in the two cohorts was 19 ng/mL, said Dr. Vacca of the University of Cagliari.

The rates of vitamin D deficiency did not differ significantly between cities and so were independent of the different UV radiation levels in the northern and southern cities. Rates of vitamin D deficiency also were independent of usual levels of vitamin D supplementation (800 IU/day), which were taken by 30% of Parisian patients and 45% of Italian patients.

Because conventional doses of vitamin D supplementation did not prevent vitamin D deficiency, higher dose supplementation may be needed in patients with systemic sclerosis, especially those with inflammatory activity, she said.

Low vitamin D levels were associated with pulmonary fibrosis (P = .04), systolic pulmonary arterial hypertension (P = .004), and inflammatory activity indicated by acute phase reactants—erythrocyte sedimentation rate (P = .004) and C-reactive protein values (P = .01).

There was a significant negative correlation between low vitamin D levels and European disease activity scores (P = −0.04). A mild negative association was seen between vitamin D deficiency and anticentromere antibodies.

Low vitamin D levels may be linked to multiple risk factors, Dr. Vacca suggested, including scarce sun exposure due to disability; insufficient intake and malabsorption of vitamin D due to gastroenteric disease involvement; or use of drugs that can alter metabolism of vitamin D, such as steroids.

There was no association between vitamin D deficiency and other markers of impaired malabsorption such as hemoglobin, ferritin, or albuminemia among other.

No associations were found between vitamin D deficiency and acro-osteolysis, calcinosis, or Medsger's disease severity score.

The patients had a mean age of 57 years, and 97% were female.

Vitamin D, which is a steroid hormone, is essential for bone and mineral homeostasis, and is widely thought to play a role in muscles, vasculature, reproduction, cellular growth and differentiation, malignancy, and the immune system.

The investigators reported no conflicts of interest related to this study.

SAN FRANCISCO — Off-pump coronary artery bypass grafting was associated with greater costs and length of hospitalization and no difference in the risks of death or stroke, compared with conventional on-pump procedures, in a review of 63,061 cases.

The findings are sure to fuel the controversy over which type of CABG is better—the conventional on-pump approach, using cardiopulmonary bypass (CPB), or the more recent off-pump CABG. Some previous studies have shown improved outcomes with off-pump CABG, whereas others have shown worse outcomes.

In the current study, 14,392 patients who underwent CABG without CPB pumps averaged 9.9 days in the hospital, compared with 10.2 days in 48,669 patients who had on-pump CABG, a statistically significant difference. After a multivariable logistic regression analysis, off-pump CABG was associated with an extra 0.6 days in the hospital and $1,497 in higher costs, Dr. Danny Chu and his associates reported at the annual meeting of the Society of Thoracic Surgeons.

In-hospital death rates—the primary outcome—were about 3% in each group. The incidence of postoperative stroke was about 2% in each group.

“Off-pump coronary artery bypass should be an alternative to, not a replacement for, the traditional on-pump CABG,” said Dr. Chu of Baylor College of Medicine, Houston. “We do not believe that performing off-pump CABG on all patients is justifiable.”

Dr. Chu and his associates had no potential conflicts of interest.

The study analyzed data on all U.S. patients undergoing isolated CABG and no concomitant cardiac operations in 2004, using records from the nonvoluntary Nationwide Inpatient Sample (NIS) database maintained by the Agency for Healthcare Research and Quality.

Several preoperative characteristics differed significantly between groups. The off-pump patients averaged a year younger in age than did on-pump patients (65 vs. 66 years) and were more likely to be female (31% vs. 29%) and to be emergency cases (29% vs. 25%).

The analysis stratified patients for risk using the Deyo Comorbidity Index.

Commenting on the study, Dr. John D. Puskas criticized the investigators' use of an administrative database like the NIS to analyze clinical outcomes. The study's conclusions “cannot be justified,” said Dr. Puskas, chief of cardiac surgery at Emory Crawford Long Hospital, Atlanta.

Dr. Puskas is a consultant to, and has received research funds from, Medtronic Inc. and Marquet Medical Systems, which make devices used in CABG (both on and off pump). He also has received royalties from coronary instruments marketed by Scanlan International Inc.

Dr. Puskas also was the primary investigator in a review of records on 42,477 consecutive, nonemergency, isolated CABG surgeries, using data from the STS National Cardiac Adult Database. His study concluded that off-pump CABG was linked with a 17% lower risk of death, a 35% lower risk of stroke, a 33% lower risk of MI, and a 29% lower risk of major adverse cardiac events compared with on-pump CABG, all significant differences.

“These are very tight data, and they are compelling. This is the most sophisticated and complete risk-adjusted assessment possible, with a very vigorous database,” he said.

A separate recent analysis of the NIS database that analyzed CABG outcomes based on patients' differing coronary anatomy found lower risks for death, MI, stroke, or major adverse cardiac events with off-pump CABG compared with on-pump, he added.

'Off-pump [CABG] should be an alternative to, not a replacement for, the traditional on-pump CABG.' DR. CHU

SAN FRANCISCO — Off-pump coronary artery bypass grafting was associated with greater costs and length of hospitalization and no difference in the risks of death or stroke, compared with conventional on-pump procedures, in a review of 63,061 cases.

The findings are sure to fuel the controversy over which type of CABG is better—the conventional on-pump approach, using cardiopulmonary bypass (CPB), or the more recent off-pump CABG. Some previous studies have shown improved outcomes with off-pump CABG, whereas others have shown worse outcomes.

In the current study, 14,392 patients who underwent CABG without CPB pumps averaged 9.9 days in the hospital, compared with 10.2 days in 48,669 patients who had on-pump CABG, a statistically significant difference. After a multivariable logistic regression analysis, off-pump CABG was associated with an extra 0.6 days in the hospital and $1,497 in higher costs, Dr. Danny Chu and his associates reported at the annual meeting of the Society of Thoracic Surgeons.

In-hospital death rates—the primary outcome—were about 3% in each group. The incidence of postoperative stroke was about 2% in each group.

“Off-pump coronary artery bypass should be an alternative to, not a replacement for, the traditional on-pump CABG,” said Dr. Chu of Baylor College of Medicine, Houston. “We do not believe that performing off-pump CABG on all patients is justifiable.”

Dr. Chu and his associates had no potential conflicts of interest.

The study analyzed data on all U.S. patients undergoing isolated CABG and no concomitant cardiac operations in 2004, using records from the nonvoluntary Nationwide Inpatient Sample (NIS) database maintained by the Agency for Healthcare Research and Quality.

Several preoperative characteristics differed significantly between groups. The off-pump patients averaged a year younger in age than did on-pump patients (65 vs. 66 years) and were more likely to be female (31% vs. 29%) and to be emergency cases (29% vs. 25%).

The analysis stratified patients for risk using the Deyo Comorbidity Index.

Commenting on the study, Dr. John D. Puskas criticized the investigators' use of an administrative database like the NIS to analyze clinical outcomes. The study's conclusions “cannot be justified,” said Dr. Puskas, chief of cardiac surgery at Emory Crawford Long Hospital, Atlanta.

Dr. Puskas is a consultant to, and has received research funds from, Medtronic Inc. and Marquet Medical Systems, which make devices used in CABG (both on and off pump). He also has received royalties from coronary instruments marketed by Scanlan International Inc.

Dr. Puskas also was the primary investigator in a review of records on 42,477 consecutive, nonemergency, isolated CABG surgeries, using data from the STS National Cardiac Adult Database. His study concluded that off-pump CABG was linked with a 17% lower risk of death, a 35% lower risk of stroke, a 33% lower risk of MI, and a 29% lower risk of major adverse cardiac events compared with on-pump CABG, all significant differences.

“These are very tight data, and they are compelling. This is the most sophisticated and complete risk-adjusted assessment possible, with a very vigorous database,” he said.

A separate recent analysis of the NIS database that analyzed CABG outcomes based on patients' differing coronary anatomy found lower risks for death, MI, stroke, or major adverse cardiac events with off-pump CABG compared with on-pump, he added.

'Off-pump [CABG] should be an alternative to, not a replacement for, the traditional on-pump CABG.' DR. CHU

SAN FRANCISCO — Off-pump coronary artery bypass grafting was associated with greater costs and length of hospitalization and no difference in the risks of death or stroke, compared with conventional on-pump procedures, in a review of 63,061 cases.

The findings are sure to fuel the controversy over which type of CABG is better—the conventional on-pump approach, using cardiopulmonary bypass (CPB), or the more recent off-pump CABG. Some previous studies have shown improved outcomes with off-pump CABG, whereas others have shown worse outcomes.

In the current study, 14,392 patients who underwent CABG without CPB pumps averaged 9.9 days in the hospital, compared with 10.2 days in 48,669 patients who had on-pump CABG, a statistically significant difference. After a multivariable logistic regression analysis, off-pump CABG was associated with an extra 0.6 days in the hospital and $1,497 in higher costs, Dr. Danny Chu and his associates reported at the annual meeting of the Society of Thoracic Surgeons.

In-hospital death rates—the primary outcome—were about 3% in each group. The incidence of postoperative stroke was about 2% in each group.

“Off-pump coronary artery bypass should be an alternative to, not a replacement for, the traditional on-pump CABG,” said Dr. Chu of Baylor College of Medicine, Houston. “We do not believe that performing off-pump CABG on all patients is justifiable.”

Dr. Chu and his associates had no potential conflicts of interest.

The study analyzed data on all U.S. patients undergoing isolated CABG and no concomitant cardiac operations in 2004, using records from the nonvoluntary Nationwide Inpatient Sample (NIS) database maintained by the Agency for Healthcare Research and Quality.

Several preoperative characteristics differed significantly between groups. The off-pump patients averaged a year younger in age than did on-pump patients (65 vs. 66 years) and were more likely to be female (31% vs. 29%) and to be emergency cases (29% vs. 25%).

The analysis stratified patients for risk using the Deyo Comorbidity Index.

Commenting on the study, Dr. John D. Puskas criticized the investigators' use of an administrative database like the NIS to analyze clinical outcomes. The study's conclusions “cannot be justified,” said Dr. Puskas, chief of cardiac surgery at Emory Crawford Long Hospital, Atlanta.

Dr. Puskas is a consultant to, and has received research funds from, Medtronic Inc. and Marquet Medical Systems, which make devices used in CABG (both on and off pump). He also has received royalties from coronary instruments marketed by Scanlan International Inc.

Dr. Puskas also was the primary investigator in a review of records on 42,477 consecutive, nonemergency, isolated CABG surgeries, using data from the STS National Cardiac Adult Database. His study concluded that off-pump CABG was linked with a 17% lower risk of death, a 35% lower risk of stroke, a 33% lower risk of MI, and a 29% lower risk of major adverse cardiac events compared with on-pump CABG, all significant differences.

“These are very tight data, and they are compelling. This is the most sophisticated and complete risk-adjusted assessment possible, with a very vigorous database,” he said.

A separate recent analysis of the NIS database that analyzed CABG outcomes based on patients' differing coronary anatomy found lower risks for death, MI, stroke, or major adverse cardiac events with off-pump CABG compared with on-pump, he added.

'Off-pump [CABG] should be an alternative to, not a replacement for, the traditional on-pump CABG.' DR. CHU

SAN FRANCISCO — Patients being treated for rheumatoid arthritis with infliximab or adalimumab—but not etanercept—were more likely to have elevated levels of liver enzymes, compared with patients on nonbiologic disease-modifying antirheumatic drugs, analyses of data on 6,861 patients found.

Most elevations in alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels with any of the treatments were transient, however, and unlikely to lead to discontinuation. Abnormal levels of ALT or AST were rare, Dr. Vibeke Strand and her associates reported in a poster presentation at the annual meeting of the American College of Rheumatology. Elevations were defined as test results above the upper limit of normal, and abnormal levels were results more than double the upper limit of normal.

After researchers controlled for the effects of other factors, the risk of elevated or abnormal liver enzyme levels was 58% higher in 1,449 patients on infliximab (Remicade) and 35% higher in 849 patients on adalimumab (Humira), but no different in 1,383 patients on etanercept (Enbrel), compared with 4,147 patients on oral DMARDs, with or without a tumor necrosis factor (TNF) inhibitor.

The investigators performed six analyses of data from the Consortium of Rheumatology Researchers of North America. Patients with normal transaminase levels at baseline were divided into three cohorts—prevalent TNF inhibitor users, patients initiating TNF inhibitor therapy, and patients on concomitant TNF inhibitor and methotrexate therapy—and their liver enzyme levels were compared with those of nonbiologic DMARD users. The study excluded patients with psoriatic arthritis.

The risk of elevated liver enzyme levels was significantly higher with infliximab in all three cohorts (a 36%-69% increase) and was higher with adalimumab in two cohorts (a 35%-44% increase). The risk of abnormal enzyme levels was significantly higher with infliximab in two cohorts (a 40%-47% increase) and was higher with adalimumab in one cohort (a 32% increase).

Assuming that enzyme levels normalized in patients for whom there were no follow-up data, 17% of 1,210 elevations persisted at the next visit, and 7% of 143 abnormalities persisted. Among patients with elevated enzyme levels, 4% discontinued a TNF inhibitor and 11% discontinued a nonbiologic DMARD. Among patients with abnormalities found on liver function tests, 6% discontinued a TNF inhibitor and 24% discontinued a DMARD.

“Use of TNF inhibitors does not appear to be associated with clinically meaningful hepatic events in most patients,” concluded Dr. Strand of Stanford (Calif.) University. The results suggest that recommendations for monitoring nonbiologic DMARD therapy could safely guide clinicians in deciding when to reduce or discontinue TNF inhibitor therapy based on liver enzyme levels, she added.

Dr. Strand is also a biopharmaceutical consultant and has received consulting fees and other compensation from Amgen (which comarkets etanercept with Wyeth), Abbott (which markets adalimumab), and Centocor (which markets infliximab). Some of her associates in the study were employees of Amgen and others were consultants or speakers for these companies or received research funds from them. Dr. Strand and her coinvestigators also had associations with multiple other pharmaceutical companies.

The cohorts and comparison group had mean ages of 56–62 years, and 73%-80% were female.

SAN FRANCISCO — Patients being treated for rheumatoid arthritis with infliximab or adalimumab—but not etanercept—were more likely to have elevated levels of liver enzymes, compared with patients on nonbiologic disease-modifying antirheumatic drugs, analyses of data on 6,861 patients found.

Most elevations in alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels with any of the treatments were transient, however, and unlikely to lead to discontinuation. Abnormal levels of ALT or AST were rare, Dr. Vibeke Strand and her associates reported in a poster presentation at the annual meeting of the American College of Rheumatology. Elevations were defined as test results above the upper limit of normal, and abnormal levels were results more than double the upper limit of normal.

After researchers controlled for the effects of other factors, the risk of elevated or abnormal liver enzyme levels was 58% higher in 1,449 patients on infliximab (Remicade) and 35% higher in 849 patients on adalimumab (Humira), but no different in 1,383 patients on etanercept (Enbrel), compared with 4,147 patients on oral DMARDs, with or without a tumor necrosis factor (TNF) inhibitor.

The investigators performed six analyses of data from the Consortium of Rheumatology Researchers of North America. Patients with normal transaminase levels at baseline were divided into three cohorts—prevalent TNF inhibitor users, patients initiating TNF inhibitor therapy, and patients on concomitant TNF inhibitor and methotrexate therapy—and their liver enzyme levels were compared with those of nonbiologic DMARD users. The study excluded patients with psoriatic arthritis.

The risk of elevated liver enzyme levels was significantly higher with infliximab in all three cohorts (a 36%-69% increase) and was higher with adalimumab in two cohorts (a 35%-44% increase). The risk of abnormal enzyme levels was significantly higher with infliximab in two cohorts (a 40%-47% increase) and was higher with adalimumab in one cohort (a 32% increase).

Assuming that enzyme levels normalized in patients for whom there were no follow-up data, 17% of 1,210 elevations persisted at the next visit, and 7% of 143 abnormalities persisted. Among patients with elevated enzyme levels, 4% discontinued a TNF inhibitor and 11% discontinued a nonbiologic DMARD. Among patients with abnormalities found on liver function tests, 6% discontinued a TNF inhibitor and 24% discontinued a DMARD.

“Use of TNF inhibitors does not appear to be associated with clinically meaningful hepatic events in most patients,” concluded Dr. Strand of Stanford (Calif.) University. The results suggest that recommendations for monitoring nonbiologic DMARD therapy could safely guide clinicians in deciding when to reduce or discontinue TNF inhibitor therapy based on liver enzyme levels, she added.

Dr. Strand is also a biopharmaceutical consultant and has received consulting fees and other compensation from Amgen (which comarkets etanercept with Wyeth), Abbott (which markets adalimumab), and Centocor (which markets infliximab). Some of her associates in the study were employees of Amgen and others were consultants or speakers for these companies or received research funds from them. Dr. Strand and her coinvestigators also had associations with multiple other pharmaceutical companies.

The cohorts and comparison group had mean ages of 56–62 years, and 73%-80% were female.

SAN FRANCISCO — Patients being treated for rheumatoid arthritis with infliximab or adalimumab—but not etanercept—were more likely to have elevated levels of liver enzymes, compared with patients on nonbiologic disease-modifying antirheumatic drugs, analyses of data on 6,861 patients found.

Most elevations in alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels with any of the treatments were transient, however, and unlikely to lead to discontinuation. Abnormal levels of ALT or AST were rare, Dr. Vibeke Strand and her associates reported in a poster presentation at the annual meeting of the American College of Rheumatology. Elevations were defined as test results above the upper limit of normal, and abnormal levels were results more than double the upper limit of normal.

After researchers controlled for the effects of other factors, the risk of elevated or abnormal liver enzyme levels was 58% higher in 1,449 patients on infliximab (Remicade) and 35% higher in 849 patients on adalimumab (Humira), but no different in 1,383 patients on etanercept (Enbrel), compared with 4,147 patients on oral DMARDs, with or without a tumor necrosis factor (TNF) inhibitor.

The investigators performed six analyses of data from the Consortium of Rheumatology Researchers of North America. Patients with normal transaminase levels at baseline were divided into three cohorts—prevalent TNF inhibitor users, patients initiating TNF inhibitor therapy, and patients on concomitant TNF inhibitor and methotrexate therapy—and their liver enzyme levels were compared with those of nonbiologic DMARD users. The study excluded patients with psoriatic arthritis.

The risk of elevated liver enzyme levels was significantly higher with infliximab in all three cohorts (a 36%-69% increase) and was higher with adalimumab in two cohorts (a 35%-44% increase). The risk of abnormal enzyme levels was significantly higher with infliximab in two cohorts (a 40%-47% increase) and was higher with adalimumab in one cohort (a 32% increase).

Assuming that enzyme levels normalized in patients for whom there were no follow-up data, 17% of 1,210 elevations persisted at the next visit, and 7% of 143 abnormalities persisted. Among patients with elevated enzyme levels, 4% discontinued a TNF inhibitor and 11% discontinued a nonbiologic DMARD. Among patients with abnormalities found on liver function tests, 6% discontinued a TNF inhibitor and 24% discontinued a DMARD.

“Use of TNF inhibitors does not appear to be associated with clinically meaningful hepatic events in most patients,” concluded Dr. Strand of Stanford (Calif.) University. The results suggest that recommendations for monitoring nonbiologic DMARD therapy could safely guide clinicians in deciding when to reduce or discontinue TNF inhibitor therapy based on liver enzyme levels, she added.

Dr. Strand is also a biopharmaceutical consultant and has received consulting fees and other compensation from Amgen (which comarkets etanercept with Wyeth), Abbott (which markets adalimumab), and Centocor (which markets infliximab). Some of her associates in the study were employees of Amgen and others were consultants or speakers for these companies or received research funds from them. Dr. Strand and her coinvestigators also had associations with multiple other pharmaceutical companies.

The cohorts and comparison group had mean ages of 56–62 years, and 73%-80% were female.

SAN FRANCISCO — Off-pump coronary artery bypass grafting was associated with greater costs and length of hospitalization and no difference in the risks of death or stroke, compared with conventional on-pump procedures in a review of 63,061 cases.

The findings are sure to fuel the controversy over which type of coronary artery bypass grafting (CABG) is better—the conventional on-pump (using cardiopulmonary bypass) approach or the more recent off-pump CABG. Some previous studies have shown improved outcomes with off-pump CABG, whereas others have shown worse outcomes.

In the current study, 14,392 patients who underwent CABG without cardiopulmonary bypass pumps averaged 10.2 days in the hospital, compared with 9.9 days in 48,669 patients who had on-pump CABG, a statistically significant difference. After a multivariable logistic regression analysis, off-pump CABG was associated with an extra 0.6 days in the hospital and $1,497 in higher costs, Dr. Danny Chu and his associates reported at the annual meeting of the Society of Thoracic Surgeons.

In-hospital death rates—the primary outcome in the analysis—were about 3% in each group. The incidence of postoperative stroke was about 2% in each group. These rates did not differ significantly between groups.

“Off-pump coronary artery bypass should be an alternative to, not a replacement for, the traditional on-pump CABG,” said Dr. Chu of Baylor College of Medicine, Houston. “We do not believe that performing off-pump CABG on all patients is justifiable.”

Dr. Chu and his associates had no potential conflicts of interest.

The study analyzed data on all U.S. patients undergoing isolated CABG and no concomitant cardiac operations in 2004, using records from the nonvoluntary Nationwide Inpatient Sample (NIS) database maintained by the Agency for Healthcare Research and Quality.

Several preoperative characteristics differed significantly between groups. The off-pump patients averaged a year younger in age than on-pump patients (65 vs. 66 years) and were more likely to be female (31% vs. 29%) and to be emergency cases (29% vs. 25%).

The analysis stratified patients for risk using the Deyo Comorbidity Index, a modification of the validated Charlson Comorbidity Index.

Commenting on the study after Dr. Chu's presentation, Dr. John D. Puskas criticized the investigators' use of an administrative database like the NIS for the purpose of clinical outcomes analysis. The study's conclusions “cannot be justified,” said Dr. Puskas, chief of cardiac surgery at Emory Crawford Long Hospital, Atlanta.

Dr. Puskas is a consultant to, and has received research funds from, Medtronic Inc. and Marquet Medical Systems, which make devices used in CABG (both on- and off-pump). He also has received royalties from coronary instruments marketed by Scanlan International Inc.

Dr. Puskas also was the primary investigator in a review of records on 42,477 consecutive, nonemergency, isolated CABG surgeries, using data from the Society of Thoracic Surgeons National Cardiac Adult Database. His study concluded that off-pump CABG was associated with a 17% lower risk of death, a 35% lower risk of stroke, a 33% lower risk of MI, and a 29% lower risk of major adverse cardiac events compared with on-pump CABG, all significant differences (Ann. Thorac. Surg. 2007;84:1447-56).

“These are very tight data, and they are compelling. This is the most sophisticated and complete risk-adjusted assessment possible, with a very vigorous database,” he said.

A separate recent analysis of the NIS database that analyzed CABG outcomes based on patients' differing coronary anatomy found lower risks for death, MI, stroke, or major adverse cardiac events with off-pump CABG than with on-pump, he added.

'Off-pump coronary artery bypass should be an alternative to, not a replacement for, the traditional on-pump CABG.' DR. CHU

SAN FRANCISCO — Off-pump coronary artery bypass grafting was associated with greater costs and length of hospitalization and no difference in the risks of death or stroke, compared with conventional on-pump procedures in a review of 63,061 cases.

The findings are sure to fuel the controversy over which type of coronary artery bypass grafting (CABG) is better—the conventional on-pump (using cardiopulmonary bypass) approach or the more recent off-pump CABG. Some previous studies have shown improved outcomes with off-pump CABG, whereas others have shown worse outcomes.

In the current study, 14,392 patients who underwent CABG without cardiopulmonary bypass pumps averaged 10.2 days in the hospital, compared with 9.9 days in 48,669 patients who had on-pump CABG, a statistically significant difference. After a multivariable logistic regression analysis, off-pump CABG was associated with an extra 0.6 days in the hospital and $1,497 in higher costs, Dr. Danny Chu and his associates reported at the annual meeting of the Society of Thoracic Surgeons.

In-hospital death rates—the primary outcome in the analysis—were about 3% in each group. The incidence of postoperative stroke was about 2% in each group. These rates did not differ significantly between groups.

“Off-pump coronary artery bypass should be an alternative to, not a replacement for, the traditional on-pump CABG,” said Dr. Chu of Baylor College of Medicine, Houston. “We do not believe that performing off-pump CABG on all patients is justifiable.”

Dr. Chu and his associates had no potential conflicts of interest.

The study analyzed data on all U.S. patients undergoing isolated CABG and no concomitant cardiac operations in 2004, using records from the nonvoluntary Nationwide Inpatient Sample (NIS) database maintained by the Agency for Healthcare Research and Quality.

Several preoperative characteristics differed significantly between groups. The off-pump patients averaged a year younger in age than on-pump patients (65 vs. 66 years) and were more likely to be female (31% vs. 29%) and to be emergency cases (29% vs. 25%).

The analysis stratified patients for risk using the Deyo Comorbidity Index, a modification of the validated Charlson Comorbidity Index.

Commenting on the study after Dr. Chu's presentation, Dr. John D. Puskas criticized the investigators' use of an administrative database like the NIS for the purpose of clinical outcomes analysis. The study's conclusions “cannot be justified,” said Dr. Puskas, chief of cardiac surgery at Emory Crawford Long Hospital, Atlanta.

Dr. Puskas is a consultant to, and has received research funds from, Medtronic Inc. and Marquet Medical Systems, which make devices used in CABG (both on- and off-pump). He also has received royalties from coronary instruments marketed by Scanlan International Inc.

Dr. Puskas also was the primary investigator in a review of records on 42,477 consecutive, nonemergency, isolated CABG surgeries, using data from the Society of Thoracic Surgeons National Cardiac Adult Database. His study concluded that off-pump CABG was associated with a 17% lower risk of death, a 35% lower risk of stroke, a 33% lower risk of MI, and a 29% lower risk of major adverse cardiac events compared with on-pump CABG, all significant differences (Ann. Thorac. Surg. 2007;84:1447-56).

“These are very tight data, and they are compelling. This is the most sophisticated and complete risk-adjusted assessment possible, with a very vigorous database,” he said.

A separate recent analysis of the NIS database that analyzed CABG outcomes based on patients' differing coronary anatomy found lower risks for death, MI, stroke, or major adverse cardiac events with off-pump CABG than with on-pump, he added.

'Off-pump coronary artery bypass should be an alternative to, not a replacement for, the traditional on-pump CABG.' DR. CHU

SAN FRANCISCO — Off-pump coronary artery bypass grafting was associated with greater costs and length of hospitalization and no difference in the risks of death or stroke, compared with conventional on-pump procedures in a review of 63,061 cases.

The findings are sure to fuel the controversy over which type of coronary artery bypass grafting (CABG) is better—the conventional on-pump (using cardiopulmonary bypass) approach or the more recent off-pump CABG. Some previous studies have shown improved outcomes with off-pump CABG, whereas others have shown worse outcomes.

In the current study, 14,392 patients who underwent CABG without cardiopulmonary bypass pumps averaged 10.2 days in the hospital, compared with 9.9 days in 48,669 patients who had on-pump CABG, a statistically significant difference. After a multivariable logistic regression analysis, off-pump CABG was associated with an extra 0.6 days in the hospital and $1,497 in higher costs, Dr. Danny Chu and his associates reported at the annual meeting of the Society of Thoracic Surgeons.

In-hospital death rates—the primary outcome in the analysis—were about 3% in each group. The incidence of postoperative stroke was about 2% in each group. These rates did not differ significantly between groups.

“Off-pump coronary artery bypass should be an alternative to, not a replacement for, the traditional on-pump CABG,” said Dr. Chu of Baylor College of Medicine, Houston. “We do not believe that performing off-pump CABG on all patients is justifiable.”

Dr. Chu and his associates had no potential conflicts of interest.

The study analyzed data on all U.S. patients undergoing isolated CABG and no concomitant cardiac operations in 2004, using records from the nonvoluntary Nationwide Inpatient Sample (NIS) database maintained by the Agency for Healthcare Research and Quality.

Several preoperative characteristics differed significantly between groups. The off-pump patients averaged a year younger in age than on-pump patients (65 vs. 66 years) and were more likely to be female (31% vs. 29%) and to be emergency cases (29% vs. 25%).

The analysis stratified patients for risk using the Deyo Comorbidity Index, a modification of the validated Charlson Comorbidity Index.

Commenting on the study after Dr. Chu's presentation, Dr. John D. Puskas criticized the investigators' use of an administrative database like the NIS for the purpose of clinical outcomes analysis. The study's conclusions “cannot be justified,” said Dr. Puskas, chief of cardiac surgery at Emory Crawford Long Hospital, Atlanta.

Dr. Puskas is a consultant to, and has received research funds from, Medtronic Inc. and Marquet Medical Systems, which make devices used in CABG (both on- and off-pump). He also has received royalties from coronary instruments marketed by Scanlan International Inc.

Dr. Puskas also was the primary investigator in a review of records on 42,477 consecutive, nonemergency, isolated CABG surgeries, using data from the Society of Thoracic Surgeons National Cardiac Adult Database. His study concluded that off-pump CABG was associated with a 17% lower risk of death, a 35% lower risk of stroke, a 33% lower risk of MI, and a 29% lower risk of major adverse cardiac events compared with on-pump CABG, all significant differences (Ann. Thorac. Surg. 2007;84:1447-56).

“These are very tight data, and they are compelling. This is the most sophisticated and complete risk-adjusted assessment possible, with a very vigorous database,” he said.

A separate recent analysis of the NIS database that analyzed CABG outcomes based on patients' differing coronary anatomy found lower risks for death, MI, stroke, or major adverse cardiac events with off-pump CABG than with on-pump, he added.

'Off-pump coronary artery bypass should be an alternative to, not a replacement for, the traditional on-pump CABG.' DR. CHU

SAN FRANCISCO — Clinicians detected underlying rheumatic disease in 17 of 28 patients referred to a multidisciplinary clinic for interstitial lung disease.

The evaluations changed the diagnosis in 11 of the 28 patients, including 4 of 15 who had been referred for idiopathic interstitial lung disease and 7 of 13 who had been referred for rheumatic disease related to interstitial lung disease. As a result, clinicians changed therapy for 14 (50%) of the patients, Dr. Flavia V. Castelino and her associates reported at the annual meeting of the American College of Rheumatology.

All patients with interstitial lung disease should be evaluated by a rheumatologist, said Dr. Castelino of Massachusetts General Hospital, Boston.

Distinguishing between interstitial lung disease that is idiopathic versus related to rheumatic disease is important because the former carries a worse prognosis, and the response to treatment may differ, Dr. Castelino said.

A separate retrospective study of 362 cases of interstitial lung disease found 5-year survival rates of approximately 40% with idiopathic disease and approximately 70% with cases that were associated with rheumatic disease (Am. J. Resp. Crit. Care Med. 2007;175:705–11).

The difference in prognosis is thought to be related to the major lung histopathology, previous data suggest. Nonspecific interstitial pneumonia was present in 4 (9%) of 47 patients with idiopathic interstitial lung disease and in 23 (83%) of 28 patients with undifferentiated connective tissue disease and interstitial lung disease in one study (Am. J. Resp. Crit. Care Med. 2007;176:691–7).

A separate previous study of 39 cases of interstitial lung disease found that community physicians were more likely to diagnose it as idiopathic disease, compared with retrospective diagnoses from a multidisciplinary academic team review by pulmonologists, radiologists, and pathologists (Am. J. Resp. Crit. Care Med. 2007;175:1054–60).

In the current prospective study of patients referred by pulmonologists over an 8-month period to a new multidisciplinary clinic at Brigham and Women's Hospital, Boston, all patients were evaluated by a pulmonologist and a rheumatologist, who took a complete history and physical examination (including capillary microscopy) and reviewed laboratory and serologic data. They reviewed available imaging and pathologic specimens in consultation with a dedicated radiologist and a pathologist experienced in interstitial lung disease.

Additional serologic tests, imaging, or biopsies were performed at the discretion of the clinic physicians. They initiated or changed therapy in collaboration with the referring physician.

Evaluations by a rheumatologist significantly affected diagnoses because of additional serologic testing (such as a myositis panel) and because the rheumatologist was able to elicit subtle clues that are suggestive of a rheumatologic diagnosis. Recognition of “mechanic's hands,” periungual erythema, abnormal capillary microscopy, and inflammatory arthritis led to new diagnoses including antisynthetase syndrome, systemic sclerosis, rheumatoid arthritis-associated interstitial lung disease, mixed connective tissue disease, dermatomyositis, and undifferentiated connective tissue disease.

The cohort was half female, with a median age of 63 years and a history of smoking in 23 patients (82%).

The investigators reported having no potential conflicts of interest related to this study.

All patients with interstitial lung disease should be evaluated by a rheumatologist. DR. CASTELINO

Clinicians detected underlying rheumatic disease in 61% of patients who were referred for interstitial lung disease. ©American College of Rheumatology Clinical Slide Collection 1972–2004

SAN FRANCISCO — Clinicians detected underlying rheumatic disease in 17 of 28 patients referred to a multidisciplinary clinic for interstitial lung disease.

The evaluations changed the diagnosis in 11 of the 28 patients, including 4 of 15 who had been referred for idiopathic interstitial lung disease and 7 of 13 who had been referred for rheumatic disease related to interstitial lung disease. As a result, clinicians changed therapy for 14 (50%) of the patients, Dr. Flavia V. Castelino and her associates reported at the annual meeting of the American College of Rheumatology.

All patients with interstitial lung disease should be evaluated by a rheumatologist, said Dr. Castelino of Massachusetts General Hospital, Boston.

Distinguishing between interstitial lung disease that is idiopathic versus related to rheumatic disease is important because the former carries a worse prognosis, and the response to treatment may differ, Dr. Castelino said.

A separate retrospective study of 362 cases of interstitial lung disease found 5-year survival rates of approximately 40% with idiopathic disease and approximately 70% with cases that were associated with rheumatic disease (Am. J. Resp. Crit. Care Med. 2007;175:705–11).

The difference in prognosis is thought to be related to the major lung histopathology, previous data suggest. Nonspecific interstitial pneumonia was present in 4 (9%) of 47 patients with idiopathic interstitial lung disease and in 23 (83%) of 28 patients with undifferentiated connective tissue disease and interstitial lung disease in one study (Am. J. Resp. Crit. Care Med. 2007;176:691–7).

A separate previous study of 39 cases of interstitial lung disease found that community physicians were more likely to diagnose it as idiopathic disease, compared with retrospective diagnoses from a multidisciplinary academic team review by pulmonologists, radiologists, and pathologists (Am. J. Resp. Crit. Care Med. 2007;175:1054–60).

In the current prospective study of patients referred by pulmonologists over an 8-month period to a new multidisciplinary clinic at Brigham and Women's Hospital, Boston, all patients were evaluated by a pulmonologist and a rheumatologist, who took a complete history and physical examination (including capillary microscopy) and reviewed laboratory and serologic data. They reviewed available imaging and pathologic specimens in consultation with a dedicated radiologist and a pathologist experienced in interstitial lung disease.

Additional serologic tests, imaging, or biopsies were performed at the discretion of the clinic physicians. They initiated or changed therapy in collaboration with the referring physician.

Evaluations by a rheumatologist significantly affected diagnoses because of additional serologic testing (such as a myositis panel) and because the rheumatologist was able to elicit subtle clues that are suggestive of a rheumatologic diagnosis. Recognition of “mechanic's hands,” periungual erythema, abnormal capillary microscopy, and inflammatory arthritis led to new diagnoses including antisynthetase syndrome, systemic sclerosis, rheumatoid arthritis-associated interstitial lung disease, mixed connective tissue disease, dermatomyositis, and undifferentiated connective tissue disease.

The cohort was half female, with a median age of 63 years and a history of smoking in 23 patients (82%).

The investigators reported having no potential conflicts of interest related to this study.

All patients with interstitial lung disease should be evaluated by a rheumatologist. DR. CASTELINO

Clinicians detected underlying rheumatic disease in 61% of patients who were referred for interstitial lung disease. ©American College of Rheumatology Clinical Slide Collection 1972–2004

SAN FRANCISCO — Clinicians detected underlying rheumatic disease in 17 of 28 patients referred to a multidisciplinary clinic for interstitial lung disease.

The evaluations changed the diagnosis in 11 of the 28 patients, including 4 of 15 who had been referred for idiopathic interstitial lung disease and 7 of 13 who had been referred for rheumatic disease related to interstitial lung disease. As a result, clinicians changed therapy for 14 (50%) of the patients, Dr. Flavia V. Castelino and her associates reported at the annual meeting of the American College of Rheumatology.

All patients with interstitial lung disease should be evaluated by a rheumatologist, said Dr. Castelino of Massachusetts General Hospital, Boston.

Distinguishing between interstitial lung disease that is idiopathic versus related to rheumatic disease is important because the former carries a worse prognosis, and the response to treatment may differ, Dr. Castelino said.

A separate retrospective study of 362 cases of interstitial lung disease found 5-year survival rates of approximately 40% with idiopathic disease and approximately 70% with cases that were associated with rheumatic disease (Am. J. Resp. Crit. Care Med. 2007;175:705–11).

The difference in prognosis is thought to be related to the major lung histopathology, previous data suggest. Nonspecific interstitial pneumonia was present in 4 (9%) of 47 patients with idiopathic interstitial lung disease and in 23 (83%) of 28 patients with undifferentiated connective tissue disease and interstitial lung disease in one study (Am. J. Resp. Crit. Care Med. 2007;176:691–7).

A separate previous study of 39 cases of interstitial lung disease found that community physicians were more likely to diagnose it as idiopathic disease, compared with retrospective diagnoses from a multidisciplinary academic team review by pulmonologists, radiologists, and pathologists (Am. J. Resp. Crit. Care Med. 2007;175:1054–60).

In the current prospective study of patients referred by pulmonologists over an 8-month period to a new multidisciplinary clinic at Brigham and Women's Hospital, Boston, all patients were evaluated by a pulmonologist and a rheumatologist, who took a complete history and physical examination (including capillary microscopy) and reviewed laboratory and serologic data. They reviewed available imaging and pathologic specimens in consultation with a dedicated radiologist and a pathologist experienced in interstitial lung disease.

Additional serologic tests, imaging, or biopsies were performed at the discretion of the clinic physicians. They initiated or changed therapy in collaboration with the referring physician.

Evaluations by a rheumatologist significantly affected diagnoses because of additional serologic testing (such as a myositis panel) and because the rheumatologist was able to elicit subtle clues that are suggestive of a rheumatologic diagnosis. Recognition of “mechanic's hands,” periungual erythema, abnormal capillary microscopy, and inflammatory arthritis led to new diagnoses including antisynthetase syndrome, systemic sclerosis, rheumatoid arthritis-associated interstitial lung disease, mixed connective tissue disease, dermatomyositis, and undifferentiated connective tissue disease.

The cohort was half female, with a median age of 63 years and a history of smoking in 23 patients (82%).

The investigators reported having no potential conflicts of interest related to this study.

All patients with interstitial lung disease should be evaluated by a rheumatologist. DR. CASTELINO

Clinicians detected underlying rheumatic disease in 61% of patients who were referred for interstitial lung disease. ©American College of Rheumatology Clinical Slide Collection 1972–2004

SAN FRANCISCO — Physicians think of fibromyalgia as a disorder of central sensitization, but thinking of it in terms of subsets of tender points may improve understanding and speed diagnosis, suggest findings from two small studies.

The 1990 American College of Rheumatology's diagnostic criteria for fibromyalgia rely heavily on patients' reports of pain, and require that a patient feel pain at a minimum of 11 out of 18 tender points. An analysis of data on 748 patients with fibromyalgia identified subsets of tender points that might be used to speed diagnosis, Dr. Terence W. Starz said in a poster presentation at the college's annual meeting.

Clinicians conducted the Manual Tender Point Survey (MTPS) on the 18 standard tender points and 3 control points on patients enrolled in a separate treatment trial. Through a principal components factor analysis, they described three key body regions with tender point subsets: the neck/shoulders, the gluteal and trochanteric tender points, and extremity points on the lateral epicondyle and knee.

Examining two tender points from each of those regions may suffice to diagnose fibromyalgia, but further research is needed to validate this strategy and to identify the most useful tender points, reported Dr. Starz, a rheumatologist at the University of Pittsburgh Medical Center, and his associates.

“I think we can get it down to around six tender points” for diagnosis, he said at the poster session.

Patients in the study averaged 50 years in age, and 95% were women.

Dr. Starz also was an investigator in a separate study led by Dr. Molly T. Vogt, also of the university, that reinforces the idea of thinking about fibromyalgia pain in regional body areas instead of as widespread pain.

A total of 50 patients with fibromyalgia who were seen in a community rheumatology practice completed a questionnaire to localize the musculoskeletal pain they experienced during daily life, and to rate their pain severity on a scale of 0-10. Clinicians performed the MTPS on 18 tender points, 3 control points, and 5 additional sites on the head, then averaged the 18 tender point scores to get a Fibromyalgia Intensity Score (FIS).

Certain areas–the posterior neck, shoulders, low back, hip girdle, and knees–were more intensely symptomatic, Dr. Starz and his associates reported in a separate poster presentation.

The diffuse pain of fibromyalgia seldom was reported by patients or clinicians in some body areas that have the largest sensory cortical representation: the lips, tongue, ears, nose, and thumb. Both the patients' subjective pain measures and the clinician measures yielded similar results.

“Is every place tender in fibromyalgia? No,” Dr. Starz said. The findings suggest that it may be important to investigate local pain generators, especially in the cervical and lumbar spine, the investigators concluded.

The severest pain most often was reported in the low back, outer hips, shoulders, back of the neck, and knees (each reported by more than 90% of patients with severe pain on FIS). Patients with higher-intensity pain were more likely to report pain in peripheral body sites than were patients with less-intense pain.

In the total cohort, 61% had no pain in the ears, either in patient reports or on clinical exam; 69% had no pain in the nose; 80% had no pain in the tongue; 81% had no pain in the lips; and 76% had no pain in fingernails.

Pain was present in the neck and back, the shoulders, and the outer hip in 94% of patients, in the knees in 92%, in the buttocks in 62%, and in the front of the neck in 60%, Dr. Starz reported.

SAN FRANCISCO — Physicians think of fibromyalgia as a disorder of central sensitization, but thinking of it in terms of subsets of tender points may improve understanding and speed diagnosis, suggest findings from two small studies.

The 1990 American College of Rheumatology's diagnostic criteria for fibromyalgia rely heavily on patients' reports of pain, and require that a patient feel pain at a minimum of 11 out of 18 tender points. An analysis of data on 748 patients with fibromyalgia identified subsets of tender points that might be used to speed diagnosis, Dr. Terence W. Starz said in a poster presentation at the college's annual meeting.

Clinicians conducted the Manual Tender Point Survey (MTPS) on the 18 standard tender points and 3 control points on patients enrolled in a separate treatment trial. Through a principal components factor analysis, they described three key body regions with tender point subsets: the neck/shoulders, the gluteal and trochanteric tender points, and extremity points on the lateral epicondyle and knee.

Examining two tender points from each of those regions may suffice to diagnose fibromyalgia, but further research is needed to validate this strategy and to identify the most useful tender points, reported Dr. Starz, a rheumatologist at the University of Pittsburgh Medical Center, and his associates.

“I think we can get it down to around six tender points” for diagnosis, he said at the poster session.

Patients in the study averaged 50 years in age, and 95% were women.

Dr. Starz also was an investigator in a separate study led by Dr. Molly T. Vogt, also of the university, that reinforces the idea of thinking about fibromyalgia pain in regional body areas instead of as widespread pain.

A total of 50 patients with fibromyalgia who were seen in a community rheumatology practice completed a questionnaire to localize the musculoskeletal pain they experienced during daily life, and to rate their pain severity on a scale of 0-10. Clinicians performed the MTPS on 18 tender points, 3 control points, and 5 additional sites on the head, then averaged the 18 tender point scores to get a Fibromyalgia Intensity Score (FIS).

Certain areas–the posterior neck, shoulders, low back, hip girdle, and knees–were more intensely symptomatic, Dr. Starz and his associates reported in a separate poster presentation.

The diffuse pain of fibromyalgia seldom was reported by patients or clinicians in some body areas that have the largest sensory cortical representation: the lips, tongue, ears, nose, and thumb. Both the patients' subjective pain measures and the clinician measures yielded similar results.

“Is every place tender in fibromyalgia? No,” Dr. Starz said. The findings suggest that it may be important to investigate local pain generators, especially in the cervical and lumbar spine, the investigators concluded.

The severest pain most often was reported in the low back, outer hips, shoulders, back of the neck, and knees (each reported by more than 90% of patients with severe pain on FIS). Patients with higher-intensity pain were more likely to report pain in peripheral body sites than were patients with less-intense pain.

In the total cohort, 61% had no pain in the ears, either in patient reports or on clinical exam; 69% had no pain in the nose; 80% had no pain in the tongue; 81% had no pain in the lips; and 76% had no pain in fingernails.

Pain was present in the neck and back, the shoulders, and the outer hip in 94% of patients, in the knees in 92%, in the buttocks in 62%, and in the front of the neck in 60%, Dr. Starz reported.

SAN FRANCISCO — Physicians think of fibromyalgia as a disorder of central sensitization, but thinking of it in terms of subsets of tender points may improve understanding and speed diagnosis, suggest findings from two small studies.

The 1990 American College of Rheumatology's diagnostic criteria for fibromyalgia rely heavily on patients' reports of pain, and require that a patient feel pain at a minimum of 11 out of 18 tender points. An analysis of data on 748 patients with fibromyalgia identified subsets of tender points that might be used to speed diagnosis, Dr. Terence W. Starz said in a poster presentation at the college's annual meeting.

Clinicians conducted the Manual Tender Point Survey (MTPS) on the 18 standard tender points and 3 control points on patients enrolled in a separate treatment trial. Through a principal components factor analysis, they described three key body regions with tender point subsets: the neck/shoulders, the gluteal and trochanteric tender points, and extremity points on the lateral epicondyle and knee.

Examining two tender points from each of those regions may suffice to diagnose fibromyalgia, but further research is needed to validate this strategy and to identify the most useful tender points, reported Dr. Starz, a rheumatologist at the University of Pittsburgh Medical Center, and his associates.

“I think we can get it down to around six tender points” for diagnosis, he said at the poster session.

Patients in the study averaged 50 years in age, and 95% were women.

Dr. Starz also was an investigator in a separate study led by Dr. Molly T. Vogt, also of the university, that reinforces the idea of thinking about fibromyalgia pain in regional body areas instead of as widespread pain.

A total of 50 patients with fibromyalgia who were seen in a community rheumatology practice completed a questionnaire to localize the musculoskeletal pain they experienced during daily life, and to rate their pain severity on a scale of 0-10. Clinicians performed the MTPS on 18 tender points, 3 control points, and 5 additional sites on the head, then averaged the 18 tender point scores to get a Fibromyalgia Intensity Score (FIS).

Certain areas–the posterior neck, shoulders, low back, hip girdle, and knees–were more intensely symptomatic, Dr. Starz and his associates reported in a separate poster presentation.

The diffuse pain of fibromyalgia seldom was reported by patients or clinicians in some body areas that have the largest sensory cortical representation: the lips, tongue, ears, nose, and thumb. Both the patients' subjective pain measures and the clinician measures yielded similar results.

“Is every place tender in fibromyalgia? No,” Dr. Starz said. The findings suggest that it may be important to investigate local pain generators, especially in the cervical and lumbar spine, the investigators concluded.

The severest pain most often was reported in the low back, outer hips, shoulders, back of the neck, and knees (each reported by more than 90% of patients with severe pain on FIS). Patients with higher-intensity pain were more likely to report pain in peripheral body sites than were patients with less-intense pain.

In the total cohort, 61% had no pain in the ears, either in patient reports or on clinical exam; 69% had no pain in the nose; 80% had no pain in the tongue; 81% had no pain in the lips; and 76% had no pain in fingernails.

Pain was present in the neck and back, the shoulders, and the outer hip in 94% of patients, in the knees in 92%, in the buttocks in 62%, and in the front of the neck in 60%, Dr. Starz reported.

STANFORD, CALIF. — A teenage patient complains of “heavy” menstrual periods. Her mother mentions that her daughter never gets periods during soccer season.

Should you evaluate the girl for abnormal uterine bleeding? Or is a bit of hand-holding going to be enough in this situation?

Test your knowledge of what's normal or abnormal for teenage menstruation by taking the true or false quiz (see box) before reading the commentary below.

The average ages at which girls reach puberty and menarche have been trending downward and vary by race, said Dr. Paula J. Hillard at a pediatric update sponsored by Stanford University.

Puberty and menarche generally arrive several months earlier for African American girls than for white girls, studies in the past decade have shown. While only 7% of white girls had “early” breast development or pubic hair by age 7 years, this occurred in 27% of African American girls (Pediatrics 1997;99:505–12).

Guidelines suggest not evaluating for precocious puberty unless breast development or pubic hair occurs before age 7 years in white girls or before age 6 years in African American girls. If there are other signs or symptoms such as severe headache or neurologic symptoms, an evaluation is in order. “It could be a brain tumor,” said Dr. Hillard, professor of obstetrics and gynecology at the university.

The age at which girls start their periods has been declining since 1800. Declines in the age of menarche up until the 1960s resulted from positive changes such as better nutrition and less infectious disease. Since then, however, declines in the age of menarche seem to be related to negative changes such as overeating and limited physical activity, resulting in obesity. Chemical pollution also may be playing a role, and is an active area of research, she said.

Over the past 20 years, the age of menarche declined by 2 months in white girls and by more than 9 months in African American girls. Federal data in 1999–2002 showed the average age of menarche to be 12.5 years in whites and 12.1 years in non-Hispanic blacks and Mexican Americans (J. Pediatr. 2005;147:753–60). The duration of menstrual bleeding has held steady, lasting 2–7 days per period in 92% of teen girls.

Evidence-based medicine suggests that “early” or “late” menarche can be defined as 2.5 standard deviations from the mean (ages 9 or 15 years for white girls), said Dr. Hillard, who did not have similar data for African American girls.

An evaluation would be appropriate if a girl has no menses by age 15 years. An evaluation also is warranted if there's no breast development by age 13 years, if menses haven't started 2.5–3 years after breast development, or if the patient is 14 years old with obesity, moderate to severe acne, and hirsutism.

Consider polycystic ovarian syndrome (PCOS) or anorexia nervosa or other eating disorders as possible causes. If the mother says her daughter never gets periods during soccer season, “this may be cause for concern,” Dr. Hillard said.

Early menstrual cycles in a girl's life may be anovulatory and shorter or longer than some others; they should not be chaotically irregular. Most cycles average 21–45 days in the first gynecologic year and trend toward shorter, more regular cycles with age. Beyond 90 days, evaluate for PCOS, eating disorders, thyroid disease, hyperprolactinemia, gonadal dysgenesis, or premature ovarian failure.

True or False Menstruation Quiz

1. The average age of puberty has been declining.

2. Pubertal development at about age 8 years constitutes precocious puberty.

3. Girls begin menstruating at an average age of 13 years.

4. The average age of menarche has been declining.

5. Normal menstrual periods last 2–7 days.

6. A girl who has not started menstruating by age 15 years should be evaluated.

7. In the first year of menses, it's normal to have anovulatory or chaotically irregular cycles.

8. Menstruation typically cycles every 21–45 days, but a 90-day cycle also is normal.

Quiz Answers: 1. True, 2. False, 3. False, 4. True, 5. True, 6. True, 7. False, 8. True

STANFORD, CALIF. — A teenage patient complains of “heavy” menstrual periods. Her mother mentions that her daughter never gets periods during soccer season.

Should you evaluate the girl for abnormal uterine bleeding? Or is a bit of hand-holding going to be enough in this situation?

Test your knowledge of what's normal or abnormal for teenage menstruation by taking the true or false quiz (see box) before reading the commentary below.

The average ages at which girls reach puberty and menarche have been trending downward and vary by race, said Dr. Paula J. Hillard at a pediatric update sponsored by Stanford University.

Puberty and menarche generally arrive several months earlier for African American girls than for white girls, studies in the past decade have shown. While only 7% of white girls had “early” breast development or pubic hair by age 7 years, this occurred in 27% of African American girls (Pediatrics 1997;99:505–12).

Guidelines suggest not evaluating for precocious puberty unless breast development or pubic hair occurs before age 7 years in white girls or before age 6 years in African American girls. If there are other signs or symptoms such as severe headache or neurologic symptoms, an evaluation is in order. “It could be a brain tumor,” said Dr. Hillard, professor of obstetrics and gynecology at the university.

The age at which girls start their periods has been declining since 1800. Declines in the age of menarche up until the 1960s resulted from positive changes such as better nutrition and less infectious disease. Since then, however, declines in the age of menarche seem to be related to negative changes such as overeating and limited physical activity, resulting in obesity. Chemical pollution also may be playing a role, and is an active area of research, she said.

Over the past 20 years, the age of menarche declined by 2 months in white girls and by more than 9 months in African American girls. Federal data in 1999–2002 showed the average age of menarche to be 12.5 years in whites and 12.1 years in non-Hispanic blacks and Mexican Americans (J. Pediatr. 2005;147:753–60). The duration of menstrual bleeding has held steady, lasting 2–7 days per period in 92% of teen girls.

Evidence-based medicine suggests that “early” or “late” menarche can be defined as 2.5 standard deviations from the mean (ages 9 or 15 years for white girls), said Dr. Hillard, who did not have similar data for African American girls.

An evaluation would be appropriate if a girl has no menses by age 15 years. An evaluation also is warranted if there's no breast development by age 13 years, if menses haven't started 2.5–3 years after breast development, or if the patient is 14 years old with obesity, moderate to severe acne, and hirsutism.

Consider polycystic ovarian syndrome (PCOS) or anorexia nervosa or other eating disorders as possible causes. If the mother says her daughter never gets periods during soccer season, “this may be cause for concern,” Dr. Hillard said.

Early menstrual cycles in a girl's life may be anovulatory and shorter or longer than some others; they should not be chaotically irregular. Most cycles average 21–45 days in the first gynecologic year and trend toward shorter, more regular cycles with age. Beyond 90 days, evaluate for PCOS, eating disorders, thyroid disease, hyperprolactinemia, gonadal dysgenesis, or premature ovarian failure.

True or False Menstruation Quiz

1. The average age of puberty has been declining.

2. Pubertal development at about age 8 years constitutes precocious puberty.

3. Girls begin menstruating at an average age of 13 years.

4. The average age of menarche has been declining.

5. Normal menstrual periods last 2–7 days.

6. A girl who has not started menstruating by age 15 years should be evaluated.

7. In the first year of menses, it's normal to have anovulatory or chaotically irregular cycles.

8. Menstruation typically cycles every 21–45 days, but a 90-day cycle also is normal.

Quiz Answers: 1. True, 2. False, 3. False, 4. True, 5. True, 6. True, 7. False, 8. True

STANFORD, CALIF. — A teenage patient complains of “heavy” menstrual periods. Her mother mentions that her daughter never gets periods during soccer season.

Should you evaluate the girl for abnormal uterine bleeding? Or is a bit of hand-holding going to be enough in this situation?

Test your knowledge of what's normal or abnormal for teenage menstruation by taking the true or false quiz (see box) before reading the commentary below.

The average ages at which girls reach puberty and menarche have been trending downward and vary by race, said Dr. Paula J. Hillard at a pediatric update sponsored by Stanford University.

Puberty and menarche generally arrive several months earlier for African American girls than for white girls, studies in the past decade have shown. While only 7% of white girls had “early” breast development or pubic hair by age 7 years, this occurred in 27% of African American girls (Pediatrics 1997;99:505–12).

Guidelines suggest not evaluating for precocious puberty unless breast development or pubic hair occurs before age 7 years in white girls or before age 6 years in African American girls. If there are other signs or symptoms such as severe headache or neurologic symptoms, an evaluation is in order. “It could be a brain tumor,” said Dr. Hillard, professor of obstetrics and gynecology at the university.

The age at which girls start their periods has been declining since 1800. Declines in the age of menarche up until the 1960s resulted from positive changes such as better nutrition and less infectious disease. Since then, however, declines in the age of menarche seem to be related to negative changes such as overeating and limited physical activity, resulting in obesity. Chemical pollution also may be playing a role, and is an active area of research, she said.

Over the past 20 years, the age of menarche declined by 2 months in white girls and by more than 9 months in African American girls. Federal data in 1999–2002 showed the average age of menarche to be 12.5 years in whites and 12.1 years in non-Hispanic blacks and Mexican Americans (J. Pediatr. 2005;147:753–60). The duration of menstrual bleeding has held steady, lasting 2–7 days per period in 92% of teen girls.

Evidence-based medicine suggests that “early” or “late” menarche can be defined as 2.5 standard deviations from the mean (ages 9 or 15 years for white girls), said Dr. Hillard, who did not have similar data for African American girls.

An evaluation would be appropriate if a girl has no menses by age 15 years. An evaluation also is warranted if there's no breast development by age 13 years, if menses haven't started 2.5–3 years after breast development, or if the patient is 14 years old with obesity, moderate to severe acne, and hirsutism.

Consider polycystic ovarian syndrome (PCOS) or anorexia nervosa or other eating disorders as possible causes. If the mother says her daughter never gets periods during soccer season, “this may be cause for concern,” Dr. Hillard said.

Early menstrual cycles in a girl's life may be anovulatory and shorter or longer than some others; they should not be chaotically irregular. Most cycles average 21–45 days in the first gynecologic year and trend toward shorter, more regular cycles with age. Beyond 90 days, evaluate for PCOS, eating disorders, thyroid disease, hyperprolactinemia, gonadal dysgenesis, or premature ovarian failure.

True or False Menstruation Quiz

1. The average age of puberty has been declining.

2. Pubertal development at about age 8 years constitutes precocious puberty.

3. Girls begin menstruating at an average age of 13 years.

4. The average age of menarche has been declining.

5. Normal menstrual periods last 2–7 days.

6. A girl who has not started menstruating by age 15 years should be evaluated.

7. In the first year of menses, it's normal to have anovulatory or chaotically irregular cycles.

8. Menstruation typically cycles every 21–45 days, but a 90-day cycle also is normal.

Quiz Answers: 1. True, 2. False, 3. False, 4. True, 5. True, 6. True, 7. False, 8. True