Sherry Boschert

Three different regimens of a new extended-release version of metformin, including two once-a-day regimens, were as effective as immediate-release metformin in reducing hemoglobin A_1c levels in adults with type 2 diabetes, Dr. Sherwyn Schwartz reported.

A double-blind, phase III trial randomized 750 patients to 24 weeks of treatment, and 706 patients with efficacy data were included in an intent-to-treat analysis. Patients on antihyperglycemic agents stopped the medications for 6 weeks before all patients began metformin at 1,000 mg once daily. Treatment was titrated over 2–3 weeks to assigned regimens of immediate-release metformin (Glucophage) at 1,500 mg/day b.i.d., or extended-release metformin (Glumetza) in dosages of once-daily 1,500 mg/day, the same dose but b.i.d., or once-daily 2,000 mg/day.

All groups showed significant reductions in hemoglobin A_1c (HbA_1c) levels by week 12. Levels continued declining until week 20, and were maintained until the end of the study at week 24, said Dr. Schwartz, an endocrinologist in a group practice in San Antonio, and his associates (Diabetes Care 2006;29:759–64). The study was funded by Depomed Inc., which makes Glumetza.

The reductions in mean HbA_1c levels were similar to results from clinical trials of Glucophage and of another extended-release metformin product (Glucophage XR, by Bristol-Myers Squibb). Glumetza is the first extended-release metformin formulation, however, to show equal efficacy in daily or twice-daily dosing, Dr. Schwartz said.

Among secondary end points in the current study, all treatment groups significantly reduced fasting plasma glucose concentrations to a comparable extent. Mean fructosamine levels declined in all groups, with a significantly greater drop in the 2,000-mg group.

In the trial, 529 patients who completed the protocol switched to the once-daily 2,000-mg dose of Glumetza in an open-label extension study. The decreases in HbA_1c from the randomized trial were maintained in the 24-week extension study.

Each of the Glumetza regimens in the randomized trial produced greater decreases in HbA_1c than did Glucophage in several subgroups: in women, in patients 65 years or older, in non-Caucasians, and in patients with a body mass index (kg/

Other studies have reported that the effects of metformin monotherapy are independent of age, ethnicity, and body weight. “Our results indicate that the 2,000-mg/day dose may be more effective in some patient populations,” Dr. Schwartz said.

There was a trend for triglyceride levels to increase slightly in patients on Glumetza (similar to trends in previous trials of extended-release metformin formulations), an effect not seen with Glucophage. The reason for this and its clinical significance are unclear.

Metformin is known to cause gastrointestinal side effects, including abdominal discomfort, nausea, and diarrhea. The overall incidence of adverse events was similar between groups. Patients in the Glumetza groups were less likely to report nausea during the first week of treatment. There was no increase in adverse events seen in the 2,000-mg/day Glumetza group.

Patients in the twice-daily drug regimen groups took 500 mg in the morning and 1,000 mg in the evening. All study drugs and placebo pills were taken after a meal.

Reasons for those who stopped treatment were similar between groups, except that fewer patients in the Glumetza 2,000-mg group stopped because of lack of efficacy compared with the Glucophage group (2% vs. 8%). Reasons included withdrawal of consent, lack of efficacy, and loss to follow-up.

Three different regimens of a new extended-release version of metformin, including two once-a-day regimens, were as effective as immediate-release metformin in reducing hemoglobin A_1c levels in adults with type 2 diabetes, Dr. Sherwyn Schwartz reported.

A double-blind, phase III trial randomized 750 patients to 24 weeks of treatment, and 706 patients with efficacy data were included in an intent-to-treat analysis. Patients on antihyperglycemic agents stopped the medications for 6 weeks before all patients began metformin at 1,000 mg once daily. Treatment was titrated over 2–3 weeks to assigned regimens of immediate-release metformin (Glucophage) at 1,500 mg/day b.i.d., or extended-release metformin (Glumetza) in dosages of once-daily 1,500 mg/day, the same dose but b.i.d., or once-daily 2,000 mg/day.

All groups showed significant reductions in hemoglobin A_1c (HbA_1c) levels by week 12. Levels continued declining until week 20, and were maintained until the end of the study at week 24, said Dr. Schwartz, an endocrinologist in a group practice in San Antonio, and his associates (Diabetes Care 2006;29:759–64). The study was funded by Depomed Inc., which makes Glumetza.

The reductions in mean HbA_1c levels were similar to results from clinical trials of Glucophage and of another extended-release metformin product (Glucophage XR, by Bristol-Myers Squibb). Glumetza is the first extended-release metformin formulation, however, to show equal efficacy in daily or twice-daily dosing, Dr. Schwartz said.

Among secondary end points in the current study, all treatment groups significantly reduced fasting plasma glucose concentrations to a comparable extent. Mean fructosamine levels declined in all groups, with a significantly greater drop in the 2,000-mg group.

In the trial, 529 patients who completed the protocol switched to the once-daily 2,000-mg dose of Glumetza in an open-label extension study. The decreases in HbA_1c from the randomized trial were maintained in the 24-week extension study.

Each of the Glumetza regimens in the randomized trial produced greater decreases in HbA_1c than did Glucophage in several subgroups: in women, in patients 65 years or older, in non-Caucasians, and in patients with a body mass index (kg/

Other studies have reported that the effects of metformin monotherapy are independent of age, ethnicity, and body weight. “Our results indicate that the 2,000-mg/day dose may be more effective in some patient populations,” Dr. Schwartz said.

There was a trend for triglyceride levels to increase slightly in patients on Glumetza (similar to trends in previous trials of extended-release metformin formulations), an effect not seen with Glucophage. The reason for this and its clinical significance are unclear.

Metformin is known to cause gastrointestinal side effects, including abdominal discomfort, nausea, and diarrhea. The overall incidence of adverse events was similar between groups. Patients in the Glumetza groups were less likely to report nausea during the first week of treatment. There was no increase in adverse events seen in the 2,000-mg/day Glumetza group.

Patients in the twice-daily drug regimen groups took 500 mg in the morning and 1,000 mg in the evening. All study drugs and placebo pills were taken after a meal.

Reasons for those who stopped treatment were similar between groups, except that fewer patients in the Glumetza 2,000-mg group stopped because of lack of efficacy compared with the Glucophage group (2% vs. 8%). Reasons included withdrawal of consent, lack of efficacy, and loss to follow-up.

Three different regimens of a new extended-release version of metformin, including two once-a-day regimens, were as effective as immediate-release metformin in reducing hemoglobin A_1c levels in adults with type 2 diabetes, Dr. Sherwyn Schwartz reported.

A double-blind, phase III trial randomized 750 patients to 24 weeks of treatment, and 706 patients with efficacy data were included in an intent-to-treat analysis. Patients on antihyperglycemic agents stopped the medications for 6 weeks before all patients began metformin at 1,000 mg once daily. Treatment was titrated over 2–3 weeks to assigned regimens of immediate-release metformin (Glucophage) at 1,500 mg/day b.i.d., or extended-release metformin (Glumetza) in dosages of once-daily 1,500 mg/day, the same dose but b.i.d., or once-daily 2,000 mg/day.

All groups showed significant reductions in hemoglobin A_1c (HbA_1c) levels by week 12. Levels continued declining until week 20, and were maintained until the end of the study at week 24, said Dr. Schwartz, an endocrinologist in a group practice in San Antonio, and his associates (Diabetes Care 2006;29:759–64). The study was funded by Depomed Inc., which makes Glumetza.

The reductions in mean HbA_1c levels were similar to results from clinical trials of Glucophage and of another extended-release metformin product (Glucophage XR, by Bristol-Myers Squibb). Glumetza is the first extended-release metformin formulation, however, to show equal efficacy in daily or twice-daily dosing, Dr. Schwartz said.

Among secondary end points in the current study, all treatment groups significantly reduced fasting plasma glucose concentrations to a comparable extent. Mean fructosamine levels declined in all groups, with a significantly greater drop in the 2,000-mg group.

In the trial, 529 patients who completed the protocol switched to the once-daily 2,000-mg dose of Glumetza in an open-label extension study. The decreases in HbA_1c from the randomized trial were maintained in the 24-week extension study.

Each of the Glumetza regimens in the randomized trial produced greater decreases in HbA_1c than did Glucophage in several subgroups: in women, in patients 65 years or older, in non-Caucasians, and in patients with a body mass index (kg/

Other studies have reported that the effects of metformin monotherapy are independent of age, ethnicity, and body weight. “Our results indicate that the 2,000-mg/day dose may be more effective in some patient populations,” Dr. Schwartz said.

There was a trend for triglyceride levels to increase slightly in patients on Glumetza (similar to trends in previous trials of extended-release metformin formulations), an effect not seen with Glucophage. The reason for this and its clinical significance are unclear.

Metformin is known to cause gastrointestinal side effects, including abdominal discomfort, nausea, and diarrhea. The overall incidence of adverse events was similar between groups. Patients in the Glumetza groups were less likely to report nausea during the first week of treatment. There was no increase in adverse events seen in the 2,000-mg/day Glumetza group.

Patients in the twice-daily drug regimen groups took 500 mg in the morning and 1,000 mg in the evening. All study drugs and placebo pills were taken after a meal.

Reasons for those who stopped treatment were similar between groups, except that fewer patients in the Glumetza 2,000-mg group stopped because of lack of efficacy compared with the Glucophage group (2% vs. 8%). Reasons included withdrawal of consent, lack of efficacy, and loss to follow-up.

SAN FRANCISCO — The largest series of head injury patients to undergo magnetic resonance imaging found brain stem injuries in 60% of 200 patients, a much higher rate than the 10% usually quoted in the literature, Dr. Raimund P. Firsching reported at the annual meeting of the American Association of Neurological Surgeons.

Fewer than 1 in 10 brain stem lesions were visible on CT scans, he said.

Investigators performed CT and MRI scans on patients within a week of head injury; all patients were in a coma for at least 1 day.

Functional and mortality outcomes 3 months after injury were associated with the location of brain injury on MRI, with much worse prognoses in patients who had brain stem lesions, said Dr. Firsching, of the department of neurosurgery at Otto-von-Guericke University, Magdeburg, Germany, who conducted the study with Dr. Dieter Woischneck, also of the university.

The results challenge the commonly held notion that when CT shows no lesions after brain trauma, a patient's failure to improve must be a result of diffuse brain injury, Dr. Firsching said.

Among patients who emerged from coma after 1 day, 63% had brain stem lesions seen on MRI.

The longer the coma lasted, the greater the likelihood of brain stem lesion: Of patients who were in a coma for 1 week, 96% had brain stem lesions. “This is really in sharp contrast to the literature,” he noted.

The imaging could not differentiate between primary and secondary lesions, he acknowledged.

Commenting on the study at the meeting, Dr. M. Ross Bullock said that it was limited by not identifying postherniation changes in the brain, by not reporting how many patients had lesions removed, and by not discussing the implications of high intracranial pressure with the MRI findings.

“If these data represent simply a very high, unusual incidence of herniation, that's not a major contribution to our knowledge base,” said Dr. Bullock, the Reynolds Professor of neurosurgery at Virginia Commonwealth University, Richmond, Va.

At his institution, MRIs on 13 patients with trauma found brain stem lesions in 10%, he noted.

Among all patients in Dr. Firsching's study, 37% had supratentorial lesions confined to the hemispheres or the corpus callosum; two-thirds of this group had a good outcome, and 10% died, Dr. Firsching reported. A lesion in a unilateral region of the brain stem, seen in 20% of patients, was associated with a slight or moderate functional handicap after 3 months, and 21% of these patients died. Severe disability was likely in the 22% of patients with bilateral mesencephalic lesions, and 21% died. Among the 21% of patients with a bilateral pontine lesion, 92% died.

Lesions on the corpus callosum did not predict the likelihood of death or the length of coma, he added. Pontine and midbrain lesions, which CT failed to detect, are most important for prognosis, he emphasized.

In nearly 10 years of doing MRIs on brain trauma patients, “we have yet to see a patient who was in a vegetative state who did not exhibit a bilateral pontine lesion,” Dr. Firsching said.

The investigators began the series of MRIs on head trauma patients after a man in a bus accident failed to emerge from his coma. The patient's brother, a neuroradiologist, insisted on getting an MRI, which showed lesions that were invisible on CT. MRI is indicated in the evaluation of some head trauma patients who don't improve over time, according to Dr. Bullock.

CT shows large extradural hematoma (left). MRI of midline shows traumatic lesion; tissue extends into brain stem (right). Courtersy Dr. Raimund P. Firsching

SAN FRANCISCO — The largest series of head injury patients to undergo magnetic resonance imaging found brain stem injuries in 60% of 200 patients, a much higher rate than the 10% usually quoted in the literature, Dr. Raimund P. Firsching reported at the annual meeting of the American Association of Neurological Surgeons.

Fewer than 1 in 10 brain stem lesions were visible on CT scans, he said.

Investigators performed CT and MRI scans on patients within a week of head injury; all patients were in a coma for at least 1 day.

Functional and mortality outcomes 3 months after injury were associated with the location of brain injury on MRI, with much worse prognoses in patients who had brain stem lesions, said Dr. Firsching, of the department of neurosurgery at Otto-von-Guericke University, Magdeburg, Germany, who conducted the study with Dr. Dieter Woischneck, also of the university.

The results challenge the commonly held notion that when CT shows no lesions after brain trauma, a patient's failure to improve must be a result of diffuse brain injury, Dr. Firsching said.

Among patients who emerged from coma after 1 day, 63% had brain stem lesions seen on MRI.

The longer the coma lasted, the greater the likelihood of brain stem lesion: Of patients who were in a coma for 1 week, 96% had brain stem lesions. “This is really in sharp contrast to the literature,” he noted.

The imaging could not differentiate between primary and secondary lesions, he acknowledged.

Commenting on the study at the meeting, Dr. M. Ross Bullock said that it was limited by not identifying postherniation changes in the brain, by not reporting how many patients had lesions removed, and by not discussing the implications of high intracranial pressure with the MRI findings.

“If these data represent simply a very high, unusual incidence of herniation, that's not a major contribution to our knowledge base,” said Dr. Bullock, the Reynolds Professor of neurosurgery at Virginia Commonwealth University, Richmond, Va.

At his institution, MRIs on 13 patients with trauma found brain stem lesions in 10%, he noted.

Among all patients in Dr. Firsching's study, 37% had supratentorial lesions confined to the hemispheres or the corpus callosum; two-thirds of this group had a good outcome, and 10% died, Dr. Firsching reported. A lesion in a unilateral region of the brain stem, seen in 20% of patients, was associated with a slight or moderate functional handicap after 3 months, and 21% of these patients died. Severe disability was likely in the 22% of patients with bilateral mesencephalic lesions, and 21% died. Among the 21% of patients with a bilateral pontine lesion, 92% died.

Lesions on the corpus callosum did not predict the likelihood of death or the length of coma, he added. Pontine and midbrain lesions, which CT failed to detect, are most important for prognosis, he emphasized.

In nearly 10 years of doing MRIs on brain trauma patients, “we have yet to see a patient who was in a vegetative state who did not exhibit a bilateral pontine lesion,” Dr. Firsching said.

The investigators began the series of MRIs on head trauma patients after a man in a bus accident failed to emerge from his coma. The patient's brother, a neuroradiologist, insisted on getting an MRI, which showed lesions that were invisible on CT. MRI is indicated in the evaluation of some head trauma patients who don't improve over time, according to Dr. Bullock.

CT shows large extradural hematoma (left). MRI of midline shows traumatic lesion; tissue extends into brain stem (right). Courtersy Dr. Raimund P. Firsching

SAN FRANCISCO — The largest series of head injury patients to undergo magnetic resonance imaging found brain stem injuries in 60% of 200 patients, a much higher rate than the 10% usually quoted in the literature, Dr. Raimund P. Firsching reported at the annual meeting of the American Association of Neurological Surgeons.

Fewer than 1 in 10 brain stem lesions were visible on CT scans, he said.

Investigators performed CT and MRI scans on patients within a week of head injury; all patients were in a coma for at least 1 day.

Functional and mortality outcomes 3 months after injury were associated with the location of brain injury on MRI, with much worse prognoses in patients who had brain stem lesions, said Dr. Firsching, of the department of neurosurgery at Otto-von-Guericke University, Magdeburg, Germany, who conducted the study with Dr. Dieter Woischneck, also of the university.

The results challenge the commonly held notion that when CT shows no lesions after brain trauma, a patient's failure to improve must be a result of diffuse brain injury, Dr. Firsching said.

Among patients who emerged from coma after 1 day, 63% had brain stem lesions seen on MRI.

The longer the coma lasted, the greater the likelihood of brain stem lesion: Of patients who were in a coma for 1 week, 96% had brain stem lesions. “This is really in sharp contrast to the literature,” he noted.

The imaging could not differentiate between primary and secondary lesions, he acknowledged.

Commenting on the study at the meeting, Dr. M. Ross Bullock said that it was limited by not identifying postherniation changes in the brain, by not reporting how many patients had lesions removed, and by not discussing the implications of high intracranial pressure with the MRI findings.

“If these data represent simply a very high, unusual incidence of herniation, that's not a major contribution to our knowledge base,” said Dr. Bullock, the Reynolds Professor of neurosurgery at Virginia Commonwealth University, Richmond, Va.

At his institution, MRIs on 13 patients with trauma found brain stem lesions in 10%, he noted.

Among all patients in Dr. Firsching's study, 37% had supratentorial lesions confined to the hemispheres or the corpus callosum; two-thirds of this group had a good outcome, and 10% died, Dr. Firsching reported. A lesion in a unilateral region of the brain stem, seen in 20% of patients, was associated with a slight or moderate functional handicap after 3 months, and 21% of these patients died. Severe disability was likely in the 22% of patients with bilateral mesencephalic lesions, and 21% died. Among the 21% of patients with a bilateral pontine lesion, 92% died.

Lesions on the corpus callosum did not predict the likelihood of death or the length of coma, he added. Pontine and midbrain lesions, which CT failed to detect, are most important for prognosis, he emphasized.

In nearly 10 years of doing MRIs on brain trauma patients, “we have yet to see a patient who was in a vegetative state who did not exhibit a bilateral pontine lesion,” Dr. Firsching said.

The investigators began the series of MRIs on head trauma patients after a man in a bus accident failed to emerge from his coma. The patient's brother, a neuroradiologist, insisted on getting an MRI, which showed lesions that were invisible on CT. MRI is indicated in the evaluation of some head trauma patients who don't improve over time, according to Dr. Bullock.

CT shows large extradural hematoma (left). MRI of midline shows traumatic lesion; tissue extends into brain stem (right). Courtersy Dr. Raimund P. Firsching

Imagine losing access to telephones, the Internet, and fax lines during a disaster, and trying to treat patients with nothing but a scratchy two-way radio to connect you with people and institutions outside your office.

It's so last century, and so avoidable, yet that's what happens after natural or man-made disasters, said Dr. Ronald C. Merrell.

Physicians should plan ahead to maintain telecommunications so that they can practice medicine independently of emergency operation centers in such situations, he advised.

“That's technology we've had since the Second World War. It's fine, but we need to find a way to access the Internet. It's hard to practice medicine over a radio,” said Dr. Merrell, director of the Medical Informatics and Technology Applications Consortium (MITAC) at Virginia Commonwealth University, Richmond, Va. MITAC is a research center sponsored by the National Aeronautic and Space Administration (NASA).

The medical needs of refugees from a disaster aren't necessarily what you might expect. Dr. Merrell and two colleagues from MITAC responded to a call from NASA after Hurricane Katrina to help an occupational medicine office at a NASA facility about 34 miles from the Mississippi coast. The office and its one physician had lost most communication with the outside world. Hundreds of people needed medical care, and within days the numbers grew to 4,000.

Telemedicine teams in other parts of the country were eager to help, but the Mississippi facility had no good way to let them know what to send. Dr. Merrell and his team set up a satellite telephone, a computer satellite dish, and other equipment that gave them 65 kilobytes of transmission speed. Phone calls were transmitted via a French satellite to Paris and back to the United States. The team even brought solar panels to provide power if needed, but they were able to use electricity from the NASA facility.

Because telemedicine isn't part of the usual disaster preparedness infrastructure, deploying the specialized equipment and then training people to practice telemedicine is time consuming, which limits the amount of help it can provide, Dr. Merrell noted. Physicians would be wise to assess the disaster plans for their clinics or hospitals and advocate for redundant telecommunications capabilities.

Having equipment and trained personnel in place made a huge difference when a devastating earthquake struck Pakistan in October 2005, Dr. Merrell said, noting that it may have been the first time that telemedicine formed the core of a successful medical response to a tragedy.

Under a grant from the U.S. Agency for International Development, Dr. Merrell and Dr. Azhar Rafiq of Virginia Commonwealth University had traveled to Pakistan about a month before the earthquake to help establish two telemedicine training facilities in Rawalpindi, just outside the capital of Islamabad. The telemedicine facilities were to enable communications with two primary care clinics in the rural Punjab area for a more integrated health system.

When the earthquake hit, “We were in touch with them within 12 hours” thanks to the telemedicine programs, he said. The Rawalpindi medical facility was the first fully intact medical site encountered by people fleeing the mountainous areas, where the earthquake had leveled brick hospitals and killed almost all of the medical workers. Soon Rawalpindi's 1,500 beds were in demand for 6,000 patients.

Telecommunications kept the facility from being overwhelmed. Medical students volunteered for brief training in telemedicine and hiked into the mountains with backpacks containing satellite phones, digital cameras, laptop computers, and mobile power sources. From the mountains they informed the hospital at Rawalpindi and other facilities about which patients were headed their way and what would be needed. The students also transmitted medical records and photographs.

After reconstructive surgery at the Rawalpindi medical facility, patients were sent back to tent facilities in the mountains to recover. Surgeons were even able to send patients with complex orthopedic repairs to the mountains, knowing that staff would be able to telecommunicate about the patients' status and any postsurgical problems that arose.

Imagine losing access to telephones, the Internet, and fax lines during a disaster, and trying to treat patients with nothing but a scratchy two-way radio to connect you with people and institutions outside your office.

It's so last century, and so avoidable, yet that's what happens after natural or man-made disasters, said Dr. Ronald C. Merrell.

Physicians should plan ahead to maintain telecommunications so that they can practice medicine independently of emergency operation centers in such situations, he advised.

“That's technology we've had since the Second World War. It's fine, but we need to find a way to access the Internet. It's hard to practice medicine over a radio,” said Dr. Merrell, director of the Medical Informatics and Technology Applications Consortium (MITAC) at Virginia Commonwealth University, Richmond, Va. MITAC is a research center sponsored by the National Aeronautic and Space Administration (NASA).

The medical needs of refugees from a disaster aren't necessarily what you might expect. Dr. Merrell and two colleagues from MITAC responded to a call from NASA after Hurricane Katrina to help an occupational medicine office at a NASA facility about 34 miles from the Mississippi coast. The office and its one physician had lost most communication with the outside world. Hundreds of people needed medical care, and within days the numbers grew to 4,000.

Telemedicine teams in other parts of the country were eager to help, but the Mississippi facility had no good way to let them know what to send. Dr. Merrell and his team set up a satellite telephone, a computer satellite dish, and other equipment that gave them 65 kilobytes of transmission speed. Phone calls were transmitted via a French satellite to Paris and back to the United States. The team even brought solar panels to provide power if needed, but they were able to use electricity from the NASA facility.

Because telemedicine isn't part of the usual disaster preparedness infrastructure, deploying the specialized equipment and then training people to practice telemedicine is time consuming, which limits the amount of help it can provide, Dr. Merrell noted. Physicians would be wise to assess the disaster plans for their clinics or hospitals and advocate for redundant telecommunications capabilities.

Having equipment and trained personnel in place made a huge difference when a devastating earthquake struck Pakistan in October 2005, Dr. Merrell said, noting that it may have been the first time that telemedicine formed the core of a successful medical response to a tragedy.

Under a grant from the U.S. Agency for International Development, Dr. Merrell and Dr. Azhar Rafiq of Virginia Commonwealth University had traveled to Pakistan about a month before the earthquake to help establish two telemedicine training facilities in Rawalpindi, just outside the capital of Islamabad. The telemedicine facilities were to enable communications with two primary care clinics in the rural Punjab area for a more integrated health system.

When the earthquake hit, “We were in touch with them within 12 hours” thanks to the telemedicine programs, he said. The Rawalpindi medical facility was the first fully intact medical site encountered by people fleeing the mountainous areas, where the earthquake had leveled brick hospitals and killed almost all of the medical workers. Soon Rawalpindi's 1,500 beds were in demand for 6,000 patients.

Telecommunications kept the facility from being overwhelmed. Medical students volunteered for brief training in telemedicine and hiked into the mountains with backpacks containing satellite phones, digital cameras, laptop computers, and mobile power sources. From the mountains they informed the hospital at Rawalpindi and other facilities about which patients were headed their way and what would be needed. The students also transmitted medical records and photographs.

After reconstructive surgery at the Rawalpindi medical facility, patients were sent back to tent facilities in the mountains to recover. Surgeons were even able to send patients with complex orthopedic repairs to the mountains, knowing that staff would be able to telecommunicate about the patients' status and any postsurgical problems that arose.

Imagine losing access to telephones, the Internet, and fax lines during a disaster, and trying to treat patients with nothing but a scratchy two-way radio to connect you with people and institutions outside your office.

It's so last century, and so avoidable, yet that's what happens after natural or man-made disasters, said Dr. Ronald C. Merrell.

Physicians should plan ahead to maintain telecommunications so that they can practice medicine independently of emergency operation centers in such situations, he advised.

“That's technology we've had since the Second World War. It's fine, but we need to find a way to access the Internet. It's hard to practice medicine over a radio,” said Dr. Merrell, director of the Medical Informatics and Technology Applications Consortium (MITAC) at Virginia Commonwealth University, Richmond, Va. MITAC is a research center sponsored by the National Aeronautic and Space Administration (NASA).

The medical needs of refugees from a disaster aren't necessarily what you might expect. Dr. Merrell and two colleagues from MITAC responded to a call from NASA after Hurricane Katrina to help an occupational medicine office at a NASA facility about 34 miles from the Mississippi coast. The office and its one physician had lost most communication with the outside world. Hundreds of people needed medical care, and within days the numbers grew to 4,000.

Telemedicine teams in other parts of the country were eager to help, but the Mississippi facility had no good way to let them know what to send. Dr. Merrell and his team set up a satellite telephone, a computer satellite dish, and other equipment that gave them 65 kilobytes of transmission speed. Phone calls were transmitted via a French satellite to Paris and back to the United States. The team even brought solar panels to provide power if needed, but they were able to use electricity from the NASA facility.

Because telemedicine isn't part of the usual disaster preparedness infrastructure, deploying the specialized equipment and then training people to practice telemedicine is time consuming, which limits the amount of help it can provide, Dr. Merrell noted. Physicians would be wise to assess the disaster plans for their clinics or hospitals and advocate for redundant telecommunications capabilities.

Having equipment and trained personnel in place made a huge difference when a devastating earthquake struck Pakistan in October 2005, Dr. Merrell said, noting that it may have been the first time that telemedicine formed the core of a successful medical response to a tragedy.

Under a grant from the U.S. Agency for International Development, Dr. Merrell and Dr. Azhar Rafiq of Virginia Commonwealth University had traveled to Pakistan about a month before the earthquake to help establish two telemedicine training facilities in Rawalpindi, just outside the capital of Islamabad. The telemedicine facilities were to enable communications with two primary care clinics in the rural Punjab area for a more integrated health system.

When the earthquake hit, “We were in touch with them within 12 hours” thanks to the telemedicine programs, he said. The Rawalpindi medical facility was the first fully intact medical site encountered by people fleeing the mountainous areas, where the earthquake had leveled brick hospitals and killed almost all of the medical workers. Soon Rawalpindi's 1,500 beds were in demand for 6,000 patients.

Telecommunications kept the facility from being overwhelmed. Medical students volunteered for brief training in telemedicine and hiked into the mountains with backpacks containing satellite phones, digital cameras, laptop computers, and mobile power sources. From the mountains they informed the hospital at Rawalpindi and other facilities about which patients were headed their way and what would be needed. The students also transmitted medical records and photographs.

After reconstructive surgery at the Rawalpindi medical facility, patients were sent back to tent facilities in the mountains to recover. Surgeons were even able to send patients with complex orthopedic repairs to the mountains, knowing that staff would be able to telecommunicate about the patients' status and any postsurgical problems that arose.

SAN FRANCISCO — Suspect chronic varicella zoster in all immunocompromised children, not just those with HIV, Dr. Christopher Bohyer said at the annual meeting of the American Academy of Dermatology.

Test zosterlike lesions in immunocompromised children for drug resistance, because chronic varicella typically implies antibiotic resistance, said Dr. Bohyer of Indiana University, Bloomington.

He presented what may be the first case of chronic varicella zoster in a child after bone marrow transplant. Other cases have been reported in children who have undergone chemotherapy or who have HIV.

Dr. Bohyer's patient was an 11-year-old boy who was diagnosed in 2003 with acute myelogenous leukemia and was treated with chemotherapy. He relapsed in April 2004, underwent donor stem cell transplant, and developed acute graft-versus-host disease.

He was out of the hospital in September 2004, when he developed significant abdominal pain. Clinicians feared this was a worsening of his graft-versus-host disease, but a GI work-up that included an intestinal biopsy showed no findings consistent with that diagnosis.

Three days after admission, he had an eruption of multiple vesicles on his head and neck. Culture identified them as varicella zoster infection, and he was treated with high-dose IV acyclovir 10 mg/kg for 15 days.

The patient went home and was doing well until a month later when he was readmitted with another unusual cutaneous eruption on his whole body.

The vesicles and papules housed varicella zoster, culture showed.

Another round of high-dose acyclovir stemmed the eruption of any new lesions, but the chronic lesions did not resolve.

Around this time the patient's condition deteriorated to the point that support was withdrawn, and he died.

SAN FRANCISCO — Suspect chronic varicella zoster in all immunocompromised children, not just those with HIV, Dr. Christopher Bohyer said at the annual meeting of the American Academy of Dermatology.

Test zosterlike lesions in immunocompromised children for drug resistance, because chronic varicella typically implies antibiotic resistance, said Dr. Bohyer of Indiana University, Bloomington.

He presented what may be the first case of chronic varicella zoster in a child after bone marrow transplant. Other cases have been reported in children who have undergone chemotherapy or who have HIV.

Dr. Bohyer's patient was an 11-year-old boy who was diagnosed in 2003 with acute myelogenous leukemia and was treated with chemotherapy. He relapsed in April 2004, underwent donor stem cell transplant, and developed acute graft-versus-host disease.

He was out of the hospital in September 2004, when he developed significant abdominal pain. Clinicians feared this was a worsening of his graft-versus-host disease, but a GI work-up that included an intestinal biopsy showed no findings consistent with that diagnosis.

Three days after admission, he had an eruption of multiple vesicles on his head and neck. Culture identified them as varicella zoster infection, and he was treated with high-dose IV acyclovir 10 mg/kg for 15 days.

The patient went home and was doing well until a month later when he was readmitted with another unusual cutaneous eruption on his whole body.

The vesicles and papules housed varicella zoster, culture showed.

Another round of high-dose acyclovir stemmed the eruption of any new lesions, but the chronic lesions did not resolve.

Around this time the patient's condition deteriorated to the point that support was withdrawn, and he died.

SAN FRANCISCO — Suspect chronic varicella zoster in all immunocompromised children, not just those with HIV, Dr. Christopher Bohyer said at the annual meeting of the American Academy of Dermatology.

Test zosterlike lesions in immunocompromised children for drug resistance, because chronic varicella typically implies antibiotic resistance, said Dr. Bohyer of Indiana University, Bloomington.

He presented what may be the first case of chronic varicella zoster in a child after bone marrow transplant. Other cases have been reported in children who have undergone chemotherapy or who have HIV.

Dr. Bohyer's patient was an 11-year-old boy who was diagnosed in 2003 with acute myelogenous leukemia and was treated with chemotherapy. He relapsed in April 2004, underwent donor stem cell transplant, and developed acute graft-versus-host disease.

He was out of the hospital in September 2004, when he developed significant abdominal pain. Clinicians feared this was a worsening of his graft-versus-host disease, but a GI work-up that included an intestinal biopsy showed no findings consistent with that diagnosis.

Three days after admission, he had an eruption of multiple vesicles on his head and neck. Culture identified them as varicella zoster infection, and he was treated with high-dose IV acyclovir 10 mg/kg for 15 days.

The patient went home and was doing well until a month later when he was readmitted with another unusual cutaneous eruption on his whole body.

The vesicles and papules housed varicella zoster, culture showed.

Another round of high-dose acyclovir stemmed the eruption of any new lesions, but the chronic lesions did not resolve.

Around this time the patient's condition deteriorated to the point that support was withdrawn, and he died.

Major cardiovascular disease is four times more common in men and eight times more common in women with type 1 diabetes, compared with nondiabetic men and women, Sabita S. Soedamah-Muthu, Ph.D., reported.

Type 1 diabetes also dramatically increases risks for fatal cardiovascular disease, major coronary heart disease, stroke, coronary revascularization, and acute coronary events, even in the modern era of emphasis on intensive glycemic control, said Dr. Soedamah-Muthu of the Royal Free and University College, London.

The first large, controlled study to evaluate absolute and relative risks of both morbidity and mortality related to cardiovascular disease in type 1 diabetics found that absolute risk levels seen in the nondiabetic population by age 60 appear in men with type 1 diabetes around ages 45–50 years and even earlier in women, said Dr. Soedamah-Muthu and associates (Diabetes Care 2006;29:798–804).

The investigators analyzed data from the General Practice Research Database, a large primary-care database from a network of 603 practices. They compared data for 7,479 patients with type 1 diabetes with data for 38,116 nondiabetic control patients, with five controls matched to each diabetic patient by age and sex.

The risk for fatal cardiovascular disease was increased 6-fold in men and 12-fold in women with type 1 diabetes, compared with controls of the same sex. The risk for major coronary heart disease was quadrupled in men and 10 times higher in women with type 1 diabetes, compared with nondiabetic patients. Strokes, both fatal and nonfatal, were four times more common in men and five times more common in women with type 1 diabetes.

Coronary revascularizations were performed 5 times more often in men and 17 times more often in women with type 1 diabetes, compared with controls. The risk for acute coronary events tripled in men and was eight times higher in women with type 1 diabetes, compared with nondiabetic controls.

It is unclear how much of these increased risks might be explained by the long duration of glycemic exposure. The average duration of diabetes in the study was 15 years. The causes of higher risks in women also are unclear.

“Whatever its basis, the ongoing dramatic elevation in CVD [cardiovascular disease] risk in type 1 diabetic patients, especially diabetic women, needs to be emphasized to clinicians, as the relatively good lipid profile of type 1 diabetic patients without renal disease could lead to their CVD risk being underappreciated,” Dr. Soedamah-Muthu wrote.

Clinicians should evaluate patients with type 1 diabetes for potential preventive interventions such as statin therapy starting at 45 years of age, possibly younger, the investigators suggested. Because traditional risk factors for cardiovascular disease may be less effective in identifying risk in diabetic than in nondiabetic patients, it might be reasonable to consider imaging to look for early cardiovascular disease in addition to measuring traditional risk factors in patients with type 1 diabetes, they added.

The absolute risk for cardiovascular disease at ages 45–55 was 11/1,000 person-years in men with type 1 diabetes and 4/1,000 person-years in male controls. In women aged 45–55 years, the absolute risk for cardiovascular disease was 10/1,000 person-years in those with type 1 diabetes and 1/1,000 person-years in controls. The hazard ratio for major cardiovascular disease among diabetics in that age group, compared with controls, was 3 for men and 10 for women.

The higher risks for cardiovascular disease in women could not be attributed to a greater propensity to diagnose or treat cardiovascular disease in diabetic women, the investigators said.

Major cardiovascular disease is four times more common in men and eight times more common in women with type 1 diabetes, compared with nondiabetic men and women, Sabita S. Soedamah-Muthu, Ph.D., reported.

Type 1 diabetes also dramatically increases risks for fatal cardiovascular disease, major coronary heart disease, stroke, coronary revascularization, and acute coronary events, even in the modern era of emphasis on intensive glycemic control, said Dr. Soedamah-Muthu of the Royal Free and University College, London.

The first large, controlled study to evaluate absolute and relative risks of both morbidity and mortality related to cardiovascular disease in type 1 diabetics found that absolute risk levels seen in the nondiabetic population by age 60 appear in men with type 1 diabetes around ages 45–50 years and even earlier in women, said Dr. Soedamah-Muthu and associates (Diabetes Care 2006;29:798–804).

The investigators analyzed data from the General Practice Research Database, a large primary-care database from a network of 603 practices. They compared data for 7,479 patients with type 1 diabetes with data for 38,116 nondiabetic control patients, with five controls matched to each diabetic patient by age and sex.

The risk for fatal cardiovascular disease was increased 6-fold in men and 12-fold in women with type 1 diabetes, compared with controls of the same sex. The risk for major coronary heart disease was quadrupled in men and 10 times higher in women with type 1 diabetes, compared with nondiabetic patients. Strokes, both fatal and nonfatal, were four times more common in men and five times more common in women with type 1 diabetes.

Coronary revascularizations were performed 5 times more often in men and 17 times more often in women with type 1 diabetes, compared with controls. The risk for acute coronary events tripled in men and was eight times higher in women with type 1 diabetes, compared with nondiabetic controls.

It is unclear how much of these increased risks might be explained by the long duration of glycemic exposure. The average duration of diabetes in the study was 15 years. The causes of higher risks in women also are unclear.

“Whatever its basis, the ongoing dramatic elevation in CVD [cardiovascular disease] risk in type 1 diabetic patients, especially diabetic women, needs to be emphasized to clinicians, as the relatively good lipid profile of type 1 diabetic patients without renal disease could lead to their CVD risk being underappreciated,” Dr. Soedamah-Muthu wrote.

Clinicians should evaluate patients with type 1 diabetes for potential preventive interventions such as statin therapy starting at 45 years of age, possibly younger, the investigators suggested. Because traditional risk factors for cardiovascular disease may be less effective in identifying risk in diabetic than in nondiabetic patients, it might be reasonable to consider imaging to look for early cardiovascular disease in addition to measuring traditional risk factors in patients with type 1 diabetes, they added.

The absolute risk for cardiovascular disease at ages 45–55 was 11/1,000 person-years in men with type 1 diabetes and 4/1,000 person-years in male controls. In women aged 45–55 years, the absolute risk for cardiovascular disease was 10/1,000 person-years in those with type 1 diabetes and 1/1,000 person-years in controls. The hazard ratio for major cardiovascular disease among diabetics in that age group, compared with controls, was 3 for men and 10 for women.

The higher risks for cardiovascular disease in women could not be attributed to a greater propensity to diagnose or treat cardiovascular disease in diabetic women, the investigators said.

Major cardiovascular disease is four times more common in men and eight times more common in women with type 1 diabetes, compared with nondiabetic men and women, Sabita S. Soedamah-Muthu, Ph.D., reported.

Type 1 diabetes also dramatically increases risks for fatal cardiovascular disease, major coronary heart disease, stroke, coronary revascularization, and acute coronary events, even in the modern era of emphasis on intensive glycemic control, said Dr. Soedamah-Muthu of the Royal Free and University College, London.

The first large, controlled study to evaluate absolute and relative risks of both morbidity and mortality related to cardiovascular disease in type 1 diabetics found that absolute risk levels seen in the nondiabetic population by age 60 appear in men with type 1 diabetes around ages 45–50 years and even earlier in women, said Dr. Soedamah-Muthu and associates (Diabetes Care 2006;29:798–804).

The investigators analyzed data from the General Practice Research Database, a large primary-care database from a network of 603 practices. They compared data for 7,479 patients with type 1 diabetes with data for 38,116 nondiabetic control patients, with five controls matched to each diabetic patient by age and sex.

The risk for fatal cardiovascular disease was increased 6-fold in men and 12-fold in women with type 1 diabetes, compared with controls of the same sex. The risk for major coronary heart disease was quadrupled in men and 10 times higher in women with type 1 diabetes, compared with nondiabetic patients. Strokes, both fatal and nonfatal, were four times more common in men and five times more common in women with type 1 diabetes.

Coronary revascularizations were performed 5 times more often in men and 17 times more often in women with type 1 diabetes, compared with controls. The risk for acute coronary events tripled in men and was eight times higher in women with type 1 diabetes, compared with nondiabetic controls.

It is unclear how much of these increased risks might be explained by the long duration of glycemic exposure. The average duration of diabetes in the study was 15 years. The causes of higher risks in women also are unclear.

“Whatever its basis, the ongoing dramatic elevation in CVD [cardiovascular disease] risk in type 1 diabetic patients, especially diabetic women, needs to be emphasized to clinicians, as the relatively good lipid profile of type 1 diabetic patients without renal disease could lead to their CVD risk being underappreciated,” Dr. Soedamah-Muthu wrote.

Clinicians should evaluate patients with type 1 diabetes for potential preventive interventions such as statin therapy starting at 45 years of age, possibly younger, the investigators suggested. Because traditional risk factors for cardiovascular disease may be less effective in identifying risk in diabetic than in nondiabetic patients, it might be reasonable to consider imaging to look for early cardiovascular disease in addition to measuring traditional risk factors in patients with type 1 diabetes, they added.

The absolute risk for cardiovascular disease at ages 45–55 was 11/1,000 person-years in men with type 1 diabetes and 4/1,000 person-years in male controls. In women aged 45–55 years, the absolute risk for cardiovascular disease was 10/1,000 person-years in those with type 1 diabetes and 1/1,000 person-years in controls. The hazard ratio for major cardiovascular disease among diabetics in that age group, compared with controls, was 3 for men and 10 for women.

The higher risks for cardiovascular disease in women could not be attributed to a greater propensity to diagnose or treat cardiovascular disease in diabetic women, the investigators said.

Offering women with type 1 diabetes support to breast-feed their newborns led to similar rates of breast-feeding among diabetic and nondiabetic women at 4 months after delivery despite high rates of morbidity in infants born to diabetic mothers, a Danish study found.

Exclusive breast-feeding is recommended for the first 4–6 months of life for all infants. Some previous reports have suggested that diabetic women may resort to early weaning because of fluctuating maternal blood glucose values and frequent episodes of symptomatic hypoglycemia.

In the current study, 86% of 102 diabetic mothers were breast-feeding 5 days after delivery, despite anticipated difficulties in initiating breast-feeding because of infant morbidities, reported Edna Stage, R.N., and her associates.

It is the largest prospective study of nursing mothers with type 1 diabetes.

Four months after delivery, 54% of the diabetic mothers were exclusively breast-feeding, compared with 50% of 9,654 randomly selected Danish women interviewed in a separate study on lactation. Among the diabetic mothers, 14% were partly breast-feeding 4 months after delivery and 32% were not breast-feeding, compared with 26% and 24%, respectively, of the control group of mothers. Neonatal morbidity occurred in 25 (45%) of 55 infants who were still exclusively breast-feeding at 4 months and in 30 (73%) of 47 infants who were not exclusively breast-feeding by 4 months, said Ms. Stage of Copenhagen University Hospital and her associates (Diabetes Care 2006;29:771–4).

Neonatal morbidity was defined as a need for continuous positive airway pressure for more than 1 hour, antibiotic treatment, IV glucose, or phototherapy.

Previous experience breast-feeding increased sixfold the likelihood of long-term exclusive breast-feeding among the diabetic mothers, and higher educational levels (more than 10 years of school) increased the likelihood sevenfold, the investigators said.

Trends toward less success in long-term breast-feeding among diabetic mothers who smoked, or who had a nonvaginal delivery, did not hold up as independent predictors after multiple logistic regression analysis. The small number of smokers in the study may have reduced the odds of finding an association between smoking and lactation, an association identified in previous studies.

The investigators studied all women with type 1 diabetes delivering consecutively at the hospital from May 2001 to February 2003. The results did not include two women who did not want to participate, two who were not invited to participate because of an investigator's vacation, and one woman who could not be identified 4 months after delivery.

During pregnancy, the diabetic women were offered prenatal classes with information on breast-feeding and a visit to the neonatal intensive care unit. In addition, a diabetes nurse specialist offered individual counseling on the benefits of breast feeding and described the possibility of using a breast pump if the infant's ability to suck was impaired.

Neonates stayed with their mothers for the first 2 hours of life, and 47% first nursed during this time. They then were admitted to the neonatal intensive care unit for 24 hours, where they received artificial feedings of mother's milk or low-immunogen formula milk, mainly by nasogastric tube, every 3 hours to prevent hypoglycemia. During that time, they also averaged two breast-feedings. Severe hypoglycemia in 30% of infants was treated with IV glucose.

The rate of breast-feeding during this early period might have been improved if the mothers had been allowed to sleep near the infants in the neonatal ICU, the investigators suggested.

“We believe that the [prenatal] classes and individual counseling about benefits and difficulties in initiating breast-feeding offered to the women were valuable,” Ms. Stage and her associates wrote.

Offering women with type 1 diabetes support to breast-feed their newborns led to similar rates of breast-feeding among diabetic and nondiabetic women at 4 months after delivery despite high rates of morbidity in infants born to diabetic mothers, a Danish study found.

Exclusive breast-feeding is recommended for the first 4–6 months of life for all infants. Some previous reports have suggested that diabetic women may resort to early weaning because of fluctuating maternal blood glucose values and frequent episodes of symptomatic hypoglycemia.

In the current study, 86% of 102 diabetic mothers were breast-feeding 5 days after delivery, despite anticipated difficulties in initiating breast-feeding because of infant morbidities, reported Edna Stage, R.N., and her associates.

It is the largest prospective study of nursing mothers with type 1 diabetes.

Four months after delivery, 54% of the diabetic mothers were exclusively breast-feeding, compared with 50% of 9,654 randomly selected Danish women interviewed in a separate study on lactation. Among the diabetic mothers, 14% were partly breast-feeding 4 months after delivery and 32% were not breast-feeding, compared with 26% and 24%, respectively, of the control group of mothers. Neonatal morbidity occurred in 25 (45%) of 55 infants who were still exclusively breast-feeding at 4 months and in 30 (73%) of 47 infants who were not exclusively breast-feeding by 4 months, said Ms. Stage of Copenhagen University Hospital and her associates (Diabetes Care 2006;29:771–4).

Neonatal morbidity was defined as a need for continuous positive airway pressure for more than 1 hour, antibiotic treatment, IV glucose, or phototherapy.

Previous experience breast-feeding increased sixfold the likelihood of long-term exclusive breast-feeding among the diabetic mothers, and higher educational levels (more than 10 years of school) increased the likelihood sevenfold, the investigators said.

Trends toward less success in long-term breast-feeding among diabetic mothers who smoked, or who had a nonvaginal delivery, did not hold up as independent predictors after multiple logistic regression analysis. The small number of smokers in the study may have reduced the odds of finding an association between smoking and lactation, an association identified in previous studies.

The investigators studied all women with type 1 diabetes delivering consecutively at the hospital from May 2001 to February 2003. The results did not include two women who did not want to participate, two who were not invited to participate because of an investigator's vacation, and one woman who could not be identified 4 months after delivery.

During pregnancy, the diabetic women were offered prenatal classes with information on breast-feeding and a visit to the neonatal intensive care unit. In addition, a diabetes nurse specialist offered individual counseling on the benefits of breast feeding and described the possibility of using a breast pump if the infant's ability to suck was impaired.

Neonates stayed with their mothers for the first 2 hours of life, and 47% first nursed during this time. They then were admitted to the neonatal intensive care unit for 24 hours, where they received artificial feedings of mother's milk or low-immunogen formula milk, mainly by nasogastric tube, every 3 hours to prevent hypoglycemia. During that time, they also averaged two breast-feedings. Severe hypoglycemia in 30% of infants was treated with IV glucose.

The rate of breast-feeding during this early period might have been improved if the mothers had been allowed to sleep near the infants in the neonatal ICU, the investigators suggested.

“We believe that the [prenatal] classes and individual counseling about benefits and difficulties in initiating breast-feeding offered to the women were valuable,” Ms. Stage and her associates wrote.

Offering women with type 1 diabetes support to breast-feed their newborns led to similar rates of breast-feeding among diabetic and nondiabetic women at 4 months after delivery despite high rates of morbidity in infants born to diabetic mothers, a Danish study found.

Exclusive breast-feeding is recommended for the first 4–6 months of life for all infants. Some previous reports have suggested that diabetic women may resort to early weaning because of fluctuating maternal blood glucose values and frequent episodes of symptomatic hypoglycemia.

In the current study, 86% of 102 diabetic mothers were breast-feeding 5 days after delivery, despite anticipated difficulties in initiating breast-feeding because of infant morbidities, reported Edna Stage, R.N., and her associates.

It is the largest prospective study of nursing mothers with type 1 diabetes.

Four months after delivery, 54% of the diabetic mothers were exclusively breast-feeding, compared with 50% of 9,654 randomly selected Danish women interviewed in a separate study on lactation. Among the diabetic mothers, 14% were partly breast-feeding 4 months after delivery and 32% were not breast-feeding, compared with 26% and 24%, respectively, of the control group of mothers. Neonatal morbidity occurred in 25 (45%) of 55 infants who were still exclusively breast-feeding at 4 months and in 30 (73%) of 47 infants who were not exclusively breast-feeding by 4 months, said Ms. Stage of Copenhagen University Hospital and her associates (Diabetes Care 2006;29:771–4).

Neonatal morbidity was defined as a need for continuous positive airway pressure for more than 1 hour, antibiotic treatment, IV glucose, or phototherapy.

Previous experience breast-feeding increased sixfold the likelihood of long-term exclusive breast-feeding among the diabetic mothers, and higher educational levels (more than 10 years of school) increased the likelihood sevenfold, the investigators said.

Trends toward less success in long-term breast-feeding among diabetic mothers who smoked, or who had a nonvaginal delivery, did not hold up as independent predictors after multiple logistic regression analysis. The small number of smokers in the study may have reduced the odds of finding an association between smoking and lactation, an association identified in previous studies.

The investigators studied all women with type 1 diabetes delivering consecutively at the hospital from May 2001 to February 2003. The results did not include two women who did not want to participate, two who were not invited to participate because of an investigator's vacation, and one woman who could not be identified 4 months after delivery.

During pregnancy, the diabetic women were offered prenatal classes with information on breast-feeding and a visit to the neonatal intensive care unit. In addition, a diabetes nurse specialist offered individual counseling on the benefits of breast feeding and described the possibility of using a breast pump if the infant's ability to suck was impaired.

Neonates stayed with their mothers for the first 2 hours of life, and 47% first nursed during this time. They then were admitted to the neonatal intensive care unit for 24 hours, where they received artificial feedings of mother's milk or low-immunogen formula milk, mainly by nasogastric tube, every 3 hours to prevent hypoglycemia. During that time, they also averaged two breast-feedings. Severe hypoglycemia in 30% of infants was treated with IV glucose.

The rate of breast-feeding during this early period might have been improved if the mothers had been allowed to sleep near the infants in the neonatal ICU, the investigators suggested.

“We believe that the [prenatal] classes and individual counseling about benefits and difficulties in initiating breast-feeding offered to the women were valuable,” Ms. Stage and her associates wrote.

Imagine losing access to telephones, the Internet, and fax lines during a disaster, and trying to treat patients with nothing but a scratchy two-way radio to connect you with people and institutions outside your office.

It's so last century and so avoidable—yet that's what happens after natural or man-made disasters, said Dr. Ronald C. Merrell. Physicians should plan ahead to maintain telecommunications so they can practice medicine independently of emergency operation centers, he advised.

After terrorists destroyed the World Trade Center in New York in 2001, the dust was so thick that it interfered with satellite communications and cell phones. After a tsunami decimated parts of Southeast Asia in 2004 and after Hurricane Katrina hit the U.S. Gulf Coast in 2005, many physicians lost phone lines and were stuck with more primitive modes of communication, like ham radios.

“That's technology we've had since the Second World War. It's fine, but we need to find a way to access the Internet. It's hard to practice medicine over a radio,” said Dr. Merrell, director of the Medical Informatics and Technology Applications Consortium (MITAC) at Virginia Commonwealth University, in Richmond. MITAC is a research center sponsored by NASA.

The medical needs of refugees from a disaster aren't necessarily what you might expect. Dr. Merrell and colleagues from MITAC responded to a call from NASA after Hurricane Katrina to help an occupational medicine office at a NASA facility about 34 miles from the Mississippi coast. The office and its one physician had lost most communication with the outside world. Hundreds of people needed medical care, and within days the numbers grew to 4,000.

Many patients were on complex regimens of medicine, but their pills had washed away in the storm. One group of mentally ill patients from an assisted living facility had lost antipsychotic medication. Others had lost refrigeration and no longer had insulin.

Telemedicine teams in other parts of the country were eager to help, but the Mississippi facility had no good way to let them know what to send. Dr. Merrell and his team set up a satellite telephone, a computer satellite dish, and other equipment that gave them 65 kilobytes of transmission speed. Phone calls were transmitted via a French satellite to Paris and back to the United States. The team even brought solar panels to provide power if needed, but they were able to use electricity from the NASA facility. The system allowed them to order medications, connect with other medical facilities, and coordinate transfers of patients to more stable environments.

Because telemedicine isn't part of the usual disaster preparedness infrastructure, deploying the specialized equipment and then training people to practice telemedicine is time consuming, which limits the help it can provide, Dr. Merrell noted.

Physicians would be wise to assess the disaster plans and advocate for redundant telecommunications capabilities. “Medicine has to have a fairly independent and broadband interface” separate from acute emergency response efforts to serve patients well in a crisis, he said.

Having equipment and trained personnel in place made a huge difference when a devastating earthquake struck Pakistan in October 2005, Dr. Merrell said, noting that it may have been the first time that telemedicine formed the core of a successful medical response to a tragedy.

Under a grant from the U.S. Agency for International Development, Dr. Merrell and Dr Azhar Rafiq of Virginia Commonwealth University had traveled to Pakistan about a month before the earthquake to help establish two telemedicine training facilities in Rawalpindi, just outside the capital, Islamabad. The telemedicine facilities were to enable communications with two primary care clinics in the rural Punjab area for a more integrated health system.

When the earthquake hit, “We were in touch with them within 12 hours” thanks to the telemedicine programs, he said. The Rawalpindi medical facility was the first fully intact medical site encountered by people fleeing the mountainous areas, where the earthquake had leveled brick hospitals and killed almost all of the medical workers. Soon Rawalpindi's 1,500 beds were in demand for 6,000 patients.

Telecommunications kept the facility from being overwhelmed. Medical students volunteered for brief training in telemedicine and hiked into the mountains with backpacks containing satellite phones, digital cameras, laptop computers, and mobile power sources. From the mountains they informed the hospital at Rawalpindi and other facilities about which patients were headed their way and what would be needed. The students also transmitted medical records and photographs.

After reconstructive surgery at the Rawalpindi medical facility, patients were sent back to tent facilities in the mountains to recover. Surgeons were even able to send patients with complex orthopedic repairs to the mountains, knowing that staff would be able to telecommunicate about the patients' status and any postsurgical problems that arose. “They never did overwhelm the hospital,” Dr. Merrell said. “They were able to use telecommunications to move patients down out of the mountains for definitive care and get them out and back to the mountains in a fraction of the usual time—in about 48 hours.”

Dr. Merrell (left) and associates at the Shahol Najaf Clinic about 20 kilometers from the epicenter. Courtesy Dr. Ronald C. Merrell

Imagine losing access to telephones, the Internet, and fax lines during a disaster, and trying to treat patients with nothing but a scratchy two-way radio to connect you with people and institutions outside your office.

It's so last century and so avoidable—yet that's what happens after natural or man-made disasters, said Dr. Ronald C. Merrell. Physicians should plan ahead to maintain telecommunications so they can practice medicine independently of emergency operation centers, he advised.

After terrorists destroyed the World Trade Center in New York in 2001, the dust was so thick that it interfered with satellite communications and cell phones. After a tsunami decimated parts of Southeast Asia in 2004 and after Hurricane Katrina hit the U.S. Gulf Coast in 2005, many physicians lost phone lines and were stuck with more primitive modes of communication, like ham radios.

“That's technology we've had since the Second World War. It's fine, but we need to find a way to access the Internet. It's hard to practice medicine over a radio,” said Dr. Merrell, director of the Medical Informatics and Technology Applications Consortium (MITAC) at Virginia Commonwealth University, in Richmond. MITAC is a research center sponsored by NASA.

The medical needs of refugees from a disaster aren't necessarily what you might expect. Dr. Merrell and colleagues from MITAC responded to a call from NASA after Hurricane Katrina to help an occupational medicine office at a NASA facility about 34 miles from the Mississippi coast. The office and its one physician had lost most communication with the outside world. Hundreds of people needed medical care, and within days the numbers grew to 4,000.

Many patients were on complex regimens of medicine, but their pills had washed away in the storm. One group of mentally ill patients from an assisted living facility had lost antipsychotic medication. Others had lost refrigeration and no longer had insulin.

Telemedicine teams in other parts of the country were eager to help, but the Mississippi facility had no good way to let them know what to send. Dr. Merrell and his team set up a satellite telephone, a computer satellite dish, and other equipment that gave them 65 kilobytes of transmission speed. Phone calls were transmitted via a French satellite to Paris and back to the United States. The team even brought solar panels to provide power if needed, but they were able to use electricity from the NASA facility. The system allowed them to order medications, connect with other medical facilities, and coordinate transfers of patients to more stable environments.

Because telemedicine isn't part of the usual disaster preparedness infrastructure, deploying the specialized equipment and then training people to practice telemedicine is time consuming, which limits the help it can provide, Dr. Merrell noted.

Physicians would be wise to assess the disaster plans and advocate for redundant telecommunications capabilities. “Medicine has to have a fairly independent and broadband interface” separate from acute emergency response efforts to serve patients well in a crisis, he said.

Having equipment and trained personnel in place made a huge difference when a devastating earthquake struck Pakistan in October 2005, Dr. Merrell said, noting that it may have been the first time that telemedicine formed the core of a successful medical response to a tragedy.

Under a grant from the U.S. Agency for International Development, Dr. Merrell and Dr Azhar Rafiq of Virginia Commonwealth University had traveled to Pakistan about a month before the earthquake to help establish two telemedicine training facilities in Rawalpindi, just outside the capital, Islamabad. The telemedicine facilities were to enable communications with two primary care clinics in the rural Punjab area for a more integrated health system.

When the earthquake hit, “We were in touch with them within 12 hours” thanks to the telemedicine programs, he said. The Rawalpindi medical facility was the first fully intact medical site encountered by people fleeing the mountainous areas, where the earthquake had leveled brick hospitals and killed almost all of the medical workers. Soon Rawalpindi's 1,500 beds were in demand for 6,000 patients.

Telecommunications kept the facility from being overwhelmed. Medical students volunteered for brief training in telemedicine and hiked into the mountains with backpacks containing satellite phones, digital cameras, laptop computers, and mobile power sources. From the mountains they informed the hospital at Rawalpindi and other facilities about which patients were headed their way and what would be needed. The students also transmitted medical records and photographs.

After reconstructive surgery at the Rawalpindi medical facility, patients were sent back to tent facilities in the mountains to recover. Surgeons were even able to send patients with complex orthopedic repairs to the mountains, knowing that staff would be able to telecommunicate about the patients' status and any postsurgical problems that arose. “They never did overwhelm the hospital,” Dr. Merrell said. “They were able to use telecommunications to move patients down out of the mountains for definitive care and get them out and back to the mountains in a fraction of the usual time—in about 48 hours.”

Dr. Merrell (left) and associates at the Shahol Najaf Clinic about 20 kilometers from the epicenter. Courtesy Dr. Ronald C. Merrell

Imagine losing access to telephones, the Internet, and fax lines during a disaster, and trying to treat patients with nothing but a scratchy two-way radio to connect you with people and institutions outside your office.

It's so last century and so avoidable—yet that's what happens after natural or man-made disasters, said Dr. Ronald C. Merrell. Physicians should plan ahead to maintain telecommunications so they can practice medicine independently of emergency operation centers, he advised.

After terrorists destroyed the World Trade Center in New York in 2001, the dust was so thick that it interfered with satellite communications and cell phones. After a tsunami decimated parts of Southeast Asia in 2004 and after Hurricane Katrina hit the U.S. Gulf Coast in 2005, many physicians lost phone lines and were stuck with more primitive modes of communication, like ham radios.

“That's technology we've had since the Second World War. It's fine, but we need to find a way to access the Internet. It's hard to practice medicine over a radio,” said Dr. Merrell, director of the Medical Informatics and Technology Applications Consortium (MITAC) at Virginia Commonwealth University, in Richmond. MITAC is a research center sponsored by NASA.

The medical needs of refugees from a disaster aren't necessarily what you might expect. Dr. Merrell and colleagues from MITAC responded to a call from NASA after Hurricane Katrina to help an occupational medicine office at a NASA facility about 34 miles from the Mississippi coast. The office and its one physician had lost most communication with the outside world. Hundreds of people needed medical care, and within days the numbers grew to 4,000.

Many patients were on complex regimens of medicine, but their pills had washed away in the storm. One group of mentally ill patients from an assisted living facility had lost antipsychotic medication. Others had lost refrigeration and no longer had insulin.

Telemedicine teams in other parts of the country were eager to help, but the Mississippi facility had no good way to let them know what to send. Dr. Merrell and his team set up a satellite telephone, a computer satellite dish, and other equipment that gave them 65 kilobytes of transmission speed. Phone calls were transmitted via a French satellite to Paris and back to the United States. The team even brought solar panels to provide power if needed, but they were able to use electricity from the NASA facility. The system allowed them to order medications, connect with other medical facilities, and coordinate transfers of patients to more stable environments.

Because telemedicine isn't part of the usual disaster preparedness infrastructure, deploying the specialized equipment and then training people to practice telemedicine is time consuming, which limits the help it can provide, Dr. Merrell noted.

Physicians would be wise to assess the disaster plans and advocate for redundant telecommunications capabilities. “Medicine has to have a fairly independent and broadband interface” separate from acute emergency response efforts to serve patients well in a crisis, he said.

Having equipment and trained personnel in place made a huge difference when a devastating earthquake struck Pakistan in October 2005, Dr. Merrell said, noting that it may have been the first time that telemedicine formed the core of a successful medical response to a tragedy.

Under a grant from the U.S. Agency for International Development, Dr. Merrell and Dr Azhar Rafiq of Virginia Commonwealth University had traveled to Pakistan about a month before the earthquake to help establish two telemedicine training facilities in Rawalpindi, just outside the capital, Islamabad. The telemedicine facilities were to enable communications with two primary care clinics in the rural Punjab area for a more integrated health system.

When the earthquake hit, “We were in touch with them within 12 hours” thanks to the telemedicine programs, he said. The Rawalpindi medical facility was the first fully intact medical site encountered by people fleeing the mountainous areas, where the earthquake had leveled brick hospitals and killed almost all of the medical workers. Soon Rawalpindi's 1,500 beds were in demand for 6,000 patients.

Telecommunications kept the facility from being overwhelmed. Medical students volunteered for brief training in telemedicine and hiked into the mountains with backpacks containing satellite phones, digital cameras, laptop computers, and mobile power sources. From the mountains they informed the hospital at Rawalpindi and other facilities about which patients were headed their way and what would be needed. The students also transmitted medical records and photographs.

After reconstructive surgery at the Rawalpindi medical facility, patients were sent back to tent facilities in the mountains to recover. Surgeons were even able to send patients with complex orthopedic repairs to the mountains, knowing that staff would be able to telecommunicate about the patients' status and any postsurgical problems that arose. “They never did overwhelm the hospital,” Dr. Merrell said. “They were able to use telecommunications to move patients down out of the mountains for definitive care and get them out and back to the mountains in a fraction of the usual time—in about 48 hours.”

Dr. Merrell (left) and associates at the Shahol Najaf Clinic about 20 kilometers from the epicenter. Courtesy Dr. Ronald C. Merrell

A single oral dose of the antiemetic ondansetron significantly reduced vomiting and mild to moderate dehydration in children treated in a pediatric emergency department for gastroenteritis, allowing more children to be rehydrated orally rather than intravenously, Dr. Stephen B. Freedman reported.

A prospective, double-blind study randomized 215 children aged 6 months through 10 years to receive a disintegrating tablet of oral ondansetron (Zofran) or placebo administered by a nurse while the physicians and research assistants were out of the room. Five seconds after placing the tablet on the patient's tongue, the nurse asked or helped the child to swallow. Children who vomited within 15 minutes received a second dose. Fifteen minutes later, clinicians started a 1-hour period of intense oral rehydration, and oral rehydration could be continued until the patient was sent home or admitted. After the first hour of oral rehydration, the treating physician could choose to give intravenous fluids.

The investigators primarily assessed how many children vomited during oral rehydration therapy by conducting phone interviews with the families 3–7 days later and reviewing patients' records.

Among 107 children in the ondansetron group, 14% vomited while receiving oral rehydration therapy, compared with 35% of 107 children in the placebo group. One child in the ondansetron group was not included in the analysis because parental consent had not been obtained before randomization, said Dr. Freedman, of the University of Toronto, and his associates (N. Engl. J. Med. 2006;354:1698–705). Ondansetron also significantly reduced the mean number of episodes of vomiting, compared with placebo (0.18 vs. 0.65 episodes, respectively). Significantly fewer children in the ondansetron group received intravenous rehydration—14%, versus 31% in the placebo group.

Among the children who did not vomit during oral rehydration in either group, intravenous fluids were started in 5% given ondansetron and 17% given placebo, a significant difference.

Contrary to a study that looked at multiple doses, the single dose of ondansetron did not cause any significant adverse events, and the groups did not differ in the rate of return visits to the emergency department (19% with ondansetron and 22% with placebo). The ondansetron group did have more episodes of diarrhea during the oral rehydration than the placebo group—1.4 vs. 0.5 episodes—but this difference was not significant.

GlaxoSmithKline, which makes ondansetron, provided the tablets but had no other role in the study, and the investigators did not report any other potential conflicts of interest.

The ondansetron dosing was 2 mg for children weighing 8–15 kg, 4 mg for those weighing 16–30 kg, and 8 mg for heavier children.

At a cost of $35.75 per 4-mg tablet, the ondansetron in the study cost a total of $3,825 but saved the hospital $4,145 by avoiding insertion of intravenous catheters (at a cost of $124.74/child) and hospitalizations ($1,900/admission).

ELSEVIER GLOBAL MEDICAL NEWS

A single oral dose of the antiemetic ondansetron significantly reduced vomiting and mild to moderate dehydration in children treated in a pediatric emergency department for gastroenteritis, allowing more children to be rehydrated orally rather than intravenously, Dr. Stephen B. Freedman reported.

A prospective, double-blind study randomized 215 children aged 6 months through 10 years to receive a disintegrating tablet of oral ondansetron (Zofran) or placebo administered by a nurse while the physicians and research assistants were out of the room. Five seconds after placing the tablet on the patient's tongue, the nurse asked or helped the child to swallow. Children who vomited within 15 minutes received a second dose. Fifteen minutes later, clinicians started a 1-hour period of intense oral rehydration, and oral rehydration could be continued until the patient was sent home or admitted. After the first hour of oral rehydration, the treating physician could choose to give intravenous fluids.

The investigators primarily assessed how many children vomited during oral rehydration therapy by conducting phone interviews with the families 3–7 days later and reviewing patients' records.

Among 107 children in the ondansetron group, 14% vomited while receiving oral rehydration therapy, compared with 35% of 107 children in the placebo group. One child in the ondansetron group was not included in the analysis because parental consent had not been obtained before randomization, said Dr. Freedman, of the University of Toronto, and his associates (N. Engl. J. Med. 2006;354:1698–705). Ondansetron also significantly reduced the mean number of episodes of vomiting, compared with placebo (0.18 vs. 0.65 episodes, respectively). Significantly fewer children in the ondansetron group received intravenous rehydration—14%, versus 31% in the placebo group.

Among the children who did not vomit during oral rehydration in either group, intravenous fluids were started in 5% given ondansetron and 17% given placebo, a significant difference.

Contrary to a study that looked at multiple doses, the single dose of ondansetron did not cause any significant adverse events, and the groups did not differ in the rate of return visits to the emergency department (19% with ondansetron and 22% with placebo). The ondansetron group did have more episodes of diarrhea during the oral rehydration than the placebo group—1.4 vs. 0.5 episodes—but this difference was not significant.

GlaxoSmithKline, which makes ondansetron, provided the tablets but had no other role in the study, and the investigators did not report any other potential conflicts of interest.

The ondansetron dosing was 2 mg for children weighing 8–15 kg, 4 mg for those weighing 16–30 kg, and 8 mg for heavier children.

At a cost of $35.75 per 4-mg tablet, the ondansetron in the study cost a total of $3,825 but saved the hospital $4,145 by avoiding insertion of intravenous catheters (at a cost of $124.74/child) and hospitalizations ($1,900/admission).

ELSEVIER GLOBAL MEDICAL NEWS

A single oral dose of the antiemetic ondansetron significantly reduced vomiting and mild to moderate dehydration in children treated in a pediatric emergency department for gastroenteritis, allowing more children to be rehydrated orally rather than intravenously, Dr. Stephen B. Freedman reported.

A prospective, double-blind study randomized 215 children aged 6 months through 10 years to receive a disintegrating tablet of oral ondansetron (Zofran) or placebo administered by a nurse while the physicians and research assistants were out of the room. Five seconds after placing the tablet on the patient's tongue, the nurse asked or helped the child to swallow. Children who vomited within 15 minutes received a second dose. Fifteen minutes later, clinicians started a 1-hour period of intense oral rehydration, and oral rehydration could be continued until the patient was sent home or admitted. After the first hour of oral rehydration, the treating physician could choose to give intravenous fluids.

The investigators primarily assessed how many children vomited during oral rehydration therapy by conducting phone interviews with the families 3–7 days later and reviewing patients' records.

Among 107 children in the ondansetron group, 14% vomited while receiving oral rehydration therapy, compared with 35% of 107 children in the placebo group. One child in the ondansetron group was not included in the analysis because parental consent had not been obtained before randomization, said Dr. Freedman, of the University of Toronto, and his associates (N. Engl. J. Med. 2006;354:1698–705). Ondansetron also significantly reduced the mean number of episodes of vomiting, compared with placebo (0.18 vs. 0.65 episodes, respectively). Significantly fewer children in the ondansetron group received intravenous rehydration—14%, versus 31% in the placebo group.

Among the children who did not vomit during oral rehydration in either group, intravenous fluids were started in 5% given ondansetron and 17% given placebo, a significant difference.

Contrary to a study that looked at multiple doses, the single dose of ondansetron did not cause any significant adverse events, and the groups did not differ in the rate of return visits to the emergency department (19% with ondansetron and 22% with placebo). The ondansetron group did have more episodes of diarrhea during the oral rehydration than the placebo group—1.4 vs. 0.5 episodes—but this difference was not significant.

GlaxoSmithKline, which makes ondansetron, provided the tablets but had no other role in the study, and the investigators did not report any other potential conflicts of interest.

The ondansetron dosing was 2 mg for children weighing 8–15 kg, 4 mg for those weighing 16–30 kg, and 8 mg for heavier children.

At a cost of $35.75 per 4-mg tablet, the ondansetron in the study cost a total of $3,825 but saved the hospital $4,145 by avoiding insertion of intravenous catheters (at a cost of $124.74/child) and hospitalizations ($1,900/admission).

ELSEVIER GLOBAL MEDICAL NEWS

Giving families of infants and children individualized dietary counseling twice a year reduced the children's intake of fat and improved their insulin sensitivity by age 9 in a long-term randomized study.

The ongoing Special Turku Coronary Risk Factor Intervention Project for Children, a Finnish study, randomized healthy 7-month-old infants in 1990 to an intervention group (540 infants) or a control group (522 infants). The control group received the basic health education provided at well-baby clinics.

A physician and a dietitian provided individualized dietary counseling to the intervention group. Twice a year, families recorded what the child consumed for 4 consecutive days (including a weekend) within 3 weeks of the follow-up visit. The dietitian reviewed the list and suggested any changes needed to pursue a healthy diet low in saturated fat and cholesterol.

Clinicians recommend that children aged 3 and older get 55%–60% of energy from carbohydrates, 10%–15% from protein, and 30% from fat (with 10% or less as saturated fat), reported Dr. Tuuli Kaitosaari of the University of Turku (Finland) and associates.

When the children reached age 7, the investigators took detailed laboratory measurements of a subset of 200 children seen consecutively for follow-up visits; of these, 167 also had blood samples taken at their 9-year follow-up visit. The 9-year-olds (78 in the intervention group and 89 in the control group) make up the current study population.

The children in the intervention group consumed significantly less total fat and less saturated fat than those in the control group. Scores on the homeostasis model assessment of insulin resistance (HOMA-IR) index at age 9 were lower in the intervention children, indicating better insulin sensitivity compared with controls (Diabetes Care 2006;29:781–5).

Multivariate analyses indicated that “our finding of decreased HOMA-IR in intervention children is to a large extent due to their lower saturated fat intake,” Dr. Kaitosaari and associates said. Other factors that did not get measured in the study, such as exercise habits, also may partly explain the intervention's effect in lowering HOMA-IR scores, he added.

Giving families of infants and children individualized dietary counseling twice a year reduced the children's intake of fat and improved their insulin sensitivity by age 9 in a long-term randomized study.

The ongoing Special Turku Coronary Risk Factor Intervention Project for Children, a Finnish study, randomized healthy 7-month-old infants in 1990 to an intervention group (540 infants) or a control group (522 infants). The control group received the basic health education provided at well-baby clinics.

A physician and a dietitian provided individualized dietary counseling to the intervention group. Twice a year, families recorded what the child consumed for 4 consecutive days (including a weekend) within 3 weeks of the follow-up visit. The dietitian reviewed the list and suggested any changes needed to pursue a healthy diet low in saturated fat and cholesterol.

Clinicians recommend that children aged 3 and older get 55%–60% of energy from carbohydrates, 10%–15% from protein, and 30% from fat (with 10% or less as saturated fat), reported Dr. Tuuli Kaitosaari of the University of Turku (Finland) and associates.

When the children reached age 7, the investigators took detailed laboratory measurements of a subset of 200 children seen consecutively for follow-up visits; of these, 167 also had blood samples taken at their 9-year follow-up visit. The 9-year-olds (78 in the intervention group and 89 in the control group) make up the current study population.

The children in the intervention group consumed significantly less total fat and less saturated fat than those in the control group. Scores on the homeostasis model assessment of insulin resistance (HOMA-IR) index at age 9 were lower in the intervention children, indicating better insulin sensitivity compared with controls (Diabetes Care 2006;29:781–5).

Multivariate analyses indicated that “our finding of decreased HOMA-IR in intervention children is to a large extent due to their lower saturated fat intake,” Dr. Kaitosaari and associates said. Other factors that did not get measured in the study, such as exercise habits, also may partly explain the intervention's effect in lowering HOMA-IR scores, he added.

Giving families of infants and children individualized dietary counseling twice a year reduced the children's intake of fat and improved their insulin sensitivity by age 9 in a long-term randomized study.

The ongoing Special Turku Coronary Risk Factor Intervention Project for Children, a Finnish study, randomized healthy 7-month-old infants in 1990 to an intervention group (540 infants) or a control group (522 infants). The control group received the basic health education provided at well-baby clinics.

A physician and a dietitian provided individualized dietary counseling to the intervention group. Twice a year, families recorded what the child consumed for 4 consecutive days (including a weekend) within 3 weeks of the follow-up visit. The dietitian reviewed the list and suggested any changes needed to pursue a healthy diet low in saturated fat and cholesterol.

Clinicians recommend that children aged 3 and older get 55%–60% of energy from carbohydrates, 10%–15% from protein, and 30% from fat (with 10% or less as saturated fat), reported Dr. Tuuli Kaitosaari of the University of Turku (Finland) and associates.

When the children reached age 7, the investigators took detailed laboratory measurements of a subset of 200 children seen consecutively for follow-up visits; of these, 167 also had blood samples taken at their 9-year follow-up visit. The 9-year-olds (78 in the intervention group and 89 in the control group) make up the current study population.

The children in the intervention group consumed significantly less total fat and less saturated fat than those in the control group. Scores on the homeostasis model assessment of insulin resistance (HOMA-IR) index at age 9 were lower in the intervention children, indicating better insulin sensitivity compared with controls (Diabetes Care 2006;29:781–5).

Multivariate analyses indicated that “our finding of decreased HOMA-IR in intervention children is to a large extent due to their lower saturated fat intake,” Dr. Kaitosaari and associates said. Other factors that did not get measured in the study, such as exercise habits, also may partly explain the intervention's effect in lowering HOMA-IR scores, he added.

Need another reason to help convince overweight and obese patients to have a healthy diet? A small, randomized, controlled study concluded that eating insoluble dietary fiber found in cereal, fruits, and vegetables improved insulin sensitivity, Dr. Martin O. Weickert reported.

Eating a diet high in insoluble fiber might be a safe, effective, and low-cost way to reduce insulin resistance in patients at risk of developing type 2 diabetes, said Dr. Weickert and his associates (Diabetes Care 2006;29:775–80).

Eating cereal fiber has been associated with a reduced risk of developing cardiovascular disease and type 2 diabetes in epidemiologic studies, but the underlying mechanism was not clear, said Dr. Weickert of the German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany.

Seventeen overweight or obese women with normal glucose metabolism and no serious health problems agreed to eat macronutrient-matched portions of bread at meal times, supplemented by standardized liquid meals, for 3 days. The women were randomized to get oat fiber-enriched white bread or regular white bread, which served as the control. After a washout period of 7 days or more, the two groups crossed over to repeat the experiment using the other type of bread.

At the end of each 3-day period of bread eating, investigators measured whole-body insulin sensitivity and took blood samples. They conducted hydrogen breath tests to assess dietary adherence; previously they had shown that fiber consumption enhances colonic fermentation. The breath tests suggested that four women did not adhere to the study diet.

For the 17 women as a whole, 3 days of fiber-enriched bread significantly improved whole-body glucose disposal, equivalent to an 8% improvement in insulin sensitivity. Fasting insulin concentrations tended to be reduced after the days of fiber, an effect that might have been significant in a larger study, the investigators suggested.

A sub-analysis that excluded the four women who probably did not ingest the test meals found a highly significant improvement in whole-body glucose disposal after 3 days of fiber-fortified bread, equivalent to a 13% improvement in insulin sensitivity.

Need another reason to help convince overweight and obese patients to have a healthy diet? A small, randomized, controlled study concluded that eating insoluble dietary fiber found in cereal, fruits, and vegetables improved insulin sensitivity, Dr. Martin O. Weickert reported.

Eating a diet high in insoluble fiber might be a safe, effective, and low-cost way to reduce insulin resistance in patients at risk of developing type 2 diabetes, said Dr. Weickert and his associates (Diabetes Care 2006;29:775–80).

Eating cereal fiber has been associated with a reduced risk of developing cardiovascular disease and type 2 diabetes in epidemiologic studies, but the underlying mechanism was not clear, said Dr. Weickert of the German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany.

Seventeen overweight or obese women with normal glucose metabolism and no serious health problems agreed to eat macronutrient-matched portions of bread at meal times, supplemented by standardized liquid meals, for 3 days. The women were randomized to get oat fiber-enriched white bread or regular white bread, which served as the control. After a washout period of 7 days or more, the two groups crossed over to repeat the experiment using the other type of bread.

At the end of each 3-day period of bread eating, investigators measured whole-body insulin sensitivity and took blood samples. They conducted hydrogen breath tests to assess dietary adherence; previously they had shown that fiber consumption enhances colonic fermentation. The breath tests suggested that four women did not adhere to the study diet.

For the 17 women as a whole, 3 days of fiber-enriched bread significantly improved whole-body glucose disposal, equivalent to an 8% improvement in insulin sensitivity. Fasting insulin concentrations tended to be reduced after the days of fiber, an effect that might have been significant in a larger study, the investigators suggested.

A sub-analysis that excluded the four women who probably did not ingest the test meals found a highly significant improvement in whole-body glucose disposal after 3 days of fiber-fortified bread, equivalent to a 13% improvement in insulin sensitivity.

Need another reason to help convince overweight and obese patients to have a healthy diet? A small, randomized, controlled study concluded that eating insoluble dietary fiber found in cereal, fruits, and vegetables improved insulin sensitivity, Dr. Martin O. Weickert reported.

Eating a diet high in insoluble fiber might be a safe, effective, and low-cost way to reduce insulin resistance in patients at risk of developing type 2 diabetes, said Dr. Weickert and his associates (Diabetes Care 2006;29:775–80).

Eating cereal fiber has been associated with a reduced risk of developing cardiovascular disease and type 2 diabetes in epidemiologic studies, but the underlying mechanism was not clear, said Dr. Weickert of the German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany.

Seventeen overweight or obese women with normal glucose metabolism and no serious health problems agreed to eat macronutrient-matched portions of bread at meal times, supplemented by standardized liquid meals, for 3 days. The women were randomized to get oat fiber-enriched white bread or regular white bread, which served as the control. After a washout period of 7 days or more, the two groups crossed over to repeat the experiment using the other type of bread.

At the end of each 3-day period of bread eating, investigators measured whole-body insulin sensitivity and took blood samples. They conducted hydrogen breath tests to assess dietary adherence; previously they had shown that fiber consumption enhances colonic fermentation. The breath tests suggested that four women did not adhere to the study diet.

For the 17 women as a whole, 3 days of fiber-enriched bread significantly improved whole-body glucose disposal, equivalent to an 8% improvement in insulin sensitivity. Fasting insulin concentrations tended to be reduced after the days of fiber, an effect that might have been significant in a larger study, the investigators suggested.

A sub-analysis that excluded the four women who probably did not ingest the test meals found a highly significant improvement in whole-body glucose disposal after 3 days of fiber-fortified bread, equivalent to a 13% improvement in insulin sensitivity.