Christine Kilgore

Multifocal tumors in papillary thyroid cancer appear to often arise as independent tumors—a finding that supports the use of bilateral thyroidectomy and radioablation of remaining tissue, according to Trisha M. Shattuck of the University of Connecticut, Farmington, and her associates.

Papillary thyroid carcinoma is the most common cancer of the thyroid gland, and it is often multifocal—typically with a “primary” tumor greater than 1 cm in diameter and additional, much smaller “microcarcinomas.”

Multifocal carcinomas have been associated with increased risks of lymph-node and distant metastases, persistent local disease after initial treatments, and regional recurrence—features that have suggested that patients be treated aggressively.

It has been unclear, however, whether multiple intrathyroid tumors are metastases of a primary tumor or whether they arise independently as individual carcinomas, the investigators said (N. Engl. J. Med. 2005;352:2406–12).

They examined tumor samples from 17 women with multifocal papillary thyroid carcinoma who underwent thyroidectomy. Using a polymerase chain reaction (PCR) assay involving the human androgen receptor gene, they analyzed tumor DNA for patterns of X-chromosome inactivation (inactivation of either the maternal or paternal X-chromosome).

Such patterns can be used to determine whether a tumor arose from one or multiple progenitor cells because the inactivated chromosome is stably transmitted from parent cell to progeny cell, the investigators explained.

Multiple tumor foci from 10 of the 17 patients were suitable for analysis; they yielded DNA of adequate quality and quantity and were heterozygous for the human androgen receptor gene polymorphism. A single X chromosome was inactivated in each focus, the investigators reported.

Tumors from 5 of the 10 patients showed discordant patterns of X-chromosome inactivation that indicated the tumors arose separately from different progenitor cells. Tumors in the other five patients showed patterns that could be interpreted as indicating either a shared or independent origin.

The findings “favor the independent clonal origins of the distinct foci in some [and possibly most] of these cases,” according to the investigators.

The findings also “imply that any thyroid tissue remaining after surgery to treat papillary thyroid cancer in patients with multifocal disease may contain—or be likely to develop—additional foci of cancer that could become recurrences.”

In an editorial, Robert D. Utiger, M.D., wrote that the evidence “supports the clinical finding that patients with papillary carcinoma who undergo thyroid lobectomy are more likely than those who undergo near total thyroidectomy to have recurrent carcinoma in the remaining lobe as well as elsewhere.”

Annual estimates of thyroid cancer diagnoses have been growing faster than the population for several decades, and the proportion of these cancers that are papillary carcinomas is growing as well, said Dr. Utiger of Harvard Medical School, Boston (N. Engl. J. Med. 2005;352:2376–8).

Multifocal tumors in papillary thyroid cancer appear to often arise as independent tumors—a finding that supports the use of bilateral thyroidectomy and radioablation of remaining tissue, according to Trisha M. Shattuck of the University of Connecticut, Farmington, and her associates.

Papillary thyroid carcinoma is the most common cancer of the thyroid gland, and it is often multifocal—typically with a “primary” tumor greater than 1 cm in diameter and additional, much smaller “microcarcinomas.”

Multifocal carcinomas have been associated with increased risks of lymph-node and distant metastases, persistent local disease after initial treatments, and regional recurrence—features that have suggested that patients be treated aggressively.

It has been unclear, however, whether multiple intrathyroid tumors are metastases of a primary tumor or whether they arise independently as individual carcinomas, the investigators said (N. Engl. J. Med. 2005;352:2406–12).

They examined tumor samples from 17 women with multifocal papillary thyroid carcinoma who underwent thyroidectomy. Using a polymerase chain reaction (PCR) assay involving the human androgen receptor gene, they analyzed tumor DNA for patterns of X-chromosome inactivation (inactivation of either the maternal or paternal X-chromosome).

Such patterns can be used to determine whether a tumor arose from one or multiple progenitor cells because the inactivated chromosome is stably transmitted from parent cell to progeny cell, the investigators explained.

Multiple tumor foci from 10 of the 17 patients were suitable for analysis; they yielded DNA of adequate quality and quantity and were heterozygous for the human androgen receptor gene polymorphism. A single X chromosome was inactivated in each focus, the investigators reported.

Tumors from 5 of the 10 patients showed discordant patterns of X-chromosome inactivation that indicated the tumors arose separately from different progenitor cells. Tumors in the other five patients showed patterns that could be interpreted as indicating either a shared or independent origin.

The findings “favor the independent clonal origins of the distinct foci in some [and possibly most] of these cases,” according to the investigators.

The findings also “imply that any thyroid tissue remaining after surgery to treat papillary thyroid cancer in patients with multifocal disease may contain—or be likely to develop—additional foci of cancer that could become recurrences.”

In an editorial, Robert D. Utiger, M.D., wrote that the evidence “supports the clinical finding that patients with papillary carcinoma who undergo thyroid lobectomy are more likely than those who undergo near total thyroidectomy to have recurrent carcinoma in the remaining lobe as well as elsewhere.”

Annual estimates of thyroid cancer diagnoses have been growing faster than the population for several decades, and the proportion of these cancers that are papillary carcinomas is growing as well, said Dr. Utiger of Harvard Medical School, Boston (N. Engl. J. Med. 2005;352:2376–8).

Multifocal tumors in papillary thyroid cancer appear to often arise as independent tumors—a finding that supports the use of bilateral thyroidectomy and radioablation of remaining tissue, according to Trisha M. Shattuck of the University of Connecticut, Farmington, and her associates.

Papillary thyroid carcinoma is the most common cancer of the thyroid gland, and it is often multifocal—typically with a “primary” tumor greater than 1 cm in diameter and additional, much smaller “microcarcinomas.”

Multifocal carcinomas have been associated with increased risks of lymph-node and distant metastases, persistent local disease after initial treatments, and regional recurrence—features that have suggested that patients be treated aggressively.

It has been unclear, however, whether multiple intrathyroid tumors are metastases of a primary tumor or whether they arise independently as individual carcinomas, the investigators said (N. Engl. J. Med. 2005;352:2406–12).

They examined tumor samples from 17 women with multifocal papillary thyroid carcinoma who underwent thyroidectomy. Using a polymerase chain reaction (PCR) assay involving the human androgen receptor gene, they analyzed tumor DNA for patterns of X-chromosome inactivation (inactivation of either the maternal or paternal X-chromosome).

Such patterns can be used to determine whether a tumor arose from one or multiple progenitor cells because the inactivated chromosome is stably transmitted from parent cell to progeny cell, the investigators explained.

Multiple tumor foci from 10 of the 17 patients were suitable for analysis; they yielded DNA of adequate quality and quantity and were heterozygous for the human androgen receptor gene polymorphism. A single X chromosome was inactivated in each focus, the investigators reported.

Tumors from 5 of the 10 patients showed discordant patterns of X-chromosome inactivation that indicated the tumors arose separately from different progenitor cells. Tumors in the other five patients showed patterns that could be interpreted as indicating either a shared or independent origin.

The findings “favor the independent clonal origins of the distinct foci in some [and possibly most] of these cases,” according to the investigators.

The findings also “imply that any thyroid tissue remaining after surgery to treat papillary thyroid cancer in patients with multifocal disease may contain—or be likely to develop—additional foci of cancer that could become recurrences.”

In an editorial, Robert D. Utiger, M.D., wrote that the evidence “supports the clinical finding that patients with papillary carcinoma who undergo thyroid lobectomy are more likely than those who undergo near total thyroidectomy to have recurrent carcinoma in the remaining lobe as well as elsewhere.”

Annual estimates of thyroid cancer diagnoses have been growing faster than the population for several decades, and the proportion of these cancers that are papillary carcinomas is growing as well, said Dr. Utiger of Harvard Medical School, Boston (N. Engl. J. Med. 2005;352:2376–8).

Women treated for hypothyroidism were less likely to develop primary breast carcinoma—and more likely to have more indolent disease when they did develop cancer—than women with normal thyroid function in a retrospective, case-control study.

The findings “strengthen the possibility of a significant role of thyroid hormones on breast cancer biology” and may indicate areas of intervention “for targeted preventive and therapeutic purposes,” said Massimo Cristofanilli, M.D., and his associates at the University of Texas M.D. Anderson Cancer Center, Houston.

The investigators compared the medical records from 1,136 women with primary breast carcinoma with those of 1,088 healthy women who visited their breast cancer-screening clinic.

Approximately 240 women reported having symptomatic primary hypothyroidism and thyroid supplementation before they were diagnosed with breast cancer or before their screening visit.

The prevalence of reported hypothyroidism was significantly greater in the control group, compared with the breast cancer group (15% vs. 7%).

Women with primary hypothyroidism had a 61% lower risk of developing invasive breast cancer, and women with breast cancer were 57% less likely to have hypothyroidism, compared with healthy women, the investigators reported (Cancer 2005;103:1122–8).

After adjustment for confounders of breast cancer risk such as family history of breast carcinoma and history of pregnancy, the association between breast cancer and hypothyroidism “essentially was unchanged and [treated hypothyroidism] remained a strong protective factor against a diagnosis of invasive breast carcinoma,” they said. The association was similar in all ethnic groups.

Among women with invasive breast cancer, patients with hypothyroidism were older at the time of diagnosis (59 vs. 51 years) and were more likely to be postmenopausal (82% vs. 64%) than patients with normal thyroid function.

Among white women specifically, those with invasive cancer who had been treated for hypothyroidism were more likely to be diagnosed with early-stage disease (95% vs. 86%) and disease without pathologic lymph node involvement (64% vs. 56%).

They also had smaller pathologic tumor size than women with invasive cancer but normal thyroid function.

The investigators restricted part of their analysis to white women to have a more homogenous population and to eliminate the influence of ethnicity.

A possible association between thyroid disease and breast carcinoma has been debated for decades and remains controversial, the investigators say. Epidemiologic studies have had conflicting results, and large prospective studies have failed to clearly demonstrate a correlation.

Women treated for hypothyroidism were less likely to develop primary breast carcinoma—and more likely to have more indolent disease when they did develop cancer—than women with normal thyroid function in a retrospective, case-control study.

The findings “strengthen the possibility of a significant role of thyroid hormones on breast cancer biology” and may indicate areas of intervention “for targeted preventive and therapeutic purposes,” said Massimo Cristofanilli, M.D., and his associates at the University of Texas M.D. Anderson Cancer Center, Houston.

The investigators compared the medical records from 1,136 women with primary breast carcinoma with those of 1,088 healthy women who visited their breast cancer-screening clinic.

Approximately 240 women reported having symptomatic primary hypothyroidism and thyroid supplementation before they were diagnosed with breast cancer or before their screening visit.

The prevalence of reported hypothyroidism was significantly greater in the control group, compared with the breast cancer group (15% vs. 7%).

Women with primary hypothyroidism had a 61% lower risk of developing invasive breast cancer, and women with breast cancer were 57% less likely to have hypothyroidism, compared with healthy women, the investigators reported (Cancer 2005;103:1122–8).

After adjustment for confounders of breast cancer risk such as family history of breast carcinoma and history of pregnancy, the association between breast cancer and hypothyroidism “essentially was unchanged and [treated hypothyroidism] remained a strong protective factor against a diagnosis of invasive breast carcinoma,” they said. The association was similar in all ethnic groups.

Among women with invasive breast cancer, patients with hypothyroidism were older at the time of diagnosis (59 vs. 51 years) and were more likely to be postmenopausal (82% vs. 64%) than patients with normal thyroid function.

Among white women specifically, those with invasive cancer who had been treated for hypothyroidism were more likely to be diagnosed with early-stage disease (95% vs. 86%) and disease without pathologic lymph node involvement (64% vs. 56%).

They also had smaller pathologic tumor size than women with invasive cancer but normal thyroid function.

The investigators restricted part of their analysis to white women to have a more homogenous population and to eliminate the influence of ethnicity.

A possible association between thyroid disease and breast carcinoma has been debated for decades and remains controversial, the investigators say. Epidemiologic studies have had conflicting results, and large prospective studies have failed to clearly demonstrate a correlation.

Women treated for hypothyroidism were less likely to develop primary breast carcinoma—and more likely to have more indolent disease when they did develop cancer—than women with normal thyroid function in a retrospective, case-control study.

The findings “strengthen the possibility of a significant role of thyroid hormones on breast cancer biology” and may indicate areas of intervention “for targeted preventive and therapeutic purposes,” said Massimo Cristofanilli, M.D., and his associates at the University of Texas M.D. Anderson Cancer Center, Houston.

The investigators compared the medical records from 1,136 women with primary breast carcinoma with those of 1,088 healthy women who visited their breast cancer-screening clinic.

Approximately 240 women reported having symptomatic primary hypothyroidism and thyroid supplementation before they were diagnosed with breast cancer or before their screening visit.

The prevalence of reported hypothyroidism was significantly greater in the control group, compared with the breast cancer group (15% vs. 7%).

Women with primary hypothyroidism had a 61% lower risk of developing invasive breast cancer, and women with breast cancer were 57% less likely to have hypothyroidism, compared with healthy women, the investigators reported (Cancer 2005;103:1122–8).

After adjustment for confounders of breast cancer risk such as family history of breast carcinoma and history of pregnancy, the association between breast cancer and hypothyroidism “essentially was unchanged and [treated hypothyroidism] remained a strong protective factor against a diagnosis of invasive breast carcinoma,” they said. The association was similar in all ethnic groups.

Among women with invasive breast cancer, patients with hypothyroidism were older at the time of diagnosis (59 vs. 51 years) and were more likely to be postmenopausal (82% vs. 64%) than patients with normal thyroid function.

Among white women specifically, those with invasive cancer who had been treated for hypothyroidism were more likely to be diagnosed with early-stage disease (95% vs. 86%) and disease without pathologic lymph node involvement (64% vs. 56%).

They also had smaller pathologic tumor size than women with invasive cancer but normal thyroid function.

The investigators restricted part of their analysis to white women to have a more homogenous population and to eliminate the influence of ethnicity.

A possible association between thyroid disease and breast carcinoma has been debated for decades and remains controversial, the investigators say. Epidemiologic studies have had conflicting results, and large prospective studies have failed to clearly demonstrate a correlation.

Less than a month after two major diabetes organizations called metabolic syndrome a poorly defined and misleading diagnosis, the American Heart Association and the National Heart, Lung, and Blood Institute issued a joint statement reaffirming that the syndrome is valid and clinically useful.

The new AHA/NHLBI scientific statement basically confirms the recommendations on diagnosis and management of metabolic syndrome that were issued in 2001 as part of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) report.

The statement also clarifies some issues and provides some minor modifications to the ATP III definition of the metabolic syndrome—a term that denotes the clustering of interrelated metabolic risk factors for atherosclerotic cardiovascular disease.

Compared with the joint statement published last month by the American Diabetes Association and the European Association for the Study of Diabetes (“Term 'Metabolic Syndrome' Called Into Question,” FAMILY PRACTICE NEWS, Sept. 1, 2005, p. 5), the AHA/NHLBI statement offers a clearly different perspective on the meaning and value of a term that's now commonplace in the medical literature.

“Metabolic syndrome is a valuable clinical tool. Physicians must pay attention to it, and they must give enough attention to lifestyle (intervention),” said Scott M. Grundy, M.D., director of the Center for Human Nutrition at the University of Texas Southwestern Medical Center in Dallas. Dr. Grundy chaired the panel that wrote the joint statement.

While the diabetes organizations questioned the value of the syndrome as a predictor of cardiovascular disease—they said, for instance, that it's “uncertain” whether it's a useful marker of cardiovascular disease risk “above and beyond the risks associated with its individual components”—the AHA/NHLBI panel maintained that it's an important and useful predictor.

The absolute short-term (10-year) risk for major coronary heart disease events is not necessarily high—and may be best assessed by Framingham risk scoring—but the longer-term risk associated with the metabolic syndrome is “undoubtedly” elevated, regardless of the Framingham score, the panel said (Circulation 2005;DOI:10.1161/circ ulationaha.105.169404).

“The long-term risk is more than the sum of the parts—the risk multiplies,” said Dr. Grundy.

“Nobody is asserting that metabolic syndrome is a disease. No one is saying it's a unified entity. It's a group of factors that tend to cluster together, and the diagnosis gives physicians an opportunity to identify people at long-term risk,” said James I. Cleeman, M.D., cochair of the panel and coordinator of the NHLBI's National Cholesterol Education Program.

“There's no question that risk increases when these risk factors (cluster),” he said in an interview.

Overall, the syndrome increases the risk for atherosclerotic cardiovascular disease 1.5–3 times and raises the risk for type 2 diabetes 3–5 times, he and Dr. Grundy said in an interview. The new statement essentially “ties up loose ends” and synthesizes information presented at NIH-sponsored conferences held after the ATP III report was released.

The statement maintains the same diagnostic criteria for metabolic syndrome—elevated waist circumference, elevated triglycerides, reduced HDL-C, elevated blood pressure, and elevated fasting glucose—and the requirement that three of the five criteria be present for a diagnosis.

It also offers the following modifications and clarifications:

▸ The threshold for elevated fasting glucose is reduced from 110 to 100 mg/dL, in accordance with the ADA's recently revised definition.

▸ Triglycerides, HDL-C levels, and blood pressure may be counted as abnormal when a patient is taking drug treatment for these factors.

▸ The threshold for waist circumference (102 cm in men and 88 cm in women) may be lowered in individuals or ethnic groups, particularly Asian Americans, who are prone to insulin resistance.

The panel maintained that individuals who have established atherosclerotic cardiovascular disease or type 2 diabetes can still have the metabolic syndrome—a position that is at odds with the ADA-EASD statement.

The modified ATP III definition is almost identical to the definition released—also last month—by the International Diabetes Federation, Dr. Cleeman said. One difference is that the IDF requires the presence of abdominal obesity for diagnosis.

More research is needed on the most appropriate therapies for patients with the metabolic syndrome, but for now the “prime emphasis” should be on lifestyle interventions, the joint statement said. Drug therapies for specific risk factors “may be indicated” when lifestyle changes are not sufficient.

It cautions, however, against prescribing drugs that purportedly target underlying causes of the syndrome (namely obesity and insulin resistance) until evidence is sufficient.

While the AHA/NHLBI statement was in the works before the ADA and EASD released their joint statement, the effort by the diabetes organizations sent at least one other group scrambling.

The American Association of Clinical Endocrinologists last month had a “rapid-response task force” reviewing its 2003 position paper on what it calls the “insulin resistance syndrome.”

“With the critical appraisal by the ADA, we want a well-thought-out, evidence-based response to clarify our position (on the issue),” said Jeffrey I. Mechanick, M.D., an endocrinologist who is leading the task force.

Less than a month after two major diabetes organizations called metabolic syndrome a poorly defined and misleading diagnosis, the American Heart Association and the National Heart, Lung, and Blood Institute issued a joint statement reaffirming that the syndrome is valid and clinically useful.

The new AHA/NHLBI scientific statement basically confirms the recommendations on diagnosis and management of metabolic syndrome that were issued in 2001 as part of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) report.

The statement also clarifies some issues and provides some minor modifications to the ATP III definition of the metabolic syndrome—a term that denotes the clustering of interrelated metabolic risk factors for atherosclerotic cardiovascular disease.

Compared with the joint statement published last month by the American Diabetes Association and the European Association for the Study of Diabetes (“Term 'Metabolic Syndrome' Called Into Question,” FAMILY PRACTICE NEWS, Sept. 1, 2005, p. 5), the AHA/NHLBI statement offers a clearly different perspective on the meaning and value of a term that's now commonplace in the medical literature.

“Metabolic syndrome is a valuable clinical tool. Physicians must pay attention to it, and they must give enough attention to lifestyle (intervention),” said Scott M. Grundy, M.D., director of the Center for Human Nutrition at the University of Texas Southwestern Medical Center in Dallas. Dr. Grundy chaired the panel that wrote the joint statement.

While the diabetes organizations questioned the value of the syndrome as a predictor of cardiovascular disease—they said, for instance, that it's “uncertain” whether it's a useful marker of cardiovascular disease risk “above and beyond the risks associated with its individual components”—the AHA/NHLBI panel maintained that it's an important and useful predictor.

The absolute short-term (10-year) risk for major coronary heart disease events is not necessarily high—and may be best assessed by Framingham risk scoring—but the longer-term risk associated with the metabolic syndrome is “undoubtedly” elevated, regardless of the Framingham score, the panel said (Circulation 2005;DOI:10.1161/circ ulationaha.105.169404).

“The long-term risk is more than the sum of the parts—the risk multiplies,” said Dr. Grundy.

“Nobody is asserting that metabolic syndrome is a disease. No one is saying it's a unified entity. It's a group of factors that tend to cluster together, and the diagnosis gives physicians an opportunity to identify people at long-term risk,” said James I. Cleeman, M.D., cochair of the panel and coordinator of the NHLBI's National Cholesterol Education Program.

“There's no question that risk increases when these risk factors (cluster),” he said in an interview.

Overall, the syndrome increases the risk for atherosclerotic cardiovascular disease 1.5–3 times and raises the risk for type 2 diabetes 3–5 times, he and Dr. Grundy said in an interview. The new statement essentially “ties up loose ends” and synthesizes information presented at NIH-sponsored conferences held after the ATP III report was released.

The statement maintains the same diagnostic criteria for metabolic syndrome—elevated waist circumference, elevated triglycerides, reduced HDL-C, elevated blood pressure, and elevated fasting glucose—and the requirement that three of the five criteria be present for a diagnosis.

It also offers the following modifications and clarifications:

▸ The threshold for elevated fasting glucose is reduced from 110 to 100 mg/dL, in accordance with the ADA's recently revised definition.

▸ Triglycerides, HDL-C levels, and blood pressure may be counted as abnormal when a patient is taking drug treatment for these factors.

▸ The threshold for waist circumference (102 cm in men and 88 cm in women) may be lowered in individuals or ethnic groups, particularly Asian Americans, who are prone to insulin resistance.

The panel maintained that individuals who have established atherosclerotic cardiovascular disease or type 2 diabetes can still have the metabolic syndrome—a position that is at odds with the ADA-EASD statement.

The modified ATP III definition is almost identical to the definition released—also last month—by the International Diabetes Federation, Dr. Cleeman said. One difference is that the IDF requires the presence of abdominal obesity for diagnosis.

More research is needed on the most appropriate therapies for patients with the metabolic syndrome, but for now the “prime emphasis” should be on lifestyle interventions, the joint statement said. Drug therapies for specific risk factors “may be indicated” when lifestyle changes are not sufficient.

It cautions, however, against prescribing drugs that purportedly target underlying causes of the syndrome (namely obesity and insulin resistance) until evidence is sufficient.

While the AHA/NHLBI statement was in the works before the ADA and EASD released their joint statement, the effort by the diabetes organizations sent at least one other group scrambling.

The American Association of Clinical Endocrinologists last month had a “rapid-response task force” reviewing its 2003 position paper on what it calls the “insulin resistance syndrome.”

“With the critical appraisal by the ADA, we want a well-thought-out, evidence-based response to clarify our position (on the issue),” said Jeffrey I. Mechanick, M.D., an endocrinologist who is leading the task force.

Less than a month after two major diabetes organizations called metabolic syndrome a poorly defined and misleading diagnosis, the American Heart Association and the National Heart, Lung, and Blood Institute issued a joint statement reaffirming that the syndrome is valid and clinically useful.

The new AHA/NHLBI scientific statement basically confirms the recommendations on diagnosis and management of metabolic syndrome that were issued in 2001 as part of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) report.

The statement also clarifies some issues and provides some minor modifications to the ATP III definition of the metabolic syndrome—a term that denotes the clustering of interrelated metabolic risk factors for atherosclerotic cardiovascular disease.

Compared with the joint statement published last month by the American Diabetes Association and the European Association for the Study of Diabetes (“Term 'Metabolic Syndrome' Called Into Question,” FAMILY PRACTICE NEWS, Sept. 1, 2005, p. 5), the AHA/NHLBI statement offers a clearly different perspective on the meaning and value of a term that's now commonplace in the medical literature.

“Metabolic syndrome is a valuable clinical tool. Physicians must pay attention to it, and they must give enough attention to lifestyle (intervention),” said Scott M. Grundy, M.D., director of the Center for Human Nutrition at the University of Texas Southwestern Medical Center in Dallas. Dr. Grundy chaired the panel that wrote the joint statement.

While the diabetes organizations questioned the value of the syndrome as a predictor of cardiovascular disease—they said, for instance, that it's “uncertain” whether it's a useful marker of cardiovascular disease risk “above and beyond the risks associated with its individual components”—the AHA/NHLBI panel maintained that it's an important and useful predictor.

The absolute short-term (10-year) risk for major coronary heart disease events is not necessarily high—and may be best assessed by Framingham risk scoring—but the longer-term risk associated with the metabolic syndrome is “undoubtedly” elevated, regardless of the Framingham score, the panel said (Circulation 2005;DOI:10.1161/circ ulationaha.105.169404).

“The long-term risk is more than the sum of the parts—the risk multiplies,” said Dr. Grundy.

“Nobody is asserting that metabolic syndrome is a disease. No one is saying it's a unified entity. It's a group of factors that tend to cluster together, and the diagnosis gives physicians an opportunity to identify people at long-term risk,” said James I. Cleeman, M.D., cochair of the panel and coordinator of the NHLBI's National Cholesterol Education Program.

“There's no question that risk increases when these risk factors (cluster),” he said in an interview.

Overall, the syndrome increases the risk for atherosclerotic cardiovascular disease 1.5–3 times and raises the risk for type 2 diabetes 3–5 times, he and Dr. Grundy said in an interview. The new statement essentially “ties up loose ends” and synthesizes information presented at NIH-sponsored conferences held after the ATP III report was released.

The statement maintains the same diagnostic criteria for metabolic syndrome—elevated waist circumference, elevated triglycerides, reduced HDL-C, elevated blood pressure, and elevated fasting glucose—and the requirement that three of the five criteria be present for a diagnosis.

It also offers the following modifications and clarifications:

▸ The threshold for elevated fasting glucose is reduced from 110 to 100 mg/dL, in accordance with the ADA's recently revised definition.

▸ Triglycerides, HDL-C levels, and blood pressure may be counted as abnormal when a patient is taking drug treatment for these factors.

▸ The threshold for waist circumference (102 cm in men and 88 cm in women) may be lowered in individuals or ethnic groups, particularly Asian Americans, who are prone to insulin resistance.

The panel maintained that individuals who have established atherosclerotic cardiovascular disease or type 2 diabetes can still have the metabolic syndrome—a position that is at odds with the ADA-EASD statement.

The modified ATP III definition is almost identical to the definition released—also last month—by the International Diabetes Federation, Dr. Cleeman said. One difference is that the IDF requires the presence of abdominal obesity for diagnosis.

More research is needed on the most appropriate therapies for patients with the metabolic syndrome, but for now the “prime emphasis” should be on lifestyle interventions, the joint statement said. Drug therapies for specific risk factors “may be indicated” when lifestyle changes are not sufficient.

It cautions, however, against prescribing drugs that purportedly target underlying causes of the syndrome (namely obesity and insulin resistance) until evidence is sufficient.

While the AHA/NHLBI statement was in the works before the ADA and EASD released their joint statement, the effort by the diabetes organizations sent at least one other group scrambling.

The American Association of Clinical Endocrinologists last month had a “rapid-response task force” reviewing its 2003 position paper on what it calls the “insulin resistance syndrome.”

“With the critical appraisal by the ADA, we want a well-thought-out, evidence-based response to clarify our position (on the issue),” said Jeffrey I. Mechanick, M.D., an endocrinologist who is leading the task force.

Findings from a national study of access to trauma centers vividly illustrate what many have suspected—some Americans have access to large numbers of trauma centers, while others have access to none.

Now, say leaders in emergency medicine, it's time to collect even more data and look more earnestly at how trauma care can be improved—not only by modifying the often politically driven placement of centers and transport, but also by examining and acting on issues of quality of care, financing, and manpower.

“This is very much a tip-of-the-iceberg analysis. [Access to trauma centers] is a huge issue, and it's important to get [these data] out there,” said Gregory Luke Larkin, M.D., immediate past chair of the American College of Emergency Physicians' Trauma and Injury Prevention Committee. Hopefully, the analysis will generate momentum in looking at access and other related issues, he added.

“It should be just the beginning of a conversation about trauma care,” said Dr. Larkin, professor of surgery, emergency medicine, and public health at the University of Texas Southwestern Medical Center at Dallas. “And it should give permission for folks to talk about it at a national level,” as well as within states, he said.

The investigators of the cross-sectional study, published last month in the Journal of the American Medical Association, found that almost 70% of all U.S. residents had access to a level I or level II trauma center within 45 minutes, and that approximately 84% had access within 60 minutes.

While almost 43 million of these residents—most living in urban areas—had access within an hour to 20 or more level I or II centers, almost 47 million—most in rural areas—had no such access to any centers.

Only 8% of rural residents—compared with 73% of suburban populations and 89% of urban populations—had access to level I and level II centers within 45 minutes. The percentages increased to 24%, 86%, and 95% when the time parameter was 60 minutes, the investigators reported (JAMA 2005:293;2626–33).

Beyond the Obvious

The study reveals much of “what we all knew intuitively,” said Jon R. Krohmer, M.D., medical director of Kent County EMS in Grand Rapids, Mich., and the ACEP liaison to the American College of Surgeons' Committee on Trauma.

It's significantly “innovative,” however, because the data sources are new and because investigators evaluated access in terms of population, as opposed to land area only. The researchers also measured access in terms of “prehospital time”—the time from receipt of an emergency call to hospital arrival—as opposed to distance or pure “transport time,” Dr. Krohmer said.

The investigators mainly used the January 2005 Trauma Center Inventory verified by the ACS Committee on Trauma, and the January 2005 version of the Atlas and Database of Air Medical Services.

“The study points out very graphically that there are areas that are potentially overserved, and areas that aren't served at all,” said Dr. Krohmer, an attending physician at Spectrum Health and medical director of Kent County EMS, both in Grand Rapids, Mich.

So, would a level I trauma center ever be built in Big Piney, Wyoming? “That's the million-dollar question,” he said. “And that's why this study should be the basis for future studies on quality of care and outcomes.

“We've asked, for instance, what is a minimal or acceptable patient volume to support a level I center? And right now, we don't have good answers,” Dr. Krohmer said.

Accessing Solutions

In their comments, the investigators question whether the access of some Americans to multiple trauma centers may be excessive, and whether “appropriate limits” on the number of centers could increase patient volumes and thus improve the quality of care—questions that both Dr. Krohmer and Dr. Larkin said are good ones.

The authors also emphasize the finding that 27% and 28% of U.S. residents had access—within 45 and 60 minutes, respectively—to level I and II centers by helicopter only.

“This, and the fact that base helipads are more moveable … makes them appealing as modifiable components of the trauma system,” wrote Charles C. Branas, Ph.D., an epidemiologist at the University of Pennsylvania, Philadelphia, and his associates.

National leadership on trauma care issues should also be better funded and more extensive, though “at this point, states need to get their systems (better) developed,” Dr. Branas told ACEP NEWS. States also need to make or strengthen arrangements for border crossings for day-to-day trauma care, he and his associates wrote.

Approximately 2%–3% of U.S. residents had access to level I and II trauma centers only via the centers and helicopters of neighboring states, the study showed. Most of the standardized interstate agreements for sharing resources, however, concern mass casualty incidents rather than day-to-day trauma care, the investigators said.

Dr. Larkin said he agrees that more “well-institutionalized” interstate arrangements are needed. He said he worries, on the other hand, that the potential of helicopters—which he said are now too often “big billboards for hospitals”—will be overstated and used as part of a cookie-cutter approach to solving access discrepancies.

He would rather see investigators and policymakers pair the new data on access with epidemiologic data—looking, for instance, at where motor vehicle crashes (the most common cause of trauma) occur most frequently.

“I hope people don't misread the data and assume it's the last word on trauma care,” said Dr. Larkin. “There is a whole host of other issues that need to be addressed.”

These include the issue of financing trauma care, a significant portion of which goes unpaid for, and issues of manpower and varying “densities” across the country of board-certified trauma surgeons and emergency physicians, he said.

Dr. Larkin emphasized that there's “a pretty big difference between level I and level II centers.” He advised paying more attention to access within 45 minutes than to access within the 60-minute time frame, since—as the investigators also point out—the so-called golden hour cutoff is supported by little scientific evidence and is probably too long.

Because the study excluded pediatric trauma centers and did not stratify access by age, the findings understate the access problems faced by the younger population, Dr. Larkin noted. “Trauma,” he said, “is the most common cause of death in the first four decades.”

Findings from a national study of access to trauma centers vividly illustrate what many have suspected—some Americans have access to large numbers of trauma centers, while others have access to none.

Now, say leaders in emergency medicine, it's time to collect even more data and look more earnestly at how trauma care can be improved—not only by modifying the often politically driven placement of centers and transport, but also by examining and acting on issues of quality of care, financing, and manpower.

“This is very much a tip-of-the-iceberg analysis. [Access to trauma centers] is a huge issue, and it's important to get [these data] out there,” said Gregory Luke Larkin, M.D., immediate past chair of the American College of Emergency Physicians' Trauma and Injury Prevention Committee. Hopefully, the analysis will generate momentum in looking at access and other related issues, he added.

“It should be just the beginning of a conversation about trauma care,” said Dr. Larkin, professor of surgery, emergency medicine, and public health at the University of Texas Southwestern Medical Center at Dallas. “And it should give permission for folks to talk about it at a national level,” as well as within states, he said.

The investigators of the cross-sectional study, published last month in the Journal of the American Medical Association, found that almost 70% of all U.S. residents had access to a level I or level II trauma center within 45 minutes, and that approximately 84% had access within 60 minutes.

While almost 43 million of these residents—most living in urban areas—had access within an hour to 20 or more level I or II centers, almost 47 million—most in rural areas—had no such access to any centers.

Only 8% of rural residents—compared with 73% of suburban populations and 89% of urban populations—had access to level I and level II centers within 45 minutes. The percentages increased to 24%, 86%, and 95% when the time parameter was 60 minutes, the investigators reported (JAMA 2005:293;2626–33).

Beyond the Obvious

The study reveals much of “what we all knew intuitively,” said Jon R. Krohmer, M.D., medical director of Kent County EMS in Grand Rapids, Mich., and the ACEP liaison to the American College of Surgeons' Committee on Trauma.

It's significantly “innovative,” however, because the data sources are new and because investigators evaluated access in terms of population, as opposed to land area only. The researchers also measured access in terms of “prehospital time”—the time from receipt of an emergency call to hospital arrival—as opposed to distance or pure “transport time,” Dr. Krohmer said.

The investigators mainly used the January 2005 Trauma Center Inventory verified by the ACS Committee on Trauma, and the January 2005 version of the Atlas and Database of Air Medical Services.

“The study points out very graphically that there are areas that are potentially overserved, and areas that aren't served at all,” said Dr. Krohmer, an attending physician at Spectrum Health and medical director of Kent County EMS, both in Grand Rapids, Mich.

So, would a level I trauma center ever be built in Big Piney, Wyoming? “That's the million-dollar question,” he said. “And that's why this study should be the basis for future studies on quality of care and outcomes.

“We've asked, for instance, what is a minimal or acceptable patient volume to support a level I center? And right now, we don't have good answers,” Dr. Krohmer said.

Accessing Solutions

In their comments, the investigators question whether the access of some Americans to multiple trauma centers may be excessive, and whether “appropriate limits” on the number of centers could increase patient volumes and thus improve the quality of care—questions that both Dr. Krohmer and Dr. Larkin said are good ones.

The authors also emphasize the finding that 27% and 28% of U.S. residents had access—within 45 and 60 minutes, respectively—to level I and II centers by helicopter only.

“This, and the fact that base helipads are more moveable … makes them appealing as modifiable components of the trauma system,” wrote Charles C. Branas, Ph.D., an epidemiologist at the University of Pennsylvania, Philadelphia, and his associates.

National leadership on trauma care issues should also be better funded and more extensive, though “at this point, states need to get their systems (better) developed,” Dr. Branas told ACEP NEWS. States also need to make or strengthen arrangements for border crossings for day-to-day trauma care, he and his associates wrote.

Approximately 2%–3% of U.S. residents had access to level I and II trauma centers only via the centers and helicopters of neighboring states, the study showed. Most of the standardized interstate agreements for sharing resources, however, concern mass casualty incidents rather than day-to-day trauma care, the investigators said.

Dr. Larkin said he agrees that more “well-institutionalized” interstate arrangements are needed. He said he worries, on the other hand, that the potential of helicopters—which he said are now too often “big billboards for hospitals”—will be overstated and used as part of a cookie-cutter approach to solving access discrepancies.

He would rather see investigators and policymakers pair the new data on access with epidemiologic data—looking, for instance, at where motor vehicle crashes (the most common cause of trauma) occur most frequently.

“I hope people don't misread the data and assume it's the last word on trauma care,” said Dr. Larkin. “There is a whole host of other issues that need to be addressed.”

These include the issue of financing trauma care, a significant portion of which goes unpaid for, and issues of manpower and varying “densities” across the country of board-certified trauma surgeons and emergency physicians, he said.

Dr. Larkin emphasized that there's “a pretty big difference between level I and level II centers.” He advised paying more attention to access within 45 minutes than to access within the 60-minute time frame, since—as the investigators also point out—the so-called golden hour cutoff is supported by little scientific evidence and is probably too long.

Because the study excluded pediatric trauma centers and did not stratify access by age, the findings understate the access problems faced by the younger population, Dr. Larkin noted. “Trauma,” he said, “is the most common cause of death in the first four decades.”

Findings from a national study of access to trauma centers vividly illustrate what many have suspected—some Americans have access to large numbers of trauma centers, while others have access to none.

Now, say leaders in emergency medicine, it's time to collect even more data and look more earnestly at how trauma care can be improved—not only by modifying the often politically driven placement of centers and transport, but also by examining and acting on issues of quality of care, financing, and manpower.

“This is very much a tip-of-the-iceberg analysis. [Access to trauma centers] is a huge issue, and it's important to get [these data] out there,” said Gregory Luke Larkin, M.D., immediate past chair of the American College of Emergency Physicians' Trauma and Injury Prevention Committee. Hopefully, the analysis will generate momentum in looking at access and other related issues, he added.

“It should be just the beginning of a conversation about trauma care,” said Dr. Larkin, professor of surgery, emergency medicine, and public health at the University of Texas Southwestern Medical Center at Dallas. “And it should give permission for folks to talk about it at a national level,” as well as within states, he said.

The investigators of the cross-sectional study, published last month in the Journal of the American Medical Association, found that almost 70% of all U.S. residents had access to a level I or level II trauma center within 45 minutes, and that approximately 84% had access within 60 minutes.

While almost 43 million of these residents—most living in urban areas—had access within an hour to 20 or more level I or II centers, almost 47 million—most in rural areas—had no such access to any centers.

Only 8% of rural residents—compared with 73% of suburban populations and 89% of urban populations—had access to level I and level II centers within 45 minutes. The percentages increased to 24%, 86%, and 95% when the time parameter was 60 minutes, the investigators reported (JAMA 2005:293;2626–33).

Beyond the Obvious

The study reveals much of “what we all knew intuitively,” said Jon R. Krohmer, M.D., medical director of Kent County EMS in Grand Rapids, Mich., and the ACEP liaison to the American College of Surgeons' Committee on Trauma.

It's significantly “innovative,” however, because the data sources are new and because investigators evaluated access in terms of population, as opposed to land area only. The researchers also measured access in terms of “prehospital time”—the time from receipt of an emergency call to hospital arrival—as opposed to distance or pure “transport time,” Dr. Krohmer said.

The investigators mainly used the January 2005 Trauma Center Inventory verified by the ACS Committee on Trauma, and the January 2005 version of the Atlas and Database of Air Medical Services.

“The study points out very graphically that there are areas that are potentially overserved, and areas that aren't served at all,” said Dr. Krohmer, an attending physician at Spectrum Health and medical director of Kent County EMS, both in Grand Rapids, Mich.

So, would a level I trauma center ever be built in Big Piney, Wyoming? “That's the million-dollar question,” he said. “And that's why this study should be the basis for future studies on quality of care and outcomes.

“We've asked, for instance, what is a minimal or acceptable patient volume to support a level I center? And right now, we don't have good answers,” Dr. Krohmer said.

Accessing Solutions

In their comments, the investigators question whether the access of some Americans to multiple trauma centers may be excessive, and whether “appropriate limits” on the number of centers could increase patient volumes and thus improve the quality of care—questions that both Dr. Krohmer and Dr. Larkin said are good ones.

The authors also emphasize the finding that 27% and 28% of U.S. residents had access—within 45 and 60 minutes, respectively—to level I and II centers by helicopter only.

“This, and the fact that base helipads are more moveable … makes them appealing as modifiable components of the trauma system,” wrote Charles C. Branas, Ph.D., an epidemiologist at the University of Pennsylvania, Philadelphia, and his associates.

National leadership on trauma care issues should also be better funded and more extensive, though “at this point, states need to get their systems (better) developed,” Dr. Branas told ACEP NEWS. States also need to make or strengthen arrangements for border crossings for day-to-day trauma care, he and his associates wrote.

Approximately 2%–3% of U.S. residents had access to level I and II trauma centers only via the centers and helicopters of neighboring states, the study showed. Most of the standardized interstate agreements for sharing resources, however, concern mass casualty incidents rather than day-to-day trauma care, the investigators said.

Dr. Larkin said he agrees that more “well-institutionalized” interstate arrangements are needed. He said he worries, on the other hand, that the potential of helicopters—which he said are now too often “big billboards for hospitals”—will be overstated and used as part of a cookie-cutter approach to solving access discrepancies.

He would rather see investigators and policymakers pair the new data on access with epidemiologic data—looking, for instance, at where motor vehicle crashes (the most common cause of trauma) occur most frequently.

“I hope people don't misread the data and assume it's the last word on trauma care,” said Dr. Larkin. “There is a whole host of other issues that need to be addressed.”

These include the issue of financing trauma care, a significant portion of which goes unpaid for, and issues of manpower and varying “densities” across the country of board-certified trauma surgeons and emergency physicians, he said.

Dr. Larkin emphasized that there's “a pretty big difference between level I and level II centers.” He advised paying more attention to access within 45 minutes than to access within the 60-minute time frame, since—as the investigators also point out—the so-called golden hour cutoff is supported by little scientific evidence and is probably too long.

Because the study excluded pediatric trauma centers and did not stratify access by age, the findings understate the access problems faced by the younger population, Dr. Larkin noted. “Trauma,” he said, “is the most common cause of death in the first four decades.”

WASHINGTON — Specially designed physical education classes that increase levels of physical activity were better for overweight children than typical classes focusing on team-oriented sports and games, according to findings from a school-based study.

During the course of a school year, the children in the fitness-focused classes lost more body fat and had greater improvements in fasting insulin levels and cardiovascular fitness, Aaron L. Carrel, M.D., said at the annual meeting of the Pediatric Academic Societies.

“We need to partner with the schools” to improve the health of overweight children, said Dr. Carrel of the department of pediatrics at the University of Wisconsin, Madison.

Dr. Carrel and his associates worked with a school district outside of Madison to randomize 50 overweight, middle-school children to either standard physical education classes, which emphasize team sports and games, or to fitness-oriented gym classes. All classes were held three times a week for 42 minutes.

The fitness-oriented classes were smaller in size—approximately 15 students, compared with 30–35—and focused on the use of equipment, such as treadmills, and other fitness-oriented activities. “In the [standard] class, there was more standing around and choosing teams,” Dr. Carrel noted at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

All students had a body mass index above the 95th percentile for age. At the beginning and end of the school year, they underwent fasting evaluation of insulin and glucose and measurement of body composition by dual x-ray absorptiometry (DXA).

They also participated in maximal oxygen consumption (VO₂ max) treadmill testing that was progressive and staged. Every minute the treadmill got steeper “until the children couldn't exercise any longer,” he said.

At baseline, there were no significant differences between the two groups in any of these measures. But after the 9-month school year was up, the children in the specially designed classes had a greater loss of body fat (4% vs. 2%), a greater increase in cardiovascular fitness (an increase in VO₂ max of nearly 3 mL/kg per minute vs. less than 1 mL/kg per minute), and greater improvement in fasting insulin (−5 μIU/mL vs. +3 μIU/mL).

Other research conducted has shown that fitness has a greater correlation with insulin than body fat, Dr. Carrel noted.

WASHINGTON — Specially designed physical education classes that increase levels of physical activity were better for overweight children than typical classes focusing on team-oriented sports and games, according to findings from a school-based study.

During the course of a school year, the children in the fitness-focused classes lost more body fat and had greater improvements in fasting insulin levels and cardiovascular fitness, Aaron L. Carrel, M.D., said at the annual meeting of the Pediatric Academic Societies.

“We need to partner with the schools” to improve the health of overweight children, said Dr. Carrel of the department of pediatrics at the University of Wisconsin, Madison.

Dr. Carrel and his associates worked with a school district outside of Madison to randomize 50 overweight, middle-school children to either standard physical education classes, which emphasize team sports and games, or to fitness-oriented gym classes. All classes were held three times a week for 42 minutes.

The fitness-oriented classes were smaller in size—approximately 15 students, compared with 30–35—and focused on the use of equipment, such as treadmills, and other fitness-oriented activities. “In the [standard] class, there was more standing around and choosing teams,” Dr. Carrel noted at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

All students had a body mass index above the 95th percentile for age. At the beginning and end of the school year, they underwent fasting evaluation of insulin and glucose and measurement of body composition by dual x-ray absorptiometry (DXA).

They also participated in maximal oxygen consumption (VO₂ max) treadmill testing that was progressive and staged. Every minute the treadmill got steeper “until the children couldn't exercise any longer,” he said.

At baseline, there were no significant differences between the two groups in any of these measures. But after the 9-month school year was up, the children in the specially designed classes had a greater loss of body fat (4% vs. 2%), a greater increase in cardiovascular fitness (an increase in VO₂ max of nearly 3 mL/kg per minute vs. less than 1 mL/kg per minute), and greater improvement in fasting insulin (−5 μIU/mL vs. +3 μIU/mL).

Other research conducted has shown that fitness has a greater correlation with insulin than body fat, Dr. Carrel noted.

WASHINGTON — Specially designed physical education classes that increase levels of physical activity were better for overweight children than typical classes focusing on team-oriented sports and games, according to findings from a school-based study.

During the course of a school year, the children in the fitness-focused classes lost more body fat and had greater improvements in fasting insulin levels and cardiovascular fitness, Aaron L. Carrel, M.D., said at the annual meeting of the Pediatric Academic Societies.

“We need to partner with the schools” to improve the health of overweight children, said Dr. Carrel of the department of pediatrics at the University of Wisconsin, Madison.

Dr. Carrel and his associates worked with a school district outside of Madison to randomize 50 overweight, middle-school children to either standard physical education classes, which emphasize team sports and games, or to fitness-oriented gym classes. All classes were held three times a week for 42 minutes.

The fitness-oriented classes were smaller in size—approximately 15 students, compared with 30–35—and focused on the use of equipment, such as treadmills, and other fitness-oriented activities. “In the [standard] class, there was more standing around and choosing teams,” Dr. Carrel noted at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

All students had a body mass index above the 95th percentile for age. At the beginning and end of the school year, they underwent fasting evaluation of insulin and glucose and measurement of body composition by dual x-ray absorptiometry (DXA).

They also participated in maximal oxygen consumption (VO₂ max) treadmill testing that was progressive and staged. Every minute the treadmill got steeper “until the children couldn't exercise any longer,” he said.

At baseline, there were no significant differences between the two groups in any of these measures. But after the 9-month school year was up, the children in the specially designed classes had a greater loss of body fat (4% vs. 2%), a greater increase in cardiovascular fitness (an increase in VO₂ max of nearly 3 mL/kg per minute vs. less than 1 mL/kg per minute), and greater improvement in fasting insulin (−5 μIU/mL vs. +3 μIU/mL).

Other research conducted has shown that fitness has a greater correlation with insulin than body fat, Dr. Carrel noted.

Contrary to popular opinion, posttraumatic stress disorder and depression in war survivors appear to develop independently of a perceived lack of redress for trauma, according to a study conducted in three former Yugoslav republics.

Impunity for those responsible for trauma is widely believed to aggravate psychological problems in survivors of war.

But a cross-sectional survey of more than 1,300 war survivors in four areas of the former Yugoslavia suggests that a general fear-induced helplessness—rather than emotional responses to impunity specifically—is the most important mediating factor in PTSD and depression, said Metin Basoglu, M.D., of the Institute of Psychiatry at King's College in London, and associates (JAMA 2005;294:580–90).

Survivors had stronger emotional responses to impunity than did individuals who did not directly experience the trauma of war (the controls)—in addition to higher rates of PTSD and depression—but they also had greater fear and loss of control over life. It was these latter factors that played the biggest role, they said.

The findings might have “important implications for reconciliation efforts in postwar countries and effective interventions for traumatized war survivors,” the investigators said.

Contrary to popular opinion, posttraumatic stress disorder and depression in war survivors appear to develop independently of a perceived lack of redress for trauma, according to a study conducted in three former Yugoslav republics.

Impunity for those responsible for trauma is widely believed to aggravate psychological problems in survivors of war.

But a cross-sectional survey of more than 1,300 war survivors in four areas of the former Yugoslavia suggests that a general fear-induced helplessness—rather than emotional responses to impunity specifically—is the most important mediating factor in PTSD and depression, said Metin Basoglu, M.D., of the Institute of Psychiatry at King's College in London, and associates (JAMA 2005;294:580–90).

Survivors had stronger emotional responses to impunity than did individuals who did not directly experience the trauma of war (the controls)—in addition to higher rates of PTSD and depression—but they also had greater fear and loss of control over life. It was these latter factors that played the biggest role, they said.

The findings might have “important implications for reconciliation efforts in postwar countries and effective interventions for traumatized war survivors,” the investigators said.

Contrary to popular opinion, posttraumatic stress disorder and depression in war survivors appear to develop independently of a perceived lack of redress for trauma, according to a study conducted in three former Yugoslav republics.

Impunity for those responsible for trauma is widely believed to aggravate psychological problems in survivors of war.

But a cross-sectional survey of more than 1,300 war survivors in four areas of the former Yugoslavia suggests that a general fear-induced helplessness—rather than emotional responses to impunity specifically—is the most important mediating factor in PTSD and depression, said Metin Basoglu, M.D., of the Institute of Psychiatry at King's College in London, and associates (JAMA 2005;294:580–90).

Survivors had stronger emotional responses to impunity than did individuals who did not directly experience the trauma of war (the controls)—in addition to higher rates of PTSD and depression—but they also had greater fear and loss of control over life. It was these latter factors that played the biggest role, they said.

The findings might have “important implications for reconciliation efforts in postwar countries and effective interventions for traumatized war survivors,” the investigators said.

Azithromycin may be an adequate agent for treating drug-resistant shigellosis, but physicians need to be aware that interpreting susceptibility of Shigella sonnei to it using standard in vitro susceptibility testing is difficult, investigators at Johns Hopkins University have reported.

Antimicrobial-resistant S. sonnei—the most common serogroup in the United States—is a growing problem in the United States, and azithromycin is recommended by the American Academy of Pediatrics and the Infectious Diseases Society of America as an oral agent for the treatment of shigellosis that can be used as an alternative to ampicillin or trimethoprim/sulfamethoxazole (TS).

There are no guidelines for in vitro azithromycin susceptibility testing for Shigella, however, and there is a lack of adequate data correlating the drug's minimal inhibitory concentration—a key component of what's measured during susceptibility testing—with clinical efficacy for the treatment of shigellosis.

In their own testing of azithromycin susceptibility, the investigators found that there were two zones of inhibition of growth for S. sonnei isolates, and that interpretations of susceptibility for a particular isolate can vary by which zone is used.

“Because azithromycin … is being increasingly used in the United States, there is an urgent need for development of validated in vitro antimicrobial breakpoints,” reported Sanjay K. Jain, M.D., and colleagues at Johns Hopkins (Pediatr. Infect. Dis. J. 2005;24:494–7).

Many pediatricians prescribe antimicrobials for children with shigellosis because they shorten the duration of illness and hasten bacteriologic cure, they said.

The investigators reviewed all Shigella isolates submitted to the Johns Hopkins microbiology laboratory during 1996–2000 and 2002—the year in which an outbreak of Shigella was observed at Johns Hopkins and nationally.

Of the 111 isolates submitted during the 1996–2000 period, 63% were resistant to ampicillin, 12% were resistant to TS, and 7% were multiresistant (resistant to both drugs).

In 2002, among 205 isolates submitted, 91% were resistant to ampicillin, 67% were resistant to TS, and 65% were multiresistant, the investigators reported.

Azithromycin may be an adequate agent for treating drug-resistant shigellosis, but physicians need to be aware that interpreting susceptibility of Shigella sonnei to it using standard in vitro susceptibility testing is difficult, investigators at Johns Hopkins University have reported.

Antimicrobial-resistant S. sonnei—the most common serogroup in the United States—is a growing problem in the United States, and azithromycin is recommended by the American Academy of Pediatrics and the Infectious Diseases Society of America as an oral agent for the treatment of shigellosis that can be used as an alternative to ampicillin or trimethoprim/sulfamethoxazole (TS).

There are no guidelines for in vitro azithromycin susceptibility testing for Shigella, however, and there is a lack of adequate data correlating the drug's minimal inhibitory concentration—a key component of what's measured during susceptibility testing—with clinical efficacy for the treatment of shigellosis.

In their own testing of azithromycin susceptibility, the investigators found that there were two zones of inhibition of growth for S. sonnei isolates, and that interpretations of susceptibility for a particular isolate can vary by which zone is used.

“Because azithromycin … is being increasingly used in the United States, there is an urgent need for development of validated in vitro antimicrobial breakpoints,” reported Sanjay K. Jain, M.D., and colleagues at Johns Hopkins (Pediatr. Infect. Dis. J. 2005;24:494–7).

Many pediatricians prescribe antimicrobials for children with shigellosis because they shorten the duration of illness and hasten bacteriologic cure, they said.

The investigators reviewed all Shigella isolates submitted to the Johns Hopkins microbiology laboratory during 1996–2000 and 2002—the year in which an outbreak of Shigella was observed at Johns Hopkins and nationally.

Of the 111 isolates submitted during the 1996–2000 period, 63% were resistant to ampicillin, 12% were resistant to TS, and 7% were multiresistant (resistant to both drugs).

In 2002, among 205 isolates submitted, 91% were resistant to ampicillin, 67% were resistant to TS, and 65% were multiresistant, the investigators reported.

Azithromycin may be an adequate agent for treating drug-resistant shigellosis, but physicians need to be aware that interpreting susceptibility of Shigella sonnei to it using standard in vitro susceptibility testing is difficult, investigators at Johns Hopkins University have reported.

Antimicrobial-resistant S. sonnei—the most common serogroup in the United States—is a growing problem in the United States, and azithromycin is recommended by the American Academy of Pediatrics and the Infectious Diseases Society of America as an oral agent for the treatment of shigellosis that can be used as an alternative to ampicillin or trimethoprim/sulfamethoxazole (TS).

There are no guidelines for in vitro azithromycin susceptibility testing for Shigella, however, and there is a lack of adequate data correlating the drug's minimal inhibitory concentration—a key component of what's measured during susceptibility testing—with clinical efficacy for the treatment of shigellosis.

In their own testing of azithromycin susceptibility, the investigators found that there were two zones of inhibition of growth for S. sonnei isolates, and that interpretations of susceptibility for a particular isolate can vary by which zone is used.

“Because azithromycin … is being increasingly used in the United States, there is an urgent need for development of validated in vitro antimicrobial breakpoints,” reported Sanjay K. Jain, M.D., and colleagues at Johns Hopkins (Pediatr. Infect. Dis. J. 2005;24:494–7).

Many pediatricians prescribe antimicrobials for children with shigellosis because they shorten the duration of illness and hasten bacteriologic cure, they said.

The investigators reviewed all Shigella isolates submitted to the Johns Hopkins microbiology laboratory during 1996–2000 and 2002—the year in which an outbreak of Shigella was observed at Johns Hopkins and nationally.

Of the 111 isolates submitted during the 1996–2000 period, 63% were resistant to ampicillin, 12% were resistant to TS, and 7% were multiresistant (resistant to both drugs).

In 2002, among 205 isolates submitted, 91% were resistant to ampicillin, 67% were resistant to TS, and 65% were multiresistant, the investigators reported.

Microfracture significantly improved knee function in patients with isolated full-thickness cartilage defects of the femur, Kai Mithoefer, M.D., reported at the annual meeting of the American Academy of Orthopaedic Surgeons.

His prospective evaluation of the common technique, which involves clearing out defective cartilage and creating a series of holes in the subchondral bone to stimulate growth of fibrocartilaginous repair tissue, showed that best results were obtained in patients who had good repair tissue fill, low BMI, and symptom duration less than 12 months.

In the study, 48 patients were evaluated, with a minimum 2-year follow-up, using a combination of validated outcomes scores—including the SF-36 and Activities of Daily Living scores—cartilage-sensitive MRI, and a subjective rating. Most patients were male; they averaged 21 years of age.

Patients with high functional scores had lower BMI and shorter preoperative symptoms, reported Dr. Mithoefer, of Massachusetts General Hospital, Cambridge.

MRI demonstrated good repair-tissue fill in the defect in 55% of patients, moderate fill in 29%, and poor fill in 17%. Patients with good fill grade “had significantly more improvement in all the scores than patients with moderate fill grade,” he said. Poor fill grade was associated with limited improvement and decreasing functional scores after 24 months. Patients with also had higher BMI and a longer duration of symptoms, he reported.

Microfracture significantly improved knee function in patients with isolated full-thickness cartilage defects of the femur, Kai Mithoefer, M.D., reported at the annual meeting of the American Academy of Orthopaedic Surgeons.

His prospective evaluation of the common technique, which involves clearing out defective cartilage and creating a series of holes in the subchondral bone to stimulate growth of fibrocartilaginous repair tissue, showed that best results were obtained in patients who had good repair tissue fill, low BMI, and symptom duration less than 12 months.

In the study, 48 patients were evaluated, with a minimum 2-year follow-up, using a combination of validated outcomes scores—including the SF-36 and Activities of Daily Living scores—cartilage-sensitive MRI, and a subjective rating. Most patients were male; they averaged 21 years of age.

Patients with high functional scores had lower BMI and shorter preoperative symptoms, reported Dr. Mithoefer, of Massachusetts General Hospital, Cambridge.

MRI demonstrated good repair-tissue fill in the defect in 55% of patients, moderate fill in 29%, and poor fill in 17%. Patients with good fill grade “had significantly more improvement in all the scores than patients with moderate fill grade,” he said. Poor fill grade was associated with limited improvement and decreasing functional scores after 24 months. Patients with also had higher BMI and a longer duration of symptoms, he reported.

Microfracture significantly improved knee function in patients with isolated full-thickness cartilage defects of the femur, Kai Mithoefer, M.D., reported at the annual meeting of the American Academy of Orthopaedic Surgeons.

His prospective evaluation of the common technique, which involves clearing out defective cartilage and creating a series of holes in the subchondral bone to stimulate growth of fibrocartilaginous repair tissue, showed that best results were obtained in patients who had good repair tissue fill, low BMI, and symptom duration less than 12 months.

In the study, 48 patients were evaluated, with a minimum 2-year follow-up, using a combination of validated outcomes scores—including the SF-36 and Activities of Daily Living scores—cartilage-sensitive MRI, and a subjective rating. Most patients were male; they averaged 21 years of age.

Patients with high functional scores had lower BMI and shorter preoperative symptoms, reported Dr. Mithoefer, of Massachusetts General Hospital, Cambridge.

MRI demonstrated good repair-tissue fill in the defect in 55% of patients, moderate fill in 29%, and poor fill in 17%. Patients with good fill grade “had significantly more improvement in all the scores than patients with moderate fill grade,” he said. Poor fill grade was associated with limited improvement and decreasing functional scores after 24 months. Patients with also had higher BMI and a longer duration of symptoms, he reported.

Children with rotavirus gastroenteritis face a small but real risk of developing enteric gram-negative sepsis, investigators have reported.

“Be aware of the possibility of this complication, especially when a child is developing a high fever and lethargy several days after the beginning of gastroenteritis,” urged Amos Adler, M.D., and his colleagues at the Sapir Medical Center in Kfar Saba, Israel.

“In such cases, prompt initiation of wide-spectrum antibiotics is crucial, even in previously diagnosed rotavirus infection,” they said (Clinical Pediatrics 2005:44;351–54).

The investigators described three previously healthy infants who developed enteric gram-negative rods (EGNR) bacteremia during rotavirus gastroenteritis. The children were hospitalized at the medical center in 2000 and 2001.

The infants had the characteristic clinical course of rotavirus gastroenteritis at the beginning of their illness. Then, 3–5 days after the onset of disease, they presented with an abrupt onset of high fever, lethargy, and poor perfusion.

Laboratory results suggested bacterial sepsis, and in one case, there also was radiographic evidence of severe intestinal injury due to pneumatosis intestinalis.

In all of them, the EGNR isolated from the blood cultures were sensitive to aminoglycosides and to second- or third-generation cephalosporins. (Stool cultures in each patient tested negative for Shigella, Salmonella, enteropathogenic Escherichia coli, and Campylobacter.)

Differentiating between secondary EGNR infection and the deterioration of rotavirus gastroenteritis to a severe course “may be difficult,” the investigators said.

It also is difficult to pinpoint the mechanism of bacterial breakthrough and spreading in these three cases, especially since rotavirus is not known to cause extensive inflammation and cell destruction, they said.

Still, the investigators said that they hypothesize the pathogenesis of the bacteremia “was dissemination of normal intestinal flora through the damaged mucosa”—just as viral infection of the respiratory tract can antecede and predispose children to colonization and invasion of bacteria such as Streptococcus pneumoniae.

It is possible that bacteremia took hold through other sites—the urinary tract or the respiratory tract, for instance—but it's less likely since no clinical or laboratory findings support it, Dr. Adler and his colleagues said.

They said they could not find in the English literature a description of EGNR bacteremia as a complication of rotavirus infection.

One of their patients, for example, was a healthy 9-month-old boy, admitted after 1 day of vomiting and diarrhea. On admission, he was afebrile and appeared lethargic and moderately dehydrated.

The child had normal blood count and electrolytes, urea 53 mg/dL, mild metabolic acidosis and normal urine analysis. His general condition improved after treatment with intravenous fluids. His diarrhea continued, but vomiting subsided. Stool bacterial cultures were negative, and rotavirus antigen was detected in his stool.

On the third day of hospitalization, his temperature rose to 39.5° C, and he became more lethargic, the investigators reported.

A plain abdominal radiograph showed intraluminal air in the small bowel (pneumatosis intestinalis) without free air or intraportal gas. Abdominal ultrasound appeared normal. Laboratory analysis showed white blood cell counts of 14,400 cells/eL with 9% bands and 59% neutrophils, urea 15 mg/dL, pH 7.37, partial pressure of carbon dioxide 20.7 mm Hg, bicarbonate 11.8 mmol/L, and normal U/A.

The infant was treated with intravenous piperacillin-tazobactam, and oral feeding was discontinued.

His fever resolved, and his general condition improved. Klebsiella pneumoniae was recovered from the blood culture and was sensitive to cephalosporins, aminoglycosides, trimethoprim-sulfamethoxazole, and amoxicillin-clavulanate.

After 4 days of fasting, the infant began receiving semi-elemental nutrition. The infant completed 10 days of intravenous antibiotics and resumed a normal diet by the 13th day of hospitalization. He was discharged and appeared to be in excellent health at follow-up 1 month later.

Children with rotavirus gastroenteritis face a small but real risk of developing enteric gram-negative sepsis, investigators have reported.

“Be aware of the possibility of this complication, especially when a child is developing a high fever and lethargy several days after the beginning of gastroenteritis,” urged Amos Adler, M.D., and his colleagues at the Sapir Medical Center in Kfar Saba, Israel.

“In such cases, prompt initiation of wide-spectrum antibiotics is crucial, even in previously diagnosed rotavirus infection,” they said (Clinical Pediatrics 2005:44;351–54).

The investigators described three previously healthy infants who developed enteric gram-negative rods (EGNR) bacteremia during rotavirus gastroenteritis. The children were hospitalized at the medical center in 2000 and 2001.

The infants had the characteristic clinical course of rotavirus gastroenteritis at the beginning of their illness. Then, 3–5 days after the onset of disease, they presented with an abrupt onset of high fever, lethargy, and poor perfusion.

Laboratory results suggested bacterial sepsis, and in one case, there also was radiographic evidence of severe intestinal injury due to pneumatosis intestinalis.

In all of them, the EGNR isolated from the blood cultures were sensitive to aminoglycosides and to second- or third-generation cephalosporins. (Stool cultures in each patient tested negative for Shigella, Salmonella, enteropathogenic Escherichia coli, and Campylobacter.)

Differentiating between secondary EGNR infection and the deterioration of rotavirus gastroenteritis to a severe course “may be difficult,” the investigators said.

It also is difficult to pinpoint the mechanism of bacterial breakthrough and spreading in these three cases, especially since rotavirus is not known to cause extensive inflammation and cell destruction, they said.

Still, the investigators said that they hypothesize the pathogenesis of the bacteremia “was dissemination of normal intestinal flora through the damaged mucosa”—just as viral infection of the respiratory tract can antecede and predispose children to colonization and invasion of bacteria such as Streptococcus pneumoniae.

It is possible that bacteremia took hold through other sites—the urinary tract or the respiratory tract, for instance—but it's less likely since no clinical or laboratory findings support it, Dr. Adler and his colleagues said.

They said they could not find in the English literature a description of EGNR bacteremia as a complication of rotavirus infection.

One of their patients, for example, was a healthy 9-month-old boy, admitted after 1 day of vomiting and diarrhea. On admission, he was afebrile and appeared lethargic and moderately dehydrated.

The child had normal blood count and electrolytes, urea 53 mg/dL, mild metabolic acidosis and normal urine analysis. His general condition improved after treatment with intravenous fluids. His diarrhea continued, but vomiting subsided. Stool bacterial cultures were negative, and rotavirus antigen was detected in his stool.

On the third day of hospitalization, his temperature rose to 39.5° C, and he became more lethargic, the investigators reported.

A plain abdominal radiograph showed intraluminal air in the small bowel (pneumatosis intestinalis) without free air or intraportal gas. Abdominal ultrasound appeared normal. Laboratory analysis showed white blood cell counts of 14,400 cells/eL with 9% bands and 59% neutrophils, urea 15 mg/dL, pH 7.37, partial pressure of carbon dioxide 20.7 mm Hg, bicarbonate 11.8 mmol/L, and normal U/A.

The infant was treated with intravenous piperacillin-tazobactam, and oral feeding was discontinued.

His fever resolved, and his general condition improved. Klebsiella pneumoniae was recovered from the blood culture and was sensitive to cephalosporins, aminoglycosides, trimethoprim-sulfamethoxazole, and amoxicillin-clavulanate.

After 4 days of fasting, the infant began receiving semi-elemental nutrition. The infant completed 10 days of intravenous antibiotics and resumed a normal diet by the 13th day of hospitalization. He was discharged and appeared to be in excellent health at follow-up 1 month later.

Children with rotavirus gastroenteritis face a small but real risk of developing enteric gram-negative sepsis, investigators have reported.

“Be aware of the possibility of this complication, especially when a child is developing a high fever and lethargy several days after the beginning of gastroenteritis,” urged Amos Adler, M.D., and his colleagues at the Sapir Medical Center in Kfar Saba, Israel.

“In such cases, prompt initiation of wide-spectrum antibiotics is crucial, even in previously diagnosed rotavirus infection,” they said (Clinical Pediatrics 2005:44;351–54).

The investigators described three previously healthy infants who developed enteric gram-negative rods (EGNR) bacteremia during rotavirus gastroenteritis. The children were hospitalized at the medical center in 2000 and 2001.

The infants had the characteristic clinical course of rotavirus gastroenteritis at the beginning of their illness. Then, 3–5 days after the onset of disease, they presented with an abrupt onset of high fever, lethargy, and poor perfusion.

Laboratory results suggested bacterial sepsis, and in one case, there also was radiographic evidence of severe intestinal injury due to pneumatosis intestinalis.

In all of them, the EGNR isolated from the blood cultures were sensitive to aminoglycosides and to second- or third-generation cephalosporins. (Stool cultures in each patient tested negative for Shigella, Salmonella, enteropathogenic Escherichia coli, and Campylobacter.)

Differentiating between secondary EGNR infection and the deterioration of rotavirus gastroenteritis to a severe course “may be difficult,” the investigators said.

It also is difficult to pinpoint the mechanism of bacterial breakthrough and spreading in these three cases, especially since rotavirus is not known to cause extensive inflammation and cell destruction, they said.

Still, the investigators said that they hypothesize the pathogenesis of the bacteremia “was dissemination of normal intestinal flora through the damaged mucosa”—just as viral infection of the respiratory tract can antecede and predispose children to colonization and invasion of bacteria such as Streptococcus pneumoniae.

It is possible that bacteremia took hold through other sites—the urinary tract or the respiratory tract, for instance—but it's less likely since no clinical or laboratory findings support it, Dr. Adler and his colleagues said.

They said they could not find in the English literature a description of EGNR bacteremia as a complication of rotavirus infection.

One of their patients, for example, was a healthy 9-month-old boy, admitted after 1 day of vomiting and diarrhea. On admission, he was afebrile and appeared lethargic and moderately dehydrated.

The child had normal blood count and electrolytes, urea 53 mg/dL, mild metabolic acidosis and normal urine analysis. His general condition improved after treatment with intravenous fluids. His diarrhea continued, but vomiting subsided. Stool bacterial cultures were negative, and rotavirus antigen was detected in his stool.

On the third day of hospitalization, his temperature rose to 39.5° C, and he became more lethargic, the investigators reported.

A plain abdominal radiograph showed intraluminal air in the small bowel (pneumatosis intestinalis) without free air or intraportal gas. Abdominal ultrasound appeared normal. Laboratory analysis showed white blood cell counts of 14,400 cells/eL with 9% bands and 59% neutrophils, urea 15 mg/dL, pH 7.37, partial pressure of carbon dioxide 20.7 mm Hg, bicarbonate 11.8 mmol/L, and normal U/A.

The infant was treated with intravenous piperacillin-tazobactam, and oral feeding was discontinued.

His fever resolved, and his general condition improved. Klebsiella pneumoniae was recovered from the blood culture and was sensitive to cephalosporins, aminoglycosides, trimethoprim-sulfamethoxazole, and amoxicillin-clavulanate.

After 4 days of fasting, the infant began receiving semi-elemental nutrition. The infant completed 10 days of intravenous antibiotics and resumed a normal diet by the 13th day of hospitalization. He was discharged and appeared to be in excellent health at follow-up 1 month later.

WASHINGTON — At least 13% of all adolescents and 54% of overweight teens are insulin resistant, and a significant proportion of these adolescents have metabolic syndrome—even according to adult definitions.

These findings, reported in various presentations at the annual meeting of the Pediatric Academic Societies, add to knowledge of the increasing prevalence of metabolic syndrome in U.S. youth.

The findings come from analyses of 1999–2000 data from the National Health and Nutrition Examination Survey (NHANES), and thus represent a national sample of U.S. adolescents.

The prevalence of the syndrome, using age-specific criteria applied to the National Cholesterol Education Program (NCEP) definition, has been reported as 4% of U.S. adolescents in 1988–1994, and 7% in 1999–2000.

The new analyses show that rates of metabolic syndrome remain sizable when teens are identified according to the two known adult definitions of the syndrome, rather than with the use of age-specific criteria.

“There is a controversy about how we should define [metabolic syndrome] in kids. Here we treated teens like adults, and we still found a significant number,” said Stephen Cook, M.D., who presented most of the findings at the meeting, in a later interview.

“These are kids who are already manifesting adult cardiovascular health problems … who could potentially be very disabled by their health early on,” he said. “You're not going to prescribe statins, but these kids need to improve their lifestyle.”

Dr. Cook and his colleagues at the American Academy of Pediatrics' Center for Child Health Research at the University of Rochester (N.Y.) analyzed the NHANES data for almost 940 adolescents, aged 12–19 years, who had not eaten for 6 hours.

Less than 5% had metabolic syndrome using the NCEP definition, and more than 5% had the syndrome according to the definition of the World Health Organization. Among overweight teens, 25% met the NCEP criteria, and 30% met the WHO criteria, Dr. Cook reported at the meeting sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

The NCEP defines metabolic syndrome as three or more of five criteria: high triglycerides, low HDL, high blood pressure, abdominal obesity, and high fasting glucose.

The WHO requires a finding of insulin resistance—by either high fasting glucose or homeostasis model assessment (HOMA) of at least the 75th percentile—plus any two of the other criteria.

In looking specifically at insulin resistance, which Dr. Cook describes as “driving” the metabolic syndrome, the investigators used two validated surrogate markers: elevated fasting insulin levels and HOMA (insulin × glucose/22.5).

The markers have been shown to correlate well with euglycemic clamp techniques in children and adolescents. Insulin resistance is defined according to these markers as fasting insulin equal to or greater than 20 μU/mL, or HOMA greater than or equal to the top quartile of the nondiabetic population.

The investigators found that insulin resistance affected 25% of U.S. teens when it was defined by HOMA (predictably, since it's a statistical definition) and 13% when it was defined by hyperinsulinemia. There were no gender or age differences.

Overweight and at risk for overweight were significantly associated with insulin resistance by both definitions. By the HOMA definition, 39% of teens at risk for overweight and 72% of overweight teens were insulin resistant. By the hyperinsulinemia definition, these numbers were 18% and 54%, respectively.

The NHANES sample was “well distributed” in terms of weight, noted Dr. Cook of the Golisano Children's Hospital at Strong, part of the University of Rochester. He is trained in pediatrics and internal medicine.

In another analysis, Dr. Cook and his associates sought to determine the association of insulin resistance with the prevalence of metabolic syndrome (defined with age-specific criteria) for this U.S. sample.

They found that more than 25% of adolescents who were insulin resistant by HOMA, and more than 40% of adolescents who were insulin resistant by the hyperinsulinemia definition had the metabolic syndrome.

“Insulin resistance is independently associated with not only the metabolic syndrome, but also with each of its components,” said Todd Florin, M.D., at the meeting. Dr. Florin, who worked with Dr. Cook as a medical student, is now a resident at the Children's Hospital of Philadelphia.

Measuring fasting insulin levels may be a “quick, inexpensive” method for assessing insulin resistance, and risk for metabolic syndrome, in adolescents, he said.

Some degree of insulin resistance is associated with puberty and is transient, Dr. Cook noted. “So while there may be 54% of overweight kids with insulin resistance, we might find it's less if we could follow them over time.”

Still, he said, the rates would remain significant—as would the fact that “metabolic syndrome and insulin resistance do predict diabetes and heart disease.”

Metabolic Syndrome: Not Just for Teens Anymore

Nearly 4% of children ages 5–11 years, and 17% of overweight children, met criteria for metabolic syndrome in a separate analysis performed by Dr. Cook and his associates.

Here they used data from the National Health and Nutrition Examination Survey III, which spanned from 1988 to 1994, rather than the more recent NHANES data that they used for their study of adolescents.

The more recent survey data did not contain enough of the elements needed to evaluate age-specific criteria for metabolic syndrome for children under 8 years of age, explained Dr. Cook.

Although the data are older, the study is the first to document metabolic syndrome in a national sample of children, he said.

Another study reported recently at the annual meeting of the American College of Sports Medicine documented metabolic syndrome in as many as 5% of 7- to 9-year-olds in Kansas. (“Insulin Resistance in 5% of Youngsters,” July 1, 2005, p. 1).

The NHANES study did not reveal any significant differences in the prevalence of metabolic syndrome by age, region of the country, or poverty level.

Gender and ethnic differences were significant, however. Almost 3% of boys and 6% of girls met criteria for the syndrome.

Metabolic syndrome was also identified in approximately 7% of Mexican Americans, 5% of whites, and 3% of African Americans.

Less than 1% of normal-weight children met the criteria, as opposed to 6% of those at risk for overweight, and 17% of overweight children.

Among overweight children, 41% had one risk factor for the syndrome, and 24% had two risk factors, Dr. Cook reported.

WASHINGTON — At least 13% of all adolescents and 54% of overweight teens are insulin resistant, and a significant proportion of these adolescents have metabolic syndrome—even according to adult definitions.

These findings, reported in various presentations at the annual meeting of the Pediatric Academic Societies, add to knowledge of the increasing prevalence of metabolic syndrome in U.S. youth.

The findings come from analyses of 1999–2000 data from the National Health and Nutrition Examination Survey (NHANES), and thus represent a national sample of U.S. adolescents.

The prevalence of the syndrome, using age-specific criteria applied to the National Cholesterol Education Program (NCEP) definition, has been reported as 4% of U.S. adolescents in 1988–1994, and 7% in 1999–2000.

The new analyses show that rates of metabolic syndrome remain sizable when teens are identified according to the two known adult definitions of the syndrome, rather than with the use of age-specific criteria.

“There is a controversy about how we should define [metabolic syndrome] in kids. Here we treated teens like adults, and we still found a significant number,” said Stephen Cook, M.D., who presented most of the findings at the meeting, in a later interview.

“These are kids who are already manifesting adult cardiovascular health problems … who could potentially be very disabled by their health early on,” he said. “You're not going to prescribe statins, but these kids need to improve their lifestyle.”

Dr. Cook and his colleagues at the American Academy of Pediatrics' Center for Child Health Research at the University of Rochester (N.Y.) analyzed the NHANES data for almost 940 adolescents, aged 12–19 years, who had not eaten for 6 hours.

Less than 5% had metabolic syndrome using the NCEP definition, and more than 5% had the syndrome according to the definition of the World Health Organization. Among overweight teens, 25% met the NCEP criteria, and 30% met the WHO criteria, Dr. Cook reported at the meeting sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

The NCEP defines metabolic syndrome as three or more of five criteria: high triglycerides, low HDL, high blood pressure, abdominal obesity, and high fasting glucose.

The WHO requires a finding of insulin resistance—by either high fasting glucose or homeostasis model assessment (HOMA) of at least the 75th percentile—plus any two of the other criteria.

In looking specifically at insulin resistance, which Dr. Cook describes as “driving” the metabolic syndrome, the investigators used two validated surrogate markers: elevated fasting insulin levels and HOMA (insulin × glucose/22.5).

The markers have been shown to correlate well with euglycemic clamp techniques in children and adolescents. Insulin resistance is defined according to these markers as fasting insulin equal to or greater than 20 μU/mL, or HOMA greater than or equal to the top quartile of the nondiabetic population.

The investigators found that insulin resistance affected 25% of U.S. teens when it was defined by HOMA (predictably, since it's a statistical definition) and 13% when it was defined by hyperinsulinemia. There were no gender or age differences.

Overweight and at risk for overweight were significantly associated with insulin resistance by both definitions. By the HOMA definition, 39% of teens at risk for overweight and 72% of overweight teens were insulin resistant. By the hyperinsulinemia definition, these numbers were 18% and 54%, respectively.

The NHANES sample was “well distributed” in terms of weight, noted Dr. Cook of the Golisano Children's Hospital at Strong, part of the University of Rochester. He is trained in pediatrics and internal medicine.

In another analysis, Dr. Cook and his associates sought to determine the association of insulin resistance with the prevalence of metabolic syndrome (defined with age-specific criteria) for this U.S. sample.

They found that more than 25% of adolescents who were insulin resistant by HOMA, and more than 40% of adolescents who were insulin resistant by the hyperinsulinemia definition had the metabolic syndrome.

“Insulin resistance is independently associated with not only the metabolic syndrome, but also with each of its components,” said Todd Florin, M.D., at the meeting. Dr. Florin, who worked with Dr. Cook as a medical student, is now a resident at the Children's Hospital of Philadelphia.

Measuring fasting insulin levels may be a “quick, inexpensive” method for assessing insulin resistance, and risk for metabolic syndrome, in adolescents, he said.

Some degree of insulin resistance is associated with puberty and is transient, Dr. Cook noted. “So while there may be 54% of overweight kids with insulin resistance, we might find it's less if we could follow them over time.”

Still, he said, the rates would remain significant—as would the fact that “metabolic syndrome and insulin resistance do predict diabetes and heart disease.”

Metabolic Syndrome: Not Just for Teens Anymore

Nearly 4% of children ages 5–11 years, and 17% of overweight children, met criteria for metabolic syndrome in a separate analysis performed by Dr. Cook and his associates.

Here they used data from the National Health and Nutrition Examination Survey III, which spanned from 1988 to 1994, rather than the more recent NHANES data that they used for their study of adolescents.

The more recent survey data did not contain enough of the elements needed to evaluate age-specific criteria for metabolic syndrome for children under 8 years of age, explained Dr. Cook.

Although the data are older, the study is the first to document metabolic syndrome in a national sample of children, he said.

Another study reported recently at the annual meeting of the American College of Sports Medicine documented metabolic syndrome in as many as 5% of 7- to 9-year-olds in Kansas. (“Insulin Resistance in 5% of Youngsters,” July 1, 2005, p. 1).

The NHANES study did not reveal any significant differences in the prevalence of metabolic syndrome by age, region of the country, or poverty level.

Gender and ethnic differences were significant, however. Almost 3% of boys and 6% of girls met criteria for the syndrome.

Metabolic syndrome was also identified in approximately 7% of Mexican Americans, 5% of whites, and 3% of African Americans.

Less than 1% of normal-weight children met the criteria, as opposed to 6% of those at risk for overweight, and 17% of overweight children.

Among overweight children, 41% had one risk factor for the syndrome, and 24% had two risk factors, Dr. Cook reported.

WASHINGTON — At least 13% of all adolescents and 54% of overweight teens are insulin resistant, and a significant proportion of these adolescents have metabolic syndrome—even according to adult definitions.

These findings, reported in various presentations at the annual meeting of the Pediatric Academic Societies, add to knowledge of the increasing prevalence of metabolic syndrome in U.S. youth.

The findings come from analyses of 1999–2000 data from the National Health and Nutrition Examination Survey (NHANES), and thus represent a national sample of U.S. adolescents.

The prevalence of the syndrome, using age-specific criteria applied to the National Cholesterol Education Program (NCEP) definition, has been reported as 4% of U.S. adolescents in 1988–1994, and 7% in 1999–2000.

The new analyses show that rates of metabolic syndrome remain sizable when teens are identified according to the two known adult definitions of the syndrome, rather than with the use of age-specific criteria.

“There is a controversy about how we should define [metabolic syndrome] in kids. Here we treated teens like adults, and we still found a significant number,” said Stephen Cook, M.D., who presented most of the findings at the meeting, in a later interview.

“These are kids who are already manifesting adult cardiovascular health problems … who could potentially be very disabled by their health early on,” he said. “You're not going to prescribe statins, but these kids need to improve their lifestyle.”

Dr. Cook and his colleagues at the American Academy of Pediatrics' Center for Child Health Research at the University of Rochester (N.Y.) analyzed the NHANES data for almost 940 adolescents, aged 12–19 years, who had not eaten for 6 hours.

Less than 5% had metabolic syndrome using the NCEP definition, and more than 5% had the syndrome according to the definition of the World Health Organization. Among overweight teens, 25% met the NCEP criteria, and 30% met the WHO criteria, Dr. Cook reported at the meeting sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

The NCEP defines metabolic syndrome as three or more of five criteria: high triglycerides, low HDL, high blood pressure, abdominal obesity, and high fasting glucose.

The WHO requires a finding of insulin resistance—by either high fasting glucose or homeostasis model assessment (HOMA) of at least the 75th percentile—plus any two of the other criteria.

In looking specifically at insulin resistance, which Dr. Cook describes as “driving” the metabolic syndrome, the investigators used two validated surrogate markers: elevated fasting insulin levels and HOMA (insulin × glucose/22.5).

The markers have been shown to correlate well with euglycemic clamp techniques in children and adolescents. Insulin resistance is defined according to these markers as fasting insulin equal to or greater than 20 μU/mL, or HOMA greater than or equal to the top quartile of the nondiabetic population.

The investigators found that insulin resistance affected 25% of U.S. teens when it was defined by HOMA (predictably, since it's a statistical definition) and 13% when it was defined by hyperinsulinemia. There were no gender or age differences.

Overweight and at risk for overweight were significantly associated with insulin resistance by both definitions. By the HOMA definition, 39% of teens at risk for overweight and 72% of overweight teens were insulin resistant. By the hyperinsulinemia definition, these numbers were 18% and 54%, respectively.

The NHANES sample was “well distributed” in terms of weight, noted Dr. Cook of the Golisano Children's Hospital at Strong, part of the University of Rochester. He is trained in pediatrics and internal medicine.

In another analysis, Dr. Cook and his associates sought to determine the association of insulin resistance with the prevalence of metabolic syndrome (defined with age-specific criteria) for this U.S. sample.

They found that more than 25% of adolescents who were insulin resistant by HOMA, and more than 40% of adolescents who were insulin resistant by the hyperinsulinemia definition had the metabolic syndrome.

“Insulin resistance is independently associated with not only the metabolic syndrome, but also with each of its components,” said Todd Florin, M.D., at the meeting. Dr. Florin, who worked with Dr. Cook as a medical student, is now a resident at the Children's Hospital of Philadelphia.

Measuring fasting insulin levels may be a “quick, inexpensive” method for assessing insulin resistance, and risk for metabolic syndrome, in adolescents, he said.

Some degree of insulin resistance is associated with puberty and is transient, Dr. Cook noted. “So while there may be 54% of overweight kids with insulin resistance, we might find it's less if we could follow them over time.”

Still, he said, the rates would remain significant—as would the fact that “metabolic syndrome and insulin resistance do predict diabetes and heart disease.”

Metabolic Syndrome: Not Just for Teens Anymore

Nearly 4% of children ages 5–11 years, and 17% of overweight children, met criteria for metabolic syndrome in a separate analysis performed by Dr. Cook and his associates.

Here they used data from the National Health and Nutrition Examination Survey III, which spanned from 1988 to 1994, rather than the more recent NHANES data that they used for their study of adolescents.

The more recent survey data did not contain enough of the elements needed to evaluate age-specific criteria for metabolic syndrome for children under 8 years of age, explained Dr. Cook.

Although the data are older, the study is the first to document metabolic syndrome in a national sample of children, he said.

Another study reported recently at the annual meeting of the American College of Sports Medicine documented metabolic syndrome in as many as 5% of 7- to 9-year-olds in Kansas. (“Insulin Resistance in 5% of Youngsters,” July 1, 2005, p. 1).

The NHANES study did not reveal any significant differences in the prevalence of metabolic syndrome by age, region of the country, or poverty level.

Gender and ethnic differences were significant, however. Almost 3% of boys and 6% of girls met criteria for the syndrome.

Metabolic syndrome was also identified in approximately 7% of Mexican Americans, 5% of whites, and 3% of African Americans.

Less than 1% of normal-weight children met the criteria, as opposed to 6% of those at risk for overweight, and 17% of overweight children.

Among overweight children, 41% had one risk factor for the syndrome, and 24% had two risk factors, Dr. Cook reported.