Sherry Boschert

KAILUA KONA, HAWAII — Tell pregnant patients to wear seat belts when in a car, and chances are that they'll do it, Dr. William G. Barsan said at a meeting on medical negligence and risk management.

One study found that 92% of mothers who got some prenatal education about seat belt use later reported using seat belts, and 83% could describe proper seat belt placement. Only 71% of mothers who did not get seat-belt advice reported using seat belts, and only 65% could describe proper seat belt placement, said Dr. Barsan, professor and chair of emergency medicine at the University of Michigan, Ann Arbor.

This did not require extensive, 20-minute education sessions but simply telling the patients at an office visit, “The studies are clear—you're better off wearing a seat belt. If you wear it, here's how you want to do it,” he added.

There seems to be some confusion among the lay public and even among some clinicians about the benefits of wearing seat belts during pregnancy. Dr. Barsan argued with his own wife about it during her pregnancy, he said at the meeting, sponsored by Boston University.

Modeling studies suggest that the risk of fetal death from a car crash is similar for an improperly restrained woman in a 10-mph crash and a properly restrained woman in a 22-mph crash. “Without wearing a seat belt, it doesn't take much to potentially cause a very bad injury to the fetus,” he said.

In another study of pregnant Michigan women in 1993, 32% reported sometimes, rarely, or never wearing seat belts, compared with 23% who said they usually wear seat belts and 45% who reported always wearing them. Those kinds of numbers may help explain results of a 2001 study in Pennsylvania that reported 500 fetal deaths after motor vehicle crashes, compared with 300 deaths of children up to age 4 years who were involved in vehicle crashes in the same time period.

Pregnant women should wear lap belts under the protuberant part of the abdomen, low down on the abdomen and pelvis, Dr. Barsan said. Shoulder belts should be worn off to the side of the uterus, between the breasts and over the mid-portion of the clavicle. There is no evidence to suggest that air bags should be disconnected in vehicles for pregnant drivers or passengers, he added.

“Wearing a seat belt properly can give a lot of protection to the baby,” he said.

This did not require extensive, 20-minute sessions but simply telling the patients at an office visit. DR. BARSAN

“Wearing a seat belt properly can give a lot of protection to the baby.” Stanford W. Carpenter

KAILUA KONA, HAWAII — Tell pregnant patients to wear seat belts when in a car, and chances are that they'll do it, Dr. William G. Barsan said at a meeting on medical negligence and risk management.

One study found that 92% of mothers who got some prenatal education about seat belt use later reported using seat belts, and 83% could describe proper seat belt placement. Only 71% of mothers who did not get seat-belt advice reported using seat belts, and only 65% could describe proper seat belt placement, said Dr. Barsan, professor and chair of emergency medicine at the University of Michigan, Ann Arbor.

This did not require extensive, 20-minute education sessions but simply telling the patients at an office visit, “The studies are clear—you're better off wearing a seat belt. If you wear it, here's how you want to do it,” he added.

There seems to be some confusion among the lay public and even among some clinicians about the benefits of wearing seat belts during pregnancy. Dr. Barsan argued with his own wife about it during her pregnancy, he said at the meeting, sponsored by Boston University.

Modeling studies suggest that the risk of fetal death from a car crash is similar for an improperly restrained woman in a 10-mph crash and a properly restrained woman in a 22-mph crash. “Without wearing a seat belt, it doesn't take much to potentially cause a very bad injury to the fetus,” he said.

In another study of pregnant Michigan women in 1993, 32% reported sometimes, rarely, or never wearing seat belts, compared with 23% who said they usually wear seat belts and 45% who reported always wearing them. Those kinds of numbers may help explain results of a 2001 study in Pennsylvania that reported 500 fetal deaths after motor vehicle crashes, compared with 300 deaths of children up to age 4 years who were involved in vehicle crashes in the same time period.

Pregnant women should wear lap belts under the protuberant part of the abdomen, low down on the abdomen and pelvis, Dr. Barsan said. Shoulder belts should be worn off to the side of the uterus, between the breasts and over the mid-portion of the clavicle. There is no evidence to suggest that air bags should be disconnected in vehicles for pregnant drivers or passengers, he added.

“Wearing a seat belt properly can give a lot of protection to the baby,” he said.

This did not require extensive, 20-minute sessions but simply telling the patients at an office visit. DR. BARSAN

“Wearing a seat belt properly can give a lot of protection to the baby.” Stanford W. Carpenter

KAILUA KONA, HAWAII — Tell pregnant patients to wear seat belts when in a car, and chances are that they'll do it, Dr. William G. Barsan said at a meeting on medical negligence and risk management.

One study found that 92% of mothers who got some prenatal education about seat belt use later reported using seat belts, and 83% could describe proper seat belt placement. Only 71% of mothers who did not get seat-belt advice reported using seat belts, and only 65% could describe proper seat belt placement, said Dr. Barsan, professor and chair of emergency medicine at the University of Michigan, Ann Arbor.

This did not require extensive, 20-minute education sessions but simply telling the patients at an office visit, “The studies are clear—you're better off wearing a seat belt. If you wear it, here's how you want to do it,” he added.

There seems to be some confusion among the lay public and even among some clinicians about the benefits of wearing seat belts during pregnancy. Dr. Barsan argued with his own wife about it during her pregnancy, he said at the meeting, sponsored by Boston University.

Modeling studies suggest that the risk of fetal death from a car crash is similar for an improperly restrained woman in a 10-mph crash and a properly restrained woman in a 22-mph crash. “Without wearing a seat belt, it doesn't take much to potentially cause a very bad injury to the fetus,” he said.

In another study of pregnant Michigan women in 1993, 32% reported sometimes, rarely, or never wearing seat belts, compared with 23% who said they usually wear seat belts and 45% who reported always wearing them. Those kinds of numbers may help explain results of a 2001 study in Pennsylvania that reported 500 fetal deaths after motor vehicle crashes, compared with 300 deaths of children up to age 4 years who were involved in vehicle crashes in the same time period.

Pregnant women should wear lap belts under the protuberant part of the abdomen, low down on the abdomen and pelvis, Dr. Barsan said. Shoulder belts should be worn off to the side of the uterus, between the breasts and over the mid-portion of the clavicle. There is no evidence to suggest that air bags should be disconnected in vehicles for pregnant drivers or passengers, he added.

“Wearing a seat belt properly can give a lot of protection to the baby,” he said.

This did not require extensive, 20-minute sessions but simply telling the patients at an office visit. DR. BARSAN

“Wearing a seat belt properly can give a lot of protection to the baby.” Stanford W. Carpenter

KAILUA KONA, HAWAII — The most commonly missed diagnoses that result in lawsuits against primary care physicians typically involve younger patients, insurance data suggest.

Half of the suits against family physicians for negligence or adverse outcome claim diagnostic error or failure to supervise or monitor cases. “These are sins not of commission but of omission,” Dr. Robert B. Taylor said at a meeting on medical negligence and risk management.

A study of 49,345 claims against family physicians found that no single medical problem accounted for more than 5% of claims, he noted. Myocardial infarction led the list with 5% of claims, followed by breast cancer and lung cancer, tied for second place with 3% of claims each (Qual. Saf. Health Care 2004;13:121–6).

A profile of negligence claims involving acute myocardial infarction emerged from a separate analysis of 349 claims by the Midwest Medical Insurance Company Risk Management Committee, said Dr. Taylor, professor of family medicine at Oregon Health and Science University, Portland.

Most of these cases involved diagnostic errors. The average patient age was 52 years—a young age for heart attacks—and 70% of these patients had no prior history of coronary artery disease. Physicians encountered a majority of these patients in their offices. Although at least 93% of the patients had typical symptoms such as chest pain, shortness of breath, or pain down the arm, physicians did not consider a diagnosis of acute myocardial infarction in half the cases, performed no diagnostic studies in 28%, and never made the diagnosis in 79%, he said at the meeting, sponsored by Boston University.

Most of these claims were filed against family physicians but involved a lower average indemnity than did claims against internists or emergency physicians involving acute myocardial infarction. “There are a lot of us” family physicians, Dr. Taylor noted. “That could be a factor. I'm not sure that we get sued more often.”

Patients claimed the physicians did not respond quickly to suspicious symptoms. Those who missed the diagnosis often attributed the symptoms to something else, such as anxiety, hyperventilation, indigestion, psychosomatic problems, or gastroesophageal reflux disease.

The take-home message: “When a relatively young person walks in with typical symptoms, even if they've never had coronary artery disease, don't take shortcuts in the evaluation” for acute myocardial infarction, Dr. Taylor said.

A separate analysis of data on 3,150 claims involving breast cancer by the Physician Insurers Association of America found two major causes of missed diagnoses. The patient's physical findings failed to impress the examiner, or the examiner failed to follow up with the patient after the initial examination of a breast lump.

Patients whose breast cancer was missed by physicians tended to be those with a chief complaint of a painless mass that they discovered themselves, and who had negative or equivocal mammograms. Sixty percent were younger than age 50 years.

“This profile I hammer into my residents,” Dr. Taylor said.

Remember that 1 in 10 women will get breast cancer in their lifetime, and don't put too much trust in mammography alone, he advised. Consider getting an ultrasound as well as a mammogram in questionable cases.

To reduce the risk of adverse events and malpractice claims, maintain your clinical competence and stay up to date with clinical guidelines, Dr. Taylor suggested. Practice relationship-based medicine.

Keep up communication with patients and their families, be alert to high-risk problems, and be thorough with lab results, return visits, and other follow-up procedures. Practice within your abilities and get consults or refer when needed, Dr. Taylor said.

'When a relatively young person walks in with typical symptoms … don't take shortcuts in the evaluation.' DR. TAYLOR

KAILUA KONA, HAWAII — The most commonly missed diagnoses that result in lawsuits against primary care physicians typically involve younger patients, insurance data suggest.

Half of the suits against family physicians for negligence or adverse outcome claim diagnostic error or failure to supervise or monitor cases. “These are sins not of commission but of omission,” Dr. Robert B. Taylor said at a meeting on medical negligence and risk management.

A study of 49,345 claims against family physicians found that no single medical problem accounted for more than 5% of claims, he noted. Myocardial infarction led the list with 5% of claims, followed by breast cancer and lung cancer, tied for second place with 3% of claims each (Qual. Saf. Health Care 2004;13:121–6).

A profile of negligence claims involving acute myocardial infarction emerged from a separate analysis of 349 claims by the Midwest Medical Insurance Company Risk Management Committee, said Dr. Taylor, professor of family medicine at Oregon Health and Science University, Portland.

Most of these cases involved diagnostic errors. The average patient age was 52 years—a young age for heart attacks—and 70% of these patients had no prior history of coronary artery disease. Physicians encountered a majority of these patients in their offices. Although at least 93% of the patients had typical symptoms such as chest pain, shortness of breath, or pain down the arm, physicians did not consider a diagnosis of acute myocardial infarction in half the cases, performed no diagnostic studies in 28%, and never made the diagnosis in 79%, he said at the meeting, sponsored by Boston University.

Most of these claims were filed against family physicians but involved a lower average indemnity than did claims against internists or emergency physicians involving acute myocardial infarction. “There are a lot of us” family physicians, Dr. Taylor noted. “That could be a factor. I'm not sure that we get sued more often.”

Patients claimed the physicians did not respond quickly to suspicious symptoms. Those who missed the diagnosis often attributed the symptoms to something else, such as anxiety, hyperventilation, indigestion, psychosomatic problems, or gastroesophageal reflux disease.

The take-home message: “When a relatively young person walks in with typical symptoms, even if they've never had coronary artery disease, don't take shortcuts in the evaluation” for acute myocardial infarction, Dr. Taylor said.

A separate analysis of data on 3,150 claims involving breast cancer by the Physician Insurers Association of America found two major causes of missed diagnoses. The patient's physical findings failed to impress the examiner, or the examiner failed to follow up with the patient after the initial examination of a breast lump.

Patients whose breast cancer was missed by physicians tended to be those with a chief complaint of a painless mass that they discovered themselves, and who had negative or equivocal mammograms. Sixty percent were younger than age 50 years.

“This profile I hammer into my residents,” Dr. Taylor said.

Remember that 1 in 10 women will get breast cancer in their lifetime, and don't put too much trust in mammography alone, he advised. Consider getting an ultrasound as well as a mammogram in questionable cases.

To reduce the risk of adverse events and malpractice claims, maintain your clinical competence and stay up to date with clinical guidelines, Dr. Taylor suggested. Practice relationship-based medicine.

Keep up communication with patients and their families, be alert to high-risk problems, and be thorough with lab results, return visits, and other follow-up procedures. Practice within your abilities and get consults or refer when needed, Dr. Taylor said.

'When a relatively young person walks in with typical symptoms … don't take shortcuts in the evaluation.' DR. TAYLOR

KAILUA KONA, HAWAII — The most commonly missed diagnoses that result in lawsuits against primary care physicians typically involve younger patients, insurance data suggest.

Half of the suits against family physicians for negligence or adverse outcome claim diagnostic error or failure to supervise or monitor cases. “These are sins not of commission but of omission,” Dr. Robert B. Taylor said at a meeting on medical negligence and risk management.

A study of 49,345 claims against family physicians found that no single medical problem accounted for more than 5% of claims, he noted. Myocardial infarction led the list with 5% of claims, followed by breast cancer and lung cancer, tied for second place with 3% of claims each (Qual. Saf. Health Care 2004;13:121–6).

A profile of negligence claims involving acute myocardial infarction emerged from a separate analysis of 349 claims by the Midwest Medical Insurance Company Risk Management Committee, said Dr. Taylor, professor of family medicine at Oregon Health and Science University, Portland.

Most of these cases involved diagnostic errors. The average patient age was 52 years—a young age for heart attacks—and 70% of these patients had no prior history of coronary artery disease. Physicians encountered a majority of these patients in their offices. Although at least 93% of the patients had typical symptoms such as chest pain, shortness of breath, or pain down the arm, physicians did not consider a diagnosis of acute myocardial infarction in half the cases, performed no diagnostic studies in 28%, and never made the diagnosis in 79%, he said at the meeting, sponsored by Boston University.

Most of these claims were filed against family physicians but involved a lower average indemnity than did claims against internists or emergency physicians involving acute myocardial infarction. “There are a lot of us” family physicians, Dr. Taylor noted. “That could be a factor. I'm not sure that we get sued more often.”

Patients claimed the physicians did not respond quickly to suspicious symptoms. Those who missed the diagnosis often attributed the symptoms to something else, such as anxiety, hyperventilation, indigestion, psychosomatic problems, or gastroesophageal reflux disease.

The take-home message: “When a relatively young person walks in with typical symptoms, even if they've never had coronary artery disease, don't take shortcuts in the evaluation” for acute myocardial infarction, Dr. Taylor said.

A separate analysis of data on 3,150 claims involving breast cancer by the Physician Insurers Association of America found two major causes of missed diagnoses. The patient's physical findings failed to impress the examiner, or the examiner failed to follow up with the patient after the initial examination of a breast lump.

Patients whose breast cancer was missed by physicians tended to be those with a chief complaint of a painless mass that they discovered themselves, and who had negative or equivocal mammograms. Sixty percent were younger than age 50 years.

“This profile I hammer into my residents,” Dr. Taylor said.

Remember that 1 in 10 women will get breast cancer in their lifetime, and don't put too much trust in mammography alone, he advised. Consider getting an ultrasound as well as a mammogram in questionable cases.

To reduce the risk of adverse events and malpractice claims, maintain your clinical competence and stay up to date with clinical guidelines, Dr. Taylor suggested. Practice relationship-based medicine.

Keep up communication with patients and their families, be alert to high-risk problems, and be thorough with lab results, return visits, and other follow-up procedures. Practice within your abilities and get consults or refer when needed, Dr. Taylor said.

'When a relatively young person walks in with typical symptoms … don't take shortcuts in the evaluation.' DR. TAYLOR

SALT LAKE CITY — Recruitment is underway for participants in the first U.S. study of laparoscopic adjustable banding for obese adolescents, Dr. Ai-Xuan Le Holterman said in a poster presentation at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Early data on the off-label use of the procedure for obese adolescents in the United States are the basis for the study protocol, which will recruit 50 patients and follow them for 5 years after the surgery. Ten adolescents have enrolled so far, and it may take 3 years before enrollment is complete because of the study's strict protocol, Dr. Holterman said.

The surgery seemed as effective in 10 adolescents as in 506 U.S. adults, said Dr. Holterman of the University of Illinois at Chicago. The adult data were drawn from patients who received laparoscopic adjustable gastric banding at the University of Illinois as part of the clinical trial that led to Food and Drug Administration approval in 2001 of the LAP-BAND device.

Dr. Holterman and her associates found that the surgery required 55 minutes in adolescents and 66 minutes in adults. Hospitalizations lasted 12 and 22 days, respectively. On average, body mass index (BMI) for adolescents fell from 49 kg/m

The adolescents had a much higher complication rate, however, with three patients (30%) developing pouch enlargement, compared with 11% of adults. The pouch enlargement required reoperation to reposition or replace the band in two adolescents (20%) and 2% of adults. More than 90% of pouch enlargements can be treated with band deflation, so the higher reoperation rate in adolescents probably reflects a delay in diagnosis of the complication.

Drawing on the results of their review, the investigators designed the trial's protocol to include closer and more frequent follow-up of the adolescents than is called for by adult protocols. So far, none of the adolescent patients enrolled in the trial have developed pouch enlargement.

In gastric bypass surgery, gastric stapling restricts food intake, and an intestinal bypass adds malabsorption to promote weight loss. In laparoscopic gastric banding, surgeons place an adjustable silicone band that induces weight loss by creating a small proximal gastric pouch. The outlet of the pouch is adjusted by controlling the lumen of the band through an inflatable reservoir accessed via a subcutaneous port.

“We encourage people to consider this before bypass because this is reversible and can be tailored to the changing lifestyle of the patient,” Dr. Holterman said. If the patient gets pregnant or ill and needs to eat more or needs more fluid, “we can adjust the band to accommodate for that.”

The impermanence of adjustable gastric bands is a drawback in the eyes of Dr. Michael Helmrath, a pediatric surgeon at Texas Children's Hospital, Houston. Experience in adults shows that the bands break in a few patients each year, necessitating replacement.

“You're dealing with a problem that is lifelong. There isn't an implantable device that's going to last the lifetime of a patient,” he said in an interview. Dr. Helmrath prefers to perform gastric bypass surgery for morbidly obese patients who fail other therapies.

Gastric bypass surgery, however, has taken a hit from two recent studies showing higher than expected rates of death and complications in some adults. In one large study, 40% of patients were readmitted to the hospital one or more times during the 3 years after gastric bypass, double their hospitalization rate in the 3 years before the surgery (JAMA 2005;294:1918–24). Another study found that 5% of Medicare patients receiving gastric bypass died within 30 days, more than double the death rates seen with other surgical procedures commonly performed on the elderly (JAMA 2005;294:1903–8).

We encourage people to consider banding before bypass because it is reversible and can be tailored to lifestyle changes. DR. HOLTERMAN

Plain anteroposterior radiograph shows the LAP-BAND device before adjustment.

Postoperative esophagogram with adjustment shows the LAP-BAND device in the proper position. Photos courtesy Dr. Ai-Xuan Le Holterman

SALT LAKE CITY — Recruitment is underway for participants in the first U.S. study of laparoscopic adjustable banding for obese adolescents, Dr. Ai-Xuan Le Holterman said in a poster presentation at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Early data on the off-label use of the procedure for obese adolescents in the United States are the basis for the study protocol, which will recruit 50 patients and follow them for 5 years after the surgery. Ten adolescents have enrolled so far, and it may take 3 years before enrollment is complete because of the study's strict protocol, Dr. Holterman said.

The surgery seemed as effective in 10 adolescents as in 506 U.S. adults, said Dr. Holterman of the University of Illinois at Chicago. The adult data were drawn from patients who received laparoscopic adjustable gastric banding at the University of Illinois as part of the clinical trial that led to Food and Drug Administration approval in 2001 of the LAP-BAND device.

Dr. Holterman and her associates found that the surgery required 55 minutes in adolescents and 66 minutes in adults. Hospitalizations lasted 12 and 22 days, respectively. On average, body mass index (BMI) for adolescents fell from 49 kg/m

The adolescents had a much higher complication rate, however, with three patients (30%) developing pouch enlargement, compared with 11% of adults. The pouch enlargement required reoperation to reposition or replace the band in two adolescents (20%) and 2% of adults. More than 90% of pouch enlargements can be treated with band deflation, so the higher reoperation rate in adolescents probably reflects a delay in diagnosis of the complication.

Drawing on the results of their review, the investigators designed the trial's protocol to include closer and more frequent follow-up of the adolescents than is called for by adult protocols. So far, none of the adolescent patients enrolled in the trial have developed pouch enlargement.

In gastric bypass surgery, gastric stapling restricts food intake, and an intestinal bypass adds malabsorption to promote weight loss. In laparoscopic gastric banding, surgeons place an adjustable silicone band that induces weight loss by creating a small proximal gastric pouch. The outlet of the pouch is adjusted by controlling the lumen of the band through an inflatable reservoir accessed via a subcutaneous port.

“We encourage people to consider this before bypass because this is reversible and can be tailored to the changing lifestyle of the patient,” Dr. Holterman said. If the patient gets pregnant or ill and needs to eat more or needs more fluid, “we can adjust the band to accommodate for that.”

The impermanence of adjustable gastric bands is a drawback in the eyes of Dr. Michael Helmrath, a pediatric surgeon at Texas Children's Hospital, Houston. Experience in adults shows that the bands break in a few patients each year, necessitating replacement.

“You're dealing with a problem that is lifelong. There isn't an implantable device that's going to last the lifetime of a patient,” he said in an interview. Dr. Helmrath prefers to perform gastric bypass surgery for morbidly obese patients who fail other therapies.

Gastric bypass surgery, however, has taken a hit from two recent studies showing higher than expected rates of death and complications in some adults. In one large study, 40% of patients were readmitted to the hospital one or more times during the 3 years after gastric bypass, double their hospitalization rate in the 3 years before the surgery (JAMA 2005;294:1918–24). Another study found that 5% of Medicare patients receiving gastric bypass died within 30 days, more than double the death rates seen with other surgical procedures commonly performed on the elderly (JAMA 2005;294:1903–8).

We encourage people to consider banding before bypass because it is reversible and can be tailored to lifestyle changes. DR. HOLTERMAN

Plain anteroposterior radiograph shows the LAP-BAND device before adjustment.

Postoperative esophagogram with adjustment shows the LAP-BAND device in the proper position. Photos courtesy Dr. Ai-Xuan Le Holterman

SALT LAKE CITY — Recruitment is underway for participants in the first U.S. study of laparoscopic adjustable banding for obese adolescents, Dr. Ai-Xuan Le Holterman said in a poster presentation at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Early data on the off-label use of the procedure for obese adolescents in the United States are the basis for the study protocol, which will recruit 50 patients and follow them for 5 years after the surgery. Ten adolescents have enrolled so far, and it may take 3 years before enrollment is complete because of the study's strict protocol, Dr. Holterman said.

The surgery seemed as effective in 10 adolescents as in 506 U.S. adults, said Dr. Holterman of the University of Illinois at Chicago. The adult data were drawn from patients who received laparoscopic adjustable gastric banding at the University of Illinois as part of the clinical trial that led to Food and Drug Administration approval in 2001 of the LAP-BAND device.

Dr. Holterman and her associates found that the surgery required 55 minutes in adolescents and 66 minutes in adults. Hospitalizations lasted 12 and 22 days, respectively. On average, body mass index (BMI) for adolescents fell from 49 kg/m

The adolescents had a much higher complication rate, however, with three patients (30%) developing pouch enlargement, compared with 11% of adults. The pouch enlargement required reoperation to reposition or replace the band in two adolescents (20%) and 2% of adults. More than 90% of pouch enlargements can be treated with band deflation, so the higher reoperation rate in adolescents probably reflects a delay in diagnosis of the complication.

Drawing on the results of their review, the investigators designed the trial's protocol to include closer and more frequent follow-up of the adolescents than is called for by adult protocols. So far, none of the adolescent patients enrolled in the trial have developed pouch enlargement.

In gastric bypass surgery, gastric stapling restricts food intake, and an intestinal bypass adds malabsorption to promote weight loss. In laparoscopic gastric banding, surgeons place an adjustable silicone band that induces weight loss by creating a small proximal gastric pouch. The outlet of the pouch is adjusted by controlling the lumen of the band through an inflatable reservoir accessed via a subcutaneous port.

“We encourage people to consider this before bypass because this is reversible and can be tailored to the changing lifestyle of the patient,” Dr. Holterman said. If the patient gets pregnant or ill and needs to eat more or needs more fluid, “we can adjust the band to accommodate for that.”

The impermanence of adjustable gastric bands is a drawback in the eyes of Dr. Michael Helmrath, a pediatric surgeon at Texas Children's Hospital, Houston. Experience in adults shows that the bands break in a few patients each year, necessitating replacement.

“You're dealing with a problem that is lifelong. There isn't an implantable device that's going to last the lifetime of a patient,” he said in an interview. Dr. Helmrath prefers to perform gastric bypass surgery for morbidly obese patients who fail other therapies.

Gastric bypass surgery, however, has taken a hit from two recent studies showing higher than expected rates of death and complications in some adults. In one large study, 40% of patients were readmitted to the hospital one or more times during the 3 years after gastric bypass, double their hospitalization rate in the 3 years before the surgery (JAMA 2005;294:1918–24). Another study found that 5% of Medicare patients receiving gastric bypass died within 30 days, more than double the death rates seen with other surgical procedures commonly performed on the elderly (JAMA 2005;294:1903–8).

We encourage people to consider banding before bypass because it is reversible and can be tailored to lifestyle changes. DR. HOLTERMAN

Plain anteroposterior radiograph shows the LAP-BAND device before adjustment.

Postoperative esophagogram with adjustment shows the LAP-BAND device in the proper position. Photos courtesy Dr. Ai-Xuan Le Holterman

SALT LAKE CITY — Abdominal pain and other gastroenterologic symptoms commonly occurred in 48 school-children but improved with time and did not keep the students out of school, according to results of a prospective study.

In the first systematic, community-based study of GI symptoms in North American schoolchildren, 48 white fourth and fifth graders in an urban private school were asked to fill out weekly confidential, eight-item symptom surveys for 16 weeks, generating 690 out of 768 possible survey responses (or children-weeks).

Students reported at least one GI symptom in 60% of children-weeks and reported headaches in 70% of children-weeks, said Dr. Miguel Saps and Dr. Carlo Di Lorenzo in a poster presentation at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

The prevalence of abdominal pain decreased significantly, from 64% of children-weeks in the first month of the study to 33% in the last month. All other symptoms decreased in prevalence over time, although not significantly.

“The natural improvement of every GI symptom can justify delaying invasive testing” and may help to reassure physicians and parents about the short-term progression of these symptoms, said Dr. Saps of Children's Memorial Hospital in Chicago and Dr. Di Lorenzo of Columbus (Ohio) Children's Hospital. The study was conducted while both physicians were at Children's Hospital of Pittsburgh.

The decline in symptoms suggests a decrease in stress as school progressed or, alternatively, seasonal variation in symptoms between the start of the study in February and the end of it in June, the doctors suggested.

'The natural improvement of every GI symptom can justify delaying invasive testing.' DR. DI LORENZO

SALT LAKE CITY — Abdominal pain and other gastroenterologic symptoms commonly occurred in 48 school-children but improved with time and did not keep the students out of school, according to results of a prospective study.

In the first systematic, community-based study of GI symptoms in North American schoolchildren, 48 white fourth and fifth graders in an urban private school were asked to fill out weekly confidential, eight-item symptom surveys for 16 weeks, generating 690 out of 768 possible survey responses (or children-weeks).

Students reported at least one GI symptom in 60% of children-weeks and reported headaches in 70% of children-weeks, said Dr. Miguel Saps and Dr. Carlo Di Lorenzo in a poster presentation at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

The prevalence of abdominal pain decreased significantly, from 64% of children-weeks in the first month of the study to 33% in the last month. All other symptoms decreased in prevalence over time, although not significantly.

“The natural improvement of every GI symptom can justify delaying invasive testing” and may help to reassure physicians and parents about the short-term progression of these symptoms, said Dr. Saps of Children's Memorial Hospital in Chicago and Dr. Di Lorenzo of Columbus (Ohio) Children's Hospital. The study was conducted while both physicians were at Children's Hospital of Pittsburgh.

The decline in symptoms suggests a decrease in stress as school progressed or, alternatively, seasonal variation in symptoms between the start of the study in February and the end of it in June, the doctors suggested.

'The natural improvement of every GI symptom can justify delaying invasive testing.' DR. DI LORENZO

SALT LAKE CITY — Abdominal pain and other gastroenterologic symptoms commonly occurred in 48 school-children but improved with time and did not keep the students out of school, according to results of a prospective study.

In the first systematic, community-based study of GI symptoms in North American schoolchildren, 48 white fourth and fifth graders in an urban private school were asked to fill out weekly confidential, eight-item symptom surveys for 16 weeks, generating 690 out of 768 possible survey responses (or children-weeks).

Students reported at least one GI symptom in 60% of children-weeks and reported headaches in 70% of children-weeks, said Dr. Miguel Saps and Dr. Carlo Di Lorenzo in a poster presentation at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

The prevalence of abdominal pain decreased significantly, from 64% of children-weeks in the first month of the study to 33% in the last month. All other symptoms decreased in prevalence over time, although not significantly.

“The natural improvement of every GI symptom can justify delaying invasive testing” and may help to reassure physicians and parents about the short-term progression of these symptoms, said Dr. Saps of Children's Memorial Hospital in Chicago and Dr. Di Lorenzo of Columbus (Ohio) Children's Hospital. The study was conducted while both physicians were at Children's Hospital of Pittsburgh.

The decline in symptoms suggests a decrease in stress as school progressed or, alternatively, seasonal variation in symptoms between the start of the study in February and the end of it in June, the doctors suggested.

'The natural improvement of every GI symptom can justify delaying invasive testing.' DR. DI LORENZO

SALT LAKE CITY — Pediatricians and family physicians choose different treatments for constipation in infants and children, a survey of 328 physicians found.

Of the 143 family physicians who responded to the mailed questionnaire, 53% treated constipation for longer than 3 months, compared with 84% of the 185 surveyed pediatricians, Dr. Douglas G. Field said. Only 1% of pediatricians treated for less than 1 month, compared with 13% of family physicians.

He presented the findings in a poster at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), which has published guidelines for managing pediatric constipation (J. Pediatr. Gastroenterol. Nutr. 1999;29:612–26).

Many children with constipation need long-term therapy to maintain a regular bowel pattern, studies have shown, so a child should be weaned from medication only after he or she has been having regular bowel movements without difficulty, said Dr. Field of Penn State Children's Hospital, Hershey, Pa., and his associates.

The difference between specialties in treatment length might explain the higher success rate reported by the pediatricians surveyed, he added. Only 4% of pediatricians referred more than 25% of their patients with constipation to pediatric gastroenterologists, compared with 31% of family physicians.

The main reason for referral by both primary care specialties was lack of response to therapy (in 65%–69% of referrals).

Most pediatricians and family physicians used suppositories and prune juice to disimpact infants with constipation, practices supported by the NASPGHAN guidelines.

For children, the most commonly used rectal treatments were enemas or suppositories, and the most common oral treatments were polyethylene glycol (by pediatricians) or mineral oil (by family physicians), again supported by the guidelines.

Family physicians veered from the guidelines, however, by using mineral oil in infants—for disimpaction in 7% of infants and for maintenance therapy in 9% of infants.

Pediatricians used mineral oil in 1% of infants for disimpaction and in 1% for maintenance therapy.

Many children with constipation need long-term therapy to maintain a regular bowel pattern. DR. FIELD

SALT LAKE CITY — Pediatricians and family physicians choose different treatments for constipation in infants and children, a survey of 328 physicians found.

Of the 143 family physicians who responded to the mailed questionnaire, 53% treated constipation for longer than 3 months, compared with 84% of the 185 surveyed pediatricians, Dr. Douglas G. Field said. Only 1% of pediatricians treated for less than 1 month, compared with 13% of family physicians.

He presented the findings in a poster at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), which has published guidelines for managing pediatric constipation (J. Pediatr. Gastroenterol. Nutr. 1999;29:612–26).

Many children with constipation need long-term therapy to maintain a regular bowel pattern, studies have shown, so a child should be weaned from medication only after he or she has been having regular bowel movements without difficulty, said Dr. Field of Penn State Children's Hospital, Hershey, Pa., and his associates.

The difference between specialties in treatment length might explain the higher success rate reported by the pediatricians surveyed, he added. Only 4% of pediatricians referred more than 25% of their patients with constipation to pediatric gastroenterologists, compared with 31% of family physicians.

The main reason for referral by both primary care specialties was lack of response to therapy (in 65%–69% of referrals).

Most pediatricians and family physicians used suppositories and prune juice to disimpact infants with constipation, practices supported by the NASPGHAN guidelines.

For children, the most commonly used rectal treatments were enemas or suppositories, and the most common oral treatments were polyethylene glycol (by pediatricians) or mineral oil (by family physicians), again supported by the guidelines.

Family physicians veered from the guidelines, however, by using mineral oil in infants—for disimpaction in 7% of infants and for maintenance therapy in 9% of infants.

Pediatricians used mineral oil in 1% of infants for disimpaction and in 1% for maintenance therapy.

Many children with constipation need long-term therapy to maintain a regular bowel pattern. DR. FIELD

SALT LAKE CITY — Pediatricians and family physicians choose different treatments for constipation in infants and children, a survey of 328 physicians found.

Of the 143 family physicians who responded to the mailed questionnaire, 53% treated constipation for longer than 3 months, compared with 84% of the 185 surveyed pediatricians, Dr. Douglas G. Field said. Only 1% of pediatricians treated for less than 1 month, compared with 13% of family physicians.

He presented the findings in a poster at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), which has published guidelines for managing pediatric constipation (J. Pediatr. Gastroenterol. Nutr. 1999;29:612–26).

Many children with constipation need long-term therapy to maintain a regular bowel pattern, studies have shown, so a child should be weaned from medication only after he or she has been having regular bowel movements without difficulty, said Dr. Field of Penn State Children's Hospital, Hershey, Pa., and his associates.

The difference between specialties in treatment length might explain the higher success rate reported by the pediatricians surveyed, he added. Only 4% of pediatricians referred more than 25% of their patients with constipation to pediatric gastroenterologists, compared with 31% of family physicians.

The main reason for referral by both primary care specialties was lack of response to therapy (in 65%–69% of referrals).

Most pediatricians and family physicians used suppositories and prune juice to disimpact infants with constipation, practices supported by the NASPGHAN guidelines.

For children, the most commonly used rectal treatments were enemas or suppositories, and the most common oral treatments were polyethylene glycol (by pediatricians) or mineral oil (by family physicians), again supported by the guidelines.

Family physicians veered from the guidelines, however, by using mineral oil in infants—for disimpaction in 7% of infants and for maintenance therapy in 9% of infants.

Pediatricians used mineral oil in 1% of infants for disimpaction and in 1% for maintenance therapy.

Many children with constipation need long-term therapy to maintain a regular bowel pattern. DR. FIELD

KAILUA KONA, HAWAII — Inform the radiologist about the specific location of any palpable mass in a patient's breast that prompted you to order a mammogram, Dr. R. James Brenner said at a meeting on medical negligence and risk management.

Avoid vague descriptions like “a general fullness in the breast upper right quadrant” and be more specific—“a palpable lump at 10 o'clock,” said Dr. Brenner, chief of breast imaging at the University of California, San Francisco.

If the radiologist doesn't know there's a palpable mass, the patient gets a screening mammography. But mention a palpable mass, preferably with a specific area for interrogation, and the radiologist can perform ultrasound and potentially detect carcinomas that can't be seen by mammography.

“I need to know from the gynecologist that he or she feels something there. Otherwise, this ultrasound is not performed, and the diagnosis is not made in a timely fashion,” he said. “This is an example where the clinician and the radiographic team either sink or swim together.”

American College of Radiology guidelines state that ultrasound examinations should be performed for mammographic masses or palpable masses that are insufficiently characterized on mammographic findings. Using ultrasonography for screening is not the standard of care, but is being investigated in a National Cancer Institute trial.

The most common reason for medical malpractice lawsuits is a delay in the diagnosis of breast cancer, according to data from the Physicians Insurance Association of America. The top two defendants are radiologists and ob.gyns. A large percentage of the litigation involves a palpable breast mass discovered by the patient, who then comes to the clinician for an evaluation. Litigated cases often lack documentation of a breast examination.

Clinicians should carefully document that they evaluated a patient for signs and symptoms of breast cancer, took a thorough clinical history, and referred the patient for genetic counseling if appropriate. Use a stamp or mnemonic in the chart to show that you examined the breasts and regional lymph nodes, Dr. Brenner suggested.

Try to reconcile clinical findings and imaging results. “The interplay between the clinical and mammographic findings often convert subthreshold findings to threshold findings. That needs to be appreciated,” he said at the meeting, sponsored by Boston University.

Insist on getting a phone call from the radiologist if there is any suspicious finding on mammography or ultrasound, because written or electronic reports can get lost or misplaced, he added.

When you do get a mammography or ultrasound report, initial it to indicate that you looked at it, and to show a potential jury that it was your decision to do something further or not to do more, Kimberly D. Baker, J.D., said in a legal commentary session after Dr. Brenner's talk.

KAILUA KONA, HAWAII — Inform the radiologist about the specific location of any palpable mass in a patient's breast that prompted you to order a mammogram, Dr. R. James Brenner said at a meeting on medical negligence and risk management.

Avoid vague descriptions like “a general fullness in the breast upper right quadrant” and be more specific—“a palpable lump at 10 o'clock,” said Dr. Brenner, chief of breast imaging at the University of California, San Francisco.

If the radiologist doesn't know there's a palpable mass, the patient gets a screening mammography. But mention a palpable mass, preferably with a specific area for interrogation, and the radiologist can perform ultrasound and potentially detect carcinomas that can't be seen by mammography.

“I need to know from the gynecologist that he or she feels something there. Otherwise, this ultrasound is not performed, and the diagnosis is not made in a timely fashion,” he said. “This is an example where the clinician and the radiographic team either sink or swim together.”

American College of Radiology guidelines state that ultrasound examinations should be performed for mammographic masses or palpable masses that are insufficiently characterized on mammographic findings. Using ultrasonography for screening is not the standard of care, but is being investigated in a National Cancer Institute trial.

The most common reason for medical malpractice lawsuits is a delay in the diagnosis of breast cancer, according to data from the Physicians Insurance Association of America. The top two defendants are radiologists and ob.gyns. A large percentage of the litigation involves a palpable breast mass discovered by the patient, who then comes to the clinician for an evaluation. Litigated cases often lack documentation of a breast examination.

Clinicians should carefully document that they evaluated a patient for signs and symptoms of breast cancer, took a thorough clinical history, and referred the patient for genetic counseling if appropriate. Use a stamp or mnemonic in the chart to show that you examined the breasts and regional lymph nodes, Dr. Brenner suggested.

Try to reconcile clinical findings and imaging results. “The interplay between the clinical and mammographic findings often convert subthreshold findings to threshold findings. That needs to be appreciated,” he said at the meeting, sponsored by Boston University.

Insist on getting a phone call from the radiologist if there is any suspicious finding on mammography or ultrasound, because written or electronic reports can get lost or misplaced, he added.

When you do get a mammography or ultrasound report, initial it to indicate that you looked at it, and to show a potential jury that it was your decision to do something further or not to do more, Kimberly D. Baker, J.D., said in a legal commentary session after Dr. Brenner's talk.

KAILUA KONA, HAWAII — Inform the radiologist about the specific location of any palpable mass in a patient's breast that prompted you to order a mammogram, Dr. R. James Brenner said at a meeting on medical negligence and risk management.

Avoid vague descriptions like “a general fullness in the breast upper right quadrant” and be more specific—“a palpable lump at 10 o'clock,” said Dr. Brenner, chief of breast imaging at the University of California, San Francisco.

If the radiologist doesn't know there's a palpable mass, the patient gets a screening mammography. But mention a palpable mass, preferably with a specific area for interrogation, and the radiologist can perform ultrasound and potentially detect carcinomas that can't be seen by mammography.

“I need to know from the gynecologist that he or she feels something there. Otherwise, this ultrasound is not performed, and the diagnosis is not made in a timely fashion,” he said. “This is an example where the clinician and the radiographic team either sink or swim together.”

American College of Radiology guidelines state that ultrasound examinations should be performed for mammographic masses or palpable masses that are insufficiently characterized on mammographic findings. Using ultrasonography for screening is not the standard of care, but is being investigated in a National Cancer Institute trial.

The most common reason for medical malpractice lawsuits is a delay in the diagnosis of breast cancer, according to data from the Physicians Insurance Association of America. The top two defendants are radiologists and ob.gyns. A large percentage of the litigation involves a palpable breast mass discovered by the patient, who then comes to the clinician for an evaluation. Litigated cases often lack documentation of a breast examination.

Clinicians should carefully document that they evaluated a patient for signs and symptoms of breast cancer, took a thorough clinical history, and referred the patient for genetic counseling if appropriate. Use a stamp or mnemonic in the chart to show that you examined the breasts and regional lymph nodes, Dr. Brenner suggested.

Try to reconcile clinical findings and imaging results. “The interplay between the clinical and mammographic findings often convert subthreshold findings to threshold findings. That needs to be appreciated,” he said at the meeting, sponsored by Boston University.

Insist on getting a phone call from the radiologist if there is any suspicious finding on mammography or ultrasound, because written or electronic reports can get lost or misplaced, he added.

When you do get a mammography or ultrasound report, initial it to indicate that you looked at it, and to show a potential jury that it was your decision to do something further or not to do more, Kimberly D. Baker, J.D., said in a legal commentary session after Dr. Brenner's talk.

SALT LAKE CITY — Recruitment is underway for participants in the first U.S. study of laparoscopic adjustable banding for obese adolescents, Dr. Ai-Xuan Le Holterman said in a poster presentation at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Early data on the off-label use of the procedure for obese adolescents in the United States are the basis for the study protocol, which will recruit 50 patients and follow them for 5 years after the surgery. Ten adolescents have enrolled so far, and it may take 3 years before enrollment is complete because of the study's strict protocol, Dr. Holterman said.

The surgery seemed as effective in 10 adolescents as in 506 U.S. adults, said Dr. Holterman of the University of Illinois at Chicago. The adult data were drawn from patients who received laparoscopic adjustable gastric banding at the University of Illinois as part of the clinical trial that led to Food and Drug Administration approval in 2001 of the LAP-BAND device.

Dr. Holterman and her associates found that operative times and hospital stays were short, and no one died. The surgery required 55 minutes in adolescents and 66 minutes in adults. Hospitalizations lasted 12 and 22 days, respectively. On average, body mass index (BMI) for adolescents fell from 49 kg/m

The adolescents had a much higher complication rate, however, with three patients (30%) developing pouch enlargement, compared with 11% of adults. The pouch enlargement required reoperation to reposition or replace the band in two adolescents (20%) and 2% of adults. More than 90% of patients with pouch enlargement usually can be treated successfully with band deflation, so the higher reoperation rate among adolescents probably reflects a delay in diagnosis of the complication.

“The highest challenge of laparoscopic adjustable gastric banding treatment for morbid obesity in adolescents is the postoperative management,” Dr. Holterman said. “Close and long-term follow-up, ensuring diet compliance, and maintaining a high index of suspicion for early detection and treatment of pouch dilatation are essential.”

The investigators designed the trial's protocol to include closer and more frequent follow-up of the adolescents than is called for by adult protocols. So far, none of the adolescent patients enrolled in the trial have developed pouch enlargement.

In gastric bypass surgery, gastric stapling restricts food intake, and an intestinal bypass adds malabsorption to promote weight loss. In laparoscopic gastric banding, surgeons place an adjustable silicone band that induces weight loss by creating a small proximal gastric pouch. The outlet of the pouch is adjusted by controlling the lumen of the band through an inflatable reservoir accessed via a subcutaneous port.

“We encourage people to consider this before bypass because this is reversible and can be tailored to the changing lifestyle of the patient,” Dr. Holterman said. Complications are treated laparoscopically.

The prevalence of obesity in U.S. children and adolescents has tripled in the past 3 decades. The procedures offer an alternative for morbidly obese patients for whom medical therapies have not worked

The impermanence of adjustable gastric bands is a drawback in the eyes of Dr. Michael Helmrath, a pediatric surgeon at Texas Children's Hospital, Houston. Experience in adults shows that the bands break in a few patients each year, necessitating replacement.

“You're dealing with a problem that is lifelong. There isn't an implantable device that's going to last the lifetime of a patient,” he said in an interview. Dr. Helmrath prefers to perform gastric bypass surgery for morbidly obese patients who fail other therapies, at least until more data emerge comparing surgical options.

Gastric bypass surgery, however, has taken a hit from two recent studies showing higher than expected rates of death and complications in some adults.

In one large study, 40% of patients were readmitted to the hospital one or more times during the 3 years after gastric bypass, double their hospitalization rate in the 3 years before the surgery (JAMA 2005;294:1918–24). Another study found that 5% of Medicare patients receiving gastric bypass died within 30 days, more than double the death rates seen with other surgical procedures commonly performed on the elderly (JAMA 2005;294:1903–8).

Although gastric bypass carries higher risks of death or complications in the first year after surgery, gastric banding may have more long-term complications, Dr. Helmrath said. Gastric bypass can lead to strictures, anastomotic leaks, or internal hernias, but adjustable gastric banding can lead to GI reflux, port erosions, and band slippage or breaking, among other complications. There are no studies comparing the two surgical procedures in adolescents.

“It's important for someone like me to get data from a good place, like the University of Illinois at Chicago, to help make decisions in the future,” Dr. Helmrath said.

Dr. Robert E. Kramer agreed that systematic, evidence-based data are needed on surgical options to help the 11 million obese children in the United States. Laparoscopic adjustable gastric banding is attractive because “if there are complications, or it doesn't seem successful, there at least is the option of removing the device and going back to the original anatomy,” said Dr. Kramer, medical director of a pediatric obesity clinic at the University of Miami.

“We see a lot of teenagers who come in, and they're looking for a quick fix,” he said in an interview. “It's difficult for them to truly appreciate the risk associated with bariatric surgery.” For that reason, he favors restricting bariatric surgery for adolescents to tertiary care centers that offer it as part of a comprehensive obesity management program for children.

The LAP-BAND device is shown in the correct 45-degree position before a final adjustment (left). After surgery, esophageal and gastric pouch emptying without dilation is evident (right). Photos courtesy Dr. Ai-Xuan Le Holterman

SALT LAKE CITY — Recruitment is underway for participants in the first U.S. study of laparoscopic adjustable banding for obese adolescents, Dr. Ai-Xuan Le Holterman said in a poster presentation at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Early data on the off-label use of the procedure for obese adolescents in the United States are the basis for the study protocol, which will recruit 50 patients and follow them for 5 years after the surgery. Ten adolescents have enrolled so far, and it may take 3 years before enrollment is complete because of the study's strict protocol, Dr. Holterman said.

The surgery seemed as effective in 10 adolescents as in 506 U.S. adults, said Dr. Holterman of the University of Illinois at Chicago. The adult data were drawn from patients who received laparoscopic adjustable gastric banding at the University of Illinois as part of the clinical trial that led to Food and Drug Administration approval in 2001 of the LAP-BAND device.

Dr. Holterman and her associates found that operative times and hospital stays were short, and no one died. The surgery required 55 minutes in adolescents and 66 minutes in adults. Hospitalizations lasted 12 and 22 days, respectively. On average, body mass index (BMI) for adolescents fell from 49 kg/m

The adolescents had a much higher complication rate, however, with three patients (30%) developing pouch enlargement, compared with 11% of adults. The pouch enlargement required reoperation to reposition or replace the band in two adolescents (20%) and 2% of adults. More than 90% of patients with pouch enlargement usually can be treated successfully with band deflation, so the higher reoperation rate among adolescents probably reflects a delay in diagnosis of the complication.

“The highest challenge of laparoscopic adjustable gastric banding treatment for morbid obesity in adolescents is the postoperative management,” Dr. Holterman said. “Close and long-term follow-up, ensuring diet compliance, and maintaining a high index of suspicion for early detection and treatment of pouch dilatation are essential.”

The investigators designed the trial's protocol to include closer and more frequent follow-up of the adolescents than is called for by adult protocols. So far, none of the adolescent patients enrolled in the trial have developed pouch enlargement.

In gastric bypass surgery, gastric stapling restricts food intake, and an intestinal bypass adds malabsorption to promote weight loss. In laparoscopic gastric banding, surgeons place an adjustable silicone band that induces weight loss by creating a small proximal gastric pouch. The outlet of the pouch is adjusted by controlling the lumen of the band through an inflatable reservoir accessed via a subcutaneous port.

“We encourage people to consider this before bypass because this is reversible and can be tailored to the changing lifestyle of the patient,” Dr. Holterman said. Complications are treated laparoscopically.

The prevalence of obesity in U.S. children and adolescents has tripled in the past 3 decades. The procedures offer an alternative for morbidly obese patients for whom medical therapies have not worked

The impermanence of adjustable gastric bands is a drawback in the eyes of Dr. Michael Helmrath, a pediatric surgeon at Texas Children's Hospital, Houston. Experience in adults shows that the bands break in a few patients each year, necessitating replacement.

“You're dealing with a problem that is lifelong. There isn't an implantable device that's going to last the lifetime of a patient,” he said in an interview. Dr. Helmrath prefers to perform gastric bypass surgery for morbidly obese patients who fail other therapies, at least until more data emerge comparing surgical options.

Gastric bypass surgery, however, has taken a hit from two recent studies showing higher than expected rates of death and complications in some adults.

In one large study, 40% of patients were readmitted to the hospital one or more times during the 3 years after gastric bypass, double their hospitalization rate in the 3 years before the surgery (JAMA 2005;294:1918–24). Another study found that 5% of Medicare patients receiving gastric bypass died within 30 days, more than double the death rates seen with other surgical procedures commonly performed on the elderly (JAMA 2005;294:1903–8).

Although gastric bypass carries higher risks of death or complications in the first year after surgery, gastric banding may have more long-term complications, Dr. Helmrath said. Gastric bypass can lead to strictures, anastomotic leaks, or internal hernias, but adjustable gastric banding can lead to GI reflux, port erosions, and band slippage or breaking, among other complications. There are no studies comparing the two surgical procedures in adolescents.

“It's important for someone like me to get data from a good place, like the University of Illinois at Chicago, to help make decisions in the future,” Dr. Helmrath said.

Dr. Robert E. Kramer agreed that systematic, evidence-based data are needed on surgical options to help the 11 million obese children in the United States. Laparoscopic adjustable gastric banding is attractive because “if there are complications, or it doesn't seem successful, there at least is the option of removing the device and going back to the original anatomy,” said Dr. Kramer, medical director of a pediatric obesity clinic at the University of Miami.

“We see a lot of teenagers who come in, and they're looking for a quick fix,” he said in an interview. “It's difficult for them to truly appreciate the risk associated with bariatric surgery.” For that reason, he favors restricting bariatric surgery for adolescents to tertiary care centers that offer it as part of a comprehensive obesity management program for children.

The LAP-BAND device is shown in the correct 45-degree position before a final adjustment (left). After surgery, esophageal and gastric pouch emptying without dilation is evident (right). Photos courtesy Dr. Ai-Xuan Le Holterman

SALT LAKE CITY — Recruitment is underway for participants in the first U.S. study of laparoscopic adjustable banding for obese adolescents, Dr. Ai-Xuan Le Holterman said in a poster presentation at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Early data on the off-label use of the procedure for obese adolescents in the United States are the basis for the study protocol, which will recruit 50 patients and follow them for 5 years after the surgery. Ten adolescents have enrolled so far, and it may take 3 years before enrollment is complete because of the study's strict protocol, Dr. Holterman said.

The surgery seemed as effective in 10 adolescents as in 506 U.S. adults, said Dr. Holterman of the University of Illinois at Chicago. The adult data were drawn from patients who received laparoscopic adjustable gastric banding at the University of Illinois as part of the clinical trial that led to Food and Drug Administration approval in 2001 of the LAP-BAND device.

Dr. Holterman and her associates found that operative times and hospital stays were short, and no one died. The surgery required 55 minutes in adolescents and 66 minutes in adults. Hospitalizations lasted 12 and 22 days, respectively. On average, body mass index (BMI) for adolescents fell from 49 kg/m

The adolescents had a much higher complication rate, however, with three patients (30%) developing pouch enlargement, compared with 11% of adults. The pouch enlargement required reoperation to reposition or replace the band in two adolescents (20%) and 2% of adults. More than 90% of patients with pouch enlargement usually can be treated successfully with band deflation, so the higher reoperation rate among adolescents probably reflects a delay in diagnosis of the complication.

“The highest challenge of laparoscopic adjustable gastric banding treatment for morbid obesity in adolescents is the postoperative management,” Dr. Holterman said. “Close and long-term follow-up, ensuring diet compliance, and maintaining a high index of suspicion for early detection and treatment of pouch dilatation are essential.”

The investigators designed the trial's protocol to include closer and more frequent follow-up of the adolescents than is called for by adult protocols. So far, none of the adolescent patients enrolled in the trial have developed pouch enlargement.

In gastric bypass surgery, gastric stapling restricts food intake, and an intestinal bypass adds malabsorption to promote weight loss. In laparoscopic gastric banding, surgeons place an adjustable silicone band that induces weight loss by creating a small proximal gastric pouch. The outlet of the pouch is adjusted by controlling the lumen of the band through an inflatable reservoir accessed via a subcutaneous port.

“We encourage people to consider this before bypass because this is reversible and can be tailored to the changing lifestyle of the patient,” Dr. Holterman said. Complications are treated laparoscopically.

The prevalence of obesity in U.S. children and adolescents has tripled in the past 3 decades. The procedures offer an alternative for morbidly obese patients for whom medical therapies have not worked

The impermanence of adjustable gastric bands is a drawback in the eyes of Dr. Michael Helmrath, a pediatric surgeon at Texas Children's Hospital, Houston. Experience in adults shows that the bands break in a few patients each year, necessitating replacement.

“You're dealing with a problem that is lifelong. There isn't an implantable device that's going to last the lifetime of a patient,” he said in an interview. Dr. Helmrath prefers to perform gastric bypass surgery for morbidly obese patients who fail other therapies, at least until more data emerge comparing surgical options.

Gastric bypass surgery, however, has taken a hit from two recent studies showing higher than expected rates of death and complications in some adults.

In one large study, 40% of patients were readmitted to the hospital one or more times during the 3 years after gastric bypass, double their hospitalization rate in the 3 years before the surgery (JAMA 2005;294:1918–24). Another study found that 5% of Medicare patients receiving gastric bypass died within 30 days, more than double the death rates seen with other surgical procedures commonly performed on the elderly (JAMA 2005;294:1903–8).

Although gastric bypass carries higher risks of death or complications in the first year after surgery, gastric banding may have more long-term complications, Dr. Helmrath said. Gastric bypass can lead to strictures, anastomotic leaks, or internal hernias, but adjustable gastric banding can lead to GI reflux, port erosions, and band slippage or breaking, among other complications. There are no studies comparing the two surgical procedures in adolescents.

“It's important for someone like me to get data from a good place, like the University of Illinois at Chicago, to help make decisions in the future,” Dr. Helmrath said.

Dr. Robert E. Kramer agreed that systematic, evidence-based data are needed on surgical options to help the 11 million obese children in the United States. Laparoscopic adjustable gastric banding is attractive because “if there are complications, or it doesn't seem successful, there at least is the option of removing the device and going back to the original anatomy,” said Dr. Kramer, medical director of a pediatric obesity clinic at the University of Miami.

“We see a lot of teenagers who come in, and they're looking for a quick fix,” he said in an interview. “It's difficult for them to truly appreciate the risk associated with bariatric surgery.” For that reason, he favors restricting bariatric surgery for adolescents to tertiary care centers that offer it as part of a comprehensive obesity management program for children.

The LAP-BAND device is shown in the correct 45-degree position before a final adjustment (left). After surgery, esophageal and gastric pouch emptying without dilation is evident (right). Photos courtesy Dr. Ai-Xuan Le Holterman

KAILUA KONA, HAWAII — Don't rely on dipsticks to detect proteinuria in pregnant patients with suspected preeclampsia, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Instead, get a 24-hour urine collection. If there's not time for that, get a 12-hour urine collection, and order a pregnancy-induced hypertension panel if there is new-onset hypertension, said Dr. Belfort, professor of maternal-fetal medicine at the University of Utah, Salt Lake City.

Dipstick results depend on protein concentrations, which are altered by urine volume. A preeclamptic woman on bed rest will mobilize fluid and increase urine output, potentially diluting urine enough that the protein concentration falls below the minimum level of 20 mg/dL read by dipsticks, he said at the conference sponsored by Boston University.

A dipstick for a woman with 3.2 g of protein in 1,500 cc/day of urine will report 20 mg/dL of protein, erroneously suggesting that only a trace of protein is present. “Until we have more sophisticated ways of determining proteinuria, the dipstick is a screening kit, and the gold standard is 24-hour urine collection,” he said.

To diagnose preeclampsia, look for proteinuria (urinary excretion of 0.3 g protein or higher in a 24-hour urine specimen) and new-onset hypertension (at least 140 mm Hg systolic or 90 mm Hg diastolic after 20 weeks' gestation).

Consider not only the blood pressure on a particular day but also the trend in blood pressure over weeks, Dr. Belfort said.

The American College of Obstetricians and Gynecologists recommends checking platelets, liver enzymes, renal function, and 12− or 24-hour urine collection for protein to rule out preeclampsia. If you order lab tests, be sure to get the results, he cautioned.

“It is possible that a physician may choose to admit the patient, order the lab, and get a dipstick the next morning before seeing the protein level in a timed collection of urine. The physician then sends the patient home on the strength of the dipstick. If you do not wait for the 24-hour urine collection … some of these patients may [come back] with a cerebral infarct,” he said.

Physicians in a consultative practice, as Dr. Belfort is, often advise other people to order labs instead of doing it themselves. It may be dangerous to send a pregnant patient with very elevated blood pressure home with a letter suggesting that her doctor order lab tests.

“There's an onus upon you to make sure that patient is going to be okay, and you don't find out about some wacky result like really low platelets or very elevated liver enzymes 3 days later as you're flipping through the paperwork on your desk,” he said.

Dr. Belfort orders the labs and either he or his staff call the patient's doctor to say the labs have been sent. They instruct the patient to call her doctor that evening if she has not been contacted about the results. All this is documented in the patient's chart.

As for labs, not every patient needs a coagulogram but get one for a patient with less than 100,000 platelets, he said. A patient with a very low platelet count and a normal coagulogram may have thrombotic thrombocytopenic purpura.

“The worst thing you can do for somebody with [thrombotic thrombocytopenic purpura] is give them a bag of platelets. It's like throwing kerosene on a fire,” he said.

Be conservative when deciding whether to admit a patient with suspected preeclampsia, Dr. Belfort suggested. Certainly any patients with headache, visual disturbances (scotomata), bruising, bleeding, significant edema, any kind of head or abdominal pain, or other complicating features should be admitted.

Think carefully about what is to be gained or lost by delaying delivery in a preeclamptic patient with a viable fetus, he added. “Beyond 32 weeks [gestation] in severe preeclampsia, there is very little to be gained in terms of survival of the fetus” by delaying delivery and risking a catastrophic outcome, he said.

KAILUA KONA, HAWAII — Don't rely on dipsticks to detect proteinuria in pregnant patients with suspected preeclampsia, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Instead, get a 24-hour urine collection. If there's not time for that, get a 12-hour urine collection, and order a pregnancy-induced hypertension panel if there is new-onset hypertension, said Dr. Belfort, professor of maternal-fetal medicine at the University of Utah, Salt Lake City.

Dipstick results depend on protein concentrations, which are altered by urine volume. A preeclamptic woman on bed rest will mobilize fluid and increase urine output, potentially diluting urine enough that the protein concentration falls below the minimum level of 20 mg/dL read by dipsticks, he said at the conference sponsored by Boston University.

A dipstick for a woman with 3.2 g of protein in 1,500 cc/day of urine will report 20 mg/dL of protein, erroneously suggesting that only a trace of protein is present. “Until we have more sophisticated ways of determining proteinuria, the dipstick is a screening kit, and the gold standard is 24-hour urine collection,” he said.

To diagnose preeclampsia, look for proteinuria (urinary excretion of 0.3 g protein or higher in a 24-hour urine specimen) and new-onset hypertension (at least 140 mm Hg systolic or 90 mm Hg diastolic after 20 weeks' gestation).

Consider not only the blood pressure on a particular day but also the trend in blood pressure over weeks, Dr. Belfort said.

The American College of Obstetricians and Gynecologists recommends checking platelets, liver enzymes, renal function, and 12− or 24-hour urine collection for protein to rule out preeclampsia. If you order lab tests, be sure to get the results, he cautioned.

“It is possible that a physician may choose to admit the patient, order the lab, and get a dipstick the next morning before seeing the protein level in a timed collection of urine. The physician then sends the patient home on the strength of the dipstick. If you do not wait for the 24-hour urine collection … some of these patients may [come back] with a cerebral infarct,” he said.

Physicians in a consultative practice, as Dr. Belfort is, often advise other people to order labs instead of doing it themselves. It may be dangerous to send a pregnant patient with very elevated blood pressure home with a letter suggesting that her doctor order lab tests.

“There's an onus upon you to make sure that patient is going to be okay, and you don't find out about some wacky result like really low platelets or very elevated liver enzymes 3 days later as you're flipping through the paperwork on your desk,” he said.

Dr. Belfort orders the labs and either he or his staff call the patient's doctor to say the labs have been sent. They instruct the patient to call her doctor that evening if she has not been contacted about the results. All this is documented in the patient's chart.

As for labs, not every patient needs a coagulogram but get one for a patient with less than 100,000 platelets, he said. A patient with a very low platelet count and a normal coagulogram may have thrombotic thrombocytopenic purpura.

“The worst thing you can do for somebody with [thrombotic thrombocytopenic purpura] is give them a bag of platelets. It's like throwing kerosene on a fire,” he said.

Be conservative when deciding whether to admit a patient with suspected preeclampsia, Dr. Belfort suggested. Certainly any patients with headache, visual disturbances (scotomata), bruising, bleeding, significant edema, any kind of head or abdominal pain, or other complicating features should be admitted.

Think carefully about what is to be gained or lost by delaying delivery in a preeclamptic patient with a viable fetus, he added. “Beyond 32 weeks [gestation] in severe preeclampsia, there is very little to be gained in terms of survival of the fetus” by delaying delivery and risking a catastrophic outcome, he said.

KAILUA KONA, HAWAII — Don't rely on dipsticks to detect proteinuria in pregnant patients with suspected preeclampsia, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Instead, get a 24-hour urine collection. If there's not time for that, get a 12-hour urine collection, and order a pregnancy-induced hypertension panel if there is new-onset hypertension, said Dr. Belfort, professor of maternal-fetal medicine at the University of Utah, Salt Lake City.

Dipstick results depend on protein concentrations, which are altered by urine volume. A preeclamptic woman on bed rest will mobilize fluid and increase urine output, potentially diluting urine enough that the protein concentration falls below the minimum level of 20 mg/dL read by dipsticks, he said at the conference sponsored by Boston University.

A dipstick for a woman with 3.2 g of protein in 1,500 cc/day of urine will report 20 mg/dL of protein, erroneously suggesting that only a trace of protein is present. “Until we have more sophisticated ways of determining proteinuria, the dipstick is a screening kit, and the gold standard is 24-hour urine collection,” he said.

To diagnose preeclampsia, look for proteinuria (urinary excretion of 0.3 g protein or higher in a 24-hour urine specimen) and new-onset hypertension (at least 140 mm Hg systolic or 90 mm Hg diastolic after 20 weeks' gestation).

Consider not only the blood pressure on a particular day but also the trend in blood pressure over weeks, Dr. Belfort said.

The American College of Obstetricians and Gynecologists recommends checking platelets, liver enzymes, renal function, and 12− or 24-hour urine collection for protein to rule out preeclampsia. If you order lab tests, be sure to get the results, he cautioned.

“It is possible that a physician may choose to admit the patient, order the lab, and get a dipstick the next morning before seeing the protein level in a timed collection of urine. The physician then sends the patient home on the strength of the dipstick. If you do not wait for the 24-hour urine collection … some of these patients may [come back] with a cerebral infarct,” he said.

Physicians in a consultative practice, as Dr. Belfort is, often advise other people to order labs instead of doing it themselves. It may be dangerous to send a pregnant patient with very elevated blood pressure home with a letter suggesting that her doctor order lab tests.

“There's an onus upon you to make sure that patient is going to be okay, and you don't find out about some wacky result like really low platelets or very elevated liver enzymes 3 days later as you're flipping through the paperwork on your desk,” he said.

Dr. Belfort orders the labs and either he or his staff call the patient's doctor to say the labs have been sent. They instruct the patient to call her doctor that evening if she has not been contacted about the results. All this is documented in the patient's chart.

As for labs, not every patient needs a coagulogram but get one for a patient with less than 100,000 platelets, he said. A patient with a very low platelet count and a normal coagulogram may have thrombotic thrombocytopenic purpura.

“The worst thing you can do for somebody with [thrombotic thrombocytopenic purpura] is give them a bag of platelets. It's like throwing kerosene on a fire,” he said.

Be conservative when deciding whether to admit a patient with suspected preeclampsia, Dr. Belfort suggested. Certainly any patients with headache, visual disturbances (scotomata), bruising, bleeding, significant edema, any kind of head or abdominal pain, or other complicating features should be admitted.

Think carefully about what is to be gained or lost by delaying delivery in a preeclamptic patient with a viable fetus, he added. “Beyond 32 weeks [gestation] in severe preeclampsia, there is very little to be gained in terms of survival of the fetus” by delaying delivery and risking a catastrophic outcome, he said.

SAN FRANCISCO — Measuring bone mineral density in older patients is as justifiable as measuring lipids, Dennis M. Black, Ph.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Lipid testing and treatment for high cholesterol is accepted as an integral part of primary care, but bone densitometry and treatment for low bone density isn't as readily accepted, said Dr. Black, professor of epidemiology and biostatistics at the university.

That's partly because measurements and treatments for osteoporosis came along well after tests and treatments for heart disease and its risk factors, he explained. The ready acceptance of lipid screening compared with bone density screening bothers some osteoporosis experts. “It might be called lipid envy,” he joked.

The value of bone density testing stacks up nicely against the value of lipid testing. Studies have shown that people with cholesterol measurements in the highest quartile have four times the risk for heart disease compared with people whose cholesterol measurements are in the lowest quartile, Dr. Black said. Stratifying hip bone density by quartile, the risk for hip fracture increases 10-fold in people whose bone density is in the lowest quartile compared with those in the highest quartile.

Heart disease risk increases from about 0.5% in the lowest low-density lipoprotein (LDL) quartile to about 4% in the highest lipid quartile. Hip fracture risk increases from about 0.5% in the highest quartile of hip bone density to about 10% in the quartile with the least hip bone density.

Cost-effectiveness compares well, too, he added. Screening lipid levels in a 52-year-old woman and treating her for an LDL level greater than 160 mg/dL costs about $400,000 per quality-adjusted life-year. Screening bone density in a 65-year-old woman and treating her with bisphosphonates for a T score of −2.5 (suggesting osteoporosis) costs about $30,000 per quality-adjusted life-year, “which is considered cost effective,” Dr. Black said.

The National Osteoporosis Foundation recommends bone mineral density testing for all women aged 65 years and older, and for postmenopausal women with a risk factor for osteoporosis.

The definition of risk factors for osteoporosis is a bit murky. Dr. Black includes postmenopausal women who have a history of fracture after menopause, whose mothers have a history of fracture (especially hip fracture), who take steroids, or who have very low body weight. Very low body weight commonly is considered being below 125 pounds, but that depends somewhat on height, he added.

The U.S. Preventive Services Task Force recommends bone mineral density measurements for all women above age 60. Medicare covers bone density tests for women over age 65.

Dr. Black recently analyzed 16 years of follow-up data on women in the Study of Osteoporotic Fractures and found that a single measurement of hip bone density is a good predictor of fracture risk. In these white women with a mean age of 71 years, 5% of those in the highest quartile of hip bone density developed a hip fracture over the 16-year period, compared with 32% of women in the lowest quartile of hip bone density.

The difference was “fairly dramatic” he said. Women in the lowest quartile of hip bone density on a single measurement at the start of the study had an immediate increase in risk for hip fracture that continued as far out as 16 years.

“If it's not possible to repeat bone density measurements in 2, 3, or 4 years, the (one) value that you have is still going to be predictive long term,” he said.

There is a growing recognition that T scores shouldn't be used for peripheral measurements. If a patient brings you a printout from a wrist bone density measurement that she got in a pharmacy, use that as an opportunity to talk about bone health and maybe get a more central bone density measurement, he suggested.

SAN FRANCISCO — Measuring bone mineral density in older patients is as justifiable as measuring lipids, Dennis M. Black, Ph.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Lipid testing and treatment for high cholesterol is accepted as an integral part of primary care, but bone densitometry and treatment for low bone density isn't as readily accepted, said Dr. Black, professor of epidemiology and biostatistics at the university.

That's partly because measurements and treatments for osteoporosis came along well after tests and treatments for heart disease and its risk factors, he explained. The ready acceptance of lipid screening compared with bone density screening bothers some osteoporosis experts. “It might be called lipid envy,” he joked.

The value of bone density testing stacks up nicely against the value of lipid testing. Studies have shown that people with cholesterol measurements in the highest quartile have four times the risk for heart disease compared with people whose cholesterol measurements are in the lowest quartile, Dr. Black said. Stratifying hip bone density by quartile, the risk for hip fracture increases 10-fold in people whose bone density is in the lowest quartile compared with those in the highest quartile.

Heart disease risk increases from about 0.5% in the lowest low-density lipoprotein (LDL) quartile to about 4% in the highest lipid quartile. Hip fracture risk increases from about 0.5% in the highest quartile of hip bone density to about 10% in the quartile with the least hip bone density.

Cost-effectiveness compares well, too, he added. Screening lipid levels in a 52-year-old woman and treating her for an LDL level greater than 160 mg/dL costs about $400,000 per quality-adjusted life-year. Screening bone density in a 65-year-old woman and treating her with bisphosphonates for a T score of −2.5 (suggesting osteoporosis) costs about $30,000 per quality-adjusted life-year, “which is considered cost effective,” Dr. Black said.

The National Osteoporosis Foundation recommends bone mineral density testing for all women aged 65 years and older, and for postmenopausal women with a risk factor for osteoporosis.

The definition of risk factors for osteoporosis is a bit murky. Dr. Black includes postmenopausal women who have a history of fracture after menopause, whose mothers have a history of fracture (especially hip fracture), who take steroids, or who have very low body weight. Very low body weight commonly is considered being below 125 pounds, but that depends somewhat on height, he added.

The U.S. Preventive Services Task Force recommends bone mineral density measurements for all women above age 60. Medicare covers bone density tests for women over age 65.

Dr. Black recently analyzed 16 years of follow-up data on women in the Study of Osteoporotic Fractures and found that a single measurement of hip bone density is a good predictor of fracture risk. In these white women with a mean age of 71 years, 5% of those in the highest quartile of hip bone density developed a hip fracture over the 16-year period, compared with 32% of women in the lowest quartile of hip bone density.

The difference was “fairly dramatic” he said. Women in the lowest quartile of hip bone density on a single measurement at the start of the study had an immediate increase in risk for hip fracture that continued as far out as 16 years.

“If it's not possible to repeat bone density measurements in 2, 3, or 4 years, the (one) value that you have is still going to be predictive long term,” he said.

There is a growing recognition that T scores shouldn't be used for peripheral measurements. If a patient brings you a printout from a wrist bone density measurement that she got in a pharmacy, use that as an opportunity to talk about bone health and maybe get a more central bone density measurement, he suggested.

SAN FRANCISCO — Measuring bone mineral density in older patients is as justifiable as measuring lipids, Dennis M. Black, Ph.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Lipid testing and treatment for high cholesterol is accepted as an integral part of primary care, but bone densitometry and treatment for low bone density isn't as readily accepted, said Dr. Black, professor of epidemiology and biostatistics at the university.

That's partly because measurements and treatments for osteoporosis came along well after tests and treatments for heart disease and its risk factors, he explained. The ready acceptance of lipid screening compared with bone density screening bothers some osteoporosis experts. “It might be called lipid envy,” he joked.

The value of bone density testing stacks up nicely against the value of lipid testing. Studies have shown that people with cholesterol measurements in the highest quartile have four times the risk for heart disease compared with people whose cholesterol measurements are in the lowest quartile, Dr. Black said. Stratifying hip bone density by quartile, the risk for hip fracture increases 10-fold in people whose bone density is in the lowest quartile compared with those in the highest quartile.

Heart disease risk increases from about 0.5% in the lowest low-density lipoprotein (LDL) quartile to about 4% in the highest lipid quartile. Hip fracture risk increases from about 0.5% in the highest quartile of hip bone density to about 10% in the quartile with the least hip bone density.

Cost-effectiveness compares well, too, he added. Screening lipid levels in a 52-year-old woman and treating her for an LDL level greater than 160 mg/dL costs about $400,000 per quality-adjusted life-year. Screening bone density in a 65-year-old woman and treating her with bisphosphonates for a T score of −2.5 (suggesting osteoporosis) costs about $30,000 per quality-adjusted life-year, “which is considered cost effective,” Dr. Black said.

The National Osteoporosis Foundation recommends bone mineral density testing for all women aged 65 years and older, and for postmenopausal women with a risk factor for osteoporosis.

The definition of risk factors for osteoporosis is a bit murky. Dr. Black includes postmenopausal women who have a history of fracture after menopause, whose mothers have a history of fracture (especially hip fracture), who take steroids, or who have very low body weight. Very low body weight commonly is considered being below 125 pounds, but that depends somewhat on height, he added.

The U.S. Preventive Services Task Force recommends bone mineral density measurements for all women above age 60. Medicare covers bone density tests for women over age 65.

Dr. Black recently analyzed 16 years of follow-up data on women in the Study of Osteoporotic Fractures and found that a single measurement of hip bone density is a good predictor of fracture risk. In these white women with a mean age of 71 years, 5% of those in the highest quartile of hip bone density developed a hip fracture over the 16-year period, compared with 32% of women in the lowest quartile of hip bone density.

The difference was “fairly dramatic” he said. Women in the lowest quartile of hip bone density on a single measurement at the start of the study had an immediate increase in risk for hip fracture that continued as far out as 16 years.

“If it's not possible to repeat bone density measurements in 2, 3, or 4 years, the (one) value that you have is still going to be predictive long term,” he said.

There is a growing recognition that T scores shouldn't be used for peripheral measurements. If a patient brings you a printout from a wrist bone density measurement that she got in a pharmacy, use that as an opportunity to talk about bone health and maybe get a more central bone density measurement, he suggested.

SAN FRANCISCO — The most important recently published articles on pediatric infectious diseases include four articles on herpes viruses and two on meningococcal vaccines, two speakers said at the annual meeting of the Infectious Diseases Society of America.

Dr. Joseph W. St. Geme III, professor of pediatrics at Duke University, Durham, N.C., and Dr. Parvin H. Azimi, director of infectious diseases at Children's Hospital, Oakland, Calif., described their picks for the most significant articles.

Getting Clinical With MRSA

Houston investigators provided clinical descriptions of the increasing number of adolescents admitted to intensive care for severe community-acquired Staphylococcus aureus infection (Pediatrics 2005;115:642–8).

“In considering pressing issues in pediatric infectious diseases, I think most of us would agree that at the top of the list, these days, is community-acquired methicillin-resistant Staph aureus” (MRSA), Dr. St. Geme said.

A review of records for a 16-month period at Texas Children's Hospital, Houston, found that 14 adolescents were admitted for sepsis and coagulopathy from community-acquired S. aureus, 12 with MRSA and 2 with methicillin-susceptible S. aureus. Thirteen patients had pulmonary involvement, and 13 had bone and/or joint infection. Of the latter group, 10 patients had infection in two or more bones or joints. Their mean age was 13 years. Three patients died.

Getting a better understanding of the factors responsible for these infections should be a priority, he said.

HSV Suppression No More

A report of a premature infant with cutaneous herpes simplex virus (HSV) disease who developed herpes encephalitis despite suppressive therapy called into question assumptions about the efficacy of oral acyclovir regimens for HSV suppression (Pediatrics 2005;115:804–9).

The authors concluded that suppressive therapy with oral acyclovir cannot be recommended at this time.

“Many of us use suppressive therapy,” Dr. Azimi said. “We really need a randomized, placebo-controlled study so we can see if it is efficacious.”

Don't Forget Early-Onset GBS

Despite a big drop in the incidence of early-onset group B streptococcal (GBS) disease since adoption of universal screening for GBS colonization, cases of early-onset GBS disease still occur, and most of these are in infants whose mothers screened negative for GBS colonization, a review of 25 cases at one hospital found (Pediatrics 2005;115:1240–6). Many of the mothers had intrapartum risk factors for neonatal infection but received no prophylactic antibiotics before delivery. Assessment of intrapartum risk factors remains important, the investigators concluded.

“In addition, this study highlights that pending the introduction of a GBS vaccine, more effective prevention of GBS disease will require more rapid, more sensitive techniques to screen for GBS colonization and GBS antibiotic resistance,” Dr. St. Geme said.

Type of Herpesvirus Matters

Congenital infections occur with human herpesvirus 6 (HHV-6) but not with the closely related human herpesvirus 7 (HHV-7), investigators reported (J. Pediatr. 2004;145:472–7). DNA tests found no HHV-7 in 2,129 cord blood samples but showed HHV-6 in 1% of 5,638 cord blood samples, similar to the rate for cytomegalovirus infection. Congenital HHV-6 infections were asymptomatic, without the acute febrile illnesses seen with postnatal infections. It's not yet known whether congenital HHV-6 infection might cause subsequent hearing loss or developmental delay, as can happen with cytomegalovirus infection.

Uncovering Details of HHV-6 Infection

Little is known about HHV-6 infection in infants, so investigators prospectively studied 277 children from birth through the first 2 years of life, testing their saliva weekly for HHV-6 DNA and reviewing parents' logs of symptoms or signs of illness. Primary HHV-6 infection occurred in 40% by 1 year of age and in 77% by age 2 (N. Engl. J. Med. 2005;352:768–76).

Infections usually were symptomatic (associated with fever, fussiness, diarrhea, and roseola) and often resulted in a visit to a physician. Having older siblings was a risk factor for HHV-6 infection, but exposure to group child care was not. Girls were more likely than boys to get HHV-6 infection.

Varicella Vaccination Saves Lives

Universal childhood vaccination against varicella reduced deaths from varicella disease by 66%, a review of national death records found (N. Engl. J. Med. 2005; 352:450–8). Deaths for which varicella was listed as the underlying cause averaged 0.41 per 1 million people in the United States in 1990–1994 but only 0.14 per million in 1999–2001, after introduction of the varicella vaccine. The greatest reduction in mortality (92%) was seen in children aged 1–4 years, but deaths from varicella fell in all age groups.

AAP Recommends MCV4

The American Academy of Pediatrics published recommendations for administering the quadrivalent meningococcal conjugate vaccine (MCV4, marketed as Menactra), which was licensed in 2005 for use in people aged 11–55 years. The guidelines call for immunizing young adolescents (aged 11–12 years), adolescents when they reach age 15 years or enter high school (whichever comes first), and college freshmen who will be living in dormitories (Pediatrics 2005;116:496–505). Approximately 1,400–3,000 cases of invasive meningococcal disease occur each year, and 10%–14% are fatal. Survivors are left with significant sequelae in 11%–19% of cases.

Is a Meningococcal Booster Needed?

Immunity waned significantly within 2–3 years after toddlers were vaccinated with MCV4, a study of sera from 48 vaccinated and 47 unvaccinated children found (Pediatr. Infect. Dis. J. 2005;24:132–6). The vaccine was given at ages 2–3 years, and sera were tested at ages 4–5 years. Although the vaccinated children had higher antibody concentrations and more frequent passive protective activity, compared with unvaccinated children, serum antibody concentrations were sufficient in only 15% of vaccinated children.

“A booster dose may be needed in this age group for prevention of meningococcal infection,” Dr. Azimi said.

Battling Biofilms

A “tantalizing” study showed that subinhibitory concentrations of aminoglycoside antibiotics induce formation of biofilms and antibiotic resistance in Pseudomonas aeruginosa, Escherichia coli, and possibly other gram-negative organisms—“potentially contributing to some chronic or recurrent infections,” Dr. St. Geme said (Nature 2005;436:1171–5).

Biofilms are aggregates of bacterial cells that form on biotic and abiotic surfaces, including human tissue. They have been implicated in cystic fibrosis, endocarditis, urinary tract infections, osteomyelitis, and otitis media, among other infections. The study identified a P. aeruginosa gene that was essential for biofilm induction and aminoglycoside resistance related to biofilms.

“In thinking about how to apply this information, one possibility is that inhibition of this novel gene product may be beneficial in early treatment of P. aeruginosa airway infection, in particular when tobramycin aerosol is being used,” Dr. St. Geme said.

More rapid, more sensitive techniques to screen for GBS colonization are required. Dr. St. Geme

A booster dose may be needed for 4− to 5-year-olds to prevent meningococcal infection. DR. AZIMI

SAN FRANCISCO — The most important recently published articles on pediatric infectious diseases include four articles on herpes viruses and two on meningococcal vaccines, two speakers said at the annual meeting of the Infectious Diseases Society of America.

Dr. Joseph W. St. Geme III, professor of pediatrics at Duke University, Durham, N.C., and Dr. Parvin H. Azimi, director of infectious diseases at Children's Hospital, Oakland, Calif., described their picks for the most significant articles.

Getting Clinical With MRSA

Houston investigators provided clinical descriptions of the increasing number of adolescents admitted to intensive care for severe community-acquired Staphylococcus aureus infection (Pediatrics 2005;115:642–8).

“In considering pressing issues in pediatric infectious diseases, I think most of us would agree that at the top of the list, these days, is community-acquired methicillin-resistant Staph aureus” (MRSA), Dr. St. Geme said.

A review of records for a 16-month period at Texas Children's Hospital, Houston, found that 14 adolescents were admitted for sepsis and coagulopathy from community-acquired S. aureus, 12 with MRSA and 2 with methicillin-susceptible S. aureus. Thirteen patients had pulmonary involvement, and 13 had bone and/or joint infection. Of the latter group, 10 patients had infection in two or more bones or joints. Their mean age was 13 years. Three patients died.

Getting a better understanding of the factors responsible for these infections should be a priority, he said.

HSV Suppression No More

A report of a premature infant with cutaneous herpes simplex virus (HSV) disease who developed herpes encephalitis despite suppressive therapy called into question assumptions about the efficacy of oral acyclovir regimens for HSV suppression (Pediatrics 2005;115:804–9).

The authors concluded that suppressive therapy with oral acyclovir cannot be recommended at this time.

“Many of us use suppressive therapy,” Dr. Azimi said. “We really need a randomized, placebo-controlled study so we can see if it is efficacious.”

Don't Forget Early-Onset GBS

Despite a big drop in the incidence of early-onset group B streptococcal (GBS) disease since adoption of universal screening for GBS colonization, cases of early-onset GBS disease still occur, and most of these are in infants whose mothers screened negative for GBS colonization, a review of 25 cases at one hospital found (Pediatrics 2005;115:1240–6). Many of the mothers had intrapartum risk factors for neonatal infection but received no prophylactic antibiotics before delivery. Assessment of intrapartum risk factors remains important, the investigators concluded.

“In addition, this study highlights that pending the introduction of a GBS vaccine, more effective prevention of GBS disease will require more rapid, more sensitive techniques to screen for GBS colonization and GBS antibiotic resistance,” Dr. St. Geme said.

Type of Herpesvirus Matters

Congenital infections occur with human herpesvirus 6 (HHV-6) but not with the closely related human herpesvirus 7 (HHV-7), investigators reported (J. Pediatr. 2004;145:472–7). DNA tests found no HHV-7 in 2,129 cord blood samples but showed HHV-6 in 1% of 5,638 cord blood samples, similar to the rate for cytomegalovirus infection. Congenital HHV-6 infections were asymptomatic, without the acute febrile illnesses seen with postnatal infections. It's not yet known whether congenital HHV-6 infection might cause subsequent hearing loss or developmental delay, as can happen with cytomegalovirus infection.

Uncovering Details of HHV-6 Infection

Little is known about HHV-6 infection in infants, so investigators prospectively studied 277 children from birth through the first 2 years of life, testing their saliva weekly for HHV-6 DNA and reviewing parents' logs of symptoms or signs of illness. Primary HHV-6 infection occurred in 40% by 1 year of age and in 77% by age 2 (N. Engl. J. Med. 2005;352:768–76).

Infections usually were symptomatic (associated with fever, fussiness, diarrhea, and roseola) and often resulted in a visit to a physician. Having older siblings was a risk factor for HHV-6 infection, but exposure to group child care was not. Girls were more likely than boys to get HHV-6 infection.

Varicella Vaccination Saves Lives

Universal childhood vaccination against varicella reduced deaths from varicella disease by 66%, a review of national death records found (N. Engl. J. Med. 2005; 352:450–8). Deaths for which varicella was listed as the underlying cause averaged 0.41 per 1 million people in the United States in 1990–1994 but only 0.14 per million in 1999–2001, after introduction of the varicella vaccine. The greatest reduction in mortality (92%) was seen in children aged 1–4 years, but deaths from varicella fell in all age groups.

AAP Recommends MCV4

The American Academy of Pediatrics published recommendations for administering the quadrivalent meningococcal conjugate vaccine (MCV4, marketed as Menactra), which was licensed in 2005 for use in people aged 11–55 years. The guidelines call for immunizing young adolescents (aged 11–12 years), adolescents when they reach age 15 years or enter high school (whichever comes first), and college freshmen who will be living in dormitories (Pediatrics 2005;116:496–505). Approximately 1,400–3,000 cases of invasive meningococcal disease occur each year, and 10%–14% are fatal. Survivors are left with significant sequelae in 11%–19% of cases.

Is a Meningococcal Booster Needed?

Immunity waned significantly within 2–3 years after toddlers were vaccinated with MCV4, a study of sera from 48 vaccinated and 47 unvaccinated children found (Pediatr. Infect. Dis. J. 2005;24:132–6). The vaccine was given at ages 2–3 years, and sera were tested at ages 4–5 years. Although the vaccinated children had higher antibody concentrations and more frequent passive protective activity, compared with unvaccinated children, serum antibody concentrations were sufficient in only 15% of vaccinated children.

“A booster dose may be needed in this age group for prevention of meningococcal infection,” Dr. Azimi said.

Battling Biofilms

A “tantalizing” study showed that subinhibitory concentrations of aminoglycoside antibiotics induce formation of biofilms and antibiotic resistance in Pseudomonas aeruginosa, Escherichia coli, and possibly other gram-negative organisms—“potentially contributing to some chronic or recurrent infections,” Dr. St. Geme said (Nature 2005;436:1171–5).

Biofilms are aggregates of bacterial cells that form on biotic and abiotic surfaces, including human tissue. They have been implicated in cystic fibrosis, endocarditis, urinary tract infections, osteomyelitis, and otitis media, among other infections. The study identified a P. aeruginosa gene that was essential for biofilm induction and aminoglycoside resistance related to biofilms.

“In thinking about how to apply this information, one possibility is that inhibition of this novel gene product may be beneficial in early treatment of P. aeruginosa airway infection, in particular when tobramycin aerosol is being used,” Dr. St. Geme said.

More rapid, more sensitive techniques to screen for GBS colonization are required. Dr. St. Geme

A booster dose may be needed for 4− to 5-year-olds to prevent meningococcal infection. DR. AZIMI

SAN FRANCISCO — The most important recently published articles on pediatric infectious diseases include four articles on herpes viruses and two on meningococcal vaccines, two speakers said at the annual meeting of the Infectious Diseases Society of America.

Dr. Joseph W. St. Geme III, professor of pediatrics at Duke University, Durham, N.C., and Dr. Parvin H. Azimi, director of infectious diseases at Children's Hospital, Oakland, Calif., described their picks for the most significant articles.

Getting Clinical With MRSA

Houston investigators provided clinical descriptions of the increasing number of adolescents admitted to intensive care for severe community-acquired Staphylococcus aureus infection (Pediatrics 2005;115:642–8).

“In considering pressing issues in pediatric infectious diseases, I think most of us would agree that at the top of the list, these days, is community-acquired methicillin-resistant Staph aureus” (MRSA), Dr. St. Geme said.

A review of records for a 16-month period at Texas Children's Hospital, Houston, found that 14 adolescents were admitted for sepsis and coagulopathy from community-acquired S. aureus, 12 with MRSA and 2 with methicillin-susceptible S. aureus. Thirteen patients had pulmonary involvement, and 13 had bone and/or joint infection. Of the latter group, 10 patients had infection in two or more bones or joints. Their mean age was 13 years. Three patients died.

Getting a better understanding of the factors responsible for these infections should be a priority, he said.

HSV Suppression No More

A report of a premature infant with cutaneous herpes simplex virus (HSV) disease who developed herpes encephalitis despite suppressive therapy called into question assumptions about the efficacy of oral acyclovir regimens for HSV suppression (Pediatrics 2005;115:804–9).

The authors concluded that suppressive therapy with oral acyclovir cannot be recommended at this time.

“Many of us use suppressive therapy,” Dr. Azimi said. “We really need a randomized, placebo-controlled study so we can see if it is efficacious.”

Don't Forget Early-Onset GBS

Despite a big drop in the incidence of early-onset group B streptococcal (GBS) disease since adoption of universal screening for GBS colonization, cases of early-onset GBS disease still occur, and most of these are in infants whose mothers screened negative for GBS colonization, a review of 25 cases at one hospital found (Pediatrics 2005;115:1240–6). Many of the mothers had intrapartum risk factors for neonatal infection but received no prophylactic antibiotics before delivery. Assessment of intrapartum risk factors remains important, the investigators concluded.

“In addition, this study highlights that pending the introduction of a GBS vaccine, more effective prevention of GBS disease will require more rapid, more sensitive techniques to screen for GBS colonization and GBS antibiotic resistance,” Dr. St. Geme said.

Type of Herpesvirus Matters

Congenital infections occur with human herpesvirus 6 (HHV-6) but not with the closely related human herpesvirus 7 (HHV-7), investigators reported (J. Pediatr. 2004;145:472–7). DNA tests found no HHV-7 in 2,129 cord blood samples but showed HHV-6 in 1% of 5,638 cord blood samples, similar to the rate for cytomegalovirus infection. Congenital HHV-6 infections were asymptomatic, without the acute febrile illnesses seen with postnatal infections. It's not yet known whether congenital HHV-6 infection might cause subsequent hearing loss or developmental delay, as can happen with cytomegalovirus infection.

Uncovering Details of HHV-6 Infection

Little is known about HHV-6 infection in infants, so investigators prospectively studied 277 children from birth through the first 2 years of life, testing their saliva weekly for HHV-6 DNA and reviewing parents' logs of symptoms or signs of illness. Primary HHV-6 infection occurred in 40% by 1 year of age and in 77% by age 2 (N. Engl. J. Med. 2005;352:768–76).

Infections usually were symptomatic (associated with fever, fussiness, diarrhea, and roseola) and often resulted in a visit to a physician. Having older siblings was a risk factor for HHV-6 infection, but exposure to group child care was not. Girls were more likely than boys to get HHV-6 infection.

Varicella Vaccination Saves Lives

Universal childhood vaccination against varicella reduced deaths from varicella disease by 66%, a review of national death records found (N. Engl. J. Med. 2005; 352:450–8). Deaths for which varicella was listed as the underlying cause averaged 0.41 per 1 million people in the United States in 1990–1994 but only 0.14 per million in 1999–2001, after introduction of the varicella vaccine. The greatest reduction in mortality (92%) was seen in children aged 1–4 years, but deaths from varicella fell in all age groups.

AAP Recommends MCV4

The American Academy of Pediatrics published recommendations for administering the quadrivalent meningococcal conjugate vaccine (MCV4, marketed as Menactra), which was licensed in 2005 for use in people aged 11–55 years. The guidelines call for immunizing young adolescents (aged 11–12 years), adolescents when they reach age 15 years or enter high school (whichever comes first), and college freshmen who will be living in dormitories (Pediatrics 2005;116:496–505). Approximately 1,400–3,000 cases of invasive meningococcal disease occur each year, and 10%–14% are fatal. Survivors are left with significant sequelae in 11%–19% of cases.

Is a Meningococcal Booster Needed?

Immunity waned significantly within 2–3 years after toddlers were vaccinated with MCV4, a study of sera from 48 vaccinated and 47 unvaccinated children found (Pediatr. Infect. Dis. J. 2005;24:132–6). The vaccine was given at ages 2–3 years, and sera were tested at ages 4–5 years. Although the vaccinated children had higher antibody concentrations and more frequent passive protective activity, compared with unvaccinated children, serum antibody concentrations were sufficient in only 15% of vaccinated children.

“A booster dose may be needed in this age group for prevention of meningococcal infection,” Dr. Azimi said.

Battling Biofilms

A “tantalizing” study showed that subinhibitory concentrations of aminoglycoside antibiotics induce formation of biofilms and antibiotic resistance in Pseudomonas aeruginosa, Escherichia coli, and possibly other gram-negative organisms—“potentially contributing to some chronic or recurrent infections,” Dr. St. Geme said (Nature 2005;436:1171–5).

Biofilms are aggregates of bacterial cells that form on biotic and abiotic surfaces, including human tissue. They have been implicated in cystic fibrosis, endocarditis, urinary tract infections, osteomyelitis, and otitis media, among other infections. The study identified a P. aeruginosa gene that was essential for biofilm induction and aminoglycoside resistance related to biofilms.

“In thinking about how to apply this information, one possibility is that inhibition of this novel gene product may be beneficial in early treatment of P. aeruginosa airway infection, in particular when tobramycin aerosol is being used,” Dr. St. Geme said.

More rapid, more sensitive techniques to screen for GBS colonization are required. Dr. St. Geme

A booster dose may be needed for 4− to 5-year-olds to prevent meningococcal infection. DR. AZIMI