Sherry Boschert

SAN FRANCISCO — Recent data challenge the assumption that sufficient levels of calcium and vitamin D are fundamental in preventing and treating osteoporotic fracture, Eric S. Orwoll, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Calcium absorption and vitamin D levels decline with age. A number of studies over the years have solidified the idea that calcium and vitamin D supplements are effective and important in preventing osteoporosis and fractures, said Dr. Orwoll, professor of medicine at Oregon Health and Science University, Portland.

A large, well-designed study stirred up controversy when results indicated that there were no differences in the rates of repeat fractures among 5,292 patients with a previous fracture who took either calcium, vitamin D (800 IU per day), or calcium and vitamin D for nearly 5 years. By 2 years into the Randomized Evaluation of Calcium or Vitamin D (RECORD) trial, only 55% of patients were still taking the calcium and vitamin D tablets, he noted.

“This is more a compliance issue than an efficacy trial, but it's in the real world,” he said. Analysis of various subgroups could find no effects on fracture rates from the supplements.

The results contradict earlier findings. A 2003 study of 2,686 people aged 65–85 years who were vitamin D deficient found a 22% lower rate of fractures after 5 years in those who took oral vitamin D (100,000 IU every 4 months), compared with those who took placebo. A 2004 metaanalysis of five randomized, controlled trials of vitamin D for people older than 60 years found a 30% lower risk of falls in those taking vitamin D.

A 2005 metaanalysis of seven randomized trials of vitamin D supplementation containing 9,820 participants each showed that people taking higher doses (700–800 IU/day) of vitamin D had lower rates of hip fractures or any nonvertebral fractures, compared with participants who took 400 IU/day. Nearly all studies included calcium supplements (JAMA 2005;293:2257–64).

Differences between the RECORD trial and earlier trials may account in part for the conflicting findings, Dr. Orwoll said. In an earlier trial in France, 800 IU/day of vitamin D significantly reduced fracture risk, compared with placebo, in frail, elderly patients with a mean age of 85 years all of whom resided in group housing and had very low baseline levels of calcium and vitamin D (Osteoporosis Int. 2002;13:257–64).

Patients in the RECORD trial were a bit younger (mean age 77 years), had somewhat higher baseline levels of calcium and vitamin D, and were home-dwelling instead of institutionalized. “So calcium and vitamin D might show the most robust effect in the frailest patients,” he suggested.

Whether or not calcium and vitamin D supplements reduce fracture risk, and in which patients, remains to be seen, but they are necessary for maintaining bone mass and muscle function, Dr. Orwoll said. Most adults don't get enough calcium and vitamin D, and current recommendations on adequate vitamin D levels are too low, he added.

The Institute of Medicine in 1997 recommended vitamin D doses of 200 IU/day for adults aged 31–50 years, 400 IU/day for ages 51–70, and 600 IU/day for older people.

A serum level of 30–35 ng/mL of 25-hydroxyvitamin D (25[OH]D) is possibly ideal for maximizing GI absorption of calcium and to avoid elevated parathyroid levels, Dr. Orwoll noted. A recent poll of six experts suggested that much higher doses of vitamin D supplements are needed. The experts said that 1,000–1,600 IU/day vitamin D would be needed to reach serum levels of 30–32 ng/mL 25(OH)D.

“We've all had this mind-set that vitamin D is this toxic compound,” Dr. Orwoll said. “The point is to liberalize your idea of how much to recommend.” Some physicians are even suggesting that 3,000–4,000 IU/day might be appropriate, he added.

Vitamin D and calcium supplements are inexpensive and safe, so there's little reason not to use them, he said. Recommended daily calcium requirements are scientifically reasonable, even though they're based more on physiologic data than on clinical outcome studies.

Institute of Medicine guidelines in 1997 recommended calcium doses of 1,000 mg/day for adults aged 25–50, 1,200 mg/day for older adults, and 1,000–1,300 mg/day for pregnant or lactating women.

Vitamin D supplementation should be at least 800–1,000 IU/day, Dr. Orwoll said. For pure nutritional inadequacy, it may be appropriate to treat with a loading dose of 50,000 IU per week for 2 months followed by 1,000 IU/day, depending on baseline vitamin D levels, he suggested. Vitamin D deficiency due to malabsorption or increased catabolism may require doses as high as 100,000 IU/day.

Lab analyses of vitamin D in serum samples can vary widely, he cautioned. “I would tend to use a well-established reference lab rather than, say, a local lab that doesn't have as much experience with it,” he said.

SAN FRANCISCO — Recent data challenge the assumption that sufficient levels of calcium and vitamin D are fundamental in preventing and treating osteoporotic fracture, Eric S. Orwoll, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Calcium absorption and vitamin D levels decline with age. A number of studies over the years have solidified the idea that calcium and vitamin D supplements are effective and important in preventing osteoporosis and fractures, said Dr. Orwoll, professor of medicine at Oregon Health and Science University, Portland.

A large, well-designed study stirred up controversy when results indicated that there were no differences in the rates of repeat fractures among 5,292 patients with a previous fracture who took either calcium, vitamin D (800 IU per day), or calcium and vitamin D for nearly 5 years. By 2 years into the Randomized Evaluation of Calcium or Vitamin D (RECORD) trial, only 55% of patients were still taking the calcium and vitamin D tablets, he noted.

“This is more a compliance issue than an efficacy trial, but it's in the real world,” he said. Analysis of various subgroups could find no effects on fracture rates from the supplements.

The results contradict earlier findings. A 2003 study of 2,686 people aged 65–85 years who were vitamin D deficient found a 22% lower rate of fractures after 5 years in those who took oral vitamin D (100,000 IU every 4 months), compared with those who took placebo. A 2004 metaanalysis of five randomized, controlled trials of vitamin D for people older than 60 years found a 30% lower risk of falls in those taking vitamin D.

A 2005 metaanalysis of seven randomized trials of vitamin D supplementation containing 9,820 participants each showed that people taking higher doses (700–800 IU/day) of vitamin D had lower rates of hip fractures or any nonvertebral fractures, compared with participants who took 400 IU/day. Nearly all studies included calcium supplements (JAMA 2005;293:2257–64).

Differences between the RECORD trial and earlier trials may account in part for the conflicting findings, Dr. Orwoll said. In an earlier trial in France, 800 IU/day of vitamin D significantly reduced fracture risk, compared with placebo, in frail, elderly patients with a mean age of 85 years all of whom resided in group housing and had very low baseline levels of calcium and vitamin D (Osteoporosis Int. 2002;13:257–64).

Patients in the RECORD trial were a bit younger (mean age 77 years), had somewhat higher baseline levels of calcium and vitamin D, and were home-dwelling instead of institutionalized. “So calcium and vitamin D might show the most robust effect in the frailest patients,” he suggested.

Whether or not calcium and vitamin D supplements reduce fracture risk, and in which patients, remains to be seen, but they are necessary for maintaining bone mass and muscle function, Dr. Orwoll said. Most adults don't get enough calcium and vitamin D, and current recommendations on adequate vitamin D levels are too low, he added.

The Institute of Medicine in 1997 recommended vitamin D doses of 200 IU/day for adults aged 31–50 years, 400 IU/day for ages 51–70, and 600 IU/day for older people.

A serum level of 30–35 ng/mL of 25-hydroxyvitamin D (25[OH]D) is possibly ideal for maximizing GI absorption of calcium and to avoid elevated parathyroid levels, Dr. Orwoll noted. A recent poll of six experts suggested that much higher doses of vitamin D supplements are needed. The experts said that 1,000–1,600 IU/day vitamin D would be needed to reach serum levels of 30–32 ng/mL 25(OH)D.

“We've all had this mind-set that vitamin D is this toxic compound,” Dr. Orwoll said. “The point is to liberalize your idea of how much to recommend.” Some physicians are even suggesting that 3,000–4,000 IU/day might be appropriate, he added.

Vitamin D and calcium supplements are inexpensive and safe, so there's little reason not to use them, he said. Recommended daily calcium requirements are scientifically reasonable, even though they're based more on physiologic data than on clinical outcome studies.

Institute of Medicine guidelines in 1997 recommended calcium doses of 1,000 mg/day for adults aged 25–50, 1,200 mg/day for older adults, and 1,000–1,300 mg/day for pregnant or lactating women.

Vitamin D supplementation should be at least 800–1,000 IU/day, Dr. Orwoll said. For pure nutritional inadequacy, it may be appropriate to treat with a loading dose of 50,000 IU per week for 2 months followed by 1,000 IU/day, depending on baseline vitamin D levels, he suggested. Vitamin D deficiency due to malabsorption or increased catabolism may require doses as high as 100,000 IU/day.

Lab analyses of vitamin D in serum samples can vary widely, he cautioned. “I would tend to use a well-established reference lab rather than, say, a local lab that doesn't have as much experience with it,” he said.

SAN FRANCISCO — Recent data challenge the assumption that sufficient levels of calcium and vitamin D are fundamental in preventing and treating osteoporotic fracture, Eric S. Orwoll, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Calcium absorption and vitamin D levels decline with age. A number of studies over the years have solidified the idea that calcium and vitamin D supplements are effective and important in preventing osteoporosis and fractures, said Dr. Orwoll, professor of medicine at Oregon Health and Science University, Portland.

A large, well-designed study stirred up controversy when results indicated that there were no differences in the rates of repeat fractures among 5,292 patients with a previous fracture who took either calcium, vitamin D (800 IU per day), or calcium and vitamin D for nearly 5 years. By 2 years into the Randomized Evaluation of Calcium or Vitamin D (RECORD) trial, only 55% of patients were still taking the calcium and vitamin D tablets, he noted.

“This is more a compliance issue than an efficacy trial, but it's in the real world,” he said. Analysis of various subgroups could find no effects on fracture rates from the supplements.

The results contradict earlier findings. A 2003 study of 2,686 people aged 65–85 years who were vitamin D deficient found a 22% lower rate of fractures after 5 years in those who took oral vitamin D (100,000 IU every 4 months), compared with those who took placebo. A 2004 metaanalysis of five randomized, controlled trials of vitamin D for people older than 60 years found a 30% lower risk of falls in those taking vitamin D.

A 2005 metaanalysis of seven randomized trials of vitamin D supplementation containing 9,820 participants each showed that people taking higher doses (700–800 IU/day) of vitamin D had lower rates of hip fractures or any nonvertebral fractures, compared with participants who took 400 IU/day. Nearly all studies included calcium supplements (JAMA 2005;293:2257–64).

Differences between the RECORD trial and earlier trials may account in part for the conflicting findings, Dr. Orwoll said. In an earlier trial in France, 800 IU/day of vitamin D significantly reduced fracture risk, compared with placebo, in frail, elderly patients with a mean age of 85 years all of whom resided in group housing and had very low baseline levels of calcium and vitamin D (Osteoporosis Int. 2002;13:257–64).

Patients in the RECORD trial were a bit younger (mean age 77 years), had somewhat higher baseline levels of calcium and vitamin D, and were home-dwelling instead of institutionalized. “So calcium and vitamin D might show the most robust effect in the frailest patients,” he suggested.

Whether or not calcium and vitamin D supplements reduce fracture risk, and in which patients, remains to be seen, but they are necessary for maintaining bone mass and muscle function, Dr. Orwoll said. Most adults don't get enough calcium and vitamin D, and current recommendations on adequate vitamin D levels are too low, he added.

The Institute of Medicine in 1997 recommended vitamin D doses of 200 IU/day for adults aged 31–50 years, 400 IU/day for ages 51–70, and 600 IU/day for older people.

A serum level of 30–35 ng/mL of 25-hydroxyvitamin D (25[OH]D) is possibly ideal for maximizing GI absorption of calcium and to avoid elevated parathyroid levels, Dr. Orwoll noted. A recent poll of six experts suggested that much higher doses of vitamin D supplements are needed. The experts said that 1,000–1,600 IU/day vitamin D would be needed to reach serum levels of 30–32 ng/mL 25(OH)D.

“We've all had this mind-set that vitamin D is this toxic compound,” Dr. Orwoll said. “The point is to liberalize your idea of how much to recommend.” Some physicians are even suggesting that 3,000–4,000 IU/day might be appropriate, he added.

Vitamin D and calcium supplements are inexpensive and safe, so there's little reason not to use them, he said. Recommended daily calcium requirements are scientifically reasonable, even though they're based more on physiologic data than on clinical outcome studies.

Institute of Medicine guidelines in 1997 recommended calcium doses of 1,000 mg/day for adults aged 25–50, 1,200 mg/day for older adults, and 1,000–1,300 mg/day for pregnant or lactating women.

Vitamin D supplementation should be at least 800–1,000 IU/day, Dr. Orwoll said. For pure nutritional inadequacy, it may be appropriate to treat with a loading dose of 50,000 IU per week for 2 months followed by 1,000 IU/day, depending on baseline vitamin D levels, he suggested. Vitamin D deficiency due to malabsorption or increased catabolism may require doses as high as 100,000 IU/day.

Lab analyses of vitamin D in serum samples can vary widely, he cautioned. “I would tend to use a well-established reference lab rather than, say, a local lab that doesn't have as much experience with it,” he said.

STANFORD, CALIF. — Adults or children whose symptoms of gastroesophageal reflux disease continue despite treatment may have allergic eosinophilic esophagitis, John A. Kerner Jr., M.D., said at a conference on perinatal and pediatric nutrition.

An esophageal biopsy will show major eosinophilic infiltration of the mucosa and submucosa in a patient with allergic eosinophilic esophagitis. The proteins that are implicated in this disorder come from the “usual suspects” in the diet—cow's milk, wheat, soy, peanut, or egg, said Dr. Kerner, professor of pediatrics and director of nutrition at Stanford (Calif.) University Medical Center.

Allergic eosinophilic esophagitis can begin anytime from infancy to adolescence. “More and more of the adult literature is pointing out that patients have been missed with this disorder,” Dr. Kerner said.

Treatment consists of avoiding the antigens, if they can be identified, switching infants to an elemental formula, and possibly using steroids. Often multiple antigens are involved, with poor correlation with skin tests for allergy, he added.

First identified in a landmark 1995 study of 10 children, allergic eosinophilic esophagitis produces symptoms that look like chronic gastroesophageal reflux disease (GERD). The child may refuse food, fail to thrive, vomit, have abdominal pain, be irritable, and have difficulty sleeping. Symptoms return despite treatment with histamine₂-receptor blockers or even fundoplication. Serum IgE levels are normal or slightly elevated, and peripheral eosinophils are uncommon in allergic eosinophilic esophagitis.

Older children and adults who have had allergic eosinophilic esophagitis for some time commonly turn up in emergency departments or clinics with esophageal stricture. Biopsies will show “sheets” of eosinophils in these patients. Seeing more than 20 eosinophils per high-power field in a biopsy is a “classic count” for diagnosing allergic eosinophilic esophagitis, although there is some debate about the exact number needed for diagnosis, Dr. Kerner said at the meeting, jointly sponsored by Symposia Medicus and Stanford University.

Endoscopy will show little circular rings that can be “fairly dramatic” and white plaques composed of eosinophilic complexes.

Restricting consumption of cow's milk will resolve symptoms in about 80% of cases. In infants with allergic eosinophilic esophagitis, 80% will improve after switching to a hydrolyzed protein formula such as Alimentum or Nutramigen. Those infants who do not respond usually do well when switched to an L-amino acid formula. Breast-fed infants with eczema and allergic eosinophilic esophagitis usually need an L-amino acid formula, Dr. Kerner said.

An inhaled steroid will alleviate acute symptoms, but they recur when the inhaled treatment is stopped. Dr. Kerner said he prefers prescribing both inhaled and topical forms. Oral steroids for a systemic effect also are an option, he said.

The first published study of allergic eosinophilic esophagitis described 10 children diagnosed with GERD whose symptoms persisted despite separate treatments with five antireflux therapies, including Nissen fundoplication in six patients.

After 6 weeks on an L-amino acid-based formula (Neocate or Neocate One), eight patients had no symptoms, and symptoms improved in the other two patients. Esophageal biopsies before and after the 6 weeks of treatment showed that intraepithelial eosinophil counts decreased significantly, from a median of 41 per high-power field to less than 1 per high-power field (Gastroenterology 1995;109:1503–12).

Symptoms returned in all patients, however, after open food challenges. “This is a real disorder,” Dr. Kerner said.

The study showed that chronic GI symptoms and histologic changes of the esophagus that were unresponsive to standard GERD treatments could be improved by using an elemental formula. “This was a breakthrough,” he said.

STANFORD, CALIF. — Adults or children whose symptoms of gastroesophageal reflux disease continue despite treatment may have allergic eosinophilic esophagitis, John A. Kerner Jr., M.D., said at a conference on perinatal and pediatric nutrition.

An esophageal biopsy will show major eosinophilic infiltration of the mucosa and submucosa in a patient with allergic eosinophilic esophagitis. The proteins that are implicated in this disorder come from the “usual suspects” in the diet—cow's milk, wheat, soy, peanut, or egg, said Dr. Kerner, professor of pediatrics and director of nutrition at Stanford (Calif.) University Medical Center.

Allergic eosinophilic esophagitis can begin anytime from infancy to adolescence. “More and more of the adult literature is pointing out that patients have been missed with this disorder,” Dr. Kerner said.

Treatment consists of avoiding the antigens, if they can be identified, switching infants to an elemental formula, and possibly using steroids. Often multiple antigens are involved, with poor correlation with skin tests for allergy, he added.

First identified in a landmark 1995 study of 10 children, allergic eosinophilic esophagitis produces symptoms that look like chronic gastroesophageal reflux disease (GERD). The child may refuse food, fail to thrive, vomit, have abdominal pain, be irritable, and have difficulty sleeping. Symptoms return despite treatment with histamine₂-receptor blockers or even fundoplication. Serum IgE levels are normal or slightly elevated, and peripheral eosinophils are uncommon in allergic eosinophilic esophagitis.

Older children and adults who have had allergic eosinophilic esophagitis for some time commonly turn up in emergency departments or clinics with esophageal stricture. Biopsies will show “sheets” of eosinophils in these patients. Seeing more than 20 eosinophils per high-power field in a biopsy is a “classic count” for diagnosing allergic eosinophilic esophagitis, although there is some debate about the exact number needed for diagnosis, Dr. Kerner said at the meeting, jointly sponsored by Symposia Medicus and Stanford University.

Endoscopy will show little circular rings that can be “fairly dramatic” and white plaques composed of eosinophilic complexes.

Restricting consumption of cow's milk will resolve symptoms in about 80% of cases. In infants with allergic eosinophilic esophagitis, 80% will improve after switching to a hydrolyzed protein formula such as Alimentum or Nutramigen. Those infants who do not respond usually do well when switched to an L-amino acid formula. Breast-fed infants with eczema and allergic eosinophilic esophagitis usually need an L-amino acid formula, Dr. Kerner said.

An inhaled steroid will alleviate acute symptoms, but they recur when the inhaled treatment is stopped. Dr. Kerner said he prefers prescribing both inhaled and topical forms. Oral steroids for a systemic effect also are an option, he said.

The first published study of allergic eosinophilic esophagitis described 10 children diagnosed with GERD whose symptoms persisted despite separate treatments with five antireflux therapies, including Nissen fundoplication in six patients.

After 6 weeks on an L-amino acid-based formula (Neocate or Neocate One), eight patients had no symptoms, and symptoms improved in the other two patients. Esophageal biopsies before and after the 6 weeks of treatment showed that intraepithelial eosinophil counts decreased significantly, from a median of 41 per high-power field to less than 1 per high-power field (Gastroenterology 1995;109:1503–12).

Symptoms returned in all patients, however, after open food challenges. “This is a real disorder,” Dr. Kerner said.

The study showed that chronic GI symptoms and histologic changes of the esophagus that were unresponsive to standard GERD treatments could be improved by using an elemental formula. “This was a breakthrough,” he said.

STANFORD, CALIF. — Adults or children whose symptoms of gastroesophageal reflux disease continue despite treatment may have allergic eosinophilic esophagitis, John A. Kerner Jr., M.D., said at a conference on perinatal and pediatric nutrition.

An esophageal biopsy will show major eosinophilic infiltration of the mucosa and submucosa in a patient with allergic eosinophilic esophagitis. The proteins that are implicated in this disorder come from the “usual suspects” in the diet—cow's milk, wheat, soy, peanut, or egg, said Dr. Kerner, professor of pediatrics and director of nutrition at Stanford (Calif.) University Medical Center.

Allergic eosinophilic esophagitis can begin anytime from infancy to adolescence. “More and more of the adult literature is pointing out that patients have been missed with this disorder,” Dr. Kerner said.

Treatment consists of avoiding the antigens, if they can be identified, switching infants to an elemental formula, and possibly using steroids. Often multiple antigens are involved, with poor correlation with skin tests for allergy, he added.

First identified in a landmark 1995 study of 10 children, allergic eosinophilic esophagitis produces symptoms that look like chronic gastroesophageal reflux disease (GERD). The child may refuse food, fail to thrive, vomit, have abdominal pain, be irritable, and have difficulty sleeping. Symptoms return despite treatment with histamine₂-receptor blockers or even fundoplication. Serum IgE levels are normal or slightly elevated, and peripheral eosinophils are uncommon in allergic eosinophilic esophagitis.

Older children and adults who have had allergic eosinophilic esophagitis for some time commonly turn up in emergency departments or clinics with esophageal stricture. Biopsies will show “sheets” of eosinophils in these patients. Seeing more than 20 eosinophils per high-power field in a biopsy is a “classic count” for diagnosing allergic eosinophilic esophagitis, although there is some debate about the exact number needed for diagnosis, Dr. Kerner said at the meeting, jointly sponsored by Symposia Medicus and Stanford University.

Endoscopy will show little circular rings that can be “fairly dramatic” and white plaques composed of eosinophilic complexes.

Restricting consumption of cow's milk will resolve symptoms in about 80% of cases. In infants with allergic eosinophilic esophagitis, 80% will improve after switching to a hydrolyzed protein formula such as Alimentum or Nutramigen. Those infants who do not respond usually do well when switched to an L-amino acid formula. Breast-fed infants with eczema and allergic eosinophilic esophagitis usually need an L-amino acid formula, Dr. Kerner said.

An inhaled steroid will alleviate acute symptoms, but they recur when the inhaled treatment is stopped. Dr. Kerner said he prefers prescribing both inhaled and topical forms. Oral steroids for a systemic effect also are an option, he said.

The first published study of allergic eosinophilic esophagitis described 10 children diagnosed with GERD whose symptoms persisted despite separate treatments with five antireflux therapies, including Nissen fundoplication in six patients.

After 6 weeks on an L-amino acid-based formula (Neocate or Neocate One), eight patients had no symptoms, and symptoms improved in the other two patients. Esophageal biopsies before and after the 6 weeks of treatment showed that intraepithelial eosinophil counts decreased significantly, from a median of 41 per high-power field to less than 1 per high-power field (Gastroenterology 1995;109:1503–12).

Symptoms returned in all patients, however, after open food challenges. “This is a real disorder,” Dr. Kerner said.

The study showed that chronic GI symptoms and histologic changes of the esophagus that were unresponsive to standard GERD treatments could be improved by using an elemental formula. “This was a breakthrough,” he said.

SAN FRANCISCO — New data for the first time support assumptions that home monitoring improves blood pressure control because of better adherence to antihypertensive therapy, Gbenga Ogedegbe, M.D., said at the annual meeting of the American Society of Hypertension.

Previous reports showed better control in hypertensive patients performing home blood pressure monitoring, compared with patients monitored in physicians' offices, and clinicians assumed this was due to better adherence to therapy with home monitoring.

The current data—part of a larger and longer study—came from patients with uncontrolled blood pressure on one or more antihypertensive medications who were randomized to home blood pressure monitoring (118 patients) or usual care in offices (60 patients) for 12 weeks. Investigators assessed adherence to therapy using the well-validated Morisky questionnaire, said Dr. Ogedegbe of Columbia University, New York.

At baseline, 47% of patients in the home monitoring group and 65% in the usual care group reported being adherent to therapy, a difference that was not statistically significant.

In the home monitoring group, the patients took their blood pressure three times per week on average, usually at different times of the day, using a “life-link” monitoring system that gave them immediate feedback on their blood pressure control (or lack of it) and electronically sent a report to their physicians.

At follow-up 12 weeks later, patients were asked four questions that have been shown to predict the likelihood of blood pressure control: In the past 4 weeks, have you been careless about taking your blood pressure medication? In the past 4 weeks, have you forgotten to take your blood pressure medication? Do you stop taking the medication when you feel better? Do you stop taking the medication when you feel worse, from side effects? Patients who answered “yes” to any of the questions were considered nonadherent to therapy.

In the home monitoring group, 31% went from being nonadherent at baseline to adherent with therapy at 12 weeks, compared with 12% of patients in the usual care group, a significant difference.

Patients in the home monitoring group were less likely to move from adherent to nonadherent (12%), compared with the usual care group (18%). The rest did not change adherence patterns.

The study was not large enough to detect any significant changes in blood pressure, Dr. Ogedegbe said.

SAN FRANCISCO — New data for the first time support assumptions that home monitoring improves blood pressure control because of better adherence to antihypertensive therapy, Gbenga Ogedegbe, M.D., said at the annual meeting of the American Society of Hypertension.

Previous reports showed better control in hypertensive patients performing home blood pressure monitoring, compared with patients monitored in physicians' offices, and clinicians assumed this was due to better adherence to therapy with home monitoring.

The current data—part of a larger and longer study—came from patients with uncontrolled blood pressure on one or more antihypertensive medications who were randomized to home blood pressure monitoring (118 patients) or usual care in offices (60 patients) for 12 weeks. Investigators assessed adherence to therapy using the well-validated Morisky questionnaire, said Dr. Ogedegbe of Columbia University, New York.

At baseline, 47% of patients in the home monitoring group and 65% in the usual care group reported being adherent to therapy, a difference that was not statistically significant.

In the home monitoring group, the patients took their blood pressure three times per week on average, usually at different times of the day, using a “life-link” monitoring system that gave them immediate feedback on their blood pressure control (or lack of it) and electronically sent a report to their physicians.

At follow-up 12 weeks later, patients were asked four questions that have been shown to predict the likelihood of blood pressure control: In the past 4 weeks, have you been careless about taking your blood pressure medication? In the past 4 weeks, have you forgotten to take your blood pressure medication? Do you stop taking the medication when you feel better? Do you stop taking the medication when you feel worse, from side effects? Patients who answered “yes” to any of the questions were considered nonadherent to therapy.

In the home monitoring group, 31% went from being nonadherent at baseline to adherent with therapy at 12 weeks, compared with 12% of patients in the usual care group, a significant difference.

Patients in the home monitoring group were less likely to move from adherent to nonadherent (12%), compared with the usual care group (18%). The rest did not change adherence patterns.

The study was not large enough to detect any significant changes in blood pressure, Dr. Ogedegbe said.

SAN FRANCISCO — New data for the first time support assumptions that home monitoring improves blood pressure control because of better adherence to antihypertensive therapy, Gbenga Ogedegbe, M.D., said at the annual meeting of the American Society of Hypertension.

Previous reports showed better control in hypertensive patients performing home blood pressure monitoring, compared with patients monitored in physicians' offices, and clinicians assumed this was due to better adherence to therapy with home monitoring.

The current data—part of a larger and longer study—came from patients with uncontrolled blood pressure on one or more antihypertensive medications who were randomized to home blood pressure monitoring (118 patients) or usual care in offices (60 patients) for 12 weeks. Investigators assessed adherence to therapy using the well-validated Morisky questionnaire, said Dr. Ogedegbe of Columbia University, New York.

At baseline, 47% of patients in the home monitoring group and 65% in the usual care group reported being adherent to therapy, a difference that was not statistically significant.

In the home monitoring group, the patients took their blood pressure three times per week on average, usually at different times of the day, using a “life-link” monitoring system that gave them immediate feedback on their blood pressure control (or lack of it) and electronically sent a report to their physicians.

At follow-up 12 weeks later, patients were asked four questions that have been shown to predict the likelihood of blood pressure control: In the past 4 weeks, have you been careless about taking your blood pressure medication? In the past 4 weeks, have you forgotten to take your blood pressure medication? Do you stop taking the medication when you feel better? Do you stop taking the medication when you feel worse, from side effects? Patients who answered “yes” to any of the questions were considered nonadherent to therapy.

In the home monitoring group, 31% went from being nonadherent at baseline to adherent with therapy at 12 weeks, compared with 12% of patients in the usual care group, a significant difference.

Patients in the home monitoring group were less likely to move from adherent to nonadherent (12%), compared with the usual care group (18%). The rest did not change adherence patterns.

The study was not large enough to detect any significant changes in blood pressure, Dr. Ogedegbe said.

SAN FRANCISCO — Recent data challenge the long-standing assumption that sufficient levels of calcium and vitamin D are fundamental in preventing and treating osteoporotic fracture, Eric S. Orwoll, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Calcium absorption and vitamin D levels decline with age. A number of studies over the years have solidified the idea that calcium and vitamin D supplements are effective and important in preventing osteoporosis and fractures, said Dr. Orwoll, who is professor of medicine at Oregon Health and Science University, Portland.

A large, well-designed study stirred up controversy when results indicated that there were no differences in the rates of repeat fractures among 5,292 patients with a previous fracture who took either calcium, vitamin D (800 IU per day), or calcium and vitamin D for nearly 5 years.

Among the total, 698 (13%) sustained a new low-trauma fracture. Of these 183 (26%) were hip fractures (Lancet 2005;365:1621–8).

Investigators observed no significant differences in the incidence of new, low-trauma fractures between patients who received calcium and those who did not (12.6% vs. 13.7%); between those who received vitamin D and those who did not (13.3% vs. 13.1%); or between patients who received combination treatment and those who received placebo (12.6% vs. 13.4%).

By 2 years into the Randomized Evaluation of Calcium or Vitamin D (RECORD) trial, only 55% of patients were still taking the calcium and vitamin D tablets, he noted during the meeting.

“This is more a compliance issue than an efficacy trial, but it's in the real world,” he said. Analysis of various subgroups could find no effects on fracture rates from the supplements.

The results contradict earlier findings. A 2003 study of 2,686 people aged 65–85 years who were vitamin D deficient found a 22% lower rate of fractures after 5 years in those who took oral vitamin D (100,000 IU every 4 months), compared with those who took placebo.

A 2004 metaanalysis of five randomized, controlled trials of vitamin D for people older than 60 years found a 30% lower risk of falls in those patients taking vitamin D.

A 2005 metaanalysis of seven randomized trials of vitamin D supplementation containing 9,820 participants each showed that people taking higher doses (700–800 IU/day) of vitamin D had lower rates of hip fractures or any nonvertebral fractures, compared with participants who took 400 IU/day. Nearly all the studies included calcium supplements (JAMA 2005;293:2257–64).

Differences between the RECORD trial and earlier trials may account in part for the conflicting findings, Dr. Orwoll said. In an earlier trial in France, 800 IU/day of vitamin D significantly reduced fracture risk, compared with placebo, in frail, elderly patients with a mean age of 85 years, all of whom resided in group housing and had very low baseline levels of calcium and vitamin D (Osteoporosis Int. 2002;13:257–64).

Patients in the RECORD trial were a bit younger (mean age 77 years), had somewhat higher baseline levels of calcium and vitamin D, and were home-dwelling instead of institutionalized.

“So calcium and vitamin D might show the most robust effect in the frailest patients,” he suggested.

Whether or not calcium and vitamin D supplements reduce fracture risk, and in which patients, remains to be seen, but they are necessary for maintaining bone mass and muscle function, Dr. Orwoll said. Most adults don't get enough calcium and vitamin D, and current recommendations on adequate vitamin D levels are too low, he added.

The Institute of Medicine in 1997 recommended vitamin D doses of 200 IU/day for adults aged 31–50 years, 400 IU/day for adults aged 51–70, and 600 IU/day for older people.

A serum level of 30–35 ng/mL of 25-hydroxyvitamin D (25[OH]D) is possibly ideal for maximizing GI absorption of calcium and to avoid elevated parathyroid levels, Dr. Orwoll noted.

A recent poll of six experts suggested that much higher doses of vitamin D supplements are needed to reach those levels. The experts said 1,000–1,600 IU/day of vitamin D would be needed to reach serum levels of 30–32 ng/mL of 25(OH)D.

“We've all had this mind-set that vitamin D is this toxic compound,” Dr. Orwoll said. “The point is to liberalize your idea of how much to recommend.” Some physicians are even suggesting that 3,000–4,000 IU/day might be appropriate, he added.

Vitamin D and calcium supplements are inexpensive and safe, so there's little reason not to use them, he said. Recommended daily calcium requirements are scientifically reasonable, even though they're based more on physiologic data than on clinical outcome studies.

Institute of Medicine guidelines in 1997 recommended calcium doses of 1,000 mg/day for adults aged 25–50, 1,200 mg/day for older adults, and 1,000–1,300 mg/day for pregnant or lactating women.

Vitamin D supplementation should be at least 800–1,000 IU/day, Dr. Orwoll said. For pure nutritional inadequacy, it may be appropriate to treat with a loading dose of 50,000 IU per week for 2 months followed by 1,000 IU/day, depending on baseline vitamin D levels, he suggested. Vitamin D deficiency due to malabsorption or increased catabolism may require doses as high as 100,000 IU/day.

Lab analyses of vitamin D in serum samples can vary widely, he cautioned. “I would tend to use a well-established reference lab rather than, say, a local lab that doesn't have as much experience with it,” he said.

SAN FRANCISCO — Recent data challenge the long-standing assumption that sufficient levels of calcium and vitamin D are fundamental in preventing and treating osteoporotic fracture, Eric S. Orwoll, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Calcium absorption and vitamin D levels decline with age. A number of studies over the years have solidified the idea that calcium and vitamin D supplements are effective and important in preventing osteoporosis and fractures, said Dr. Orwoll, who is professor of medicine at Oregon Health and Science University, Portland.

A large, well-designed study stirred up controversy when results indicated that there were no differences in the rates of repeat fractures among 5,292 patients with a previous fracture who took either calcium, vitamin D (800 IU per day), or calcium and vitamin D for nearly 5 years.

Among the total, 698 (13%) sustained a new low-trauma fracture. Of these 183 (26%) were hip fractures (Lancet 2005;365:1621–8).

Investigators observed no significant differences in the incidence of new, low-trauma fractures between patients who received calcium and those who did not (12.6% vs. 13.7%); between those who received vitamin D and those who did not (13.3% vs. 13.1%); or between patients who received combination treatment and those who received placebo (12.6% vs. 13.4%).

By 2 years into the Randomized Evaluation of Calcium or Vitamin D (RECORD) trial, only 55% of patients were still taking the calcium and vitamin D tablets, he noted during the meeting.

“This is more a compliance issue than an efficacy trial, but it's in the real world,” he said. Analysis of various subgroups could find no effects on fracture rates from the supplements.

The results contradict earlier findings. A 2003 study of 2,686 people aged 65–85 years who were vitamin D deficient found a 22% lower rate of fractures after 5 years in those who took oral vitamin D (100,000 IU every 4 months), compared with those who took placebo.

A 2004 metaanalysis of five randomized, controlled trials of vitamin D for people older than 60 years found a 30% lower risk of falls in those patients taking vitamin D.

A 2005 metaanalysis of seven randomized trials of vitamin D supplementation containing 9,820 participants each showed that people taking higher doses (700–800 IU/day) of vitamin D had lower rates of hip fractures or any nonvertebral fractures, compared with participants who took 400 IU/day. Nearly all the studies included calcium supplements (JAMA 2005;293:2257–64).

Differences between the RECORD trial and earlier trials may account in part for the conflicting findings, Dr. Orwoll said. In an earlier trial in France, 800 IU/day of vitamin D significantly reduced fracture risk, compared with placebo, in frail, elderly patients with a mean age of 85 years, all of whom resided in group housing and had very low baseline levels of calcium and vitamin D (Osteoporosis Int. 2002;13:257–64).

Patients in the RECORD trial were a bit younger (mean age 77 years), had somewhat higher baseline levels of calcium and vitamin D, and were home-dwelling instead of institutionalized.

“So calcium and vitamin D might show the most robust effect in the frailest patients,” he suggested.

Whether or not calcium and vitamin D supplements reduce fracture risk, and in which patients, remains to be seen, but they are necessary for maintaining bone mass and muscle function, Dr. Orwoll said. Most adults don't get enough calcium and vitamin D, and current recommendations on adequate vitamin D levels are too low, he added.

The Institute of Medicine in 1997 recommended vitamin D doses of 200 IU/day for adults aged 31–50 years, 400 IU/day for adults aged 51–70, and 600 IU/day for older people.

A serum level of 30–35 ng/mL of 25-hydroxyvitamin D (25[OH]D) is possibly ideal for maximizing GI absorption of calcium and to avoid elevated parathyroid levels, Dr. Orwoll noted.

A recent poll of six experts suggested that much higher doses of vitamin D supplements are needed to reach those levels. The experts said 1,000–1,600 IU/day of vitamin D would be needed to reach serum levels of 30–32 ng/mL of 25(OH)D.

“We've all had this mind-set that vitamin D is this toxic compound,” Dr. Orwoll said. “The point is to liberalize your idea of how much to recommend.” Some physicians are even suggesting that 3,000–4,000 IU/day might be appropriate, he added.

Vitamin D and calcium supplements are inexpensive and safe, so there's little reason not to use them, he said. Recommended daily calcium requirements are scientifically reasonable, even though they're based more on physiologic data than on clinical outcome studies.

Institute of Medicine guidelines in 1997 recommended calcium doses of 1,000 mg/day for adults aged 25–50, 1,200 mg/day for older adults, and 1,000–1,300 mg/day for pregnant or lactating women.

Vitamin D supplementation should be at least 800–1,000 IU/day, Dr. Orwoll said. For pure nutritional inadequacy, it may be appropriate to treat with a loading dose of 50,000 IU per week for 2 months followed by 1,000 IU/day, depending on baseline vitamin D levels, he suggested. Vitamin D deficiency due to malabsorption or increased catabolism may require doses as high as 100,000 IU/day.

Lab analyses of vitamin D in serum samples can vary widely, he cautioned. “I would tend to use a well-established reference lab rather than, say, a local lab that doesn't have as much experience with it,” he said.

SAN FRANCISCO — Recent data challenge the long-standing assumption that sufficient levels of calcium and vitamin D are fundamental in preventing and treating osteoporotic fracture, Eric S. Orwoll, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Calcium absorption and vitamin D levels decline with age. A number of studies over the years have solidified the idea that calcium and vitamin D supplements are effective and important in preventing osteoporosis and fractures, said Dr. Orwoll, who is professor of medicine at Oregon Health and Science University, Portland.

A large, well-designed study stirred up controversy when results indicated that there were no differences in the rates of repeat fractures among 5,292 patients with a previous fracture who took either calcium, vitamin D (800 IU per day), or calcium and vitamin D for nearly 5 years.

Among the total, 698 (13%) sustained a new low-trauma fracture. Of these 183 (26%) were hip fractures (Lancet 2005;365:1621–8).

Investigators observed no significant differences in the incidence of new, low-trauma fractures between patients who received calcium and those who did not (12.6% vs. 13.7%); between those who received vitamin D and those who did not (13.3% vs. 13.1%); or between patients who received combination treatment and those who received placebo (12.6% vs. 13.4%).

By 2 years into the Randomized Evaluation of Calcium or Vitamin D (RECORD) trial, only 55% of patients were still taking the calcium and vitamin D tablets, he noted during the meeting.

“This is more a compliance issue than an efficacy trial, but it's in the real world,” he said. Analysis of various subgroups could find no effects on fracture rates from the supplements.

The results contradict earlier findings. A 2003 study of 2,686 people aged 65–85 years who were vitamin D deficient found a 22% lower rate of fractures after 5 years in those who took oral vitamin D (100,000 IU every 4 months), compared with those who took placebo.

A 2004 metaanalysis of five randomized, controlled trials of vitamin D for people older than 60 years found a 30% lower risk of falls in those patients taking vitamin D.

A 2005 metaanalysis of seven randomized trials of vitamin D supplementation containing 9,820 participants each showed that people taking higher doses (700–800 IU/day) of vitamin D had lower rates of hip fractures or any nonvertebral fractures, compared with participants who took 400 IU/day. Nearly all the studies included calcium supplements (JAMA 2005;293:2257–64).

Differences between the RECORD trial and earlier trials may account in part for the conflicting findings, Dr. Orwoll said. In an earlier trial in France, 800 IU/day of vitamin D significantly reduced fracture risk, compared with placebo, in frail, elderly patients with a mean age of 85 years, all of whom resided in group housing and had very low baseline levels of calcium and vitamin D (Osteoporosis Int. 2002;13:257–64).

Patients in the RECORD trial were a bit younger (mean age 77 years), had somewhat higher baseline levels of calcium and vitamin D, and were home-dwelling instead of institutionalized.

“So calcium and vitamin D might show the most robust effect in the frailest patients,” he suggested.

Whether or not calcium and vitamin D supplements reduce fracture risk, and in which patients, remains to be seen, but they are necessary for maintaining bone mass and muscle function, Dr. Orwoll said. Most adults don't get enough calcium and vitamin D, and current recommendations on adequate vitamin D levels are too low, he added.

The Institute of Medicine in 1997 recommended vitamin D doses of 200 IU/day for adults aged 31–50 years, 400 IU/day for adults aged 51–70, and 600 IU/day for older people.

A serum level of 30–35 ng/mL of 25-hydroxyvitamin D (25[OH]D) is possibly ideal for maximizing GI absorption of calcium and to avoid elevated parathyroid levels, Dr. Orwoll noted.

A recent poll of six experts suggested that much higher doses of vitamin D supplements are needed to reach those levels. The experts said 1,000–1,600 IU/day of vitamin D would be needed to reach serum levels of 30–32 ng/mL of 25(OH)D.

“We've all had this mind-set that vitamin D is this toxic compound,” Dr. Orwoll said. “The point is to liberalize your idea of how much to recommend.” Some physicians are even suggesting that 3,000–4,000 IU/day might be appropriate, he added.

Vitamin D and calcium supplements are inexpensive and safe, so there's little reason not to use them, he said. Recommended daily calcium requirements are scientifically reasonable, even though they're based more on physiologic data than on clinical outcome studies.

Institute of Medicine guidelines in 1997 recommended calcium doses of 1,000 mg/day for adults aged 25–50, 1,200 mg/day for older adults, and 1,000–1,300 mg/day for pregnant or lactating women.

Vitamin D supplementation should be at least 800–1,000 IU/day, Dr. Orwoll said. For pure nutritional inadequacy, it may be appropriate to treat with a loading dose of 50,000 IU per week for 2 months followed by 1,000 IU/day, depending on baseline vitamin D levels, he suggested. Vitamin D deficiency due to malabsorption or increased catabolism may require doses as high as 100,000 IU/day.

Lab analyses of vitamin D in serum samples can vary widely, he cautioned. “I would tend to use a well-established reference lab rather than, say, a local lab that doesn't have as much experience with it,” he said.

SAN DIEGO — A pregnant woman successfully delivered twins at term after undergoing laparoscopic cholecystectomy for symptomatic gall bladder disease during the first trimester, Kathy Gohar, M.D., said.

Cholecystectomy is one of the most common nonobstetric surgeries performed during pregnancy, but limited experience with the relatively new laparoscopic approach makes it controversial. About 10%–40% of patients with symptomatic gallstone disease require surgical treatment, said Dr. Gohar of Albert Einstein Medical Center, Philadelphia, and her associates.

Potential advantages of laparoscopic cholecystectomy include less need for narcotics that cause fetal depression, less postoperative pain, shorter hospital stay, a smaller incision, quicker return of bowel activity, and less chance of incisional hernia, compared with open cholecystectomy.

The 24-year-old woman with twins at 17 weeks' gestation came to the emergency department complaining of 4 days of abdominal pain with nausea and vomiting. She recently had been admitted to a separate hospital for biliary colic and had been treated conservatively with IV hydration, antiemetics, and analgesics. Approximately 60% of patients with symptomatic gallstone disease will require additional hospitalizations after receiving conservative medical management.

The patient had stable vital signs and no fever. Her abdomen was soft with positive bowel sounds and tenderness in the right upper quadrant with deep palpation.

Dr. Gohar and her associates resumed the medical management strategies, but the patient failed oral feeding and continued to have nausea, vomiting, diarrhea, and abdominal pain. An ultrasound exam showed a 19-mm solitary gallstone at the neck of the gall bladder. The common bile duct measured 5.3 mm on imaging, and no pericholecystic fluid or gall bladder wall thickening was observed.

The patient was given preoperative antibiotics and the tocolytic agent indomethacin and taken to the operating room for laparoscopic cholecystectomy. During surgery, her abdominal tissues were fragile and at times bled easily, Dr. Gohar said. Surgeons removed the gall bladder, found it to be filled with mucinous fluid, and diagnosed hydrops of the gall bladder.

After two postoperative days without any intrauterine contractions, the patient was discharged. She developed no complications and subsequently delivered healthy twins at 36 weeks' gestation.

The ideal time for cholecystectomy during pregnancy is not during the first trimester, as in this case, but in the second trimester. By that time, the woman has passed the time of greatest risk for spontaneous abortion, organogenesis is complete, induction of premature labor is less likely than later in pregnancy, and the uterus is not too large for operative intervention, Dr. Gohar said.

She and her associates followed recommendations in the medical literature for management of gall bladder disease during pregnancy. They obtained a preoperative obstetrical consultation and monitored for uterine contractions before and after surgery. Use of tocolytics is advised from 20 to 32 weeks' gestation in these cases, she noted.

Surgeons placed the patient in a left anterior oblique position to displace the uterus from the inferior vena cava. They used a pneumoperitoneum compression device, since pregnancy induces a hypercoagulable state and the pneumoperitoneum enhances venous stasis in the lower extremities. Fetal heart monitoring was conducted before and during surgery.

After measuring the uterine fundus height, they inserted the primary trocar via the Hasson technique (at the supraumbilical subxiphoid or left upper quadrant) and inserted the secondary trocars higher than called for in nonpregnant patients. They monitored maternal end-tidal carbon dioxide measurements to indirectly gauge fetal carbon dioxide levels.

If an intraoperative cholangiogram is needed during pregnancy, a lead shield should be employed to protect the gravid uterus, and fluoroscopy should be used selectively, Dr. Gohar added. Patients with enlarged uteri are better candidates for open cholecystectomy than the laparoscopic approach to provide sufficient abdominal access.

SAN DIEGO — A pregnant woman successfully delivered twins at term after undergoing laparoscopic cholecystectomy for symptomatic gall bladder disease during the first trimester, Kathy Gohar, M.D., said.

Cholecystectomy is one of the most common nonobstetric surgeries performed during pregnancy, but limited experience with the relatively new laparoscopic approach makes it controversial. About 10%–40% of patients with symptomatic gallstone disease require surgical treatment, said Dr. Gohar of Albert Einstein Medical Center, Philadelphia, and her associates.

Potential advantages of laparoscopic cholecystectomy include less need for narcotics that cause fetal depression, less postoperative pain, shorter hospital stay, a smaller incision, quicker return of bowel activity, and less chance of incisional hernia, compared with open cholecystectomy.

The 24-year-old woman with twins at 17 weeks' gestation came to the emergency department complaining of 4 days of abdominal pain with nausea and vomiting. She recently had been admitted to a separate hospital for biliary colic and had been treated conservatively with IV hydration, antiemetics, and analgesics. Approximately 60% of patients with symptomatic gallstone disease will require additional hospitalizations after receiving conservative medical management.

The patient had stable vital signs and no fever. Her abdomen was soft with positive bowel sounds and tenderness in the right upper quadrant with deep palpation.

Dr. Gohar and her associates resumed the medical management strategies, but the patient failed oral feeding and continued to have nausea, vomiting, diarrhea, and abdominal pain. An ultrasound exam showed a 19-mm solitary gallstone at the neck of the gall bladder. The common bile duct measured 5.3 mm on imaging, and no pericholecystic fluid or gall bladder wall thickening was observed.

The patient was given preoperative antibiotics and the tocolytic agent indomethacin and taken to the operating room for laparoscopic cholecystectomy. During surgery, her abdominal tissues were fragile and at times bled easily, Dr. Gohar said. Surgeons removed the gall bladder, found it to be filled with mucinous fluid, and diagnosed hydrops of the gall bladder.

After two postoperative days without any intrauterine contractions, the patient was discharged. She developed no complications and subsequently delivered healthy twins at 36 weeks' gestation.

The ideal time for cholecystectomy during pregnancy is not during the first trimester, as in this case, but in the second trimester. By that time, the woman has passed the time of greatest risk for spontaneous abortion, organogenesis is complete, induction of premature labor is less likely than later in pregnancy, and the uterus is not too large for operative intervention, Dr. Gohar said.

She and her associates followed recommendations in the medical literature for management of gall bladder disease during pregnancy. They obtained a preoperative obstetrical consultation and monitored for uterine contractions before and after surgery. Use of tocolytics is advised from 20 to 32 weeks' gestation in these cases, she noted.

Surgeons placed the patient in a left anterior oblique position to displace the uterus from the inferior vena cava. They used a pneumoperitoneum compression device, since pregnancy induces a hypercoagulable state and the pneumoperitoneum enhances venous stasis in the lower extremities. Fetal heart monitoring was conducted before and during surgery.

After measuring the uterine fundus height, they inserted the primary trocar via the Hasson technique (at the supraumbilical subxiphoid or left upper quadrant) and inserted the secondary trocars higher than called for in nonpregnant patients. They monitored maternal end-tidal carbon dioxide measurements to indirectly gauge fetal carbon dioxide levels.

If an intraoperative cholangiogram is needed during pregnancy, a lead shield should be employed to protect the gravid uterus, and fluoroscopy should be used selectively, Dr. Gohar added. Patients with enlarged uteri are better candidates for open cholecystectomy than the laparoscopic approach to provide sufficient abdominal access.

SAN DIEGO — A pregnant woman successfully delivered twins at term after undergoing laparoscopic cholecystectomy for symptomatic gall bladder disease during the first trimester, Kathy Gohar, M.D., said.

Cholecystectomy is one of the most common nonobstetric surgeries performed during pregnancy, but limited experience with the relatively new laparoscopic approach makes it controversial. About 10%–40% of patients with symptomatic gallstone disease require surgical treatment, said Dr. Gohar of Albert Einstein Medical Center, Philadelphia, and her associates.

Potential advantages of laparoscopic cholecystectomy include less need for narcotics that cause fetal depression, less postoperative pain, shorter hospital stay, a smaller incision, quicker return of bowel activity, and less chance of incisional hernia, compared with open cholecystectomy.

The 24-year-old woman with twins at 17 weeks' gestation came to the emergency department complaining of 4 days of abdominal pain with nausea and vomiting. She recently had been admitted to a separate hospital for biliary colic and had been treated conservatively with IV hydration, antiemetics, and analgesics. Approximately 60% of patients with symptomatic gallstone disease will require additional hospitalizations after receiving conservative medical management.

The patient had stable vital signs and no fever. Her abdomen was soft with positive bowel sounds and tenderness in the right upper quadrant with deep palpation.

Dr. Gohar and her associates resumed the medical management strategies, but the patient failed oral feeding and continued to have nausea, vomiting, diarrhea, and abdominal pain. An ultrasound exam showed a 19-mm solitary gallstone at the neck of the gall bladder. The common bile duct measured 5.3 mm on imaging, and no pericholecystic fluid or gall bladder wall thickening was observed.

The patient was given preoperative antibiotics and the tocolytic agent indomethacin and taken to the operating room for laparoscopic cholecystectomy. During surgery, her abdominal tissues were fragile and at times bled easily, Dr. Gohar said. Surgeons removed the gall bladder, found it to be filled with mucinous fluid, and diagnosed hydrops of the gall bladder.

After two postoperative days without any intrauterine contractions, the patient was discharged. She developed no complications and subsequently delivered healthy twins at 36 weeks' gestation.

The ideal time for cholecystectomy during pregnancy is not during the first trimester, as in this case, but in the second trimester. By that time, the woman has passed the time of greatest risk for spontaneous abortion, organogenesis is complete, induction of premature labor is less likely than later in pregnancy, and the uterus is not too large for operative intervention, Dr. Gohar said.

She and her associates followed recommendations in the medical literature for management of gall bladder disease during pregnancy. They obtained a preoperative obstetrical consultation and monitored for uterine contractions before and after surgery. Use of tocolytics is advised from 20 to 32 weeks' gestation in these cases, she noted.

Surgeons placed the patient in a left anterior oblique position to displace the uterus from the inferior vena cava. They used a pneumoperitoneum compression device, since pregnancy induces a hypercoagulable state and the pneumoperitoneum enhances venous stasis in the lower extremities. Fetal heart monitoring was conducted before and during surgery.

After measuring the uterine fundus height, they inserted the primary trocar via the Hasson technique (at the supraumbilical subxiphoid or left upper quadrant) and inserted the secondary trocars higher than called for in nonpregnant patients. They monitored maternal end-tidal carbon dioxide measurements to indirectly gauge fetal carbon dioxide levels.

If an intraoperative cholangiogram is needed during pregnancy, a lead shield should be employed to protect the gravid uterus, and fluoroscopy should be used selectively, Dr. Gohar added. Patients with enlarged uteri are better candidates for open cholecystectomy than the laparoscopic approach to provide sufficient abdominal access.

SAN FRANCISCO — Preliminary evidence suggests that it's reasonable to give poststroke patients supplements of folate and vitamin B₁₂ to prevent fractures, Steven R. Cummings, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Supplementation also might reduce fracture risk in patients who are housebound or elderly, who might be deficient in these vitamins. “I don't yet think you can rely on this as a treatment for osteoporosis in other settings until we have more data,” added Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

He has applied for a grant to study whether these safe and inexpensive supplements might reduce fracture risk in all kinds of people, but results will not be available for at least 2 years, if he gets the grant.

Stroke doubles to quadruples the risk of subsequent hip fracture. A high homocysteine level is a risk factor for stroke and for osteoporosis in the elderly, even though it is not associated with decreased bone density, several large cohort studies have shown. Vitamin B₁₂ commonly is used with folate to suppress homocysteine concentrations.

In a Dutch study of more than 1,100 people in two cohorts, those with homocysteine levels in the highest quartile had nearly double the risk for hip fracture or nonspine fractures over a 6- to 8-year period compared with those with the lowest-quartile levels (N. Engl. J. Med. 2004;350:2033–41).

In a separate, double-blind study, approximately 559 Japanese patients who had had a stroke were randomized to 2 years of dietary supplementation with placebo or 5 mg folate/day and 1,500 mcg B₁₂/day. Homocysteine levels decreased by 38% in the treatment group and increased by 31% in the placebo group. The treatment group had 78% fewer hip fractures, compared with the placebo group (JAMA 2005;293:1121–2).

“That is the biggest fracture reduction that I have seen yet in the field of osteoporosis. That is impressive,” Dr. Cummings said. The results are even more impressive considering that both groups showed about a 3% loss in metacarpal bone mineral density, and patients physically fell at similar rates (two per year in each group).

“These kinds of numbers make me think that this is almost too good to be true,” he added. Because folate and vitamin B₁₂ are so safe and inexpensive, though, it's reasonable in the meantime to offer them to select groups of patients.

No one knows how these agents might work to decrease fracture risk. “We assumed that all of the effect would be in bone density, but it's not,” he said.

Dr. Cummings and other researchers also have their eyes on another safe and inexpensive agent that might prevent and treat osteoporosis—nitrates.

A 1998 observational study found that women who took nitrates intermittently had 3%–5% higher bone mineral densities in hips and heels, compared with women who did not take nitrates or took them continuously.

A separate study reported by investigators at the University of Toronto randomly assigned postmenopausal women with osteopenia or osteoporosis to take 5 mg or 20 mg of nitrates or placebo each day. After 4–6 months, measures of bone resorption decreased by 36% in the 5-mg group and by 45% in the 20-mg group, compared with placebo.

“That's sort of like what you get from estrogen, and close to what you get with some bisphosphonates,” he said. Estrogen and bisphosphonates do not affect bone formation, but nitrates increased markers of bone formation by 16% and 23%, compared with placebo in this study.

Raising the funding needed for studies is difficult, however, because no pharmaceutical company stands to profit from sales of nitrates, Dr. Cummings said.

SAN FRANCISCO — Preliminary evidence suggests that it's reasonable to give poststroke patients supplements of folate and vitamin B₁₂ to prevent fractures, Steven R. Cummings, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Supplementation also might reduce fracture risk in patients who are housebound or elderly, who might be deficient in these vitamins. “I don't yet think you can rely on this as a treatment for osteoporosis in other settings until we have more data,” added Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

He has applied for a grant to study whether these safe and inexpensive supplements might reduce fracture risk in all kinds of people, but results will not be available for at least 2 years, if he gets the grant.

Stroke doubles to quadruples the risk of subsequent hip fracture. A high homocysteine level is a risk factor for stroke and for osteoporosis in the elderly, even though it is not associated with decreased bone density, several large cohort studies have shown. Vitamin B₁₂ commonly is used with folate to suppress homocysteine concentrations.

In a Dutch study of more than 1,100 people in two cohorts, those with homocysteine levels in the highest quartile had nearly double the risk for hip fracture or nonspine fractures over a 6- to 8-year period compared with those with the lowest-quartile levels (N. Engl. J. Med. 2004;350:2033–41).

In a separate, double-blind study, approximately 559 Japanese patients who had had a stroke were randomized to 2 years of dietary supplementation with placebo or 5 mg folate/day and 1,500 mcg B₁₂/day. Homocysteine levels decreased by 38% in the treatment group and increased by 31% in the placebo group. The treatment group had 78% fewer hip fractures, compared with the placebo group (JAMA 2005;293:1121–2).

“That is the biggest fracture reduction that I have seen yet in the field of osteoporosis. That is impressive,” Dr. Cummings said. The results are even more impressive considering that both groups showed about a 3% loss in metacarpal bone mineral density, and patients physically fell at similar rates (two per year in each group).

“These kinds of numbers make me think that this is almost too good to be true,” he added. Because folate and vitamin B₁₂ are so safe and inexpensive, though, it's reasonable in the meantime to offer them to select groups of patients.

No one knows how these agents might work to decrease fracture risk. “We assumed that all of the effect would be in bone density, but it's not,” he said.

Dr. Cummings and other researchers also have their eyes on another safe and inexpensive agent that might prevent and treat osteoporosis—nitrates.

A 1998 observational study found that women who took nitrates intermittently had 3%–5% higher bone mineral densities in hips and heels, compared with women who did not take nitrates or took them continuously.

A separate study reported by investigators at the University of Toronto randomly assigned postmenopausal women with osteopenia or osteoporosis to take 5 mg or 20 mg of nitrates or placebo each day. After 4–6 months, measures of bone resorption decreased by 36% in the 5-mg group and by 45% in the 20-mg group, compared with placebo.

“That's sort of like what you get from estrogen, and close to what you get with some bisphosphonates,” he said. Estrogen and bisphosphonates do not affect bone formation, but nitrates increased markers of bone formation by 16% and 23%, compared with placebo in this study.

Raising the funding needed for studies is difficult, however, because no pharmaceutical company stands to profit from sales of nitrates, Dr. Cummings said.

SAN FRANCISCO — Preliminary evidence suggests that it's reasonable to give poststroke patients supplements of folate and vitamin B₁₂ to prevent fractures, Steven R. Cummings, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Supplementation also might reduce fracture risk in patients who are housebound or elderly, who might be deficient in these vitamins. “I don't yet think you can rely on this as a treatment for osteoporosis in other settings until we have more data,” added Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

He has applied for a grant to study whether these safe and inexpensive supplements might reduce fracture risk in all kinds of people, but results will not be available for at least 2 years, if he gets the grant.

Stroke doubles to quadruples the risk of subsequent hip fracture. A high homocysteine level is a risk factor for stroke and for osteoporosis in the elderly, even though it is not associated with decreased bone density, several large cohort studies have shown. Vitamin B₁₂ commonly is used with folate to suppress homocysteine concentrations.

In a Dutch study of more than 1,100 people in two cohorts, those with homocysteine levels in the highest quartile had nearly double the risk for hip fracture or nonspine fractures over a 6- to 8-year period compared with those with the lowest-quartile levels (N. Engl. J. Med. 2004;350:2033–41).

In a separate, double-blind study, approximately 559 Japanese patients who had had a stroke were randomized to 2 years of dietary supplementation with placebo or 5 mg folate/day and 1,500 mcg B₁₂/day. Homocysteine levels decreased by 38% in the treatment group and increased by 31% in the placebo group. The treatment group had 78% fewer hip fractures, compared with the placebo group (JAMA 2005;293:1121–2).

“That is the biggest fracture reduction that I have seen yet in the field of osteoporosis. That is impressive,” Dr. Cummings said. The results are even more impressive considering that both groups showed about a 3% loss in metacarpal bone mineral density, and patients physically fell at similar rates (two per year in each group).

“These kinds of numbers make me think that this is almost too good to be true,” he added. Because folate and vitamin B₁₂ are so safe and inexpensive, though, it's reasonable in the meantime to offer them to select groups of patients.

No one knows how these agents might work to decrease fracture risk. “We assumed that all of the effect would be in bone density, but it's not,” he said.

Dr. Cummings and other researchers also have their eyes on another safe and inexpensive agent that might prevent and treat osteoporosis—nitrates.

A 1998 observational study found that women who took nitrates intermittently had 3%–5% higher bone mineral densities in hips and heels, compared with women who did not take nitrates or took them continuously.

A separate study reported by investigators at the University of Toronto randomly assigned postmenopausal women with osteopenia or osteoporosis to take 5 mg or 20 mg of nitrates or placebo each day. After 4–6 months, measures of bone resorption decreased by 36% in the 5-mg group and by 45% in the 20-mg group, compared with placebo.

“That's sort of like what you get from estrogen, and close to what you get with some bisphosphonates,” he said. Estrogen and bisphosphonates do not affect bone formation, but nitrates increased markers of bone formation by 16% and 23%, compared with placebo in this study.

Raising the funding needed for studies is difficult, however, because no pharmaceutical company stands to profit from sales of nitrates, Dr. Cummings 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,” Dr. Black joked.

By the numbers, 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, he said. Stratifying hip bone density by quartile, the risk for hip fracture increases 10-fold in people whose bone density is 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 with 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, you know that 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, Dr. Black added.

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,” Dr. Black joked.

By the numbers, 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, he said. Stratifying hip bone density by quartile, the risk for hip fracture increases 10-fold in people whose bone density is 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 with 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, you know that 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, Dr. Black added.

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,” Dr. Black joked.

By the numbers, 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, he said. Stratifying hip bone density by quartile, the risk for hip fracture increases 10-fold in people whose bone density is 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 with 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, you know that 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, Dr. Black added.

SAN FRANCISCO — Physicians who see patients with osteoporosis should have a visual acuity chart on the office wall to check eyesight, Steven R. Cummings, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Reduced visual acuity greatly increases the risk for falling and for hip fractures. Usually poor vision is due to treatable risk factors such as the need for an updated glasses prescription, or cataracts, said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

Impaired vision can double or quadruple the risk for hip fracture. At least one study shows that repairing cataracts can reduce the risk of falling by 34% (Br. J. Ophthalmol. 2005;89:53–9).

Dr. Cummings noted that the following additional risk factors are worth addressing to prevent fractures:

▸ Vertebral fracture. Having a vertebral fracture—even a painless, asymptomatic one that's detected only by x-ray—increases the risk for future vertebral fracture two- to fourfold. Older women with a previous vertebral fracture have a 1%–3% annual rate of hip fracture, and randomized trials suggest that pharmacologic treatment can lower that risk.

▸ Nonspine fracture. Having any kind of nonspine fracture nearly doubles or triples the risk for having a future nonspine fracture. This is especially true in men, and is independent of bone mineral density. Even with normal bone density, having a nonspine fracture makes a future nonspine fracture more likely.

▸ Familial history. People who had a parent develop a hip fracture have double the risk for hip fracture themselves, compared with people whose parents did not have hip fractures. This is true regardless of bone mineral density. A wrist fracture in a parent increases an offspring's risk of wrist fracture. “There's some suggestion that this increased familial risk may be specific to the type of fracture,” he said.

Studies have found no association, however, between patients' reports of parents who had osteoporosis or spine fractures and the patients' own risk for those problems, probably because “osteoporosis” and “spine fracture” are rather nonspecific terms used with different meanings.

▸ Weight. Women have a higher risk for serious fractures if they are losing weight involuntarily compared with maintaining or gaining weight. The involuntary weight loss is a marker for frailty. Fractures of the hip, humerus, spine or pelvis commonly are referred to as “frailty fractures,” he noted. Voluntary weight loss through diet or exercise diminishes a woman's bone mineral density, but it's not clear whether this increases fracture risk.

▸ Corticosteroid use. Taking more than 10 mg/day of prednisone or comparable doses of other corticosteroids reduces spinal bone density by 5%–10% in the first year, with most of the loss in the first 6 months. Higher doses reduce spinal bone density even more. Fracture risk increases even more quickly—within 1–2 months of starting corticosteroids. “There's a suggestion here that corticosteroids increase your risk for fractures in ways besides causing bone loss,” perhaps by killing osteocytes in bone and limiting the ability of bone to respond to stimulators, he said.

Consider starting preventive therapy to prevent fractures if patients who will be taking steroids for at least several months have low bone densities or a history of fracture, Dr. Cummings suggested.

▸ Smoking. Cigarette smoking approximately doubles the risk for hip fracture regardless of bone density, probably because smoking is associated with poorer health, weaker muscles, and impaired balance.

▸ Diabetes. Patients with diabetes have triple the risk for foot fractures and double the risk for humerus or hip fractures, compared with nondiabetic patients. If you see a patient with one of these fractures, look for diabetes, and watch for these fractures in patients already diagnosed with diabetes, he advised.

▸ Stroke. Patients who have had a stroke or who are in nursing homes are at very high risk for hip fractures, warranting pharmacotherapy to preserve and strengthen bone. Each year 4%–6% of nursing home patients develop hip fractures. In patients over age 70 who have had a stroke, 3%–5% of women and 2% of men develop hip fractures per year.

SAN FRANCISCO — Physicians who see patients with osteoporosis should have a visual acuity chart on the office wall to check eyesight, Steven R. Cummings, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Reduced visual acuity greatly increases the risk for falling and for hip fractures. Usually poor vision is due to treatable risk factors such as the need for an updated glasses prescription, or cataracts, said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

Impaired vision can double or quadruple the risk for hip fracture. At least one study shows that repairing cataracts can reduce the risk of falling by 34% (Br. J. Ophthalmol. 2005;89:53–9).

Dr. Cummings noted that the following additional risk factors are worth addressing to prevent fractures:

▸ Vertebral fracture. Having a vertebral fracture—even a painless, asymptomatic one that's detected only by x-ray—increases the risk for future vertebral fracture two- to fourfold. Older women with a previous vertebral fracture have a 1%–3% annual rate of hip fracture, and randomized trials suggest that pharmacologic treatment can lower that risk.

▸ Nonspine fracture. Having any kind of nonspine fracture nearly doubles or triples the risk for having a future nonspine fracture. This is especially true in men, and is independent of bone mineral density. Even with normal bone density, having a nonspine fracture makes a future nonspine fracture more likely.

▸ Familial history. People who had a parent develop a hip fracture have double the risk for hip fracture themselves, compared with people whose parents did not have hip fractures. This is true regardless of bone mineral density. A wrist fracture in a parent increases an offspring's risk of wrist fracture. “There's some suggestion that this increased familial risk may be specific to the type of fracture,” he said.

Studies have found no association, however, between patients' reports of parents who had osteoporosis or spine fractures and the patients' own risk for those problems, probably because “osteoporosis” and “spine fracture” are rather nonspecific terms used with different meanings.

▸ Weight. Women have a higher risk for serious fractures if they are losing weight involuntarily compared with maintaining or gaining weight. The involuntary weight loss is a marker for frailty. Fractures of the hip, humerus, spine or pelvis commonly are referred to as “frailty fractures,” he noted. Voluntary weight loss through diet or exercise diminishes a woman's bone mineral density, but it's not clear whether this increases fracture risk.

▸ Corticosteroid use. Taking more than 10 mg/day of prednisone or comparable doses of other corticosteroids reduces spinal bone density by 5%–10% in the first year, with most of the loss in the first 6 months. Higher doses reduce spinal bone density even more. Fracture risk increases even more quickly—within 1–2 months of starting corticosteroids. “There's a suggestion here that corticosteroids increase your risk for fractures in ways besides causing bone loss,” perhaps by killing osteocytes in bone and limiting the ability of bone to respond to stimulators, he said.

Consider starting preventive therapy to prevent fractures if patients who will be taking steroids for at least several months have low bone densities or a history of fracture, Dr. Cummings suggested.

▸ Smoking. Cigarette smoking approximately doubles the risk for hip fracture regardless of bone density, probably because smoking is associated with poorer health, weaker muscles, and impaired balance.

▸ Diabetes. Patients with diabetes have triple the risk for foot fractures and double the risk for humerus or hip fractures, compared with nondiabetic patients. If you see a patient with one of these fractures, look for diabetes, and watch for these fractures in patients already diagnosed with diabetes, he advised.

▸ Stroke. Patients who have had a stroke or who are in nursing homes are at very high risk for hip fractures, warranting pharmacotherapy to preserve and strengthen bone. Each year 4%–6% of nursing home patients develop hip fractures. In patients over age 70 who have had a stroke, 3%–5% of women and 2% of men develop hip fractures per year.

SAN FRANCISCO — Physicians who see patients with osteoporosis should have a visual acuity chart on the office wall to check eyesight, Steven R. Cummings, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Reduced visual acuity greatly increases the risk for falling and for hip fractures. Usually poor vision is due to treatable risk factors such as the need for an updated glasses prescription, or cataracts, said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

Impaired vision can double or quadruple the risk for hip fracture. At least one study shows that repairing cataracts can reduce the risk of falling by 34% (Br. J. Ophthalmol. 2005;89:53–9).

Dr. Cummings noted that the following additional risk factors are worth addressing to prevent fractures:

▸ Vertebral fracture. Having a vertebral fracture—even a painless, asymptomatic one that's detected only by x-ray—increases the risk for future vertebral fracture two- to fourfold. Older women with a previous vertebral fracture have a 1%–3% annual rate of hip fracture, and randomized trials suggest that pharmacologic treatment can lower that risk.

▸ Nonspine fracture. Having any kind of nonspine fracture nearly doubles or triples the risk for having a future nonspine fracture. This is especially true in men, and is independent of bone mineral density. Even with normal bone density, having a nonspine fracture makes a future nonspine fracture more likely.

▸ Familial history. People who had a parent develop a hip fracture have double the risk for hip fracture themselves, compared with people whose parents did not have hip fractures. This is true regardless of bone mineral density. A wrist fracture in a parent increases an offspring's risk of wrist fracture. “There's some suggestion that this increased familial risk may be specific to the type of fracture,” he said.

Studies have found no association, however, between patients' reports of parents who had osteoporosis or spine fractures and the patients' own risk for those problems, probably because “osteoporosis” and “spine fracture” are rather nonspecific terms used with different meanings.

▸ Weight. Women have a higher risk for serious fractures if they are losing weight involuntarily compared with maintaining or gaining weight. The involuntary weight loss is a marker for frailty. Fractures of the hip, humerus, spine or pelvis commonly are referred to as “frailty fractures,” he noted. Voluntary weight loss through diet or exercise diminishes a woman's bone mineral density, but it's not clear whether this increases fracture risk.

▸ Corticosteroid use. Taking more than 10 mg/day of prednisone or comparable doses of other corticosteroids reduces spinal bone density by 5%–10% in the first year, with most of the loss in the first 6 months. Higher doses reduce spinal bone density even more. Fracture risk increases even more quickly—within 1–2 months of starting corticosteroids. “There's a suggestion here that corticosteroids increase your risk for fractures in ways besides causing bone loss,” perhaps by killing osteocytes in bone and limiting the ability of bone to respond to stimulators, he said.

Consider starting preventive therapy to prevent fractures if patients who will be taking steroids for at least several months have low bone densities or a history of fracture, Dr. Cummings suggested.

▸ Smoking. Cigarette smoking approximately doubles the risk for hip fracture regardless of bone density, probably because smoking is associated with poorer health, weaker muscles, and impaired balance.

▸ Diabetes. Patients with diabetes have triple the risk for foot fractures and double the risk for humerus or hip fractures, compared with nondiabetic patients. If you see a patient with one of these fractures, look for diabetes, and watch for these fractures in patients already diagnosed with diabetes, he advised.

▸ Stroke. Patients who have had a stroke or who are in nursing homes are at very high risk for hip fractures, warranting pharmacotherapy to preserve and strengthen bone. Each year 4%–6% of nursing home patients develop hip fractures. In patients over age 70 who have had a stroke, 3%–5% of women and 2% of men develop hip fractures per year.

STANFORD, CALIF. — Children or adults whose symptoms of gastroesophageal reflux disease continue despite treatment may have allergic eosinophilic esophagitis, John A. Kerner Jr., M.D., said at a conference on perinatal and pediatric nutrition.

An esophageal biopsy will show major eosinophilic infiltration of the mucosa and submucosa in a patient with allergic eosinophilic esophagitis. The proteins that are implicated in this disorder come from the “usual suspects” in the diet—cow's milk, wheat, soy, peanut, or egg, said Dr. Kerner, professor of pediatrics and director of nutrition at Stanford (Calif.) University Medical Center.

Treatment consists of avoiding the antigens, if they can be identified, switching infants to an elemental formula, and possibly using steroids. Often multiple antigens are involved, with poor correlation with skin tests for allergy, he added.

First identified in a landmark 1995 study of 10 children, allergic eosinophilic esophagitis produces symptoms that look like chronic gastroesophageal reflux disease (GERD). The child may refuse food, fail to thrive, vomit, have abdominal pain, be irritable, and have difficulty sleeping. Symptoms return despite treatment with histamine₂-receptor blockers or even fundoplication. Serum IgE levels are normal or slightly elevated, and peripheral eosinophils are uncommon in allergic eosinophilic esophagitis.

Allergic eosinophilic esophagitis can begin anytime from infancy to adolescence. “More and more of the adult literature is pointing out that patients have been missed with this disorder,” Dr. Kerner said.

Older children and adults who have had allergic eosinophilic esophagitis for some time commonly turn up in emergency departments or clinics with esophageal stricture. Biopsies will show “sheets” of eosinophils in these patients, he added.

Seeing more than 20 eosinophils per high-power field in a biopsy is a “classic count” for diagnosing allergic eosinophilic esophagitis, although there is some debate about the exact number needed for diagnosis, Dr. Kerner said at the meeting, jointly sponsored by Symposia Medicus and Stanford University.

Endoscopy will show little circular rings that can be “fairly dramatic” and white plaques composed of eosinophilic complexes.

Restricting consumption of cow's milk will resolve symptoms in approximately 80% of cases. In infants with allergic eosinophilic esophagitis, 80% will improve after switching to a hydrolyzed protein formula such as Alimentum or Nutramigen. Those who don't respond usually do well when switched to an L-amino acid formula. Breast-fed infants with eczema and allergic eosinophilic esophagitis usually need an L-amino acid formula, Dr. Kerner said.

An inhaled steroid will alleviate acute symptoms, but symptoms recur when the inhaled treatment is stopped. When prescribing steroids for this disorder, Dr.Kerner said that he prefers using both inhaled and topical forms. Oral steroids for a systemic effect also are an option, he said.

The first published study of allergic eosinophilic esophagitis described 10 children who had been diagnosed with GERD and whose symptoms persisted despite separate treatments with five antireflux therapies, including Nissen fundoplication in six patients.

After 6 weeks on an L-amino acid-based formula (Neocate or Neocate One), eight patients had no symptoms, and symptoms improved in the other two patients. Esophageal biopsies before and after the 6 weeks of treatment showed that intraepithelial eosinophil counts decreased significantly, from a median of 41 per high-power field to less than 1 per high-power field (Gastroenterology 1995;109:1503–12).

Symptoms returned in all patients, however, after open food challenges. “This is a real disorder,” Dr. Kerner said.

The study showed that chronic GI symptoms and histologic changes of the esophagus that were unresponsive to standard GERD treatments could be improved by using an elemental formula. “This was a breakthrough,” he said.

STANFORD, CALIF. — Children or adults whose symptoms of gastroesophageal reflux disease continue despite treatment may have allergic eosinophilic esophagitis, John A. Kerner Jr., M.D., said at a conference on perinatal and pediatric nutrition.

An esophageal biopsy will show major eosinophilic infiltration of the mucosa and submucosa in a patient with allergic eosinophilic esophagitis. The proteins that are implicated in this disorder come from the “usual suspects” in the diet—cow's milk, wheat, soy, peanut, or egg, said Dr. Kerner, professor of pediatrics and director of nutrition at Stanford (Calif.) University Medical Center.

Treatment consists of avoiding the antigens, if they can be identified, switching infants to an elemental formula, and possibly using steroids. Often multiple antigens are involved, with poor correlation with skin tests for allergy, he added.

First identified in a landmark 1995 study of 10 children, allergic eosinophilic esophagitis produces symptoms that look like chronic gastroesophageal reflux disease (GERD). The child may refuse food, fail to thrive, vomit, have abdominal pain, be irritable, and have difficulty sleeping. Symptoms return despite treatment with histamine₂-receptor blockers or even fundoplication. Serum IgE levels are normal or slightly elevated, and peripheral eosinophils are uncommon in allergic eosinophilic esophagitis.

Allergic eosinophilic esophagitis can begin anytime from infancy to adolescence. “More and more of the adult literature is pointing out that patients have been missed with this disorder,” Dr. Kerner said.

Older children and adults who have had allergic eosinophilic esophagitis for some time commonly turn up in emergency departments or clinics with esophageal stricture. Biopsies will show “sheets” of eosinophils in these patients, he added.

Seeing more than 20 eosinophils per high-power field in a biopsy is a “classic count” for diagnosing allergic eosinophilic esophagitis, although there is some debate about the exact number needed for diagnosis, Dr. Kerner said at the meeting, jointly sponsored by Symposia Medicus and Stanford University.

Endoscopy will show little circular rings that can be “fairly dramatic” and white plaques composed of eosinophilic complexes.

Restricting consumption of cow's milk will resolve symptoms in approximately 80% of cases. In infants with allergic eosinophilic esophagitis, 80% will improve after switching to a hydrolyzed protein formula such as Alimentum or Nutramigen. Those who don't respond usually do well when switched to an L-amino acid formula. Breast-fed infants with eczema and allergic eosinophilic esophagitis usually need an L-amino acid formula, Dr. Kerner said.

An inhaled steroid will alleviate acute symptoms, but symptoms recur when the inhaled treatment is stopped. When prescribing steroids for this disorder, Dr.Kerner said that he prefers using both inhaled and topical forms. Oral steroids for a systemic effect also are an option, he said.

The first published study of allergic eosinophilic esophagitis described 10 children who had been diagnosed with GERD and whose symptoms persisted despite separate treatments with five antireflux therapies, including Nissen fundoplication in six patients.

After 6 weeks on an L-amino acid-based formula (Neocate or Neocate One), eight patients had no symptoms, and symptoms improved in the other two patients. Esophageal biopsies before and after the 6 weeks of treatment showed that intraepithelial eosinophil counts decreased significantly, from a median of 41 per high-power field to less than 1 per high-power field (Gastroenterology 1995;109:1503–12).

Symptoms returned in all patients, however, after open food challenges. “This is a real disorder,” Dr. Kerner said.

The study showed that chronic GI symptoms and histologic changes of the esophagus that were unresponsive to standard GERD treatments could be improved by using an elemental formula. “This was a breakthrough,” he said.

STANFORD, CALIF. — Children or adults whose symptoms of gastroesophageal reflux disease continue despite treatment may have allergic eosinophilic esophagitis, John A. Kerner Jr., M.D., said at a conference on perinatal and pediatric nutrition.

An esophageal biopsy will show major eosinophilic infiltration of the mucosa and submucosa in a patient with allergic eosinophilic esophagitis. The proteins that are implicated in this disorder come from the “usual suspects” in the diet—cow's milk, wheat, soy, peanut, or egg, said Dr. Kerner, professor of pediatrics and director of nutrition at Stanford (Calif.) University Medical Center.

Treatment consists of avoiding the antigens, if they can be identified, switching infants to an elemental formula, and possibly using steroids. Often multiple antigens are involved, with poor correlation with skin tests for allergy, he added.

First identified in a landmark 1995 study of 10 children, allergic eosinophilic esophagitis produces symptoms that look like chronic gastroesophageal reflux disease (GERD). The child may refuse food, fail to thrive, vomit, have abdominal pain, be irritable, and have difficulty sleeping. Symptoms return despite treatment with histamine₂-receptor blockers or even fundoplication. Serum IgE levels are normal or slightly elevated, and peripheral eosinophils are uncommon in allergic eosinophilic esophagitis.

Allergic eosinophilic esophagitis can begin anytime from infancy to adolescence. “More and more of the adult literature is pointing out that patients have been missed with this disorder,” Dr. Kerner said.

Older children and adults who have had allergic eosinophilic esophagitis for some time commonly turn up in emergency departments or clinics with esophageal stricture. Biopsies will show “sheets” of eosinophils in these patients, he added.

Seeing more than 20 eosinophils per high-power field in a biopsy is a “classic count” for diagnosing allergic eosinophilic esophagitis, although there is some debate about the exact number needed for diagnosis, Dr. Kerner said at the meeting, jointly sponsored by Symposia Medicus and Stanford University.

Endoscopy will show little circular rings that can be “fairly dramatic” and white plaques composed of eosinophilic complexes.

Restricting consumption of cow's milk will resolve symptoms in approximately 80% of cases. In infants with allergic eosinophilic esophagitis, 80% will improve after switching to a hydrolyzed protein formula such as Alimentum or Nutramigen. Those who don't respond usually do well when switched to an L-amino acid formula. Breast-fed infants with eczema and allergic eosinophilic esophagitis usually need an L-amino acid formula, Dr. Kerner said.

An inhaled steroid will alleviate acute symptoms, but symptoms recur when the inhaled treatment is stopped. When prescribing steroids for this disorder, Dr.Kerner said that he prefers using both inhaled and topical forms. Oral steroids for a systemic effect also are an option, he said.

The first published study of allergic eosinophilic esophagitis described 10 children who had been diagnosed with GERD and whose symptoms persisted despite separate treatments with five antireflux therapies, including Nissen fundoplication in six patients.

After 6 weeks on an L-amino acid-based formula (Neocate or Neocate One), eight patients had no symptoms, and symptoms improved in the other two patients. Esophageal biopsies before and after the 6 weeks of treatment showed that intraepithelial eosinophil counts decreased significantly, from a median of 41 per high-power field to less than 1 per high-power field (Gastroenterology 1995;109:1503–12).

Symptoms returned in all patients, however, after open food challenges. “This is a real disorder,” Dr. Kerner said.

The study showed that chronic GI symptoms and histologic changes of the esophagus that were unresponsive to standard GERD treatments could be improved by using an elemental formula. “This was a breakthrough,” he said.

SAN FRANCISCO — A group prenatal care program designed to empower pregnant women is spreading across the United States, Margaret Hutchison said at a meeting on antepartum and intrapartum management.

More than 60 sites offering prenatal care in 28 states have started CenteringPregnancy programs—mostly in public clinics, with some in HMOs and military clinics, said Ms. Hutchison, a certified nurse-midwife at San Francisco General Hospital, a teaching hospital of the University of California, which also sponsored the meeting.

Developed by a certified nurse-midwife and pilot-tested in 1993, the CenteringPregnancy model groups 8–12 women of similar gestational age for 10 facilitated 2-hour meetings starting at gestational weeks 12–16. The groups usually meet monthly for the first 4 months and twice monthly after that. The women do self-care activities, such as measuring weight, taking blood pressure readings, and charting.

“This is an important part. It's not a group to just sit and talk,” Ms. Hutchison explained. “Empowerment is the key.”

The group discusses specific topics related to pregnancy and parenting, guided by “self-assessment sheets,” with the emphasis varying among core topics, such as smoking cessation or community building.

Ms. Hutchison said she started a CenteringPregnancy program at San Francisco General Hospital to help the many immigrant Hispanic females seen at her institution who seemed socially isolated. “I wanted them to have someone to call after we've sent them home with a baby,” she said.

Ms. Hutchison said she has no financial relationship with the nonprofit group that owns the program trademark, the Centering Pregnancy & Parenting Association Inc.

During group time, the women take turns having “mat time” with a health provider who conducts pregnancy risk assessments within the group space, sometimes on a floor mat that can be behind a screen if privacy is needed.

Staying in the room to conduct assessments is important, she explained. Moving a woman into a separate room interrupts the group process and reasserts the traditional hierarchical relationship between providers and patients.

Because the program, which demands change from health care providers, is so different from traditional care, it is not an easy one to implement. (See box.) Billing has not been an issue, because the program fits into standard reimbursement systems, she said.

The program improved birth weights in a nonrandomized trial of 458 low-income women at two institutions. The women either participated in a CenteringPregnancy group or received traditional care, with the groups matched by age, race, parity, and date of delivery.

Average birth weight in the CenteringPregnancy group was 3,228 g—significantly higher than the average of 3,159 g in the control group.

The CenteringPregnancy group showed a nonsignificant trend toward fewer low-birth-weight babies. In that study, 7% of babies born to the CenteringPregnancy group and 10% in the control group had low birth weights, defined as less than 500 g (Obstet. Gynecol. 2003;102[pt. 1]:1051–7).

The rate of preterm deliveries did not differ between groups, but preterm babies in the CenteringPregnancy group were significantly older and larger, born at 34.8 weeks and 2,398 g, compared with 32.6 weeks and 1,990 g in the control group.

The first randomized, controlled trial of CenteringPregnancy involves thousands of women and should conclude in the next 6 months, Ms. Hutchison said.

Pregnancy Care Models Differ

Traditional Care

Physical assessment is primary.

Education is mostly one-on-one.

Communication is didactic.

Process of care is disempowering.

Psychosocial support is incidental.

CenteringPregnancy Care

Physical assessment is simply one aspect of care.

Education is both group-based and interactive.

Communication is both interactive and facilitated.

Process of care is empowering.

Psychosocial support and community-building are primary.

Source: Ms. Hutchison

SAN FRANCISCO — A group prenatal care program designed to empower pregnant women is spreading across the United States, Margaret Hutchison said at a meeting on antepartum and intrapartum management.

More than 60 sites offering prenatal care in 28 states have started CenteringPregnancy programs—mostly in public clinics, with some in HMOs and military clinics, said Ms. Hutchison, a certified nurse-midwife at San Francisco General Hospital, a teaching hospital of the University of California, which also sponsored the meeting.

Developed by a certified nurse-midwife and pilot-tested in 1993, the CenteringPregnancy model groups 8–12 women of similar gestational age for 10 facilitated 2-hour meetings starting at gestational weeks 12–16. The groups usually meet monthly for the first 4 months and twice monthly after that. The women do self-care activities, such as measuring weight, taking blood pressure readings, and charting.

“This is an important part. It's not a group to just sit and talk,” Ms. Hutchison explained. “Empowerment is the key.”

The group discusses specific topics related to pregnancy and parenting, guided by “self-assessment sheets,” with the emphasis varying among core topics, such as smoking cessation or community building.

Ms. Hutchison said she started a CenteringPregnancy program at San Francisco General Hospital to help the many immigrant Hispanic females seen at her institution who seemed socially isolated. “I wanted them to have someone to call after we've sent them home with a baby,” she said.

Ms. Hutchison said she has no financial relationship with the nonprofit group that owns the program trademark, the Centering Pregnancy & Parenting Association Inc.

During group time, the women take turns having “mat time” with a health provider who conducts pregnancy risk assessments within the group space, sometimes on a floor mat that can be behind a screen if privacy is needed.

Staying in the room to conduct assessments is important, she explained. Moving a woman into a separate room interrupts the group process and reasserts the traditional hierarchical relationship between providers and patients.

Because the program, which demands change from health care providers, is so different from traditional care, it is not an easy one to implement. (See box.) Billing has not been an issue, because the program fits into standard reimbursement systems, she said.

The program improved birth weights in a nonrandomized trial of 458 low-income women at two institutions. The women either participated in a CenteringPregnancy group or received traditional care, with the groups matched by age, race, parity, and date of delivery.

Average birth weight in the CenteringPregnancy group was 3,228 g—significantly higher than the average of 3,159 g in the control group.

The CenteringPregnancy group showed a nonsignificant trend toward fewer low-birth-weight babies. In that study, 7% of babies born to the CenteringPregnancy group and 10% in the control group had low birth weights, defined as less than 500 g (Obstet. Gynecol. 2003;102[pt. 1]:1051–7).

The rate of preterm deliveries did not differ between groups, but preterm babies in the CenteringPregnancy group were significantly older and larger, born at 34.8 weeks and 2,398 g, compared with 32.6 weeks and 1,990 g in the control group.

The first randomized, controlled trial of CenteringPregnancy involves thousands of women and should conclude in the next 6 months, Ms. Hutchison said.

Pregnancy Care Models Differ

Traditional Care

Physical assessment is primary.

Education is mostly one-on-one.

Communication is didactic.

Process of care is disempowering.

Psychosocial support is incidental.

CenteringPregnancy Care

Physical assessment is simply one aspect of care.

Education is both group-based and interactive.

Communication is both interactive and facilitated.

Process of care is empowering.

Psychosocial support and community-building are primary.

Source: Ms. Hutchison

SAN FRANCISCO — A group prenatal care program designed to empower pregnant women is spreading across the United States, Margaret Hutchison said at a meeting on antepartum and intrapartum management.

More than 60 sites offering prenatal care in 28 states have started CenteringPregnancy programs—mostly in public clinics, with some in HMOs and military clinics, said Ms. Hutchison, a certified nurse-midwife at San Francisco General Hospital, a teaching hospital of the University of California, which also sponsored the meeting.

Developed by a certified nurse-midwife and pilot-tested in 1993, the CenteringPregnancy model groups 8–12 women of similar gestational age for 10 facilitated 2-hour meetings starting at gestational weeks 12–16. The groups usually meet monthly for the first 4 months and twice monthly after that. The women do self-care activities, such as measuring weight, taking blood pressure readings, and charting.

“This is an important part. It's not a group to just sit and talk,” Ms. Hutchison explained. “Empowerment is the key.”

The group discusses specific topics related to pregnancy and parenting, guided by “self-assessment sheets,” with the emphasis varying among core topics, such as smoking cessation or community building.

Ms. Hutchison said she started a CenteringPregnancy program at San Francisco General Hospital to help the many immigrant Hispanic females seen at her institution who seemed socially isolated. “I wanted them to have someone to call after we've sent them home with a baby,” she said.

Ms. Hutchison said she has no financial relationship with the nonprofit group that owns the program trademark, the Centering Pregnancy & Parenting Association Inc.

During group time, the women take turns having “mat time” with a health provider who conducts pregnancy risk assessments within the group space, sometimes on a floor mat that can be behind a screen if privacy is needed.

Staying in the room to conduct assessments is important, she explained. Moving a woman into a separate room interrupts the group process and reasserts the traditional hierarchical relationship between providers and patients.

Because the program, which demands change from health care providers, is so different from traditional care, it is not an easy one to implement. (See box.) Billing has not been an issue, because the program fits into standard reimbursement systems, she said.

The program improved birth weights in a nonrandomized trial of 458 low-income women at two institutions. The women either participated in a CenteringPregnancy group or received traditional care, with the groups matched by age, race, parity, and date of delivery.

Average birth weight in the CenteringPregnancy group was 3,228 g—significantly higher than the average of 3,159 g in the control group.

The CenteringPregnancy group showed a nonsignificant trend toward fewer low-birth-weight babies. In that study, 7% of babies born to the CenteringPregnancy group and 10% in the control group had low birth weights, defined as less than 500 g (Obstet. Gynecol. 2003;102[pt. 1]:1051–7).

The rate of preterm deliveries did not differ between groups, but preterm babies in the CenteringPregnancy group were significantly older and larger, born at 34.8 weeks and 2,398 g, compared with 32.6 weeks and 1,990 g in the control group.

The first randomized, controlled trial of CenteringPregnancy involves thousands of women and should conclude in the next 6 months, Ms. Hutchison said.

Pregnancy Care Models Differ

Traditional Care

Physical assessment is primary.

Education is mostly one-on-one.

Communication is didactic.

Process of care is disempowering.

Psychosocial support is incidental.

CenteringPregnancy Care

Physical assessment is simply one aspect of care.

Education is both group-based and interactive.

Communication is both interactive and facilitated.

Process of care is empowering.

Psychosocial support and community-building are primary.

Source: Ms. Hutchison