Sherry Boschert

SAN FRANCISCO — New guidelines from three major heart-specialty organizations on the use of implantable devices for heart rhythm abnormalities emphasize talking with patients about their needs and desires, and stress optimizing medical therapy.

“For the first time, we have addressed human needs and not just numbers,” such as ejection fractions, when considering implanting pacemakers, defibrillators, or cardiac resynchronization therapy (CRT) devices, Dr. Andrew E. Epstein said at a press conference at the annual meeting of the Hearth Rhythm Society (HRS). “We really need to talk to patients, be at the bedside, find out what they want, and see that their issues are addressed,” he said.

This has been implied in previous guidelines but never made as explicit as in the new guidelines issued jointly by the American College of Cardiology (ACC), the American Heart Association (AHA), and the HRS, said Dr. Epstein, chair of the joint task force that produced the new guidelines and professor of medicine at the University of Alabama at Birmingham.

“Especially with devices, the issue of recalls and safety advisories has interfered with the trust of the public with physicians. I think we have a credibility issue,” he said.

In addition to guidance on talking with patients before implanting devices, the guidelines for the first time also provide guidance on talking with patients about end-of-life care and when to turn off the devices.

The ACC/AHA/HRS “2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities” updates the 2002 joint guidelines by the ACC and AHA, and, more than ever, emphasizes the need for optimal medical therapy before the implantation of a cardiac device is considered.

“We're trying to emphasize that a global approach to patients is what saves lives,” Dr. Epstein said.

Optimal medical therapy may improve a patient's ejection fraction and quality of life after a heart attack to the point where an implantable device is not indicated.

The guidelines are the first to cover all cardiac implantable devices.

Data from recent studies and advances in device technology influenced some key changes in recommendations.

For example, evidence from MADIT II (the second Multicenter Automatic Defibrillator Implantation Trial) elevated the recommendation—that implantable cardiac defibrillators (ICDs) be used for primary prevention of sudden cardiac arrest in patients who have ischemic cardiomyopathy due to prior MI, have a left ventricular ejection fraction of less than 30%, and are New York Heart Association functional class I—from a class IIa recommendation (“it is reasonable”) to a class I recommendation (it “should be performed/administered”).

“We can very strongly tell physicians that primary prevention of sudden cardiac arrest is very important,” Dr. Epstein said.

Some studies published in recent years have made the issue of which ejection fraction should be the cutoff for initiating the consideration of implantable devices “very murky,” he added.

The new guidelines clarify that patients who have an ejection fraction of 35% or less should be considered for device implantation.

The section on the use of CRTs to manage heart failure has been expanded greatly, thanks to an abundance of recent trial data.

The guidelines primarily are evidence based, will be reviewed annually, and will evolve as technology advances.

“Indications for ICDs, CRT devices, and combined ICDs and CRT devices are [continually changing] and can be expected to change further as new trials are reported,” Dr. Epstein said.

In addition to addressing cardiac arrhythmias, heart failure, congenital heart disease, and sudden cardiac arrest as indications for device-based therapy, the new guidelines for the first time also address treatment for genetic disorders, including catecholaminergic polymorphic ventricular tachycardia, Brugada syndrome, arrhythmogenic right ventricular cardiomyopathy, and short QT syndrome.

The full text of the guidelines is posted on each group's Web site (www.acc.orgmy.americanheart.orgwww.hrsonline.org

The guidelines emphasize the need for optimal medical therapy before considering the implantation of a cardiac device, such as the pacemaker shown in the x-ray at left. ©UHB Trust/Getty Images

SAN FRANCISCO — New guidelines from three major heart-specialty organizations on the use of implantable devices for heart rhythm abnormalities emphasize talking with patients about their needs and desires, and stress optimizing medical therapy.

“For the first time, we have addressed human needs and not just numbers,” such as ejection fractions, when considering implanting pacemakers, defibrillators, or cardiac resynchronization therapy (CRT) devices, Dr. Andrew E. Epstein said at a press conference at the annual meeting of the Hearth Rhythm Society (HRS). “We really need to talk to patients, be at the bedside, find out what they want, and see that their issues are addressed,” he said.

This has been implied in previous guidelines but never made as explicit as in the new guidelines issued jointly by the American College of Cardiology (ACC), the American Heart Association (AHA), and the HRS, said Dr. Epstein, chair of the joint task force that produced the new guidelines and professor of medicine at the University of Alabama at Birmingham.

“Especially with devices, the issue of recalls and safety advisories has interfered with the trust of the public with physicians. I think we have a credibility issue,” he said.

In addition to guidance on talking with patients before implanting devices, the guidelines for the first time also provide guidance on talking with patients about end-of-life care and when to turn off the devices.

The ACC/AHA/HRS “2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities” updates the 2002 joint guidelines by the ACC and AHA, and, more than ever, emphasizes the need for optimal medical therapy before the implantation of a cardiac device is considered.

“We're trying to emphasize that a global approach to patients is what saves lives,” Dr. Epstein said.

Optimal medical therapy may improve a patient's ejection fraction and quality of life after a heart attack to the point where an implantable device is not indicated.

The guidelines are the first to cover all cardiac implantable devices.

Data from recent studies and advances in device technology influenced some key changes in recommendations.

For example, evidence from MADIT II (the second Multicenter Automatic Defibrillator Implantation Trial) elevated the recommendation—that implantable cardiac defibrillators (ICDs) be used for primary prevention of sudden cardiac arrest in patients who have ischemic cardiomyopathy due to prior MI, have a left ventricular ejection fraction of less than 30%, and are New York Heart Association functional class I—from a class IIa recommendation (“it is reasonable”) to a class I recommendation (it “should be performed/administered”).

“We can very strongly tell physicians that primary prevention of sudden cardiac arrest is very important,” Dr. Epstein said.

Some studies published in recent years have made the issue of which ejection fraction should be the cutoff for initiating the consideration of implantable devices “very murky,” he added.

The new guidelines clarify that patients who have an ejection fraction of 35% or less should be considered for device implantation.

The section on the use of CRTs to manage heart failure has been expanded greatly, thanks to an abundance of recent trial data.

The guidelines primarily are evidence based, will be reviewed annually, and will evolve as technology advances.

“Indications for ICDs, CRT devices, and combined ICDs and CRT devices are [continually changing] and can be expected to change further as new trials are reported,” Dr. Epstein said.

In addition to addressing cardiac arrhythmias, heart failure, congenital heart disease, and sudden cardiac arrest as indications for device-based therapy, the new guidelines for the first time also address treatment for genetic disorders, including catecholaminergic polymorphic ventricular tachycardia, Brugada syndrome, arrhythmogenic right ventricular cardiomyopathy, and short QT syndrome.

The full text of the guidelines is posted on each group's Web site (www.acc.orgmy.americanheart.orgwww.hrsonline.org

The guidelines emphasize the need for optimal medical therapy before considering the implantation of a cardiac device, such as the pacemaker shown in the x-ray at left. ©UHB Trust/Getty Images

SAN FRANCISCO — New guidelines from three major heart-specialty organizations on the use of implantable devices for heart rhythm abnormalities emphasize talking with patients about their needs and desires, and stress optimizing medical therapy.

“For the first time, we have addressed human needs and not just numbers,” such as ejection fractions, when considering implanting pacemakers, defibrillators, or cardiac resynchronization therapy (CRT) devices, Dr. Andrew E. Epstein said at a press conference at the annual meeting of the Hearth Rhythm Society (HRS). “We really need to talk to patients, be at the bedside, find out what they want, and see that their issues are addressed,” he said.

This has been implied in previous guidelines but never made as explicit as in the new guidelines issued jointly by the American College of Cardiology (ACC), the American Heart Association (AHA), and the HRS, said Dr. Epstein, chair of the joint task force that produced the new guidelines and professor of medicine at the University of Alabama at Birmingham.

“Especially with devices, the issue of recalls and safety advisories has interfered with the trust of the public with physicians. I think we have a credibility issue,” he said.

In addition to guidance on talking with patients before implanting devices, the guidelines for the first time also provide guidance on talking with patients about end-of-life care and when to turn off the devices.

The ACC/AHA/HRS “2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities” updates the 2002 joint guidelines by the ACC and AHA, and, more than ever, emphasizes the need for optimal medical therapy before the implantation of a cardiac device is considered.

“We're trying to emphasize that a global approach to patients is what saves lives,” Dr. Epstein said.

Optimal medical therapy may improve a patient's ejection fraction and quality of life after a heart attack to the point where an implantable device is not indicated.

The guidelines are the first to cover all cardiac implantable devices.

Data from recent studies and advances in device technology influenced some key changes in recommendations.

For example, evidence from MADIT II (the second Multicenter Automatic Defibrillator Implantation Trial) elevated the recommendation—that implantable cardiac defibrillators (ICDs) be used for primary prevention of sudden cardiac arrest in patients who have ischemic cardiomyopathy due to prior MI, have a left ventricular ejection fraction of less than 30%, and are New York Heart Association functional class I—from a class IIa recommendation (“it is reasonable”) to a class I recommendation (it “should be performed/administered”).

“We can very strongly tell physicians that primary prevention of sudden cardiac arrest is very important,” Dr. Epstein said.

Some studies published in recent years have made the issue of which ejection fraction should be the cutoff for initiating the consideration of implantable devices “very murky,” he added.

The new guidelines clarify that patients who have an ejection fraction of 35% or less should be considered for device implantation.

The section on the use of CRTs to manage heart failure has been expanded greatly, thanks to an abundance of recent trial data.

The guidelines primarily are evidence based, will be reviewed annually, and will evolve as technology advances.

“Indications for ICDs, CRT devices, and combined ICDs and CRT devices are [continually changing] and can be expected to change further as new trials are reported,” Dr. Epstein said.

In addition to addressing cardiac arrhythmias, heart failure, congenital heart disease, and sudden cardiac arrest as indications for device-based therapy, the new guidelines for the first time also address treatment for genetic disorders, including catecholaminergic polymorphic ventricular tachycardia, Brugada syndrome, arrhythmogenic right ventricular cardiomyopathy, and short QT syndrome.

The full text of the guidelines is posted on each group's Web site (www.acc.orgmy.americanheart.orgwww.hrsonline.org

The guidelines emphasize the need for optimal medical therapy before considering the implantation of a cardiac device, such as the pacemaker shown in the x-ray at left. ©UHB Trust/Getty Images

SAN FRANCISCO — Zoledronic acid therapy increased bone mineral density in men with nonmetastatic prostate cancer even when started more than a year after initiation of androgen deprivation therapy, Dr. William R. Broderick reported at a symposium on genitourinary cancers.

The double-blind study included 93 men with nonmetastatic prostate cancer who were initiating or already on androgen deprivation therapy (ADT). The patients were randomized to receive four courses of 4 mg IV of the bisphosphonate zoledronic acid at 3-month intervals or intravenous placebo therapy on the same schedule. All patients had bone mineral density T scores at or below −2.0 at baseline. Their bone densities in the lumbar spine, hips, and femoral necks were checked at 6 and 12 months by dual-energy x-ray absorptiometry (DXA) scans.

Among 50 men who had been on ADT for less than 1 year, spinal bone mineral density increased by 6% in the 26 randomized to zoledronic acid therapy and decreased by 3% in 24 men randomized to placebo. Among 43 men who had been on ADT for 1 year or longer, spinal bone mineral density increased by 6% in the 22 randomized to zoledronic acid therapy and by 2% in 21 men randomized to placebo, Dr. Broderick said at the symposium, which was sponsored by the American Society of Clinical Oncology, the American Society for Therapeutic Radiology and Oncology, and the Society of Urologic Oncology.

Spine density results differed significantly between the zoledronic acid and placebo groups, but did not between patients stratified by their amount of time on ADT, said Dr. Broderick of the Veterans Affairs Hospital in Hines, Ill., and of Loyola University Chicago, Maywood.

The study was funded by Novartis, which markets zoledronic acid as Zometa.

Androgen deprivation therapy for prostate cancer has been associated with increased risks for osteoporosis and fracture. Previous studies have shown that initiating bisphosphonate therapy when starting ADT can delay the development of osteopenia or osteoporosis, but no studies have looked at starting bisphosphonate therapy in these patients after they've been on androgen deprivation therapy for more than a year.

“It makes sense conceptually, but we never had the data to show it. Now we do,” Dr. Broderick said at his poster session. The current results also suggest that “perhaps we don't need to start bisphosphonate therapy up front in everyone,” which could save some expense and avoid side effects, he added. “Perhaps we can delay bisphosphonate therapy in these patients until we are starting to see that they are becoming osteopenic.”

The study was not designed to identify the best timing for starting bisphosphonate therapy in men on ADT, “but it does give us evidence that zoledronic acid works if we do start it at a later point in time” than usual, he said.

All the men in the study were started on 1,000 mg/day of supplemental calcium, 400 IU/day of vitamin D, counseling, weight-bearing exercise, and smoking cessation programs (if applicable). Demographics and other characteristics were similar between the group on androgen deprivation therapy for less than 1 year and the group with 1 or more years of ADT, except that those on ADT were significantly older—72 years, compared with 69 years.

SAN FRANCISCO — Zoledronic acid therapy increased bone mineral density in men with nonmetastatic prostate cancer even when started more than a year after initiation of androgen deprivation therapy, Dr. William R. Broderick reported at a symposium on genitourinary cancers.

The double-blind study included 93 men with nonmetastatic prostate cancer who were initiating or already on androgen deprivation therapy (ADT). The patients were randomized to receive four courses of 4 mg IV of the bisphosphonate zoledronic acid at 3-month intervals or intravenous placebo therapy on the same schedule. All patients had bone mineral density T scores at or below −2.0 at baseline. Their bone densities in the lumbar spine, hips, and femoral necks were checked at 6 and 12 months by dual-energy x-ray absorptiometry (DXA) scans.

Among 50 men who had been on ADT for less than 1 year, spinal bone mineral density increased by 6% in the 26 randomized to zoledronic acid therapy and decreased by 3% in 24 men randomized to placebo. Among 43 men who had been on ADT for 1 year or longer, spinal bone mineral density increased by 6% in the 22 randomized to zoledronic acid therapy and by 2% in 21 men randomized to placebo, Dr. Broderick said at the symposium, which was sponsored by the American Society of Clinical Oncology, the American Society for Therapeutic Radiology and Oncology, and the Society of Urologic Oncology.

Spine density results differed significantly between the zoledronic acid and placebo groups, but did not between patients stratified by their amount of time on ADT, said Dr. Broderick of the Veterans Affairs Hospital in Hines, Ill., and of Loyola University Chicago, Maywood.

The study was funded by Novartis, which markets zoledronic acid as Zometa.

Androgen deprivation therapy for prostate cancer has been associated with increased risks for osteoporosis and fracture. Previous studies have shown that initiating bisphosphonate therapy when starting ADT can delay the development of osteopenia or osteoporosis, but no studies have looked at starting bisphosphonate therapy in these patients after they've been on androgen deprivation therapy for more than a year.

“It makes sense conceptually, but we never had the data to show it. Now we do,” Dr. Broderick said at his poster session. The current results also suggest that “perhaps we don't need to start bisphosphonate therapy up front in everyone,” which could save some expense and avoid side effects, he added. “Perhaps we can delay bisphosphonate therapy in these patients until we are starting to see that they are becoming osteopenic.”

The study was not designed to identify the best timing for starting bisphosphonate therapy in men on ADT, “but it does give us evidence that zoledronic acid works if we do start it at a later point in time” than usual, he said.

All the men in the study were started on 1,000 mg/day of supplemental calcium, 400 IU/day of vitamin D, counseling, weight-bearing exercise, and smoking cessation programs (if applicable). Demographics and other characteristics were similar between the group on androgen deprivation therapy for less than 1 year and the group with 1 or more years of ADT, except that those on ADT were significantly older—72 years, compared with 69 years.

SAN FRANCISCO — Zoledronic acid therapy increased bone mineral density in men with nonmetastatic prostate cancer even when started more than a year after initiation of androgen deprivation therapy, Dr. William R. Broderick reported at a symposium on genitourinary cancers.

The double-blind study included 93 men with nonmetastatic prostate cancer who were initiating or already on androgen deprivation therapy (ADT). The patients were randomized to receive four courses of 4 mg IV of the bisphosphonate zoledronic acid at 3-month intervals or intravenous placebo therapy on the same schedule. All patients had bone mineral density T scores at or below −2.0 at baseline. Their bone densities in the lumbar spine, hips, and femoral necks were checked at 6 and 12 months by dual-energy x-ray absorptiometry (DXA) scans.

Among 50 men who had been on ADT for less than 1 year, spinal bone mineral density increased by 6% in the 26 randomized to zoledronic acid therapy and decreased by 3% in 24 men randomized to placebo. Among 43 men who had been on ADT for 1 year or longer, spinal bone mineral density increased by 6% in the 22 randomized to zoledronic acid therapy and by 2% in 21 men randomized to placebo, Dr. Broderick said at the symposium, which was sponsored by the American Society of Clinical Oncology, the American Society for Therapeutic Radiology and Oncology, and the Society of Urologic Oncology.

Spine density results differed significantly between the zoledronic acid and placebo groups, but did not between patients stratified by their amount of time on ADT, said Dr. Broderick of the Veterans Affairs Hospital in Hines, Ill., and of Loyola University Chicago, Maywood.

The study was funded by Novartis, which markets zoledronic acid as Zometa.

Androgen deprivation therapy for prostate cancer has been associated with increased risks for osteoporosis and fracture. Previous studies have shown that initiating bisphosphonate therapy when starting ADT can delay the development of osteopenia or osteoporosis, but no studies have looked at starting bisphosphonate therapy in these patients after they've been on androgen deprivation therapy for more than a year.

“It makes sense conceptually, but we never had the data to show it. Now we do,” Dr. Broderick said at his poster session. The current results also suggest that “perhaps we don't need to start bisphosphonate therapy up front in everyone,” which could save some expense and avoid side effects, he added. “Perhaps we can delay bisphosphonate therapy in these patients until we are starting to see that they are becoming osteopenic.”

The study was not designed to identify the best timing for starting bisphosphonate therapy in men on ADT, “but it does give us evidence that zoledronic acid works if we do start it at a later point in time” than usual, he said.

All the men in the study were started on 1,000 mg/day of supplemental calcium, 400 IU/day of vitamin D, counseling, weight-bearing exercise, and smoking cessation programs (if applicable). Demographics and other characteristics were similar between the group on androgen deprivation therapy for less than 1 year and the group with 1 or more years of ADT, except that those on ADT were significantly older—72 years, compared with 69 years.

NEWPORT BEACH, CALIF. — Among 64 adolescent females with platelet function disorders, 26 (41%) presented with menorrhagia, which was the only symptom at presentation in 16 patients (25%) in the cohort, a retrospective review found.

Ten patients (16%) who presented with menorrhagia also had one or more symptoms of bleeding disorders, including epistaxis in nine patients, easy bruising in five patients, bleeding during surgery and/or dental procedures in four patients, and gingival bleeding in one patient, Dr. Lawrence S. Amesse and his associates reported in a poster presentation at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Platelet function disorders should be considered as an etiology in all adolescents with menorrhagia, said Dr. Amesse, a reproductive endocrinologist at Wright State University, Dayton, Ohio.

Menorrhagia is a common problem, but little is known about presentation patterns or associated findings in adolescent girls, he noted. Platelet function disorders, which are hemostatic conditions, have drawn increasing attention as a cause of menorrhagia in adolescents. Inherited bleeding disorders are more common than previously suspected, affecting 1%–3% of the U.S. population, separate data suggest.

The review of records found 64 females aged 9–22 years with platelet function disorders who were seen at the West Central Ohio Hemophilia Center and a university pediatric/adolescent gynecology service in 2001–2007. The patients presenting with menorrhagia were 10–19 years of age and were diagnosed with platelet function disorders at a mean age of 15 years.

Among the 26 patients presenting with menorrhagia, 22 presented with primary menorrhagia; in 4 patients, it was a secondary finding.

The records identified definitive causes of the platelet function disorders in 24 of the 26 patients with menorrhagia. Although von Willebrand's disease is the most common inherited bleeding disorder in the general population, storage pool defects were the main etiology in these girls with platelet function disorders and menorrhagia, affecting 15 of the 24 patients, Dr. Amesse reported.

Seven patients had aspirinlike disorders (two of which were combined aspirinlike disorders and storage pool defects), one patient had a synthesis defect, and one patient had von Willebrand's disease. The two patients with no definitive etiology elucidated were labeled “dysfunctional,” the records showed.

Treatment with a single agent seemed to be as effective as combination therapy in controlling menorrhagia in this cohort, Dr. Amesse said. Eleven of 19 patients treated with aminocaproic acid, desmopressin acetate, or oral contraceptives achieved menstrual control. Nine of the 11 who gained control of menorrhagia had presented with primary menorrhagia and received only oral contraceptive therapy.

No patients whose menorrhagia was a secondary finding needed more than a single agent as treatment. Combination therapy in seven patients who presented with primary menorrhagia controlled menstrual bleeding in three of them.

A 2004 report on women with bleeding disorders from the National Heart, Lung, and Blood Institute said that data on menorrhagia in adolescence are extremely limited and the contribution of bleeding disorders to menorrhagia in adolescents is unknown.

A separate small, prospective study of 115 females with menorrhagia—from adolescents to perimenopausal women—found underlying hemostatic abnormalities in 47%, including platelet dysfunction, von Willebrand's disease, and coagulation factor deficiencies. Adolescents were as likely to have hemostatic abnormalities as were women aged 20–44 years (Obstet. Gynecol. 2005;105:61–6). Women presenting with menorrhagia should be considered for further hemostatic evaluation, the authors suggested.

NEWPORT BEACH, CALIF. — Among 64 adolescent females with platelet function disorders, 26 (41%) presented with menorrhagia, which was the only symptom at presentation in 16 patients (25%) in the cohort, a retrospective review found.

Ten patients (16%) who presented with menorrhagia also had one or more symptoms of bleeding disorders, including epistaxis in nine patients, easy bruising in five patients, bleeding during surgery and/or dental procedures in four patients, and gingival bleeding in one patient, Dr. Lawrence S. Amesse and his associates reported in a poster presentation at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Platelet function disorders should be considered as an etiology in all adolescents with menorrhagia, said Dr. Amesse, a reproductive endocrinologist at Wright State University, Dayton, Ohio.

Menorrhagia is a common problem, but little is known about presentation patterns or associated findings in adolescent girls, he noted. Platelet function disorders, which are hemostatic conditions, have drawn increasing attention as a cause of menorrhagia in adolescents. Inherited bleeding disorders are more common than previously suspected, affecting 1%–3% of the U.S. population, separate data suggest.

The review of records found 64 females aged 9–22 years with platelet function disorders who were seen at the West Central Ohio Hemophilia Center and a university pediatric/adolescent gynecology service in 2001–2007. The patients presenting with menorrhagia were 10–19 years of age and were diagnosed with platelet function disorders at a mean age of 15 years.

Among the 26 patients presenting with menorrhagia, 22 presented with primary menorrhagia; in 4 patients, it was a secondary finding.

The records identified definitive causes of the platelet function disorders in 24 of the 26 patients with menorrhagia. Although von Willebrand's disease is the most common inherited bleeding disorder in the general population, storage pool defects were the main etiology in these girls with platelet function disorders and menorrhagia, affecting 15 of the 24 patients, Dr. Amesse reported.

Seven patients had aspirinlike disorders (two of which were combined aspirinlike disorders and storage pool defects), one patient had a synthesis defect, and one patient had von Willebrand's disease. The two patients with no definitive etiology elucidated were labeled “dysfunctional,” the records showed.

Treatment with a single agent seemed to be as effective as combination therapy in controlling menorrhagia in this cohort, Dr. Amesse said. Eleven of 19 patients treated with aminocaproic acid, desmopressin acetate, or oral contraceptives achieved menstrual control. Nine of the 11 who gained control of menorrhagia had presented with primary menorrhagia and received only oral contraceptive therapy.

No patients whose menorrhagia was a secondary finding needed more than a single agent as treatment. Combination therapy in seven patients who presented with primary menorrhagia controlled menstrual bleeding in three of them.

A 2004 report on women with bleeding disorders from the National Heart, Lung, and Blood Institute said that data on menorrhagia in adolescence are extremely limited and the contribution of bleeding disorders to menorrhagia in adolescents is unknown.

A separate small, prospective study of 115 females with menorrhagia—from adolescents to perimenopausal women—found underlying hemostatic abnormalities in 47%, including platelet dysfunction, von Willebrand's disease, and coagulation factor deficiencies. Adolescents were as likely to have hemostatic abnormalities as were women aged 20–44 years (Obstet. Gynecol. 2005;105:61–6). Women presenting with menorrhagia should be considered for further hemostatic evaluation, the authors suggested.

NEWPORT BEACH, CALIF. — Among 64 adolescent females with platelet function disorders, 26 (41%) presented with menorrhagia, which was the only symptom at presentation in 16 patients (25%) in the cohort, a retrospective review found.

Ten patients (16%) who presented with menorrhagia also had one or more symptoms of bleeding disorders, including epistaxis in nine patients, easy bruising in five patients, bleeding during surgery and/or dental procedures in four patients, and gingival bleeding in one patient, Dr. Lawrence S. Amesse and his associates reported in a poster presentation at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Platelet function disorders should be considered as an etiology in all adolescents with menorrhagia, said Dr. Amesse, a reproductive endocrinologist at Wright State University, Dayton, Ohio.

Menorrhagia is a common problem, but little is known about presentation patterns or associated findings in adolescent girls, he noted. Platelet function disorders, which are hemostatic conditions, have drawn increasing attention as a cause of menorrhagia in adolescents. Inherited bleeding disorders are more common than previously suspected, affecting 1%–3% of the U.S. population, separate data suggest.

The review of records found 64 females aged 9–22 years with platelet function disorders who were seen at the West Central Ohio Hemophilia Center and a university pediatric/adolescent gynecology service in 2001–2007. The patients presenting with menorrhagia were 10–19 years of age and were diagnosed with platelet function disorders at a mean age of 15 years.

Among the 26 patients presenting with menorrhagia, 22 presented with primary menorrhagia; in 4 patients, it was a secondary finding.

The records identified definitive causes of the platelet function disorders in 24 of the 26 patients with menorrhagia. Although von Willebrand's disease is the most common inherited bleeding disorder in the general population, storage pool defects were the main etiology in these girls with platelet function disorders and menorrhagia, affecting 15 of the 24 patients, Dr. Amesse reported.

Seven patients had aspirinlike disorders (two of which were combined aspirinlike disorders and storage pool defects), one patient had a synthesis defect, and one patient had von Willebrand's disease. The two patients with no definitive etiology elucidated were labeled “dysfunctional,” the records showed.

Treatment with a single agent seemed to be as effective as combination therapy in controlling menorrhagia in this cohort, Dr. Amesse said. Eleven of 19 patients treated with aminocaproic acid, desmopressin acetate, or oral contraceptives achieved menstrual control. Nine of the 11 who gained control of menorrhagia had presented with primary menorrhagia and received only oral contraceptive therapy.

No patients whose menorrhagia was a secondary finding needed more than a single agent as treatment. Combination therapy in seven patients who presented with primary menorrhagia controlled menstrual bleeding in three of them.

A 2004 report on women with bleeding disorders from the National Heart, Lung, and Blood Institute said that data on menorrhagia in adolescence are extremely limited and the contribution of bleeding disorders to menorrhagia in adolescents is unknown.

A separate small, prospective study of 115 females with menorrhagia—from adolescents to perimenopausal women—found underlying hemostatic abnormalities in 47%, including platelet dysfunction, von Willebrand's disease, and coagulation factor deficiencies. Adolescents were as likely to have hemostatic abnormalities as were women aged 20–44 years (Obstet. Gynecol. 2005;105:61–6). Women presenting with menorrhagia should be considered for further hemostatic evaluation, the authors suggested.

SAN FRANCISCO — Check serum bile acid levels to determine if severe itching during pregnancy is the result of intrahepatic cholestasis of pregnancy, advises a dermatologic pathologist.

“Intrahepatic cholestasis of pregnancy is about the only dermatosis of pregnancy that has poor outcomes for the unborn,” Dr. Senait W. Dyson said at a meeting sponsored by Skin Disease Education Foundation.

An uncommon problem in the United States, intrahepatic cholestasis of pregnancy (also called prurigo gravidarum or obstetric cholestasis) is a reversible form of cholestasis that presents in late pregnancy and persists until delivery.

The disease increases the risk of intrauterine fetal distress and leads to a three- to fourfold increase in the risk of stillbirth.

It typically presents during the third trimester and resolves within days after delivery. Clinically, the problem is characterized by generalized, severe pruritus without primary skin lesions, said Dr. Dyson, director of dermatopathology at the University of California, Irvine. Involvement of the palms and soles is common. You'll seldom see jaundice with intrahepatic cholestasis of pregnancy.

The main diagnostic finding is increased serum bile acids in all cases, resulting from impaired bile flow. Elevated serum bile acid levels greater than 4.07 mcg/mL (10 micromol/L) in these patients can reach as high as 16 mcg/mL (40 micromol/L), she said.

Some patients will have abnormal liver function tests. Histology is nonspecific, and immunofluorescence tests will be negative.

Prolonged disease causes vitamin K deficiency and increases the risk for bleeding in the mother. It is not clear whether the bleeding risk increases in the infant. Check prothrombin times in women with intrahepatic cholestasis of pregnancy, Dr. Dyson advised. Women with increased prothrombin times should get vitamin K injections.

“Treatments that I use for other cholestasis diseases are not helpful in this condition,” she noted.

Antihistamines will help control the pruritus. Ursodeoxycholic acid (UDCA), the only approved medication to treat primary biliary cirrhosis, also helps improve pruritus in patients with intrahepatic cholestasis of pregnancy. Dr. Dyson said that most medical centers, including her institution, dose UDCA at 14 mg/kg per day t.i.d. to treat intrahepatic cholestasis of pregnancy from the time of diagnosis until delivery. Some clinicians suggest that dosages as high as 20–25 mg/kg per day t.i.d. might be better.

Delivery by 38 weeks' gestation is advisable, and some physicians suggest elective delivery by 37 weeks to decrease the risk of stillbirth, but it's not clear whether the potential benefits of delivering at 37 weeks outweigh the risks from preterm delivery, Dr. Dyson said.

“It's definitely agreed that patients should have frequent nonstress tests” and biophysical profiles to assess for fetal stress starting at 34 weeks' gestation, she said.

The incidence of intrahepatic cholestasis of pregnancy worldwide ranges from 10 to 760 cases per 10,000 pregnancies, with a higher incidence seen in Latin America (especially in Chile and Bolivia) and low rates in the United States and Europe.

Dr. Dyson reported having no conflicts of interest.

Skin Disease Education Foundation and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — Check serum bile acid levels to determine if severe itching during pregnancy is the result of intrahepatic cholestasis of pregnancy, advises a dermatologic pathologist.

“Intrahepatic cholestasis of pregnancy is about the only dermatosis of pregnancy that has poor outcomes for the unborn,” Dr. Senait W. Dyson said at a meeting sponsored by Skin Disease Education Foundation.

An uncommon problem in the United States, intrahepatic cholestasis of pregnancy (also called prurigo gravidarum or obstetric cholestasis) is a reversible form of cholestasis that presents in late pregnancy and persists until delivery.

The disease increases the risk of intrauterine fetal distress and leads to a three- to fourfold increase in the risk of stillbirth.

It typically presents during the third trimester and resolves within days after delivery. Clinically, the problem is characterized by generalized, severe pruritus without primary skin lesions, said Dr. Dyson, director of dermatopathology at the University of California, Irvine. Involvement of the palms and soles is common. You'll seldom see jaundice with intrahepatic cholestasis of pregnancy.

The main diagnostic finding is increased serum bile acids in all cases, resulting from impaired bile flow. Elevated serum bile acid levels greater than 4.07 mcg/mL (10 micromol/L) in these patients can reach as high as 16 mcg/mL (40 micromol/L), she said.

Some patients will have abnormal liver function tests. Histology is nonspecific, and immunofluorescence tests will be negative.

Prolonged disease causes vitamin K deficiency and increases the risk for bleeding in the mother. It is not clear whether the bleeding risk increases in the infant. Check prothrombin times in women with intrahepatic cholestasis of pregnancy, Dr. Dyson advised. Women with increased prothrombin times should get vitamin K injections.

“Treatments that I use for other cholestasis diseases are not helpful in this condition,” she noted.

Antihistamines will help control the pruritus. Ursodeoxycholic acid (UDCA), the only approved medication to treat primary biliary cirrhosis, also helps improve pruritus in patients with intrahepatic cholestasis of pregnancy. Dr. Dyson said that most medical centers, including her institution, dose UDCA at 14 mg/kg per day t.i.d. to treat intrahepatic cholestasis of pregnancy from the time of diagnosis until delivery. Some clinicians suggest that dosages as high as 20–25 mg/kg per day t.i.d. might be better.

Delivery by 38 weeks' gestation is advisable, and some physicians suggest elective delivery by 37 weeks to decrease the risk of stillbirth, but it's not clear whether the potential benefits of delivering at 37 weeks outweigh the risks from preterm delivery, Dr. Dyson said.

“It's definitely agreed that patients should have frequent nonstress tests” and biophysical profiles to assess for fetal stress starting at 34 weeks' gestation, she said.

The incidence of intrahepatic cholestasis of pregnancy worldwide ranges from 10 to 760 cases per 10,000 pregnancies, with a higher incidence seen in Latin America (especially in Chile and Bolivia) and low rates in the United States and Europe.

Dr. Dyson reported having no conflicts of interest.

Skin Disease Education Foundation and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — Check serum bile acid levels to determine if severe itching during pregnancy is the result of intrahepatic cholestasis of pregnancy, advises a dermatologic pathologist.

“Intrahepatic cholestasis of pregnancy is about the only dermatosis of pregnancy that has poor outcomes for the unborn,” Dr. Senait W. Dyson said at a meeting sponsored by Skin Disease Education Foundation.

An uncommon problem in the United States, intrahepatic cholestasis of pregnancy (also called prurigo gravidarum or obstetric cholestasis) is a reversible form of cholestasis that presents in late pregnancy and persists until delivery.

The disease increases the risk of intrauterine fetal distress and leads to a three- to fourfold increase in the risk of stillbirth.

It typically presents during the third trimester and resolves within days after delivery. Clinically, the problem is characterized by generalized, severe pruritus without primary skin lesions, said Dr. Dyson, director of dermatopathology at the University of California, Irvine. Involvement of the palms and soles is common. You'll seldom see jaundice with intrahepatic cholestasis of pregnancy.

The main diagnostic finding is increased serum bile acids in all cases, resulting from impaired bile flow. Elevated serum bile acid levels greater than 4.07 mcg/mL (10 micromol/L) in these patients can reach as high as 16 mcg/mL (40 micromol/L), she said.

Some patients will have abnormal liver function tests. Histology is nonspecific, and immunofluorescence tests will be negative.

Prolonged disease causes vitamin K deficiency and increases the risk for bleeding in the mother. It is not clear whether the bleeding risk increases in the infant. Check prothrombin times in women with intrahepatic cholestasis of pregnancy, Dr. Dyson advised. Women with increased prothrombin times should get vitamin K injections.

“Treatments that I use for other cholestasis diseases are not helpful in this condition,” she noted.

Antihistamines will help control the pruritus. Ursodeoxycholic acid (UDCA), the only approved medication to treat primary biliary cirrhosis, also helps improve pruritus in patients with intrahepatic cholestasis of pregnancy. Dr. Dyson said that most medical centers, including her institution, dose UDCA at 14 mg/kg per day t.i.d. to treat intrahepatic cholestasis of pregnancy from the time of diagnosis until delivery. Some clinicians suggest that dosages as high as 20–25 mg/kg per day t.i.d. might be better.

Delivery by 38 weeks' gestation is advisable, and some physicians suggest elective delivery by 37 weeks to decrease the risk of stillbirth, but it's not clear whether the potential benefits of delivering at 37 weeks outweigh the risks from preterm delivery, Dr. Dyson said.

“It's definitely agreed that patients should have frequent nonstress tests” and biophysical profiles to assess for fetal stress starting at 34 weeks' gestation, she said.

The incidence of intrahepatic cholestasis of pregnancy worldwide ranges from 10 to 760 cases per 10,000 pregnancies, with a higher incidence seen in Latin America (especially in Chile and Bolivia) and low rates in the United States and Europe.

Dr. Dyson reported having no conflicts of interest.

Skin Disease Education Foundation and this news organization are wholly owned subsidiaries of Elsevier.

Clinicians should assess older men for risk factors for osteoporosis and measure bone density by dual-energy x-ray absorptiometry if any risk factors are present, a new guideline from the American College of Physicians recommends.

How old is “older” is left open to interpretation and is one point of difference between the ACP guideline and guidelines issued by the National Osteoporosis Foundation (NOF) in February 2008.

The new NOF guidelines include screening and treatment in men as well as women, and recommend bone density testing in men aged 50–69 who have risk factors for osteoporosis and in all men aged 70 or older (RHEUMATOLOGY NEWS, May 2008, p. 1).

The ACP guidelines (Ann. Intern. Med. 2008;148:680-4) focus specifically on screening in men and notes the appropriate age at which to start risk assessment is uncertain. The medical evidence in the literature shows that by 65, at least 6% of men have osteoporosis proved by dual-energy x-ray absorptiometry (DXA), Dr. Amir Qaseem said in an interview.

The ACP plans to issue a separate new guideline for treating osteoporosis in men in the near future, added Dr. Qaseem, lead author of the guideline and a senior medical associate for the ACP.

The main risk factors for osteoporosis in men are age older than 70, a body mass index of 25 kg/m

The new ACP guideline is based on a systematic review of evidence published in 1990–2007 conducted by the federal Agency for Healthcare Research and Quality's evidence-based practice center in Southern California.

The prevalence of osteoporosis is estimated to be 7% in white, 5% in black, and 3% in Hispanic men, Dr. Qaseem noted. Over the next 15 years the rate of osteoporosis in U.S. men is expected to increase by half, with a doubling or tripling of hip fracture rates by 2040.

The prevalence of osteoporosis in Asian American men and other ethnic groups is unknown because of a lack of data. More research is needed, the guideline states.

Clinicians should assess older men for risk factors for osteoporosis and measure bone density by dual-energy x-ray absorptiometry if any risk factors are present, a new guideline from the American College of Physicians recommends.

How old is “older” is left open to interpretation and is one point of difference between the ACP guideline and guidelines issued by the National Osteoporosis Foundation (NOF) in February 2008.

The new NOF guidelines include screening and treatment in men as well as women, and recommend bone density testing in men aged 50–69 who have risk factors for osteoporosis and in all men aged 70 or older (RHEUMATOLOGY NEWS, May 2008, p. 1).

The ACP guidelines (Ann. Intern. Med. 2008;148:680-4) focus specifically on screening in men and notes the appropriate age at which to start risk assessment is uncertain. The medical evidence in the literature shows that by 65, at least 6% of men have osteoporosis proved by dual-energy x-ray absorptiometry (DXA), Dr. Amir Qaseem said in an interview.

The ACP plans to issue a separate new guideline for treating osteoporosis in men in the near future, added Dr. Qaseem, lead author of the guideline and a senior medical associate for the ACP.

The main risk factors for osteoporosis in men are age older than 70, a body mass index of 25 kg/m

The new ACP guideline is based on a systematic review of evidence published in 1990–2007 conducted by the federal Agency for Healthcare Research and Quality's evidence-based practice center in Southern California.

The prevalence of osteoporosis is estimated to be 7% in white, 5% in black, and 3% in Hispanic men, Dr. Qaseem noted. Over the next 15 years the rate of osteoporosis in U.S. men is expected to increase by half, with a doubling or tripling of hip fracture rates by 2040.

The prevalence of osteoporosis in Asian American men and other ethnic groups is unknown because of a lack of data. More research is needed, the guideline states.

Clinicians should assess older men for risk factors for osteoporosis and measure bone density by dual-energy x-ray absorptiometry if any risk factors are present, a new guideline from the American College of Physicians recommends.

How old is “older” is left open to interpretation and is one point of difference between the ACP guideline and guidelines issued by the National Osteoporosis Foundation (NOF) in February 2008.

The new NOF guidelines include screening and treatment in men as well as women, and recommend bone density testing in men aged 50–69 who have risk factors for osteoporosis and in all men aged 70 or older (RHEUMATOLOGY NEWS, May 2008, p. 1).

The ACP guidelines (Ann. Intern. Med. 2008;148:680-4) focus specifically on screening in men and notes the appropriate age at which to start risk assessment is uncertain. The medical evidence in the literature shows that by 65, at least 6% of men have osteoporosis proved by dual-energy x-ray absorptiometry (DXA), Dr. Amir Qaseem said in an interview.

The ACP plans to issue a separate new guideline for treating osteoporosis in men in the near future, added Dr. Qaseem, lead author of the guideline and a senior medical associate for the ACP.

The main risk factors for osteoporosis in men are age older than 70, a body mass index of 25 kg/m

The new ACP guideline is based on a systematic review of evidence published in 1990–2007 conducted by the federal Agency for Healthcare Research and Quality's evidence-based practice center in Southern California.

The prevalence of osteoporosis is estimated to be 7% in white, 5% in black, and 3% in Hispanic men, Dr. Qaseem noted. Over the next 15 years the rate of osteoporosis in U.S. men is expected to increase by half, with a doubling or tripling of hip fracture rates by 2040.

The prevalence of osteoporosis in Asian American men and other ethnic groups is unknown because of a lack of data. More research is needed, the guideline states.

SAN FRANCISCO — Patients with type 1 diabetes were more likely than those with type 2 diabetes to die or develop perioperative complications after undergoing total knee or hip arthroplasty, a review of 65,769 cases found.

The risk of death related to total joint arthroplasty in type 2 diabetes patients was 56% lower than that in type 1 diabetes patients, Dr. Michael P. Bolognesi and his associates reported in a poster presentation at the annual meeting of the American Academy of Orthopaedic Surgeons.

The investigators used federal data from the 2003 National Inpatient Sample to compare rates of complications between 8,728 patients with type 1 diabetes and 57,041 patients with type 2 diabetes who underwent primary and revision arthroplasties of the hip or knee from 1998 to 2003. Their analysis was based on regression modeling to control for the potential confounding effects of age, race, gender, and median household income by zip code.

Type 2 diabetes patients were about 30% less likely than type 1 diabetics to develop a urinary tract infection, pneumonia, or postoperative hemorrhage; they were about 50% less likely to develop an infection related to the surgery. The rate of myocardial infarction also was lower in type 2 diabetics, said Dr. Bolognesi of Duke University, Durham, N.C.

Each of the differences they found between groups was statistically significant.

A bivariate analysis that directly compared complications in the two diabetes groups without adjusting for confounders showed that 0.7% with type 1 diabetes and 0.3% with type 2 diabetes died in association with the total joint replacement surgery, he reported. Rates of surgery-associated myocardial infarction were 0.06% with type 1 diabetes and 0.02% with type 2 diabetes. Perioperative urinary infections occurred in 5% of patients with type 1 diabetes and in 3% with type 2 diabetes. Pneumonia developed in 0.8% of the type 1 diabetes group and in 0.5% of the type 2 diabetes group.

Postoperative hemorrhage after total knee or hip arthroplasty was seen in 2% of the type 1 diabetes group and in 1% of the type 2 diabetes group. Infection occurred in 0.8% of patients with type 1 diabetes and in 0.4% with type 2 diabetes.

Each of these differences between groups in the bivariate analysis was statistically significant. Dr. Bolognesi is a consultant to four companies that market orthopedic products, instruments, or implants: ORTHOsoft Inc., DePuy Orthopaedics Inc., Zimmer Inc., and AMEDICA Corp. He owns stock or has stock options in two of those companies.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Patients with type 1 diabetes were more likely than those with type 2 diabetes to die or develop perioperative complications after undergoing total knee or hip arthroplasty, a review of 65,769 cases found.

The risk of death related to total joint arthroplasty in type 2 diabetes patients was 56% lower than that in type 1 diabetes patients, Dr. Michael P. Bolognesi and his associates reported in a poster presentation at the annual meeting of the American Academy of Orthopaedic Surgeons.

The investigators used federal data from the 2003 National Inpatient Sample to compare rates of complications between 8,728 patients with type 1 diabetes and 57,041 patients with type 2 diabetes who underwent primary and revision arthroplasties of the hip or knee from 1998 to 2003. Their analysis was based on regression modeling to control for the potential confounding effects of age, race, gender, and median household income by zip code.

Type 2 diabetes patients were about 30% less likely than type 1 diabetics to develop a urinary tract infection, pneumonia, or postoperative hemorrhage; they were about 50% less likely to develop an infection related to the surgery. The rate of myocardial infarction also was lower in type 2 diabetics, said Dr. Bolognesi of Duke University, Durham, N.C.

Each of the differences they found between groups was statistically significant.

A bivariate analysis that directly compared complications in the two diabetes groups without adjusting for confounders showed that 0.7% with type 1 diabetes and 0.3% with type 2 diabetes died in association with the total joint replacement surgery, he reported. Rates of surgery-associated myocardial infarction were 0.06% with type 1 diabetes and 0.02% with type 2 diabetes. Perioperative urinary infections occurred in 5% of patients with type 1 diabetes and in 3% with type 2 diabetes. Pneumonia developed in 0.8% of the type 1 diabetes group and in 0.5% of the type 2 diabetes group.

Postoperative hemorrhage after total knee or hip arthroplasty was seen in 2% of the type 1 diabetes group and in 1% of the type 2 diabetes group. Infection occurred in 0.8% of patients with type 1 diabetes and in 0.4% with type 2 diabetes.

Each of these differences between groups in the bivariate analysis was statistically significant. Dr. Bolognesi is a consultant to four companies that market orthopedic products, instruments, or implants: ORTHOsoft Inc., DePuy Orthopaedics Inc., Zimmer Inc., and AMEDICA Corp. He owns stock or has stock options in two of those companies.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Patients with type 1 diabetes were more likely than those with type 2 diabetes to die or develop perioperative complications after undergoing total knee or hip arthroplasty, a review of 65,769 cases found.

The risk of death related to total joint arthroplasty in type 2 diabetes patients was 56% lower than that in type 1 diabetes patients, Dr. Michael P. Bolognesi and his associates reported in a poster presentation at the annual meeting of the American Academy of Orthopaedic Surgeons.

The investigators used federal data from the 2003 National Inpatient Sample to compare rates of complications between 8,728 patients with type 1 diabetes and 57,041 patients with type 2 diabetes who underwent primary and revision arthroplasties of the hip or knee from 1998 to 2003. Their analysis was based on regression modeling to control for the potential confounding effects of age, race, gender, and median household income by zip code.

Type 2 diabetes patients were about 30% less likely than type 1 diabetics to develop a urinary tract infection, pneumonia, or postoperative hemorrhage; they were about 50% less likely to develop an infection related to the surgery. The rate of myocardial infarction also was lower in type 2 diabetics, said Dr. Bolognesi of Duke University, Durham, N.C.

Each of the differences they found between groups was statistically significant.

A bivariate analysis that directly compared complications in the two diabetes groups without adjusting for confounders showed that 0.7% with type 1 diabetes and 0.3% with type 2 diabetes died in association with the total joint replacement surgery, he reported. Rates of surgery-associated myocardial infarction were 0.06% with type 1 diabetes and 0.02% with type 2 diabetes. Perioperative urinary infections occurred in 5% of patients with type 1 diabetes and in 3% with type 2 diabetes. Pneumonia developed in 0.8% of the type 1 diabetes group and in 0.5% of the type 2 diabetes group.

Postoperative hemorrhage after total knee or hip arthroplasty was seen in 2% of the type 1 diabetes group and in 1% of the type 2 diabetes group. Infection occurred in 0.8% of patients with type 1 diabetes and in 0.4% with type 2 diabetes.

Each of these differences between groups in the bivariate analysis was statistically significant. Dr. Bolognesi is a consultant to four companies that market orthopedic products, instruments, or implants: ORTHOsoft Inc., DePuy Orthopaedics Inc., Zimmer Inc., and AMEDICA Corp. He owns stock or has stock options in two of those companies.

ELSEVIER GLOBAL MEDICAL NEWS

Providers should assess older men for risk factors for osteoporosis and measure bone density by dual-energy x-ray absorptiometry if any risk factors are present, a new guideline from the American College of Physicians recommends.

How old is “older” is left open to interpretation and is one point of difference between the new guideline and separate new guidelines issued by the National Osteoporosis Foundation (NOF) in February 2008. The recommendation by the ACP is the first from the organization to specifically address osteoporosis in men (Ann. Intern. Med. 2008;148:680–4).

The new NOF guidelines for the first time include screening and treatment in men as well as women, and recommend doing bone density testing in men aged 50–69 years who have risk factors for osteoporosis and in all men aged 70 years or older.

The new ACP guideline focuses specifically on osteoporosis screening in men and notes that the appropriate age at which to start risk assessment is uncertain. The medical evidence in the literature shows that by age 65 years, at least 6% of men have osteoporosis proved by dual-energy x-ray absorptiometry (DXA), so “assessment of risk factors before this age is reasonable” for most men, Dr. Amir Qaseem said in an interview.

The ACP plans to issue a separate new guideline for treating osteoporosis in men in the near future, added Dr. Qaseem, lead author of the guideline and a senior medical associate for the ACP.

The main risk factors for osteoporosis in men that should prompt providers to consider ordering a DXA scan are age older than 70 years, low body weight (a body mass index of 25 kg/m

If a man with risk factors declines a bone density test, the provider should periodically revisit the topic with him and explain that the DXA scan is a painless, noninvasive test.

The new ACP guideline is based on a review of evidence published in 1990–2007 conducted by the federal Agency for Healthcare Research and Quality's evidence-based practice center in Southern California. Another article in the same issue describes the review of evidence (Ann. Intern. Med. 2008;148:685–701).

The prevalence of osteoporosis is estimated to be 7% in white men, 5% in black men, and 3% in Hispanic men. Because it's “viewed as a disease of women,” it is underdiagnosed and undertreated in men, causing substantial morbidity and mortality, said Dr. Qaseem. In the next 15 years as the population ages, the rate of osteoporosis in men is expected to increase by half, with a doubling or tripling of hip fracture rates by 2040.

The prevalence of osteoporosis in Asian American men and other ethnic groups is unknown because of a lack of data. More research is needed on multiple aspects of screening for osteoporosis in men, the guideline states.

The medical evidence in the literature shows that by age 65 years, at least 6% of men have osteoporosis. DR. QASEEM

Providers should assess older men for risk factors for osteoporosis and measure bone density by dual-energy x-ray absorptiometry if any risk factors are present, a new guideline from the American College of Physicians recommends.

How old is “older” is left open to interpretation and is one point of difference between the new guideline and separate new guidelines issued by the National Osteoporosis Foundation (NOF) in February 2008. The recommendation by the ACP is the first from the organization to specifically address osteoporosis in men (Ann. Intern. Med. 2008;148:680–4).

The new NOF guidelines for the first time include screening and treatment in men as well as women, and recommend doing bone density testing in men aged 50–69 years who have risk factors for osteoporosis and in all men aged 70 years or older.

The new ACP guideline focuses specifically on osteoporosis screening in men and notes that the appropriate age at which to start risk assessment is uncertain. The medical evidence in the literature shows that by age 65 years, at least 6% of men have osteoporosis proved by dual-energy x-ray absorptiometry (DXA), so “assessment of risk factors before this age is reasonable” for most men, Dr. Amir Qaseem said in an interview.

The ACP plans to issue a separate new guideline for treating osteoporosis in men in the near future, added Dr. Qaseem, lead author of the guideline and a senior medical associate for the ACP.

The main risk factors for osteoporosis in men that should prompt providers to consider ordering a DXA scan are age older than 70 years, low body weight (a body mass index of 25 kg/m

If a man with risk factors declines a bone density test, the provider should periodically revisit the topic with him and explain that the DXA scan is a painless, noninvasive test.

The new ACP guideline is based on a review of evidence published in 1990–2007 conducted by the federal Agency for Healthcare Research and Quality's evidence-based practice center in Southern California. Another article in the same issue describes the review of evidence (Ann. Intern. Med. 2008;148:685–701).

The prevalence of osteoporosis is estimated to be 7% in white men, 5% in black men, and 3% in Hispanic men. Because it's “viewed as a disease of women,” it is underdiagnosed and undertreated in men, causing substantial morbidity and mortality, said Dr. Qaseem. In the next 15 years as the population ages, the rate of osteoporosis in men is expected to increase by half, with a doubling or tripling of hip fracture rates by 2040.

The prevalence of osteoporosis in Asian American men and other ethnic groups is unknown because of a lack of data. More research is needed on multiple aspects of screening for osteoporosis in men, the guideline states.

The medical evidence in the literature shows that by age 65 years, at least 6% of men have osteoporosis. DR. QASEEM

Providers should assess older men for risk factors for osteoporosis and measure bone density by dual-energy x-ray absorptiometry if any risk factors are present, a new guideline from the American College of Physicians recommends.

How old is “older” is left open to interpretation and is one point of difference between the new guideline and separate new guidelines issued by the National Osteoporosis Foundation (NOF) in February 2008. The recommendation by the ACP is the first from the organization to specifically address osteoporosis in men (Ann. Intern. Med. 2008;148:680–4).

The new NOF guidelines for the first time include screening and treatment in men as well as women, and recommend doing bone density testing in men aged 50–69 years who have risk factors for osteoporosis and in all men aged 70 years or older.

The new ACP guideline focuses specifically on osteoporosis screening in men and notes that the appropriate age at which to start risk assessment is uncertain. The medical evidence in the literature shows that by age 65 years, at least 6% of men have osteoporosis proved by dual-energy x-ray absorptiometry (DXA), so “assessment of risk factors before this age is reasonable” for most men, Dr. Amir Qaseem said in an interview.

The ACP plans to issue a separate new guideline for treating osteoporosis in men in the near future, added Dr. Qaseem, lead author of the guideline and a senior medical associate for the ACP.

The main risk factors for osteoporosis in men that should prompt providers to consider ordering a DXA scan are age older than 70 years, low body weight (a body mass index of 25 kg/m

If a man with risk factors declines a bone density test, the provider should periodically revisit the topic with him and explain that the DXA scan is a painless, noninvasive test.

The new ACP guideline is based on a review of evidence published in 1990–2007 conducted by the federal Agency for Healthcare Research and Quality's evidence-based practice center in Southern California. Another article in the same issue describes the review of evidence (Ann. Intern. Med. 2008;148:685–701).

The prevalence of osteoporosis is estimated to be 7% in white men, 5% in black men, and 3% in Hispanic men. Because it's “viewed as a disease of women,” it is underdiagnosed and undertreated in men, causing substantial morbidity and mortality, said Dr. Qaseem. In the next 15 years as the population ages, the rate of osteoporosis in men is expected to increase by half, with a doubling or tripling of hip fracture rates by 2040.

The prevalence of osteoporosis in Asian American men and other ethnic groups is unknown because of a lack of data. More research is needed on multiple aspects of screening for osteoporosis in men, the guideline states.

The medical evidence in the literature shows that by age 65 years, at least 6% of men have osteoporosis. DR. QASEEM

SAN FRANCISCO — Weight loss after bariatric surgery induces a drop in bone mineral density and increases the risk for falls and fractures, but it's unclear whether most of theses changes are clinically significant, Dr. Brian N. Sabowitz said.

The sparse data that exist tend to look at relative changes. They don't give absolute numbers that might show whether a patient's new bone density or fracture risk after weight loss from bariatric surgery is any higher than bone density or fracture risk in someone who already is at the target weight that the surgical patient eventually achieves, he said at the annual meeting of the International Society for Clinical Densitometry.

Obese people are likely to have vitamin D deficiency, which has been associated with an increased risk of fracture, noted Dr. Sabowitz, founder of a weight-loss clinic that performs bariatric surgery in Lake Havasu City, Ariz., where he also was a patient to undergo his own Roux-en-Y gastric bypass. In addition, Dr. Sabowitz is medical director of an osteoporosis center in Lake Havasu City.

Fifteen of 18 patients he saw in January 2008 for consults before bariatric surgery had deficient vitamin D levels. A prospective, controlled study in 2007 of 19 obese and 19 nonobese patients found serum levels of vitamin D were 60% lower in the obese group than in the controls. When they were exposed to UV radiation, obese patients absorbed half as much vitamin D, probably because the fat-soluble vitamin was being sequestered in adipose tissue instead of reaching the bloodstream, the study showed.

Physiologic changes from bariatric surgery—whether gastric banding or gastric bypass surgery—make it more difficult for micronutrients to be absorbed. One study of 21 women found that 36% of ingested calcium entered the bloodstream before gastric bypass surgery, which reduced calcium absorption to 24%. Bariatric surgery also can lead to deficiencies in levels of vitamin B₁₂, folate, thiamine, and iron.

“This can all add up to weakness, ataxia, falling, and fractures. A lot of the nutritional deficiencies that can occur with this surgery can increase fracture risk by increasing the risk of falling,” Dr. Sabowitz said.

Getting a baseline bone density measurement in an obese patient before bariatric surgery can be difficult, and fat may alter the scan results. For densitometry of the femoral neck, be sure to move the fat panus out of the way, he advised. If nothing else, get scans of the bilateral forearms to have some baseline measurement.

A 1992 study found decreased levels of serum calcium, osteocalcin, 25-hydroxyvitamin D, and other markers of bone health in 26 women 10 years after gastric bypass surgery, compared with levels in 7 control women who lost weight without surgery. A trend toward lower bone density at the femoral neck in the surgery group did not reach statistical significance.

Another separate study found that forearm bone density was higher in eight obese patients than in eight normal-weight controls at baseline, but 1 year after bariatric surgery on the obese patients forearm densities were similar between groups (Braz. J. Med. Biol. Res. 2007;40:509–17). Femoral neck bone mineral density in the surgery patients dropped to levels significantly lower than in the control group, however, so the risk remains “controversial,” he said.

Data from the National Health and Nutrition Examination Survey suggest that fracture risk doubles in obese people who lose 10% of body weight, but the survey doesn't compare the absolute fracture risk after weight loss with that in controls, he added. “We don't have very good ways to treat patients who get osteoporosis because of weight loss, if that's what's happening,” Dr. Sabowitz said.

Bariatric surgery patients must switch their medications to liquid or crushable alternatives to get the medicine past the physiologic obstacles created by the surgery. Bisphosphonates come in pill form not amenable to this. There is no evidence for using antiresorptive agents in premenopausal women who may become osteoporotic because of bariatric surgery and weight loss.

“The main thing is to optimize preoperative status” by normalizing vitamin D and calcium levels and getting baseline readings of bone density and bone turnover markers to help with decision making, Dr. Sabowitz said.

He sends an occupational therapist to each patient's house to look for hazardous carpets, cords, or other things that might cause a fall. “We can really do a lot for these patients by just making sure we minimize their risk of falling,” he said.

After bariatric surgery, put patients on liquid or chewable calcium and vitamin D supplements. Get quarterly measures of vitamin D, parathyroid hormone, and bone turnover markers, he said. Dr. Sabowitz gets annual bone density scans, mainly to accumulate data.

Start treatment for osteoporosis using the same criteria used for patients who have not had bariatric surgery and weight loss—mainly because there are no data to do otherwise. Some clinicians have suggested considering a large weight loss to be a risk factor for osteoporosis, which might prompt treatment in a patient with a T score of -1.5 plus this risk factor, “but there are no good data to support doing that,” he said.

'The main thing is to optimize preoperative status' by normalizing vitamin D and calcium levels. DR. SABOWITZ

SAN FRANCISCO — Weight loss after bariatric surgery induces a drop in bone mineral density and increases the risk for falls and fractures, but it's unclear whether most of theses changes are clinically significant, Dr. Brian N. Sabowitz said.

The sparse data that exist tend to look at relative changes. They don't give absolute numbers that might show whether a patient's new bone density or fracture risk after weight loss from bariatric surgery is any higher than bone density or fracture risk in someone who already is at the target weight that the surgical patient eventually achieves, he said at the annual meeting of the International Society for Clinical Densitometry.

Obese people are likely to have vitamin D deficiency, which has been associated with an increased risk of fracture, noted Dr. Sabowitz, founder of a weight-loss clinic that performs bariatric surgery in Lake Havasu City, Ariz., where he also was a patient to undergo his own Roux-en-Y gastric bypass. In addition, Dr. Sabowitz is medical director of an osteoporosis center in Lake Havasu City.

Fifteen of 18 patients he saw in January 2008 for consults before bariatric surgery had deficient vitamin D levels. A prospective, controlled study in 2007 of 19 obese and 19 nonobese patients found serum levels of vitamin D were 60% lower in the obese group than in the controls. When they were exposed to UV radiation, obese patients absorbed half as much vitamin D, probably because the fat-soluble vitamin was being sequestered in adipose tissue instead of reaching the bloodstream, the study showed.

Physiologic changes from bariatric surgery—whether gastric banding or gastric bypass surgery—make it more difficult for micronutrients to be absorbed. One study of 21 women found that 36% of ingested calcium entered the bloodstream before gastric bypass surgery, which reduced calcium absorption to 24%. Bariatric surgery also can lead to deficiencies in levels of vitamin B₁₂, folate, thiamine, and iron.

“This can all add up to weakness, ataxia, falling, and fractures. A lot of the nutritional deficiencies that can occur with this surgery can increase fracture risk by increasing the risk of falling,” Dr. Sabowitz said.

Getting a baseline bone density measurement in an obese patient before bariatric surgery can be difficult, and fat may alter the scan results. For densitometry of the femoral neck, be sure to move the fat panus out of the way, he advised. If nothing else, get scans of the bilateral forearms to have some baseline measurement.

A 1992 study found decreased levels of serum calcium, osteocalcin, 25-hydroxyvitamin D, and other markers of bone health in 26 women 10 years after gastric bypass surgery, compared with levels in 7 control women who lost weight without surgery. A trend toward lower bone density at the femoral neck in the surgery group did not reach statistical significance.

Another separate study found that forearm bone density was higher in eight obese patients than in eight normal-weight controls at baseline, but 1 year after bariatric surgery on the obese patients forearm densities were similar between groups (Braz. J. Med. Biol. Res. 2007;40:509–17). Femoral neck bone mineral density in the surgery patients dropped to levels significantly lower than in the control group, however, so the risk remains “controversial,” he said.

Data from the National Health and Nutrition Examination Survey suggest that fracture risk doubles in obese people who lose 10% of body weight, but the survey doesn't compare the absolute fracture risk after weight loss with that in controls, he added. “We don't have very good ways to treat patients who get osteoporosis because of weight loss, if that's what's happening,” Dr. Sabowitz said.

Bariatric surgery patients must switch their medications to liquid or crushable alternatives to get the medicine past the physiologic obstacles created by the surgery. Bisphosphonates come in pill form not amenable to this. There is no evidence for using antiresorptive agents in premenopausal women who may become osteoporotic because of bariatric surgery and weight loss.

“The main thing is to optimize preoperative status” by normalizing vitamin D and calcium levels and getting baseline readings of bone density and bone turnover markers to help with decision making, Dr. Sabowitz said.

He sends an occupational therapist to each patient's house to look for hazardous carpets, cords, or other things that might cause a fall. “We can really do a lot for these patients by just making sure we minimize their risk of falling,” he said.

After bariatric surgery, put patients on liquid or chewable calcium and vitamin D supplements. Get quarterly measures of vitamin D, parathyroid hormone, and bone turnover markers, he said. Dr. Sabowitz gets annual bone density scans, mainly to accumulate data.

Start treatment for osteoporosis using the same criteria used for patients who have not had bariatric surgery and weight loss—mainly because there are no data to do otherwise. Some clinicians have suggested considering a large weight loss to be a risk factor for osteoporosis, which might prompt treatment in a patient with a T score of -1.5 plus this risk factor, “but there are no good data to support doing that,” he said.

'The main thing is to optimize preoperative status' by normalizing vitamin D and calcium levels. DR. SABOWITZ

SAN FRANCISCO — Weight loss after bariatric surgery induces a drop in bone mineral density and increases the risk for falls and fractures, but it's unclear whether most of theses changes are clinically significant, Dr. Brian N. Sabowitz said.

The sparse data that exist tend to look at relative changes. They don't give absolute numbers that might show whether a patient's new bone density or fracture risk after weight loss from bariatric surgery is any higher than bone density or fracture risk in someone who already is at the target weight that the surgical patient eventually achieves, he said at the annual meeting of the International Society for Clinical Densitometry.

Obese people are likely to have vitamin D deficiency, which has been associated with an increased risk of fracture, noted Dr. Sabowitz, founder of a weight-loss clinic that performs bariatric surgery in Lake Havasu City, Ariz., where he also was a patient to undergo his own Roux-en-Y gastric bypass. In addition, Dr. Sabowitz is medical director of an osteoporosis center in Lake Havasu City.

Fifteen of 18 patients he saw in January 2008 for consults before bariatric surgery had deficient vitamin D levels. A prospective, controlled study in 2007 of 19 obese and 19 nonobese patients found serum levels of vitamin D were 60% lower in the obese group than in the controls. When they were exposed to UV radiation, obese patients absorbed half as much vitamin D, probably because the fat-soluble vitamin was being sequestered in adipose tissue instead of reaching the bloodstream, the study showed.

Physiologic changes from bariatric surgery—whether gastric banding or gastric bypass surgery—make it more difficult for micronutrients to be absorbed. One study of 21 women found that 36% of ingested calcium entered the bloodstream before gastric bypass surgery, which reduced calcium absorption to 24%. Bariatric surgery also can lead to deficiencies in levels of vitamin B₁₂, folate, thiamine, and iron.

“This can all add up to weakness, ataxia, falling, and fractures. A lot of the nutritional deficiencies that can occur with this surgery can increase fracture risk by increasing the risk of falling,” Dr. Sabowitz said.

Getting a baseline bone density measurement in an obese patient before bariatric surgery can be difficult, and fat may alter the scan results. For densitometry of the femoral neck, be sure to move the fat panus out of the way, he advised. If nothing else, get scans of the bilateral forearms to have some baseline measurement.

A 1992 study found decreased levels of serum calcium, osteocalcin, 25-hydroxyvitamin D, and other markers of bone health in 26 women 10 years after gastric bypass surgery, compared with levels in 7 control women who lost weight without surgery. A trend toward lower bone density at the femoral neck in the surgery group did not reach statistical significance.

Another separate study found that forearm bone density was higher in eight obese patients than in eight normal-weight controls at baseline, but 1 year after bariatric surgery on the obese patients forearm densities were similar between groups (Braz. J. Med. Biol. Res. 2007;40:509–17). Femoral neck bone mineral density in the surgery patients dropped to levels significantly lower than in the control group, however, so the risk remains “controversial,” he said.

Data from the National Health and Nutrition Examination Survey suggest that fracture risk doubles in obese people who lose 10% of body weight, but the survey doesn't compare the absolute fracture risk after weight loss with that in controls, he added. “We don't have very good ways to treat patients who get osteoporosis because of weight loss, if that's what's happening,” Dr. Sabowitz said.

Bariatric surgery patients must switch their medications to liquid or crushable alternatives to get the medicine past the physiologic obstacles created by the surgery. Bisphosphonates come in pill form not amenable to this. There is no evidence for using antiresorptive agents in premenopausal women who may become osteoporotic because of bariatric surgery and weight loss.

“The main thing is to optimize preoperative status” by normalizing vitamin D and calcium levels and getting baseline readings of bone density and bone turnover markers to help with decision making, Dr. Sabowitz said.

He sends an occupational therapist to each patient's house to look for hazardous carpets, cords, or other things that might cause a fall. “We can really do a lot for these patients by just making sure we minimize their risk of falling,” he said.

After bariatric surgery, put patients on liquid or chewable calcium and vitamin D supplements. Get quarterly measures of vitamin D, parathyroid hormone, and bone turnover markers, he said. Dr. Sabowitz gets annual bone density scans, mainly to accumulate data.

Start treatment for osteoporosis using the same criteria used for patients who have not had bariatric surgery and weight loss—mainly because there are no data to do otherwise. Some clinicians have suggested considering a large weight loss to be a risk factor for osteoporosis, which might prompt treatment in a patient with a T score of -1.5 plus this risk factor, “but there are no good data to support doing that,” he said.

'The main thing is to optimize preoperative status' by normalizing vitamin D and calcium levels. DR. SABOWITZ

NEWPORT BEACH, CALIF. — A study of 61 parents of infants and children up to 10 years of age suggests that parents may favor the idea of giving the human papillomavirus vaccine at a very young age rather than during adolescence.

The study also found that parents with higher socioeconomic status and education levels were more likely to reject human papillomavirus (HPV) immunization for their children at any age, a finding that could help target educational efforts for the HPV vaccine toward those demographics, Dr. Ellen S. Rome said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

One HPV vaccine, Gardasil, is approved for use in females aged 9–26 years, and another is being considered for approval by the Food and Drug Administration. Dr. Rome is on the speaker's bureau of Merck & Co., which markets Gardasil.

The HPV vaccine could follow the example of the hepatitis B vaccine, she suggested, which started as a vaccine for teenagers and later shifted to administration during infancy. Studies on the use of HPV vaccine in infants and children would need to be conducted for that to happen, added Dr. Rome, head of adolescent medicine at the Cleveland Clinic. She presented the current study on behalf of the lead investigator, Dr. Laura Gillespie, also of the Cleveland Clinic, and her associates.

Parents recruited from the clinic's main campus, emergency department, and regional satellite offices answered a questionnaire about demographics, attitudes about immunization, knowledge about HPV, and willingness to have their children vaccinated against HPV. The parents then were given a one-page educational sheet from the Centers for Disease Control and Prevention about HPV; after reading it, they completed a second questionnaire.

Before the intervention (the educational sheet), 25 parents said they wanted their children to get the HPV vaccine, 6 did not, and 30 were undecided. The higher the socioeconomic status—either income or educational level—of the parents, the less likely they were to want their children to get the HPV vaccine.

"Low-income families may have more realistic fears about what a sexually transmitted disease or HPV could mean for their child," Dr. Rome speculated.

None of the parents who initially were for or against the vaccine changed their minds after reading the educational sheet. Among the 30 undecided parents, 12 favored vaccination after they read the sheet, 15 opposed it, and 3 did not answer the question about whether they would accept the HPV vaccine if it was offered.

Beliefs that the HPV vaccine is safe and effective were significantly associated with acceptance after the intervention. Parents with higher education or income may require more aggressive education from physicians about the vaccine's safety and efficacy, the investigators suggested.

Among the 37 parents who approved of the HPV vaccine after the intervention, 29 (78%) said they'd prefer that it be given to young children instead of to teenagers.

"They wanted to make it a baby shot," Dr. Rome said.

The reason for that echoes findings from two previous studies of HPV vaccine acceptance by parents of children aged 10 years or older. "Parents still think that this shot is a license to have sex" if it is given to adolescents, Dr. Rome said. "That's a myth that we're still continuing to try to work towards busting."

Parents with more boys in their homes were more favorable toward the HPV vaccine, "giving us hope that when the shot is available for boys," parents will approve, she said. Merck is pursuing approval for the vaccine in boys.

She does not believe that religious beliefs played a significant role in accepting or rejecting the vaccine, based on her knowledge of participants, but the influence of religion was not analyzed specifically.

Since the completion of the study, the investigators began a separate study looking at current vaccination rates within their institution. They're finding near-100% acceptance of the HPV vaccine by physicians and parents in the clinic's urban offices, but the regional satellite offices have higher rates of "late adopters" who are resistant to use of the vaccine or who reserve it for older adolescents, she said.

"The more yuppified the practice, the higher the rates of late adopters among physicians and parents," she said.

NEWPORT BEACH, CALIF. — A study of 61 parents of infants and children up to 10 years of age suggests that parents may favor the idea of giving the human papillomavirus vaccine at a very young age rather than during adolescence.

The study also found that parents with higher socioeconomic status and education levels were more likely to reject human papillomavirus (HPV) immunization for their children at any age, a finding that could help target educational efforts for the HPV vaccine toward those demographics, Dr. Ellen S. Rome said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

One HPV vaccine, Gardasil, is approved for use in females aged 9–26 years, and another is being considered for approval by the Food and Drug Administration. Dr. Rome is on the speaker's bureau of Merck & Co., which markets Gardasil.

The HPV vaccine could follow the example of the hepatitis B vaccine, she suggested, which started as a vaccine for teenagers and later shifted to administration during infancy. Studies on the use of HPV vaccine in infants and children would need to be conducted for that to happen, added Dr. Rome, head of adolescent medicine at the Cleveland Clinic. She presented the current study on behalf of the lead investigator, Dr. Laura Gillespie, also of the Cleveland Clinic, and her associates.

Parents recruited from the clinic's main campus, emergency department, and regional satellite offices answered a questionnaire about demographics, attitudes about immunization, knowledge about HPV, and willingness to have their children vaccinated against HPV. The parents then were given a one-page educational sheet from the Centers for Disease Control and Prevention about HPV; after reading it, they completed a second questionnaire.

Before the intervention (the educational sheet), 25 parents said they wanted their children to get the HPV vaccine, 6 did not, and 30 were undecided. The higher the socioeconomic status—either income or educational level—of the parents, the less likely they were to want their children to get the HPV vaccine.

"Low-income families may have more realistic fears about what a sexually transmitted disease or HPV could mean for their child," Dr. Rome speculated.

None of the parents who initially were for or against the vaccine changed their minds after reading the educational sheet. Among the 30 undecided parents, 12 favored vaccination after they read the sheet, 15 opposed it, and 3 did not answer the question about whether they would accept the HPV vaccine if it was offered.

Beliefs that the HPV vaccine is safe and effective were significantly associated with acceptance after the intervention. Parents with higher education or income may require more aggressive education from physicians about the vaccine's safety and efficacy, the investigators suggested.

Among the 37 parents who approved of the HPV vaccine after the intervention, 29 (78%) said they'd prefer that it be given to young children instead of to teenagers.

"They wanted to make it a baby shot," Dr. Rome said.

The reason for that echoes findings from two previous studies of HPV vaccine acceptance by parents of children aged 10 years or older. "Parents still think that this shot is a license to have sex" if it is given to adolescents, Dr. Rome said. "That's a myth that we're still continuing to try to work towards busting."

Parents with more boys in their homes were more favorable toward the HPV vaccine, "giving us hope that when the shot is available for boys," parents will approve, she said. Merck is pursuing approval for the vaccine in boys.

She does not believe that religious beliefs played a significant role in accepting or rejecting the vaccine, based on her knowledge of participants, but the influence of religion was not analyzed specifically.

Since the completion of the study, the investigators began a separate study looking at current vaccination rates within their institution. They're finding near-100% acceptance of the HPV vaccine by physicians and parents in the clinic's urban offices, but the regional satellite offices have higher rates of "late adopters" who are resistant to use of the vaccine or who reserve it for older adolescents, she said.

"The more yuppified the practice, the higher the rates of late adopters among physicians and parents," she said.

NEWPORT BEACH, CALIF. — A study of 61 parents of infants and children up to 10 years of age suggests that parents may favor the idea of giving the human papillomavirus vaccine at a very young age rather than during adolescence.

The study also found that parents with higher socioeconomic status and education levels were more likely to reject human papillomavirus (HPV) immunization for their children at any age, a finding that could help target educational efforts for the HPV vaccine toward those demographics, Dr. Ellen S. Rome said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

One HPV vaccine, Gardasil, is approved for use in females aged 9–26 years, and another is being considered for approval by the Food and Drug Administration. Dr. Rome is on the speaker's bureau of Merck & Co., which markets Gardasil.

The HPV vaccine could follow the example of the hepatitis B vaccine, she suggested, which started as a vaccine for teenagers and later shifted to administration during infancy. Studies on the use of HPV vaccine in infants and children would need to be conducted for that to happen, added Dr. Rome, head of adolescent medicine at the Cleveland Clinic. She presented the current study on behalf of the lead investigator, Dr. Laura Gillespie, also of the Cleveland Clinic, and her associates.

Parents recruited from the clinic's main campus, emergency department, and regional satellite offices answered a questionnaire about demographics, attitudes about immunization, knowledge about HPV, and willingness to have their children vaccinated against HPV. The parents then were given a one-page educational sheet from the Centers for Disease Control and Prevention about HPV; after reading it, they completed a second questionnaire.

Before the intervention (the educational sheet), 25 parents said they wanted their children to get the HPV vaccine, 6 did not, and 30 were undecided. The higher the socioeconomic status—either income or educational level—of the parents, the less likely they were to want their children to get the HPV vaccine.

"Low-income families may have more realistic fears about what a sexually transmitted disease or HPV could mean for their child," Dr. Rome speculated.

None of the parents who initially were for or against the vaccine changed their minds after reading the educational sheet. Among the 30 undecided parents, 12 favored vaccination after they read the sheet, 15 opposed it, and 3 did not answer the question about whether they would accept the HPV vaccine if it was offered.

Beliefs that the HPV vaccine is safe and effective were significantly associated with acceptance after the intervention. Parents with higher education or income may require more aggressive education from physicians about the vaccine's safety and efficacy, the investigators suggested.

Among the 37 parents who approved of the HPV vaccine after the intervention, 29 (78%) said they'd prefer that it be given to young children instead of to teenagers.

"They wanted to make it a baby shot," Dr. Rome said.

The reason for that echoes findings from two previous studies of HPV vaccine acceptance by parents of children aged 10 years or older. "Parents still think that this shot is a license to have sex" if it is given to adolescents, Dr. Rome said. "That's a myth that we're still continuing to try to work towards busting."

Parents with more boys in their homes were more favorable toward the HPV vaccine, "giving us hope that when the shot is available for boys," parents will approve, she said. Merck is pursuing approval for the vaccine in boys.

She does not believe that religious beliefs played a significant role in accepting or rejecting the vaccine, based on her knowledge of participants, but the influence of religion was not analyzed specifically.

Since the completion of the study, the investigators began a separate study looking at current vaccination rates within their institution. They're finding near-100% acceptance of the HPV vaccine by physicians and parents in the clinic's urban offices, but the regional satellite offices have higher rates of "late adopters" who are resistant to use of the vaccine or who reserve it for older adolescents, she said.

"The more yuppified the practice, the higher the rates of late adopters among physicians and parents," she said.

SAN FRANCISCO — Weight loss after bariatric surgery induces a drop in bone mineral density and increases the risk for falls and fractures, but it's unclear whether most of theses changes are clinically significant, Dr. Brian N. Sabowitz said.

The sparse data that exist tend to look at relative changes. They don't give absolute numbers that might show whether a patient's new bone density or fracture risk after weight loss from bariatric surgery is any higher than bone density or fracture risk in someone who already is at the target weight that the surgical patient eventually achieves, he said at the annual meeting of the International Society for Clinical Densitometry.

Obese people are likely to have vitamin D deficiency, which has been associated with an increased risk of fracture, noted Dr. Sabowitz, founder of a weight-loss clinic that performs bariatric surgery in Lake Havasu City, Ariz., where he also was a patient to undergo his own Roux-en-Y gastric bypass. In addition, Dr. Sabowitz is medical director of an osteoporosis center in Lake Havasu City.

Fifteen of 18 patients he saw in January 2008 for consults before bariatric surgery had deficient vitamin D levels. A prospective, controlled study in 2007 of 19 obese and 19 nonobese patients found serum levels of vitamin D were 60% lower in the obese group than in the controls. When they were exposed to UV radiation, obese patients absorbed half as much vitamin D, probably because the fat-soluble vitamin was being sequestered in adipose tissue instead of reaching the bloodstream.

Physiologic changes from bariatric surgery—whether gastric banding or gastric bypass surgery—make it more difficult for micronutrients to be absorbed. One study of 21 women found that 36% of ingested calcium entered the bloodstream before gastric bypass surgery, which reduced calcium absorption to 24%. Bariatric surgery also can lead to deficiencies in levels of vitamin B12, folate, thiamine, and iron.

Getting a baseline bone density measurement in an obese patient before bariatric surgery can be difficult, and fat may alter the scan results. For densitometry of the femoral neck, be sure to move the fat panus out of the way, he advised. If nothing else, get scans of the bilateral forearms to have some baseline measurement.

A 1992 study found decreased levels of serum calcium, osteocalcin, 25-hydroxyvitamin D, and other markers of bone health in 26 women 10 years after gastric bypass surgery, compared with levels in 7 control women who lost weight without surgery. A trend toward lower bone density at the femoral neck in the surgery group did not reach statistical significance.

Another separate study found that forearm bone density was higher in eight obese patients than in eight normal-weight controls at baseline, but 1 year after bariatric surgery on the obese patients forearm densities were similar between groups (Braz. J. Med. Biol. Res. 2007;40: 509-17). Femoral neck bone mineral density in the surgery patients dropped to levels significantly lower than in the control group, however, so the risk remains “controversial,” he said.

Data from the National Health and Nutrition Examination Survey suggest that fracture risk doubles in obese people who lose 10% of body weight, but the survey doesn't compare the absolute fracture risk after weight loss with that in controls.

“We don't have very good ways to treat patients who get osteoporosis because of weight loss, if that's what's happening,” he said. Bariatric surgery patients must switch their medications to liquid or crushable alternatives to get the medicine past the physiologic obstacles created by the surgery. Bisphosphonates come in pill form and are not amenable to this.

“The main thing is to optimize preoperative status” by normalizing vitamin D and calcium levels and getting baseline readings of bone density and bone turnover markers to help with decision making, Dr. Sabowitz said.

If nothing else, get scans of the bilateral forearms to have some baseline measurement. DR. SABOWITZ

SAN FRANCISCO — Weight loss after bariatric surgery induces a drop in bone mineral density and increases the risk for falls and fractures, but it's unclear whether most of theses changes are clinically significant, Dr. Brian N. Sabowitz said.

The sparse data that exist tend to look at relative changes. They don't give absolute numbers that might show whether a patient's new bone density or fracture risk after weight loss from bariatric surgery is any higher than bone density or fracture risk in someone who already is at the target weight that the surgical patient eventually achieves, he said at the annual meeting of the International Society for Clinical Densitometry.

Obese people are likely to have vitamin D deficiency, which has been associated with an increased risk of fracture, noted Dr. Sabowitz, founder of a weight-loss clinic that performs bariatric surgery in Lake Havasu City, Ariz., where he also was a patient to undergo his own Roux-en-Y gastric bypass. In addition, Dr. Sabowitz is medical director of an osteoporosis center in Lake Havasu City.

Fifteen of 18 patients he saw in January 2008 for consults before bariatric surgery had deficient vitamin D levels. A prospective, controlled study in 2007 of 19 obese and 19 nonobese patients found serum levels of vitamin D were 60% lower in the obese group than in the controls. When they were exposed to UV radiation, obese patients absorbed half as much vitamin D, probably because the fat-soluble vitamin was being sequestered in adipose tissue instead of reaching the bloodstream.

Physiologic changes from bariatric surgery—whether gastric banding or gastric bypass surgery—make it more difficult for micronutrients to be absorbed. One study of 21 women found that 36% of ingested calcium entered the bloodstream before gastric bypass surgery, which reduced calcium absorption to 24%. Bariatric surgery also can lead to deficiencies in levels of vitamin B12, folate, thiamine, and iron.

Getting a baseline bone density measurement in an obese patient before bariatric surgery can be difficult, and fat may alter the scan results. For densitometry of the femoral neck, be sure to move the fat panus out of the way, he advised. If nothing else, get scans of the bilateral forearms to have some baseline measurement.

A 1992 study found decreased levels of serum calcium, osteocalcin, 25-hydroxyvitamin D, and other markers of bone health in 26 women 10 years after gastric bypass surgery, compared with levels in 7 control women who lost weight without surgery. A trend toward lower bone density at the femoral neck in the surgery group did not reach statistical significance.

Another separate study found that forearm bone density was higher in eight obese patients than in eight normal-weight controls at baseline, but 1 year after bariatric surgery on the obese patients forearm densities were similar between groups (Braz. J. Med. Biol. Res. 2007;40: 509-17). Femoral neck bone mineral density in the surgery patients dropped to levels significantly lower than in the control group, however, so the risk remains “controversial,” he said.

Data from the National Health and Nutrition Examination Survey suggest that fracture risk doubles in obese people who lose 10% of body weight, but the survey doesn't compare the absolute fracture risk after weight loss with that in controls.

“We don't have very good ways to treat patients who get osteoporosis because of weight loss, if that's what's happening,” he said. Bariatric surgery patients must switch their medications to liquid or crushable alternatives to get the medicine past the physiologic obstacles created by the surgery. Bisphosphonates come in pill form and are not amenable to this.

“The main thing is to optimize preoperative status” by normalizing vitamin D and calcium levels and getting baseline readings of bone density and bone turnover markers to help with decision making, Dr. Sabowitz said.

If nothing else, get scans of the bilateral forearms to have some baseline measurement. DR. SABOWITZ

SAN FRANCISCO — Weight loss after bariatric surgery induces a drop in bone mineral density and increases the risk for falls and fractures, but it's unclear whether most of theses changes are clinically significant, Dr. Brian N. Sabowitz said.

The sparse data that exist tend to look at relative changes. They don't give absolute numbers that might show whether a patient's new bone density or fracture risk after weight loss from bariatric surgery is any higher than bone density or fracture risk in someone who already is at the target weight that the surgical patient eventually achieves, he said at the annual meeting of the International Society for Clinical Densitometry.

Obese people are likely to have vitamin D deficiency, which has been associated with an increased risk of fracture, noted Dr. Sabowitz, founder of a weight-loss clinic that performs bariatric surgery in Lake Havasu City, Ariz., where he also was a patient to undergo his own Roux-en-Y gastric bypass. In addition, Dr. Sabowitz is medical director of an osteoporosis center in Lake Havasu City.

Fifteen of 18 patients he saw in January 2008 for consults before bariatric surgery had deficient vitamin D levels. A prospective, controlled study in 2007 of 19 obese and 19 nonobese patients found serum levels of vitamin D were 60% lower in the obese group than in the controls. When they were exposed to UV radiation, obese patients absorbed half as much vitamin D, probably because the fat-soluble vitamin was being sequestered in adipose tissue instead of reaching the bloodstream.

Physiologic changes from bariatric surgery—whether gastric banding or gastric bypass surgery—make it more difficult for micronutrients to be absorbed. One study of 21 women found that 36% of ingested calcium entered the bloodstream before gastric bypass surgery, which reduced calcium absorption to 24%. Bariatric surgery also can lead to deficiencies in levels of vitamin B12, folate, thiamine, and iron.

Getting a baseline bone density measurement in an obese patient before bariatric surgery can be difficult, and fat may alter the scan results. For densitometry of the femoral neck, be sure to move the fat panus out of the way, he advised. If nothing else, get scans of the bilateral forearms to have some baseline measurement.

A 1992 study found decreased levels of serum calcium, osteocalcin, 25-hydroxyvitamin D, and other markers of bone health in 26 women 10 years after gastric bypass surgery, compared with levels in 7 control women who lost weight without surgery. A trend toward lower bone density at the femoral neck in the surgery group did not reach statistical significance.

Another separate study found that forearm bone density was higher in eight obese patients than in eight normal-weight controls at baseline, but 1 year after bariatric surgery on the obese patients forearm densities were similar between groups (Braz. J. Med. Biol. Res. 2007;40: 509-17). Femoral neck bone mineral density in the surgery patients dropped to levels significantly lower than in the control group, however, so the risk remains “controversial,” he said.

Data from the National Health and Nutrition Examination Survey suggest that fracture risk doubles in obese people who lose 10% of body weight, but the survey doesn't compare the absolute fracture risk after weight loss with that in controls.

“We don't have very good ways to treat patients who get osteoporosis because of weight loss, if that's what's happening,” he said. Bariatric surgery patients must switch their medications to liquid or crushable alternatives to get the medicine past the physiologic obstacles created by the surgery. Bisphosphonates come in pill form and are not amenable to this.

“The main thing is to optimize preoperative status” by normalizing vitamin D and calcium levels and getting baseline readings of bone density and bone turnover markers to help with decision making, Dr. Sabowitz said.

If nothing else, get scans of the bilateral forearms to have some baseline measurement. DR. SABOWITZ