Melinda Tanzola

Exercise-induced weight loss does not lead to declines in bone mineral density at fracture-relevant sites after 12 months, but weight through calorie restriction does, according to a randomized, controlled trial of 48 adults.

Regional BMD at the total hip and at the intertrochanter decreased significantly more with calorie restriction than they did without in a control group. BMD did not change significantly with exercise, compared with controls, study investigators reported.

The researchers randomized 48 nonobese but mostly overweight adults aged 50–60 years to three groups. The 19 subjects in the calorie restriction group decreased energy intake by 16% during the first 3 months and by 20% during the subsequent 9 months. The 19 subjects in the exercise group decreased overall energy intake by the same amount through exercise; they exercised a mean of 5.8 times per week for 62.5 minutes per session. The most common modes of exercise were walking and/or jogging, followed by elliptical training and cycling.

The remaining 10 participants did not change their diet or exercise habits, wrote Dr. Dennis T. Villareal of Washington University, St. Louis, and colleagues (Arch. Intern. Med. 2006;166:2502–10).

Overall, in the calorie restriction group, BMD decreased 2.2% at the lumbar spine, 2.2% in the total hip, and 2.1% in the intertrochanter.

Markers of bone turnover increased significantly in both the calorie-restriction and exercise groups.

Relative reductions in body weight after 1 year were similar with calorie restriction (10.7%) and with exercise (8.4%), whereas the control group did not lose weight (1.2%).

These findings indicate that exercise was associated with weight loss but not loss of BMD, whereas weight loss due to calorie restriction was significantly associated with changes in hip BMD.

The most practical approach to weight loss is a combined regimen of calorie restriction and exercise, the researchers noted.

Exercise-induced weight loss does not lead to declines in bone mineral density at fracture-relevant sites after 12 months, but weight through calorie restriction does, according to a randomized, controlled trial of 48 adults.

Regional BMD at the total hip and at the intertrochanter decreased significantly more with calorie restriction than they did without in a control group. BMD did not change significantly with exercise, compared with controls, study investigators reported.

The researchers randomized 48 nonobese but mostly overweight adults aged 50–60 years to three groups. The 19 subjects in the calorie restriction group decreased energy intake by 16% during the first 3 months and by 20% during the subsequent 9 months. The 19 subjects in the exercise group decreased overall energy intake by the same amount through exercise; they exercised a mean of 5.8 times per week for 62.5 minutes per session. The most common modes of exercise were walking and/or jogging, followed by elliptical training and cycling.

The remaining 10 participants did not change their diet or exercise habits, wrote Dr. Dennis T. Villareal of Washington University, St. Louis, and colleagues (Arch. Intern. Med. 2006;166:2502–10).

Overall, in the calorie restriction group, BMD decreased 2.2% at the lumbar spine, 2.2% in the total hip, and 2.1% in the intertrochanter.

Markers of bone turnover increased significantly in both the calorie-restriction and exercise groups.

Relative reductions in body weight after 1 year were similar with calorie restriction (10.7%) and with exercise (8.4%), whereas the control group did not lose weight (1.2%).

These findings indicate that exercise was associated with weight loss but not loss of BMD, whereas weight loss due to calorie restriction was significantly associated with changes in hip BMD.

The most practical approach to weight loss is a combined regimen of calorie restriction and exercise, the researchers noted.

Exercise-induced weight loss does not lead to declines in bone mineral density at fracture-relevant sites after 12 months, but weight through calorie restriction does, according to a randomized, controlled trial of 48 adults.

Regional BMD at the total hip and at the intertrochanter decreased significantly more with calorie restriction than they did without in a control group. BMD did not change significantly with exercise, compared with controls, study investigators reported.

The researchers randomized 48 nonobese but mostly overweight adults aged 50–60 years to three groups. The 19 subjects in the calorie restriction group decreased energy intake by 16% during the first 3 months and by 20% during the subsequent 9 months. The 19 subjects in the exercise group decreased overall energy intake by the same amount through exercise; they exercised a mean of 5.8 times per week for 62.5 minutes per session. The most common modes of exercise were walking and/or jogging, followed by elliptical training and cycling.

The remaining 10 participants did not change their diet or exercise habits, wrote Dr. Dennis T. Villareal of Washington University, St. Louis, and colleagues (Arch. Intern. Med. 2006;166:2502–10).

Overall, in the calorie restriction group, BMD decreased 2.2% at the lumbar spine, 2.2% in the total hip, and 2.1% in the intertrochanter.

Markers of bone turnover increased significantly in both the calorie-restriction and exercise groups.

Relative reductions in body weight after 1 year were similar with calorie restriction (10.7%) and with exercise (8.4%), whereas the control group did not lose weight (1.2%).

These findings indicate that exercise was associated with weight loss but not loss of BMD, whereas weight loss due to calorie restriction was significantly associated with changes in hip BMD.

The most practical approach to weight loss is a combined regimen of calorie restriction and exercise, the researchers noted.

ATLANTA — Women in perimenopause have unique issues that should be considered when developing a contraceptive plan, Dr. Miriam Zieman said at a conference on contraceptive technology that was sponsored by Contemporary Forums.

Older women are generally less fertile and thus their bodies may be more forgiving in terms of contraceptive efficacy. However, perimenopausal women often still ovulate for several years and thus the potential for pregnancy exists. In fact, the abortion ratio (number of abortions per 1000 live births) is high in women over 40.

To more easily gauge progress through perimenopause, women should keep a menstrual diary of any bleeding or spotting that occurs. “Taking an accurate menstrual history is so important to our diagnosis during these ages,” said Dr. Zieman of Emory University, Atlanta.

Comorbidities, including hypertension, heart disease, and obesity, are more common in older women. These conditions can affect the choice of contraception, because the risks associated with contraception generally increase with age. In general, though, “combination contraceptives can be safely used by lean, healthy, nonsmoking women until menopause,” Dr. Zieman said.

Because women older than 40 are often finished with childbearing, they tend to prefer long-term contraceptive methods. Indeed, data from the Centers for Disease Control and Prevention show that tubal sterilization is the most common contraceptive method in women aged 35–39 and 40–44.

Dr. Zieman suggested that intrauterine devices should be considered more frequently, as they are reversible, less risky than sterilization, and safe for most women. IUDs can also be used in a broader range of women, including those with contraindications to estrogen-containing hormonal contraception. Women with venous thromboembolism, arterial vascular disease, and acute liver disease; women who smoke; and those with migraine are all candidates for the copper IUD, and most can use the levonorgestrel system. For specific information, see the World Health Organization medical eligibility criteria at http://www.who.int/reproductive-health/publications/mec/iuds.html

For women without contraindications, combination oral contraceptives may be a good option, as they provide noncontraceptive benefits, such as improving menorrhagia, reducing vasomotor symptoms, and reducing the risk of endometrial and ovarian cancers.

Progesterone-only pills may be more appropriate choices for women with estrogen-contraindicating comorbidities such as hypertension.

Depot medroxyprogesterone acetate (DMPA) would be another good progestin-only option for perimenopausal women not planning to have more children. Women with hypertension can use DMPA as long as their blood pressure is controlled below 160/100, according to the World Health Organization guidelines.

When using methods that interfere with menstruation, the decision of when to stop contraception because of suspected menopause is arbitrary.

Follicle-stimulating hormone testing is not a reliable indicator of potential fertility in women older than 45 years. Moreover, in women using oral contraception, FSH testing cannot sensitively predict menopause on day 7 of the pill-free interval.

Dr. Zieman suggested that a woman may consider discontinuing oral contraceptives at age 50, while continuing to protect herself from pregnancy, in order to evaluate her menstrual status. Alternatively, she may want to continue them until age 55, at which point she has likely entered menopause.

The safety of continuing oral contraception through that age is not fully understood, and decisions should be made on an individual basis, taking into account how the woman feels about continuing with pills, she said.

Dr. Zieman has received honoraria from or consulted for Ortho, Barr, Berlex, Organon, and Wyeth.

ATLANTA — Women in perimenopause have unique issues that should be considered when developing a contraceptive plan, Dr. Miriam Zieman said at a conference on contraceptive technology that was sponsored by Contemporary Forums.

Older women are generally less fertile and thus their bodies may be more forgiving in terms of contraceptive efficacy. However, perimenopausal women often still ovulate for several years and thus the potential for pregnancy exists. In fact, the abortion ratio (number of abortions per 1000 live births) is high in women over 40.

To more easily gauge progress through perimenopause, women should keep a menstrual diary of any bleeding or spotting that occurs. “Taking an accurate menstrual history is so important to our diagnosis during these ages,” said Dr. Zieman of Emory University, Atlanta.

Comorbidities, including hypertension, heart disease, and obesity, are more common in older women. These conditions can affect the choice of contraception, because the risks associated with contraception generally increase with age. In general, though, “combination contraceptives can be safely used by lean, healthy, nonsmoking women until menopause,” Dr. Zieman said.

Because women older than 40 are often finished with childbearing, they tend to prefer long-term contraceptive methods. Indeed, data from the Centers for Disease Control and Prevention show that tubal sterilization is the most common contraceptive method in women aged 35–39 and 40–44.

Dr. Zieman suggested that intrauterine devices should be considered more frequently, as they are reversible, less risky than sterilization, and safe for most women. IUDs can also be used in a broader range of women, including those with contraindications to estrogen-containing hormonal contraception. Women with venous thromboembolism, arterial vascular disease, and acute liver disease; women who smoke; and those with migraine are all candidates for the copper IUD, and most can use the levonorgestrel system. For specific information, see the World Health Organization medical eligibility criteria at http://www.who.int/reproductive-health/publications/mec/iuds.html

For women without contraindications, combination oral contraceptives may be a good option, as they provide noncontraceptive benefits, such as improving menorrhagia, reducing vasomotor symptoms, and reducing the risk of endometrial and ovarian cancers.

Progesterone-only pills may be more appropriate choices for women with estrogen-contraindicating comorbidities such as hypertension.

Depot medroxyprogesterone acetate (DMPA) would be another good progestin-only option for perimenopausal women not planning to have more children. Women with hypertension can use DMPA as long as their blood pressure is controlled below 160/100, according to the World Health Organization guidelines.

When using methods that interfere with menstruation, the decision of when to stop contraception because of suspected menopause is arbitrary.

Follicle-stimulating hormone testing is not a reliable indicator of potential fertility in women older than 45 years. Moreover, in women using oral contraception, FSH testing cannot sensitively predict menopause on day 7 of the pill-free interval.

Dr. Zieman suggested that a woman may consider discontinuing oral contraceptives at age 50, while continuing to protect herself from pregnancy, in order to evaluate her menstrual status. Alternatively, she may want to continue them until age 55, at which point she has likely entered menopause.

The safety of continuing oral contraception through that age is not fully understood, and decisions should be made on an individual basis, taking into account how the woman feels about continuing with pills, she said.

Dr. Zieman has received honoraria from or consulted for Ortho, Barr, Berlex, Organon, and Wyeth.

ATLANTA — Women in perimenopause have unique issues that should be considered when developing a contraceptive plan, Dr. Miriam Zieman said at a conference on contraceptive technology that was sponsored by Contemporary Forums.

Older women are generally less fertile and thus their bodies may be more forgiving in terms of contraceptive efficacy. However, perimenopausal women often still ovulate for several years and thus the potential for pregnancy exists. In fact, the abortion ratio (number of abortions per 1000 live births) is high in women over 40.

To more easily gauge progress through perimenopause, women should keep a menstrual diary of any bleeding or spotting that occurs. “Taking an accurate menstrual history is so important to our diagnosis during these ages,” said Dr. Zieman of Emory University, Atlanta.

Comorbidities, including hypertension, heart disease, and obesity, are more common in older women. These conditions can affect the choice of contraception, because the risks associated with contraception generally increase with age. In general, though, “combination contraceptives can be safely used by lean, healthy, nonsmoking women until menopause,” Dr. Zieman said.

Because women older than 40 are often finished with childbearing, they tend to prefer long-term contraceptive methods. Indeed, data from the Centers for Disease Control and Prevention show that tubal sterilization is the most common contraceptive method in women aged 35–39 and 40–44.

Dr. Zieman suggested that intrauterine devices should be considered more frequently, as they are reversible, less risky than sterilization, and safe for most women. IUDs can also be used in a broader range of women, including those with contraindications to estrogen-containing hormonal contraception. Women with venous thromboembolism, arterial vascular disease, and acute liver disease; women who smoke; and those with migraine are all candidates for the copper IUD, and most can use the levonorgestrel system. For specific information, see the World Health Organization medical eligibility criteria at http://www.who.int/reproductive-health/publications/mec/iuds.html

For women without contraindications, combination oral contraceptives may be a good option, as they provide noncontraceptive benefits, such as improving menorrhagia, reducing vasomotor symptoms, and reducing the risk of endometrial and ovarian cancers.

Progesterone-only pills may be more appropriate choices for women with estrogen-contraindicating comorbidities such as hypertension.

Depot medroxyprogesterone acetate (DMPA) would be another good progestin-only option for perimenopausal women not planning to have more children. Women with hypertension can use DMPA as long as their blood pressure is controlled below 160/100, according to the World Health Organization guidelines.

When using methods that interfere with menstruation, the decision of when to stop contraception because of suspected menopause is arbitrary.

Follicle-stimulating hormone testing is not a reliable indicator of potential fertility in women older than 45 years. Moreover, in women using oral contraception, FSH testing cannot sensitively predict menopause on day 7 of the pill-free interval.

Dr. Zieman suggested that a woman may consider discontinuing oral contraceptives at age 50, while continuing to protect herself from pregnancy, in order to evaluate her menstrual status. Alternatively, she may want to continue them until age 55, at which point she has likely entered menopause.

The safety of continuing oral contraception through that age is not fully understood, and decisions should be made on an individual basis, taking into account how the woman feels about continuing with pills, she said.

Dr. Zieman has received honoraria from or consulted for Ortho, Barr, Berlex, Organon, and Wyeth.

Exercise-induced weight loss does not lead to declines in bone mineral density at fracture-relevant sites after 12 months, but weight loss caused by calorie restriction does, according to results of a randomized, controlled trial of 48 adults.

Regional BMD at the total hip and at the intertrochanter decreased significantly more with calorie restriction than they did without intervention in a control group.

BMD did not change significantly with exercise, compared with controls, study investigators reported.

The researchers randomized 48 nonobese but mostly overweight adults aged 50–60 years to three groups. The 19 subjects in the calorie-restriction group decreased energy intake by 16% during the first 3 months and by 20% during the subsequent 9 months.

The 19 subjects in the exercise group decreased overall energy intake by the same amount through exercise; they exercised a mean of 5.8 times per week for 62.5 minutes per session. The most common modes of exercise were walking and/or jogging, followed by elliptical training and cycling.

The remaining 10 participants did not receive advice to change their diet or exercise habits, wrote Dr. Dennis T. Villareal of Washington University, St. Louis, and colleagues (Arch. Intern. Med. 2006;166:2502–10).

Overall, in the calorie restriction group, BMD decreased 2.2% at the lumbar spine, 2.2% in the total hip, and 2.1% in the intertrochanter.

Markers of bone turnover increased significantly in both the calorie-restriction and exercise groups.

Relative reductions in body weight after 1 year were similar with calorie restriction (10.7%) and with exercise (8.4%), whereas the control group did not lose weight (1.2%).

These findings indicate that exercise was associated with weight loss but not loss of BMD, whereas weight loss due to calorie restriction was significantly associated with changes in hip BMD.

“Because the amount of exercise required to achieve clinically meaningful weight loss is large, a more practical approach for weight reduction is a combination of calorie restriction and exercise,” the authors wrote.

Exercise-induced weight loss does not lead to declines in bone mineral density at fracture-relevant sites after 12 months, but weight loss caused by calorie restriction does, according to results of a randomized, controlled trial of 48 adults.

Regional BMD at the total hip and at the intertrochanter decreased significantly more with calorie restriction than they did without intervention in a control group.

BMD did not change significantly with exercise, compared with controls, study investigators reported.

The researchers randomized 48 nonobese but mostly overweight adults aged 50–60 years to three groups. The 19 subjects in the calorie-restriction group decreased energy intake by 16% during the first 3 months and by 20% during the subsequent 9 months.

The 19 subjects in the exercise group decreased overall energy intake by the same amount through exercise; they exercised a mean of 5.8 times per week for 62.5 minutes per session. The most common modes of exercise were walking and/or jogging, followed by elliptical training and cycling.

The remaining 10 participants did not receive advice to change their diet or exercise habits, wrote Dr. Dennis T. Villareal of Washington University, St. Louis, and colleagues (Arch. Intern. Med. 2006;166:2502–10).

Overall, in the calorie restriction group, BMD decreased 2.2% at the lumbar spine, 2.2% in the total hip, and 2.1% in the intertrochanter.

Markers of bone turnover increased significantly in both the calorie-restriction and exercise groups.

Relative reductions in body weight after 1 year were similar with calorie restriction (10.7%) and with exercise (8.4%), whereas the control group did not lose weight (1.2%).

These findings indicate that exercise was associated with weight loss but not loss of BMD, whereas weight loss due to calorie restriction was significantly associated with changes in hip BMD.

“Because the amount of exercise required to achieve clinically meaningful weight loss is large, a more practical approach for weight reduction is a combination of calorie restriction and exercise,” the authors wrote.

Exercise-induced weight loss does not lead to declines in bone mineral density at fracture-relevant sites after 12 months, but weight loss caused by calorie restriction does, according to results of a randomized, controlled trial of 48 adults.

Regional BMD at the total hip and at the intertrochanter decreased significantly more with calorie restriction than they did without intervention in a control group.

BMD did not change significantly with exercise, compared with controls, study investigators reported.

The researchers randomized 48 nonobese but mostly overweight adults aged 50–60 years to three groups. The 19 subjects in the calorie-restriction group decreased energy intake by 16% during the first 3 months and by 20% during the subsequent 9 months.

The 19 subjects in the exercise group decreased overall energy intake by the same amount through exercise; they exercised a mean of 5.8 times per week for 62.5 minutes per session. The most common modes of exercise were walking and/or jogging, followed by elliptical training and cycling.

The remaining 10 participants did not receive advice to change their diet or exercise habits, wrote Dr. Dennis T. Villareal of Washington University, St. Louis, and colleagues (Arch. Intern. Med. 2006;166:2502–10).

Overall, in the calorie restriction group, BMD decreased 2.2% at the lumbar spine, 2.2% in the total hip, and 2.1% in the intertrochanter.

Markers of bone turnover increased significantly in both the calorie-restriction and exercise groups.

Relative reductions in body weight after 1 year were similar with calorie restriction (10.7%) and with exercise (8.4%), whereas the control group did not lose weight (1.2%).

These findings indicate that exercise was associated with weight loss but not loss of BMD, whereas weight loss due to calorie restriction was significantly associated with changes in hip BMD.

“Because the amount of exercise required to achieve clinically meaningful weight loss is large, a more practical approach for weight reduction is a combination of calorie restriction and exercise,” the authors wrote.

Management practices for treating diabetic ketoacidosis (DKA) vary widely among 59 internal medicine departments in Denmark, according to results of a questionnaire-based study in press in an upcoming issue of Diabetes Research and Clinical Practice.

The study identified 24 different insulin regimens and 21 fluid protocols used at the responding departments (Diab. Res. Clin. Pract. 2006 [Epub doi:10.1016/j.diabres.2006.10.013]). “In many cases, the treatment routines employed are not supported by evidence from clinical trials,” wrote lead author Dr. Otto M. Henriksen of the endocrine section at Bispebjerg Hospital, University of Copenhagen, and colleagues.

Overall, 32% of departments managed all patients with DKA in an intensive care unit, whereas 22% used a general medical unit and 32% used an acute medical admission unit.

Most respondents administered an initial regular insulin dose of 10–20 U (median, 16 U) followed by a lower-dose hourly administration of 4–10 U/hour (median, 6 U/hour) of regular insulin. The most common criterion for stopping intensive insulin was resolution of acidosis, used by 76% of departments, followed by the ability to eat and drink (42%), resolution of ketosis (31%), and near-normoglycemia (25%); 53% waited until patients attained at least two of these individual criteria.

Almost all of the respondents used isotonic saline for hydration; 83% administered separate potassium infusions of isotonic potassium-sodium-chloride, and 10% used isotonic potassium chloride.

The recommended fluid administration volumes for the first 8 hours of treatment ranged from 3,750 to 7,700 mL, with a median of 4,800 mL. A mean of 44% of the total volume was derived from potassium supplementation (range, 29%–56%).

More than two-thirds of departments relied on degree of acidosis alone to determine bicarbonate use; 36% used an arterial pH below 7.1 as their threshold to initiate treatment. Another 11% of departments supplemented degree of acidosis with clinical criteria.

In terms of acidosis monitoring, 39% of departments used arterial punctures, 30% used venous blood samples, and 20% used an interchangeable method. Ketosis was most often monitored using a urine dipstick (77%).

Rates of serious complications within the prior 5 years, which were based solely on respondents' recollections, were significantly lower than would be expected from a national registry and included five deaths, four cerebral edemas, and three thromboembolic events.

“The results do suggest that treatment of DKA is perceived as relatively uncomplicated regardless of routine management guidelines,” the researchers concluded. They proposed that national, evidence-based guidelines could reduce durations of hospitalization and increase the cost-effectiveness of DKA treatments.

Management practices for treating diabetic ketoacidosis (DKA) vary widely among 59 internal medicine departments in Denmark, according to results of a questionnaire-based study in press in an upcoming issue of Diabetes Research and Clinical Practice.

The study identified 24 different insulin regimens and 21 fluid protocols used at the responding departments (Diab. Res. Clin. Pract. 2006 [Epub doi:10.1016/j.diabres.2006.10.013]). “In many cases, the treatment routines employed are not supported by evidence from clinical trials,” wrote lead author Dr. Otto M. Henriksen of the endocrine section at Bispebjerg Hospital, University of Copenhagen, and colleagues.

Overall, 32% of departments managed all patients with DKA in an intensive care unit, whereas 22% used a general medical unit and 32% used an acute medical admission unit.

Most respondents administered an initial regular insulin dose of 10–20 U (median, 16 U) followed by a lower-dose hourly administration of 4–10 U/hour (median, 6 U/hour) of regular insulin. The most common criterion for stopping intensive insulin was resolution of acidosis, used by 76% of departments, followed by the ability to eat and drink (42%), resolution of ketosis (31%), and near-normoglycemia (25%); 53% waited until patients attained at least two of these individual criteria.

Almost all of the respondents used isotonic saline for hydration; 83% administered separate potassium infusions of isotonic potassium-sodium-chloride, and 10% used isotonic potassium chloride.

The recommended fluid administration volumes for the first 8 hours of treatment ranged from 3,750 to 7,700 mL, with a median of 4,800 mL. A mean of 44% of the total volume was derived from potassium supplementation (range, 29%–56%).

More than two-thirds of departments relied on degree of acidosis alone to determine bicarbonate use; 36% used an arterial pH below 7.1 as their threshold to initiate treatment. Another 11% of departments supplemented degree of acidosis with clinical criteria.

In terms of acidosis monitoring, 39% of departments used arterial punctures, 30% used venous blood samples, and 20% used an interchangeable method. Ketosis was most often monitored using a urine dipstick (77%).

Rates of serious complications within the prior 5 years, which were based solely on respondents' recollections, were significantly lower than would be expected from a national registry and included five deaths, four cerebral edemas, and three thromboembolic events.

“The results do suggest that treatment of DKA is perceived as relatively uncomplicated regardless of routine management guidelines,” the researchers concluded. They proposed that national, evidence-based guidelines could reduce durations of hospitalization and increase the cost-effectiveness of DKA treatments.

Management practices for treating diabetic ketoacidosis (DKA) vary widely among 59 internal medicine departments in Denmark, according to results of a questionnaire-based study in press in an upcoming issue of Diabetes Research and Clinical Practice.

The study identified 24 different insulin regimens and 21 fluid protocols used at the responding departments (Diab. Res. Clin. Pract. 2006 [Epub doi:10.1016/j.diabres.2006.10.013]). “In many cases, the treatment routines employed are not supported by evidence from clinical trials,” wrote lead author Dr. Otto M. Henriksen of the endocrine section at Bispebjerg Hospital, University of Copenhagen, and colleagues.

Overall, 32% of departments managed all patients with DKA in an intensive care unit, whereas 22% used a general medical unit and 32% used an acute medical admission unit.

Most respondents administered an initial regular insulin dose of 10–20 U (median, 16 U) followed by a lower-dose hourly administration of 4–10 U/hour (median, 6 U/hour) of regular insulin. The most common criterion for stopping intensive insulin was resolution of acidosis, used by 76% of departments, followed by the ability to eat and drink (42%), resolution of ketosis (31%), and near-normoglycemia (25%); 53% waited until patients attained at least two of these individual criteria.

Almost all of the respondents used isotonic saline for hydration; 83% administered separate potassium infusions of isotonic potassium-sodium-chloride, and 10% used isotonic potassium chloride.

The recommended fluid administration volumes for the first 8 hours of treatment ranged from 3,750 to 7,700 mL, with a median of 4,800 mL. A mean of 44% of the total volume was derived from potassium supplementation (range, 29%–56%).

More than two-thirds of departments relied on degree of acidosis alone to determine bicarbonate use; 36% used an arterial pH below 7.1 as their threshold to initiate treatment. Another 11% of departments supplemented degree of acidosis with clinical criteria.

In terms of acidosis monitoring, 39% of departments used arterial punctures, 30% used venous blood samples, and 20% used an interchangeable method. Ketosis was most often monitored using a urine dipstick (77%).

Rates of serious complications within the prior 5 years, which were based solely on respondents' recollections, were significantly lower than would be expected from a national registry and included five deaths, four cerebral edemas, and three thromboembolic events.

“The results do suggest that treatment of DKA is perceived as relatively uncomplicated regardless of routine management guidelines,” the researchers concluded. They proposed that national, evidence-based guidelines could reduce durations of hospitalization and increase the cost-effectiveness of DKA treatments.

Coffee consumption appears to significantly reduce the risk of developing type 2 diabetes over a 13-year period, according to a prospective follow-up Finnish study.

Drinking at least seven cups of coffee per day reduced the risk of type 2 diabetes by 39%, compared with drinking up to two cups per day, after adjusting for confounding factors in this study of 21,385 Finnish individuals (48% men) aged 35–74 without coronary heart disease or stroke (Int. J. Obes. 2006;30:1742–9).

The risk reduction with high coffee consumption was higher for women (48%) than for men (36%). Drinking three to six cups per day reduced the risk by 29% in women and 23% in men. The incremental risk reductions for each daily cup of coffee consumed were 9% for women and 3% for men.

Overall, 964 cases of type 2 diabetes were identified in the study. High levels of physical activity reduced the risk by 50% in men and 45% in women, compared with low levels of physical activity, after adjusting for confounding factors. Moderate activity provided risk reductions of 38% and 20%, respectively.

Body mass index (BMI) was significantly associated with type 2 diabetes, while alcohol appeared to have a protective effect. The risk reductions with consuming more than 100 g of alcohol per week were 26% and 77% for men and women, respectively, while the risk reductions from drinking 1–100 g per week were 9% and 26%, respectively.

The authors noted that coffee drinking reduced the risk of type 2 diabetes across all levels of BMI, physical activity, and alcohol consumption. Among obese individuals, drinking at least seven cups of coffee per day decreased the relative risk of type 2 diabetes by almost half (see box).

Coffee consumption correlated with bread consumption and current smoking and was inversely correlated with blood pressure, education, low levels of physical activity, and consumption of tea, alcohol, and fruits and vegetables.

Lead author Dr. Gang Hu and colleagues of the National Public Health Institute in Helsinki suggested multiple potential mechanisms for the protective effects of coffee, including the thermogenic effects of caffeine, the presence of magnesium in coffee, and various effects of coffee in the gastric tract.

The authors noted several limitations to their study, including the fact that glucose tolerance tests were not performed with either baseline or follow-up surveys; “therefore, we could have missed some cases of asymptomatic and diet-treated diabetes, although the clinical diagnosis of diabetes from the hospital discharge register may in part avoid this potential underdiagnosis,” they wrote. “Another source of misclassification may be that we used self-report for data on coffee intake. Misclassification is inevitable and usually results in a biased estimate of the association of exposure and risk of type 2 diabetes.”

The authors also noted that they did not assess the effect of caffeine on diabetes risk because they did not have information available about the subjects' consumption of cola and chocolate. Finally, “we cannot completely exclude… some unmeasured factors, including coffee additives ([such as] sugar and milk), and several dietary factors,” they wrote.

ELSEVIER GLOBAL MEDICAL NEWS

Coffee consumption appears to significantly reduce the risk of developing type 2 diabetes over a 13-year period, according to a prospective follow-up Finnish study.

Drinking at least seven cups of coffee per day reduced the risk of type 2 diabetes by 39%, compared with drinking up to two cups per day, after adjusting for confounding factors in this study of 21,385 Finnish individuals (48% men) aged 35–74 without coronary heart disease or stroke (Int. J. Obes. 2006;30:1742–9).

The risk reduction with high coffee consumption was higher for women (48%) than for men (36%). Drinking three to six cups per day reduced the risk by 29% in women and 23% in men. The incremental risk reductions for each daily cup of coffee consumed were 9% for women and 3% for men.

Overall, 964 cases of type 2 diabetes were identified in the study. High levels of physical activity reduced the risk by 50% in men and 45% in women, compared with low levels of physical activity, after adjusting for confounding factors. Moderate activity provided risk reductions of 38% and 20%, respectively.

Body mass index (BMI) was significantly associated with type 2 diabetes, while alcohol appeared to have a protective effect. The risk reductions with consuming more than 100 g of alcohol per week were 26% and 77% for men and women, respectively, while the risk reductions from drinking 1–100 g per week were 9% and 26%, respectively.

The authors noted that coffee drinking reduced the risk of type 2 diabetes across all levels of BMI, physical activity, and alcohol consumption. Among obese individuals, drinking at least seven cups of coffee per day decreased the relative risk of type 2 diabetes by almost half (see box).

Coffee consumption correlated with bread consumption and current smoking and was inversely correlated with blood pressure, education, low levels of physical activity, and consumption of tea, alcohol, and fruits and vegetables.

Lead author Dr. Gang Hu and colleagues of the National Public Health Institute in Helsinki suggested multiple potential mechanisms for the protective effects of coffee, including the thermogenic effects of caffeine, the presence of magnesium in coffee, and various effects of coffee in the gastric tract.

The authors noted several limitations to their study, including the fact that glucose tolerance tests were not performed with either baseline or follow-up surveys; “therefore, we could have missed some cases of asymptomatic and diet-treated diabetes, although the clinical diagnosis of diabetes from the hospital discharge register may in part avoid this potential underdiagnosis,” they wrote. “Another source of misclassification may be that we used self-report for data on coffee intake. Misclassification is inevitable and usually results in a biased estimate of the association of exposure and risk of type 2 diabetes.”

The authors also noted that they did not assess the effect of caffeine on diabetes risk because they did not have information available about the subjects' consumption of cola and chocolate. Finally, “we cannot completely exclude… some unmeasured factors, including coffee additives ([such as] sugar and milk), and several dietary factors,” they wrote.

ELSEVIER GLOBAL MEDICAL NEWS

Coffee consumption appears to significantly reduce the risk of developing type 2 diabetes over a 13-year period, according to a prospective follow-up Finnish study.

Drinking at least seven cups of coffee per day reduced the risk of type 2 diabetes by 39%, compared with drinking up to two cups per day, after adjusting for confounding factors in this study of 21,385 Finnish individuals (48% men) aged 35–74 without coronary heart disease or stroke (Int. J. Obes. 2006;30:1742–9).

The risk reduction with high coffee consumption was higher for women (48%) than for men (36%). Drinking three to six cups per day reduced the risk by 29% in women and 23% in men. The incremental risk reductions for each daily cup of coffee consumed were 9% for women and 3% for men.

Overall, 964 cases of type 2 diabetes were identified in the study. High levels of physical activity reduced the risk by 50% in men and 45% in women, compared with low levels of physical activity, after adjusting for confounding factors. Moderate activity provided risk reductions of 38% and 20%, respectively.

Body mass index (BMI) was significantly associated with type 2 diabetes, while alcohol appeared to have a protective effect. The risk reductions with consuming more than 100 g of alcohol per week were 26% and 77% for men and women, respectively, while the risk reductions from drinking 1–100 g per week were 9% and 26%, respectively.

The authors noted that coffee drinking reduced the risk of type 2 diabetes across all levels of BMI, physical activity, and alcohol consumption. Among obese individuals, drinking at least seven cups of coffee per day decreased the relative risk of type 2 diabetes by almost half (see box).

Coffee consumption correlated with bread consumption and current smoking and was inversely correlated with blood pressure, education, low levels of physical activity, and consumption of tea, alcohol, and fruits and vegetables.

Lead author Dr. Gang Hu and colleagues of the National Public Health Institute in Helsinki suggested multiple potential mechanisms for the protective effects of coffee, including the thermogenic effects of caffeine, the presence of magnesium in coffee, and various effects of coffee in the gastric tract.

The authors noted several limitations to their study, including the fact that glucose tolerance tests were not performed with either baseline or follow-up surveys; “therefore, we could have missed some cases of asymptomatic and diet-treated diabetes, although the clinical diagnosis of diabetes from the hospital discharge register may in part avoid this potential underdiagnosis,” they wrote. “Another source of misclassification may be that we used self-report for data on coffee intake. Misclassification is inevitable and usually results in a biased estimate of the association of exposure and risk of type 2 diabetes.”

The authors also noted that they did not assess the effect of caffeine on diabetes risk because they did not have information available about the subjects' consumption of cola and chocolate. Finally, “we cannot completely exclude… some unmeasured factors, including coffee additives ([such as] sugar and milk), and several dietary factors,” they wrote.

ELSEVIER GLOBAL MEDICAL NEWS

ATLANTA — Novel contraceptives currently being developed include norprogesterone-derived progestins, new barrier methods, and combination spermicides-microbicides, reported Dr. Michelle Fox at a conference on contraceptive technology sponsored by Contemporary Forums.

“We've made a lot of progress in contraception, but we are still far from the ideal,” said Dr. Fox, who is director of family planning at the University of Maryland, Baltimore.

The only contraceptive that Dr. Fox predicted would be approved within the next year is a continuous combined oral contraceptive pill that contains 90 mcg of levonorgestrel and 20 mcg of ethinyl estradiol, to be taken daily.

The product, named Lybrel by Wyeth Pharmaceuticals, has no hormone-free period and has demonstrated favorable bleeding patterns in clinical trials.

In contrast with today's testosterone-based progestins, new progestins under development are being derived from 19-norprogesterone, a compound that is not androgenic and may better inhibit ovulation.

One such norprogesterone-based product is Nestorone, which is being developed by the Population Council. A limitation of Nestorone is its inactivity when delivered orally. Because the compound is readily absorbed through the vaginal mucosa and skin, Nestorone-based combined hormonal vaginal rings and spray-on contraceptives are being developed.

New barrier methods being evaluated include a one-size silicone diaphragm that would not require individual fitting and a female condom that is more comfortable and easier to use.

A hot topic of research is the quest to develop a spermicide alternative to nonoxynol-9. Currently, all spermicidal products in the United States contain nonoxynol-9. While the compound is considered safe for most users, it is a detergent that disrupts epithelial surfaces. A recent study suggested that frequent use of nonoxynol-9 by sex workers could increase the risk of HIV transmission in high-risk women.

Several buffer-based spermicides are currently under development. These compounds inhibit sperm by maintaining the acidic environment of the vagina.

They have also been shown to inhibit multiple sexually transmitted infections in animal models.

One product, Acidform, forms a protective bioadhesive coating over the cervix and vagina. A 2004 study showed that Acidform can be applied up to 10 hours before anticipated intercourse.

Finally, a new surfactant product has demonstrated less irritation than nonoxynol-9 and has potent activity against both sperm and a range of pathogens in vitro. The contraceptive efficacy of the product is currently being evaluated in a phase III trial.

ATLANTA — Novel contraceptives currently being developed include norprogesterone-derived progestins, new barrier methods, and combination spermicides-microbicides, reported Dr. Michelle Fox at a conference on contraceptive technology sponsored by Contemporary Forums.

“We've made a lot of progress in contraception, but we are still far from the ideal,” said Dr. Fox, who is director of family planning at the University of Maryland, Baltimore.

The only contraceptive that Dr. Fox predicted would be approved within the next year is a continuous combined oral contraceptive pill that contains 90 mcg of levonorgestrel and 20 mcg of ethinyl estradiol, to be taken daily.

The product, named Lybrel by Wyeth Pharmaceuticals, has no hormone-free period and has demonstrated favorable bleeding patterns in clinical trials.

In contrast with today's testosterone-based progestins, new progestins under development are being derived from 19-norprogesterone, a compound that is not androgenic and may better inhibit ovulation.

One such norprogesterone-based product is Nestorone, which is being developed by the Population Council. A limitation of Nestorone is its inactivity when delivered orally. Because the compound is readily absorbed through the vaginal mucosa and skin, Nestorone-based combined hormonal vaginal rings and spray-on contraceptives are being developed.

New barrier methods being evaluated include a one-size silicone diaphragm that would not require individual fitting and a female condom that is more comfortable and easier to use.

A hot topic of research is the quest to develop a spermicide alternative to nonoxynol-9. Currently, all spermicidal products in the United States contain nonoxynol-9. While the compound is considered safe for most users, it is a detergent that disrupts epithelial surfaces. A recent study suggested that frequent use of nonoxynol-9 by sex workers could increase the risk of HIV transmission in high-risk women.

Several buffer-based spermicides are currently under development. These compounds inhibit sperm by maintaining the acidic environment of the vagina.

They have also been shown to inhibit multiple sexually transmitted infections in animal models.

One product, Acidform, forms a protective bioadhesive coating over the cervix and vagina. A 2004 study showed that Acidform can be applied up to 10 hours before anticipated intercourse.

Finally, a new surfactant product has demonstrated less irritation than nonoxynol-9 and has potent activity against both sperm and a range of pathogens in vitro. The contraceptive efficacy of the product is currently being evaluated in a phase III trial.

ATLANTA — Novel contraceptives currently being developed include norprogesterone-derived progestins, new barrier methods, and combination spermicides-microbicides, reported Dr. Michelle Fox at a conference on contraceptive technology sponsored by Contemporary Forums.

“We've made a lot of progress in contraception, but we are still far from the ideal,” said Dr. Fox, who is director of family planning at the University of Maryland, Baltimore.

The only contraceptive that Dr. Fox predicted would be approved within the next year is a continuous combined oral contraceptive pill that contains 90 mcg of levonorgestrel and 20 mcg of ethinyl estradiol, to be taken daily.

The product, named Lybrel by Wyeth Pharmaceuticals, has no hormone-free period and has demonstrated favorable bleeding patterns in clinical trials.

In contrast with today's testosterone-based progestins, new progestins under development are being derived from 19-norprogesterone, a compound that is not androgenic and may better inhibit ovulation.

One such norprogesterone-based product is Nestorone, which is being developed by the Population Council. A limitation of Nestorone is its inactivity when delivered orally. Because the compound is readily absorbed through the vaginal mucosa and skin, Nestorone-based combined hormonal vaginal rings and spray-on contraceptives are being developed.

New barrier methods being evaluated include a one-size silicone diaphragm that would not require individual fitting and a female condom that is more comfortable and easier to use.

A hot topic of research is the quest to develop a spermicide alternative to nonoxynol-9. Currently, all spermicidal products in the United States contain nonoxynol-9. While the compound is considered safe for most users, it is a detergent that disrupts epithelial surfaces. A recent study suggested that frequent use of nonoxynol-9 by sex workers could increase the risk of HIV transmission in high-risk women.

Several buffer-based spermicides are currently under development. These compounds inhibit sperm by maintaining the acidic environment of the vagina.

They have also been shown to inhibit multiple sexually transmitted infections in animal models.

One product, Acidform, forms a protective bioadhesive coating over the cervix and vagina. A 2004 study showed that Acidform can be applied up to 10 hours before anticipated intercourse.

Finally, a new surfactant product has demonstrated less irritation than nonoxynol-9 and has potent activity against both sperm and a range of pathogens in vitro. The contraceptive efficacy of the product is currently being evaluated in a phase III trial.

ATLANTA — Several strategies have been shown to increase vaccination coverage in children, Dr. Jeanne M. Santoli said at a meeting on clinical vaccinology sponsored by the National Foundation for Infectious Diseases.

Five interventions have been recommended by the Task Force on Community Preventive Services on the basis of strong evidence of their effectiveness in increasing vaccination rates (Am. J. Prev. Med. 2000;18[1 Suppl.]:97–140).

One strategy that clinicians may be able to implement in practice is a client reminder-recall system, in which families are informed by mail or by telephone that the child is due or overdue for a vaccination.

A 1999 study involving 2,000 children younger than age 2 showed that immunization rates increased 20% by the end of a reminder, recall, and outreach immunization program (Pediatrics 1999;103:31–8). The researchers observed spillover benefits of the program, including an 11% increase in preventive visits, a 12% increase in anemia screening, and an 8% increase in lead screening.

“Despite this proven benefit [of recall systems], the use of this strategy is not nearly what we might hope,” said Dr. Santoli, deputy director of the Immunization Services Division for the National Center for Immunization and Respiratory Diseases, a part of the Centers for Disease Control and Prevention. Self-reported use of recall systems by pediatricians remains low, at less than 25% across multiple studies.

Providers might not see the need for such systems, she said, because most tend to overestimate vaccination coverage in their practices. Variations in the degree of computerization and the organization of medical records also can affect the feasibility of implementing such a program.

Out-of-pocket cost reductions are other interventions with strong evidence to back them. Dr. Santoli said the cost to fully vaccinate children, with fees calculated based on federal vaccine contracts, has increased dramatically, from $45 in 1985 to $894 in 2006. The addition of the human papillomavirus vaccine would bring the total cost up to $1,182, not including vaccine administration fees.

The CDC's Vaccines for Children program is a comprehensive intervention for reducing costs, under which providers receive vaccine replacements to immunize eligible children. Dr. Santoli estimated that 40 million children in the United States under the age of 18 are eligible for the program. Studies of program participation suggest that “the program is reaching the children that it was intended to serve,” she noted at the meeting, which was also sponsored by Emory University.

Other interventions suggested by the task force on the basis of strong evidence include provider reminder-recall systems and assessment, feedback for providers, and multicomponent interventions.

Interventions with “sufficient” evidence include vaccination requirements for child care, school, and college; school vaccination programs (when focused on new vaccines); vaccination programs in Women, Infants, and Children settings; and home visits. “When there are state requirements [for entry into school] and they are enforced, they can have an important impact on vaccination rates,” Dr. Santoli said.

Certain interventions have not demonstrated sufficient increases in vaccine coverage. These include education-only programs, vaccination programs in child care centers, client or family incentives, and client-held medical records.

In considering strategies for increasing vaccinations, it is important to consider the barriers to vaccination. Parental attitudes, provider attitudes, and access to care were previously considered the primary barriers, said Dr. Santoli. However, the literature indicates that socioeconomic factors, a late start on vaccinations, an information gap, provider practices, and clinic factors are the key barriers to immunization. By addressing these barriers with proven interventions, clinicians may be able to improve vaccination rates in their practices.

ATLANTA — Several strategies have been shown to increase vaccination coverage in children, Dr. Jeanne M. Santoli said at a meeting on clinical vaccinology sponsored by the National Foundation for Infectious Diseases.

Five interventions have been recommended by the Task Force on Community Preventive Services on the basis of strong evidence of their effectiveness in increasing vaccination rates (Am. J. Prev. Med. 2000;18[1 Suppl.]:97–140).

One strategy that clinicians may be able to implement in practice is a client reminder-recall system, in which families are informed by mail or by telephone that the child is due or overdue for a vaccination.

A 1999 study involving 2,000 children younger than age 2 showed that immunization rates increased 20% by the end of a reminder, recall, and outreach immunization program (Pediatrics 1999;103:31–8). The researchers observed spillover benefits of the program, including an 11% increase in preventive visits, a 12% increase in anemia screening, and an 8% increase in lead screening.

“Despite this proven benefit [of recall systems], the use of this strategy is not nearly what we might hope,” said Dr. Santoli, deputy director of the Immunization Services Division for the National Center for Immunization and Respiratory Diseases, a part of the Centers for Disease Control and Prevention. Self-reported use of recall systems by pediatricians remains low, at less than 25% across multiple studies.

Providers might not see the need for such systems, she said, because most tend to overestimate vaccination coverage in their practices. Variations in the degree of computerization and the organization of medical records also can affect the feasibility of implementing such a program.

Out-of-pocket cost reductions are other interventions with strong evidence to back them. Dr. Santoli said the cost to fully vaccinate children, with fees calculated based on federal vaccine contracts, has increased dramatically, from $45 in 1985 to $894 in 2006. The addition of the human papillomavirus vaccine would bring the total cost up to $1,182, not including vaccine administration fees.

The CDC's Vaccines for Children program is a comprehensive intervention for reducing costs, under which providers receive vaccine replacements to immunize eligible children. Dr. Santoli estimated that 40 million children in the United States under the age of 18 are eligible for the program. Studies of program participation suggest that “the program is reaching the children that it was intended to serve,” she noted at the meeting, which was also sponsored by Emory University.

Other interventions suggested by the task force on the basis of strong evidence include provider reminder-recall systems and assessment, feedback for providers, and multicomponent interventions.

Interventions with “sufficient” evidence include vaccination requirements for child care, school, and college; school vaccination programs (when focused on new vaccines); vaccination programs in Women, Infants, and Children settings; and home visits. “When there are state requirements [for entry into school] and they are enforced, they can have an important impact on vaccination rates,” Dr. Santoli said.

Certain interventions have not demonstrated sufficient increases in vaccine coverage. These include education-only programs, vaccination programs in child care centers, client or family incentives, and client-held medical records.

In considering strategies for increasing vaccinations, it is important to consider the barriers to vaccination. Parental attitudes, provider attitudes, and access to care were previously considered the primary barriers, said Dr. Santoli. However, the literature indicates that socioeconomic factors, a late start on vaccinations, an information gap, provider practices, and clinic factors are the key barriers to immunization. By addressing these barriers with proven interventions, clinicians may be able to improve vaccination rates in their practices.

ATLANTA — Several strategies have been shown to increase vaccination coverage in children, Dr. Jeanne M. Santoli said at a meeting on clinical vaccinology sponsored by the National Foundation for Infectious Diseases.

Five interventions have been recommended by the Task Force on Community Preventive Services on the basis of strong evidence of their effectiveness in increasing vaccination rates (Am. J. Prev. Med. 2000;18[1 Suppl.]:97–140).

One strategy that clinicians may be able to implement in practice is a client reminder-recall system, in which families are informed by mail or by telephone that the child is due or overdue for a vaccination.

A 1999 study involving 2,000 children younger than age 2 showed that immunization rates increased 20% by the end of a reminder, recall, and outreach immunization program (Pediatrics 1999;103:31–8). The researchers observed spillover benefits of the program, including an 11% increase in preventive visits, a 12% increase in anemia screening, and an 8% increase in lead screening.

“Despite this proven benefit [of recall systems], the use of this strategy is not nearly what we might hope,” said Dr. Santoli, deputy director of the Immunization Services Division for the National Center for Immunization and Respiratory Diseases, a part of the Centers for Disease Control and Prevention. Self-reported use of recall systems by pediatricians remains low, at less than 25% across multiple studies.

Providers might not see the need for such systems, she said, because most tend to overestimate vaccination coverage in their practices. Variations in the degree of computerization and the organization of medical records also can affect the feasibility of implementing such a program.

Out-of-pocket cost reductions are other interventions with strong evidence to back them. Dr. Santoli said the cost to fully vaccinate children, with fees calculated based on federal vaccine contracts, has increased dramatically, from $45 in 1985 to $894 in 2006. The addition of the human papillomavirus vaccine would bring the total cost up to $1,182, not including vaccine administration fees.

The CDC's Vaccines for Children program is a comprehensive intervention for reducing costs, under which providers receive vaccine replacements to immunize eligible children. Dr. Santoli estimated that 40 million children in the United States under the age of 18 are eligible for the program. Studies of program participation suggest that “the program is reaching the children that it was intended to serve,” she noted at the meeting, which was also sponsored by Emory University.

Other interventions suggested by the task force on the basis of strong evidence include provider reminder-recall systems and assessment, feedback for providers, and multicomponent interventions.

Interventions with “sufficient” evidence include vaccination requirements for child care, school, and college; school vaccination programs (when focused on new vaccines); vaccination programs in Women, Infants, and Children settings; and home visits. “When there are state requirements [for entry into school] and they are enforced, they can have an important impact on vaccination rates,” Dr. Santoli said.

Certain interventions have not demonstrated sufficient increases in vaccine coverage. These include education-only programs, vaccination programs in child care centers, client or family incentives, and client-held medical records.

In considering strategies for increasing vaccinations, it is important to consider the barriers to vaccination. Parental attitudes, provider attitudes, and access to care were previously considered the primary barriers, said Dr. Santoli. However, the literature indicates that socioeconomic factors, a late start on vaccinations, an information gap, provider practices, and clinic factors are the key barriers to immunization. By addressing these barriers with proven interventions, clinicians may be able to improve vaccination rates in their practices.

Hormone therapy with conjugated equine estrogen, with or without progestin, does not appear to reduce the risk of early-stage age-related macular degeneration in older women.

The Women's Health Initiative (WHI) Sight Exam study was designed to assess the association between hormone therapy and age-related macular degeneration (AMD) in women at least 65 years of age. A total of 4,262 women were recruited from the WHI randomized clinical trials of hormone therapy, in which they had been randomized an average of 5 years earlier to receive conjugated equine estrogen (CEE) with or without progestin, or placebo. Two previous studies had shown a reduction in risk of AMD of 30%–40% with hormone therapy.

For the current study, the women underwent fundus photography and the images were graded for AMD severity based on a six-level scale. The primary outcome of the WHI Sight Exam was any AMD.

After adjustment for confounding factors, CEE with or without progestin had no effect on the overall incidence of early AMD. Overall, 21.0% of women in the study had any AMD, with the incidence ranging from 14.7% in women aged 65–69 years to 29.8% in women aged 75 or older. Only 1.1% of women had evidence of late AMD (Arch. Ophthalmol. 2006;124:988–92).

To minimize the effect of preexisting AMD, study investigator Dr. Mary N. Haan, of the University of Michigan, Ann Arbor, and her associates excluded women who had been diagnosed with AMD before the WHI randomization. However, the investigators could not be completely certain which women had disease at randomization and which developed AMD after randomization. Moreover, they were not able to evaluate the women with a longer follow-up because the WHI trials were discontinued early.

Women taking CEE and progestin were 17% less likely than those taking placebo to have soft drusen, which has been associated with a risk of developing late-stage AMD and visual impairment.

“If this treatment does reduce the development of soft drusen, it could be beneficial for prevention of later-stage disease,” the researchers noted. But they also concluded that hormone treatment “does not influence the occurrence of early AMD.”

Hormone therapy with conjugated equine estrogen, with or without progestin, does not appear to reduce the risk of early-stage age-related macular degeneration in older women.

The Women's Health Initiative (WHI) Sight Exam study was designed to assess the association between hormone therapy and age-related macular degeneration (AMD) in women at least 65 years of age. A total of 4,262 women were recruited from the WHI randomized clinical trials of hormone therapy, in which they had been randomized an average of 5 years earlier to receive conjugated equine estrogen (CEE) with or without progestin, or placebo. Two previous studies had shown a reduction in risk of AMD of 30%–40% with hormone therapy.

For the current study, the women underwent fundus photography and the images were graded for AMD severity based on a six-level scale. The primary outcome of the WHI Sight Exam was any AMD.

After adjustment for confounding factors, CEE with or without progestin had no effect on the overall incidence of early AMD. Overall, 21.0% of women in the study had any AMD, with the incidence ranging from 14.7% in women aged 65–69 years to 29.8% in women aged 75 or older. Only 1.1% of women had evidence of late AMD (Arch. Ophthalmol. 2006;124:988–92).

To minimize the effect of preexisting AMD, study investigator Dr. Mary N. Haan, of the University of Michigan, Ann Arbor, and her associates excluded women who had been diagnosed with AMD before the WHI randomization. However, the investigators could not be completely certain which women had disease at randomization and which developed AMD after randomization. Moreover, they were not able to evaluate the women with a longer follow-up because the WHI trials were discontinued early.

Women taking CEE and progestin were 17% less likely than those taking placebo to have soft drusen, which has been associated with a risk of developing late-stage AMD and visual impairment.

“If this treatment does reduce the development of soft drusen, it could be beneficial for prevention of later-stage disease,” the researchers noted. But they also concluded that hormone treatment “does not influence the occurrence of early AMD.”

Hormone therapy with conjugated equine estrogen, with or without progestin, does not appear to reduce the risk of early-stage age-related macular degeneration in older women.

The Women's Health Initiative (WHI) Sight Exam study was designed to assess the association between hormone therapy and age-related macular degeneration (AMD) in women at least 65 years of age. A total of 4,262 women were recruited from the WHI randomized clinical trials of hormone therapy, in which they had been randomized an average of 5 years earlier to receive conjugated equine estrogen (CEE) with or without progestin, or placebo. Two previous studies had shown a reduction in risk of AMD of 30%–40% with hormone therapy.

For the current study, the women underwent fundus photography and the images were graded for AMD severity based on a six-level scale. The primary outcome of the WHI Sight Exam was any AMD.

After adjustment for confounding factors, CEE with or without progestin had no effect on the overall incidence of early AMD. Overall, 21.0% of women in the study had any AMD, with the incidence ranging from 14.7% in women aged 65–69 years to 29.8% in women aged 75 or older. Only 1.1% of women had evidence of late AMD (Arch. Ophthalmol. 2006;124:988–92).

To minimize the effect of preexisting AMD, study investigator Dr. Mary N. Haan, of the University of Michigan, Ann Arbor, and her associates excluded women who had been diagnosed with AMD before the WHI randomization. However, the investigators could not be completely certain which women had disease at randomization and which developed AMD after randomization. Moreover, they were not able to evaluate the women with a longer follow-up because the WHI trials were discontinued early.

Women taking CEE and progestin were 17% less likely than those taking placebo to have soft drusen, which has been associated with a risk of developing late-stage AMD and visual impairment.

“If this treatment does reduce the development of soft drusen, it could be beneficial for prevention of later-stage disease,” the researchers noted. But they also concluded that hormone treatment “does not influence the occurrence of early AMD.”

MIAMI — In young children, think apophysitis instead of tendonitis, Dr. Teri McCambridge said at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.

Dr. McCambridge of Johns Hopkins University, Baltimore, emphasized that excessive participation in a single sport is often a culprit. The American Academy of Pediatrics recommends restricting organized sports participation to children at least 6 years of age, while specialization in one sport should be reserved for adolescents.

The way a young tennis player grips the racket or the placement of cleats on a soccer player's shoes can contribute to an overuse injury such as apophysitis. Dr. McCambridge recommended that physicians look for these fixable causes and consult with a coach or other knowledgeable person if they do not know what to look for in a particular sport.

The last apophyseal centers to close in the lower extremity are those in the hips, and, therefore, physicians should watch for apophysitis of the hip in older athletes.

Calcaneal apophysitis, or Sever's Disease, tends to occur early in the growth spurt. It's most common in sports in which children wear cleats or do not wear shoes. Children with calcaneal apophysitis often complain of ankle pain, although upon closer examination the source turns out to be the heel.

Dr. McCambridge said that x-rays are generally not warranted except in certain instances, such as in children with atypical features or nighttime pain, those on the extremes of the expected age range, and those who do not improve after treatment.

Physicians should be aware of other potential causes of joint pain in children, including tendonitis and, rarely, stress fractures, osteomas, tumors, or rheumatologic conditions. Rest is a critical treatment for apophysitis. Children with calcaneal apophysitis also can use ice and should avoid walking barefoot. Dr. McCambridge suggested that when a child has no pain with daily living, they can return to their sport with modifications.

Another common traction apophysitis is Osgood-Schlatter disease (OSD), which occurs at the tibial tuberosity in children aged 11–15 years. Children often present with pain over the anterior tibia, pain with activity, and pain with full flexion. They also tend to have swelling and palpable tenderness at the tibial tuberosity. Chronic OSD carries the risk of long-term problems due to the formation of painful, nonunited ossicles resulting from fragmentation of the tibial tuberosity.

Because of this risk, Dr. McCambridge tends to radiograph OSD more than any other apophyseal injury.

MIAMI — In young children, think apophysitis instead of tendonitis, Dr. Teri McCambridge said at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.

Dr. McCambridge of Johns Hopkins University, Baltimore, emphasized that excessive participation in a single sport is often a culprit. The American Academy of Pediatrics recommends restricting organized sports participation to children at least 6 years of age, while specialization in one sport should be reserved for adolescents.

The way a young tennis player grips the racket or the placement of cleats on a soccer player's shoes can contribute to an overuse injury such as apophysitis. Dr. McCambridge recommended that physicians look for these fixable causes and consult with a coach or other knowledgeable person if they do not know what to look for in a particular sport.

The last apophyseal centers to close in the lower extremity are those in the hips, and, therefore, physicians should watch for apophysitis of the hip in older athletes.

Calcaneal apophysitis, or Sever's Disease, tends to occur early in the growth spurt. It's most common in sports in which children wear cleats or do not wear shoes. Children with calcaneal apophysitis often complain of ankle pain, although upon closer examination the source turns out to be the heel.

Dr. McCambridge said that x-rays are generally not warranted except in certain instances, such as in children with atypical features or nighttime pain, those on the extremes of the expected age range, and those who do not improve after treatment.

Physicians should be aware of other potential causes of joint pain in children, including tendonitis and, rarely, stress fractures, osteomas, tumors, or rheumatologic conditions. Rest is a critical treatment for apophysitis. Children with calcaneal apophysitis also can use ice and should avoid walking barefoot. Dr. McCambridge suggested that when a child has no pain with daily living, they can return to their sport with modifications.

Another common traction apophysitis is Osgood-Schlatter disease (OSD), which occurs at the tibial tuberosity in children aged 11–15 years. Children often present with pain over the anterior tibia, pain with activity, and pain with full flexion. They also tend to have swelling and palpable tenderness at the tibial tuberosity. Chronic OSD carries the risk of long-term problems due to the formation of painful, nonunited ossicles resulting from fragmentation of the tibial tuberosity.

Because of this risk, Dr. McCambridge tends to radiograph OSD more than any other apophyseal injury.

MIAMI — In young children, think apophysitis instead of tendonitis, Dr. Teri McCambridge said at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.

Dr. McCambridge of Johns Hopkins University, Baltimore, emphasized that excessive participation in a single sport is often a culprit. The American Academy of Pediatrics recommends restricting organized sports participation to children at least 6 years of age, while specialization in one sport should be reserved for adolescents.

The way a young tennis player grips the racket or the placement of cleats on a soccer player's shoes can contribute to an overuse injury such as apophysitis. Dr. McCambridge recommended that physicians look for these fixable causes and consult with a coach or other knowledgeable person if they do not know what to look for in a particular sport.

The last apophyseal centers to close in the lower extremity are those in the hips, and, therefore, physicians should watch for apophysitis of the hip in older athletes.

Calcaneal apophysitis, or Sever's Disease, tends to occur early in the growth spurt. It's most common in sports in which children wear cleats or do not wear shoes. Children with calcaneal apophysitis often complain of ankle pain, although upon closer examination the source turns out to be the heel.

Dr. McCambridge said that x-rays are generally not warranted except in certain instances, such as in children with atypical features or nighttime pain, those on the extremes of the expected age range, and those who do not improve after treatment.

Physicians should be aware of other potential causes of joint pain in children, including tendonitis and, rarely, stress fractures, osteomas, tumors, or rheumatologic conditions. Rest is a critical treatment for apophysitis. Children with calcaneal apophysitis also can use ice and should avoid walking barefoot. Dr. McCambridge suggested that when a child has no pain with daily living, they can return to their sport with modifications.

Another common traction apophysitis is Osgood-Schlatter disease (OSD), which occurs at the tibial tuberosity in children aged 11–15 years. Children often present with pain over the anterior tibia, pain with activity, and pain with full flexion. They also tend to have swelling and palpable tenderness at the tibial tuberosity. Chronic OSD carries the risk of long-term problems due to the formation of painful, nonunited ossicles resulting from fragmentation of the tibial tuberosity.

Because of this risk, Dr. McCambridge tends to radiograph OSD more than any other apophyseal injury.

MIAMI — For serious young baseball players, adherence to recommended pitching limitations and proper management of overuse injuries can help ensure continued healthy pitching, Dr. Andrew Gregory explained at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.

The highly repetitive action of pitching can result in overuse injuries of two joints, generally referred to as Little League elbow or Little League shoulder.

Young pitchers are often serious in their sport, sometimes playing on multiple teams at once in hopes of earning a college scholarship or playing professionally. Such intense participation at an early age, however, can have long-term consequences. About one-third of Little League pitchers never play in high school because of overuse in their younger years, according to Dr. Gregory of the departments of orthopedics and pediatrics at Vanderbilt University in Nashville, Tenn.

This number may seem high, but pain is a common occurrence in pitching. According to a review of 476 pitchers aged 9–14 years, 7% of youth pitching results in pain, and 28% of pitchers report elbow pain at least once in a season. As Dr. Gregory explained, “They're subjecting themselves to this maximal force over and over again, by trying to throw as hard as they can every time.”

Most young pitchers with Little League elbow will present with medial elbow pain that occurs only with throwing; they also may not be able to fully straighten the arm. “It is a constellation of problems, the first being stress injury to the medial epicondyle apophysis,” Dr. Gregory said in an interview. He explained that continuing to pitch through the pain can lead to a loss of blood supply to the joint and irritation of the ulnar nerve.

The main treatment should be rest from all throwing. Treatment also should include ice, NSAIDs for pain, scapular and core stabilization, and a gradual return to throwing after 6–12 weeks, when throwing no longer hurts. Pitching should be resumed only when the athlete can throw without any pain.

Dr. Gregory said that patients should be referred in the following cases: an acute injury with a “pop,” significant widening of the apophysis visible on x-ray, opening with valgus stress, or persistent pain with throwing despite following treatment measures.

Little League elbow is seen in players aged 9–14 years. After the medial epicondylar apophysis closes at age 15–17 years in boys (age 14 in girls), these symptoms are likely caused by injury to the ligament instead.

Dr. Gregory reviewed pitching restrictions that were designed to minimize the likelihood of developing an overuse injury. (See box.) He recommended that physicians have handouts with safety tips to give to parents.

A fragmented medial epicondyle apophysis is common in pitchers. Courtesy Dr. Andrew Gregory

'They're subjecting themselves to this maximal force over and over again,' by pitching as hard as they can. DR. GREGORY

Preventing Pitching Injuries

▸ Observe the following pitch count limits:

• 9− to 10-year-olds: 50 pitches/game, 75/week, 1,000/season, 2,000/year

• 11− to 12-year-olds: 75 pitches/game, 100/week, 1,000/season, 3,000/year

• 13− to 14-year-olds: 75 pitches/game, 125/week, 1,000/season, 3,000/year

▸ Do not throw curveballs before age 14 or sliders before age 16.

▸ Avoid pitching “showcases.”

▸ Pitch for only one team at a time.

▸ Do not pitch and catch for the same team.

MIAMI — For serious young baseball players, adherence to recommended pitching limitations and proper management of overuse injuries can help ensure continued healthy pitching, Dr. Andrew Gregory explained at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.

The highly repetitive action of pitching can result in overuse injuries of two joints, generally referred to as Little League elbow or Little League shoulder.

Young pitchers are often serious in their sport, sometimes playing on multiple teams at once in hopes of earning a college scholarship or playing professionally. Such intense participation at an early age, however, can have long-term consequences. About one-third of Little League pitchers never play in high school because of overuse in their younger years, according to Dr. Gregory of the departments of orthopedics and pediatrics at Vanderbilt University in Nashville, Tenn.

This number may seem high, but pain is a common occurrence in pitching. According to a review of 476 pitchers aged 9–14 years, 7% of youth pitching results in pain, and 28% of pitchers report elbow pain at least once in a season. As Dr. Gregory explained, “They're subjecting themselves to this maximal force over and over again, by trying to throw as hard as they can every time.”

Most young pitchers with Little League elbow will present with medial elbow pain that occurs only with throwing; they also may not be able to fully straighten the arm. “It is a constellation of problems, the first being stress injury to the medial epicondyle apophysis,” Dr. Gregory said in an interview. He explained that continuing to pitch through the pain can lead to a loss of blood supply to the joint and irritation of the ulnar nerve.

The main treatment should be rest from all throwing. Treatment also should include ice, NSAIDs for pain, scapular and core stabilization, and a gradual return to throwing after 6–12 weeks, when throwing no longer hurts. Pitching should be resumed only when the athlete can throw without any pain.

Dr. Gregory said that patients should be referred in the following cases: an acute injury with a “pop,” significant widening of the apophysis visible on x-ray, opening with valgus stress, or persistent pain with throwing despite following treatment measures.

Little League elbow is seen in players aged 9–14 years. After the medial epicondylar apophysis closes at age 15–17 years in boys (age 14 in girls), these symptoms are likely caused by injury to the ligament instead.

Dr. Gregory reviewed pitching restrictions that were designed to minimize the likelihood of developing an overuse injury. (See box.) He recommended that physicians have handouts with safety tips to give to parents.

A fragmented medial epicondyle apophysis is common in pitchers. Courtesy Dr. Andrew Gregory

'They're subjecting themselves to this maximal force over and over again,' by pitching as hard as they can. DR. GREGORY

Preventing Pitching Injuries

▸ Observe the following pitch count limits:

• 9− to 10-year-olds: 50 pitches/game, 75/week, 1,000/season, 2,000/year

• 11− to 12-year-olds: 75 pitches/game, 100/week, 1,000/season, 3,000/year

• 13− to 14-year-olds: 75 pitches/game, 125/week, 1,000/season, 3,000/year

▸ Do not throw curveballs before age 14 or sliders before age 16.

▸ Avoid pitching “showcases.”

▸ Pitch for only one team at a time.

▸ Do not pitch and catch for the same team.

MIAMI — For serious young baseball players, adherence to recommended pitching limitations and proper management of overuse injuries can help ensure continued healthy pitching, Dr. Andrew Gregory explained at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.

The highly repetitive action of pitching can result in overuse injuries of two joints, generally referred to as Little League elbow or Little League shoulder.

Young pitchers are often serious in their sport, sometimes playing on multiple teams at once in hopes of earning a college scholarship or playing professionally. Such intense participation at an early age, however, can have long-term consequences. About one-third of Little League pitchers never play in high school because of overuse in their younger years, according to Dr. Gregory of the departments of orthopedics and pediatrics at Vanderbilt University in Nashville, Tenn.

This number may seem high, but pain is a common occurrence in pitching. According to a review of 476 pitchers aged 9–14 years, 7% of youth pitching results in pain, and 28% of pitchers report elbow pain at least once in a season. As Dr. Gregory explained, “They're subjecting themselves to this maximal force over and over again, by trying to throw as hard as they can every time.”

Most young pitchers with Little League elbow will present with medial elbow pain that occurs only with throwing; they also may not be able to fully straighten the arm. “It is a constellation of problems, the first being stress injury to the medial epicondyle apophysis,” Dr. Gregory said in an interview. He explained that continuing to pitch through the pain can lead to a loss of blood supply to the joint and irritation of the ulnar nerve.

The main treatment should be rest from all throwing. Treatment also should include ice, NSAIDs for pain, scapular and core stabilization, and a gradual return to throwing after 6–12 weeks, when throwing no longer hurts. Pitching should be resumed only when the athlete can throw without any pain.

Dr. Gregory said that patients should be referred in the following cases: an acute injury with a “pop,” significant widening of the apophysis visible on x-ray, opening with valgus stress, or persistent pain with throwing despite following treatment measures.

Little League elbow is seen in players aged 9–14 years. After the medial epicondylar apophysis closes at age 15–17 years in boys (age 14 in girls), these symptoms are likely caused by injury to the ligament instead.

Dr. Gregory reviewed pitching restrictions that were designed to minimize the likelihood of developing an overuse injury. (See box.) He recommended that physicians have handouts with safety tips to give to parents.

A fragmented medial epicondyle apophysis is common in pitchers. Courtesy Dr. Andrew Gregory

'They're subjecting themselves to this maximal force over and over again,' by pitching as hard as they can. DR. GREGORY

Preventing Pitching Injuries

▸ Observe the following pitch count limits:

• 9− to 10-year-olds: 50 pitches/game, 75/week, 1,000/season, 2,000/year

• 11− to 12-year-olds: 75 pitches/game, 100/week, 1,000/season, 3,000/year

• 13− to 14-year-olds: 75 pitches/game, 125/week, 1,000/season, 3,000/year

▸ Do not throw curveballs before age 14 or sliders before age 16.

▸ Avoid pitching “showcases.”

▸ Pitch for only one team at a time.

▸ Do not pitch and catch for the same team.