John R. Bell

Ultrasound findings from a cross-sectional study of 162 postmenopausal women might help explain the paradox that women with type 2 diabetes can have higher bone mineral density than nondiabetic women and yet have a greater risk of fractures.

The study confirmed previous reports that bone mineral density (BMD) as measured by dual x-ray absorptiometry (DXA) is higher in women with type 2 diabetes than in women without diabetes. Yet a new diagnostic tool, quantitative ultrasound, revealed that the speed of sound through bone was lower in diabetic women.

This may indicate that their denser bone is in some way of lesser quality, compared with the bone of women without type 2 diabetes.

The findings suggest that quantitative ultrasound is a useful tool in detecting impaired bone quality in postmenopausal women with type 2 diabetes, and that it might have greater promise than DXA in detecting bone defects in diabetic patients, the authors wrote.

Dr. Bei Tao of Shanghai (China) Jiao-tong University School of Medicine and colleagues enrolled 76 postmenopausal women with type 2 diabetes and 86 nondiabetic postmenopausal women. In the diabetic women, mean BMD as measured by DXA was 1.06 g/m

Quantitative ultrasound was used to assess the axial speed of sound along the distal third of the radius, the proximal phalanx of the third finger, and the midshaft of the tibia. The speed of sound was higher at all three locations in the nondiabetic women, compared with the diabetic women (see bar chart), the investigators reported online in the Journal of Clinical Endocrine Metabolism (2008 Mar. 4 [doi:10.1210/jc.2007–1760]).

Among the nondiabetic women, BMD at each site correlated significantly with the speed-of-sound measurements. But among the diabetic women, only the speed of sound at the phalangeal site correlated significantly with all three BMD values; the speed of sound in the tibia correlated with none of the BMD values, and the speed of sound in the radius correlated with only the BMD of the femoral neck.

ELSEVIER GLOBAL MEDICAL NEWS

Ultrasound findings from a cross-sectional study of 162 postmenopausal women might help explain the paradox that women with type 2 diabetes can have higher bone mineral density than nondiabetic women and yet have a greater risk of fractures.

The study confirmed previous reports that bone mineral density (BMD) as measured by dual x-ray absorptiometry (DXA) is higher in women with type 2 diabetes than in women without diabetes. Yet a new diagnostic tool, quantitative ultrasound, revealed that the speed of sound through bone was lower in diabetic women.

This may indicate that their denser bone is in some way of lesser quality, compared with the bone of women without type 2 diabetes.

The findings suggest that quantitative ultrasound is a useful tool in detecting impaired bone quality in postmenopausal women with type 2 diabetes, and that it might have greater promise than DXA in detecting bone defects in diabetic patients, the authors wrote.

Dr. Bei Tao of Shanghai (China) Jiao-tong University School of Medicine and colleagues enrolled 76 postmenopausal women with type 2 diabetes and 86 nondiabetic postmenopausal women. In the diabetic women, mean BMD as measured by DXA was 1.06 g/m

Quantitative ultrasound was used to assess the axial speed of sound along the distal third of the radius, the proximal phalanx of the third finger, and the midshaft of the tibia. The speed of sound was higher at all three locations in the nondiabetic women, compared with the diabetic women (see bar chart), the investigators reported online in the Journal of Clinical Endocrine Metabolism (2008 Mar. 4 [doi:10.1210/jc.2007–1760]).

Among the nondiabetic women, BMD at each site correlated significantly with the speed-of-sound measurements. But among the diabetic women, only the speed of sound at the phalangeal site correlated significantly with all three BMD values; the speed of sound in the tibia correlated with none of the BMD values, and the speed of sound in the radius correlated with only the BMD of the femoral neck.

ELSEVIER GLOBAL MEDICAL NEWS

Ultrasound findings from a cross-sectional study of 162 postmenopausal women might help explain the paradox that women with type 2 diabetes can have higher bone mineral density than nondiabetic women and yet have a greater risk of fractures.

The study confirmed previous reports that bone mineral density (BMD) as measured by dual x-ray absorptiometry (DXA) is higher in women with type 2 diabetes than in women without diabetes. Yet a new diagnostic tool, quantitative ultrasound, revealed that the speed of sound through bone was lower in diabetic women.

This may indicate that their denser bone is in some way of lesser quality, compared with the bone of women without type 2 diabetes.

The findings suggest that quantitative ultrasound is a useful tool in detecting impaired bone quality in postmenopausal women with type 2 diabetes, and that it might have greater promise than DXA in detecting bone defects in diabetic patients, the authors wrote.

Dr. Bei Tao of Shanghai (China) Jiao-tong University School of Medicine and colleagues enrolled 76 postmenopausal women with type 2 diabetes and 86 nondiabetic postmenopausal women. In the diabetic women, mean BMD as measured by DXA was 1.06 g/m

Quantitative ultrasound was used to assess the axial speed of sound along the distal third of the radius, the proximal phalanx of the third finger, and the midshaft of the tibia. The speed of sound was higher at all three locations in the nondiabetic women, compared with the diabetic women (see bar chart), the investigators reported online in the Journal of Clinical Endocrine Metabolism (2008 Mar. 4 [doi:10.1210/jc.2007–1760]).

Among the nondiabetic women, BMD at each site correlated significantly with the speed-of-sound measurements. But among the diabetic women, only the speed of sound at the phalangeal site correlated significantly with all three BMD values; the speed of sound in the tibia correlated with none of the BMD values, and the speed of sound in the radius correlated with only the BMD of the femoral neck.

ELSEVIER GLOBAL MEDICAL NEWS

Smokers who were told their “lung age” after spirometry had more than double the rate of quitting 12 months later than did smokers who were given only a clinical measure of lung performance, according to data from a randomized controlled trial.

Awareness of lung age seems to be as effective as is nicotine replacement, counseling, and bupropion in spurring smokers to quit—and it is also cheaper, the authors noted in their study.

Dr. Gary Parkes of the Limes Surgery, Hoddesdon, England, and colleagues enrolled 561 current smokers from five primary care practices in one English county. Patients were at least 35 years old (mean age, 53 years) and did not have a history of lung disease or use supplemental oxygen. All were given a series of spirometric tests, were advised during the visit to quit smoking, and were offered referral to a support service.

Each patient was randomized to receive one of two types of information: Those patients in the intervention group received an individualized explanation of their level of forced expiratory volume in 1 second (FEV₁), along with a verbal explanation of their lung age and a graphic explaining the concept of lung age. Lung age was calculated using a previously established formula. (See box.) Patients in the control group received only a letter indicating their FEV₁ score, with no further explanation.

In each group, the average number of cigarettes smoked daily was 17. The mean number of pack-years was 30 in the control group (281 persons) and 31 in the intervention group (280 persons).

At 12 months, there were 249 control participants, 32 having been lost to follow-up. In the intervention group, there were also 249 patients remaining, with 31 lost to follow-up. However, those lost to follow-up were included as if they had continued to smoke. In the controls, there were 18 patients (6%) who quit smoking, as verified by carbon-monoxide breath testing. In the intervention group, 38 patients quit (14%).

The investigators analyzed the data in the intervention group to determine if those with a greater lung-age deficit were more likely to quit than those with a smaller deficit or none. Contrary to previously published findings, they found no significant difference in quit rates based on disclosed lung damage, although they cautioned that the study was not powered to detect such a difference. (BMJ 2008 March 6 [Epub doi:10.1136/bmj.39503.582396.25]).

“This apparent win-win situation might explain the apparently paradoxical finding that knowing one's lung age helps a smoker to quit,” the authors wrote. “If lung age is normal, there is an incentive to stop before it is too late. If lung age is abnormal, this is a clear message the lungs are undergoing accelerated deterioration that would be slowed if the smoker stopped.”

The researchers disclosed no potential conflicts of interest.

How to Calculate aPatient's Lung Age

▸ For men: Lung age = (2.87 × height [in inches]) - (31.25 × observed FEV₁ [in liters]) - 39.375

▸ For women: Lung age = (3.56 × height [in inches]) - (40 × observed FEV₁ [in liters]) - 77.28

Smokers who were told their “lung age” after spirometry had more than double the rate of quitting 12 months later than did smokers who were given only a clinical measure of lung performance, according to data from a randomized controlled trial.

Awareness of lung age seems to be as effective as is nicotine replacement, counseling, and bupropion in spurring smokers to quit—and it is also cheaper, the authors noted in their study.

Dr. Gary Parkes of the Limes Surgery, Hoddesdon, England, and colleagues enrolled 561 current smokers from five primary care practices in one English county. Patients were at least 35 years old (mean age, 53 years) and did not have a history of lung disease or use supplemental oxygen. All were given a series of spirometric tests, were advised during the visit to quit smoking, and were offered referral to a support service.

Each patient was randomized to receive one of two types of information: Those patients in the intervention group received an individualized explanation of their level of forced expiratory volume in 1 second (FEV₁), along with a verbal explanation of their lung age and a graphic explaining the concept of lung age. Lung age was calculated using a previously established formula. (See box.) Patients in the control group received only a letter indicating their FEV₁ score, with no further explanation.

In each group, the average number of cigarettes smoked daily was 17. The mean number of pack-years was 30 in the control group (281 persons) and 31 in the intervention group (280 persons).

At 12 months, there were 249 control participants, 32 having been lost to follow-up. In the intervention group, there were also 249 patients remaining, with 31 lost to follow-up. However, those lost to follow-up were included as if they had continued to smoke. In the controls, there were 18 patients (6%) who quit smoking, as verified by carbon-monoxide breath testing. In the intervention group, 38 patients quit (14%).

The investigators analyzed the data in the intervention group to determine if those with a greater lung-age deficit were more likely to quit than those with a smaller deficit or none. Contrary to previously published findings, they found no significant difference in quit rates based on disclosed lung damage, although they cautioned that the study was not powered to detect such a difference. (BMJ 2008 March 6 [Epub doi:10.1136/bmj.39503.582396.25]).

“This apparent win-win situation might explain the apparently paradoxical finding that knowing one's lung age helps a smoker to quit,” the authors wrote. “If lung age is normal, there is an incentive to stop before it is too late. If lung age is abnormal, this is a clear message the lungs are undergoing accelerated deterioration that would be slowed if the smoker stopped.”

The researchers disclosed no potential conflicts of interest.

How to Calculate aPatient's Lung Age

▸ For men: Lung age = (2.87 × height [in inches]) - (31.25 × observed FEV₁ [in liters]) - 39.375

▸ For women: Lung age = (3.56 × height [in inches]) - (40 × observed FEV₁ [in liters]) - 77.28

Smokers who were told their “lung age” after spirometry had more than double the rate of quitting 12 months later than did smokers who were given only a clinical measure of lung performance, according to data from a randomized controlled trial.

Awareness of lung age seems to be as effective as is nicotine replacement, counseling, and bupropion in spurring smokers to quit—and it is also cheaper, the authors noted in their study.

Dr. Gary Parkes of the Limes Surgery, Hoddesdon, England, and colleagues enrolled 561 current smokers from five primary care practices in one English county. Patients were at least 35 years old (mean age, 53 years) and did not have a history of lung disease or use supplemental oxygen. All were given a series of spirometric tests, were advised during the visit to quit smoking, and were offered referral to a support service.

Each patient was randomized to receive one of two types of information: Those patients in the intervention group received an individualized explanation of their level of forced expiratory volume in 1 second (FEV₁), along with a verbal explanation of their lung age and a graphic explaining the concept of lung age. Lung age was calculated using a previously established formula. (See box.) Patients in the control group received only a letter indicating their FEV₁ score, with no further explanation.

In each group, the average number of cigarettes smoked daily was 17. The mean number of pack-years was 30 in the control group (281 persons) and 31 in the intervention group (280 persons).

At 12 months, there were 249 control participants, 32 having been lost to follow-up. In the intervention group, there were also 249 patients remaining, with 31 lost to follow-up. However, those lost to follow-up were included as if they had continued to smoke. In the controls, there were 18 patients (6%) who quit smoking, as verified by carbon-monoxide breath testing. In the intervention group, 38 patients quit (14%).

The investigators analyzed the data in the intervention group to determine if those with a greater lung-age deficit were more likely to quit than those with a smaller deficit or none. Contrary to previously published findings, they found no significant difference in quit rates based on disclosed lung damage, although they cautioned that the study was not powered to detect such a difference. (BMJ 2008 March 6 [Epub doi:10.1136/bmj.39503.582396.25]).

“This apparent win-win situation might explain the apparently paradoxical finding that knowing one's lung age helps a smoker to quit,” the authors wrote. “If lung age is normal, there is an incentive to stop before it is too late. If lung age is abnormal, this is a clear message the lungs are undergoing accelerated deterioration that would be slowed if the smoker stopped.”

The researchers disclosed no potential conflicts of interest.

How to Calculate aPatient's Lung Age

▸ For men: Lung age = (2.87 × height [in inches]) - (31.25 × observed FEV₁ [in liters]) - 39.375

▸ For women: Lung age = (3.56 × height [in inches]) - (40 × observed FEV₁ [in liters]) - 77.28

Use of a 25-mm needle was associated with less risk of redness and pain than was use of a 16-mm needle among children receiving their fifth diphtheria-tetanus-acellular pertussis vaccine, according to results from a prospective randomized trial.

The results also suggested that the thigh should be considered as the site for the fifth injection, the investigators reported.

Dr. Lisa A. Jackson of the epidemiology department of the University of Washington, Seattle, and colleagues reported results from 1,315 pediatric patients (median age 54 months) in a study funded by Sanofi-Pasteur Inc.

Most (1,174 patients) received the vaccination in the arm; 141 were injected in the thigh. Among those injected in the arm, there was a significantly greater proportion with any injection-site redness (76%) among the 381 on whom a 16-mm needle was used than there was among the 793 patients on whom the 25-mm needle was used (65%).

Swelling was also significantly less common among patients injected in the arm with the longer versus the shorter needle (reported in 67% and 55%, respectively), as was pain (61% vs. 53%).

The same trend was seen for each reaction among patients injected in the thigh, but the differences did not reach significance (Pediatrics 2008;121;e646–52).

Relative risks adjusted for age, gender, and body mass index (BMI) showed that the risk for several localized reactions was less when the injection site was the thigh, rather than the arm, especially redness (relative risk 0.63) and swelling (RR 0.53).

“Together these findings suggest that a 16-mm needle should not be used for administration of the fifth DTaP vaccine injections and that vaccination in the thigh is an option that may be considered by parents and providers who would like to decrease the risk of local reactions characterized by redness and swelling,” they wrote, adding that these findings are consistent with those of similar studies in the literature.

Both practices are consistent with guidelines from the American Academy of Pediatrics and the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, they noted.

The investigators cautioned that neither the needle length nor the injection site was randomized, and that the latter factor seemed to correlate with the size of the child.

However, their analyses did control for BMI. “In analyses restricted to children with a BMI of 14.50 to 16.79 kg/m

Dr. Jackson has served as a consultant to Sanofi Pasteur in the past and is on the speakers' bureau for Sanofi Pasteur.

She has also received research funding from Wyeth Pharmaceuticals, ID Biomedical Corp., GlaxoSmithKline Inc., and Novartis, and has served as a consultant to Wyeth and Novartis.

Use of a 25-mm needle was associated with less risk of redness and pain than was use of a 16-mm needle among children receiving their fifth diphtheria-tetanus-acellular pertussis vaccine, according to results from a prospective randomized trial.

The results also suggested that the thigh should be considered as the site for the fifth injection, the investigators reported.

Dr. Lisa A. Jackson of the epidemiology department of the University of Washington, Seattle, and colleagues reported results from 1,315 pediatric patients (median age 54 months) in a study funded by Sanofi-Pasteur Inc.

Most (1,174 patients) received the vaccination in the arm; 141 were injected in the thigh. Among those injected in the arm, there was a significantly greater proportion with any injection-site redness (76%) among the 381 on whom a 16-mm needle was used than there was among the 793 patients on whom the 25-mm needle was used (65%).

Swelling was also significantly less common among patients injected in the arm with the longer versus the shorter needle (reported in 67% and 55%, respectively), as was pain (61% vs. 53%).

The same trend was seen for each reaction among patients injected in the thigh, but the differences did not reach significance (Pediatrics 2008;121;e646–52).

Relative risks adjusted for age, gender, and body mass index (BMI) showed that the risk for several localized reactions was less when the injection site was the thigh, rather than the arm, especially redness (relative risk 0.63) and swelling (RR 0.53).

“Together these findings suggest that a 16-mm needle should not be used for administration of the fifth DTaP vaccine injections and that vaccination in the thigh is an option that may be considered by parents and providers who would like to decrease the risk of local reactions characterized by redness and swelling,” they wrote, adding that these findings are consistent with those of similar studies in the literature.

Both practices are consistent with guidelines from the American Academy of Pediatrics and the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, they noted.

The investigators cautioned that neither the needle length nor the injection site was randomized, and that the latter factor seemed to correlate with the size of the child.

However, their analyses did control for BMI. “In analyses restricted to children with a BMI of 14.50 to 16.79 kg/m

Dr. Jackson has served as a consultant to Sanofi Pasteur in the past and is on the speakers' bureau for Sanofi Pasteur.

She has also received research funding from Wyeth Pharmaceuticals, ID Biomedical Corp., GlaxoSmithKline Inc., and Novartis, and has served as a consultant to Wyeth and Novartis.

Use of a 25-mm needle was associated with less risk of redness and pain than was use of a 16-mm needle among children receiving their fifth diphtheria-tetanus-acellular pertussis vaccine, according to results from a prospective randomized trial.

The results also suggested that the thigh should be considered as the site for the fifth injection, the investigators reported.

Dr. Lisa A. Jackson of the epidemiology department of the University of Washington, Seattle, and colleagues reported results from 1,315 pediatric patients (median age 54 months) in a study funded by Sanofi-Pasteur Inc.

Most (1,174 patients) received the vaccination in the arm; 141 were injected in the thigh. Among those injected in the arm, there was a significantly greater proportion with any injection-site redness (76%) among the 381 on whom a 16-mm needle was used than there was among the 793 patients on whom the 25-mm needle was used (65%).

Swelling was also significantly less common among patients injected in the arm with the longer versus the shorter needle (reported in 67% and 55%, respectively), as was pain (61% vs. 53%).

The same trend was seen for each reaction among patients injected in the thigh, but the differences did not reach significance (Pediatrics 2008;121;e646–52).

Relative risks adjusted for age, gender, and body mass index (BMI) showed that the risk for several localized reactions was less when the injection site was the thigh, rather than the arm, especially redness (relative risk 0.63) and swelling (RR 0.53).

“Together these findings suggest that a 16-mm needle should not be used for administration of the fifth DTaP vaccine injections and that vaccination in the thigh is an option that may be considered by parents and providers who would like to decrease the risk of local reactions characterized by redness and swelling,” they wrote, adding that these findings are consistent with those of similar studies in the literature.

Both practices are consistent with guidelines from the American Academy of Pediatrics and the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, they noted.

The investigators cautioned that neither the needle length nor the injection site was randomized, and that the latter factor seemed to correlate with the size of the child.

However, their analyses did control for BMI. “In analyses restricted to children with a BMI of 14.50 to 16.79 kg/m

Dr. Jackson has served as a consultant to Sanofi Pasteur in the past and is on the speakers' bureau for Sanofi Pasteur.

She has also received research funding from Wyeth Pharmaceuticals, ID Biomedical Corp., GlaxoSmithKline Inc., and Novartis, and has served as a consultant to Wyeth and Novartis.

A 1997 state requirement that all children in Illinois receive the hepatitis B vaccine series in order to enter the fifth grade has not only raised the rate of vaccination to more than 90% in a group of Chicago-area high school students but also has narrowed the vaccination disparity between white students and black or Hispanic students, according to results of a retrospective cohort study.

Ensuring that at least 90% of all students receive the complete vaccine is a goal of the U.S. Department of Health and Human Services Healthy People 2010 program, the authors noted.

The study analyzed vaccination data for the senior class of six Chicago high schools for each of the years 2000–2005.

The six cohorts comprised a total of 106,541 students and included four cohorts who had entered fifth grade before the mandate took effect in October 1997 and two cohorts who had entered fifth grade after the mandate.

In each cohort, 50%–51% were black, 30%–34% were Hispanic, 11%–13% were white, and 5%–6% were Asian American, Dr. Julie Morita of the Chicago Department of Public Health and her colleagues reported (Pediatrics 2008;121:e547–52).

School administrators were permitted to give a 1-year extension to students who had begun the vaccination series, and the investigators wrote that they suspect the mandate was inconsistently enforced, the investigators said.

Still, there was a distinct increase in vaccination coverage after the mandate; the first cohort of students to enter fifth grade after it took effect (that is, in the fall of 1997) had a vaccination coverage level of 38%, compared with 4% for the last group of students to enter fifth grade before the mandate.

By the time this cohort had reached the 12th grade, the coverage rates for white, black, and Hispanic students were 97%, 92%, and 96%, respectively. The rates for the second postmandate cohort were even higher (98%, 96%, and 98%, respectively).

There also was a narrowing of the coverage gap among ethnic groups, even among students who entered fifth grade before the mandate took effect.

Among students who started fifth grade in 1996, 8% of whites, 3% of blacks, and 4% of Hispanics had received the full hepatitis B series by fifth grade.

But by 2000, when that cohort had entered ninth grade, the rate of coverage had risen to 46%, 32%, and 40%, respectively.

This trend was even stronger in the second postmandate cohort; by the time the students who had entered fifth grade in 1998 reached the ninth grade, 93% of whites, 89% of blacks, and 93% of Hispanics were fully vaccinated against hepatitis B.

The investigators did not include vaccination data for Asian American students.

The ninth grade is an important threshold for hepatitis B vaccination, the authors noted, because vaccination by this age “protects most vaccine recipients before the onset of sexual activity, the most common mode of hepatitis B transmission.”

The investigators noted that the demonstrated effectiveness of the Illinois vaccination mandate could be useful to clinicians and legislators seeking to increase coverage rates for other childhood and adolescent vaccinations—particularly the human papillomavirus vaccine, which is also given in a three-dose series.

Dr. Morita and her colleagues noted that, before the mandate took effect, a host of community programs were in place, such as school-based vaccination drives and programs to provide vaccinations to children from low-income families.

In addition, the mandate came 3 years after the American Academy of Pediatrics, the American Academy of Family Physicians, and the Advisory Committee on Immunization Practices recommended routine vaccination of adolescents against hepatitis B.

A 1997 state requirement that all children in Illinois receive the hepatitis B vaccine series in order to enter the fifth grade has not only raised the rate of vaccination to more than 90% in a group of Chicago-area high school students but also has narrowed the vaccination disparity between white students and black or Hispanic students, according to results of a retrospective cohort study.

Ensuring that at least 90% of all students receive the complete vaccine is a goal of the U.S. Department of Health and Human Services Healthy People 2010 program, the authors noted.

The study analyzed vaccination data for the senior class of six Chicago high schools for each of the years 2000–2005.

The six cohorts comprised a total of 106,541 students and included four cohorts who had entered fifth grade before the mandate took effect in October 1997 and two cohorts who had entered fifth grade after the mandate.

In each cohort, 50%–51% were black, 30%–34% were Hispanic, 11%–13% were white, and 5%–6% were Asian American, Dr. Julie Morita of the Chicago Department of Public Health and her colleagues reported (Pediatrics 2008;121:e547–52).

School administrators were permitted to give a 1-year extension to students who had begun the vaccination series, and the investigators wrote that they suspect the mandate was inconsistently enforced, the investigators said.

Still, there was a distinct increase in vaccination coverage after the mandate; the first cohort of students to enter fifth grade after it took effect (that is, in the fall of 1997) had a vaccination coverage level of 38%, compared with 4% for the last group of students to enter fifth grade before the mandate.

By the time this cohort had reached the 12th grade, the coverage rates for white, black, and Hispanic students were 97%, 92%, and 96%, respectively. The rates for the second postmandate cohort were even higher (98%, 96%, and 98%, respectively).

There also was a narrowing of the coverage gap among ethnic groups, even among students who entered fifth grade before the mandate took effect.

Among students who started fifth grade in 1996, 8% of whites, 3% of blacks, and 4% of Hispanics had received the full hepatitis B series by fifth grade.

But by 2000, when that cohort had entered ninth grade, the rate of coverage had risen to 46%, 32%, and 40%, respectively.

This trend was even stronger in the second postmandate cohort; by the time the students who had entered fifth grade in 1998 reached the ninth grade, 93% of whites, 89% of blacks, and 93% of Hispanics were fully vaccinated against hepatitis B.

The investigators did not include vaccination data for Asian American students.

The ninth grade is an important threshold for hepatitis B vaccination, the authors noted, because vaccination by this age “protects most vaccine recipients before the onset of sexual activity, the most common mode of hepatitis B transmission.”

The investigators noted that the demonstrated effectiveness of the Illinois vaccination mandate could be useful to clinicians and legislators seeking to increase coverage rates for other childhood and adolescent vaccinations—particularly the human papillomavirus vaccine, which is also given in a three-dose series.

Dr. Morita and her colleagues noted that, before the mandate took effect, a host of community programs were in place, such as school-based vaccination drives and programs to provide vaccinations to children from low-income families.

In addition, the mandate came 3 years after the American Academy of Pediatrics, the American Academy of Family Physicians, and the Advisory Committee on Immunization Practices recommended routine vaccination of adolescents against hepatitis B.

A 1997 state requirement that all children in Illinois receive the hepatitis B vaccine series in order to enter the fifth grade has not only raised the rate of vaccination to more than 90% in a group of Chicago-area high school students but also has narrowed the vaccination disparity between white students and black or Hispanic students, according to results of a retrospective cohort study.

Ensuring that at least 90% of all students receive the complete vaccine is a goal of the U.S. Department of Health and Human Services Healthy People 2010 program, the authors noted.

The study analyzed vaccination data for the senior class of six Chicago high schools for each of the years 2000–2005.

The six cohorts comprised a total of 106,541 students and included four cohorts who had entered fifth grade before the mandate took effect in October 1997 and two cohorts who had entered fifth grade after the mandate.

In each cohort, 50%–51% were black, 30%–34% were Hispanic, 11%–13% were white, and 5%–6% were Asian American, Dr. Julie Morita of the Chicago Department of Public Health and her colleagues reported (Pediatrics 2008;121:e547–52).

School administrators were permitted to give a 1-year extension to students who had begun the vaccination series, and the investigators wrote that they suspect the mandate was inconsistently enforced, the investigators said.

Still, there was a distinct increase in vaccination coverage after the mandate; the first cohort of students to enter fifth grade after it took effect (that is, in the fall of 1997) had a vaccination coverage level of 38%, compared with 4% for the last group of students to enter fifth grade before the mandate.

By the time this cohort had reached the 12th grade, the coverage rates for white, black, and Hispanic students were 97%, 92%, and 96%, respectively. The rates for the second postmandate cohort were even higher (98%, 96%, and 98%, respectively).

There also was a narrowing of the coverage gap among ethnic groups, even among students who entered fifth grade before the mandate took effect.

Among students who started fifth grade in 1996, 8% of whites, 3% of blacks, and 4% of Hispanics had received the full hepatitis B series by fifth grade.

But by 2000, when that cohort had entered ninth grade, the rate of coverage had risen to 46%, 32%, and 40%, respectively.

This trend was even stronger in the second postmandate cohort; by the time the students who had entered fifth grade in 1998 reached the ninth grade, 93% of whites, 89% of blacks, and 93% of Hispanics were fully vaccinated against hepatitis B.

The investigators did not include vaccination data for Asian American students.

The ninth grade is an important threshold for hepatitis B vaccination, the authors noted, because vaccination by this age “protects most vaccine recipients before the onset of sexual activity, the most common mode of hepatitis B transmission.”

The investigators noted that the demonstrated effectiveness of the Illinois vaccination mandate could be useful to clinicians and legislators seeking to increase coverage rates for other childhood and adolescent vaccinations—particularly the human papillomavirus vaccine, which is also given in a three-dose series.

Dr. Morita and her colleagues noted that, before the mandate took effect, a host of community programs were in place, such as school-based vaccination drives and programs to provide vaccinations to children from low-income families.

In addition, the mandate came 3 years after the American Academy of Pediatrics, the American Academy of Family Physicians, and the Advisory Committee on Immunization Practices recommended routine vaccination of adolescents against hepatitis B.

Ultrasound findings from a cross-sectional study of 162 postmenopausal women might help explain the paradox that women with type 2 diabetes can have higher bone mineral density than nondiabetic women and yet have a greater risk of fractures.

The study confirmed previous reports that bone mineral density (BMD) as measured by dual x-ray absorptiometry (DXA) is higher in women with type 2 diabetes than in women without diabetes. Yet a new diagnostic tool, quantitative ultrasound, revealed that the speed of sound through bone was lower in diabetic women. This may indicate that their denser bone is in some way of lesser quality, compared with the bone of women without type 2 diabetes.

The findings suggest that quantitative ultrasound is a useful tool in detecting impaired bone quality in postmenopausal women with type 2 diabetes, and that it might have greater promise than DXA in detecting bone defects in diabetic patients, the authors wrote.

Dr. Bei Tao of Shanghai (China) Jiao-tong University School of Medicine and colleagues enrolled 76 postmenopausal women with type 2 diabetes and 86 nondiabetic postmenopausal women. In the diabetic women, mean BMD as measured by DXA was 1.06 g/m

Quantitative ultrasound was used to assess the axial speed of sound along the distal third of the radius, the proximal phalanx of the third finger, and the midshaft of the tibia. The speed of sound was higher at all three locations in the nondiabetic women, compared with the diabetic women (see box), the investigators reported online in the Journal of Clinical Endocrine Metabolism (2008 Mar. 4 [doi:10.1210/jc.2007–1760]).

Among the nondiabetic women, BMD at each site correlated significantly with the speed of sound measurements. But among the diabetic women, only the speed of sound at the phalangeal site correlated significantly with all three BMD values; the speed of sound in the tibia correlated with none of the BMD values, and the speed of sound in the radius correlated with only the BMD of the femoral neck.

ELSEVIER GLOBAL MEDICAL NEWS

Ultrasound findings from a cross-sectional study of 162 postmenopausal women might help explain the paradox that women with type 2 diabetes can have higher bone mineral density than nondiabetic women and yet have a greater risk of fractures.

The study confirmed previous reports that bone mineral density (BMD) as measured by dual x-ray absorptiometry (DXA) is higher in women with type 2 diabetes than in women without diabetes. Yet a new diagnostic tool, quantitative ultrasound, revealed that the speed of sound through bone was lower in diabetic women. This may indicate that their denser bone is in some way of lesser quality, compared with the bone of women without type 2 diabetes.

The findings suggest that quantitative ultrasound is a useful tool in detecting impaired bone quality in postmenopausal women with type 2 diabetes, and that it might have greater promise than DXA in detecting bone defects in diabetic patients, the authors wrote.

Dr. Bei Tao of Shanghai (China) Jiao-tong University School of Medicine and colleagues enrolled 76 postmenopausal women with type 2 diabetes and 86 nondiabetic postmenopausal women. In the diabetic women, mean BMD as measured by DXA was 1.06 g/m

Quantitative ultrasound was used to assess the axial speed of sound along the distal third of the radius, the proximal phalanx of the third finger, and the midshaft of the tibia. The speed of sound was higher at all three locations in the nondiabetic women, compared with the diabetic women (see box), the investigators reported online in the Journal of Clinical Endocrine Metabolism (2008 Mar. 4 [doi:10.1210/jc.2007–1760]).

Among the nondiabetic women, BMD at each site correlated significantly with the speed of sound measurements. But among the diabetic women, only the speed of sound at the phalangeal site correlated significantly with all three BMD values; the speed of sound in the tibia correlated with none of the BMD values, and the speed of sound in the radius correlated with only the BMD of the femoral neck.

ELSEVIER GLOBAL MEDICAL NEWS

Ultrasound findings from a cross-sectional study of 162 postmenopausal women might help explain the paradox that women with type 2 diabetes can have higher bone mineral density than nondiabetic women and yet have a greater risk of fractures.

The study confirmed previous reports that bone mineral density (BMD) as measured by dual x-ray absorptiometry (DXA) is higher in women with type 2 diabetes than in women without diabetes. Yet a new diagnostic tool, quantitative ultrasound, revealed that the speed of sound through bone was lower in diabetic women. This may indicate that their denser bone is in some way of lesser quality, compared with the bone of women without type 2 diabetes.

The findings suggest that quantitative ultrasound is a useful tool in detecting impaired bone quality in postmenopausal women with type 2 diabetes, and that it might have greater promise than DXA in detecting bone defects in diabetic patients, the authors wrote.

Dr. Bei Tao of Shanghai (China) Jiao-tong University School of Medicine and colleagues enrolled 76 postmenopausal women with type 2 diabetes and 86 nondiabetic postmenopausal women. In the diabetic women, mean BMD as measured by DXA was 1.06 g/m

Quantitative ultrasound was used to assess the axial speed of sound along the distal third of the radius, the proximal phalanx of the third finger, and the midshaft of the tibia. The speed of sound was higher at all three locations in the nondiabetic women, compared with the diabetic women (see box), the investigators reported online in the Journal of Clinical Endocrine Metabolism (2008 Mar. 4 [doi:10.1210/jc.2007–1760]).

Among the nondiabetic women, BMD at each site correlated significantly with the speed of sound measurements. But among the diabetic women, only the speed of sound at the phalangeal site correlated significantly with all three BMD values; the speed of sound in the tibia correlated with none of the BMD values, and the speed of sound in the radius correlated with only the BMD of the femoral neck.

ELSEVIER GLOBAL MEDICAL NEWS

SAN ANTONIO — Methotrexate appears to be a safe and effective long-term systemic therapy for pediatric atopic dermatitis, according to a poster presented at the annual meeting of the American Academy of Dermatology.

A systemic therapy for this most common of childhood dermatologic conditions has long been needed, noted Dr. Christopher Rouse of St. Louis University, who disclosed no potential conflicts of interest.

Other therapies have been studied, but none has received approval from the Food and Drug Administration for atopic dermatitis (AD). Meanwhile, methotrexate has been used since 1959 for pediatric conditions including rheumatoid arthritis, Crohn's disease, and psoriasis.

Dr. Rouse reviewed the cases of 26 children (14 boys and 12 girls) with severe AD, all of whom had been previously treated with other therapies. Each patient was given 0.5 mg/kg of methotrexate, to a maximum of 15 mg/week, as well as 0.5–1 mg/day of folic acid on days when methotrexate was not taken.

Each patient was seen monthly for 3 months and every 3 months thereafter and given kidney and liver function tests. The mean age at onset of AD was 9 years. The mean starting dose was 0.49 mg/kg per week; the mean maximum dose was 0.55 mg/kg per week. The mean duration on methotrexate was 9.4 months.

In 50% of the patients, the AD was well controlled on methotrexate alone. In 25%, the disease was controlled but not clear, requiring the addition of topical steroids. In 20% of patients, the AD was controlled with flares. Two children experienced no improvement in their disease, he reported.

Adverse events included transient elevated liver enzymes in seven patients and gastrointestinal symptoms in seven patients. Five children had staphylococcus-associated skin eruptions, two children had pneumonia, and two had urticaria.

Dr. Rouse cautioned that his retrospective study involved a small number of patients and that there was no standardized method of assessing improvement, but he was sanguine about the implications for pediatric AD. Methotrexate tablets are safer and more readily available than liquid methotrexate and are small enough for children to take without difficulty. Moreover, the tablets obviate the risk that a pharmacy will compound the liquid formulation improperly, he noted. Response might take 2–3 months of treatment.

In a separate presentation, Dr. Alice Gottlieb, professor and chair of dermatology at Tufts University, Boston, noted that care must be taken not to give significant doses of methotrexate with amoxicillin, because the toxicity of this combination is largely unknown in primary care. The combination of methotrexate and Bactrim (trimethoprim-sulfamethoxazole) is also toxic, she said.

In a previously published open-label study of 20 patients, investigators found that methotrexate was safe and effective for adults with atopic dermatitis, although two of those patients discontinued the drug because of nausea and/or elevated liver enzymes (Eur. J. Dermatol. 2006;16:155–8).

Care must be taken not togive large doses of methotrexatewith amoxicillin because of unknown toxicity. DR. GOTTLIEB

SAN ANTONIO — Methotrexate appears to be a safe and effective long-term systemic therapy for pediatric atopic dermatitis, according to a poster presented at the annual meeting of the American Academy of Dermatology.

A systemic therapy for this most common of childhood dermatologic conditions has long been needed, noted Dr. Christopher Rouse of St. Louis University, who disclosed no potential conflicts of interest.

Other therapies have been studied, but none has received approval from the Food and Drug Administration for atopic dermatitis (AD). Meanwhile, methotrexate has been used since 1959 for pediatric conditions including rheumatoid arthritis, Crohn's disease, and psoriasis.

Dr. Rouse reviewed the cases of 26 children (14 boys and 12 girls) with severe AD, all of whom had been previously treated with other therapies. Each patient was given 0.5 mg/kg of methotrexate, to a maximum of 15 mg/week, as well as 0.5–1 mg/day of folic acid on days when methotrexate was not taken.

Each patient was seen monthly for 3 months and every 3 months thereafter and given kidney and liver function tests. The mean age at onset of AD was 9 years. The mean starting dose was 0.49 mg/kg per week; the mean maximum dose was 0.55 mg/kg per week. The mean duration on methotrexate was 9.4 months.

In 50% of the patients, the AD was well controlled on methotrexate alone. In 25%, the disease was controlled but not clear, requiring the addition of topical steroids. In 20% of patients, the AD was controlled with flares. Two children experienced no improvement in their disease, he reported.

Adverse events included transient elevated liver enzymes in seven patients and gastrointestinal symptoms in seven patients. Five children had staphylococcus-associated skin eruptions, two children had pneumonia, and two had urticaria.

Dr. Rouse cautioned that his retrospective study involved a small number of patients and that there was no standardized method of assessing improvement, but he was sanguine about the implications for pediatric AD. Methotrexate tablets are safer and more readily available than liquid methotrexate and are small enough for children to take without difficulty. Moreover, the tablets obviate the risk that a pharmacy will compound the liquid formulation improperly, he noted. Response might take 2–3 months of treatment.

In a separate presentation, Dr. Alice Gottlieb, professor and chair of dermatology at Tufts University, Boston, noted that care must be taken not to give significant doses of methotrexate with amoxicillin, because the toxicity of this combination is largely unknown in primary care. The combination of methotrexate and Bactrim (trimethoprim-sulfamethoxazole) is also toxic, she said.

In a previously published open-label study of 20 patients, investigators found that methotrexate was safe and effective for adults with atopic dermatitis, although two of those patients discontinued the drug because of nausea and/or elevated liver enzymes (Eur. J. Dermatol. 2006;16:155–8).

Care must be taken not togive large doses of methotrexatewith amoxicillin because of unknown toxicity. DR. GOTTLIEB

SAN ANTONIO — Methotrexate appears to be a safe and effective long-term systemic therapy for pediatric atopic dermatitis, according to a poster presented at the annual meeting of the American Academy of Dermatology.

A systemic therapy for this most common of childhood dermatologic conditions has long been needed, noted Dr. Christopher Rouse of St. Louis University, who disclosed no potential conflicts of interest.

Other therapies have been studied, but none has received approval from the Food and Drug Administration for atopic dermatitis (AD). Meanwhile, methotrexate has been used since 1959 for pediatric conditions including rheumatoid arthritis, Crohn's disease, and psoriasis.

Dr. Rouse reviewed the cases of 26 children (14 boys and 12 girls) with severe AD, all of whom had been previously treated with other therapies. Each patient was given 0.5 mg/kg of methotrexate, to a maximum of 15 mg/week, as well as 0.5–1 mg/day of folic acid on days when methotrexate was not taken.

Each patient was seen monthly for 3 months and every 3 months thereafter and given kidney and liver function tests. The mean age at onset of AD was 9 years. The mean starting dose was 0.49 mg/kg per week; the mean maximum dose was 0.55 mg/kg per week. The mean duration on methotrexate was 9.4 months.

In 50% of the patients, the AD was well controlled on methotrexate alone. In 25%, the disease was controlled but not clear, requiring the addition of topical steroids. In 20% of patients, the AD was controlled with flares. Two children experienced no improvement in their disease, he reported.

Adverse events included transient elevated liver enzymes in seven patients and gastrointestinal symptoms in seven patients. Five children had staphylococcus-associated skin eruptions, two children had pneumonia, and two had urticaria.

Dr. Rouse cautioned that his retrospective study involved a small number of patients and that there was no standardized method of assessing improvement, but he was sanguine about the implications for pediatric AD. Methotrexate tablets are safer and more readily available than liquid methotrexate and are small enough for children to take without difficulty. Moreover, the tablets obviate the risk that a pharmacy will compound the liquid formulation improperly, he noted. Response might take 2–3 months of treatment.

In a separate presentation, Dr. Alice Gottlieb, professor and chair of dermatology at Tufts University, Boston, noted that care must be taken not to give significant doses of methotrexate with amoxicillin, because the toxicity of this combination is largely unknown in primary care. The combination of methotrexate and Bactrim (trimethoprim-sulfamethoxazole) is also toxic, she said.

In a previously published open-label study of 20 patients, investigators found that methotrexate was safe and effective for adults with atopic dermatitis, although two of those patients discontinued the drug because of nausea and/or elevated liver enzymes (Eur. J. Dermatol. 2006;16:155–8).

Care must be taken not togive large doses of methotrexatewith amoxicillin because of unknown toxicity. DR. GOTTLIEB

Newer-generation hypertension drugs were no better than thiazide-type diuretics at preventing heart failure and cardiovascular disease events in hypertensive patients with metabolic syndrome, and in some cases they were worse, according to findings from a subgroup analysis.

These recent findings from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), suggest that results reported earlier for the cohort overall also hold true for the subset of patients with metabolic syndrome: Despite the fact that the newer agents have a more favorable metabolic profile, the evidence fails to support their use as first-line therapy. In black patients with metabolic syndrome, in particular, the angiotensin-converting enzyme (ACE) inhibitor lisinopril was associated with higher stroke and end-stage renal disease risks and should not be considered as first-line.

Dr. Jackson T. Wright Jr. of Case Western Reserve University, Cleveland, and colleagues compared rates of adverse events among the 37,291 male and female ALLHAT participants with metabolic or cardiometabolic syndrome who were at least aged 55 years and who were randomly assigned to take the calcium-channel blocker amlodipine (Norvasc) (7,945 patients), the β-blocker doxazosin (Cardura) (7,928 patients), the ACE inhibitor lisinopril (Prinivil, Zestril) (7,948 patients), or the thiazide-type diuretic chlorthalidone (13,470 patients).

All of the patients, regardless of race, showed greater risk of heart failure with all three of the newer drugs than with chlorthalidone. For black patients, the relative risks of HF with amlodipine, lisinopril, and doxazosin were 1.5, 1.49, and 1.88, respectively, compared with chlorthalidone; for nonblack patients, the RRs were 1.5, 1.20, and 1.82 (Arch. Intern. Med. 2008;168:207–17).

Regarding combined cardiovascular disease end points (including heart disease, stroke, other treated angina, any heart failure, or peripheral arterial disease), compared with chlorthalidone, lisinopril and doxazosin were both associated with greater risk rates among black patients (RR 1.24 and 1.37, respectively) and nonblack patients (RR 1.10 and 1.18).

A higher risk for stroke was seen only among black patients taking lisinopril (RR 1.37) or doxazosin (RR 1.49). Lisinopril also conferred a higher risk of end-stage renal disease among black patients (RR 1.7).

The investigators used the National Cholesterol Education Program definition of metabolic syndrome but replaced waist circumference with body mass index. Mean follow-up was about 5 years for all comparisons except that of β-blockers with chlorthalidone, which was roughly 3 years.

The authors' strongest statement was regarding the use of ACE inhibitors in black patients: “The magnitude of the excess risk of [end-stage renal disease] (70%), heart failure (49%), and stroke (37%) and the increased risk of combined CVD and combined CHD strongly argue against the preference of ACE inhibitors over diuretics as the initial therapy in black patients with [metabolic syndrome],” Dr. Wright and colleagues wrote.

They acknowledged that a criticism of the previous ALLHAT findings was that the follow-up was too short for the metabolic benefits of the newer drugs to translate into reductions in the risk for the adverse events. However, until long-term data are available, they predicted no change to the outcome of that study or the subanalysis, given the small metabolic changes seen with the drugs in question and that drug-induced increases in blood glucose do not carry the same risk for adverse clinical outcomes as other factors, such as sedentary lifestyle.

ALLHAT was funded by the National Institutes of Health and by Pfizer Inc. Individual authors disclosed financial support from multiple industry sources.

Newer-generation hypertension drugs were no better than thiazide-type diuretics at preventing heart failure and cardiovascular disease events in hypertensive patients with metabolic syndrome, and in some cases they were worse, according to findings from a subgroup analysis.

These recent findings from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), suggest that results reported earlier for the cohort overall also hold true for the subset of patients with metabolic syndrome: Despite the fact that the newer agents have a more favorable metabolic profile, the evidence fails to support their use as first-line therapy. In black patients with metabolic syndrome, in particular, the angiotensin-converting enzyme (ACE) inhibitor lisinopril was associated with higher stroke and end-stage renal disease risks and should not be considered as first-line.

Dr. Jackson T. Wright Jr. of Case Western Reserve University, Cleveland, and colleagues compared rates of adverse events among the 37,291 male and female ALLHAT participants with metabolic or cardiometabolic syndrome who were at least aged 55 years and who were randomly assigned to take the calcium-channel blocker amlodipine (Norvasc) (7,945 patients), the β-blocker doxazosin (Cardura) (7,928 patients), the ACE inhibitor lisinopril (Prinivil, Zestril) (7,948 patients), or the thiazide-type diuretic chlorthalidone (13,470 patients).

All of the patients, regardless of race, showed greater risk of heart failure with all three of the newer drugs than with chlorthalidone. For black patients, the relative risks of HF with amlodipine, lisinopril, and doxazosin were 1.5, 1.49, and 1.88, respectively, compared with chlorthalidone; for nonblack patients, the RRs were 1.5, 1.20, and 1.82 (Arch. Intern. Med. 2008;168:207–17).

Regarding combined cardiovascular disease end points (including heart disease, stroke, other treated angina, any heart failure, or peripheral arterial disease), compared with chlorthalidone, lisinopril and doxazosin were both associated with greater risk rates among black patients (RR 1.24 and 1.37, respectively) and nonblack patients (RR 1.10 and 1.18).

A higher risk for stroke was seen only among black patients taking lisinopril (RR 1.37) or doxazosin (RR 1.49). Lisinopril also conferred a higher risk of end-stage renal disease among black patients (RR 1.7).

The investigators used the National Cholesterol Education Program definition of metabolic syndrome but replaced waist circumference with body mass index. Mean follow-up was about 5 years for all comparisons except that of β-blockers with chlorthalidone, which was roughly 3 years.

The authors' strongest statement was regarding the use of ACE inhibitors in black patients: “The magnitude of the excess risk of [end-stage renal disease] (70%), heart failure (49%), and stroke (37%) and the increased risk of combined CVD and combined CHD strongly argue against the preference of ACE inhibitors over diuretics as the initial therapy in black patients with [metabolic syndrome],” Dr. Wright and colleagues wrote.

They acknowledged that a criticism of the previous ALLHAT findings was that the follow-up was too short for the metabolic benefits of the newer drugs to translate into reductions in the risk for the adverse events. However, until long-term data are available, they predicted no change to the outcome of that study or the subanalysis, given the small metabolic changes seen with the drugs in question and that drug-induced increases in blood glucose do not carry the same risk for adverse clinical outcomes as other factors, such as sedentary lifestyle.

ALLHAT was funded by the National Institutes of Health and by Pfizer Inc. Individual authors disclosed financial support from multiple industry sources.

Newer-generation hypertension drugs were no better than thiazide-type diuretics at preventing heart failure and cardiovascular disease events in hypertensive patients with metabolic syndrome, and in some cases they were worse, according to findings from a subgroup analysis.

These recent findings from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), suggest that results reported earlier for the cohort overall also hold true for the subset of patients with metabolic syndrome: Despite the fact that the newer agents have a more favorable metabolic profile, the evidence fails to support their use as first-line therapy. In black patients with metabolic syndrome, in particular, the angiotensin-converting enzyme (ACE) inhibitor lisinopril was associated with higher stroke and end-stage renal disease risks and should not be considered as first-line.

Dr. Jackson T. Wright Jr. of Case Western Reserve University, Cleveland, and colleagues compared rates of adverse events among the 37,291 male and female ALLHAT participants with metabolic or cardiometabolic syndrome who were at least aged 55 years and who were randomly assigned to take the calcium-channel blocker amlodipine (Norvasc) (7,945 patients), the β-blocker doxazosin (Cardura) (7,928 patients), the ACE inhibitor lisinopril (Prinivil, Zestril) (7,948 patients), or the thiazide-type diuretic chlorthalidone (13,470 patients).

All of the patients, regardless of race, showed greater risk of heart failure with all three of the newer drugs than with chlorthalidone. For black patients, the relative risks of HF with amlodipine, lisinopril, and doxazosin were 1.5, 1.49, and 1.88, respectively, compared with chlorthalidone; for nonblack patients, the RRs were 1.5, 1.20, and 1.82 (Arch. Intern. Med. 2008;168:207–17).

Regarding combined cardiovascular disease end points (including heart disease, stroke, other treated angina, any heart failure, or peripheral arterial disease), compared with chlorthalidone, lisinopril and doxazosin were both associated with greater risk rates among black patients (RR 1.24 and 1.37, respectively) and nonblack patients (RR 1.10 and 1.18).

A higher risk for stroke was seen only among black patients taking lisinopril (RR 1.37) or doxazosin (RR 1.49). Lisinopril also conferred a higher risk of end-stage renal disease among black patients (RR 1.7).

The investigators used the National Cholesterol Education Program definition of metabolic syndrome but replaced waist circumference with body mass index. Mean follow-up was about 5 years for all comparisons except that of β-blockers with chlorthalidone, which was roughly 3 years.

The authors' strongest statement was regarding the use of ACE inhibitors in black patients: “The magnitude of the excess risk of [end-stage renal disease] (70%), heart failure (49%), and stroke (37%) and the increased risk of combined CVD and combined CHD strongly argue against the preference of ACE inhibitors over diuretics as the initial therapy in black patients with [metabolic syndrome],” Dr. Wright and colleagues wrote.

They acknowledged that a criticism of the previous ALLHAT findings was that the follow-up was too short for the metabolic benefits of the newer drugs to translate into reductions in the risk for the adverse events. However, until long-term data are available, they predicted no change to the outcome of that study or the subanalysis, given the small metabolic changes seen with the drugs in question and that drug-induced increases in blood glucose do not carry the same risk for adverse clinical outcomes as other factors, such as sedentary lifestyle.

ALLHAT was funded by the National Institutes of Health and by Pfizer Inc. Individual authors disclosed financial support from multiple industry sources.

NEW YORK — Subclinical hypothyroidism with a thyroid-stimulating hormone level of 10–20 mU/L was associated with an almost twofold risk of clinical heart failure in a study of more than 3,000 older adults.

The findings, presented by Dr. Douglas Bauer at the annual meeting of the American Thyroid Association, come from an analysis of participants in the prospective Cardiovascular Health Study, which includes persons from Medicare population-based listings at four university hospitals in the United States and is funded by the National Institutes of Health.

Dr. Bauer and his colleagues recruited 3,065 participants who were free of heart failure at baseline and not taking any medication known to affect thyroid function. Any participants who initiated T4 replacement during the study were removed from the analysis, and 21 were excluded because of insufficient serum for testing. Participants were followed for 12 years and were contacted every 6 months for assessment of outcomes, said Dr. Bauer of the University of California, San Francisco.

Of the 495 persons (16%) with hypothyroidism, 448 had a TSH level between 4.5 mU/L and 9.9 mU/L and 47 had a TSH level of 10–20 mU/L. Hyperthyroidism (TSH level below 0.45 mU/L and normal T4 value) was found in 44 persons. All hypothyroidism and hyperthyroidism in the study was subclinical.

Echocardiograms were obtained for all participants at baseline and at 5 years' follow-up and read by blinded clinicians (including cardiologists). Some participants experienced heart failure before the 5-year follow-up, and their clinical echocardiograms were also included.

At 12 years' follow-up, 660 persons (22%) had heart failure. In the 47 participants with a TSH level of 10–20 mU/L, there were 45 heart failure events per 1,000 person-years, compared with 22 events per 1,000 person-years in euthyroid participants. Multivariate analysis showed an unadjusted hazard ratio of 2.03 for those with a TSH level of 10–20 mU/L, versus euthyroid participants—a significant difference. (Adjusted for confounding factors, the hazard ratio was 1.88.) No increase in heart failure risk was seen in the hypothyroid participants with TSH levels of 4.5–9.9 mU/L or in euthyroid persons, versus those with TSH levels below that range. There was no difference in the heart failure rate between men and women.

Moreover, at 12 years, impaired cardiac function was associated with TSH levels of 10–20 mU/L: The percentage of participants who had an abnormal left ventricular ejection fraction at time of incident heart failure was 80% in the high-TSH hypothyroid group, compared with 39% in the lower-TSH hypothyroid group, 44% in the euthyroid group, and 33% in the hyperthyroid group.

Dr. Bauer and colleagues concluded that “subclinical hypothyroidism is associated with a moderately increased risk of clinical events of congestive heart failure among older individuals with a TSH greater than 10 [mU/L].”

He acknowledged that the study was limited by a shorter follow-up period for the echocardiography data than for the heart failure data (5 years vs. 12 years), as well as missing follow-up echocardiograms for some participants.

Several studies have established an association between subclinical hypothyroid and hyperthyroid disease and cardiac dysfunction, Dr. Bauer said. But most studies have looked at subtle abnormalities in contractility, rather than at more clinically important measures, such as left ventricular ejection fraction. Also, most of those studies have been limited by small sample sizes and lack of randomization.

NEW YORK — Subclinical hypothyroidism with a thyroid-stimulating hormone level of 10–20 mU/L was associated with an almost twofold risk of clinical heart failure in a study of more than 3,000 older adults.

The findings, presented by Dr. Douglas Bauer at the annual meeting of the American Thyroid Association, come from an analysis of participants in the prospective Cardiovascular Health Study, which includes persons from Medicare population-based listings at four university hospitals in the United States and is funded by the National Institutes of Health.

Dr. Bauer and his colleagues recruited 3,065 participants who were free of heart failure at baseline and not taking any medication known to affect thyroid function. Any participants who initiated T4 replacement during the study were removed from the analysis, and 21 were excluded because of insufficient serum for testing. Participants were followed for 12 years and were contacted every 6 months for assessment of outcomes, said Dr. Bauer of the University of California, San Francisco.

Of the 495 persons (16%) with hypothyroidism, 448 had a TSH level between 4.5 mU/L and 9.9 mU/L and 47 had a TSH level of 10–20 mU/L. Hyperthyroidism (TSH level below 0.45 mU/L and normal T4 value) was found in 44 persons. All hypothyroidism and hyperthyroidism in the study was subclinical.

Echocardiograms were obtained for all participants at baseline and at 5 years' follow-up and read by blinded clinicians (including cardiologists). Some participants experienced heart failure before the 5-year follow-up, and their clinical echocardiograms were also included.

At 12 years' follow-up, 660 persons (22%) had heart failure. In the 47 participants with a TSH level of 10–20 mU/L, there were 45 heart failure events per 1,000 person-years, compared with 22 events per 1,000 person-years in euthyroid participants. Multivariate analysis showed an unadjusted hazard ratio of 2.03 for those with a TSH level of 10–20 mU/L, versus euthyroid participants—a significant difference. (Adjusted for confounding factors, the hazard ratio was 1.88.) No increase in heart failure risk was seen in the hypothyroid participants with TSH levels of 4.5–9.9 mU/L or in euthyroid persons, versus those with TSH levels below that range. There was no difference in the heart failure rate between men and women.

Moreover, at 12 years, impaired cardiac function was associated with TSH levels of 10–20 mU/L: The percentage of participants who had an abnormal left ventricular ejection fraction at time of incident heart failure was 80% in the high-TSH hypothyroid group, compared with 39% in the lower-TSH hypothyroid group, 44% in the euthyroid group, and 33% in the hyperthyroid group.

Dr. Bauer and colleagues concluded that “subclinical hypothyroidism is associated with a moderately increased risk of clinical events of congestive heart failure among older individuals with a TSH greater than 10 [mU/L].”

He acknowledged that the study was limited by a shorter follow-up period for the echocardiography data than for the heart failure data (5 years vs. 12 years), as well as missing follow-up echocardiograms for some participants.

Several studies have established an association between subclinical hypothyroid and hyperthyroid disease and cardiac dysfunction, Dr. Bauer said. But most studies have looked at subtle abnormalities in contractility, rather than at more clinically important measures, such as left ventricular ejection fraction. Also, most of those studies have been limited by small sample sizes and lack of randomization.

NEW YORK — Subclinical hypothyroidism with a thyroid-stimulating hormone level of 10–20 mU/L was associated with an almost twofold risk of clinical heart failure in a study of more than 3,000 older adults.

The findings, presented by Dr. Douglas Bauer at the annual meeting of the American Thyroid Association, come from an analysis of participants in the prospective Cardiovascular Health Study, which includes persons from Medicare population-based listings at four university hospitals in the United States and is funded by the National Institutes of Health.

Dr. Bauer and his colleagues recruited 3,065 participants who were free of heart failure at baseline and not taking any medication known to affect thyroid function. Any participants who initiated T4 replacement during the study were removed from the analysis, and 21 were excluded because of insufficient serum for testing. Participants were followed for 12 years and were contacted every 6 months for assessment of outcomes, said Dr. Bauer of the University of California, San Francisco.

Of the 495 persons (16%) with hypothyroidism, 448 had a TSH level between 4.5 mU/L and 9.9 mU/L and 47 had a TSH level of 10–20 mU/L. Hyperthyroidism (TSH level below 0.45 mU/L and normal T4 value) was found in 44 persons. All hypothyroidism and hyperthyroidism in the study was subclinical.

Echocardiograms were obtained for all participants at baseline and at 5 years' follow-up and read by blinded clinicians (including cardiologists). Some participants experienced heart failure before the 5-year follow-up, and their clinical echocardiograms were also included.

At 12 years' follow-up, 660 persons (22%) had heart failure. In the 47 participants with a TSH level of 10–20 mU/L, there were 45 heart failure events per 1,000 person-years, compared with 22 events per 1,000 person-years in euthyroid participants. Multivariate analysis showed an unadjusted hazard ratio of 2.03 for those with a TSH level of 10–20 mU/L, versus euthyroid participants—a significant difference. (Adjusted for confounding factors, the hazard ratio was 1.88.) No increase in heart failure risk was seen in the hypothyroid participants with TSH levels of 4.5–9.9 mU/L or in euthyroid persons, versus those with TSH levels below that range. There was no difference in the heart failure rate between men and women.

Moreover, at 12 years, impaired cardiac function was associated with TSH levels of 10–20 mU/L: The percentage of participants who had an abnormal left ventricular ejection fraction at time of incident heart failure was 80% in the high-TSH hypothyroid group, compared with 39% in the lower-TSH hypothyroid group, 44% in the euthyroid group, and 33% in the hyperthyroid group.

Dr. Bauer and colleagues concluded that “subclinical hypothyroidism is associated with a moderately increased risk of clinical events of congestive heart failure among older individuals with a TSH greater than 10 [mU/L].”

He acknowledged that the study was limited by a shorter follow-up period for the echocardiography data than for the heart failure data (5 years vs. 12 years), as well as missing follow-up echocardiograms for some participants.

Several studies have established an association between subclinical hypothyroid and hyperthyroid disease and cardiac dysfunction, Dr. Bauer said. But most studies have looked at subtle abnormalities in contractility, rather than at more clinically important measures, such as left ventricular ejection fraction. Also, most of those studies have been limited by small sample sizes and lack of randomization.

An outbreak of norovirus in a District of Columbia elementary school last year was probably transmitted by unclean computer mouses and keyboards.

The Centers for Disease Control and Prevention was notified after 27 students and two staff members experienced symptoms of gastroenteritis (defined as nausea, vomiting, or diarrhea) within a 4-day period.

After inspecting the classrooms, CDC staff administered questionnaires to all staff and students. Results showed that students assigned to one particular first-grade classroom had almost double the risk of gastroenteritis during the 4-day period (relative risk 1.94). The affected classroom was the one that housed the school's computers, which were shared by students and staff. Foodborne illness was ruled out because no food was served at the school (MMWR 2008;56:1340–3).

Environmental samples taken from a computer mouse and keyboard contained norovirus subtype GII. This strain also was found in stool samples from two persons who had been on the site.

At the CDC's urging, the school cleaned all shared computer surfaces with a bleach solution, and all students and staff were restricted from the school until 72 hours after resolution of their illness to avoid recontamination.

In a commentary, the CDC noted that prior research has shown that norovirus can be transmitted to fomites and that a surrogate marker for norovirus, feline calcivirus, has been shown to survive on computer mouses and keyboards for up to 2 days.

An outbreak of norovirus in a District of Columbia elementary school last year was probably transmitted by unclean computer mouses and keyboards.

The Centers for Disease Control and Prevention was notified after 27 students and two staff members experienced symptoms of gastroenteritis (defined as nausea, vomiting, or diarrhea) within a 4-day period.

After inspecting the classrooms, CDC staff administered questionnaires to all staff and students. Results showed that students assigned to one particular first-grade classroom had almost double the risk of gastroenteritis during the 4-day period (relative risk 1.94). The affected classroom was the one that housed the school's computers, which were shared by students and staff. Foodborne illness was ruled out because no food was served at the school (MMWR 2008;56:1340–3).

Environmental samples taken from a computer mouse and keyboard contained norovirus subtype GII. This strain also was found in stool samples from two persons who had been on the site.

At the CDC's urging, the school cleaned all shared computer surfaces with a bleach solution, and all students and staff were restricted from the school until 72 hours after resolution of their illness to avoid recontamination.

In a commentary, the CDC noted that prior research has shown that norovirus can be transmitted to fomites and that a surrogate marker for norovirus, feline calcivirus, has been shown to survive on computer mouses and keyboards for up to 2 days.

An outbreak of norovirus in a District of Columbia elementary school last year was probably transmitted by unclean computer mouses and keyboards.

The Centers for Disease Control and Prevention was notified after 27 students and two staff members experienced symptoms of gastroenteritis (defined as nausea, vomiting, or diarrhea) within a 4-day period.

After inspecting the classrooms, CDC staff administered questionnaires to all staff and students. Results showed that students assigned to one particular first-grade classroom had almost double the risk of gastroenteritis during the 4-day period (relative risk 1.94). The affected classroom was the one that housed the school's computers, which were shared by students and staff. Foodborne illness was ruled out because no food was served at the school (MMWR 2008;56:1340–3).

Environmental samples taken from a computer mouse and keyboard contained norovirus subtype GII. This strain also was found in stool samples from two persons who had been on the site.

At the CDC's urging, the school cleaned all shared computer surfaces with a bleach solution, and all students and staff were restricted from the school until 72 hours after resolution of their illness to avoid recontamination.

In a commentary, the CDC noted that prior research has shown that norovirus can be transmitted to fomites and that a surrogate marker for norovirus, feline calcivirus, has been shown to survive on computer mouses and keyboards for up to 2 days.

An outbreak of norovirus in a District of Columbia elementary school last year was probably transmitted by unclean computer mice and keyboards.

The Centers for Disease Control and Prevention was notified after 27 students and two staff members experienced symptoms of gastroenteritis (defined as nausea, vomiting, or diarrhea) within a 4-day period.

After inspecting the classrooms, CDC staff administered questionnaires to all staff and students. Results showed that students assigned to one particular first-grade classroom had almost double the risk of gastroenteritis during the 4-day period (relative risk 1.94). The affected classroom was the one that housed the school's computers, which were shared by students and staff. Foodborne illness was ruled out because no food was served at the school (MMWR 2008;56:1340–3).

Environmental samples taken from a computer mouse and keyboard contained norovirus subtype GII. This strain also was found in stool samples from two persons who had been on the site.

At the CDC's urging, the school cleaned all shared computer surfaces with a bleach solution, and all students and staff were restricted from the school until 72 hours after resolution of their illness to avoid recontamination.

In a commentary, the CDC noted that prior research has shown that norovirus can be transmitted to fomites and that a surrogate marker for norovirus, feline calcivirus, has been shown to survive on computer mice and keyboards for up to 2 days.

An outbreak of norovirus in a District of Columbia elementary school last year was probably transmitted by unclean computer mice and keyboards.

The Centers for Disease Control and Prevention was notified after 27 students and two staff members experienced symptoms of gastroenteritis (defined as nausea, vomiting, or diarrhea) within a 4-day period.

After inspecting the classrooms, CDC staff administered questionnaires to all staff and students. Results showed that students assigned to one particular first-grade classroom had almost double the risk of gastroenteritis during the 4-day period (relative risk 1.94). The affected classroom was the one that housed the school's computers, which were shared by students and staff. Foodborne illness was ruled out because no food was served at the school (MMWR 2008;56:1340–3).

Environmental samples taken from a computer mouse and keyboard contained norovirus subtype GII. This strain also was found in stool samples from two persons who had been on the site.

At the CDC's urging, the school cleaned all shared computer surfaces with a bleach solution, and all students and staff were restricted from the school until 72 hours after resolution of their illness to avoid recontamination.

In a commentary, the CDC noted that prior research has shown that norovirus can be transmitted to fomites and that a surrogate marker for norovirus, feline calcivirus, has been shown to survive on computer mice and keyboards for up to 2 days.

An outbreak of norovirus in a District of Columbia elementary school last year was probably transmitted by unclean computer mice and keyboards.

The Centers for Disease Control and Prevention was notified after 27 students and two staff members experienced symptoms of gastroenteritis (defined as nausea, vomiting, or diarrhea) within a 4-day period.

After inspecting the classrooms, CDC staff administered questionnaires to all staff and students. Results showed that students assigned to one particular first-grade classroom had almost double the risk of gastroenteritis during the 4-day period (relative risk 1.94). The affected classroom was the one that housed the school's computers, which were shared by students and staff. Foodborne illness was ruled out because no food was served at the school (MMWR 2008;56:1340–3).

Environmental samples taken from a computer mouse and keyboard contained norovirus subtype GII. This strain also was found in stool samples from two persons who had been on the site.

At the CDC's urging, the school cleaned all shared computer surfaces with a bleach solution, and all students and staff were restricted from the school until 72 hours after resolution of their illness to avoid recontamination.

In a commentary, the CDC noted that prior research has shown that norovirus can be transmitted to fomites and that a surrogate marker for norovirus, feline calcivirus, has been shown to survive on computer mice and keyboards for up to 2 days.