Sherry Boschert

SAN FRANCISCO — Helping patients—even overweight patients—to avoid gaining more weight is an important therapeutic goal by itself, Dr. Robert Baron said at a diabetes update sponsored by the University of California, San Francisco.

“It's very, very hard to get people to lose weight. Therefore, our priority in a large number of our patients should be to prevent further weight gain,” said Dr. Baron, professor of medicine at the university. “In our society, the default position is to gain weight. You need to have a strategy even to maintain your weight, and that's especially true as you age.”

Recent data support the classic goals of being as fit as possible at one's current weight, preventing weight gain, and then considering attempts at weight loss, he emphasized. Being overweight by itself is not necessarily a risk factor for mortality, other data show. The presence or absence of metabolic syndrome plays a key role in level of risk.

A 2005 meta-analysis of three National Health and Nutrition Examination Surveys (NHANES I, II, and III) found no increased risk for mortality in people who fit the conventional definition of overweight for white people—a body mass index of at least 25 kg/m

“This is controversial, but I think it creates a need for some humility and diagnostic uncertainty about people who are overweight,” he added.

Although the prevalence of obesity has been increasing, the mortality risk associated with obesity decreased between the first of the three surveys (NHANES I) and the more recent NHANES III; however, this could be because of methodologic differences.

The presence of metabolic syndrome doubled the risk for mortality in normal-weight people, increased absolute risk of death by about 50% in overweight people, and increased risk of death by 13% in obese people, a separate 2005 study of 19,173 men found.

Patients who are overweight may not be at increased risk if they are metabolically normal, but the presence of metabolic syndrome or other signs of insulin resistance changes the clinical picture.

“Your BMI is your initial screening test, if you will, and evaluation of metabolic syndrome becomes your more accurate, second-level test to sort out which patients in the overweight category and Class I obese [BMI of at least 30 but lower than 35] need more particularly aggressive interventions,” he said.

Eating less and exercising are still the mainstays of weight loss strategies but must be pursued with greater intensity than many people realize if weight loss is to be the result.

Exercise alone won't do it, and casually “watching what you eat” won't work for most patients. Weight loss requires a diet of “low calories, low calories, low calories” that usually must be monitored quantitatively by the dieter, Dr. Baron advised. Combining calorie restriction with exercise and behavioral therapy traditionally offers the best approach.

Patients who do diet and exercise drop a mean of 8% of their original body weight in the first year, although some patients lose more and some gain weight instead, he added.

In addition, patients who have lost weight need a disciplined strategy to maintain that weight loss, data suggest.

Data on 3,000 successful dieters (mostly white women) who enrolled in the National Weight Control Registry and maintained a 30-pound or greater weight loss for 1 year showed three key steps to keeping the pounds off: high levels of physical activity, diets low in fat and high in fiber, and regular self-monitoring of weight.

'In our society, the default position is to gain weight. You need to have a strategy even to maintain your weight.' DR. BARON

SAN FRANCISCO — Helping patients—even overweight patients—to avoid gaining more weight is an important therapeutic goal by itself, Dr. Robert Baron said at a diabetes update sponsored by the University of California, San Francisco.

“It's very, very hard to get people to lose weight. Therefore, our priority in a large number of our patients should be to prevent further weight gain,” said Dr. Baron, professor of medicine at the university. “In our society, the default position is to gain weight. You need to have a strategy even to maintain your weight, and that's especially true as you age.”

Recent data support the classic goals of being as fit as possible at one's current weight, preventing weight gain, and then considering attempts at weight loss, he emphasized. Being overweight by itself is not necessarily a risk factor for mortality, other data show. The presence or absence of metabolic syndrome plays a key role in level of risk.

A 2005 meta-analysis of three National Health and Nutrition Examination Surveys (NHANES I, II, and III) found no increased risk for mortality in people who fit the conventional definition of overweight for white people—a body mass index of at least 25 kg/m

“This is controversial, but I think it creates a need for some humility and diagnostic uncertainty about people who are overweight,” he added.

Although the prevalence of obesity has been increasing, the mortality risk associated with obesity decreased between the first of the three surveys (NHANES I) and the more recent NHANES III; however, this could be because of methodologic differences.

The presence of metabolic syndrome doubled the risk for mortality in normal-weight people, increased absolute risk of death by about 50% in overweight people, and increased risk of death by 13% in obese people, a separate 2005 study of 19,173 men found.

Patients who are overweight may not be at increased risk if they are metabolically normal, but the presence of metabolic syndrome or other signs of insulin resistance changes the clinical picture.

“Your BMI is your initial screening test, if you will, and evaluation of metabolic syndrome becomes your more accurate, second-level test to sort out which patients in the overweight category and Class I obese [BMI of at least 30 but lower than 35] need more particularly aggressive interventions,” he said.

Eating less and exercising are still the mainstays of weight loss strategies but must be pursued with greater intensity than many people realize if weight loss is to be the result.

Exercise alone won't do it, and casually “watching what you eat” won't work for most patients. Weight loss requires a diet of “low calories, low calories, low calories” that usually must be monitored quantitatively by the dieter, Dr. Baron advised. Combining calorie restriction with exercise and behavioral therapy traditionally offers the best approach.

Patients who do diet and exercise drop a mean of 8% of their original body weight in the first year, although some patients lose more and some gain weight instead, he added.

In addition, patients who have lost weight need a disciplined strategy to maintain that weight loss, data suggest.

Data on 3,000 successful dieters (mostly white women) who enrolled in the National Weight Control Registry and maintained a 30-pound or greater weight loss for 1 year showed three key steps to keeping the pounds off: high levels of physical activity, diets low in fat and high in fiber, and regular self-monitoring of weight.

'In our society, the default position is to gain weight. You need to have a strategy even to maintain your weight.' DR. BARON

SAN FRANCISCO — Helping patients—even overweight patients—to avoid gaining more weight is an important therapeutic goal by itself, Dr. Robert Baron said at a diabetes update sponsored by the University of California, San Francisco.

“It's very, very hard to get people to lose weight. Therefore, our priority in a large number of our patients should be to prevent further weight gain,” said Dr. Baron, professor of medicine at the university. “In our society, the default position is to gain weight. You need to have a strategy even to maintain your weight, and that's especially true as you age.”

Recent data support the classic goals of being as fit as possible at one's current weight, preventing weight gain, and then considering attempts at weight loss, he emphasized. Being overweight by itself is not necessarily a risk factor for mortality, other data show. The presence or absence of metabolic syndrome plays a key role in level of risk.

A 2005 meta-analysis of three National Health and Nutrition Examination Surveys (NHANES I, II, and III) found no increased risk for mortality in people who fit the conventional definition of overweight for white people—a body mass index of at least 25 kg/m

“This is controversial, but I think it creates a need for some humility and diagnostic uncertainty about people who are overweight,” he added.

Although the prevalence of obesity has been increasing, the mortality risk associated with obesity decreased between the first of the three surveys (NHANES I) and the more recent NHANES III; however, this could be because of methodologic differences.

The presence of metabolic syndrome doubled the risk for mortality in normal-weight people, increased absolute risk of death by about 50% in overweight people, and increased risk of death by 13% in obese people, a separate 2005 study of 19,173 men found.

Patients who are overweight may not be at increased risk if they are metabolically normal, but the presence of metabolic syndrome or other signs of insulin resistance changes the clinical picture.

“Your BMI is your initial screening test, if you will, and evaluation of metabolic syndrome becomes your more accurate, second-level test to sort out which patients in the overweight category and Class I obese [BMI of at least 30 but lower than 35] need more particularly aggressive interventions,” he said.

Eating less and exercising are still the mainstays of weight loss strategies but must be pursued with greater intensity than many people realize if weight loss is to be the result.

Exercise alone won't do it, and casually “watching what you eat” won't work for most patients. Weight loss requires a diet of “low calories, low calories, low calories” that usually must be monitored quantitatively by the dieter, Dr. Baron advised. Combining calorie restriction with exercise and behavioral therapy traditionally offers the best approach.

Patients who do diet and exercise drop a mean of 8% of their original body weight in the first year, although some patients lose more and some gain weight instead, he added.

In addition, patients who have lost weight need a disciplined strategy to maintain that weight loss, data suggest.

Data on 3,000 successful dieters (mostly white women) who enrolled in the National Weight Control Registry and maintained a 30-pound or greater weight loss for 1 year showed three key steps to keeping the pounds off: high levels of physical activity, diets low in fat and high in fiber, and regular self-monitoring of weight.

'In our society, the default position is to gain weight. You need to have a strategy even to maintain your weight.' DR. BARON

SAN FRANCISCO — Abiding by four practice patterns might avoid nearly two-thirds of the costs of malpractice litigation for hospital-based obstetrics, Dr. Steven L. Clark said in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

A review of all 189 closed perinatal malpractice claims in one health care system between 2000 and 2005 found that 61% involved substandard care. These accounted for 79% of the approximately $168 million paid out during that period in court judgments or to settle cases out of court, reported Dr. Clark of the Hospital Corporation of America, Nashville, Tenn., and his associates.

Substandard care was defined as practice that was at odds with (or was judged by a treating physician or defense consultant to be at odds with) guidelines published by the American College of Obstetricians and Gynecologists.

Millions of dollars in litigation costs might have been avoided if these four practices had been followed:

▸ Practicing obstetrics in a facility with 24-hour in-house obstetric coverage. This might have eliminated 23% of cases (and 14% of total litigation costs) related to fetal monitoring for deliveries other than vaginal births after previous C-section (VBACs).

▸ Adhering to existing checklist-driven protocols for administering oxytocin, misoprostol, and magnesium sulfate. This might have avoided 45% of cases and 27% of total costs related to fetal monitoring in non-VBAC deliveries, as well as 16% of maternal injury cases (and 3% of total costs).

Following either of these first two practices might have avoided an additional 17% of other cases (and 10% of total costs) related to fetal monitoring.

▸ Taking a more conservative approach to VBAC by limiting VBAC to spontaneous labors progressing without augmentation and without repetitive moderate or severe variable decelerations.

▸ Using a comprehensive, standardized procedure note for complete and consistent documentation in cases of shoulder dystocia. This could have avoided 54% of fetal losses (and 4% of all litigation costs) associated with shoulder dystocia.

Modest alterations in obstetric practice could significantly reduce allegations of malpractice, the investigators concluded.

The largest number of malpractice suits (64) were related to fetal hypoxia, and 60 of these involved substandard care.

These cases accounted for the largest share of litigation costs ($89 million).

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Abiding by four practice patterns might avoid nearly two-thirds of the costs of malpractice litigation for hospital-based obstetrics, Dr. Steven L. Clark said in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

A review of all 189 closed perinatal malpractice claims in one health care system between 2000 and 2005 found that 61% involved substandard care. These accounted for 79% of the approximately $168 million paid out during that period in court judgments or to settle cases out of court, reported Dr. Clark of the Hospital Corporation of America, Nashville, Tenn., and his associates.

Substandard care was defined as practice that was at odds with (or was judged by a treating physician or defense consultant to be at odds with) guidelines published by the American College of Obstetricians and Gynecologists.

Millions of dollars in litigation costs might have been avoided if these four practices had been followed:

▸ Practicing obstetrics in a facility with 24-hour in-house obstetric coverage. This might have eliminated 23% of cases (and 14% of total litigation costs) related to fetal monitoring for deliveries other than vaginal births after previous C-section (VBACs).

▸ Adhering to existing checklist-driven protocols for administering oxytocin, misoprostol, and magnesium sulfate. This might have avoided 45% of cases and 27% of total costs related to fetal monitoring in non-VBAC deliveries, as well as 16% of maternal injury cases (and 3% of total costs).

Following either of these first two practices might have avoided an additional 17% of other cases (and 10% of total costs) related to fetal monitoring.

▸ Taking a more conservative approach to VBAC by limiting VBAC to spontaneous labors progressing without augmentation and without repetitive moderate or severe variable decelerations.

▸ Using a comprehensive, standardized procedure note for complete and consistent documentation in cases of shoulder dystocia. This could have avoided 54% of fetal losses (and 4% of all litigation costs) associated with shoulder dystocia.

Modest alterations in obstetric practice could significantly reduce allegations of malpractice, the investigators concluded.

The largest number of malpractice suits (64) were related to fetal hypoxia, and 60 of these involved substandard care.

These cases accounted for the largest share of litigation costs ($89 million).

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Abiding by four practice patterns might avoid nearly two-thirds of the costs of malpractice litigation for hospital-based obstetrics, Dr. Steven L. Clark said in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

A review of all 189 closed perinatal malpractice claims in one health care system between 2000 and 2005 found that 61% involved substandard care. These accounted for 79% of the approximately $168 million paid out during that period in court judgments or to settle cases out of court, reported Dr. Clark of the Hospital Corporation of America, Nashville, Tenn., and his associates.

Substandard care was defined as practice that was at odds with (or was judged by a treating physician or defense consultant to be at odds with) guidelines published by the American College of Obstetricians and Gynecologists.

Millions of dollars in litigation costs might have been avoided if these four practices had been followed:

▸ Practicing obstetrics in a facility with 24-hour in-house obstetric coverage. This might have eliminated 23% of cases (and 14% of total litigation costs) related to fetal monitoring for deliveries other than vaginal births after previous C-section (VBACs).

▸ Adhering to existing checklist-driven protocols for administering oxytocin, misoprostol, and magnesium sulfate. This might have avoided 45% of cases and 27% of total costs related to fetal monitoring in non-VBAC deliveries, as well as 16% of maternal injury cases (and 3% of total costs).

Following either of these first two practices might have avoided an additional 17% of other cases (and 10% of total costs) related to fetal monitoring.

▸ Taking a more conservative approach to VBAC by limiting VBAC to spontaneous labors progressing without augmentation and without repetitive moderate or severe variable decelerations.

▸ Using a comprehensive, standardized procedure note for complete and consistent documentation in cases of shoulder dystocia. This could have avoided 54% of fetal losses (and 4% of all litigation costs) associated with shoulder dystocia.

Modest alterations in obstetric practice could significantly reduce allegations of malpractice, the investigators concluded.

The largest number of malpractice suits (64) were related to fetal hypoxia, and 60 of these involved substandard care.

These cases accounted for the largest share of litigation costs ($89 million).

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Repeating one of the assays used in serum-integrated screening for Down syndrome could halve the false-positive rate, Dr. Fergal D. Malone said at the annual meeting of the Society for Maternal-Fetal Medicine.

Adding another repeat assay could reduce the false-positive rate by a further 25%, said Dr. Malone, professor and chairman of ob.gyn. at the Royal College of Surgeons, Dublin.

Conventional serum-integrated screening entails collecting first- and second-trimester blood samples. The first-trimester sample is assayed for pregnancy-associated plasma protein A (PAPP-A) and assays are performed on the second-trimester sample for several other markers of Down syndrome risk: alpha-fetoprotein, total HCG, unconjugated estriol, and inhibin A. The marker results are combined in a single assessment of risk for trisomy 21.

Serum-integrated screening detects 90% of Down syndrome cases with a 4.9% false-positive rate. If the PAPP-A assay is simply repeated on the second-trimester serum sample, the false-positive rate would drop to 1.9%, according to a modeling study that Dr. Malone and associates conducted using data from the First and Second Trimester Evaluation of Risk trial.

Doing an HCG assay on the first-trimester sample in addition to repeating the PAPP-A assay on the second-trimester sample should further reduce the false-positive rate to 1.4%, he added.

Repeating the PAPP-A assay would improve the Down syndrome detection rate to about 92%. Doing the PAPP-A and the HCG assays on first- and second-trimester samples would increase detection to nearly 100%, he calculated.

A similar benefit is seen when repeating PAPP-A measures in fully integrated screening for Down syndrome, which combines first-trimester imaging of nuchal translucency with serum-integrated screening. Fully integrated screening detects 90% of Down syndrome cases with a 1.3% false-positive rate. Repeating the PAPP-A assay on the second-trimester serum sample would decrease the false-positive rate to 0.5%, Dr. Malone said.

Reducing false positives could reduce the use of invasive tests for Down syndrome and terminations of some pregnancies, and improve the cost-effectiveness of screening.

These preliminary modeling results must be supported by prospective studies before repeat-measures screening is adopted in clinical practice, he cautioned.

The concept of repeat-measures screening expands screening strategies beyond conventional notions of evaluating each marker individually and measuring it at the one time point where it provides the best information. Measuring PAPP-A alone at 10 weeks' gestation, for example, detects 85% of Down syndrome cases with a 17% false-positive rate. Measuring PAPP-A alone only in the second trimester produces a massive 60% false-positive rate.

“Conventional wisdom says that PAPP-A in the first but not the second trimester is the way to proceed,” Dr. Malone noted. “However, things are not that simple.”

Measuring PAPP-A at 10 weeks and again between 14 and 22 weeks has not been recommended because the marker is highly correlated across gestation ages and is a poor marker for detection in the second trimester alone.

“It may surprise you, therefore, to see that PAPP-A in the first and second trimester has been estimated to provide a huge improvement in performance, for an 85% detection rate and only a 2% screen positive rate,” he said.

A low PAPP-A at 10 weeks accurately identifies trisomy 21 but falsely identifies quite a few unaffected infants. PAPP-A levels tend to be higher in Down syndrome cases in the second trimester.

“Having the added knowledge of what the second-trimester PAPP-A value is allows us to almost completely discriminate Down syndrome from normal pregnancies,” Dr. Malone said.

SAN FRANCISCO — Repeating one of the assays used in serum-integrated screening for Down syndrome could halve the false-positive rate, Dr. Fergal D. Malone said at the annual meeting of the Society for Maternal-Fetal Medicine.

Adding another repeat assay could reduce the false-positive rate by a further 25%, said Dr. Malone, professor and chairman of ob.gyn. at the Royal College of Surgeons, Dublin.

Conventional serum-integrated screening entails collecting first- and second-trimester blood samples. The first-trimester sample is assayed for pregnancy-associated plasma protein A (PAPP-A) and assays are performed on the second-trimester sample for several other markers of Down syndrome risk: alpha-fetoprotein, total HCG, unconjugated estriol, and inhibin A. The marker results are combined in a single assessment of risk for trisomy 21.

Serum-integrated screening detects 90% of Down syndrome cases with a 4.9% false-positive rate. If the PAPP-A assay is simply repeated on the second-trimester serum sample, the false-positive rate would drop to 1.9%, according to a modeling study that Dr. Malone and associates conducted using data from the First and Second Trimester Evaluation of Risk trial.

Doing an HCG assay on the first-trimester sample in addition to repeating the PAPP-A assay on the second-trimester sample should further reduce the false-positive rate to 1.4%, he added.

Repeating the PAPP-A assay would improve the Down syndrome detection rate to about 92%. Doing the PAPP-A and the HCG assays on first- and second-trimester samples would increase detection to nearly 100%, he calculated.

A similar benefit is seen when repeating PAPP-A measures in fully integrated screening for Down syndrome, which combines first-trimester imaging of nuchal translucency with serum-integrated screening. Fully integrated screening detects 90% of Down syndrome cases with a 1.3% false-positive rate. Repeating the PAPP-A assay on the second-trimester serum sample would decrease the false-positive rate to 0.5%, Dr. Malone said.

Reducing false positives could reduce the use of invasive tests for Down syndrome and terminations of some pregnancies, and improve the cost-effectiveness of screening.

These preliminary modeling results must be supported by prospective studies before repeat-measures screening is adopted in clinical practice, he cautioned.

The concept of repeat-measures screening expands screening strategies beyond conventional notions of evaluating each marker individually and measuring it at the one time point where it provides the best information. Measuring PAPP-A alone at 10 weeks' gestation, for example, detects 85% of Down syndrome cases with a 17% false-positive rate. Measuring PAPP-A alone only in the second trimester produces a massive 60% false-positive rate.

“Conventional wisdom says that PAPP-A in the first but not the second trimester is the way to proceed,” Dr. Malone noted. “However, things are not that simple.”

Measuring PAPP-A at 10 weeks and again between 14 and 22 weeks has not been recommended because the marker is highly correlated across gestation ages and is a poor marker for detection in the second trimester alone.

“It may surprise you, therefore, to see that PAPP-A in the first and second trimester has been estimated to provide a huge improvement in performance, for an 85% detection rate and only a 2% screen positive rate,” he said.

A low PAPP-A at 10 weeks accurately identifies trisomy 21 but falsely identifies quite a few unaffected infants. PAPP-A levels tend to be higher in Down syndrome cases in the second trimester.

“Having the added knowledge of what the second-trimester PAPP-A value is allows us to almost completely discriminate Down syndrome from normal pregnancies,” Dr. Malone said.

SAN FRANCISCO — Repeating one of the assays used in serum-integrated screening for Down syndrome could halve the false-positive rate, Dr. Fergal D. Malone said at the annual meeting of the Society for Maternal-Fetal Medicine.

Adding another repeat assay could reduce the false-positive rate by a further 25%, said Dr. Malone, professor and chairman of ob.gyn. at the Royal College of Surgeons, Dublin.

Conventional serum-integrated screening entails collecting first- and second-trimester blood samples. The first-trimester sample is assayed for pregnancy-associated plasma protein A (PAPP-A) and assays are performed on the second-trimester sample for several other markers of Down syndrome risk: alpha-fetoprotein, total HCG, unconjugated estriol, and inhibin A. The marker results are combined in a single assessment of risk for trisomy 21.

Serum-integrated screening detects 90% of Down syndrome cases with a 4.9% false-positive rate. If the PAPP-A assay is simply repeated on the second-trimester serum sample, the false-positive rate would drop to 1.9%, according to a modeling study that Dr. Malone and associates conducted using data from the First and Second Trimester Evaluation of Risk trial.

Doing an HCG assay on the first-trimester sample in addition to repeating the PAPP-A assay on the second-trimester sample should further reduce the false-positive rate to 1.4%, he added.

Repeating the PAPP-A assay would improve the Down syndrome detection rate to about 92%. Doing the PAPP-A and the HCG assays on first- and second-trimester samples would increase detection to nearly 100%, he calculated.

A similar benefit is seen when repeating PAPP-A measures in fully integrated screening for Down syndrome, which combines first-trimester imaging of nuchal translucency with serum-integrated screening. Fully integrated screening detects 90% of Down syndrome cases with a 1.3% false-positive rate. Repeating the PAPP-A assay on the second-trimester serum sample would decrease the false-positive rate to 0.5%, Dr. Malone said.

Reducing false positives could reduce the use of invasive tests for Down syndrome and terminations of some pregnancies, and improve the cost-effectiveness of screening.

These preliminary modeling results must be supported by prospective studies before repeat-measures screening is adopted in clinical practice, he cautioned.

The concept of repeat-measures screening expands screening strategies beyond conventional notions of evaluating each marker individually and measuring it at the one time point where it provides the best information. Measuring PAPP-A alone at 10 weeks' gestation, for example, detects 85% of Down syndrome cases with a 17% false-positive rate. Measuring PAPP-A alone only in the second trimester produces a massive 60% false-positive rate.

“Conventional wisdom says that PAPP-A in the first but not the second trimester is the way to proceed,” Dr. Malone noted. “However, things are not that simple.”

Measuring PAPP-A at 10 weeks and again between 14 and 22 weeks has not been recommended because the marker is highly correlated across gestation ages and is a poor marker for detection in the second trimester alone.

“It may surprise you, therefore, to see that PAPP-A in the first and second trimester has been estimated to provide a huge improvement in performance, for an 85% detection rate and only a 2% screen positive rate,” he said.

A low PAPP-A at 10 weeks accurately identifies trisomy 21 but falsely identifies quite a few unaffected infants. PAPP-A levels tend to be higher in Down syndrome cases in the second trimester.

“Having the added knowledge of what the second-trimester PAPP-A value is allows us to almost completely discriminate Down syndrome from normal pregnancies,” Dr. Malone said.

SEATTLE — One-fourth of 182 women with peripartum cardiomyopathy developed major adverse events, half of which were death or heart transplantation, Dr. Sorel Goland reported in a poster presentation at the annual meeting of the Heart Failure Society of America.

Women with peripartum cardiomyopathy who had very low ejection fractions of 25% or who were not white were most likely to develop major adverse events, 50% of which occurred before the diagnosis of peripartum cardiomyopathy was made, said Dr. Goland of the department of cardiology at Cedars-Sinai Medical Center, Los Angeles, and associates. A diagnostic delay of a week or more raised the risk for death or heart transplant fivefold.

“Early diagnosis and aggressive therapy, including treatment of heart failure, anticoagulation, and sudden death prevention, should improve the outcome of patients,” the investigators stated.

The clinical profile of peripartum cardiomyopathy and risk factors for complications have not been well characterized due to its low incidence. Peripartum cardiomyopathy occurs during pregnancy or the postpartum period for unknown reasons and can cause severe complications.

The retrospective review of 182 patients found that 25% died, had a heart transplantation, developed cardiopulmonary arrest, required temporary circulatory support by an intra-aortic balloon pump or a left ventricular assist device, developed pulmonary edema or thromboembolic complications, or received a pacemaker or implantable cardioverter defibrillator. Of the 46 major adverse events, 36 (78%) occurred within 6 months of the diagnosis of peripartum cardiomyopathy.

Of the 182 patients, 24 (13%) died or underwent heart transplantation; 16 of the 24 deaths or transplants happened within 6 months of diagnosis.

Patients with ejection fractions of 25% or less had quadruple the risk for major adverse events in general and for death or heart transplant, compared with patients with higher ejection fractions. Nonwhites were three times as likely to develop major complications and four times likely to die or need a heart transplant, compared with whites.

ELSEVIER GLOBAL MEDICAL NEWS

SEATTLE — One-fourth of 182 women with peripartum cardiomyopathy developed major adverse events, half of which were death or heart transplantation, Dr. Sorel Goland reported in a poster presentation at the annual meeting of the Heart Failure Society of America.

Women with peripartum cardiomyopathy who had very low ejection fractions of 25% or who were not white were most likely to develop major adverse events, 50% of which occurred before the diagnosis of peripartum cardiomyopathy was made, said Dr. Goland of the department of cardiology at Cedars-Sinai Medical Center, Los Angeles, and associates. A diagnostic delay of a week or more raised the risk for death or heart transplant fivefold.

“Early diagnosis and aggressive therapy, including treatment of heart failure, anticoagulation, and sudden death prevention, should improve the outcome of patients,” the investigators stated.

The clinical profile of peripartum cardiomyopathy and risk factors for complications have not been well characterized due to its low incidence. Peripartum cardiomyopathy occurs during pregnancy or the postpartum period for unknown reasons and can cause severe complications.

The retrospective review of 182 patients found that 25% died, had a heart transplantation, developed cardiopulmonary arrest, required temporary circulatory support by an intra-aortic balloon pump or a left ventricular assist device, developed pulmonary edema or thromboembolic complications, or received a pacemaker or implantable cardioverter defibrillator. Of the 46 major adverse events, 36 (78%) occurred within 6 months of the diagnosis of peripartum cardiomyopathy.

Of the 182 patients, 24 (13%) died or underwent heart transplantation; 16 of the 24 deaths or transplants happened within 6 months of diagnosis.

Patients with ejection fractions of 25% or less had quadruple the risk for major adverse events in general and for death or heart transplant, compared with patients with higher ejection fractions. Nonwhites were three times as likely to develop major complications and four times likely to die or need a heart transplant, compared with whites.

ELSEVIER GLOBAL MEDICAL NEWS

SEATTLE — One-fourth of 182 women with peripartum cardiomyopathy developed major adverse events, half of which were death or heart transplantation, Dr. Sorel Goland reported in a poster presentation at the annual meeting of the Heart Failure Society of America.

Women with peripartum cardiomyopathy who had very low ejection fractions of 25% or who were not white were most likely to develop major adverse events, 50% of which occurred before the diagnosis of peripartum cardiomyopathy was made, said Dr. Goland of the department of cardiology at Cedars-Sinai Medical Center, Los Angeles, and associates. A diagnostic delay of a week or more raised the risk for death or heart transplant fivefold.

“Early diagnosis and aggressive therapy, including treatment of heart failure, anticoagulation, and sudden death prevention, should improve the outcome of patients,” the investigators stated.

The clinical profile of peripartum cardiomyopathy and risk factors for complications have not been well characterized due to its low incidence. Peripartum cardiomyopathy occurs during pregnancy or the postpartum period for unknown reasons and can cause severe complications.

The retrospective review of 182 patients found that 25% died, had a heart transplantation, developed cardiopulmonary arrest, required temporary circulatory support by an intra-aortic balloon pump or a left ventricular assist device, developed pulmonary edema or thromboembolic complications, or received a pacemaker or implantable cardioverter defibrillator. Of the 46 major adverse events, 36 (78%) occurred within 6 months of the diagnosis of peripartum cardiomyopathy.

Of the 182 patients, 24 (13%) died or underwent heart transplantation; 16 of the 24 deaths or transplants happened within 6 months of diagnosis.

Patients with ejection fractions of 25% or less had quadruple the risk for major adverse events in general and for death or heart transplant, compared with patients with higher ejection fractions. Nonwhites were three times as likely to develop major complications and four times likely to die or need a heart transplant, compared with whites.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Maternal peripartum cardiomyopathy, seen in 1 in 3,000 live births, generally carries a good prognosis, Dr. Michael Crawford said at a meeting sponsored by the California chapter of the American College of Cardiology.

Diagnosis of peripartum cardiomyopathy—or of other heart diseases during pregnancy—often is delayed because the symptoms of pregnancy are alike, said Dr. Crawford, professor of medicine at the University of California, San Francisco.

A majority of women with peripartum cardiomyopathy recover after delivery, but 10%–20% require heart transplantation and 1%–2% die, data suggest. The patient's ejection fraction 2 months after diagnosis appears to be the best prognostic factor, he said at the meeting, also sponsored by the university.

Treatment differs for pregnant women compared with nonpregnant patients because some drugs shouldn't be used until after delivery. ACE inhibitors and warfarin are teratogenic, and β-blockers can lead to fetal bradycardia. “You get by with diuretics, digoxin, and hydralazine during pregnancy,” Dr. Crawford said.

In a recent study at a large medical center, ejection fractions improved at least 15% in 62% of women with peripartum cardiomyopathy, remained unchanged in 25%, and declined in 13% (Am. Heart J. 2006;152:509–13).

Ejection fractions returned to normal in 45%. Ten percent of patients required transplantation. No patients died during an average 43-month follow-up. The initial echocardiogram, obtained between 1 month prepartum and 5 months post partum, did not predict which patients required transplantation, nor which had final ejection fractions below or above 50%. “Don't get discouraged with the first echo,” Dr. Crawford said. Echocardiograms 2 months later predicted outcomes in that study.

Patients with ejection fractions below 20% probably are headed for transplant. Those with ejection fractions between 20% and 50% should see some improvement but are unlikely to return to normal. If the 2-month ejection fraction is above 40%, the patient is likely to recover fully (defined as an ejection fraction greater than 50%), he said.

Shortness of breath and decreased exercise capacity—symptoms of cardiomyopathy—also are symptoms of a normal pregnancy. Fatigue, orthopnea, and dizziness or syncope, which might be symptoms of other heart disease, can also be caused by pregnancy.

Electrocardiograms in normal pregnancies often detect sinus tachycardia, and may show nonspecific ST-T changes. As the pregnancy advances, the heart's axis shifts more to the left. Physical findings in normal pregnancies may include jugular venous distention, an enlarged left ventricle apex, right ventricle heave, a palpable pulmonary artery pulse, third heart sounds, systolic ejection murmurs, venous hums, or a mammary souffle noise if you listen over the breast.

The most common peripartum cardiovascular problem is venous thromboembolism, which is the leading cause of death in pregnancy, he added. Consider prophylactic medication in women with risk factors.

Coronary artery disease during pregnancy is more common than one might think, perhaps because more women are having children later in life, he added. Maternal MI occurs in 6 out of 100,000 deliveries, three to four times more common than is expected in age-matched nonpregnant women.

Elevated troponin levels are abnormal in pregnancy, and are a red flag. Thrombolytics can be used without causing a lot of fetal complications. Around 5% of women with peripartum MI die.

SAN FRANCISCO — Maternal peripartum cardiomyopathy, seen in 1 in 3,000 live births, generally carries a good prognosis, Dr. Michael Crawford said at a meeting sponsored by the California chapter of the American College of Cardiology.

Diagnosis of peripartum cardiomyopathy—or of other heart diseases during pregnancy—often is delayed because the symptoms of pregnancy are alike, said Dr. Crawford, professor of medicine at the University of California, San Francisco.

A majority of women with peripartum cardiomyopathy recover after delivery, but 10%–20% require heart transplantation and 1%–2% die, data suggest. The patient's ejection fraction 2 months after diagnosis appears to be the best prognostic factor, he said at the meeting, also sponsored by the university.

Treatment differs for pregnant women compared with nonpregnant patients because some drugs shouldn't be used until after delivery. ACE inhibitors and warfarin are teratogenic, and β-blockers can lead to fetal bradycardia. “You get by with diuretics, digoxin, and hydralazine during pregnancy,” Dr. Crawford said.

In a recent study at a large medical center, ejection fractions improved at least 15% in 62% of women with peripartum cardiomyopathy, remained unchanged in 25%, and declined in 13% (Am. Heart J. 2006;152:509–13).

Ejection fractions returned to normal in 45%. Ten percent of patients required transplantation. No patients died during an average 43-month follow-up. The initial echocardiogram, obtained between 1 month prepartum and 5 months post partum, did not predict which patients required transplantation, nor which had final ejection fractions below or above 50%. “Don't get discouraged with the first echo,” Dr. Crawford said. Echocardiograms 2 months later predicted outcomes in that study.

Patients with ejection fractions below 20% probably are headed for transplant. Those with ejection fractions between 20% and 50% should see some improvement but are unlikely to return to normal. If the 2-month ejection fraction is above 40%, the patient is likely to recover fully (defined as an ejection fraction greater than 50%), he said.

Shortness of breath and decreased exercise capacity—symptoms of cardiomyopathy—also are symptoms of a normal pregnancy. Fatigue, orthopnea, and dizziness or syncope, which might be symptoms of other heart disease, can also be caused by pregnancy.

Electrocardiograms in normal pregnancies often detect sinus tachycardia, and may show nonspecific ST-T changes. As the pregnancy advances, the heart's axis shifts more to the left. Physical findings in normal pregnancies may include jugular venous distention, an enlarged left ventricle apex, right ventricle heave, a palpable pulmonary artery pulse, third heart sounds, systolic ejection murmurs, venous hums, or a mammary souffle noise if you listen over the breast.

The most common peripartum cardiovascular problem is venous thromboembolism, which is the leading cause of death in pregnancy, he added. Consider prophylactic medication in women with risk factors.

Coronary artery disease during pregnancy is more common than one might think, perhaps because more women are having children later in life, he added. Maternal MI occurs in 6 out of 100,000 deliveries, three to four times more common than is expected in age-matched nonpregnant women.

Elevated troponin levels are abnormal in pregnancy, and are a red flag. Thrombolytics can be used without causing a lot of fetal complications. Around 5% of women with peripartum MI die.

SAN FRANCISCO — Maternal peripartum cardiomyopathy, seen in 1 in 3,000 live births, generally carries a good prognosis, Dr. Michael Crawford said at a meeting sponsored by the California chapter of the American College of Cardiology.

Diagnosis of peripartum cardiomyopathy—or of other heart diseases during pregnancy—often is delayed because the symptoms of pregnancy are alike, said Dr. Crawford, professor of medicine at the University of California, San Francisco.

A majority of women with peripartum cardiomyopathy recover after delivery, but 10%–20% require heart transplantation and 1%–2% die, data suggest. The patient's ejection fraction 2 months after diagnosis appears to be the best prognostic factor, he said at the meeting, also sponsored by the university.

Treatment differs for pregnant women compared with nonpregnant patients because some drugs shouldn't be used until after delivery. ACE inhibitors and warfarin are teratogenic, and β-blockers can lead to fetal bradycardia. “You get by with diuretics, digoxin, and hydralazine during pregnancy,” Dr. Crawford said.

In a recent study at a large medical center, ejection fractions improved at least 15% in 62% of women with peripartum cardiomyopathy, remained unchanged in 25%, and declined in 13% (Am. Heart J. 2006;152:509–13).

Ejection fractions returned to normal in 45%. Ten percent of patients required transplantation. No patients died during an average 43-month follow-up. The initial echocardiogram, obtained between 1 month prepartum and 5 months post partum, did not predict which patients required transplantation, nor which had final ejection fractions below or above 50%. “Don't get discouraged with the first echo,” Dr. Crawford said. Echocardiograms 2 months later predicted outcomes in that study.

Patients with ejection fractions below 20% probably are headed for transplant. Those with ejection fractions between 20% and 50% should see some improvement but are unlikely to return to normal. If the 2-month ejection fraction is above 40%, the patient is likely to recover fully (defined as an ejection fraction greater than 50%), he said.

Shortness of breath and decreased exercise capacity—symptoms of cardiomyopathy—also are symptoms of a normal pregnancy. Fatigue, orthopnea, and dizziness or syncope, which might be symptoms of other heart disease, can also be caused by pregnancy.

Electrocardiograms in normal pregnancies often detect sinus tachycardia, and may show nonspecific ST-T changes. As the pregnancy advances, the heart's axis shifts more to the left. Physical findings in normal pregnancies may include jugular venous distention, an enlarged left ventricle apex, right ventricle heave, a palpable pulmonary artery pulse, third heart sounds, systolic ejection murmurs, venous hums, or a mammary souffle noise if you listen over the breast.

The most common peripartum cardiovascular problem is venous thromboembolism, which is the leading cause of death in pregnancy, he added. Consider prophylactic medication in women with risk factors.

Coronary artery disease during pregnancy is more common than one might think, perhaps because more women are having children later in life, he added. Maternal MI occurs in 6 out of 100,000 deliveries, three to four times more common than is expected in age-matched nonpregnant women.

Elevated troponin levels are abnormal in pregnancy, and are a red flag. Thrombolytics can be used without causing a lot of fetal complications. Around 5% of women with peripartum MI die.

SAN FRANCISCO — Continued use of clopidogrel significantly decreased the risk of death or MI at 2 years in patients with intracoronary drug-eluting stents, compared with bare-metal stents or in patients with either kind of stent who stopped clopidogrel after 6 months of use, Dr. John S. MacGregor reported.

Patients with drug-eluting stents who stopped taking clopidogrel after 6 months of use fared the worst, compared with the other three groups, according to a study published online by investigators at Duke University, Durham, N.C., Dr. MacGregor said at a meeting sponsored by the California chapter of the American College of Cardiology.

All patients had been free of major cardiac events after stent implantation and 6 months of clopidogrel use. Patients with drug-eluting stents who stopped clopidogrel were more than twice as likely to die or have an MI by 24 months, compared with patients with drug-eluting stents who continued clopidogrel, said Dr. MacGregor of the University of California, San Francisco.

The rates of death or MI in patients with bare-metal stents who were on or off clopidogrel fell between the rates for the drug-eluting-stent groups, and they were significantly higher than rates in patients who had drug-eluting stents and who continued clopidogrel (JAMA 2007;297 [Epub doi:10.1001/jama.297.2.joc60179]).

Similar findings emerged for patients who were free of major cardiac events at 12 months after stent insertion. By 24 months, the rates of death or MI were 0% in patients with drug-eluting stents who continued clopidogrel, 5% in patients on drug-eluting stents who stopped clopidogrel or in patients with bare-metal stents who continued clopidogrel, and 4% in patients with bare-metal stents who stopped clopidogrel, he said at the meeting, also sponsored by the university.

Multiple investigators in the Duke study disclosed receiving research funding or having other financial ties with the companies that market clopidogrel, Sanofi-Aventis and Bristol-Myers Squibb.

Previous studies have shown that drug-eluting stents decrease the risk for major adverse cardiac events in the first 3–6 months after insertion, compared with bare-metal stents. Use of clopidogrel is recommended for 3 months after insertion of a sirolimus-coated stent or for 6 months after insertion of a paclitaxel-coated stent.

In a study presented at the 2006 American College of Cardiology meeting, however, the risk for death or MI, or for nonfatal MI, more than tripled in patients with drug-eluting stents who stopped taking clopidogrel, compared with patients with bare-metal stents who continued clopidogrel, he said. The 743 patients in the randomized Basal Stent Kosten Effektivitäts-Late Thrombotic Events (BASKET-LATE) trial had been event free after 6 months of clopidogrel use, and were followed for another 6–12 months off the drug.

These and other studies raise concerns that the recommended regimen of clopidogrel after insertion of drug-eluting stents is insufficient.

“My bias is to have people with drug-eluting stents take Plavix [clopidogrel] indefinitely unless they have bleeding problems,” Dr. MacGregor said.

Further studies are needed to determine the optimal duration of clopidogrel therapy after stent implantation and to include rates of side effects from extended-duration clopidogrel.

Two out of three recent placebo-controlled trials of long-term clopidogrel use found that taking clopidogrel plus aspirin for 1–2.5 years significantly increased the rate of major or moderate bleeding events, compared with taking clopidogrel plus placebo, he said.

About 600,000 U.S. patients receive intracoronary stents each year. One year of clopidogrel therapy costs approximately $1,400. Long-term clopidogrel use also might interfere with valuable procedures like colonoscopy or noncardiac surgery.

By 24 months, the rate of death or MI was 0% for those patients with drug-eluting stents who took clopidogrel. DR. MACGREGOR

SAN FRANCISCO — Continued use of clopidogrel significantly decreased the risk of death or MI at 2 years in patients with intracoronary drug-eluting stents, compared with bare-metal stents or in patients with either kind of stent who stopped clopidogrel after 6 months of use, Dr. John S. MacGregor reported.

Patients with drug-eluting stents who stopped taking clopidogrel after 6 months of use fared the worst, compared with the other three groups, according to a study published online by investigators at Duke University, Durham, N.C., Dr. MacGregor said at a meeting sponsored by the California chapter of the American College of Cardiology.

All patients had been free of major cardiac events after stent implantation and 6 months of clopidogrel use. Patients with drug-eluting stents who stopped clopidogrel were more than twice as likely to die or have an MI by 24 months, compared with patients with drug-eluting stents who continued clopidogrel, said Dr. MacGregor of the University of California, San Francisco.

The rates of death or MI in patients with bare-metal stents who were on or off clopidogrel fell between the rates for the drug-eluting-stent groups, and they were significantly higher than rates in patients who had drug-eluting stents and who continued clopidogrel (JAMA 2007;297 [Epub doi:10.1001/jama.297.2.joc60179]).

Similar findings emerged for patients who were free of major cardiac events at 12 months after stent insertion. By 24 months, the rates of death or MI were 0% in patients with drug-eluting stents who continued clopidogrel, 5% in patients on drug-eluting stents who stopped clopidogrel or in patients with bare-metal stents who continued clopidogrel, and 4% in patients with bare-metal stents who stopped clopidogrel, he said at the meeting, also sponsored by the university.

Multiple investigators in the Duke study disclosed receiving research funding or having other financial ties with the companies that market clopidogrel, Sanofi-Aventis and Bristol-Myers Squibb.

Previous studies have shown that drug-eluting stents decrease the risk for major adverse cardiac events in the first 3–6 months after insertion, compared with bare-metal stents. Use of clopidogrel is recommended for 3 months after insertion of a sirolimus-coated stent or for 6 months after insertion of a paclitaxel-coated stent.

In a study presented at the 2006 American College of Cardiology meeting, however, the risk for death or MI, or for nonfatal MI, more than tripled in patients with drug-eluting stents who stopped taking clopidogrel, compared with patients with bare-metal stents who continued clopidogrel, he said. The 743 patients in the randomized Basal Stent Kosten Effektivitäts-Late Thrombotic Events (BASKET-LATE) trial had been event free after 6 months of clopidogrel use, and were followed for another 6–12 months off the drug.

These and other studies raise concerns that the recommended regimen of clopidogrel after insertion of drug-eluting stents is insufficient.

“My bias is to have people with drug-eluting stents take Plavix [clopidogrel] indefinitely unless they have bleeding problems,” Dr. MacGregor said.

Further studies are needed to determine the optimal duration of clopidogrel therapy after stent implantation and to include rates of side effects from extended-duration clopidogrel.

Two out of three recent placebo-controlled trials of long-term clopidogrel use found that taking clopidogrel plus aspirin for 1–2.5 years significantly increased the rate of major or moderate bleeding events, compared with taking clopidogrel plus placebo, he said.

About 600,000 U.S. patients receive intracoronary stents each year. One year of clopidogrel therapy costs approximately $1,400. Long-term clopidogrel use also might interfere with valuable procedures like colonoscopy or noncardiac surgery.

By 24 months, the rate of death or MI was 0% for those patients with drug-eluting stents who took clopidogrel. DR. MACGREGOR

SAN FRANCISCO — Continued use of clopidogrel significantly decreased the risk of death or MI at 2 years in patients with intracoronary drug-eluting stents, compared with bare-metal stents or in patients with either kind of stent who stopped clopidogrel after 6 months of use, Dr. John S. MacGregor reported.

Patients with drug-eluting stents who stopped taking clopidogrel after 6 months of use fared the worst, compared with the other three groups, according to a study published online by investigators at Duke University, Durham, N.C., Dr. MacGregor said at a meeting sponsored by the California chapter of the American College of Cardiology.

All patients had been free of major cardiac events after stent implantation and 6 months of clopidogrel use. Patients with drug-eluting stents who stopped clopidogrel were more than twice as likely to die or have an MI by 24 months, compared with patients with drug-eluting stents who continued clopidogrel, said Dr. MacGregor of the University of California, San Francisco.

The rates of death or MI in patients with bare-metal stents who were on or off clopidogrel fell between the rates for the drug-eluting-stent groups, and they were significantly higher than rates in patients who had drug-eluting stents and who continued clopidogrel (JAMA 2007;297 [Epub doi:10.1001/jama.297.2.joc60179]).

Similar findings emerged for patients who were free of major cardiac events at 12 months after stent insertion. By 24 months, the rates of death or MI were 0% in patients with drug-eluting stents who continued clopidogrel, 5% in patients on drug-eluting stents who stopped clopidogrel or in patients with bare-metal stents who continued clopidogrel, and 4% in patients with bare-metal stents who stopped clopidogrel, he said at the meeting, also sponsored by the university.

Multiple investigators in the Duke study disclosed receiving research funding or having other financial ties with the companies that market clopidogrel, Sanofi-Aventis and Bristol-Myers Squibb.

Previous studies have shown that drug-eluting stents decrease the risk for major adverse cardiac events in the first 3–6 months after insertion, compared with bare-metal stents. Use of clopidogrel is recommended for 3 months after insertion of a sirolimus-coated stent or for 6 months after insertion of a paclitaxel-coated stent.

In a study presented at the 2006 American College of Cardiology meeting, however, the risk for death or MI, or for nonfatal MI, more than tripled in patients with drug-eluting stents who stopped taking clopidogrel, compared with patients with bare-metal stents who continued clopidogrel, he said. The 743 patients in the randomized Basal Stent Kosten Effektivitäts-Late Thrombotic Events (BASKET-LATE) trial had been event free after 6 months of clopidogrel use, and were followed for another 6–12 months off the drug.

These and other studies raise concerns that the recommended regimen of clopidogrel after insertion of drug-eluting stents is insufficient.

“My bias is to have people with drug-eluting stents take Plavix [clopidogrel] indefinitely unless they have bleeding problems,” Dr. MacGregor said.

Further studies are needed to determine the optimal duration of clopidogrel therapy after stent implantation and to include rates of side effects from extended-duration clopidogrel.

Two out of three recent placebo-controlled trials of long-term clopidogrel use found that taking clopidogrel plus aspirin for 1–2.5 years significantly increased the rate of major or moderate bleeding events, compared with taking clopidogrel plus placebo, he said.

About 600,000 U.S. patients receive intracoronary stents each year. One year of clopidogrel therapy costs approximately $1,400. Long-term clopidogrel use also might interfere with valuable procedures like colonoscopy or noncardiac surgery.

By 24 months, the rate of death or MI was 0% for those patients with drug-eluting stents who took clopidogrel. DR. MACGREGOR

SAN FRANCISCO — Helping patients, even overweight patients, to avoid gaining more weight is an important therapeutic goal by itself, Dr. Robert Baron said at a diabetes update sponsored by the University of California, San Francisco.

“It's very, very hard to get people to lose weight. Our priority in a large number of our patients should be to prevent further weight gain,” said Dr. Baron, professor of medicine at the university. “In our society, the default position is to gain weight. You need to have a strategy to maintain your weight, especially [with age].”

Recent data support the classic goals of being as fit as possible at one's current weight, preventing weight gain, and then considering attempts at weight loss, he emphasized. Being overweight by itself is not necessarily a risk factor for mortality, other data show. The presence or absence of metabolic syndrome plays a key role in level of risk.

A 2005 meta-analysis of three National Health and Nutrition Examination Surveys (NHANES I, II and III) found no increased risk for mortality in people who fit the conventional definition of overweight for white people (a body mass index [kg/m2] of at least 25 but less than 30), although the mortality risk did increase among the obese.

Although the prevalence of obesity has increased, the mortality risk associated with obesity decreased between the first of the three surveys, NHANES I, and the more recent NHANES III, although this could be because of methodologic differences.

Data from a separate study in 2005 of 19,173 men showed that the presence of metabolic syndrome doubled the risk for mortality in normal-weight people, added about 50% in absolute risk for death in overweight people, and increased risk for death by 13% in obese people.

Overweight patients may not be at increased risk if they are metabolically normal, but the presence of the metabolic syndrome or other signs of insulin-resistance changes the clinical picture, Dr. Baron said. “Your BMI is your initial screening test, and evaluation of metabolic syndrome becomes your more accurate, second-level test to sort out which patients in the overweight category and Class I obese [BMI of at least 30 but lower than 35] need more particularly aggressive interventions.”

Data on 3,000 successful dieters (mostly white women) who enrolled in the National Weight Control Registry and maintained a 30-pound or greater weight loss for 1 year showed three key steps to keeping the pounds off: high levels of physical activity; diets low in fat and high in fiber, and regular self-monitoring of weight.

Most of the patients did an hour a day of moderately intense exercise, 6–7 days a week, to burn 2,545 kcal/week for women or 3,293 kcal/week for men. Most checked their weight daily or weekly.

Their “grazing” diets consisted of five meals or snacks a day, providing 1,381 kcal/day from foods made up of 24% fat, 19% protein, and 56% carbohydrates. The calorie levels of their weight maintenance diets were similar to those during their weight loss.

SAN FRANCISCO — Helping patients, even overweight patients, to avoid gaining more weight is an important therapeutic goal by itself, Dr. Robert Baron said at a diabetes update sponsored by the University of California, San Francisco.

“It's very, very hard to get people to lose weight. Our priority in a large number of our patients should be to prevent further weight gain,” said Dr. Baron, professor of medicine at the university. “In our society, the default position is to gain weight. You need to have a strategy to maintain your weight, especially [with age].”

Recent data support the classic goals of being as fit as possible at one's current weight, preventing weight gain, and then considering attempts at weight loss, he emphasized. Being overweight by itself is not necessarily a risk factor for mortality, other data show. The presence or absence of metabolic syndrome plays a key role in level of risk.

A 2005 meta-analysis of three National Health and Nutrition Examination Surveys (NHANES I, II and III) found no increased risk for mortality in people who fit the conventional definition of overweight for white people (a body mass index [kg/m2] of at least 25 but less than 30), although the mortality risk did increase among the obese.

Although the prevalence of obesity has increased, the mortality risk associated with obesity decreased between the first of the three surveys, NHANES I, and the more recent NHANES III, although this could be because of methodologic differences.

Data from a separate study in 2005 of 19,173 men showed that the presence of metabolic syndrome doubled the risk for mortality in normal-weight people, added about 50% in absolute risk for death in overweight people, and increased risk for death by 13% in obese people.

Overweight patients may not be at increased risk if they are metabolically normal, but the presence of the metabolic syndrome or other signs of insulin-resistance changes the clinical picture, Dr. Baron said. “Your BMI is your initial screening test, and evaluation of metabolic syndrome becomes your more accurate, second-level test to sort out which patients in the overweight category and Class I obese [BMI of at least 30 but lower than 35] need more particularly aggressive interventions.”

Data on 3,000 successful dieters (mostly white women) who enrolled in the National Weight Control Registry and maintained a 30-pound or greater weight loss for 1 year showed three key steps to keeping the pounds off: high levels of physical activity; diets low in fat and high in fiber, and regular self-monitoring of weight.

Most of the patients did an hour a day of moderately intense exercise, 6–7 days a week, to burn 2,545 kcal/week for women or 3,293 kcal/week for men. Most checked their weight daily or weekly.

Their “grazing” diets consisted of five meals or snacks a day, providing 1,381 kcal/day from foods made up of 24% fat, 19% protein, and 56% carbohydrates. The calorie levels of their weight maintenance diets were similar to those during their weight loss.

SAN FRANCISCO — Helping patients, even overweight patients, to avoid gaining more weight is an important therapeutic goal by itself, Dr. Robert Baron said at a diabetes update sponsored by the University of California, San Francisco.

“It's very, very hard to get people to lose weight. Our priority in a large number of our patients should be to prevent further weight gain,” said Dr. Baron, professor of medicine at the university. “In our society, the default position is to gain weight. You need to have a strategy to maintain your weight, especially [with age].”

Recent data support the classic goals of being as fit as possible at one's current weight, preventing weight gain, and then considering attempts at weight loss, he emphasized. Being overweight by itself is not necessarily a risk factor for mortality, other data show. The presence or absence of metabolic syndrome plays a key role in level of risk.

A 2005 meta-analysis of three National Health and Nutrition Examination Surveys (NHANES I, II and III) found no increased risk for mortality in people who fit the conventional definition of overweight for white people (a body mass index [kg/m2] of at least 25 but less than 30), although the mortality risk did increase among the obese.

Although the prevalence of obesity has increased, the mortality risk associated with obesity decreased between the first of the three surveys, NHANES I, and the more recent NHANES III, although this could be because of methodologic differences.

Data from a separate study in 2005 of 19,173 men showed that the presence of metabolic syndrome doubled the risk for mortality in normal-weight people, added about 50% in absolute risk for death in overweight people, and increased risk for death by 13% in obese people.

Overweight patients may not be at increased risk if they are metabolically normal, but the presence of the metabolic syndrome or other signs of insulin-resistance changes the clinical picture, Dr. Baron said. “Your BMI is your initial screening test, and evaluation of metabolic syndrome becomes your more accurate, second-level test to sort out which patients in the overweight category and Class I obese [BMI of at least 30 but lower than 35] need more particularly aggressive interventions.”

Data on 3,000 successful dieters (mostly white women) who enrolled in the National Weight Control Registry and maintained a 30-pound or greater weight loss for 1 year showed three key steps to keeping the pounds off: high levels of physical activity; diets low in fat and high in fiber, and regular self-monitoring of weight.

Most of the patients did an hour a day of moderately intense exercise, 6–7 days a week, to burn 2,545 kcal/week for women or 3,293 kcal/week for men. Most checked their weight daily or weekly.

Their “grazing” diets consisted of five meals or snacks a day, providing 1,381 kcal/day from foods made up of 24% fat, 19% protein, and 56% carbohydrates. The calorie levels of their weight maintenance diets were similar to those during their weight loss.

SAN FRANCISCO — Medications for weight loss are little help as monotherapy, and it's questionable whether the benefits outweigh the risks, Dr. Robert Baron said at a diabetes update sponsored by the University of California, San Francisco.

Approved weight-loss medications such as sibutramine or orlistat produce an average 5% drop in weight beyond the weight loss achieved on placebo when used alone. Dieting alone leads to an average 8% weight loss beyond that achieved with placebo. The efficacy of drug and diet therapies are about the same, but medications carry potential side effects and cost more, said Dr. Baron, professor of medicine at the university.

He has no association with companies that make the drugs he discussed. His practice includes a small bariatric practice, but he chooses not to prescribe medications for weight loss.

There are no data to show that weight loss from medical therapy improves mortality. Trial end points are based on weight changes alone. Improving an intermediate end point such as weight doesn't necessarily reflect beneficial changes in mortality, “so be cautious with the use of drugs” for weight loss, he advised.

In the clinical trials that led to approval of some drugs for weight loss, the drugs were studied in combination with lifestyle modifications. The combination generally induces greater weight loss, and is the only way in which these medications should be used, he said.

National Institutes of Health guidelines recommend that drug therapy for weight loss may be considered in patients with a body mass index (BMI) of at least 30 kg/m2 or in patients with a BMI of 27 kg/m2 plus comorbidity. In this framework, nearly every patient with type II diabetes would qualify for a weight-loss medication, but in practice few should use one, he believes.

Dr. Baron advised against prescribing weight-loss medications during the patient's first visit. Instead, he suggested, start motivated patients on the same strategy used in clinical trials for these medications by beginning with a run-in period of lifestyle modifications with a low-calorie diet, structured exercise, and behavioral therapy. After 1 month, only those who are adherent and who are losing weight should qualify for consideration for a weight-loss medication.

If you choose to use a weight-loss drug, prescribe no more than 1 months' worth initially. “The data are very clear that the outcome at 1 month correlates very well to the outcome at 12 months. If the patient hasn't lost weight at 1 month, you can stop the drug with impunity,” he said. Counsel the patient about this strategy before beginning drug therapy.

Some medications used for other purposes can have weight-loss benefits. The most clinically useful of these is the antidepressant bupropion. In a randomized trial involving 327 obese patients, 5% of those on bupropion 300–400 mg lost modest amounts of weight, compared with 2% of those on placebo. “I would never prescribe this as a weight-loss drug,” but for overweight or obese patients who are depressed, “I now use bupropion as my drug of first choice.”

Dr. Baron cautioned against advertisements claiming that one drug is more effective than another based on the weight lost from baseline. Weight loss should be compared with the weight loss on placebo, he emphasized.

SAN FRANCISCO — Medications for weight loss are little help as monotherapy, and it's questionable whether the benefits outweigh the risks, Dr. Robert Baron said at a diabetes update sponsored by the University of California, San Francisco.

Approved weight-loss medications such as sibutramine or orlistat produce an average 5% drop in weight beyond the weight loss achieved on placebo when used alone. Dieting alone leads to an average 8% weight loss beyond that achieved with placebo. The efficacy of drug and diet therapies are about the same, but medications carry potential side effects and cost more, said Dr. Baron, professor of medicine at the university.

He has no association with companies that make the drugs he discussed. His practice includes a small bariatric practice, but he chooses not to prescribe medications for weight loss.

There are no data to show that weight loss from medical therapy improves mortality. Trial end points are based on weight changes alone. Improving an intermediate end point such as weight doesn't necessarily reflect beneficial changes in mortality, “so be cautious with the use of drugs” for weight loss, he advised.

In the clinical trials that led to approval of some drugs for weight loss, the drugs were studied in combination with lifestyle modifications. The combination generally induces greater weight loss, and is the only way in which these medications should be used, he said.

National Institutes of Health guidelines recommend that drug therapy for weight loss may be considered in patients with a body mass index (BMI) of at least 30 kg/m2 or in patients with a BMI of 27 kg/m2 plus comorbidity. In this framework, nearly every patient with type II diabetes would qualify for a weight-loss medication, but in practice few should use one, he believes.

Dr. Baron advised against prescribing weight-loss medications during the patient's first visit. Instead, he suggested, start motivated patients on the same strategy used in clinical trials for these medications by beginning with a run-in period of lifestyle modifications with a low-calorie diet, structured exercise, and behavioral therapy. After 1 month, only those who are adherent and who are losing weight should qualify for consideration for a weight-loss medication.

If you choose to use a weight-loss drug, prescribe no more than 1 months' worth initially. “The data are very clear that the outcome at 1 month correlates very well to the outcome at 12 months. If the patient hasn't lost weight at 1 month, you can stop the drug with impunity,” he said. Counsel the patient about this strategy before beginning drug therapy.

Some medications used for other purposes can have weight-loss benefits. The most clinically useful of these is the antidepressant bupropion. In a randomized trial involving 327 obese patients, 5% of those on bupropion 300–400 mg lost modest amounts of weight, compared with 2% of those on placebo. “I would never prescribe this as a weight-loss drug,” but for overweight or obese patients who are depressed, “I now use bupropion as my drug of first choice.”

Dr. Baron cautioned against advertisements claiming that one drug is more effective than another based on the weight lost from baseline. Weight loss should be compared with the weight loss on placebo, he emphasized.

SAN FRANCISCO — Medications for weight loss are little help as monotherapy, and it's questionable whether the benefits outweigh the risks, Dr. Robert Baron said at a diabetes update sponsored by the University of California, San Francisco.

Approved weight-loss medications such as sibutramine or orlistat produce an average 5% drop in weight beyond the weight loss achieved on placebo when used alone. Dieting alone leads to an average 8% weight loss beyond that achieved with placebo. The efficacy of drug and diet therapies are about the same, but medications carry potential side effects and cost more, said Dr. Baron, professor of medicine at the university.

He has no association with companies that make the drugs he discussed. His practice includes a small bariatric practice, but he chooses not to prescribe medications for weight loss.

There are no data to show that weight loss from medical therapy improves mortality. Trial end points are based on weight changes alone. Improving an intermediate end point such as weight doesn't necessarily reflect beneficial changes in mortality, “so be cautious with the use of drugs” for weight loss, he advised.

In the clinical trials that led to approval of some drugs for weight loss, the drugs were studied in combination with lifestyle modifications. The combination generally induces greater weight loss, and is the only way in which these medications should be used, he said.

National Institutes of Health guidelines recommend that drug therapy for weight loss may be considered in patients with a body mass index (BMI) of at least 30 kg/m2 or in patients with a BMI of 27 kg/m2 plus comorbidity. In this framework, nearly every patient with type II diabetes would qualify for a weight-loss medication, but in practice few should use one, he believes.

Dr. Baron advised against prescribing weight-loss medications during the patient's first visit. Instead, he suggested, start motivated patients on the same strategy used in clinical trials for these medications by beginning with a run-in period of lifestyle modifications with a low-calorie diet, structured exercise, and behavioral therapy. After 1 month, only those who are adherent and who are losing weight should qualify for consideration for a weight-loss medication.

If you choose to use a weight-loss drug, prescribe no more than 1 months' worth initially. “The data are very clear that the outcome at 1 month correlates very well to the outcome at 12 months. If the patient hasn't lost weight at 1 month, you can stop the drug with impunity,” he said. Counsel the patient about this strategy before beginning drug therapy.

Some medications used for other purposes can have weight-loss benefits. The most clinically useful of these is the antidepressant bupropion. In a randomized trial involving 327 obese patients, 5% of those on bupropion 300–400 mg lost modest amounts of weight, compared with 2% of those on placebo. “I would never prescribe this as a weight-loss drug,” but for overweight or obese patients who are depressed, “I now use bupropion as my drug of first choice.”

Dr. Baron cautioned against advertisements claiming that one drug is more effective than another based on the weight lost from baseline. Weight loss should be compared with the weight loss on placebo, he emphasized.

SAN FRANCISCO — Two oral medications deserve further investigation as alternative therapies for gestational diabetes, results of separate small studies suggest.

Acarbose or metformin might be helpful if additional research supports these preliminary findings, investigators said in separate poster presentations at the annual meeting of the Society for Maternal-Fetal Medicine.

Neither drug is approved for the treatment of gestational diabetes. Both are Food and Drug Administration pregnancy category B. Injected insulin or oral glyburide are approved to treat gestational diabetes.

An oral option other than glyburide might allow patients to be managed on one or potentially two oral agents before resorting to injections of insulin, Dr. Jacquelyn Cortez said in an interview at one of the posters. She and her associates conducted a prospective, double-blind trial that randomized 59 women diagnosed with gestational diabetes in their second or third trimester, prior to 34 weeks' gestation, to 50 mg acarbose t.i.d. or identical placebo pills taken with meals. All had failed diet therapy.

At regular follow-ups, if more than half of the patient's fasting glucose values were above 95 mg/dL, or more than half of her postprandial glucose values were above 135 mg/dL, the dosage was increased to 100 mg t.i.d. If this did not control blood glucose levels, she was considered to have failed single-agent therapy and started on a second agent.

Fewer patients in the acarbose group failed monotherapy and required a second agent, compared with the placebo group, but the difference did not quite reach statistical significance. Women in the acarbose group gained significantly less weight (19 pounds) than did those on placebo (27 pounds), said Dr. Cortez of the department of reproductive medicine at the University of California, San Diego.

Postprandial blood glucose levels were significantly lower on acarbose therapy (122 mg/dL), compared with placebo (130 mg/dL). There were no differences between groups in perinatal outcomes.

The failure rate with acarbose in this study and failure rates with glyburide in other studies are high, but women on acarbose in the present study did not develop the hypoglycemia sometimes seen with glyburide, Dr. Cortez noted. Acarbose is a glycosidase inhibitor that prevents intestinal breakdown of starches to glucose in the upper small bowel.

Metformin, an insulin sensitizer, was the subject of a separate review of data from two randomized trials in which 67 women with gestational diabetes took the drug. Of these, 59 met glycemic goals of fasting glucose values lower than 105 mg/dL and 2-hour postprandial glucose values lower than 120 mg/dL, reported Dr. Lisa E. Moore of the University of New Mexico, Albuquerque, and associates. The eight who did not meet glycemic goals started insulin therapy.

Macrosomia occurred in four infants (6%), and all were delivered vaginally. The primary cesarean delivery rate (excluding elective repeat C-sections) was 15% (10 patients). There were no cases of fetal anomalies or maternal or fetal hypoglycemia. Eight neonates had hyperbilirubinemia, and two had 5-minute Apgar scores lower than 5.

The efficacy rate with metformin seemed similar to success rates with glyburide in other studies, Dr. Moore said. Failure of metformin was not predicted by maternal BMI or the value of the 1-hour glucose challenge test. Metformin is not approved in the United States for this indication, but there are data from other countries on its use in gestational diabetes. Dr. Cortez and Dr. Moore have no financial relationships with the drugs' manufacturers.

SAN FRANCISCO — Two oral medications deserve further investigation as alternative therapies for gestational diabetes, results of separate small studies suggest.

Acarbose or metformin might be helpful if additional research supports these preliminary findings, investigators said in separate poster presentations at the annual meeting of the Society for Maternal-Fetal Medicine.

Neither drug is approved for the treatment of gestational diabetes. Both are Food and Drug Administration pregnancy category B. Injected insulin or oral glyburide are approved to treat gestational diabetes.

An oral option other than glyburide might allow patients to be managed on one or potentially two oral agents before resorting to injections of insulin, Dr. Jacquelyn Cortez said in an interview at one of the posters. She and her associates conducted a prospective, double-blind trial that randomized 59 women diagnosed with gestational diabetes in their second or third trimester, prior to 34 weeks' gestation, to 50 mg acarbose t.i.d. or identical placebo pills taken with meals. All had failed diet therapy.

At regular follow-ups, if more than half of the patient's fasting glucose values were above 95 mg/dL, or more than half of her postprandial glucose values were above 135 mg/dL, the dosage was increased to 100 mg t.i.d. If this did not control blood glucose levels, she was considered to have failed single-agent therapy and started on a second agent.

Fewer patients in the acarbose group failed monotherapy and required a second agent, compared with the placebo group, but the difference did not quite reach statistical significance. Women in the acarbose group gained significantly less weight (19 pounds) than did those on placebo (27 pounds), said Dr. Cortez of the department of reproductive medicine at the University of California, San Diego.

Postprandial blood glucose levels were significantly lower on acarbose therapy (122 mg/dL), compared with placebo (130 mg/dL). There were no differences between groups in perinatal outcomes.

The failure rate with acarbose in this study and failure rates with glyburide in other studies are high, but women on acarbose in the present study did not develop the hypoglycemia sometimes seen with glyburide, Dr. Cortez noted. Acarbose is a glycosidase inhibitor that prevents intestinal breakdown of starches to glucose in the upper small bowel.

Metformin, an insulin sensitizer, was the subject of a separate review of data from two randomized trials in which 67 women with gestational diabetes took the drug. Of these, 59 met glycemic goals of fasting glucose values lower than 105 mg/dL and 2-hour postprandial glucose values lower than 120 mg/dL, reported Dr. Lisa E. Moore of the University of New Mexico, Albuquerque, and associates. The eight who did not meet glycemic goals started insulin therapy.

Macrosomia occurred in four infants (6%), and all were delivered vaginally. The primary cesarean delivery rate (excluding elective repeat C-sections) was 15% (10 patients). There were no cases of fetal anomalies or maternal or fetal hypoglycemia. Eight neonates had hyperbilirubinemia, and two had 5-minute Apgar scores lower than 5.

The efficacy rate with metformin seemed similar to success rates with glyburide in other studies, Dr. Moore said. Failure of metformin was not predicted by maternal BMI or the value of the 1-hour glucose challenge test. Metformin is not approved in the United States for this indication, but there are data from other countries on its use in gestational diabetes. Dr. Cortez and Dr. Moore have no financial relationships with the drugs' manufacturers.

SAN FRANCISCO — Two oral medications deserve further investigation as alternative therapies for gestational diabetes, results of separate small studies suggest.

Acarbose or metformin might be helpful if additional research supports these preliminary findings, investigators said in separate poster presentations at the annual meeting of the Society for Maternal-Fetal Medicine.

Neither drug is approved for the treatment of gestational diabetes. Both are Food and Drug Administration pregnancy category B. Injected insulin or oral glyburide are approved to treat gestational diabetes.

An oral option other than glyburide might allow patients to be managed on one or potentially two oral agents before resorting to injections of insulin, Dr. Jacquelyn Cortez said in an interview at one of the posters. She and her associates conducted a prospective, double-blind trial that randomized 59 women diagnosed with gestational diabetes in their second or third trimester, prior to 34 weeks' gestation, to 50 mg acarbose t.i.d. or identical placebo pills taken with meals. All had failed diet therapy.

At regular follow-ups, if more than half of the patient's fasting glucose values were above 95 mg/dL, or more than half of her postprandial glucose values were above 135 mg/dL, the dosage was increased to 100 mg t.i.d. If this did not control blood glucose levels, she was considered to have failed single-agent therapy and started on a second agent.

Fewer patients in the acarbose group failed monotherapy and required a second agent, compared with the placebo group, but the difference did not quite reach statistical significance. Women in the acarbose group gained significantly less weight (19 pounds) than did those on placebo (27 pounds), said Dr. Cortez of the department of reproductive medicine at the University of California, San Diego.

Postprandial blood glucose levels were significantly lower on acarbose therapy (122 mg/dL), compared with placebo (130 mg/dL). There were no differences between groups in perinatal outcomes.

The failure rate with acarbose in this study and failure rates with glyburide in other studies are high, but women on acarbose in the present study did not develop the hypoglycemia sometimes seen with glyburide, Dr. Cortez noted. Acarbose is a glycosidase inhibitor that prevents intestinal breakdown of starches to glucose in the upper small bowel.

Metformin, an insulin sensitizer, was the subject of a separate review of data from two randomized trials in which 67 women with gestational diabetes took the drug. Of these, 59 met glycemic goals of fasting glucose values lower than 105 mg/dL and 2-hour postprandial glucose values lower than 120 mg/dL, reported Dr. Lisa E. Moore of the University of New Mexico, Albuquerque, and associates. The eight who did not meet glycemic goals started insulin therapy.

Macrosomia occurred in four infants (6%), and all were delivered vaginally. The primary cesarean delivery rate (excluding elective repeat C-sections) was 15% (10 patients). There were no cases of fetal anomalies or maternal or fetal hypoglycemia. Eight neonates had hyperbilirubinemia, and two had 5-minute Apgar scores lower than 5.

The efficacy rate with metformin seemed similar to success rates with glyburide in other studies, Dr. Moore said. Failure of metformin was not predicted by maternal BMI or the value of the 1-hour glucose challenge test. Metformin is not approved in the United States for this indication, but there are data from other countries on its use in gestational diabetes. Dr. Cortez and Dr. Moore have no financial relationships with the drugs' manufacturers.

SAN FRANCISCO — Routine thyroxine therapy for benign thyroid nodules is no longer recommended, Dr. Hossein Gharib said at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

Thyroxine does not shrink most benign thyroid nodules. In those that do shrink, size increases if the drug therapy is stopped. Long-term thyroxine therapy can be costly and may contribute to hyperthyroidism over time in some patients, said Dr. Gharib, professor of medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

Fine-needle biopsy, a reliable diagnostic tool when done by an experienced clinician, can determine if a thyroid nodule is malignant or benign. Malignant lesions should be treated by surgery. Goiters that are benign but large and symptomatic should be treated by surgery or by radioactive iodine therapy, he said at the meeting. OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

Thyroid nodules are detectable by palpation in 5% of the U.S. population and by ultrasound in 50%. More than 100 million U.S. residents have thyroid nodules, and 300,000 new nodules are detected each year. In 95% of cases, thyroid nodules are deemed benign and can be followed by observation, said Dr. Gharib, who has no association with the companies that make the treatments he discussed.

The incidence of thyroid cancer peaks in women at around 12 cases per 100,000 women, between ages 30 and 50 years. In men, incidence peaks at around 8 per 100,000 between ages 70 and 80 years.

SAN FRANCISCO — Routine thyroxine therapy for benign thyroid nodules is no longer recommended, Dr. Hossein Gharib said at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

Thyroxine does not shrink most benign thyroid nodules. In those that do shrink, size increases if the drug therapy is stopped. Long-term thyroxine therapy can be costly and may contribute to hyperthyroidism over time in some patients, said Dr. Gharib, professor of medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

Fine-needle biopsy, a reliable diagnostic tool when done by an experienced clinician, can determine if a thyroid nodule is malignant or benign. Malignant lesions should be treated by surgery. Goiters that are benign but large and symptomatic should be treated by surgery or by radioactive iodine therapy, he said at the meeting. OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

Thyroid nodules are detectable by palpation in 5% of the U.S. population and by ultrasound in 50%. More than 100 million U.S. residents have thyroid nodules, and 300,000 new nodules are detected each year. In 95% of cases, thyroid nodules are deemed benign and can be followed by observation, said Dr. Gharib, who has no association with the companies that make the treatments he discussed.

The incidence of thyroid cancer peaks in women at around 12 cases per 100,000 women, between ages 30 and 50 years. In men, incidence peaks at around 8 per 100,000 between ages 70 and 80 years.

SAN FRANCISCO — Routine thyroxine therapy for benign thyroid nodules is no longer recommended, Dr. Hossein Gharib said at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

Thyroxine does not shrink most benign thyroid nodules. In those that do shrink, size increases if the drug therapy is stopped. Long-term thyroxine therapy can be costly and may contribute to hyperthyroidism over time in some patients, said Dr. Gharib, professor of medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

Fine-needle biopsy, a reliable diagnostic tool when done by an experienced clinician, can determine if a thyroid nodule is malignant or benign. Malignant lesions should be treated by surgery. Goiters that are benign but large and symptomatic should be treated by surgery or by radioactive iodine therapy, he said at the meeting. OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

Thyroid nodules are detectable by palpation in 5% of the U.S. population and by ultrasound in 50%. More than 100 million U.S. residents have thyroid nodules, and 300,000 new nodules are detected each year. In 95% of cases, thyroid nodules are deemed benign and can be followed by observation, said Dr. Gharib, who has no association with the companies that make the treatments he discussed.

The incidence of thyroid cancer peaks in women at around 12 cases per 100,000 women, between ages 30 and 50 years. In men, incidence peaks at around 8 per 100,000 between ages 70 and 80 years.