Betsy Bates

MONTEREY, CALIF. — Harvard Medical School hematologist Dr. Jerome Groopman has said that "people talk about technical errors in medicine, but no one talks about thinking errors."

This sentiment registered with Dr. Bari B. Cunningham, a pediatric dermatologist at the University of California, San Diego, and Rady Children's Hospital, prompting her to air her "missteps and misdiagnoses" with colleagues at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

"The only real mistake is the one from which we learn nothing," she said, quoting self-help author John Powell.

In looking back at her own errors, Dr. Cunningham saw evidence of the four types of errors cited by Dr. Groopman in his book, "Where Doctors Go Wrong":

▸ "I Recognize the Type." These are attribution errors based on stereotypes, she said, such as the Hodgkin's lymphoma that goes undiagnosed in an anxious, neurotic 50-year-old patient with pruritus.

▸ "I Just Saw a Case Like This." After four cases of viral exanthem, it may be tough to recognize the distinctions that mark a drug eruption. On the other hand, a rare diagnosis that leaves a "deep impression" may heighten consideration of that "zebra" in the next 10 patients with more typical conditions, she pointed out.

▸ "I've Got to Do Something." A physician may have a tendency to panic when faced with a rapidly spreading condition, but "as dermatologists we have time" to consider the differential diagnosis before whipping out the prescription pad, said Dr. Cunningham. Look it up. Consult with a colleague, she advised.

▸ "I Hate (or Love) This Patient." It's fairly obvious that one's irritation with a given patient can lead to an oversight, but the reverse is also true: Physicians may be a reluctant to acknowledge signs or symptoms of a serious disease in patients to whom they have grown close.

Dr. Cunningham recalled that she was reassured with the rapid resolution of left-sided facial Sturge-Weber syndrome in a toddler following pulsed dye laser treatments and a check by an ophthalmologist. A few years later, she felt "incredibly responsible" when the child was diagnosed with advanced glaucoma, because she had not realized or informed the family that even low-risk patients with V1 (fifth cranial nerve, ophthalmic division) Sturge-Weber syndrome require annual ophthalmic examinations.

Referring to another case, she said she was lucky to have considered Kawasaki disease in an Asian American baby boy with a groin rash that she might have missed on a busy afternoon in a private practice. An insistent mother emphasized that the rash began with a fever.

"There was a fellow there, and I was trying to do the right thing and said, 'You always want to have Kawasaki disease in your differential.' Lo and behold, this child was sent for an echocardiogram and had a dilated coronary artery," Dr. Cunningham said. Manifestations of this potentially fatal disease may be subtle and incomplete in infants, but in this case the fever was a critical factor leading to further evaluation according to a published algorithm (Pediatrics 2004;114:1708–33).

" Kawasaki disease has surpassed rheumatic fever as the most common acquired heart disease in children" under 5 years old in the United States, she said. "Never ignore your gut, or the parent's!"

Reviewing a final case, Dr. Cunningham recalled being consulted by the parents of an 8-month-old; they had been told that the fast-growing lesion on his posterior thigh was a hemangioma. "The father was a physician and they didn't buy it," she commented. Her own doubts were somewhat assuaged when a surgical biopsy performed in the operating room was read by a pathologist as a hemangioma.

Still, the rapid growth, the fact that the lesion did not appear until the child was 4 months of age, and the bloodless surgery made her continue to doubt the diagnosis.

MRI revealed the lesion was a virtually avascular "very well-circumscribed, nonenhancing mass" that eventually proved to be a lipoblastoma containing primitive adipocytes, she said. Although benign, such lesions continue to grow and do not resolve on their own, and may recur.

We have time to consider the differential diagnosis before whipping out the prescription pad. DR. CUNNINGHAM

MONTEREY, CALIF. — Harvard Medical School hematologist Dr. Jerome Groopman has said that "people talk about technical errors in medicine, but no one talks about thinking errors."

This sentiment registered with Dr. Bari B. Cunningham, a pediatric dermatologist at the University of California, San Diego, and Rady Children's Hospital, prompting her to air her "missteps and misdiagnoses" with colleagues at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

"The only real mistake is the one from which we learn nothing," she said, quoting self-help author John Powell.

In looking back at her own errors, Dr. Cunningham saw evidence of the four types of errors cited by Dr. Groopman in his book, "Where Doctors Go Wrong":

▸ "I Recognize the Type." These are attribution errors based on stereotypes, she said, such as the Hodgkin's lymphoma that goes undiagnosed in an anxious, neurotic 50-year-old patient with pruritus.

▸ "I Just Saw a Case Like This." After four cases of viral exanthem, it may be tough to recognize the distinctions that mark a drug eruption. On the other hand, a rare diagnosis that leaves a "deep impression" may heighten consideration of that "zebra" in the next 10 patients with more typical conditions, she pointed out.

▸ "I've Got to Do Something." A physician may have a tendency to panic when faced with a rapidly spreading condition, but "as dermatologists we have time" to consider the differential diagnosis before whipping out the prescription pad, said Dr. Cunningham. Look it up. Consult with a colleague, she advised.

▸ "I Hate (or Love) This Patient." It's fairly obvious that one's irritation with a given patient can lead to an oversight, but the reverse is also true: Physicians may be a reluctant to acknowledge signs or symptoms of a serious disease in patients to whom they have grown close.

Dr. Cunningham recalled that she was reassured with the rapid resolution of left-sided facial Sturge-Weber syndrome in a toddler following pulsed dye laser treatments and a check by an ophthalmologist. A few years later, she felt "incredibly responsible" when the child was diagnosed with advanced glaucoma, because she had not realized or informed the family that even low-risk patients with V1 (fifth cranial nerve, ophthalmic division) Sturge-Weber syndrome require annual ophthalmic examinations.

Referring to another case, she said she was lucky to have considered Kawasaki disease in an Asian American baby boy with a groin rash that she might have missed on a busy afternoon in a private practice. An insistent mother emphasized that the rash began with a fever.

"There was a fellow there, and I was trying to do the right thing and said, 'You always want to have Kawasaki disease in your differential.' Lo and behold, this child was sent for an echocardiogram and had a dilated coronary artery," Dr. Cunningham said. Manifestations of this potentially fatal disease may be subtle and incomplete in infants, but in this case the fever was a critical factor leading to further evaluation according to a published algorithm (Pediatrics 2004;114:1708–33).

" Kawasaki disease has surpassed rheumatic fever as the most common acquired heart disease in children" under 5 years old in the United States, she said. "Never ignore your gut, or the parent's!"

Reviewing a final case, Dr. Cunningham recalled being consulted by the parents of an 8-month-old; they had been told that the fast-growing lesion on his posterior thigh was a hemangioma. "The father was a physician and they didn't buy it," she commented. Her own doubts were somewhat assuaged when a surgical biopsy performed in the operating room was read by a pathologist as a hemangioma.

Still, the rapid growth, the fact that the lesion did not appear until the child was 4 months of age, and the bloodless surgery made her continue to doubt the diagnosis.

MRI revealed the lesion was a virtually avascular "very well-circumscribed, nonenhancing mass" that eventually proved to be a lipoblastoma containing primitive adipocytes, she said. Although benign, such lesions continue to grow and do not resolve on their own, and may recur.

We have time to consider the differential diagnosis before whipping out the prescription pad. DR. CUNNINGHAM

MONTEREY, CALIF. — Harvard Medical School hematologist Dr. Jerome Groopman has said that "people talk about technical errors in medicine, but no one talks about thinking errors."

This sentiment registered with Dr. Bari B. Cunningham, a pediatric dermatologist at the University of California, San Diego, and Rady Children's Hospital, prompting her to air her "missteps and misdiagnoses" with colleagues at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

"The only real mistake is the one from which we learn nothing," she said, quoting self-help author John Powell.

In looking back at her own errors, Dr. Cunningham saw evidence of the four types of errors cited by Dr. Groopman in his book, "Where Doctors Go Wrong":

▸ "I Recognize the Type." These are attribution errors based on stereotypes, she said, such as the Hodgkin's lymphoma that goes undiagnosed in an anxious, neurotic 50-year-old patient with pruritus.

▸ "I Just Saw a Case Like This." After four cases of viral exanthem, it may be tough to recognize the distinctions that mark a drug eruption. On the other hand, a rare diagnosis that leaves a "deep impression" may heighten consideration of that "zebra" in the next 10 patients with more typical conditions, she pointed out.

▸ "I've Got to Do Something." A physician may have a tendency to panic when faced with a rapidly spreading condition, but "as dermatologists we have time" to consider the differential diagnosis before whipping out the prescription pad, said Dr. Cunningham. Look it up. Consult with a colleague, she advised.

▸ "I Hate (or Love) This Patient." It's fairly obvious that one's irritation with a given patient can lead to an oversight, but the reverse is also true: Physicians may be a reluctant to acknowledge signs or symptoms of a serious disease in patients to whom they have grown close.

Dr. Cunningham recalled that she was reassured with the rapid resolution of left-sided facial Sturge-Weber syndrome in a toddler following pulsed dye laser treatments and a check by an ophthalmologist. A few years later, she felt "incredibly responsible" when the child was diagnosed with advanced glaucoma, because she had not realized or informed the family that even low-risk patients with V1 (fifth cranial nerve, ophthalmic division) Sturge-Weber syndrome require annual ophthalmic examinations.

Referring to another case, she said she was lucky to have considered Kawasaki disease in an Asian American baby boy with a groin rash that she might have missed on a busy afternoon in a private practice. An insistent mother emphasized that the rash began with a fever.

"There was a fellow there, and I was trying to do the right thing and said, 'You always want to have Kawasaki disease in your differential.' Lo and behold, this child was sent for an echocardiogram and had a dilated coronary artery," Dr. Cunningham said. Manifestations of this potentially fatal disease may be subtle and incomplete in infants, but in this case the fever was a critical factor leading to further evaluation according to a published algorithm (Pediatrics 2004;114:1708–33).

" Kawasaki disease has surpassed rheumatic fever as the most common acquired heart disease in children" under 5 years old in the United States, she said. "Never ignore your gut, or the parent's!"

Reviewing a final case, Dr. Cunningham recalled being consulted by the parents of an 8-month-old; they had been told that the fast-growing lesion on his posterior thigh was a hemangioma. "The father was a physician and they didn't buy it," she commented. Her own doubts were somewhat assuaged when a surgical biopsy performed in the operating room was read by a pathologist as a hemangioma.

Still, the rapid growth, the fact that the lesion did not appear until the child was 4 months of age, and the bloodless surgery made her continue to doubt the diagnosis.

MRI revealed the lesion was a virtually avascular "very well-circumscribed, nonenhancing mass" that eventually proved to be a lipoblastoma containing primitive adipocytes, she said. Although benign, such lesions continue to grow and do not resolve on their own, and may recur.

We have time to consider the differential diagnosis before whipping out the prescription pad. DR. CUNNINGHAM

SAN DIEGO — Long-term use of metronidazole gel remains the mainstay of treatment for women with recurrent bacterial vaginosis, said Dr. Jeanne Marrazzo of the division of allergy and infectious disease at the University of Washington, Seattle.

Patients are instructed to use intravaginal metronidazole gel 0.75% at bedtime for 10–14 days, then biweekly—Monday and Thursday, for example—for approximately 6 months before retesting, Dr. Marrazzo said at Perspectives in Women's Health, a conference sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

“The problem is cost,” she said. Generic products exist in the gel formulation, but they offer little cost advantage over the branded products.

The mechanism of action in this regimen remains uncertain, although it may suppress overall anaerobic overgrowth for so long that the patient's lactobacillus population can recover. Suppression of an unknown pathogen may also be at work, she said.

Dr. Marrazzo said research suggests benefit from condom use during intercourse in the initial and suppression treatment regimens, again, for reasons that are not fully understood. “Condom use … in my mind, should be part of the counseling of patients with recurrent BV,” she said.

As of today, there are no good alternatives to metronidazole gel for these patients, she explained. Over-the-counter lactobacillus remedies and yogurt are not good options.

“You don't want to use bovine lactobacilli in the human vagina. It's really not a very good thing,” she stressed. “These [remedies] really aren't going to work, although some people will say anecdotally that they do.”

Early trials assessing the efficacy of intravaginal capsules containing the probiotic Lactobacillus crispatus have proven “very disappointing,” she said. The organism nonetheless remains under evaluation as a potentially useful agent for repletion of normal vaginal lactobacilli, since it is one of the three most common lactic-acid-producing bacteria in the healthy vagina.

Research demonstrates that it adheres well to vaginal epithelial cells; in 2006, Dr. Marrazzo and her associates reported a high rate of satisfaction among 232 women who were “very willing” to use an intravaginal capsule containing lactobacillus (J. Womens Health 2006;15:1053–60).

Women in Dr. Marrazzo's study said they were willing to use the product again, regardless of the clinical response they received.

Dr. Marrazzo stated that she had no financial disclosures.

OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

SAN DIEGO — Long-term use of metronidazole gel remains the mainstay of treatment for women with recurrent bacterial vaginosis, said Dr. Jeanne Marrazzo of the division of allergy and infectious disease at the University of Washington, Seattle.

Patients are instructed to use intravaginal metronidazole gel 0.75% at bedtime for 10–14 days, then biweekly—Monday and Thursday, for example—for approximately 6 months before retesting, Dr. Marrazzo said at Perspectives in Women's Health, a conference sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

“The problem is cost,” she said. Generic products exist in the gel formulation, but they offer little cost advantage over the branded products.

The mechanism of action in this regimen remains uncertain, although it may suppress overall anaerobic overgrowth for so long that the patient's lactobacillus population can recover. Suppression of an unknown pathogen may also be at work, she said.

Dr. Marrazzo said research suggests benefit from condom use during intercourse in the initial and suppression treatment regimens, again, for reasons that are not fully understood. “Condom use … in my mind, should be part of the counseling of patients with recurrent BV,” she said.

As of today, there are no good alternatives to metronidazole gel for these patients, she explained. Over-the-counter lactobacillus remedies and yogurt are not good options.

“You don't want to use bovine lactobacilli in the human vagina. It's really not a very good thing,” she stressed. “These [remedies] really aren't going to work, although some people will say anecdotally that they do.”

Early trials assessing the efficacy of intravaginal capsules containing the probiotic Lactobacillus crispatus have proven “very disappointing,” she said. The organism nonetheless remains under evaluation as a potentially useful agent for repletion of normal vaginal lactobacilli, since it is one of the three most common lactic-acid-producing bacteria in the healthy vagina.

Research demonstrates that it adheres well to vaginal epithelial cells; in 2006, Dr. Marrazzo and her associates reported a high rate of satisfaction among 232 women who were “very willing” to use an intravaginal capsule containing lactobacillus (J. Womens Health 2006;15:1053–60).

Women in Dr. Marrazzo's study said they were willing to use the product again, regardless of the clinical response they received.

Dr. Marrazzo stated that she had no financial disclosures.

OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

SAN DIEGO — Long-term use of metronidazole gel remains the mainstay of treatment for women with recurrent bacterial vaginosis, said Dr. Jeanne Marrazzo of the division of allergy and infectious disease at the University of Washington, Seattle.

Patients are instructed to use intravaginal metronidazole gel 0.75% at bedtime for 10–14 days, then biweekly—Monday and Thursday, for example—for approximately 6 months before retesting, Dr. Marrazzo said at Perspectives in Women's Health, a conference sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

“The problem is cost,” she said. Generic products exist in the gel formulation, but they offer little cost advantage over the branded products.

The mechanism of action in this regimen remains uncertain, although it may suppress overall anaerobic overgrowth for so long that the patient's lactobacillus population can recover. Suppression of an unknown pathogen may also be at work, she said.

Dr. Marrazzo said research suggests benefit from condom use during intercourse in the initial and suppression treatment regimens, again, for reasons that are not fully understood. “Condom use … in my mind, should be part of the counseling of patients with recurrent BV,” she said.

As of today, there are no good alternatives to metronidazole gel for these patients, she explained. Over-the-counter lactobacillus remedies and yogurt are not good options.

“You don't want to use bovine lactobacilli in the human vagina. It's really not a very good thing,” she stressed. “These [remedies] really aren't going to work, although some people will say anecdotally that they do.”

Early trials assessing the efficacy of intravaginal capsules containing the probiotic Lactobacillus crispatus have proven “very disappointing,” she said. The organism nonetheless remains under evaluation as a potentially useful agent for repletion of normal vaginal lactobacilli, since it is one of the three most common lactic-acid-producing bacteria in the healthy vagina.

Research demonstrates that it adheres well to vaginal epithelial cells; in 2006, Dr. Marrazzo and her associates reported a high rate of satisfaction among 232 women who were “very willing” to use an intravaginal capsule containing lactobacillus (J. Womens Health 2006;15:1053–60).

Women in Dr. Marrazzo's study said they were willing to use the product again, regardless of the clinical response they received.

Dr. Marrazzo stated that she had no financial disclosures.

OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

BEVERLY HILLS, CALIF. – New ways of thinking about the underlying causes of osteoarthritis may lead to targeted therapeutic advances similar to those currently available for rheumatoid arthritis, Dr. Steven R. Ytterberg said at the annual meeting of the American Association for Hand Surgery.

The first conceptual shift is the notion that osteoarthritis probably is not a disease, but a clinical and pathologic outcome arising from a range of disorders, explained Dr. Ytterberg, a clinical rheumatologist and researcher at the Mayo Clinic, Rochester, Minn.

He noted wide disparities in the characteristics of primary vs. secondary osteo-arthritis; localized, single-joint disease vs. generalized osteoarthritis; and osteoarthritis associated with osteophyte necrosis, inflammation, or crystal deposition.

Dr. Ytterberg compared, for instance, inflammatory, erosive osteoarthritis of the hands with diffuse idiopathic skeletal hyperostosis (DISH). “Is this all the same disease? I don't know that it makes sense that it is.”

Another major shift is in the way researchers are studying development of osteoarthritis. “With osteoarthritis, the focus has always been on cartilage. To begin to see frayed cartilage through the arthroscope has always been presumed to be where the action is,” he said.

Microscopic disruption of the extracellular matrix, and later, macroscopic clefts in the cartilage were seen as progressive evidence of encroaching disease.

Now, the focus has shifted, and the target of research is bone.

“A large amount of information is now calling attention to what's going on in the chondrocytes: potential changes in cell-signaling pathways.”

Many researchers are now beginning to believe that “subchondral bone is where the problem is,” with cartilage abnormalities perhaps the downstream effect of abnormal wear in response to bone changes, said Dr. Ytterberg.

Other researchers are pursuing the hypothesis that osteoarthritis is an enthesopathy.

These theoretical research constructs are currently in their infancy but could help to better characterize what is now a diffusely defined set of symptoms that may or may not have common mechanistic origins, he said.

“This may open avenues of thinking [regarding] therapy for osteoarthritis, much like [the targeted therapies] we now have for rheumatoid arthritis,” he noted.

BEVERLY HILLS, CALIF. – New ways of thinking about the underlying causes of osteoarthritis may lead to targeted therapeutic advances similar to those currently available for rheumatoid arthritis, Dr. Steven R. Ytterberg said at the annual meeting of the American Association for Hand Surgery.

The first conceptual shift is the notion that osteoarthritis probably is not a disease, but a clinical and pathologic outcome arising from a range of disorders, explained Dr. Ytterberg, a clinical rheumatologist and researcher at the Mayo Clinic, Rochester, Minn.

He noted wide disparities in the characteristics of primary vs. secondary osteo-arthritis; localized, single-joint disease vs. generalized osteoarthritis; and osteoarthritis associated with osteophyte necrosis, inflammation, or crystal deposition.

Dr. Ytterberg compared, for instance, inflammatory, erosive osteoarthritis of the hands with diffuse idiopathic skeletal hyperostosis (DISH). “Is this all the same disease? I don't know that it makes sense that it is.”

Another major shift is in the way researchers are studying development of osteoarthritis. “With osteoarthritis, the focus has always been on cartilage. To begin to see frayed cartilage through the arthroscope has always been presumed to be where the action is,” he said.

Microscopic disruption of the extracellular matrix, and later, macroscopic clefts in the cartilage were seen as progressive evidence of encroaching disease.

Now, the focus has shifted, and the target of research is bone.

“A large amount of information is now calling attention to what's going on in the chondrocytes: potential changes in cell-signaling pathways.”

Many researchers are now beginning to believe that “subchondral bone is where the problem is,” with cartilage abnormalities perhaps the downstream effect of abnormal wear in response to bone changes, said Dr. Ytterberg.

Other researchers are pursuing the hypothesis that osteoarthritis is an enthesopathy.

These theoretical research constructs are currently in their infancy but could help to better characterize what is now a diffusely defined set of symptoms that may or may not have common mechanistic origins, he said.

“This may open avenues of thinking [regarding] therapy for osteoarthritis, much like [the targeted therapies] we now have for rheumatoid arthritis,” he noted.

BEVERLY HILLS, CALIF. – New ways of thinking about the underlying causes of osteoarthritis may lead to targeted therapeutic advances similar to those currently available for rheumatoid arthritis, Dr. Steven R. Ytterberg said at the annual meeting of the American Association for Hand Surgery.

The first conceptual shift is the notion that osteoarthritis probably is not a disease, but a clinical and pathologic outcome arising from a range of disorders, explained Dr. Ytterberg, a clinical rheumatologist and researcher at the Mayo Clinic, Rochester, Minn.

He noted wide disparities in the characteristics of primary vs. secondary osteo-arthritis; localized, single-joint disease vs. generalized osteoarthritis; and osteoarthritis associated with osteophyte necrosis, inflammation, or crystal deposition.

Dr. Ytterberg compared, for instance, inflammatory, erosive osteoarthritis of the hands with diffuse idiopathic skeletal hyperostosis (DISH). “Is this all the same disease? I don't know that it makes sense that it is.”

Another major shift is in the way researchers are studying development of osteoarthritis. “With osteoarthritis, the focus has always been on cartilage. To begin to see frayed cartilage through the arthroscope has always been presumed to be where the action is,” he said.

Microscopic disruption of the extracellular matrix, and later, macroscopic clefts in the cartilage were seen as progressive evidence of encroaching disease.

Now, the focus has shifted, and the target of research is bone.

“A large amount of information is now calling attention to what's going on in the chondrocytes: potential changes in cell-signaling pathways.”

Many researchers are now beginning to believe that “subchondral bone is where the problem is,” with cartilage abnormalities perhaps the downstream effect of abnormal wear in response to bone changes, said Dr. Ytterberg.

Other researchers are pursuing the hypothesis that osteoarthritis is an enthesopathy.

These theoretical research constructs are currently in their infancy but could help to better characterize what is now a diffusely defined set of symptoms that may or may not have common mechanistic origins, he said.

“This may open avenues of thinking [regarding] therapy for osteoarthritis, much like [the targeted therapies] we now have for rheumatoid arthritis,” he noted.

SAN DIEGO – Long-term use of metronidazole gel remains the mainstay of treatment for women with recurrent bacterial vaginosis, said Dr. Jeanne Marrazzo of the division of allergy and infectious disease at the University of Washington, Seattle.

Patients are advised to use intravaginal metronidazole gel 0.75% at bedtime for 10-14 days, then biweekly for about 6 months before retesting, Dr. Marrazzo said at Perspectives in Women's Health, a conference sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

The mechanism of action in this regimen is not fully understood, although it may suppress overall anaerobic overgrowth for so long that the patient's lactobacillus population can recover. Suppression of an unknown pathogen may also be at work, she said.

“The problem is cost,” she said. Generic products exist in the gel formulation but offer little cost advantage over the branded products. Research suggests benefit from condom use during intercourse in the initial and suppression treatment regimens, again, for reasons that are not fully understood. “Condom use should be part of the counseling of patients with recurrent BV.”

At present, there are no good alternatives to metronidazole gel for these patients, she noted. Over-the-counter lactobacillus remedies and yogurt are not good options. “You don't want to use bovine lactobacilli in the human vagina. … These [remedies] really aren't going to work, although some people will say anecdotally that they do.”

Early trials assessing the efficacy of intravaginal capsules containing the probiotic Lactobacillus crispatus have proven disappointing, she said. But the organism remains under evaluation as a potentially useful agent for repletion of normal vaginal lactobacilli, since it is one of the three most common lactic-acid-producing bacteria in the healthy vagina.

Research shows it adheres well to vaginal epithelial cells; in 2006, Dr. Marrazzo and her associates reported a high rate of satisfaction in 232 women who used an intravaginal capsule containing lactobacillus (J. Womens Health 2006;15: 1053-60). Women in the study said they would use the product again, regardless of the clinical response they received.

Dr. Marrazzo had no financial disclosures. FAMILY PRACTICE NEWS is published by the International Medical News Group, a division of Elsevier.

SAN DIEGO – Long-term use of metronidazole gel remains the mainstay of treatment for women with recurrent bacterial vaginosis, said Dr. Jeanne Marrazzo of the division of allergy and infectious disease at the University of Washington, Seattle.

Patients are advised to use intravaginal metronidazole gel 0.75% at bedtime for 10-14 days, then biweekly for about 6 months before retesting, Dr. Marrazzo said at Perspectives in Women's Health, a conference sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

The mechanism of action in this regimen is not fully understood, although it may suppress overall anaerobic overgrowth for so long that the patient's lactobacillus population can recover. Suppression of an unknown pathogen may also be at work, she said.

“The problem is cost,” she said. Generic products exist in the gel formulation but offer little cost advantage over the branded products. Research suggests benefit from condom use during intercourse in the initial and suppression treatment regimens, again, for reasons that are not fully understood. “Condom use should be part of the counseling of patients with recurrent BV.”

At present, there are no good alternatives to metronidazole gel for these patients, she noted. Over-the-counter lactobacillus remedies and yogurt are not good options. “You don't want to use bovine lactobacilli in the human vagina. … These [remedies] really aren't going to work, although some people will say anecdotally that they do.”

Early trials assessing the efficacy of intravaginal capsules containing the probiotic Lactobacillus crispatus have proven disappointing, she said. But the organism remains under evaluation as a potentially useful agent for repletion of normal vaginal lactobacilli, since it is one of the three most common lactic-acid-producing bacteria in the healthy vagina.

Research shows it adheres well to vaginal epithelial cells; in 2006, Dr. Marrazzo and her associates reported a high rate of satisfaction in 232 women who used an intravaginal capsule containing lactobacillus (J. Womens Health 2006;15: 1053-60). Women in the study said they would use the product again, regardless of the clinical response they received.

Dr. Marrazzo had no financial disclosures. FAMILY PRACTICE NEWS is published by the International Medical News Group, a division of Elsevier.

SAN DIEGO – Long-term use of metronidazole gel remains the mainstay of treatment for women with recurrent bacterial vaginosis, said Dr. Jeanne Marrazzo of the division of allergy and infectious disease at the University of Washington, Seattle.

Patients are advised to use intravaginal metronidazole gel 0.75% at bedtime for 10-14 days, then biweekly for about 6 months before retesting, Dr. Marrazzo said at Perspectives in Women's Health, a conference sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

The mechanism of action in this regimen is not fully understood, although it may suppress overall anaerobic overgrowth for so long that the patient's lactobacillus population can recover. Suppression of an unknown pathogen may also be at work, she said.

“The problem is cost,” she said. Generic products exist in the gel formulation but offer little cost advantage over the branded products. Research suggests benefit from condom use during intercourse in the initial and suppression treatment regimens, again, for reasons that are not fully understood. “Condom use should be part of the counseling of patients with recurrent BV.”

At present, there are no good alternatives to metronidazole gel for these patients, she noted. Over-the-counter lactobacillus remedies and yogurt are not good options. “You don't want to use bovine lactobacilli in the human vagina. … These [remedies] really aren't going to work, although some people will say anecdotally that they do.”

Early trials assessing the efficacy of intravaginal capsules containing the probiotic Lactobacillus crispatus have proven disappointing, she said. But the organism remains under evaluation as a potentially useful agent for repletion of normal vaginal lactobacilli, since it is one of the three most common lactic-acid-producing bacteria in the healthy vagina.

Research shows it adheres well to vaginal epithelial cells; in 2006, Dr. Marrazzo and her associates reported a high rate of satisfaction in 232 women who used an intravaginal capsule containing lactobacillus (J. Womens Health 2006;15: 1053-60). Women in the study said they would use the product again, regardless of the clinical response they received.

Dr. Marrazzo had no financial disclosures. FAMILY PRACTICE NEWS is published by the International Medical News Group, a division of Elsevier.

SAN DIEGO – Resistance to gonorrhea is climbing just as treatment options are dwindling, making for a potential public health crisis if more drug choices are not brought to market soon.

“The situation is really not good. We're hanging by a thread, with a very serious resistance problem. If we lose cephalo-sporins [to resistance], we will really be up a creek,” Dr. Jeanne Marrazzo said at Perspectives in Women's Health, sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

Practically speaking, ceftriaxone (125 mg intramuscularly, in a single dose) remains the only available regimen recommended by the Centers for Disease Control and Prevention for the treatment of gonorrhea, which is the second-most commonly reported infectious disease in the United States.

After years of decline or stability, U.S. rates of gonorrhea rose for the second straight year in 2006, with about 358,000 new cases reported, according to CDC surveillance statistics.

Many infectious disease specialists are wary of dependence on a single drug to treat a widespread infectious disease because of the threat of resistance, and gonorrhea seems particularly susceptible.

Widespread resistance long ago took penicillins, sulfa drugs, tetracycline, and spectinomycin off the table for the treatment of gonococcal infections. By April of last year, fluoroquinolones, including ciprofloxacin, ofloxacin, and levofloxacin, also lost their “recommended” status because of resistance documented in sites in the United States and other countries.

Cefixime remains on the CDC's recommended list; however, it is currently unavailable in the United States, except in a liquid pediatric formula approved last year.

One problem with the pediatric formula is that it has a limited shelf life once reconstituted.

Dr. Marrazzo explained that Wyeth Pharmaceuticals discontinued manufacture of cefixime tablets, which were once marketed as Suprax, when the drug's patent expired in 2002.

Exclusive rights to the drug are now held by a company that is based in India. She said it is rumored that the company is working with the Food and Drug Administration to obtain approval to market 400-mg tablets in the United States.

Alternative regimens suggested by the CDC include spectinomycin, which is also no longer being manufactured in the United States, and single-dose cephalosporin regimens.

All patients with gonorrhea should be cotreated for chlamydia unless it is ruled out with a highly sensitive test.

The lack of availability of spectinomycin complicates management of patients who are allergic to cephalosporins, according to Dr. Marrazzo of the Seattle STD/HIV Prevention Training Center and the University of Washington, Seattle.

The CDC “cluelessly” recommends desensitizing patients, said Dr. Marrazzo, who added that the suggestion is impractical for a busy clinic.

Such cases in allergic patients might call for special consideration of high-dose azithromycin, but the 2-g dose required can cause gastrointestinal problems, even with split doses that are administered several hours apart. In any case, resistance to azithromycin is likely increasing, so “that's going to be a short-term fix,” she added.

If fluoroquinolones are the only remaining option in cephalosporin-allergic patients, then Dr. Marrazzo recommends that one obtain a culture before treatment to ensure sensitivity, or that one obtain a test of cure in 3-5 days by culture or 3 weeks if a nucleic acid amplification test is used.

Dr. Marrazzo disclosed that she is a consultant to Mission Pharmacal Co. and she serves on the speakers' bureaus of 3M and Merck. FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS. are published by the International Medical News Group, which is a division of Elsevier.

SAN DIEGO – Resistance to gonorrhea is climbing just as treatment options are dwindling, making for a potential public health crisis if more drug choices are not brought to market soon.

“The situation is really not good. We're hanging by a thread, with a very serious resistance problem. If we lose cephalo-sporins [to resistance], we will really be up a creek,” Dr. Jeanne Marrazzo said at Perspectives in Women's Health, sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

Practically speaking, ceftriaxone (125 mg intramuscularly, in a single dose) remains the only available regimen recommended by the Centers for Disease Control and Prevention for the treatment of gonorrhea, which is the second-most commonly reported infectious disease in the United States.

After years of decline or stability, U.S. rates of gonorrhea rose for the second straight year in 2006, with about 358,000 new cases reported, according to CDC surveillance statistics.

Many infectious disease specialists are wary of dependence on a single drug to treat a widespread infectious disease because of the threat of resistance, and gonorrhea seems particularly susceptible.

Widespread resistance long ago took penicillins, sulfa drugs, tetracycline, and spectinomycin off the table for the treatment of gonococcal infections. By April of last year, fluoroquinolones, including ciprofloxacin, ofloxacin, and levofloxacin, also lost their “recommended” status because of resistance documented in sites in the United States and other countries.

Cefixime remains on the CDC's recommended list; however, it is currently unavailable in the United States, except in a liquid pediatric formula approved last year.

One problem with the pediatric formula is that it has a limited shelf life once reconstituted.

Dr. Marrazzo explained that Wyeth Pharmaceuticals discontinued manufacture of cefixime tablets, which were once marketed as Suprax, when the drug's patent expired in 2002.

Exclusive rights to the drug are now held by a company that is based in India. She said it is rumored that the company is working with the Food and Drug Administration to obtain approval to market 400-mg tablets in the United States.

Alternative regimens suggested by the CDC include spectinomycin, which is also no longer being manufactured in the United States, and single-dose cephalosporin regimens.

All patients with gonorrhea should be cotreated for chlamydia unless it is ruled out with a highly sensitive test.

The lack of availability of spectinomycin complicates management of patients who are allergic to cephalosporins, according to Dr. Marrazzo of the Seattle STD/HIV Prevention Training Center and the University of Washington, Seattle.

The CDC “cluelessly” recommends desensitizing patients, said Dr. Marrazzo, who added that the suggestion is impractical for a busy clinic.

Such cases in allergic patients might call for special consideration of high-dose azithromycin, but the 2-g dose required can cause gastrointestinal problems, even with split doses that are administered several hours apart. In any case, resistance to azithromycin is likely increasing, so “that's going to be a short-term fix,” she added.

If fluoroquinolones are the only remaining option in cephalosporin-allergic patients, then Dr. Marrazzo recommends that one obtain a culture before treatment to ensure sensitivity, or that one obtain a test of cure in 3-5 days by culture or 3 weeks if a nucleic acid amplification test is used.

Dr. Marrazzo disclosed that she is a consultant to Mission Pharmacal Co. and she serves on the speakers' bureaus of 3M and Merck. FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS. are published by the International Medical News Group, which is a division of Elsevier.

SAN DIEGO – Resistance to gonorrhea is climbing just as treatment options are dwindling, making for a potential public health crisis if more drug choices are not brought to market soon.

“The situation is really not good. We're hanging by a thread, with a very serious resistance problem. If we lose cephalo-sporins [to resistance], we will really be up a creek,” Dr. Jeanne Marrazzo said at Perspectives in Women's Health, sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

Practically speaking, ceftriaxone (125 mg intramuscularly, in a single dose) remains the only available regimen recommended by the Centers for Disease Control and Prevention for the treatment of gonorrhea, which is the second-most commonly reported infectious disease in the United States.

After years of decline or stability, U.S. rates of gonorrhea rose for the second straight year in 2006, with about 358,000 new cases reported, according to CDC surveillance statistics.

Many infectious disease specialists are wary of dependence on a single drug to treat a widespread infectious disease because of the threat of resistance, and gonorrhea seems particularly susceptible.

Widespread resistance long ago took penicillins, sulfa drugs, tetracycline, and spectinomycin off the table for the treatment of gonococcal infections. By April of last year, fluoroquinolones, including ciprofloxacin, ofloxacin, and levofloxacin, also lost their “recommended” status because of resistance documented in sites in the United States and other countries.

Cefixime remains on the CDC's recommended list; however, it is currently unavailable in the United States, except in a liquid pediatric formula approved last year.

One problem with the pediatric formula is that it has a limited shelf life once reconstituted.

Dr. Marrazzo explained that Wyeth Pharmaceuticals discontinued manufacture of cefixime tablets, which were once marketed as Suprax, when the drug's patent expired in 2002.

Exclusive rights to the drug are now held by a company that is based in India. She said it is rumored that the company is working with the Food and Drug Administration to obtain approval to market 400-mg tablets in the United States.

Alternative regimens suggested by the CDC include spectinomycin, which is also no longer being manufactured in the United States, and single-dose cephalosporin regimens.

All patients with gonorrhea should be cotreated for chlamydia unless it is ruled out with a highly sensitive test.

The lack of availability of spectinomycin complicates management of patients who are allergic to cephalosporins, according to Dr. Marrazzo of the Seattle STD/HIV Prevention Training Center and the University of Washington, Seattle.

The CDC “cluelessly” recommends desensitizing patients, said Dr. Marrazzo, who added that the suggestion is impractical for a busy clinic.

Such cases in allergic patients might call for special consideration of high-dose azithromycin, but the 2-g dose required can cause gastrointestinal problems, even with split doses that are administered several hours apart. In any case, resistance to azithromycin is likely increasing, so “that's going to be a short-term fix,” she added.

If fluoroquinolones are the only remaining option in cephalosporin-allergic patients, then Dr. Marrazzo recommends that one obtain a culture before treatment to ensure sensitivity, or that one obtain a test of cure in 3-5 days by culture or 3 weeks if a nucleic acid amplification test is used.

Dr. Marrazzo disclosed that she is a consultant to Mission Pharmacal Co. and she serves on the speakers' bureaus of 3M and Merck. FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS. are published by the International Medical News Group, which is a division of Elsevier.

SAN DIEGO — The human papillomavirus vaccine, although still not recommended for use in pregnancy, is no longer listed as contraindicated by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.

“This may lessen the concern when a woman inadvertently receives a dose before learning she is pregnant,” Dr. Hal Lawrence said at Perspectives in Women's Health sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

“Given time and more data, multiple doses of the vaccine may prove to be safe during pregnancy, offering clinicians an opportunity to initiate or complete the three-dose series during a period of routine office visits,” added Dr. Lawrence, vice president for practice activities, American College of Obstetricians and Gynecologists.

For now, however, neither intentional initiation of the vaccine series nor delivery of doses two and three during pregnancy is recommended, according to updated information available from the CDC's Guidelines for Vaccinating Pregnant Women, available at www.cdc.gov/vaccines/pubs/pre-guide.htm

The HPV vaccine contains neither live nor attenuated viral particles; instead, it contains particles engineered to resemble the L1 protein on the virus's outer capsule.

Although it provokes a robust immune response, “it does not have any actual viral activity,” said Dr. Lawrence. To date no adverse events related to the mother or the developing fetus have been associated with administering the vaccine during pregnancy.

In an interview, Dr. Lawrence emphasized that the data are limited. “What we are really saying is that while no adverse events have been reported, there is not enough information to recommend HPV vaccination in pregnancy,” he said.

Dr. Lawrence said that clinicians with patients who received the HPV vaccine during pregnancy are encouraged to call the HPV Vaccine Pregnancy Registry at 800-986-8999 to add to the information base. As HPV vaccinations during pregnancy are identified and pregnancy outcomes are tracked, the CDC and other organizations may reevaluate use of the vaccine during pregnancy.

In other news regarding HPV vaccines, Dr. Lawrence cited recent data showing partial blocking of 10 additional HPV strains, in addition to HPV 6, 11, 16, and 18, the four covered by the quadrivalent vaccine. “This may boost protection [against cervical cancer] to 90%,” he said.

HPV is also responsible for the majority of anal and vulvar cancers in young women and for head, neck, and oral cancers, any of which could potentially be prevented with the HPV vaccine, he said.

OB.GYN. NEWS, FAMILY PRACTICE NEWS, and INTERNAL MEDICINE NEWS are published by the International Medical News Group, a division of Elsevier.

SAN DIEGO — The human papillomavirus vaccine, although still not recommended for use in pregnancy, is no longer listed as contraindicated by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.

“This may lessen the concern when a woman inadvertently receives a dose before learning she is pregnant,” Dr. Hal Lawrence said at Perspectives in Women's Health sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

“Given time and more data, multiple doses of the vaccine may prove to be safe during pregnancy, offering clinicians an opportunity to initiate or complete the three-dose series during a period of routine office visits,” added Dr. Lawrence, vice president for practice activities, American College of Obstetricians and Gynecologists.

For now, however, neither intentional initiation of the vaccine series nor delivery of doses two and three during pregnancy is recommended, according to updated information available from the CDC's Guidelines for Vaccinating Pregnant Women, available at www.cdc.gov/vaccines/pubs/pre-guide.htm

The HPV vaccine contains neither live nor attenuated viral particles; instead, it contains particles engineered to resemble the L1 protein on the virus's outer capsule.

Although it provokes a robust immune response, “it does not have any actual viral activity,” said Dr. Lawrence. To date no adverse events related to the mother or the developing fetus have been associated with administering the vaccine during pregnancy.

In an interview, Dr. Lawrence emphasized that the data are limited. “What we are really saying is that while no adverse events have been reported, there is not enough information to recommend HPV vaccination in pregnancy,” he said.

Dr. Lawrence said that clinicians with patients who received the HPV vaccine during pregnancy are encouraged to call the HPV Vaccine Pregnancy Registry at 800-986-8999 to add to the information base. As HPV vaccinations during pregnancy are identified and pregnancy outcomes are tracked, the CDC and other organizations may reevaluate use of the vaccine during pregnancy.

In other news regarding HPV vaccines, Dr. Lawrence cited recent data showing partial blocking of 10 additional HPV strains, in addition to HPV 6, 11, 16, and 18, the four covered by the quadrivalent vaccine. “This may boost protection [against cervical cancer] to 90%,” he said.

HPV is also responsible for the majority of anal and vulvar cancers in young women and for head, neck, and oral cancers, any of which could potentially be prevented with the HPV vaccine, he said.

OB.GYN. NEWS, FAMILY PRACTICE NEWS, and INTERNAL MEDICINE NEWS are published by the International Medical News Group, a division of Elsevier.

SAN DIEGO — The human papillomavirus vaccine, although still not recommended for use in pregnancy, is no longer listed as contraindicated by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.

“This may lessen the concern when a woman inadvertently receives a dose before learning she is pregnant,” Dr. Hal Lawrence said at Perspectives in Women's Health sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

“Given time and more data, multiple doses of the vaccine may prove to be safe during pregnancy, offering clinicians an opportunity to initiate or complete the three-dose series during a period of routine office visits,” added Dr. Lawrence, vice president for practice activities, American College of Obstetricians and Gynecologists.

For now, however, neither intentional initiation of the vaccine series nor delivery of doses two and three during pregnancy is recommended, according to updated information available from the CDC's Guidelines for Vaccinating Pregnant Women, available at www.cdc.gov/vaccines/pubs/pre-guide.htm

The HPV vaccine contains neither live nor attenuated viral particles; instead, it contains particles engineered to resemble the L1 protein on the virus's outer capsule.

Although it provokes a robust immune response, “it does not have any actual viral activity,” said Dr. Lawrence. To date no adverse events related to the mother or the developing fetus have been associated with administering the vaccine during pregnancy.

In an interview, Dr. Lawrence emphasized that the data are limited. “What we are really saying is that while no adverse events have been reported, there is not enough information to recommend HPV vaccination in pregnancy,” he said.

Dr. Lawrence said that clinicians with patients who received the HPV vaccine during pregnancy are encouraged to call the HPV Vaccine Pregnancy Registry at 800-986-8999 to add to the information base. As HPV vaccinations during pregnancy are identified and pregnancy outcomes are tracked, the CDC and other organizations may reevaluate use of the vaccine during pregnancy.

In other news regarding HPV vaccines, Dr. Lawrence cited recent data showing partial blocking of 10 additional HPV strains, in addition to HPV 6, 11, 16, and 18, the four covered by the quadrivalent vaccine. “This may boost protection [against cervical cancer] to 90%,” he said.

HPV is also responsible for the majority of anal and vulvar cancers in young women and for head, neck, and oral cancers, any of which could potentially be prevented with the HPV vaccine, he said.

OB.GYN. NEWS, FAMILY PRACTICE NEWS, and INTERNAL MEDICINE NEWS are published by the International Medical News Group, a division of Elsevier.

SAN DIEGO, CALIF. – “Diabesity,” as Dr. David Heber calls type 2 diabetes, is a lifestyle disease, not a diagnosis that necessarily requires heavy lifting of the prescription pad.

Too many physicians begin and end the conversation by saying, “You have diabetes and I have a drug for you,” he said at the Perspectives in Women's Health meeting.

Obesity, which packs proinflammatory adipocytes around the heart, liver, and intestines, stands as the greatest threat to women's health in the modern world, said Dr. Heber, professor of medicine and director of the University of California at Los Angeles Center for Human Nutrition.

It costs $130 billion in the United States each year, impacting nearly every organ system in the body, including the reproductive system (Dr. Heber calls polycystic ovary syndrome “diabetes of the ovary”), musculoskeletal system, and the hepatic system, rapidly becoming a leading cause of liver transplantation.

Dr. Heber emphasized that judging patients by appearance alone, or even body mass index, will miss many women at increased risk for cardiovascular disease and diabetes because of abdominal fat.

“Women have higher body fat than men at every BMI,” he said, quoting one study that found that 45% of women with normal BMIs had excess internal fat.

In his office, he uses a bioelectrical impedance meter to measure skeletal muscle versus fat tissue mass, from which calculations can be made for the number of calories per day required to reduce weight in a certain period of time.

The next step is to discuss with patients the need for lifestyle modification to preserve health in a way that they can envision.

Unfortunately, both emotions and nature work in opposition to weight loss, since “psychology trumps physiology every time. You eat when you are not hungry. Nature wants you to hold on to calories.”

Diabetes, he said, “is great genes in the wrong century.”

For many people, then, a whole restructuring of views about food must counteract impulses and a food industry that has conditioned us to crave foods that are sweet, bland, oily, and creamy “so that you can consume a large amount of food without realizing it,” Dr. Heber said.

Focusing on fruits and vegetables, whole grains, fish, spices, and nuts in a color-coordinated diet (see box) can provide fewer calories and fewer proinflammatory foods, as described in Dr. Heber's book for lay audiences, “What Color Is Your Diet?” (New York: HarperCollins Publishers, 2001.)

Replacing two meals a day (one per day for weight maintenance after weight loss) with high protein, low-calorie, meal replacement shakes makes the transition even easier.

Drinking thick shakes for two meals makes people want chewy, crunchy, colorful foods for snacks and the third meal of the day, he explained. Fruits and vegetables fit that bill.

The strategy also helps patients learn to self-monitor their eating and to better gauge portion sizes and estimate calories.

Perspectives in Women's Health is sponsored by several publications of the International Medical News Group, a division of Elsevier.

Brighten Mealtimes for Weight Loss

Dr. Heber encourages his diabetes patients to eat from the following color groups of fruits and vegetables:

▸ Red. Tomato products, soups, sauces, juices (contain lycopene).

▸ Red/purple. Red wine, grapes, berries, plums (contain anthocyanins, ellagitannins).

▸ Orange. Carrots, mango, apricot, sweet potato (contain β-carotene/α-carotene).

▸ Orange/yellow. Citrus fruits, papaya, peaches (contain citrus flavonoids).

▸ Yellow/green. Spinach, corn, avocado, green beans (contain lutein/zeaxanthin).

▸ Green. Broccoli, Brussels sprouts, cabbage (contain glucosinolates, indoles).

▸ White/green. Garlic, onions, chives, asparagus (contain allyl sulfides).

Dr. Heber tells his patients to avoid white and beige foods, such as white bread.

SAN DIEGO, CALIF. – “Diabesity,” as Dr. David Heber calls type 2 diabetes, is a lifestyle disease, not a diagnosis that necessarily requires heavy lifting of the prescription pad.

Too many physicians begin and end the conversation by saying, “You have diabetes and I have a drug for you,” he said at the Perspectives in Women's Health meeting.

Obesity, which packs proinflammatory adipocytes around the heart, liver, and intestines, stands as the greatest threat to women's health in the modern world, said Dr. Heber, professor of medicine and director of the University of California at Los Angeles Center for Human Nutrition.

It costs $130 billion in the United States each year, impacting nearly every organ system in the body, including the reproductive system (Dr. Heber calls polycystic ovary syndrome “diabetes of the ovary”), musculoskeletal system, and the hepatic system, rapidly becoming a leading cause of liver transplantation.

Dr. Heber emphasized that judging patients by appearance alone, or even body mass index, will miss many women at increased risk for cardiovascular disease and diabetes because of abdominal fat.

“Women have higher body fat than men at every BMI,” he said, quoting one study that found that 45% of women with normal BMIs had excess internal fat.

In his office, he uses a bioelectrical impedance meter to measure skeletal muscle versus fat tissue mass, from which calculations can be made for the number of calories per day required to reduce weight in a certain period of time.

The next step is to discuss with patients the need for lifestyle modification to preserve health in a way that they can envision.

Unfortunately, both emotions and nature work in opposition to weight loss, since “psychology trumps physiology every time. You eat when you are not hungry. Nature wants you to hold on to calories.”

Diabetes, he said, “is great genes in the wrong century.”

For many people, then, a whole restructuring of views about food must counteract impulses and a food industry that has conditioned us to crave foods that are sweet, bland, oily, and creamy “so that you can consume a large amount of food without realizing it,” Dr. Heber said.

Focusing on fruits and vegetables, whole grains, fish, spices, and nuts in a color-coordinated diet (see box) can provide fewer calories and fewer proinflammatory foods, as described in Dr. Heber's book for lay audiences, “What Color Is Your Diet?” (New York: HarperCollins Publishers, 2001.)

Replacing two meals a day (one per day for weight maintenance after weight loss) with high protein, low-calorie, meal replacement shakes makes the transition even easier.

Drinking thick shakes for two meals makes people want chewy, crunchy, colorful foods for snacks and the third meal of the day, he explained. Fruits and vegetables fit that bill.

The strategy also helps patients learn to self-monitor their eating and to better gauge portion sizes and estimate calories.

Perspectives in Women's Health is sponsored by several publications of the International Medical News Group, a division of Elsevier.

Brighten Mealtimes for Weight Loss

Dr. Heber encourages his diabetes patients to eat from the following color groups of fruits and vegetables:

▸ Red. Tomato products, soups, sauces, juices (contain lycopene).

▸ Red/purple. Red wine, grapes, berries, plums (contain anthocyanins, ellagitannins).

▸ Orange. Carrots, mango, apricot, sweet potato (contain β-carotene/α-carotene).

▸ Orange/yellow. Citrus fruits, papaya, peaches (contain citrus flavonoids).

▸ Yellow/green. Spinach, corn, avocado, green beans (contain lutein/zeaxanthin).

▸ Green. Broccoli, Brussels sprouts, cabbage (contain glucosinolates, indoles).

▸ White/green. Garlic, onions, chives, asparagus (contain allyl sulfides).

Dr. Heber tells his patients to avoid white and beige foods, such as white bread.

SAN DIEGO, CALIF. – “Diabesity,” as Dr. David Heber calls type 2 diabetes, is a lifestyle disease, not a diagnosis that necessarily requires heavy lifting of the prescription pad.

Too many physicians begin and end the conversation by saying, “You have diabetes and I have a drug for you,” he said at the Perspectives in Women's Health meeting.

Obesity, which packs proinflammatory adipocytes around the heart, liver, and intestines, stands as the greatest threat to women's health in the modern world, said Dr. Heber, professor of medicine and director of the University of California at Los Angeles Center for Human Nutrition.

It costs $130 billion in the United States each year, impacting nearly every organ system in the body, including the reproductive system (Dr. Heber calls polycystic ovary syndrome “diabetes of the ovary”), musculoskeletal system, and the hepatic system, rapidly becoming a leading cause of liver transplantation.

Dr. Heber emphasized that judging patients by appearance alone, or even body mass index, will miss many women at increased risk for cardiovascular disease and diabetes because of abdominal fat.

“Women have higher body fat than men at every BMI,” he said, quoting one study that found that 45% of women with normal BMIs had excess internal fat.

In his office, he uses a bioelectrical impedance meter to measure skeletal muscle versus fat tissue mass, from which calculations can be made for the number of calories per day required to reduce weight in a certain period of time.

The next step is to discuss with patients the need for lifestyle modification to preserve health in a way that they can envision.

Unfortunately, both emotions and nature work in opposition to weight loss, since “psychology trumps physiology every time. You eat when you are not hungry. Nature wants you to hold on to calories.”

Diabetes, he said, “is great genes in the wrong century.”

For many people, then, a whole restructuring of views about food must counteract impulses and a food industry that has conditioned us to crave foods that are sweet, bland, oily, and creamy “so that you can consume a large amount of food without realizing it,” Dr. Heber said.

Focusing on fruits and vegetables, whole grains, fish, spices, and nuts in a color-coordinated diet (see box) can provide fewer calories and fewer proinflammatory foods, as described in Dr. Heber's book for lay audiences, “What Color Is Your Diet?” (New York: HarperCollins Publishers, 2001.)

Replacing two meals a day (one per day for weight maintenance after weight loss) with high protein, low-calorie, meal replacement shakes makes the transition even easier.

Drinking thick shakes for two meals makes people want chewy, crunchy, colorful foods for snacks and the third meal of the day, he explained. Fruits and vegetables fit that bill.

The strategy also helps patients learn to self-monitor their eating and to better gauge portion sizes and estimate calories.

Perspectives in Women's Health is sponsored by several publications of the International Medical News Group, a division of Elsevier.

Brighten Mealtimes for Weight Loss

Dr. Heber encourages his diabetes patients to eat from the following color groups of fruits and vegetables:

▸ Red. Tomato products, soups, sauces, juices (contain lycopene).

▸ Red/purple. Red wine, grapes, berries, plums (contain anthocyanins, ellagitannins).

▸ Orange. Carrots, mango, apricot, sweet potato (contain β-carotene/α-carotene).

▸ Orange/yellow. Citrus fruits, papaya, peaches (contain citrus flavonoids).

▸ Yellow/green. Spinach, corn, avocado, green beans (contain lutein/zeaxanthin).

▸ Green. Broccoli, Brussels sprouts, cabbage (contain glucosinolates, indoles).

▸ White/green. Garlic, onions, chives, asparagus (contain allyl sulfides).

Dr. Heber tells his patients to avoid white and beige foods, such as white bread.

'There is not [yet] enough information to recommend HPV vaccination in pregnancy.' DR. LAWRENCE

LA JOLLA, CALIF. — The human papillomavirus vaccine, although still not recommended for use in pregnancy, was no longer listed as contraindicated by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices as of early last year.

“This may lessen the concern when a woman inadvertently receives a dose before learning she is pregnant,” Dr. Hal Lawrence said at Perspectives in Women's Health sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

“Given time and more data, multiple doses of the vaccine may prove to be safe during pregnancy, offering clinicians an opportunity to initiate or complete the three-dose series during a period of routine office visits,” added Dr. Lawrence, vice president for practice activities, American College of Obstetricians and Gynecologists, and a member of the editorial advisory board of OB.GYN. NEWS.

For now, however, neither intentional initiation of the vaccine series nor delivery of doses two and three during pregnancy is recommended, according to updated vaccine information from the CDC's Guidelines for Vaccinating Pregnant Women, available online at www.cdc.gov/vaccines/pubs/preg-guide.htm

The HPV vaccine contains neither live nor attenuated viral particles; instead, it contains viruslike particles engineered to resemble the L1 protein on the outer capsule of the virus.

Although it provokes a robust immune response, “it does not have any actual viral activity,” said Dr. Lawrence. This mechanism is reassuring, and to date no adverse events related to mothers or developing fetuses have been associated with administering the HPV vaccine during pregnancy.

In an interview following the meeting, however, Dr. Lawrence emphasized that the data are limited. “What we are really saying is that while no adverse events have been reported, there is not enough information to recommend HPV vaccination in pregnancy,” he said.

Dr. Lawrence said that clinicians with patients who received the HPV vaccine during pregnancy are encouraged to call the HPV Vaccine Pregnancy Registry at 800-986-8999 to add to the information base. As HPV vaccinations during pregnancy are identified and pregnancy outcomes are tracked, the CDC and other organizations may reevaluate use of the vaccine during pregnancy.

In other news regarding HPV vaccines, Dr. Lawrence cited recent data showing partial blocking of 10 additional HPV strains, in addition to HPV 6, 11, 16, and 18, the four covered by the quadrivalent vaccine. “This may boost protection [against cervical cancer] to 90%,” he said at the meeting.

HPV is also responsible for the majority of anal and vulvar cancers in young women and for head, neck, and oral cancers as well, any of which could potentially be prevented with the HPV vaccine, according to Dr. Lawrence. For additional information, see ACOG Committee Opinion No. 344 and ACOG Practice Bulletin No. 61.

OB.GYN. NEWS, FAMILY PRACTICE NEWS, and INTERNAL MEDICINE NEWS are published by the International Medical News Group, a division of Elsevier.

'There is not [yet] enough information to recommend HPV vaccination in pregnancy.' DR. LAWRENCE

LA JOLLA, CALIF. — The human papillomavirus vaccine, although still not recommended for use in pregnancy, was no longer listed as contraindicated by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices as of early last year.

“This may lessen the concern when a woman inadvertently receives a dose before learning she is pregnant,” Dr. Hal Lawrence said at Perspectives in Women's Health sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

“Given time and more data, multiple doses of the vaccine may prove to be safe during pregnancy, offering clinicians an opportunity to initiate or complete the three-dose series during a period of routine office visits,” added Dr. Lawrence, vice president for practice activities, American College of Obstetricians and Gynecologists, and a member of the editorial advisory board of OB.GYN. NEWS.

For now, however, neither intentional initiation of the vaccine series nor delivery of doses two and three during pregnancy is recommended, according to updated vaccine information from the CDC's Guidelines for Vaccinating Pregnant Women, available online at www.cdc.gov/vaccines/pubs/preg-guide.htm

The HPV vaccine contains neither live nor attenuated viral particles; instead, it contains viruslike particles engineered to resemble the L1 protein on the outer capsule of the virus.

Although it provokes a robust immune response, “it does not have any actual viral activity,” said Dr. Lawrence. This mechanism is reassuring, and to date no adverse events related to mothers or developing fetuses have been associated with administering the HPV vaccine during pregnancy.

In an interview following the meeting, however, Dr. Lawrence emphasized that the data are limited. “What we are really saying is that while no adverse events have been reported, there is not enough information to recommend HPV vaccination in pregnancy,” he said.

Dr. Lawrence said that clinicians with patients who received the HPV vaccine during pregnancy are encouraged to call the HPV Vaccine Pregnancy Registry at 800-986-8999 to add to the information base. As HPV vaccinations during pregnancy are identified and pregnancy outcomes are tracked, the CDC and other organizations may reevaluate use of the vaccine during pregnancy.

In other news regarding HPV vaccines, Dr. Lawrence cited recent data showing partial blocking of 10 additional HPV strains, in addition to HPV 6, 11, 16, and 18, the four covered by the quadrivalent vaccine. “This may boost protection [against cervical cancer] to 90%,” he said at the meeting.

HPV is also responsible for the majority of anal and vulvar cancers in young women and for head, neck, and oral cancers as well, any of which could potentially be prevented with the HPV vaccine, according to Dr. Lawrence. For additional information, see ACOG Committee Opinion No. 344 and ACOG Practice Bulletin No. 61.

OB.GYN. NEWS, FAMILY PRACTICE NEWS, and INTERNAL MEDICINE NEWS are published by the International Medical News Group, a division of Elsevier.

'There is not [yet] enough information to recommend HPV vaccination in pregnancy.' DR. LAWRENCE

LA JOLLA, CALIF. — The human papillomavirus vaccine, although still not recommended for use in pregnancy, was no longer listed as contraindicated by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices as of early last year.

“This may lessen the concern when a woman inadvertently receives a dose before learning she is pregnant,” Dr. Hal Lawrence said at Perspectives in Women's Health sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

“Given time and more data, multiple doses of the vaccine may prove to be safe during pregnancy, offering clinicians an opportunity to initiate or complete the three-dose series during a period of routine office visits,” added Dr. Lawrence, vice president for practice activities, American College of Obstetricians and Gynecologists, and a member of the editorial advisory board of OB.GYN. NEWS.

For now, however, neither intentional initiation of the vaccine series nor delivery of doses two and three during pregnancy is recommended, according to updated vaccine information from the CDC's Guidelines for Vaccinating Pregnant Women, available online at www.cdc.gov/vaccines/pubs/preg-guide.htm

The HPV vaccine contains neither live nor attenuated viral particles; instead, it contains viruslike particles engineered to resemble the L1 protein on the outer capsule of the virus.

Although it provokes a robust immune response, “it does not have any actual viral activity,” said Dr. Lawrence. This mechanism is reassuring, and to date no adverse events related to mothers or developing fetuses have been associated with administering the HPV vaccine during pregnancy.

In an interview following the meeting, however, Dr. Lawrence emphasized that the data are limited. “What we are really saying is that while no adverse events have been reported, there is not enough information to recommend HPV vaccination in pregnancy,” he said.

Dr. Lawrence said that clinicians with patients who received the HPV vaccine during pregnancy are encouraged to call the HPV Vaccine Pregnancy Registry at 800-986-8999 to add to the information base. As HPV vaccinations during pregnancy are identified and pregnancy outcomes are tracked, the CDC and other organizations may reevaluate use of the vaccine during pregnancy.

In other news regarding HPV vaccines, Dr. Lawrence cited recent data showing partial blocking of 10 additional HPV strains, in addition to HPV 6, 11, 16, and 18, the four covered by the quadrivalent vaccine. “This may boost protection [against cervical cancer] to 90%,” he said at the meeting.

HPV is also responsible for the majority of anal and vulvar cancers in young women and for head, neck, and oral cancers as well, any of which could potentially be prevented with the HPV vaccine, according to Dr. Lawrence. For additional information, see ACOG Committee Opinion No. 344 and ACOG Practice Bulletin No. 61.

OB.GYN. NEWS, FAMILY PRACTICE NEWS, and INTERNAL MEDICINE NEWS are published by the International Medical News Group, a division of Elsevier.

STANFORD, CALIF. — Increasing evidence suggests that children with autism have a normal head circumference at birth, but that many develop macroencephaly in childhood, Dr. Antonio Y. Hardan said at a recent pediatric update sponsored by Stanford (Calif.) University.

Distinguishing features within the brain are evident in utero, with abnormal neuronal migration and a decrease in the size of the cerebellum seen in the first trimester.

Both findings have important implications for research into the causes, and one day perhaps the prevention, of autism.

The first suggestion of abnormal head circumference in children with autism appeared in 1943, with Dr. Leo Kanner's groundbreaking description of 11 children with what would come to be known as autistic features. He noted that five had “relatively large heads,” and one had “markedly prominent” occipital and frontal regions.

Since the advent of modern neuroimaging techniques, nine studies have found increased brain size in individuals with autism, but four studies have had negative findings, said Dr. Hardan, director of the autism and developmental disabilities clinic at Stanford's Lucile Packard Children's Hospital. Recent work in Dr. Hardan's laboratory and other centers may explain this discrepancy.

One of the negative studies measured only brain area, not total volume, and two included mostly adults.

It has now become clear that changes occur over time.

Head circumference at birth is no different in children who go on to exhibit autism than in normal children, but during childhood, the total brain volume of autistic children is significantly larger than their age-matched peers. In adulthood, the brain size of individuals with autism appears to normalize or even atrophy slightly, but the head circumference in about 20%-30% of individuals with autism will remain larger than normal.

“The brain can shrink, but the cranial box cannot,” Dr. Hardan noted.

A study at the University of Pittsburgh found that despite differences in early childhood, by age 12, brain volumes among children with autism were the same as in normally developing children, when controlled for height (Neurology 2002;59:175–83).

Research from the University of California, San Diego, found that patterns of brain growth were irregular in very young children with autism, with 2- and 3-year-olds possessing 39% more cerebellar white matter, 18% more cerebral white matter, and 12% more cerebral cortical gray matter than their peers, but with differences dissipating as the children grew older (Neurology 2001;57:245–54). Abnormally accelerated growth of some regions of the brain gave way over time to abnormally slowed brain growth.

Dr. Hardan's group has found that among children aged 8–12 with autism, compared with healthy controls, increases in gray matter volume and total brain size may be explained by marked increases in total sulcal and gyral thicknesses in the cerebrum and temporal and parietal lobes, but not in the frontal and occipital lobes.

Cortical thickness, striking in young children, also decreases over time, he said.

Importantly, cortical thickness abnormalities in autism can be distinguished from those in children with attention-deficit/hyperactivity disorder, which are thinner at baseline than in normal children and continue to decrease over time.

The specific patterns of cortical thickness abnormalities may offer important new clues as to the underlying defects in neural circuitry that may explain behavioral and social deficits in children with autism, he explained.

Dr. Hardan also underscored the importance of functional MRI imaging for children with autism, which is another new avenue of research into the neurobiology of autism.

Rather than looking at the brain itself, this approach studies cortical activation within the brain as children with autism are shown images of faces or objects. Unlike in normal children, the fusiform gyrus is activated when children with autism look at objects, not faces.

Related research has tracked the visual focus of very young children and demonstrated that those with autism focus on the chin or cheek of a human face, rather than the eyes, as is the case for normal subjects shown still images or movies. The same pattern has now been seen in how toddlers at high risk of developing autism focus on their mothers' faces, he said.

The technique might be used to intervene early with children at risk for autism, and also can be used to objectively measure improvement when medications or behavioral interventions are employed.

STANFORD, CALIF. — Increasing evidence suggests that children with autism have a normal head circumference at birth, but that many develop macroencephaly in childhood, Dr. Antonio Y. Hardan said at a recent pediatric update sponsored by Stanford (Calif.) University.

Distinguishing features within the brain are evident in utero, with abnormal neuronal migration and a decrease in the size of the cerebellum seen in the first trimester.

Both findings have important implications for research into the causes, and one day perhaps the prevention, of autism.

The first suggestion of abnormal head circumference in children with autism appeared in 1943, with Dr. Leo Kanner's groundbreaking description of 11 children with what would come to be known as autistic features. He noted that five had “relatively large heads,” and one had “markedly prominent” occipital and frontal regions.

Since the advent of modern neuroimaging techniques, nine studies have found increased brain size in individuals with autism, but four studies have had negative findings, said Dr. Hardan, director of the autism and developmental disabilities clinic at Stanford's Lucile Packard Children's Hospital. Recent work in Dr. Hardan's laboratory and other centers may explain this discrepancy.

One of the negative studies measured only brain area, not total volume, and two included mostly adults.

It has now become clear that changes occur over time.

Head circumference at birth is no different in children who go on to exhibit autism than in normal children, but during childhood, the total brain volume of autistic children is significantly larger than their age-matched peers. In adulthood, the brain size of individuals with autism appears to normalize or even atrophy slightly, but the head circumference in about 20%-30% of individuals with autism will remain larger than normal.

“The brain can shrink, but the cranial box cannot,” Dr. Hardan noted.

A study at the University of Pittsburgh found that despite differences in early childhood, by age 12, brain volumes among children with autism were the same as in normally developing children, when controlled for height (Neurology 2002;59:175–83).

Research from the University of California, San Diego, found that patterns of brain growth were irregular in very young children with autism, with 2- and 3-year-olds possessing 39% more cerebellar white matter, 18% more cerebral white matter, and 12% more cerebral cortical gray matter than their peers, but with differences dissipating as the children grew older (Neurology 2001;57:245–54). Abnormally accelerated growth of some regions of the brain gave way over time to abnormally slowed brain growth.

Dr. Hardan's group has found that among children aged 8–12 with autism, compared with healthy controls, increases in gray matter volume and total brain size may be explained by marked increases in total sulcal and gyral thicknesses in the cerebrum and temporal and parietal lobes, but not in the frontal and occipital lobes.

Cortical thickness, striking in young children, also decreases over time, he said.

Importantly, cortical thickness abnormalities in autism can be distinguished from those in children with attention-deficit/hyperactivity disorder, which are thinner at baseline than in normal children and continue to decrease over time.

The specific patterns of cortical thickness abnormalities may offer important new clues as to the underlying defects in neural circuitry that may explain behavioral and social deficits in children with autism, he explained.

Dr. Hardan also underscored the importance of functional MRI imaging for children with autism, which is another new avenue of research into the neurobiology of autism.

Rather than looking at the brain itself, this approach studies cortical activation within the brain as children with autism are shown images of faces or objects. Unlike in normal children, the fusiform gyrus is activated when children with autism look at objects, not faces.

Related research has tracked the visual focus of very young children and demonstrated that those with autism focus on the chin or cheek of a human face, rather than the eyes, as is the case for normal subjects shown still images or movies. The same pattern has now been seen in how toddlers at high risk of developing autism focus on their mothers' faces, he said.

The technique might be used to intervene early with children at risk for autism, and also can be used to objectively measure improvement when medications or behavioral interventions are employed.

STANFORD, CALIF. — Increasing evidence suggests that children with autism have a normal head circumference at birth, but that many develop macroencephaly in childhood, Dr. Antonio Y. Hardan said at a recent pediatric update sponsored by Stanford (Calif.) University.

Distinguishing features within the brain are evident in utero, with abnormal neuronal migration and a decrease in the size of the cerebellum seen in the first trimester.

Both findings have important implications for research into the causes, and one day perhaps the prevention, of autism.

The first suggestion of abnormal head circumference in children with autism appeared in 1943, with Dr. Leo Kanner's groundbreaking description of 11 children with what would come to be known as autistic features. He noted that five had “relatively large heads,” and one had “markedly prominent” occipital and frontal regions.

Since the advent of modern neuroimaging techniques, nine studies have found increased brain size in individuals with autism, but four studies have had negative findings, said Dr. Hardan, director of the autism and developmental disabilities clinic at Stanford's Lucile Packard Children's Hospital. Recent work in Dr. Hardan's laboratory and other centers may explain this discrepancy.

One of the negative studies measured only brain area, not total volume, and two included mostly adults.

It has now become clear that changes occur over time.

Head circumference at birth is no different in children who go on to exhibit autism than in normal children, but during childhood, the total brain volume of autistic children is significantly larger than their age-matched peers. In adulthood, the brain size of individuals with autism appears to normalize or even atrophy slightly, but the head circumference in about 20%-30% of individuals with autism will remain larger than normal.

“The brain can shrink, but the cranial box cannot,” Dr. Hardan noted.

A study at the University of Pittsburgh found that despite differences in early childhood, by age 12, brain volumes among children with autism were the same as in normally developing children, when controlled for height (Neurology 2002;59:175–83).

Research from the University of California, San Diego, found that patterns of brain growth were irregular in very young children with autism, with 2- and 3-year-olds possessing 39% more cerebellar white matter, 18% more cerebral white matter, and 12% more cerebral cortical gray matter than their peers, but with differences dissipating as the children grew older (Neurology 2001;57:245–54). Abnormally accelerated growth of some regions of the brain gave way over time to abnormally slowed brain growth.

Dr. Hardan's group has found that among children aged 8–12 with autism, compared with healthy controls, increases in gray matter volume and total brain size may be explained by marked increases in total sulcal and gyral thicknesses in the cerebrum and temporal and parietal lobes, but not in the frontal and occipital lobes.

Cortical thickness, striking in young children, also decreases over time, he said.

Importantly, cortical thickness abnormalities in autism can be distinguished from those in children with attention-deficit/hyperactivity disorder, which are thinner at baseline than in normal children and continue to decrease over time.

The specific patterns of cortical thickness abnormalities may offer important new clues as to the underlying defects in neural circuitry that may explain behavioral and social deficits in children with autism, he explained.

Dr. Hardan also underscored the importance of functional MRI imaging for children with autism, which is another new avenue of research into the neurobiology of autism.

Rather than looking at the brain itself, this approach studies cortical activation within the brain as children with autism are shown images of faces or objects. Unlike in normal children, the fusiform gyrus is activated when children with autism look at objects, not faces.

Related research has tracked the visual focus of very young children and demonstrated that those with autism focus on the chin or cheek of a human face, rather than the eyes, as is the case for normal subjects shown still images or movies. The same pattern has now been seen in how toddlers at high risk of developing autism focus on their mothers' faces, he said.

The technique might be used to intervene early with children at risk for autism, and also can be used to objectively measure improvement when medications or behavioral interventions are employed.

BEVERLY HILLS, CALIF. — New ideas about the causes of osteoarthritis may lead to targeted therapeutic advances like those currently available for rheumatoid arthritis, Dr. Steven R. Ytterberg said at the annual meeting of the American Association for Hand Surgery.

The first conceptual shift is the notion that osteoarthritis probably is not a disease, but a clinical and pathologic outcome arising from a range of disorders, explained Dr. Ytterberg, a clinical rheumatologist and researcher at the Mayo Clinic, Rochester, Minn.

He noted wide disparities in the characteristics of primary vs. secondary osteoarthritis; localized, single-joint disease vs. generalized osteoarthritis; and osteoarthritis associated with osteophyte necrosis, inflammation, or crystal deposition. Dr. Ytterberg compared, for instance, inflammatory, erosive osteoarthritis of the hands with diffuse idiopathic skeletal hyperostosis (DISH).

“Is this all the same disease? I don't know that it makes sense that it is,” he said.

Another major shift is in the way researchers are studying development of osteoarthritis.

“With osteoarthritis, the focus has always been on cartilage. To begin to see frayed cartilage through the arthroscope has always been presumed to be where the action is.”

Microscopic disruption of the extracellular matrix, and later, macroscopic clefts in the cartilage were seen as progressive evidence of encroaching disease.

Now, the focus has shifted, and the target of research is bone. “A large amount of information is now calling attention to what's going on in the chondrocytes: potential changes in cell-signaling pathways,” he said.

Many researchers are now beginning to believe that “subchondral bone is where the problem is,” with cartilage abnormalities perhaps the downstream effect of abnormal wear in response to bone changes, said Dr. Ytterberg.

Others are pursuing the hypothesis that osteoarthritis is an enthesopathy.

These theories, still in their infancy, could one day help characterize a diffusely defined symptom set that may or may not have common origins, he said.

BEVERLY HILLS, CALIF. — New ideas about the causes of osteoarthritis may lead to targeted therapeutic advances like those currently available for rheumatoid arthritis, Dr. Steven R. Ytterberg said at the annual meeting of the American Association for Hand Surgery.

The first conceptual shift is the notion that osteoarthritis probably is not a disease, but a clinical and pathologic outcome arising from a range of disorders, explained Dr. Ytterberg, a clinical rheumatologist and researcher at the Mayo Clinic, Rochester, Minn.

He noted wide disparities in the characteristics of primary vs. secondary osteoarthritis; localized, single-joint disease vs. generalized osteoarthritis; and osteoarthritis associated with osteophyte necrosis, inflammation, or crystal deposition. Dr. Ytterberg compared, for instance, inflammatory, erosive osteoarthritis of the hands with diffuse idiopathic skeletal hyperostosis (DISH).

“Is this all the same disease? I don't know that it makes sense that it is,” he said.

Another major shift is in the way researchers are studying development of osteoarthritis.

“With osteoarthritis, the focus has always been on cartilage. To begin to see frayed cartilage through the arthroscope has always been presumed to be where the action is.”

Microscopic disruption of the extracellular matrix, and later, macroscopic clefts in the cartilage were seen as progressive evidence of encroaching disease.

Now, the focus has shifted, and the target of research is bone. “A large amount of information is now calling attention to what's going on in the chondrocytes: potential changes in cell-signaling pathways,” he said.

Many researchers are now beginning to believe that “subchondral bone is where the problem is,” with cartilage abnormalities perhaps the downstream effect of abnormal wear in response to bone changes, said Dr. Ytterberg.

Others are pursuing the hypothesis that osteoarthritis is an enthesopathy.

These theories, still in their infancy, could one day help characterize a diffusely defined symptom set that may or may not have common origins, he said.

BEVERLY HILLS, CALIF. — New ideas about the causes of osteoarthritis may lead to targeted therapeutic advances like those currently available for rheumatoid arthritis, Dr. Steven R. Ytterberg said at the annual meeting of the American Association for Hand Surgery.

The first conceptual shift is the notion that osteoarthritis probably is not a disease, but a clinical and pathologic outcome arising from a range of disorders, explained Dr. Ytterberg, a clinical rheumatologist and researcher at the Mayo Clinic, Rochester, Minn.

He noted wide disparities in the characteristics of primary vs. secondary osteoarthritis; localized, single-joint disease vs. generalized osteoarthritis; and osteoarthritis associated with osteophyte necrosis, inflammation, or crystal deposition. Dr. Ytterberg compared, for instance, inflammatory, erosive osteoarthritis of the hands with diffuse idiopathic skeletal hyperostosis (DISH).

“Is this all the same disease? I don't know that it makes sense that it is,” he said.

Another major shift is in the way researchers are studying development of osteoarthritis.

“With osteoarthritis, the focus has always been on cartilage. To begin to see frayed cartilage through the arthroscope has always been presumed to be where the action is.”

Microscopic disruption of the extracellular matrix, and later, macroscopic clefts in the cartilage were seen as progressive evidence of encroaching disease.

Now, the focus has shifted, and the target of research is bone. “A large amount of information is now calling attention to what's going on in the chondrocytes: potential changes in cell-signaling pathways,” he said.

Many researchers are now beginning to believe that “subchondral bone is where the problem is,” with cartilage abnormalities perhaps the downstream effect of abnormal wear in response to bone changes, said Dr. Ytterberg.

Others are pursuing the hypothesis that osteoarthritis is an enthesopathy.

These theories, still in their infancy, could one day help characterize a diffusely defined symptom set that may or may not have common origins, he said.