Robert Finn

SAN FRANCISCO — Physicians who are treating patients with knee injury or possible arthritis may initially be inclined to order anterior-posterior and lateral views—or sunrise views—of the knee and occasionally even an MRI. But in most cases, the resulting films are not particularly useful and can actually be misleading, Dr. W. Dilworth Cannon said at a conference on sports medicine sponsored by the University of California, San Francisco.

Dr. Cannon, of the department of orthopaedic surgery at UCSF, said he regards the supine anterior-posterior (AP) view of the knee to be “pretty worthless unless the patient can't stand. … Someone could have severe advanced degenerative arthritis, and if you just look at the AP, you may miss it.”

Although the supine lateral is worth ordering, a posterior-anterior (PA) bent-knee standing film is better than the supine AP. The patient faces away from the x-ray tube, with knees placed against the cassette and bent at least 25 degrees; the x-ray beam is aimed 10 degrees caudally, which provides a more useful view of the joint.

Dr. Cannon specifies a 30-degree or 45-degree patellofemoral axial view.

Dr. Cannon also suggested that physicians not order MRIs and instead, leave them to the orthopedic surgeon. He said many of the MRIs that come into his office from primary care physicians are of relatively poor quality.

SAN FRANCISCO — Physicians who are treating patients with knee injury or possible arthritis may initially be inclined to order anterior-posterior and lateral views—or sunrise views—of the knee and occasionally even an MRI. But in most cases, the resulting films are not particularly useful and can actually be misleading, Dr. W. Dilworth Cannon said at a conference on sports medicine sponsored by the University of California, San Francisco.

Dr. Cannon, of the department of orthopaedic surgery at UCSF, said he regards the supine anterior-posterior (AP) view of the knee to be “pretty worthless unless the patient can't stand. … Someone could have severe advanced degenerative arthritis, and if you just look at the AP, you may miss it.”

Although the supine lateral is worth ordering, a posterior-anterior (PA) bent-knee standing film is better than the supine AP. The patient faces away from the x-ray tube, with knees placed against the cassette and bent at least 25 degrees; the x-ray beam is aimed 10 degrees caudally, which provides a more useful view of the joint.

Dr. Cannon specifies a 30-degree or 45-degree patellofemoral axial view.

Dr. Cannon also suggested that physicians not order MRIs and instead, leave them to the orthopedic surgeon. He said many of the MRIs that come into his office from primary care physicians are of relatively poor quality.

SAN FRANCISCO — Physicians who are treating patients with knee injury or possible arthritis may initially be inclined to order anterior-posterior and lateral views—or sunrise views—of the knee and occasionally even an MRI. But in most cases, the resulting films are not particularly useful and can actually be misleading, Dr. W. Dilworth Cannon said at a conference on sports medicine sponsored by the University of California, San Francisco.

Dr. Cannon, of the department of orthopaedic surgery at UCSF, said he regards the supine anterior-posterior (AP) view of the knee to be “pretty worthless unless the patient can't stand. … Someone could have severe advanced degenerative arthritis, and if you just look at the AP, you may miss it.”

Although the supine lateral is worth ordering, a posterior-anterior (PA) bent-knee standing film is better than the supine AP. The patient faces away from the x-ray tube, with knees placed against the cassette and bent at least 25 degrees; the x-ray beam is aimed 10 degrees caudally, which provides a more useful view of the joint.

Dr. Cannon specifies a 30-degree or 45-degree patellofemoral axial view.

Dr. Cannon also suggested that physicians not order MRIs and instead, leave them to the orthopedic surgeon. He said many of the MRIs that come into his office from primary care physicians are of relatively poor quality.

Clinical testing on current weight-loss drugs has been inadequate to determine whether their benefits outweigh the risks of long-term use, according to a literature review by Canadian researchers.

The review, by Dr. Raj S. Padwal and Dr. Sumit R. Majumdar of the University of Alberta, Edmonton, took a close look at the two drugs currently approved by the Food and Drug Administration for the treatment of obesity—orlistat (Xenical) and sibutramine (Meridia)–and at another drug, rimonabant (Acomplia), that has not yet received FDA approval (Lancet 2007;369:71–7).

Although the three drugs all work by different mechanisms, clinical trials show that they tend to result in about the same modest degree of weight loss: an average of 5 kg (11 lbs), or roughly 5% of body weight. They all have side effects, but in general the side effects have been judged to be tolerable.

None of the drugs has been subjected to long-term testing. It's unknown, for example, whether the weight loss induced by these drugs translates to decreases in obesity-related morbidity and mortality. Dr. Padwal and Dr. Majumdar describe this as “a major gap in knowledge.”

It's also unknown whether use of the drugs results in improvements in other consequences of obesity, such as osteoarthritis, gastroesophageal reflux disease, and reduced quality of life.

Furthermore, the existing clinical trials for orlistat, sibutramine, and rimonabant were all marred by high levels of attrition. In general, 40%–50% of all the patients enrolled in those trials dropped out before the trials were concluded. This makes it difficult to assess the drugs' true levels of efficacy and safety in the general population.

“We think that antiobesity drug trials powered to show clinically important reductions in major obesity-related morbidity and mortality should be required either before these drugs are approved for widespread use or as a condition of ongoing approval,” the authors wrote.

They advanced three justifications for this conclusion. First, drugs that improve secondary end points, such as weight loss, may not in the long run improve more clinically relevant end points, such as cardiovascular morbidity and mortality.

Second, a drug's toxicity may not be apparent on initial release. Rimonabant, for example, appears to decrease hunger by blocking endocannabinoid receptors in the brain. Preliminary data suggest that endocannabinoids may work to prevent stroke, limit the size of myocardial infarctions, and inhibit cancer-cell proliferation. Blocking endocannabinoid receptors on a long-term basis may therefore have unintended negative consequences.

Third, new drugs are expensive, and the enormous potential market for obesity drugs amplifies their cost to society. The lack of proof that these drugs improve overall outcomes makes it difficult to justify those costs.

Bariatric surgery is the only treatment proven to produce consistent and effective long-term weight loss, but Dr. Padwal and Dr. Majumdar described bariatric surgery as “neither a feasible nor desirable population-based treatment for obesity.” They wrote that although it's important to address all aspects of the environment that encourage obesity, the search for novel drug treatments is both legitimate and necessary.

Clinical testing on current weight-loss drugs has been inadequate to determine whether their benefits outweigh the risks of long-term use, according to a literature review by Canadian researchers.

The review, by Dr. Raj S. Padwal and Dr. Sumit R. Majumdar of the University of Alberta, Edmonton, took a close look at the two drugs currently approved by the Food and Drug Administration for the treatment of obesity—orlistat (Xenical) and sibutramine (Meridia)–and at another drug, rimonabant (Acomplia), that has not yet received FDA approval (Lancet 2007;369:71–7).

Although the three drugs all work by different mechanisms, clinical trials show that they tend to result in about the same modest degree of weight loss: an average of 5 kg (11 lbs), or roughly 5% of body weight. They all have side effects, but in general the side effects have been judged to be tolerable.

None of the drugs has been subjected to long-term testing. It's unknown, for example, whether the weight loss induced by these drugs translates to decreases in obesity-related morbidity and mortality. Dr. Padwal and Dr. Majumdar describe this as “a major gap in knowledge.”

It's also unknown whether use of the drugs results in improvements in other consequences of obesity, such as osteoarthritis, gastroesophageal reflux disease, and reduced quality of life.

Furthermore, the existing clinical trials for orlistat, sibutramine, and rimonabant were all marred by high levels of attrition. In general, 40%–50% of all the patients enrolled in those trials dropped out before the trials were concluded. This makes it difficult to assess the drugs' true levels of efficacy and safety in the general population.

“We think that antiobesity drug trials powered to show clinically important reductions in major obesity-related morbidity and mortality should be required either before these drugs are approved for widespread use or as a condition of ongoing approval,” the authors wrote.

They advanced three justifications for this conclusion. First, drugs that improve secondary end points, such as weight loss, may not in the long run improve more clinically relevant end points, such as cardiovascular morbidity and mortality.

Second, a drug's toxicity may not be apparent on initial release. Rimonabant, for example, appears to decrease hunger by blocking endocannabinoid receptors in the brain. Preliminary data suggest that endocannabinoids may work to prevent stroke, limit the size of myocardial infarctions, and inhibit cancer-cell proliferation. Blocking endocannabinoid receptors on a long-term basis may therefore have unintended negative consequences.

Third, new drugs are expensive, and the enormous potential market for obesity drugs amplifies their cost to society. The lack of proof that these drugs improve overall outcomes makes it difficult to justify those costs.

Bariatric surgery is the only treatment proven to produce consistent and effective long-term weight loss, but Dr. Padwal and Dr. Majumdar described bariatric surgery as “neither a feasible nor desirable population-based treatment for obesity.” They wrote that although it's important to address all aspects of the environment that encourage obesity, the search for novel drug treatments is both legitimate and necessary.

Clinical testing on current weight-loss drugs has been inadequate to determine whether their benefits outweigh the risks of long-term use, according to a literature review by Canadian researchers.

The review, by Dr. Raj S. Padwal and Dr. Sumit R. Majumdar of the University of Alberta, Edmonton, took a close look at the two drugs currently approved by the Food and Drug Administration for the treatment of obesity—orlistat (Xenical) and sibutramine (Meridia)–and at another drug, rimonabant (Acomplia), that has not yet received FDA approval (Lancet 2007;369:71–7).

Although the three drugs all work by different mechanisms, clinical trials show that they tend to result in about the same modest degree of weight loss: an average of 5 kg (11 lbs), or roughly 5% of body weight. They all have side effects, but in general the side effects have been judged to be tolerable.

None of the drugs has been subjected to long-term testing. It's unknown, for example, whether the weight loss induced by these drugs translates to decreases in obesity-related morbidity and mortality. Dr. Padwal and Dr. Majumdar describe this as “a major gap in knowledge.”

It's also unknown whether use of the drugs results in improvements in other consequences of obesity, such as osteoarthritis, gastroesophageal reflux disease, and reduced quality of life.

Furthermore, the existing clinical trials for orlistat, sibutramine, and rimonabant were all marred by high levels of attrition. In general, 40%–50% of all the patients enrolled in those trials dropped out before the trials were concluded. This makes it difficult to assess the drugs' true levels of efficacy and safety in the general population.

“We think that antiobesity drug trials powered to show clinically important reductions in major obesity-related morbidity and mortality should be required either before these drugs are approved for widespread use or as a condition of ongoing approval,” the authors wrote.

They advanced three justifications for this conclusion. First, drugs that improve secondary end points, such as weight loss, may not in the long run improve more clinically relevant end points, such as cardiovascular morbidity and mortality.

Second, a drug's toxicity may not be apparent on initial release. Rimonabant, for example, appears to decrease hunger by blocking endocannabinoid receptors in the brain. Preliminary data suggest that endocannabinoids may work to prevent stroke, limit the size of myocardial infarctions, and inhibit cancer-cell proliferation. Blocking endocannabinoid receptors on a long-term basis may therefore have unintended negative consequences.

Third, new drugs are expensive, and the enormous potential market for obesity drugs amplifies their cost to society. The lack of proof that these drugs improve overall outcomes makes it difficult to justify those costs.

Bariatric surgery is the only treatment proven to produce consistent and effective long-term weight loss, but Dr. Padwal and Dr. Majumdar described bariatric surgery as “neither a feasible nor desirable population-based treatment for obesity.” They wrote that although it's important to address all aspects of the environment that encourage obesity, the search for novel drug treatments is both legitimate and necessary.

Patients with diabetic neuropathy who monitor their foot temperature daily can reduce their risk of ulceration more than fourfold, according to an article by Lawrence A. Lavery, D.P.M., of Texas A&M University, College Station, and colleagues.

In a physician-blinded trial, 173 patients with a previous history of diabetic foot ulceration were randomly assigned to one of three groups: standard therapy, structured foot examination, or enhanced therapy (Diabetes Care 2007;30:14–20).

Patients who were assigned to standard therapy received therapeutic insoles and footwear, participated in an educational program focused on foot complications and self-care, and had a lower extremity evaluation by a physician every 8 weeks. Those assigned to the structured foot examination group received the standard therapy as well as training to conduct a detailed self-examination with the assistance of a mirror to identify redness, discoloration, swelling, and local warmth.

The patients in the enhanced therapy group also received the standard therapy and were also taught to use a digital infrared thermometer to measure and record daily temperatures at six sites on each foot.

Of the 59 patients in the enhanced therapy group, 5 experienced ulceration over the 15-month treatment period, compared with 17 of the 58 patients in the standard group and 17 of the 56 patients in the structured foot examination group, a significant difference. The mean time to ulcerate was 378.5 days in the standard therapy group, 377.3 days in the structured foot examination group, and 429.5 days in the enhanced therapy group. The enhanced therapy group was significantly better than each of the other two groups, and those two groups did not differ from each other.

Patients in the enhanced therapy group were 4.48 times less likely to develop foot ulceration than those in the standard therapy group and 4.71 times less likely to develop foot ulceration than those in the structured foot examination group.

Within the enhanced therapy group, patients who were compliant with recording foot temperatures at least 50% of the time were 50 times less likely to develop an ulcer than were patients who were not compliant. Four of the five foot ulcers were in patients who were not compliant.

Patients in the enhanced therapy group were taught to monitor temperatures on the great toe, the first, third, and fifth metatarsal head region, the midfoot, and the heel of each foot using a TempTouch digital infrared thermometer, available by prescription from Xilas Medical, San Antonio. They were instructed to contact the research nurse if skin temperatures were elevated by more than 4° F (2.2° C), compared with the corresponding side on the opposite foot for 2 consecutive days. They were also instructed to decrease their activity until temperatures normalized.

About 88% of the patients in the enhanced therapy group were compliant with daily temperature measurements. This compares quite favorably with published rates of compliance with daily glucose monitoring, which can be as low as 33%.

“It seems likely that the cost-benefit of home temperature monitoring might be much better than that for use in glucose strips for home monitoring,” the investigators wrote. “In addition, a tool to adjust activity could help with the dilemma of exercising for better health versus the need to rest and protect the foot to avoid foot ulcers.”

Several of the study's authors disclosed close relationships with Xilas Medical. Dr. Lavery owns stock in the company, and is a consultant and a member of its clinical advisory board. Two of the other authors are members of the company's board of directors. The study was supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases.

Patients took daily temperatures at six sites on each foot using an infrared foot thermometer. Xilas Medical, Inc.

Patients with diabetic neuropathy who monitor their foot temperature daily can reduce their risk of ulceration more than fourfold, according to an article by Lawrence A. Lavery, D.P.M., of Texas A&M University, College Station, and colleagues.

In a physician-blinded trial, 173 patients with a previous history of diabetic foot ulceration were randomly assigned to one of three groups: standard therapy, structured foot examination, or enhanced therapy (Diabetes Care 2007;30:14–20).

Patients who were assigned to standard therapy received therapeutic insoles and footwear, participated in an educational program focused on foot complications and self-care, and had a lower extremity evaluation by a physician every 8 weeks. Those assigned to the structured foot examination group received the standard therapy as well as training to conduct a detailed self-examination with the assistance of a mirror to identify redness, discoloration, swelling, and local warmth.

The patients in the enhanced therapy group also received the standard therapy and were also taught to use a digital infrared thermometer to measure and record daily temperatures at six sites on each foot.

Of the 59 patients in the enhanced therapy group, 5 experienced ulceration over the 15-month treatment period, compared with 17 of the 58 patients in the standard group and 17 of the 56 patients in the structured foot examination group, a significant difference. The mean time to ulcerate was 378.5 days in the standard therapy group, 377.3 days in the structured foot examination group, and 429.5 days in the enhanced therapy group. The enhanced therapy group was significantly better than each of the other two groups, and those two groups did not differ from each other.

Patients in the enhanced therapy group were 4.48 times less likely to develop foot ulceration than those in the standard therapy group and 4.71 times less likely to develop foot ulceration than those in the structured foot examination group.

Within the enhanced therapy group, patients who were compliant with recording foot temperatures at least 50% of the time were 50 times less likely to develop an ulcer than were patients who were not compliant. Four of the five foot ulcers were in patients who were not compliant.

Patients in the enhanced therapy group were taught to monitor temperatures on the great toe, the first, third, and fifth metatarsal head region, the midfoot, and the heel of each foot using a TempTouch digital infrared thermometer, available by prescription from Xilas Medical, San Antonio. They were instructed to contact the research nurse if skin temperatures were elevated by more than 4° F (2.2° C), compared with the corresponding side on the opposite foot for 2 consecutive days. They were also instructed to decrease their activity until temperatures normalized.

About 88% of the patients in the enhanced therapy group were compliant with daily temperature measurements. This compares quite favorably with published rates of compliance with daily glucose monitoring, which can be as low as 33%.

“It seems likely that the cost-benefit of home temperature monitoring might be much better than that for use in glucose strips for home monitoring,” the investigators wrote. “In addition, a tool to adjust activity could help with the dilemma of exercising for better health versus the need to rest and protect the foot to avoid foot ulcers.”

Several of the study's authors disclosed close relationships with Xilas Medical. Dr. Lavery owns stock in the company, and is a consultant and a member of its clinical advisory board. Two of the other authors are members of the company's board of directors. The study was supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases.

Patients took daily temperatures at six sites on each foot using an infrared foot thermometer. Xilas Medical, Inc.

Patients with diabetic neuropathy who monitor their foot temperature daily can reduce their risk of ulceration more than fourfold, according to an article by Lawrence A. Lavery, D.P.M., of Texas A&M University, College Station, and colleagues.

In a physician-blinded trial, 173 patients with a previous history of diabetic foot ulceration were randomly assigned to one of three groups: standard therapy, structured foot examination, or enhanced therapy (Diabetes Care 2007;30:14–20).

Patients who were assigned to standard therapy received therapeutic insoles and footwear, participated in an educational program focused on foot complications and self-care, and had a lower extremity evaluation by a physician every 8 weeks. Those assigned to the structured foot examination group received the standard therapy as well as training to conduct a detailed self-examination with the assistance of a mirror to identify redness, discoloration, swelling, and local warmth.

The patients in the enhanced therapy group also received the standard therapy and were also taught to use a digital infrared thermometer to measure and record daily temperatures at six sites on each foot.

Of the 59 patients in the enhanced therapy group, 5 experienced ulceration over the 15-month treatment period, compared with 17 of the 58 patients in the standard group and 17 of the 56 patients in the structured foot examination group, a significant difference. The mean time to ulcerate was 378.5 days in the standard therapy group, 377.3 days in the structured foot examination group, and 429.5 days in the enhanced therapy group. The enhanced therapy group was significantly better than each of the other two groups, and those two groups did not differ from each other.

Patients in the enhanced therapy group were 4.48 times less likely to develop foot ulceration than those in the standard therapy group and 4.71 times less likely to develop foot ulceration than those in the structured foot examination group.

Within the enhanced therapy group, patients who were compliant with recording foot temperatures at least 50% of the time were 50 times less likely to develop an ulcer than were patients who were not compliant. Four of the five foot ulcers were in patients who were not compliant.

Patients in the enhanced therapy group were taught to monitor temperatures on the great toe, the first, third, and fifth metatarsal head region, the midfoot, and the heel of each foot using a TempTouch digital infrared thermometer, available by prescription from Xilas Medical, San Antonio. They were instructed to contact the research nurse if skin temperatures were elevated by more than 4° F (2.2° C), compared with the corresponding side on the opposite foot for 2 consecutive days. They were also instructed to decrease their activity until temperatures normalized.

About 88% of the patients in the enhanced therapy group were compliant with daily temperature measurements. This compares quite favorably with published rates of compliance with daily glucose monitoring, which can be as low as 33%.

“It seems likely that the cost-benefit of home temperature monitoring might be much better than that for use in glucose strips for home monitoring,” the investigators wrote. “In addition, a tool to adjust activity could help with the dilemma of exercising for better health versus the need to rest and protect the foot to avoid foot ulcers.”

Several of the study's authors disclosed close relationships with Xilas Medical. Dr. Lavery owns stock in the company, and is a consultant and a member of its clinical advisory board. Two of the other authors are members of the company's board of directors. The study was supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases.

Patients took daily temperatures at six sites on each foot using an infrared foot thermometer. Xilas Medical, Inc.

Many diabetic patients with foot ulcers have peripheral arterial disease, infection, and disabling comorbidities, according to a large European study.

Of 1,229 consecutive patients presenting with new foot ulcers at 14 hospitals in 10 European countries, only 24% had neither peripheral arterial disease (PAD) nor infection, reported Dr. Leonne Prompers of University Hospital Maastricht, the Netherlands, and colleagues (Diabetologia 2007;50:18–25).

Twenty-seven percent had infection alone, 18% had PAD alone, and 31% had both PAD and infection.

In addition, 32% of the patients had one or more disabling comorbidities, including 15% with severe visual impairment, 6% with end-stage renal disease, and 11% with heart failure or severe angina pectoris. Ten percent were unable to stand or walk without help.

The European Study Group on Diabetes and the Lower Extremity (Eurodiale) enrolled the patients between September 2003 and October 2004 and followed them for 1 year. This report tabulates the patients' baseline data; follow-up data will be published at a later date.

“These baseline data … contain an important message: many patients with diabetic foot ulcers are severely ill, and this is reflected by the severe underlying pathology and the presence of disabling comorbidity,” the authors wrote. “Follow-up data on these patients, which are expected in the coming year, could give us more insight into the implications of the severity of this disease for clinical outcome, resource utilization and quality of life.”

In patients with both PAD and infection, foot ulcers tended to be deep and at nonplantar locations. Increasing disease severity was significantly associated with age and prevalence of disabling comorbidity.

Overall, 48% of the ulcers were on the plantar surface. Twenty-two percent of patients had the classic plantar forefoot or midfoot ulcer. The most common ulcer site was the dorsal or interdigital area of the toes, which was affected in 32% of the patients.

Deep ulcers, extending below the subcutis into tendons, muscle, or bone, were found in 45% of the patients.

The study has important implications for the evidence-based treatment of diabetic foot ulcers, wrote the authors. For example, there is relatively little published evidence on how to treat patients with the most severe disease. In addition, most studies focus solely on the management of plantar foot ulceration and do not include the management of nonplantar ulcers, despite the fact that healing rates might be lower in dorsal ulcers, compared with plantar ulcers, they noted.

Many diabetic patients with foot ulcers have peripheral arterial disease, infection, and disabling comorbidities, according to a large European study.

Of 1,229 consecutive patients presenting with new foot ulcers at 14 hospitals in 10 European countries, only 24% had neither peripheral arterial disease (PAD) nor infection, reported Dr. Leonne Prompers of University Hospital Maastricht, the Netherlands, and colleagues (Diabetologia 2007;50:18–25).

Twenty-seven percent had infection alone, 18% had PAD alone, and 31% had both PAD and infection.

In addition, 32% of the patients had one or more disabling comorbidities, including 15% with severe visual impairment, 6% with end-stage renal disease, and 11% with heart failure or severe angina pectoris. Ten percent were unable to stand or walk without help.

The European Study Group on Diabetes and the Lower Extremity (Eurodiale) enrolled the patients between September 2003 and October 2004 and followed them for 1 year. This report tabulates the patients' baseline data; follow-up data will be published at a later date.

“These baseline data … contain an important message: many patients with diabetic foot ulcers are severely ill, and this is reflected by the severe underlying pathology and the presence of disabling comorbidity,” the authors wrote. “Follow-up data on these patients, which are expected in the coming year, could give us more insight into the implications of the severity of this disease for clinical outcome, resource utilization and quality of life.”

In patients with both PAD and infection, foot ulcers tended to be deep and at nonplantar locations. Increasing disease severity was significantly associated with age and prevalence of disabling comorbidity.

Overall, 48% of the ulcers were on the plantar surface. Twenty-two percent of patients had the classic plantar forefoot or midfoot ulcer. The most common ulcer site was the dorsal or interdigital area of the toes, which was affected in 32% of the patients.

Deep ulcers, extending below the subcutis into tendons, muscle, or bone, were found in 45% of the patients.

The study has important implications for the evidence-based treatment of diabetic foot ulcers, wrote the authors. For example, there is relatively little published evidence on how to treat patients with the most severe disease. In addition, most studies focus solely on the management of plantar foot ulceration and do not include the management of nonplantar ulcers, despite the fact that healing rates might be lower in dorsal ulcers, compared with plantar ulcers, they noted.

Many diabetic patients with foot ulcers have peripheral arterial disease, infection, and disabling comorbidities, according to a large European study.

Of 1,229 consecutive patients presenting with new foot ulcers at 14 hospitals in 10 European countries, only 24% had neither peripheral arterial disease (PAD) nor infection, reported Dr. Leonne Prompers of University Hospital Maastricht, the Netherlands, and colleagues (Diabetologia 2007;50:18–25).

Twenty-seven percent had infection alone, 18% had PAD alone, and 31% had both PAD and infection.

In addition, 32% of the patients had one or more disabling comorbidities, including 15% with severe visual impairment, 6% with end-stage renal disease, and 11% with heart failure or severe angina pectoris. Ten percent were unable to stand or walk without help.

The European Study Group on Diabetes and the Lower Extremity (Eurodiale) enrolled the patients between September 2003 and October 2004 and followed them for 1 year. This report tabulates the patients' baseline data; follow-up data will be published at a later date.

“These baseline data … contain an important message: many patients with diabetic foot ulcers are severely ill, and this is reflected by the severe underlying pathology and the presence of disabling comorbidity,” the authors wrote. “Follow-up data on these patients, which are expected in the coming year, could give us more insight into the implications of the severity of this disease for clinical outcome, resource utilization and quality of life.”

In patients with both PAD and infection, foot ulcers tended to be deep and at nonplantar locations. Increasing disease severity was significantly associated with age and prevalence of disabling comorbidity.

Overall, 48% of the ulcers were on the plantar surface. Twenty-two percent of patients had the classic plantar forefoot or midfoot ulcer. The most common ulcer site was the dorsal or interdigital area of the toes, which was affected in 32% of the patients.

Deep ulcers, extending below the subcutis into tendons, muscle, or bone, were found in 45% of the patients.

The study has important implications for the evidence-based treatment of diabetic foot ulcers, wrote the authors. For example, there is relatively little published evidence on how to treat patients with the most severe disease. In addition, most studies focus solely on the management of plantar foot ulceration and do not include the management of nonplantar ulcers, despite the fact that healing rates might be lower in dorsal ulcers, compared with plantar ulcers, they noted.

SANTA MONICA, CALIF. — Fertility drugs can be used safely in patients who experience infertility after conservative management of early-stage borderline ovarian tumors, according to a poster presentation by Dr. Anne Fortin at the biennial meeting of the International Gynecologic Cancer Society.

The use of fertility drugs is theoretically contraindicated in patients treated for ovarian malignancies, but only 4 of 30 patients (13%) developed a recurrence after fertility treatment.

Generally the recurrence rate is 15% for stage I borderline ovarian tumors and 20% for stage II-IV tumors, according to published sources (www.emedicine.com/med/topic3233.htm

Thirteen of the patients (43%) became pregnant. Among those were one miscarriage, one premature delivery at 20 weeks of amenorrhea, and 11 normal pregnancies, including one set of twins and one set of triplets.

In the multicenter, retrospective study, the investigators, from Universitaire Bichat, Paris, and Institut Gustav Roussy, Villejuif, France, identified 30 women from 27 centers who had conservative surgery for borderline ovarian tumors that was aimed at preserving subsequent fertility.

To be included in the study, patients had either simple ovarian stimulation with clomiphene citrate or in vitro fertilization with hyperstimulation.

Eight of the patients underwent cystectomy, 17 underwent oophorectomy or salpingo-oophorectomy, and 5 underwent salpingo-oophorectomy and contralateral cystectomy. After histology it was found that 23 of the patients had a serous tumor and 7 had a mucinous tumor or a mixed tumor. Twenty of the patients had stage I disease, four had stage II disease, four had stage III disease, and two patients were not staged.

Twenty-five of the patients were treated for infertility; the other five were stimulated at relapse and were referred to as “emergency cases.” Of the patients with infertility, the median period of infertility before treatment was 20 months.

Three of the five patients requiring emergency treatment and 10 of the 25 patients treated for infertility became pregnant.

The median follow-up after conservative treatment of the ovarian tumor was 93 months, and the median follow-up after infertility treatment was 42 months.

Of the four patients with recurrences, two were disease free for 12 months, one for 40 months, and one for 84 months.

The authors concluded that fertility drugs may be safely used in patients who were infertile after conservative management of an early-stage borderline ovarian tumor that has been carefully followed up. They wrote that the number of patients with advanced-stage disease was too small to draw conclusions regarding the effect of fertility drugs.

SANTA MONICA, CALIF. — Fertility drugs can be used safely in patients who experience infertility after conservative management of early-stage borderline ovarian tumors, according to a poster presentation by Dr. Anne Fortin at the biennial meeting of the International Gynecologic Cancer Society.

The use of fertility drugs is theoretically contraindicated in patients treated for ovarian malignancies, but only 4 of 30 patients (13%) developed a recurrence after fertility treatment.

Generally the recurrence rate is 15% for stage I borderline ovarian tumors and 20% for stage II-IV tumors, according to published sources (www.emedicine.com/med/topic3233.htm

Thirteen of the patients (43%) became pregnant. Among those were one miscarriage, one premature delivery at 20 weeks of amenorrhea, and 11 normal pregnancies, including one set of twins and one set of triplets.

In the multicenter, retrospective study, the investigators, from Universitaire Bichat, Paris, and Institut Gustav Roussy, Villejuif, France, identified 30 women from 27 centers who had conservative surgery for borderline ovarian tumors that was aimed at preserving subsequent fertility.

To be included in the study, patients had either simple ovarian stimulation with clomiphene citrate or in vitro fertilization with hyperstimulation.

Eight of the patients underwent cystectomy, 17 underwent oophorectomy or salpingo-oophorectomy, and 5 underwent salpingo-oophorectomy and contralateral cystectomy. After histology it was found that 23 of the patients had a serous tumor and 7 had a mucinous tumor or a mixed tumor. Twenty of the patients had stage I disease, four had stage II disease, four had stage III disease, and two patients were not staged.

Twenty-five of the patients were treated for infertility; the other five were stimulated at relapse and were referred to as “emergency cases.” Of the patients with infertility, the median period of infertility before treatment was 20 months.

Three of the five patients requiring emergency treatment and 10 of the 25 patients treated for infertility became pregnant.

The median follow-up after conservative treatment of the ovarian tumor was 93 months, and the median follow-up after infertility treatment was 42 months.

Of the four patients with recurrences, two were disease free for 12 months, one for 40 months, and one for 84 months.

The authors concluded that fertility drugs may be safely used in patients who were infertile after conservative management of an early-stage borderline ovarian tumor that has been carefully followed up. They wrote that the number of patients with advanced-stage disease was too small to draw conclusions regarding the effect of fertility drugs.

SANTA MONICA, CALIF. — Fertility drugs can be used safely in patients who experience infertility after conservative management of early-stage borderline ovarian tumors, according to a poster presentation by Dr. Anne Fortin at the biennial meeting of the International Gynecologic Cancer Society.

The use of fertility drugs is theoretically contraindicated in patients treated for ovarian malignancies, but only 4 of 30 patients (13%) developed a recurrence after fertility treatment.

Generally the recurrence rate is 15% for stage I borderline ovarian tumors and 20% for stage II-IV tumors, according to published sources (www.emedicine.com/med/topic3233.htm

Thirteen of the patients (43%) became pregnant. Among those were one miscarriage, one premature delivery at 20 weeks of amenorrhea, and 11 normal pregnancies, including one set of twins and one set of triplets.

In the multicenter, retrospective study, the investigators, from Universitaire Bichat, Paris, and Institut Gustav Roussy, Villejuif, France, identified 30 women from 27 centers who had conservative surgery for borderline ovarian tumors that was aimed at preserving subsequent fertility.

To be included in the study, patients had either simple ovarian stimulation with clomiphene citrate or in vitro fertilization with hyperstimulation.

Eight of the patients underwent cystectomy, 17 underwent oophorectomy or salpingo-oophorectomy, and 5 underwent salpingo-oophorectomy and contralateral cystectomy. After histology it was found that 23 of the patients had a serous tumor and 7 had a mucinous tumor or a mixed tumor. Twenty of the patients had stage I disease, four had stage II disease, four had stage III disease, and two patients were not staged.

Twenty-five of the patients were treated for infertility; the other five were stimulated at relapse and were referred to as “emergency cases.” Of the patients with infertility, the median period of infertility before treatment was 20 months.

Three of the five patients requiring emergency treatment and 10 of the 25 patients treated for infertility became pregnant.

The median follow-up after conservative treatment of the ovarian tumor was 93 months, and the median follow-up after infertility treatment was 42 months.

Of the four patients with recurrences, two were disease free for 12 months, one for 40 months, and one for 84 months.

The authors concluded that fertility drugs may be safely used in patients who were infertile after conservative management of an early-stage borderline ovarian tumor that has been carefully followed up. They wrote that the number of patients with advanced-stage disease was too small to draw conclusions regarding the effect of fertility drugs.

Clinical testing on current weight-loss drugs has been inadequate to determine whether their benefits outweigh the risks of long-term use, according to a literature review by Canadian researchers.

The review, by Dr. Raj S. Padwal and Dr. Sumit R. Majumdar of the University of Alberta, Edmonton, took a close look at the two drugs currently approved by the Food and Drug Administration for the treatment of obesity—orlistat (Xenical) and sibutramine (Meridia)—and at another drug, rimonabant (Acomplia), that has not yet received FDA approval (Lancet 2007;369:71–7).

Although the three drugs all work by different mechanisms, clinical trials show that they tend to result in about the same modest degree of weight loss: an average of 5 kg (11 lbs), or roughly 5% of body weight. They all have side effects, but in general the side effects have been judged to be tolerable.

None of the drugs has been subjected to long-term testing. It's unknown, for example, whether the weight loss induced by these drugs translates to decreases in obesity-related morbidity and mortality. Dr. Padwal and Dr. Majumdar describe this as “a major gap in knowledge.”

It's also unknown whether use of the drugs results in improvements in some of the other consequences of obesity, such as osteoarthritis, gastroesophageal reflux disease, sleep apnea, and reduced quality of life.

Furthermore, the existing clinical trials for orlistat, sibutramine, and rimonabant were all marred by high levels of attrition. In general, 40%–50% of all the patients enrolled in those trials dropped out before the trials were concluded. This makes it difficult to assess the drugs' true levels of efficacy and safety in the general population.

“We think that antiobesity drug trials powered to show clinically important reductions in major obesity-related morbidity and mortality should be required either before these drugs are approved for widespread use or as a condition of ongoing approval,” the authors wrote.

They advanced three justifications for this conclusion. First, drugs that improve secondary end points, such as weight loss, may not in the long run improve more clinically relevant end points, such as cardiovascular morbidity and mortality.

Second, a drug's toxicity may not be apparent on initial release. Rimonabant, for example, appears to decrease hunger by blocking endocannabinoid receptors in the brain. Preliminary data suggest that endocannabinoids may work to prevent stroke, limit the size of myocardial infarctions, and inhibit cancer-cell proliferation. Blocking endocannabinoid receptors on a long-term basis may therefore have unintended negative consequences.

Third, new drugs are expensive, and the enormous potential market for obesity drugs amplifies their cost to society. The lack of proof that these drugs improve overall outcomes makes it difficult to justify those costs.

Bariatric surgery is the only treatment proven to produce consistent and effective long-term weight loss, but Dr. Padwal and Dr. Majumdar described bariatric surgery as “neither a feasible nor desirable population-based treatment for obesity.”

They wrote that although it's important to address all aspects of the environment that encourage obesity, the search for novel drug treatments is both legitimate and necessary.

“However,” they wrote, “in our efforts to fill the therapeutic void” that characterizes contemporary obesity management, “the benefits of obesity pharmacotherapy must outweigh the risks and costs.”

Clinical testing on current weight-loss drugs has been inadequate to determine whether their benefits outweigh the risks of long-term use, according to a literature review by Canadian researchers.

The review, by Dr. Raj S. Padwal and Dr. Sumit R. Majumdar of the University of Alberta, Edmonton, took a close look at the two drugs currently approved by the Food and Drug Administration for the treatment of obesity—orlistat (Xenical) and sibutramine (Meridia)—and at another drug, rimonabant (Acomplia), that has not yet received FDA approval (Lancet 2007;369:71–7).

Although the three drugs all work by different mechanisms, clinical trials show that they tend to result in about the same modest degree of weight loss: an average of 5 kg (11 lbs), or roughly 5% of body weight. They all have side effects, but in general the side effects have been judged to be tolerable.

None of the drugs has been subjected to long-term testing. It's unknown, for example, whether the weight loss induced by these drugs translates to decreases in obesity-related morbidity and mortality. Dr. Padwal and Dr. Majumdar describe this as “a major gap in knowledge.”

It's also unknown whether use of the drugs results in improvements in some of the other consequences of obesity, such as osteoarthritis, gastroesophageal reflux disease, sleep apnea, and reduced quality of life.

Furthermore, the existing clinical trials for orlistat, sibutramine, and rimonabant were all marred by high levels of attrition. In general, 40%–50% of all the patients enrolled in those trials dropped out before the trials were concluded. This makes it difficult to assess the drugs' true levels of efficacy and safety in the general population.

“We think that antiobesity drug trials powered to show clinically important reductions in major obesity-related morbidity and mortality should be required either before these drugs are approved for widespread use or as a condition of ongoing approval,” the authors wrote.

They advanced three justifications for this conclusion. First, drugs that improve secondary end points, such as weight loss, may not in the long run improve more clinically relevant end points, such as cardiovascular morbidity and mortality.

Second, a drug's toxicity may not be apparent on initial release. Rimonabant, for example, appears to decrease hunger by blocking endocannabinoid receptors in the brain. Preliminary data suggest that endocannabinoids may work to prevent stroke, limit the size of myocardial infarctions, and inhibit cancer-cell proliferation. Blocking endocannabinoid receptors on a long-term basis may therefore have unintended negative consequences.

Third, new drugs are expensive, and the enormous potential market for obesity drugs amplifies their cost to society. The lack of proof that these drugs improve overall outcomes makes it difficult to justify those costs.

Bariatric surgery is the only treatment proven to produce consistent and effective long-term weight loss, but Dr. Padwal and Dr. Majumdar described bariatric surgery as “neither a feasible nor desirable population-based treatment for obesity.”

They wrote that although it's important to address all aspects of the environment that encourage obesity, the search for novel drug treatments is both legitimate and necessary.

“However,” they wrote, “in our efforts to fill the therapeutic void” that characterizes contemporary obesity management, “the benefits of obesity pharmacotherapy must outweigh the risks and costs.”

Clinical testing on current weight-loss drugs has been inadequate to determine whether their benefits outweigh the risks of long-term use, according to a literature review by Canadian researchers.

The review, by Dr. Raj S. Padwal and Dr. Sumit R. Majumdar of the University of Alberta, Edmonton, took a close look at the two drugs currently approved by the Food and Drug Administration for the treatment of obesity—orlistat (Xenical) and sibutramine (Meridia)—and at another drug, rimonabant (Acomplia), that has not yet received FDA approval (Lancet 2007;369:71–7).

Although the three drugs all work by different mechanisms, clinical trials show that they tend to result in about the same modest degree of weight loss: an average of 5 kg (11 lbs), or roughly 5% of body weight. They all have side effects, but in general the side effects have been judged to be tolerable.

None of the drugs has been subjected to long-term testing. It's unknown, for example, whether the weight loss induced by these drugs translates to decreases in obesity-related morbidity and mortality. Dr. Padwal and Dr. Majumdar describe this as “a major gap in knowledge.”

It's also unknown whether use of the drugs results in improvements in some of the other consequences of obesity, such as osteoarthritis, gastroesophageal reflux disease, sleep apnea, and reduced quality of life.

Furthermore, the existing clinical trials for orlistat, sibutramine, and rimonabant were all marred by high levels of attrition. In general, 40%–50% of all the patients enrolled in those trials dropped out before the trials were concluded. This makes it difficult to assess the drugs' true levels of efficacy and safety in the general population.

“We think that antiobesity drug trials powered to show clinically important reductions in major obesity-related morbidity and mortality should be required either before these drugs are approved for widespread use or as a condition of ongoing approval,” the authors wrote.

They advanced three justifications for this conclusion. First, drugs that improve secondary end points, such as weight loss, may not in the long run improve more clinically relevant end points, such as cardiovascular morbidity and mortality.

Second, a drug's toxicity may not be apparent on initial release. Rimonabant, for example, appears to decrease hunger by blocking endocannabinoid receptors in the brain. Preliminary data suggest that endocannabinoids may work to prevent stroke, limit the size of myocardial infarctions, and inhibit cancer-cell proliferation. Blocking endocannabinoid receptors on a long-term basis may therefore have unintended negative consequences.

Third, new drugs are expensive, and the enormous potential market for obesity drugs amplifies their cost to society. The lack of proof that these drugs improve overall outcomes makes it difficult to justify those costs.

Bariatric surgery is the only treatment proven to produce consistent and effective long-term weight loss, but Dr. Padwal and Dr. Majumdar described bariatric surgery as “neither a feasible nor desirable population-based treatment for obesity.”

They wrote that although it's important to address all aspects of the environment that encourage obesity, the search for novel drug treatments is both legitimate and necessary.

“However,” they wrote, “in our efforts to fill the therapeutic void” that characterizes contemporary obesity management, “the benefits of obesity pharmacotherapy must outweigh the risks and costs.”

SAN FRANCISCO — There's no truth in the belief that a person can become dependent on orthotic soles—in fact, orthotics can be very useful in correcting certain foot problems, according to Dr. Anthony Luke, at a conference on sports medicine sponsored by the University of California, San Francisco.

“Do you want to wear more comfortable shoes, or do you want to wear crummy shoes? Because that's really all you are doing,” said Dr. Luke of the department of orthopedic surgery at the university.

“You're putting an insert in. You're not doing surgery on [patients], and you're not taping it to their foot for the rest of their lives. I don't know how you necessarily become dependent, [although] I certainly run into people who really love their orthotics and never want to go without them,” he commented. It is not certain, however, that $400 custom-made orthotics are substantially better than over-the-counter brands available in stores.

The primary purpose of orthotics is to improve the efficiency of a person's gait by helping to control excessive or unwanted motion. It's also possible to use them to relieve the weight load on sensitive areas of the foot. If a patient has metatarsal pain, for example, then pads can be added to the orthotic to decrease pressure on the painful area.

To determine whether a runner would benefit from orthotics, one should first examine the foot when it's not bearing weight and when it's in the subtalar neutral position—neither pronated nor supinated. Many methods for determining subtalar neutral have been proposed, and there is controversy in the literature about which is best.

Dr. Luke said that he has the patient lie prone on the examining table, then lifts the patient's foot by the fifth metatarsal. He then places his other hand on the opposite side of the ankle and rocks the foot back and forth, causing the calcaneus and the talus to invert and evert. The aim, he said, is to “find that position where the talus is no longer banging into my fingers. That's going to be subtalar neutral.”

Next, he looks at the Achilles' tendon and the angle of the calcaneus. A heel that is turned inward indicates a heel varus, which suggests the patient has trouble unlocking the midfoot. Conversely, if the heel is valgus, then the patient is starting off in a bad position, and it is no wonder they're pronating, he said.

Orthotics can be customized to correct specific problems. For example, they can include a lift if there is a discrepancy in leg length. And they can have posts added in areas needing special support to achieve a subtalar neutral position.

A number of different materials can be used to construct orthotics, but Dr. Luke noted that he is suspicious of especially rigid materials. “It's kind of like running on a very hard surface.”

But before prescribing custom orthotics, Dr. Luke suggested that patients try an over-the-counter pair. There's little compelling evidence that custom orthotics are significantly better than those that are bought over the counter—and custom orthotics are as much as 10 times more expensive.

If nothing else, the cheaper orthotics can be used as testers, and although the correction may not be perfect, the patient will likely experience at least some improvement.

An easy way of testing whether an orthotic is doing its job or not, is to have the patient take it out of the shoe, put it on the floor, then stand on it. The doctor should then compare the patient's stance in the orthotic with the stance when he or she is standing on the floor. If the device corrects a patient's pronation (for example) in the static position, then there is a good chance it will correct the pronation in motion. However, if the orthotic doesn't even correct the static position, then it will probably not be that useful for a patient in motion.

Orthotics can be customized to help correct a patient's specific problem, such as pronation or a discrepancy in leg length. Courtesy Dr. Anthony Luke

SAN FRANCISCO — There's no truth in the belief that a person can become dependent on orthotic soles—in fact, orthotics can be very useful in correcting certain foot problems, according to Dr. Anthony Luke, at a conference on sports medicine sponsored by the University of California, San Francisco.

“Do you want to wear more comfortable shoes, or do you want to wear crummy shoes? Because that's really all you are doing,” said Dr. Luke of the department of orthopedic surgery at the university.

“You're putting an insert in. You're not doing surgery on [patients], and you're not taping it to their foot for the rest of their lives. I don't know how you necessarily become dependent, [although] I certainly run into people who really love their orthotics and never want to go without them,” he commented. It is not certain, however, that $400 custom-made orthotics are substantially better than over-the-counter brands available in stores.

The primary purpose of orthotics is to improve the efficiency of a person's gait by helping to control excessive or unwanted motion. It's also possible to use them to relieve the weight load on sensitive areas of the foot. If a patient has metatarsal pain, for example, then pads can be added to the orthotic to decrease pressure on the painful area.

To determine whether a runner would benefit from orthotics, one should first examine the foot when it's not bearing weight and when it's in the subtalar neutral position—neither pronated nor supinated. Many methods for determining subtalar neutral have been proposed, and there is controversy in the literature about which is best.

Dr. Luke said that he has the patient lie prone on the examining table, then lifts the patient's foot by the fifth metatarsal. He then places his other hand on the opposite side of the ankle and rocks the foot back and forth, causing the calcaneus and the talus to invert and evert. The aim, he said, is to “find that position where the talus is no longer banging into my fingers. That's going to be subtalar neutral.”

Next, he looks at the Achilles' tendon and the angle of the calcaneus. A heel that is turned inward indicates a heel varus, which suggests the patient has trouble unlocking the midfoot. Conversely, if the heel is valgus, then the patient is starting off in a bad position, and it is no wonder they're pronating, he said.

Orthotics can be customized to correct specific problems. For example, they can include a lift if there is a discrepancy in leg length. And they can have posts added in areas needing special support to achieve a subtalar neutral position.

A number of different materials can be used to construct orthotics, but Dr. Luke noted that he is suspicious of especially rigid materials. “It's kind of like running on a very hard surface.”

But before prescribing custom orthotics, Dr. Luke suggested that patients try an over-the-counter pair. There's little compelling evidence that custom orthotics are significantly better than those that are bought over the counter—and custom orthotics are as much as 10 times more expensive.

If nothing else, the cheaper orthotics can be used as testers, and although the correction may not be perfect, the patient will likely experience at least some improvement.

An easy way of testing whether an orthotic is doing its job or not, is to have the patient take it out of the shoe, put it on the floor, then stand on it. The doctor should then compare the patient's stance in the orthotic with the stance when he or she is standing on the floor. If the device corrects a patient's pronation (for example) in the static position, then there is a good chance it will correct the pronation in motion. However, if the orthotic doesn't even correct the static position, then it will probably not be that useful for a patient in motion.

Orthotics can be customized to help correct a patient's specific problem, such as pronation or a discrepancy in leg length. Courtesy Dr. Anthony Luke

SAN FRANCISCO — There's no truth in the belief that a person can become dependent on orthotic soles—in fact, orthotics can be very useful in correcting certain foot problems, according to Dr. Anthony Luke, at a conference on sports medicine sponsored by the University of California, San Francisco.

“Do you want to wear more comfortable shoes, or do you want to wear crummy shoes? Because that's really all you are doing,” said Dr. Luke of the department of orthopedic surgery at the university.

“You're putting an insert in. You're not doing surgery on [patients], and you're not taping it to their foot for the rest of their lives. I don't know how you necessarily become dependent, [although] I certainly run into people who really love their orthotics and never want to go without them,” he commented. It is not certain, however, that $400 custom-made orthotics are substantially better than over-the-counter brands available in stores.

The primary purpose of orthotics is to improve the efficiency of a person's gait by helping to control excessive or unwanted motion. It's also possible to use them to relieve the weight load on sensitive areas of the foot. If a patient has metatarsal pain, for example, then pads can be added to the orthotic to decrease pressure on the painful area.

To determine whether a runner would benefit from orthotics, one should first examine the foot when it's not bearing weight and when it's in the subtalar neutral position—neither pronated nor supinated. Many methods for determining subtalar neutral have been proposed, and there is controversy in the literature about which is best.

Dr. Luke said that he has the patient lie prone on the examining table, then lifts the patient's foot by the fifth metatarsal. He then places his other hand on the opposite side of the ankle and rocks the foot back and forth, causing the calcaneus and the talus to invert and evert. The aim, he said, is to “find that position where the talus is no longer banging into my fingers. That's going to be subtalar neutral.”

Next, he looks at the Achilles' tendon and the angle of the calcaneus. A heel that is turned inward indicates a heel varus, which suggests the patient has trouble unlocking the midfoot. Conversely, if the heel is valgus, then the patient is starting off in a bad position, and it is no wonder they're pronating, he said.

Orthotics can be customized to correct specific problems. For example, they can include a lift if there is a discrepancy in leg length. And they can have posts added in areas needing special support to achieve a subtalar neutral position.

A number of different materials can be used to construct orthotics, but Dr. Luke noted that he is suspicious of especially rigid materials. “It's kind of like running on a very hard surface.”

But before prescribing custom orthotics, Dr. Luke suggested that patients try an over-the-counter pair. There's little compelling evidence that custom orthotics are significantly better than those that are bought over the counter—and custom orthotics are as much as 10 times more expensive.

If nothing else, the cheaper orthotics can be used as testers, and although the correction may not be perfect, the patient will likely experience at least some improvement.

An easy way of testing whether an orthotic is doing its job or not, is to have the patient take it out of the shoe, put it on the floor, then stand on it. The doctor should then compare the patient's stance in the orthotic with the stance when he or she is standing on the floor. If the device corrects a patient's pronation (for example) in the static position, then there is a good chance it will correct the pronation in motion. However, if the orthotic doesn't even correct the static position, then it will probably not be that useful for a patient in motion.

Orthotics can be customized to help correct a patient's specific problem, such as pronation or a discrepancy in leg length. Courtesy Dr. Anthony Luke

SAN FRANCISCO — When a patient with a running injury arrives in a busy primary-care office, there's usually not enough time for the provider to do a full orthopedic examination, but several high-yield static assessments can help the provider conduct an efficient exam within the standard 15-minute office visit, Dr. Anthony Luke said at a conference on sports medicine sponsored by the University of California, San Francisco.

The first thing to evaluate, according to Dr. Luke, of the department of orthopedic surgery at the university, is the patient's alignment. Dr. Luke asks the patient to stand with ankles together, and if he can fit four fingers between the patient's heels, the gap indicates a significant valgus condition.

Then he asks the patient to stand with feet placed apart a distance equal to the shoulder width, and—while watching the patient from both the front and the back—he instructs the patient to rise up on the toes and then go back down again.

“I want to see how high the arch gets, and, as they come down, how it rolls in. This helps you know [whether it's] a flexible flat foot. If they go up and they don't recreate the arch, then there's a problem there, either a tendon problem or a structural problem, such as tarsal coalition.”

This test also allows for further evaluation of varus and valgus conditions, either of which could be behind pronation or other foot problems.

Next, Dr. Luke has the patient squat while keeping the heels flat on the floor. “If they don't get too far, sometimes they have limited dorsiflexion in their ankles, and that could lead to a problem.”

While the patient is squatting, Dr. Luke instructs the patient to do a duck walk, which will indicate whether there are any problems with the hips or knees.

Then he recommends conducting four tests of flexibility:

▸ The Thomas test is used to assess the hip flexor.

The test is conducted by having the patient lie back on the examination table and then raise both of the knees up to the chest. The patient should then hold one knee up while allowing the other leg to drop down.

Meanwhile, the physician should have a hand on the patient's pelvis. At the moment the pelvis begins to rock, the physician should note the angle between the lowered thigh and the table. An angle of greater than 30 degrees indicates a significant loss of flexibility.

▸ The Ely test assesses the quadriceps and is done while the patient is prone. The physician should flex the ankle toward the buttocks and see how tight the patient is on each side.

▸ Ober's test assesses the iliotibial band.

It is done with the patient lying on one side and holding the lower knee in a flexed position.

The physician should stabilize the patient's pelvis with one hand and, with the other hand, hold the patient's ankle and abduct and extend the hip. The physician should then lift the hand that is holding the ankle while continuing to stabilize the pelvis.

In a patient with normal flexibility, the leg will remain parallel to the table. In an especially flexible patient, the leg will dip down a bit farther. However, if the leg hangs up, this would indicate a tight iliotibial band.

▸ The popliteal angle test assesses hamstring flexibility, and is done with the patient supine.

The patient should first bend the hip to 90 degrees and the knee to 90 degrees. The physician should then passively extend the leg, noting the angle of the knee. Low popliteal angles (as little as 120–130 degrees) are common in long-distance runners and indicate a lack of hamstring flexibility.

One of four tests measuring flexibility, the Thomas test (patient position shown above), assesses the loss of flexiblity in the hip flexor. Courtesy Dr. Anthony Luke

SAN FRANCISCO — When a patient with a running injury arrives in a busy primary-care office, there's usually not enough time for the provider to do a full orthopedic examination, but several high-yield static assessments can help the provider conduct an efficient exam within the standard 15-minute office visit, Dr. Anthony Luke said at a conference on sports medicine sponsored by the University of California, San Francisco.

The first thing to evaluate, according to Dr. Luke, of the department of orthopedic surgery at the university, is the patient's alignment. Dr. Luke asks the patient to stand with ankles together, and if he can fit four fingers between the patient's heels, the gap indicates a significant valgus condition.

Then he asks the patient to stand with feet placed apart a distance equal to the shoulder width, and—while watching the patient from both the front and the back—he instructs the patient to rise up on the toes and then go back down again.

“I want to see how high the arch gets, and, as they come down, how it rolls in. This helps you know [whether it's] a flexible flat foot. If they go up and they don't recreate the arch, then there's a problem there, either a tendon problem or a structural problem, such as tarsal coalition.”

This test also allows for further evaluation of varus and valgus conditions, either of which could be behind pronation or other foot problems.

Next, Dr. Luke has the patient squat while keeping the heels flat on the floor. “If they don't get too far, sometimes they have limited dorsiflexion in their ankles, and that could lead to a problem.”

While the patient is squatting, Dr. Luke instructs the patient to do a duck walk, which will indicate whether there are any problems with the hips or knees.

Then he recommends conducting four tests of flexibility:

▸ The Thomas test is used to assess the hip flexor.

The test is conducted by having the patient lie back on the examination table and then raise both of the knees up to the chest. The patient should then hold one knee up while allowing the other leg to drop down.

Meanwhile, the physician should have a hand on the patient's pelvis. At the moment the pelvis begins to rock, the physician should note the angle between the lowered thigh and the table. An angle of greater than 30 degrees indicates a significant loss of flexibility.

▸ The Ely test assesses the quadriceps and is done while the patient is prone. The physician should flex the ankle toward the buttocks and see how tight the patient is on each side.

▸ Ober's test assesses the iliotibial band.

It is done with the patient lying on one side and holding the lower knee in a flexed position.

The physician should stabilize the patient's pelvis with one hand and, with the other hand, hold the patient's ankle and abduct and extend the hip. The physician should then lift the hand that is holding the ankle while continuing to stabilize the pelvis.

In a patient with normal flexibility, the leg will remain parallel to the table. In an especially flexible patient, the leg will dip down a bit farther. However, if the leg hangs up, this would indicate a tight iliotibial band.

▸ The popliteal angle test assesses hamstring flexibility, and is done with the patient supine.

The patient should first bend the hip to 90 degrees and the knee to 90 degrees. The physician should then passively extend the leg, noting the angle of the knee. Low popliteal angles (as little as 120–130 degrees) are common in long-distance runners and indicate a lack of hamstring flexibility.

One of four tests measuring flexibility, the Thomas test (patient position shown above), assesses the loss of flexiblity in the hip flexor. Courtesy Dr. Anthony Luke

SAN FRANCISCO — When a patient with a running injury arrives in a busy primary-care office, there's usually not enough time for the provider to do a full orthopedic examination, but several high-yield static assessments can help the provider conduct an efficient exam within the standard 15-minute office visit, Dr. Anthony Luke said at a conference on sports medicine sponsored by the University of California, San Francisco.

The first thing to evaluate, according to Dr. Luke, of the department of orthopedic surgery at the university, is the patient's alignment. Dr. Luke asks the patient to stand with ankles together, and if he can fit four fingers between the patient's heels, the gap indicates a significant valgus condition.

Then he asks the patient to stand with feet placed apart a distance equal to the shoulder width, and—while watching the patient from both the front and the back—he instructs the patient to rise up on the toes and then go back down again.

“I want to see how high the arch gets, and, as they come down, how it rolls in. This helps you know [whether it's] a flexible flat foot. If they go up and they don't recreate the arch, then there's a problem there, either a tendon problem or a structural problem, such as tarsal coalition.”

This test also allows for further evaluation of varus and valgus conditions, either of which could be behind pronation or other foot problems.

Next, Dr. Luke has the patient squat while keeping the heels flat on the floor. “If they don't get too far, sometimes they have limited dorsiflexion in their ankles, and that could lead to a problem.”

While the patient is squatting, Dr. Luke instructs the patient to do a duck walk, which will indicate whether there are any problems with the hips or knees.

Then he recommends conducting four tests of flexibility:

▸ The Thomas test is used to assess the hip flexor.

The test is conducted by having the patient lie back on the examination table and then raise both of the knees up to the chest. The patient should then hold one knee up while allowing the other leg to drop down.

Meanwhile, the physician should have a hand on the patient's pelvis. At the moment the pelvis begins to rock, the physician should note the angle between the lowered thigh and the table. An angle of greater than 30 degrees indicates a significant loss of flexibility.

▸ The Ely test assesses the quadriceps and is done while the patient is prone. The physician should flex the ankle toward the buttocks and see how tight the patient is on each side.

▸ Ober's test assesses the iliotibial band.

It is done with the patient lying on one side and holding the lower knee in a flexed position.

The physician should stabilize the patient's pelvis with one hand and, with the other hand, hold the patient's ankle and abduct and extend the hip. The physician should then lift the hand that is holding the ankle while continuing to stabilize the pelvis.

In a patient with normal flexibility, the leg will remain parallel to the table. In an especially flexible patient, the leg will dip down a bit farther. However, if the leg hangs up, this would indicate a tight iliotibial band.

▸ The popliteal angle test assesses hamstring flexibility, and is done with the patient supine.

The patient should first bend the hip to 90 degrees and the knee to 90 degrees. The physician should then passively extend the leg, noting the angle of the knee. Low popliteal angles (as little as 120–130 degrees) are common in long-distance runners and indicate a lack of hamstring flexibility.

One of four tests measuring flexibility, the Thomas test (patient position shown above), assesses the loss of flexiblity in the hip flexor. Courtesy Dr. Anthony Luke

SANTA MONICA, CALIF. — While hysteroscopy is the most accurate tool for evaluating abnormal uterine bleeding, the technique can cause the intraperitoneal spread of malignant endometrial cells. This has raised concerns that hysteroscopy might be responsible for a worse prognosis in women with endometrial cancer.

But in a poster presentation at the biennial meeting of the International Gynecologic Cancer Society, Dr. A. Ben Arie and colleagues found no evidence that hysteroscopy was associated with an increase in endometrial cancer recurrences.

The retrospective study involved 392 women provisionally diagnosed with stage I endometrial adenocarcinoma at five medical centers in Israel. Dr. Ben Arie of Kaplan Medical Center, Rehovot, Israel, and colleagues examined the women's medical records, retrieving data on mode of diagnosis, histologic type, grade and stage of the disease, and the patient's outcome.

Three different diagnostic methods were employed in the women—25% had an endometrial biopsy, 49% had uterine curettage, and 26% had hysteroscopy. Endometrial adenocarcinoma was found in 88.5% of the women, and the other 11.5% had uterine serous papillary cancer, clear cell cancer, or small cell cancer. The cancer was stage I in 81% of the women, stage II in 2% of the women, and stage III in 17% of the women.

At a mean follow-up time of 55 months (range 12–233 months), recurrences were found in 5% of the women who had hysteroscopy, 4.7% of the women who had curettage, and 13.1% of the women who had endometrial biopsy. There was no statistically significant difference in the recurrence rate among the three diagnostic methods.

SANTA MONICA, CALIF. — While hysteroscopy is the most accurate tool for evaluating abnormal uterine bleeding, the technique can cause the intraperitoneal spread of malignant endometrial cells. This has raised concerns that hysteroscopy might be responsible for a worse prognosis in women with endometrial cancer.

But in a poster presentation at the biennial meeting of the International Gynecologic Cancer Society, Dr. A. Ben Arie and colleagues found no evidence that hysteroscopy was associated with an increase in endometrial cancer recurrences.

The retrospective study involved 392 women provisionally diagnosed with stage I endometrial adenocarcinoma at five medical centers in Israel. Dr. Ben Arie of Kaplan Medical Center, Rehovot, Israel, and colleagues examined the women's medical records, retrieving data on mode of diagnosis, histologic type, grade and stage of the disease, and the patient's outcome.

Three different diagnostic methods were employed in the women—25% had an endometrial biopsy, 49% had uterine curettage, and 26% had hysteroscopy. Endometrial adenocarcinoma was found in 88.5% of the women, and the other 11.5% had uterine serous papillary cancer, clear cell cancer, or small cell cancer. The cancer was stage I in 81% of the women, stage II in 2% of the women, and stage III in 17% of the women.

At a mean follow-up time of 55 months (range 12–233 months), recurrences were found in 5% of the women who had hysteroscopy, 4.7% of the women who had curettage, and 13.1% of the women who had endometrial biopsy. There was no statistically significant difference in the recurrence rate among the three diagnostic methods.

SANTA MONICA, CALIF. — While hysteroscopy is the most accurate tool for evaluating abnormal uterine bleeding, the technique can cause the intraperitoneal spread of malignant endometrial cells. This has raised concerns that hysteroscopy might be responsible for a worse prognosis in women with endometrial cancer.

But in a poster presentation at the biennial meeting of the International Gynecologic Cancer Society, Dr. A. Ben Arie and colleagues found no evidence that hysteroscopy was associated with an increase in endometrial cancer recurrences.

The retrospective study involved 392 women provisionally diagnosed with stage I endometrial adenocarcinoma at five medical centers in Israel. Dr. Ben Arie of Kaplan Medical Center, Rehovot, Israel, and colleagues examined the women's medical records, retrieving data on mode of diagnosis, histologic type, grade and stage of the disease, and the patient's outcome.

Three different diagnostic methods were employed in the women—25% had an endometrial biopsy, 49% had uterine curettage, and 26% had hysteroscopy. Endometrial adenocarcinoma was found in 88.5% of the women, and the other 11.5% had uterine serous papillary cancer, clear cell cancer, or small cell cancer. The cancer was stage I in 81% of the women, stage II in 2% of the women, and stage III in 17% of the women.

At a mean follow-up time of 55 months (range 12–233 months), recurrences were found in 5% of the women who had hysteroscopy, 4.7% of the women who had curettage, and 13.1% of the women who had endometrial biopsy. There was no statistically significant difference in the recurrence rate among the three diagnostic methods.

SANTA MONICA, CALIF. — Persistent abdominal distention, but not transient bloating, is associated with ovarian cancer, and clinicians should listen to their patients carefully to distinguish between the symptoms, according to a poster presentation by Dr. Clare R. Bankhead at the biennial meeting of the International Gynecologic Cancer Society.

Dr. Bankhead of the University of Oxford (England), and her colleagues conducted semistructured interviews with 124 women who were referred for evaluation of suspected ovarian malignancies. The investigators conducted a qualitative thematic analysis of the interviews to extract potential symptoms of ovarian cancer, and they conducted a multivariate quantitative analysis of the reported symptoms to determine which ones were associated with a diagnosis of ovarian cancer.

Of the 124 women, 44 were eventually diagnosed with malignancies. Forty of the malignancies were ovarian primary cancers (25 of which were at an advanced stage), two were peritoneal cancers, and the remaining two were gynecological cancers whose primary sites were unknown. Of the 80 women without cancer, 59 had benign gynecologic pathology and 21 had normal findings.

After adjusting for other symptoms, women with persistent abdominal distention with or without bloating were 5.2 times as likely to be diagnosed with ovarian cancer as women with neither bloating nor distention. This odds ratio was statistically significant. Bloating alone, on the other hand, was not associated with an increased or decreased chance of being diagnosed with ovarian cancer.

Four other symptoms emerged in the multivariate analysis as being significantly associated with ovarian cancer diagnoses. They were early satiety (odds ratio 5.0), loss of appetite (odds ratio 3.2), postmenopausal bleeding (odds ratio 9.2), and progressive worsening of symptoms (odds ratio 3.6).

“The findings emphasize the need to listen carefully to women's accounts of abdominal symptoms,” the investigators wrote. “Clinicians should clarify whether women are describing bloating [fluctuating discomfort] or distention, and whether the symptoms are transient or persistent, in order to distinguish between them.”

SANTA MONICA, CALIF. — Persistent abdominal distention, but not transient bloating, is associated with ovarian cancer, and clinicians should listen to their patients carefully to distinguish between the symptoms, according to a poster presentation by Dr. Clare R. Bankhead at the biennial meeting of the International Gynecologic Cancer Society.

Dr. Bankhead of the University of Oxford (England), and her colleagues conducted semistructured interviews with 124 women who were referred for evaluation of suspected ovarian malignancies. The investigators conducted a qualitative thematic analysis of the interviews to extract potential symptoms of ovarian cancer, and they conducted a multivariate quantitative analysis of the reported symptoms to determine which ones were associated with a diagnosis of ovarian cancer.

Of the 124 women, 44 were eventually diagnosed with malignancies. Forty of the malignancies were ovarian primary cancers (25 of which were at an advanced stage), two were peritoneal cancers, and the remaining two were gynecological cancers whose primary sites were unknown. Of the 80 women without cancer, 59 had benign gynecologic pathology and 21 had normal findings.

After adjusting for other symptoms, women with persistent abdominal distention with or without bloating were 5.2 times as likely to be diagnosed with ovarian cancer as women with neither bloating nor distention. This odds ratio was statistically significant. Bloating alone, on the other hand, was not associated with an increased or decreased chance of being diagnosed with ovarian cancer.

Four other symptoms emerged in the multivariate analysis as being significantly associated with ovarian cancer diagnoses. They were early satiety (odds ratio 5.0), loss of appetite (odds ratio 3.2), postmenopausal bleeding (odds ratio 9.2), and progressive worsening of symptoms (odds ratio 3.6).

“The findings emphasize the need to listen carefully to women's accounts of abdominal symptoms,” the investigators wrote. “Clinicians should clarify whether women are describing bloating [fluctuating discomfort] or distention, and whether the symptoms are transient or persistent, in order to distinguish between them.”

SANTA MONICA, CALIF. — Persistent abdominal distention, but not transient bloating, is associated with ovarian cancer, and clinicians should listen to their patients carefully to distinguish between the symptoms, according to a poster presentation by Dr. Clare R. Bankhead at the biennial meeting of the International Gynecologic Cancer Society.

Dr. Bankhead of the University of Oxford (England), and her colleagues conducted semistructured interviews with 124 women who were referred for evaluation of suspected ovarian malignancies. The investigators conducted a qualitative thematic analysis of the interviews to extract potential symptoms of ovarian cancer, and they conducted a multivariate quantitative analysis of the reported symptoms to determine which ones were associated with a diagnosis of ovarian cancer.

Of the 124 women, 44 were eventually diagnosed with malignancies. Forty of the malignancies were ovarian primary cancers (25 of which were at an advanced stage), two were peritoneal cancers, and the remaining two were gynecological cancers whose primary sites were unknown. Of the 80 women without cancer, 59 had benign gynecologic pathology and 21 had normal findings.

After adjusting for other symptoms, women with persistent abdominal distention with or without bloating were 5.2 times as likely to be diagnosed with ovarian cancer as women with neither bloating nor distention. This odds ratio was statistically significant. Bloating alone, on the other hand, was not associated with an increased or decreased chance of being diagnosed with ovarian cancer.

Four other symptoms emerged in the multivariate analysis as being significantly associated with ovarian cancer diagnoses. They were early satiety (odds ratio 5.0), loss of appetite (odds ratio 3.2), postmenopausal bleeding (odds ratio 9.2), and progressive worsening of symptoms (odds ratio 3.6).

“The findings emphasize the need to listen carefully to women's accounts of abdominal symptoms,” the investigators wrote. “Clinicians should clarify whether women are describing bloating [fluctuating discomfort] or distention, and whether the symptoms are transient or persistent, in order to distinguish between them.”