Heidi Splete

Sepsis patients with diabetes are significantly less likely to experience acute respiratory failure than are patients without diabetes, according to data from a review of 930 million hospitalizations over 25 years.

Previous studies have shown that sepsis is common in people with diabetes, and that those patients are less likely to develop acute lung injuries as a result of sepsis. But those studies did not compare organ dysfunction in sepsis patients with and without diabetes.

Dr. Annette Esper of Emory University in Atlanta and her colleagues reviewed National Hospital Discharge Survey data from 1979-2003. The researchers identified 12.5 million cases of sepsis, and 17% of the patients had diabetes. Among those with diabetes and sepsis, 57% were women and 64% were white. The average age was 68 years.

Overall, patients with diabetes and sepsis were significantly more likely to develop acute renal failure than were patients without diabetes (13% vs. 7%), but were significantly less likely (9% vs. 14%) to develop acute respiratory failure (Crit. Care 2009 Feb. 12 [doi:10.1186/cc7717]).

The difference in acute respiratory failure persisted regardless of the infection source. Among patients with a respiratory source of sepsis, those with diabetes were significantly less likely to develop acute respiratory failure than were those without diabetes (16% vs. 23%). The difference in acute respiratory failure rates was also significant for patients with and without diabetes (6% vs. 10%) who had nonpulmonary sources of infection.

Although the overall fatality rate for sepsis patients with diabetes was significantly lower than for those without diabetes (19% vs. 21%), the fatality rates between patients with and without diabetes who developed acute respiratory failure were not significantly different (52% vs. 48%).

Theories as to why respiratory failure rates differ between patients with and without diabetes include blunted inflammatory response to organ dysfunction in people with diabetes, and the possibility that diabetes patients may be hospitalized for sepsis sooner because they are more alert to signs of infection. Diabetes medications may play a role, too. “Many medications administered to patients with [diabetes], including insulin and thiazolidinediones, are known to have anti-inflammatory effects in addition to lowering blood glucose,” they noted.

The researchers had no financial conflicts to disclose.

Sepsis patients with diabetes are significantly less likely to experience acute respiratory failure than are patients without diabetes, according to data from a review of 930 million hospitalizations over 25 years.

Previous studies have shown that sepsis is common in people with diabetes, and that those patients are less likely to develop acute lung injuries as a result of sepsis. But those studies did not compare organ dysfunction in sepsis patients with and without diabetes.

Dr. Annette Esper of Emory University in Atlanta and her colleagues reviewed National Hospital Discharge Survey data from 1979-2003. The researchers identified 12.5 million cases of sepsis, and 17% of the patients had diabetes. Among those with diabetes and sepsis, 57% were women and 64% were white. The average age was 68 years.

Overall, patients with diabetes and sepsis were significantly more likely to develop acute renal failure than were patients without diabetes (13% vs. 7%), but were significantly less likely (9% vs. 14%) to develop acute respiratory failure (Crit. Care 2009 Feb. 12 [doi:10.1186/cc7717]).

The difference in acute respiratory failure persisted regardless of the infection source. Among patients with a respiratory source of sepsis, those with diabetes were significantly less likely to develop acute respiratory failure than were those without diabetes (16% vs. 23%). The difference in acute respiratory failure rates was also significant for patients with and without diabetes (6% vs. 10%) who had nonpulmonary sources of infection.

Although the overall fatality rate for sepsis patients with diabetes was significantly lower than for those without diabetes (19% vs. 21%), the fatality rates between patients with and without diabetes who developed acute respiratory failure were not significantly different (52% vs. 48%).

Theories as to why respiratory failure rates differ between patients with and without diabetes include blunted inflammatory response to organ dysfunction in people with diabetes, and the possibility that diabetes patients may be hospitalized for sepsis sooner because they are more alert to signs of infection. Diabetes medications may play a role, too. “Many medications administered to patients with [diabetes], including insulin and thiazolidinediones, are known to have anti-inflammatory effects in addition to lowering blood glucose,” they noted.

The researchers had no financial conflicts to disclose.

Sepsis patients with diabetes are significantly less likely to experience acute respiratory failure than are patients without diabetes, according to data from a review of 930 million hospitalizations over 25 years.

Previous studies have shown that sepsis is common in people with diabetes, and that those patients are less likely to develop acute lung injuries as a result of sepsis. But those studies did not compare organ dysfunction in sepsis patients with and without diabetes.

Dr. Annette Esper of Emory University in Atlanta and her colleagues reviewed National Hospital Discharge Survey data from 1979-2003. The researchers identified 12.5 million cases of sepsis, and 17% of the patients had diabetes. Among those with diabetes and sepsis, 57% were women and 64% were white. The average age was 68 years.

Overall, patients with diabetes and sepsis were significantly more likely to develop acute renal failure than were patients without diabetes (13% vs. 7%), but were significantly less likely (9% vs. 14%) to develop acute respiratory failure (Crit. Care 2009 Feb. 12 [doi:10.1186/cc7717]).

The difference in acute respiratory failure persisted regardless of the infection source. Among patients with a respiratory source of sepsis, those with diabetes were significantly less likely to develop acute respiratory failure than were those without diabetes (16% vs. 23%). The difference in acute respiratory failure rates was also significant for patients with and without diabetes (6% vs. 10%) who had nonpulmonary sources of infection.

Although the overall fatality rate for sepsis patients with diabetes was significantly lower than for those without diabetes (19% vs. 21%), the fatality rates between patients with and without diabetes who developed acute respiratory failure were not significantly different (52% vs. 48%).

Theories as to why respiratory failure rates differ between patients with and without diabetes include blunted inflammatory response to organ dysfunction in people with diabetes, and the possibility that diabetes patients may be hospitalized for sepsis sooner because they are more alert to signs of infection. Diabetes medications may play a role, too. “Many medications administered to patients with [diabetes], including insulin and thiazolidinediones, are known to have anti-inflammatory effects in addition to lowering blood glucose,” they noted.

The researchers had no financial conflicts to disclose.

More than 40% of American adults aged 20 years and older have hyperglycemic conditions, according to review of data from the 2005–2006 National Health and Nutrition Examination Survey.

In this study, Catherine Cowie, Ph.D., of the National Institutes of Health and her colleagues compared NHANES data for 1988–1994 with data for 2005–2006 (Diabetes Care 2009;32:287–94). The total crude prevalence of diabetes, including diagnosed and undiagnosed cases based on fasting plasma glucose or 2-hour glucose tests, was 13% in individuals aged 20 years and older. The total diabetes prevalence peaked at approximately 30% among all age groups older than 60 years, and the prevalence of diabetes was approximately the same in both men and women.

After the researchers controlled for age and sex, the total diabetes prevalence was 70% higher in non-Hispanic blacks and 80% higher in Mexican Americans, compared with non-Hispanic whites.

The total crude prevalence of prediabetes, including both diagnosed and undiagnosed cases based on impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) tests was 30%, and this prevalence was highest among individuals aged 75 years and older, where it reached 47%.

The total prevalence of diabetes and prediabetes, both diagnosed and undiagnosed, was significantly higher in men, compared with women (48% vs. 34%), but most of this difference was because of the greater prevalence of prediabetes among men. And the prevalence of any hyperglycemic condition was significantly higher in non-Hispanic blacks, compared with whites (44% vs. 39%), and in Mexican Americans vs. non-Hispanic whites (52% vs. 39%).

When the researchers compared the 2005–2006 data with the data for 1988–1994, they found that the crude prevalence of diagnosed diabetes rose significantly, from 5% to 8%.

“The sheer magnitude of prevalence of hyperglycemic conditions found in 2005–2006 portends all the consequences of diabetes, including its myriad of complications and costs both to individuals and to society,” the researchers wrote.

The researchers had no financial conflicts to disclose.

More than 40% of American adults aged 20 years and older have hyperglycemic conditions, according to review of data from the 2005–2006 National Health and Nutrition Examination Survey.

In this study, Catherine Cowie, Ph.D., of the National Institutes of Health and her colleagues compared NHANES data for 1988–1994 with data for 2005–2006 (Diabetes Care 2009;32:287–94). The total crude prevalence of diabetes, including diagnosed and undiagnosed cases based on fasting plasma glucose or 2-hour glucose tests, was 13% in individuals aged 20 years and older. The total diabetes prevalence peaked at approximately 30% among all age groups older than 60 years, and the prevalence of diabetes was approximately the same in both men and women.

After the researchers controlled for age and sex, the total diabetes prevalence was 70% higher in non-Hispanic blacks and 80% higher in Mexican Americans, compared with non-Hispanic whites.

The total crude prevalence of prediabetes, including both diagnosed and undiagnosed cases based on impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) tests was 30%, and this prevalence was highest among individuals aged 75 years and older, where it reached 47%.

The total prevalence of diabetes and prediabetes, both diagnosed and undiagnosed, was significantly higher in men, compared with women (48% vs. 34%), but most of this difference was because of the greater prevalence of prediabetes among men. And the prevalence of any hyperglycemic condition was significantly higher in non-Hispanic blacks, compared with whites (44% vs. 39%), and in Mexican Americans vs. non-Hispanic whites (52% vs. 39%).

When the researchers compared the 2005–2006 data with the data for 1988–1994, they found that the crude prevalence of diagnosed diabetes rose significantly, from 5% to 8%.

“The sheer magnitude of prevalence of hyperglycemic conditions found in 2005–2006 portends all the consequences of diabetes, including its myriad of complications and costs both to individuals and to society,” the researchers wrote.

The researchers had no financial conflicts to disclose.

More than 40% of American adults aged 20 years and older have hyperglycemic conditions, according to review of data from the 2005–2006 National Health and Nutrition Examination Survey.

In this study, Catherine Cowie, Ph.D., of the National Institutes of Health and her colleagues compared NHANES data for 1988–1994 with data for 2005–2006 (Diabetes Care 2009;32:287–94). The total crude prevalence of diabetes, including diagnosed and undiagnosed cases based on fasting plasma glucose or 2-hour glucose tests, was 13% in individuals aged 20 years and older. The total diabetes prevalence peaked at approximately 30% among all age groups older than 60 years, and the prevalence of diabetes was approximately the same in both men and women.

After the researchers controlled for age and sex, the total diabetes prevalence was 70% higher in non-Hispanic blacks and 80% higher in Mexican Americans, compared with non-Hispanic whites.

The total crude prevalence of prediabetes, including both diagnosed and undiagnosed cases based on impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) tests was 30%, and this prevalence was highest among individuals aged 75 years and older, where it reached 47%.

The total prevalence of diabetes and prediabetes, both diagnosed and undiagnosed, was significantly higher in men, compared with women (48% vs. 34%), but most of this difference was because of the greater prevalence of prediabetes among men. And the prevalence of any hyperglycemic condition was significantly higher in non-Hispanic blacks, compared with whites (44% vs. 39%), and in Mexican Americans vs. non-Hispanic whites (52% vs. 39%).

When the researchers compared the 2005–2006 data with the data for 1988–1994, they found that the crude prevalence of diagnosed diabetes rose significantly, from 5% to 8%.

“The sheer magnitude of prevalence of hyperglycemic conditions found in 2005–2006 portends all the consequences of diabetes, including its myriad of complications and costs both to individuals and to society,” the researchers wrote.

The researchers had no financial conflicts to disclose.

A midlife diagnosis of diabetes increases the risk of developing Alzheimer's disease and vascular dementia, based on results of a twin study including more than 13,000 individuals.

Previous studies have shown that people with diabetes are at increased risk for dementia, but little is known about the mechanism of action, wrote Dr. Weili Xu of the Karolinska Institutet, Stockholm, and the Stockholm Gerontology Research Center. Dr. Xu and colleagues conducted this twin study to examine the effect of diabetes on dementia and assess the possible role of genetics (Diabetes 2009;58:71–7).

Data were taken from a national registry of Swedish twins who were at least 65 years old when they entered the study between 1998 and 2001. Of 13,693 study participants, 13,056 had no dementia, 467 had dementia, and 170 had questionable dementia, based on DSM-IV criteria. Midlife diabetes was defined as the onset of type 2 diabetes before age 65 years.

A total of 1,396 individuals had type 2 diabetes; 643 developed diabetes before age 65 years and 753 developed diabetes at age 65 years or older.

Overall, diabetes was significantly associated with an increased risk of dementia (increased risk of 63%), and patients whose diabetes was diagnosed at midlife were more than twice as likely to develop dementia as those diagnosed with diabetes later in life (increased risk of 176%), even after controlling for diabetes duration and twin factors.

In addition, data from co-twin matched case-control analyses showed that the effect of midlife diabetes on dementia remained significant while the effect of later-life diabetes diagnosis on dementia did not.

These data suggest that adult lifestyle traits such as diet, exercise, smoking, and diabetes control may have a substantial impact on the link between midlife diabetes and dementia. But “unmeasured familial factors” including genetic factors and environmental influences in early life might contribute to the association between late-life diabetes diagnosis and dementia, the researchers noted.

The study's limitations include the prevalence of dementia cases, the use of self-reports, and the lack of information about genes and environmental factors.

The study was supported in part by research grants from sources including the National Institute on Aging and the American Alzheimer's Association. The researchers disclosed no financial conflicts of interest.

A midlife diagnosis of diabetes increases the risk of developing Alzheimer's disease and vascular dementia, based on results of a twin study including more than 13,000 individuals.

Previous studies have shown that people with diabetes are at increased risk for dementia, but little is known about the mechanism of action, wrote Dr. Weili Xu of the Karolinska Institutet, Stockholm, and the Stockholm Gerontology Research Center. Dr. Xu and colleagues conducted this twin study to examine the effect of diabetes on dementia and assess the possible role of genetics (Diabetes 2009;58:71–7).

Data were taken from a national registry of Swedish twins who were at least 65 years old when they entered the study between 1998 and 2001. Of 13,693 study participants, 13,056 had no dementia, 467 had dementia, and 170 had questionable dementia, based on DSM-IV criteria. Midlife diabetes was defined as the onset of type 2 diabetes before age 65 years.

A total of 1,396 individuals had type 2 diabetes; 643 developed diabetes before age 65 years and 753 developed diabetes at age 65 years or older.

Overall, diabetes was significantly associated with an increased risk of dementia (increased risk of 63%), and patients whose diabetes was diagnosed at midlife were more than twice as likely to develop dementia as those diagnosed with diabetes later in life (increased risk of 176%), even after controlling for diabetes duration and twin factors.

In addition, data from co-twin matched case-control analyses showed that the effect of midlife diabetes on dementia remained significant while the effect of later-life diabetes diagnosis on dementia did not.

These data suggest that adult lifestyle traits such as diet, exercise, smoking, and diabetes control may have a substantial impact on the link between midlife diabetes and dementia. But “unmeasured familial factors” including genetic factors and environmental influences in early life might contribute to the association between late-life diabetes diagnosis and dementia, the researchers noted.

The study's limitations include the prevalence of dementia cases, the use of self-reports, and the lack of information about genes and environmental factors.

The study was supported in part by research grants from sources including the National Institute on Aging and the American Alzheimer's Association. The researchers disclosed no financial conflicts of interest.

A midlife diagnosis of diabetes increases the risk of developing Alzheimer's disease and vascular dementia, based on results of a twin study including more than 13,000 individuals.

Previous studies have shown that people with diabetes are at increased risk for dementia, but little is known about the mechanism of action, wrote Dr. Weili Xu of the Karolinska Institutet, Stockholm, and the Stockholm Gerontology Research Center. Dr. Xu and colleagues conducted this twin study to examine the effect of diabetes on dementia and assess the possible role of genetics (Diabetes 2009;58:71–7).

Data were taken from a national registry of Swedish twins who were at least 65 years old when they entered the study between 1998 and 2001. Of 13,693 study participants, 13,056 had no dementia, 467 had dementia, and 170 had questionable dementia, based on DSM-IV criteria. Midlife diabetes was defined as the onset of type 2 diabetes before age 65 years.

A total of 1,396 individuals had type 2 diabetes; 643 developed diabetes before age 65 years and 753 developed diabetes at age 65 years or older.

Overall, diabetes was significantly associated with an increased risk of dementia (increased risk of 63%), and patients whose diabetes was diagnosed at midlife were more than twice as likely to develop dementia as those diagnosed with diabetes later in life (increased risk of 176%), even after controlling for diabetes duration and twin factors.

In addition, data from co-twin matched case-control analyses showed that the effect of midlife diabetes on dementia remained significant while the effect of later-life diabetes diagnosis on dementia did not.

These data suggest that adult lifestyle traits such as diet, exercise, smoking, and diabetes control may have a substantial impact on the link between midlife diabetes and dementia. But “unmeasured familial factors” including genetic factors and environmental influences in early life might contribute to the association between late-life diabetes diagnosis and dementia, the researchers noted.

The study's limitations include the prevalence of dementia cases, the use of self-reports, and the lack of information about genes and environmental factors.

The study was supported in part by research grants from sources including the National Institute on Aging and the American Alzheimer's Association. The researchers disclosed no financial conflicts of interest.

RIO GRANDE, P.R. — Exercise does not increase foot ulcer rates in adults with diabetic peripheral neuropathy, based on data from 79 adults aged 50 years and older.

The American Diabetes Association recommends moderate physical activity for people with diabetes, but the organization also recommends that people with diabetes and neuropathy limit weight-bearing activity to reduce the risk of foot ulcers.

“This was based on a long-standing assumption that repetitive mechanical stimulation, which the feet endure during walking, would lead to foot ulcers in those with neuropathy, an assumption that has remained untested since rat foot pad studies in the 1970s,” said Dr. Joseph LeMaster of the University of Missouri-Columbia.

Previous studies have shown that people with diabetes who walk regularly can reduce their risk of developing complications such as cardiovascular disease, Dr. LeMaster said.

To determine whether regular walking increased the risk of foot ulcers, Dr. LeMaster and his colleagues conducted a randomized, controlled trial known as Feet First, in which 41 adults received an intervention that included leg strengthening and balance exercises, directions for a self-guided walking program, and telephone support every 2 weeks. Dr. LeMaster presented the results at the annual meeting of the North American Primary Care Research Group.

Both the intervention group and a control group of 38 adults received foot care education, regular foot checks, and eight sessions with a physical therapist, but the control group received no additional exercise intervention. The average age of the patients was 66 years, and 51% were women (Phys. Ther. 2008;88:1385–98).

After 6 months, the average number of total daily steps taken was not significantly different between the two groups, although the total steps decreased by 13% in the control group. But participants in the intervention group increased the steps taken during a 30-minute exercise session by 14% from baseline, compared with a 6% decrease in the control group.

Although the activity level was less than the researchers hoped for, the results suggest that the intervention helped prevent a decrease in activity, Dr. LeMaster said.

Overall, 22 lesions occurred in the intervention group and 14 in the control group after 6 months, but this difference was not significant. This number increased to 27 lesions in the intervention group and 21 in the control group after 12 months. The total of 48 lesions excluded 9 lesions that resulted from trauma during self-care (such as cutting a toe while trimming a toenail).

The overall ulcer rates were similar between the groups at 6 months, but by 12 months the rate of weight-bearing full-thickness plantar lesions was higher in the control group, compared with the intervention group (five lesions vs. one).

“We conclude that intervention achieved a modest increase in daily ambulatory activity,” Dr. LeMaster said. “Prescribing these patients a carefully monitored program in which they gradually increase walking over several months is probably safe,” he said. But he noted that careful attention to footwear and regular foot checks are important.

The study was limited by wide confidence intervals, “so we can only draw preliminary conclusions about the effect of the intervention on foot ulcers,” he said.

But gradually increasing activity is the key to success for diabetic neuropathy patients, he said during a question-and-answer session. When asked what clinicians can tell diabetic neuropathy patients about increasing activity, he emphasized using a pedometer to ensure a gradual increase in activity. Ulcers are more likely to occur when someone has been inactive and tries to increase activity too quickly, he said.

The Feet First study was sponsored by the Robert Wood Johnson Foundation. Dr. LeMaster and his colleagues have received funding from the National Institutes of Health for a follow-up study that will involve working more closely with patients to increase activity.

RIO GRANDE, P.R. — Exercise does not increase foot ulcer rates in adults with diabetic peripheral neuropathy, based on data from 79 adults aged 50 years and older.

The American Diabetes Association recommends moderate physical activity for people with diabetes, but the organization also recommends that people with diabetes and neuropathy limit weight-bearing activity to reduce the risk of foot ulcers.

“This was based on a long-standing assumption that repetitive mechanical stimulation, which the feet endure during walking, would lead to foot ulcers in those with neuropathy, an assumption that has remained untested since rat foot pad studies in the 1970s,” said Dr. Joseph LeMaster of the University of Missouri-Columbia.

Previous studies have shown that people with diabetes who walk regularly can reduce their risk of developing complications such as cardiovascular disease, Dr. LeMaster said.

To determine whether regular walking increased the risk of foot ulcers, Dr. LeMaster and his colleagues conducted a randomized, controlled trial known as Feet First, in which 41 adults received an intervention that included leg strengthening and balance exercises, directions for a self-guided walking program, and telephone support every 2 weeks. Dr. LeMaster presented the results at the annual meeting of the North American Primary Care Research Group.

Both the intervention group and a control group of 38 adults received foot care education, regular foot checks, and eight sessions with a physical therapist, but the control group received no additional exercise intervention. The average age of the patients was 66 years, and 51% were women (Phys. Ther. 2008;88:1385–98).

After 6 months, the average number of total daily steps taken was not significantly different between the two groups, although the total steps decreased by 13% in the control group. But participants in the intervention group increased the steps taken during a 30-minute exercise session by 14% from baseline, compared with a 6% decrease in the control group.

Although the activity level was less than the researchers hoped for, the results suggest that the intervention helped prevent a decrease in activity, Dr. LeMaster said.

Overall, 22 lesions occurred in the intervention group and 14 in the control group after 6 months, but this difference was not significant. This number increased to 27 lesions in the intervention group and 21 in the control group after 12 months. The total of 48 lesions excluded 9 lesions that resulted from trauma during self-care (such as cutting a toe while trimming a toenail).

The overall ulcer rates were similar between the groups at 6 months, but by 12 months the rate of weight-bearing full-thickness plantar lesions was higher in the control group, compared with the intervention group (five lesions vs. one).

“We conclude that intervention achieved a modest increase in daily ambulatory activity,” Dr. LeMaster said. “Prescribing these patients a carefully monitored program in which they gradually increase walking over several months is probably safe,” he said. But he noted that careful attention to footwear and regular foot checks are important.

The study was limited by wide confidence intervals, “so we can only draw preliminary conclusions about the effect of the intervention on foot ulcers,” he said.

But gradually increasing activity is the key to success for diabetic neuropathy patients, he said during a question-and-answer session. When asked what clinicians can tell diabetic neuropathy patients about increasing activity, he emphasized using a pedometer to ensure a gradual increase in activity. Ulcers are more likely to occur when someone has been inactive and tries to increase activity too quickly, he said.

The Feet First study was sponsored by the Robert Wood Johnson Foundation. Dr. LeMaster and his colleagues have received funding from the National Institutes of Health for a follow-up study that will involve working more closely with patients to increase activity.

RIO GRANDE, P.R. — Exercise does not increase foot ulcer rates in adults with diabetic peripheral neuropathy, based on data from 79 adults aged 50 years and older.

The American Diabetes Association recommends moderate physical activity for people with diabetes, but the organization also recommends that people with diabetes and neuropathy limit weight-bearing activity to reduce the risk of foot ulcers.

“This was based on a long-standing assumption that repetitive mechanical stimulation, which the feet endure during walking, would lead to foot ulcers in those with neuropathy, an assumption that has remained untested since rat foot pad studies in the 1970s,” said Dr. Joseph LeMaster of the University of Missouri-Columbia.

Previous studies have shown that people with diabetes who walk regularly can reduce their risk of developing complications such as cardiovascular disease, Dr. LeMaster said.

To determine whether regular walking increased the risk of foot ulcers, Dr. LeMaster and his colleagues conducted a randomized, controlled trial known as Feet First, in which 41 adults received an intervention that included leg strengthening and balance exercises, directions for a self-guided walking program, and telephone support every 2 weeks. Dr. LeMaster presented the results at the annual meeting of the North American Primary Care Research Group.

Both the intervention group and a control group of 38 adults received foot care education, regular foot checks, and eight sessions with a physical therapist, but the control group received no additional exercise intervention. The average age of the patients was 66 years, and 51% were women (Phys. Ther. 2008;88:1385–98).

After 6 months, the average number of total daily steps taken was not significantly different between the two groups, although the total steps decreased by 13% in the control group. But participants in the intervention group increased the steps taken during a 30-minute exercise session by 14% from baseline, compared with a 6% decrease in the control group.

Although the activity level was less than the researchers hoped for, the results suggest that the intervention helped prevent a decrease in activity, Dr. LeMaster said.

Overall, 22 lesions occurred in the intervention group and 14 in the control group after 6 months, but this difference was not significant. This number increased to 27 lesions in the intervention group and 21 in the control group after 12 months. The total of 48 lesions excluded 9 lesions that resulted from trauma during self-care (such as cutting a toe while trimming a toenail).

The overall ulcer rates were similar between the groups at 6 months, but by 12 months the rate of weight-bearing full-thickness plantar lesions was higher in the control group, compared with the intervention group (five lesions vs. one).

“We conclude that intervention achieved a modest increase in daily ambulatory activity,” Dr. LeMaster said. “Prescribing these patients a carefully monitored program in which they gradually increase walking over several months is probably safe,” he said. But he noted that careful attention to footwear and regular foot checks are important.

The study was limited by wide confidence intervals, “so we can only draw preliminary conclusions about the effect of the intervention on foot ulcers,” he said.

But gradually increasing activity is the key to success for diabetic neuropathy patients, he said during a question-and-answer session. When asked what clinicians can tell diabetic neuropathy patients about increasing activity, he emphasized using a pedometer to ensure a gradual increase in activity. Ulcers are more likely to occur when someone has been inactive and tries to increase activity too quickly, he said.

The Feet First study was sponsored by the Robert Wood Johnson Foundation. Dr. LeMaster and his colleagues have received funding from the National Institutes of Health for a follow-up study that will involve working more closely with patients to increase activity.

WASHINGTON — Using hormonal contraceptives might weaken a woman's natural immunity to the herpesvirus, according to findings from a pilot study of healthy women aged 18–35 years.

Findings from previous epidemiologic studies suggest that women who use hormonal contraception are at increased risk for sexually transmitted infections and herpes simplex virus (HSV) shedding. Yet clinical studies have shown that “cervicovaginal lavage fluid protects against HSV, HIV, and bacteria,” lead author Dr. Gail F. Shust said at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America.

Dr. Shust and colleagues from Albert Einstein College of Medicine, New York, measured anti-HSV activity and levels of immunity associated with hormonal contraception use by collecting samples of cervicovaginal lavage (CVL) fluid from 16 women once a week for 3–8 weeks. Nine women had normal ovulatory cycles and served as controls, and seven women used hormonal contraception.

When average values from the repeat CVL samples from each woman were compared, in the follicular phase, women using hormonal contraception showed significantly less anti-HSV activity compared with the controls. In the luteal phase, the difference did not reach statistical significance.

When individual fluid samples were compared (for a total of 94 samples), the anti-HSV activity in women using hormonal contraception was significantly lower, compared with the controls, in both the follicular and luteal phases.

Correlations between anti-HSV activity and specific mucosal mediators that can inhibit herpes infection were measured through a Spearman's rank correlation coefficient analysis. Based on this measure, anti-HSV activity was positively correlated with levels of human neutrophil peptides (HNPs) 1, 2, and 3 (Spearman's rho = 0.45), lactoferrin (rs = 0.52), lysozyme (rs = 0.58), and IgA (rs = 0.44). In addition, anti-HSV activity was negatively correlated with interferon-alpha 2 (rs = −0.36). Each of these correlations was statistically significant.

The study was limited by its small size and intrasubject and intersubject variability in anti-HSV activity.

These findings may provide a biologic explanation for the epidemiologic findings of increased risk for acquisition of sexually transmitted infections, and for HSV shedding, in the setting of hormonal contraception, the researchers said. Dr. Shust reported no financial conflicts of interest.

WASHINGTON — Using hormonal contraceptives might weaken a woman's natural immunity to the herpesvirus, according to findings from a pilot study of healthy women aged 18–35 years.

Findings from previous epidemiologic studies suggest that women who use hormonal contraception are at increased risk for sexually transmitted infections and herpes simplex virus (HSV) shedding. Yet clinical studies have shown that “cervicovaginal lavage fluid protects against HSV, HIV, and bacteria,” lead author Dr. Gail F. Shust said at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America.

Dr. Shust and colleagues from Albert Einstein College of Medicine, New York, measured anti-HSV activity and levels of immunity associated with hormonal contraception use by collecting samples of cervicovaginal lavage (CVL) fluid from 16 women once a week for 3–8 weeks. Nine women had normal ovulatory cycles and served as controls, and seven women used hormonal contraception.

When average values from the repeat CVL samples from each woman were compared, in the follicular phase, women using hormonal contraception showed significantly less anti-HSV activity compared with the controls. In the luteal phase, the difference did not reach statistical significance.

When individual fluid samples were compared (for a total of 94 samples), the anti-HSV activity in women using hormonal contraception was significantly lower, compared with the controls, in both the follicular and luteal phases.

Correlations between anti-HSV activity and specific mucosal mediators that can inhibit herpes infection were measured through a Spearman's rank correlation coefficient analysis. Based on this measure, anti-HSV activity was positively correlated with levels of human neutrophil peptides (HNPs) 1, 2, and 3 (Spearman's rho = 0.45), lactoferrin (rs = 0.52), lysozyme (rs = 0.58), and IgA (rs = 0.44). In addition, anti-HSV activity was negatively correlated with interferon-alpha 2 (rs = −0.36). Each of these correlations was statistically significant.

The study was limited by its small size and intrasubject and intersubject variability in anti-HSV activity.

These findings may provide a biologic explanation for the epidemiologic findings of increased risk for acquisition of sexually transmitted infections, and for HSV shedding, in the setting of hormonal contraception, the researchers said. Dr. Shust reported no financial conflicts of interest.

WASHINGTON — Using hormonal contraceptives might weaken a woman's natural immunity to the herpesvirus, according to findings from a pilot study of healthy women aged 18–35 years.

Findings from previous epidemiologic studies suggest that women who use hormonal contraception are at increased risk for sexually transmitted infections and herpes simplex virus (HSV) shedding. Yet clinical studies have shown that “cervicovaginal lavage fluid protects against HSV, HIV, and bacteria,” lead author Dr. Gail F. Shust said at the jointly held annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the annual meeting of the Infectious Diseases Society of America.

Dr. Shust and colleagues from Albert Einstein College of Medicine, New York, measured anti-HSV activity and levels of immunity associated with hormonal contraception use by collecting samples of cervicovaginal lavage (CVL) fluid from 16 women once a week for 3–8 weeks. Nine women had normal ovulatory cycles and served as controls, and seven women used hormonal contraception.

When average values from the repeat CVL samples from each woman were compared, in the follicular phase, women using hormonal contraception showed significantly less anti-HSV activity compared with the controls. In the luteal phase, the difference did not reach statistical significance.

When individual fluid samples were compared (for a total of 94 samples), the anti-HSV activity in women using hormonal contraception was significantly lower, compared with the controls, in both the follicular and luteal phases.

Correlations between anti-HSV activity and specific mucosal mediators that can inhibit herpes infection were measured through a Spearman's rank correlation coefficient analysis. Based on this measure, anti-HSV activity was positively correlated with levels of human neutrophil peptides (HNPs) 1, 2, and 3 (Spearman's rho = 0.45), lactoferrin (rs = 0.52), lysozyme (rs = 0.58), and IgA (rs = 0.44). In addition, anti-HSV activity was negatively correlated with interferon-alpha 2 (rs = −0.36). Each of these correlations was statistically significant.

The study was limited by its small size and intrasubject and intersubject variability in anti-HSV activity.

These findings may provide a biologic explanation for the epidemiologic findings of increased risk for acquisition of sexually transmitted infections, and for HSV shedding, in the setting of hormonal contraception, the researchers said. Dr. Shust reported no financial conflicts of interest.

RIO GRANDE, P.R. — A majority of health care providers said they would not insert an IUD before obtaining Pap test or colposcopy results in a recently postpartum woman with low-grade squamous epithelial lesions, according to results of a survey of nearly 300 participants.

Although evidence does not support a connection between IUDs and an increased risk of cervical dysplasia, many providers require screening tests before inserting IUDs, which may leave women vulnerable to unintended pregnancy, the researchers said.

To determine health care providers' attitudes about screening tests and IUDs, Dr. Tara Stein and Dr. Marji Gold of Albert Einstein College of Medicine, New York, surveyed 294 providers: 214 colposcopy providers and 80 providers who do not perform colposcopies. The average age of the participants was 44 years. Approximately half of the providers reported that they had inserted 1–20 IUDs during the past year. The participants were recruited for the survey while attending academic conferences, and the results were presented in a poster at the annual meeting of the North American Primary Care Research Group.

Overall, 88% of colposcopy providers and 90% of noncolposcopy providers said that they would insert an IUD without Pap test or colposcopy results if the patient were a 30-year-old woman whose last normal Pap was 2 years ago.

By contrast, 27% of colposcopy providers and 17% of noncolposcopy providers said that they would insert an IUD without Pap or colposcopy results if the patient were a 28-year-old woman who was 6 weeks post partum with a history of low-grade squamous epithelial lesions (LSIL) during pregnancy.

Although the presence of LSIL increases the risk of cervical dysplasia, only 1% of the survey respondents said they believed that the copper T 380 and levonorgestrel intrauterine systems worsen cervical dysplasia.

The researchers had no financial conflicts to disclose.

RIO GRANDE, P.R. — A majority of health care providers said they would not insert an IUD before obtaining Pap test or colposcopy results in a recently postpartum woman with low-grade squamous epithelial lesions, according to results of a survey of nearly 300 participants.

Although evidence does not support a connection between IUDs and an increased risk of cervical dysplasia, many providers require screening tests before inserting IUDs, which may leave women vulnerable to unintended pregnancy, the researchers said.

To determine health care providers' attitudes about screening tests and IUDs, Dr. Tara Stein and Dr. Marji Gold of Albert Einstein College of Medicine, New York, surveyed 294 providers: 214 colposcopy providers and 80 providers who do not perform colposcopies. The average age of the participants was 44 years. Approximately half of the providers reported that they had inserted 1–20 IUDs during the past year. The participants were recruited for the survey while attending academic conferences, and the results were presented in a poster at the annual meeting of the North American Primary Care Research Group.

Overall, 88% of colposcopy providers and 90% of noncolposcopy providers said that they would insert an IUD without Pap test or colposcopy results if the patient were a 30-year-old woman whose last normal Pap was 2 years ago.

By contrast, 27% of colposcopy providers and 17% of noncolposcopy providers said that they would insert an IUD without Pap or colposcopy results if the patient were a 28-year-old woman who was 6 weeks post partum with a history of low-grade squamous epithelial lesions (LSIL) during pregnancy.

Although the presence of LSIL increases the risk of cervical dysplasia, only 1% of the survey respondents said they believed that the copper T 380 and levonorgestrel intrauterine systems worsen cervical dysplasia.

The researchers had no financial conflicts to disclose.

RIO GRANDE, P.R. — A majority of health care providers said they would not insert an IUD before obtaining Pap test or colposcopy results in a recently postpartum woman with low-grade squamous epithelial lesions, according to results of a survey of nearly 300 participants.

Although evidence does not support a connection between IUDs and an increased risk of cervical dysplasia, many providers require screening tests before inserting IUDs, which may leave women vulnerable to unintended pregnancy, the researchers said.

To determine health care providers' attitudes about screening tests and IUDs, Dr. Tara Stein and Dr. Marji Gold of Albert Einstein College of Medicine, New York, surveyed 294 providers: 214 colposcopy providers and 80 providers who do not perform colposcopies. The average age of the participants was 44 years. Approximately half of the providers reported that they had inserted 1–20 IUDs during the past year. The participants were recruited for the survey while attending academic conferences, and the results were presented in a poster at the annual meeting of the North American Primary Care Research Group.

Overall, 88% of colposcopy providers and 90% of noncolposcopy providers said that they would insert an IUD without Pap test or colposcopy results if the patient were a 30-year-old woman whose last normal Pap was 2 years ago.

By contrast, 27% of colposcopy providers and 17% of noncolposcopy providers said that they would insert an IUD without Pap or colposcopy results if the patient were a 28-year-old woman who was 6 weeks post partum with a history of low-grade squamous epithelial lesions (LSIL) during pregnancy.

Although the presence of LSIL increases the risk of cervical dysplasia, only 1% of the survey respondents said they believed that the copper T 380 and levonorgestrel intrauterine systems worsen cervical dysplasia.

The researchers had no financial conflicts to disclose.

A revised high-tech tool from the Department of Health and Human Services may make filling out a pre-exam checklist in the doctor's office obsolete, if doctors and patients will use it.

“We know that a large percentage of our risk for developing certain diseases is related to genetics and related to our family histories,” acting Surgeon General Steven Galson said in an interview.

In the future, providers will predict risk and plan therapy based on information obtained from a drop of blood, but that future is still far off, Dr. Galson said.

“We know that today, by using family history, we can get a lot of information that can help clinicians,” he emphasized. The online tool, called My Family Health Portrait, collects information in a standard way that's easy for family members to share and for providers to use, he said.

“We'd like to see every single American have the opportunity to input their data into this tool and enable their physicians to treat them with a better understanding of family history,” he added.

“Family history can provide important insights into future risk of developing a wide variety of serious medical conditions like cardiovascular disease, diabetes, and many types of cancers,” Dr. Greg Feero, a senior adviser for genomic medicine at the National Institutes of Health, said in an interview.

But many time-strapped clinicians fail to collect family history during an office visit.

“The tool offers doctors and patients a convenient way to collect and organize an expanded range of family history information outside of the time constraints and pressures of the office visit,” Dr. Feero said.

My Family Health Portrait was introduced in 2004 as a form that patients could print and take to their medical appointments. But the revised version (available at https://familyhistory.hhs.gov

For example, if you create a file with your own history, you are prompted to note the dates when you had certain diseases (if any) or to add diseases not on the default list. You can also add health information about your immediate family members (siblings, parents, children, aunts, and uncles) with options to add more family members. If you give your brother the file, it asks him whether he is a family member and reorients the data around him. This prevents the duplication of data; your brother would only need to input health data that are unique to him.

According to the Department of Health and Human Services, building the basics of a family health history should take about 15–20 minutes. Beyond that, the more family members someone includes, the longer it takes. The history may be downloaded onto a patient's own computer, and it is not automatically accessible by the government or by any health care provider without the patient's permission.

Doctors who start an exam with an accurate family history at hand can spend their time reviewing and interpreting the information, rather than collecting it, Dr. Feero said.

“Importantly, the new tool is designed using accepted data standards, so that the data file it creates has the potential to be shared electronically with electronic health record and personalized health record systems,” Dr. Feero noted. “Ultimately, this same standards-based design should allow the development of automated tools to help clinicians interpret the information the patients provide them.”

But how easy is it for clinicians to promote the tool to patients, and use it in practice? “If the clinician currently uses a paper-based patient family history intake form for new patients, or for yearly physicals, the provider could simply ask patients to complete the new tool online and supply them either with the data file or a paper version,” Dr. Feero explained. “If secure e-mail systems are available to the patient and provider, this might be another option for transferring the information.”

Alternatively, the entire program is available for downloading and customizing at no charge. Providers can install the My Family Health Portrait software as part of their health information technology system. Patients could complete the information at a kiosk or laptop in the waiting room, and have the electronic file sent directly to their physicians for review.

An electronic family history is potentially useful, Dr. Charles Scott, a pediatrician in private practice in Medford, N.J., said in an interview. But it would have to be reviewed and incorporated carefully, so that patients would not be able to access medical files other than their own if they completed the history in a doctor's office, he said. Software compatibility could be a problem in some practices, he added.

And it's important to remember the personal touch, no matter how much electronic media become part of medical practice. “My fear is that we may get so involved with our data entry in the e-chart that we will forget to warmly interact face to face with our patients,” Dr. Scott said.

Clinicians can continue to remind patients to provide as much family history as possible, but it may take time to resolve technical and privacy issues before an electronic family health history becomes a seamless part of an electronic medical record, he said.

Dr. Scott had no financial conflicts to disclose. Dr. Feero is an employee of the National Institutes of Health, which is part of the Department of Health and Human Services.

A revised high-tech tool from the Department of Health and Human Services may make filling out a pre-exam checklist in the doctor's office obsolete, if doctors and patients will use it.

“We know that a large percentage of our risk for developing certain diseases is related to genetics and related to our family histories,” acting Surgeon General Steven Galson said in an interview.

In the future, providers will predict risk and plan therapy based on information obtained from a drop of blood, but that future is still far off, Dr. Galson said.

“We know that today, by using family history, we can get a lot of information that can help clinicians,” he emphasized. The online tool, called My Family Health Portrait, collects information in a standard way that's easy for family members to share and for providers to use, he said.

“We'd like to see every single American have the opportunity to input their data into this tool and enable their physicians to treat them with a better understanding of family history,” he added.

“Family history can provide important insights into future risk of developing a wide variety of serious medical conditions like cardiovascular disease, diabetes, and many types of cancers,” Dr. Greg Feero, a senior adviser for genomic medicine at the National Institutes of Health, said in an interview.

But many time-strapped clinicians fail to collect family history during an office visit.

“The tool offers doctors and patients a convenient way to collect and organize an expanded range of family history information outside of the time constraints and pressures of the office visit,” Dr. Feero said.

My Family Health Portrait was introduced in 2004 as a form that patients could print and take to their medical appointments. But the revised version (available at https://familyhistory.hhs.gov

For example, if you create a file with your own history, you are prompted to note the dates when you had certain diseases (if any) or to add diseases not on the default list. You can also add health information about your immediate family members (siblings, parents, children, aunts, and uncles) with options to add more family members. If you give your brother the file, it asks him whether he is a family member and reorients the data around him. This prevents the duplication of data; your brother would only need to input health data that are unique to him.

According to the Department of Health and Human Services, building the basics of a family health history should take about 15–20 minutes. Beyond that, the more family members someone includes, the longer it takes. The history may be downloaded onto a patient's own computer, and it is not automatically accessible by the government or by any health care provider without the patient's permission.

Doctors who start an exam with an accurate family history at hand can spend their time reviewing and interpreting the information, rather than collecting it, Dr. Feero said.

“Importantly, the new tool is designed using accepted data standards, so that the data file it creates has the potential to be shared electronically with electronic health record and personalized health record systems,” Dr. Feero noted. “Ultimately, this same standards-based design should allow the development of automated tools to help clinicians interpret the information the patients provide them.”

But how easy is it for clinicians to promote the tool to patients, and use it in practice? “If the clinician currently uses a paper-based patient family history intake form for new patients, or for yearly physicals, the provider could simply ask patients to complete the new tool online and supply them either with the data file or a paper version,” Dr. Feero explained. “If secure e-mail systems are available to the patient and provider, this might be another option for transferring the information.”

Alternatively, the entire program is available for downloading and customizing at no charge. Providers can install the My Family Health Portrait software as part of their health information technology system. Patients could complete the information at a kiosk or laptop in the waiting room, and have the electronic file sent directly to their physicians for review.

An electronic family history is potentially useful, Dr. Charles Scott, a pediatrician in private practice in Medford, N.J., said in an interview. But it would have to be reviewed and incorporated carefully, so that patients would not be able to access medical files other than their own if they completed the history in a doctor's office, he said. Software compatibility could be a problem in some practices, he added.

And it's important to remember the personal touch, no matter how much electronic media become part of medical practice. “My fear is that we may get so involved with our data entry in the e-chart that we will forget to warmly interact face to face with our patients,” Dr. Scott said.

Clinicians can continue to remind patients to provide as much family history as possible, but it may take time to resolve technical and privacy issues before an electronic family health history becomes a seamless part of an electronic medical record, he said.

Dr. Scott had no financial conflicts to disclose. Dr. Feero is an employee of the National Institutes of Health, which is part of the Department of Health and Human Services.

A revised high-tech tool from the Department of Health and Human Services may make filling out a pre-exam checklist in the doctor's office obsolete, if doctors and patients will use it.

“We know that a large percentage of our risk for developing certain diseases is related to genetics and related to our family histories,” acting Surgeon General Steven Galson said in an interview.

In the future, providers will predict risk and plan therapy based on information obtained from a drop of blood, but that future is still far off, Dr. Galson said.

“We know that today, by using family history, we can get a lot of information that can help clinicians,” he emphasized. The online tool, called My Family Health Portrait, collects information in a standard way that's easy for family members to share and for providers to use, he said.

“We'd like to see every single American have the opportunity to input their data into this tool and enable their physicians to treat them with a better understanding of family history,” he added.

“Family history can provide important insights into future risk of developing a wide variety of serious medical conditions like cardiovascular disease, diabetes, and many types of cancers,” Dr. Greg Feero, a senior adviser for genomic medicine at the National Institutes of Health, said in an interview.

But many time-strapped clinicians fail to collect family history during an office visit.

“The tool offers doctors and patients a convenient way to collect and organize an expanded range of family history information outside of the time constraints and pressures of the office visit,” Dr. Feero said.

My Family Health Portrait was introduced in 2004 as a form that patients could print and take to their medical appointments. But the revised version (available at https://familyhistory.hhs.gov

For example, if you create a file with your own history, you are prompted to note the dates when you had certain diseases (if any) or to add diseases not on the default list. You can also add health information about your immediate family members (siblings, parents, children, aunts, and uncles) with options to add more family members. If you give your brother the file, it asks him whether he is a family member and reorients the data around him. This prevents the duplication of data; your brother would only need to input health data that are unique to him.

According to the Department of Health and Human Services, building the basics of a family health history should take about 15–20 minutes. Beyond that, the more family members someone includes, the longer it takes. The history may be downloaded onto a patient's own computer, and it is not automatically accessible by the government or by any health care provider without the patient's permission.

Doctors who start an exam with an accurate family history at hand can spend their time reviewing and interpreting the information, rather than collecting it, Dr. Feero said.

“Importantly, the new tool is designed using accepted data standards, so that the data file it creates has the potential to be shared electronically with electronic health record and personalized health record systems,” Dr. Feero noted. “Ultimately, this same standards-based design should allow the development of automated tools to help clinicians interpret the information the patients provide them.”

But how easy is it for clinicians to promote the tool to patients, and use it in practice? “If the clinician currently uses a paper-based patient family history intake form for new patients, or for yearly physicals, the provider could simply ask patients to complete the new tool online and supply them either with the data file or a paper version,” Dr. Feero explained. “If secure e-mail systems are available to the patient and provider, this might be another option for transferring the information.”

Alternatively, the entire program is available for downloading and customizing at no charge. Providers can install the My Family Health Portrait software as part of their health information technology system. Patients could complete the information at a kiosk or laptop in the waiting room, and have the electronic file sent directly to their physicians for review.

An electronic family history is potentially useful, Dr. Charles Scott, a pediatrician in private practice in Medford, N.J., said in an interview. But it would have to be reviewed and incorporated carefully, so that patients would not be able to access medical files other than their own if they completed the history in a doctor's office, he said. Software compatibility could be a problem in some practices, he added.

And it's important to remember the personal touch, no matter how much electronic media become part of medical practice. “My fear is that we may get so involved with our data entry in the e-chart that we will forget to warmly interact face to face with our patients,” Dr. Scott said.

Clinicians can continue to remind patients to provide as much family history as possible, but it may take time to resolve technical and privacy issues before an electronic family health history becomes a seamless part of an electronic medical record, he said.

Dr. Scott had no financial conflicts to disclose. Dr. Feero is an employee of the National Institutes of Health, which is part of the Department of Health and Human Services.

RIO GRANDE, P.R. — Primary care physicians don't appear to treat depression any more aggressively in patients who have medical comorbidities, compared with other patients, despite mounting evidence showing that depression may worsen medical outcomes.

The conclusions were based on a review of more than 20,000 adult records. “There is good evidence that the rate of depression is higher in persons with certain medical comorbidities,” Dr. James Gill said at the annual meeting of the North American Primary Care Research Group. “You could make the argument that persons with depression should be treated more aggressively if they have comorbid conditions,” he added.

In a previous study, Dr. Gill, president of Delaware Valley Outcomes Research LLC, reviewed a large database of patients treated by a range of medical specialists and found no significant differences among the specialists in terms of their use of antidepressant medications to treat depressed patients with and without medical comorbidities (Int. J. Psychiatry 2008;38:203–15).

In order to focus on primary care physicians specifically, Dr. Gill conducted a secondary analysis of 209 family medicine and general internal medicine physicians and 24,876 of their patients, aged 18 years and older, who had diagnoses of depression.

The study population included 1,849 patients with incident depression diagnosed during the 1-year period from October 2006 through October 2007. Study participants had at least one office visit during the year and an active diagnosis of depression as of the end of the year. Data were collected from electronic medical records via the Medical Quality Improvement Consortium.

Approximately 75% of the patients were on any type of antidepressant medication at the study's end. A total of 92% were taking at least the minimum dosage of their prescribed medications, and almost half (49%) were taking the full dosage.

In addition, about one-quarter of the patients in the study had at least one of the six medical comorbidities included in the review: coronary heart disease, heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, cancer, and diabetes. The most common comorbidity was diabetes, affecting 13%.

After the researchers controlled for age, gender, and additional comorbidities, none of the six comorbidities were a significant predictor of any antidepressant medication use or of the dosage. Nor did the researchers find any significant differences in medication use by comorbidity in a subanalysis for the patients with incident depression during the observation year.

Patients with comorbid conditions were slightly more likely to be taking the maximum dosage of an antidepressant, and patients with medical comorbidities in the incident group were slightly less likely to be on medications.

Primary care providers may not be treating depression aggresively due to concerns about medication side effects and the cost of additional medications. The study was limited by a lack of information about the severity of the patients' depression, Dr. Gill said.

But the question remains as to whether treating depression more aggressively can improve the comorbidities, he added, and more research is needed to explore this topic.

Dr. Gill had no financial conflicts to disclose.

RIO GRANDE, P.R. — Primary care physicians don't appear to treat depression any more aggressively in patients who have medical comorbidities, compared with other patients, despite mounting evidence showing that depression may worsen medical outcomes.

The conclusions were based on a review of more than 20,000 adult records. “There is good evidence that the rate of depression is higher in persons with certain medical comorbidities,” Dr. James Gill said at the annual meeting of the North American Primary Care Research Group. “You could make the argument that persons with depression should be treated more aggressively if they have comorbid conditions,” he added.

In a previous study, Dr. Gill, president of Delaware Valley Outcomes Research LLC, reviewed a large database of patients treated by a range of medical specialists and found no significant differences among the specialists in terms of their use of antidepressant medications to treat depressed patients with and without medical comorbidities (Int. J. Psychiatry 2008;38:203–15).

In order to focus on primary care physicians specifically, Dr. Gill conducted a secondary analysis of 209 family medicine and general internal medicine physicians and 24,876 of their patients, aged 18 years and older, who had diagnoses of depression.

The study population included 1,849 patients with incident depression diagnosed during the 1-year period from October 2006 through October 2007. Study participants had at least one office visit during the year and an active diagnosis of depression as of the end of the year. Data were collected from electronic medical records via the Medical Quality Improvement Consortium.

Approximately 75% of the patients were on any type of antidepressant medication at the study's end. A total of 92% were taking at least the minimum dosage of their prescribed medications, and almost half (49%) were taking the full dosage.

In addition, about one-quarter of the patients in the study had at least one of the six medical comorbidities included in the review: coronary heart disease, heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, cancer, and diabetes. The most common comorbidity was diabetes, affecting 13%.

After the researchers controlled for age, gender, and additional comorbidities, none of the six comorbidities were a significant predictor of any antidepressant medication use or of the dosage. Nor did the researchers find any significant differences in medication use by comorbidity in a subanalysis for the patients with incident depression during the observation year.

Patients with comorbid conditions were slightly more likely to be taking the maximum dosage of an antidepressant, and patients with medical comorbidities in the incident group were slightly less likely to be on medications.

Primary care providers may not be treating depression aggresively due to concerns about medication side effects and the cost of additional medications. The study was limited by a lack of information about the severity of the patients' depression, Dr. Gill said.

But the question remains as to whether treating depression more aggressively can improve the comorbidities, he added, and more research is needed to explore this topic.

Dr. Gill had no financial conflicts to disclose.

RIO GRANDE, P.R. — Primary care physicians don't appear to treat depression any more aggressively in patients who have medical comorbidities, compared with other patients, despite mounting evidence showing that depression may worsen medical outcomes.

The conclusions were based on a review of more than 20,000 adult records. “There is good evidence that the rate of depression is higher in persons with certain medical comorbidities,” Dr. James Gill said at the annual meeting of the North American Primary Care Research Group. “You could make the argument that persons with depression should be treated more aggressively if they have comorbid conditions,” he added.

In a previous study, Dr. Gill, president of Delaware Valley Outcomes Research LLC, reviewed a large database of patients treated by a range of medical specialists and found no significant differences among the specialists in terms of their use of antidepressant medications to treat depressed patients with and without medical comorbidities (Int. J. Psychiatry 2008;38:203–15).

In order to focus on primary care physicians specifically, Dr. Gill conducted a secondary analysis of 209 family medicine and general internal medicine physicians and 24,876 of their patients, aged 18 years and older, who had diagnoses of depression.

The study population included 1,849 patients with incident depression diagnosed during the 1-year period from October 2006 through October 2007. Study participants had at least one office visit during the year and an active diagnosis of depression as of the end of the year. Data were collected from electronic medical records via the Medical Quality Improvement Consortium.

Approximately 75% of the patients were on any type of antidepressant medication at the study's end. A total of 92% were taking at least the minimum dosage of their prescribed medications, and almost half (49%) were taking the full dosage.

In addition, about one-quarter of the patients in the study had at least one of the six medical comorbidities included in the review: coronary heart disease, heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, cancer, and diabetes. The most common comorbidity was diabetes, affecting 13%.

After the researchers controlled for age, gender, and additional comorbidities, none of the six comorbidities were a significant predictor of any antidepressant medication use or of the dosage. Nor did the researchers find any significant differences in medication use by comorbidity in a subanalysis for the patients with incident depression during the observation year.

Patients with comorbid conditions were slightly more likely to be taking the maximum dosage of an antidepressant, and patients with medical comorbidities in the incident group were slightly less likely to be on medications.

Primary care providers may not be treating depression aggresively due to concerns about medication side effects and the cost of additional medications. The study was limited by a lack of information about the severity of the patients' depression, Dr. Gill said.

But the question remains as to whether treating depression more aggressively can improve the comorbidities, he added, and more research is needed to explore this topic.

Dr. Gill had no financial conflicts to disclose.

RIO GRANDE, P.R. — Approximately one in four elderly black women have osteoporosis, findings from a small study suggest.

Physicians should not ignore the possibility of osteoporosis in their older black female patients, although these women are not usually considered at high risk, compared with other demographic groups, said Dr. Sally P. Weaver, research director of the McLennan County Medical Education and Research Foundation, Waco, Tex.

Previous studies of osteoporosis in women have focused mainly on white women because of evidence of an elevated risk for osteoporosis in that population. Yet older women of any ethnicity are prone to age-related fractures if their bone mineral density (BMD) is low, she said in an interview.

Dr. Weaver and colleagues measured BMD scans from the electronic health records of 44 black women aged 70 years and older. Patients with conditions that could affect bone turnover, vitamin D absorption, or calcium absorption were excluded from the study.

About 50% of the study participants met the criteria for osteopenia and 10% met the criteria for osteoporosis at the left femoral neck. Approximately 25% met criteria for osteopenia or osteoporosis at the lumbar spine. Overall, the left femoral neck had the lowest regional BMD, with an average T score of −1.23. Dr. Weaver presented the results in a poster at the annual meeting of the North American Primary Care Research Group.

Dr. Weaver had no financial conflicts to disclose.

RIO GRANDE, P.R. — Approximately one in four elderly black women have osteoporosis, findings from a small study suggest.

Physicians should not ignore the possibility of osteoporosis in their older black female patients, although these women are not usually considered at high risk, compared with other demographic groups, said Dr. Sally P. Weaver, research director of the McLennan County Medical Education and Research Foundation, Waco, Tex.

Previous studies of osteoporosis in women have focused mainly on white women because of evidence of an elevated risk for osteoporosis in that population. Yet older women of any ethnicity are prone to age-related fractures if their bone mineral density (BMD) is low, she said in an interview.

Dr. Weaver and colleagues measured BMD scans from the electronic health records of 44 black women aged 70 years and older. Patients with conditions that could affect bone turnover, vitamin D absorption, or calcium absorption were excluded from the study.

About 50% of the study participants met the criteria for osteopenia and 10% met the criteria for osteoporosis at the left femoral neck. Approximately 25% met criteria for osteopenia or osteoporosis at the lumbar spine. Overall, the left femoral neck had the lowest regional BMD, with an average T score of −1.23. Dr. Weaver presented the results in a poster at the annual meeting of the North American Primary Care Research Group.

Dr. Weaver had no financial conflicts to disclose.

RIO GRANDE, P.R. — Approximately one in four elderly black women have osteoporosis, findings from a small study suggest.

Physicians should not ignore the possibility of osteoporosis in their older black female patients, although these women are not usually considered at high risk, compared with other demographic groups, said Dr. Sally P. Weaver, research director of the McLennan County Medical Education and Research Foundation, Waco, Tex.

Previous studies of osteoporosis in women have focused mainly on white women because of evidence of an elevated risk for osteoporosis in that population. Yet older women of any ethnicity are prone to age-related fractures if their bone mineral density (BMD) is low, she said in an interview.

Dr. Weaver and colleagues measured BMD scans from the electronic health records of 44 black women aged 70 years and older. Patients with conditions that could affect bone turnover, vitamin D absorption, or calcium absorption were excluded from the study.

About 50% of the study participants met the criteria for osteopenia and 10% met the criteria for osteoporosis at the left femoral neck. Approximately 25% met criteria for osteopenia or osteoporosis at the lumbar spine. Overall, the left femoral neck had the lowest regional BMD, with an average T score of −1.23. Dr. Weaver presented the results in a poster at the annual meeting of the North American Primary Care Research Group.

Dr. Weaver had no financial conflicts to disclose.

Youth with type 1 diabetes are at significant risk for vitamin D deficiency, based on results of a study of 128 children and adolescents.

Chronic vitamin D deficiency in childhood contributes to bone deformity and reduced bone mass, which could increase fracture risk in adulthood. Because previous research suggests that type 1 diabetes itself is associated with reduced bone mineral density, children and teens with type 1 diabetes may be at even greater risk for skeletal weakness, Dr. Britta M. Svoren of the Joslin (Mass.) Diabetes Center and colleagues noted in the Journal of Pediatrics (2009;154:132–4).

In this study, the researchers measured serum 25-hydroxyvitamin D (25[OH]D) in infants, children, and teens younger than 18 years with type 1 diabetes in the United States. Vitamin D sufficiency, insufficiency, and deficiency were defined as 25(OH)D levels of 30 ng/mL or higher, 21–29 ng/mL, and 20 ng/mL or lower, respectively.

Overall, only 31 participants (24%) met the criteria for sufficient vitamin D, while 78 (61%) had insufficient vitamin D, and 19 (15%) were vitamin D deficient.

When the children were divided into three age groups, 22% of adolescents aged 12–18 years were vitamin D deficient, compared with 12% of those aged 0–5 years and none of the children aged 6–11 years.

After investigators controlled for factors including age, sex, ethnicity, body mass index, and diabetes control (based on hemoglobin A_1c measures), older age was significantly associated with lower 25(OH)D concentrations, and the mean 25(OH)D concentration was significantly lower in the oldest age group (12–18 years) at 24.2 ng/dL, compared with the youngest age group (0–5 years) at 30.8 ng/dL; those aged 6–11 years were in the middle with a mean 25(OH)D concentration of 26.8 ng/dL.

Ethnicity also was associated with lower 25(OH)D levels, which were significantly more common among nonwhites.

Adolescents with type 1 diabetes have additional risk factors for skeletal weakness, including hyperglycemia and hypercalciuria. Lifestyle factors such as drinking less milk and getting less sun exposure also can play a role. Consumption of sugar-free colas, which is common in teens with diabetes, is an additional risk factor for poor bone health because the beverages contain phosphoric acid, “which is known to reduce intestinal calcium absorption,” Dr. Svoren and her associates said.

“Many of these risk factors may not be modifiable because of the inherent presence of diabetes mellitus, [so] ensuring vitamin D sufficiency throughout childhood and during the time of maximal bone mineral accrual seems particularly warranted in this population,” they said.

Dr. Svoren and colleagues said that providers should monitor vitamin D in youth with type 1 diabetes and consider vitamin D supplements for those who aren't getting enough vitamin D through their diets.

The results support findings from previous studies showing evidence of vitamin D deficiency in children and adolescents with type 1 diabetes, but more research is needed to confirm the findings and identify the causes of vitamin D deficiency in this population, they said.

The study was funded by grants from the National Institutes of Health, the Charles H. Hood Foundation, and Eli Lilly & Co. The researchers reported that they had no relevant financial conflicts to disclose.

Youth with type 1 diabetes are at significant risk for vitamin D deficiency, based on results of a study of 128 children and adolescents.

Chronic vitamin D deficiency in childhood contributes to bone deformity and reduced bone mass, which could increase fracture risk in adulthood. Because previous research suggests that type 1 diabetes itself is associated with reduced bone mineral density, children and teens with type 1 diabetes may be at even greater risk for skeletal weakness, Dr. Britta M. Svoren of the Joslin (Mass.) Diabetes Center and colleagues noted in the Journal of Pediatrics (2009;154:132–4).

In this study, the researchers measured serum 25-hydroxyvitamin D (25[OH]D) in infants, children, and teens younger than 18 years with type 1 diabetes in the United States. Vitamin D sufficiency, insufficiency, and deficiency were defined as 25(OH)D levels of 30 ng/mL or higher, 21–29 ng/mL, and 20 ng/mL or lower, respectively.

Overall, only 31 participants (24%) met the criteria for sufficient vitamin D, while 78 (61%) had insufficient vitamin D, and 19 (15%) were vitamin D deficient.

When the children were divided into three age groups, 22% of adolescents aged 12–18 years were vitamin D deficient, compared with 12% of those aged 0–5 years and none of the children aged 6–11 years.

After investigators controlled for factors including age, sex, ethnicity, body mass index, and diabetes control (based on hemoglobin A_1c measures), older age was significantly associated with lower 25(OH)D concentrations, and the mean 25(OH)D concentration was significantly lower in the oldest age group (12–18 years) at 24.2 ng/dL, compared with the youngest age group (0–5 years) at 30.8 ng/dL; those aged 6–11 years were in the middle with a mean 25(OH)D concentration of 26.8 ng/dL.

Ethnicity also was associated with lower 25(OH)D levels, which were significantly more common among nonwhites.

Adolescents with type 1 diabetes have additional risk factors for skeletal weakness, including hyperglycemia and hypercalciuria. Lifestyle factors such as drinking less milk and getting less sun exposure also can play a role. Consumption of sugar-free colas, which is common in teens with diabetes, is an additional risk factor for poor bone health because the beverages contain phosphoric acid, “which is known to reduce intestinal calcium absorption,” Dr. Svoren and her associates said.

“Many of these risk factors may not be modifiable because of the inherent presence of diabetes mellitus, [so] ensuring vitamin D sufficiency throughout childhood and during the time of maximal bone mineral accrual seems particularly warranted in this population,” they said.

Dr. Svoren and colleagues said that providers should monitor vitamin D in youth with type 1 diabetes and consider vitamin D supplements for those who aren't getting enough vitamin D through their diets.

The results support findings from previous studies showing evidence of vitamin D deficiency in children and adolescents with type 1 diabetes, but more research is needed to confirm the findings and identify the causes of vitamin D deficiency in this population, they said.

The study was funded by grants from the National Institutes of Health, the Charles H. Hood Foundation, and Eli Lilly & Co. The researchers reported that they had no relevant financial conflicts to disclose.

Youth with type 1 diabetes are at significant risk for vitamin D deficiency, based on results of a study of 128 children and adolescents.

Chronic vitamin D deficiency in childhood contributes to bone deformity and reduced bone mass, which could increase fracture risk in adulthood. Because previous research suggests that type 1 diabetes itself is associated with reduced bone mineral density, children and teens with type 1 diabetes may be at even greater risk for skeletal weakness, Dr. Britta M. Svoren of the Joslin (Mass.) Diabetes Center and colleagues noted in the Journal of Pediatrics (2009;154:132–4).

In this study, the researchers measured serum 25-hydroxyvitamin D (25[OH]D) in infants, children, and teens younger than 18 years with type 1 diabetes in the United States. Vitamin D sufficiency, insufficiency, and deficiency were defined as 25(OH)D levels of 30 ng/mL or higher, 21–29 ng/mL, and 20 ng/mL or lower, respectively.

Overall, only 31 participants (24%) met the criteria for sufficient vitamin D, while 78 (61%) had insufficient vitamin D, and 19 (15%) were vitamin D deficient.

When the children were divided into three age groups, 22% of adolescents aged 12–18 years were vitamin D deficient, compared with 12% of those aged 0–5 years and none of the children aged 6–11 years.

After investigators controlled for factors including age, sex, ethnicity, body mass index, and diabetes control (based on hemoglobin A_1c measures), older age was significantly associated with lower 25(OH)D concentrations, and the mean 25(OH)D concentration was significantly lower in the oldest age group (12–18 years) at 24.2 ng/dL, compared with the youngest age group (0–5 years) at 30.8 ng/dL; those aged 6–11 years were in the middle with a mean 25(OH)D concentration of 26.8 ng/dL.

Ethnicity also was associated with lower 25(OH)D levels, which were significantly more common among nonwhites.

Adolescents with type 1 diabetes have additional risk factors for skeletal weakness, including hyperglycemia and hypercalciuria. Lifestyle factors such as drinking less milk and getting less sun exposure also can play a role. Consumption of sugar-free colas, which is common in teens with diabetes, is an additional risk factor for poor bone health because the beverages contain phosphoric acid, “which is known to reduce intestinal calcium absorption,” Dr. Svoren and her associates said.

“Many of these risk factors may not be modifiable because of the inherent presence of diabetes mellitus, [so] ensuring vitamin D sufficiency throughout childhood and during the time of maximal bone mineral accrual seems particularly warranted in this population,” they said.

Dr. Svoren and colleagues said that providers should monitor vitamin D in youth with type 1 diabetes and consider vitamin D supplements for those who aren't getting enough vitamin D through their diets.

The results support findings from previous studies showing evidence of vitamin D deficiency in children and adolescents with type 1 diabetes, but more research is needed to confirm the findings and identify the causes of vitamin D deficiency in this population, they said.

The study was funded by grants from the National Institutes of Health, the Charles H. Hood Foundation, and Eli Lilly & Co. The researchers reported that they had no relevant financial conflicts to disclose.