Damian McNamara

TAMPA – The treatment of osteoporosis is in flux because of a variety of forces, including a substantial increase in the number of aging patients deemed eligible for treatments, a leading geriatrician said. Just as baby boomers begin reaching senior status, a recently developed tool for assessing people's fracture risk is increasing the number of patients considered suitable for preventive therapy.

Meanwhile, those therapy options are multiplying, and emerging evidence suggests that one, bisphosphonates, is associated with an increased risk for atypical fractures, although the absolute risk appears to be low, Dr. Barbara Messinger-Rapport, said at the meeting.

The assessment tool making a difference is the Web-based Fracture Risk Assessment Tool (FRAX), released by the World Health Organization in 2008. FRAX guides clinicians to consider drug therapy for patients with T scores (deviations from healthy bone density) of −2.5 or lower at the femoral neck or spine, a T score between −1.0 and −2.5 as well as a 3% or higher calculated risk for hip fracture over 10 years, or a 20% or greater risk of major osteoporosis-related fracture.

Even if a person's T score never reaches −2.5, his or her hip fracture risk can climb to 3% or higher, said Dr. Messinger-Rapport, director of the Center for Geriatric Medicine at the Cleveland Clinic and medical director of the Fairfax Health Care Center Nursing Home, also in Cleveland. “This could widen the number of people who could be put on treatment.”

Bisphosphonates remain the most-common treatment strategy, but optimal duration of therapy, timing of drug holidays, and how age and gender play into risk for adverse events remains unclear, she said.

A newer option, the monoclonal antibody denosumab (Prolia, Amgen), significantly reduced vertebral fractures compared with a placebo in published studies. Administered as a subcutaneous injection every 6 months, denosumab also may be more convenient than agents requiring infusion, Dr. Messinger-Rapport said.

Higher cost is a consideration, however. Wholesale cost of denosumab is approximately $850/60-mg subcutaneous injection. In contrast, generic alendronate costs $100-$200/year; brand-name oral bisphosphonate costs up to $1,000/year; and zoledronic acid, delivered via intravenous infusion, is approximately $1,100/year, she said.

Denosumab's impact on clinical care is not yet known, Dr. Messinger-Rapport said. She suggested that clinicians consider this agent in high-risk elders, women or men with osteoporosis, men with prostate cancer with androgen deprivation, patients with metastatic prostate or breast cancer, and possibly patients with renal impairment (denosumab clearance is not renal). Also consider denosumab for patients who cannot tolerate a bisphosphonate either orally or by infusion, she added.

Researchers showed a 68% decrease in vertebral fractures, a 40% decline in hip fractures, and a 20% decrease in nonvertebral fractures with denosumab versus placebo in the FREEDOM study of osteoporotic women treated for 36 months (N. Engl. J. Med. 2009;361:756-65). A similar 62% decrease in vertebral fractures with denosumab, compared with placebo, was observed in a 24-month study of men with androgen deprivation for prostate cancer (N. Engl. J. Med. 2009;361:745-55).

Researchers also have examined reports of atypical femoral fractures associated with bisphosphonate use and found an association. For example, in a study published last year, 17 of 20 atypical femoral fractures occurred in patients taking oral bisphosphonates (N. Engl. J. Med. 2010;363:1848-9).

In a letter (N. Engl. J. Med. 2010; 362:1848-9), the researchers stated that although they found the association, “overall the anti-fracture effects of bisphosphonates far outweigh their potential risks.”

More recently, other investigators found an increased risk of subtrochanteric and femoral shaft fractures in women treated for 5 years or more with oral bisphosphonates (JAMA 2011;305:783-9). The authors stated that the absolute risk of the atypical fractures is low, however.

Dr. Messinger-Rapport listed the contraindications to bisphosphonates as a prior allergic reaction, vitamin D depletion (less than 30 ng/mL), hypocalcemia, dysphagia, esophageal disorders, and severe gastroesophageal reflux disorder.

A person attending the meeting asked if it is appropriate to continue bisphosphonate therapy after a patient's T score improves. “Yes, even if the T score only improves by a few percentage points,” Dr. Messinger-Rapport replied, because there is a disproportionate benefit in terms of fracture risk reduction.

Dr. Messinger-Rapport has disclosed that she is a member of the editorial board for the National Osteoporosis Foundation.

To watch an interview with Dr. Messinger-Rapport, scan this QR code with a smartphone.

TAMPA – The treatment of osteoporosis is in flux because of a variety of forces, including a substantial increase in the number of aging patients deemed eligible for treatments, a leading geriatrician said. Just as baby boomers begin reaching senior status, a recently developed tool for assessing people's fracture risk is increasing the number of patients considered suitable for preventive therapy.

Meanwhile, those therapy options are multiplying, and emerging evidence suggests that one, bisphosphonates, is associated with an increased risk for atypical fractures, although the absolute risk appears to be low, Dr. Barbara Messinger-Rapport, said at the meeting.

The assessment tool making a difference is the Web-based Fracture Risk Assessment Tool (FRAX), released by the World Health Organization in 2008. FRAX guides clinicians to consider drug therapy for patients with T scores (deviations from healthy bone density) of −2.5 or lower at the femoral neck or spine, a T score between −1.0 and −2.5 as well as a 3% or higher calculated risk for hip fracture over 10 years, or a 20% or greater risk of major osteoporosis-related fracture.

Even if a person's T score never reaches −2.5, his or her hip fracture risk can climb to 3% or higher, said Dr. Messinger-Rapport, director of the Center for Geriatric Medicine at the Cleveland Clinic and medical director of the Fairfax Health Care Center Nursing Home, also in Cleveland. “This could widen the number of people who could be put on treatment.”

Bisphosphonates remain the most-common treatment strategy, but optimal duration of therapy, timing of drug holidays, and how age and gender play into risk for adverse events remains unclear, she said.

A newer option, the monoclonal antibody denosumab (Prolia, Amgen), significantly reduced vertebral fractures compared with a placebo in published studies. Administered as a subcutaneous injection every 6 months, denosumab also may be more convenient than agents requiring infusion, Dr. Messinger-Rapport said.

Higher cost is a consideration, however. Wholesale cost of denosumab is approximately $850/60-mg subcutaneous injection. In contrast, generic alendronate costs $100-$200/year; brand-name oral bisphosphonate costs up to $1,000/year; and zoledronic acid, delivered via intravenous infusion, is approximately $1,100/year, she said.

Denosumab's impact on clinical care is not yet known, Dr. Messinger-Rapport said. She suggested that clinicians consider this agent in high-risk elders, women or men with osteoporosis, men with prostate cancer with androgen deprivation, patients with metastatic prostate or breast cancer, and possibly patients with renal impairment (denosumab clearance is not renal). Also consider denosumab for patients who cannot tolerate a bisphosphonate either orally or by infusion, she added.

Researchers showed a 68% decrease in vertebral fractures, a 40% decline in hip fractures, and a 20% decrease in nonvertebral fractures with denosumab versus placebo in the FREEDOM study of osteoporotic women treated for 36 months (N. Engl. J. Med. 2009;361:756-65). A similar 62% decrease in vertebral fractures with denosumab, compared with placebo, was observed in a 24-month study of men with androgen deprivation for prostate cancer (N. Engl. J. Med. 2009;361:745-55).

Researchers also have examined reports of atypical femoral fractures associated with bisphosphonate use and found an association. For example, in a study published last year, 17 of 20 atypical femoral fractures occurred in patients taking oral bisphosphonates (N. Engl. J. Med. 2010;363:1848-9).

In a letter (N. Engl. J. Med. 2010; 362:1848-9), the researchers stated that although they found the association, “overall the anti-fracture effects of bisphosphonates far outweigh their potential risks.”

More recently, other investigators found an increased risk of subtrochanteric and femoral shaft fractures in women treated for 5 years or more with oral bisphosphonates (JAMA 2011;305:783-9). The authors stated that the absolute risk of the atypical fractures is low, however.

Dr. Messinger-Rapport listed the contraindications to bisphosphonates as a prior allergic reaction, vitamin D depletion (less than 30 ng/mL), hypocalcemia, dysphagia, esophageal disorders, and severe gastroesophageal reflux disorder.

A person attending the meeting asked if it is appropriate to continue bisphosphonate therapy after a patient's T score improves. “Yes, even if the T score only improves by a few percentage points,” Dr. Messinger-Rapport replied, because there is a disproportionate benefit in terms of fracture risk reduction.

Dr. Messinger-Rapport has disclosed that she is a member of the editorial board for the National Osteoporosis Foundation.

To watch an interview with Dr. Messinger-Rapport, scan this QR code with a smartphone.

TAMPA – The treatment of osteoporosis is in flux because of a variety of forces, including a substantial increase in the number of aging patients deemed eligible for treatments, a leading geriatrician said. Just as baby boomers begin reaching senior status, a recently developed tool for assessing people's fracture risk is increasing the number of patients considered suitable for preventive therapy.

Meanwhile, those therapy options are multiplying, and emerging evidence suggests that one, bisphosphonates, is associated with an increased risk for atypical fractures, although the absolute risk appears to be low, Dr. Barbara Messinger-Rapport, said at the meeting.

The assessment tool making a difference is the Web-based Fracture Risk Assessment Tool (FRAX), released by the World Health Organization in 2008. FRAX guides clinicians to consider drug therapy for patients with T scores (deviations from healthy bone density) of −2.5 or lower at the femoral neck or spine, a T score between −1.0 and −2.5 as well as a 3% or higher calculated risk for hip fracture over 10 years, or a 20% or greater risk of major osteoporosis-related fracture.

Even if a person's T score never reaches −2.5, his or her hip fracture risk can climb to 3% or higher, said Dr. Messinger-Rapport, director of the Center for Geriatric Medicine at the Cleveland Clinic and medical director of the Fairfax Health Care Center Nursing Home, also in Cleveland. “This could widen the number of people who could be put on treatment.”

Bisphosphonates remain the most-common treatment strategy, but optimal duration of therapy, timing of drug holidays, and how age and gender play into risk for adverse events remains unclear, she said.

A newer option, the monoclonal antibody denosumab (Prolia, Amgen), significantly reduced vertebral fractures compared with a placebo in published studies. Administered as a subcutaneous injection every 6 months, denosumab also may be more convenient than agents requiring infusion, Dr. Messinger-Rapport said.

Higher cost is a consideration, however. Wholesale cost of denosumab is approximately $850/60-mg subcutaneous injection. In contrast, generic alendronate costs $100-$200/year; brand-name oral bisphosphonate costs up to $1,000/year; and zoledronic acid, delivered via intravenous infusion, is approximately $1,100/year, she said.

Denosumab's impact on clinical care is not yet known, Dr. Messinger-Rapport said. She suggested that clinicians consider this agent in high-risk elders, women or men with osteoporosis, men with prostate cancer with androgen deprivation, patients with metastatic prostate or breast cancer, and possibly patients with renal impairment (denosumab clearance is not renal). Also consider denosumab for patients who cannot tolerate a bisphosphonate either orally or by infusion, she added.

Researchers showed a 68% decrease in vertebral fractures, a 40% decline in hip fractures, and a 20% decrease in nonvertebral fractures with denosumab versus placebo in the FREEDOM study of osteoporotic women treated for 36 months (N. Engl. J. Med. 2009;361:756-65). A similar 62% decrease in vertebral fractures with denosumab, compared with placebo, was observed in a 24-month study of men with androgen deprivation for prostate cancer (N. Engl. J. Med. 2009;361:745-55).

Researchers also have examined reports of atypical femoral fractures associated with bisphosphonate use and found an association. For example, in a study published last year, 17 of 20 atypical femoral fractures occurred in patients taking oral bisphosphonates (N. Engl. J. Med. 2010;363:1848-9).

In a letter (N. Engl. J. Med. 2010; 362:1848-9), the researchers stated that although they found the association, “overall the anti-fracture effects of bisphosphonates far outweigh their potential risks.”

More recently, other investigators found an increased risk of subtrochanteric and femoral shaft fractures in women treated for 5 years or more with oral bisphosphonates (JAMA 2011;305:783-9). The authors stated that the absolute risk of the atypical fractures is low, however.

Dr. Messinger-Rapport listed the contraindications to bisphosphonates as a prior allergic reaction, vitamin D depletion (less than 30 ng/mL), hypocalcemia, dysphagia, esophageal disorders, and severe gastroesophageal reflux disorder.

A person attending the meeting asked if it is appropriate to continue bisphosphonate therapy after a patient's T score improves. “Yes, even if the T score only improves by a few percentage points,” Dr. Messinger-Rapport replied, because there is a disproportionate benefit in terms of fracture risk reduction.

Dr. Messinger-Rapport has disclosed that she is a member of the editorial board for the National Osteoporosis Foundation.

To watch an interview with Dr. Messinger-Rapport, scan this QR code with a smartphone.

Major Finding: Most children – 89% – drank sugar-sweetened beverages, and half of the children snacked “often” or “very often” on chips, cheese puffs, and similar items.

Data Source: A survey of 136 parents or guardians of children aged 2-11 years with a body mass index at the 95th percentile or greater for age and sex. The families were all low income.

Disclosures: Dr. Cluss said she had no relevant financial disclosures.

DENVER – Drinking sugar-sweetened beverages, not eating breakfast, and eating too many low-nutrient, high-fat snacks were among the modifiable risk factors for obesity found in a cross-sectional survey of obese, low-income children.

Remind parents and guardians of the importance of eating breakfast every day, particularly if they have an older, obese child, Patricia Cluss, Ph.D., said at the meeting.

In addition, younger children were significantly less likely to eat enough vegetables, according to the survey of 136 parents or guardians of children aged 2-11 years with a body mass index at the 95th percentile or greater for age and sex.

“I'm not sure we would have predicted this: As children got older, they ate more vegetables,” Dr. Cluss said.

Most children – 89% – drank sugar-sweetened beverages. “This is probably not a surprise to this audience,” Dr. Cluss said.

Counsel all your families with obese children to eliminate or significantly reduce their consumption of sugar-sweetened beverages, Dr. Cluss said.

The total number of meals and snacks eaten per day was another modifiable factor identified in the study. A total of 28% of parents reported their obese child ate five or more meals and snacks per day.

Intake of low-nutrient, high-fat snacks was another modifiable risk factor, according to the study. Half the children snacked “often” or “very often” on chips, cheese puffs, and similar items. “It's horrifying to see how much of their daily calorie consumption – these are kids in the 99th percentile for BMI – can come from high-calorie snacks with almost no nutrition,” said Dr. Cluss, a psychiatrist at the University of Pittsburgh.

Dr. Cluss, lead researcher Linda J. Ewing, Ph.D., and their associates assessed this population because, although approximately 30% of children and adolescents are overweight or obese, minorities and low-income groups are at higher risk.

The cohort of children skewed older (half were aged 9-11 years). In addition, 39% had a BMI in the 99th or greater percentile, “so this is a very obese sample.” The majority of caregivers were women (96%) and parents (94%); most of the 6% who were guardians were close relatives. The mean age of the adults was 35 years (range, 22-71 years). A majority were black (75%), 20% were white, and 5% were other race/ethnicities. About 93% of adults had at least a high school diploma.

More than two-thirds (71%) of parents and guardians were obese themselves, “but that was not a requirement for participation,” Dr. Cluss said.

However, having an obese caregiver significantly increased the chances the child was eating five or more meals/snacks per day.

A meeting attendee asked Dr. Cluss if she recommends no snacks or healthy snacks. “On the surface, eating three meals and two snacks may not be all that bad, depending on how healthy the snack is,” she replied.

All families in the study were insured by Medicaid. The majority (79%) lived in households with annual incomes of $25,000 or less, which included 49% with household incomes of $15,000 or less. The relatively lower-income caregivers were significantly more likely to shop for food at a convenience store as compared with a supermarket, according to Dr. Cluss said.

“This could reflect their preference, but the lower-income sample may be living in areas where a convenience store is the only place they can buy food if they don't have transportation,” she explained.

The majority of surveys were completed in a pediatric primary care clinic setting, but a few were done in the child's home when transportation was an issue, she said.

Overall, 37% of adults in the study said they “almost never” ate together with the child without the television on. However, caregivers and children from households with annual incomes of $15,000 or less were more likely to eat without the television on, which Dr. Cluss called an intriguing finding that warrants further research.

Dr. Cluss said they plan to validate these initial results using food recall data. She said, “I think future food recall data will give us a better picture versus the initial survey data.”

To view a video interview with Dr. Cluss, scan this QR code with a smart phone.

'It's horrifying to see how much of their daily calorie consumption … [is] from snacks with almost no nutrition.'

Source DR. CLUSS

Major Finding: Most children – 89% – drank sugar-sweetened beverages, and half of the children snacked “often” or “very often” on chips, cheese puffs, and similar items.

Data Source: A survey of 136 parents or guardians of children aged 2-11 years with a body mass index at the 95th percentile or greater for age and sex. The families were all low income.

Disclosures: Dr. Cluss said she had no relevant financial disclosures.

DENVER – Drinking sugar-sweetened beverages, not eating breakfast, and eating too many low-nutrient, high-fat snacks were among the modifiable risk factors for obesity found in a cross-sectional survey of obese, low-income children.

Remind parents and guardians of the importance of eating breakfast every day, particularly if they have an older, obese child, Patricia Cluss, Ph.D., said at the meeting.

In addition, younger children were significantly less likely to eat enough vegetables, according to the survey of 136 parents or guardians of children aged 2-11 years with a body mass index at the 95th percentile or greater for age and sex.

“I'm not sure we would have predicted this: As children got older, they ate more vegetables,” Dr. Cluss said.

Most children – 89% – drank sugar-sweetened beverages. “This is probably not a surprise to this audience,” Dr. Cluss said.

Counsel all your families with obese children to eliminate or significantly reduce their consumption of sugar-sweetened beverages, Dr. Cluss said.

The total number of meals and snacks eaten per day was another modifiable factor identified in the study. A total of 28% of parents reported their obese child ate five or more meals and snacks per day.

Intake of low-nutrient, high-fat snacks was another modifiable risk factor, according to the study. Half the children snacked “often” or “very often” on chips, cheese puffs, and similar items. “It's horrifying to see how much of their daily calorie consumption – these are kids in the 99th percentile for BMI – can come from high-calorie snacks with almost no nutrition,” said Dr. Cluss, a psychiatrist at the University of Pittsburgh.

Dr. Cluss, lead researcher Linda J. Ewing, Ph.D., and their associates assessed this population because, although approximately 30% of children and adolescents are overweight or obese, minorities and low-income groups are at higher risk.

The cohort of children skewed older (half were aged 9-11 years). In addition, 39% had a BMI in the 99th or greater percentile, “so this is a very obese sample.” The majority of caregivers were women (96%) and parents (94%); most of the 6% who were guardians were close relatives. The mean age of the adults was 35 years (range, 22-71 years). A majority were black (75%), 20% were white, and 5% were other race/ethnicities. About 93% of adults had at least a high school diploma.

More than two-thirds (71%) of parents and guardians were obese themselves, “but that was not a requirement for participation,” Dr. Cluss said.

However, having an obese caregiver significantly increased the chances the child was eating five or more meals/snacks per day.

A meeting attendee asked Dr. Cluss if she recommends no snacks or healthy snacks. “On the surface, eating three meals and two snacks may not be all that bad, depending on how healthy the snack is,” she replied.

All families in the study were insured by Medicaid. The majority (79%) lived in households with annual incomes of $25,000 or less, which included 49% with household incomes of $15,000 or less. The relatively lower-income caregivers were significantly more likely to shop for food at a convenience store as compared with a supermarket, according to Dr. Cluss said.

“This could reflect their preference, but the lower-income sample may be living in areas where a convenience store is the only place they can buy food if they don't have transportation,” she explained.

The majority of surveys were completed in a pediatric primary care clinic setting, but a few were done in the child's home when transportation was an issue, she said.

Overall, 37% of adults in the study said they “almost never” ate together with the child without the television on. However, caregivers and children from households with annual incomes of $15,000 or less were more likely to eat without the television on, which Dr. Cluss called an intriguing finding that warrants further research.

Dr. Cluss said they plan to validate these initial results using food recall data. She said, “I think future food recall data will give us a better picture versus the initial survey data.”

To view a video interview with Dr. Cluss, scan this QR code with a smart phone.

'It's horrifying to see how much of their daily calorie consumption … [is] from snacks with almost no nutrition.'

Source DR. CLUSS

Major Finding: Most children – 89% – drank sugar-sweetened beverages, and half of the children snacked “often” or “very often” on chips, cheese puffs, and similar items.

Data Source: A survey of 136 parents or guardians of children aged 2-11 years with a body mass index at the 95th percentile or greater for age and sex. The families were all low income.

Disclosures: Dr. Cluss said she had no relevant financial disclosures.

DENVER – Drinking sugar-sweetened beverages, not eating breakfast, and eating too many low-nutrient, high-fat snacks were among the modifiable risk factors for obesity found in a cross-sectional survey of obese, low-income children.

Remind parents and guardians of the importance of eating breakfast every day, particularly if they have an older, obese child, Patricia Cluss, Ph.D., said at the meeting.

In addition, younger children were significantly less likely to eat enough vegetables, according to the survey of 136 parents or guardians of children aged 2-11 years with a body mass index at the 95th percentile or greater for age and sex.

“I'm not sure we would have predicted this: As children got older, they ate more vegetables,” Dr. Cluss said.

Most children – 89% – drank sugar-sweetened beverages. “This is probably not a surprise to this audience,” Dr. Cluss said.

Counsel all your families with obese children to eliminate or significantly reduce their consumption of sugar-sweetened beverages, Dr. Cluss said.

The total number of meals and snacks eaten per day was another modifiable factor identified in the study. A total of 28% of parents reported their obese child ate five or more meals and snacks per day.

Intake of low-nutrient, high-fat snacks was another modifiable risk factor, according to the study. Half the children snacked “often” or “very often” on chips, cheese puffs, and similar items. “It's horrifying to see how much of their daily calorie consumption – these are kids in the 99th percentile for BMI – can come from high-calorie snacks with almost no nutrition,” said Dr. Cluss, a psychiatrist at the University of Pittsburgh.

Dr. Cluss, lead researcher Linda J. Ewing, Ph.D., and their associates assessed this population because, although approximately 30% of children and adolescents are overweight or obese, minorities and low-income groups are at higher risk.

The cohort of children skewed older (half were aged 9-11 years). In addition, 39% had a BMI in the 99th or greater percentile, “so this is a very obese sample.” The majority of caregivers were women (96%) and parents (94%); most of the 6% who were guardians were close relatives. The mean age of the adults was 35 years (range, 22-71 years). A majority were black (75%), 20% were white, and 5% were other race/ethnicities. About 93% of adults had at least a high school diploma.

More than two-thirds (71%) of parents and guardians were obese themselves, “but that was not a requirement for participation,” Dr. Cluss said.

However, having an obese caregiver significantly increased the chances the child was eating five or more meals/snacks per day.

A meeting attendee asked Dr. Cluss if she recommends no snacks or healthy snacks. “On the surface, eating three meals and two snacks may not be all that bad, depending on how healthy the snack is,” she replied.

All families in the study were insured by Medicaid. The majority (79%) lived in households with annual incomes of $25,000 or less, which included 49% with household incomes of $15,000 or less. The relatively lower-income caregivers were significantly more likely to shop for food at a convenience store as compared with a supermarket, according to Dr. Cluss said.

“This could reflect their preference, but the lower-income sample may be living in areas where a convenience store is the only place they can buy food if they don't have transportation,” she explained.

The majority of surveys were completed in a pediatric primary care clinic setting, but a few were done in the child's home when transportation was an issue, she said.

Overall, 37% of adults in the study said they “almost never” ate together with the child without the television on. However, caregivers and children from households with annual incomes of $15,000 or less were more likely to eat without the television on, which Dr. Cluss called an intriguing finding that warrants further research.

Dr. Cluss said they plan to validate these initial results using food recall data. She said, “I think future food recall data will give us a better picture versus the initial survey data.”

To view a video interview with Dr. Cluss, scan this QR code with a smart phone.

'It's horrifying to see how much of their daily calorie consumption … [is] from snacks with almost no nutrition.'

Source DR. CLUSS

DENVER – Bariatric surgery resulted in significant weight loss at 1 year in a study of 890 morbidly obese adolescents who had the procedure at a designated center of excellence.

“This is one of the first reports of a national scope … revealing the prevalence estimates of weight loss among adolescent patients,” Dr. Nestor de la Cruz-Munoz said at the meeting. “Bariatric surgery has the potential to be a safe and effective treatment option for significant weight loss in U.S. adolescents, irrespective of gender.”

Fewer than 1% of bariatric surgery cases in the country are being done on adolescents, and “very little is know about the short-term and long-term outcomes in terms of weight and associated health consequences in these patients,” said Dr. de la Cruz-Munoz, a bariatric surgeon at the University of Miami.

To find out more, he and his coworkers evaluated all patients aged 11-19 years old who had bariatric surgery from June 2007 through October 2010 in the prospective BOLD (Bariatric Outcomes Longitudinal Database) registry.

Weight decreased from a mean 138 kg at baseline to 110 kg at 1 year in these 890 patients. Baseline mean z score changed from 2.86 to 2.31, and the weight percentile of these adolescents (compared with the general population) decreased from 99.6% to 97.1%. In addition, the body mass index z score decreased from 2.6 to 2.11 during this time. Assessments were also done at 6 months post surgery in all patients. “All of those [changes] were statistically significant,” Dr. de la Cruz-Munoz said.

“Bariatric surgery results in significant weight loss among morbidly obese multiethnic adolescents at 1 year post surgery, for both boys and girls,” he said.

Broken down by sex, the mean baseline weight was 162 kg for boys and 129 for girls. The mean z score decreased from 3.52 to 2.77 for boys and from 2.64 to 2.12 for girls. “The weight percentages for boys started at about as high as you can get (99.95%) and ended up at 98.7%,” Dr. de la Cruz-Munoz said.

At the same time, weight percentages for girls decreased from 99.46% to 95.97%. The BMI z score decreased from a baseline 3.15 in boys to 2.57 at 1 year. For girls, this measure decreased from 2.42 to 1.92. Again, all these changes were statistically significant.

“The most rapid weight loss was in the first 6 months,” he said.

One patient died from cardiac failure 5 months after surgery, resulting in a mortality rate of 0.11% in the cohort. In all, 141 postoperative adverse events were reported. Nausea and vomiting were the most common (13%), followed by vitamin D deficiency (8%).

Gastric bypass was the most common type of bariatric surgery in these adolescents, performed in 454 patients (51%). Gastric banding was a close second and was performed in 436 patients (49%). No gastric sleeve procedures were done in this age group during this time.

Consistent with adult data, about 80% were females; mean age was 18 years, and 69% were white, 15% Hispanic, 11% black, and 5% other.

There are now more than 375,000 patients in the BOLD registry, so adolescents represent only 0.7%. The independent, nonprofit Surgical Review Corporation (SRC) administers the American Society for Metabolic and Bariatric Surgery Center of Excellence (BSCOE) program. The SRC developed BOLD in 2007 to help ensure compliance with the BSCOE program. There are 440 facilities currently designated as centers of excellence, with 758 surgeons; approximately 100 additional facilities have provisional status, Dr. de la Cruz-Munoz said.

Dr. de la Cruz-Munoz is a member of the SRC's surgical review committee and a consultant for Ethicon Endo-Surgery Inc.

To watch an interview with Dr. de la Cruz-Munoz, scan this QR code with a smartphone.

DENVER – Bariatric surgery resulted in significant weight loss at 1 year in a study of 890 morbidly obese adolescents who had the procedure at a designated center of excellence.

“This is one of the first reports of a national scope … revealing the prevalence estimates of weight loss among adolescent patients,” Dr. Nestor de la Cruz-Munoz said at the meeting. “Bariatric surgery has the potential to be a safe and effective treatment option for significant weight loss in U.S. adolescents, irrespective of gender.”

Fewer than 1% of bariatric surgery cases in the country are being done on adolescents, and “very little is know about the short-term and long-term outcomes in terms of weight and associated health consequences in these patients,” said Dr. de la Cruz-Munoz, a bariatric surgeon at the University of Miami.

To find out more, he and his coworkers evaluated all patients aged 11-19 years old who had bariatric surgery from June 2007 through October 2010 in the prospective BOLD (Bariatric Outcomes Longitudinal Database) registry.

Weight decreased from a mean 138 kg at baseline to 110 kg at 1 year in these 890 patients. Baseline mean z score changed from 2.86 to 2.31, and the weight percentile of these adolescents (compared with the general population) decreased from 99.6% to 97.1%. In addition, the body mass index z score decreased from 2.6 to 2.11 during this time. Assessments were also done at 6 months post surgery in all patients. “All of those [changes] were statistically significant,” Dr. de la Cruz-Munoz said.

“Bariatric surgery results in significant weight loss among morbidly obese multiethnic adolescents at 1 year post surgery, for both boys and girls,” he said.

Broken down by sex, the mean baseline weight was 162 kg for boys and 129 for girls. The mean z score decreased from 3.52 to 2.77 for boys and from 2.64 to 2.12 for girls. “The weight percentages for boys started at about as high as you can get (99.95%) and ended up at 98.7%,” Dr. de la Cruz-Munoz said.

At the same time, weight percentages for girls decreased from 99.46% to 95.97%. The BMI z score decreased from a baseline 3.15 in boys to 2.57 at 1 year. For girls, this measure decreased from 2.42 to 1.92. Again, all these changes were statistically significant.

“The most rapid weight loss was in the first 6 months,” he said.

One patient died from cardiac failure 5 months after surgery, resulting in a mortality rate of 0.11% in the cohort. In all, 141 postoperative adverse events were reported. Nausea and vomiting were the most common (13%), followed by vitamin D deficiency (8%).

Gastric bypass was the most common type of bariatric surgery in these adolescents, performed in 454 patients (51%). Gastric banding was a close second and was performed in 436 patients (49%). No gastric sleeve procedures were done in this age group during this time.

Consistent with adult data, about 80% were females; mean age was 18 years, and 69% were white, 15% Hispanic, 11% black, and 5% other.

There are now more than 375,000 patients in the BOLD registry, so adolescents represent only 0.7%. The independent, nonprofit Surgical Review Corporation (SRC) administers the American Society for Metabolic and Bariatric Surgery Center of Excellence (BSCOE) program. The SRC developed BOLD in 2007 to help ensure compliance with the BSCOE program. There are 440 facilities currently designated as centers of excellence, with 758 surgeons; approximately 100 additional facilities have provisional status, Dr. de la Cruz-Munoz said.

Dr. de la Cruz-Munoz is a member of the SRC's surgical review committee and a consultant for Ethicon Endo-Surgery Inc.

To watch an interview with Dr. de la Cruz-Munoz, scan this QR code with a smartphone.

DENVER – Bariatric surgery resulted in significant weight loss at 1 year in a study of 890 morbidly obese adolescents who had the procedure at a designated center of excellence.

“This is one of the first reports of a national scope … revealing the prevalence estimates of weight loss among adolescent patients,” Dr. Nestor de la Cruz-Munoz said at the meeting. “Bariatric surgery has the potential to be a safe and effective treatment option for significant weight loss in U.S. adolescents, irrespective of gender.”

Fewer than 1% of bariatric surgery cases in the country are being done on adolescents, and “very little is know about the short-term and long-term outcomes in terms of weight and associated health consequences in these patients,” said Dr. de la Cruz-Munoz, a bariatric surgeon at the University of Miami.

To find out more, he and his coworkers evaluated all patients aged 11-19 years old who had bariatric surgery from June 2007 through October 2010 in the prospective BOLD (Bariatric Outcomes Longitudinal Database) registry.

Weight decreased from a mean 138 kg at baseline to 110 kg at 1 year in these 890 patients. Baseline mean z score changed from 2.86 to 2.31, and the weight percentile of these adolescents (compared with the general population) decreased from 99.6% to 97.1%. In addition, the body mass index z score decreased from 2.6 to 2.11 during this time. Assessments were also done at 6 months post surgery in all patients. “All of those [changes] were statistically significant,” Dr. de la Cruz-Munoz said.

“Bariatric surgery results in significant weight loss among morbidly obese multiethnic adolescents at 1 year post surgery, for both boys and girls,” he said.

Broken down by sex, the mean baseline weight was 162 kg for boys and 129 for girls. The mean z score decreased from 3.52 to 2.77 for boys and from 2.64 to 2.12 for girls. “The weight percentages for boys started at about as high as you can get (99.95%) and ended up at 98.7%,” Dr. de la Cruz-Munoz said.

At the same time, weight percentages for girls decreased from 99.46% to 95.97%. The BMI z score decreased from a baseline 3.15 in boys to 2.57 at 1 year. For girls, this measure decreased from 2.42 to 1.92. Again, all these changes were statistically significant.

“The most rapid weight loss was in the first 6 months,” he said.

One patient died from cardiac failure 5 months after surgery, resulting in a mortality rate of 0.11% in the cohort. In all, 141 postoperative adverse events were reported. Nausea and vomiting were the most common (13%), followed by vitamin D deficiency (8%).

Gastric bypass was the most common type of bariatric surgery in these adolescents, performed in 454 patients (51%). Gastric banding was a close second and was performed in 436 patients (49%). No gastric sleeve procedures were done in this age group during this time.

Consistent with adult data, about 80% were females; mean age was 18 years, and 69% were white, 15% Hispanic, 11% black, and 5% other.

There are now more than 375,000 patients in the BOLD registry, so adolescents represent only 0.7%. The independent, nonprofit Surgical Review Corporation (SRC) administers the American Society for Metabolic and Bariatric Surgery Center of Excellence (BSCOE) program. The SRC developed BOLD in 2007 to help ensure compliance with the BSCOE program. There are 440 facilities currently designated as centers of excellence, with 758 surgeons; approximately 100 additional facilities have provisional status, Dr. de la Cruz-Munoz said.

Dr. de la Cruz-Munoz is a member of the SRC's surgical review committee and a consultant for Ethicon Endo-Surgery Inc.

To watch an interview with Dr. de la Cruz-Munoz, scan this QR code with a smartphone.

HONOLULU – Diabetes can be a challenge to control, depression can be difficult to treat and keep in remission, and growing evidence suggests the combination can be especially problematic for patients. And as if this adverse synergy were not bad enough, having these two conditions more than doubles the likelihood that a patient will develop dementia, Dr. Wayne J. Katon said.

Screening all patients with type 2 diabetes for depression, therefore, could have a big impact, he said at the meeting. The American Diabetes Association has endorsed such screening since 2005.

Given the bidirectional relationship between these conditions, physicians treating patients with depression also should assess, counsel, and monitor them for the development of diabetes. “Some of our psychiatric education will be pushing residents to keep up their medical skills to do monitoring. If we only train psychiatrists to do blood pressure monitoring alone, it would make a big difference,” said Dr. Katon, professor of psychiatry and behavioral sciences at the University of Washington in Seattle.

This dual comorbidity puts patients at increased risk for earlier mortality.

Major depression predicts an increased likelihood of cigarette smoking during adolescence (and more difficulty quitting), a sedentary lifestyle, and obesity. Patients with major depression also can feature decreased insulin sensitivity, increased inflammatory markers, and high cortisol levels, which all become risk factors for diabetes and heart disease.

“You can see why you would be at higher risk of earlier mortality,” Dr. Katon said.

Diabetes and depression are independent risk factors for dementia, based on the findings in a prospective study of 3,837 primary care patients (J. Gen. Intern. Med. 2010;25:423-9). “It looks like these are particularly bad conditions to have together in terms of risk of dementia,” he said.

Dr. Katon and his colleagues found that 7.9% of patients with diabetes and major depression developed dementia over a 5-year period (based on ICD-9 codes) compared with 4.8% of those with diabetes alone (fully adjusted hazard ratio, 2.69). “This was not explained by depression being a prodrome for dementia,” he said.

A more than twofold increased risk for dementia is “especially frightening,” Dr. Katon added. “It speaks to the importance of more aggressively screening diabetics for depression and more effectively treating them.”

Beyond having an increased risk of mortality and dementia, people with diabetes and depression also have lower levels of self-care, do not exercise as much, and are not as adherent to medications, compared with nondepressed diabetics (Diabetes Care 2004;27:2154-60).

In this study, those with diabetes and major depression had significantly more nonadherent medication days over time, compared with nondepressed diabetics. “This does not portend well for increased risk of morbidity and mortality,” Dr. Katon said.

Session moderator Dr. Herbert Pardes commented, “This is a big deal. The comorbidity of depression with a major medical condition … people have got to pay attention to the medical health as part of the comorbidities.” Dr. Pardes is president and CEO of the New York Presbyterian Hospital in New York City.

The baseline severity of diabetes (higher number of symptoms) was a strong predictor of a patient having major depression in a 5-year follow-up study (Psychosomatics 2009;50:570-9).

Dr. Katon and his coauthors also found having one or more coronary procedures during the 5 years predicted major depression in this prospective study of 2,759 primary care patients with diabetes.

The study also revealed a higher likelihood for all-cause mortality associated with depression (hazard ratio, 1.53, vs. 1.23 for those without depression). “Diabetics with major depression were about 50% more likely to die than nondepressed diabetics over 5 years,” Dr. Katon said.

After confounders, including cigarette smoking and a sedentary lifestyle were controlled for, major depression was associated with more microvascular complications (HR, 1.33 vs. 1.05); more macrovascular complications (1.38 vs. 1.32), and a higher prevalence of foot ulcers (1.99 vs. 1.22).

Diabetes, depression, and coronary artery disease appear to be one of the “natural clusters of illnesses that doctors see,” Dr. Katon said. These illnesses each have a high prevalence, high comorbidity, and bidirectional adverse interactions.

Depression, chronic pain, and substance abuse comprise another natural cluster, he added “but that is a whole other lecture for another day.”

Dr. Katon said he has received honoraria from Forest Laboratories, Lilly, Pfizer, and Wyeth.

HONOLULU – Diabetes can be a challenge to control, depression can be difficult to treat and keep in remission, and growing evidence suggests the combination can be especially problematic for patients. And as if this adverse synergy were not bad enough, having these two conditions more than doubles the likelihood that a patient will develop dementia, Dr. Wayne J. Katon said.

Screening all patients with type 2 diabetes for depression, therefore, could have a big impact, he said at the meeting. The American Diabetes Association has endorsed such screening since 2005.

Given the bidirectional relationship between these conditions, physicians treating patients with depression also should assess, counsel, and monitor them for the development of diabetes. “Some of our psychiatric education will be pushing residents to keep up their medical skills to do monitoring. If we only train psychiatrists to do blood pressure monitoring alone, it would make a big difference,” said Dr. Katon, professor of psychiatry and behavioral sciences at the University of Washington in Seattle.

This dual comorbidity puts patients at increased risk for earlier mortality.

Major depression predicts an increased likelihood of cigarette smoking during adolescence (and more difficulty quitting), a sedentary lifestyle, and obesity. Patients with major depression also can feature decreased insulin sensitivity, increased inflammatory markers, and high cortisol levels, which all become risk factors for diabetes and heart disease.

“You can see why you would be at higher risk of earlier mortality,” Dr. Katon said.

Diabetes and depression are independent risk factors for dementia, based on the findings in a prospective study of 3,837 primary care patients (J. Gen. Intern. Med. 2010;25:423-9). “It looks like these are particularly bad conditions to have together in terms of risk of dementia,” he said.

Dr. Katon and his colleagues found that 7.9% of patients with diabetes and major depression developed dementia over a 5-year period (based on ICD-9 codes) compared with 4.8% of those with diabetes alone (fully adjusted hazard ratio, 2.69). “This was not explained by depression being a prodrome for dementia,” he said.

A more than twofold increased risk for dementia is “especially frightening,” Dr. Katon added. “It speaks to the importance of more aggressively screening diabetics for depression and more effectively treating them.”

Beyond having an increased risk of mortality and dementia, people with diabetes and depression also have lower levels of self-care, do not exercise as much, and are not as adherent to medications, compared with nondepressed diabetics (Diabetes Care 2004;27:2154-60).

In this study, those with diabetes and major depression had significantly more nonadherent medication days over time, compared with nondepressed diabetics. “This does not portend well for increased risk of morbidity and mortality,” Dr. Katon said.

Session moderator Dr. Herbert Pardes commented, “This is a big deal. The comorbidity of depression with a major medical condition … people have got to pay attention to the medical health as part of the comorbidities.” Dr. Pardes is president and CEO of the New York Presbyterian Hospital in New York City.

The baseline severity of diabetes (higher number of symptoms) was a strong predictor of a patient having major depression in a 5-year follow-up study (Psychosomatics 2009;50:570-9).

Dr. Katon and his coauthors also found having one or more coronary procedures during the 5 years predicted major depression in this prospective study of 2,759 primary care patients with diabetes.

The study also revealed a higher likelihood for all-cause mortality associated with depression (hazard ratio, 1.53, vs. 1.23 for those without depression). “Diabetics with major depression were about 50% more likely to die than nondepressed diabetics over 5 years,” Dr. Katon said.

After confounders, including cigarette smoking and a sedentary lifestyle were controlled for, major depression was associated with more microvascular complications (HR, 1.33 vs. 1.05); more macrovascular complications (1.38 vs. 1.32), and a higher prevalence of foot ulcers (1.99 vs. 1.22).

Diabetes, depression, and coronary artery disease appear to be one of the “natural clusters of illnesses that doctors see,” Dr. Katon said. These illnesses each have a high prevalence, high comorbidity, and bidirectional adverse interactions.

Depression, chronic pain, and substance abuse comprise another natural cluster, he added “but that is a whole other lecture for another day.”

Dr. Katon said he has received honoraria from Forest Laboratories, Lilly, Pfizer, and Wyeth.

HONOLULU – Diabetes can be a challenge to control, depression can be difficult to treat and keep in remission, and growing evidence suggests the combination can be especially problematic for patients. And as if this adverse synergy were not bad enough, having these two conditions more than doubles the likelihood that a patient will develop dementia, Dr. Wayne J. Katon said.

Screening all patients with type 2 diabetes for depression, therefore, could have a big impact, he said at the meeting. The American Diabetes Association has endorsed such screening since 2005.

Given the bidirectional relationship between these conditions, physicians treating patients with depression also should assess, counsel, and monitor them for the development of diabetes. “Some of our psychiatric education will be pushing residents to keep up their medical skills to do monitoring. If we only train psychiatrists to do blood pressure monitoring alone, it would make a big difference,” said Dr. Katon, professor of psychiatry and behavioral sciences at the University of Washington in Seattle.

This dual comorbidity puts patients at increased risk for earlier mortality.

Major depression predicts an increased likelihood of cigarette smoking during adolescence (and more difficulty quitting), a sedentary lifestyle, and obesity. Patients with major depression also can feature decreased insulin sensitivity, increased inflammatory markers, and high cortisol levels, which all become risk factors for diabetes and heart disease.

“You can see why you would be at higher risk of earlier mortality,” Dr. Katon said.

Diabetes and depression are independent risk factors for dementia, based on the findings in a prospective study of 3,837 primary care patients (J. Gen. Intern. Med. 2010;25:423-9). “It looks like these are particularly bad conditions to have together in terms of risk of dementia,” he said.

Dr. Katon and his colleagues found that 7.9% of patients with diabetes and major depression developed dementia over a 5-year period (based on ICD-9 codes) compared with 4.8% of those with diabetes alone (fully adjusted hazard ratio, 2.69). “This was not explained by depression being a prodrome for dementia,” he said.

A more than twofold increased risk for dementia is “especially frightening,” Dr. Katon added. “It speaks to the importance of more aggressively screening diabetics for depression and more effectively treating them.”

Beyond having an increased risk of mortality and dementia, people with diabetes and depression also have lower levels of self-care, do not exercise as much, and are not as adherent to medications, compared with nondepressed diabetics (Diabetes Care 2004;27:2154-60).

In this study, those with diabetes and major depression had significantly more nonadherent medication days over time, compared with nondepressed diabetics. “This does not portend well for increased risk of morbidity and mortality,” Dr. Katon said.

Session moderator Dr. Herbert Pardes commented, “This is a big deal. The comorbidity of depression with a major medical condition … people have got to pay attention to the medical health as part of the comorbidities.” Dr. Pardes is president and CEO of the New York Presbyterian Hospital in New York City.

The baseline severity of diabetes (higher number of symptoms) was a strong predictor of a patient having major depression in a 5-year follow-up study (Psychosomatics 2009;50:570-9).

Dr. Katon and his coauthors also found having one or more coronary procedures during the 5 years predicted major depression in this prospective study of 2,759 primary care patients with diabetes.

The study also revealed a higher likelihood for all-cause mortality associated with depression (hazard ratio, 1.53, vs. 1.23 for those without depression). “Diabetics with major depression were about 50% more likely to die than nondepressed diabetics over 5 years,” Dr. Katon said.

After confounders, including cigarette smoking and a sedentary lifestyle were controlled for, major depression was associated with more microvascular complications (HR, 1.33 vs. 1.05); more macrovascular complications (1.38 vs. 1.32), and a higher prevalence of foot ulcers (1.99 vs. 1.22).

Diabetes, depression, and coronary artery disease appear to be one of the “natural clusters of illnesses that doctors see,” Dr. Katon said. These illnesses each have a high prevalence, high comorbidity, and bidirectional adverse interactions.

Depression, chronic pain, and substance abuse comprise another natural cluster, he added “but that is a whole other lecture for another day.”

Dr. Katon said he has received honoraria from Forest Laboratories, Lilly, Pfizer, and Wyeth.

TAMPA – The treatment of osteoporosis is in flux because of a variety of forces, including a substantial increase in the number of aging patients deemed eligible for treatments, a leading geriatrician said. Just as baby boomers begin reaching senior status, a recently developed tool for assessing people's fracture risk is increasing the number of patients considered suitable for preventive therapy.

Meanwhile, those therapy options are multiplying, and emerging evidence suggests that one, bisphosphonates, is associated with an increased risk for atypical fractures, although the absolute risk appears to be low, Dr. Barbara Messinger-Rapport, said at the meeting.

The assessment tool making a difference is the Web-based Fracture Risk Assessment Tool (FRAX), released by the World Health Organization in 2008. FRAX guides clinicians to consider drug therapy for patients with T scores (deviations from healthy bone density) of –2.5 or lower at the femoral neck or spine, a T score between –1.0 and –2.5 as well as a 3% or higher calculated risk for hip fracture over 10 years, or a 20% or greater risk of major osteoporosis-related fracture.

Even if a person's T score never reaches –2.5, his or her hip fracture risk can climb to 3% or higher, said Dr. Messinger-Rapport, director of the Center for Geriatric Medicine at the Cleveland Clinic and medical director of the Fairfax Health Care Center Nursing Home, also in Cleveland. “This could widen the number of people who could be put on treatment.”

Bisphosphonates remain the most-common treatment strategy, but optimal duration of therapy, timing of drug holidays, and how age and gender play into risk for adverse events remains unclear, she said.

A newer option, the monoclonal antibody denosumab (Prolia, Amgen), significantly reduced vertebral fractures compared with a placebo in published studies. Administered as a subcutaneous injection every 6 months, denosumab also may be more convenient than agents requiring infusion, Dr. Messinger-Rapport said.

Higher cost is a consideration, however. Wholesale cost of denosumab is approximately $850 per 60-mg subcutaneous injection. In contrast, generic alendronate costs $100–$200/year; brand-name oral bisphosphonate costs up to $1,000 a year; and zoledronic acid, delivered via intravenous infusion, is about $1,100 a year, she said.

Denosumab's impact on clinical care is not yet known, Dr. Messinger-Rapport said. She suggested that clinicians consider this agent in high-risk elders, women or men with osteoporosis, men with prostate cancer with androgen deprivation, patients with metastatic prostate or breast cancer, and possibly patients with renal impairment (denosumab clearance is not renal). Also consider denosumab for patients who cannot tolerate a bisphosphonate either orally or by infusion, she added.

Researchers showed a 68% decrease in vertebral fractures, a 40% decline in hip fractures, and a 20% decrease in nonvertebral fractures with denosumab versus placebo in the FREEDOM study of osteoporotic women treated for 36 months (N. Engl. J. Med. 2009;361:756–65). A similar 62% decrease in vertebral fractures with denosumab, compared with placebo, was observed in a 24-month study of men with androgen deprivation for prostate cancer (N. Engl. J. Med. 2009;361:745–55).

Researchers also have examined reports of atypical femoral fractures associated with bisphosphonate use and found an association. For example, in a study published last year, 17 of 20 atypical femoral fractures occurred in patients taking oral bisphosphonates (N. Engl. J. Med. 2010;363:1848–9). In a New England Journal letter (N. Engl. J. Med. 2010;362:1848–9), the researchers stated that although they found the association, “overall the anti-fracture effects of bisphosphonates far outweigh their potential risks.”

More recently, other investigators found an increased risk of subtrochanteric and femoral shaft fractures in women treated for 5 years or more with oral bisphosphonates (JAMA 2011;305:783-9). The authors stated that the absolute risk of the atypical fractures is low, however.

Dr. Messinger-Rapport listed contraindications to bisphosphonates as a prior allergic reaction, vitamin D depletion (less than 30 ng/mL), hypocalcemia, dysphagia, esophageal disorders, and severe gastroesophageal reflux disorder.

A person attending the meeting asked if it is appropriate to continue bisphosphonate therapy after a patient's T score improves. “Yes, even if the T score only improves by a few percentage points,” Dr. Messinger-Rapport replied, because there is a disproportionate benefit in terms of fracture risk reduction.

Dr. Messinger-Rapport is a member of the National Osteoporosis Foundation's editorial board.

To watch an interview with Dr. Messinger-Rapport, scan this QR code with a smartphone.

TAMPA – The treatment of osteoporosis is in flux because of a variety of forces, including a substantial increase in the number of aging patients deemed eligible for treatments, a leading geriatrician said. Just as baby boomers begin reaching senior status, a recently developed tool for assessing people's fracture risk is increasing the number of patients considered suitable for preventive therapy.

Meanwhile, those therapy options are multiplying, and emerging evidence suggests that one, bisphosphonates, is associated with an increased risk for atypical fractures, although the absolute risk appears to be low, Dr. Barbara Messinger-Rapport, said at the meeting.

The assessment tool making a difference is the Web-based Fracture Risk Assessment Tool (FRAX), released by the World Health Organization in 2008. FRAX guides clinicians to consider drug therapy for patients with T scores (deviations from healthy bone density) of –2.5 or lower at the femoral neck or spine, a T score between –1.0 and –2.5 as well as a 3% or higher calculated risk for hip fracture over 10 years, or a 20% or greater risk of major osteoporosis-related fracture.

Even if a person's T score never reaches –2.5, his or her hip fracture risk can climb to 3% or higher, said Dr. Messinger-Rapport, director of the Center for Geriatric Medicine at the Cleveland Clinic and medical director of the Fairfax Health Care Center Nursing Home, also in Cleveland. “This could widen the number of people who could be put on treatment.”

Bisphosphonates remain the most-common treatment strategy, but optimal duration of therapy, timing of drug holidays, and how age and gender play into risk for adverse events remains unclear, she said.

A newer option, the monoclonal antibody denosumab (Prolia, Amgen), significantly reduced vertebral fractures compared with a placebo in published studies. Administered as a subcutaneous injection every 6 months, denosumab also may be more convenient than agents requiring infusion, Dr. Messinger-Rapport said.

Higher cost is a consideration, however. Wholesale cost of denosumab is approximately $850 per 60-mg subcutaneous injection. In contrast, generic alendronate costs $100–$200/year; brand-name oral bisphosphonate costs up to $1,000 a year; and zoledronic acid, delivered via intravenous infusion, is about $1,100 a year, she said.

Denosumab's impact on clinical care is not yet known, Dr. Messinger-Rapport said. She suggested that clinicians consider this agent in high-risk elders, women or men with osteoporosis, men with prostate cancer with androgen deprivation, patients with metastatic prostate or breast cancer, and possibly patients with renal impairment (denosumab clearance is not renal). Also consider denosumab for patients who cannot tolerate a bisphosphonate either orally or by infusion, she added.

Researchers showed a 68% decrease in vertebral fractures, a 40% decline in hip fractures, and a 20% decrease in nonvertebral fractures with denosumab versus placebo in the FREEDOM study of osteoporotic women treated for 36 months (N. Engl. J. Med. 2009;361:756–65). A similar 62% decrease in vertebral fractures with denosumab, compared with placebo, was observed in a 24-month study of men with androgen deprivation for prostate cancer (N. Engl. J. Med. 2009;361:745–55).

Researchers also have examined reports of atypical femoral fractures associated with bisphosphonate use and found an association. For example, in a study published last year, 17 of 20 atypical femoral fractures occurred in patients taking oral bisphosphonates (N. Engl. J. Med. 2010;363:1848–9). In a New England Journal letter (N. Engl. J. Med. 2010;362:1848–9), the researchers stated that although they found the association, “overall the anti-fracture effects of bisphosphonates far outweigh their potential risks.”

More recently, other investigators found an increased risk of subtrochanteric and femoral shaft fractures in women treated for 5 years or more with oral bisphosphonates (JAMA 2011;305:783-9). The authors stated that the absolute risk of the atypical fractures is low, however.

Dr. Messinger-Rapport listed contraindications to bisphosphonates as a prior allergic reaction, vitamin D depletion (less than 30 ng/mL), hypocalcemia, dysphagia, esophageal disorders, and severe gastroesophageal reflux disorder.

A person attending the meeting asked if it is appropriate to continue bisphosphonate therapy after a patient's T score improves. “Yes, even if the T score only improves by a few percentage points,” Dr. Messinger-Rapport replied, because there is a disproportionate benefit in terms of fracture risk reduction.

Dr. Messinger-Rapport is a member of the National Osteoporosis Foundation's editorial board.

To watch an interview with Dr. Messinger-Rapport, scan this QR code with a smartphone.

TAMPA – The treatment of osteoporosis is in flux because of a variety of forces, including a substantial increase in the number of aging patients deemed eligible for treatments, a leading geriatrician said. Just as baby boomers begin reaching senior status, a recently developed tool for assessing people's fracture risk is increasing the number of patients considered suitable for preventive therapy.

Meanwhile, those therapy options are multiplying, and emerging evidence suggests that one, bisphosphonates, is associated with an increased risk for atypical fractures, although the absolute risk appears to be low, Dr. Barbara Messinger-Rapport, said at the meeting.

The assessment tool making a difference is the Web-based Fracture Risk Assessment Tool (FRAX), released by the World Health Organization in 2008. FRAX guides clinicians to consider drug therapy for patients with T scores (deviations from healthy bone density) of –2.5 or lower at the femoral neck or spine, a T score between –1.0 and –2.5 as well as a 3% or higher calculated risk for hip fracture over 10 years, or a 20% or greater risk of major osteoporosis-related fracture.

Even if a person's T score never reaches –2.5, his or her hip fracture risk can climb to 3% or higher, said Dr. Messinger-Rapport, director of the Center for Geriatric Medicine at the Cleveland Clinic and medical director of the Fairfax Health Care Center Nursing Home, also in Cleveland. “This could widen the number of people who could be put on treatment.”

Bisphosphonates remain the most-common treatment strategy, but optimal duration of therapy, timing of drug holidays, and how age and gender play into risk for adverse events remains unclear, she said.

A newer option, the monoclonal antibody denosumab (Prolia, Amgen), significantly reduced vertebral fractures compared with a placebo in published studies. Administered as a subcutaneous injection every 6 months, denosumab also may be more convenient than agents requiring infusion, Dr. Messinger-Rapport said.

Higher cost is a consideration, however. Wholesale cost of denosumab is approximately $850 per 60-mg subcutaneous injection. In contrast, generic alendronate costs $100–$200/year; brand-name oral bisphosphonate costs up to $1,000 a year; and zoledronic acid, delivered via intravenous infusion, is about $1,100 a year, she said.

Denosumab's impact on clinical care is not yet known, Dr. Messinger-Rapport said. She suggested that clinicians consider this agent in high-risk elders, women or men with osteoporosis, men with prostate cancer with androgen deprivation, patients with metastatic prostate or breast cancer, and possibly patients with renal impairment (denosumab clearance is not renal). Also consider denosumab for patients who cannot tolerate a bisphosphonate either orally or by infusion, she added.

Researchers showed a 68% decrease in vertebral fractures, a 40% decline in hip fractures, and a 20% decrease in nonvertebral fractures with denosumab versus placebo in the FREEDOM study of osteoporotic women treated for 36 months (N. Engl. J. Med. 2009;361:756–65). A similar 62% decrease in vertebral fractures with denosumab, compared with placebo, was observed in a 24-month study of men with androgen deprivation for prostate cancer (N. Engl. J. Med. 2009;361:745–55).

Researchers also have examined reports of atypical femoral fractures associated with bisphosphonate use and found an association. For example, in a study published last year, 17 of 20 atypical femoral fractures occurred in patients taking oral bisphosphonates (N. Engl. J. Med. 2010;363:1848–9). In a New England Journal letter (N. Engl. J. Med. 2010;362:1848–9), the researchers stated that although they found the association, “overall the anti-fracture effects of bisphosphonates far outweigh their potential risks.”

More recently, other investigators found an increased risk of subtrochanteric and femoral shaft fractures in women treated for 5 years or more with oral bisphosphonates (JAMA 2011;305:783-9). The authors stated that the absolute risk of the atypical fractures is low, however.

Dr. Messinger-Rapport listed contraindications to bisphosphonates as a prior allergic reaction, vitamin D depletion (less than 30 ng/mL), hypocalcemia, dysphagia, esophageal disorders, and severe gastroesophageal reflux disorder.

A person attending the meeting asked if it is appropriate to continue bisphosphonate therapy after a patient's T score improves. “Yes, even if the T score only improves by a few percentage points,” Dr. Messinger-Rapport replied, because there is a disproportionate benefit in terms of fracture risk reduction.

Dr. Messinger-Rapport is a member of the National Osteoporosis Foundation's editorial board.

To watch an interview with Dr. Messinger-Rapport, scan this QR code with a smartphone.

Major Finding: In July 2009, only 50% of charts at one site had percent BMI calculated. This figure grew to 85% by June 2010.

Data Source: A 1-year pilot study of pediatric and family physician residents at five residency programs testing their knowledge about pediatric obesity.

Disclosures: The Anthem Blue Cross and Blue Shield Foundation funds the Fit for Residents project. Dr. Slusser said she owns stock in Amgen, Bristol-Myers Squibb, Merck, and Novo Nordisk.

DENVER – Pediatric and family physician residents' knowledge about pediatric obesity significantly improved at five residency programs that adopted a new curriculum, a 1-year pilot study has shown.

Resident attitudes about prevention, management, referral, and advocacy improved as well, although the changes were not statistically significant.

The training made a difference clinically. Greater attention to interpretation of body mass index (BMI) measurements, nutrition, and physical activity was noted through periodic chart reviews for participants in the “Fit for Residents” training, Dr. Wendy Slusser said at the meeting.

In July 2009, for example, only 50% of charts at one site had percent BMI calculated. This figure grew to 85% by June 2010. “Luckily, once [residents] really started calculating BMI, they were doing it correctly as well. That was a nice thing to see,” Dr. Slusser said.

The training was a mix of online, didactic, and experiential learning. “They did some teaching to the residents … and then around midstudy, they developed a stamp that they included on their charts that triggered the resident to not only calculate and plot the BMI, but to interpret it,” Dr. Slusser said.

Initially, a panel of expert physicians developed a childhood overweight prevention and management curriculum. Their aim was to better arm future clinicians with the skills necessary to combat obesity in children and adolescents, said Dr. Slusser, a pediatrician and medical director of the UCLA Fit for Healthy Weight program. The Fit for Residents program is a collaboration among the American Academy of Pediatrics, the American Academy of Family Physicians, and the University of California, Los Angeles. The Fit for Residents training adopts a chronic care model and was designed to be similar to a successful AAP breastfeeding residency curriculum, Dr. Slusser said.

Residents completed a baseline survey about their knowledge and attitudes regarding pediatric obesity. Then the residents at the additional training sites received a 2-day, in-person orientation to the curriculum that included training in motivational interviewing and quality improvement. They also participated in group problem solving. UCLA faculty made monthly telephone calls to key residency faculty once a month on an individual basis and once quarterly as a group call.

Dr. Slusser and her colleagues gauged the efficacy of the project by comparing resident responses to surveys before and after the initiative. The investigators also reviewed 20 charts once a month at each of the 10 residency programs to determine changes in clinical practice.

Resident knowledge about pediatric obesity did change significantly at the five residency programs with the new curriculum. In contrast, no significant change was observed at the five comparison sites.

Very few practices documented that physicians asked patients about physical activity, Dr. Slusser said. However, one program with paper charts added a lifestyle log that made residents much more likely to assess physical activity, she added.

A meeting attendee asked about implementation of the curriculum at sites with paper versus electronic medical records (EMRs). Two of the sites had EMRs, Dr. Slusser replied. Improvements in resident knowledge and attitudes did not differ between sites with different record types, but programs with EMRs adopted changes faster and more efficiently than paper-based sites.

The 10 pediatric and family physician residency programs studied were in California. The five primary care residency programs that added the new curriculum were Children's Hospital and Research Center Oakland, Contra Costa Family Practice, White Memorial Pediatrics and Family Medicine, Harbor-UCLA Pediatrics, and Scripps Family Practice.

The next step is to complete data analysis and to refine the curriculum and tools based on the 1-year experience, Dr. Slusser said. “We next hope to engage residency programs at the national level.”

Resident knowledge about pediatric obesity did change significantly at the programs with the new curriculum.

Source DR. SLUSSER

Major Finding: In July 2009, only 50% of charts at one site had percent BMI calculated. This figure grew to 85% by June 2010.

Data Source: A 1-year pilot study of pediatric and family physician residents at five residency programs testing their knowledge about pediatric obesity.

Disclosures: The Anthem Blue Cross and Blue Shield Foundation funds the Fit for Residents project. Dr. Slusser said she owns stock in Amgen, Bristol-Myers Squibb, Merck, and Novo Nordisk.

DENVER – Pediatric and family physician residents' knowledge about pediatric obesity significantly improved at five residency programs that adopted a new curriculum, a 1-year pilot study has shown.

Resident attitudes about prevention, management, referral, and advocacy improved as well, although the changes were not statistically significant.

The training made a difference clinically. Greater attention to interpretation of body mass index (BMI) measurements, nutrition, and physical activity was noted through periodic chart reviews for participants in the “Fit for Residents” training, Dr. Wendy Slusser said at the meeting.

In July 2009, for example, only 50% of charts at one site had percent BMI calculated. This figure grew to 85% by June 2010. “Luckily, once [residents] really started calculating BMI, they were doing it correctly as well. That was a nice thing to see,” Dr. Slusser said.

The training was a mix of online, didactic, and experiential learning. “They did some teaching to the residents … and then around midstudy, they developed a stamp that they included on their charts that triggered the resident to not only calculate and plot the BMI, but to interpret it,” Dr. Slusser said.

Initially, a panel of expert physicians developed a childhood overweight prevention and management curriculum. Their aim was to better arm future clinicians with the skills necessary to combat obesity in children and adolescents, said Dr. Slusser, a pediatrician and medical director of the UCLA Fit for Healthy Weight program. The Fit for Residents program is a collaboration among the American Academy of Pediatrics, the American Academy of Family Physicians, and the University of California, Los Angeles. The Fit for Residents training adopts a chronic care model and was designed to be similar to a successful AAP breastfeeding residency curriculum, Dr. Slusser said.

Residents completed a baseline survey about their knowledge and attitudes regarding pediatric obesity. Then the residents at the additional training sites received a 2-day, in-person orientation to the curriculum that included training in motivational interviewing and quality improvement. They also participated in group problem solving. UCLA faculty made monthly telephone calls to key residency faculty once a month on an individual basis and once quarterly as a group call.

Dr. Slusser and her colleagues gauged the efficacy of the project by comparing resident responses to surveys before and after the initiative. The investigators also reviewed 20 charts once a month at each of the 10 residency programs to determine changes in clinical practice.

Resident knowledge about pediatric obesity did change significantly at the five residency programs with the new curriculum. In contrast, no significant change was observed at the five comparison sites.

Very few practices documented that physicians asked patients about physical activity, Dr. Slusser said. However, one program with paper charts added a lifestyle log that made residents much more likely to assess physical activity, she added.

A meeting attendee asked about implementation of the curriculum at sites with paper versus electronic medical records (EMRs). Two of the sites had EMRs, Dr. Slusser replied. Improvements in resident knowledge and attitudes did not differ between sites with different record types, but programs with EMRs adopted changes faster and more efficiently than paper-based sites.

The 10 pediatric and family physician residency programs studied were in California. The five primary care residency programs that added the new curriculum were Children's Hospital and Research Center Oakland, Contra Costa Family Practice, White Memorial Pediatrics and Family Medicine, Harbor-UCLA Pediatrics, and Scripps Family Practice.

The next step is to complete data analysis and to refine the curriculum and tools based on the 1-year experience, Dr. Slusser said. “We next hope to engage residency programs at the national level.”

Resident knowledge about pediatric obesity did change significantly at the programs with the new curriculum.

Source DR. SLUSSER

Major Finding: In July 2009, only 50% of charts at one site had percent BMI calculated. This figure grew to 85% by June 2010.

Data Source: A 1-year pilot study of pediatric and family physician residents at five residency programs testing their knowledge about pediatric obesity.

Disclosures: The Anthem Blue Cross and Blue Shield Foundation funds the Fit for Residents project. Dr. Slusser said she owns stock in Amgen, Bristol-Myers Squibb, Merck, and Novo Nordisk.

DENVER – Pediatric and family physician residents' knowledge about pediatric obesity significantly improved at five residency programs that adopted a new curriculum, a 1-year pilot study has shown.

Resident attitudes about prevention, management, referral, and advocacy improved as well, although the changes were not statistically significant.

The training made a difference clinically. Greater attention to interpretation of body mass index (BMI) measurements, nutrition, and physical activity was noted through periodic chart reviews for participants in the “Fit for Residents” training, Dr. Wendy Slusser said at the meeting.

In July 2009, for example, only 50% of charts at one site had percent BMI calculated. This figure grew to 85% by June 2010. “Luckily, once [residents] really started calculating BMI, they were doing it correctly as well. That was a nice thing to see,” Dr. Slusser said.

The training was a mix of online, didactic, and experiential learning. “They did some teaching to the residents … and then around midstudy, they developed a stamp that they included on their charts that triggered the resident to not only calculate and plot the BMI, but to interpret it,” Dr. Slusser said.

Initially, a panel of expert physicians developed a childhood overweight prevention and management curriculum. Their aim was to better arm future clinicians with the skills necessary to combat obesity in children and adolescents, said Dr. Slusser, a pediatrician and medical director of the UCLA Fit for Healthy Weight program. The Fit for Residents program is a collaboration among the American Academy of Pediatrics, the American Academy of Family Physicians, and the University of California, Los Angeles. The Fit for Residents training adopts a chronic care model and was designed to be similar to a successful AAP breastfeeding residency curriculum, Dr. Slusser said.

Residents completed a baseline survey about their knowledge and attitudes regarding pediatric obesity. Then the residents at the additional training sites received a 2-day, in-person orientation to the curriculum that included training in motivational interviewing and quality improvement. They also participated in group problem solving. UCLA faculty made monthly telephone calls to key residency faculty once a month on an individual basis and once quarterly as a group call.

Dr. Slusser and her colleagues gauged the efficacy of the project by comparing resident responses to surveys before and after the initiative. The investigators also reviewed 20 charts once a month at each of the 10 residency programs to determine changes in clinical practice.

Resident knowledge about pediatric obesity did change significantly at the five residency programs with the new curriculum. In contrast, no significant change was observed at the five comparison sites.

Very few practices documented that physicians asked patients about physical activity, Dr. Slusser said. However, one program with paper charts added a lifestyle log that made residents much more likely to assess physical activity, she added.

A meeting attendee asked about implementation of the curriculum at sites with paper versus electronic medical records (EMRs). Two of the sites had EMRs, Dr. Slusser replied. Improvements in resident knowledge and attitudes did not differ between sites with different record types, but programs with EMRs adopted changes faster and more efficiently than paper-based sites.

The 10 pediatric and family physician residency programs studied were in California. The five primary care residency programs that added the new curriculum were Children's Hospital and Research Center Oakland, Contra Costa Family Practice, White Memorial Pediatrics and Family Medicine, Harbor-UCLA Pediatrics, and Scripps Family Practice.

The next step is to complete data analysis and to refine the curriculum and tools based on the 1-year experience, Dr. Slusser said. “We next hope to engage residency programs at the national level.”

Resident knowledge about pediatric obesity did change significantly at the programs with the new curriculum.

Source DR. SLUSSER

MIAMI BEACH – An antibiotic-coated monofilament suture provides strength, flexibility, and elasticity for dermatologic surgery, but requires an extra throw to prevent knot slippage and comes with an initial learning curve, Dr. Susan H. Weinkle said.

"I’ve been using the same sutures almost 30 years until about 9 months ago," Dr. Weinkle said at this year’s South Beach Symposium.

The Monocryl Plus (poliglecaprone 25, Ethicon) is an absorbable, monofilament suture coated with triclosan antibiotic. The antibiotic "is the plus" and it can lower wound closing costs, Dr. Weinkle said.

The suture can be buried or it can run along the surface of the skin, Dr. Weinkle said. This product is associated with low tissue reactivity, so you get wounds with very little inflammation. "If someone cannot get back to my office quickly enough for suture removal, there [still] is very little reaction."

Absorption of the suture begins in about 12 days and can take considerably longer. "That’s a good thing. It stays underneath for up to 120 days, which is longer than Vicryl would last," Dr. Weinkle said. "However, (the sutures) don’t absorb fast enough on the skin. You still need to see the patient back." She asks patients to return to check wound healing anyway, especially to rule out any hematoma "because everyone I do surgery on is on (a blood thinner)."

"When I sew with Vicryl (polyglactin 910 suture, Ethicon), I tend to only put three knots in the wound. Two throws to start, and then another one on top of that." With this monofilament suture, a fourth throw is generally required to secure the knot, Dr. Weinkle said.

Wound infection risk generally is lower with a monofilament suture. In contrast, although easier to use, braided or twisted multifilament sutures carry a higher infection risk. "In a braided suture you have many more areas for fluid and bacteria to get in – that is very important."

There is an initial learning curve with this monofilament suture and "you are not going to love it in the beginning," said Dr. Weinkle, a private practice dermatologist and Mohs surgeon in Bradenton, Fla. "I sent some of these to a colleague in town and he did not like them." She added: "That is only because he tried one pack. You need at least eight packages until you can actually bond with this suture."

This suture features good elasticity, an imperative for wounds where a lot of local anesthesia was injected and edema results when the wound is closed. The suture stretches, and when that edema dissipates, the suture needs to come back down, she explained.

Using one monofilament suture compared to a two-suture closure can save costs, Dr. Weinkle said. The cost of one monofilament suture to close both deeply and superficially is about $12, compared with almost $18 to use a combination of Vicryl and nylon sutures. "Say you work 48 weeks a year and you do 30 incisions a week." Save $6 on each of these 1,440 annual wound closures "and you're looking at a savings of $8,640."

How you buy this suture is also important, Dr. Weinkle said. "I have a low overhead because I check the prices." Multiple national distributors carry this suture. "Make sure whoever you are buying from knows you’re a surgeon. Otherwise, you may end up paying more money for the same packet of sutures because you’re a dermatologist – you're a different category," Dr. Weinkle said. Also consider joining a group purchasing organization.

"Talk to your rep, say you'd like some samples, and say you'll need at least eight packs," Dr. Weinkle said. "I'm telling you, this is going to save you money and do an even better job for your patients."

Dr. Weinkle said that she did not have any relevant financial disclosures.

MIAMI BEACH – An antibiotic-coated monofilament suture provides strength, flexibility, and elasticity for dermatologic surgery, but requires an extra throw to prevent knot slippage and comes with an initial learning curve, Dr. Susan H. Weinkle said.

"I’ve been using the same sutures almost 30 years until about 9 months ago," Dr. Weinkle said at this year’s South Beach Symposium.

The Monocryl Plus (poliglecaprone 25, Ethicon) is an absorbable, monofilament suture coated with triclosan antibiotic. The antibiotic "is the plus" and it can lower wound closing costs, Dr. Weinkle said.

The suture can be buried or it can run along the surface of the skin, Dr. Weinkle said. This product is associated with low tissue reactivity, so you get wounds with very little inflammation. "If someone cannot get back to my office quickly enough for suture removal, there [still] is very little reaction."

Absorption of the suture begins in about 12 days and can take considerably longer. "That’s a good thing. It stays underneath for up to 120 days, which is longer than Vicryl would last," Dr. Weinkle said. "However, (the sutures) don’t absorb fast enough on the skin. You still need to see the patient back." She asks patients to return to check wound healing anyway, especially to rule out any hematoma "because everyone I do surgery on is on (a blood thinner)."

"When I sew with Vicryl (polyglactin 910 suture, Ethicon), I tend to only put three knots in the wound. Two throws to start, and then another one on top of that." With this monofilament suture, a fourth throw is generally required to secure the knot, Dr. Weinkle said.

Wound infection risk generally is lower with a monofilament suture. In contrast, although easier to use, braided or twisted multifilament sutures carry a higher infection risk. "In a braided suture you have many more areas for fluid and bacteria to get in – that is very important."

There is an initial learning curve with this monofilament suture and "you are not going to love it in the beginning," said Dr. Weinkle, a private practice dermatologist and Mohs surgeon in Bradenton, Fla. "I sent some of these to a colleague in town and he did not like them." She added: "That is only because he tried one pack. You need at least eight packages until you can actually bond with this suture."

This suture features good elasticity, an imperative for wounds where a lot of local anesthesia was injected and edema results when the wound is closed. The suture stretches, and when that edema dissipates, the suture needs to come back down, she explained.

Using one monofilament suture compared to a two-suture closure can save costs, Dr. Weinkle said. The cost of one monofilament suture to close both deeply and superficially is about $12, compared with almost $18 to use a combination of Vicryl and nylon sutures. "Say you work 48 weeks a year and you do 30 incisions a week." Save $6 on each of these 1,440 annual wound closures "and you're looking at a savings of $8,640."

How you buy this suture is also important, Dr. Weinkle said. "I have a low overhead because I check the prices." Multiple national distributors carry this suture. "Make sure whoever you are buying from knows you’re a surgeon. Otherwise, you may end up paying more money for the same packet of sutures because you’re a dermatologist – you're a different category," Dr. Weinkle said. Also consider joining a group purchasing organization.

"Talk to your rep, say you'd like some samples, and say you'll need at least eight packs," Dr. Weinkle said. "I'm telling you, this is going to save you money and do an even better job for your patients."

Dr. Weinkle said that she did not have any relevant financial disclosures.

MIAMI BEACH – An antibiotic-coated monofilament suture provides strength, flexibility, and elasticity for dermatologic surgery, but requires an extra throw to prevent knot slippage and comes with an initial learning curve, Dr. Susan H. Weinkle said.

"I’ve been using the same sutures almost 30 years until about 9 months ago," Dr. Weinkle said at this year’s South Beach Symposium.

The Monocryl Plus (poliglecaprone 25, Ethicon) is an absorbable, monofilament suture coated with triclosan antibiotic. The antibiotic "is the plus" and it can lower wound closing costs, Dr. Weinkle said.

The suture can be buried or it can run along the surface of the skin, Dr. Weinkle said. This product is associated with low tissue reactivity, so you get wounds with very little inflammation. "If someone cannot get back to my office quickly enough for suture removal, there [still] is very little reaction."

Absorption of the suture begins in about 12 days and can take considerably longer. "That’s a good thing. It stays underneath for up to 120 days, which is longer than Vicryl would last," Dr. Weinkle said. "However, (the sutures) don’t absorb fast enough on the skin. You still need to see the patient back." She asks patients to return to check wound healing anyway, especially to rule out any hematoma "because everyone I do surgery on is on (a blood thinner)."

"When I sew with Vicryl (polyglactin 910 suture, Ethicon), I tend to only put three knots in the wound. Two throws to start, and then another one on top of that." With this monofilament suture, a fourth throw is generally required to secure the knot, Dr. Weinkle said.

Wound infection risk generally is lower with a monofilament suture. In contrast, although easier to use, braided or twisted multifilament sutures carry a higher infection risk. "In a braided suture you have many more areas for fluid and bacteria to get in – that is very important."

There is an initial learning curve with this monofilament suture and "you are not going to love it in the beginning," said Dr. Weinkle, a private practice dermatologist and Mohs surgeon in Bradenton, Fla. "I sent some of these to a colleague in town and he did not like them." She added: "That is only because he tried one pack. You need at least eight packages until you can actually bond with this suture."

This suture features good elasticity, an imperative for wounds where a lot of local anesthesia was injected and edema results when the wound is closed. The suture stretches, and when that edema dissipates, the suture needs to come back down, she explained.

Using one monofilament suture compared to a two-suture closure can save costs, Dr. Weinkle said. The cost of one monofilament suture to close both deeply and superficially is about $12, compared with almost $18 to use a combination of Vicryl and nylon sutures. "Say you work 48 weeks a year and you do 30 incisions a week." Save $6 on each of these 1,440 annual wound closures "and you're looking at a savings of $8,640."

How you buy this suture is also important, Dr. Weinkle said. "I have a low overhead because I check the prices." Multiple national distributors carry this suture. "Make sure whoever you are buying from knows you’re a surgeon. Otherwise, you may end up paying more money for the same packet of sutures because you’re a dermatologist – you're a different category," Dr. Weinkle said. Also consider joining a group purchasing organization.

"Talk to your rep, say you'd like some samples, and say you'll need at least eight packs," Dr. Weinkle said. "I'm telling you, this is going to save you money and do an even better job for your patients."

Dr. Weinkle said that she did not have any relevant financial disclosures.

HONOLULU – When it comes to personality disorders, the DSM-5 might feature a reduction in the number of designated disorders, a greater emphasis on and rating of functional impairment, and a move from categorical to dimensional patient assessment, Dr. John M. Oldham said.

Antisocial, avoidant, borderline, obsessive-compulsive, and schizotypal are the personality disorders included in the current proposal for the next edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM).

"The list is based on literature reviews and the robustness of evidence. We have good data for the five that are on here," Dr. Oldham, a member of the DSM-5 Personality and Personality Disorders Work Group, said at the annual meeting of the American Psychiatric Association.

This move would halve the number of categorical personality disorders featured in the DSM-IV-R. If this plan goes forward, schizoid, paranoid, histrionic, and dependent personality disorders would not appear in the DSM-5.

Dr. Oldham is a proponent of adding the remaining disorder in this section of the DSM-IV-R, narcissistic personality disorder, to the DSM-5 before its release in 2103.

"We got a lot of pushback from the comments that came in about narcissistic not being on the list." The work group did not include narcissistic personality disorder with initial revisions posted online in February 2010 at www.dsm5.org, citing a lack of robust research support.

"My argument here is ... how many patients with narcissistic personality disorder are going to line up to participate in a research protocol for a disorder they don’t think they have? It’s not surprising we don’t have a large database, but it doesn’t mean we don’t have to take care of these patients," said Dr. Oldham, American Psychiatric Association president and professor and executive vice chair of the Menninger department of psychiatry and behavioral sciences, Baylor University College of Medicine, Houston.

If someone does not meet criteria for one of these five disorders, you can use a "Personality Traits Assessment" to describe the patient, Dr. Oldham said. The work group developed specific, narrative definitions for 25 relevant traits. Negative affectivity, for example, would be defined as frequent experience of a wide range of negative emotions and interpersonal manifestations of those emotions.

Many of these new proposals will be featured in an update to the DSM-5 personality disorders page soon, Dr. Oldham said. At that time, a second comment period will begin.

A total of 18 dimensional assessment models were proposed. The one the work group chose begins with initial determination of a patient’s "levels of personality functioning." Ratings range from extreme impairment (1); to serious (2); moderate (3); some impairment (4); or healthy functioning (5).

"We’re trying to define a healthy sense of identity and self-directedness," Dr. Oldham said. Experiencing yourself as unique (with clear boundaries between you and others); being capable of accurate self appraisal; and showing a capacity to regulate a range of emotional experience are examples. Empathy; tolerance of difference; and a capacity to relate to others in a comfortable, intimate, in-depth way are examples of interpersonal factors.

"In our hybrid model, you do your assessment of levels, you then look at traits, and you see whether you have met the criteria for the five, or I hope six, personality disorders," Dr. Oldham said.

Minimizing use of the PDNOS or "personality disorder not otherwise specified" as a diagnosis is an aim of the new Personality Traits Assessment. "There is also a lot of use of PDNOS" and the designation often is used incorrectly, Dr. Oldham said. "It’s supposed to mean you don’t have any of the above [criteria]. Most people use it to mean ‘mixed.’ "

Although not as straightforward, trait assessment better addresses the heterogeneity of patient presentations, Dr. Oldham said.

"Then we have to make sure the patient meets the general criteria that are similar to what is in DSM-IV," Dr. Oldham said.

A dimensional approach is complex but better addresses the "excessive co-occurrence" of the personality disorders, compared with categorical assessment, Dr. Oldham said. Dimensional assessments are used in some research settings, but might not be as easy to apply in a fast-paced medical setting. "That was among the questions we wrestled with: How useful is this ... in a busy clinical practice?"

However, "this is hopefully a way to describe personality pathology of all patients." Improved tracking of patient progress over time is another advantage, he said.

No matter what the final outcome of revisions, "these are important disorders for us to know about. The clinical significance of the personality disorders in the DSM is quite significant," Dr. Oldham said. Using DSM-IV-R definitions, approximately 10%-13% of people have a personality disorder. "These are prevalent in clinical settings and in the general population."

Some of these disorders, especially borderline, antisocial, and schizotypal, cause high rates of social and occupational impairment, Dr. Oldham said. "There is really an enormous impact on quality of life."

Dr. Oldham said he had no relevant disclosures.

HONOLULU – When it comes to personality disorders, the DSM-5 might feature a reduction in the number of designated disorders, a greater emphasis on and rating of functional impairment, and a move from categorical to dimensional patient assessment, Dr. John M. Oldham said.

Antisocial, avoidant, borderline, obsessive-compulsive, and schizotypal are the personality disorders included in the current proposal for the next edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM).

"The list is based on literature reviews and the robustness of evidence. We have good data for the five that are on here," Dr. Oldham, a member of the DSM-5 Personality and Personality Disorders Work Group, said at the annual meeting of the American Psychiatric Association.

This move would halve the number of categorical personality disorders featured in the DSM-IV-R. If this plan goes forward, schizoid, paranoid, histrionic, and dependent personality disorders would not appear in the DSM-5.

Dr. Oldham is a proponent of adding the remaining disorder in this section of the DSM-IV-R, narcissistic personality disorder, to the DSM-5 before its release in 2103.

"We got a lot of pushback from the comments that came in about narcissistic not being on the list." The work group did not include narcissistic personality disorder with initial revisions posted online in February 2010 at www.dsm5.org, citing a lack of robust research support.

"My argument here is ... how many patients with narcissistic personality disorder are going to line up to participate in a research protocol for a disorder they don’t think they have? It’s not surprising we don’t have a large database, but it doesn’t mean we don’t have to take care of these patients," said Dr. Oldham, American Psychiatric Association president and professor and executive vice chair of the Menninger department of psychiatry and behavioral sciences, Baylor University College of Medicine, Houston.

If someone does not meet criteria for one of these five disorders, you can use a "Personality Traits Assessment" to describe the patient, Dr. Oldham said. The work group developed specific, narrative definitions for 25 relevant traits. Negative affectivity, for example, would be defined as frequent experience of a wide range of negative emotions and interpersonal manifestations of those emotions.

Many of these new proposals will be featured in an update to the DSM-5 personality disorders page soon, Dr. Oldham said. At that time, a second comment period will begin.

A total of 18 dimensional assessment models were proposed. The one the work group chose begins with initial determination of a patient’s "levels of personality functioning." Ratings range from extreme impairment (1); to serious (2); moderate (3); some impairment (4); or healthy functioning (5).

"We’re trying to define a healthy sense of identity and self-directedness," Dr. Oldham said. Experiencing yourself as unique (with clear boundaries between you and others); being capable of accurate self appraisal; and showing a capacity to regulate a range of emotional experience are examples. Empathy; tolerance of difference; and a capacity to relate to others in a comfortable, intimate, in-depth way are examples of interpersonal factors.

"In our hybrid model, you do your assessment of levels, you then look at traits, and you see whether you have met the criteria for the five, or I hope six, personality disorders," Dr. Oldham said.

Minimizing use of the PDNOS or "personality disorder not otherwise specified" as a diagnosis is an aim of the new Personality Traits Assessment. "There is also a lot of use of PDNOS" and the designation often is used incorrectly, Dr. Oldham said. "It’s supposed to mean you don’t have any of the above [criteria]. Most people use it to mean ‘mixed.’ "

Although not as straightforward, trait assessment better addresses the heterogeneity of patient presentations, Dr. Oldham said.

"Then we have to make sure the patient meets the general criteria that are similar to what is in DSM-IV," Dr. Oldham said.

A dimensional approach is complex but better addresses the "excessive co-occurrence" of the personality disorders, compared with categorical assessment, Dr. Oldham said. Dimensional assessments are used in some research settings, but might not be as easy to apply in a fast-paced medical setting. "That was among the questions we wrestled with: How useful is this ... in a busy clinical practice?"

However, "this is hopefully a way to describe personality pathology of all patients." Improved tracking of patient progress over time is another advantage, he said.

No matter what the final outcome of revisions, "these are important disorders for us to know about. The clinical significance of the personality disorders in the DSM is quite significant," Dr. Oldham said. Using DSM-IV-R definitions, approximately 10%-13% of people have a personality disorder. "These are prevalent in clinical settings and in the general population."

Some of these disorders, especially borderline, antisocial, and schizotypal, cause high rates of social and occupational impairment, Dr. Oldham said. "There is really an enormous impact on quality of life."

Dr. Oldham said he had no relevant disclosures.

HONOLULU – When it comes to personality disorders, the DSM-5 might feature a reduction in the number of designated disorders, a greater emphasis on and rating of functional impairment, and a move from categorical to dimensional patient assessment, Dr. John M. Oldham said.

Antisocial, avoidant, borderline, obsessive-compulsive, and schizotypal are the personality disorders included in the current proposal for the next edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM).

"The list is based on literature reviews and the robustness of evidence. We have good data for the five that are on here," Dr. Oldham, a member of the DSM-5 Personality and Personality Disorders Work Group, said at the annual meeting of the American Psychiatric Association.

This move would halve the number of categorical personality disorders featured in the DSM-IV-R. If this plan goes forward, schizoid, paranoid, histrionic, and dependent personality disorders would not appear in the DSM-5.

Dr. Oldham is a proponent of adding the remaining disorder in this section of the DSM-IV-R, narcissistic personality disorder, to the DSM-5 before its release in 2103.

"We got a lot of pushback from the comments that came in about narcissistic not being on the list." The work group did not include narcissistic personality disorder with initial revisions posted online in February 2010 at www.dsm5.org, citing a lack of robust research support.

"My argument here is ... how many patients with narcissistic personality disorder are going to line up to participate in a research protocol for a disorder they don’t think they have? It’s not surprising we don’t have a large database, but it doesn’t mean we don’t have to take care of these patients," said Dr. Oldham, American Psychiatric Association president and professor and executive vice chair of the Menninger department of psychiatry and behavioral sciences, Baylor University College of Medicine, Houston.

If someone does not meet criteria for one of these five disorders, you can use a "Personality Traits Assessment" to describe the patient, Dr. Oldham said. The work group developed specific, narrative definitions for 25 relevant traits. Negative affectivity, for example, would be defined as frequent experience of a wide range of negative emotions and interpersonal manifestations of those emotions.

Many of these new proposals will be featured in an update to the DSM-5 personality disorders page soon, Dr. Oldham said. At that time, a second comment period will begin.

A total of 18 dimensional assessment models were proposed. The one the work group chose begins with initial determination of a patient’s "levels of personality functioning." Ratings range from extreme impairment (1); to serious (2); moderate (3); some impairment (4); or healthy functioning (5).

"We’re trying to define a healthy sense of identity and self-directedness," Dr. Oldham said. Experiencing yourself as unique (with clear boundaries between you and others); being capable of accurate self appraisal; and showing a capacity to regulate a range of emotional experience are examples. Empathy; tolerance of difference; and a capacity to relate to others in a comfortable, intimate, in-depth way are examples of interpersonal factors.

"In our hybrid model, you do your assessment of levels, you then look at traits, and you see whether you have met the criteria for the five, or I hope six, personality disorders," Dr. Oldham said.

Minimizing use of the PDNOS or "personality disorder not otherwise specified" as a diagnosis is an aim of the new Personality Traits Assessment. "There is also a lot of use of PDNOS" and the designation often is used incorrectly, Dr. Oldham said. "It’s supposed to mean you don’t have any of the above [criteria]. Most people use it to mean ‘mixed.’ "

Although not as straightforward, trait assessment better addresses the heterogeneity of patient presentations, Dr. Oldham said.

"Then we have to make sure the patient meets the general criteria that are similar to what is in DSM-IV," Dr. Oldham said.

A dimensional approach is complex but better addresses the "excessive co-occurrence" of the personality disorders, compared with categorical assessment, Dr. Oldham said. Dimensional assessments are used in some research settings, but might not be as easy to apply in a fast-paced medical setting. "That was among the questions we wrestled with: How useful is this ... in a busy clinical practice?"

However, "this is hopefully a way to describe personality pathology of all patients." Improved tracking of patient progress over time is another advantage, he said.

No matter what the final outcome of revisions, "these are important disorders for us to know about. The clinical significance of the personality disorders in the DSM is quite significant," Dr. Oldham said. Using DSM-IV-R definitions, approximately 10%-13% of people have a personality disorder. "These are prevalent in clinical settings and in the general population."

Some of these disorders, especially borderline, antisocial, and schizotypal, cause high rates of social and occupational impairment, Dr. Oldham said. "There is really an enormous impact on quality of life."

Dr. Oldham said he had no relevant disclosures.

HONOLULU – When it comes to personality disorders, the DSM-5 might feature a reduction in the number of designated disorders, a greater emphasis on and rating of functional impairment, and a move from categorical to dimensional patient assessment, Dr. John M. Oldham said.

Antisocial, avoidant, borderline, obsessive-compulsive, and schizotypal are the personality disorders included in the current proposal for the next edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM).

"The list is based on literature reviews and the robustness of evidence. We have good data for the five that are on here," Dr. Oldham, a member of the DSM-5 Personality and Personality Disorders Work Group, said at the annual meeting of the American Psychiatric Association.

This move would halve the number of categorical personality disorders featured in the DSM-IV-R. If this plan goes forward, schizoid, paranoid, histrionic, and dependent personality disorders would not appear in the DSM-5.

Dr. Oldham is a proponent of adding the remaining disorder in this section of the DSM-IV-R, narcissistic personality disorder, to the DSM-5 before its release in 2013.

"We got a lot of pushback from the comments that came in about narcissistic not being on the list." The work group did not include narcissistic personality disorder with initial revisions posted online in February 2010 at www.dsm5.org, citing a lack of robust research support.

"My argument here is ... how many patients with narcissistic personality disorder are going to line up to participate in a research protocol for a disorder they don’t think they have? It’s not surprising we don’t have a large database, but it doesn’t mean we don’t have to take care of these patients," said Dr. Oldham, American Psychiatric Association president and professor and executive vice chair of the Menninger department of psychiatry and behavioral sciences, Baylor University College of Medicine, Houston.

If someone does not meet criteria for one of these five disorders, you can use a "Personality Traits Assessment" to describe the patient, Dr. Oldham said. The work group developed specific, narrative definitions for 25 relevant traits. Negative affectivity, for example, would be defined as frequent experience of a wide range of negative emotions and interpersonal manifestations of those emotions.

Many of these new proposals will be featured in an update to the DSM-5 personality disorders page soon, Dr. Oldham said. At that time, a second comment period will begin.

A total of 18 dimensional assessment models were proposed. The one the work group chose begins with initial determination of a patient’s "levels of personality functioning." Ratings range from extreme impairment (1); to serious (2); moderate (3); some impairment (4); or healthy functioning (5).

"We’re trying to define a healthy sense of identity and self-directedness," Dr. Oldham said. Experiencing yourself as unique (with clear boundaries between you and others); being capable of accurate self appraisal; and showing a capacity to regulate a range of emotional experience are examples. Empathy; tolerance of difference; and a capacity to relate to others in a comfortable, intimate, in-depth way are examples of interpersonal factors.

"In our hybrid model, you do your assessment of levels, you then look at traits, and you see whether you have met the criteria for the five, or I hope six, personality disorders," Dr. Oldham said.

Minimizing use of the PDNOS or "personality disorder not otherwise specified" as a diagnosis is an aim of the new Personality Traits Assessment. "There is also a lot of use of PDNOS" and the designation often is used incorrectly, Dr. Oldham said. "It’s supposed to mean you don’t have any of the above [criteria]. Most people use it to mean ‘mixed.’ "

Although not as straightforward, trait assessment better addresses the heterogeneity of patient presentations, Dr. Oldham said.

"Then we have to make sure the patient meets the general criteria that are similar to what is in DSM-IV," Dr. Oldham said.

A dimensional approach is complex but better addresses the "excessive co-occurrence" of the personality disorders, compared with categorical assessment, Dr. Oldham said. Dimensional assessments are used in some research settings, but might not be as easy to apply in a fast-paced medical setting. "That was among the questions we wrestled with: How useful is this ... in a busy clinical practice?"

However, "this is hopefully a way to describe personality pathology of all patients." Improved tracking of patient progress over time is another advantage, he said.

No matter what the final outcome of revisions, "these are important disorders for us to know about. The clinical significance of the personality disorders in the DSM is quite significant," Dr. Oldham said. Using DSM-IV-R definitions, approximately 10%-13% of people have a personality disorder. "These are prevalent in clinical settings and in the general population."

Some of these disorders, especially borderline, antisocial, and schizotypal, cause high rates of social and occupational impairment, Dr. Oldham said. "There is really an enormous impact on quality of life."

Dr. Oldham said he had no relevant disclosures.

HONOLULU – When it comes to personality disorders, the DSM-5 might feature a reduction in the number of designated disorders, a greater emphasis on and rating of functional impairment, and a move from categorical to dimensional patient assessment, Dr. John M. Oldham said.

Antisocial, avoidant, borderline, obsessive-compulsive, and schizotypal are the personality disorders included in the current proposal for the next edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM).

"The list is based on literature reviews and the robustness of evidence. We have good data for the five that are on here," Dr. Oldham, a member of the DSM-5 Personality and Personality Disorders Work Group, said at the annual meeting of the American Psychiatric Association.

This move would halve the number of categorical personality disorders featured in the DSM-IV-R. If this plan goes forward, schizoid, paranoid, histrionic, and dependent personality disorders would not appear in the DSM-5.

Dr. Oldham is a proponent of adding the remaining disorder in this section of the DSM-IV-R, narcissistic personality disorder, to the DSM-5 before its release in 2013.

"We got a lot of pushback from the comments that came in about narcissistic not being on the list." The work group did not include narcissistic personality disorder with initial revisions posted online in February 2010 at www.dsm5.org, citing a lack of robust research support.

"My argument here is ... how many patients with narcissistic personality disorder are going to line up to participate in a research protocol for a disorder they don’t think they have? It’s not surprising we don’t have a large database, but it doesn’t mean we don’t have to take care of these patients," said Dr. Oldham, American Psychiatric Association president and professor and executive vice chair of the Menninger department of psychiatry and behavioral sciences, Baylor University College of Medicine, Houston.

If someone does not meet criteria for one of these five disorders, you can use a "Personality Traits Assessment" to describe the patient, Dr. Oldham said. The work group developed specific, narrative definitions for 25 relevant traits. Negative affectivity, for example, would be defined as frequent experience of a wide range of negative emotions and interpersonal manifestations of those emotions.

Many of these new proposals will be featured in an update to the DSM-5 personality disorders page soon, Dr. Oldham said. At that time, a second comment period will begin.

A total of 18 dimensional assessment models were proposed. The one the work group chose begins with initial determination of a patient’s "levels of personality functioning." Ratings range from extreme impairment (1); to serious (2); moderate (3); some impairment (4); or healthy functioning (5).

"We’re trying to define a healthy sense of identity and self-directedness," Dr. Oldham said. Experiencing yourself as unique (with clear boundaries between you and others); being capable of accurate self appraisal; and showing a capacity to regulate a range of emotional experience are examples. Empathy; tolerance of difference; and a capacity to relate to others in a comfortable, intimate, in-depth way are examples of interpersonal factors.

"In our hybrid model, you do your assessment of levels, you then look at traits, and you see whether you have met the criteria for the five, or I hope six, personality disorders," Dr. Oldham said.

Minimizing use of the PDNOS or "personality disorder not otherwise specified" as a diagnosis is an aim of the new Personality Traits Assessment. "There is also a lot of use of PDNOS" and the designation often is used incorrectly, Dr. Oldham said. "It’s supposed to mean you don’t have any of the above [criteria]. Most people use it to mean ‘mixed.’ "

Although not as straightforward, trait assessment better addresses the heterogeneity of patient presentations, Dr. Oldham said.

"Then we have to make sure the patient meets the general criteria that are similar to what is in DSM-IV," Dr. Oldham said.

A dimensional approach is complex but better addresses the "excessive co-occurrence" of the personality disorders, compared with categorical assessment, Dr. Oldham said. Dimensional assessments are used in some research settings, but might not be as easy to apply in a fast-paced medical setting. "That was among the questions we wrestled with: How useful is this ... in a busy clinical practice?"

However, "this is hopefully a way to describe personality pathology of all patients." Improved tracking of patient progress over time is another advantage, he said.

No matter what the final outcome of revisions, "these are important disorders for us to know about. The clinical significance of the personality disorders in the DSM is quite significant," Dr. Oldham said. Using DSM-IV-R definitions, approximately 10%-13% of people have a personality disorder. "These are prevalent in clinical settings and in the general population."

Some of these disorders, especially borderline, antisocial, and schizotypal, cause high rates of social and occupational impairment, Dr. Oldham said. "There is really an enormous impact on quality of life."

Dr. Oldham said he had no relevant disclosures.

HONOLULU – When it comes to personality disorders, the DSM-5 might feature a reduction in the number of designated disorders, a greater emphasis on and rating of functional impairment, and a move from categorical to dimensional patient assessment, Dr. John M. Oldham said.

Antisocial, avoidant, borderline, obsessive-compulsive, and schizotypal are the personality disorders included in the current proposal for the next edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM).

"The list is based on literature reviews and the robustness of evidence. We have good data for the five that are on here," Dr. Oldham, a member of the DSM-5 Personality and Personality Disorders Work Group, said at the annual meeting of the American Psychiatric Association.

This move would halve the number of categorical personality disorders featured in the DSM-IV-R. If this plan goes forward, schizoid, paranoid, histrionic, and dependent personality disorders would not appear in the DSM-5.

Dr. Oldham is a proponent of adding the remaining disorder in this section of the DSM-IV-R, narcissistic personality disorder, to the DSM-5 before its release in 2013.

"We got a lot of pushback from the comments that came in about narcissistic not being on the list." The work group did not include narcissistic personality disorder with initial revisions posted online in February 2010 at www.dsm5.org, citing a lack of robust research support.

"My argument here is ... how many patients with narcissistic personality disorder are going to line up to participate in a research protocol for a disorder they don’t think they have? It’s not surprising we don’t have a large database, but it doesn’t mean we don’t have to take care of these patients," said Dr. Oldham, American Psychiatric Association president and professor and executive vice chair of the Menninger department of psychiatry and behavioral sciences, Baylor University College of Medicine, Houston.

If someone does not meet criteria for one of these five disorders, you can use a "Personality Traits Assessment" to describe the patient, Dr. Oldham said. The work group developed specific, narrative definitions for 25 relevant traits. Negative affectivity, for example, would be defined as frequent experience of a wide range of negative emotions and interpersonal manifestations of those emotions.

Many of these new proposals will be featured in an update to the DSM-5 personality disorders page soon, Dr. Oldham said. At that time, a second comment period will begin.

A total of 18 dimensional assessment models were proposed. The one the work group chose begins with initial determination of a patient’s "levels of personality functioning." Ratings range from extreme impairment (1); to serious (2); moderate (3); some impairment (4); or healthy functioning (5).

"We’re trying to define a healthy sense of identity and self-directedness," Dr. Oldham said. Experiencing yourself as unique (with clear boundaries between you and others); being capable of accurate self appraisal; and showing a capacity to regulate a range of emotional experience are examples. Empathy; tolerance of difference; and a capacity to relate to others in a comfortable, intimate, in-depth way are examples of interpersonal factors.

"In our hybrid model, you do your assessment of levels, you then look at traits, and you see whether you have met the criteria for the five, or I hope six, personality disorders," Dr. Oldham said.

Minimizing use of the PDNOS or "personality disorder not otherwise specified" as a diagnosis is an aim of the new Personality Traits Assessment. "There is also a lot of use of PDNOS" and the designation often is used incorrectly, Dr. Oldham said. "It’s supposed to mean you don’t have any of the above [criteria]. Most people use it to mean ‘mixed.’ "

Although not as straightforward, trait assessment better addresses the heterogeneity of patient presentations, Dr. Oldham said.

"Then we have to make sure the patient meets the general criteria that are similar to what is in DSM-IV," Dr. Oldham said.

A dimensional approach is complex but better addresses the "excessive co-occurrence" of the personality disorders, compared with categorical assessment, Dr. Oldham said. Dimensional assessments are used in some research settings, but might not be as easy to apply in a fast-paced medical setting. "That was among the questions we wrestled with: How useful is this ... in a busy clinical practice?"

However, "this is hopefully a way to describe personality pathology of all patients." Improved tracking of patient progress over time is another advantage, he said.

No matter what the final outcome of revisions, "these are important disorders for us to know about. The clinical significance of the personality disorders in the DSM is quite significant," Dr. Oldham said. Using DSM-IV-R definitions, approximately 10%-13% of people have a personality disorder. "These are prevalent in clinical settings and in the general population."

Some of these disorders, especially borderline, antisocial, and schizotypal, cause high rates of social and occupational impairment, Dr. Oldham said. "There is really an enormous impact on quality of life."

Dr. Oldham said he had no relevant disclosures.

FORT LAUDERDALE, FLA. – More children are achieving long-term survival following repair of a congenital diaphragmatic hernia, but "this new group of survivors does not appear to have much greater sequelae," Dr. Melinda Solomon said.

For example, despite early pulmonary hypertension and decreased pulmonary artery size, their cardiac function tends to be normal in adulthood. Exercise impairments tend to be mild as well, Dr. Solomon said at a seminar on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

"The issue used to be: Can we get these patients to survive and make it to adulthood?" Dr. Solomon said.

They are not entirely free of adverse sequelae, however; obstructive findings and the incidence of asthmalike symptoms can be significantly increased in this population, according to long-term follow-up studies. Recurrence of the hernia is also a lifelong concern, said Dr. Solomon of the division of respiratory medicine at the Hospital for Sick Children in Toronto.

In a long-term follow-up study done in the Netherlands, mean forced expiratory volume in 1 second (FEV₁) was significantly lower among 53 survivors at –1.63, compared with 0.08 among controls (Eur. J. Respir. 2009;34:1140-7). "Prebronchodilatation, the FEV₁ was below the lower limit of normal in 46% of patients but not in controls," Dr. Solomon said. The residual volume/total lung capacity (RV/TLC) ratio exceeded the upper limit of normal in 52% of affected children and in none of the controls, a significant difference.

The same study did not reveal a difference in exercise performance between groups. "This is good news" that children with congenital diaphragmatic hernia can have normal exercise capacity in adulthood, Dr. Solomon said.

All cardiac indexes from exercise testing were within the normal range in another follow-up study of 23 children and 23 case-matched controls at the Hospital for Sick Children (Pediatr. Pulmonol. 2006;41:522-9).

Echocardiography revealed that "they actually had very good myocardial function but, as expected, a smaller pulmonary artery on the affected side," Dr. Solomon said. Pulmonary function testing revealed abnormalities even 10-16 years after treatment, she added, but FEV₁ was in the normal range. For example, mean FEV₁ as percent predicted was 83% in patients versus 98% in controls; mean RV/TLC ratio was 31% in patients versus 22% in controls.

Some degree of obstructive disease is common among survivors. Airway hyperactivity with asthmalike symptoms, for example, can last well into adulthood, Dr. Solomon said. It is sometimes difficult to determine who should be prescribed bronchodilators, she added. The 2009 study in the Netherlands found that 28% of affected children responded to these agents, compared with 6% of controls.

Musculoskeletal abnormalities such as scoliosis, pectus excavatum, and chest wall asymmetry develop in almost one-third of patients, Dr. Solomon said. "This often bothers the family as the respiratory issues resolve. It’s important to warn them in advance."

Long-term neurocognitive function remains unclear, and sensorineural hearing loss and its association with congenital diaphragmatic hernia are controversial (Int. J. Pediatr. Otorhinolaryngol. 2010;74:1176-9). Because such hearing loss occurs both in those who undergo extracorporeal membrane oxygenation and in those who don’t, the underlying etiology remains unknown, she said.

Another unanswered question is whether patch repair or video-assisted thoracic surgery (VATS) yields better long-term outcomes, Dr. Solomon said. Although many studies in the literature point to a higher recurrence rate with patch repairs, at her institution, "VATS has a much higher incidence of recurrence."

Congenital diaphragmatic hernia occurs in about 1 in every 3,000 live births. About 85% are left sided, the classic posterolateral Bochdalek hernia. Comorbidities affect approximately 40%-50% of these children; congenital heart disease, in particular, is associated with an increased risk of mortality.

Dr. Solomon said she had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – More children are achieving long-term survival following repair of a congenital diaphragmatic hernia, but "this new group of survivors does not appear to have much greater sequelae," Dr. Melinda Solomon said.

For example, despite early pulmonary hypertension and decreased pulmonary artery size, their cardiac function tends to be normal in adulthood. Exercise impairments tend to be mild as well, Dr. Solomon said at a seminar on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

"The issue used to be: Can we get these patients to survive and make it to adulthood?" Dr. Solomon said.

They are not entirely free of adverse sequelae, however; obstructive findings and the incidence of asthmalike symptoms can be significantly increased in this population, according to long-term follow-up studies. Recurrence of the hernia is also a lifelong concern, said Dr. Solomon of the division of respiratory medicine at the Hospital for Sick Children in Toronto.

In a long-term follow-up study done in the Netherlands, mean forced expiratory volume in 1 second (FEV₁) was significantly lower among 53 survivors at –1.63, compared with 0.08 among controls (Eur. J. Respir. 2009;34:1140-7). "Prebronchodilatation, the FEV₁ was below the lower limit of normal in 46% of patients but not in controls," Dr. Solomon said. The residual volume/total lung capacity (RV/TLC) ratio exceeded the upper limit of normal in 52% of affected children and in none of the controls, a significant difference.

The same study did not reveal a difference in exercise performance between groups. "This is good news" that children with congenital diaphragmatic hernia can have normal exercise capacity in adulthood, Dr. Solomon said.

All cardiac indexes from exercise testing were within the normal range in another follow-up study of 23 children and 23 case-matched controls at the Hospital for Sick Children (Pediatr. Pulmonol. 2006;41:522-9).

Echocardiography revealed that "they actually had very good myocardial function but, as expected, a smaller pulmonary artery on the affected side," Dr. Solomon said. Pulmonary function testing revealed abnormalities even 10-16 years after treatment, she added, but FEV₁ was in the normal range. For example, mean FEV₁ as percent predicted was 83% in patients versus 98% in controls; mean RV/TLC ratio was 31% in patients versus 22% in controls.

Some degree of obstructive disease is common among survivors. Airway hyperactivity with asthmalike symptoms, for example, can last well into adulthood, Dr. Solomon said. It is sometimes difficult to determine who should be prescribed bronchodilators, she added. The 2009 study in the Netherlands found that 28% of affected children responded to these agents, compared with 6% of controls.

Musculoskeletal abnormalities such as scoliosis, pectus excavatum, and chest wall asymmetry develop in almost one-third of patients, Dr. Solomon said. "This often bothers the family as the respiratory issues resolve. It’s important to warn them in advance."

Long-term neurocognitive function remains unclear, and sensorineural hearing loss and its association with congenital diaphragmatic hernia are controversial (Int. J. Pediatr. Otorhinolaryngol. 2010;74:1176-9). Because such hearing loss occurs both in those who undergo extracorporeal membrane oxygenation and in those who don’t, the underlying etiology remains unknown, she said.

Another unanswered question is whether patch repair or video-assisted thoracic surgery (VATS) yields better long-term outcomes, Dr. Solomon said. Although many studies in the literature point to a higher recurrence rate with patch repairs, at her institution, "VATS has a much higher incidence of recurrence."

Congenital diaphragmatic hernia occurs in about 1 in every 3,000 live births. About 85% are left sided, the classic posterolateral Bochdalek hernia. Comorbidities affect approximately 40%-50% of these children; congenital heart disease, in particular, is associated with an increased risk of mortality.

Dr. Solomon said she had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – More children are achieving long-term survival following repair of a congenital diaphragmatic hernia, but "this new group of survivors does not appear to have much greater sequelae," Dr. Melinda Solomon said.

For example, despite early pulmonary hypertension and decreased pulmonary artery size, their cardiac function tends to be normal in adulthood. Exercise impairments tend to be mild as well, Dr. Solomon said at a seminar on pediatric pulmonology sponsored by the American College of Chest Physicians and the American Academy of Pediatrics.

"The issue used to be: Can we get these patients to survive and make it to adulthood?" Dr. Solomon said.

They are not entirely free of adverse sequelae, however; obstructive findings and the incidence of asthmalike symptoms can be significantly increased in this population, according to long-term follow-up studies. Recurrence of the hernia is also a lifelong concern, said Dr. Solomon of the division of respiratory medicine at the Hospital for Sick Children in Toronto.

In a long-term follow-up study done in the Netherlands, mean forced expiratory volume in 1 second (FEV₁) was significantly lower among 53 survivors at –1.63, compared with 0.08 among controls (Eur. J. Respir. 2009;34:1140-7). "Prebronchodilatation, the FEV₁ was below the lower limit of normal in 46% of patients but not in controls," Dr. Solomon said. The residual volume/total lung capacity (RV/TLC) ratio exceeded the upper limit of normal in 52% of affected children and in none of the controls, a significant difference.

The same study did not reveal a difference in exercise performance between groups. "This is good news" that children with congenital diaphragmatic hernia can have normal exercise capacity in adulthood, Dr. Solomon said.

All cardiac indexes from exercise testing were within the normal range in another follow-up study of 23 children and 23 case-matched controls at the Hospital for Sick Children (Pediatr. Pulmonol. 2006;41:522-9).

Echocardiography revealed that "they actually had very good myocardial function but, as expected, a smaller pulmonary artery on the affected side," Dr. Solomon said. Pulmonary function testing revealed abnormalities even 10-16 years after treatment, she added, but FEV₁ was in the normal range. For example, mean FEV₁ as percent predicted was 83% in patients versus 98% in controls; mean RV/TLC ratio was 31% in patients versus 22% in controls.

Some degree of obstructive disease is common among survivors. Airway hyperactivity with asthmalike symptoms, for example, can last well into adulthood, Dr. Solomon said. It is sometimes difficult to determine who should be prescribed bronchodilators, she added. The 2009 study in the Netherlands found that 28% of affected children responded to these agents, compared with 6% of controls.

Musculoskeletal abnormalities such as scoliosis, pectus excavatum, and chest wall asymmetry develop in almost one-third of patients, Dr. Solomon said. "This often bothers the family as the respiratory issues resolve. It’s important to warn them in advance."

Long-term neurocognitive function remains unclear, and sensorineural hearing loss and its association with congenital diaphragmatic hernia are controversial (Int. J. Pediatr. Otorhinolaryngol. 2010;74:1176-9). Because such hearing loss occurs both in those who undergo extracorporeal membrane oxygenation and in those who don’t, the underlying etiology remains unknown, she said.

Another unanswered question is whether patch repair or video-assisted thoracic surgery (VATS) yields better long-term outcomes, Dr. Solomon said. Although many studies in the literature point to a higher recurrence rate with patch repairs, at her institution, "VATS has a much higher incidence of recurrence."

Congenital diaphragmatic hernia occurs in about 1 in every 3,000 live births. About 85% are left sided, the classic posterolateral Bochdalek hernia. Comorbidities affect approximately 40%-50% of these children; congenital heart disease, in particular, is associated with an increased risk of mortality.

Dr. Solomon said she had no relevant financial disclosures.