Heidi Splete

Adults who suffered transient neurological attacks with nonfocal symptoms were at increased risk of developing major vascular disease and dementia in a study of more than 6,000 adults aged 55 years and older.

The findings challenge the perception that nonfocal transient neurological attacks (TNAs) are harmless. “TNAs with nonfocal symptoms were almost as frequent as focal TNAs, and had an equally unfavorable overall subsequent clinical course with a slightly higher risk of stroke and a higher risk of vascular dementia than persons without TNA,” the investigators wrote. The authors defined TNA as an episode of neurological dysfunction lasting less than 24 hours (usually from 2 to 15 minutes).

Although focal TNAs (better known as transient ischemic attacks or TIAs) have been characterized, a variety of diagnoses have been applied to nonfocal and mixed TNAs (focal and nonfocal symptoms in the same attack). Focal and mixed TNAs are often considered benign and have not been well studied, Dr. Michiel J. Bos of Erasmus University Medical Centre in Rotterdam, the Netherlands, and colleagues, noted.

To study the incidence and prognosis of each of these three types of TNA, the investigators followed 6,062 community-dwelling adults with no history of stroke, myocardial infarction, or dementia. The participants were part of the Rotterdam Study, an ongoing population-based cohort study.

The subjects enrolled between 1990 and 1993 and were followed until Jan. 1, 2005. The median age of the patients at baseline was 68 years, and 3,758 (62%) were women (JAMA 2007;298:2877–85).

A total of 548 individuals experienced TNAs during the study period of 60,535 person-years. Categorized by their symptoms, 282 TNAs were considered focal, 228 were nonfocal, and 38 were mixed.

Overall, focal and nonfocal TNAs occurred with similar frequency, with incidence rates of 4.7 per 1,000 person-years and 3.8 per 1,000 person-years, respectively. The incidence rates for both types increased with age. The incidence rate for mixed TNAs was much lower—0.6 per 1,000 person years—and the incidence was not clearly associated with age.

Those who met criteria for focal TNAs had a higher risk of subsequent stroke (hazard ratio 2.14) than did those without TNA, after adjustment for age and sex, but there was no observable difference in the risk for MI or dementia.

The participants with nonfocal TNAs were at greater risk of both stroke (HR, 1.56) and dementia (HR, 1.59), compared with subjects without TNAs. And they were at especially high risk for vascular dementia (HR, 5.05). There was no difference in risk for MI in this subgroup.

Those with mixed TNAs also were at increased risk of stroke (HR, 2.48), ischemic heart disease (HR, 2.26), vascular death (HR, 2.54), and dementia (HR, 3.46), compared with individuals who didn't experience TNAs. Notably, the risk of vascular dementia was much higher among those with mixed TNAs (HR, 21.5).

The clinical implication of the findings is that nonfocal TNAs deserve to be taken seriously, Dr. S. Claiborne Johnston, a neurologist at the University of California, San Francisco, wrote in an accompanying editorial (JAMA 2007;298:2912–3).

“The study argues that, whatever is causing these events, the prognosis justifies greater attention,” according to Dr. Johnston.

“Even though TNA is likely to be only of transient utility because clinicians must quickly move to more specific diagnoses to provide appropriate treatment for patients, this entity should be considered a rally cry for more extensive evaluation or consultation in these patients, as well as for further research,” he wrote.

None of the researchers or Dr. Johnston reported any financial conflicts related to this study.

Occurrence of a TNA is a rally cry for extensive evaluation in these patients and further research. DR. JOHNSTON

Adults who suffered transient neurological attacks with nonfocal symptoms were at increased risk of developing major vascular disease and dementia in a study of more than 6,000 adults aged 55 years and older.

The findings challenge the perception that nonfocal transient neurological attacks (TNAs) are harmless. “TNAs with nonfocal symptoms were almost as frequent as focal TNAs, and had an equally unfavorable overall subsequent clinical course with a slightly higher risk of stroke and a higher risk of vascular dementia than persons without TNA,” the investigators wrote. The authors defined TNA as an episode of neurological dysfunction lasting less than 24 hours (usually from 2 to 15 minutes).

Although focal TNAs (better known as transient ischemic attacks or TIAs) have been characterized, a variety of diagnoses have been applied to nonfocal and mixed TNAs (focal and nonfocal symptoms in the same attack). Focal and mixed TNAs are often considered benign and have not been well studied, Dr. Michiel J. Bos of Erasmus University Medical Centre in Rotterdam, the Netherlands, and colleagues, noted.

To study the incidence and prognosis of each of these three types of TNA, the investigators followed 6,062 community-dwelling adults with no history of stroke, myocardial infarction, or dementia. The participants were part of the Rotterdam Study, an ongoing population-based cohort study.

The subjects enrolled between 1990 and 1993 and were followed until Jan. 1, 2005. The median age of the patients at baseline was 68 years, and 3,758 (62%) were women (JAMA 2007;298:2877–85).

A total of 548 individuals experienced TNAs during the study period of 60,535 person-years. Categorized by their symptoms, 282 TNAs were considered focal, 228 were nonfocal, and 38 were mixed.

Overall, focal and nonfocal TNAs occurred with similar frequency, with incidence rates of 4.7 per 1,000 person-years and 3.8 per 1,000 person-years, respectively. The incidence rates for both types increased with age. The incidence rate for mixed TNAs was much lower—0.6 per 1,000 person years—and the incidence was not clearly associated with age.

Those who met criteria for focal TNAs had a higher risk of subsequent stroke (hazard ratio 2.14) than did those without TNA, after adjustment for age and sex, but there was no observable difference in the risk for MI or dementia.

The participants with nonfocal TNAs were at greater risk of both stroke (HR, 1.56) and dementia (HR, 1.59), compared with subjects without TNAs. And they were at especially high risk for vascular dementia (HR, 5.05). There was no difference in risk for MI in this subgroup.

Those with mixed TNAs also were at increased risk of stroke (HR, 2.48), ischemic heart disease (HR, 2.26), vascular death (HR, 2.54), and dementia (HR, 3.46), compared with individuals who didn't experience TNAs. Notably, the risk of vascular dementia was much higher among those with mixed TNAs (HR, 21.5).

The clinical implication of the findings is that nonfocal TNAs deserve to be taken seriously, Dr. S. Claiborne Johnston, a neurologist at the University of California, San Francisco, wrote in an accompanying editorial (JAMA 2007;298:2912–3).

“The study argues that, whatever is causing these events, the prognosis justifies greater attention,” according to Dr. Johnston.

“Even though TNA is likely to be only of transient utility because clinicians must quickly move to more specific diagnoses to provide appropriate treatment for patients, this entity should be considered a rally cry for more extensive evaluation or consultation in these patients, as well as for further research,” he wrote.

None of the researchers or Dr. Johnston reported any financial conflicts related to this study.

Occurrence of a TNA is a rally cry for extensive evaluation in these patients and further research. DR. JOHNSTON

Adults who suffered transient neurological attacks with nonfocal symptoms were at increased risk of developing major vascular disease and dementia in a study of more than 6,000 adults aged 55 years and older.

The findings challenge the perception that nonfocal transient neurological attacks (TNAs) are harmless. “TNAs with nonfocal symptoms were almost as frequent as focal TNAs, and had an equally unfavorable overall subsequent clinical course with a slightly higher risk of stroke and a higher risk of vascular dementia than persons without TNA,” the investigators wrote. The authors defined TNA as an episode of neurological dysfunction lasting less than 24 hours (usually from 2 to 15 minutes).

Although focal TNAs (better known as transient ischemic attacks or TIAs) have been characterized, a variety of diagnoses have been applied to nonfocal and mixed TNAs (focal and nonfocal symptoms in the same attack). Focal and mixed TNAs are often considered benign and have not been well studied, Dr. Michiel J. Bos of Erasmus University Medical Centre in Rotterdam, the Netherlands, and colleagues, noted.

To study the incidence and prognosis of each of these three types of TNA, the investigators followed 6,062 community-dwelling adults with no history of stroke, myocardial infarction, or dementia. The participants were part of the Rotterdam Study, an ongoing population-based cohort study.

The subjects enrolled between 1990 and 1993 and were followed until Jan. 1, 2005. The median age of the patients at baseline was 68 years, and 3,758 (62%) were women (JAMA 2007;298:2877–85).

A total of 548 individuals experienced TNAs during the study period of 60,535 person-years. Categorized by their symptoms, 282 TNAs were considered focal, 228 were nonfocal, and 38 were mixed.

Overall, focal and nonfocal TNAs occurred with similar frequency, with incidence rates of 4.7 per 1,000 person-years and 3.8 per 1,000 person-years, respectively. The incidence rates for both types increased with age. The incidence rate for mixed TNAs was much lower—0.6 per 1,000 person years—and the incidence was not clearly associated with age.

Those who met criteria for focal TNAs had a higher risk of subsequent stroke (hazard ratio 2.14) than did those without TNA, after adjustment for age and sex, but there was no observable difference in the risk for MI or dementia.

The participants with nonfocal TNAs were at greater risk of both stroke (HR, 1.56) and dementia (HR, 1.59), compared with subjects without TNAs. And they were at especially high risk for vascular dementia (HR, 5.05). There was no difference in risk for MI in this subgroup.

Those with mixed TNAs also were at increased risk of stroke (HR, 2.48), ischemic heart disease (HR, 2.26), vascular death (HR, 2.54), and dementia (HR, 3.46), compared with individuals who didn't experience TNAs. Notably, the risk of vascular dementia was much higher among those with mixed TNAs (HR, 21.5).

The clinical implication of the findings is that nonfocal TNAs deserve to be taken seriously, Dr. S. Claiborne Johnston, a neurologist at the University of California, San Francisco, wrote in an accompanying editorial (JAMA 2007;298:2912–3).

“The study argues that, whatever is causing these events, the prognosis justifies greater attention,” according to Dr. Johnston.

“Even though TNA is likely to be only of transient utility because clinicians must quickly move to more specific diagnoses to provide appropriate treatment for patients, this entity should be considered a rally cry for more extensive evaluation or consultation in these patients, as well as for further research,” he wrote.

None of the researchers or Dr. Johnston reported any financial conflicts related to this study.

Occurrence of a TNA is a rally cry for extensive evaluation in these patients and further research. DR. JOHNSTON

Infants excrete the ethyl mercury used in thimerosal-containing vaccines too quickly for the mercury to build up in their systems, according to a recent study.

The findings may help to quell chronic concerns that thimerosal-containing vaccines can increase a child's risk for developmental problems, such as autism. These concerns led to the removal of thimerosal from most vaccines given to children in the United States and Europe as of March 2001, although it remains a component of vaccines used in other countries.

Previous studies have described how the body processes methyl mercury—the type associated with the consumption of fish—but so far, few studies have examined how the body processes ethyl mercury after exposure via intramuscular injection.

In this study, Dr. Michael Pichichero of the University of Rochester (N.Y.), and his colleagues evaluated the ethyl mercury in blood, urine, and stool samples from 216 healthy children prior to vaccination with thimerosal-containing vaccines and again at several points between 12 hours and 30 days after vaccination, depending on the age group.

The study population included 72 newborns, 72 2-month-old infants, and 72 6-month-old infants who were vaccinated at a children's hospital in Argentina between February 2003 and February 2004 (Pediatrics 2008;121:e208–14).

The main hypothesis of the study was that ethyl mercury does not stay long in the bloodstreams of vaccinated infants. Complete pre- and postvaccination blood samples were available from 128 children (59%): 40 newborns, 50 2-month-olds, and 38 6-month-olds.

Overall, the blood mercury levels in all three age groups were highest at the first postvaccination measurements—12 hours after vaccination for newborns and 24 hours after vaccination for the 2-month-olds and 6-month-olds.

In all of the age groups, blood mercury levels quickly dropped and the levels in most of the children had returned to normal by 11 days after vaccination.

The average maximal blood mercury levels following vaccinations for the newborns, 2-month-olds, and 6-month-olds were 5.0 ng/mL, 3.6 ng/mL, and 2.8 ng/mL, respectively.

Even the highest level of mercury was relatively low. The overall highest level detected in the study was 8.0 ng/mL, and it was noted in a newborn 12 hours after a birth dose of a hepatitis B virus (HBV) vaccine that included 32.5 mcg of mercury.

Another important finding was that the prevaccination levels among the 6-month-olds were not higher than the prevaccination levels among the 2-month-olds. This suggests that ethyl mercury does not accumulate in the blood as a result of exposure to thimerosal-containing vaccines, the researchers commented.

“Using a model that accounted for baseline mercury levels, ethyl mercury dosage, and timing of vaccination, we estimated the blood half-life of mercury after administration of thimerosal to be 3.7 days, which did not vary significantly by age group,” the researchers wrote.

“This study is very timely for something that pediatricians are going to be facing,” Dr. Pichichero said in an interview. The ABC-TV network recently aired the debut of a fictional series about a lawyer, “Eli Stone,” that suggested a conspiracy between vaccine companies and physicians to keep an association between vaccines and autism under wraps.

“So every pediatrician in America is going to face parents who see this fictional program,” added Dr. Pichichero. “We are going to have parents wondering whether their doctors are in cahoots with the vaccine companies.”

Dr. Pichichero feels that this study virtually eliminates the argument that mercury can accumulate to unsafe levels in children as a result of standard infant vaccinations. “Our study shows beyond a shadow of a doubt that that is not true given how quickly ethyl mercury disappeared from the blood,” he said.

In fact, inorganic mercury was found in almost all the stool samples in all age groups. Mercury levels in the stool increased shortly after vaccinations in all age groups, but then they began to decline, which suggests that the mercury is leaving the body in the stool, Dr. Pichichero said. By contrast, the urine samples in all age groups showed barely detectable levels of mercury, which suggests that the kidneys are likely not affected, he added.

The results were limited by the combination of methyl and ethyl mercury in the blood samples from some children and by the researchers' inability to identify the exact proportion of mercury excreted through the stool and urine.

However, the short half-life of ethyl mercury in the blood suggests a need to reassess the risk of thimerosal as a preservative, they wrote.

Dr. Pichichero is an unpaid consultant for the World Health Organization on vaccine-related issues, and he has served as a consultant to several vaccine manufacturers including GlaxoSmithKline Biologicals, Sanofi Pasteur, Wyeth Pharmaceuticals, MedImmune, and Merck & Co.

The findings support results from recent studies, including a study conducted by the Centers for Disease Control and Prevention that showed no association between exposure to ethyl mercury from thimerosal-containing vaccines during infancy and neuropsychological outcomes at age 7–10 years (N. Engl. J. Med. 2007;357:1281–92).

Additionally, a population-based study that was conducted in California last year showed an increase in the prevalence of autism in the years since thimerosal-containing vaccines were discontinued (Arch. Gen. Psychiatry 2008;65:19–24).

The blood half-life of mercury after administration was estimated to be 3.7 days, and did not vary by age group. DR. PICHICHERO

Infants excrete the ethyl mercury used in thimerosal-containing vaccines too quickly for the mercury to build up in their systems, according to a recent study.

The findings may help to quell chronic concerns that thimerosal-containing vaccines can increase a child's risk for developmental problems, such as autism. These concerns led to the removal of thimerosal from most vaccines given to children in the United States and Europe as of March 2001, although it remains a component of vaccines used in other countries.

Previous studies have described how the body processes methyl mercury—the type associated with the consumption of fish—but so far, few studies have examined how the body processes ethyl mercury after exposure via intramuscular injection.

In this study, Dr. Michael Pichichero of the University of Rochester (N.Y.), and his colleagues evaluated the ethyl mercury in blood, urine, and stool samples from 216 healthy children prior to vaccination with thimerosal-containing vaccines and again at several points between 12 hours and 30 days after vaccination, depending on the age group.

The study population included 72 newborns, 72 2-month-old infants, and 72 6-month-old infants who were vaccinated at a children's hospital in Argentina between February 2003 and February 2004 (Pediatrics 2008;121:e208–14).

The main hypothesis of the study was that ethyl mercury does not stay long in the bloodstreams of vaccinated infants. Complete pre- and postvaccination blood samples were available from 128 children (59%): 40 newborns, 50 2-month-olds, and 38 6-month-olds.

Overall, the blood mercury levels in all three age groups were highest at the first postvaccination measurements—12 hours after vaccination for newborns and 24 hours after vaccination for the 2-month-olds and 6-month-olds.

In all of the age groups, blood mercury levels quickly dropped and the levels in most of the children had returned to normal by 11 days after vaccination.

The average maximal blood mercury levels following vaccinations for the newborns, 2-month-olds, and 6-month-olds were 5.0 ng/mL, 3.6 ng/mL, and 2.8 ng/mL, respectively.

Even the highest level of mercury was relatively low. The overall highest level detected in the study was 8.0 ng/mL, and it was noted in a newborn 12 hours after a birth dose of a hepatitis B virus (HBV) vaccine that included 32.5 mcg of mercury.

Another important finding was that the prevaccination levels among the 6-month-olds were not higher than the prevaccination levels among the 2-month-olds. This suggests that ethyl mercury does not accumulate in the blood as a result of exposure to thimerosal-containing vaccines, the researchers commented.

“Using a model that accounted for baseline mercury levels, ethyl mercury dosage, and timing of vaccination, we estimated the blood half-life of mercury after administration of thimerosal to be 3.7 days, which did not vary significantly by age group,” the researchers wrote.

“This study is very timely for something that pediatricians are going to be facing,” Dr. Pichichero said in an interview. The ABC-TV network recently aired the debut of a fictional series about a lawyer, “Eli Stone,” that suggested a conspiracy between vaccine companies and physicians to keep an association between vaccines and autism under wraps.

“So every pediatrician in America is going to face parents who see this fictional program,” added Dr. Pichichero. “We are going to have parents wondering whether their doctors are in cahoots with the vaccine companies.”

Dr. Pichichero feels that this study virtually eliminates the argument that mercury can accumulate to unsafe levels in children as a result of standard infant vaccinations. “Our study shows beyond a shadow of a doubt that that is not true given how quickly ethyl mercury disappeared from the blood,” he said.

In fact, inorganic mercury was found in almost all the stool samples in all age groups. Mercury levels in the stool increased shortly after vaccinations in all age groups, but then they began to decline, which suggests that the mercury is leaving the body in the stool, Dr. Pichichero said. By contrast, the urine samples in all age groups showed barely detectable levels of mercury, which suggests that the kidneys are likely not affected, he added.

The results were limited by the combination of methyl and ethyl mercury in the blood samples from some children and by the researchers' inability to identify the exact proportion of mercury excreted through the stool and urine.

However, the short half-life of ethyl mercury in the blood suggests a need to reassess the risk of thimerosal as a preservative, they wrote.

Dr. Pichichero is an unpaid consultant for the World Health Organization on vaccine-related issues, and he has served as a consultant to several vaccine manufacturers including GlaxoSmithKline Biologicals, Sanofi Pasteur, Wyeth Pharmaceuticals, MedImmune, and Merck & Co.

The findings support results from recent studies, including a study conducted by the Centers for Disease Control and Prevention that showed no association between exposure to ethyl mercury from thimerosal-containing vaccines during infancy and neuropsychological outcomes at age 7–10 years (N. Engl. J. Med. 2007;357:1281–92).

Additionally, a population-based study that was conducted in California last year showed an increase in the prevalence of autism in the years since thimerosal-containing vaccines were discontinued (Arch. Gen. Psychiatry 2008;65:19–24).

The blood half-life of mercury after administration was estimated to be 3.7 days, and did not vary by age group. DR. PICHICHERO

Infants excrete the ethyl mercury used in thimerosal-containing vaccines too quickly for the mercury to build up in their systems, according to a recent study.

The findings may help to quell chronic concerns that thimerosal-containing vaccines can increase a child's risk for developmental problems, such as autism. These concerns led to the removal of thimerosal from most vaccines given to children in the United States and Europe as of March 2001, although it remains a component of vaccines used in other countries.

Previous studies have described how the body processes methyl mercury—the type associated with the consumption of fish—but so far, few studies have examined how the body processes ethyl mercury after exposure via intramuscular injection.

In this study, Dr. Michael Pichichero of the University of Rochester (N.Y.), and his colleagues evaluated the ethyl mercury in blood, urine, and stool samples from 216 healthy children prior to vaccination with thimerosal-containing vaccines and again at several points between 12 hours and 30 days after vaccination, depending on the age group.

The study population included 72 newborns, 72 2-month-old infants, and 72 6-month-old infants who were vaccinated at a children's hospital in Argentina between February 2003 and February 2004 (Pediatrics 2008;121:e208–14).

The main hypothesis of the study was that ethyl mercury does not stay long in the bloodstreams of vaccinated infants. Complete pre- and postvaccination blood samples were available from 128 children (59%): 40 newborns, 50 2-month-olds, and 38 6-month-olds.

Overall, the blood mercury levels in all three age groups were highest at the first postvaccination measurements—12 hours after vaccination for newborns and 24 hours after vaccination for the 2-month-olds and 6-month-olds.

In all of the age groups, blood mercury levels quickly dropped and the levels in most of the children had returned to normal by 11 days after vaccination.

The average maximal blood mercury levels following vaccinations for the newborns, 2-month-olds, and 6-month-olds were 5.0 ng/mL, 3.6 ng/mL, and 2.8 ng/mL, respectively.

Even the highest level of mercury was relatively low. The overall highest level detected in the study was 8.0 ng/mL, and it was noted in a newborn 12 hours after a birth dose of a hepatitis B virus (HBV) vaccine that included 32.5 mcg of mercury.

Another important finding was that the prevaccination levels among the 6-month-olds were not higher than the prevaccination levels among the 2-month-olds. This suggests that ethyl mercury does not accumulate in the blood as a result of exposure to thimerosal-containing vaccines, the researchers commented.

“Using a model that accounted for baseline mercury levels, ethyl mercury dosage, and timing of vaccination, we estimated the blood half-life of mercury after administration of thimerosal to be 3.7 days, which did not vary significantly by age group,” the researchers wrote.

“This study is very timely for something that pediatricians are going to be facing,” Dr. Pichichero said in an interview. The ABC-TV network recently aired the debut of a fictional series about a lawyer, “Eli Stone,” that suggested a conspiracy between vaccine companies and physicians to keep an association between vaccines and autism under wraps.

“So every pediatrician in America is going to face parents who see this fictional program,” added Dr. Pichichero. “We are going to have parents wondering whether their doctors are in cahoots with the vaccine companies.”

Dr. Pichichero feels that this study virtually eliminates the argument that mercury can accumulate to unsafe levels in children as a result of standard infant vaccinations. “Our study shows beyond a shadow of a doubt that that is not true given how quickly ethyl mercury disappeared from the blood,” he said.

In fact, inorganic mercury was found in almost all the stool samples in all age groups. Mercury levels in the stool increased shortly after vaccinations in all age groups, but then they began to decline, which suggests that the mercury is leaving the body in the stool, Dr. Pichichero said. By contrast, the urine samples in all age groups showed barely detectable levels of mercury, which suggests that the kidneys are likely not affected, he added.

The results were limited by the combination of methyl and ethyl mercury in the blood samples from some children and by the researchers' inability to identify the exact proportion of mercury excreted through the stool and urine.

However, the short half-life of ethyl mercury in the blood suggests a need to reassess the risk of thimerosal as a preservative, they wrote.

Dr. Pichichero is an unpaid consultant for the World Health Organization on vaccine-related issues, and he has served as a consultant to several vaccine manufacturers including GlaxoSmithKline Biologicals, Sanofi Pasteur, Wyeth Pharmaceuticals, MedImmune, and Merck & Co.

The findings support results from recent studies, including a study conducted by the Centers for Disease Control and Prevention that showed no association between exposure to ethyl mercury from thimerosal-containing vaccines during infancy and neuropsychological outcomes at age 7–10 years (N. Engl. J. Med. 2007;357:1281–92).

Additionally, a population-based study that was conducted in California last year showed an increase in the prevalence of autism in the years since thimerosal-containing vaccines were discontinued (Arch. Gen. Psychiatry 2008;65:19–24).

The blood half-life of mercury after administration was estimated to be 3.7 days, and did not vary by age group. DR. PICHICHERO

Infants excrete the ethyl mercury used in thimerosal-containing vaccines too quickly for the mercury to build up in their systems, study results show.

The findings may help to quell chronic concerns that thimerosal-containing vaccines can increase a child's risk for developmental problems, such as autism. These concerns led to the removal of thimerosal from most vaccines given to children in the United States and Europe as of March 2001, although it remains a component of vaccines used in other countries.

Previous studies have described how the body processes methyl mercury–the type associated with the consumption of fish–but few studies have examined how the body processes ethyl mercury after exposure via intramuscular injection.

In this study, Dr. Michael Pichichero of the University of Rochester (N.Y.) and his colleagues evaluated the ethyl mercury in blood, urine, and stool samples from 216 healthy children prior to vaccination with thimerosal-containing vaccines and again at several points from 12 hours to 30 days after vaccination, depending on the age group. The study population comprised 72 newborns, 72 2-month-old infants, and 72 6-month-old infants who were vaccinated at a children's hospital in Argentina between February 2003 and February 2004 (Pediatrics 2008;121:e208-14).

The main hypothesis of the study was that ethyl mercury does not stay long in the bloodstreams of vaccinated infants. Complete pre- and postvaccination blood samples were available from 128 children (59%): 40 newborns, 50 2-month-olds, and 38 6-month-olds. Overall, the blood mercury levels in all three age groups were highest at the first postvaccination measurements–12 hours after vaccination for newborns and 24 hours after vaccination for the 2-month-olds and 6-month-olds. In all age groups, the blood mercury levels quickly dropped and the levels in most of the children had returned to normal by 11 days after vaccination.

The average maximal blood mercury levels after vaccinations for the newborns, 2-month-olds, and 6-month-olds were 5.0 ng/mL, 3.6 ng/mL, and 2.8 ng/mL, respectively.

Another important finding was that the prevaccination levels among the 6-month-olds were not higher than the prevaccination levels among the 2-month-olds, which suggests that ethyl mercury does not accumulate in the blood as a result of exposure to thimerosal-containing vaccines, the researchers noted.

“Using a model that accounted for baseline mercury levels, ethyl mercury dosage, and timing of vaccination, we estimated the blood half-life of mercury after administration of thimerosal to be 3.7 days, which did not vary significantly by age group,” the researchers wrote.

“This study is very timely for something that pediatricians are going to be facing,” Dr. Pichichero said in an interview. The ABC-TV network recently aired the debut of a fictional series about a lawyer, “Eli Stone,” that suggested a conspiracy between vaccine companies and physicians to keep an association between vaccines and autism under wraps. “So every pediatrician in America is going to face parents who see this fictional program,” he said. “We are going to have parents wondering whether their doctors are in cahoots with the vaccine companies.”

Dr. Pichichero feels that this study virtually eliminates the argument that mercury can accumulate to unsafe levels in children as a result of standard infant vaccinations. “Our study shows beyond a shadow of a doubt that that is not true given how quickly ethyl mercury disappeared from the blood,” he said.

In fact, inorganic mercury was found in almost all the stool samples in all age groups. Mercury levels in the stool increased shortly after vaccinations in all age groups, but then they began to decline, which suggests that the mercury is leaving the body in the stool, Dr. Pichichero said. By contrast, the urine samples in all age groups showed barely detectable levels of mercury, which suggests that the kidneys are likely not affected, he added.

Dr. Pichichero is an unpaid consultant for the World Health Organization on vaccine-related issues, and he has served as a consultant to several vaccine manufacturers including GlaxoSmithKline Biologicals, Sanofi Pasteur, Wyeth Pharmaceuticals, MedImmune, and Merck & Co.

Infants excrete the ethyl mercury used in thimerosal-containing vaccines too quickly for the mercury to build up in their systems, study results show.

The findings may help to quell chronic concerns that thimerosal-containing vaccines can increase a child's risk for developmental problems, such as autism. These concerns led to the removal of thimerosal from most vaccines given to children in the United States and Europe as of March 2001, although it remains a component of vaccines used in other countries.

Previous studies have described how the body processes methyl mercury–the type associated with the consumption of fish–but few studies have examined how the body processes ethyl mercury after exposure via intramuscular injection.

In this study, Dr. Michael Pichichero of the University of Rochester (N.Y.) and his colleagues evaluated the ethyl mercury in blood, urine, and stool samples from 216 healthy children prior to vaccination with thimerosal-containing vaccines and again at several points from 12 hours to 30 days after vaccination, depending on the age group. The study population comprised 72 newborns, 72 2-month-old infants, and 72 6-month-old infants who were vaccinated at a children's hospital in Argentina between February 2003 and February 2004 (Pediatrics 2008;121:e208-14).

The main hypothesis of the study was that ethyl mercury does not stay long in the bloodstreams of vaccinated infants. Complete pre- and postvaccination blood samples were available from 128 children (59%): 40 newborns, 50 2-month-olds, and 38 6-month-olds. Overall, the blood mercury levels in all three age groups were highest at the first postvaccination measurements–12 hours after vaccination for newborns and 24 hours after vaccination for the 2-month-olds and 6-month-olds. In all age groups, the blood mercury levels quickly dropped and the levels in most of the children had returned to normal by 11 days after vaccination.

The average maximal blood mercury levels after vaccinations for the newborns, 2-month-olds, and 6-month-olds were 5.0 ng/mL, 3.6 ng/mL, and 2.8 ng/mL, respectively.

Another important finding was that the prevaccination levels among the 6-month-olds were not higher than the prevaccination levels among the 2-month-olds, which suggests that ethyl mercury does not accumulate in the blood as a result of exposure to thimerosal-containing vaccines, the researchers noted.

“Using a model that accounted for baseline mercury levels, ethyl mercury dosage, and timing of vaccination, we estimated the blood half-life of mercury after administration of thimerosal to be 3.7 days, which did not vary significantly by age group,” the researchers wrote.

“This study is very timely for something that pediatricians are going to be facing,” Dr. Pichichero said in an interview. The ABC-TV network recently aired the debut of a fictional series about a lawyer, “Eli Stone,” that suggested a conspiracy between vaccine companies and physicians to keep an association between vaccines and autism under wraps. “So every pediatrician in America is going to face parents who see this fictional program,” he said. “We are going to have parents wondering whether their doctors are in cahoots with the vaccine companies.”

Dr. Pichichero feels that this study virtually eliminates the argument that mercury can accumulate to unsafe levels in children as a result of standard infant vaccinations. “Our study shows beyond a shadow of a doubt that that is not true given how quickly ethyl mercury disappeared from the blood,” he said.

In fact, inorganic mercury was found in almost all the stool samples in all age groups. Mercury levels in the stool increased shortly after vaccinations in all age groups, but then they began to decline, which suggests that the mercury is leaving the body in the stool, Dr. Pichichero said. By contrast, the urine samples in all age groups showed barely detectable levels of mercury, which suggests that the kidneys are likely not affected, he added.

Dr. Pichichero is an unpaid consultant for the World Health Organization on vaccine-related issues, and he has served as a consultant to several vaccine manufacturers including GlaxoSmithKline Biologicals, Sanofi Pasteur, Wyeth Pharmaceuticals, MedImmune, and Merck & Co.

Infants excrete the ethyl mercury used in thimerosal-containing vaccines too quickly for the mercury to build up in their systems, study results show.

The findings may help to quell chronic concerns that thimerosal-containing vaccines can increase a child's risk for developmental problems, such as autism. These concerns led to the removal of thimerosal from most vaccines given to children in the United States and Europe as of March 2001, although it remains a component of vaccines used in other countries.

Previous studies have described how the body processes methyl mercury–the type associated with the consumption of fish–but few studies have examined how the body processes ethyl mercury after exposure via intramuscular injection.

In this study, Dr. Michael Pichichero of the University of Rochester (N.Y.) and his colleagues evaluated the ethyl mercury in blood, urine, and stool samples from 216 healthy children prior to vaccination with thimerosal-containing vaccines and again at several points from 12 hours to 30 days after vaccination, depending on the age group. The study population comprised 72 newborns, 72 2-month-old infants, and 72 6-month-old infants who were vaccinated at a children's hospital in Argentina between February 2003 and February 2004 (Pediatrics 2008;121:e208-14).

The main hypothesis of the study was that ethyl mercury does not stay long in the bloodstreams of vaccinated infants. Complete pre- and postvaccination blood samples were available from 128 children (59%): 40 newborns, 50 2-month-olds, and 38 6-month-olds. Overall, the blood mercury levels in all three age groups were highest at the first postvaccination measurements–12 hours after vaccination for newborns and 24 hours after vaccination for the 2-month-olds and 6-month-olds. In all age groups, the blood mercury levels quickly dropped and the levels in most of the children had returned to normal by 11 days after vaccination.

The average maximal blood mercury levels after vaccinations for the newborns, 2-month-olds, and 6-month-olds were 5.0 ng/mL, 3.6 ng/mL, and 2.8 ng/mL, respectively.

Another important finding was that the prevaccination levels among the 6-month-olds were not higher than the prevaccination levels among the 2-month-olds, which suggests that ethyl mercury does not accumulate in the blood as a result of exposure to thimerosal-containing vaccines, the researchers noted.

“Using a model that accounted for baseline mercury levels, ethyl mercury dosage, and timing of vaccination, we estimated the blood half-life of mercury after administration of thimerosal to be 3.7 days, which did not vary significantly by age group,” the researchers wrote.

“This study is very timely for something that pediatricians are going to be facing,” Dr. Pichichero said in an interview. The ABC-TV network recently aired the debut of a fictional series about a lawyer, “Eli Stone,” that suggested a conspiracy between vaccine companies and physicians to keep an association between vaccines and autism under wraps. “So every pediatrician in America is going to face parents who see this fictional program,” he said. “We are going to have parents wondering whether their doctors are in cahoots with the vaccine companies.”

Dr. Pichichero feels that this study virtually eliminates the argument that mercury can accumulate to unsafe levels in children as a result of standard infant vaccinations. “Our study shows beyond a shadow of a doubt that that is not true given how quickly ethyl mercury disappeared from the blood,” he said.

In fact, inorganic mercury was found in almost all the stool samples in all age groups. Mercury levels in the stool increased shortly after vaccinations in all age groups, but then they began to decline, which suggests that the mercury is leaving the body in the stool, Dr. Pichichero said. By contrast, the urine samples in all age groups showed barely detectable levels of mercury, which suggests that the kidneys are likely not affected, he added.

Dr. Pichichero is an unpaid consultant for the World Health Organization on vaccine-related issues, and he has served as a consultant to several vaccine manufacturers including GlaxoSmithKline Biologicals, Sanofi Pasteur, Wyeth Pharmaceuticals, MedImmune, and Merck & Co.

Adults who suffered transient neurological attacks with nonfocal symptoms were at increased risk of developing major vascular disease and dementia in a study of more than 6,000 adults aged 55 years and older.

The findings challenge the perception that nonfocal transient neurological attacks (TNAs) are harmless. “TNAs with nonfocal symptoms were almost as frequent as focal TNAs, and had an equally unfavorable overall subsequent clinical course with a slightly higher risk of stroke and a higher risk of vascular dementia than persons without TNA,” the investigators wrote.

The authors defined TNA as an episode of neurological dysfunction lasting less than 24 hours (usually from 2 to 15 minutes). Although focal TNAs (better known as transient ischemic attacks or TIAs) have been characterized, a variety of diagnoses have been applied to nonfocal and mixed TNAs (focal and nonfocal symptoms in the same attack). Focal and mixed TNAs are often considered benign and have not been well studied, Dr. Michiel J. Bos of Erasmus University Medical Centre in Rotterdam, the Netherlands, and colleagues, noted.

To study the incidence and prognosis of each of these three types of TNAs, the investigators followed 6,062 community-dwelling adults with no history of stroke, myocardial infarction, or dementia. The participants were part of the Rotterdam Study, an ongoing population-based cohort study. The subjects enrolled between 1990 and 1993 and were followed until Jan. 1, 2005. The median age of the patients at baseline was 68 years, and 3,758 (62%) were women (JAMA 2007;298: 2877–85).

A total of 548 individuals experienced TNAs during the study period of 60,535 person-years. Categorized by their symptoms, 282 TNAs were considered focal, 228 were nonfocal, and 38 were mixed.

Overall, focal and nonfocal TNAs occurred with similar frequency, with incidence rates of 4.7 per 1,000 person-years and 3.8 per 1,000 person-years, respectively. The incidence rates for both types increased with age. The incidence rate for mixed TNAs was much lower—0.6 per 1,000 person years—and the incidence was not clearly associated with age.

Those who met criteria for focal TNAs had a higher risk of subsequent stroke (hazard ratio, 2.14) than did those without TNA, after adjustment for age and sex, but there was no observable difference in the risk for MI or dementia.

The participants with nonfocal TNAs were at greater risk of both stroke (HR, 1.56) and dementia (HR, 1.59), compared with subjects without TNAs. And they were at especially high risk for vascular dementia (HR, 5.05). There was no difference in risk for MI in this subgroup.

Those with mixed TNAs also were at increased risk of stroke (HR, 2.48), ischemic heart disease (HR, 2.26), vascular death (HR, 2.54), and dementia (HR, 3.46), compared with individuals who didn't experience TNAs. Notably, the risk of vascular dementia was much higher among those with mixed TNAs (HR, 21.5).

The clinical implication of the findings is that nonfocal TNAs deserve to be taken seriously, according to Dr. S. Claiborne Johnston, a neurologist at the University of California, San Francisco, who wrote an accompanying editorial (JAMA 2007;298:2912–3).

“The study argues that, whatever is causing these events, the prognosis justifies greater attention,” Dr. Johnston noted. “Even though TNA is likely to be only of transient utility because clinicians must quickly move to more specific diagnoses to provide appropriate treatment for patients, this entity should be considered a rally cry for more extensive evaluation or consultation in these patients, as well as for further research,” he wrote.

None of the researchers or Dr. Johnston reported any financial conflicts related to this study.

Adults who suffered transient neurological attacks with nonfocal symptoms were at increased risk of developing major vascular disease and dementia in a study of more than 6,000 adults aged 55 years and older.

The findings challenge the perception that nonfocal transient neurological attacks (TNAs) are harmless. “TNAs with nonfocal symptoms were almost as frequent as focal TNAs, and had an equally unfavorable overall subsequent clinical course with a slightly higher risk of stroke and a higher risk of vascular dementia than persons without TNA,” the investigators wrote.

The authors defined TNA as an episode of neurological dysfunction lasting less than 24 hours (usually from 2 to 15 minutes). Although focal TNAs (better known as transient ischemic attacks or TIAs) have been characterized, a variety of diagnoses have been applied to nonfocal and mixed TNAs (focal and nonfocal symptoms in the same attack). Focal and mixed TNAs are often considered benign and have not been well studied, Dr. Michiel J. Bos of Erasmus University Medical Centre in Rotterdam, the Netherlands, and colleagues, noted.

To study the incidence and prognosis of each of these three types of TNAs, the investigators followed 6,062 community-dwelling adults with no history of stroke, myocardial infarction, or dementia. The participants were part of the Rotterdam Study, an ongoing population-based cohort study. The subjects enrolled between 1990 and 1993 and were followed until Jan. 1, 2005. The median age of the patients at baseline was 68 years, and 3,758 (62%) were women (JAMA 2007;298: 2877–85).

A total of 548 individuals experienced TNAs during the study period of 60,535 person-years. Categorized by their symptoms, 282 TNAs were considered focal, 228 were nonfocal, and 38 were mixed.

Overall, focal and nonfocal TNAs occurred with similar frequency, with incidence rates of 4.7 per 1,000 person-years and 3.8 per 1,000 person-years, respectively. The incidence rates for both types increased with age. The incidence rate for mixed TNAs was much lower—0.6 per 1,000 person years—and the incidence was not clearly associated with age.

Those who met criteria for focal TNAs had a higher risk of subsequent stroke (hazard ratio, 2.14) than did those without TNA, after adjustment for age and sex, but there was no observable difference in the risk for MI or dementia.

The participants with nonfocal TNAs were at greater risk of both stroke (HR, 1.56) and dementia (HR, 1.59), compared with subjects without TNAs. And they were at especially high risk for vascular dementia (HR, 5.05). There was no difference in risk for MI in this subgroup.

Those with mixed TNAs also were at increased risk of stroke (HR, 2.48), ischemic heart disease (HR, 2.26), vascular death (HR, 2.54), and dementia (HR, 3.46), compared with individuals who didn't experience TNAs. Notably, the risk of vascular dementia was much higher among those with mixed TNAs (HR, 21.5).

The clinical implication of the findings is that nonfocal TNAs deserve to be taken seriously, according to Dr. S. Claiborne Johnston, a neurologist at the University of California, San Francisco, who wrote an accompanying editorial (JAMA 2007;298:2912–3).

“The study argues that, whatever is causing these events, the prognosis justifies greater attention,” Dr. Johnston noted. “Even though TNA is likely to be only of transient utility because clinicians must quickly move to more specific diagnoses to provide appropriate treatment for patients, this entity should be considered a rally cry for more extensive evaluation or consultation in these patients, as well as for further research,” he wrote.

None of the researchers or Dr. Johnston reported any financial conflicts related to this study.

Adults who suffered transient neurological attacks with nonfocal symptoms were at increased risk of developing major vascular disease and dementia in a study of more than 6,000 adults aged 55 years and older.

The findings challenge the perception that nonfocal transient neurological attacks (TNAs) are harmless. “TNAs with nonfocal symptoms were almost as frequent as focal TNAs, and had an equally unfavorable overall subsequent clinical course with a slightly higher risk of stroke and a higher risk of vascular dementia than persons without TNA,” the investigators wrote.

The authors defined TNA as an episode of neurological dysfunction lasting less than 24 hours (usually from 2 to 15 minutes). Although focal TNAs (better known as transient ischemic attacks or TIAs) have been characterized, a variety of diagnoses have been applied to nonfocal and mixed TNAs (focal and nonfocal symptoms in the same attack). Focal and mixed TNAs are often considered benign and have not been well studied, Dr. Michiel J. Bos of Erasmus University Medical Centre in Rotterdam, the Netherlands, and colleagues, noted.

To study the incidence and prognosis of each of these three types of TNAs, the investigators followed 6,062 community-dwelling adults with no history of stroke, myocardial infarction, or dementia. The participants were part of the Rotterdam Study, an ongoing population-based cohort study. The subjects enrolled between 1990 and 1993 and were followed until Jan. 1, 2005. The median age of the patients at baseline was 68 years, and 3,758 (62%) were women (JAMA 2007;298: 2877–85).

A total of 548 individuals experienced TNAs during the study period of 60,535 person-years. Categorized by their symptoms, 282 TNAs were considered focal, 228 were nonfocal, and 38 were mixed.

Overall, focal and nonfocal TNAs occurred with similar frequency, with incidence rates of 4.7 per 1,000 person-years and 3.8 per 1,000 person-years, respectively. The incidence rates for both types increased with age. The incidence rate for mixed TNAs was much lower—0.6 per 1,000 person years—and the incidence was not clearly associated with age.

Those who met criteria for focal TNAs had a higher risk of subsequent stroke (hazard ratio, 2.14) than did those without TNA, after adjustment for age and sex, but there was no observable difference in the risk for MI or dementia.

The participants with nonfocal TNAs were at greater risk of both stroke (HR, 1.56) and dementia (HR, 1.59), compared with subjects without TNAs. And they were at especially high risk for vascular dementia (HR, 5.05). There was no difference in risk for MI in this subgroup.

Those with mixed TNAs also were at increased risk of stroke (HR, 2.48), ischemic heart disease (HR, 2.26), vascular death (HR, 2.54), and dementia (HR, 3.46), compared with individuals who didn't experience TNAs. Notably, the risk of vascular dementia was much higher among those with mixed TNAs (HR, 21.5).

The clinical implication of the findings is that nonfocal TNAs deserve to be taken seriously, according to Dr. S. Claiborne Johnston, a neurologist at the University of California, San Francisco, who wrote an accompanying editorial (JAMA 2007;298:2912–3).

“The study argues that, whatever is causing these events, the prognosis justifies greater attention,” Dr. Johnston noted. “Even though TNA is likely to be only of transient utility because clinicians must quickly move to more specific diagnoses to provide appropriate treatment for patients, this entity should be considered a rally cry for more extensive evaluation or consultation in these patients, as well as for further research,” he wrote.

None of the researchers or Dr. Johnston reported any financial conflicts related to this study.

Low bone mineral density and a prevalent vertebral fracture were long-term independent predictors of an increased risk of vertebral fractures in women aged 65–99 who were followed for almost 15 years.

Previous studies have shown links between low BMD and an increased risk of a new vertebral fracture and between a prevalent vertebral fracture and an increased risk of a new vertebral fracture after an average of nearly 4 years.

But this study was the first to assess the long-term absolute risk of vertebral fracture based on follow-up evaluations of community-dwelling older women (JAMA 2007;298:2761–67).

In this study, Jane A. Cauley, Dr.PH., of the department of epidemiology at the University of Pittsburgh, and her colleagues reviewed data from 2,680 white women who took part in the longitudinal Study of Osteoporotic Fractures. The average age at baseline was 68.8 years and the average age at follow-up was 83.8 years.

After an average of 14.9 years, 487 women (18.2%) had incident vertebral fractures. This number included 163 of the 394 women (41.4%) who had a prevalent vertebral fracture at baseline and 324 of the 2,286 women (14.2%) who didn't have a vertebral fracture at baseline.

Overall, women with a prevalent fracture were more than four times as likely to suffer an incident vertebral fracture during the follow-up period, compared with those with no fracture history. The association remained significant after the researchers controlled for BMD and other risk factors for vertebral fracture, and the risk was greatest in women who had at least two prevalent vertebral fractures when they enrolled in the investigation.

In addition, a low baseline BMD at several sites (the calcaneus, distal radius, total hip, femoral neck, and lumbar spine) was a significant predictor of incident vertebral fractures during the follow-up period.

After adjustment for risk factors including smoking, body mass index, and estrogen use, about a third of women with a hip BMD T score of −2.5 or less (which is considered osteoporotic) developed incident fractures during the follow-up, compared with about 10% of those with normal BMD scores.

Women with both a prevalent vertebral fracture and total hip BMD T scores of −2.5 or less had an absolute risk of an incident vertebral fracture greater then 50%, compared with a 9% risk among women with a normal BMD and no fracture history.

But women with baseline prevalent vertebral fractures were at increased risk of additional fractures during the follow-up period regardless of BMD, and the interaction between BMD and prevalent vertebral fractures was not statistically significant.

This finding suggests that the presence of a vertebral fracture may indicate deterioration in bone quality, not just bone density, the investigators wrote. “Our results support the recommendation that older women with a prevalent vertebral fracture should be treated for osteoporosis irrespective of BMD.”

In addition, women who had incident fractures tended to be older, thinner, and less likely to report estrogen use. The results were consistent with the short-term findings from the Study of Osteoporotic Fractures and from other similar studies. But the study was limited by its inclusion of white women only, and the results may not be applicable to men or women of other ethnicities. Also, the absolute risk of vertebral fractures may be higher than reported because the study subjects who returned for the follow-up examinations were healthier at baseline than were patients who were lost to follow-up, the researchers noted.

Dr. Cauley has received research support from Merck & Co., Eli Lilly & Co., Pfizer Pharmaceuticals, and Novartis Pharmaceuticals. She also has received consulting fees from Novartis and Eli Lilly, and she serves on the speakers board for Merck. The Study of Osteoporotic Fractures is funded by the National Institutes of Health.

Low bone mineral density and a prevalent vertebral fracture were long-term independent predictors of an increased risk of vertebral fractures in women aged 65–99 who were followed for almost 15 years.

Previous studies have shown links between low BMD and an increased risk of a new vertebral fracture and between a prevalent vertebral fracture and an increased risk of a new vertebral fracture after an average of nearly 4 years.

But this study was the first to assess the long-term absolute risk of vertebral fracture based on follow-up evaluations of community-dwelling older women (JAMA 2007;298:2761–67).

In this study, Jane A. Cauley, Dr.PH., of the department of epidemiology at the University of Pittsburgh, and her colleagues reviewed data from 2,680 white women who took part in the longitudinal Study of Osteoporotic Fractures. The average age at baseline was 68.8 years and the average age at follow-up was 83.8 years.

After an average of 14.9 years, 487 women (18.2%) had incident vertebral fractures. This number included 163 of the 394 women (41.4%) who had a prevalent vertebral fracture at baseline and 324 of the 2,286 women (14.2%) who didn't have a vertebral fracture at baseline.

Overall, women with a prevalent fracture were more than four times as likely to suffer an incident vertebral fracture during the follow-up period, compared with those with no fracture history. The association remained significant after the researchers controlled for BMD and other risk factors for vertebral fracture, and the risk was greatest in women who had at least two prevalent vertebral fractures when they enrolled in the investigation.

In addition, a low baseline BMD at several sites (the calcaneus, distal radius, total hip, femoral neck, and lumbar spine) was a significant predictor of incident vertebral fractures during the follow-up period.

After adjustment for risk factors including smoking, body mass index, and estrogen use, about a third of women with a hip BMD T score of −2.5 or less (which is considered osteoporotic) developed incident fractures during the follow-up, compared with about 10% of those with normal BMD scores.

Women with both a prevalent vertebral fracture and total hip BMD T scores of −2.5 or less had an absolute risk of an incident vertebral fracture greater then 50%, compared with a 9% risk among women with a normal BMD and no fracture history.

But women with baseline prevalent vertebral fractures were at increased risk of additional fractures during the follow-up period regardless of BMD, and the interaction between BMD and prevalent vertebral fractures was not statistically significant.

This finding suggests that the presence of a vertebral fracture may indicate deterioration in bone quality, not just bone density, the investigators wrote. “Our results support the recommendation that older women with a prevalent vertebral fracture should be treated for osteoporosis irrespective of BMD.”

In addition, women who had incident fractures tended to be older, thinner, and less likely to report estrogen use. The results were consistent with the short-term findings from the Study of Osteoporotic Fractures and from other similar studies. But the study was limited by its inclusion of white women only, and the results may not be applicable to men or women of other ethnicities. Also, the absolute risk of vertebral fractures may be higher than reported because the study subjects who returned for the follow-up examinations were healthier at baseline than were patients who were lost to follow-up, the researchers noted.

Dr. Cauley has received research support from Merck & Co., Eli Lilly & Co., Pfizer Pharmaceuticals, and Novartis Pharmaceuticals. She also has received consulting fees from Novartis and Eli Lilly, and she serves on the speakers board for Merck. The Study of Osteoporotic Fractures is funded by the National Institutes of Health.

Low bone mineral density and a prevalent vertebral fracture were long-term independent predictors of an increased risk of vertebral fractures in women aged 65–99 who were followed for almost 15 years.

Previous studies have shown links between low BMD and an increased risk of a new vertebral fracture and between a prevalent vertebral fracture and an increased risk of a new vertebral fracture after an average of nearly 4 years.

But this study was the first to assess the long-term absolute risk of vertebral fracture based on follow-up evaluations of community-dwelling older women (JAMA 2007;298:2761–67).

In this study, Jane A. Cauley, Dr.PH., of the department of epidemiology at the University of Pittsburgh, and her colleagues reviewed data from 2,680 white women who took part in the longitudinal Study of Osteoporotic Fractures. The average age at baseline was 68.8 years and the average age at follow-up was 83.8 years.

After an average of 14.9 years, 487 women (18.2%) had incident vertebral fractures. This number included 163 of the 394 women (41.4%) who had a prevalent vertebral fracture at baseline and 324 of the 2,286 women (14.2%) who didn't have a vertebral fracture at baseline.

Overall, women with a prevalent fracture were more than four times as likely to suffer an incident vertebral fracture during the follow-up period, compared with those with no fracture history. The association remained significant after the researchers controlled for BMD and other risk factors for vertebral fracture, and the risk was greatest in women who had at least two prevalent vertebral fractures when they enrolled in the investigation.

In addition, a low baseline BMD at several sites (the calcaneus, distal radius, total hip, femoral neck, and lumbar spine) was a significant predictor of incident vertebral fractures during the follow-up period.

After adjustment for risk factors including smoking, body mass index, and estrogen use, about a third of women with a hip BMD T score of −2.5 or less (which is considered osteoporotic) developed incident fractures during the follow-up, compared with about 10% of those with normal BMD scores.

Women with both a prevalent vertebral fracture and total hip BMD T scores of −2.5 or less had an absolute risk of an incident vertebral fracture greater then 50%, compared with a 9% risk among women with a normal BMD and no fracture history.

But women with baseline prevalent vertebral fractures were at increased risk of additional fractures during the follow-up period regardless of BMD, and the interaction between BMD and prevalent vertebral fractures was not statistically significant.

This finding suggests that the presence of a vertebral fracture may indicate deterioration in bone quality, not just bone density, the investigators wrote. “Our results support the recommendation that older women with a prevalent vertebral fracture should be treated for osteoporosis irrespective of BMD.”

In addition, women who had incident fractures tended to be older, thinner, and less likely to report estrogen use. The results were consistent with the short-term findings from the Study of Osteoporotic Fractures and from other similar studies. But the study was limited by its inclusion of white women only, and the results may not be applicable to men or women of other ethnicities. Also, the absolute risk of vertebral fractures may be higher than reported because the study subjects who returned for the follow-up examinations were healthier at baseline than were patients who were lost to follow-up, the researchers noted.

Dr. Cauley has received research support from Merck & Co., Eli Lilly & Co., Pfizer Pharmaceuticals, and Novartis Pharmaceuticals. She also has received consulting fees from Novartis and Eli Lilly, and she serves on the speakers board for Merck. The Study of Osteoporotic Fractures is funded by the National Institutes of Health.

New cases of diabetes were significantly more common among pancreatic cancer patients before their cancer diagnoses, compared with controls, according to data from 736 pancreatic cancer patients and 1,875 controls.

Although previous studies have shown a link between existing diabetes and pancreatic cancer, the temporal relationship between the two diseases—and whether this relationship might be used to predict cancer—is not well understood, wrote Dr. Suresh T. Chari and colleagues at the Mayo Clinic in Rochester, Minn.

To determine the prevalence of new-onset diabetes in pancreatic cancer patients and the temporal association between these conditions, the researchers reviewed records of pancreatic cancer patients and control patients seen at the Mayo Clinic between January 15, 1981, and July 9, 2004.

They assigned two matched controls to each cancer case. The mean age of both patients and controls was 69 years, and approximately 50% of the subjects in each group were men.

A subject was considered to have diabetes if he or she had a fasting blood glucose level greater than 126 mg/dL or was taking diabetes medication. The proportion of cases and controls with diabetes was compared in each 12-month interval, starting with 60 months prior to a cancer diagnosis for cancer patients (Gastroenterology 2008;134:95–101).

Overall, significantly more pancreatic cancer patients met the criteria for diabetes, compared with controls, any time during the 60-month period before pancreatic cancer diagnosis (40% vs. 19%). But the proportions of individuals with diabetes were not significantly different between the cancer group and the control group during the 12-month intervals from 60 months to 48 months and from 48 months to 36 months prior to cancer diagnosis.

In contrast, starting with 36 months before a cancer diagnosis, the prevalence of diabetes in the pancreatic cancer patients rose steadily for each 12-month interval, while the prevalence of diabetes in the controls remained relatively stable throughout the study period. New-onset diabetes was defined as diabetes with onset at 24 months or less prior to a cancer diagnosis.

Diabetes was more likely to be new onset in patients with pancreatic cancer than in controls (52.3% compared with 23.6%, respectively) among the subjects with diabetes for whom diabetes duration was known; this difference was highly significant.

“The very high prevalence of diabetes in pancreatic cancer and its close temporal association with the diagnosis of cancer provide strong epidemiologic evidence to support the notion that pancreatic cancer causes diabetes mellitus,” the researchers wrote.

The findings support data from small clinical studies in which the removal of tumors from pancreatic cancer patients with diabetes has improved their glucose tolerance and reversed their metabolic defects.

But prospective studies are needed to show the benefits of screening older adults with new-onset diabetes for pancreatic cancer, and such screening would be helpful only if a type of new-onset diabetes that is associated with pancreatic cancer could be distinguished from type 2 diabetes, perhaps with the use of a biomarker test, the researchers noted.

In an editorial that accompanied the article, Dr. Niels Teich, of the University of Leipzig in Germany wrote that there is a lack of practical criteria that could be used to rule out pancreatic cancer in new-onset diabetes patients (Gastroenterology 2008;134:344–5).

The study findings invite more research to determine whether new-onset diabetes in pancreatic cancer patients is different from new-onset type 2 diabetes mellitus in general, and whether new-onset diabetes could be an early sign of this cancer in otherwise asymptomatic persons, he noted.

“The data available today clearly suggest that diabetes mellitus can be both a long-standing cause of pancreatic cancer, and, as shown now, an early manifestation of the disease,” Dr. Teich said.

ELSEVIER GLOBAL MEDICAL NEWS

New cases of diabetes were significantly more common among pancreatic cancer patients before their cancer diagnoses, compared with controls, according to data from 736 pancreatic cancer patients and 1,875 controls.

Although previous studies have shown a link between existing diabetes and pancreatic cancer, the temporal relationship between the two diseases—and whether this relationship might be used to predict cancer—is not well understood, wrote Dr. Suresh T. Chari and colleagues at the Mayo Clinic in Rochester, Minn.

To determine the prevalence of new-onset diabetes in pancreatic cancer patients and the temporal association between these conditions, the researchers reviewed records of pancreatic cancer patients and control patients seen at the Mayo Clinic between January 15, 1981, and July 9, 2004.

They assigned two matched controls to each cancer case. The mean age of both patients and controls was 69 years, and approximately 50% of the subjects in each group were men.

A subject was considered to have diabetes if he or she had a fasting blood glucose level greater than 126 mg/dL or was taking diabetes medication. The proportion of cases and controls with diabetes was compared in each 12-month interval, starting with 60 months prior to a cancer diagnosis for cancer patients (Gastroenterology 2008;134:95–101).

Overall, significantly more pancreatic cancer patients met the criteria for diabetes, compared with controls, any time during the 60-month period before pancreatic cancer diagnosis (40% vs. 19%). But the proportions of individuals with diabetes were not significantly different between the cancer group and the control group during the 12-month intervals from 60 months to 48 months and from 48 months to 36 months prior to cancer diagnosis.

In contrast, starting with 36 months before a cancer diagnosis, the prevalence of diabetes in the pancreatic cancer patients rose steadily for each 12-month interval, while the prevalence of diabetes in the controls remained relatively stable throughout the study period. New-onset diabetes was defined as diabetes with onset at 24 months or less prior to a cancer diagnosis.

Diabetes was more likely to be new onset in patients with pancreatic cancer than in controls (52.3% compared with 23.6%, respectively) among the subjects with diabetes for whom diabetes duration was known; this difference was highly significant.

“The very high prevalence of diabetes in pancreatic cancer and its close temporal association with the diagnosis of cancer provide strong epidemiologic evidence to support the notion that pancreatic cancer causes diabetes mellitus,” the researchers wrote.

The findings support data from small clinical studies in which the removal of tumors from pancreatic cancer patients with diabetes has improved their glucose tolerance and reversed their metabolic defects.

But prospective studies are needed to show the benefits of screening older adults with new-onset diabetes for pancreatic cancer, and such screening would be helpful only if a type of new-onset diabetes that is associated with pancreatic cancer could be distinguished from type 2 diabetes, perhaps with the use of a biomarker test, the researchers noted.

In an editorial that accompanied the article, Dr. Niels Teich, of the University of Leipzig in Germany wrote that there is a lack of practical criteria that could be used to rule out pancreatic cancer in new-onset diabetes patients (Gastroenterology 2008;134:344–5).

The study findings invite more research to determine whether new-onset diabetes in pancreatic cancer patients is different from new-onset type 2 diabetes mellitus in general, and whether new-onset diabetes could be an early sign of this cancer in otherwise asymptomatic persons, he noted.

“The data available today clearly suggest that diabetes mellitus can be both a long-standing cause of pancreatic cancer, and, as shown now, an early manifestation of the disease,” Dr. Teich said.

ELSEVIER GLOBAL MEDICAL NEWS

New cases of diabetes were significantly more common among pancreatic cancer patients before their cancer diagnoses, compared with controls, according to data from 736 pancreatic cancer patients and 1,875 controls.

Although previous studies have shown a link between existing diabetes and pancreatic cancer, the temporal relationship between the two diseases—and whether this relationship might be used to predict cancer—is not well understood, wrote Dr. Suresh T. Chari and colleagues at the Mayo Clinic in Rochester, Minn.

To determine the prevalence of new-onset diabetes in pancreatic cancer patients and the temporal association between these conditions, the researchers reviewed records of pancreatic cancer patients and control patients seen at the Mayo Clinic between January 15, 1981, and July 9, 2004.

They assigned two matched controls to each cancer case. The mean age of both patients and controls was 69 years, and approximately 50% of the subjects in each group were men.

A subject was considered to have diabetes if he or she had a fasting blood glucose level greater than 126 mg/dL or was taking diabetes medication. The proportion of cases and controls with diabetes was compared in each 12-month interval, starting with 60 months prior to a cancer diagnosis for cancer patients (Gastroenterology 2008;134:95–101).

Overall, significantly more pancreatic cancer patients met the criteria for diabetes, compared with controls, any time during the 60-month period before pancreatic cancer diagnosis (40% vs. 19%). But the proportions of individuals with diabetes were not significantly different between the cancer group and the control group during the 12-month intervals from 60 months to 48 months and from 48 months to 36 months prior to cancer diagnosis.

In contrast, starting with 36 months before a cancer diagnosis, the prevalence of diabetes in the pancreatic cancer patients rose steadily for each 12-month interval, while the prevalence of diabetes in the controls remained relatively stable throughout the study period. New-onset diabetes was defined as diabetes with onset at 24 months or less prior to a cancer diagnosis.

Diabetes was more likely to be new onset in patients with pancreatic cancer than in controls (52.3% compared with 23.6%, respectively) among the subjects with diabetes for whom diabetes duration was known; this difference was highly significant.

“The very high prevalence of diabetes in pancreatic cancer and its close temporal association with the diagnosis of cancer provide strong epidemiologic evidence to support the notion that pancreatic cancer causes diabetes mellitus,” the researchers wrote.

The findings support data from small clinical studies in which the removal of tumors from pancreatic cancer patients with diabetes has improved their glucose tolerance and reversed their metabolic defects.

But prospective studies are needed to show the benefits of screening older adults with new-onset diabetes for pancreatic cancer, and such screening would be helpful only if a type of new-onset diabetes that is associated with pancreatic cancer could be distinguished from type 2 diabetes, perhaps with the use of a biomarker test, the researchers noted.

In an editorial that accompanied the article, Dr. Niels Teich, of the University of Leipzig in Germany wrote that there is a lack of practical criteria that could be used to rule out pancreatic cancer in new-onset diabetes patients (Gastroenterology 2008;134:344–5).

The study findings invite more research to determine whether new-onset diabetes in pancreatic cancer patients is different from new-onset type 2 diabetes mellitus in general, and whether new-onset diabetes could be an early sign of this cancer in otherwise asymptomatic persons, he noted.

“The data available today clearly suggest that diabetes mellitus can be both a long-standing cause of pancreatic cancer, and, as shown now, an early manifestation of the disease,” Dr. Teich said.

ELSEVIER GLOBAL MEDICAL NEWS

Rates of methicillin-resistant Staphylococcus aureus infections were reduced by more than half when all newly admitted hospital patients were tested for MRSA, according to results from three hospitals.

Methicillin-resistant S. aureus (MRSA) has become a fixture in many hospitals in the United States, and the resulting MRSA infections are causing poor health outcomes and increasing health care costs, reported Dr. Ari Robicsek of Evanston (Ill.) Northwestern Healthcare and his colleagues.

To cut MRSA infection rates, the researchers implemented a universal MRSA surveillance program at a three-hospital organization in Chicago.

Their observational study compared MRSA rates during a baseline year when patients were not universally screened at the time of hospital admission with MRSA rates after conducting polymerase chain reaction-based nasal tests for MRSA. The tests were conducted on all patients admitted to the ICU for 1 year and on all patients admitted to the hospital for another year (Ann. Intern. Med. 2008;148:409–18).

During the ICU surveillance year, 3,334 of 4,392 patients (76%) admitted to the ICU were tested for MRSA and 277 (8%) were positive. During the universal screening year, 62,035 of 73,464 patients (84%) admitted to the hospital were tested for MRSA and 3,926 (6%) were positive. Patients who tested positive were isolated. Of the 2,085 patients for whom mupirocin data were available, 1,288 (62%) received at least four doses of mupirocin.

During the year of universal surveillance, the total number of isolation days was 11,454 across the three hospitals. “With no surveillance, clinical cultures alone would have captured 2,036 of those days,” the investigators noted. “Thus, 9,418 MRSA patient-days would have been spent without infection control contact precautions to limit MRSA spread.”

Overall, the prevalence density of clinical infections caused by MRSA decreased from 8.9/10,000 patient-days during the baseline year to 7.4/10,000 patient days during the ICU screening year, but this difference was not statistically significant. By contrast, prevalence density decreased significantly from baseline to 3.9/10,000 patient-days during the universal screening year.

In addition, the prevalence density of four types of MRSA infections—bloodstream, respiratory tract, urinary tract, and surgical site infections—dropped significantly between baseline and the end of the universal screening year.

This improvement in MRSA rates following universal screening persisted for up to 30 days after the patients left the hospital but had no apparent effect on infection rates from 31 days to 180 days. The types of infections represented the major body sites that might be affected by culture-confirmed MRSA, the researchers noted.

To control for a possible unrecognized coinfection, the researchers also compared changes in rates of hospital-associated MRSA bacteremia with rates of hospital-associated methicillin-susceptible S. aureus (MSSA) bacteremia. The MRSA bacteremia rates decreased significantly after the surveillance program was implemented, but MSSA bacteremia rates did not.

The study was limited by the lack of an unscreened control group and the inclusion of only one hospital organization, but the findings support results from previous studies in which anything less than universal screening detected fewer than 20% of patients with MRSA infections.

“Given the intermediate size and community-based nature of our three hospitals, our experience is probably representative of most U.S. hospitals,” the investigators wrote.

But using the same MRSA screening strategy for every hospital may not be feasible. In an editorial, Dr. Ebbing Lautenbach of the University of Pennsylvania, Philadelphia, observed that commitment and support of each hospital's administration is needed for universal MRSA screening to succeed and that the cost of rapid screening tests may be a barrier for some facilities (Ann. Intern. Med. 2008;148:474–6). “We need better evidence to point us toward what works best in the complex universe of MRSA screening,” he said.

ELSEVIER GLOBAL MEDICAL NEWS

Rates of methicillin-resistant Staphylococcus aureus infections were reduced by more than half when all newly admitted hospital patients were tested for MRSA, according to results from three hospitals.

Methicillin-resistant S. aureus (MRSA) has become a fixture in many hospitals in the United States, and the resulting MRSA infections are causing poor health outcomes and increasing health care costs, reported Dr. Ari Robicsek of Evanston (Ill.) Northwestern Healthcare and his colleagues.

To cut MRSA infection rates, the researchers implemented a universal MRSA surveillance program at a three-hospital organization in Chicago.

Their observational study compared MRSA rates during a baseline year when patients were not universally screened at the time of hospital admission with MRSA rates after conducting polymerase chain reaction-based nasal tests for MRSA. The tests were conducted on all patients admitted to the ICU for 1 year and on all patients admitted to the hospital for another year (Ann. Intern. Med. 2008;148:409–18).

During the ICU surveillance year, 3,334 of 4,392 patients (76%) admitted to the ICU were tested for MRSA and 277 (8%) were positive. During the universal screening year, 62,035 of 73,464 patients (84%) admitted to the hospital were tested for MRSA and 3,926 (6%) were positive. Patients who tested positive were isolated. Of the 2,085 patients for whom mupirocin data were available, 1,288 (62%) received at least four doses of mupirocin.

During the year of universal surveillance, the total number of isolation days was 11,454 across the three hospitals. “With no surveillance, clinical cultures alone would have captured 2,036 of those days,” the investigators noted. “Thus, 9,418 MRSA patient-days would have been spent without infection control contact precautions to limit MRSA spread.”

Overall, the prevalence density of clinical infections caused by MRSA decreased from 8.9/10,000 patient-days during the baseline year to 7.4/10,000 patient days during the ICU screening year, but this difference was not statistically significant. By contrast, prevalence density decreased significantly from baseline to 3.9/10,000 patient-days during the universal screening year.

In addition, the prevalence density of four types of MRSA infections—bloodstream, respiratory tract, urinary tract, and surgical site infections—dropped significantly between baseline and the end of the universal screening year.

This improvement in MRSA rates following universal screening persisted for up to 30 days after the patients left the hospital but had no apparent effect on infection rates from 31 days to 180 days. The types of infections represented the major body sites that might be affected by culture-confirmed MRSA, the researchers noted.

To control for a possible unrecognized coinfection, the researchers also compared changes in rates of hospital-associated MRSA bacteremia with rates of hospital-associated methicillin-susceptible S. aureus (MSSA) bacteremia. The MRSA bacteremia rates decreased significantly after the surveillance program was implemented, but MSSA bacteremia rates did not.

The study was limited by the lack of an unscreened control group and the inclusion of only one hospital organization, but the findings support results from previous studies in which anything less than universal screening detected fewer than 20% of patients with MRSA infections.

“Given the intermediate size and community-based nature of our three hospitals, our experience is probably representative of most U.S. hospitals,” the investigators wrote.

But using the same MRSA screening strategy for every hospital may not be feasible. In an editorial, Dr. Ebbing Lautenbach of the University of Pennsylvania, Philadelphia, observed that commitment and support of each hospital's administration is needed for universal MRSA screening to succeed and that the cost of rapid screening tests may be a barrier for some facilities (Ann. Intern. Med. 2008;148:474–6). “We need better evidence to point us toward what works best in the complex universe of MRSA screening,” he said.

ELSEVIER GLOBAL MEDICAL NEWS

Rates of methicillin-resistant Staphylococcus aureus infections were reduced by more than half when all newly admitted hospital patients were tested for MRSA, according to results from three hospitals.

Methicillin-resistant S. aureus (MRSA) has become a fixture in many hospitals in the United States, and the resulting MRSA infections are causing poor health outcomes and increasing health care costs, reported Dr. Ari Robicsek of Evanston (Ill.) Northwestern Healthcare and his colleagues.

To cut MRSA infection rates, the researchers implemented a universal MRSA surveillance program at a three-hospital organization in Chicago.

Their observational study compared MRSA rates during a baseline year when patients were not universally screened at the time of hospital admission with MRSA rates after conducting polymerase chain reaction-based nasal tests for MRSA. The tests were conducted on all patients admitted to the ICU for 1 year and on all patients admitted to the hospital for another year (Ann. Intern. Med. 2008;148:409–18).

During the ICU surveillance year, 3,334 of 4,392 patients (76%) admitted to the ICU were tested for MRSA and 277 (8%) were positive. During the universal screening year, 62,035 of 73,464 patients (84%) admitted to the hospital were tested for MRSA and 3,926 (6%) were positive. Patients who tested positive were isolated. Of the 2,085 patients for whom mupirocin data were available, 1,288 (62%) received at least four doses of mupirocin.

During the year of universal surveillance, the total number of isolation days was 11,454 across the three hospitals. “With no surveillance, clinical cultures alone would have captured 2,036 of those days,” the investigators noted. “Thus, 9,418 MRSA patient-days would have been spent without infection control contact precautions to limit MRSA spread.”

Overall, the prevalence density of clinical infections caused by MRSA decreased from 8.9/10,000 patient-days during the baseline year to 7.4/10,000 patient days during the ICU screening year, but this difference was not statistically significant. By contrast, prevalence density decreased significantly from baseline to 3.9/10,000 patient-days during the universal screening year.

In addition, the prevalence density of four types of MRSA infections—bloodstream, respiratory tract, urinary tract, and surgical site infections—dropped significantly between baseline and the end of the universal screening year.

This improvement in MRSA rates following universal screening persisted for up to 30 days after the patients left the hospital but had no apparent effect on infection rates from 31 days to 180 days. The types of infections represented the major body sites that might be affected by culture-confirmed MRSA, the researchers noted.

To control for a possible unrecognized coinfection, the researchers also compared changes in rates of hospital-associated MRSA bacteremia with rates of hospital-associated methicillin-susceptible S. aureus (MSSA) bacteremia. The MRSA bacteremia rates decreased significantly after the surveillance program was implemented, but MSSA bacteremia rates did not.

The study was limited by the lack of an unscreened control group and the inclusion of only one hospital organization, but the findings support results from previous studies in which anything less than universal screening detected fewer than 20% of patients with MRSA infections.

“Given the intermediate size and community-based nature of our three hospitals, our experience is probably representative of most U.S. hospitals,” the investigators wrote.

But using the same MRSA screening strategy for every hospital may not be feasible. In an editorial, Dr. Ebbing Lautenbach of the University of Pennsylvania, Philadelphia, observed that commitment and support of each hospital's administration is needed for universal MRSA screening to succeed and that the cost of rapid screening tests may be a barrier for some facilities (Ann. Intern. Med. 2008;148:474–6). “We need better evidence to point us toward what works best in the complex universe of MRSA screening,” he said.

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — The dermatologists who successfully add aesthetic services to their practices are those who use their expertise to show patients that they are the safe, smart choice, Catherine Maley said at the annual meeting of the American Academy for Facial Plastic and Reconstructive Surgery.

"Aesthetic dermatology is the business of feelings and emotions," said Ms. Maley, president of Cosmetic Image Marketing, a San Francisco-based marketing, public relations, and advertising firm that specializes in helping physicians build aesthetic practices.

"What you want to do is differentiate yourself from the medispas," she pointed out. A dermatologist competing in the aesthetic market should emphasize his or her medical training so patients recognize that they are paying for expertise.

"The aesthetic patient needs to understand that you are not the cheapest: You are the best," she said.

"Think of the psychology of the aesthetic patient. The bottom line is that she wants to look and feel better but she wants peace of mind. She wants to know that she is not going to regret anything and she is going to get a good result every time," Ms. Maley said.

Don't try to compete with medispas on price. Instead, sell the value. "You want those preferred patients who care about safety and credibility," she said.

How do dermatologists sell value? By emphasizing their credentials.

Use the logo from every society to which you belong on your cards, flyers, and promotional materials, including hospital and school affiliations. Put those logos everywhere because it enhances credibility with patients. "If you are board certified, say so in your promotional materials and explain to patients just what that means in terms of extra training," Ms. Maley said.

"If you work with vendors, use those affiliations and let patients know that you have been called on to speak or do research or train others," she added.

Create high-quality promotional handouts and cards to promote the aesthetic practice. A public relations agent can help create promotional materials, or there may be an interested and talented staff member who can design promotional pieces. Be sure to include patient photos and testimonials in your in-office and external promotional material. A dermatologist who is lucky enough to have a celebrity patient should ask for his or her permission to display a photo and short testimonial in the office.

Use testimonials generously, Ms. Maley emphasized. Provide high-quality photo albums with patients from a range of ages and ethnic backgrounds. Create a "what our patients say about us" album for written thank-you notes, e-mails, or postprocedure surveys.

"It's very compelling for patients to read about how great you are from other patients, not just from you," Ms. Maley said. The more testimonials, the better. Patient survey data have shown that prospective aesthetic patients associate quantity of patient testimonials with experience and expertise. Consider taking videos of patients who want to share their positive experiences, and put the videos together on a loop to show in the waiting room or post them on a Web site, Ms. Maley suggested.

And don't underestimate the importance of appearing in print.

"Any time you publish or you are quoted, don't miss that opportunity for public relations," she said.

Pull together a collection of quotes and design a PR piece for patient information packets and for the practice's Web site. One way to get written about or interviewed is to send a media kit to local print and TV reporters and to follow up with a personal phone call to pitch story ideas related to your expertise.

"Remember that it is not about you. It is about what you can do for their readers and viewers," Ms. Maley cautioned. "But the PR can really pay off and set you up as an expert in your community."

WASHINGTON — The dermatologists who successfully add aesthetic services to their practices are those who use their expertise to show patients that they are the safe, smart choice, Catherine Maley said at the annual meeting of the American Academy for Facial Plastic and Reconstructive Surgery.

"Aesthetic dermatology is the business of feelings and emotions," said Ms. Maley, president of Cosmetic Image Marketing, a San Francisco-based marketing, public relations, and advertising firm that specializes in helping physicians build aesthetic practices.

"What you want to do is differentiate yourself from the medispas," she pointed out. A dermatologist competing in the aesthetic market should emphasize his or her medical training so patients recognize that they are paying for expertise.

"The aesthetic patient needs to understand that you are not the cheapest: You are the best," she said.

"Think of the psychology of the aesthetic patient. The bottom line is that she wants to look and feel better but she wants peace of mind. She wants to know that she is not going to regret anything and she is going to get a good result every time," Ms. Maley said.

Don't try to compete with medispas on price. Instead, sell the value. "You want those preferred patients who care about safety and credibility," she said.

How do dermatologists sell value? By emphasizing their credentials.

Use the logo from every society to which you belong on your cards, flyers, and promotional materials, including hospital and school affiliations. Put those logos everywhere because it enhances credibility with patients. "If you are board certified, say so in your promotional materials and explain to patients just what that means in terms of extra training," Ms. Maley said.

"If you work with vendors, use those affiliations and let patients know that you have been called on to speak or do research or train others," she added.

Create high-quality promotional handouts and cards to promote the aesthetic practice. A public relations agent can help create promotional materials, or there may be an interested and talented staff member who can design promotional pieces. Be sure to include patient photos and testimonials in your in-office and external promotional material. A dermatologist who is lucky enough to have a celebrity patient should ask for his or her permission to display a photo and short testimonial in the office.

Use testimonials generously, Ms. Maley emphasized. Provide high-quality photo albums with patients from a range of ages and ethnic backgrounds. Create a "what our patients say about us" album for written thank-you notes, e-mails, or postprocedure surveys.

"It's very compelling for patients to read about how great you are from other patients, not just from you," Ms. Maley said. The more testimonials, the better. Patient survey data have shown that prospective aesthetic patients associate quantity of patient testimonials with experience and expertise. Consider taking videos of patients who want to share their positive experiences, and put the videos together on a loop to show in the waiting room or post them on a Web site, Ms. Maley suggested.

And don't underestimate the importance of appearing in print.

"Any time you publish or you are quoted, don't miss that opportunity for public relations," she said.

Pull together a collection of quotes and design a PR piece for patient information packets and for the practice's Web site. One way to get written about or interviewed is to send a media kit to local print and TV reporters and to follow up with a personal phone call to pitch story ideas related to your expertise.

"Remember that it is not about you. It is about what you can do for their readers and viewers," Ms. Maley cautioned. "But the PR can really pay off and set you up as an expert in your community."

WASHINGTON — The dermatologists who successfully add aesthetic services to their practices are those who use their expertise to show patients that they are the safe, smart choice, Catherine Maley said at the annual meeting of the American Academy for Facial Plastic and Reconstructive Surgery.

"Aesthetic dermatology is the business of feelings and emotions," said Ms. Maley, president of Cosmetic Image Marketing, a San Francisco-based marketing, public relations, and advertising firm that specializes in helping physicians build aesthetic practices.

"What you want to do is differentiate yourself from the medispas," she pointed out. A dermatologist competing in the aesthetic market should emphasize his or her medical training so patients recognize that they are paying for expertise.

"The aesthetic patient needs to understand that you are not the cheapest: You are the best," she said.

"Think of the psychology of the aesthetic patient. The bottom line is that she wants to look and feel better but she wants peace of mind. She wants to know that she is not going to regret anything and she is going to get a good result every time," Ms. Maley said.

Don't try to compete with medispas on price. Instead, sell the value. "You want those preferred patients who care about safety and credibility," she said.

How do dermatologists sell value? By emphasizing their credentials.

Use the logo from every society to which you belong on your cards, flyers, and promotional materials, including hospital and school affiliations. Put those logos everywhere because it enhances credibility with patients. "If you are board certified, say so in your promotional materials and explain to patients just what that means in terms of extra training," Ms. Maley said.

"If you work with vendors, use those affiliations and let patients know that you have been called on to speak or do research or train others," she added.

Create high-quality promotional handouts and cards to promote the aesthetic practice. A public relations agent can help create promotional materials, or there may be an interested and talented staff member who can design promotional pieces. Be sure to include patient photos and testimonials in your in-office and external promotional material. A dermatologist who is lucky enough to have a celebrity patient should ask for his or her permission to display a photo and short testimonial in the office.

Use testimonials generously, Ms. Maley emphasized. Provide high-quality photo albums with patients from a range of ages and ethnic backgrounds. Create a "what our patients say about us" album for written thank-you notes, e-mails, or postprocedure surveys.

"It's very compelling for patients to read about how great you are from other patients, not just from you," Ms. Maley said. The more testimonials, the better. Patient survey data have shown that prospective aesthetic patients associate quantity of patient testimonials with experience and expertise. Consider taking videos of patients who want to share their positive experiences, and put the videos together on a loop to show in the waiting room or post them on a Web site, Ms. Maley suggested.

And don't underestimate the importance of appearing in print.

"Any time you publish or you are quoted, don't miss that opportunity for public relations," she said.

Pull together a collection of quotes and design a PR piece for patient information packets and for the practice's Web site. One way to get written about or interviewed is to send a media kit to local print and TV reporters and to follow up with a personal phone call to pitch story ideas related to your expertise.

"Remember that it is not about you. It is about what you can do for their readers and viewers," Ms. Maley cautioned. "But the PR can really pay off and set you up as an expert in your community."

WASHINGTON — Preimplantation genetic diagnosis before in vitro fertilization reduced the rate of pregnancy loss for couples with a history of miscarriage after natural conception, and especially for couples with three to five prior miscarriages, according to findings presented at the annual meeting of the American Society for Reproductive Medicine.

“Half of the miscarriages in recurrent pregnancy loss patients are due to aneuploidy,” said John Garrisi, Ph.D., laboratory director of the Institute for Reproductive Medicine and Science at Saint Barnabas in Livingston, N.J.

Previous studies have revealed a higher rate of chromosomal abnormalities in the embryos of patients with recurrent pregnancy losses, compared with age-matched controls, he added.

The effects of both aneuploidy and preimplantation genetic diagnosis (PGD) on pregnancy loss remain controversial. “In any case, we want to reduce the miscarriage rates,” Dr. Garrisi said.

To determine the effectiveness of PGD for reducing pregnancy loss in couples with a history of such losses, Dr. Garrisi and colleagues reviewed data from 135 women with a history of pregnancy loss after natural conception who then underwent IVF and PGD.

The researchers compared the results with those of 117 infertile women with a history of recurrent pregnancy loss after IVF who then underwent PGD, and they also compared the results with those of 45 control patients with a history of recurrent pregnancy loss who underwent IVF without PGD.

Overall, the miscarriage rate after PGD was lower than the predicted loss rate (based on patient history of loss) across all groups. When the data were separated by the number of losses, the greatest difference between the observed loss rate and predicted loss rate was seen among women with histories of three to five losses (41% vs. 24%). The observed and predicted loss rates were 28% vs. 32% among women with histories of two pregnancy losses and 44% vs. 47% among women with histories of more than five pregnancy losses.

But the statistically significant differences appeared in the natural conception group. The observed pregnancy loss rate in these patients after IVF and PGD was 17%, compared with the predicted loss rate of 41%.

The reduction in miscarriage rates was not statistically significant among the infertile women or the controls.

The average age of women in all groups was 37 years. When the data were analyzed by age, the difference between observed and predicted miscarriage rates was significantly greater among women younger than 38 years (18% vs. 33%) compared with women aged 38 years and older (39% vs. 43%).

Of note, the aneuploidy rate was significantly higher in women younger than 37 years compared with women aged 38 and older, independent of the number of pregnancy losses.

As for clinical implications, the lack of a significant reduction in the miscarriage rate for infertile patients who underwent PGD with IVF suggests that other confounding infertility factors may mask potential benefits from preimplantation genetic screening (PGS) to identify abnormal embryos, Dr. Garrisi said.

But Dr. Garrisi noted that he and his colleagues continue to use PGS in ART patients. “For the patients in this group who experience recurrent pregnancy loss, we expect PGS to benefit as PGD does in the spontaneous conception group,” Dr. Garrisi noted.

WASHINGTON — Preimplantation genetic diagnosis before in vitro fertilization reduced the rate of pregnancy loss for couples with a history of miscarriage after natural conception, and especially for couples with three to five prior miscarriages, according to findings presented at the annual meeting of the American Society for Reproductive Medicine.

“Half of the miscarriages in recurrent pregnancy loss patients are due to aneuploidy,” said John Garrisi, Ph.D., laboratory director of the Institute for Reproductive Medicine and Science at Saint Barnabas in Livingston, N.J.

Previous studies have revealed a higher rate of chromosomal abnormalities in the embryos of patients with recurrent pregnancy losses, compared with age-matched controls, he added.

The effects of both aneuploidy and preimplantation genetic diagnosis (PGD) on pregnancy loss remain controversial. “In any case, we want to reduce the miscarriage rates,” Dr. Garrisi said.

To determine the effectiveness of PGD for reducing pregnancy loss in couples with a history of such losses, Dr. Garrisi and colleagues reviewed data from 135 women with a history of pregnancy loss after natural conception who then underwent IVF and PGD.

The researchers compared the results with those of 117 infertile women with a history of recurrent pregnancy loss after IVF who then underwent PGD, and they also compared the results with those of 45 control patients with a history of recurrent pregnancy loss who underwent IVF without PGD.

Overall, the miscarriage rate after PGD was lower than the predicted loss rate (based on patient history of loss) across all groups. When the data were separated by the number of losses, the greatest difference between the observed loss rate and predicted loss rate was seen among women with histories of three to five losses (41% vs. 24%). The observed and predicted loss rates were 28% vs. 32% among women with histories of two pregnancy losses and 44% vs. 47% among women with histories of more than five pregnancy losses.

But the statistically significant differences appeared in the natural conception group. The observed pregnancy loss rate in these patients after IVF and PGD was 17%, compared with the predicted loss rate of 41%.

The reduction in miscarriage rates was not statistically significant among the infertile women or the controls.

The average age of women in all groups was 37 years. When the data were analyzed by age, the difference between observed and predicted miscarriage rates was significantly greater among women younger than 38 years (18% vs. 33%) compared with women aged 38 years and older (39% vs. 43%).

Of note, the aneuploidy rate was significantly higher in women younger than 37 years compared with women aged 38 and older, independent of the number of pregnancy losses.

As for clinical implications, the lack of a significant reduction in the miscarriage rate for infertile patients who underwent PGD with IVF suggests that other confounding infertility factors may mask potential benefits from preimplantation genetic screening (PGS) to identify abnormal embryos, Dr. Garrisi said.

But Dr. Garrisi noted that he and his colleagues continue to use PGS in ART patients. “For the patients in this group who experience recurrent pregnancy loss, we expect PGS to benefit as PGD does in the spontaneous conception group,” Dr. Garrisi noted.

WASHINGTON — Preimplantation genetic diagnosis before in vitro fertilization reduced the rate of pregnancy loss for couples with a history of miscarriage after natural conception, and especially for couples with three to five prior miscarriages, according to findings presented at the annual meeting of the American Society for Reproductive Medicine.

“Half of the miscarriages in recurrent pregnancy loss patients are due to aneuploidy,” said John Garrisi, Ph.D., laboratory director of the Institute for Reproductive Medicine and Science at Saint Barnabas in Livingston, N.J.

Previous studies have revealed a higher rate of chromosomal abnormalities in the embryos of patients with recurrent pregnancy losses, compared with age-matched controls, he added.

The effects of both aneuploidy and preimplantation genetic diagnosis (PGD) on pregnancy loss remain controversial. “In any case, we want to reduce the miscarriage rates,” Dr. Garrisi said.

To determine the effectiveness of PGD for reducing pregnancy loss in couples with a history of such losses, Dr. Garrisi and colleagues reviewed data from 135 women with a history of pregnancy loss after natural conception who then underwent IVF and PGD.

The researchers compared the results with those of 117 infertile women with a history of recurrent pregnancy loss after IVF who then underwent PGD, and they also compared the results with those of 45 control patients with a history of recurrent pregnancy loss who underwent IVF without PGD.

Overall, the miscarriage rate after PGD was lower than the predicted loss rate (based on patient history of loss) across all groups. When the data were separated by the number of losses, the greatest difference between the observed loss rate and predicted loss rate was seen among women with histories of three to five losses (41% vs. 24%). The observed and predicted loss rates were 28% vs. 32% among women with histories of two pregnancy losses and 44% vs. 47% among women with histories of more than five pregnancy losses.

But the statistically significant differences appeared in the natural conception group. The observed pregnancy loss rate in these patients after IVF and PGD was 17%, compared with the predicted loss rate of 41%.

The reduction in miscarriage rates was not statistically significant among the infertile women or the controls.

The average age of women in all groups was 37 years. When the data were analyzed by age, the difference between observed and predicted miscarriage rates was significantly greater among women younger than 38 years (18% vs. 33%) compared with women aged 38 years and older (39% vs. 43%).

Of note, the aneuploidy rate was significantly higher in women younger than 37 years compared with women aged 38 and older, independent of the number of pregnancy losses.

As for clinical implications, the lack of a significant reduction in the miscarriage rate for infertile patients who underwent PGD with IVF suggests that other confounding infertility factors may mask potential benefits from preimplantation genetic screening (PGS) to identify abnormal embryos, Dr. Garrisi said.

But Dr. Garrisi noted that he and his colleagues continue to use PGS in ART patients. “For the patients in this group who experience recurrent pregnancy loss, we expect PGS to benefit as PGD does in the spontaneous conception group,” Dr. Garrisi noted.

WASHINGTON — Children who were conceived from surgically retrieved sperm had no greater risk of cognitive and behavioral problems than did those conceived from ejaculated sperm, according to a study of 3-year follow-up data from 874 children.

Surgically retrieved sperm have been associated with an increased risk of genetic defects in previous studies. Because intracytoplasmic sperm injection (ICSI) is the technique of choice in cases of male infertility, concerns have been raised about an increased risk of developmental delays in children conceived from surgically retrieved sperm.

But the clinical implications of this study are that the origin of the sperm was not a factor in the percentage of IVF children who were at risk for cognitive and behavioral problems, Queenie V. Neri, a biologist at the Center for Reproductive Medicine and Infertility at the Cornell University Medical School, New York, reported in a presentation at the annual meeting of the American Society for Reproductive Medicine.

To investigate the cognitive and behavioral profiles of children conceived using assisted reproductive technology according to sperm origin, Ms. Neri compared data from 74 children conceived via ICSI with surgically retrieved sperm, 516 children conceived via ICSI with ejaculated sperm, and 284 children conceived via IVF but not ICSI.

Ms. Neri worked under the guidance of Dr. Zev Rosenwaks and Dr. Gianpiero D. Palermo, both of Cornell University.

The Ages & Stages Questionnaire (ASQ) and Social Skills Rating System (SSRS) were used to assess the children's communication skills, fine motor skills, gross motor skills, social skills, and problem-solving skills at 3 years of age.

Overall, 87.1% of the children had ASQ scores in the normal range, compared with 12.9% who scored in the at-risk range (meaning at risk for further developmental delays or abnormalities). The at-risk group included 10.4% of the IVF children, 11.4% of the children conceived via ICSI with ejaculated sperm, and significantly fewer (2.8%) of the children conceived via ICSI with surgically retrieved sperm.

Within the subset of at-risk children conceived via ICSI, those conceived from surgically retrieved sperm scored significantly higher on measures of gross and fine-motor skills on the ASQ than did those conceived from ejaculated sperm.

These children also scored higher on measures of communication, problem solving, and personal/social development, but the differences were not statistically significant.

Similarly, 81.8% of the children overall had SSRS scores in the normal range, compared with 18.2% of children in the at-risk range.

The at-risk group included 17.2% of the IVF children, 20.1% of the children conceived via ICSI from ejaculated sperm, and 15.8% of those conceived via ICSI from surgically retrieved sperm.

In the subset of children conceived via ICSI, the percentage of children at risk for problems with social skills was significantly lower among those conceived with surgically retrieved sperm, compared with those who were conceived with ejaculated sperm.

In addition, children who were part of multiple gestations were significantly more likely to be in the at-risk score range for the SSRS in both the IVF (non-ICSI) group and the ICSI group conceived from ejaculated sperm.

However, the difference in at-risk SSRS scores between multiples and singletons was not significant for children who were conceived via ICSI with surgically retrieved sperm.

Although the results from this study suggest that there is no negative association between sperm characteristics and child development, ongoing follow-up is important in detecting malformations that appear after birth, Ms. Neri said.

WASHINGTON — Children who were conceived from surgically retrieved sperm had no greater risk of cognitive and behavioral problems than did those conceived from ejaculated sperm, according to a study of 3-year follow-up data from 874 children.

Surgically retrieved sperm have been associated with an increased risk of genetic defects in previous studies. Because intracytoplasmic sperm injection (ICSI) is the technique of choice in cases of male infertility, concerns have been raised about an increased risk of developmental delays in children conceived from surgically retrieved sperm.

But the clinical implications of this study are that the origin of the sperm was not a factor in the percentage of IVF children who were at risk for cognitive and behavioral problems, Queenie V. Neri, a biologist at the Center for Reproductive Medicine and Infertility at the Cornell University Medical School, New York, reported in a presentation at the annual meeting of the American Society for Reproductive Medicine.

To investigate the cognitive and behavioral profiles of children conceived using assisted reproductive technology according to sperm origin, Ms. Neri compared data from 74 children conceived via ICSI with surgically retrieved sperm, 516 children conceived via ICSI with ejaculated sperm, and 284 children conceived via IVF but not ICSI.

Ms. Neri worked under the guidance of Dr. Zev Rosenwaks and Dr. Gianpiero D. Palermo, both of Cornell University.

The Ages & Stages Questionnaire (ASQ) and Social Skills Rating System (SSRS) were used to assess the children's communication skills, fine motor skills, gross motor skills, social skills, and problem-solving skills at 3 years of age.

Overall, 87.1% of the children had ASQ scores in the normal range, compared with 12.9% who scored in the at-risk range (meaning at risk for further developmental delays or abnormalities). The at-risk group included 10.4% of the IVF children, 11.4% of the children conceived via ICSI with ejaculated sperm, and significantly fewer (2.8%) of the children conceived via ICSI with surgically retrieved sperm.

Within the subset of at-risk children conceived via ICSI, those conceived from surgically retrieved sperm scored significantly higher on measures of gross and fine-motor skills on the ASQ than did those conceived from ejaculated sperm.

These children also scored higher on measures of communication, problem solving, and personal/social development, but the differences were not statistically significant.

Similarly, 81.8% of the children overall had SSRS scores in the normal range, compared with 18.2% of children in the at-risk range.

The at-risk group included 17.2% of the IVF children, 20.1% of the children conceived via ICSI from ejaculated sperm, and 15.8% of those conceived via ICSI from surgically retrieved sperm.

In the subset of children conceived via ICSI, the percentage of children at risk for problems with social skills was significantly lower among those conceived with surgically retrieved sperm, compared with those who were conceived with ejaculated sperm.

In addition, children who were part of multiple gestations were significantly more likely to be in the at-risk score range for the SSRS in both the IVF (non-ICSI) group and the ICSI group conceived from ejaculated sperm.

However, the difference in at-risk SSRS scores between multiples and singletons was not significant for children who were conceived via ICSI with surgically retrieved sperm.

Although the results from this study suggest that there is no negative association between sperm characteristics and child development, ongoing follow-up is important in detecting malformations that appear after birth, Ms. Neri said.

WASHINGTON — Children who were conceived from surgically retrieved sperm had no greater risk of cognitive and behavioral problems than did those conceived from ejaculated sperm, according to a study of 3-year follow-up data from 874 children.

Surgically retrieved sperm have been associated with an increased risk of genetic defects in previous studies. Because intracytoplasmic sperm injection (ICSI) is the technique of choice in cases of male infertility, concerns have been raised about an increased risk of developmental delays in children conceived from surgically retrieved sperm.

But the clinical implications of this study are that the origin of the sperm was not a factor in the percentage of IVF children who were at risk for cognitive and behavioral problems, Queenie V. Neri, a biologist at the Center for Reproductive Medicine and Infertility at the Cornell University Medical School, New York, reported in a presentation at the annual meeting of the American Society for Reproductive Medicine.

To investigate the cognitive and behavioral profiles of children conceived using assisted reproductive technology according to sperm origin, Ms. Neri compared data from 74 children conceived via ICSI with surgically retrieved sperm, 516 children conceived via ICSI with ejaculated sperm, and 284 children conceived via IVF but not ICSI.

Ms. Neri worked under the guidance of Dr. Zev Rosenwaks and Dr. Gianpiero D. Palermo, both of Cornell University.

The Ages & Stages Questionnaire (ASQ) and Social Skills Rating System (SSRS) were used to assess the children's communication skills, fine motor skills, gross motor skills, social skills, and problem-solving skills at 3 years of age.

Overall, 87.1% of the children had ASQ scores in the normal range, compared with 12.9% who scored in the at-risk range (meaning at risk for further developmental delays or abnormalities). The at-risk group included 10.4% of the IVF children, 11.4% of the children conceived via ICSI with ejaculated sperm, and significantly fewer (2.8%) of the children conceived via ICSI with surgically retrieved sperm.

Within the subset of at-risk children conceived via ICSI, those conceived from surgically retrieved sperm scored significantly higher on measures of gross and fine-motor skills on the ASQ than did those conceived from ejaculated sperm.

These children also scored higher on measures of communication, problem solving, and personal/social development, but the differences were not statistically significant.

Similarly, 81.8% of the children overall had SSRS scores in the normal range, compared with 18.2% of children in the at-risk range.

The at-risk group included 17.2% of the IVF children, 20.1% of the children conceived via ICSI from ejaculated sperm, and 15.8% of those conceived via ICSI from surgically retrieved sperm.

In the subset of children conceived via ICSI, the percentage of children at risk for problems with social skills was significantly lower among those conceived with surgically retrieved sperm, compared with those who were conceived with ejaculated sperm.

In addition, children who were part of multiple gestations were significantly more likely to be in the at-risk score range for the SSRS in both the IVF (non-ICSI) group and the ICSI group conceived from ejaculated sperm.

However, the difference in at-risk SSRS scores between multiples and singletons was not significant for children who were conceived via ICSI with surgically retrieved sperm.

Although the results from this study suggest that there is no negative association between sperm characteristics and child development, ongoing follow-up is important in detecting malformations that appear after birth, Ms. Neri said.