Debra L. Beck

TORONTO – Radiofrequency ablation with or without endoscopic mucosal resection resulted in complete remission of high-grade dysplasia in 79% of patients and Barrett’s esophagus in 49%, and none of the patients required esophagectomy, according to Dr. Michal J. Lada.

"Endoscopic treatment of early neoplasia is a safe and effective modality," said Dr. Lada. "The use of esophagectomy for high-grade dysplasia has been eliminated since 2008 in our center and has been significantly decreased for intramucosal disease as primary therapy."

Early neoplasia is increasingly being identified because of better surveillance of known Barrett’s esophagus. Once Barrett’s is identified, it carries a 0.4% risk of progression to adenocarcinoma. For the year 2014, it is estimated that 18,100 people will be diagnosed with esophageal cancer, and 15,450 will die of the disease.

While esophagectomy was once advocated as the optimal treatment for high-grade dysplasia or intramucosal adenocarcinoma, it is associated with significant morbidity and impaired long-term alimentary outcomes. Radiofrequency ablation coupled with endoscopic mucosal resection (EMR) has emerged as the standard of care in the management of these patients, said Dr. Lada of the University of Rochester (N.Y.) Medical Center.

The 57 patients in this retrospective study (45 with high-grade dysplasia and 12 with intramucosal adenocarcinoma) underwent a total of 181 ablation procedures (mean of 3.2 per patient) between 2007 and 2012. EMR prior to ablation was applied liberally for any mucosal irregularities or nodules, being used in 61% of patients overall, and as a first procedure in 49%, for a total of 58 EMR procedures. With surveillance endoscopies every 2 months throughout treatment included, patients underwent a total of 753 procedures, averaging 13.2 procedures per patient.

"When we proposed this therapy to patients for high-grade dysplasia or intramucosal disease, we offered the option of esophagectomy, with the full disclosure that endoscopic treatment is a lifelong commitment rather than a single event," said Dr. Lada. "Esophagectomy can really be viewed as kind of a radical prophylaxis."

The mean age of treated patients was 66.2 years and 88% were male. Most patients had gastroesophageal reflux disease (89%) and were taking proton pump inhibitors (89%) on a long-term basis, Dr. Lada reported at the annual meeting of the American Association for Thoracic Surgery.

Complete remission of dysplasia was achieved in 79% of patients (45 of 57), with a median time of remission of 11.5 months. Complete remission of Barrett’s esophagus was achieved in 49% (28 of 57 patients), within a median of 18.4 months. All patients without complete remission continued endoscopic treatment.

The recurrence of dysplasia was observed in 21% of patients, with a time to recurrence of 29.1 months, and a return of Barrett’s esophagus was seen in only 7%, during a median of 14.8 months. Seven percent of patients progressed from high-grade dysplasia to intramucosal adenocarcinoma over a median of 12.6 months, but all of them were treated endoscopically. No patients required esophagectomy or developed metastatic disease.

There were six deaths during follow-up, none from esophageal cancer. There were also no major complications of treatment and only two minor complications.

"The use of endoscopic therapies appears justified as the new standard of care in the majority of patients with Barrett’s and early esophageal neoplasia," said Dr. Lada.

"Endoscopic therapy, using combinations of endoscopic resection and ablation, has revolutionized the treatment of patients with high-grade dysplasia and superficial adenocarcinomas. This strategy represents a major paradigm shift in the management of this disease, and I applaud the authors for being early adopters of this approach," commented Dr. Steven R. Demeester, a professor in the department of cardiothoracic surgery at the University of Southern California, Los Angeles, and an invited discussant on the paper.

"It’s an interesting paradox that while we now have endoscopic, organ-preserving techniques to treat these patients, at the same time there seems to be an increasing nihilism among our gastroenterology colleagues about the benefits of surveillance for Barrett’s esophagus," Dr. Demeester said.

Dr. Lada countered that, as an established referral center for reflux disease, the center’s referral numbers continue to increase.

Dr. Lada reported no financial disclosures. Dr. Demeester is a consultant for C2 Therapeutics, Bard/Davol, and Novadaq.

TORONTO – Radiofrequency ablation with or without endoscopic mucosal resection resulted in complete remission of high-grade dysplasia in 79% of patients and Barrett’s esophagus in 49%, and none of the patients required esophagectomy, according to Dr. Michal J. Lada.

"Endoscopic treatment of early neoplasia is a safe and effective modality," said Dr. Lada. "The use of esophagectomy for high-grade dysplasia has been eliminated since 2008 in our center and has been significantly decreased for intramucosal disease as primary therapy."

Early neoplasia is increasingly being identified because of better surveillance of known Barrett’s esophagus. Once Barrett’s is identified, it carries a 0.4% risk of progression to adenocarcinoma. For the year 2014, it is estimated that 18,100 people will be diagnosed with esophageal cancer, and 15,450 will die of the disease.

While esophagectomy was once advocated as the optimal treatment for high-grade dysplasia or intramucosal adenocarcinoma, it is associated with significant morbidity and impaired long-term alimentary outcomes. Radiofrequency ablation coupled with endoscopic mucosal resection (EMR) has emerged as the standard of care in the management of these patients, said Dr. Lada of the University of Rochester (N.Y.) Medical Center.

The 57 patients in this retrospective study (45 with high-grade dysplasia and 12 with intramucosal adenocarcinoma) underwent a total of 181 ablation procedures (mean of 3.2 per patient) between 2007 and 2012. EMR prior to ablation was applied liberally for any mucosal irregularities or nodules, being used in 61% of patients overall, and as a first procedure in 49%, for a total of 58 EMR procedures. With surveillance endoscopies every 2 months throughout treatment included, patients underwent a total of 753 procedures, averaging 13.2 procedures per patient.

"When we proposed this therapy to patients for high-grade dysplasia or intramucosal disease, we offered the option of esophagectomy, with the full disclosure that endoscopic treatment is a lifelong commitment rather than a single event," said Dr. Lada. "Esophagectomy can really be viewed as kind of a radical prophylaxis."

The mean age of treated patients was 66.2 years and 88% were male. Most patients had gastroesophageal reflux disease (89%) and were taking proton pump inhibitors (89%) on a long-term basis, Dr. Lada reported at the annual meeting of the American Association for Thoracic Surgery.

Complete remission of dysplasia was achieved in 79% of patients (45 of 57), with a median time of remission of 11.5 months. Complete remission of Barrett’s esophagus was achieved in 49% (28 of 57 patients), within a median of 18.4 months. All patients without complete remission continued endoscopic treatment.

The recurrence of dysplasia was observed in 21% of patients, with a time to recurrence of 29.1 months, and a return of Barrett’s esophagus was seen in only 7%, during a median of 14.8 months. Seven percent of patients progressed from high-grade dysplasia to intramucosal adenocarcinoma over a median of 12.6 months, but all of them were treated endoscopically. No patients required esophagectomy or developed metastatic disease.

There were six deaths during follow-up, none from esophageal cancer. There were also no major complications of treatment and only two minor complications.

"The use of endoscopic therapies appears justified as the new standard of care in the majority of patients with Barrett’s and early esophageal neoplasia," said Dr. Lada.

"Endoscopic therapy, using combinations of endoscopic resection and ablation, has revolutionized the treatment of patients with high-grade dysplasia and superficial adenocarcinomas. This strategy represents a major paradigm shift in the management of this disease, and I applaud the authors for being early adopters of this approach," commented Dr. Steven R. Demeester, a professor in the department of cardiothoracic surgery at the University of Southern California, Los Angeles, and an invited discussant on the paper.

"It’s an interesting paradox that while we now have endoscopic, organ-preserving techniques to treat these patients, at the same time there seems to be an increasing nihilism among our gastroenterology colleagues about the benefits of surveillance for Barrett’s esophagus," Dr. Demeester said.

Dr. Lada countered that, as an established referral center for reflux disease, the center’s referral numbers continue to increase.

Dr. Lada reported no financial disclosures. Dr. Demeester is a consultant for C2 Therapeutics, Bard/Davol, and Novadaq.

TORONTO – Radiofrequency ablation with or without endoscopic mucosal resection resulted in complete remission of high-grade dysplasia in 79% of patients and Barrett’s esophagus in 49%, and none of the patients required esophagectomy, according to Dr. Michal J. Lada.

"Endoscopic treatment of early neoplasia is a safe and effective modality," said Dr. Lada. "The use of esophagectomy for high-grade dysplasia has been eliminated since 2008 in our center and has been significantly decreased for intramucosal disease as primary therapy."

Early neoplasia is increasingly being identified because of better surveillance of known Barrett’s esophagus. Once Barrett’s is identified, it carries a 0.4% risk of progression to adenocarcinoma. For the year 2014, it is estimated that 18,100 people will be diagnosed with esophageal cancer, and 15,450 will die of the disease.

While esophagectomy was once advocated as the optimal treatment for high-grade dysplasia or intramucosal adenocarcinoma, it is associated with significant morbidity and impaired long-term alimentary outcomes. Radiofrequency ablation coupled with endoscopic mucosal resection (EMR) has emerged as the standard of care in the management of these patients, said Dr. Lada of the University of Rochester (N.Y.) Medical Center.

The 57 patients in this retrospective study (45 with high-grade dysplasia and 12 with intramucosal adenocarcinoma) underwent a total of 181 ablation procedures (mean of 3.2 per patient) between 2007 and 2012. EMR prior to ablation was applied liberally for any mucosal irregularities or nodules, being used in 61% of patients overall, and as a first procedure in 49%, for a total of 58 EMR procedures. With surveillance endoscopies every 2 months throughout treatment included, patients underwent a total of 753 procedures, averaging 13.2 procedures per patient.

"When we proposed this therapy to patients for high-grade dysplasia or intramucosal disease, we offered the option of esophagectomy, with the full disclosure that endoscopic treatment is a lifelong commitment rather than a single event," said Dr. Lada. "Esophagectomy can really be viewed as kind of a radical prophylaxis."

The mean age of treated patients was 66.2 years and 88% were male. Most patients had gastroesophageal reflux disease (89%) and were taking proton pump inhibitors (89%) on a long-term basis, Dr. Lada reported at the annual meeting of the American Association for Thoracic Surgery.

Complete remission of dysplasia was achieved in 79% of patients (45 of 57), with a median time of remission of 11.5 months. Complete remission of Barrett’s esophagus was achieved in 49% (28 of 57 patients), within a median of 18.4 months. All patients without complete remission continued endoscopic treatment.

The recurrence of dysplasia was observed in 21% of patients, with a time to recurrence of 29.1 months, and a return of Barrett’s esophagus was seen in only 7%, during a median of 14.8 months. Seven percent of patients progressed from high-grade dysplasia to intramucosal adenocarcinoma over a median of 12.6 months, but all of them were treated endoscopically. No patients required esophagectomy or developed metastatic disease.

There were six deaths during follow-up, none from esophageal cancer. There were also no major complications of treatment and only two minor complications.

"The use of endoscopic therapies appears justified as the new standard of care in the majority of patients with Barrett’s and early esophageal neoplasia," said Dr. Lada.

"Endoscopic therapy, using combinations of endoscopic resection and ablation, has revolutionized the treatment of patients with high-grade dysplasia and superficial adenocarcinomas. This strategy represents a major paradigm shift in the management of this disease, and I applaud the authors for being early adopters of this approach," commented Dr. Steven R. Demeester, a professor in the department of cardiothoracic surgery at the University of Southern California, Los Angeles, and an invited discussant on the paper.

"It’s an interesting paradox that while we now have endoscopic, organ-preserving techniques to treat these patients, at the same time there seems to be an increasing nihilism among our gastroenterology colleagues about the benefits of surveillance for Barrett’s esophagus," Dr. Demeester said.

Dr. Lada countered that, as an established referral center for reflux disease, the center’s referral numbers continue to increase.

Dr. Lada reported no financial disclosures. Dr. Demeester is a consultant for C2 Therapeutics, Bard/Davol, and Novadaq.

TORONTO — Disordered eating behaviors are common in obese adolescents seeking treatment and were associated with higher body mass index z scores at 6 months, in a small study.

This is the first study to consider the impact that disordered eating might have on adolescent obesity treatment, said Dr. Carolyn B. Jasik, a clinical research fellow in adolescent medicine at the University of California, San Francisco, at the annual meeting of the Society of Adolescent Health and Medicine.

Dr. Jasik and her colleagues conducted a chart review of 116 adolescents aged 12–18 years (mean age 14.7 years) who presented for weight management.

Disordered eating behaviors are those that do not meet criteria for clinical eating disorders and can lead to weight gain or loss. At intake, patients were screened for eight disordered eating behaviors in the last month: binge eating without loss of control, eating alone, hiding food, night eating, lying about intake, loss of control, binge eating with loss of control, and guilt or depression about food intake. At least one disordered eating behavior was reported by 63% of participants.

The study's main outcome was change in BMI z score between baseline and follow-up in the 52 participants (45%) who returned for follow-up within 6 months.

The mean change in BMI z score was –0.04. Patients without any disordered eating behavior showed a greater reduction in BMI z score (−0.09 vs. −0.01) and BMI (−0.9 vs. 0.11 points) than did those with at least one such behavior.

Disclosures: Dr. Jasik reported no financial conflicts of interest.

TORONTO — Disordered eating behaviors are common in obese adolescents seeking treatment and were associated with higher body mass index z scores at 6 months, in a small study.

This is the first study to consider the impact that disordered eating might have on adolescent obesity treatment, said Dr. Carolyn B. Jasik, a clinical research fellow in adolescent medicine at the University of California, San Francisco, at the annual meeting of the Society of Adolescent Health and Medicine.

Dr. Jasik and her colleagues conducted a chart review of 116 adolescents aged 12–18 years (mean age 14.7 years) who presented for weight management.

Disordered eating behaviors are those that do not meet criteria for clinical eating disorders and can lead to weight gain or loss. At intake, patients were screened for eight disordered eating behaviors in the last month: binge eating without loss of control, eating alone, hiding food, night eating, lying about intake, loss of control, binge eating with loss of control, and guilt or depression about food intake. At least one disordered eating behavior was reported by 63% of participants.

The study's main outcome was change in BMI z score between baseline and follow-up in the 52 participants (45%) who returned for follow-up within 6 months.

The mean change in BMI z score was –0.04. Patients without any disordered eating behavior showed a greater reduction in BMI z score (−0.09 vs. −0.01) and BMI (−0.9 vs. 0.11 points) than did those with at least one such behavior.

Disclosures: Dr. Jasik reported no financial conflicts of interest.

TORONTO — Disordered eating behaviors are common in obese adolescents seeking treatment and were associated with higher body mass index z scores at 6 months, in a small study.

This is the first study to consider the impact that disordered eating might have on adolescent obesity treatment, said Dr. Carolyn B. Jasik, a clinical research fellow in adolescent medicine at the University of California, San Francisco, at the annual meeting of the Society of Adolescent Health and Medicine.

Dr. Jasik and her colleagues conducted a chart review of 116 adolescents aged 12–18 years (mean age 14.7 years) who presented for weight management.

Disordered eating behaviors are those that do not meet criteria for clinical eating disorders and can lead to weight gain or loss. At intake, patients were screened for eight disordered eating behaviors in the last month: binge eating without loss of control, eating alone, hiding food, night eating, lying about intake, loss of control, binge eating with loss of control, and guilt or depression about food intake. At least one disordered eating behavior was reported by 63% of participants.

The study's main outcome was change in BMI z score between baseline and follow-up in the 52 participants (45%) who returned for follow-up within 6 months.

The mean change in BMI z score was –0.04. Patients without any disordered eating behavior showed a greater reduction in BMI z score (−0.09 vs. −0.01) and BMI (−0.9 vs. 0.11 points) than did those with at least one such behavior.

Disclosures: Dr. Jasik reported no financial conflicts of interest.

TORONTO – Disordered eating behaviors are common in teens seeking obesity treatment and were associated with higher body mass index z scores at 6 months of follow-up, a new study shows.

This finding suggests that disordered eating behavior might be a barrier to successful obesity treatment, compelling weight management clinics to both screen for disordered eating at intake and to apply targeted therapies because standard treatments are unlikely to be effective for these adolescents.

This is the first study to consider the impact that disordered eating might have on adolescent obesity treatment, said Dr. Carolyn B. Jasik, a clinical research fellow in adolescent medicine at the University of California, San Francisco, who presented her results at the meeting.

Dr. Jasik and her colleagues conducted a chart review of 116 adolescents aged 12-18 years who presented for weight management. At intake, patients completed a screen for eight disordered eating behaviors in the last month: binge eating without loss of control, eating alone, hiding food, night eating, lying about intake, loss of control, binge eating with loss of control, and guilt or depression about food intake.

Sixty-three percent of study participants reported at least one disordered eating behavior at baseline. “I would entirely change the way we approach obesity management,” she said.

Disclosures: Dr. Jasik reported no financial conflicts of interest.

TORONTO – Disordered eating behaviors are common in teens seeking obesity treatment and were associated with higher body mass index z scores at 6 months of follow-up, a new study shows.

This finding suggests that disordered eating behavior might be a barrier to successful obesity treatment, compelling weight management clinics to both screen for disordered eating at intake and to apply targeted therapies because standard treatments are unlikely to be effective for these adolescents.

This is the first study to consider the impact that disordered eating might have on adolescent obesity treatment, said Dr. Carolyn B. Jasik, a clinical research fellow in adolescent medicine at the University of California, San Francisco, who presented her results at the meeting.

Dr. Jasik and her colleagues conducted a chart review of 116 adolescents aged 12-18 years who presented for weight management. At intake, patients completed a screen for eight disordered eating behaviors in the last month: binge eating without loss of control, eating alone, hiding food, night eating, lying about intake, loss of control, binge eating with loss of control, and guilt or depression about food intake.

Sixty-three percent of study participants reported at least one disordered eating behavior at baseline. “I would entirely change the way we approach obesity management,” she said.

Disclosures: Dr. Jasik reported no financial conflicts of interest.

TORONTO – Disordered eating behaviors are common in teens seeking obesity treatment and were associated with higher body mass index z scores at 6 months of follow-up, a new study shows.

This finding suggests that disordered eating behavior might be a barrier to successful obesity treatment, compelling weight management clinics to both screen for disordered eating at intake and to apply targeted therapies because standard treatments are unlikely to be effective for these adolescents.

This is the first study to consider the impact that disordered eating might have on adolescent obesity treatment, said Dr. Carolyn B. Jasik, a clinical research fellow in adolescent medicine at the University of California, San Francisco, who presented her results at the meeting.

Dr. Jasik and her colleagues conducted a chart review of 116 adolescents aged 12-18 years who presented for weight management. At intake, patients completed a screen for eight disordered eating behaviors in the last month: binge eating without loss of control, eating alone, hiding food, night eating, lying about intake, loss of control, binge eating with loss of control, and guilt or depression about food intake.

Sixty-three percent of study participants reported at least one disordered eating behavior at baseline. “I would entirely change the way we approach obesity management,” she said.

Disclosures: Dr. Jasik reported no financial conflicts of interest.

TORONTO – Functional magnetic resonance imaging has shown that even very low levels of nicotine exposure can cause detectable changes in the adolescent brain's addiction centers, some of which differ from nicotine-related changes seen in adult brains, a study showed.

Previous research has also revealed differences in the effects of smoking on adolescents, compared with adults, Dr. Mark L. Rubinstein of the University of California, San Francisco, said at the meeting.

“We know that people who start smoking as teenagers are more likely to become lifelong smokers than those who start smoking as adults. In addition, teens seem to be more susceptible to nicotine addiction, reporting addiction with much lower levels of smoking–sometimes even without smoking daily.”

Pharmacotherapy for smoking cessation is also less effective in teens than in adults. The current research aimed to discover underlying brain effects that might account for these differences.

In adult smokers, functional MRI has shown that both nicotine and smoking cues produce activity in the mesolimbic addiction system, specifically in the amygdala, the orbital frontal complex, the hippocampus, and the prefrontal cortex. Previous studies of heavy smokers in their teens found similar results. However, because the majority of adolescents smoke only two to five cigarettes per day, Dr. Rubinstein's research used 12 light smokers (one to five cigarettes per day [mean 3.6] for at least 6 months) aged 13-17, along with 12 smoking-naive adolescents of the same age as controls.

“We wondered if this might give us a better indication of the way adolescent brains work, and also a better idea of how early addiction processes work in the brain,” he said.

Because cue exposure has the same effects on brain activity as actual nicotine, participants passively viewed a set of smoking-related images, then a set of neutral images, with process repeated eight times.

Functional analysis of their brains during this process found that nonsmokers showed no brain activation in any area.

In smokers, however, smoking cues were significantly associated with activity in the anterior cingulate (in the frontal cortex), the middle occipital gyrus, and the hippocampus–all of which lie within the brain's addiction centers.

“The hippocampus is involved with memory, specifically drug reward memories and conditioned responses,” Dr. Rubinstein said. “The cingulate gyrus, which is in the frontal lobe, is involved in inhibitory control, and importantly, the frontal cortex, specifically the prefrontal cortex, is the last part of the teenage brain to develop.

The medial occipital lobes are involved in visuospatial processing; this is subtracting the activation that occurs when smokers stare at neutral images, so they're paying more attention to the smoking images, which is no surprise but has been associated with addiction in adults.”

Although these results were similar to those seen in adult smokers, a significant difference was found: In adults, the lateral orbital frontal complex is usually activated, but in these teenaged light smokers, the medial orbital frontal complex was affected.

“The orbital frontal complex is involved in reward-related learning and impulse control, and a lot of people think that the medial orbital frontal complex might be the most important in impulse control,” said Dr. Rubinstein.

“One of our theories is that the medial orbital frontal complex may be important in the development of addiction rather than the maintenance of addiction.”

This is supported by the observation that these teen smokers scored only 2.8 on the modified Fagerström Tolerance Questionnaire, indicating no or very light addiction.

“Clinically, this says to us that even at very light/low levels of nicotine exposure, you may already be causing changes in the brain,” he concluded.

Dr. Rubenstein reported no relevant financial relationships.

In teen smokers, smoking cues were significantly associated with activity in the brain's addiction centers.

Source Images courtesy Dr. Mark L. Rubinstein

TORONTO – Functional magnetic resonance imaging has shown that even very low levels of nicotine exposure can cause detectable changes in the adolescent brain's addiction centers, some of which differ from nicotine-related changes seen in adult brains, a study showed.

Previous research has also revealed differences in the effects of smoking on adolescents, compared with adults, Dr. Mark L. Rubinstein of the University of California, San Francisco, said at the meeting.

“We know that people who start smoking as teenagers are more likely to become lifelong smokers than those who start smoking as adults. In addition, teens seem to be more susceptible to nicotine addiction, reporting addiction with much lower levels of smoking–sometimes even without smoking daily.”

Pharmacotherapy for smoking cessation is also less effective in teens than in adults. The current research aimed to discover underlying brain effects that might account for these differences.

In adult smokers, functional MRI has shown that both nicotine and smoking cues produce activity in the mesolimbic addiction system, specifically in the amygdala, the orbital frontal complex, the hippocampus, and the prefrontal cortex. Previous studies of heavy smokers in their teens found similar results. However, because the majority of adolescents smoke only two to five cigarettes per day, Dr. Rubinstein's research used 12 light smokers (one to five cigarettes per day [mean 3.6] for at least 6 months) aged 13-17, along with 12 smoking-naive adolescents of the same age as controls.

“We wondered if this might give us a better indication of the way adolescent brains work, and also a better idea of how early addiction processes work in the brain,” he said.

Because cue exposure has the same effects on brain activity as actual nicotine, participants passively viewed a set of smoking-related images, then a set of neutral images, with process repeated eight times.

Functional analysis of their brains during this process found that nonsmokers showed no brain activation in any area.

In smokers, however, smoking cues were significantly associated with activity in the anterior cingulate (in the frontal cortex), the middle occipital gyrus, and the hippocampus–all of which lie within the brain's addiction centers.

“The hippocampus is involved with memory, specifically drug reward memories and conditioned responses,” Dr. Rubinstein said. “The cingulate gyrus, which is in the frontal lobe, is involved in inhibitory control, and importantly, the frontal cortex, specifically the prefrontal cortex, is the last part of the teenage brain to develop.

The medial occipital lobes are involved in visuospatial processing; this is subtracting the activation that occurs when smokers stare at neutral images, so they're paying more attention to the smoking images, which is no surprise but has been associated with addiction in adults.”

Although these results were similar to those seen in adult smokers, a significant difference was found: In adults, the lateral orbital frontal complex is usually activated, but in these teenaged light smokers, the medial orbital frontal complex was affected.

“The orbital frontal complex is involved in reward-related learning and impulse control, and a lot of people think that the medial orbital frontal complex might be the most important in impulse control,” said Dr. Rubinstein.

“One of our theories is that the medial orbital frontal complex may be important in the development of addiction rather than the maintenance of addiction.”

This is supported by the observation that these teen smokers scored only 2.8 on the modified Fagerström Tolerance Questionnaire, indicating no or very light addiction.

“Clinically, this says to us that even at very light/low levels of nicotine exposure, you may already be causing changes in the brain,” he concluded.

Dr. Rubenstein reported no relevant financial relationships.

In teen smokers, smoking cues were significantly associated with activity in the brain's addiction centers.

Source Images courtesy Dr. Mark L. Rubinstein

TORONTO – Functional magnetic resonance imaging has shown that even very low levels of nicotine exposure can cause detectable changes in the adolescent brain's addiction centers, some of which differ from nicotine-related changes seen in adult brains, a study showed.

Previous research has also revealed differences in the effects of smoking on adolescents, compared with adults, Dr. Mark L. Rubinstein of the University of California, San Francisco, said at the meeting.

“We know that people who start smoking as teenagers are more likely to become lifelong smokers than those who start smoking as adults. In addition, teens seem to be more susceptible to nicotine addiction, reporting addiction with much lower levels of smoking–sometimes even without smoking daily.”

Pharmacotherapy for smoking cessation is also less effective in teens than in adults. The current research aimed to discover underlying brain effects that might account for these differences.

In adult smokers, functional MRI has shown that both nicotine and smoking cues produce activity in the mesolimbic addiction system, specifically in the amygdala, the orbital frontal complex, the hippocampus, and the prefrontal cortex. Previous studies of heavy smokers in their teens found similar results. However, because the majority of adolescents smoke only two to five cigarettes per day, Dr. Rubinstein's research used 12 light smokers (one to five cigarettes per day [mean 3.6] for at least 6 months) aged 13-17, along with 12 smoking-naive adolescents of the same age as controls.

“We wondered if this might give us a better indication of the way adolescent brains work, and also a better idea of how early addiction processes work in the brain,” he said.

Because cue exposure has the same effects on brain activity as actual nicotine, participants passively viewed a set of smoking-related images, then a set of neutral images, with process repeated eight times.

Functional analysis of their brains during this process found that nonsmokers showed no brain activation in any area.

In smokers, however, smoking cues were significantly associated with activity in the anterior cingulate (in the frontal cortex), the middle occipital gyrus, and the hippocampus–all of which lie within the brain's addiction centers.

“The hippocampus is involved with memory, specifically drug reward memories and conditioned responses,” Dr. Rubinstein said. “The cingulate gyrus, which is in the frontal lobe, is involved in inhibitory control, and importantly, the frontal cortex, specifically the prefrontal cortex, is the last part of the teenage brain to develop.

The medial occipital lobes are involved in visuospatial processing; this is subtracting the activation that occurs when smokers stare at neutral images, so they're paying more attention to the smoking images, which is no surprise but has been associated with addiction in adults.”

Although these results were similar to those seen in adult smokers, a significant difference was found: In adults, the lateral orbital frontal complex is usually activated, but in these teenaged light smokers, the medial orbital frontal complex was affected.

“The orbital frontal complex is involved in reward-related learning and impulse control, and a lot of people think that the medial orbital frontal complex might be the most important in impulse control,” said Dr. Rubinstein.

“One of our theories is that the medial orbital frontal complex may be important in the development of addiction rather than the maintenance of addiction.”

This is supported by the observation that these teen smokers scored only 2.8 on the modified Fagerström Tolerance Questionnaire, indicating no or very light addiction.

“Clinically, this says to us that even at very light/low levels of nicotine exposure, you may already be causing changes in the brain,” he concluded.

Dr. Rubenstein reported no relevant financial relationships.

In teen smokers, smoking cues were significantly associated with activity in the brain's addiction centers.

Source Images courtesy Dr. Mark L. Rubinstein

TORONTO — Vitamin D supplementation needs to be considered in all adolescents, especially during the winter months, in higher latitudes, and when good sunscreen habits are enforced, according to Dr. Catherine M. Gordon.

“We get vitamin D either from the sun or from supplements or food,” she said at the meeting. “A sunscreen of SPF 8 or above reduces vitamin D production by about 97.5%, and most children use a much higher SPF.”

Also, among individuals with darkly pigmented skin, melanin competes with vitamin D precursors for photons.

Individuals living in northern latitudes during winter months cannot produce vitamin D₃. Researchers found that on cloudless days in Boston, sunlight did not initiate cutaneous production of vitamin D from November through February (J. Clin. Endocrinol. Metab. 1988;67:373-8).

The American Academy of Pediatrics in 2008 recommended 400 IU across the pediatric age spectrum, including adolescents, she said.

However, many health providers for adults recommend that their patients receive 1,000 IU as a daily supplementation dose.

“Many of us believe that adolescents are not that different from adults, and that 1,000 IU daily would be the appropriate dose,” Dr. Gordon said.

The Food and Nutrition Board of the National Academy of Sciences set the lowest observed adverse effect level for humans at 2,000 IU vitamin D daily. However, “this is probably wrong,” she said. Adults in Canada studied at a high latitude and with not a lot of sun exposure who were given 4,000 IU for 2-5 months achieved just high-normal levels of vitamin D with no signs of toxicity (Am. J. Clin. Nutr. 2001;73:288).

Although the current safety limit for vitamin D is 2,000 IU a day, many studies have shown that daily intakes of 10,000 a day were required before manifestations of toxicity were reported, said Dr. Gordon of the divisions of adolescent medicine and endocrinology at Children's Hospital Boston and director of the hospital's bone health program.

Although vitamin D can be found in fatty fishes and cod liver oils—“not a favorite among adolescents”—as well as fortified milk and juice, concern exists about the reliability of the milk supply for vitamin D delivery, noted Dr. Gordon. One study found that 15% of milk samples in the United States and Canada had no detectable vitamin D, and more than half had less than 80% of the vitamin D content stated on the label (N. Engl. J. Med. 1993;329:1507).

In one study, Dr. Gordon found that 42% of 307 healthy adolescents tested had vitamin D levels of 20 ng/mL or less; 24% had 15 ng/mL or less of detectable serum 25-hydroxyvitamin D (Arch. Pediatr. Adolesc. Med. 2004;158:531-7).

Some individuals are at particularly high risk. Vitamin D deficiency occurs in individuals with inflammatory bowel disease with associated malabsorption, in patients with cystic fibrosis, and in patients with seizure disorders because anticonvulsants increase vitamin D metabolism.

Anorexia nervosa patients actually have a low prevalence of vitamin D deficiency because they tend to be compliant with multivitamins and calcium.

On the other end of the spectrum, obese patients are at high risk for vitamin D deficiency because “it appears that vitamin D is sequestered in fat tissue,” she said.

Disclosures: None were reported.

TORONTO — Vitamin D supplementation needs to be considered in all adolescents, especially during the winter months, in higher latitudes, and when good sunscreen habits are enforced, according to Dr. Catherine M. Gordon.

“We get vitamin D either from the sun or from supplements or food,” she said at the meeting. “A sunscreen of SPF 8 or above reduces vitamin D production by about 97.5%, and most children use a much higher SPF.”

Also, among individuals with darkly pigmented skin, melanin competes with vitamin D precursors for photons.

Individuals living in northern latitudes during winter months cannot produce vitamin D₃. Researchers found that on cloudless days in Boston, sunlight did not initiate cutaneous production of vitamin D from November through February (J. Clin. Endocrinol. Metab. 1988;67:373-8).

The American Academy of Pediatrics in 2008 recommended 400 IU across the pediatric age spectrum, including adolescents, she said.

However, many health providers for adults recommend that their patients receive 1,000 IU as a daily supplementation dose.

“Many of us believe that adolescents are not that different from adults, and that 1,000 IU daily would be the appropriate dose,” Dr. Gordon said.

The Food and Nutrition Board of the National Academy of Sciences set the lowest observed adverse effect level for humans at 2,000 IU vitamin D daily. However, “this is probably wrong,” she said. Adults in Canada studied at a high latitude and with not a lot of sun exposure who were given 4,000 IU for 2-5 months achieved just high-normal levels of vitamin D with no signs of toxicity (Am. J. Clin. Nutr. 2001;73:288).

Although the current safety limit for vitamin D is 2,000 IU a day, many studies have shown that daily intakes of 10,000 a day were required before manifestations of toxicity were reported, said Dr. Gordon of the divisions of adolescent medicine and endocrinology at Children's Hospital Boston and director of the hospital's bone health program.

Although vitamin D can be found in fatty fishes and cod liver oils—“not a favorite among adolescents”—as well as fortified milk and juice, concern exists about the reliability of the milk supply for vitamin D delivery, noted Dr. Gordon. One study found that 15% of milk samples in the United States and Canada had no detectable vitamin D, and more than half had less than 80% of the vitamin D content stated on the label (N. Engl. J. Med. 1993;329:1507).

In one study, Dr. Gordon found that 42% of 307 healthy adolescents tested had vitamin D levels of 20 ng/mL or less; 24% had 15 ng/mL or less of detectable serum 25-hydroxyvitamin D (Arch. Pediatr. Adolesc. Med. 2004;158:531-7).

Some individuals are at particularly high risk. Vitamin D deficiency occurs in individuals with inflammatory bowel disease with associated malabsorption, in patients with cystic fibrosis, and in patients with seizure disorders because anticonvulsants increase vitamin D metabolism.

Anorexia nervosa patients actually have a low prevalence of vitamin D deficiency because they tend to be compliant with multivitamins and calcium.

On the other end of the spectrum, obese patients are at high risk for vitamin D deficiency because “it appears that vitamin D is sequestered in fat tissue,” she said.

Disclosures: None were reported.

TORONTO — Vitamin D supplementation needs to be considered in all adolescents, especially during the winter months, in higher latitudes, and when good sunscreen habits are enforced, according to Dr. Catherine M. Gordon.

“We get vitamin D either from the sun or from supplements or food,” she said at the meeting. “A sunscreen of SPF 8 or above reduces vitamin D production by about 97.5%, and most children use a much higher SPF.”

Also, among individuals with darkly pigmented skin, melanin competes with vitamin D precursors for photons.

Individuals living in northern latitudes during winter months cannot produce vitamin D₃. Researchers found that on cloudless days in Boston, sunlight did not initiate cutaneous production of vitamin D from November through February (J. Clin. Endocrinol. Metab. 1988;67:373-8).

The American Academy of Pediatrics in 2008 recommended 400 IU across the pediatric age spectrum, including adolescents, she said.

However, many health providers for adults recommend that their patients receive 1,000 IU as a daily supplementation dose.

“Many of us believe that adolescents are not that different from adults, and that 1,000 IU daily would be the appropriate dose,” Dr. Gordon said.

The Food and Nutrition Board of the National Academy of Sciences set the lowest observed adverse effect level for humans at 2,000 IU vitamin D daily. However, “this is probably wrong,” she said. Adults in Canada studied at a high latitude and with not a lot of sun exposure who were given 4,000 IU for 2-5 months achieved just high-normal levels of vitamin D with no signs of toxicity (Am. J. Clin. Nutr. 2001;73:288).

Although the current safety limit for vitamin D is 2,000 IU a day, many studies have shown that daily intakes of 10,000 a day were required before manifestations of toxicity were reported, said Dr. Gordon of the divisions of adolescent medicine and endocrinology at Children's Hospital Boston and director of the hospital's bone health program.

Although vitamin D can be found in fatty fishes and cod liver oils—“not a favorite among adolescents”—as well as fortified milk and juice, concern exists about the reliability of the milk supply for vitamin D delivery, noted Dr. Gordon. One study found that 15% of milk samples in the United States and Canada had no detectable vitamin D, and more than half had less than 80% of the vitamin D content stated on the label (N. Engl. J. Med. 1993;329:1507).

In one study, Dr. Gordon found that 42% of 307 healthy adolescents tested had vitamin D levels of 20 ng/mL or less; 24% had 15 ng/mL or less of detectable serum 25-hydroxyvitamin D (Arch. Pediatr. Adolesc. Med. 2004;158:531-7).

Some individuals are at particularly high risk. Vitamin D deficiency occurs in individuals with inflammatory bowel disease with associated malabsorption, in patients with cystic fibrosis, and in patients with seizure disorders because anticonvulsants increase vitamin D metabolism.

Anorexia nervosa patients actually have a low prevalence of vitamin D deficiency because they tend to be compliant with multivitamins and calcium.

On the other end of the spectrum, obese patients are at high risk for vitamin D deficiency because “it appears that vitamin D is sequestered in fat tissue,” she said.

Disclosures: None were reported.

Major Finding: Of girls and women who self-identified as black, 11% received all three doses of the HPV vaccine, compared with 22% of the white females and 15% of those identified as other races.

Data Source: A retrospective review of medical records on 3,297 females, aged 9–26 years, who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic, pediatric medical center with multiple primary care and specialty clinics.

Disclosures: Dr. Widdice said she had no conflicts of interest.

TORONTO — Girls and women who identified themselves as white were twice as likely as those who identified themselves as black to complete the three-shot vaccination series against the human papillomavirus, according to a retrospective review of medical records.

“This is concerning because, historically, black women have had lower rates of cervical cancer screening and been more at risk from dying of cervical cancer. With unequal distribution of the vaccine, the racial disparity in cervical cancer may worsen,” said Dr. Lea Widdice, an assistant professor of pediatrics at the Cincinnati Children's Hospital Medical Center. Dr. Widdice presented her results in a poster at the meeting.

Moreover, only 14% of females initiating the HPV vaccine series actually completed the three-shot series within 7 months of the first dose. Clinical recommendations for the vaccine are to get the third shot 6 months after the first.

Dr. Widdice and her colleagues conducted a retrospective review of medical records from 3,297 females, aged 9–26 years, who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic, pediatric medical center with multiple primary care and specialty clinics.

Overall, 11% of the black girls and women received all three doses of the vaccine, compared with 22% of the white females and 15% of those identified as other races.

Patients were predominately from primary care (95%), and 65% used Medicaid. The majority (67%) self-identified as black, 29% said they were white, and 4% were classified as other races.

Interestingly, even after controlling for factors such as type of insurance and the different types of clinics giving the vaccine (primary care pediatrics, adolescent primary care, adolescent specialty clinics, or other specialty clinics), race was still strongly associated with getting all three doses on schedule.

Dr. Widdice said that to maximize the public health benefits of the vaccine, interventions to improve adherence are needed. “School-based clinics, in addition to doctor's clinics, may be an effective way to get the vaccine to more people,” she said in an interview.

Major Finding: Of girls and women who self-identified as black, 11% received all three doses of the HPV vaccine, compared with 22% of the white females and 15% of those identified as other races.

Data Source: A retrospective review of medical records on 3,297 females, aged 9–26 years, who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic, pediatric medical center with multiple primary care and specialty clinics.

Disclosures: Dr. Widdice said she had no conflicts of interest.

TORONTO — Girls and women who identified themselves as white were twice as likely as those who identified themselves as black to complete the three-shot vaccination series against the human papillomavirus, according to a retrospective review of medical records.

“This is concerning because, historically, black women have had lower rates of cervical cancer screening and been more at risk from dying of cervical cancer. With unequal distribution of the vaccine, the racial disparity in cervical cancer may worsen,” said Dr. Lea Widdice, an assistant professor of pediatrics at the Cincinnati Children's Hospital Medical Center. Dr. Widdice presented her results in a poster at the meeting.

Moreover, only 14% of females initiating the HPV vaccine series actually completed the three-shot series within 7 months of the first dose. Clinical recommendations for the vaccine are to get the third shot 6 months after the first.

Dr. Widdice and her colleagues conducted a retrospective review of medical records from 3,297 females, aged 9–26 years, who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic, pediatric medical center with multiple primary care and specialty clinics.

Overall, 11% of the black girls and women received all three doses of the vaccine, compared with 22% of the white females and 15% of those identified as other races.

Patients were predominately from primary care (95%), and 65% used Medicaid. The majority (67%) self-identified as black, 29% said they were white, and 4% were classified as other races.

Interestingly, even after controlling for factors such as type of insurance and the different types of clinics giving the vaccine (primary care pediatrics, adolescent primary care, adolescent specialty clinics, or other specialty clinics), race was still strongly associated with getting all three doses on schedule.

Dr. Widdice said that to maximize the public health benefits of the vaccine, interventions to improve adherence are needed. “School-based clinics, in addition to doctor's clinics, may be an effective way to get the vaccine to more people,” she said in an interview.

Major Finding: Of girls and women who self-identified as black, 11% received all three doses of the HPV vaccine, compared with 22% of the white females and 15% of those identified as other races.

Data Source: A retrospective review of medical records on 3,297 females, aged 9–26 years, who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic, pediatric medical center with multiple primary care and specialty clinics.

Disclosures: Dr. Widdice said she had no conflicts of interest.

TORONTO — Girls and women who identified themselves as white were twice as likely as those who identified themselves as black to complete the three-shot vaccination series against the human papillomavirus, according to a retrospective review of medical records.

“This is concerning because, historically, black women have had lower rates of cervical cancer screening and been more at risk from dying of cervical cancer. With unequal distribution of the vaccine, the racial disparity in cervical cancer may worsen,” said Dr. Lea Widdice, an assistant professor of pediatrics at the Cincinnati Children's Hospital Medical Center. Dr. Widdice presented her results in a poster at the meeting.

Moreover, only 14% of females initiating the HPV vaccine series actually completed the three-shot series within 7 months of the first dose. Clinical recommendations for the vaccine are to get the third shot 6 months after the first.

Dr. Widdice and her colleagues conducted a retrospective review of medical records from 3,297 females, aged 9–26 years, who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic, pediatric medical center with multiple primary care and specialty clinics.

Overall, 11% of the black girls and women received all three doses of the vaccine, compared with 22% of the white females and 15% of those identified as other races.

Patients were predominately from primary care (95%), and 65% used Medicaid. The majority (67%) self-identified as black, 29% said they were white, and 4% were classified as other races.

Interestingly, even after controlling for factors such as type of insurance and the different types of clinics giving the vaccine (primary care pediatrics, adolescent primary care, adolescent specialty clinics, or other specialty clinics), race was still strongly associated with getting all three doses on schedule.

Dr. Widdice said that to maximize the public health benefits of the vaccine, interventions to improve adherence are needed. “School-based clinics, in addition to doctor's clinics, may be an effective way to get the vaccine to more people,” she said in an interview.

TORONTO — Bone mineral density loss in adolescents receiving depot medroxyprogesterone acetate for contraception was substantially or fully reversible following discontinuation of the drug, based on study results.

In girls who lost more than 5% of bone mineral density (BMD) during treatment, complete recovery was less likely, reported Dr. Zeev Harel, professor of pediatrics at Brown University, Providence, R.I.

The study involved 98 healthy adolescents aged 12-18 who initiated depot medroxyprogesterone acetate (DMPA) intramuscular injections for contraception and provided BMD data for up to 300 weeks after cessation of DMPA. BMD was assessed by dual-energy x-ray absorptiometry (DXA).

At the time of DMPA cessation, participants showed mean BMD declines from baseline at the lumbar spine (2.7%), hip (4.1%), and femoral neck (3.9%). Within 60 weeks of DMPA discontinuation, mean BMD values for the lumbar spine had returned to baseline levels. By 240 weeks, they had increased by 4.7% above baseline. Full recovery of mean BMD was not seen until 240 weeks in the hip and 180 weeks in the femoral neck.

Postcessation gains were smaller in girls who exhibited a 5% or greater BMD loss during treatment; mean BMD remained below baseline at 240 weeks (Contraception 2010;81:281-91).

Pfizer funded the study. Dr. Harel has financial ties with Merck & Co., Teva/Duramed, Ortho-McNeil, GlaxoSmithKline, Novartis, and Warner Chilcott.

TORONTO — Bone mineral density loss in adolescents receiving depot medroxyprogesterone acetate for contraception was substantially or fully reversible following discontinuation of the drug, based on study results.

In girls who lost more than 5% of bone mineral density (BMD) during treatment, complete recovery was less likely, reported Dr. Zeev Harel, professor of pediatrics at Brown University, Providence, R.I.

The study involved 98 healthy adolescents aged 12-18 who initiated depot medroxyprogesterone acetate (DMPA) intramuscular injections for contraception and provided BMD data for up to 300 weeks after cessation of DMPA. BMD was assessed by dual-energy x-ray absorptiometry (DXA).

At the time of DMPA cessation, participants showed mean BMD declines from baseline at the lumbar spine (2.7%), hip (4.1%), and femoral neck (3.9%). Within 60 weeks of DMPA discontinuation, mean BMD values for the lumbar spine had returned to baseline levels. By 240 weeks, they had increased by 4.7% above baseline. Full recovery of mean BMD was not seen until 240 weeks in the hip and 180 weeks in the femoral neck.

Postcessation gains were smaller in girls who exhibited a 5% or greater BMD loss during treatment; mean BMD remained below baseline at 240 weeks (Contraception 2010;81:281-91).

Pfizer funded the study. Dr. Harel has financial ties with Merck & Co., Teva/Duramed, Ortho-McNeil, GlaxoSmithKline, Novartis, and Warner Chilcott.

TORONTO — Bone mineral density loss in adolescents receiving depot medroxyprogesterone acetate for contraception was substantially or fully reversible following discontinuation of the drug, based on study results.

In girls who lost more than 5% of bone mineral density (BMD) during treatment, complete recovery was less likely, reported Dr. Zeev Harel, professor of pediatrics at Brown University, Providence, R.I.

The study involved 98 healthy adolescents aged 12-18 who initiated depot medroxyprogesterone acetate (DMPA) intramuscular injections for contraception and provided BMD data for up to 300 weeks after cessation of DMPA. BMD was assessed by dual-energy x-ray absorptiometry (DXA).

At the time of DMPA cessation, participants showed mean BMD declines from baseline at the lumbar spine (2.7%), hip (4.1%), and femoral neck (3.9%). Within 60 weeks of DMPA discontinuation, mean BMD values for the lumbar spine had returned to baseline levels. By 240 weeks, they had increased by 4.7% above baseline. Full recovery of mean BMD was not seen until 240 weeks in the hip and 180 weeks in the femoral neck.

Postcessation gains were smaller in girls who exhibited a 5% or greater BMD loss during treatment; mean BMD remained below baseline at 240 weeks (Contraception 2010;81:281-91).

Pfizer funded the study. Dr. Harel has financial ties with Merck & Co., Teva/Duramed, Ortho-McNeil, GlaxoSmithKline, Novartis, and Warner Chilcott.

Major Finding: Eleven percent of girls who self-identified as black received all three doses of the HPV vaccine, compared with 22% of the white girls and 15% of those identified as other races.

Data Source: A retrospective study of medical records on 3,297 girls between ages 9 and 26 years who received the first HPV vaccine dose between June 2006 and June 2008 from an urban medical center.

Disclosures: None was reported.

TORONTO — Girls who identified themselves as white were twice as likely as those who identified themselves as black to complete the three-shot vaccination series against the human papillomavirus, according to a retrospective investigation of medical records.

“This is concerning because, historically, black women have had lower rates of cervical cancer screening and been more at risk from dying of cervical cancer. With unequal distribution of the vaccine, the racial disparity in cervical cancer may worsen,” Dr. Lea Widdice said in a poster at the meeting.

Moreover, overall, only 14% of girls initiating the HPV vaccine series actually completed the three-shot series within 7 months of the first dose.

Clinical recommendations for the vaccine are to get the third shot 6 months after the first.

Dr. Widdice and her colleagues conducted a retrospective investigation of medical records on 3,297 girls between ages 9 and 26 years who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic pediatric medical center with multiple primary care and specialty clinics.

Overall, 11% of the black girls received all three doses of the vaccine, compared with 22% of the white girls and 15% of those identified as other races, reported Dr. Widdice, a pediatrician at the Cincinnati Children's Hospital Medical Center.

Patients were predominantly from primary care (95%) and 65% used Medicaid. The majority (67%) self-identified as black, 29% said they were white, and 4% were classified as other races.

Even after investigators controlled for factors such as type of insurance and the different types of clinics giving the vaccine (primary care pediatrics, adolescent primary care, adolescent specialty clinics, or other specialty clinics), race was still strongly associated with getting all three of the doses on schedule.

Major Finding: Eleven percent of girls who self-identified as black received all three doses of the HPV vaccine, compared with 22% of the white girls and 15% of those identified as other races.

Data Source: A retrospective study of medical records on 3,297 girls between ages 9 and 26 years who received the first HPV vaccine dose between June 2006 and June 2008 from an urban medical center.

Disclosures: None was reported.

TORONTO — Girls who identified themselves as white were twice as likely as those who identified themselves as black to complete the three-shot vaccination series against the human papillomavirus, according to a retrospective investigation of medical records.

“This is concerning because, historically, black women have had lower rates of cervical cancer screening and been more at risk from dying of cervical cancer. With unequal distribution of the vaccine, the racial disparity in cervical cancer may worsen,” Dr. Lea Widdice said in a poster at the meeting.

Moreover, overall, only 14% of girls initiating the HPV vaccine series actually completed the three-shot series within 7 months of the first dose.

Clinical recommendations for the vaccine are to get the third shot 6 months after the first.

Dr. Widdice and her colleagues conducted a retrospective investigation of medical records on 3,297 girls between ages 9 and 26 years who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic pediatric medical center with multiple primary care and specialty clinics.

Overall, 11% of the black girls received all three doses of the vaccine, compared with 22% of the white girls and 15% of those identified as other races, reported Dr. Widdice, a pediatrician at the Cincinnati Children's Hospital Medical Center.

Patients were predominantly from primary care (95%) and 65% used Medicaid. The majority (67%) self-identified as black, 29% said they were white, and 4% were classified as other races.

Even after investigators controlled for factors such as type of insurance and the different types of clinics giving the vaccine (primary care pediatrics, adolescent primary care, adolescent specialty clinics, or other specialty clinics), race was still strongly associated with getting all three of the doses on schedule.

Major Finding: Eleven percent of girls who self-identified as black received all three doses of the HPV vaccine, compared with 22% of the white girls and 15% of those identified as other races.

Data Source: A retrospective study of medical records on 3,297 girls between ages 9 and 26 years who received the first HPV vaccine dose between June 2006 and June 2008 from an urban medical center.

Disclosures: None was reported.

TORONTO — Girls who identified themselves as white were twice as likely as those who identified themselves as black to complete the three-shot vaccination series against the human papillomavirus, according to a retrospective investigation of medical records.

“This is concerning because, historically, black women have had lower rates of cervical cancer screening and been more at risk from dying of cervical cancer. With unequal distribution of the vaccine, the racial disparity in cervical cancer may worsen,” Dr. Lea Widdice said in a poster at the meeting.

Moreover, overall, only 14% of girls initiating the HPV vaccine series actually completed the three-shot series within 7 months of the first dose.

Clinical recommendations for the vaccine are to get the third shot 6 months after the first.

Dr. Widdice and her colleagues conducted a retrospective investigation of medical records on 3,297 girls between ages 9 and 26 years who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic pediatric medical center with multiple primary care and specialty clinics.

Overall, 11% of the black girls received all three doses of the vaccine, compared with 22% of the white girls and 15% of those identified as other races, reported Dr. Widdice, a pediatrician at the Cincinnati Children's Hospital Medical Center.

Patients were predominantly from primary care (95%) and 65% used Medicaid. The majority (67%) self-identified as black, 29% said they were white, and 4% were classified as other races.

Even after investigators controlled for factors such as type of insurance and the different types of clinics giving the vaccine (primary care pediatrics, adolescent primary care, adolescent specialty clinics, or other specialty clinics), race was still strongly associated with getting all three of the doses on schedule.

Major Finding: Eleven percent of girls who self-identified as black received all three doses of the HPV vaccine, compared with 22% of the white girls and 15% of those identified as other races.

Data Source: A retrospective review of medical records on 3,297 girls between ages 9 and 26 years, and who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic, pediatric medical center with multiple primary care and specialty clinics.

Disclosures: None was reported.

TORONTO — Girls who identified themselves as white were twice as likely as those who identified themselves as black to complete the three-shot vaccination series against the human papillomavirus, according to a retrospective review of medical records.

“This is concerning because, historically, black women have had lower rates of cervical cancer screening and been more at risk from dying of cervical cancer. With unequal distribution of the vaccine, the racial disparity in cervical cancer may worsen,”said Dr. Lea Widdice, an assistant professor of pediatrics at the Cincinnati Children's Hospital Medical Center. Dr. Widdice presented her results in a poster.

Moreover, overall only 14% of girls initiating the HPV vaccine series actually completed the three-shot series within 7 months of the first dose. Clinical recommendations for the vaccine are to get the third shot 6 months after the first.

Dr. Widdice and her colleagues conducted a retrospective review of medical records on 3,297 girls between ages 9 and 26 years, and who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic, pediatric medical center with multiple primary care and specialty clinics.

Overall, 11% of the black girls received all three doses of the vaccine, compared with 22% of the white girls and 15% of those identified as other races. Patients were predominately from primary care (95%) and 65% used Medicaid. The majority (67%) self-identified as black, 29% said they were white, and 4% were classified as other races.

Race was still associated with getting all three doses on schedule even after controlling for type of insurance and the different clinics giving the vaccine.

Major Finding: Eleven percent of girls who self-identified as black received all three doses of the HPV vaccine, compared with 22% of the white girls and 15% of those identified as other races.

Data Source: A retrospective review of medical records on 3,297 girls between ages 9 and 26 years, and who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic, pediatric medical center with multiple primary care and specialty clinics.

Disclosures: None was reported.

TORONTO — Girls who identified themselves as white were twice as likely as those who identified themselves as black to complete the three-shot vaccination series against the human papillomavirus, according to a retrospective review of medical records.

“This is concerning because, historically, black women have had lower rates of cervical cancer screening and been more at risk from dying of cervical cancer. With unequal distribution of the vaccine, the racial disparity in cervical cancer may worsen,”said Dr. Lea Widdice, an assistant professor of pediatrics at the Cincinnati Children's Hospital Medical Center. Dr. Widdice presented her results in a poster.

Moreover, overall only 14% of girls initiating the HPV vaccine series actually completed the three-shot series within 7 months of the first dose. Clinical recommendations for the vaccine are to get the third shot 6 months after the first.

Dr. Widdice and her colleagues conducted a retrospective review of medical records on 3,297 girls between ages 9 and 26 years, and who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic, pediatric medical center with multiple primary care and specialty clinics.

Overall, 11% of the black girls received all three doses of the vaccine, compared with 22% of the white girls and 15% of those identified as other races. Patients were predominately from primary care (95%) and 65% used Medicaid. The majority (67%) self-identified as black, 29% said they were white, and 4% were classified as other races.

Race was still associated with getting all three doses on schedule even after controlling for type of insurance and the different clinics giving the vaccine.

Major Finding: Eleven percent of girls who self-identified as black received all three doses of the HPV vaccine, compared with 22% of the white girls and 15% of those identified as other races.

Data Source: A retrospective review of medical records on 3,297 girls between ages 9 and 26 years, and who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic, pediatric medical center with multiple primary care and specialty clinics.

Disclosures: None was reported.

TORONTO — Girls who identified themselves as white were twice as likely as those who identified themselves as black to complete the three-shot vaccination series against the human papillomavirus, according to a retrospective review of medical records.

“This is concerning because, historically, black women have had lower rates of cervical cancer screening and been more at risk from dying of cervical cancer. With unequal distribution of the vaccine, the racial disparity in cervical cancer may worsen,”said Dr. Lea Widdice, an assistant professor of pediatrics at the Cincinnati Children's Hospital Medical Center. Dr. Widdice presented her results in a poster.

Moreover, overall only 14% of girls initiating the HPV vaccine series actually completed the three-shot series within 7 months of the first dose. Clinical recommendations for the vaccine are to get the third shot 6 months after the first.

Dr. Widdice and her colleagues conducted a retrospective review of medical records on 3,297 girls between ages 9 and 26 years, and who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic, pediatric medical center with multiple primary care and specialty clinics.

Overall, 11% of the black girls received all three doses of the vaccine, compared with 22% of the white girls and 15% of those identified as other races. Patients were predominately from primary care (95%) and 65% used Medicaid. The majority (67%) self-identified as black, 29% said they were white, and 4% were classified as other races.

Race was still associated with getting all three doses on schedule even after controlling for type of insurance and the different clinics giving the vaccine.

Major Finding: Within 60 weeks of DMPA discontinuation, mean BMD values for the lumbar spine had returned to baseline levels. At the hip, full recovery of mean BMD took 240 weeks and at the femoral neck, 180 weeks.

Data Source: BMD values for up to 300 weeks after cessation of DMPA in 98 healthy female adolescents who initiated the injections for contraception between the ages of 12 and 18.

Disclosures: The study was funded by a grant from Pfizer Inc. Editorial assistance for the publication of the results was provided by Anthemis Consulting Ltd. and funded by Pfizer. Dr. Harel disclosed financial relationships with Merck & Co., Teva/Duramed, Ortho-McNeil, GlaxoSmithKline, Novartis, and Warner Chilcott.

TORONTO — Bone mineral density loss in female adolescents receiving depot medroxyprogesterone acetate for contraception was substantially or fully reversible following discontinuation of the drug, according to study results.

In girls who lost more than 5% of bone mineral density (BMD) during treatment, however, complete recovery was less likely. Also, recovery was generally greater and faster in the lumbar spine than the hip.

“If someone loses about 2%-4% of bone mineral density on Depo, then when they stop the injections, their BMD will recover and there is no risk,” said principal investigator Dr. Zeev Harel, professor of pediatrics Brown University, Providence, R.I. “The longer they use Depo, the more shots they get, the more BMD they lose; it's somewhat more difficult to recover.”

Participants included 98 healthy female adolescents between the ages of 12 and 18 who initiated depot medroxyprogesterone acetate (DMPA, Depo-Provera) intramuscular injections for contraception and provided BMD data for up to 300 weeks after cessation of DMPA. BMD was assessed by dual-energy x-ray absorptiometry at the lumbar spine, hip, and femoral neck.

During the study period, 19.4% of participants received 17 or more injections of DMPA, 15.3% received 13–16 injections, 17.3% received 9–12 injections, 24.5% received 5–8 injections, and 23.5% received 4 or fewer injections. Overall, the median total number of DMPA injections received was nine, Dr. Harel reported in a poster presentation during the annual meeting.

At the time of DMPA cessation, participants showed mean BMD declines from baseline of 2.7% at the lumbar spine, 4.1% at the hip, and 3.9% at the femoral neck.

Within 60 weeks of DMPA discontinuation, mean BMD values for the lumbar spine had returned to baseline levels. By 240 weeks, they had increased by 4.7% above baseline. Recovery occurred more slowly at the hip and femoral neck, with full recovery of mean BMD not seen until 240 weeks in the hip and 180 weeks in the femoral neck.

Postcessation gains were smaller in girls who exhibited a 5% or greater BMD loss during treatment, with mean BMD remaining below baseline at 240 weeks, also published in Contraception (2010;81:281-91).

Participants who had a 5% or greater loss of BMD had received a significantly greater number of DMPA injections (median, 13) than did those with less than 5% loss (median, 5).

The investigators noted five patient factors that affected BMD loss during DPMA treatment. Dr. Harel explained that those who had adequate calcium intake, adequate vitamin D intake, no smoking, and lower alcohol intake tended to lose less BMD during treatment. “The fifth factor, and one we have no control over, was weight,” he said. “Those who were a bit more overweight tended to lose less BMD.”

A 15% gain in BMD was seen in the control group. “In girls this age, over about 8–9 years, they can gain 15% in bone mineral density,” said Dr. Harel.

My Take

Weigh the Risk-Benefit Ratio

I think Dr Harel's data are encouraging in that some of the BMD loss appears to be reversible. On the flip side, it doesn't appear that the losses were completely reversible, so one worries in a young person on Depo-Provera that she might have skeletal deficits as she reaches peak bone mass.

Having said that, I'm an adolescent medicine physician, and for some patients Depo-Provera keeps them from becoming pregnant most effectively, so I think a clinician has to very carefully weigh the risk-benefit ratio. As we know, pregnancy is a high bone turnover state, so they're breaking down their skeleton when they should be accruing it.

We don't have the long-term outcome data to say whether these girls go on to be at higher risk for osteoporosis and for fractures, but these data are sorely needed, and I think they stimulate us to want to design those long-term studies to look at the health outcomes that accompany those changes in bone density.

Catherine M. Gordon, M.D., is the director of the bone health program at Children's Hospital Boston. Dr. Gordon reported no relevant financial disclosures.

VITALS

Major Finding: Within 60 weeks of DMPA discontinuation, mean BMD values for the lumbar spine had returned to baseline levels. At the hip, full recovery of mean BMD took 240 weeks and at the femoral neck, 180 weeks.

Data Source: BMD values for up to 300 weeks after cessation of DMPA in 98 healthy female adolescents who initiated the injections for contraception between the ages of 12 and 18.

Disclosures: The study was funded by a grant from Pfizer Inc. Editorial assistance for the publication of the results was provided by Anthemis Consulting Ltd. and funded by Pfizer. Dr. Harel disclosed financial relationships with Merck & Co., Teva/Duramed, Ortho-McNeil, GlaxoSmithKline, Novartis, and Warner Chilcott.

TORONTO — Bone mineral density loss in female adolescents receiving depot medroxyprogesterone acetate for contraception was substantially or fully reversible following discontinuation of the drug, according to study results.

In girls who lost more than 5% of bone mineral density (BMD) during treatment, however, complete recovery was less likely. Also, recovery was generally greater and faster in the lumbar spine than the hip.

“If someone loses about 2%-4% of bone mineral density on Depo, then when they stop the injections, their BMD will recover and there is no risk,” said principal investigator Dr. Zeev Harel, professor of pediatrics Brown University, Providence, R.I. “The longer they use Depo, the more shots they get, the more BMD they lose; it's somewhat more difficult to recover.”

Participants included 98 healthy female adolescents between the ages of 12 and 18 who initiated depot medroxyprogesterone acetate (DMPA, Depo-Provera) intramuscular injections for contraception and provided BMD data for up to 300 weeks after cessation of DMPA. BMD was assessed by dual-energy x-ray absorptiometry at the lumbar spine, hip, and femoral neck.

During the study period, 19.4% of participants received 17 or more injections of DMPA, 15.3% received 13–16 injections, 17.3% received 9–12 injections, 24.5% received 5–8 injections, and 23.5% received 4 or fewer injections. Overall, the median total number of DMPA injections received was nine, Dr. Harel reported in a poster presentation during the annual meeting.

At the time of DMPA cessation, participants showed mean BMD declines from baseline of 2.7% at the lumbar spine, 4.1% at the hip, and 3.9% at the femoral neck.

Within 60 weeks of DMPA discontinuation, mean BMD values for the lumbar spine had returned to baseline levels. By 240 weeks, they had increased by 4.7% above baseline. Recovery occurred more slowly at the hip and femoral neck, with full recovery of mean BMD not seen until 240 weeks in the hip and 180 weeks in the femoral neck.

Postcessation gains were smaller in girls who exhibited a 5% or greater BMD loss during treatment, with mean BMD remaining below baseline at 240 weeks, also published in Contraception (2010;81:281-91).

Participants who had a 5% or greater loss of BMD had received a significantly greater number of DMPA injections (median, 13) than did those with less than 5% loss (median, 5).

The investigators noted five patient factors that affected BMD loss during DPMA treatment. Dr. Harel explained that those who had adequate calcium intake, adequate vitamin D intake, no smoking, and lower alcohol intake tended to lose less BMD during treatment. “The fifth factor, and one we have no control over, was weight,” he said. “Those who were a bit more overweight tended to lose less BMD.”

A 15% gain in BMD was seen in the control group. “In girls this age, over about 8–9 years, they can gain 15% in bone mineral density,” said Dr. Harel.

My Take

Weigh the Risk-Benefit Ratio

I think Dr Harel's data are encouraging in that some of the BMD loss appears to be reversible. On the flip side, it doesn't appear that the losses were completely reversible, so one worries in a young person on Depo-Provera that she might have skeletal deficits as she reaches peak bone mass.

Having said that, I'm an adolescent medicine physician, and for some patients Depo-Provera keeps them from becoming pregnant most effectively, so I think a clinician has to very carefully weigh the risk-benefit ratio. As we know, pregnancy is a high bone turnover state, so they're breaking down their skeleton when they should be accruing it.

We don't have the long-term outcome data to say whether these girls go on to be at higher risk for osteoporosis and for fractures, but these data are sorely needed, and I think they stimulate us to want to design those long-term studies to look at the health outcomes that accompany those changes in bone density.

Catherine M. Gordon, M.D., is the director of the bone health program at Children's Hospital Boston. Dr. Gordon reported no relevant financial disclosures.

VITALS

Major Finding: Within 60 weeks of DMPA discontinuation, mean BMD values for the lumbar spine had returned to baseline levels. At the hip, full recovery of mean BMD took 240 weeks and at the femoral neck, 180 weeks.

Data Source: BMD values for up to 300 weeks after cessation of DMPA in 98 healthy female adolescents who initiated the injections for contraception between the ages of 12 and 18.

Disclosures: The study was funded by a grant from Pfizer Inc. Editorial assistance for the publication of the results was provided by Anthemis Consulting Ltd. and funded by Pfizer. Dr. Harel disclosed financial relationships with Merck & Co., Teva/Duramed, Ortho-McNeil, GlaxoSmithKline, Novartis, and Warner Chilcott.

TORONTO — Bone mineral density loss in female adolescents receiving depot medroxyprogesterone acetate for contraception was substantially or fully reversible following discontinuation of the drug, according to study results.

In girls who lost more than 5% of bone mineral density (BMD) during treatment, however, complete recovery was less likely. Also, recovery was generally greater and faster in the lumbar spine than the hip.

“If someone loses about 2%-4% of bone mineral density on Depo, then when they stop the injections, their BMD will recover and there is no risk,” said principal investigator Dr. Zeev Harel, professor of pediatrics Brown University, Providence, R.I. “The longer they use Depo, the more shots they get, the more BMD they lose; it's somewhat more difficult to recover.”

Participants included 98 healthy female adolescents between the ages of 12 and 18 who initiated depot medroxyprogesterone acetate (DMPA, Depo-Provera) intramuscular injections for contraception and provided BMD data for up to 300 weeks after cessation of DMPA. BMD was assessed by dual-energy x-ray absorptiometry at the lumbar spine, hip, and femoral neck.

During the study period, 19.4% of participants received 17 or more injections of DMPA, 15.3% received 13–16 injections, 17.3% received 9–12 injections, 24.5% received 5–8 injections, and 23.5% received 4 or fewer injections. Overall, the median total number of DMPA injections received was nine, Dr. Harel reported in a poster presentation during the annual meeting.

At the time of DMPA cessation, participants showed mean BMD declines from baseline of 2.7% at the lumbar spine, 4.1% at the hip, and 3.9% at the femoral neck.

Within 60 weeks of DMPA discontinuation, mean BMD values for the lumbar spine had returned to baseline levels. By 240 weeks, they had increased by 4.7% above baseline. Recovery occurred more slowly at the hip and femoral neck, with full recovery of mean BMD not seen until 240 weeks in the hip and 180 weeks in the femoral neck.

Postcessation gains were smaller in girls who exhibited a 5% or greater BMD loss during treatment, with mean BMD remaining below baseline at 240 weeks, also published in Contraception (2010;81:281-91).

Participants who had a 5% or greater loss of BMD had received a significantly greater number of DMPA injections (median, 13) than did those with less than 5% loss (median, 5).

The investigators noted five patient factors that affected BMD loss during DPMA treatment. Dr. Harel explained that those who had adequate calcium intake, adequate vitamin D intake, no smoking, and lower alcohol intake tended to lose less BMD during treatment. “The fifth factor, and one we have no control over, was weight,” he said. “Those who were a bit more overweight tended to lose less BMD.”

A 15% gain in BMD was seen in the control group. “In girls this age, over about 8–9 years, they can gain 15% in bone mineral density,” said Dr. Harel.

My Take

Weigh the Risk-Benefit Ratio

I think Dr Harel's data are encouraging in that some of the BMD loss appears to be reversible. On the flip side, it doesn't appear that the losses were completely reversible, so one worries in a young person on Depo-Provera that she might have skeletal deficits as she reaches peak bone mass.

Having said that, I'm an adolescent medicine physician, and for some patients Depo-Provera keeps them from becoming pregnant most effectively, so I think a clinician has to very carefully weigh the risk-benefit ratio. As we know, pregnancy is a high bone turnover state, so they're breaking down their skeleton when they should be accruing it.

We don't have the long-term outcome data to say whether these girls go on to be at higher risk for osteoporosis and for fractures, but these data are sorely needed, and I think they stimulate us to want to design those long-term studies to look at the health outcomes that accompany those changes in bone density.

Catherine M. Gordon, M.D., is the director of the bone health program at Children's Hospital Boston. Dr. Gordon reported no relevant financial disclosures.

VITALS