Robert Finn

The majority of children with asthma fail to get vaccinated for influenza even when they visit health care providers during the flu season.

Addressing these missed opportunities for vaccination could significantly improve vaccination rates among these children, according to results of a recently published study.

In this retrospective study of 4,358 asthmatic children (aged 5–18 years) in the Michigan Medicaid program, only 17% had a flu vaccination during the 2001–2002 flu season, and only 22% had a flu vaccination during the 2002–2003 season. Less than 10% of children received influenza vaccinations in both seasons, and 71% were not vaccinated in either season (Arch. Pediatr. Adolesc. Med. 2006;160:966–71).

During 2001–2002, 73% of the children had at least one missed opportunity for vaccination, defined as visits during the flu season (October-January) when a vaccine-eligible child is seen by a health care professional, yet no vaccine is administered. During the 2002–2003 flu season, 69% of the children had at least one missed opportunity.

In each of the seasons, close to 50% of the missed opportunities occurred in October, and nearly three-quarters occurred in either October or November.

These figures demonstrate that missed opportunities to vaccinate for influenza are more common than vaccination among these children and frequently occur in successive influenza seasons, said Kevin J. Dombkowski, Dr.P.H., and his colleagues from the University of Michigan, Ann Arbor. They said that their study was the first to look at children with public insurance over successive flu seasons. But the results were similar to earlier studies of privately insured children with asthma, which also found that missed opportunities for flu vaccination abounded.

The investigators calculated that even a modest reduction in missed opportunities could substantially increase influenza vaccination rates. A 25% reduction in missed opportunities would result in an overall 35% vaccination rate among children with asthma, and a 50% reduction in missed opportunities would translate into an overall vaccination rate of 49%.

Dr. Dombkowski and his associates suggested that standing orders and reminder-recall systems could reduce the rate of missed opportunities for vaccination. They urged that emphasis be placed on implementing physician-focused reminder systems, but that reminder systems that prompt parents to request vaccination also may be effective.

The majority of children with asthma fail to get vaccinated for influenza even when they visit health care providers during the flu season.

Addressing these missed opportunities for vaccination could significantly improve vaccination rates among these children, according to results of a recently published study.

In this retrospective study of 4,358 asthmatic children (aged 5–18 years) in the Michigan Medicaid program, only 17% had a flu vaccination during the 2001–2002 flu season, and only 22% had a flu vaccination during the 2002–2003 season. Less than 10% of children received influenza vaccinations in both seasons, and 71% were not vaccinated in either season (Arch. Pediatr. Adolesc. Med. 2006;160:966–71).

During 2001–2002, 73% of the children had at least one missed opportunity for vaccination, defined as visits during the flu season (October-January) when a vaccine-eligible child is seen by a health care professional, yet no vaccine is administered. During the 2002–2003 flu season, 69% of the children had at least one missed opportunity.

In each of the seasons, close to 50% of the missed opportunities occurred in October, and nearly three-quarters occurred in either October or November.

These figures demonstrate that missed opportunities to vaccinate for influenza are more common than vaccination among these children and frequently occur in successive influenza seasons, said Kevin J. Dombkowski, Dr.P.H., and his colleagues from the University of Michigan, Ann Arbor. They said that their study was the first to look at children with public insurance over successive flu seasons. But the results were similar to earlier studies of privately insured children with asthma, which also found that missed opportunities for flu vaccination abounded.

The investigators calculated that even a modest reduction in missed opportunities could substantially increase influenza vaccination rates. A 25% reduction in missed opportunities would result in an overall 35% vaccination rate among children with asthma, and a 50% reduction in missed opportunities would translate into an overall vaccination rate of 49%.

Dr. Dombkowski and his associates suggested that standing orders and reminder-recall systems could reduce the rate of missed opportunities for vaccination. They urged that emphasis be placed on implementing physician-focused reminder systems, but that reminder systems that prompt parents to request vaccination also may be effective.

The majority of children with asthma fail to get vaccinated for influenza even when they visit health care providers during the flu season.

Addressing these missed opportunities for vaccination could significantly improve vaccination rates among these children, according to results of a recently published study.

In this retrospective study of 4,358 asthmatic children (aged 5–18 years) in the Michigan Medicaid program, only 17% had a flu vaccination during the 2001–2002 flu season, and only 22% had a flu vaccination during the 2002–2003 season. Less than 10% of children received influenza vaccinations in both seasons, and 71% were not vaccinated in either season (Arch. Pediatr. Adolesc. Med. 2006;160:966–71).

During 2001–2002, 73% of the children had at least one missed opportunity for vaccination, defined as visits during the flu season (October-January) when a vaccine-eligible child is seen by a health care professional, yet no vaccine is administered. During the 2002–2003 flu season, 69% of the children had at least one missed opportunity.

In each of the seasons, close to 50% of the missed opportunities occurred in October, and nearly three-quarters occurred in either October or November.

These figures demonstrate that missed opportunities to vaccinate for influenza are more common than vaccination among these children and frequently occur in successive influenza seasons, said Kevin J. Dombkowski, Dr.P.H., and his colleagues from the University of Michigan, Ann Arbor. They said that their study was the first to look at children with public insurance over successive flu seasons. But the results were similar to earlier studies of privately insured children with asthma, which also found that missed opportunities for flu vaccination abounded.

The investigators calculated that even a modest reduction in missed opportunities could substantially increase influenza vaccination rates. A 25% reduction in missed opportunities would result in an overall 35% vaccination rate among children with asthma, and a 50% reduction in missed opportunities would translate into an overall vaccination rate of 49%.

Dr. Dombkowski and his associates suggested that standing orders and reminder-recall systems could reduce the rate of missed opportunities for vaccination. They urged that emphasis be placed on implementing physician-focused reminder systems, but that reminder systems that prompt parents to request vaccination also may be effective.

SAN FRANCISCO — Antiresorptive therapy should be continued even in patients showing no apparent response, Dr. Douglas C. Bauer said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Monitoring response with periodic bone mineral density (BMD) testing may be misleading, said Dr. Bauer, of UCSF. Furthermore, studies show that antiresorptive therapy decreases fracture risk even when BMD declines. And a patient whose BMD declines in the first year of therapy will often see an improvement in subsequent years.

Those advocating periodic monitoring cite several potential advantages of the practice, including increases in patient satisfaction, improvements in adherence, and the ability to change to more effective therapy in the presence of a nonresponse.

But Dr. Bauer pointed out that there are no studies demonstrating that monitoring improves patient satisfaction or adherence. Although it is true that many patients stop taking drugs to prevent osteoporosis, more than half of those who discontinue do so within 6 months of beginning therapy, he said. Measuring BMD 1–2 years following diagnosis is therefore unlikely to encourage adherence in the majority of patients.

In addition, changes in BMD on subsequent measurements may be misleading. Although BMD is usually considered a very precise measurement, with precision errors in the neighborhood of 1%–2%, some apparent changes in BMD may be due to noise or to small differences in patient position, Dr. Bauer said.

To figure out what changes in BMD measurements are due to chance, Dr. Bauer recommended using the “least significant change” formula. The least significant change in any measurement is defined as three times the measurement's long-term reproducibility. For example, if a dual-energy x-ray absorptiometry instrument has a long-term coefficient of variation of 1.5%, then its least significant change would be 4.5%, meaning that changes of less than 4.5% from measurement to measurement may well be due to chance.

But even if a patient's BMD truly is declining, that does not necessarily mean that the patient is failing to respond to treatment, since he or she may well have lost more bone without treatment, he added.

And an initial loss of bone during treatment doesn't mean that this loss will continue. Dr. Bauer quoted one study that showed that of patients who lost more than 4% of their BMD during the first year of treatment, 92% gained BMD in the second year, and the average increase during the second year was 4.8%. On the other hand, of patients who gained more than 8% in BMD during the first year, only 36% continue to gain BMD in the second year, and as a whole that group lost 1% of their BMD during that second-year.

An analysis of a clinical trial of alendronate versus placebo compared the patients who lost most BMD while taking alendronate with those who lost most BMD while taking placebo. Fracture risk was reduced by about 50% in those taking alendronate despite their loss of BMD.

Clinicians should consider secondary causes of osteoporosis in patients who are losing BMD despite antiresorptive therapy, Dr. Bauer said. Among the common secondary causes of bone loss are weight loss; medications such as corticosteroids, aromatase inhibitors, and glitazones; inflammatory diseases or myeloma; or malabsorption.

“It's very useful to have these conversations [with patients] about follow-up measurements at the time you start therapy as opposed to having these conversations a year later or 2 years later,” Dr. Bauer said.

“I always make a point … to say that bone mineral density is a terrific test to decide who should be treated or who shouldn't be treated. But it's a lousy test to tell us whether you're benefiting from the therapy or not,” he said.

SAN FRANCISCO — Antiresorptive therapy should be continued even in patients showing no apparent response, Dr. Douglas C. Bauer said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Monitoring response with periodic bone mineral density (BMD) testing may be misleading, said Dr. Bauer, of UCSF. Furthermore, studies show that antiresorptive therapy decreases fracture risk even when BMD declines. And a patient whose BMD declines in the first year of therapy will often see an improvement in subsequent years.

Those advocating periodic monitoring cite several potential advantages of the practice, including increases in patient satisfaction, improvements in adherence, and the ability to change to more effective therapy in the presence of a nonresponse.

But Dr. Bauer pointed out that there are no studies demonstrating that monitoring improves patient satisfaction or adherence. Although it is true that many patients stop taking drugs to prevent osteoporosis, more than half of those who discontinue do so within 6 months of beginning therapy, he said. Measuring BMD 1–2 years following diagnosis is therefore unlikely to encourage adherence in the majority of patients.

In addition, changes in BMD on subsequent measurements may be misleading. Although BMD is usually considered a very precise measurement, with precision errors in the neighborhood of 1%–2%, some apparent changes in BMD may be due to noise or to small differences in patient position, Dr. Bauer said.

To figure out what changes in BMD measurements are due to chance, Dr. Bauer recommended using the “least significant change” formula. The least significant change in any measurement is defined as three times the measurement's long-term reproducibility. For example, if a dual-energy x-ray absorptiometry instrument has a long-term coefficient of variation of 1.5%, then its least significant change would be 4.5%, meaning that changes of less than 4.5% from measurement to measurement may well be due to chance.

But even if a patient's BMD truly is declining, that does not necessarily mean that the patient is failing to respond to treatment, since he or she may well have lost more bone without treatment, he added.

And an initial loss of bone during treatment doesn't mean that this loss will continue. Dr. Bauer quoted one study that showed that of patients who lost more than 4% of their BMD during the first year of treatment, 92% gained BMD in the second year, and the average increase during the second year was 4.8%. On the other hand, of patients who gained more than 8% in BMD during the first year, only 36% continue to gain BMD in the second year, and as a whole that group lost 1% of their BMD during that second-year.

An analysis of a clinical trial of alendronate versus placebo compared the patients who lost most BMD while taking alendronate with those who lost most BMD while taking placebo. Fracture risk was reduced by about 50% in those taking alendronate despite their loss of BMD.

Clinicians should consider secondary causes of osteoporosis in patients who are losing BMD despite antiresorptive therapy, Dr. Bauer said. Among the common secondary causes of bone loss are weight loss; medications such as corticosteroids, aromatase inhibitors, and glitazones; inflammatory diseases or myeloma; or malabsorption.

“It's very useful to have these conversations [with patients] about follow-up measurements at the time you start therapy as opposed to having these conversations a year later or 2 years later,” Dr. Bauer said.

“I always make a point … to say that bone mineral density is a terrific test to decide who should be treated or who shouldn't be treated. But it's a lousy test to tell us whether you're benefiting from the therapy or not,” he said.

SAN FRANCISCO — Antiresorptive therapy should be continued even in patients showing no apparent response, Dr. Douglas C. Bauer said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Monitoring response with periodic bone mineral density (BMD) testing may be misleading, said Dr. Bauer, of UCSF. Furthermore, studies show that antiresorptive therapy decreases fracture risk even when BMD declines. And a patient whose BMD declines in the first year of therapy will often see an improvement in subsequent years.

Those advocating periodic monitoring cite several potential advantages of the practice, including increases in patient satisfaction, improvements in adherence, and the ability to change to more effective therapy in the presence of a nonresponse.

But Dr. Bauer pointed out that there are no studies demonstrating that monitoring improves patient satisfaction or adherence. Although it is true that many patients stop taking drugs to prevent osteoporosis, more than half of those who discontinue do so within 6 months of beginning therapy, he said. Measuring BMD 1–2 years following diagnosis is therefore unlikely to encourage adherence in the majority of patients.

In addition, changes in BMD on subsequent measurements may be misleading. Although BMD is usually considered a very precise measurement, with precision errors in the neighborhood of 1%–2%, some apparent changes in BMD may be due to noise or to small differences in patient position, Dr. Bauer said.

To figure out what changes in BMD measurements are due to chance, Dr. Bauer recommended using the “least significant change” formula. The least significant change in any measurement is defined as three times the measurement's long-term reproducibility. For example, if a dual-energy x-ray absorptiometry instrument has a long-term coefficient of variation of 1.5%, then its least significant change would be 4.5%, meaning that changes of less than 4.5% from measurement to measurement may well be due to chance.

But even if a patient's BMD truly is declining, that does not necessarily mean that the patient is failing to respond to treatment, since he or she may well have lost more bone without treatment, he added.

And an initial loss of bone during treatment doesn't mean that this loss will continue. Dr. Bauer quoted one study that showed that of patients who lost more than 4% of their BMD during the first year of treatment, 92% gained BMD in the second year, and the average increase during the second year was 4.8%. On the other hand, of patients who gained more than 8% in BMD during the first year, only 36% continue to gain BMD in the second year, and as a whole that group lost 1% of their BMD during that second-year.

An analysis of a clinical trial of alendronate versus placebo compared the patients who lost most BMD while taking alendronate with those who lost most BMD while taking placebo. Fracture risk was reduced by about 50% in those taking alendronate despite their loss of BMD.

Clinicians should consider secondary causes of osteoporosis in patients who are losing BMD despite antiresorptive therapy, Dr. Bauer said. Among the common secondary causes of bone loss are weight loss; medications such as corticosteroids, aromatase inhibitors, and glitazones; inflammatory diseases or myeloma; or malabsorption.

“It's very useful to have these conversations [with patients] about follow-up measurements at the time you start therapy as opposed to having these conversations a year later or 2 years later,” Dr. Bauer said.

“I always make a point … to say that bone mineral density is a terrific test to decide who should be treated or who shouldn't be treated. But it's a lousy test to tell us whether you're benefiting from the therapy or not,” he said.

SAN FRANCISCO — Finding one possible cause of secondary osteoporosis does not mean there aren't other causes as well, Dr. Diana Antoniucci reported at a meeting on osteoporosis sponsored by the University of California, San Francisco.

“Having one secondary cause of osteoporosis does not preclude you from having another, so even if one contributor is obvious from the history, you can still consider laboratory testing,” said Dr. Antoniucci, of UCSF. (See sidebar for suggestions on which tests to order.) She listed four frequent causes of secondary osteoporosis for physicians to consider.

Glucocorticoid Use

This is the most common cause of drug-induced osteoporosis. In these patients, prevention is the best strategy. All patients should be taking supplemental calcium and vitamin D, Dr. Antoniucci said, and if the patient has already been diagnosed with osteoporosis or is otherwise at high risk, the physician should measure bone mineral density (BMD) with dual-energy x-ray absorptiometry (DXA). Clinical trials have shown that bisphosphonates halt bone loss and reduce fractures in patients taking glucocorticoids, and alendronate and risedronate are both approved for this indication. They should be considered for any patient on glucocorticoids with low BMD.

Vitamin D Deficiency

This deficiency is common in the general population. Depending on the study population, the prevalence appears to range between 9% and 50%. When severe, vitamin D deficiency is associated with osteomalacia, which is indistinguishable from low bone density on DXA. Less-severe vitamin D deficiency is associated with secondary hyperparathyroidism.

One difficulty in the assessment and treatment of vitamin D deficiency is that there is no general agreement as to what constitutes a sufficient level of 25-hydroxyvitamin D, Dr. Antoniucci noted. A level of 20 ng/mL appears to be necessary for normal parathyroid dynamics, 32–36 ng/mL appears to be necessary for maximal intestinal calcium transport, and 30–40 ng/mL is the level that several randomized controlled trials have determined is necessary for fracture reduction.

“The good news is that vitamin D insufficiency is treatable,” Dr. Antoniucci said. “Replacement reestablishes vitamin D stores, and it improves bone mineral density because it allows optimal calcification of preexisting osteoid.”

Celiac Disease

Somewhere between 9% and 12% of patients with osteoporosis also have celiac disease. Conversely, about 50% of patients with celiac disease have a BMD that is two standard deviations or more under the mean. Among patients with celiac disease, those with a low BMD are more likely to have villous atrophy, an indication of more severe disease.

The pathogenesis of bone disease in these patients is likely multifactorial, according to Dr. Antoniucci. They tend to have worse calcium absorption from the gut, especially before their disease is diagnosed, which can be many years in some patients. They also can have vitamin D deficiency from secondary hyperparathyroidism. Some women with celiac disease also have infertility and amenorrhea, both of which can lead to poor bone health.

At least one study has demonstrated that among patients with celiac disease, a strict gluten-free diet over the period of a year can improve bone mass in both men and women (Arch. Intern. Med. 2005;165:393–9). The authors of that study concluded that it's worth screening patients with unexplained osteoporosis for celiac disease.

Dr. Antoniucci is not so sure that that's a good idea. “First of all, what exactly is 'unexplained osteoporosis'? And secondly, it might be a very expensive way to be treating the disease,” she said.

Androgen Deprivation Therapy

This is a common treatment for men with prostate cancer, but the longer a man is on this therapy, the greater his BMD loss and the greater his chance of fracture. After 10 years on androgen deprivation therapy, about 20% of men will have experienced a fracture, a risk fivefold greater than in age-matched controls. Slender white men seem to be at greatest risk, she said, noting that both pamidronate and zoledronate have been shown to prevent bone loss caused by androgen deprivation therapy.

Telling Lab Tests To Keep on Hand

There is no consensus on whom to evaluate for secondary osteoporosis, said Dr. Antoniucci. However, “most people would agree that we should evaluate virtually all men with low T-scores, premenopausal women with low z-scores or fragility fractures, and postmenopausal women.” A standard laboratory work-up should include:

▸ Electrolyte levels

▸ Renal and hepatic function

▸ Complete blood count

▸ 24-hour urine calcium excretion (can provide important information if the result is very high or low)

▸ 25-hydroxyvitamin D levels

▸ Testosterone levels

▸ Thyroid-stimulating hormone levels (in patients on thyroid hormone replacement)

Additional tests should be dictated by the patient's history and physical exam and the physician's clinical judgment.

SAN FRANCISCO — Finding one possible cause of secondary osteoporosis does not mean there aren't other causes as well, Dr. Diana Antoniucci reported at a meeting on osteoporosis sponsored by the University of California, San Francisco.

“Having one secondary cause of osteoporosis does not preclude you from having another, so even if one contributor is obvious from the history, you can still consider laboratory testing,” said Dr. Antoniucci, of UCSF. (See sidebar for suggestions on which tests to order.) She listed four frequent causes of secondary osteoporosis for physicians to consider.

Glucocorticoid Use

This is the most common cause of drug-induced osteoporosis. In these patients, prevention is the best strategy. All patients should be taking supplemental calcium and vitamin D, Dr. Antoniucci said, and if the patient has already been diagnosed with osteoporosis or is otherwise at high risk, the physician should measure bone mineral density (BMD) with dual-energy x-ray absorptiometry (DXA). Clinical trials have shown that bisphosphonates halt bone loss and reduce fractures in patients taking glucocorticoids, and alendronate and risedronate are both approved for this indication. They should be considered for any patient on glucocorticoids with low BMD.

Vitamin D Deficiency

This deficiency is common in the general population. Depending on the study population, the prevalence appears to range between 9% and 50%. When severe, vitamin D deficiency is associated with osteomalacia, which is indistinguishable from low bone density on DXA. Less-severe vitamin D deficiency is associated with secondary hyperparathyroidism.

One difficulty in the assessment and treatment of vitamin D deficiency is that there is no general agreement as to what constitutes a sufficient level of 25-hydroxyvitamin D, Dr. Antoniucci noted. A level of 20 ng/mL appears to be necessary for normal parathyroid dynamics, 32–36 ng/mL appears to be necessary for maximal intestinal calcium transport, and 30–40 ng/mL is the level that several randomized controlled trials have determined is necessary for fracture reduction.

“The good news is that vitamin D insufficiency is treatable,” Dr. Antoniucci said. “Replacement reestablishes vitamin D stores, and it improves bone mineral density because it allows optimal calcification of preexisting osteoid.”

Celiac Disease

Somewhere between 9% and 12% of patients with osteoporosis also have celiac disease. Conversely, about 50% of patients with celiac disease have a BMD that is two standard deviations or more under the mean. Among patients with celiac disease, those with a low BMD are more likely to have villous atrophy, an indication of more severe disease.

The pathogenesis of bone disease in these patients is likely multifactorial, according to Dr. Antoniucci. They tend to have worse calcium absorption from the gut, especially before their disease is diagnosed, which can be many years in some patients. They also can have vitamin D deficiency from secondary hyperparathyroidism. Some women with celiac disease also have infertility and amenorrhea, both of which can lead to poor bone health.

At least one study has demonstrated that among patients with celiac disease, a strict gluten-free diet over the period of a year can improve bone mass in both men and women (Arch. Intern. Med. 2005;165:393–9). The authors of that study concluded that it's worth screening patients with unexplained osteoporosis for celiac disease.

Dr. Antoniucci is not so sure that that's a good idea. “First of all, what exactly is 'unexplained osteoporosis'? And secondly, it might be a very expensive way to be treating the disease,” she said.

Androgen Deprivation Therapy

This is a common treatment for men with prostate cancer, but the longer a man is on this therapy, the greater his BMD loss and the greater his chance of fracture. After 10 years on androgen deprivation therapy, about 20% of men will have experienced a fracture, a risk fivefold greater than in age-matched controls. Slender white men seem to be at greatest risk, she said, noting that both pamidronate and zoledronate have been shown to prevent bone loss caused by androgen deprivation therapy.

Telling Lab Tests To Keep on Hand

There is no consensus on whom to evaluate for secondary osteoporosis, said Dr. Antoniucci. However, “most people would agree that we should evaluate virtually all men with low T-scores, premenopausal women with low z-scores or fragility fractures, and postmenopausal women.” A standard laboratory work-up should include:

▸ Electrolyte levels

▸ Renal and hepatic function

▸ Complete blood count

▸ 24-hour urine calcium excretion (can provide important information if the result is very high or low)

▸ 25-hydroxyvitamin D levels

▸ Testosterone levels

▸ Thyroid-stimulating hormone levels (in patients on thyroid hormone replacement)

Additional tests should be dictated by the patient's history and physical exam and the physician's clinical judgment.

SAN FRANCISCO — Finding one possible cause of secondary osteoporosis does not mean there aren't other causes as well, Dr. Diana Antoniucci reported at a meeting on osteoporosis sponsored by the University of California, San Francisco.

“Having one secondary cause of osteoporosis does not preclude you from having another, so even if one contributor is obvious from the history, you can still consider laboratory testing,” said Dr. Antoniucci, of UCSF. (See sidebar for suggestions on which tests to order.) She listed four frequent causes of secondary osteoporosis for physicians to consider.

Glucocorticoid Use

This is the most common cause of drug-induced osteoporosis. In these patients, prevention is the best strategy. All patients should be taking supplemental calcium and vitamin D, Dr. Antoniucci said, and if the patient has already been diagnosed with osteoporosis or is otherwise at high risk, the physician should measure bone mineral density (BMD) with dual-energy x-ray absorptiometry (DXA). Clinical trials have shown that bisphosphonates halt bone loss and reduce fractures in patients taking glucocorticoids, and alendronate and risedronate are both approved for this indication. They should be considered for any patient on glucocorticoids with low BMD.

Vitamin D Deficiency

This deficiency is common in the general population. Depending on the study population, the prevalence appears to range between 9% and 50%. When severe, vitamin D deficiency is associated with osteomalacia, which is indistinguishable from low bone density on DXA. Less-severe vitamin D deficiency is associated with secondary hyperparathyroidism.

One difficulty in the assessment and treatment of vitamin D deficiency is that there is no general agreement as to what constitutes a sufficient level of 25-hydroxyvitamin D, Dr. Antoniucci noted. A level of 20 ng/mL appears to be necessary for normal parathyroid dynamics, 32–36 ng/mL appears to be necessary for maximal intestinal calcium transport, and 30–40 ng/mL is the level that several randomized controlled trials have determined is necessary for fracture reduction.

“The good news is that vitamin D insufficiency is treatable,” Dr. Antoniucci said. “Replacement reestablishes vitamin D stores, and it improves bone mineral density because it allows optimal calcification of preexisting osteoid.”

Celiac Disease

Somewhere between 9% and 12% of patients with osteoporosis also have celiac disease. Conversely, about 50% of patients with celiac disease have a BMD that is two standard deviations or more under the mean. Among patients with celiac disease, those with a low BMD are more likely to have villous atrophy, an indication of more severe disease.

The pathogenesis of bone disease in these patients is likely multifactorial, according to Dr. Antoniucci. They tend to have worse calcium absorption from the gut, especially before their disease is diagnosed, which can be many years in some patients. They also can have vitamin D deficiency from secondary hyperparathyroidism. Some women with celiac disease also have infertility and amenorrhea, both of which can lead to poor bone health.

At least one study has demonstrated that among patients with celiac disease, a strict gluten-free diet over the period of a year can improve bone mass in both men and women (Arch. Intern. Med. 2005;165:393–9). The authors of that study concluded that it's worth screening patients with unexplained osteoporosis for celiac disease.

Dr. Antoniucci is not so sure that that's a good idea. “First of all, what exactly is 'unexplained osteoporosis'? And secondly, it might be a very expensive way to be treating the disease,” she said.

Androgen Deprivation Therapy

This is a common treatment for men with prostate cancer, but the longer a man is on this therapy, the greater his BMD loss and the greater his chance of fracture. After 10 years on androgen deprivation therapy, about 20% of men will have experienced a fracture, a risk fivefold greater than in age-matched controls. Slender white men seem to be at greatest risk, she said, noting that both pamidronate and zoledronate have been shown to prevent bone loss caused by androgen deprivation therapy.

Telling Lab Tests To Keep on Hand

There is no consensus on whom to evaluate for secondary osteoporosis, said Dr. Antoniucci. However, “most people would agree that we should evaluate virtually all men with low T-scores, premenopausal women with low z-scores or fragility fractures, and postmenopausal women.” A standard laboratory work-up should include:

▸ Electrolyte levels

▸ Renal and hepatic function

▸ Complete blood count

▸ 24-hour urine calcium excretion (can provide important information if the result is very high or low)

▸ 25-hydroxyvitamin D levels

▸ Testosterone levels

▸ Thyroid-stimulating hormone levels (in patients on thyroid hormone replacement)

Additional tests should be dictated by the patient's history and physical exam and the physician's clinical judgment.

SAN FRANCISCO – A study of adolescent mothers revealed that frequent contact with the father of their baby was associated with several beneficial effects, including improved maternal mental health and less endorsement of physical punishment for the child, Dr. Lee Savio Beers reported in a poster at the annual meeting of the Pediatric Academic Societies.

The study involved 138 mothers under the age of 20 years whose children were younger than 12 months old, said Dr. Beers of Children's National Medical Center, Washington, D.C., who conducted the study with Amy Lewin, Psy.D., and several other colleagues.

The women came from an urban population, and 94% were African American. They were questioned about the father's involvement in parenting the child, and they completed several standardized instruments intended to measure, for example, their mental health and level of self-esteem.

Only the 130 mothers who were 16–19 years old were asked about the age of the father. Eighteen percent of these fathers were age 17 or younger, 30% were 18–21, and the rest were 22 years old or older. Legal concerns prevented the investigators from asking younger mothers about the age of their child's father.

Overall, 52% of the fathers had completed high school, 30% were currently in school, 43% were employed, and 29% had children with other mothers.

The mothers reported a large amount of paternal contact with the babies; 62% of the mothers reported contact several times a week or more, 25% reported contact 1–8 times per month, and 14% reported rare contact or none at all, Dr. Beers said.

Sixty-one percent of mothers reported that they were satisfied with the level of paternal contact, 27% said that the contact was not frequent enough, and 12% said that their contact with the father was too frequent.

Although 75% of the mothers wanted the fathers to have frequent contact with the baby during the next 12 months, they had lower expectations for caregiving. Only 63% expected the fathers to feed the baby, 43% expected the fathers to change the diapers, and 35% expected the fathers to attend the baby's medical appointments, she said.

Fifty-two percent of the mothers reported being in a romantic relationship with the father of their baby; 85% said that these men treated them with respect, and 24% reported having arguments with the men often or very often, Dr. Beers reported at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

Daily contact with the father clearly had beneficial effects. Compared with mothers who had less-than-daily contact with the father, mothers with daily contact had significantly lower levels of depression, had significantly higher levels of self-esteem, and were significantly less likely to say that they endorsed physical punishment of their child.

The investigators found several outcomes among mothers satisfied with the level of paternal contact that were not considered positive in adolescent parents: these mothers were significantly less likely to live with their own mothers or grandmothers, significantly more likely to have more than one child, and were significantly less likely to be in school.

Mothers with daily contact with the father had less depression and higher self-esteem. DR. BEERS

SAN FRANCISCO – A study of adolescent mothers revealed that frequent contact with the father of their baby was associated with several beneficial effects, including improved maternal mental health and less endorsement of physical punishment for the child, Dr. Lee Savio Beers reported in a poster at the annual meeting of the Pediatric Academic Societies.

The study involved 138 mothers under the age of 20 years whose children were younger than 12 months old, said Dr. Beers of Children's National Medical Center, Washington, D.C., who conducted the study with Amy Lewin, Psy.D., and several other colleagues.

The women came from an urban population, and 94% were African American. They were questioned about the father's involvement in parenting the child, and they completed several standardized instruments intended to measure, for example, their mental health and level of self-esteem.

Only the 130 mothers who were 16–19 years old were asked about the age of the father. Eighteen percent of these fathers were age 17 or younger, 30% were 18–21, and the rest were 22 years old or older. Legal concerns prevented the investigators from asking younger mothers about the age of their child's father.

Overall, 52% of the fathers had completed high school, 30% were currently in school, 43% were employed, and 29% had children with other mothers.

The mothers reported a large amount of paternal contact with the babies; 62% of the mothers reported contact several times a week or more, 25% reported contact 1–8 times per month, and 14% reported rare contact or none at all, Dr. Beers said.

Sixty-one percent of mothers reported that they were satisfied with the level of paternal contact, 27% said that the contact was not frequent enough, and 12% said that their contact with the father was too frequent.

Although 75% of the mothers wanted the fathers to have frequent contact with the baby during the next 12 months, they had lower expectations for caregiving. Only 63% expected the fathers to feed the baby, 43% expected the fathers to change the diapers, and 35% expected the fathers to attend the baby's medical appointments, she said.

Fifty-two percent of the mothers reported being in a romantic relationship with the father of their baby; 85% said that these men treated them with respect, and 24% reported having arguments with the men often or very often, Dr. Beers reported at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

Daily contact with the father clearly had beneficial effects. Compared with mothers who had less-than-daily contact with the father, mothers with daily contact had significantly lower levels of depression, had significantly higher levels of self-esteem, and were significantly less likely to say that they endorsed physical punishment of their child.

The investigators found several outcomes among mothers satisfied with the level of paternal contact that were not considered positive in adolescent parents: these mothers were significantly less likely to live with their own mothers or grandmothers, significantly more likely to have more than one child, and were significantly less likely to be in school.

Mothers with daily contact with the father had less depression and higher self-esteem. DR. BEERS

SAN FRANCISCO – A study of adolescent mothers revealed that frequent contact with the father of their baby was associated with several beneficial effects, including improved maternal mental health and less endorsement of physical punishment for the child, Dr. Lee Savio Beers reported in a poster at the annual meeting of the Pediatric Academic Societies.

The study involved 138 mothers under the age of 20 years whose children were younger than 12 months old, said Dr. Beers of Children's National Medical Center, Washington, D.C., who conducted the study with Amy Lewin, Psy.D., and several other colleagues.

The women came from an urban population, and 94% were African American. They were questioned about the father's involvement in parenting the child, and they completed several standardized instruments intended to measure, for example, their mental health and level of self-esteem.

Only the 130 mothers who were 16–19 years old were asked about the age of the father. Eighteen percent of these fathers were age 17 or younger, 30% were 18–21, and the rest were 22 years old or older. Legal concerns prevented the investigators from asking younger mothers about the age of their child's father.

Overall, 52% of the fathers had completed high school, 30% were currently in school, 43% were employed, and 29% had children with other mothers.

The mothers reported a large amount of paternal contact with the babies; 62% of the mothers reported contact several times a week or more, 25% reported contact 1–8 times per month, and 14% reported rare contact or none at all, Dr. Beers said.

Sixty-one percent of mothers reported that they were satisfied with the level of paternal contact, 27% said that the contact was not frequent enough, and 12% said that their contact with the father was too frequent.

Although 75% of the mothers wanted the fathers to have frequent contact with the baby during the next 12 months, they had lower expectations for caregiving. Only 63% expected the fathers to feed the baby, 43% expected the fathers to change the diapers, and 35% expected the fathers to attend the baby's medical appointments, she said.

Fifty-two percent of the mothers reported being in a romantic relationship with the father of their baby; 85% said that these men treated them with respect, and 24% reported having arguments with the men often or very often, Dr. Beers reported at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

Daily contact with the father clearly had beneficial effects. Compared with mothers who had less-than-daily contact with the father, mothers with daily contact had significantly lower levels of depression, had significantly higher levels of self-esteem, and were significantly less likely to say that they endorsed physical punishment of their child.

The investigators found several outcomes among mothers satisfied with the level of paternal contact that were not considered positive in adolescent parents: these mothers were significantly less likely to live with their own mothers or grandmothers, significantly more likely to have more than one child, and were significantly less likely to be in school.

Mothers with daily contact with the father had less depression and higher self-esteem. DR. BEERS

SAN FRANCISCO – Children of mothers with chronic depression are almost four times as likely to have multiple behavior problems at the age of 3 years as are children of mothers without depression, according to a poster presentation by Dr. Diane L. Langkamp at the annual meeting of the Pediatric Academic Societies.

In addition, both maternal smoking and the lack of health insurance for the child significantly increased the odds of multiple child-behavior problems, wrote Dr. Langkamp and her coinvestigators from the Ohio State University in Columbus.

The investigators of the current study analyzed the results of the 1988 National Maternal and Infant Health Survey–a nationally representative, weighted sample of 9,953 children who were born in the United States that year–and also analyzed a 1991 follow-up to that survey with the same mothers.

When the mothers were first interviewed, their children's ages averaged 17 months; at the follow-up the children's ages averaged 35 months.

At each interview, the original investigators administered the Center for Epidemiologic Studies Depression Scale (CES-D). Scores greater than 15 on that scale are associated with substantial symptoms of clinical depression.

Among the women surveyed, those whose scores were greater than 15 during both interviews were judged to have chronic depression for the purposes of the study. They were compared with women whose scores were 15 or less during both interviews.

At the 1991 follow-up, mothers were asked about the degree or frequency of several types of child behavior or emotional state, such as exhibiting behaviors that were difficult for the mother to manage, the frequency of temper tantrums, and fearfulness.

After adjusting for the mother's smoking status, the child's health insurance status, and maternal race, the odds of multiple behavior problems for children of mothers with chronic depression were 3.69 times higher compared with the children of mothers who did not have depression, Dr. Langkamp and her associates reported.

Maternal smoking increased the odds of behavior problems by 48%, and the lack of health insurance for the child increased the odds of behavior problems by another 50%.

There was also a significant interaction between race and the child's having chronic illness: The odds of behavior problems were higher for African American and Hispanic children with chronic illnesses but not for white children, the investigators said.

Additionally, the investigators found that if the child's birth father lived in the home, significant protection was provided against the effects of the mother's chronic depression on the child's behavior, they noted.

The odds of not having multiple behavior problems were four times higher for children of chronically depressed mothers living with the child's birth father compared with children of mothers not living with the child's birth father, Dr. Langkamp and her associates wrote.

On the other hand, having another adult–such as a grandparent–living in the home provided no protection against child behavior problems in the presence of maternal chronic depression.

Interventions aimed at reducing maternal smoking in the treatment of depression in mothers of young children may have a positive effect on the behavior of those children, concluded the investigators at the meeting, which was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO – Children of mothers with chronic depression are almost four times as likely to have multiple behavior problems at the age of 3 years as are children of mothers without depression, according to a poster presentation by Dr. Diane L. Langkamp at the annual meeting of the Pediatric Academic Societies.

In addition, both maternal smoking and the lack of health insurance for the child significantly increased the odds of multiple child-behavior problems, wrote Dr. Langkamp and her coinvestigators from the Ohio State University in Columbus.

The investigators of the current study analyzed the results of the 1988 National Maternal and Infant Health Survey–a nationally representative, weighted sample of 9,953 children who were born in the United States that year–and also analyzed a 1991 follow-up to that survey with the same mothers.

When the mothers were first interviewed, their children's ages averaged 17 months; at the follow-up the children's ages averaged 35 months.

At each interview, the original investigators administered the Center for Epidemiologic Studies Depression Scale (CES-D). Scores greater than 15 on that scale are associated with substantial symptoms of clinical depression.

Among the women surveyed, those whose scores were greater than 15 during both interviews were judged to have chronic depression for the purposes of the study. They were compared with women whose scores were 15 or less during both interviews.

At the 1991 follow-up, mothers were asked about the degree or frequency of several types of child behavior or emotional state, such as exhibiting behaviors that were difficult for the mother to manage, the frequency of temper tantrums, and fearfulness.

After adjusting for the mother's smoking status, the child's health insurance status, and maternal race, the odds of multiple behavior problems for children of mothers with chronic depression were 3.69 times higher compared with the children of mothers who did not have depression, Dr. Langkamp and her associates reported.

Maternal smoking increased the odds of behavior problems by 48%, and the lack of health insurance for the child increased the odds of behavior problems by another 50%.

There was also a significant interaction between race and the child's having chronic illness: The odds of behavior problems were higher for African American and Hispanic children with chronic illnesses but not for white children, the investigators said.

Additionally, the investigators found that if the child's birth father lived in the home, significant protection was provided against the effects of the mother's chronic depression on the child's behavior, they noted.

The odds of not having multiple behavior problems were four times higher for children of chronically depressed mothers living with the child's birth father compared with children of mothers not living with the child's birth father, Dr. Langkamp and her associates wrote.

On the other hand, having another adult–such as a grandparent–living in the home provided no protection against child behavior problems in the presence of maternal chronic depression.

Interventions aimed at reducing maternal smoking in the treatment of depression in mothers of young children may have a positive effect on the behavior of those children, concluded the investigators at the meeting, which was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO – Children of mothers with chronic depression are almost four times as likely to have multiple behavior problems at the age of 3 years as are children of mothers without depression, according to a poster presentation by Dr. Diane L. Langkamp at the annual meeting of the Pediatric Academic Societies.

In addition, both maternal smoking and the lack of health insurance for the child significantly increased the odds of multiple child-behavior problems, wrote Dr. Langkamp and her coinvestigators from the Ohio State University in Columbus.

The investigators of the current study analyzed the results of the 1988 National Maternal and Infant Health Survey–a nationally representative, weighted sample of 9,953 children who were born in the United States that year–and also analyzed a 1991 follow-up to that survey with the same mothers.

When the mothers were first interviewed, their children's ages averaged 17 months; at the follow-up the children's ages averaged 35 months.

At each interview, the original investigators administered the Center for Epidemiologic Studies Depression Scale (CES-D). Scores greater than 15 on that scale are associated with substantial symptoms of clinical depression.

Among the women surveyed, those whose scores were greater than 15 during both interviews were judged to have chronic depression for the purposes of the study. They were compared with women whose scores were 15 or less during both interviews.

At the 1991 follow-up, mothers were asked about the degree or frequency of several types of child behavior or emotional state, such as exhibiting behaviors that were difficult for the mother to manage, the frequency of temper tantrums, and fearfulness.

After adjusting for the mother's smoking status, the child's health insurance status, and maternal race, the odds of multiple behavior problems for children of mothers with chronic depression were 3.69 times higher compared with the children of mothers who did not have depression, Dr. Langkamp and her associates reported.

Maternal smoking increased the odds of behavior problems by 48%, and the lack of health insurance for the child increased the odds of behavior problems by another 50%.

There was also a significant interaction between race and the child's having chronic illness: The odds of behavior problems were higher for African American and Hispanic children with chronic illnesses but not for white children, the investigators said.

Additionally, the investigators found that if the child's birth father lived in the home, significant protection was provided against the effects of the mother's chronic depression on the child's behavior, they noted.

The odds of not having multiple behavior problems were four times higher for children of chronically depressed mothers living with the child's birth father compared with children of mothers not living with the child's birth father, Dr. Langkamp and her associates wrote.

On the other hand, having another adult–such as a grandparent–living in the home provided no protection against child behavior problems in the presence of maternal chronic depression.

Interventions aimed at reducing maternal smoking in the treatment of depression in mothers of young children may have a positive effect on the behavior of those children, concluded the investigators at the meeting, which was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

MONTEREY, CALIF. — Closing defects is one of the most challenging tasks in dermatologic surgery, but at the annual meeting of the Pacific Dermatologic Association, Dr. Michael J. Fazio shared several clinical pearls that make the job easier and improve the cosmetic results.

To start with, "don't scrimp on the setup," said Dr. Fazio of the University of California, Davis. "Get yourself some nice instruments. I always like to use the golden-handled instruments that have a bit of a sharper edge to them. They last longer, and they sharpen better. They're a little more expensive, but they go on forever."

Dr. Fazio finds that skin hooks provide a more delicate and elegant way of handling tissue, compared with forceps. With forceps, it's important not to pinch down too tightly. Tissue held by the forceps may become necrotic.

Dr. Fazio is a proponent of using bicarbonate in local anesthesia, and he recommends that any physicians who are not using bicarb should try a self-injection. They'll see that the injection is far more painful without bicarbonate. He recommends a 1:10 dilution, adding 5 mL of stock bicarbonate solution to 50 mL of lidocaine with epinephrine. Bicarbonate can destabilize the lidocaine solution over a long period of time, but that's usually not an issue in a busy dermatologic surgery practice.

When preparing to remove a lesion, mark the favorable lines of closure before injecting the anesthetic, which may cause distortion. During creation of the ellipse, it's important that it be long enough; Dr. Fazio prefers that the length be at least three times as long as the width. Inexperienced residents are often reluctant to lengthen the ellipse sufficiently, fearing that the scar will be too large. "If you make a quality scar, you're not going to see it," Dr. Fazio said. "If you make a scar and it's too small, you're going to have lumps on both sides [that] are going to be very noticeable."

Undermine the entire ellipse, the ends as well as the sides, to allow the tissue to slide. As the ellipse is closed it will tend to elongate, and if the ends aren't mobile they will pucker up.

"As I got older and more experienced I started letting things heal more by second intention," Dr. Fazio said. But one needs to be selective in allowing things to heal by themselves. The results tend to be better on convex surfaces of the face than on concave surfaces, for example.

Be aware that wounds healed by second intention tend to shrink by about 50%, so it's not a good idea around free tissue margins such as the eye, nose, and mouth. But on the upper forehead—or even on the scalp in patients lacking hair—second-intention healing can work superbly, especially with a large defect in which it would otherwise be necessary to mobilize a large flap and undermine a wide area.

Second-intention healing also works well in the extremities, and Dr. Fazio prefers this to skin grafts. With split-thickness skin grafts, patients often complain about pain at the donor site, the graft itself can easily become infected, and it can take up to 3 months to heal.

Dr. Fazio's favorite suture materials are 6–0 fast-absorbing gut and 5–0 monofilament. He advocates closing defects subcutaneously so that the cutaneous sutures are used only for epidermal kissing. He has his patients return in a week for suture removal, but the fast-absorbing gut will be mostly or entirely gone by then, so the return visit is mainly for patient reassurance.

Dr. Fazio favors subcutaneous mattress sutures, which work as well as cutaneous vertical mattress sutures but don't give the railroad-track effect. He applies the subcutaneous sutures every 2–4 mm along the scar line so that there's tension on the surface. He then closes the epidermis with a running suture using the 6–0 fast-absorbing gut.

MONTEREY, CALIF. — Closing defects is one of the most challenging tasks in dermatologic surgery, but at the annual meeting of the Pacific Dermatologic Association, Dr. Michael J. Fazio shared several clinical pearls that make the job easier and improve the cosmetic results.

To start with, "don't scrimp on the setup," said Dr. Fazio of the University of California, Davis. "Get yourself some nice instruments. I always like to use the golden-handled instruments that have a bit of a sharper edge to them. They last longer, and they sharpen better. They're a little more expensive, but they go on forever."

Dr. Fazio finds that skin hooks provide a more delicate and elegant way of handling tissue, compared with forceps. With forceps, it's important not to pinch down too tightly. Tissue held by the forceps may become necrotic.

Dr. Fazio is a proponent of using bicarbonate in local anesthesia, and he recommends that any physicians who are not using bicarb should try a self-injection. They'll see that the injection is far more painful without bicarbonate. He recommends a 1:10 dilution, adding 5 mL of stock bicarbonate solution to 50 mL of lidocaine with epinephrine. Bicarbonate can destabilize the lidocaine solution over a long period of time, but that's usually not an issue in a busy dermatologic surgery practice.

When preparing to remove a lesion, mark the favorable lines of closure before injecting the anesthetic, which may cause distortion. During creation of the ellipse, it's important that it be long enough; Dr. Fazio prefers that the length be at least three times as long as the width. Inexperienced residents are often reluctant to lengthen the ellipse sufficiently, fearing that the scar will be too large. "If you make a quality scar, you're not going to see it," Dr. Fazio said. "If you make a scar and it's too small, you're going to have lumps on both sides [that] are going to be very noticeable."

Undermine the entire ellipse, the ends as well as the sides, to allow the tissue to slide. As the ellipse is closed it will tend to elongate, and if the ends aren't mobile they will pucker up.

"As I got older and more experienced I started letting things heal more by second intention," Dr. Fazio said. But one needs to be selective in allowing things to heal by themselves. The results tend to be better on convex surfaces of the face than on concave surfaces, for example.

Be aware that wounds healed by second intention tend to shrink by about 50%, so it's not a good idea around free tissue margins such as the eye, nose, and mouth. But on the upper forehead—or even on the scalp in patients lacking hair—second-intention healing can work superbly, especially with a large defect in which it would otherwise be necessary to mobilize a large flap and undermine a wide area.

Second-intention healing also works well in the extremities, and Dr. Fazio prefers this to skin grafts. With split-thickness skin grafts, patients often complain about pain at the donor site, the graft itself can easily become infected, and it can take up to 3 months to heal.

Dr. Fazio's favorite suture materials are 6–0 fast-absorbing gut and 5–0 monofilament. He advocates closing defects subcutaneously so that the cutaneous sutures are used only for epidermal kissing. He has his patients return in a week for suture removal, but the fast-absorbing gut will be mostly or entirely gone by then, so the return visit is mainly for patient reassurance.

Dr. Fazio favors subcutaneous mattress sutures, which work as well as cutaneous vertical mattress sutures but don't give the railroad-track effect. He applies the subcutaneous sutures every 2–4 mm along the scar line so that there's tension on the surface. He then closes the epidermis with a running suture using the 6–0 fast-absorbing gut.

MONTEREY, CALIF. — Closing defects is one of the most challenging tasks in dermatologic surgery, but at the annual meeting of the Pacific Dermatologic Association, Dr. Michael J. Fazio shared several clinical pearls that make the job easier and improve the cosmetic results.

To start with, "don't scrimp on the setup," said Dr. Fazio of the University of California, Davis. "Get yourself some nice instruments. I always like to use the golden-handled instruments that have a bit of a sharper edge to them. They last longer, and they sharpen better. They're a little more expensive, but they go on forever."

Dr. Fazio finds that skin hooks provide a more delicate and elegant way of handling tissue, compared with forceps. With forceps, it's important not to pinch down too tightly. Tissue held by the forceps may become necrotic.

Dr. Fazio is a proponent of using bicarbonate in local anesthesia, and he recommends that any physicians who are not using bicarb should try a self-injection. They'll see that the injection is far more painful without bicarbonate. He recommends a 1:10 dilution, adding 5 mL of stock bicarbonate solution to 50 mL of lidocaine with epinephrine. Bicarbonate can destabilize the lidocaine solution over a long period of time, but that's usually not an issue in a busy dermatologic surgery practice.

When preparing to remove a lesion, mark the favorable lines of closure before injecting the anesthetic, which may cause distortion. During creation of the ellipse, it's important that it be long enough; Dr. Fazio prefers that the length be at least three times as long as the width. Inexperienced residents are often reluctant to lengthen the ellipse sufficiently, fearing that the scar will be too large. "If you make a quality scar, you're not going to see it," Dr. Fazio said. "If you make a scar and it's too small, you're going to have lumps on both sides [that] are going to be very noticeable."

Undermine the entire ellipse, the ends as well as the sides, to allow the tissue to slide. As the ellipse is closed it will tend to elongate, and if the ends aren't mobile they will pucker up.

"As I got older and more experienced I started letting things heal more by second intention," Dr. Fazio said. But one needs to be selective in allowing things to heal by themselves. The results tend to be better on convex surfaces of the face than on concave surfaces, for example.

Be aware that wounds healed by second intention tend to shrink by about 50%, so it's not a good idea around free tissue margins such as the eye, nose, and mouth. But on the upper forehead—or even on the scalp in patients lacking hair—second-intention healing can work superbly, especially with a large defect in which it would otherwise be necessary to mobilize a large flap and undermine a wide area.

Second-intention healing also works well in the extremities, and Dr. Fazio prefers this to skin grafts. With split-thickness skin grafts, patients often complain about pain at the donor site, the graft itself can easily become infected, and it can take up to 3 months to heal.

Dr. Fazio's favorite suture materials are 6–0 fast-absorbing gut and 5–0 monofilament. He advocates closing defects subcutaneously so that the cutaneous sutures are used only for epidermal kissing. He has his patients return in a week for suture removal, but the fast-absorbing gut will be mostly or entirely gone by then, so the return visit is mainly for patient reassurance.

Dr. Fazio favors subcutaneous mattress sutures, which work as well as cutaneous vertical mattress sutures but don't give the railroad-track effect. He applies the subcutaneous sutures every 2–4 mm along the scar line so that there's tension on the surface. He then closes the epidermis with a running suture using the 6–0 fast-absorbing gut.

MONTEREY, CALIF. — Curettage followed by imiquimod produces better results on basal cell carcinoma than do electrodesiccation and curettage or imiquimod alone, Dr. Abel Torres reported at the annual meeting of the Pacific Dermatologic Association.

Lesions removed with electrodesiccation and curettage commonly have hypertrophic scarring, said Dr. Torres of Loma Linda (Calif.) Medical Center. Imiquimod alone can have relatively good cosmetic results, but there may be some persistent redness and hypopigmentation. Lesions treated with curettage followed by 6 weeks of imiquimod have less persistent redness and hypopigmentation.

The multicenter study enrolled 22 patients at each site, with approximately 60 so far completing the 1-year follow-up.

After treatment with vigorous curettage, and after a 1-week waiting period, patients applied topical 5% imiquimod to the lesion sites 5 days a week for 6 weeks.

Dr. Torres cautioned that this is an off-label use of imiquimod.

MONTEREY, CALIF. — Curettage followed by imiquimod produces better results on basal cell carcinoma than do electrodesiccation and curettage or imiquimod alone, Dr. Abel Torres reported at the annual meeting of the Pacific Dermatologic Association.

Lesions removed with electrodesiccation and curettage commonly have hypertrophic scarring, said Dr. Torres of Loma Linda (Calif.) Medical Center. Imiquimod alone can have relatively good cosmetic results, but there may be some persistent redness and hypopigmentation. Lesions treated with curettage followed by 6 weeks of imiquimod have less persistent redness and hypopigmentation.

The multicenter study enrolled 22 patients at each site, with approximately 60 so far completing the 1-year follow-up.

After treatment with vigorous curettage, and after a 1-week waiting period, patients applied topical 5% imiquimod to the lesion sites 5 days a week for 6 weeks.

Dr. Torres cautioned that this is an off-label use of imiquimod.

MONTEREY, CALIF. — Curettage followed by imiquimod produces better results on basal cell carcinoma than do electrodesiccation and curettage or imiquimod alone, Dr. Abel Torres reported at the annual meeting of the Pacific Dermatologic Association.

Lesions removed with electrodesiccation and curettage commonly have hypertrophic scarring, said Dr. Torres of Loma Linda (Calif.) Medical Center. Imiquimod alone can have relatively good cosmetic results, but there may be some persistent redness and hypopigmentation. Lesions treated with curettage followed by 6 weeks of imiquimod have less persistent redness and hypopigmentation.

The multicenter study enrolled 22 patients at each site, with approximately 60 so far completing the 1-year follow-up.

After treatment with vigorous curettage, and after a 1-week waiting period, patients applied topical 5% imiquimod to the lesion sites 5 days a week for 6 weeks.

Dr. Torres cautioned that this is an off-label use of imiquimod.

SAN FRANCISCO — “It's a pretty exciting time for drug development in osteoporosis,” Dr. Deborah Sellmeyer said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

While joking that her information was “sourced from Google and rumor and various investment brochures,” Dr. Sellmeyer, director of the Center for Osteoporosis at the university, listed some of the osteoporosis drugs in the pipeline.

A fracture trial for a full-length version of parathyroid hormone (PTH [1–84]) has been completed, and a new drug application (NDA) was submitted to the Food and Drug Administration in July 2005. “The latest rumors are that there needs to be little more safety data coming in before that one's going to go much further,” she said.

Meanwhile, inhaled-powder and oral forms of PTH are in phase I and phase II trials, and at least one PTH analogue is in phase III. “Everyone's looking for the magic combination that will be able to replicate the PTH skeletal effect and get rid of the hypercalcemic effect.”

Oral calcitonin preparations are in phase I and phase II. And low-dose and ultralow-dose estrogen remain fertile areas of research. The hope is that these preparations will replicate the beneficial bone effects of estrogen while avoiding its harmful vascular effects. Although two low-dose patches and one low-dose pill have already been approved for the prevention of osteoporosis and for the treatment of vasomotor symptoms, no fracture data are yet available.

Zoledronic acid, a once-a-year intravenous bisphosphonate, is approved for hypercalcemia of malignancy and is now in a phase III trial to determine whether it prevents osteoporotic fractures. This agent is likely to benefit people who cannot tolerate oral bisphosphonates, people in assisted-living situations, and people who have difficulty remembering to take medication.

There are several new selective estrogen receptor modulators under development, with three—lasofoxifene, bazedoxifene, and arzoxifene—in phase III or beyond. An NDA for lasofoxifene was submitted to the FDA in 2004, but the manufacturer apparently received a nonapprovable letter in September 2005, putting the drug in limbo. An NDA for bazedoxifene has been submitted for the prevention of osteoporosis, and an NDA is planned for 2007 for a combination of bazedoxifene and estrogen for osteoporosis treatment and possible premenopausal use. Results from a phase III trial of arzoxifene are expected in 2010.

Tibolone is a drug that “likes every steroid receptor it ever met,” in Dr. Sellmeyer's words. Its three metabolites separately have affinities for estrogen, progesterone, and androgen receptors. A recently completed 24-month prevention trial in 90 women showed no difference in vaginal spotting between tibolone and placebo. Interestingly, the women taking placebo experienced a 12% weight gain, whereas those taking tibolone experienced no average weight gain. A multinational fracture study involving 4,000 women is expected to conclude sometime this year.

It's been known for decades that strontium improves bone mineral density (BMD), but it was never developed for osteoporosis prevention or treatment because it's a nonpatentable chemical element. Recently, however, a proprietary formulation of strontium—strontium ranelate—has shown some promise. A granular form has already been approved for use in Europe and the United Kingdom, and a once-a-day pill finished a phase I trial in September 2005. Strontium ranelate is likely to complicate interpretation of BMD testing because it has a higher density than calcium.

Denosumab, or AMG 162, is a monoclonal antibody that seems to lower bone resorption. Currently in a phase III fracture trial on postmenopausal women, it will require two subcutaneous injections per year.

Isosorbide mononitrate, long used for the pain of angina, appears to improve several bone markers in postmenopausal women. A BMD trial is underway.

In one study, the combination of folate and vitamin B₁₂ greatly decreased the incidence of hip fractures, but it involved patients who experienced stroke and hemiplegia. If this combination proves equally efficacious in other populations, it would provide a remarkably inexpensive and safe intervention for osteoporosis. Finally, β-blockers constitute another class of drugs that may have bone effects, but random trials are needed to establish whether they have a place in osteoporosis therapy.

SAN FRANCISCO — “It's a pretty exciting time for drug development in osteoporosis,” Dr. Deborah Sellmeyer said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

While joking that her information was “sourced from Google and rumor and various investment brochures,” Dr. Sellmeyer, director of the Center for Osteoporosis at the university, listed some of the osteoporosis drugs in the pipeline.

A fracture trial for a full-length version of parathyroid hormone (PTH [1–84]) has been completed, and a new drug application (NDA) was submitted to the Food and Drug Administration in July 2005. “The latest rumors are that there needs to be little more safety data coming in before that one's going to go much further,” she said.

Meanwhile, inhaled-powder and oral forms of PTH are in phase I and phase II trials, and at least one PTH analogue is in phase III. “Everyone's looking for the magic combination that will be able to replicate the PTH skeletal effect and get rid of the hypercalcemic effect.”

Oral calcitonin preparations are in phase I and phase II. And low-dose and ultralow-dose estrogen remain fertile areas of research. The hope is that these preparations will replicate the beneficial bone effects of estrogen while avoiding its harmful vascular effects. Although two low-dose patches and one low-dose pill have already been approved for the prevention of osteoporosis and for the treatment of vasomotor symptoms, no fracture data are yet available.

Zoledronic acid, a once-a-year intravenous bisphosphonate, is approved for hypercalcemia of malignancy and is now in a phase III trial to determine whether it prevents osteoporotic fractures. This agent is likely to benefit people who cannot tolerate oral bisphosphonates, people in assisted-living situations, and people who have difficulty remembering to take medication.

There are several new selective estrogen receptor modulators under development, with three—lasofoxifene, bazedoxifene, and arzoxifene—in phase III or beyond. An NDA for lasofoxifene was submitted to the FDA in 2004, but the manufacturer apparently received a nonapprovable letter in September 2005, putting the drug in limbo. An NDA for bazedoxifene has been submitted for the prevention of osteoporosis, and an NDA is planned for 2007 for a combination of bazedoxifene and estrogen for osteoporosis treatment and possible premenopausal use. Results from a phase III trial of arzoxifene are expected in 2010.

Tibolone is a drug that “likes every steroid receptor it ever met,” in Dr. Sellmeyer's words. Its three metabolites separately have affinities for estrogen, progesterone, and androgen receptors. A recently completed 24-month prevention trial in 90 women showed no difference in vaginal spotting between tibolone and placebo. Interestingly, the women taking placebo experienced a 12% weight gain, whereas those taking tibolone experienced no average weight gain. A multinational fracture study involving 4,000 women is expected to conclude sometime this year.

It's been known for decades that strontium improves bone mineral density (BMD), but it was never developed for osteoporosis prevention or treatment because it's a nonpatentable chemical element. Recently, however, a proprietary formulation of strontium—strontium ranelate—has shown some promise. A granular form has already been approved for use in Europe and the United Kingdom, and a once-a-day pill finished a phase I trial in September 2005. Strontium ranelate is likely to complicate interpretation of BMD testing because it has a higher density than calcium.

Denosumab, or AMG 162, is a monoclonal antibody that seems to lower bone resorption. Currently in a phase III fracture trial on postmenopausal women, it will require two subcutaneous injections per year.

Isosorbide mononitrate, long used for the pain of angina, appears to improve several bone markers in postmenopausal women. A BMD trial is underway.

In one study, the combination of folate and vitamin B₁₂ greatly decreased the incidence of hip fractures, but it involved patients who experienced stroke and hemiplegia. If this combination proves equally efficacious in other populations, it would provide a remarkably inexpensive and safe intervention for osteoporosis. Finally, β-blockers constitute another class of drugs that may have bone effects, but random trials are needed to establish whether they have a place in osteoporosis therapy.

SAN FRANCISCO — “It's a pretty exciting time for drug development in osteoporosis,” Dr. Deborah Sellmeyer said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

While joking that her information was “sourced from Google and rumor and various investment brochures,” Dr. Sellmeyer, director of the Center for Osteoporosis at the university, listed some of the osteoporosis drugs in the pipeline.

A fracture trial for a full-length version of parathyroid hormone (PTH [1–84]) has been completed, and a new drug application (NDA) was submitted to the Food and Drug Administration in July 2005. “The latest rumors are that there needs to be little more safety data coming in before that one's going to go much further,” she said.

Meanwhile, inhaled-powder and oral forms of PTH are in phase I and phase II trials, and at least one PTH analogue is in phase III. “Everyone's looking for the magic combination that will be able to replicate the PTH skeletal effect and get rid of the hypercalcemic effect.”

Oral calcitonin preparations are in phase I and phase II. And low-dose and ultralow-dose estrogen remain fertile areas of research. The hope is that these preparations will replicate the beneficial bone effects of estrogen while avoiding its harmful vascular effects. Although two low-dose patches and one low-dose pill have already been approved for the prevention of osteoporosis and for the treatment of vasomotor symptoms, no fracture data are yet available.

Zoledronic acid, a once-a-year intravenous bisphosphonate, is approved for hypercalcemia of malignancy and is now in a phase III trial to determine whether it prevents osteoporotic fractures. This agent is likely to benefit people who cannot tolerate oral bisphosphonates, people in assisted-living situations, and people who have difficulty remembering to take medication.

There are several new selective estrogen receptor modulators under development, with three—lasofoxifene, bazedoxifene, and arzoxifene—in phase III or beyond. An NDA for lasofoxifene was submitted to the FDA in 2004, but the manufacturer apparently received a nonapprovable letter in September 2005, putting the drug in limbo. An NDA for bazedoxifene has been submitted for the prevention of osteoporosis, and an NDA is planned for 2007 for a combination of bazedoxifene and estrogen for osteoporosis treatment and possible premenopausal use. Results from a phase III trial of arzoxifene are expected in 2010.

Tibolone is a drug that “likes every steroid receptor it ever met,” in Dr. Sellmeyer's words. Its three metabolites separately have affinities for estrogen, progesterone, and androgen receptors. A recently completed 24-month prevention trial in 90 women showed no difference in vaginal spotting between tibolone and placebo. Interestingly, the women taking placebo experienced a 12% weight gain, whereas those taking tibolone experienced no average weight gain. A multinational fracture study involving 4,000 women is expected to conclude sometime this year.

It's been known for decades that strontium improves bone mineral density (BMD), but it was never developed for osteoporosis prevention or treatment because it's a nonpatentable chemical element. Recently, however, a proprietary formulation of strontium—strontium ranelate—has shown some promise. A granular form has already been approved for use in Europe and the United Kingdom, and a once-a-day pill finished a phase I trial in September 2005. Strontium ranelate is likely to complicate interpretation of BMD testing because it has a higher density than calcium.

Denosumab, or AMG 162, is a monoclonal antibody that seems to lower bone resorption. Currently in a phase III fracture trial on postmenopausal women, it will require two subcutaneous injections per year.

Isosorbide mononitrate, long used for the pain of angina, appears to improve several bone markers in postmenopausal women. A BMD trial is underway.

In one study, the combination of folate and vitamin B₁₂ greatly decreased the incidence of hip fractures, but it involved patients who experienced stroke and hemiplegia. If this combination proves equally efficacious in other populations, it would provide a remarkably inexpensive and safe intervention for osteoporosis. Finally, β-blockers constitute another class of drugs that may have bone effects, but random trials are needed to establish whether they have a place in osteoporosis therapy.

ATLANTA — Clinicians should consider secondary causes when a patient's hypertension does not respond to aggressive treatment, Dr. Angela L. Brown said at a meeting sponsored by the International Society on Hypertension in Blacks.

The first rule, though, is that one must be careful in defining when hypertension is truly refractory, said Dr. Brown of Washington University in St. Louis. Hypertension is considered refractory only if a blood pressure under 140/90 mm/Hg cannot be achieved despite the use of three antihypertensive medications at their maximal doses, one of which must be a diuretic.

Too often, she said, other physicians refer patients with “refractory hypertension” who are on only two antihypertensives or who are at only the starting doses.

There are many secondary causes of hypertension. Renal hypertension and endocrine hypertension are probably the most common, but other causes include aortic coarctation, sleep apnea, and panic disorder.

In addition, there are many exogenous substances that can raise blood pressure. Ethanol and caffeine are probably the most prominent of these, but physicians should carefully question patients about other possible causes, including cocaine, nicotine, sympathomimetics, chlorpromazine, erythropoietin, oral contraceptives, cyclosporine, tricyclic antidepressants, MAO inhibitors, and certain herbal supplements, such as the Chinese stimulant ma huang (ephedrine).

NSAIDs, corticosteroids, and sodium chloride can also interfere with antihypertensive therapy.

Anabolic steroids can also cause hypertension. “Particularly when you see young men who are athletic or buff, ask them about anabolic steroids,” Dr. Brown advised. But she warned that the physician may not get an honest answer unless the young athlete's parents are out of the room.

Dr. Brown suggested a number of screening tests that can uncover some of the secondary causes, particularly the endocrine ones. (See box.)

But she placed a special emphasis on renal function.

“I think it's really important that we know the patient's level of kidney dysfunction,” she said. “We get the serum creatinines, and we often see a creatinine of 1.4 or 1.6 [mg/dL], and we think, 'Oh, that's not too bad.' But it's clear that once the GFR [glomerular filtration rate] diminishes, and particularly around 45% or so, your thiazide diuretic is not going to be as effective.”

Two equations have been developed for estimating GFR based on a patient's serum creatinine, age, and weight, with correction factors for the patient's gender and race (black versus nonblack), and there are Web sites where one can perform the calculations easily (www.medcalc.com/gfr.html

“Some labs have actually started reporting the estimated GFR,” Dr. Brown said. “You actually get a much clearer picture of where the kidney level is. … I think this is one of the most common causes of what is deemed to be resistant hypertension in my patients, and it is inadequate diuretic therapy.”

The meeting was cosponsored by the American Society of Hypertension.

Narrow Down The Possibilities

▸ For hyperthyroidism or hypothyroidism, test TSH, free T4.

▸ For pheochromocytoma, test plasma metanephrines.

▸ For primary aldosteronism, test morning plasma potassium; aldosterone:renin ratio.

▸ For Cushing's syndrome, administer the overnight dexamethasone suppression test.

▸ For hyperparathyroidism, administer a test for albumin-corrected serum calcium; intact parathyroid hormone; serum chloride:phosphate ratio.

▸ For renal artery stenosis, use the renal artery duplex scan; captopril renogram.

Source: Dr. Brown

ATLANTA — Clinicians should consider secondary causes when a patient's hypertension does not respond to aggressive treatment, Dr. Angela L. Brown said at a meeting sponsored by the International Society on Hypertension in Blacks.

The first rule, though, is that one must be careful in defining when hypertension is truly refractory, said Dr. Brown of Washington University in St. Louis. Hypertension is considered refractory only if a blood pressure under 140/90 mm/Hg cannot be achieved despite the use of three antihypertensive medications at their maximal doses, one of which must be a diuretic.

Too often, she said, other physicians refer patients with “refractory hypertension” who are on only two antihypertensives or who are at only the starting doses.

There are many secondary causes of hypertension. Renal hypertension and endocrine hypertension are probably the most common, but other causes include aortic coarctation, sleep apnea, and panic disorder.

In addition, there are many exogenous substances that can raise blood pressure. Ethanol and caffeine are probably the most prominent of these, but physicians should carefully question patients about other possible causes, including cocaine, nicotine, sympathomimetics, chlorpromazine, erythropoietin, oral contraceptives, cyclosporine, tricyclic antidepressants, MAO inhibitors, and certain herbal supplements, such as the Chinese stimulant ma huang (ephedrine).

NSAIDs, corticosteroids, and sodium chloride can also interfere with antihypertensive therapy.

Anabolic steroids can also cause hypertension. “Particularly when you see young men who are athletic or buff, ask them about anabolic steroids,” Dr. Brown advised. But she warned that the physician may not get an honest answer unless the young athlete's parents are out of the room.

Dr. Brown suggested a number of screening tests that can uncover some of the secondary causes, particularly the endocrine ones. (See box.)

But she placed a special emphasis on renal function.

“I think it's really important that we know the patient's level of kidney dysfunction,” she said. “We get the serum creatinines, and we often see a creatinine of 1.4 or 1.6 [mg/dL], and we think, 'Oh, that's not too bad.' But it's clear that once the GFR [glomerular filtration rate] diminishes, and particularly around 45% or so, your thiazide diuretic is not going to be as effective.”

Two equations have been developed for estimating GFR based on a patient's serum creatinine, age, and weight, with correction factors for the patient's gender and race (black versus nonblack), and there are Web sites where one can perform the calculations easily (www.medcalc.com/gfr.html

“Some labs have actually started reporting the estimated GFR,” Dr. Brown said. “You actually get a much clearer picture of where the kidney level is. … I think this is one of the most common causes of what is deemed to be resistant hypertension in my patients, and it is inadequate diuretic therapy.”

The meeting was cosponsored by the American Society of Hypertension.

Narrow Down The Possibilities

▸ For hyperthyroidism or hypothyroidism, test TSH, free T4.

▸ For pheochromocytoma, test plasma metanephrines.

▸ For primary aldosteronism, test morning plasma potassium; aldosterone:renin ratio.

▸ For Cushing's syndrome, administer the overnight dexamethasone suppression test.

▸ For hyperparathyroidism, administer a test for albumin-corrected serum calcium; intact parathyroid hormone; serum chloride:phosphate ratio.

▸ For renal artery stenosis, use the renal artery duplex scan; captopril renogram.

Source: Dr. Brown

ATLANTA — Clinicians should consider secondary causes when a patient's hypertension does not respond to aggressive treatment, Dr. Angela L. Brown said at a meeting sponsored by the International Society on Hypertension in Blacks.

The first rule, though, is that one must be careful in defining when hypertension is truly refractory, said Dr. Brown of Washington University in St. Louis. Hypertension is considered refractory only if a blood pressure under 140/90 mm/Hg cannot be achieved despite the use of three antihypertensive medications at their maximal doses, one of which must be a diuretic.

Too often, she said, other physicians refer patients with “refractory hypertension” who are on only two antihypertensives or who are at only the starting doses.

There are many secondary causes of hypertension. Renal hypertension and endocrine hypertension are probably the most common, but other causes include aortic coarctation, sleep apnea, and panic disorder.

In addition, there are many exogenous substances that can raise blood pressure. Ethanol and caffeine are probably the most prominent of these, but physicians should carefully question patients about other possible causes, including cocaine, nicotine, sympathomimetics, chlorpromazine, erythropoietin, oral contraceptives, cyclosporine, tricyclic antidepressants, MAO inhibitors, and certain herbal supplements, such as the Chinese stimulant ma huang (ephedrine).

NSAIDs, corticosteroids, and sodium chloride can also interfere with antihypertensive therapy.

Anabolic steroids can also cause hypertension. “Particularly when you see young men who are athletic or buff, ask them about anabolic steroids,” Dr. Brown advised. But she warned that the physician may not get an honest answer unless the young athlete's parents are out of the room.

Dr. Brown suggested a number of screening tests that can uncover some of the secondary causes, particularly the endocrine ones. (See box.)

But she placed a special emphasis on renal function.

“I think it's really important that we know the patient's level of kidney dysfunction,” she said. “We get the serum creatinines, and we often see a creatinine of 1.4 or 1.6 [mg/dL], and we think, 'Oh, that's not too bad.' But it's clear that once the GFR [glomerular filtration rate] diminishes, and particularly around 45% or so, your thiazide diuretic is not going to be as effective.”

Two equations have been developed for estimating GFR based on a patient's serum creatinine, age, and weight, with correction factors for the patient's gender and race (black versus nonblack), and there are Web sites where one can perform the calculations easily (www.medcalc.com/gfr.html

“Some labs have actually started reporting the estimated GFR,” Dr. Brown said. “You actually get a much clearer picture of where the kidney level is. … I think this is one of the most common causes of what is deemed to be resistant hypertension in my patients, and it is inadequate diuretic therapy.”

The meeting was cosponsored by the American Society of Hypertension.

Narrow Down The Possibilities

▸ For hyperthyroidism or hypothyroidism, test TSH, free T4.

▸ For pheochromocytoma, test plasma metanephrines.

▸ For primary aldosteronism, test morning plasma potassium; aldosterone:renin ratio.

▸ For Cushing's syndrome, administer the overnight dexamethasone suppression test.

▸ For hyperparathyroidism, administer a test for albumin-corrected serum calcium; intact parathyroid hormone; serum chloride:phosphate ratio.

▸ For renal artery stenosis, use the renal artery duplex scan; captopril renogram.

Source: Dr. Brown

ATLANTA — Rosuvastatin was more effective than atorvastatin in treating hyperlipidemia in a 6-week open-label trial in African Americans, Dr. Keith C. Ferdinand reported at a meeting sponsored by the International Society on Hypertension in Blacks.

The African American Rosuvastatin Investigation of Efficacy and Safety (ARIES) trial involved 774 adult African Americans with LDL cholesterol levels between 160 and 300 mg/dL and triglyceride levels below 400 mg/dL. They were randomized to receive either 10 or 20 mg per day of rosuvastatin (Crestor, AstraZeneca) or 10 or 20 mg per day of atorvastatin (Lipitor, Pfizer), reported Dr. Ferdinand, chief science officer of the Association of Black Cardiologists, Atlanta, and professor of clinical pharmacology at Xavier University College of Pharmacy in New Orleans. After 6 weeks, average LDL cholesterol levels were reduced significantly more in each of the rosuvastatin groups than they were in the corresponding atorvastatin groups. In fact, patients receiving the lower dose of rosuvastatin had a decline in LDL of about the same degree as patients receiving the higher dose of atorvastatin (Am. J. Cardiol. 2006;97:229–35). Similarly, rosuvastatin resulted in significantly greater reductions in total cholesterol, non-HDL cholesterol, and apolipoprotein B than milligram-equivalent doses of atorvastatin. The ratios of LDL cholesterol to HDL cholesterol, total cholesterol to HDL cholesterol, non-HDL cholesterol to HDL cholesterol, and apo B to apo A-I were also significantly better in patients taking rosuvastatin than in those taking atorvastatin.

Dr. Ferdinand has received grants from AstraZeneca, Pfizer, and Merck. The meeting was cosponsored by the American Society of Hypertension. The ARIES study was sponsored by AstraZeneca.

ATLANTA — Rosuvastatin was more effective than atorvastatin in treating hyperlipidemia in a 6-week open-label trial in African Americans, Dr. Keith C. Ferdinand reported at a meeting sponsored by the International Society on Hypertension in Blacks.

The African American Rosuvastatin Investigation of Efficacy and Safety (ARIES) trial involved 774 adult African Americans with LDL cholesterol levels between 160 and 300 mg/dL and triglyceride levels below 400 mg/dL. They were randomized to receive either 10 or 20 mg per day of rosuvastatin (Crestor, AstraZeneca) or 10 or 20 mg per day of atorvastatin (Lipitor, Pfizer), reported Dr. Ferdinand, chief science officer of the Association of Black Cardiologists, Atlanta, and professor of clinical pharmacology at Xavier University College of Pharmacy in New Orleans. After 6 weeks, average LDL cholesterol levels were reduced significantly more in each of the rosuvastatin groups than they were in the corresponding atorvastatin groups. In fact, patients receiving the lower dose of rosuvastatin had a decline in LDL of about the same degree as patients receiving the higher dose of atorvastatin (Am. J. Cardiol. 2006;97:229–35). Similarly, rosuvastatin resulted in significantly greater reductions in total cholesterol, non-HDL cholesterol, and apolipoprotein B than milligram-equivalent doses of atorvastatin. The ratios of LDL cholesterol to HDL cholesterol, total cholesterol to HDL cholesterol, non-HDL cholesterol to HDL cholesterol, and apo B to apo A-I were also significantly better in patients taking rosuvastatin than in those taking atorvastatin.

Dr. Ferdinand has received grants from AstraZeneca, Pfizer, and Merck. The meeting was cosponsored by the American Society of Hypertension. The ARIES study was sponsored by AstraZeneca.

ATLANTA — Rosuvastatin was more effective than atorvastatin in treating hyperlipidemia in a 6-week open-label trial in African Americans, Dr. Keith C. Ferdinand reported at a meeting sponsored by the International Society on Hypertension in Blacks.

The African American Rosuvastatin Investigation of Efficacy and Safety (ARIES) trial involved 774 adult African Americans with LDL cholesterol levels between 160 and 300 mg/dL and triglyceride levels below 400 mg/dL. They were randomized to receive either 10 or 20 mg per day of rosuvastatin (Crestor, AstraZeneca) or 10 or 20 mg per day of atorvastatin (Lipitor, Pfizer), reported Dr. Ferdinand, chief science officer of the Association of Black Cardiologists, Atlanta, and professor of clinical pharmacology at Xavier University College of Pharmacy in New Orleans. After 6 weeks, average LDL cholesterol levels were reduced significantly more in each of the rosuvastatin groups than they were in the corresponding atorvastatin groups. In fact, patients receiving the lower dose of rosuvastatin had a decline in LDL of about the same degree as patients receiving the higher dose of atorvastatin (Am. J. Cardiol. 2006;97:229–35). Similarly, rosuvastatin resulted in significantly greater reductions in total cholesterol, non-HDL cholesterol, and apolipoprotein B than milligram-equivalent doses of atorvastatin. The ratios of LDL cholesterol to HDL cholesterol, total cholesterol to HDL cholesterol, non-HDL cholesterol to HDL cholesterol, and apo B to apo A-I were also significantly better in patients taking rosuvastatin than in those taking atorvastatin.

Dr. Ferdinand has received grants from AstraZeneca, Pfizer, and Merck. The meeting was cosponsored by the American Society of Hypertension. The ARIES study was sponsored by AstraZeneca.