Sherry Boschert

SAN FRANCISCO — Three years of yoga practice did not change bone mineral density in 31 postmenopausal women, compared with bone densities in 31 inactive women.

Proponents of yoga have wondered whether it might produce bone benefits similar to those seen with weight-bearing exercises. Previous data have shown skeletal tissue responds to site-specific stresses.

Yoga consists of movements and poses using body weight as a form of resistance, and contorts the joints with torque and strain. Results of the current cross-sectional study suggest yoga doesn't provide enough of a stimulus to increase bone mineral densities to levels significantly above those in inactive women, Millie Sweesy-Barger and associates said in a poster presentation at the annual meeting of the International Society for Clinical Densitometry.

Women in the yoga group had a 3-year history of practicing yoga at least twice a week in sessions of 60 minutes or longer. Those in the inactive group reported less than 2 hours of physical activity a week over the past 3 years. Participants underwent dual-energy x-ray absorptiometry (DXA) scans of the lumbar spine, left and right femurs, nondominant distal radius, and whole body. The mean age of the women was 60 years in the inactive group and 58 years in the yoga group. The cohort included 59 whites and 3 Asian Americans.

No significant differences between groups were seen in bone mineral densities at any sites. Higher mean bone mineral density in the distal radius in the inactive group, compared with the yoga group, became statistically insignificant after controlling for the effects of age, height, body mass, body mass index (BMI), percent body fat, fat mass, lean body mass, and calcium intake, said Ms. Sweesy-Barger, a student in the department of kinesiology and physical therapy at California State University, Long Beach. The yoga group had significantly lower mean measurements of body mass, percent body fat, fat mass, and BMI, compared with the inactive group, she added.

There is substantial evidence showing significant physical and psychological benefits of exercise programs for older adults, 55% of whom in the United States either have osteoporosis or are at risk of developing the disease, Ms. Sweesy-Barger noted. “To the aging, nonathletic postmeno- pausal woman, the question becomes, which activities are most effective for mitigating the loss of bone?”

Understanding how bone adapts to various forms of physical activity will help inform public health strategies to prevent and manage osteoporosis, she said.

SAN FRANCISCO — Three years of yoga practice did not change bone mineral density in 31 postmenopausal women, compared with bone densities in 31 inactive women.

Proponents of yoga have wondered whether it might produce bone benefits similar to those seen with weight-bearing exercises. Previous data have shown skeletal tissue responds to site-specific stresses.

Yoga consists of movements and poses using body weight as a form of resistance, and contorts the joints with torque and strain. Results of the current cross-sectional study suggest yoga doesn't provide enough of a stimulus to increase bone mineral densities to levels significantly above those in inactive women, Millie Sweesy-Barger and associates said in a poster presentation at the annual meeting of the International Society for Clinical Densitometry.

Women in the yoga group had a 3-year history of practicing yoga at least twice a week in sessions of 60 minutes or longer. Those in the inactive group reported less than 2 hours of physical activity a week over the past 3 years. Participants underwent dual-energy x-ray absorptiometry (DXA) scans of the lumbar spine, left and right femurs, nondominant distal radius, and whole body. The mean age of the women was 60 years in the inactive group and 58 years in the yoga group. The cohort included 59 whites and 3 Asian Americans.

No significant differences between groups were seen in bone mineral densities at any sites. Higher mean bone mineral density in the distal radius in the inactive group, compared with the yoga group, became statistically insignificant after controlling for the effects of age, height, body mass, body mass index (BMI), percent body fat, fat mass, lean body mass, and calcium intake, said Ms. Sweesy-Barger, a student in the department of kinesiology and physical therapy at California State University, Long Beach. The yoga group had significantly lower mean measurements of body mass, percent body fat, fat mass, and BMI, compared with the inactive group, she added.

There is substantial evidence showing significant physical and psychological benefits of exercise programs for older adults, 55% of whom in the United States either have osteoporosis or are at risk of developing the disease, Ms. Sweesy-Barger noted. “To the aging, nonathletic postmeno- pausal woman, the question becomes, which activities are most effective for mitigating the loss of bone?”

Understanding how bone adapts to various forms of physical activity will help inform public health strategies to prevent and manage osteoporosis, she said.

SAN FRANCISCO — Three years of yoga practice did not change bone mineral density in 31 postmenopausal women, compared with bone densities in 31 inactive women.

Proponents of yoga have wondered whether it might produce bone benefits similar to those seen with weight-bearing exercises. Previous data have shown skeletal tissue responds to site-specific stresses.

Yoga consists of movements and poses using body weight as a form of resistance, and contorts the joints with torque and strain. Results of the current cross-sectional study suggest yoga doesn't provide enough of a stimulus to increase bone mineral densities to levels significantly above those in inactive women, Millie Sweesy-Barger and associates said in a poster presentation at the annual meeting of the International Society for Clinical Densitometry.

Women in the yoga group had a 3-year history of practicing yoga at least twice a week in sessions of 60 minutes or longer. Those in the inactive group reported less than 2 hours of physical activity a week over the past 3 years. Participants underwent dual-energy x-ray absorptiometry (DXA) scans of the lumbar spine, left and right femurs, nondominant distal radius, and whole body. The mean age of the women was 60 years in the inactive group and 58 years in the yoga group. The cohort included 59 whites and 3 Asian Americans.

No significant differences between groups were seen in bone mineral densities at any sites. Higher mean bone mineral density in the distal radius in the inactive group, compared with the yoga group, became statistically insignificant after controlling for the effects of age, height, body mass, body mass index (BMI), percent body fat, fat mass, lean body mass, and calcium intake, said Ms. Sweesy-Barger, a student in the department of kinesiology and physical therapy at California State University, Long Beach. The yoga group had significantly lower mean measurements of body mass, percent body fat, fat mass, and BMI, compared with the inactive group, she added.

There is substantial evidence showing significant physical and psychological benefits of exercise programs for older adults, 55% of whom in the United States either have osteoporosis or are at risk of developing the disease, Ms. Sweesy-Barger noted. “To the aging, nonathletic postmeno- pausal woman, the question becomes, which activities are most effective for mitigating the loss of bone?”

Understanding how bone adapts to various forms of physical activity will help inform public health strategies to prevent and manage osteoporosis, she said.

SAN FRANCISCO — New guidelines for preventing and treating osteoporosis and a new online tool to quantify the risk of future fracture should help providers target therapy to patients who are most likely to benefit from it.

“Quantitative fracture risk assessment has finally arrived,” Dr. Marjorie M. Luckey said at the annual meeting of the International Society for Clinical Densitometry.

In February 2008, the National Osteoporosis Foundation (NOF) updated the “Clinician's Guide to Prevention and Treatment of Osteoporosis,” first published in 1999 and last revised in 2003 with only minor changes. The guidelines are available at www.nof.orgwww.shef.ac.uk/FRAX

Previous NOF guidelines applied only to postmenopausal white women and based intervention recommendations entirely on a patient's T score, with some modification of the level of intervention based on clinical risk factors, said Dr. Luckey, medical director of the osteoporosis and metabolic bone disease center at St. Barnabas Ambulatory Care Center, Livingston, N.Y.

The new guidelines also include recommendations for men over age 50 years and postmenopausal women of races/ethnicities other than white and base the thresholds for intervention largely on a patient's estimated 10-year fracture risk. The new document also updates the economic modeling that informs treatment recommendations.

“The 2008 NOF guidelines are a hybrid, rather than going entirely to fracture risk-based guidelines. There are some patients who will get treated based on their T score, and others who will get treated based on their fracture risk,” said Dr. Luckey, also of Mount Sinai School of Medicine, New York. This should have the effect of shifting some treatment from younger patients who have modestly reduced bone density levels (T scores of -2.0 or better) to treat an older population, “which most of us think is an appropriate move to treat patients who are at high risk for fracture.”

As in the previous guidelines, the benefits of a healthy lifestyle and adequate calcium and vitamin D levels are emphasized. Patients should be assessed clinically to determine if they are at risk for osteoporosis, and bone density testing should be done if appropriate. Treatment is recommended for patients with a previous hip or vertebral fracture, regardless of bone density, for patients with T scores of -2.5 or lower, and for osteopenic patients with T scores between -1.0 and -2.5 if they have secondary causes of osteoporosis that can affect fracture risk, such as being totally immobilized or on glucocorticoids.

A new recommendation in the 2008 guidelines is to consider treating osteopenic patients if their 10-year probability of hip fracture is 3% or greater or their 10-year risk of a major fracture is 20% or greater, using the FRAX model.

The guidelines have not changed recommendations for the 10 million U.S. residents with osteoporosis but only for those among the 34 million U.S. residents with osteopenia who have no history of fracture and are not immobilized or on steroids. “Their level of risk should be assessed using the 10-year fracture rate model,” she said.

The quantitative risk assessment adds a tool for providers but clinical judgment to individualize treatment decisions is just as important. “These fracture risk estimates should be used to facilitate the discussion you have with a patient about whether or not to go on pharmacotherapy,” Dr. Luckey emphasized.

The online FRAX tool allows users to choose models for different countries, with separate models in the United States for white, black, Hispanic, or Asian patients. The user answers questions about the patient's age, sex, weight, and height.

Questions about clinical risk factors include entries for current smoking, parental hip fracture, and patient history of fracture. A question about glucocorticoid use does not specify past or current use, but the model “is most accurately used if the patient has been on 3 months or more of 5 mg of prednisone equivalent per day currently or in the recent past,” Dr. Luckey said.

The only secondary cause of osteoporosis specifically mentioned is rheumatoid arthritis. Although another question generically asks if the patient has another secondary cause of osteoporosis, “it's a dummy variable” in the model that does not contribute to the online calculation of fracture risk, she noted.

A question about “alcohol 3 more units per day” is a typo that should read, “alcohol 3 or more units per day,” she added. A unit of alcohol is a standard glass of beer, an ounce of hard liquor, or a 4-ounce glass of weak wine. A 6-ounce glass of wine with 13%-14% alcohol content provides 2 units of alcohol.

Bone density can be entered as a T score or Z score. The model assumes that a T score was calculated using a white female reference database, so if you're not sure what reference database was used to get a T score for nonwhite women, enter a Z score, she advised. Male T scores are based on a male database, so enter a Z score in the FRAX model, which will convert a Z score to a T score.

Then click on the “calculate” button to get the estimated 10-year risk for hip fracture and all major fractures. The tool should not be used for premenopausal women, men under 50 years old, or patients who have started pharmacotherapy for bone health. It will underestimate risk in some patients because it does not include all risk factors and all secondary causes of osteoporosis. Keep your clinical thinking cap on, she advised.

Dr. Luckey is associated with multiple companies that make osteoporosis medications. She is a consultant and speaker for Eli Lilly & Co. and Merck & Co., and she is a consultant and received grants from Amgen Inc. Dr. Luckey is a speaker and received grant funds from Proctor & Gamble Corp. She also is a speaker for Sanofi Aventis and Novartis Corp. and received grants from Roche/GlaxoSmithKline.

'Quantitative fracture risk assessment has finally arrived' but keep your clinical thinking cap on. DR. LUCKEY

SAN FRANCISCO — New guidelines for preventing and treating osteoporosis and a new online tool to quantify the risk of future fracture should help providers target therapy to patients who are most likely to benefit from it.

“Quantitative fracture risk assessment has finally arrived,” Dr. Marjorie M. Luckey said at the annual meeting of the International Society for Clinical Densitometry.

In February 2008, the National Osteoporosis Foundation (NOF) updated the “Clinician's Guide to Prevention and Treatment of Osteoporosis,” first published in 1999 and last revised in 2003 with only minor changes. The guidelines are available at www.nof.orgwww.shef.ac.uk/FRAX

Previous NOF guidelines applied only to postmenopausal white women and based intervention recommendations entirely on a patient's T score, with some modification of the level of intervention based on clinical risk factors, said Dr. Luckey, medical director of the osteoporosis and metabolic bone disease center at St. Barnabas Ambulatory Care Center, Livingston, N.Y.

The new guidelines also include recommendations for men over age 50 years and postmenopausal women of races/ethnicities other than white and base the thresholds for intervention largely on a patient's estimated 10-year fracture risk. The new document also updates the economic modeling that informs treatment recommendations.

“The 2008 NOF guidelines are a hybrid, rather than going entirely to fracture risk-based guidelines. There are some patients who will get treated based on their T score, and others who will get treated based on their fracture risk,” said Dr. Luckey, also of Mount Sinai School of Medicine, New York. This should have the effect of shifting some treatment from younger patients who have modestly reduced bone density levels (T scores of -2.0 or better) to treat an older population, “which most of us think is an appropriate move to treat patients who are at high risk for fracture.”

As in the previous guidelines, the benefits of a healthy lifestyle and adequate calcium and vitamin D levels are emphasized. Patients should be assessed clinically to determine if they are at risk for osteoporosis, and bone density testing should be done if appropriate. Treatment is recommended for patients with a previous hip or vertebral fracture, regardless of bone density, for patients with T scores of -2.5 or lower, and for osteopenic patients with T scores between -1.0 and -2.5 if they have secondary causes of osteoporosis that can affect fracture risk, such as being totally immobilized or on glucocorticoids.

A new recommendation in the 2008 guidelines is to consider treating osteopenic patients if their 10-year probability of hip fracture is 3% or greater or their 10-year risk of a major fracture is 20% or greater, using the FRAX model.

The guidelines have not changed recommendations for the 10 million U.S. residents with osteoporosis but only for those among the 34 million U.S. residents with osteopenia who have no history of fracture and are not immobilized or on steroids. “Their level of risk should be assessed using the 10-year fracture rate model,” she said.

The quantitative risk assessment adds a tool for providers but clinical judgment to individualize treatment decisions is just as important. “These fracture risk estimates should be used to facilitate the discussion you have with a patient about whether or not to go on pharmacotherapy,” Dr. Luckey emphasized.

The online FRAX tool allows users to choose models for different countries, with separate models in the United States for white, black, Hispanic, or Asian patients. The user answers questions about the patient's age, sex, weight, and height.

Questions about clinical risk factors include entries for current smoking, parental hip fracture, and patient history of fracture. A question about glucocorticoid use does not specify past or current use, but the model “is most accurately used if the patient has been on 3 months or more of 5 mg of prednisone equivalent per day currently or in the recent past,” Dr. Luckey said.

The only secondary cause of osteoporosis specifically mentioned is rheumatoid arthritis. Although another question generically asks if the patient has another secondary cause of osteoporosis, “it's a dummy variable” in the model that does not contribute to the online calculation of fracture risk, she noted.

A question about “alcohol 3 more units per day” is a typo that should read, “alcohol 3 or more units per day,” she added. A unit of alcohol is a standard glass of beer, an ounce of hard liquor, or a 4-ounce glass of weak wine. A 6-ounce glass of wine with 13%-14% alcohol content provides 2 units of alcohol.

Bone density can be entered as a T score or Z score. The model assumes that a T score was calculated using a white female reference database, so if you're not sure what reference database was used to get a T score for nonwhite women, enter a Z score, she advised. Male T scores are based on a male database, so enter a Z score in the FRAX model, which will convert a Z score to a T score.

Then click on the “calculate” button to get the estimated 10-year risk for hip fracture and all major fractures. The tool should not be used for premenopausal women, men under 50 years old, or patients who have started pharmacotherapy for bone health. It will underestimate risk in some patients because it does not include all risk factors and all secondary causes of osteoporosis. Keep your clinical thinking cap on, she advised.

Dr. Luckey is associated with multiple companies that make osteoporosis medications. She is a consultant and speaker for Eli Lilly & Co. and Merck & Co., and she is a consultant and received grants from Amgen Inc. Dr. Luckey is a speaker and received grant funds from Proctor & Gamble Corp. She also is a speaker for Sanofi Aventis and Novartis Corp. and received grants from Roche/GlaxoSmithKline.

'Quantitative fracture risk assessment has finally arrived' but keep your clinical thinking cap on. DR. LUCKEY

SAN FRANCISCO — New guidelines for preventing and treating osteoporosis and a new online tool to quantify the risk of future fracture should help providers target therapy to patients who are most likely to benefit from it.

“Quantitative fracture risk assessment has finally arrived,” Dr. Marjorie M. Luckey said at the annual meeting of the International Society for Clinical Densitometry.

In February 2008, the National Osteoporosis Foundation (NOF) updated the “Clinician's Guide to Prevention and Treatment of Osteoporosis,” first published in 1999 and last revised in 2003 with only minor changes. The guidelines are available at www.nof.orgwww.shef.ac.uk/FRAX

Previous NOF guidelines applied only to postmenopausal white women and based intervention recommendations entirely on a patient's T score, with some modification of the level of intervention based on clinical risk factors, said Dr. Luckey, medical director of the osteoporosis and metabolic bone disease center at St. Barnabas Ambulatory Care Center, Livingston, N.Y.

The new guidelines also include recommendations for men over age 50 years and postmenopausal women of races/ethnicities other than white and base the thresholds for intervention largely on a patient's estimated 10-year fracture risk. The new document also updates the economic modeling that informs treatment recommendations.

“The 2008 NOF guidelines are a hybrid, rather than going entirely to fracture risk-based guidelines. There are some patients who will get treated based on their T score, and others who will get treated based on their fracture risk,” said Dr. Luckey, also of Mount Sinai School of Medicine, New York. This should have the effect of shifting some treatment from younger patients who have modestly reduced bone density levels (T scores of -2.0 or better) to treat an older population, “which most of us think is an appropriate move to treat patients who are at high risk for fracture.”

As in the previous guidelines, the benefits of a healthy lifestyle and adequate calcium and vitamin D levels are emphasized. Patients should be assessed clinically to determine if they are at risk for osteoporosis, and bone density testing should be done if appropriate. Treatment is recommended for patients with a previous hip or vertebral fracture, regardless of bone density, for patients with T scores of -2.5 or lower, and for osteopenic patients with T scores between -1.0 and -2.5 if they have secondary causes of osteoporosis that can affect fracture risk, such as being totally immobilized or on glucocorticoids.

A new recommendation in the 2008 guidelines is to consider treating osteopenic patients if their 10-year probability of hip fracture is 3% or greater or their 10-year risk of a major fracture is 20% or greater, using the FRAX model.

The guidelines have not changed recommendations for the 10 million U.S. residents with osteoporosis but only for those among the 34 million U.S. residents with osteopenia who have no history of fracture and are not immobilized or on steroids. “Their level of risk should be assessed using the 10-year fracture rate model,” she said.

The quantitative risk assessment adds a tool for providers but clinical judgment to individualize treatment decisions is just as important. “These fracture risk estimates should be used to facilitate the discussion you have with a patient about whether or not to go on pharmacotherapy,” Dr. Luckey emphasized.

The online FRAX tool allows users to choose models for different countries, with separate models in the United States for white, black, Hispanic, or Asian patients. The user answers questions about the patient's age, sex, weight, and height.

Questions about clinical risk factors include entries for current smoking, parental hip fracture, and patient history of fracture. A question about glucocorticoid use does not specify past or current use, but the model “is most accurately used if the patient has been on 3 months or more of 5 mg of prednisone equivalent per day currently or in the recent past,” Dr. Luckey said.

The only secondary cause of osteoporosis specifically mentioned is rheumatoid arthritis. Although another question generically asks if the patient has another secondary cause of osteoporosis, “it's a dummy variable” in the model that does not contribute to the online calculation of fracture risk, she noted.

A question about “alcohol 3 more units per day” is a typo that should read, “alcohol 3 or more units per day,” she added. A unit of alcohol is a standard glass of beer, an ounce of hard liquor, or a 4-ounce glass of weak wine. A 6-ounce glass of wine with 13%-14% alcohol content provides 2 units of alcohol.

Bone density can be entered as a T score or Z score. The model assumes that a T score was calculated using a white female reference database, so if you're not sure what reference database was used to get a T score for nonwhite women, enter a Z score, she advised. Male T scores are based on a male database, so enter a Z score in the FRAX model, which will convert a Z score to a T score.

Then click on the “calculate” button to get the estimated 10-year risk for hip fracture and all major fractures. The tool should not be used for premenopausal women, men under 50 years old, or patients who have started pharmacotherapy for bone health. It will underestimate risk in some patients because it does not include all risk factors and all secondary causes of osteoporosis. Keep your clinical thinking cap on, she advised.

Dr. Luckey is associated with multiple companies that make osteoporosis medications. She is a consultant and speaker for Eli Lilly & Co. and Merck & Co., and she is a consultant and received grants from Amgen Inc. Dr. Luckey is a speaker and received grant funds from Proctor & Gamble Corp. She also is a speaker for Sanofi Aventis and Novartis Corp. and received grants from Roche/GlaxoSmithKline.

'Quantitative fracture risk assessment has finally arrived' but keep your clinical thinking cap on. DR. LUCKEY

SAN FRANCISCO — Complications after total knee or hip arthroplasty in patients with diabetes were significantly more common in those with higher hemoglobin A_1c levels, a retrospective study of 119 patients found.

The overall rate of medical and surgical complications was more than 50% in patients with a hemoglobin A_1c (HbA_1c) level greater than 7%, and less than 40% in those with an HbA_1c level below 7%, study investigators reported.

“We believe that the HbA_1c test should be a routine preoperative test ordered for diabetes patients prior to total joint arthroplasty,” Dr. Yossef C. Blum said during a poster session at the annual meeting of the American Academy of Orthopaedic Surgeons. “Patients with significantly elevated HbA_1c levels should have their glycemic control better optimized prior to undergoing total hip arthroplasty or total knee arthroplasty, as well as in the perioperative period.”

In a review of inpatient and outpatient charts of total knee or hip arthroplasty performed by a single surgeon at one institution from 2000 to 2007, Dr. Blum and his associates found 199 patients whose HbA_1c level had been measured in the year before surgery or within 3 months after the surgery. Patients were excluded from the study if they had conditions other than diabetes that led to an immunosuppressed state, such as HIV or rheumatoid arthritis.

Patients did not have to have a diagnosis of diabetes to be included in the study—just an HbA_1c measurement—because up to a third of people with diabetes do not have a formal diagnosis, he and his associates reported.

In all, 73% of the patients underwent total knee arthroplasty and 27% had total hip arthroplasty. Patients had a mean age of 68 years. The cohort was 76% male, 34% white, 34% black, 23% Hispanic, and 9% other races/ethnicities. Their mean body mass index was 34 kg/m

The investigators performed a multivariate analysis looking for associations between HbA_1c levels and outcomes within 3 months of the surgery, said Dr. Blum of Montefiore Medical Center, New York.

Higher HbA_1c levels were significantly associated with an increased risk for any complications, surgical site complications, and wound complications after total knee or hip arthroplasty, Dr. Blum and his associates reported.

Only four surgical site infections occurred—too few to demonstrate a specific association between HbA_1c levels and wound infection—but “it is notable that three of four infections occurred in patients with an HbA_1c [level] above 7.5%,” he said.

Although too few medical complications occurred to demonstrate a significant association with HbA_1c levels, an association might be seen in a larger study, he added. The current study found no association between HbA_1c level and the risk of non-surgical-site infections, urinary retention, or discharge after surgery to an inpatient facility.

Overall, 43% of the patients developed medical or surgical complications.

“Future studies with increased numbers of patients may help determine a cutoff HbA_1c level above which total hip arthroplasty or total knee arthroplasty can be considered too high risk,” Dr. Blum said.

Recommendations from the American Diabetes Association set a treatment goal of an HbA_1c level below 7%.

A 2003 review by other investigators of 290 diabetes patients who underwent noncardiac surgeries found that those with an HbA_1c level above 7% had a statistically significant increased risk for postoperative complications, Dr. Blum said.

There have been few studies in the past 2 decades on the results of total knee arthroplasty in diabetes patients, and even fewer studies on the results of total hip arthroplasty in diabetes patients, Dr. Blum noted. Some reports suggest a risk of 1%–7% for deep infection in diabetes patients after total knee arthroplasty, and overall wound complication rates of 1%–12%.

A 1983 study of outcomes after total hip arthroplasty in diabetes patients reported superficial infections in 10% of the patients and deep infections in 7%.

Other studies suggest that diabetes patients may be more prone to perioperative complications including urinary tract infections, pneumonia, sepsis, cardiac problems, and postoperative neuropathy.

SAN FRANCISCO — Complications after total knee or hip arthroplasty in patients with diabetes were significantly more common in those with higher hemoglobin A_1c levels, a retrospective study of 119 patients found.

The overall rate of medical and surgical complications was more than 50% in patients with a hemoglobin A_1c (HbA_1c) level greater than 7%, and less than 40% in those with an HbA_1c level below 7%, study investigators reported.

“We believe that the HbA_1c test should be a routine preoperative test ordered for diabetes patients prior to total joint arthroplasty,” Dr. Yossef C. Blum said during a poster session at the annual meeting of the American Academy of Orthopaedic Surgeons. “Patients with significantly elevated HbA_1c levels should have their glycemic control better optimized prior to undergoing total hip arthroplasty or total knee arthroplasty, as well as in the perioperative period.”

In a review of inpatient and outpatient charts of total knee or hip arthroplasty performed by a single surgeon at one institution from 2000 to 2007, Dr. Blum and his associates found 199 patients whose HbA_1c level had been measured in the year before surgery or within 3 months after the surgery. Patients were excluded from the study if they had conditions other than diabetes that led to an immunosuppressed state, such as HIV or rheumatoid arthritis.

Patients did not have to have a diagnosis of diabetes to be included in the study—just an HbA_1c measurement—because up to a third of people with diabetes do not have a formal diagnosis, he and his associates reported.

In all, 73% of the patients underwent total knee arthroplasty and 27% had total hip arthroplasty. Patients had a mean age of 68 years. The cohort was 76% male, 34% white, 34% black, 23% Hispanic, and 9% other races/ethnicities. Their mean body mass index was 34 kg/m

The investigators performed a multivariate analysis looking for associations between HbA_1c levels and outcomes within 3 months of the surgery, said Dr. Blum of Montefiore Medical Center, New York.

Higher HbA_1c levels were significantly associated with an increased risk for any complications, surgical site complications, and wound complications after total knee or hip arthroplasty, Dr. Blum and his associates reported.

Only four surgical site infections occurred—too few to demonstrate a specific association between HbA_1c levels and wound infection—but “it is notable that three of four infections occurred in patients with an HbA_1c [level] above 7.5%,” he said.

Although too few medical complications occurred to demonstrate a significant association with HbA_1c levels, an association might be seen in a larger study, he added. The current study found no association between HbA_1c level and the risk of non-surgical-site infections, urinary retention, or discharge after surgery to an inpatient facility.

Overall, 43% of the patients developed medical or surgical complications.

“Future studies with increased numbers of patients may help determine a cutoff HbA_1c level above which total hip arthroplasty or total knee arthroplasty can be considered too high risk,” Dr. Blum said.

Recommendations from the American Diabetes Association set a treatment goal of an HbA_1c level below 7%.

A 2003 review by other investigators of 290 diabetes patients who underwent noncardiac surgeries found that those with an HbA_1c level above 7% had a statistically significant increased risk for postoperative complications, Dr. Blum said.

There have been few studies in the past 2 decades on the results of total knee arthroplasty in diabetes patients, and even fewer studies on the results of total hip arthroplasty in diabetes patients, Dr. Blum noted. Some reports suggest a risk of 1%–7% for deep infection in diabetes patients after total knee arthroplasty, and overall wound complication rates of 1%–12%.

A 1983 study of outcomes after total hip arthroplasty in diabetes patients reported superficial infections in 10% of the patients and deep infections in 7%.

Other studies suggest that diabetes patients may be more prone to perioperative complications including urinary tract infections, pneumonia, sepsis, cardiac problems, and postoperative neuropathy.

SAN FRANCISCO — Complications after total knee or hip arthroplasty in patients with diabetes were significantly more common in those with higher hemoglobin A_1c levels, a retrospective study of 119 patients found.

The overall rate of medical and surgical complications was more than 50% in patients with a hemoglobin A_1c (HbA_1c) level greater than 7%, and less than 40% in those with an HbA_1c level below 7%, study investigators reported.

“We believe that the HbA_1c test should be a routine preoperative test ordered for diabetes patients prior to total joint arthroplasty,” Dr. Yossef C. Blum said during a poster session at the annual meeting of the American Academy of Orthopaedic Surgeons. “Patients with significantly elevated HbA_1c levels should have their glycemic control better optimized prior to undergoing total hip arthroplasty or total knee arthroplasty, as well as in the perioperative period.”

In a review of inpatient and outpatient charts of total knee or hip arthroplasty performed by a single surgeon at one institution from 2000 to 2007, Dr. Blum and his associates found 199 patients whose HbA_1c level had been measured in the year before surgery or within 3 months after the surgery. Patients were excluded from the study if they had conditions other than diabetes that led to an immunosuppressed state, such as HIV or rheumatoid arthritis.

Patients did not have to have a diagnosis of diabetes to be included in the study—just an HbA_1c measurement—because up to a third of people with diabetes do not have a formal diagnosis, he and his associates reported.

In all, 73% of the patients underwent total knee arthroplasty and 27% had total hip arthroplasty. Patients had a mean age of 68 years. The cohort was 76% male, 34% white, 34% black, 23% Hispanic, and 9% other races/ethnicities. Their mean body mass index was 34 kg/m

The investigators performed a multivariate analysis looking for associations between HbA_1c levels and outcomes within 3 months of the surgery, said Dr. Blum of Montefiore Medical Center, New York.

Higher HbA_1c levels were significantly associated with an increased risk for any complications, surgical site complications, and wound complications after total knee or hip arthroplasty, Dr. Blum and his associates reported.

Only four surgical site infections occurred—too few to demonstrate a specific association between HbA_1c levels and wound infection—but “it is notable that three of four infections occurred in patients with an HbA_1c [level] above 7.5%,” he said.

Although too few medical complications occurred to demonstrate a significant association with HbA_1c levels, an association might be seen in a larger study, he added. The current study found no association between HbA_1c level and the risk of non-surgical-site infections, urinary retention, or discharge after surgery to an inpatient facility.

Overall, 43% of the patients developed medical or surgical complications.

“Future studies with increased numbers of patients may help determine a cutoff HbA_1c level above which total hip arthroplasty or total knee arthroplasty can be considered too high risk,” Dr. Blum said.

Recommendations from the American Diabetes Association set a treatment goal of an HbA_1c level below 7%.

A 2003 review by other investigators of 290 diabetes patients who underwent noncardiac surgeries found that those with an HbA_1c level above 7% had a statistically significant increased risk for postoperative complications, Dr. Blum said.

There have been few studies in the past 2 decades on the results of total knee arthroplasty in diabetes patients, and even fewer studies on the results of total hip arthroplasty in diabetes patients, Dr. Blum noted. Some reports suggest a risk of 1%–7% for deep infection in diabetes patients after total knee arthroplasty, and overall wound complication rates of 1%–12%.

A 1983 study of outcomes after total hip arthroplasty in diabetes patients reported superficial infections in 10% of the patients and deep infections in 7%.

Other studies suggest that diabetes patients may be more prone to perioperative complications including urinary tract infections, pneumonia, sepsis, cardiac problems, and postoperative neuropathy.

SAN FRANCISCO — Osteoporotic women treated with teriparatide often gain lumbar spine bone mineral density and lower their risk of vertebral fracture, even if they lose hip bone mineral density, Dr. Nelson B. Watts reported in a poster presentation at the annual meeting of the International Society for Clinical Densitometry.

Previous studies have shown that increased areal lumbar spine bone mineral density (BMD) accounts for 30%–41% of the reduction in vertebral fracture risk from teriparatide treatment. In clinical practice, loss of BMD in other areas, such as the femoral neck, has been viewed by some as a lack of response to therapy.

The current post hoc analysis of data on 1,216 women found that vertebral fracture risk was independent of gains or losses in femoral neck BMD in women taking teriparatide, compared with women on placebo, reported Dr. Watts, program director of the bone health and osteoporosis center at the University of Cincinnati, and his associates.

The investigators analyzed data on women with a history of vertebral fractures who were randomized to take 20 or 40 mcg/day of teriparatide or placebo in the double-blind Fracture Prevention Trial. The women self-administered the treatments subcutaneously and also received daily supplements of 1,000 mg of calcium and 400–1,200 IU of vitamin D.

The current analysis focused on a subset of 1,216 women who had femoral neck BMD measured both at baseline and after 12 months of therapy by dual-energy x-ray absorptiometry (DXA) and who had lateral thoracic and lumbar spine radiographs taken both at baseline and at the study end point, a median of 19 months from baseline.

The risk of vertebral fracture was calculated for women on placebo and for women in four subgroups of teriparatide therapy based on changes in femoral neck BMD 1 year from baseline. The women on teriparatide were divided as follows: those who lost more than 4% of femoral neck BMD, those who lost up to 4% in density, those who gained up to 4% in density, and those who gained more than 4% in femoral neck BMD.

In the combined teriparatide groups, a significantly greater proportion (35%) gained more than 4% in femoral neck BMD, compared with those on placebo (17%). This finding supports previous studies that showed that teriparatide can improve bone geometric strength at the femoral neck, compared with placebo.

Women in the current study showed significant reductions in vertebral fracture risk on teriparatide therapy, compared with placebo, regardless of changes in femoral neck BMD at 1 year, Dr. Watts reported.

Among women with greater than a 4% loss in femoral neck density, 2 (2%) of 82 women on teriparatide developed vertebral fractures, compared with 14 (23%) of 61 women on placebo. Among women with up to a 4% loss in femoral neck density, 5 (3%) of 182 women on teriparatide and 15 (10%) of 149 women on placebo developed vertebral fractures.

Among women with up to a 4% gain in femoral neck BMD, vertebral fractures were seen in 5 (3%) of 182 women on teriparatide and 19 (15%) of 124 women on placebo. Among women with greater than a 4% gain in femoral neck density, 14 (5%) of 282 on teriparatide and 9 (14%) of 66 on placebo developed vertebral fractures.

Lumbar spine BMD increased significantly more in women on teriparatide, compared with placebo, regardless of changes in femoral neck density. Lumbar spine density increased by 3% or greater in 78%–92% of women on teriparatide in the four femoral neck subgroups.

The study was funded by the company that makes teriparatide, Eli Lilly & Co., which also provided the layout for the poster. Dr. Watts is a consultant for the company. His report was rated one of the top posters at the meeting.

Vertebral fracture risk was independent of gains and losses in femoral neck BMD. DR. WATTS

SAN FRANCISCO — Osteoporotic women treated with teriparatide often gain lumbar spine bone mineral density and lower their risk of vertebral fracture, even if they lose hip bone mineral density, Dr. Nelson B. Watts reported in a poster presentation at the annual meeting of the International Society for Clinical Densitometry.

Previous studies have shown that increased areal lumbar spine bone mineral density (BMD) accounts for 30%–41% of the reduction in vertebral fracture risk from teriparatide treatment. In clinical practice, loss of BMD in other areas, such as the femoral neck, has been viewed by some as a lack of response to therapy.

The current post hoc analysis of data on 1,216 women found that vertebral fracture risk was independent of gains or losses in femoral neck BMD in women taking teriparatide, compared with women on placebo, reported Dr. Watts, program director of the bone health and osteoporosis center at the University of Cincinnati, and his associates.

The investigators analyzed data on women with a history of vertebral fractures who were randomized to take 20 or 40 mcg/day of teriparatide or placebo in the double-blind Fracture Prevention Trial. The women self-administered the treatments subcutaneously and also received daily supplements of 1,000 mg of calcium and 400–1,200 IU of vitamin D.

The current analysis focused on a subset of 1,216 women who had femoral neck BMD measured both at baseline and after 12 months of therapy by dual-energy x-ray absorptiometry (DXA) and who had lateral thoracic and lumbar spine radiographs taken both at baseline and at the study end point, a median of 19 months from baseline.

The risk of vertebral fracture was calculated for women on placebo and for women in four subgroups of teriparatide therapy based on changes in femoral neck BMD 1 year from baseline. The women on teriparatide were divided as follows: those who lost more than 4% of femoral neck BMD, those who lost up to 4% in density, those who gained up to 4% in density, and those who gained more than 4% in femoral neck BMD.

In the combined teriparatide groups, a significantly greater proportion (35%) gained more than 4% in femoral neck BMD, compared with those on placebo (17%). This finding supports previous studies that showed that teriparatide can improve bone geometric strength at the femoral neck, compared with placebo.

Women in the current study showed significant reductions in vertebral fracture risk on teriparatide therapy, compared with placebo, regardless of changes in femoral neck BMD at 1 year, Dr. Watts reported.

Among women with greater than a 4% loss in femoral neck density, 2 (2%) of 82 women on teriparatide developed vertebral fractures, compared with 14 (23%) of 61 women on placebo. Among women with up to a 4% loss in femoral neck density, 5 (3%) of 182 women on teriparatide and 15 (10%) of 149 women on placebo developed vertebral fractures.

Among women with up to a 4% gain in femoral neck BMD, vertebral fractures were seen in 5 (3%) of 182 women on teriparatide and 19 (15%) of 124 women on placebo. Among women with greater than a 4% gain in femoral neck density, 14 (5%) of 282 on teriparatide and 9 (14%) of 66 on placebo developed vertebral fractures.

Lumbar spine BMD increased significantly more in women on teriparatide, compared with placebo, regardless of changes in femoral neck density. Lumbar spine density increased by 3% or greater in 78%–92% of women on teriparatide in the four femoral neck subgroups.

The study was funded by the company that makes teriparatide, Eli Lilly & Co., which also provided the layout for the poster. Dr. Watts is a consultant for the company. His report was rated one of the top posters at the meeting.

Vertebral fracture risk was independent of gains and losses in femoral neck BMD. DR. WATTS

SAN FRANCISCO — Osteoporotic women treated with teriparatide often gain lumbar spine bone mineral density and lower their risk of vertebral fracture, even if they lose hip bone mineral density, Dr. Nelson B. Watts reported in a poster presentation at the annual meeting of the International Society for Clinical Densitometry.

Previous studies have shown that increased areal lumbar spine bone mineral density (BMD) accounts for 30%–41% of the reduction in vertebral fracture risk from teriparatide treatment. In clinical practice, loss of BMD in other areas, such as the femoral neck, has been viewed by some as a lack of response to therapy.

The current post hoc analysis of data on 1,216 women found that vertebral fracture risk was independent of gains or losses in femoral neck BMD in women taking teriparatide, compared with women on placebo, reported Dr. Watts, program director of the bone health and osteoporosis center at the University of Cincinnati, and his associates.

The investigators analyzed data on women with a history of vertebral fractures who were randomized to take 20 or 40 mcg/day of teriparatide or placebo in the double-blind Fracture Prevention Trial. The women self-administered the treatments subcutaneously and also received daily supplements of 1,000 mg of calcium and 400–1,200 IU of vitamin D.

The current analysis focused on a subset of 1,216 women who had femoral neck BMD measured both at baseline and after 12 months of therapy by dual-energy x-ray absorptiometry (DXA) and who had lateral thoracic and lumbar spine radiographs taken both at baseline and at the study end point, a median of 19 months from baseline.

The risk of vertebral fracture was calculated for women on placebo and for women in four subgroups of teriparatide therapy based on changes in femoral neck BMD 1 year from baseline. The women on teriparatide were divided as follows: those who lost more than 4% of femoral neck BMD, those who lost up to 4% in density, those who gained up to 4% in density, and those who gained more than 4% in femoral neck BMD.

In the combined teriparatide groups, a significantly greater proportion (35%) gained more than 4% in femoral neck BMD, compared with those on placebo (17%). This finding supports previous studies that showed that teriparatide can improve bone geometric strength at the femoral neck, compared with placebo.

Women in the current study showed significant reductions in vertebral fracture risk on teriparatide therapy, compared with placebo, regardless of changes in femoral neck BMD at 1 year, Dr. Watts reported.

Among women with greater than a 4% loss in femoral neck density, 2 (2%) of 82 women on teriparatide developed vertebral fractures, compared with 14 (23%) of 61 women on placebo. Among women with up to a 4% loss in femoral neck density, 5 (3%) of 182 women on teriparatide and 15 (10%) of 149 women on placebo developed vertebral fractures.

Among women with up to a 4% gain in femoral neck BMD, vertebral fractures were seen in 5 (3%) of 182 women on teriparatide and 19 (15%) of 124 women on placebo. Among women with greater than a 4% gain in femoral neck density, 14 (5%) of 282 on teriparatide and 9 (14%) of 66 on placebo developed vertebral fractures.

Lumbar spine BMD increased significantly more in women on teriparatide, compared with placebo, regardless of changes in femoral neck density. Lumbar spine density increased by 3% or greater in 78%–92% of women on teriparatide in the four femoral neck subgroups.

The study was funded by the company that makes teriparatide, Eli Lilly & Co., which also provided the layout for the poster. Dr. Watts is a consultant for the company. His report was rated one of the top posters at the meeting.

Vertebral fracture risk was independent of gains and losses in femoral neck BMD. DR. WATTS

SAN FRANCISCO — Patients who gain range of motion and improved function after total knee replacement also increase their level of sports activity, a study of 417 patients found.

There have been little data on the relationship between changes in objective or functional outcomes after total knee arthroplasty and changes in activity level. The number of articles published on this topic grew from around 5 per year in 1996 to 20 or so in 2006, according to Dr. Michael A. Mont, director of joint preservation and reconstruction at Sinai Hospital, Baltimore.

He and his associates conducted a survey of 162 men and 255 women receiving total knee arthroplasty. All of the patients underwent the procedure to treat pain associated with osteoarthritis.

The survey asked about the hours and types of sports activity the patients had participated in during the year prior to surgery and up to a mean of 3 years after surgery. The researchers compared the survey results with evaluations of the knee using Knee Society objective and functional scores and a 10-point satisfaction scale.

They found a positive correlation between increases in Knee Society functional scores and increases in weighted activity scores. Every 10-point increase in Knee Society functional score predicted a 1.2-point increase in the weighted activity score, Dr. Mont said in a poster presentation at the annual meeting of the American Academy of Orthopaedic Surgeons.

The investigators used a new questionnaire to derive the weighted activity score, which accounted for the impact level of a sports activity and the amount of time a patient spent in that activity. The calculation begins by assigning 1 point to low-impact activities (including aerobics, bicycling, golf, dancing, gardening, or others), 2 points to moderate-impact activities (ice skating, skiing, or singles tennis, among others), or 3 points to higher-impact activities (including baseball, basketball, football, gymnastics, jogging, and other activities).

The investigators then multiplied the frequency of an activity (in days per week) by the duration (in hours per day) reported by a patient, and multiplied the product by the number of impact points. Calculations were done for each activity reported by a patient, and the sums added up to the weighted activity score.

A highly active patient might report cycling, golf, singles tennis, and basketball. Cycling 7 days per week for 1 hour per day, multiplied by 1 impact point, is 7 points. One 3-hour golf outing per week multiplied by 1 impact point totals 3 points. Singles tennis 1 day per week for 1 hour multiplied by 2 impact points totals 2 points. Basketball 1 day per week for a half-hour multiplied by 3 impact points totals 1.5 points. Summing up all the activity points (7 plus 3 plus 2 plus 1.5) gives a weighted activity score of 13.5 points.

A low-activity patient who reports speedwalking 1 hour per week (totaling 1 point) and gardening a half-hour per week (totaling 0.5 point) would have a weighted activity score of 1.5.

Overall, Knee Society functional scores increased by a mean of 48 points from the preoperative assessment to the final follow-up. The corresponding increase in weighted activity score was 2.5 points, with a mean weighted activity score of 6.2 points at the final follow-up, he said.

Weighted activity scores increased for 53% of patients, decreased for 19%, and did not change for 29%. Patients under 60 years old were significantly more likely to increase their activity scores after knee replacement than were older patients.

Dr. Mont is a consultant for Wright Medical Technology, and he and two coinvestigators are consultants for Stryker. Both companies market artificial knee implants.

SAN FRANCISCO — Patients who gain range of motion and improved function after total knee replacement also increase their level of sports activity, a study of 417 patients found.

There have been little data on the relationship between changes in objective or functional outcomes after total knee arthroplasty and changes in activity level. The number of articles published on this topic grew from around 5 per year in 1996 to 20 or so in 2006, according to Dr. Michael A. Mont, director of joint preservation and reconstruction at Sinai Hospital, Baltimore.

He and his associates conducted a survey of 162 men and 255 women receiving total knee arthroplasty. All of the patients underwent the procedure to treat pain associated with osteoarthritis.

The survey asked about the hours and types of sports activity the patients had participated in during the year prior to surgery and up to a mean of 3 years after surgery. The researchers compared the survey results with evaluations of the knee using Knee Society objective and functional scores and a 10-point satisfaction scale.

They found a positive correlation between increases in Knee Society functional scores and increases in weighted activity scores. Every 10-point increase in Knee Society functional score predicted a 1.2-point increase in the weighted activity score, Dr. Mont said in a poster presentation at the annual meeting of the American Academy of Orthopaedic Surgeons.

The investigators used a new questionnaire to derive the weighted activity score, which accounted for the impact level of a sports activity and the amount of time a patient spent in that activity. The calculation begins by assigning 1 point to low-impact activities (including aerobics, bicycling, golf, dancing, gardening, or others), 2 points to moderate-impact activities (ice skating, skiing, or singles tennis, among others), or 3 points to higher-impact activities (including baseball, basketball, football, gymnastics, jogging, and other activities).

The investigators then multiplied the frequency of an activity (in days per week) by the duration (in hours per day) reported by a patient, and multiplied the product by the number of impact points. Calculations were done for each activity reported by a patient, and the sums added up to the weighted activity score.

A highly active patient might report cycling, golf, singles tennis, and basketball. Cycling 7 days per week for 1 hour per day, multiplied by 1 impact point, is 7 points. One 3-hour golf outing per week multiplied by 1 impact point totals 3 points. Singles tennis 1 day per week for 1 hour multiplied by 2 impact points totals 2 points. Basketball 1 day per week for a half-hour multiplied by 3 impact points totals 1.5 points. Summing up all the activity points (7 plus 3 plus 2 plus 1.5) gives a weighted activity score of 13.5 points.

A low-activity patient who reports speedwalking 1 hour per week (totaling 1 point) and gardening a half-hour per week (totaling 0.5 point) would have a weighted activity score of 1.5.

Overall, Knee Society functional scores increased by a mean of 48 points from the preoperative assessment to the final follow-up. The corresponding increase in weighted activity score was 2.5 points, with a mean weighted activity score of 6.2 points at the final follow-up, he said.

Weighted activity scores increased for 53% of patients, decreased for 19%, and did not change for 29%. Patients under 60 years old were significantly more likely to increase their activity scores after knee replacement than were older patients.

Dr. Mont is a consultant for Wright Medical Technology, and he and two coinvestigators are consultants for Stryker. Both companies market artificial knee implants.

SAN FRANCISCO — Patients who gain range of motion and improved function after total knee replacement also increase their level of sports activity, a study of 417 patients found.

There have been little data on the relationship between changes in objective or functional outcomes after total knee arthroplasty and changes in activity level. The number of articles published on this topic grew from around 5 per year in 1996 to 20 or so in 2006, according to Dr. Michael A. Mont, director of joint preservation and reconstruction at Sinai Hospital, Baltimore.

He and his associates conducted a survey of 162 men and 255 women receiving total knee arthroplasty. All of the patients underwent the procedure to treat pain associated with osteoarthritis.

The survey asked about the hours and types of sports activity the patients had participated in during the year prior to surgery and up to a mean of 3 years after surgery. The researchers compared the survey results with evaluations of the knee using Knee Society objective and functional scores and a 10-point satisfaction scale.

They found a positive correlation between increases in Knee Society functional scores and increases in weighted activity scores. Every 10-point increase in Knee Society functional score predicted a 1.2-point increase in the weighted activity score, Dr. Mont said in a poster presentation at the annual meeting of the American Academy of Orthopaedic Surgeons.

The investigators used a new questionnaire to derive the weighted activity score, which accounted for the impact level of a sports activity and the amount of time a patient spent in that activity. The calculation begins by assigning 1 point to low-impact activities (including aerobics, bicycling, golf, dancing, gardening, or others), 2 points to moderate-impact activities (ice skating, skiing, or singles tennis, among others), or 3 points to higher-impact activities (including baseball, basketball, football, gymnastics, jogging, and other activities).

The investigators then multiplied the frequency of an activity (in days per week) by the duration (in hours per day) reported by a patient, and multiplied the product by the number of impact points. Calculations were done for each activity reported by a patient, and the sums added up to the weighted activity score.

A highly active patient might report cycling, golf, singles tennis, and basketball. Cycling 7 days per week for 1 hour per day, multiplied by 1 impact point, is 7 points. One 3-hour golf outing per week multiplied by 1 impact point totals 3 points. Singles tennis 1 day per week for 1 hour multiplied by 2 impact points totals 2 points. Basketball 1 day per week for a half-hour multiplied by 3 impact points totals 1.5 points. Summing up all the activity points (7 plus 3 plus 2 plus 1.5) gives a weighted activity score of 13.5 points.

A low-activity patient who reports speedwalking 1 hour per week (totaling 1 point) and gardening a half-hour per week (totaling 0.5 point) would have a weighted activity score of 1.5.

Overall, Knee Society functional scores increased by a mean of 48 points from the preoperative assessment to the final follow-up. The corresponding increase in weighted activity score was 2.5 points, with a mean weighted activity score of 6.2 points at the final follow-up, he said.

Weighted activity scores increased for 53% of patients, decreased for 19%, and did not change for 29%. Patients under 60 years old were significantly more likely to increase their activity scores after knee replacement than were older patients.

Dr. Mont is a consultant for Wright Medical Technology, and he and two coinvestigators are consultants for Stryker. Both companies market artificial knee implants.

SAN FRANCISCO — Women with osteoporosis treated with teriparatide often gain lumbar spine bone mineral density and lower their risk of vertebral fracture, even if they lose hip bone mineral density, Dr. Nelson B. Watts reported in a poster presentation at the annual meeting of the International Society for Clinical Densitometry.

Previous studies have shown that increased areal lumbar spine bone mineral density (BMD) accounts for 30%–41% of the reduction in vertebral fracture risk from teriparatide treatment. In clinical practice, loss of BMD in other areas, such as the femoral neck, has been viewed by some as a lack of response to therapy.

The current post hoc analysis of data on 1,216 women found vertebral fracture risk was independent of gains or losses in femoral neck BMD in women taking teriparatide, compared with women on placebo, reported Dr. Watts, program director of the bone health and osteoporosis center at the University of Cincinnati.

The investigators analyzed data on women with a history of vertebral fractures randomized to take 20 or 40 mcg/day of teriparatide or placebo in the double-blind Fracture Prevention Trial. The women self-administered the treatments subcutaneously and also received daily supplements of 1,000 mg of calcium and 400–1,200 IU of vitamin D.

The current analysis focused on a subset of 1,216 women who had femoral neck BMD measured both at baseline and after 12 months of therapy by dual-energy x-ray absorptiometry (DXA) and who had lateral thoracic and lumbar spine radiographs taken both at baseline and at the study end point, a median of 19 months from baseline.

The risk of vertebral fracture was calculated for women on placebo and for women in four subgroups of teriparatide therapy based on changes in femoral neck BMD 1 year from baseline. The women on teriparatide were divided as follows: those who lost more than 4% of femoral neck BMD, those who lost up to 4% in density, those who gained up to 4% in density, and those who gained more than 4% in femoral neck BMD.

In the combined teriparatide groups, a significantly greater proportion (35%) gained more than 4% in femoral neck BMD, compared with those on placebo (17%).

Women also showed significant reductions in vertebral fracture risk on teriparatide therapy, compared with placebo, regardless of changes in femoral neck BMD at 1 year, Dr. Watts reported.

Among women with greater than a 4% loss in femoral neck density, 2 (2%) of 82 women on teriparatide developed vertebral fractures, compared with 14 (23%) of 61 women on placebo. Among women with up to a 4% loss in femoral neck density, 5 (3%) of 182 women on teriparatide and 15 (10%) of 149 women on placebo developed vertebral fractures.

Among women with up to a 4% gain in femoral neck BMD, vertebral fractures were seen in 5 (3%) of 182 women on teriparatide and 19 (15%) of 124 women on placebo. Among women with greater than a 4% gain in femoral neck density, 14 (5%) of 282 on teriparatide and 9 (14%) of 66 on placebo developed vertebral fractures.

Lumbar spine BMD increased significantly more in women on teriparatide, compared with placebo, regardless of changes in femoral neck density. Lumbar spine density increased by 3% or greater in 78%–92% of women on teriparatide in the four femoral neck subgroups.

The study was funded by the maker of teriparatide, Eli Lilly & Co., which also provided the layout for the poster. Dr. Watts is a consultant for the company. His report was rated one of the top posters at the meeting.

In the combined teriparatide groups, 35% gained more than 4% in neck BMD versus 17% of those on placebo. DR. WATTS

SAN FRANCISCO — Women with osteoporosis treated with teriparatide often gain lumbar spine bone mineral density and lower their risk of vertebral fracture, even if they lose hip bone mineral density, Dr. Nelson B. Watts reported in a poster presentation at the annual meeting of the International Society for Clinical Densitometry.

Previous studies have shown that increased areal lumbar spine bone mineral density (BMD) accounts for 30%–41% of the reduction in vertebral fracture risk from teriparatide treatment. In clinical practice, loss of BMD in other areas, such as the femoral neck, has been viewed by some as a lack of response to therapy.

The current post hoc analysis of data on 1,216 women found vertebral fracture risk was independent of gains or losses in femoral neck BMD in women taking teriparatide, compared with women on placebo, reported Dr. Watts, program director of the bone health and osteoporosis center at the University of Cincinnati.

The investigators analyzed data on women with a history of vertebral fractures randomized to take 20 or 40 mcg/day of teriparatide or placebo in the double-blind Fracture Prevention Trial. The women self-administered the treatments subcutaneously and also received daily supplements of 1,000 mg of calcium and 400–1,200 IU of vitamin D.

The current analysis focused on a subset of 1,216 women who had femoral neck BMD measured both at baseline and after 12 months of therapy by dual-energy x-ray absorptiometry (DXA) and who had lateral thoracic and lumbar spine radiographs taken both at baseline and at the study end point, a median of 19 months from baseline.

The risk of vertebral fracture was calculated for women on placebo and for women in four subgroups of teriparatide therapy based on changes in femoral neck BMD 1 year from baseline. The women on teriparatide were divided as follows: those who lost more than 4% of femoral neck BMD, those who lost up to 4% in density, those who gained up to 4% in density, and those who gained more than 4% in femoral neck BMD.

In the combined teriparatide groups, a significantly greater proportion (35%) gained more than 4% in femoral neck BMD, compared with those on placebo (17%).

Women also showed significant reductions in vertebral fracture risk on teriparatide therapy, compared with placebo, regardless of changes in femoral neck BMD at 1 year, Dr. Watts reported.

Among women with greater than a 4% loss in femoral neck density, 2 (2%) of 82 women on teriparatide developed vertebral fractures, compared with 14 (23%) of 61 women on placebo. Among women with up to a 4% loss in femoral neck density, 5 (3%) of 182 women on teriparatide and 15 (10%) of 149 women on placebo developed vertebral fractures.

Among women with up to a 4% gain in femoral neck BMD, vertebral fractures were seen in 5 (3%) of 182 women on teriparatide and 19 (15%) of 124 women on placebo. Among women with greater than a 4% gain in femoral neck density, 14 (5%) of 282 on teriparatide and 9 (14%) of 66 on placebo developed vertebral fractures.

Lumbar spine BMD increased significantly more in women on teriparatide, compared with placebo, regardless of changes in femoral neck density. Lumbar spine density increased by 3% or greater in 78%–92% of women on teriparatide in the four femoral neck subgroups.

The study was funded by the maker of teriparatide, Eli Lilly & Co., which also provided the layout for the poster. Dr. Watts is a consultant for the company. His report was rated one of the top posters at the meeting.

In the combined teriparatide groups, 35% gained more than 4% in neck BMD versus 17% of those on placebo. DR. WATTS

SAN FRANCISCO — Women with osteoporosis treated with teriparatide often gain lumbar spine bone mineral density and lower their risk of vertebral fracture, even if they lose hip bone mineral density, Dr. Nelson B. Watts reported in a poster presentation at the annual meeting of the International Society for Clinical Densitometry.

Previous studies have shown that increased areal lumbar spine bone mineral density (BMD) accounts for 30%–41% of the reduction in vertebral fracture risk from teriparatide treatment. In clinical practice, loss of BMD in other areas, such as the femoral neck, has been viewed by some as a lack of response to therapy.

The current post hoc analysis of data on 1,216 women found vertebral fracture risk was independent of gains or losses in femoral neck BMD in women taking teriparatide, compared with women on placebo, reported Dr. Watts, program director of the bone health and osteoporosis center at the University of Cincinnati.

The investigators analyzed data on women with a history of vertebral fractures randomized to take 20 or 40 mcg/day of teriparatide or placebo in the double-blind Fracture Prevention Trial. The women self-administered the treatments subcutaneously and also received daily supplements of 1,000 mg of calcium and 400–1,200 IU of vitamin D.

The current analysis focused on a subset of 1,216 women who had femoral neck BMD measured both at baseline and after 12 months of therapy by dual-energy x-ray absorptiometry (DXA) and who had lateral thoracic and lumbar spine radiographs taken both at baseline and at the study end point, a median of 19 months from baseline.

The risk of vertebral fracture was calculated for women on placebo and for women in four subgroups of teriparatide therapy based on changes in femoral neck BMD 1 year from baseline. The women on teriparatide were divided as follows: those who lost more than 4% of femoral neck BMD, those who lost up to 4% in density, those who gained up to 4% in density, and those who gained more than 4% in femoral neck BMD.

In the combined teriparatide groups, a significantly greater proportion (35%) gained more than 4% in femoral neck BMD, compared with those on placebo (17%).

Women also showed significant reductions in vertebral fracture risk on teriparatide therapy, compared with placebo, regardless of changes in femoral neck BMD at 1 year, Dr. Watts reported.

Among women with greater than a 4% loss in femoral neck density, 2 (2%) of 82 women on teriparatide developed vertebral fractures, compared with 14 (23%) of 61 women on placebo. Among women with up to a 4% loss in femoral neck density, 5 (3%) of 182 women on teriparatide and 15 (10%) of 149 women on placebo developed vertebral fractures.

Among women with up to a 4% gain in femoral neck BMD, vertebral fractures were seen in 5 (3%) of 182 women on teriparatide and 19 (15%) of 124 women on placebo. Among women with greater than a 4% gain in femoral neck density, 14 (5%) of 282 on teriparatide and 9 (14%) of 66 on placebo developed vertebral fractures.

Lumbar spine BMD increased significantly more in women on teriparatide, compared with placebo, regardless of changes in femoral neck density. Lumbar spine density increased by 3% or greater in 78%–92% of women on teriparatide in the four femoral neck subgroups.

The study was funded by the maker of teriparatide, Eli Lilly & Co., which also provided the layout for the poster. Dr. Watts is a consultant for the company. His report was rated one of the top posters at the meeting.

In the combined teriparatide groups, 35% gained more than 4% in neck BMD versus 17% of those on placebo. DR. WATTS

SAN FRANCISCO — Here's whatdoesn't work when trying to help patients self-manage their diabetes:

▸ Urging them to use more will power. “You need to get serious about your diabetes.”

▸ Threatening them with bad outcomes. “Do you want to go blind?”

▸ Giving them advice. “Maybe if you joined a nice fitness center …”

These strategies don't work because they're based on the flawed premises that people are unmotivated, lazy, or in denial about their diabetes, said William Polonsky, Ph.D., at a meeting sponsored by the American Diabetes Association. “There's no evidence for this, and there's pretty good evidence that this is wrong.”

Although data on how to help patients improve self-care are scarce, seven core behavioral strategies seem likely to make a difference, said Dr. Polonsky, a psychologist who founded and directs the Behavioral Diabetes Institute, San Diego. The strategies follow:

▸ Make it real. Many patients don't think that having diabetes is a big deal. Give them personalized metabolic feedback about their hemoglobin A_1c (HbA_1c) levels, blood pressure, and lipid levels. Instead of talking about “good” or “bad” levels, talk about “safe” ranges, and being in a “safe place” or “unsafe place” with these metabolic measures, he suggested.

A pilot study he led recently invited 36 patients with type 2 diabetes to a “Diabetes Extravaganza,” a festive 2-hour group session designed to make diabetes seem more “real” by helping patients understand their metabolic data. Before the end of the session, patients were given a form with their HbA_1c, blood pressure, and LDL cholesterol levels and asked to check off whether their levels were “safe” or not. The average baseline HbA_1c level of 9.1% declined to 7.9% just 3 months later, a mean decline of 1.2% that was statistically significant.

▸ Make it hopeful. Pop quiz: Diabetes is the leading cause of adult blindness, amputation, and kidney failure. True or false?

False. Poorly controlled diabetes leads to these problems. “Well-controlled diabetes is the leading cause of nothing,” Dr. Polonsky said.

▸ Make it understandable. Be cautious about use of jargon. Explain the reasons for your recommendations, and be specific about procedures. On the flip side, don't provide too much information. Dr. Polonsky likes to quote the poet William Butler Yeats: “Education is not the filling of a pail but the lighting of a fire.”

Make patient visits interactive by asking what the patients heard from you and what they'll do. Make sure their recall is in agreement with yours.

▸ Make it implementable. Ask questions that help patients develop a step-by-step plan for taking action. One example: “I'm glad you've decided to start exercising. What's the first step you'll take to do that?”

▸ Make it collaborative. Shared decision making works best to motivate patients, Dr. Polonsky said. Some physicians invite patients to pull a chair up to the computer to fill out the electronic medical record together. “This becomes an opportunity to talk together,” he said.

▸ Make it often. Patients who have more contacts and time with you or your staff are more likely to do well. “This is probably the most impossible” strategy for busy providers, he said. A 2003 study suggested that using case managers (nurses) for more frequent patient contacts doubled the likelihood of diabetes being well controlled.

▸ Make this possible for clinical practice. Start by adopting even one strategy to incorporate these ideas into your practice. Schedule group patient visits (such as the diabetes extravaganza), or form “teamlets” of staff and family volunteers to comanage patients. Early evidence suggests that automated phone call systems might help patients feel more connected to care.

Lastly, “Make sure patients leave a visit with a follow-up appointment,” he said.

Patients who have more contacts and time with you or your staff are more likely to do well. DR. POLONSKY

SAN FRANCISCO — Here's whatdoesn't work when trying to help patients self-manage their diabetes:

▸ Urging them to use more will power. “You need to get serious about your diabetes.”

▸ Threatening them with bad outcomes. “Do you want to go blind?”

▸ Giving them advice. “Maybe if you joined a nice fitness center …”

These strategies don't work because they're based on the flawed premises that people are unmotivated, lazy, or in denial about their diabetes, said William Polonsky, Ph.D., at a meeting sponsored by the American Diabetes Association. “There's no evidence for this, and there's pretty good evidence that this is wrong.”

Although data on how to help patients improve self-care are scarce, seven core behavioral strategies seem likely to make a difference, said Dr. Polonsky, a psychologist who founded and directs the Behavioral Diabetes Institute, San Diego. The strategies follow:

▸ Make it real. Many patients don't think that having diabetes is a big deal. Give them personalized metabolic feedback about their hemoglobin A_1c (HbA_1c) levels, blood pressure, and lipid levels. Instead of talking about “good” or “bad” levels, talk about “safe” ranges, and being in a “safe place” or “unsafe place” with these metabolic measures, he suggested.

A pilot study he led recently invited 36 patients with type 2 diabetes to a “Diabetes Extravaganza,” a festive 2-hour group session designed to make diabetes seem more “real” by helping patients understand their metabolic data. Before the end of the session, patients were given a form with their HbA_1c, blood pressure, and LDL cholesterol levels and asked to check off whether their levels were “safe” or not. The average baseline HbA_1c level of 9.1% declined to 7.9% just 3 months later, a mean decline of 1.2% that was statistically significant.

▸ Make it hopeful. Pop quiz: Diabetes is the leading cause of adult blindness, amputation, and kidney failure. True or false?

False. Poorly controlled diabetes leads to these problems. “Well-controlled diabetes is the leading cause of nothing,” Dr. Polonsky said.

▸ Make it understandable. Be cautious about use of jargon. Explain the reasons for your recommendations, and be specific about procedures. On the flip side, don't provide too much information. Dr. Polonsky likes to quote the poet William Butler Yeats: “Education is not the filling of a pail but the lighting of a fire.”

Make patient visits interactive by asking what the patients heard from you and what they'll do. Make sure their recall is in agreement with yours.

▸ Make it implementable. Ask questions that help patients develop a step-by-step plan for taking action. One example: “I'm glad you've decided to start exercising. What's the first step you'll take to do that?”

▸ Make it collaborative. Shared decision making works best to motivate patients, Dr. Polonsky said. Some physicians invite patients to pull a chair up to the computer to fill out the electronic medical record together. “This becomes an opportunity to talk together,” he said.

▸ Make it often. Patients who have more contacts and time with you or your staff are more likely to do well. “This is probably the most impossible” strategy for busy providers, he said. A 2003 study suggested that using case managers (nurses) for more frequent patient contacts doubled the likelihood of diabetes being well controlled.

▸ Make this possible for clinical practice. Start by adopting even one strategy to incorporate these ideas into your practice. Schedule group patient visits (such as the diabetes extravaganza), or form “teamlets” of staff and family volunteers to comanage patients. Early evidence suggests that automated phone call systems might help patients feel more connected to care.

Lastly, “Make sure patients leave a visit with a follow-up appointment,” he said.

Patients who have more contacts and time with you or your staff are more likely to do well. DR. POLONSKY

SAN FRANCISCO — Here's whatdoesn't work when trying to help patients self-manage their diabetes:

▸ Urging them to use more will power. “You need to get serious about your diabetes.”

▸ Threatening them with bad outcomes. “Do you want to go blind?”

▸ Giving them advice. “Maybe if you joined a nice fitness center …”

These strategies don't work because they're based on the flawed premises that people are unmotivated, lazy, or in denial about their diabetes, said William Polonsky, Ph.D., at a meeting sponsored by the American Diabetes Association. “There's no evidence for this, and there's pretty good evidence that this is wrong.”

Although data on how to help patients improve self-care are scarce, seven core behavioral strategies seem likely to make a difference, said Dr. Polonsky, a psychologist who founded and directs the Behavioral Diabetes Institute, San Diego. The strategies follow:

▸ Make it real. Many patients don't think that having diabetes is a big deal. Give them personalized metabolic feedback about their hemoglobin A_1c (HbA_1c) levels, blood pressure, and lipid levels. Instead of talking about “good” or “bad” levels, talk about “safe” ranges, and being in a “safe place” or “unsafe place” with these metabolic measures, he suggested.

A pilot study he led recently invited 36 patients with type 2 diabetes to a “Diabetes Extravaganza,” a festive 2-hour group session designed to make diabetes seem more “real” by helping patients understand their metabolic data. Before the end of the session, patients were given a form with their HbA_1c, blood pressure, and LDL cholesterol levels and asked to check off whether their levels were “safe” or not. The average baseline HbA_1c level of 9.1% declined to 7.9% just 3 months later, a mean decline of 1.2% that was statistically significant.

▸ Make it hopeful. Pop quiz: Diabetes is the leading cause of adult blindness, amputation, and kidney failure. True or false?

False. Poorly controlled diabetes leads to these problems. “Well-controlled diabetes is the leading cause of nothing,” Dr. Polonsky said.

▸ Make it understandable. Be cautious about use of jargon. Explain the reasons for your recommendations, and be specific about procedures. On the flip side, don't provide too much information. Dr. Polonsky likes to quote the poet William Butler Yeats: “Education is not the filling of a pail but the lighting of a fire.”

Make patient visits interactive by asking what the patients heard from you and what they'll do. Make sure their recall is in agreement with yours.

▸ Make it implementable. Ask questions that help patients develop a step-by-step plan for taking action. One example: “I'm glad you've decided to start exercising. What's the first step you'll take to do that?”

▸ Make it collaborative. Shared decision making works best to motivate patients, Dr. Polonsky said. Some physicians invite patients to pull a chair up to the computer to fill out the electronic medical record together. “This becomes an opportunity to talk together,” he said.

▸ Make it often. Patients who have more contacts and time with you or your staff are more likely to do well. “This is probably the most impossible” strategy for busy providers, he said. A 2003 study suggested that using case managers (nurses) for more frequent patient contacts doubled the likelihood of diabetes being well controlled.

▸ Make this possible for clinical practice. Start by adopting even one strategy to incorporate these ideas into your practice. Schedule group patient visits (such as the diabetes extravaganza), or form “teamlets” of staff and family volunteers to comanage patients. Early evidence suggests that automated phone call systems might help patients feel more connected to care.

Lastly, “Make sure patients leave a visit with a follow-up appointment,” he said.

Patients who have more contacts and time with you or your staff are more likely to do well. DR. POLONSKY

SAN FRANCISCO – Sleep should be viewed as a vital sign, and primary care physicians should address sleep disturbances routinely in all visits with older adults, Dr. Harrison G. Bloom said at the annual meeting of the Gerontological Society of America.

“Although there has been more than a decade of discussion about the prevalence and low detection rates of sleep problems, little has changed in primary care practice in recognition of sleep problems in the elderly,” said Dr. Bloom of the International Longevity Center, New York.

A first draft of new guidelines for the assessment and treatment of sleep disorders in older people should be ready for discussion within the next few months, produced by his organization in collaboration with other groups, he said.

“Sleep disorders are prevalent in older individuals and have important consequences, yet very seldom are looked at. It should be a vital sign,” Dr. Phyllis C. Zee said in a separate presentation at the same session.

She and her associates interviewed older adults aged 65–102 years in 11 primary care offices in the Chicago area and compared the findings with patient charts. Although 70% of the adults complained of some sort of sleep disturbance, only 11% of charts mentioned sleep disturbance, even for patients who reported five or more sleep problems (such as insomnia, difficulty falling asleep, early awakening, or restless legs syndrome).

“Sleep problems are so common with aging, yet they're not on the radar screen of most primary care physicians,” said Dr. Zee, professor of neurology and director of the sleep disorders center at Northwestern University, Chicago.

Symptoms of some treatable sleep disorders, particularly sleep apnea or rapid eye movement (REM) sleep behavior disorder, may be mistaken for cognitive decline or dementia in the elderly, Dr. Zee said.

Multiple factors contribute to the high prevalence of insomnia in the elderly, including medication use, comorbid medical or psychiatric conditions, and psychosocial factors such as bereavement.

An assessment of the quantity and quality of sleep should be integrated into the routine review of systems in all examinations of older adults, with further assessment to look for the causes of any sleep problems, Dr. Zee said. “Sleep in older people really is a barometer of health,” she commented.

A growing database of studies directly associates sleep disorders with problems of attention and memory, depression, nighttime falls, metabolic dysfunction, and lower quality of life, Dr. Andrew A. Monjan said in the same session at the meeting.

Counter to common misconceptions, sleep disturbances are not a natural part of aging but are associated with comorbidities, according to an analysis of epidemiologic data on more than 10,000 adults, said Dr. Monjan of the National Institute on Aging.

A 2003 telephone poll of 1,500 older people (aged 55–84 years) randomly selected by the institute and the National Sleep Foundation also dispelled the notion that older people need less sleep. They reported needing as much sleep per night as many younger people.

People who had four or more medical problems were more likely to report getting less than 6 hours of sleep or having insomnia or excessive daytime sleepiness. Few said that they had been diagnosed with insomnia by their physician, and even fewer had been treated for insomnia, he added.

People who reported bodily pain or who were obese were more likely to report sleep disturbances. The prevalence of all kinds of sleep disturbances decreased among people who said that they got more exercise.

A study at the University of Chicago showed that limiting sleep to 4 hours per night for 6 nights in healthy young adults produced evidence of impaired glucose clearance and increased insulin resistance, Dr. Monjan said.

The proportion of people in the United States who report getting fewer than 6 hours of sleep per night increased to more than 25% in 2004. Sleep deprivation may be a contributing factor in the current epidemics of obesity and diabetes, he suggested.

SAN FRANCISCO – Sleep should be viewed as a vital sign, and primary care physicians should address sleep disturbances routinely in all visits with older adults, Dr. Harrison G. Bloom said at the annual meeting of the Gerontological Society of America.

“Although there has been more than a decade of discussion about the prevalence and low detection rates of sleep problems, little has changed in primary care practice in recognition of sleep problems in the elderly,” said Dr. Bloom of the International Longevity Center, New York.

A first draft of new guidelines for the assessment and treatment of sleep disorders in older people should be ready for discussion within the next few months, produced by his organization in collaboration with other groups, he said.

“Sleep disorders are prevalent in older individuals and have important consequences, yet very seldom are looked at. It should be a vital sign,” Dr. Phyllis C. Zee said in a separate presentation at the same session.

She and her associates interviewed older adults aged 65–102 years in 11 primary care offices in the Chicago area and compared the findings with patient charts. Although 70% of the adults complained of some sort of sleep disturbance, only 11% of charts mentioned sleep disturbance, even for patients who reported five or more sleep problems (such as insomnia, difficulty falling asleep, early awakening, or restless legs syndrome).

“Sleep problems are so common with aging, yet they're not on the radar screen of most primary care physicians,” said Dr. Zee, professor of neurology and director of the sleep disorders center at Northwestern University, Chicago.

Symptoms of some treatable sleep disorders, particularly sleep apnea or rapid eye movement (REM) sleep behavior disorder, may be mistaken for cognitive decline or dementia in the elderly, Dr. Zee said.

Multiple factors contribute to the high prevalence of insomnia in the elderly, including medication use, comorbid medical or psychiatric conditions, and psychosocial factors such as bereavement.

An assessment of the quantity and quality of sleep should be integrated into the routine review of systems in all examinations of older adults, with further assessment to look for the causes of any sleep problems, Dr. Zee said. “Sleep in older people really is a barometer of health,” she commented.

A growing database of studies directly associates sleep disorders with problems of attention and memory, depression, nighttime falls, metabolic dysfunction, and lower quality of life, Dr. Andrew A. Monjan said in the same session at the meeting.

Counter to common misconceptions, sleep disturbances are not a natural part of aging but are associated with comorbidities, according to an analysis of epidemiologic data on more than 10,000 adults, said Dr. Monjan of the National Institute on Aging.

A 2003 telephone poll of 1,500 older people (aged 55–84 years) randomly selected by the institute and the National Sleep Foundation also dispelled the notion that older people need less sleep. They reported needing as much sleep per night as many younger people.

People who had four or more medical problems were more likely to report getting less than 6 hours of sleep or having insomnia or excessive daytime sleepiness. Few said that they had been diagnosed with insomnia by their physician, and even fewer had been treated for insomnia, he added.

People who reported bodily pain or who were obese were more likely to report sleep disturbances. The prevalence of all kinds of sleep disturbances decreased among people who said that they got more exercise.

A study at the University of Chicago showed that limiting sleep to 4 hours per night for 6 nights in healthy young adults produced evidence of impaired glucose clearance and increased insulin resistance, Dr. Monjan said.

The proportion of people in the United States who report getting fewer than 6 hours of sleep per night increased to more than 25% in 2004. Sleep deprivation may be a contributing factor in the current epidemics of obesity and diabetes, he suggested.

SAN FRANCISCO – Sleep should be viewed as a vital sign, and primary care physicians should address sleep disturbances routinely in all visits with older adults, Dr. Harrison G. Bloom said at the annual meeting of the Gerontological Society of America.

“Although there has been more than a decade of discussion about the prevalence and low detection rates of sleep problems, little has changed in primary care practice in recognition of sleep problems in the elderly,” said Dr. Bloom of the International Longevity Center, New York.

A first draft of new guidelines for the assessment and treatment of sleep disorders in older people should be ready for discussion within the next few months, produced by his organization in collaboration with other groups, he said.

“Sleep disorders are prevalent in older individuals and have important consequences, yet very seldom are looked at. It should be a vital sign,” Dr. Phyllis C. Zee said in a separate presentation at the same session.

She and her associates interviewed older adults aged 65–102 years in 11 primary care offices in the Chicago area and compared the findings with patient charts. Although 70% of the adults complained of some sort of sleep disturbance, only 11% of charts mentioned sleep disturbance, even for patients who reported five or more sleep problems (such as insomnia, difficulty falling asleep, early awakening, or restless legs syndrome).

“Sleep problems are so common with aging, yet they're not on the radar screen of most primary care physicians,” said Dr. Zee, professor of neurology and director of the sleep disorders center at Northwestern University, Chicago.

Symptoms of some treatable sleep disorders, particularly sleep apnea or rapid eye movement (REM) sleep behavior disorder, may be mistaken for cognitive decline or dementia in the elderly, Dr. Zee said.

Multiple factors contribute to the high prevalence of insomnia in the elderly, including medication use, comorbid medical or psychiatric conditions, and psychosocial factors such as bereavement.

An assessment of the quantity and quality of sleep should be integrated into the routine review of systems in all examinations of older adults, with further assessment to look for the causes of any sleep problems, Dr. Zee said. “Sleep in older people really is a barometer of health,” she commented.

A growing database of studies directly associates sleep disorders with problems of attention and memory, depression, nighttime falls, metabolic dysfunction, and lower quality of life, Dr. Andrew A. Monjan said in the same session at the meeting.

Counter to common misconceptions, sleep disturbances are not a natural part of aging but are associated with comorbidities, according to an analysis of epidemiologic data on more than 10,000 adults, said Dr. Monjan of the National Institute on Aging.

A 2003 telephone poll of 1,500 older people (aged 55–84 years) randomly selected by the institute and the National Sleep Foundation also dispelled the notion that older people need less sleep. They reported needing as much sleep per night as many younger people.

People who had four or more medical problems were more likely to report getting less than 6 hours of sleep or having insomnia or excessive daytime sleepiness. Few said that they had been diagnosed with insomnia by their physician, and even fewer had been treated for insomnia, he added.

People who reported bodily pain or who were obese were more likely to report sleep disturbances. The prevalence of all kinds of sleep disturbances decreased among people who said that they got more exercise.

A study at the University of Chicago showed that limiting sleep to 4 hours per night for 6 nights in healthy young adults produced evidence of impaired glucose clearance and increased insulin resistance, Dr. Monjan said.

The proportion of people in the United States who report getting fewer than 6 hours of sleep per night increased to more than 25% in 2004. Sleep deprivation may be a contributing factor in the current epidemics of obesity and diabetes, he suggested.

SAN FRANCISCO – Reports of difficulty falling asleep were associated with poorer performance on some cognitive measures in a study of 174 elderly community-dwelling blacks.

Self-reported sleep trouble appears to be a unique predictor of cognitive performance, even after controlling for age, gender, education, depression, and current health, reported Alyssa A. Gamaldo of the psychology department at North Carolina State University, Raleigh, and her associates.

When asked whether they had experienced any trouble falling asleep in the past year, 29% of participants said they did, a rate that is consistent with the findings of previous, more rigorous studies of sleep difficulties, she said at the annual meeting of the Gerontological Society of America. From 10% to 40% of older adults reported sleep difficulties in earlier studies. Investigators in the current study analyzed data from a subset of blacks in the Baltimore Longitudinal Study of Aging. Participants were living independently and had a mean age of 73 years, a mean education of 10 years, and a mean monthly income of $800.

Those who reported sleep trouble tended to perform worse on measures of short-term memory and working memory.

Participants also completed the Mini-Mental State Examination to measure global cognitive status and the California Verbal Learning Test to measure episodic memory, but results for these were not significantly different between adults who did or did not have trouble sleeping.

Several previous studies have suggested that the relationship between self-reported sleep difficulties and cognitive performance might be moderated by depression. In the current study, however, neither depression nor older age appeared to exacerbate differences in cognitive performance, Ms. Gamaldo said.

SAN FRANCISCO – Reports of difficulty falling asleep were associated with poorer performance on some cognitive measures in a study of 174 elderly community-dwelling blacks.

Self-reported sleep trouble appears to be a unique predictor of cognitive performance, even after controlling for age, gender, education, depression, and current health, reported Alyssa A. Gamaldo of the psychology department at North Carolina State University, Raleigh, and her associates.

When asked whether they had experienced any trouble falling asleep in the past year, 29% of participants said they did, a rate that is consistent with the findings of previous, more rigorous studies of sleep difficulties, she said at the annual meeting of the Gerontological Society of America. From 10% to 40% of older adults reported sleep difficulties in earlier studies. Investigators in the current study analyzed data from a subset of blacks in the Baltimore Longitudinal Study of Aging. Participants were living independently and had a mean age of 73 years, a mean education of 10 years, and a mean monthly income of $800.

Those who reported sleep trouble tended to perform worse on measures of short-term memory and working memory.

Participants also completed the Mini-Mental State Examination to measure global cognitive status and the California Verbal Learning Test to measure episodic memory, but results for these were not significantly different between adults who did or did not have trouble sleeping.

Several previous studies have suggested that the relationship between self-reported sleep difficulties and cognitive performance might be moderated by depression. In the current study, however, neither depression nor older age appeared to exacerbate differences in cognitive performance, Ms. Gamaldo said.

SAN FRANCISCO – Reports of difficulty falling asleep were associated with poorer performance on some cognitive measures in a study of 174 elderly community-dwelling blacks.

Self-reported sleep trouble appears to be a unique predictor of cognitive performance, even after controlling for age, gender, education, depression, and current health, reported Alyssa A. Gamaldo of the psychology department at North Carolina State University, Raleigh, and her associates.

When asked whether they had experienced any trouble falling asleep in the past year, 29% of participants said they did, a rate that is consistent with the findings of previous, more rigorous studies of sleep difficulties, she said at the annual meeting of the Gerontological Society of America. From 10% to 40% of older adults reported sleep difficulties in earlier studies. Investigators in the current study analyzed data from a subset of blacks in the Baltimore Longitudinal Study of Aging. Participants were living independently and had a mean age of 73 years, a mean education of 10 years, and a mean monthly income of $800.

Those who reported sleep trouble tended to perform worse on measures of short-term memory and working memory.

Participants also completed the Mini-Mental State Examination to measure global cognitive status and the California Verbal Learning Test to measure episodic memory, but results for these were not significantly different between adults who did or did not have trouble sleeping.

Several previous studies have suggested that the relationship between self-reported sleep difficulties and cognitive performance might be moderated by depression. In the current study, however, neither depression nor older age appeared to exacerbate differences in cognitive performance, Ms. Gamaldo said.

SAN FRANCISCO — Meniscus injury in patients undergoing anterior cruciate ligament reconstruction was three times more likely to be repairable when the repair was done within 12 weeks of the injury, based on the results of a retrospective study.

The findings corroborate those of several previous studies that linked increased meniscus pathology with longer wait times from injury to ACL reconstruction, Jason Akindolire said at the annual meeting of the American Academy of Orthopaedic Surgeons.

Mr. Akindolire and his associates reviewed the records of 317 consecutive patients, aged 40 years or younger, who underwent ACL reconstructions in 2003–2005 at two clinics—one operating in the Canadian national system of guaranteed health care, where wait times can be longer than those in the United States, and the other a private clinic in Mississippi, where many of the fees for service are paid by third-party payers.

Patient demographics were similar, with a mean age of 23 years in Canada and 22 years in Mississippi. Practice patterns at the clinics were similar. The study excluded patients who had multiligament injuries or a history of ipsilateral surgery.

Mean wait times from injury to ACL reconstruction were 76 weeks (median 40 weeks) in the Canadian clinic and 23 weeks (median 4.4 weeks) in the U.S. clinic, reported Mr. Akindolire, a graduate student in sports medicine at the University of Western Ontario, London.

Among patients with meniscus pathology, those at the U.S. clinic were 78% more likely to have a repairable tear, compared with patients at the Canadian clinic.

Meniscus tears were less amenable to repair as the time to ACL reconstruction increased, he said. The odds of meniscal pathology being repairable were 2.6 for patients who underwent ACL reconstruction less than 12 weeks after injury, compared with those who had later surgery, and were 1.7 for patients who underwent ACL reconstruction less than 26 weeks after injury, compared with those who had surgery later.

As the time between injury and ACL reconstruction increased, the complexity of meniscus tears also increased, Mr. Akindolire added. Over time, more bucket-handle tears and complex degenerative tears were seen in his review of intraoperative diagrams and notes.

“There is merit to providing expeditious ACL reconstruction—within 12 weeks, perhaps,” he said. “By doing that, we may be able to preserve the menisci. And in doing that, hopefully, we will improve the long-term prognosis of these patients.”

A separate retrospective study by other investigators in 2004 reported that patients who wait 2 or more years for ACL reconstruction are nearly twice as likely to develop immediate meniscal pathology, compared with patients whose ACL was treated within 1 year, he noted.

Another retrospective study in 2005 reported that patients who waited 26 weeks or more for ACL reconstruction had a significantly greater risk of developing meniscal pathology, compared with patients who underwent ACL surgery within 2 weeks of injury.

Separate data have shown that “a meniscus tear is a strong independent predictor for the development of osteoarthritis,” Mr. Akindolire said.

SAN FRANCISCO — Meniscus injury in patients undergoing anterior cruciate ligament reconstruction was three times more likely to be repairable when the repair was done within 12 weeks of the injury, based on the results of a retrospective study.

The findings corroborate those of several previous studies that linked increased meniscus pathology with longer wait times from injury to ACL reconstruction, Jason Akindolire said at the annual meeting of the American Academy of Orthopaedic Surgeons.

Mr. Akindolire and his associates reviewed the records of 317 consecutive patients, aged 40 years or younger, who underwent ACL reconstructions in 2003–2005 at two clinics—one operating in the Canadian national system of guaranteed health care, where wait times can be longer than those in the United States, and the other a private clinic in Mississippi, where many of the fees for service are paid by third-party payers.

Patient demographics were similar, with a mean age of 23 years in Canada and 22 years in Mississippi. Practice patterns at the clinics were similar. The study excluded patients who had multiligament injuries or a history of ipsilateral surgery.

Mean wait times from injury to ACL reconstruction were 76 weeks (median 40 weeks) in the Canadian clinic and 23 weeks (median 4.4 weeks) in the U.S. clinic, reported Mr. Akindolire, a graduate student in sports medicine at the University of Western Ontario, London.

Among patients with meniscus pathology, those at the U.S. clinic were 78% more likely to have a repairable tear, compared with patients at the Canadian clinic.

Meniscus tears were less amenable to repair as the time to ACL reconstruction increased, he said. The odds of meniscal pathology being repairable were 2.6 for patients who underwent ACL reconstruction less than 12 weeks after injury, compared with those who had later surgery, and were 1.7 for patients who underwent ACL reconstruction less than 26 weeks after injury, compared with those who had surgery later.

As the time between injury and ACL reconstruction increased, the complexity of meniscus tears also increased, Mr. Akindolire added. Over time, more bucket-handle tears and complex degenerative tears were seen in his review of intraoperative diagrams and notes.

“There is merit to providing expeditious ACL reconstruction—within 12 weeks, perhaps,” he said. “By doing that, we may be able to preserve the menisci. And in doing that, hopefully, we will improve the long-term prognosis of these patients.”

A separate retrospective study by other investigators in 2004 reported that patients who wait 2 or more years for ACL reconstruction are nearly twice as likely to develop immediate meniscal pathology, compared with patients whose ACL was treated within 1 year, he noted.

Another retrospective study in 2005 reported that patients who waited 26 weeks or more for ACL reconstruction had a significantly greater risk of developing meniscal pathology, compared with patients who underwent ACL surgery within 2 weeks of injury.

Separate data have shown that “a meniscus tear is a strong independent predictor for the development of osteoarthritis,” Mr. Akindolire said.

SAN FRANCISCO — Meniscus injury in patients undergoing anterior cruciate ligament reconstruction was three times more likely to be repairable when the repair was done within 12 weeks of the injury, based on the results of a retrospective study.

The findings corroborate those of several previous studies that linked increased meniscus pathology with longer wait times from injury to ACL reconstruction, Jason Akindolire said at the annual meeting of the American Academy of Orthopaedic Surgeons.

Mr. Akindolire and his associates reviewed the records of 317 consecutive patients, aged 40 years or younger, who underwent ACL reconstructions in 2003–2005 at two clinics—one operating in the Canadian national system of guaranteed health care, where wait times can be longer than those in the United States, and the other a private clinic in Mississippi, where many of the fees for service are paid by third-party payers.

Patient demographics were similar, with a mean age of 23 years in Canada and 22 years in Mississippi. Practice patterns at the clinics were similar. The study excluded patients who had multiligament injuries or a history of ipsilateral surgery.

Mean wait times from injury to ACL reconstruction were 76 weeks (median 40 weeks) in the Canadian clinic and 23 weeks (median 4.4 weeks) in the U.S. clinic, reported Mr. Akindolire, a graduate student in sports medicine at the University of Western Ontario, London.

Among patients with meniscus pathology, those at the U.S. clinic were 78% more likely to have a repairable tear, compared with patients at the Canadian clinic.

Meniscus tears were less amenable to repair as the time to ACL reconstruction increased, he said. The odds of meniscal pathology being repairable were 2.6 for patients who underwent ACL reconstruction less than 12 weeks after injury, compared with those who had later surgery, and were 1.7 for patients who underwent ACL reconstruction less than 26 weeks after injury, compared with those who had surgery later.

As the time between injury and ACL reconstruction increased, the complexity of meniscus tears also increased, Mr. Akindolire added. Over time, more bucket-handle tears and complex degenerative tears were seen in his review of intraoperative diagrams and notes.

“There is merit to providing expeditious ACL reconstruction—within 12 weeks, perhaps,” he said. “By doing that, we may be able to preserve the menisci. And in doing that, hopefully, we will improve the long-term prognosis of these patients.”

A separate retrospective study by other investigators in 2004 reported that patients who wait 2 or more years for ACL reconstruction are nearly twice as likely to develop immediate meniscal pathology, compared with patients whose ACL was treated within 1 year, he noted.

Another retrospective study in 2005 reported that patients who waited 26 weeks or more for ACL reconstruction had a significantly greater risk of developing meniscal pathology, compared with patients who underwent ACL surgery within 2 weeks of injury.

Separate data have shown that “a meniscus tear is a strong independent predictor for the development of osteoarthritis,” Mr. Akindolire said.