Sherry Boschert

SAN FRANCISCO — A yet to be released tool developed by the World Health Organization should help physicians calculate an individual's absolute risk for bone fracture and provide a basis for counseling patients regarding treatment, experts said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

The expected WHO model will estimate an individual's risk of developing a fragility fracture over the next decade, based on factors that may include age, bone mineral density of the femoral neck, a history of previous fracture, family history of fracture, smoking and alcohol use, steroid use, and the presence of rheumatoid arthritis.

At this point no one knows exactly which factors will be included in the model, said Steven T. Harris, M.D., clinical professor of medicine at the University of California, San Francisco.

Calculating absolute risk for fracture greatly assists therapeutic decision-making, he said. For example, a 2001 model looked at the 10-year probability of fractures in the hip, forearm, humerus, or spine based simply on age and bone density. A 45-year-old with a T score of -3 (which is consistent with osteoporosis) has about a 10% risk of fracture over the next 10 years, but the fracture risk increases to 30% in a 75-year-old with the same bone density.

The WHO model “is going to be far better than telling someone they have osteoporosis, giving them a prescription, and saying goodbye,” Dr. Harris said. “Getting people engaged in conversation about what their risk is, and what can be done with contemporary treatment, is going to make therapy a lot more rational.”

If a clinician could tell a 55-year-old patient who is osteopenic (with a T score of -2) that the patient's absolute risk for fracture is 10% over the next 10 years, and that contemporary treatments could reduce that risk to 5%, that should help the patient decide whether the potential improvement is worth the cost or inconvenience associated with therapy.

Calculations of absolute risk also are likely to be used by insurers in the near future to decide whether to cover medical therapy for improving bone density. It may be that therapy for someone with a 20% risk of fracture will be covered, but patients with a 10% risk will have to pay for the medications themselves.

The new WHO index is due to be released “imminently,” which probably means in the first half of 2006, Steven R. Cummings, M.D., said in a separate presentation at the meeting.

He noted that the WHO's fracture risk index is based on data from about 60,000 women in 12 cohorts of patients, mostly Europeans, and needs to be validated in other populations, including that of the United States.

Some studies have been using the index to compare the value of bone density measurements with the value of other risk factors in predicting future fractures. Using the index alone without measuring bone density seems to be pretty good at predicting hip fractures, and is modestly valuable in predicting other types of osteoporotic fractures.

Having “an index of risk factors may be useful, particularly in places where you don't have bone density testing, or if you're deciding whether or not” to measure a patient's bone density, 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.

Adding bone density measurement to other factors in the index strengthens the ability to predict hip fracture and mildly strengthens the ability to predict other fractures, but the opposite does not seem to be true. “It's not clear that adding risk factors, once you know the bone density, will substantially improve the clinical judgments you can make about treatment with medication,” he said.

SAN FRANCISCO — A yet to be released tool developed by the World Health Organization should help physicians calculate an individual's absolute risk for bone fracture and provide a basis for counseling patients regarding treatment, experts said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

The expected WHO model will estimate an individual's risk of developing a fragility fracture over the next decade, based on factors that may include age, bone mineral density of the femoral neck, a history of previous fracture, family history of fracture, smoking and alcohol use, steroid use, and the presence of rheumatoid arthritis.

At this point no one knows exactly which factors will be included in the model, said Steven T. Harris, M.D., clinical professor of medicine at the University of California, San Francisco.

Calculating absolute risk for fracture greatly assists therapeutic decision-making, he said. For example, a 2001 model looked at the 10-year probability of fractures in the hip, forearm, humerus, or spine based simply on age and bone density. A 45-year-old with a T score of -3 (which is consistent with osteoporosis) has about a 10% risk of fracture over the next 10 years, but the fracture risk increases to 30% in a 75-year-old with the same bone density.

The WHO model “is going to be far better than telling someone they have osteoporosis, giving them a prescription, and saying goodbye,” Dr. Harris said. “Getting people engaged in conversation about what their risk is, and what can be done with contemporary treatment, is going to make therapy a lot more rational.”

If a clinician could tell a 55-year-old patient who is osteopenic (with a T score of -2) that the patient's absolute risk for fracture is 10% over the next 10 years, and that contemporary treatments could reduce that risk to 5%, that should help the patient decide whether the potential improvement is worth the cost or inconvenience associated with therapy.

Calculations of absolute risk also are likely to be used by insurers in the near future to decide whether to cover medical therapy for improving bone density. It may be that therapy for someone with a 20% risk of fracture will be covered, but patients with a 10% risk will have to pay for the medications themselves.

The new WHO index is due to be released “imminently,” which probably means in the first half of 2006, Steven R. Cummings, M.D., said in a separate presentation at the meeting.

He noted that the WHO's fracture risk index is based on data from about 60,000 women in 12 cohorts of patients, mostly Europeans, and needs to be validated in other populations, including that of the United States.

Some studies have been using the index to compare the value of bone density measurements with the value of other risk factors in predicting future fractures. Using the index alone without measuring bone density seems to be pretty good at predicting hip fractures, and is modestly valuable in predicting other types of osteoporotic fractures.

Having “an index of risk factors may be useful, particularly in places where you don't have bone density testing, or if you're deciding whether or not” to measure a patient's bone density, 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.

Adding bone density measurement to other factors in the index strengthens the ability to predict hip fracture and mildly strengthens the ability to predict other fractures, but the opposite does not seem to be true. “It's not clear that adding risk factors, once you know the bone density, will substantially improve the clinical judgments you can make about treatment with medication,” he said.

SAN FRANCISCO — A yet to be released tool developed by the World Health Organization should help physicians calculate an individual's absolute risk for bone fracture and provide a basis for counseling patients regarding treatment, experts said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

The expected WHO model will estimate an individual's risk of developing a fragility fracture over the next decade, based on factors that may include age, bone mineral density of the femoral neck, a history of previous fracture, family history of fracture, smoking and alcohol use, steroid use, and the presence of rheumatoid arthritis.

At this point no one knows exactly which factors will be included in the model, said Steven T. Harris, M.D., clinical professor of medicine at the University of California, San Francisco.

Calculating absolute risk for fracture greatly assists therapeutic decision-making, he said. For example, a 2001 model looked at the 10-year probability of fractures in the hip, forearm, humerus, or spine based simply on age and bone density. A 45-year-old with a T score of -3 (which is consistent with osteoporosis) has about a 10% risk of fracture over the next 10 years, but the fracture risk increases to 30% in a 75-year-old with the same bone density.

The WHO model “is going to be far better than telling someone they have osteoporosis, giving them a prescription, and saying goodbye,” Dr. Harris said. “Getting people engaged in conversation about what their risk is, and what can be done with contemporary treatment, is going to make therapy a lot more rational.”

If a clinician could tell a 55-year-old patient who is osteopenic (with a T score of -2) that the patient's absolute risk for fracture is 10% over the next 10 years, and that contemporary treatments could reduce that risk to 5%, that should help the patient decide whether the potential improvement is worth the cost or inconvenience associated with therapy.

Calculations of absolute risk also are likely to be used by insurers in the near future to decide whether to cover medical therapy for improving bone density. It may be that therapy for someone with a 20% risk of fracture will be covered, but patients with a 10% risk will have to pay for the medications themselves.

The new WHO index is due to be released “imminently,” which probably means in the first half of 2006, Steven R. Cummings, M.D., said in a separate presentation at the meeting.

He noted that the WHO's fracture risk index is based on data from about 60,000 women in 12 cohorts of patients, mostly Europeans, and needs to be validated in other populations, including that of the United States.

Some studies have been using the index to compare the value of bone density measurements with the value of other risk factors in predicting future fractures. Using the index alone without measuring bone density seems to be pretty good at predicting hip fractures, and is modestly valuable in predicting other types of osteoporotic fractures.

Having “an index of risk factors may be useful, particularly in places where you don't have bone density testing, or if you're deciding whether or not” to measure a patient's bone density, 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.

Adding bone density measurement to other factors in the index strengthens the ability to predict hip fracture and mildly strengthens the ability to predict other fractures, but the opposite does not seem to be true. “It's not clear that adding risk factors, once you know the bone density, will substantially improve the clinical judgments you can make about treatment with medication,” he 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 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,” added Dr. Cummings. 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, he said.

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. “You might be doing double good for bone, suppressing resorption, and also stimulating bone formation” with nitrates he 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 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,” added Dr. Cummings. 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, he said.

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. “You might be doing double good for bone, suppressing resorption, and also stimulating bone formation” with nitrates he 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 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,” added Dr. Cummings. 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, he said.

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. “You might be doing double good for bone, suppressing resorption, and also stimulating bone formation” with nitrates he said.

SAN FRANCISCO — A majority of 1,536 elderly women taking medication to prevent or treat osteoporosis were deficient in vitamin D, a study of community-dwelling patients found.

The findings echo a previous study that found 56% of medical inpatients had vitamin D deficiency. “This is a very common problem” that deserves more attention, Dolores M. Shoback, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Physicians should look more carefully for vitamin D deficiency in inpatients and outpatients, even those who are ambulatory, on prescription therapy for osteoporosis, and lacking risk factors for vitamin D deficiency—”many of the patients, probably, in our own practices,” said Dr. Shoback, professor of medicine at the university.

The recent outpatient study included postmenopausal women at 61 locations in North America who had been taking bisphosphonates, calcitonin, or a selective estrogen receptor modulator for at least 3 months under a physician's care to prevent or treat osteoporosis. They averaged 71 years in age, and were 92% white. Investigators administered a questionnaire to assess risk factors for vitamin D deficiency and measured the women's serum concentrations of parathyroid hormone (PTH) and 25-hydroxyvitamin D—known as 25(OH)D—the form of vitamin D stored in the body.

They found that 52% of the 1,536 women had levels of 25(OH)D lower than 30 ng/mL. Of these, 36% had levels below 25 ng/mL, and 18% were below 20 ng/mL, showing that most of the women with inadequate vitamin D were severely deficient (J. Clin. Endocrinol. Metab. 2005;90:3215–24).

“We aren't doing a good job with the people we're actively treating for osteoporosis,” said Dr. Shoback. Vitamin D deficiency is one of the most common causes of secondary osteoporosis.

Although there's no consensus on how much vitamin D the human body needs, the idea that 15–25 ng/mL is adequate has been replaced in the last few years by general cutoffs closer to 30 ng/mL or higher, she said. Some experts say people need at least 20 ng/mL 25(OH)D or else PTH levels rise and frank hyperparathyroidism develops. Others say that elderly people need 32–36 ng/mL to maximize intestinal calcium transport.

In the study patients tended to develop secondary hyperparathyroidism at 25(OH)D levels of 25 ng/mL and lower. Many physicians use PTH levels to help diagnose vitamin D deficiency, but the study found that high PTH is not 100% sensitive for low vitamin D. Only 75% of women with 25(OH)D levels of 0–9 ng/mL had secondary hyperparathyroidism. “This surprised me,” Dr. Shoback said.

Women who had not discussed vitamin D and bone health with their doctors were more likely to have 25(OH)D levels below 30 ng/mL. “Sometimes we think we're talking to the wall or ourselves, but these discussions actually may be having some kind of an impact,” Dr. Shoback said.

Other risk factors for vitamin D deficiency included age older than 80, a body mass index over 30 kg/m

Among patients with none of these risk factors, 32% had inadequate levels of 25(OH)D. “There just seem to be people out there who have vitamin D deficiency,” she said.

The 1998 inpatient study that detected vitamin D deficiency in 56% of 290 patients consecutively admitted to a hospital medical service also found that risk factors predicted the deficiency only about 60% of the time. The investigators recommended that medical inpatients be screened for vitamin D deficiency, she noted. Taking multivitamins did not prevent vitamin D deficiency in that study.

Dr. Shoback has no affiliation with companies that make vitamin D supplements.

SAN FRANCISCO — A majority of 1,536 elderly women taking medication to prevent or treat osteoporosis were deficient in vitamin D, a study of community-dwelling patients found.

The findings echo a previous study that found 56% of medical inpatients had vitamin D deficiency. “This is a very common problem” that deserves more attention, Dolores M. Shoback, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Physicians should look more carefully for vitamin D deficiency in inpatients and outpatients, even those who are ambulatory, on prescription therapy for osteoporosis, and lacking risk factors for vitamin D deficiency—”many of the patients, probably, in our own practices,” said Dr. Shoback, professor of medicine at the university.

The recent outpatient study included postmenopausal women at 61 locations in North America who had been taking bisphosphonates, calcitonin, or a selective estrogen receptor modulator for at least 3 months under a physician's care to prevent or treat osteoporosis. They averaged 71 years in age, and were 92% white. Investigators administered a questionnaire to assess risk factors for vitamin D deficiency and measured the women's serum concentrations of parathyroid hormone (PTH) and 25-hydroxyvitamin D—known as 25(OH)D—the form of vitamin D stored in the body.

They found that 52% of the 1,536 women had levels of 25(OH)D lower than 30 ng/mL. Of these, 36% had levels below 25 ng/mL, and 18% were below 20 ng/mL, showing that most of the women with inadequate vitamin D were severely deficient (J. Clin. Endocrinol. Metab. 2005;90:3215–24).

“We aren't doing a good job with the people we're actively treating for osteoporosis,” said Dr. Shoback. Vitamin D deficiency is one of the most common causes of secondary osteoporosis.

Although there's no consensus on how much vitamin D the human body needs, the idea that 15–25 ng/mL is adequate has been replaced in the last few years by general cutoffs closer to 30 ng/mL or higher, she said. Some experts say people need at least 20 ng/mL 25(OH)D or else PTH levels rise and frank hyperparathyroidism develops. Others say that elderly people need 32–36 ng/mL to maximize intestinal calcium transport.

In the study patients tended to develop secondary hyperparathyroidism at 25(OH)D levels of 25 ng/mL and lower. Many physicians use PTH levels to help diagnose vitamin D deficiency, but the study found that high PTH is not 100% sensitive for low vitamin D. Only 75% of women with 25(OH)D levels of 0–9 ng/mL had secondary hyperparathyroidism. “This surprised me,” Dr. Shoback said.

Women who had not discussed vitamin D and bone health with their doctors were more likely to have 25(OH)D levels below 30 ng/mL. “Sometimes we think we're talking to the wall or ourselves, but these discussions actually may be having some kind of an impact,” Dr. Shoback said.

Other risk factors for vitamin D deficiency included age older than 80, a body mass index over 30 kg/m

Among patients with none of these risk factors, 32% had inadequate levels of 25(OH)D. “There just seem to be people out there who have vitamin D deficiency,” she said.

The 1998 inpatient study that detected vitamin D deficiency in 56% of 290 patients consecutively admitted to a hospital medical service also found that risk factors predicted the deficiency only about 60% of the time. The investigators recommended that medical inpatients be screened for vitamin D deficiency, she noted. Taking multivitamins did not prevent vitamin D deficiency in that study.

Dr. Shoback has no affiliation with companies that make vitamin D supplements.

SAN FRANCISCO — A majority of 1,536 elderly women taking medication to prevent or treat osteoporosis were deficient in vitamin D, a study of community-dwelling patients found.

The findings echo a previous study that found 56% of medical inpatients had vitamin D deficiency. “This is a very common problem” that deserves more attention, Dolores M. Shoback, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Physicians should look more carefully for vitamin D deficiency in inpatients and outpatients, even those who are ambulatory, on prescription therapy for osteoporosis, and lacking risk factors for vitamin D deficiency—”many of the patients, probably, in our own practices,” said Dr. Shoback, professor of medicine at the university.

The recent outpatient study included postmenopausal women at 61 locations in North America who had been taking bisphosphonates, calcitonin, or a selective estrogen receptor modulator for at least 3 months under a physician's care to prevent or treat osteoporosis. They averaged 71 years in age, and were 92% white. Investigators administered a questionnaire to assess risk factors for vitamin D deficiency and measured the women's serum concentrations of parathyroid hormone (PTH) and 25-hydroxyvitamin D—known as 25(OH)D—the form of vitamin D stored in the body.

They found that 52% of the 1,536 women had levels of 25(OH)D lower than 30 ng/mL. Of these, 36% had levels below 25 ng/mL, and 18% were below 20 ng/mL, showing that most of the women with inadequate vitamin D were severely deficient (J. Clin. Endocrinol. Metab. 2005;90:3215–24).

“We aren't doing a good job with the people we're actively treating for osteoporosis,” said Dr. Shoback. Vitamin D deficiency is one of the most common causes of secondary osteoporosis.

Although there's no consensus on how much vitamin D the human body needs, the idea that 15–25 ng/mL is adequate has been replaced in the last few years by general cutoffs closer to 30 ng/mL or higher, she said. Some experts say people need at least 20 ng/mL 25(OH)D or else PTH levels rise and frank hyperparathyroidism develops. Others say that elderly people need 32–36 ng/mL to maximize intestinal calcium transport.

In the study patients tended to develop secondary hyperparathyroidism at 25(OH)D levels of 25 ng/mL and lower. Many physicians use PTH levels to help diagnose vitamin D deficiency, but the study found that high PTH is not 100% sensitive for low vitamin D. Only 75% of women with 25(OH)D levels of 0–9 ng/mL had secondary hyperparathyroidism. “This surprised me,” Dr. Shoback said.

Women who had not discussed vitamin D and bone health with their doctors were more likely to have 25(OH)D levels below 30 ng/mL. “Sometimes we think we're talking to the wall or ourselves, but these discussions actually may be having some kind of an impact,” Dr. Shoback said.

Other risk factors for vitamin D deficiency included age older than 80, a body mass index over 30 kg/m

Among patients with none of these risk factors, 32% had inadequate levels of 25(OH)D. “There just seem to be people out there who have vitamin D deficiency,” she said.

The 1998 inpatient study that detected vitamin D deficiency in 56% of 290 patients consecutively admitted to a hospital medical service also found that risk factors predicted the deficiency only about 60% of the time. The investigators recommended that medical inpatients be screened for vitamin D deficiency, she noted. Taking multivitamins did not prevent vitamin D deficiency in that study.

Dr. Shoback has no affiliation with companies that make vitamin D supplements.

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 hip fractures. Usually poor vision is due to treatable 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 fractures. 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. 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 during the first 6 months. Higher doses of steroids 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 about doubles the risk for hip fracture regardless of a person's 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 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 hip fractures. Usually poor vision is due to treatable 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 fractures. 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. 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 during the first 6 months. Higher doses of steroids 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 about doubles the risk for hip fracture regardless of a person's 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 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 hip fractures. Usually poor vision is due to treatable 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 fractures. 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. 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 during the first 6 months. Higher doses of steroids 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 about doubles the risk for hip fracture regardless of a person's 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 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 — Ambulatory blood pressure monitoring in the general population was a better predictor of cardiovascular mortality and morbidity than in-office blood pressure measurements in a 10-year study, Tine Willum Hansen, M.D., reported.

The investigators recorded baseline ambulatory and in-office blood pressure readings and other risk factors in 1,700 people aged 41–72 years who had no major cardiovascular diseases. The subjects were followed up 9.5 years later; 156 subjects had died of cardiovascular disease, had a stroke, or developed ischemic heart disease during that decade, she said at the annual meeting of the American Society of Hypertension.

For ambulatory measurements, every 10-mm Hg increase in systolic blood pressure at baseline, the relative risk for these three end points combined (cardiovascular death, ischemic heart disease, and stroke) increased by 35%. For every 10-mm Hg increase in diastolic blood pressure at baseline, the relative risk increased 27%, said Dr. Hansen of the Research Center for Prevention and Health, Copenhagen.

In contrast, for in-office measurements at baseline, every 10-mm Hg increase in systolic blood pressure raised the risk of the combined end points by 18%, and each 10-mm Hg increase in diastolic pressure raised the risk by 11%.

Only ambulatory blood pressure was a significant predictor of risk for the combined end points, Dr. Hansen said.

Compared with normotensive subjects at baseline, those with sustained hypertension based on either ambulatory or in-office measurements were more than twice as likely to die of cardiovascular disease or develop ischemic heart disease or stroke. Of normotensive subjects, 6% developed one of these end points, compared with 17% of those with sustained hypertension—a significant difference.

Compared with normotensives, subjects with isolated ambulatory hypertension showed a trend toward increased risk for the combined end points; this trend did not reach statistical significance. A similar trend was not seen in subjects with isolated in-office hypertension.

Among 474 “nondippers” (people whose blood pressures fell less than 10% at night) based on ambulatory measurements, those with hypertension had a 68% higher risk for the combined end points than did normotensive subjects, Dr. Hansen said.

SAN FRANCISCO — Ambulatory blood pressure monitoring in the general population was a better predictor of cardiovascular mortality and morbidity than in-office blood pressure measurements in a 10-year study, Tine Willum Hansen, M.D., reported.

The investigators recorded baseline ambulatory and in-office blood pressure readings and other risk factors in 1,700 people aged 41–72 years who had no major cardiovascular diseases. The subjects were followed up 9.5 years later; 156 subjects had died of cardiovascular disease, had a stroke, or developed ischemic heart disease during that decade, she said at the annual meeting of the American Society of Hypertension.

For ambulatory measurements, every 10-mm Hg increase in systolic blood pressure at baseline, the relative risk for these three end points combined (cardiovascular death, ischemic heart disease, and stroke) increased by 35%. For every 10-mm Hg increase in diastolic blood pressure at baseline, the relative risk increased 27%, said Dr. Hansen of the Research Center for Prevention and Health, Copenhagen.

In contrast, for in-office measurements at baseline, every 10-mm Hg increase in systolic blood pressure raised the risk of the combined end points by 18%, and each 10-mm Hg increase in diastolic pressure raised the risk by 11%.

Only ambulatory blood pressure was a significant predictor of risk for the combined end points, Dr. Hansen said.

Compared with normotensive subjects at baseline, those with sustained hypertension based on either ambulatory or in-office measurements were more than twice as likely to die of cardiovascular disease or develop ischemic heart disease or stroke. Of normotensive subjects, 6% developed one of these end points, compared with 17% of those with sustained hypertension—a significant difference.

Compared with normotensives, subjects with isolated ambulatory hypertension showed a trend toward increased risk for the combined end points; this trend did not reach statistical significance. A similar trend was not seen in subjects with isolated in-office hypertension.

Among 474 “nondippers” (people whose blood pressures fell less than 10% at night) based on ambulatory measurements, those with hypertension had a 68% higher risk for the combined end points than did normotensive subjects, Dr. Hansen said.

SAN FRANCISCO — Ambulatory blood pressure monitoring in the general population was a better predictor of cardiovascular mortality and morbidity than in-office blood pressure measurements in a 10-year study, Tine Willum Hansen, M.D., reported.

The investigators recorded baseline ambulatory and in-office blood pressure readings and other risk factors in 1,700 people aged 41–72 years who had no major cardiovascular diseases. The subjects were followed up 9.5 years later; 156 subjects had died of cardiovascular disease, had a stroke, or developed ischemic heart disease during that decade, she said at the annual meeting of the American Society of Hypertension.

For ambulatory measurements, every 10-mm Hg increase in systolic blood pressure at baseline, the relative risk for these three end points combined (cardiovascular death, ischemic heart disease, and stroke) increased by 35%. For every 10-mm Hg increase in diastolic blood pressure at baseline, the relative risk increased 27%, said Dr. Hansen of the Research Center for Prevention and Health, Copenhagen.

In contrast, for in-office measurements at baseline, every 10-mm Hg increase in systolic blood pressure raised the risk of the combined end points by 18%, and each 10-mm Hg increase in diastolic pressure raised the risk by 11%.

Only ambulatory blood pressure was a significant predictor of risk for the combined end points, Dr. Hansen said.

Compared with normotensive subjects at baseline, those with sustained hypertension based on either ambulatory or in-office measurements were more than twice as likely to die of cardiovascular disease or develop ischemic heart disease or stroke. Of normotensive subjects, 6% developed one of these end points, compared with 17% of those with sustained hypertension—a significant difference.

Compared with normotensives, subjects with isolated ambulatory hypertension showed a trend toward increased risk for the combined end points; this trend did not reach statistical significance. A similar trend was not seen in subjects with isolated in-office hypertension.

Among 474 “nondippers” (people whose blood pressures fell less than 10% at night) based on ambulatory measurements, those with hypertension had a 68% higher risk for the combined end points than did normotensive subjects, Dr. Hansen said.

SAN FRANCISCO — Most physicians believe in urging hypertensive patients to alter their lifestyle in beneficial ways, even though this seldom happens, Norman Kaplan, M.D., said at the annual meeting of the American Society of Hypertension.

“I'm not sure that we're going to be depending as much on lifestyle modifications as we have in the past” because of the recognition that high blood pressures need to be lowered quickly, said Dr. Kaplan, professor of medicine at the University of Texas, Dallas. He described lifestyle modifications that do and don't work in treating hypertension:

▸ Smoking cessation. Usually found at the bottom of lists of lifestyle modifications for treating hypertension, smoking cessation deserves first mention because it is the major reversible cardiovascular risk factor in hypertensive smokers. Until recently, physicians didn't recognize the pressor effects of nicotine because patients weren't allowed to smoke during blood pressure measurements. Ambulatory monitoring consistently shows higher blood pressures while smoking.

Advise patients repeatedly to stop smoking, and explain or show to them the pressor effect of smoking, Dr. Kaplan said. Nicotine replacement products such as patches should not have persistent pressor effects but advise patients to check their blood pressure on these products because some people may be particularly sensitive.

▸ Weight loss. Significant weight loss reduces blood pressure, but most dieters put the pounds back on in a short amount of time. Studies comparing weight loss diets suggest that the cheapest and “probably the most logical” method—Weight Watchers—may be the best diet strategy, he said.

For morbidly obese people (body mass index greater than 40 kg/m

Gastric banding surgeries have been less successful in morbidly obese patients. It appears that enough food is forced past the banded stomach over time that the patient regains the weight initially lost after surgery.

▸ Physical activity. Unhealthy diets and physical inactivity share equal blame for Americans' march toward morbid obesity.

Duration is more important than intensity of physical activity for lowering blood pressure, studies show. Thirty minutes on a treadmill at 50%–75% of maximal heart rate significantly reduced blood pressure with effects persisting over 24 hours, one study found, he said.

A metaanalysis of studies on diabetic patients found that walking as little as 2 hours or more each week reduced mortality by about 40%, compared with less active patients, Dr. Kaplan said.

▸ Sodium reduction. Patients who reduce their sodium intake typically return to old habits over time. The result is that no difference is seen after 5 years, according to an analysis of about 30 studies.

High-sodium foods abound in U.S. culture, with 1,000–3,000 mg sodium in some fast food items. “Most people have no perception of what they're eating when they eat this kind of food,” he said.

▸ Moderation of alcohol. Drinking modest amounts of alcohol while eating food does not increase the risk of hypertension and may even provide some cardiovascular benefits, he said. Consuming alcohol without food or having more than three drinks per day increases the risk for hypertension and other health problems.

▸ Increasing potassium. Hypertensive patients can reduce their blood pressure by taking 40–80 mmol/day of supplemental potassium, but it's better to recommend that patients eat more fruits and vegetables to boost their potassium intake. One reason the Dietary Approaches to Stop Hypertension diet works is that it triples the typical potassium intake, Dr. Kaplan noted.

▸ Reducing caffeine. Be aware that the first cup of the day causes a pressor effect in many people. Advise patients monitoring their blood pressure to check before and after drinking coffee or tea containing caffeine, he advised.

▸ Calcium or magnesium. These minerals, in the form of supplements, have no significant effect on hypertension, Dr. Kaplan said.

SAN FRANCISCO — Most physicians believe in urging hypertensive patients to alter their lifestyle in beneficial ways, even though this seldom happens, Norman Kaplan, M.D., said at the annual meeting of the American Society of Hypertension.

“I'm not sure that we're going to be depending as much on lifestyle modifications as we have in the past” because of the recognition that high blood pressures need to be lowered quickly, said Dr. Kaplan, professor of medicine at the University of Texas, Dallas. He described lifestyle modifications that do and don't work in treating hypertension:

▸ Smoking cessation. Usually found at the bottom of lists of lifestyle modifications for treating hypertension, smoking cessation deserves first mention because it is the major reversible cardiovascular risk factor in hypertensive smokers. Until recently, physicians didn't recognize the pressor effects of nicotine because patients weren't allowed to smoke during blood pressure measurements. Ambulatory monitoring consistently shows higher blood pressures while smoking.

Advise patients repeatedly to stop smoking, and explain or show to them the pressor effect of smoking, Dr. Kaplan said. Nicotine replacement products such as patches should not have persistent pressor effects but advise patients to check their blood pressure on these products because some people may be particularly sensitive.

▸ Weight loss. Significant weight loss reduces blood pressure, but most dieters put the pounds back on in a short amount of time. Studies comparing weight loss diets suggest that the cheapest and “probably the most logical” method—Weight Watchers—may be the best diet strategy, he said.

For morbidly obese people (body mass index greater than 40 kg/m

Gastric banding surgeries have been less successful in morbidly obese patients. It appears that enough food is forced past the banded stomach over time that the patient regains the weight initially lost after surgery.

▸ Physical activity. Unhealthy diets and physical inactivity share equal blame for Americans' march toward morbid obesity.

Duration is more important than intensity of physical activity for lowering blood pressure, studies show. Thirty minutes on a treadmill at 50%–75% of maximal heart rate significantly reduced blood pressure with effects persisting over 24 hours, one study found, he said.

A metaanalysis of studies on diabetic patients found that walking as little as 2 hours or more each week reduced mortality by about 40%, compared with less active patients, Dr. Kaplan said.

▸ Sodium reduction. Patients who reduce their sodium intake typically return to old habits over time. The result is that no difference is seen after 5 years, according to an analysis of about 30 studies.

High-sodium foods abound in U.S. culture, with 1,000–3,000 mg sodium in some fast food items. “Most people have no perception of what they're eating when they eat this kind of food,” he said.

▸ Moderation of alcohol. Drinking modest amounts of alcohol while eating food does not increase the risk of hypertension and may even provide some cardiovascular benefits, he said. Consuming alcohol without food or having more than three drinks per day increases the risk for hypertension and other health problems.

▸ Increasing potassium. Hypertensive patients can reduce their blood pressure by taking 40–80 mmol/day of supplemental potassium, but it's better to recommend that patients eat more fruits and vegetables to boost their potassium intake. One reason the Dietary Approaches to Stop Hypertension diet works is that it triples the typical potassium intake, Dr. Kaplan noted.

▸ Reducing caffeine. Be aware that the first cup of the day causes a pressor effect in many people. Advise patients monitoring their blood pressure to check before and after drinking coffee or tea containing caffeine, he advised.

▸ Calcium or magnesium. These minerals, in the form of supplements, have no significant effect on hypertension, Dr. Kaplan said.

SAN FRANCISCO — Most physicians believe in urging hypertensive patients to alter their lifestyle in beneficial ways, even though this seldom happens, Norman Kaplan, M.D., said at the annual meeting of the American Society of Hypertension.

“I'm not sure that we're going to be depending as much on lifestyle modifications as we have in the past” because of the recognition that high blood pressures need to be lowered quickly, said Dr. Kaplan, professor of medicine at the University of Texas, Dallas. He described lifestyle modifications that do and don't work in treating hypertension:

▸ Smoking cessation. Usually found at the bottom of lists of lifestyle modifications for treating hypertension, smoking cessation deserves first mention because it is the major reversible cardiovascular risk factor in hypertensive smokers. Until recently, physicians didn't recognize the pressor effects of nicotine because patients weren't allowed to smoke during blood pressure measurements. Ambulatory monitoring consistently shows higher blood pressures while smoking.

Advise patients repeatedly to stop smoking, and explain or show to them the pressor effect of smoking, Dr. Kaplan said. Nicotine replacement products such as patches should not have persistent pressor effects but advise patients to check their blood pressure on these products because some people may be particularly sensitive.

▸ Weight loss. Significant weight loss reduces blood pressure, but most dieters put the pounds back on in a short amount of time. Studies comparing weight loss diets suggest that the cheapest and “probably the most logical” method—Weight Watchers—may be the best diet strategy, he said.

For morbidly obese people (body mass index greater than 40 kg/m

Gastric banding surgeries have been less successful in morbidly obese patients. It appears that enough food is forced past the banded stomach over time that the patient regains the weight initially lost after surgery.

▸ Physical activity. Unhealthy diets and physical inactivity share equal blame for Americans' march toward morbid obesity.

Duration is more important than intensity of physical activity for lowering blood pressure, studies show. Thirty minutes on a treadmill at 50%–75% of maximal heart rate significantly reduced blood pressure with effects persisting over 24 hours, one study found, he said.

A metaanalysis of studies on diabetic patients found that walking as little as 2 hours or more each week reduced mortality by about 40%, compared with less active patients, Dr. Kaplan said.

▸ Sodium reduction. Patients who reduce their sodium intake typically return to old habits over time. The result is that no difference is seen after 5 years, according to an analysis of about 30 studies.

High-sodium foods abound in U.S. culture, with 1,000–3,000 mg sodium in some fast food items. “Most people have no perception of what they're eating when they eat this kind of food,” he said.

▸ Moderation of alcohol. Drinking modest amounts of alcohol while eating food does not increase the risk of hypertension and may even provide some cardiovascular benefits, he said. Consuming alcohol without food or having more than three drinks per day increases the risk for hypertension and other health problems.

▸ Increasing potassium. Hypertensive patients can reduce their blood pressure by taking 40–80 mmol/day of supplemental potassium, but it's better to recommend that patients eat more fruits and vegetables to boost their potassium intake. One reason the Dietary Approaches to Stop Hypertension diet works is that it triples the typical potassium intake, Dr. Kaplan noted.

▸ Reducing caffeine. Be aware that the first cup of the day causes a pressor effect in many people. Advise patients monitoring their blood pressure to check before and after drinking coffee or tea containing caffeine, he advised.

▸ Calcium or magnesium. These minerals, in the form of supplements, have no significant effect on hypertension, Dr. Kaplan said.

SAN FRANCISCO — Data from recent studies call into question the recommendation that physicians delay administration of epidural anesthesia to nulliparous women in labor, Michael P. Nageotte, M.D., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The American College of Obstetricians and Gynecologists has recommended that “when feasible, obstetric practitioners should delay the administration of epidural anesthesia in nulliparous women until the cervical dilatation reaches 4–5 cm, and that other forms of analgesia be used until that time,” noted Dr. Nageotte, professor of obstetrics and gynecology at the University of California, Irvine. Giving an epidural when the cervix is dilated less than 4 cm has been associated with a higher rate of cesarean delivery.

Investigators at Northwestern University, Chicago, led a recent study of 750 term nulliparous women who had experienced spontaneous labor or spontaneous rupture of the membranes. All of the women had a cervix that was dilated less than 4 cm on the initial exam and were told at the time of randomization that they would get an epidural if needed.

The women were randomly assigned to receive either an intrathecal injection of fentanyl or systemic hydromorphone when they first requested analgesia. A woman's second request for analgesia resulted in administration of an epidural in the intrathecal group or assessment of cervical dilation in the systemic analgesia group. Women in the systemic group got an epidural if the cervix was dilated at least 4 cm, or received a second dose of systemic hydromorphone and were given an epidural upon their third request for analgesia.

The rate of cesarean delivery did not differ significantly between groups, but it was slightly higher in the delayed-epidural group, compared with the early-epidural group—21% vs. 18% (N. Engl. J. Med. 2005;352:655–65). The early-epidural group also had a significantly shorter time from receiving the first analgesia to complete cervical dilation (295 vs. 385 minutes) and a significantly shorter time from first analgesia to vaginal birth (398 vs. 479 minutes).

Women in the early-epidural group had better pain scores and were less likely to have babies with low Apgar scores at 1 minute.

SAN FRANCISCO — Data from recent studies call into question the recommendation that physicians delay administration of epidural anesthesia to nulliparous women in labor, Michael P. Nageotte, M.D., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The American College of Obstetricians and Gynecologists has recommended that “when feasible, obstetric practitioners should delay the administration of epidural anesthesia in nulliparous women until the cervical dilatation reaches 4–5 cm, and that other forms of analgesia be used until that time,” noted Dr. Nageotte, professor of obstetrics and gynecology at the University of California, Irvine. Giving an epidural when the cervix is dilated less than 4 cm has been associated with a higher rate of cesarean delivery.

Investigators at Northwestern University, Chicago, led a recent study of 750 term nulliparous women who had experienced spontaneous labor or spontaneous rupture of the membranes. All of the women had a cervix that was dilated less than 4 cm on the initial exam and were told at the time of randomization that they would get an epidural if needed.

The women were randomly assigned to receive either an intrathecal injection of fentanyl or systemic hydromorphone when they first requested analgesia. A woman's second request for analgesia resulted in administration of an epidural in the intrathecal group or assessment of cervical dilation in the systemic analgesia group. Women in the systemic group got an epidural if the cervix was dilated at least 4 cm, or received a second dose of systemic hydromorphone and were given an epidural upon their third request for analgesia.

The rate of cesarean delivery did not differ significantly between groups, but it was slightly higher in the delayed-epidural group, compared with the early-epidural group—21% vs. 18% (N. Engl. J. Med. 2005;352:655–65). The early-epidural group also had a significantly shorter time from receiving the first analgesia to complete cervical dilation (295 vs. 385 minutes) and a significantly shorter time from first analgesia to vaginal birth (398 vs. 479 minutes).

Women in the early-epidural group had better pain scores and were less likely to have babies with low Apgar scores at 1 minute.

SAN FRANCISCO — Data from recent studies call into question the recommendation that physicians delay administration of epidural anesthesia to nulliparous women in labor, Michael P. Nageotte, M.D., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The American College of Obstetricians and Gynecologists has recommended that “when feasible, obstetric practitioners should delay the administration of epidural anesthesia in nulliparous women until the cervical dilatation reaches 4–5 cm, and that other forms of analgesia be used until that time,” noted Dr. Nageotte, professor of obstetrics and gynecology at the University of California, Irvine. Giving an epidural when the cervix is dilated less than 4 cm has been associated with a higher rate of cesarean delivery.

Investigators at Northwestern University, Chicago, led a recent study of 750 term nulliparous women who had experienced spontaneous labor or spontaneous rupture of the membranes. All of the women had a cervix that was dilated less than 4 cm on the initial exam and were told at the time of randomization that they would get an epidural if needed.

The women were randomly assigned to receive either an intrathecal injection of fentanyl or systemic hydromorphone when they first requested analgesia. A woman's second request for analgesia resulted in administration of an epidural in the intrathecal group or assessment of cervical dilation in the systemic analgesia group. Women in the systemic group got an epidural if the cervix was dilated at least 4 cm, or received a second dose of systemic hydromorphone and were given an epidural upon their third request for analgesia.

The rate of cesarean delivery did not differ significantly between groups, but it was slightly higher in the delayed-epidural group, compared with the early-epidural group—21% vs. 18% (N. Engl. J. Med. 2005;352:655–65). The early-epidural group also had a significantly shorter time from receiving the first analgesia to complete cervical dilation (295 vs. 385 minutes) and a significantly shorter time from first analgesia to vaginal birth (398 vs. 479 minutes).

Women in the early-epidural group had better pain scores and were less likely to have babies with low Apgar scores at 1 minute.

SAN FRANCISCO — If a cesarean wound must be opened days after the surgery, one of the best ways to help it heal by secondary intention is to get the patient into the shower, Harriet W. Hopf, M.D., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Even with the best of care, some cesarean section wounds need to be opened 4–7 days after the surgery, because they either fail to heal or become infected, said Dr. Hopf of the university. Open wounds heal best when you reduce the bacterial load, keep the wound moist, and pay attention to nutrition and perfusion.

A wound requires several elements for good healing—the right amount of inflammation, protein, oxygen (perfusion), and a proper environment. An infected wound is too inflamed and slow to heal. Most infection comes from bacteria on the skin. Rinsing a wound with normal saline doesn't provide enough volume to remove bacteria. The cold saline induces local vasoconstriction, while a warm shower induces local vasodilation, enhancing perfusion of the wound.

“Just get them in the shower” daily, said Dr. Hopf. “It works so well. That's the primary intervention that I make when I see a patient.” Have patients shower with mild soap and not with bacteriocidal products that not only kill bacteria but inactivate white cells and harm granulating tissue, which delays healing.

If you need to open a cesarean wound, usually by that time the patient no longer has an intravenous line or catheter to get in the way of showering. If she's still on an intravenous line, saline lock it, cover it with a Tegaderm dressing, and have her shower, Dr. Hopf said in an interview. If the patient still has a bladder catheter, skip the shower but use a basin of warm tap water and a 60-mL syringe to irrigate the wound.

For women on steroids, which interfere with healing, applying ointment containing vitamins A and D (typically used for diaper rash) will reverse the steroid effect and help pull macrophages into the wound for healing.

Make sure the patient has adequate pain control, which promotes healing by reducing vasoconstriction and enables dressing changes. Optimize perfusion by keeping the patient warm, giving her plenty of fluids, aggressively managing pain and edema, and encouraging smokers to quit.

Wounds need protein to heal, and lactation uses much of the body's protein. Encourage women who've had C-sections to eat plenty of protein.

“It's hard to get the protein to the wound because the protein is going someplace else,” she said. Over-the-counter protein supplements that contain the amino acid arginine can improve wound healing if needed.

Patients deficient in vitamin A, vitamin C, or zinc will heal more slowly. To replenish them, Dr. Hopf recommends a 10-day course of daily vitamin A (25,000 international units) and zinc (220 mg). A larger amount can be toxic. Vitamin C is nontoxic, and all patients with wounds should get 500–100 mg daily.

Try to keep the wound moist and the surrounding skin dry for best healing. Wounds often start off exudating and later become dry, so don't necessarily use the same dressing throughout healing.

Any of the more than 1,000 wound dressing products available will enable significantly better healing than traditional “wet-to-damp” dressings with saline and gauze, Dr. Hopf stressed.

The commercial products cost more initially, but get changed once daily instead of t.i.d. changes for wet-to-damp dressings, which require more labor and materials. In the end, the cost is about the same, and the patient experiences less pain with commercial dressings, she said. Dr. Hopf said she has no financial relationship with wound-dressing companies.

For an exudating wound, fluff calcium alginate (Sorbsan) and fill the wound loosely with it to absorb exudate, maintain a moist environment, and protect skin from maceration.

SAN FRANCISCO — If a cesarean wound must be opened days after the surgery, one of the best ways to help it heal by secondary intention is to get the patient into the shower, Harriet W. Hopf, M.D., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Even with the best of care, some cesarean section wounds need to be opened 4–7 days after the surgery, because they either fail to heal or become infected, said Dr. Hopf of the university. Open wounds heal best when you reduce the bacterial load, keep the wound moist, and pay attention to nutrition and perfusion.

A wound requires several elements for good healing—the right amount of inflammation, protein, oxygen (perfusion), and a proper environment. An infected wound is too inflamed and slow to heal. Most infection comes from bacteria on the skin. Rinsing a wound with normal saline doesn't provide enough volume to remove bacteria. The cold saline induces local vasoconstriction, while a warm shower induces local vasodilation, enhancing perfusion of the wound.

“Just get them in the shower” daily, said Dr. Hopf. “It works so well. That's the primary intervention that I make when I see a patient.” Have patients shower with mild soap and not with bacteriocidal products that not only kill bacteria but inactivate white cells and harm granulating tissue, which delays healing.

If you need to open a cesarean wound, usually by that time the patient no longer has an intravenous line or catheter to get in the way of showering. If she's still on an intravenous line, saline lock it, cover it with a Tegaderm dressing, and have her shower, Dr. Hopf said in an interview. If the patient still has a bladder catheter, skip the shower but use a basin of warm tap water and a 60-mL syringe to irrigate the wound.

For women on steroids, which interfere with healing, applying ointment containing vitamins A and D (typically used for diaper rash) will reverse the steroid effect and help pull macrophages into the wound for healing.

Make sure the patient has adequate pain control, which promotes healing by reducing vasoconstriction and enables dressing changes. Optimize perfusion by keeping the patient warm, giving her plenty of fluids, aggressively managing pain and edema, and encouraging smokers to quit.

Wounds need protein to heal, and lactation uses much of the body's protein. Encourage women who've had C-sections to eat plenty of protein.

“It's hard to get the protein to the wound because the protein is going someplace else,” she said. Over-the-counter protein supplements that contain the amino acid arginine can improve wound healing if needed.

Patients deficient in vitamin A, vitamin C, or zinc will heal more slowly. To replenish them, Dr. Hopf recommends a 10-day course of daily vitamin A (25,000 international units) and zinc (220 mg). A larger amount can be toxic. Vitamin C is nontoxic, and all patients with wounds should get 500–100 mg daily.

Try to keep the wound moist and the surrounding skin dry for best healing. Wounds often start off exudating and later become dry, so don't necessarily use the same dressing throughout healing.

Any of the more than 1,000 wound dressing products available will enable significantly better healing than traditional “wet-to-damp” dressings with saline and gauze, Dr. Hopf stressed.

The commercial products cost more initially, but get changed once daily instead of t.i.d. changes for wet-to-damp dressings, which require more labor and materials. In the end, the cost is about the same, and the patient experiences less pain with commercial dressings, she said. Dr. Hopf said she has no financial relationship with wound-dressing companies.

For an exudating wound, fluff calcium alginate (Sorbsan) and fill the wound loosely with it to absorb exudate, maintain a moist environment, and protect skin from maceration.

SAN FRANCISCO — If a cesarean wound must be opened days after the surgery, one of the best ways to help it heal by secondary intention is to get the patient into the shower, Harriet W. Hopf, M.D., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Even with the best of care, some cesarean section wounds need to be opened 4–7 days after the surgery, because they either fail to heal or become infected, said Dr. Hopf of the university. Open wounds heal best when you reduce the bacterial load, keep the wound moist, and pay attention to nutrition and perfusion.

A wound requires several elements for good healing—the right amount of inflammation, protein, oxygen (perfusion), and a proper environment. An infected wound is too inflamed and slow to heal. Most infection comes from bacteria on the skin. Rinsing a wound with normal saline doesn't provide enough volume to remove bacteria. The cold saline induces local vasoconstriction, while a warm shower induces local vasodilation, enhancing perfusion of the wound.

“Just get them in the shower” daily, said Dr. Hopf. “It works so well. That's the primary intervention that I make when I see a patient.” Have patients shower with mild soap and not with bacteriocidal products that not only kill bacteria but inactivate white cells and harm granulating tissue, which delays healing.

If you need to open a cesarean wound, usually by that time the patient no longer has an intravenous line or catheter to get in the way of showering. If she's still on an intravenous line, saline lock it, cover it with a Tegaderm dressing, and have her shower, Dr. Hopf said in an interview. If the patient still has a bladder catheter, skip the shower but use a basin of warm tap water and a 60-mL syringe to irrigate the wound.

For women on steroids, which interfere with healing, applying ointment containing vitamins A and D (typically used for diaper rash) will reverse the steroid effect and help pull macrophages into the wound for healing.

Make sure the patient has adequate pain control, which promotes healing by reducing vasoconstriction and enables dressing changes. Optimize perfusion by keeping the patient warm, giving her plenty of fluids, aggressively managing pain and edema, and encouraging smokers to quit.

Wounds need protein to heal, and lactation uses much of the body's protein. Encourage women who've had C-sections to eat plenty of protein.

“It's hard to get the protein to the wound because the protein is going someplace else,” she said. Over-the-counter protein supplements that contain the amino acid arginine can improve wound healing if needed.

Patients deficient in vitamin A, vitamin C, or zinc will heal more slowly. To replenish them, Dr. Hopf recommends a 10-day course of daily vitamin A (25,000 international units) and zinc (220 mg). A larger amount can be toxic. Vitamin C is nontoxic, and all patients with wounds should get 500–100 mg daily.

Try to keep the wound moist and the surrounding skin dry for best healing. Wounds often start off exudating and later become dry, so don't necessarily use the same dressing throughout healing.

Any of the more than 1,000 wound dressing products available will enable significantly better healing than traditional “wet-to-damp” dressings with saline and gauze, Dr. Hopf stressed.

The commercial products cost more initially, but get changed once daily instead of t.i.d. changes for wet-to-damp dressings, which require more labor and materials. In the end, the cost is about the same, and the patient experiences less pain with commercial dressings, she said. Dr. Hopf said she has no financial relationship with wound-dressing companies.

For an exudating wound, fluff calcium alginate (Sorbsan) and fill the wound loosely with it to absorb exudate, maintain a moist environment, and protect skin from maceration.

SAN FRANCISCO — Data from recent studies call into question the recommendation that physicians delay administration of epidural anesthesia to nulliparous women in labor, Michael P. Nageotte, M.D., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The American College of Obstetricians and Gynecologists has recommended that “when feasible, obstetric practitioners should delay the administration of epidural anesthesia in nulliparous women until the cervical dilatation reaches 4–5 cm, and that other forms of analgesia be used until that time,” noted Dr. Nageotte, who is professor of obstetrics and gynecology at the University of California, Irvine.

Giving an epidural when the cervix is dilated less than 4 cm has been associated with a higher rate of cesarean delivery.

Investigators at Northwestern University, Chicago, led a recent study of 750 term nulliparous women who had experienced spontaneous labor or spontaneous rupture of the membranes. All of the women had a cervix that was dilated less than 4 cm on the initial exam and were told at the time of randomization that they would get an epidural if needed.

The women who participated were randomly assigned to receive either an intrathecal injection of fentanyl or systemic hydromorphone when they first requested analgesia. A woman's second request for analgesia resulted in administration of an epidural in the intrathecal group or assessment of cervical dilation in the systemic analgesia group. Women in the systemic group got an epidural if the cervix was dilated at least 4 cm, or received a second dose of systemic hydromorphone and were given an epidural upon their third request for analgesia.

The rate of cesarean delivery did not differ significantly between groups, but it was slightly higher in the delayed-epidural group, compared with the early-epidural group—21% vs. 18% (N. Engl. J. Med. 2005;352:655–65). The early-epidural group also had a significantly shorter time from receiving the first analgesia to complete cervical dilation (295 vs. 385 minutes) and a significantly shorter time from first analgesia to vaginal birth (398 vs. 479 minutes).

Women in the early-epidural group had better pain scores and were less likely to have babies with low Apgar scores at 1 minute. Rates of oxytocin use or intrapartum fever did not differ between groups.

In addition, Dr. Nageotte said he has reviewed two unpublished studies from Israel and from the United States that also suggest that delaying epidurals is not beneficial.

SAN FRANCISCO — Data from recent studies call into question the recommendation that physicians delay administration of epidural anesthesia to nulliparous women in labor, Michael P. Nageotte, M.D., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The American College of Obstetricians and Gynecologists has recommended that “when feasible, obstetric practitioners should delay the administration of epidural anesthesia in nulliparous women until the cervical dilatation reaches 4–5 cm, and that other forms of analgesia be used until that time,” noted Dr. Nageotte, who is professor of obstetrics and gynecology at the University of California, Irvine.

Giving an epidural when the cervix is dilated less than 4 cm has been associated with a higher rate of cesarean delivery.

Investigators at Northwestern University, Chicago, led a recent study of 750 term nulliparous women who had experienced spontaneous labor or spontaneous rupture of the membranes. All of the women had a cervix that was dilated less than 4 cm on the initial exam and were told at the time of randomization that they would get an epidural if needed.

The women who participated were randomly assigned to receive either an intrathecal injection of fentanyl or systemic hydromorphone when they first requested analgesia. A woman's second request for analgesia resulted in administration of an epidural in the intrathecal group or assessment of cervical dilation in the systemic analgesia group. Women in the systemic group got an epidural if the cervix was dilated at least 4 cm, or received a second dose of systemic hydromorphone and were given an epidural upon their third request for analgesia.

The rate of cesarean delivery did not differ significantly between groups, but it was slightly higher in the delayed-epidural group, compared with the early-epidural group—21% vs. 18% (N. Engl. J. Med. 2005;352:655–65). The early-epidural group also had a significantly shorter time from receiving the first analgesia to complete cervical dilation (295 vs. 385 minutes) and a significantly shorter time from first analgesia to vaginal birth (398 vs. 479 minutes).

Women in the early-epidural group had better pain scores and were less likely to have babies with low Apgar scores at 1 minute. Rates of oxytocin use or intrapartum fever did not differ between groups.

In addition, Dr. Nageotte said he has reviewed two unpublished studies from Israel and from the United States that also suggest that delaying epidurals is not beneficial.

SAN FRANCISCO — Data from recent studies call into question the recommendation that physicians delay administration of epidural anesthesia to nulliparous women in labor, Michael P. Nageotte, M.D., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The American College of Obstetricians and Gynecologists has recommended that “when feasible, obstetric practitioners should delay the administration of epidural anesthesia in nulliparous women until the cervical dilatation reaches 4–5 cm, and that other forms of analgesia be used until that time,” noted Dr. Nageotte, who is professor of obstetrics and gynecology at the University of California, Irvine.

Giving an epidural when the cervix is dilated less than 4 cm has been associated with a higher rate of cesarean delivery.

Investigators at Northwestern University, Chicago, led a recent study of 750 term nulliparous women who had experienced spontaneous labor or spontaneous rupture of the membranes. All of the women had a cervix that was dilated less than 4 cm on the initial exam and were told at the time of randomization that they would get an epidural if needed.

The women who participated were randomly assigned to receive either an intrathecal injection of fentanyl or systemic hydromorphone when they first requested analgesia. A woman's second request for analgesia resulted in administration of an epidural in the intrathecal group or assessment of cervical dilation in the systemic analgesia group. Women in the systemic group got an epidural if the cervix was dilated at least 4 cm, or received a second dose of systemic hydromorphone and were given an epidural upon their third request for analgesia.

The rate of cesarean delivery did not differ significantly between groups, but it was slightly higher in the delayed-epidural group, compared with the early-epidural group—21% vs. 18% (N. Engl. J. Med. 2005;352:655–65). The early-epidural group also had a significantly shorter time from receiving the first analgesia to complete cervical dilation (295 vs. 385 minutes) and a significantly shorter time from first analgesia to vaginal birth (398 vs. 479 minutes).

Women in the early-epidural group had better pain scores and were less likely to have babies with low Apgar scores at 1 minute. Rates of oxytocin use or intrapartum fever did not differ between groups.

In addition, Dr. Nageotte said he has reviewed two unpublished studies from Israel and from the United States that also suggest that delaying epidurals is not beneficial.

SAN FRANCISCO — Recent data may make trials of labor to deliver twins in vertex/nonvertex positions a thing of the past, Yasser Y. El-Sayed, M.D., predicted.

A large retrospective cohort study found significantly greater safety in planned cesarean deliveries, compared with vaginal delivery of both twins or vaginal delivery of the first (vertex) twin and an emergency C-section after a failed attempt at vaginal delivery of the second (nonvertex) twin (Am. J. Obstet. Gynecol. 2005;192:840–7).

“Breech extraction of the second twin may very well go the way of the singleton breech” delivery, said Dr. El-Sayed of Stanford (Calif.) University.

Breech delivery of singletons generally has been shunned since the 2000 Term Breech Trial found greater morbidity from vaginal breech deliveries of singletons, compared with planned C-sections (Lancet 2000;356:1375–83).

The more recent study looked at all U.S. twin births in 1995–1997 and found 15,185 twin vertex/nonvertex pairs delivered when they were at or greater than 24 weeks' gestation and weighed at least 500 g. In 37.7% of cases, both twins were delivered by planned C-section, and in 46.8%, both twins were delivered vaginally. In 15.5%, the first twin was delivered vaginally and a trial of labor failed for the nonvertex twin, who then was delivered by emergency C-section.

Compared with the planned C-section group, babies in the vaginal delivery-only group had significantly higher rates of all-cause neonatal death, death not related to congenital anomalies, asphyxia-related death, newborn infant injury, low Apgar scores, ventilation use, and seizures.

The emergency C-section group had significantly higher rates of asphyxia-related death, newborn infant injury, low Apgar scores, and ventilation use, compared with the planned C-section group.

Many of these differences remained in subgroup analyses of infants weighing less than or more than 1,500 g. That finding contradicts the results of less well-designed retrospective studies suggesting that breech delivery of a nonvertex twin was safe for babies weighing at least 1,500 g, Dr. El-Sayed noted.

Authors of the twin study said their results were consistent with those of the singleton Term Breech Trial and concluded that planned C-section delivery causes the least morbidity to nonvertex second twins or to singletons.

In the twin study, emergency C-sections were needed for almost 25% of nonvertex twins who underwent an attempted vaginal delivery.

“The authors of the study suggest that perhaps this alone should lead to routine cesarean section for vertex/nonvertex twins,” Dr. El-Sayed said.

SAN FRANCISCO — Recent data may make trials of labor to deliver twins in vertex/nonvertex positions a thing of the past, Yasser Y. El-Sayed, M.D., predicted.

A large retrospective cohort study found significantly greater safety in planned cesarean deliveries, compared with vaginal delivery of both twins or vaginal delivery of the first (vertex) twin and an emergency C-section after a failed attempt at vaginal delivery of the second (nonvertex) twin (Am. J. Obstet. Gynecol. 2005;192:840–7).

“Breech extraction of the second twin may very well go the way of the singleton breech” delivery, said Dr. El-Sayed of Stanford (Calif.) University.

Breech delivery of singletons generally has been shunned since the 2000 Term Breech Trial found greater morbidity from vaginal breech deliveries of singletons, compared with planned C-sections (Lancet 2000;356:1375–83).

The more recent study looked at all U.S. twin births in 1995–1997 and found 15,185 twin vertex/nonvertex pairs delivered when they were at or greater than 24 weeks' gestation and weighed at least 500 g. In 37.7% of cases, both twins were delivered by planned C-section, and in 46.8%, both twins were delivered vaginally. In 15.5%, the first twin was delivered vaginally and a trial of labor failed for the nonvertex twin, who then was delivered by emergency C-section.

Compared with the planned C-section group, babies in the vaginal delivery-only group had significantly higher rates of all-cause neonatal death, death not related to congenital anomalies, asphyxia-related death, newborn infant injury, low Apgar scores, ventilation use, and seizures.

The emergency C-section group had significantly higher rates of asphyxia-related death, newborn infant injury, low Apgar scores, and ventilation use, compared with the planned C-section group.

Many of these differences remained in subgroup analyses of infants weighing less than or more than 1,500 g. That finding contradicts the results of less well-designed retrospective studies suggesting that breech delivery of a nonvertex twin was safe for babies weighing at least 1,500 g, Dr. El-Sayed noted.

Authors of the twin study said their results were consistent with those of the singleton Term Breech Trial and concluded that planned C-section delivery causes the least morbidity to nonvertex second twins or to singletons.

In the twin study, emergency C-sections were needed for almost 25% of nonvertex twins who underwent an attempted vaginal delivery.

“The authors of the study suggest that perhaps this alone should lead to routine cesarean section for vertex/nonvertex twins,” Dr. El-Sayed said.

SAN FRANCISCO — Recent data may make trials of labor to deliver twins in vertex/nonvertex positions a thing of the past, Yasser Y. El-Sayed, M.D., predicted.

A large retrospective cohort study found significantly greater safety in planned cesarean deliveries, compared with vaginal delivery of both twins or vaginal delivery of the first (vertex) twin and an emergency C-section after a failed attempt at vaginal delivery of the second (nonvertex) twin (Am. J. Obstet. Gynecol. 2005;192:840–7).

“Breech extraction of the second twin may very well go the way of the singleton breech” delivery, said Dr. El-Sayed of Stanford (Calif.) University.

Breech delivery of singletons generally has been shunned since the 2000 Term Breech Trial found greater morbidity from vaginal breech deliveries of singletons, compared with planned C-sections (Lancet 2000;356:1375–83).

The more recent study looked at all U.S. twin births in 1995–1997 and found 15,185 twin vertex/nonvertex pairs delivered when they were at or greater than 24 weeks' gestation and weighed at least 500 g. In 37.7% of cases, both twins were delivered by planned C-section, and in 46.8%, both twins were delivered vaginally. In 15.5%, the first twin was delivered vaginally and a trial of labor failed for the nonvertex twin, who then was delivered by emergency C-section.

Compared with the planned C-section group, babies in the vaginal delivery-only group had significantly higher rates of all-cause neonatal death, death not related to congenital anomalies, asphyxia-related death, newborn infant injury, low Apgar scores, ventilation use, and seizures.

The emergency C-section group had significantly higher rates of asphyxia-related death, newborn infant injury, low Apgar scores, and ventilation use, compared with the planned C-section group.

Many of these differences remained in subgroup analyses of infants weighing less than or more than 1,500 g. That finding contradicts the results of less well-designed retrospective studies suggesting that breech delivery of a nonvertex twin was safe for babies weighing at least 1,500 g, Dr. El-Sayed noted.

Authors of the twin study said their results were consistent with those of the singleton Term Breech Trial and concluded that planned C-section delivery causes the least morbidity to nonvertex second twins or to singletons.

In the twin study, emergency C-sections were needed for almost 25% of nonvertex twins who underwent an attempted vaginal delivery.

“The authors of the study suggest that perhaps this alone should lead to routine cesarean section for vertex/nonvertex twins,” Dr. El-Sayed said.