Bruce Jancin

SAN ANTONIO – Accelerated partial-breast brachytherapy, delivered as part of breast-conserving therapy for early breast cancer, was associated with twice the mastectomy rate when compared with standard whole-breast irradiation in a large study.

Moreover, accelerated partial-breast brachytherapy entailed substantially higher rates of both acute and late complications, Dr. Benjamin D. Smith said in a presentation of the study findings at the San Antonio Breast Cancer Symposium.

Investigators reviewed Medicare claims data for all 130,535 beneficiaries whose early breast cancer was treated with lumpectomy followed by adjuvant radiation during 2000-2007. The use of accelerated partial-breast brachytherapy in this population rose from less than 1% in 2000 to 13% in 2007.

The incidence of mastectomy during 5 years of follow-up was 4% in 7,291 brachytherapy recipients, compared with 2% after whole breast irradiation (P less than .001). Upon adjustment for the brachytherapy recipients’ older average age, more comorbid conditions, and lesser rate of positive axillary lymph nodes, brachytherapy was associated with a 2.2-fold increased risk of losing the treated breast within 5 years, reported Dr. Smith, a radiation oncologist at the University of Texas M.D. Anderson Cancer Center, Houston.

"When we adjusted for various clinical and sociodemographic factors, to our surprise brachytherapy was the variable that had the strongest correlation with the risk of subsequent mastectomy," he noted.

Partial-breast brachytherapy was also associated with significantly higher rates of postoperative wound infection and acute noninfectious complications as well as increased 5-year rates of fat necrosis and breast pain. Fat necrosis is considered a marker of tissue injury caused by surgery and/or radiotherapy.

Within 1 year of breast cancer diagnosis, infectious complications involving breast or surrounding skin or soft tissues occurred in 16% of women treated with brachytherapy vs. 10% of those who received standard whole breast radiation.

Noninfectious complications including surgical wound breakdown, postoperative bleeding, or seroma formation were twice as common with brachytherapy at 16% and 8%, respectively.

Five-year rates of fat necrosis (9% vs. 4%) and breast pain (15% vs. 12%) also were higher with brachytherapy.

Accelerated partial-breast brachytherapy was developed to address the shortcomings of whole-breast irradiation, the historic standard of care, which entails up to 7 weeks of daily Monday-through-Friday treatment. Whole-breast irradiation is inconvenient. Indeed, it’s such a hardship, especially for patients in rural areas distant from a radiotherapy center, that some women opt for mastectomy as a matter of convenience. Moreover, 15%-30% of women who undergo lumpectomy forgo prescribed radiation therapy, placing themselves at increased risk of local recurrence.

Accelerated partial-breast brachytherapy may improve patient compliance with radiotherapy. It shortens the treatment course to 1 week. It entails temporary placement of radioactive beads within the breast via a catheter system. This method delivers radiation only to breast tissue immediately adjacent to the lumpectomy. This technique is but one of several forms of partial breast irradiation, however; the new findings don’t apply to 3-D external beam radiation, for example.

Accelerated partial breast brachytherapy has boomed in popularity in recent years, especially in community practice. But these new data may put the brakes on that trend.

"This study has changed the way that I think about these two different treatment options, and it’s changed the way I practice," Dr. Smith said in an interview.

Dr. Jennifer A. Ligibel, who chaired a press conference where Dr. Smith presented his findings, said the study carries an important message: "Although observational data using a claims database are no substitute for a randomized trial with long-term follow-up, what we see in this study is that this technique was not as effective and it was also associated with a lot more complications. So if your argument in using this is that it’s sparing patients from additional problems, we’re not seeing that in this study.

"I think this study really does give pause to the incorporation of accelerated partial-breast brachytherapy into routine clinical practice. These results should make people wait for the results of the ongoing randomized trials before they offer this as a standard procedure for their patients," added Dr. Ligibel of Dana-Farber Cancer Center, Boston.

The major randomized trial underway is the National Surgical Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 study. The NSABP B-39/RTOG 0413 trial has enrolled 4,000 of a planned 4,500 patients with early breast cancer. The emphasis is on patients under age 50, since they have a higher local recurrence risk than older women. Participants are randomized to whole-breast radiation or various forms of partial breast irradiation after lumpectomy. Mature results aren’t expected until mid-decade.

Dr. Smith and Dr. Ligibel declared having no relevant financial interests.

SAN ANTONIO – Accelerated partial-breast brachytherapy, delivered as part of breast-conserving therapy for early breast cancer, was associated with twice the mastectomy rate when compared with standard whole-breast irradiation in a large study.

Moreover, accelerated partial-breast brachytherapy entailed substantially higher rates of both acute and late complications, Dr. Benjamin D. Smith said in a presentation of the study findings at the San Antonio Breast Cancer Symposium.

Investigators reviewed Medicare claims data for all 130,535 beneficiaries whose early breast cancer was treated with lumpectomy followed by adjuvant radiation during 2000-2007. The use of accelerated partial-breast brachytherapy in this population rose from less than 1% in 2000 to 13% in 2007.

The incidence of mastectomy during 5 years of follow-up was 4% in 7,291 brachytherapy recipients, compared with 2% after whole breast irradiation (P less than .001). Upon adjustment for the brachytherapy recipients’ older average age, more comorbid conditions, and lesser rate of positive axillary lymph nodes, brachytherapy was associated with a 2.2-fold increased risk of losing the treated breast within 5 years, reported Dr. Smith, a radiation oncologist at the University of Texas M.D. Anderson Cancer Center, Houston.

"When we adjusted for various clinical and sociodemographic factors, to our surprise brachytherapy was the variable that had the strongest correlation with the risk of subsequent mastectomy," he noted.

Partial-breast brachytherapy was also associated with significantly higher rates of postoperative wound infection and acute noninfectious complications as well as increased 5-year rates of fat necrosis and breast pain. Fat necrosis is considered a marker of tissue injury caused by surgery and/or radiotherapy.

Within 1 year of breast cancer diagnosis, infectious complications involving breast or surrounding skin or soft tissues occurred in 16% of women treated with brachytherapy vs. 10% of those who received standard whole breast radiation.

Noninfectious complications including surgical wound breakdown, postoperative bleeding, or seroma formation were twice as common with brachytherapy at 16% and 8%, respectively.

Five-year rates of fat necrosis (9% vs. 4%) and breast pain (15% vs. 12%) also were higher with brachytherapy.

Accelerated partial-breast brachytherapy was developed to address the shortcomings of whole-breast irradiation, the historic standard of care, which entails up to 7 weeks of daily Monday-through-Friday treatment. Whole-breast irradiation is inconvenient. Indeed, it’s such a hardship, especially for patients in rural areas distant from a radiotherapy center, that some women opt for mastectomy as a matter of convenience. Moreover, 15%-30% of women who undergo lumpectomy forgo prescribed radiation therapy, placing themselves at increased risk of local recurrence.

Accelerated partial-breast brachytherapy may improve patient compliance with radiotherapy. It shortens the treatment course to 1 week. It entails temporary placement of radioactive beads within the breast via a catheter system. This method delivers radiation only to breast tissue immediately adjacent to the lumpectomy. This technique is but one of several forms of partial breast irradiation, however; the new findings don’t apply to 3-D external beam radiation, for example.

Accelerated partial breast brachytherapy has boomed in popularity in recent years, especially in community practice. But these new data may put the brakes on that trend.

"This study has changed the way that I think about these two different treatment options, and it’s changed the way I practice," Dr. Smith said in an interview.

Dr. Jennifer A. Ligibel, who chaired a press conference where Dr. Smith presented his findings, said the study carries an important message: "Although observational data using a claims database are no substitute for a randomized trial with long-term follow-up, what we see in this study is that this technique was not as effective and it was also associated with a lot more complications. So if your argument in using this is that it’s sparing patients from additional problems, we’re not seeing that in this study.

"I think this study really does give pause to the incorporation of accelerated partial-breast brachytherapy into routine clinical practice. These results should make people wait for the results of the ongoing randomized trials before they offer this as a standard procedure for their patients," added Dr. Ligibel of Dana-Farber Cancer Center, Boston.

The major randomized trial underway is the National Surgical Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 study. The NSABP B-39/RTOG 0413 trial has enrolled 4,000 of a planned 4,500 patients with early breast cancer. The emphasis is on patients under age 50, since they have a higher local recurrence risk than older women. Participants are randomized to whole-breast radiation or various forms of partial breast irradiation after lumpectomy. Mature results aren’t expected until mid-decade.

Dr. Smith and Dr. Ligibel declared having no relevant financial interests.

SAN ANTONIO – Accelerated partial-breast brachytherapy, delivered as part of breast-conserving therapy for early breast cancer, was associated with twice the mastectomy rate when compared with standard whole-breast irradiation in a large study.

Moreover, accelerated partial-breast brachytherapy entailed substantially higher rates of both acute and late complications, Dr. Benjamin D. Smith said in a presentation of the study findings at the San Antonio Breast Cancer Symposium.

Investigators reviewed Medicare claims data for all 130,535 beneficiaries whose early breast cancer was treated with lumpectomy followed by adjuvant radiation during 2000-2007. The use of accelerated partial-breast brachytherapy in this population rose from less than 1% in 2000 to 13% in 2007.

The incidence of mastectomy during 5 years of follow-up was 4% in 7,291 brachytherapy recipients, compared with 2% after whole breast irradiation (P less than .001). Upon adjustment for the brachytherapy recipients’ older average age, more comorbid conditions, and lesser rate of positive axillary lymph nodes, brachytherapy was associated with a 2.2-fold increased risk of losing the treated breast within 5 years, reported Dr. Smith, a radiation oncologist at the University of Texas M.D. Anderson Cancer Center, Houston.

"When we adjusted for various clinical and sociodemographic factors, to our surprise brachytherapy was the variable that had the strongest correlation with the risk of subsequent mastectomy," he noted.

Partial-breast brachytherapy was also associated with significantly higher rates of postoperative wound infection and acute noninfectious complications as well as increased 5-year rates of fat necrosis and breast pain. Fat necrosis is considered a marker of tissue injury caused by surgery and/or radiotherapy.

Within 1 year of breast cancer diagnosis, infectious complications involving breast or surrounding skin or soft tissues occurred in 16% of women treated with brachytherapy vs. 10% of those who received standard whole breast radiation.

Noninfectious complications including surgical wound breakdown, postoperative bleeding, or seroma formation were twice as common with brachytherapy at 16% and 8%, respectively.

Five-year rates of fat necrosis (9% vs. 4%) and breast pain (15% vs. 12%) also were higher with brachytherapy.

Accelerated partial-breast brachytherapy was developed to address the shortcomings of whole-breast irradiation, the historic standard of care, which entails up to 7 weeks of daily Monday-through-Friday treatment. Whole-breast irradiation is inconvenient. Indeed, it’s such a hardship, especially for patients in rural areas distant from a radiotherapy center, that some women opt for mastectomy as a matter of convenience. Moreover, 15%-30% of women who undergo lumpectomy forgo prescribed radiation therapy, placing themselves at increased risk of local recurrence.

Accelerated partial-breast brachytherapy may improve patient compliance with radiotherapy. It shortens the treatment course to 1 week. It entails temporary placement of radioactive beads within the breast via a catheter system. This method delivers radiation only to breast tissue immediately adjacent to the lumpectomy. This technique is but one of several forms of partial breast irradiation, however; the new findings don’t apply to 3-D external beam radiation, for example.

Accelerated partial breast brachytherapy has boomed in popularity in recent years, especially in community practice. But these new data may put the brakes on that trend.

"This study has changed the way that I think about these two different treatment options, and it’s changed the way I practice," Dr. Smith said in an interview.

Dr. Jennifer A. Ligibel, who chaired a press conference where Dr. Smith presented his findings, said the study carries an important message: "Although observational data using a claims database are no substitute for a randomized trial with long-term follow-up, what we see in this study is that this technique was not as effective and it was also associated with a lot more complications. So if your argument in using this is that it’s sparing patients from additional problems, we’re not seeing that in this study.

"I think this study really does give pause to the incorporation of accelerated partial-breast brachytherapy into routine clinical practice. These results should make people wait for the results of the ongoing randomized trials before they offer this as a standard procedure for their patients," added Dr. Ligibel of Dana-Farber Cancer Center, Boston.

The major randomized trial underway is the National Surgical Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 study. The NSABP B-39/RTOG 0413 trial has enrolled 4,000 of a planned 4,500 patients with early breast cancer. The emphasis is on patients under age 50, since they have a higher local recurrence risk than older women. Participants are randomized to whole-breast radiation or various forms of partial breast irradiation after lumpectomy. Mature results aren’t expected until mid-decade.

Dr. Smith and Dr. Ligibel declared having no relevant financial interests.

LISBON – The tower technique is a novel method of injecting hyaluronic acid fillers that is particularly well suited for anatomic locations where underlying structural support for soft tissue has been lost because of aging.

The tower technique creates a deep base of scaffolding that extends through the entire subcutis. It reintroduces lost structural support for the overlying facial soft tissue rather than simply filling lines, Dr. C. William Hanke explained in a plenary lecture at the annual congress of the European Academy of Dermatology and Venereology.

"The Big Three with facial aging are skin quality, facial volume, and laxity. Volume trumps the other two. ... You can improve skin quality and laxity with volume alone," said Dr. Hanke of the Laser and Skin Surgery Center of Indiana, Carmel.

Areas particularly amenable to the tower technique include the nasolabial folds, marionette lines, the brow region, the chin compartment, and the prejowl sulcus. The best areas in which to employ the tower technique have underlying bony structural support, a thick subcutis, or an overlying thick dermis.

The technique is easily mastered, he said. "You take your syringe of hyaluronic acid and point it straight down at the bone, perpendicular, and then you inject as you withdraw. You deposit decreasing amounts of the filler as you withdraw the needle, creating a pyramid-like tower," he explained. "This is really an amazing thing in that it props up the skin right before your eyes. It’s minimally painful, there are a minimum number of injections, and the complications – such as bruising – are very minimal as well."

Dr. Hanke generally utilizes 30-gauge half-inch needles for the injections. For a nasolabial fold or superior marionette line he creates two or three towers, injecting 0.1-0.2 mL of filler into each. Inferior marionette lines get one or two towers, with 0.1-0.3 mL of product placed in each. The lateral brow lift entails two or three towers, each with 0.1 mL of filler.

Restoring support of the mental area requires one to three towers, each constructed of 0.2-0.3 mL of filler placed from the periosteum to the deep dermis. The prejowl sulcus can be shored up with one or two towers, each containing 0.2-0.3 mL of filler.

The tower technique is for use with hyaluronic acid fillers. It’s not appropriate for poly-L-lactic acid or calcium hydroxyapatite fillers, which need to be placed deeper or in a single plane.

Dr. Hanke noted that he didn’t come up with the tower technique.

"I first heard about it in Germany. I think other people were using it, too. I’ve [also] heard about this technique from the Canadians. They call it the tent pole technique," he said.

Dr. Hanke and his colleagues recently wrote a detailed how-to guide to the tower technique (J. Drugs Dermatol. 2011;10:1277-80).

He reported having no relevant financial interests.

LISBON – The tower technique is a novel method of injecting hyaluronic acid fillers that is particularly well suited for anatomic locations where underlying structural support for soft tissue has been lost because of aging.

The tower technique creates a deep base of scaffolding that extends through the entire subcutis. It reintroduces lost structural support for the overlying facial soft tissue rather than simply filling lines, Dr. C. William Hanke explained in a plenary lecture at the annual congress of the European Academy of Dermatology and Venereology.

"The Big Three with facial aging are skin quality, facial volume, and laxity. Volume trumps the other two. ... You can improve skin quality and laxity with volume alone," said Dr. Hanke of the Laser and Skin Surgery Center of Indiana, Carmel.

Areas particularly amenable to the tower technique include the nasolabial folds, marionette lines, the brow region, the chin compartment, and the prejowl sulcus. The best areas in which to employ the tower technique have underlying bony structural support, a thick subcutis, or an overlying thick dermis.

The technique is easily mastered, he said. "You take your syringe of hyaluronic acid and point it straight down at the bone, perpendicular, and then you inject as you withdraw. You deposit decreasing amounts of the filler as you withdraw the needle, creating a pyramid-like tower," he explained. "This is really an amazing thing in that it props up the skin right before your eyes. It’s minimally painful, there are a minimum number of injections, and the complications – such as bruising – are very minimal as well."

Dr. Hanke generally utilizes 30-gauge half-inch needles for the injections. For a nasolabial fold or superior marionette line he creates two or three towers, injecting 0.1-0.2 mL of filler into each. Inferior marionette lines get one or two towers, with 0.1-0.3 mL of product placed in each. The lateral brow lift entails two or three towers, each with 0.1 mL of filler.

Restoring support of the mental area requires one to three towers, each constructed of 0.2-0.3 mL of filler placed from the periosteum to the deep dermis. The prejowl sulcus can be shored up with one or two towers, each containing 0.2-0.3 mL of filler.

The tower technique is for use with hyaluronic acid fillers. It’s not appropriate for poly-L-lactic acid or calcium hydroxyapatite fillers, which need to be placed deeper or in a single plane.

Dr. Hanke noted that he didn’t come up with the tower technique.

"I first heard about it in Germany. I think other people were using it, too. I’ve [also] heard about this technique from the Canadians. They call it the tent pole technique," he said.

Dr. Hanke and his colleagues recently wrote a detailed how-to guide to the tower technique (J. Drugs Dermatol. 2011;10:1277-80).

He reported having no relevant financial interests.

LISBON – The tower technique is a novel method of injecting hyaluronic acid fillers that is particularly well suited for anatomic locations where underlying structural support for soft tissue has been lost because of aging.

The tower technique creates a deep base of scaffolding that extends through the entire subcutis. It reintroduces lost structural support for the overlying facial soft tissue rather than simply filling lines, Dr. C. William Hanke explained in a plenary lecture at the annual congress of the European Academy of Dermatology and Venereology.

"The Big Three with facial aging are skin quality, facial volume, and laxity. Volume trumps the other two. ... You can improve skin quality and laxity with volume alone," said Dr. Hanke of the Laser and Skin Surgery Center of Indiana, Carmel.

Areas particularly amenable to the tower technique include the nasolabial folds, marionette lines, the brow region, the chin compartment, and the prejowl sulcus. The best areas in which to employ the tower technique have underlying bony structural support, a thick subcutis, or an overlying thick dermis.

The technique is easily mastered, he said. "You take your syringe of hyaluronic acid and point it straight down at the bone, perpendicular, and then you inject as you withdraw. You deposit decreasing amounts of the filler as you withdraw the needle, creating a pyramid-like tower," he explained. "This is really an amazing thing in that it props up the skin right before your eyes. It’s minimally painful, there are a minimum number of injections, and the complications – such as bruising – are very minimal as well."

Dr. Hanke generally utilizes 30-gauge half-inch needles for the injections. For a nasolabial fold or superior marionette line he creates two or three towers, injecting 0.1-0.2 mL of filler into each. Inferior marionette lines get one or two towers, with 0.1-0.3 mL of product placed in each. The lateral brow lift entails two or three towers, each with 0.1 mL of filler.

Restoring support of the mental area requires one to three towers, each constructed of 0.2-0.3 mL of filler placed from the periosteum to the deep dermis. The prejowl sulcus can be shored up with one or two towers, each containing 0.2-0.3 mL of filler.

The tower technique is for use with hyaluronic acid fillers. It’s not appropriate for poly-L-lactic acid or calcium hydroxyapatite fillers, which need to be placed deeper or in a single plane.

Dr. Hanke noted that he didn’t come up with the tower technique.

"I first heard about it in Germany. I think other people were using it, too. I’ve [also] heard about this technique from the Canadians. They call it the tent pole technique," he said.

Dr. Hanke and his colleagues recently wrote a detailed how-to guide to the tower technique (J. Drugs Dermatol. 2011;10:1277-80).

He reported having no relevant financial interests.

ORLANDO – A history of forced sex before 18 years of age was associated with a 56% increased risk of premature cardiovascular events among women participating in the Nurses' Health Study II.

In all, 11% of the nurses enrolled in the study reported having been raped or subjected to other forms of severe forced sexual activity during childhood or adolescence. They had a 56% increased rate of acute MI or stroke before age 60, compared with those who had no history of early sexual abuse. The association was stronger for stroke than MI, Janet Wilson Rich-Edwards, Sc.D., reported at the annual scientific sessions of the American Heart Association.

The Nurses' Health Study II is the latest and far and away the largest of three studies by different research groups showing that sexually abused girls are at significantly increased cardiovascular risk as adults. It was also the most rigorous of the studies in terms of ascertainment of cardiovascular events, which were typically validated by participants’ medical records, explained Dr. Rich-Edwards of the department of epidemiology at Brigham and Women’s Hospital, Boston.

She and her colleagues were able to analyze the impact of the standard cardiovascular risk factors as mediators of the association between early sexual abuse and premature cardiovascular events. The investigators found that smoking, alcohol consumption, diabetes, adult body mass index, and hypertension accounted for 38% of the association between forced sexual activity and cardiovascular events.

"That still leaves a lot of the risk left unexplained," she noted.

This analysis of the Nurses’ Health Study II included more than 67,000 nurses, most of them white, who in 2001 completed a questionnaire on sexual and physical abuse and who were 43-60 years old in 2007. By that year, 513 cases of stroke or MI had occurred in this relatively young population.

In addition to the 11% of subjects who reported forced sex before age 18, another 22% reported sexual touching-only by an older person. Some 9% of study participants indicated that they had experienced severe physical abuse (defined as having been hit repeatedly with an object, choked, or burned) before age 18.

Nurses with a history of childhood sexual touching but no further childhood sexual abuse had a cardiovascular event rate similar to that of women with no history whatsoever of childhood sexual abuse, in an analysis that was adjusted for age, race, parental cardiovascular disease history, body type at age 5 years, and parental education.

Women with a history of rape or other forced sex before age 18 had a 56% increased relative risk when the same factors were taken into account. When rates of the standard adult cardiovascular risk factors also were factored into the analysis, this association was somewhat attenuated. However, childhood forced sexual activity remained independently associated with a highly significant 34% increased risk of cardiovascular events, compared with women who had no history of early sexual abuse.

Severe physical abuse prior to age 18 was associated with an adjusted 46% increased risk of MI or stroke in the first-round analysis. However, when the results were further adjusted for the standard adult cardiovascular risk factors, the conventional risk factors were found to account for 47% of the association between severe physical abuse and cardiovascular disease. After that adjustment, severe physical abuse was associated with a residual 23% increased risk of cardiovascular events, which wasn’t statistically significant.

"It’s clear that this association is strong ... and we need to do a better job screening for and identifying childhood sexual abuse at an early age."

The 11% rate of rape or other forced sex prior to age 18 that was reported in this study is consistent with the findings of a landmark national telephone survey of 8,000 women conducted jointly by the National Institute of Justice and the Centers for Disease Control and Prevention in 1995-1996. In that National Violence Against Women study, 18% of surveyed women reported having been raped; 22% of first rapes occurred before age 12, and another 32% occurred at age 12-17.

"I have to say, no matter how many times I see these results, the data shock me every time," Dr. Rich-Edwards commented.

An important clinical implication of the Nurses’ Health Study II findings is that childhood sexual abuse has long-lasting effects. "There’s a really long tail of chronic disease that ensues from this," she stressed.

Given that close to 40% of the increased premature cardiovascular event rate in women with a history of childhood sex abuse can be explained by elevated levels of the standard cardiovascular risk factors, risk factor modification efforts should probably be applied at an earlier age in such women. Heightened stress reactivity among women with a history of abuse might figure in their increased cardiovascular risk, and future studies will examine specific interventions, she continued.

"I think our findings are probably most relevant to adult primary care practices. In that setting, it’s really first and foremost a matter of talking about the issue of childhood abuse and helping women to normalize it to some extent.

"Physicians can point out to them that although they may have had their bodies disrespected as children, there’s a lot they can do as adults to take good care of themselves, including all of our standard cardiovascular prevention efforts," Dr. Rich-Edwards said.

AHA President-elect Donna K. Arnett, Ph.D., professor and chair of the department of epidemiology at the University of Alabama at Birmingham, had this to say about the Nurses’ Health Study II findings: "It’s clear that this association is strong, it’s associated with traditional cardiovascular risk factors, and we need to do a better job screening for and identifying childhood sexual abuse at an early age."

The study was funded by the National Institutes of Health. Dr. Rich-Edwards reported no financial conflicts.

ORLANDO – A history of forced sex before 18 years of age was associated with a 56% increased risk of premature cardiovascular events among women participating in the Nurses' Health Study II.

In all, 11% of the nurses enrolled in the study reported having been raped or subjected to other forms of severe forced sexual activity during childhood or adolescence. They had a 56% increased rate of acute MI or stroke before age 60, compared with those who had no history of early sexual abuse. The association was stronger for stroke than MI, Janet Wilson Rich-Edwards, Sc.D., reported at the annual scientific sessions of the American Heart Association.

The Nurses' Health Study II is the latest and far and away the largest of three studies by different research groups showing that sexually abused girls are at significantly increased cardiovascular risk as adults. It was also the most rigorous of the studies in terms of ascertainment of cardiovascular events, which were typically validated by participants’ medical records, explained Dr. Rich-Edwards of the department of epidemiology at Brigham and Women’s Hospital, Boston.

She and her colleagues were able to analyze the impact of the standard cardiovascular risk factors as mediators of the association between early sexual abuse and premature cardiovascular events. The investigators found that smoking, alcohol consumption, diabetes, adult body mass index, and hypertension accounted for 38% of the association between forced sexual activity and cardiovascular events.

"That still leaves a lot of the risk left unexplained," she noted.

This analysis of the Nurses’ Health Study II included more than 67,000 nurses, most of them white, who in 2001 completed a questionnaire on sexual and physical abuse and who were 43-60 years old in 2007. By that year, 513 cases of stroke or MI had occurred in this relatively young population.

In addition to the 11% of subjects who reported forced sex before age 18, another 22% reported sexual touching-only by an older person. Some 9% of study participants indicated that they had experienced severe physical abuse (defined as having been hit repeatedly with an object, choked, or burned) before age 18.

Nurses with a history of childhood sexual touching but no further childhood sexual abuse had a cardiovascular event rate similar to that of women with no history whatsoever of childhood sexual abuse, in an analysis that was adjusted for age, race, parental cardiovascular disease history, body type at age 5 years, and parental education.

Women with a history of rape or other forced sex before age 18 had a 56% increased relative risk when the same factors were taken into account. When rates of the standard adult cardiovascular risk factors also were factored into the analysis, this association was somewhat attenuated. However, childhood forced sexual activity remained independently associated with a highly significant 34% increased risk of cardiovascular events, compared with women who had no history of early sexual abuse.

Severe physical abuse prior to age 18 was associated with an adjusted 46% increased risk of MI or stroke in the first-round analysis. However, when the results were further adjusted for the standard adult cardiovascular risk factors, the conventional risk factors were found to account for 47% of the association between severe physical abuse and cardiovascular disease. After that adjustment, severe physical abuse was associated with a residual 23% increased risk of cardiovascular events, which wasn’t statistically significant.

"It’s clear that this association is strong ... and we need to do a better job screening for and identifying childhood sexual abuse at an early age."

The 11% rate of rape or other forced sex prior to age 18 that was reported in this study is consistent with the findings of a landmark national telephone survey of 8,000 women conducted jointly by the National Institute of Justice and the Centers for Disease Control and Prevention in 1995-1996. In that National Violence Against Women study, 18% of surveyed women reported having been raped; 22% of first rapes occurred before age 12, and another 32% occurred at age 12-17.

"I have to say, no matter how many times I see these results, the data shock me every time," Dr. Rich-Edwards commented.

An important clinical implication of the Nurses’ Health Study II findings is that childhood sexual abuse has long-lasting effects. "There’s a really long tail of chronic disease that ensues from this," she stressed.

Given that close to 40% of the increased premature cardiovascular event rate in women with a history of childhood sex abuse can be explained by elevated levels of the standard cardiovascular risk factors, risk factor modification efforts should probably be applied at an earlier age in such women. Heightened stress reactivity among women with a history of abuse might figure in their increased cardiovascular risk, and future studies will examine specific interventions, she continued.

"I think our findings are probably most relevant to adult primary care practices. In that setting, it’s really first and foremost a matter of talking about the issue of childhood abuse and helping women to normalize it to some extent.

"Physicians can point out to them that although they may have had their bodies disrespected as children, there’s a lot they can do as adults to take good care of themselves, including all of our standard cardiovascular prevention efforts," Dr. Rich-Edwards said.

AHA President-elect Donna K. Arnett, Ph.D., professor and chair of the department of epidemiology at the University of Alabama at Birmingham, had this to say about the Nurses’ Health Study II findings: "It’s clear that this association is strong, it’s associated with traditional cardiovascular risk factors, and we need to do a better job screening for and identifying childhood sexual abuse at an early age."

The study was funded by the National Institutes of Health. Dr. Rich-Edwards reported no financial conflicts.

ORLANDO – A history of forced sex before 18 years of age was associated with a 56% increased risk of premature cardiovascular events among women participating in the Nurses' Health Study II.

In all, 11% of the nurses enrolled in the study reported having been raped or subjected to other forms of severe forced sexual activity during childhood or adolescence. They had a 56% increased rate of acute MI or stroke before age 60, compared with those who had no history of early sexual abuse. The association was stronger for stroke than MI, Janet Wilson Rich-Edwards, Sc.D., reported at the annual scientific sessions of the American Heart Association.

The Nurses' Health Study II is the latest and far and away the largest of three studies by different research groups showing that sexually abused girls are at significantly increased cardiovascular risk as adults. It was also the most rigorous of the studies in terms of ascertainment of cardiovascular events, which were typically validated by participants’ medical records, explained Dr. Rich-Edwards of the department of epidemiology at Brigham and Women’s Hospital, Boston.

She and her colleagues were able to analyze the impact of the standard cardiovascular risk factors as mediators of the association between early sexual abuse and premature cardiovascular events. The investigators found that smoking, alcohol consumption, diabetes, adult body mass index, and hypertension accounted for 38% of the association between forced sexual activity and cardiovascular events.

"That still leaves a lot of the risk left unexplained," she noted.

This analysis of the Nurses’ Health Study II included more than 67,000 nurses, most of them white, who in 2001 completed a questionnaire on sexual and physical abuse and who were 43-60 years old in 2007. By that year, 513 cases of stroke or MI had occurred in this relatively young population.

In addition to the 11% of subjects who reported forced sex before age 18, another 22% reported sexual touching-only by an older person. Some 9% of study participants indicated that they had experienced severe physical abuse (defined as having been hit repeatedly with an object, choked, or burned) before age 18.

Nurses with a history of childhood sexual touching but no further childhood sexual abuse had a cardiovascular event rate similar to that of women with no history whatsoever of childhood sexual abuse, in an analysis that was adjusted for age, race, parental cardiovascular disease history, body type at age 5 years, and parental education.

Women with a history of rape or other forced sex before age 18 had a 56% increased relative risk when the same factors were taken into account. When rates of the standard adult cardiovascular risk factors also were factored into the analysis, this association was somewhat attenuated. However, childhood forced sexual activity remained independently associated with a highly significant 34% increased risk of cardiovascular events, compared with women who had no history of early sexual abuse.

Severe physical abuse prior to age 18 was associated with an adjusted 46% increased risk of MI or stroke in the first-round analysis. However, when the results were further adjusted for the standard adult cardiovascular risk factors, the conventional risk factors were found to account for 47% of the association between severe physical abuse and cardiovascular disease. After that adjustment, severe physical abuse was associated with a residual 23% increased risk of cardiovascular events, which wasn’t statistically significant.

"It’s clear that this association is strong ... and we need to do a better job screening for and identifying childhood sexual abuse at an early age."

The 11% rate of rape or other forced sex prior to age 18 that was reported in this study is consistent with the findings of a landmark national telephone survey of 8,000 women conducted jointly by the National Institute of Justice and the Centers for Disease Control and Prevention in 1995-1996. In that National Violence Against Women study, 18% of surveyed women reported having been raped; 22% of first rapes occurred before age 12, and another 32% occurred at age 12-17.

"I have to say, no matter how many times I see these results, the data shock me every time," Dr. Rich-Edwards commented.

An important clinical implication of the Nurses’ Health Study II findings is that childhood sexual abuse has long-lasting effects. "There’s a really long tail of chronic disease that ensues from this," she stressed.

Given that close to 40% of the increased premature cardiovascular event rate in women with a history of childhood sex abuse can be explained by elevated levels of the standard cardiovascular risk factors, risk factor modification efforts should probably be applied at an earlier age in such women. Heightened stress reactivity among women with a history of abuse might figure in their increased cardiovascular risk, and future studies will examine specific interventions, she continued.

"I think our findings are probably most relevant to adult primary care practices. In that setting, it’s really first and foremost a matter of talking about the issue of childhood abuse and helping women to normalize it to some extent.

"Physicians can point out to them that although they may have had their bodies disrespected as children, there’s a lot they can do as adults to take good care of themselves, including all of our standard cardiovascular prevention efforts," Dr. Rich-Edwards said.

AHA President-elect Donna K. Arnett, Ph.D., professor and chair of the department of epidemiology at the University of Alabama at Birmingham, had this to say about the Nurses’ Health Study II findings: "It’s clear that this association is strong, it’s associated with traditional cardiovascular risk factors, and we need to do a better job screening for and identifying childhood sexual abuse at an early age."

The study was funded by the National Institutes of Health. Dr. Rich-Edwards reported no financial conflicts.

LISBON – Applying a fast-drying cyanoacrylate glue to the proximal nail fold once or twice weekly is an inexpensive and effective treatment for the habit-tic condition of onychotillomania.

Onychotillomania is often categorized as a compulsive psychiatric disorder. The same psychiatric medications employed in cases of obsessive-compulsive disorder, including selective serotonin reuptake inhibitors, are sometimes prescribed to good effect.

Gluing the problem nail – it is most often a thumbnail – can work, and at negligible cost, with low risk, and no risk of systemic side effects stemming from psychiatric medications, Dr. Veronique Blatiere said at the annual congress of the European Academy of Dermatology and Venereology.

©2009 Elsevier Inc. All rights reserved.

The likely mechanisms of benefit from the cyanoacrylate glue, such as Super Glue or Krazy Glue, are twofold: the built-up layer of glue creates a physical barrier that helps protect the proximal nail fold against the patient’s mindless repetitive picking, and, at the same time, the artificial layer promotes self-awareness of the tic habit, said Dr. Blatiere, a dermatologist at the University of Montpellier (France).

She credited the instant nail-gluing therapy to Dr. Daniel S. Ring, a Chesterfield, Mo., dermatologist who presented the approach in the Archives of Dermatology (2010;146:1222-3).

Dr. Ring described onychotillomania as a common condition given little attention in most dermatologic textbooks. Onset is typically in adulthood, and patients frequently bring up the problem as an "oh, by the way" afterthought during an office visit scheduled for another reason.

Patients typically display parallel transverse ridges running from the proximal nail fold to the distal nail plate along with a lack of cuticle. These changes result from years of picking at the cuticle or pushing it back.

In his report, Dr. Ring described two cases in detail and mentioned 10 others successfully treated with glue. The affected nails typically normalized after 3-6 months of weekly gluing.

Dr. Blatiere said that instant-drying cyanoacrylate glues may also be worth investigating for the treatment of chronic paronychia.

However, she noted that a potential hazard of applying this therapy for months at a time is development of an allergic contact dermatitis to the acrylate.

Neither Dr. Ring nor Dr. Blatiere reported having any financial conflicts.

LISBON – Applying a fast-drying cyanoacrylate glue to the proximal nail fold once or twice weekly is an inexpensive and effective treatment for the habit-tic condition of onychotillomania.

Onychotillomania is often categorized as a compulsive psychiatric disorder. The same psychiatric medications employed in cases of obsessive-compulsive disorder, including selective serotonin reuptake inhibitors, are sometimes prescribed to good effect.

Gluing the problem nail – it is most often a thumbnail – can work, and at negligible cost, with low risk, and no risk of systemic side effects stemming from psychiatric medications, Dr. Veronique Blatiere said at the annual congress of the European Academy of Dermatology and Venereology.

©2009 Elsevier Inc. All rights reserved.

The likely mechanisms of benefit from the cyanoacrylate glue, such as Super Glue or Krazy Glue, are twofold: the built-up layer of glue creates a physical barrier that helps protect the proximal nail fold against the patient’s mindless repetitive picking, and, at the same time, the artificial layer promotes self-awareness of the tic habit, said Dr. Blatiere, a dermatologist at the University of Montpellier (France).

She credited the instant nail-gluing therapy to Dr. Daniel S. Ring, a Chesterfield, Mo., dermatologist who presented the approach in the Archives of Dermatology (2010;146:1222-3).

Dr. Ring described onychotillomania as a common condition given little attention in most dermatologic textbooks. Onset is typically in adulthood, and patients frequently bring up the problem as an "oh, by the way" afterthought during an office visit scheduled for another reason.

Patients typically display parallel transverse ridges running from the proximal nail fold to the distal nail plate along with a lack of cuticle. These changes result from years of picking at the cuticle or pushing it back.

In his report, Dr. Ring described two cases in detail and mentioned 10 others successfully treated with glue. The affected nails typically normalized after 3-6 months of weekly gluing.

Dr. Blatiere said that instant-drying cyanoacrylate glues may also be worth investigating for the treatment of chronic paronychia.

However, she noted that a potential hazard of applying this therapy for months at a time is development of an allergic contact dermatitis to the acrylate.

Neither Dr. Ring nor Dr. Blatiere reported having any financial conflicts.

LISBON – Applying a fast-drying cyanoacrylate glue to the proximal nail fold once or twice weekly is an inexpensive and effective treatment for the habit-tic condition of onychotillomania.

Onychotillomania is often categorized as a compulsive psychiatric disorder. The same psychiatric medications employed in cases of obsessive-compulsive disorder, including selective serotonin reuptake inhibitors, are sometimes prescribed to good effect.

Gluing the problem nail – it is most often a thumbnail – can work, and at negligible cost, with low risk, and no risk of systemic side effects stemming from psychiatric medications, Dr. Veronique Blatiere said at the annual congress of the European Academy of Dermatology and Venereology.

©2009 Elsevier Inc. All rights reserved.

The likely mechanisms of benefit from the cyanoacrylate glue, such as Super Glue or Krazy Glue, are twofold: the built-up layer of glue creates a physical barrier that helps protect the proximal nail fold against the patient’s mindless repetitive picking, and, at the same time, the artificial layer promotes self-awareness of the tic habit, said Dr. Blatiere, a dermatologist at the University of Montpellier (France).

She credited the instant nail-gluing therapy to Dr. Daniel S. Ring, a Chesterfield, Mo., dermatologist who presented the approach in the Archives of Dermatology (2010;146:1222-3).

Dr. Ring described onychotillomania as a common condition given little attention in most dermatologic textbooks. Onset is typically in adulthood, and patients frequently bring up the problem as an "oh, by the way" afterthought during an office visit scheduled for another reason.

Patients typically display parallel transverse ridges running from the proximal nail fold to the distal nail plate along with a lack of cuticle. These changes result from years of picking at the cuticle or pushing it back.

In his report, Dr. Ring described two cases in detail and mentioned 10 others successfully treated with glue. The affected nails typically normalized after 3-6 months of weekly gluing.

Dr. Blatiere said that instant-drying cyanoacrylate glues may also be worth investigating for the treatment of chronic paronychia.

However, she noted that a potential hazard of applying this therapy for months at a time is development of an allergic contact dermatitis to the acrylate.

Neither Dr. Ring nor Dr. Blatiere reported having any financial conflicts.

LISBON – Neck liposuction using tumescent local anesthesia is the cosmetic dermatology procedure having the optimal combination of high patient satisfaction, minimal complications, and a short learning curve.

"What I consider to be the No. 1, home-run procedure in all of dermatosurgery is liposuction of the neck," Dr. C. William Hanke, a dermatologic surgeon, said during a plenary lecture at the annual congress of the European Academy of Dermatology and Venereology.

"A long, youthful neck is felt to be a sign of beauty. When patients lose that – when their neck fills in with fat, and when the face and the neck become one – it’s not felt to be a sign of beauty. And that’s when liposuction of the neck comes in," explained Dr. Hanke of the Laser and Skin Surgery Center of Indiana, Carmel.

It is important to understand, however, that liposuction is no substitute for weight loss. The ideal candidate for neck liposuction is a young patient with good skin elasticity who has excess submandibular fat resulting in lost definition of the mandibular border.

Using liposuction to remove adipose tissue lying superficial to the platysmal muscle in such a patient, and redraping the skin to reduce the cervicomental angle to a well-defined 105-120 degrees with sharp mandibular demarcation, brings stellar cosmetic results.

In contrast, an elderly patient who is overweight or obese and has poor skin quality and redundant neck skin may need additional procedures, such as platysmal plication and laser resurfacing, he said.

Basically, neck liposuction entails filling the neck with tumescent anesthesia. "Any dermatologist can learn this," Dr. Hanke said. The fat is then suctioned using a combination of 1- to 3-mm cannulas with spatula tips placed through a primary entry point located in the mental crease. Additional holes can be placed for suctioning the lateral neck. The patient is entirely awake for the procedure, which can be performed in an office surgical suite, an ambulatory surgery center, or a hospital operating room.

"We sweep across the neck, suctioning the fat and transecting the septae that run through the fat. We can march into the jowls as well," he said.

Neuropraxia of the marginal mandibular nerve occurs in roughly 5% of cases of neck liposuction. The interruption of motor function typically lasts 4-6 weeks and is never permanent. The marginal mandibular nerve lies deep to the platysma, and the muscle would actually have to be punctured by the cannula to cause permanent nerve injury, Dr. Hanke said.

Immediately after the procedure he has patients wear a compression garment 24 hours a day for the first 1-2 days except while showering, then for 2-4 hours daily for 1-2 weeks. The compression garment helps in redraping the skin, prevents hematomas, speeds absorption of tumescent fluid, and prevents skin wrinkling.

Serious complications are exceedingly rare. In fact, in an early national survey of more than 15,000 patients treated with liposuction using tumescent local anesthesia, Dr. Hanke and coworkers reported no deaths or complications requiring hospital transfer (Dermatol. Surg. 1995;21:459-62).

The finding was confirmed in another national survey, this one involving nearly 67,000 liposuction procedures performed by dermatologic surgeons from 1994 to 2000 (Dermatol. Surg. 2002;28:971-8).

Occasionally, the platysmal bands are unmasked by neck liposuction. This is an unwelcome event, but marked improvement can be achieved through injection of small doses of botulinum toxin.

Dr. Hanke noted that he and Dr. William G. Stebbins recently performed an in-depth review of neck rejuvenation via liposuction, including proper patient selection, technical aspects of the procedure, postop care, and ancillary techniques (Dermatol. Ther. 2011;24:28-40).

Dr. Hanke reported having no financial conflicts of interest.

LISBON – Neck liposuction using tumescent local anesthesia is the cosmetic dermatology procedure having the optimal combination of high patient satisfaction, minimal complications, and a short learning curve.

"What I consider to be the No. 1, home-run procedure in all of dermatosurgery is liposuction of the neck," Dr. C. William Hanke, a dermatologic surgeon, said during a plenary lecture at the annual congress of the European Academy of Dermatology and Venereology.

"A long, youthful neck is felt to be a sign of beauty. When patients lose that – when their neck fills in with fat, and when the face and the neck become one – it’s not felt to be a sign of beauty. And that’s when liposuction of the neck comes in," explained Dr. Hanke of the Laser and Skin Surgery Center of Indiana, Carmel.

It is important to understand, however, that liposuction is no substitute for weight loss. The ideal candidate for neck liposuction is a young patient with good skin elasticity who has excess submandibular fat resulting in lost definition of the mandibular border.

Using liposuction to remove adipose tissue lying superficial to the platysmal muscle in such a patient, and redraping the skin to reduce the cervicomental angle to a well-defined 105-120 degrees with sharp mandibular demarcation, brings stellar cosmetic results.

In contrast, an elderly patient who is overweight or obese and has poor skin quality and redundant neck skin may need additional procedures, such as platysmal plication and laser resurfacing, he said.

Basically, neck liposuction entails filling the neck with tumescent anesthesia. "Any dermatologist can learn this," Dr. Hanke said. The fat is then suctioned using a combination of 1- to 3-mm cannulas with spatula tips placed through a primary entry point located in the mental crease. Additional holes can be placed for suctioning the lateral neck. The patient is entirely awake for the procedure, which can be performed in an office surgical suite, an ambulatory surgery center, or a hospital operating room.

"We sweep across the neck, suctioning the fat and transecting the septae that run through the fat. We can march into the jowls as well," he said.

Neuropraxia of the marginal mandibular nerve occurs in roughly 5% of cases of neck liposuction. The interruption of motor function typically lasts 4-6 weeks and is never permanent. The marginal mandibular nerve lies deep to the platysma, and the muscle would actually have to be punctured by the cannula to cause permanent nerve injury, Dr. Hanke said.

Immediately after the procedure he has patients wear a compression garment 24 hours a day for the first 1-2 days except while showering, then for 2-4 hours daily for 1-2 weeks. The compression garment helps in redraping the skin, prevents hematomas, speeds absorption of tumescent fluid, and prevents skin wrinkling.

Serious complications are exceedingly rare. In fact, in an early national survey of more than 15,000 patients treated with liposuction using tumescent local anesthesia, Dr. Hanke and coworkers reported no deaths or complications requiring hospital transfer (Dermatol. Surg. 1995;21:459-62).

The finding was confirmed in another national survey, this one involving nearly 67,000 liposuction procedures performed by dermatologic surgeons from 1994 to 2000 (Dermatol. Surg. 2002;28:971-8).

Occasionally, the platysmal bands are unmasked by neck liposuction. This is an unwelcome event, but marked improvement can be achieved through injection of small doses of botulinum toxin.

Dr. Hanke noted that he and Dr. William G. Stebbins recently performed an in-depth review of neck rejuvenation via liposuction, including proper patient selection, technical aspects of the procedure, postop care, and ancillary techniques (Dermatol. Ther. 2011;24:28-40).

Dr. Hanke reported having no financial conflicts of interest.

LISBON – Neck liposuction using tumescent local anesthesia is the cosmetic dermatology procedure having the optimal combination of high patient satisfaction, minimal complications, and a short learning curve.

"What I consider to be the No. 1, home-run procedure in all of dermatosurgery is liposuction of the neck," Dr. C. William Hanke, a dermatologic surgeon, said during a plenary lecture at the annual congress of the European Academy of Dermatology and Venereology.

"A long, youthful neck is felt to be a sign of beauty. When patients lose that – when their neck fills in with fat, and when the face and the neck become one – it’s not felt to be a sign of beauty. And that’s when liposuction of the neck comes in," explained Dr. Hanke of the Laser and Skin Surgery Center of Indiana, Carmel.

It is important to understand, however, that liposuction is no substitute for weight loss. The ideal candidate for neck liposuction is a young patient with good skin elasticity who has excess submandibular fat resulting in lost definition of the mandibular border.

Using liposuction to remove adipose tissue lying superficial to the platysmal muscle in such a patient, and redraping the skin to reduce the cervicomental angle to a well-defined 105-120 degrees with sharp mandibular demarcation, brings stellar cosmetic results.

In contrast, an elderly patient who is overweight or obese and has poor skin quality and redundant neck skin may need additional procedures, such as platysmal plication and laser resurfacing, he said.

Basically, neck liposuction entails filling the neck with tumescent anesthesia. "Any dermatologist can learn this," Dr. Hanke said. The fat is then suctioned using a combination of 1- to 3-mm cannulas with spatula tips placed through a primary entry point located in the mental crease. Additional holes can be placed for suctioning the lateral neck. The patient is entirely awake for the procedure, which can be performed in an office surgical suite, an ambulatory surgery center, or a hospital operating room.

"We sweep across the neck, suctioning the fat and transecting the septae that run through the fat. We can march into the jowls as well," he said.

Neuropraxia of the marginal mandibular nerve occurs in roughly 5% of cases of neck liposuction. The interruption of motor function typically lasts 4-6 weeks and is never permanent. The marginal mandibular nerve lies deep to the platysma, and the muscle would actually have to be punctured by the cannula to cause permanent nerve injury, Dr. Hanke said.

Immediately after the procedure he has patients wear a compression garment 24 hours a day for the first 1-2 days except while showering, then for 2-4 hours daily for 1-2 weeks. The compression garment helps in redraping the skin, prevents hematomas, speeds absorption of tumescent fluid, and prevents skin wrinkling.

Serious complications are exceedingly rare. In fact, in an early national survey of more than 15,000 patients treated with liposuction using tumescent local anesthesia, Dr. Hanke and coworkers reported no deaths or complications requiring hospital transfer (Dermatol. Surg. 1995;21:459-62).

The finding was confirmed in another national survey, this one involving nearly 67,000 liposuction procedures performed by dermatologic surgeons from 1994 to 2000 (Dermatol. Surg. 2002;28:971-8).

Occasionally, the platysmal bands are unmasked by neck liposuction. This is an unwelcome event, but marked improvement can be achieved through injection of small doses of botulinum toxin.

Dr. Hanke noted that he and Dr. William G. Stebbins recently performed an in-depth review of neck rejuvenation via liposuction, including proper patient selection, technical aspects of the procedure, postop care, and ancillary techniques (Dermatol. Ther. 2011;24:28-40).

Dr. Hanke reported having no financial conflicts of interest.

SAN DIEGO – Bisphosphonate use to treat osteoporosis was associated with a lower risk for bone metastases in women who later were diagnosed with breast cancer and continued on bisphosphonate therapy, according to findings from a retrospective cohort study.

This protective effect of bisphosphonates against bone metastases was independent of the stage of breast cancer at the time of diagnosis, Dr. Richard Kremer reported at the meeting.

Surprisingly, the 2% of study participants who stopped bisphosphonate therapy when diagnosed with breast cancer actually had a higher rate of developing bone metastases than did never-users of the medication, added Dr. Kremer of McGill University, Montreal.

The findings were gleaned from an administrative database that included 16,669 women diagnosed with local breast cancer and 4,850 diagnosed with regional disease during 1998-2005 and followed for a median of 5 years.

Ongoing randomized, double-blind, placebo-controlled clinical trials, such as the National Surgical Adjuvant Breast and Bowel Project B-34, are expected to provide definitive answers as to whether prescribing bisphosphonates protects against bone metastases. At present, the approved indication for bisphosphonates in the setting of cancer is for pain relief and prevention of fractures in patients with known bone metastases.

Among the 2,221 women who used a bisphosphonate in the 2-year period prior to diagnosis of their malignancy, 4% developed bone metastases. Of the other 19,298 women, 6.5% developed bone metastases.

Upon adjustment for breast cancer stage, comorbid conditions, age, and socioeconomic status, using a bisphosphonate prior to diagnosis of malignancy was associated with a 22% reduction in the risk of developing bone metastases. A definite dose-response effect was evident; the longer a woman was on a bisphosphonate, the greater her reduction in risk of bone metastases.

“Our study suggests that bisphosphonate therapy for treatment of osteoporosis produces significant additional benefit in preventing an important complication of breast cancer,” he said.

There is, however, a catch: The great majority of women who took a bisphosphonate during the 2 years prior to diagnosis of breast cancer continued to do so afterwards. Roughly 10% of breast cancer patients in the study were on a bisphosphonate both before and after diagnosis of their malignancy, 20% went on a bisphosphonate only upon being diagnosed with breast cancer, and just 2% of women took a bisphosphonate only prior to their breast cancer diagnosis. Nearly 70% of subjects were never on a bisphosphonate.

Women with localized breast cancer and a documented lack of lymph node involvement had a 27% reduction in their risk of developing bone metastases if they received a bisphosphonate both before and after diagnosis of their cancer, a 45% risk reduction if they went on the medication only following diagnosis of breast cancer, and a paradoxical twofold increased risk if they were on a bisphosphonate during the 2 years prior to diagnosis and then stopped.

Women with regional breast cancer who stopped taking a bisphosphonate within 2 years prior to diagnosis had a nonsignificant 19% increased risk of bone metastases compared with women never on the medication.

In contrast, they had a 49% reduction in risk if they received a bisphosphonate both before and after their diagnosis, and the same magnitude of risk reduction if they went on the drug only after their breast cancer was detected.

Dr. Kremer disclosed that he serves on the speakers bureaus of Merck Frosst Canada and Sanofi-Aventis.

SAN DIEGO – Bisphosphonate use to treat osteoporosis was associated with a lower risk for bone metastases in women who later were diagnosed with breast cancer and continued on bisphosphonate therapy, according to findings from a retrospective cohort study.

This protective effect of bisphosphonates against bone metastases was independent of the stage of breast cancer at the time of diagnosis, Dr. Richard Kremer reported at the meeting.

Surprisingly, the 2% of study participants who stopped bisphosphonate therapy when diagnosed with breast cancer actually had a higher rate of developing bone metastases than did never-users of the medication, added Dr. Kremer of McGill University, Montreal.

The findings were gleaned from an administrative database that included 16,669 women diagnosed with local breast cancer and 4,850 diagnosed with regional disease during 1998-2005 and followed for a median of 5 years.

Ongoing randomized, double-blind, placebo-controlled clinical trials, such as the National Surgical Adjuvant Breast and Bowel Project B-34, are expected to provide definitive answers as to whether prescribing bisphosphonates protects against bone metastases. At present, the approved indication for bisphosphonates in the setting of cancer is for pain relief and prevention of fractures in patients with known bone metastases.

Among the 2,221 women who used a bisphosphonate in the 2-year period prior to diagnosis of their malignancy, 4% developed bone metastases. Of the other 19,298 women, 6.5% developed bone metastases.

Upon adjustment for breast cancer stage, comorbid conditions, age, and socioeconomic status, using a bisphosphonate prior to diagnosis of malignancy was associated with a 22% reduction in the risk of developing bone metastases. A definite dose-response effect was evident; the longer a woman was on a bisphosphonate, the greater her reduction in risk of bone metastases.

“Our study suggests that bisphosphonate therapy for treatment of osteoporosis produces significant additional benefit in preventing an important complication of breast cancer,” he said.

There is, however, a catch: The great majority of women who took a bisphosphonate during the 2 years prior to diagnosis of breast cancer continued to do so afterwards. Roughly 10% of breast cancer patients in the study were on a bisphosphonate both before and after diagnosis of their malignancy, 20% went on a bisphosphonate only upon being diagnosed with breast cancer, and just 2% of women took a bisphosphonate only prior to their breast cancer diagnosis. Nearly 70% of subjects were never on a bisphosphonate.

Women with localized breast cancer and a documented lack of lymph node involvement had a 27% reduction in their risk of developing bone metastases if they received a bisphosphonate both before and after diagnosis of their cancer, a 45% risk reduction if they went on the medication only following diagnosis of breast cancer, and a paradoxical twofold increased risk if they were on a bisphosphonate during the 2 years prior to diagnosis and then stopped.

Women with regional breast cancer who stopped taking a bisphosphonate within 2 years prior to diagnosis had a nonsignificant 19% increased risk of bone metastases compared with women never on the medication.

In contrast, they had a 49% reduction in risk if they received a bisphosphonate both before and after their diagnosis, and the same magnitude of risk reduction if they went on the drug only after their breast cancer was detected.

Dr. Kremer disclosed that he serves on the speakers bureaus of Merck Frosst Canada and Sanofi-Aventis.

SAN DIEGO – Bisphosphonate use to treat osteoporosis was associated with a lower risk for bone metastases in women who later were diagnosed with breast cancer and continued on bisphosphonate therapy, according to findings from a retrospective cohort study.

This protective effect of bisphosphonates against bone metastases was independent of the stage of breast cancer at the time of diagnosis, Dr. Richard Kremer reported at the meeting.

Surprisingly, the 2% of study participants who stopped bisphosphonate therapy when diagnosed with breast cancer actually had a higher rate of developing bone metastases than did never-users of the medication, added Dr. Kremer of McGill University, Montreal.

The findings were gleaned from an administrative database that included 16,669 women diagnosed with local breast cancer and 4,850 diagnosed with regional disease during 1998-2005 and followed for a median of 5 years.

Ongoing randomized, double-blind, placebo-controlled clinical trials, such as the National Surgical Adjuvant Breast and Bowel Project B-34, are expected to provide definitive answers as to whether prescribing bisphosphonates protects against bone metastases. At present, the approved indication for bisphosphonates in the setting of cancer is for pain relief and prevention of fractures in patients with known bone metastases.

Among the 2,221 women who used a bisphosphonate in the 2-year period prior to diagnosis of their malignancy, 4% developed bone metastases. Of the other 19,298 women, 6.5% developed bone metastases.

Upon adjustment for breast cancer stage, comorbid conditions, age, and socioeconomic status, using a bisphosphonate prior to diagnosis of malignancy was associated with a 22% reduction in the risk of developing bone metastases. A definite dose-response effect was evident; the longer a woman was on a bisphosphonate, the greater her reduction in risk of bone metastases.

“Our study suggests that bisphosphonate therapy for treatment of osteoporosis produces significant additional benefit in preventing an important complication of breast cancer,” he said.

There is, however, a catch: The great majority of women who took a bisphosphonate during the 2 years prior to diagnosis of breast cancer continued to do so afterwards. Roughly 10% of breast cancer patients in the study were on a bisphosphonate both before and after diagnosis of their malignancy, 20% went on a bisphosphonate only upon being diagnosed with breast cancer, and just 2% of women took a bisphosphonate only prior to their breast cancer diagnosis. Nearly 70% of subjects were never on a bisphosphonate.

Women with localized breast cancer and a documented lack of lymph node involvement had a 27% reduction in their risk of developing bone metastases if they received a bisphosphonate both before and after diagnosis of their cancer, a 45% risk reduction if they went on the medication only following diagnosis of breast cancer, and a paradoxical twofold increased risk if they were on a bisphosphonate during the 2 years prior to diagnosis and then stopped.

Women with regional breast cancer who stopped taking a bisphosphonate within 2 years prior to diagnosis had a nonsignificant 19% increased risk of bone metastases compared with women never on the medication.

In contrast, they had a 49% reduction in risk if they received a bisphosphonate both before and after their diagnosis, and the same magnitude of risk reduction if they went on the drug only after their breast cancer was detected.

Dr. Kremer disclosed that he serves on the speakers bureaus of Merck Frosst Canada and Sanofi-Aventis.

SAN DIEGO – Angiotensin-converting enzyme inhibitors may reduce the risk of age-related bone loss in elderly men.

A retrospective analysis of longitudinal data from the prospective Health ABC (Dynamics of Health, Aging and Body Composition Study) found that femoral neck bone mineral density was significantly greater in elderly men on an ACE inhibitor for 5 or more years for treatment of hypertension than in those who were not on long-term ACE inhibitor therapy, Dr. Nahid Rianon reported.

This secondary analysis of Health ABC involved 583 men with a mean age of 83 years. At 10-year follow-up, femoral neck bone mineral density was 0.04 g/cm

Of note, the same magnitude of improvement in femoral neck bone mineral density was seen after just 5 years of ACE inhibitor therapy. In other words, no further divergence in bone mineral density occurred during years 5-10.

Osteoporosis and hypertension are two major age-related chronic diseases that at present are managed separately using different classes of drugs. If ACE inhibitors can be shown to be beneficial in both of these extremely common diseases, management would be considerably simplified, observed Dr. Rianon of the University of Texas, Houston.

Health ABC is sponsored by the National Institute on Aging. Dr. Rianon declared having no financial conflicts.

SAN DIEGO – Angiotensin-converting enzyme inhibitors may reduce the risk of age-related bone loss in elderly men.

A retrospective analysis of longitudinal data from the prospective Health ABC (Dynamics of Health, Aging and Body Composition Study) found that femoral neck bone mineral density was significantly greater in elderly men on an ACE inhibitor for 5 or more years for treatment of hypertension than in those who were not on long-term ACE inhibitor therapy, Dr. Nahid Rianon reported.

This secondary analysis of Health ABC involved 583 men with a mean age of 83 years. At 10-year follow-up, femoral neck bone mineral density was 0.04 g/cm

Of note, the same magnitude of improvement in femoral neck bone mineral density was seen after just 5 years of ACE inhibitor therapy. In other words, no further divergence in bone mineral density occurred during years 5-10.

Osteoporosis and hypertension are two major age-related chronic diseases that at present are managed separately using different classes of drugs. If ACE inhibitors can be shown to be beneficial in both of these extremely common diseases, management would be considerably simplified, observed Dr. Rianon of the University of Texas, Houston.

Health ABC is sponsored by the National Institute on Aging. Dr. Rianon declared having no financial conflicts.

SAN DIEGO – Angiotensin-converting enzyme inhibitors may reduce the risk of age-related bone loss in elderly men.

A retrospective analysis of longitudinal data from the prospective Health ABC (Dynamics of Health, Aging and Body Composition Study) found that femoral neck bone mineral density was significantly greater in elderly men on an ACE inhibitor for 5 or more years for treatment of hypertension than in those who were not on long-term ACE inhibitor therapy, Dr. Nahid Rianon reported.

This secondary analysis of Health ABC involved 583 men with a mean age of 83 years. At 10-year follow-up, femoral neck bone mineral density was 0.04 g/cm

Of note, the same magnitude of improvement in femoral neck bone mineral density was seen after just 5 years of ACE inhibitor therapy. In other words, no further divergence in bone mineral density occurred during years 5-10.

Osteoporosis and hypertension are two major age-related chronic diseases that at present are managed separately using different classes of drugs. If ACE inhibitors can be shown to be beneficial in both of these extremely common diseases, management would be considerably simplified, observed Dr. Rianon of the University of Texas, Houston.

Health ABC is sponsored by the National Institute on Aging. Dr. Rianon declared having no financial conflicts.

SAN DIEGO – The widely used, Web-based fracture risk assessment tool known as FRAX seriously underestimates the risk of major osteoporotic and hip fractures in patients with diabetes, according to a large Canadian study.

This finding indicates diabetes is an independent risk factor for fractures above and beyond the risk factors incorporated in the FRAX tool, which include age, gender, smoking, fracture history, and glucocorticoid use – but not diabetes.

“One implication of our findings is that FRAX should be applied cautiously in clinical situations involving diabetic patients,” said Lora Giangregorio, Ph.D.

“Future iterations of the FRAX tool might consider adding diabetes to the list of risk factors,” added Dr. Giangregorio of the University of Waterloo (Ontario).

She presented an analysis of a large Manitoba Province–wide database that included 3,518 patients with type 1 or type 2 diabetes and 36,085 nondiabetic controls, all at least 50 years old when they underwent bone mineral density testing during 1987-2008.

The FRAX tool was used to calculate 10-year fracture risk probabilities; actual incidence of major osteoporotic or hip fractures was determined through 2008.

The key finding: After the researchers controlled for FRAX fracture probability scores and use of osteoporotic medications, diabetes was independently associated with a 59% increased fracture rate in an average 10 years of follow-up.

Diabetes was a stronger predictor of hip fracture risk in younger subjects. Indeed, it was independently associated with a 5.3-fold increased risk of hip fracture in individuals younger than age 65, compared with a 2.1-fold increase in those who were older. In contrast, the risk of major osteoporotic fractures in diabetes patients was not related to age.

The fracture probability curves for diabetic and nondiabetic subjects diverged from the beginning of follow-up and continued to separate.

The study did not differentiate between type 1 and type 2 diabetes. However, in another study presented at the meeting, Dr. Ling Oei of Erasmus University, Rotterdam, the Netherlands, noted that type 2 diabetics are paradoxically at increased risk of osteoporotic fractures even though their BMD is typically normal or even increased.

In a prospective, population-based study of 203 patients with adequately controlled type 2 diabetes, 217 others with inadequately controlled disease, and 3,715 nondiabetic controls, Dr. Oei and coworkers showed that women with inadequately controlled diabetes had significantly lower BMD at both the lumbar spine and femoral neck, compared with women in the other two groups.

After the researchers controlled for age, femoral neck BMD, and body mass index, women with inadequately controlled type 2 diabetes had a 1.6-fold increased risk of fracture during an average 8.2-year follow-up, compared with patients who had adequately controlled type 2 diabetes or patients without diabetes, according to the Dutch investigators.

'Future iterations of the FRAX tool might consider adding diabetes to the list of risk factors.'

Source DR. GIANGREGORIO

SAN DIEGO – The widely used, Web-based fracture risk assessment tool known as FRAX seriously underestimates the risk of major osteoporotic and hip fractures in patients with diabetes, according to a large Canadian study.

This finding indicates diabetes is an independent risk factor for fractures above and beyond the risk factors incorporated in the FRAX tool, which include age, gender, smoking, fracture history, and glucocorticoid use – but not diabetes.

“One implication of our findings is that FRAX should be applied cautiously in clinical situations involving diabetic patients,” said Lora Giangregorio, Ph.D.

“Future iterations of the FRAX tool might consider adding diabetes to the list of risk factors,” added Dr. Giangregorio of the University of Waterloo (Ontario).

She presented an analysis of a large Manitoba Province–wide database that included 3,518 patients with type 1 or type 2 diabetes and 36,085 nondiabetic controls, all at least 50 years old when they underwent bone mineral density testing during 1987-2008.

The FRAX tool was used to calculate 10-year fracture risk probabilities; actual incidence of major osteoporotic or hip fractures was determined through 2008.

The key finding: After the researchers controlled for FRAX fracture probability scores and use of osteoporotic medications, diabetes was independently associated with a 59% increased fracture rate in an average 10 years of follow-up.

Diabetes was a stronger predictor of hip fracture risk in younger subjects. Indeed, it was independently associated with a 5.3-fold increased risk of hip fracture in individuals younger than age 65, compared with a 2.1-fold increase in those who were older. In contrast, the risk of major osteoporotic fractures in diabetes patients was not related to age.

The fracture probability curves for diabetic and nondiabetic subjects diverged from the beginning of follow-up and continued to separate.

The study did not differentiate between type 1 and type 2 diabetes. However, in another study presented at the meeting, Dr. Ling Oei of Erasmus University, Rotterdam, the Netherlands, noted that type 2 diabetics are paradoxically at increased risk of osteoporotic fractures even though their BMD is typically normal or even increased.

In a prospective, population-based study of 203 patients with adequately controlled type 2 diabetes, 217 others with inadequately controlled disease, and 3,715 nondiabetic controls, Dr. Oei and coworkers showed that women with inadequately controlled diabetes had significantly lower BMD at both the lumbar spine and femoral neck, compared with women in the other two groups.

After the researchers controlled for age, femoral neck BMD, and body mass index, women with inadequately controlled type 2 diabetes had a 1.6-fold increased risk of fracture during an average 8.2-year follow-up, compared with patients who had adequately controlled type 2 diabetes or patients without diabetes, according to the Dutch investigators.

'Future iterations of the FRAX tool might consider adding diabetes to the list of risk factors.'

Source DR. GIANGREGORIO

SAN DIEGO – The widely used, Web-based fracture risk assessment tool known as FRAX seriously underestimates the risk of major osteoporotic and hip fractures in patients with diabetes, according to a large Canadian study.

This finding indicates diabetes is an independent risk factor for fractures above and beyond the risk factors incorporated in the FRAX tool, which include age, gender, smoking, fracture history, and glucocorticoid use – but not diabetes.

“One implication of our findings is that FRAX should be applied cautiously in clinical situations involving diabetic patients,” said Lora Giangregorio, Ph.D.

“Future iterations of the FRAX tool might consider adding diabetes to the list of risk factors,” added Dr. Giangregorio of the University of Waterloo (Ontario).

She presented an analysis of a large Manitoba Province–wide database that included 3,518 patients with type 1 or type 2 diabetes and 36,085 nondiabetic controls, all at least 50 years old when they underwent bone mineral density testing during 1987-2008.

The FRAX tool was used to calculate 10-year fracture risk probabilities; actual incidence of major osteoporotic or hip fractures was determined through 2008.

The key finding: After the researchers controlled for FRAX fracture probability scores and use of osteoporotic medications, diabetes was independently associated with a 59% increased fracture rate in an average 10 years of follow-up.

Diabetes was a stronger predictor of hip fracture risk in younger subjects. Indeed, it was independently associated with a 5.3-fold increased risk of hip fracture in individuals younger than age 65, compared with a 2.1-fold increase in those who were older. In contrast, the risk of major osteoporotic fractures in diabetes patients was not related to age.

The fracture probability curves for diabetic and nondiabetic subjects diverged from the beginning of follow-up and continued to separate.

The study did not differentiate between type 1 and type 2 diabetes. However, in another study presented at the meeting, Dr. Ling Oei of Erasmus University, Rotterdam, the Netherlands, noted that type 2 diabetics are paradoxically at increased risk of osteoporotic fractures even though their BMD is typically normal or even increased.

In a prospective, population-based study of 203 patients with adequately controlled type 2 diabetes, 217 others with inadequately controlled disease, and 3,715 nondiabetic controls, Dr. Oei and coworkers showed that women with inadequately controlled diabetes had significantly lower BMD at both the lumbar spine and femoral neck, compared with women in the other two groups.

After the researchers controlled for age, femoral neck BMD, and body mass index, women with inadequately controlled type 2 diabetes had a 1.6-fold increased risk of fracture during an average 8.2-year follow-up, compared with patients who had adequately controlled type 2 diabetes or patients without diabetes, according to the Dutch investigators.

'Future iterations of the FRAX tool might consider adding diabetes to the list of risk factors.'

Source DR. GIANGREGORIO

SAN DIEGO – The risk of hip fracture nearly doubles during the week following a new prescription for a loop diuretic.

In contrast, there is no spike in the risk of hip fracture in the 7 days following a new prescription for other classes of diuretics or for ACE inhibitors, according to an analysis of the massive The Health Improvement Network (THIN) database involving more than 400 U.K. primary care practices.

The most likely explanation for the short-term jump in risk of hip fracture may be related to the prominent urinary symptoms that often accompany a new prescription for loop diuretics. The resultant rush to the bathroom could lead to an increased rate of falls during that initial adjustment period, Dr. Sarah D. Berry speculated at the meeting.

She reported on 28,703 subjects who experienced an incident hip fracture and more than 2 million others who did not during 15.1 million person-years of follow-up recorded in the THIN primary care database. In a nested, case-crossover study, she and her coworkers compared the occurrence of new diuretic prescriptions in the 7 days prior to the hip fracture to the occurrence of new diuretic prescriptions during the control period 31-37 days before the fracture.

The adjusted odds ratio of an incident hip fracture was significantly increased by 80% during the 7 days following a new prescription for a loop diuretic. That being said, it needs to be emphasized that the absolute risk during this week-long window of increased vulnerability remained low: 2.9 hip fractures per 100,000 new loop diuretic prescriptions, according to Dr. Berry of the Hebrew SeniorLife Institute for Aging Research and Beth Israel Deaconess Medical Center, Boston.

Counseling vulnerable older adults and their caregivers about the need for increased awareness and careful ambulation to the bathroom during the 7 days after going on a loop diuretic might help reduce hip fractures, she added.

Dr. Berry declared having no financial conflicts regarding the study, which was supported by the National Institutes of Health and Hebrew SeniorLife.

SAN DIEGO – The risk of hip fracture nearly doubles during the week following a new prescription for a loop diuretic.

In contrast, there is no spike in the risk of hip fracture in the 7 days following a new prescription for other classes of diuretics or for ACE inhibitors, according to an analysis of the massive The Health Improvement Network (THIN) database involving more than 400 U.K. primary care practices.

The most likely explanation for the short-term jump in risk of hip fracture may be related to the prominent urinary symptoms that often accompany a new prescription for loop diuretics. The resultant rush to the bathroom could lead to an increased rate of falls during that initial adjustment period, Dr. Sarah D. Berry speculated at the meeting.

She reported on 28,703 subjects who experienced an incident hip fracture and more than 2 million others who did not during 15.1 million person-years of follow-up recorded in the THIN primary care database. In a nested, case-crossover study, she and her coworkers compared the occurrence of new diuretic prescriptions in the 7 days prior to the hip fracture to the occurrence of new diuretic prescriptions during the control period 31-37 days before the fracture.

The adjusted odds ratio of an incident hip fracture was significantly increased by 80% during the 7 days following a new prescription for a loop diuretic. That being said, it needs to be emphasized that the absolute risk during this week-long window of increased vulnerability remained low: 2.9 hip fractures per 100,000 new loop diuretic prescriptions, according to Dr. Berry of the Hebrew SeniorLife Institute for Aging Research and Beth Israel Deaconess Medical Center, Boston.

Counseling vulnerable older adults and their caregivers about the need for increased awareness and careful ambulation to the bathroom during the 7 days after going on a loop diuretic might help reduce hip fractures, she added.

Dr. Berry declared having no financial conflicts regarding the study, which was supported by the National Institutes of Health and Hebrew SeniorLife.

SAN DIEGO – The risk of hip fracture nearly doubles during the week following a new prescription for a loop diuretic.

In contrast, there is no spike in the risk of hip fracture in the 7 days following a new prescription for other classes of diuretics or for ACE inhibitors, according to an analysis of the massive The Health Improvement Network (THIN) database involving more than 400 U.K. primary care practices.

The most likely explanation for the short-term jump in risk of hip fracture may be related to the prominent urinary symptoms that often accompany a new prescription for loop diuretics. The resultant rush to the bathroom could lead to an increased rate of falls during that initial adjustment period, Dr. Sarah D. Berry speculated at the meeting.

She reported on 28,703 subjects who experienced an incident hip fracture and more than 2 million others who did not during 15.1 million person-years of follow-up recorded in the THIN primary care database. In a nested, case-crossover study, she and her coworkers compared the occurrence of new diuretic prescriptions in the 7 days prior to the hip fracture to the occurrence of new diuretic prescriptions during the control period 31-37 days before the fracture.

The adjusted odds ratio of an incident hip fracture was significantly increased by 80% during the 7 days following a new prescription for a loop diuretic. That being said, it needs to be emphasized that the absolute risk during this week-long window of increased vulnerability remained low: 2.9 hip fractures per 100,000 new loop diuretic prescriptions, according to Dr. Berry of the Hebrew SeniorLife Institute for Aging Research and Beth Israel Deaconess Medical Center, Boston.

Counseling vulnerable older adults and their caregivers about the need for increased awareness and careful ambulation to the bathroom during the 7 days after going on a loop diuretic might help reduce hip fractures, she added.

Dr. Berry declared having no financial conflicts regarding the study, which was supported by the National Institutes of Health and Hebrew SeniorLife.

SAN DIEGO – Depression and subclinical cardiovascular abnormalities in patients with primary hyperparathyroidism are emerging as two novel indications for parathyroidectomy.

Primary hyperparathyroidism is no longer typically characterized by the classic florid manifestations involving metabolic bone disease, GI disturbances, and nephrolithiasis. In an era of routine serum calcium measurement, most affected patients are largely asymptomatic, or they report nonspecific symptoms involving mood, cognition, and neuromuscular function.

Studies presented at the annual meeting of the American Society for Bone and Mineral Research indicate that clinically significant depression is more frequent and severe in patients with primary hyperparathyroidism, and subclinical cardiovascular abnormalities are more common as well.

Moreover, investigators presented evidence that both conditions respond favorably to parathyroidectomy. The clear implication for clinical practice, according to the presenters, is that assessment for depression as well as a cardiovascular evaluation including carotid ultrasound and an echocardiogram should become part of the routine evaluation of patients with primary hyperparathyroidism (PHP). Positive findings may be an appropriate indication for parathyroidectomy in patients who otherwise don’t meet the surgical criteria.

Depression

Dr. Rachel Espiritu presented a prospective, nonrandomized, case-control study involving 169 patients with PHP and 85 controls with benign, nontoxic forms of thyroid disease. At baseline, 88 PHP patients underwent parathyroidectomy, while the other 81 were observed for the yearlong study period. The controls with benign thyroid disease underwent thyroidectomy at baseline.

The validated Patient Health Questionnaire–9 (PHQ-9) was used to identify subjects with clinically significant depression. All study participants took the test at baseline and at 1, 3, 6, and 12 months. The three groups were similar in terms of history of depression, use of antidepressant medications, and experience with psychotherapy.

Average baseline PHQ-9 scores were significantly higher in the 169 patients with PHP than in controls by a margin of 1.71 points out of the theoretically possible 27. Major depression, as defined by a score of 10 or more, was twice as common in the PHP patients, with a baseline prevalence of 31% compared with 15% in the thyroid disease group. The PHP patients who had a baseline serum calcium of 11 mg/dL or higher had a median PHQ-9 score of 9 compared with 4 in those with a lower calcium level.

Parathyroidectomy resulted in a large, durable reduction in PHQ-9 scores. The scores dropped by an age- and gender-adjusted average of 64% 1 month post surgery, with a 66% reduction at 1 year compared with baseline, reported Dr. Espiritu of the Mayo Clinic, Rochester, Minn.

A PHQ-9 score of 10 or greater was present at baseline in 43% of the parathyroidectomy group. The prevalence plunged to 7% at 1 month post surgery and remained there at 1 year. In contrast, the prevalence of scores of 10-plus remained unchanged over the course of the year in the 81 PHP patients in the observation arm.

PHQ-9 scores also declined following thyroidectomy in the control group. But the reductions were significantly greater in the parathyroidectomy group at every time point.

Dr. Espiritu concluded that a PHQ-9 score of 10 or more or ongoing depression in a patient with PHP warrants consideration of parathyroid surgery.

Cardiovascular Abnormalities

Dr. Marcella Walker reported on 44 patients with mild hyperparathyroidism who underwent carotid ultrasound and echocardiographic studies before postparathyroidectomy and 12 and 24 months afterward.

Selected subclinical cardiovascular abnormalities present at baseline improved and often normalized during the second year of follow-up. Increased carotid stiffness, present in 17 of 44 patients at baseline, normalized in 8 patients and decreased without reaching normal range to a lesser extent in the others. Increased intima-media thickness, present in 32 patients at baseline, declined from an average of 0.99 mm at baseline to 0.97 mm 2 years later.

Diastolic dysfunction, as defined by an abnormal early to late mitral annular velocity ratio, was present in 11 patients at baseline and normalized postsurgically in all cases. Similarly, another indicator of diastolic dysfunction – an elevated intravascular relaxation time – was identified in eight patients preoperatively, all of whom improved to within normal range post parathyroidectomy, according to Dr. Walker of Columbia University, New York.

On the other hand, baseline abnormalities in left ventricular mass index remained unchanged following surgery. Nor was any improvement seen in maximal carotid plaque thickness or carotid plaque number, she noted.

The changes noted in cardiovascular parameters following parathyroidectomy can’t be attributed to reductions in blood pressure or body mass index, as both parameters remained unaltered during the 2-year study period.

No financial conflicts of interest were reported.

SAN DIEGO – Depression and subclinical cardiovascular abnormalities in patients with primary hyperparathyroidism are emerging as two novel indications for parathyroidectomy.

Primary hyperparathyroidism is no longer typically characterized by the classic florid manifestations involving metabolic bone disease, GI disturbances, and nephrolithiasis. In an era of routine serum calcium measurement, most affected patients are largely asymptomatic, or they report nonspecific symptoms involving mood, cognition, and neuromuscular function.

Studies presented at the annual meeting of the American Society for Bone and Mineral Research indicate that clinically significant depression is more frequent and severe in patients with primary hyperparathyroidism, and subclinical cardiovascular abnormalities are more common as well.

Moreover, investigators presented evidence that both conditions respond favorably to parathyroidectomy. The clear implication for clinical practice, according to the presenters, is that assessment for depression as well as a cardiovascular evaluation including carotid ultrasound and an echocardiogram should become part of the routine evaluation of patients with primary hyperparathyroidism (PHP). Positive findings may be an appropriate indication for parathyroidectomy in patients who otherwise don’t meet the surgical criteria.

Depression

Dr. Rachel Espiritu presented a prospective, nonrandomized, case-control study involving 169 patients with PHP and 85 controls with benign, nontoxic forms of thyroid disease. At baseline, 88 PHP patients underwent parathyroidectomy, while the other 81 were observed for the yearlong study period. The controls with benign thyroid disease underwent thyroidectomy at baseline.

The validated Patient Health Questionnaire–9 (PHQ-9) was used to identify subjects with clinically significant depression. All study participants took the test at baseline and at 1, 3, 6, and 12 months. The three groups were similar in terms of history of depression, use of antidepressant medications, and experience with psychotherapy.

Average baseline PHQ-9 scores were significantly higher in the 169 patients with PHP than in controls by a margin of 1.71 points out of the theoretically possible 27. Major depression, as defined by a score of 10 or more, was twice as common in the PHP patients, with a baseline prevalence of 31% compared with 15% in the thyroid disease group. The PHP patients who had a baseline serum calcium of 11 mg/dL or higher had a median PHQ-9 score of 9 compared with 4 in those with a lower calcium level.

Parathyroidectomy resulted in a large, durable reduction in PHQ-9 scores. The scores dropped by an age- and gender-adjusted average of 64% 1 month post surgery, with a 66% reduction at 1 year compared with baseline, reported Dr. Espiritu of the Mayo Clinic, Rochester, Minn.

A PHQ-9 score of 10 or greater was present at baseline in 43% of the parathyroidectomy group. The prevalence plunged to 7% at 1 month post surgery and remained there at 1 year. In contrast, the prevalence of scores of 10-plus remained unchanged over the course of the year in the 81 PHP patients in the observation arm.

PHQ-9 scores also declined following thyroidectomy in the control group. But the reductions were significantly greater in the parathyroidectomy group at every time point.

Dr. Espiritu concluded that a PHQ-9 score of 10 or more or ongoing depression in a patient with PHP warrants consideration of parathyroid surgery.

Cardiovascular Abnormalities

Dr. Marcella Walker reported on 44 patients with mild hyperparathyroidism who underwent carotid ultrasound and echocardiographic studies before postparathyroidectomy and 12 and 24 months afterward.

Selected subclinical cardiovascular abnormalities present at baseline improved and often normalized during the second year of follow-up. Increased carotid stiffness, present in 17 of 44 patients at baseline, normalized in 8 patients and decreased without reaching normal range to a lesser extent in the others. Increased intima-media thickness, present in 32 patients at baseline, declined from an average of 0.99 mm at baseline to 0.97 mm 2 years later.

Diastolic dysfunction, as defined by an abnormal early to late mitral annular velocity ratio, was present in 11 patients at baseline and normalized postsurgically in all cases. Similarly, another indicator of diastolic dysfunction – an elevated intravascular relaxation time – was identified in eight patients preoperatively, all of whom improved to within normal range post parathyroidectomy, according to Dr. Walker of Columbia University, New York.

On the other hand, baseline abnormalities in left ventricular mass index remained unchanged following surgery. Nor was any improvement seen in maximal carotid plaque thickness or carotid plaque number, she noted.

The changes noted in cardiovascular parameters following parathyroidectomy can’t be attributed to reductions in blood pressure or body mass index, as both parameters remained unaltered during the 2-year study period.

No financial conflicts of interest were reported.

SAN DIEGO – Depression and subclinical cardiovascular abnormalities in patients with primary hyperparathyroidism are emerging as two novel indications for parathyroidectomy.

Primary hyperparathyroidism is no longer typically characterized by the classic florid manifestations involving metabolic bone disease, GI disturbances, and nephrolithiasis. In an era of routine serum calcium measurement, most affected patients are largely asymptomatic, or they report nonspecific symptoms involving mood, cognition, and neuromuscular function.

Studies presented at the annual meeting of the American Society for Bone and Mineral Research indicate that clinically significant depression is more frequent and severe in patients with primary hyperparathyroidism, and subclinical cardiovascular abnormalities are more common as well.

Moreover, investigators presented evidence that both conditions respond favorably to parathyroidectomy. The clear implication for clinical practice, according to the presenters, is that assessment for depression as well as a cardiovascular evaluation including carotid ultrasound and an echocardiogram should become part of the routine evaluation of patients with primary hyperparathyroidism (PHP). Positive findings may be an appropriate indication for parathyroidectomy in patients who otherwise don’t meet the surgical criteria.

Depression

Dr. Rachel Espiritu presented a prospective, nonrandomized, case-control study involving 169 patients with PHP and 85 controls with benign, nontoxic forms of thyroid disease. At baseline, 88 PHP patients underwent parathyroidectomy, while the other 81 were observed for the yearlong study period. The controls with benign thyroid disease underwent thyroidectomy at baseline.

The validated Patient Health Questionnaire–9 (PHQ-9) was used to identify subjects with clinically significant depression. All study participants took the test at baseline and at 1, 3, 6, and 12 months. The three groups were similar in terms of history of depression, use of antidepressant medications, and experience with psychotherapy.

Average baseline PHQ-9 scores were significantly higher in the 169 patients with PHP than in controls by a margin of 1.71 points out of the theoretically possible 27. Major depression, as defined by a score of 10 or more, was twice as common in the PHP patients, with a baseline prevalence of 31% compared with 15% in the thyroid disease group. The PHP patients who had a baseline serum calcium of 11 mg/dL or higher had a median PHQ-9 score of 9 compared with 4 in those with a lower calcium level.

Parathyroidectomy resulted in a large, durable reduction in PHQ-9 scores. The scores dropped by an age- and gender-adjusted average of 64% 1 month post surgery, with a 66% reduction at 1 year compared with baseline, reported Dr. Espiritu of the Mayo Clinic, Rochester, Minn.

A PHQ-9 score of 10 or greater was present at baseline in 43% of the parathyroidectomy group. The prevalence plunged to 7% at 1 month post surgery and remained there at 1 year. In contrast, the prevalence of scores of 10-plus remained unchanged over the course of the year in the 81 PHP patients in the observation arm.

PHQ-9 scores also declined following thyroidectomy in the control group. But the reductions were significantly greater in the parathyroidectomy group at every time point.

Dr. Espiritu concluded that a PHQ-9 score of 10 or more or ongoing depression in a patient with PHP warrants consideration of parathyroid surgery.

Cardiovascular Abnormalities

Dr. Marcella Walker reported on 44 patients with mild hyperparathyroidism who underwent carotid ultrasound and echocardiographic studies before postparathyroidectomy and 12 and 24 months afterward.

Selected subclinical cardiovascular abnormalities present at baseline improved and often normalized during the second year of follow-up. Increased carotid stiffness, present in 17 of 44 patients at baseline, normalized in 8 patients and decreased without reaching normal range to a lesser extent in the others. Increased intima-media thickness, present in 32 patients at baseline, declined from an average of 0.99 mm at baseline to 0.97 mm 2 years later.

Diastolic dysfunction, as defined by an abnormal early to late mitral annular velocity ratio, was present in 11 patients at baseline and normalized postsurgically in all cases. Similarly, another indicator of diastolic dysfunction – an elevated intravascular relaxation time – was identified in eight patients preoperatively, all of whom improved to within normal range post parathyroidectomy, according to Dr. Walker of Columbia University, New York.

On the other hand, baseline abnormalities in left ventricular mass index remained unchanged following surgery. Nor was any improvement seen in maximal carotid plaque thickness or carotid plaque number, she noted.

The changes noted in cardiovascular parameters following parathyroidectomy can’t be attributed to reductions in blood pressure or body mass index, as both parameters remained unaltered during the 2-year study period.

No financial conflicts of interest were reported.