Kerri Wachter

The American College of Rheumatology is billing its new online image bank as the “most comprehensive online collection of rheumatology-related images,” running the alphabet from avascular necrosis to vasculitis.

The collection includes more than 1,500 clinical, pathological, and radiologic images of both common and rare rheumatic disorders. The primary purpose of the image bank is as a teaching tool. “It's a great teaching tool for people training in rheumatology,” said Dr. Alan Baer, chair of the ACR's Audiovisual Aids Subcommittee, which is the arm of ACR that oversaw the development of the image bank.

In addition to their usefulness in training the next generation of rheumatologists, the images can also be used when rheumatologists “go out into the community to give talks to their colleagues or laypeople.”

The images are arranged in sections by type of disorder—soft-tissue rheumatic syndromes, for example. Within a section, images are presented alphabetically by condition.

The image bank is the descendant of the college's slide collection, which got its start in 1958 with a collection of pathology slides. The collection has been revised and supplemented several times since then. “For many years, it was a 35-mm collection. But within the past decade, it became a CD-ROM collection,” said Dr. Baer, who is both chief of rheumatology and director of the Johns Hopkins University Clinical Practice, both at Good Samaritan Hospital, Baltimore. “For a number of years, we have recognized the need to put the image bank online and make it Internet accessible. That's what we've accomplished in the last year.”

Certainly it's easy enough to find rheumatology images through search engines, such as Google. However, the committee makes “a very concerted effort to ensure that these are top-quality images that are carefully annotated.” In fact, the images and any accompanying material are carefully scrutinized for accuracy, and additional information may be requested.

“It's a very reliable source of images,” said Dr. Baer.

Over the years, the collection has grown from pathology, histology, clinical photos, and x-rays to include newer imaging modalities such as MRI, CT, and sonography.

Dr. Baer hopes to expand the online collection to include video in the future. “We want to move to some of the new imaging formats.”

Video “opens up a whole new arena for us.” For example, “you could watch someone examine a certain joint or watch procedures being performed.”

Video would be particularly useful for including ultrasound imaging in the collection.

Ultrasound is dynamic by nature and it's hard to capture the diagnostic process with a static image, he noted.

“This is a great opportunity to create a whole new type of educational tool,” said Dr. Baer.

The image bank can be found at www.rheumatology.org

These images from a patient with Wegener's granulomatosis illustrate what the ACR has on offer.

Source American College of Rheumatology Image Bank

The American College of Rheumatology is billing its new online image bank as the “most comprehensive online collection of rheumatology-related images,” running the alphabet from avascular necrosis to vasculitis.

The collection includes more than 1,500 clinical, pathological, and radiologic images of both common and rare rheumatic disorders. The primary purpose of the image bank is as a teaching tool. “It's a great teaching tool for people training in rheumatology,” said Dr. Alan Baer, chair of the ACR's Audiovisual Aids Subcommittee, which is the arm of ACR that oversaw the development of the image bank.

In addition to their usefulness in training the next generation of rheumatologists, the images can also be used when rheumatologists “go out into the community to give talks to their colleagues or laypeople.”

The images are arranged in sections by type of disorder—soft-tissue rheumatic syndromes, for example. Within a section, images are presented alphabetically by condition.

The image bank is the descendant of the college's slide collection, which got its start in 1958 with a collection of pathology slides. The collection has been revised and supplemented several times since then. “For many years, it was a 35-mm collection. But within the past decade, it became a CD-ROM collection,” said Dr. Baer, who is both chief of rheumatology and director of the Johns Hopkins University Clinical Practice, both at Good Samaritan Hospital, Baltimore. “For a number of years, we have recognized the need to put the image bank online and make it Internet accessible. That's what we've accomplished in the last year.”

Certainly it's easy enough to find rheumatology images through search engines, such as Google. However, the committee makes “a very concerted effort to ensure that these are top-quality images that are carefully annotated.” In fact, the images and any accompanying material are carefully scrutinized for accuracy, and additional information may be requested.

“It's a very reliable source of images,” said Dr. Baer.

Over the years, the collection has grown from pathology, histology, clinical photos, and x-rays to include newer imaging modalities such as MRI, CT, and sonography.

Dr. Baer hopes to expand the online collection to include video in the future. “We want to move to some of the new imaging formats.”

Video “opens up a whole new arena for us.” For example, “you could watch someone examine a certain joint or watch procedures being performed.”

Video would be particularly useful for including ultrasound imaging in the collection.

Ultrasound is dynamic by nature and it's hard to capture the diagnostic process with a static image, he noted.

“This is a great opportunity to create a whole new type of educational tool,” said Dr. Baer.

The image bank can be found at www.rheumatology.org

These images from a patient with Wegener's granulomatosis illustrate what the ACR has on offer.

Source American College of Rheumatology Image Bank

The American College of Rheumatology is billing its new online image bank as the “most comprehensive online collection of rheumatology-related images,” running the alphabet from avascular necrosis to vasculitis.

The collection includes more than 1,500 clinical, pathological, and radiologic images of both common and rare rheumatic disorders. The primary purpose of the image bank is as a teaching tool. “It's a great teaching tool for people training in rheumatology,” said Dr. Alan Baer, chair of the ACR's Audiovisual Aids Subcommittee, which is the arm of ACR that oversaw the development of the image bank.

In addition to their usefulness in training the next generation of rheumatologists, the images can also be used when rheumatologists “go out into the community to give talks to their colleagues or laypeople.”

The images are arranged in sections by type of disorder—soft-tissue rheumatic syndromes, for example. Within a section, images are presented alphabetically by condition.

The image bank is the descendant of the college's slide collection, which got its start in 1958 with a collection of pathology slides. The collection has been revised and supplemented several times since then. “For many years, it was a 35-mm collection. But within the past decade, it became a CD-ROM collection,” said Dr. Baer, who is both chief of rheumatology and director of the Johns Hopkins University Clinical Practice, both at Good Samaritan Hospital, Baltimore. “For a number of years, we have recognized the need to put the image bank online and make it Internet accessible. That's what we've accomplished in the last year.”

Certainly it's easy enough to find rheumatology images through search engines, such as Google. However, the committee makes “a very concerted effort to ensure that these are top-quality images that are carefully annotated.” In fact, the images and any accompanying material are carefully scrutinized for accuracy, and additional information may be requested.

“It's a very reliable source of images,” said Dr. Baer.

Over the years, the collection has grown from pathology, histology, clinical photos, and x-rays to include newer imaging modalities such as MRI, CT, and sonography.

Dr. Baer hopes to expand the online collection to include video in the future. “We want to move to some of the new imaging formats.”

Video “opens up a whole new arena for us.” For example, “you could watch someone examine a certain joint or watch procedures being performed.”

Video would be particularly useful for including ultrasound imaging in the collection.

Ultrasound is dynamic by nature and it's hard to capture the diagnostic process with a static image, he noted.

“This is a great opportunity to create a whole new type of educational tool,” said Dr. Baer.

The image bank can be found at www.rheumatology.org

These images from a patient with Wegener's granulomatosis illustrate what the ACR has on offer.

Source American College of Rheumatology Image Bank

WASHINGTON — Refuting inaccurate information about vaccines and providing additional education are key to addressing parental concerns about childhood immunizations, according to Dr. Gary S. Marshall.

Many parents have concerns about the safety and necessity of childhood immunizations or simply refuse to vaccinate their child. It comes down to what the parents believe. “We have to fight the belief with the science,” he said at the annual meeting of the American Academy of Pediatrics.

Dr. Marshall recommended beginning the discussion before the baby is born, if possible. He also recommended having materials and resources that parents can take home. Be persistent and keep repeating your message. “Ultimately, though, you will have to make the decision about how long you're going to fight the fight.”

“It is legal and ethical to discontinue with that family. Whether it does any good is the question,” he pointed out. The American Medical Association Code of Ethics (E-8.115 and E-10.05) notes that while physicians are obligated to support continuity of care, it is ethically permissible for physicians to decline a potential patient when “the treatment request is known to be scientifically invalid.” Likewise, the AAP's All Star Pediatrics' Vaccine Policy Statement provides language for asking parents who refuse to vaccinate their children to find another physician for their child (www.aap.org/securemoc/immunizations/allstarpediatrics.doc

During his talk, Dr. Marshall offered several vaccine truths to keep in mind when dealing with concerned parents.

Vaccines Save Lives

“We've made tremendous progress in controlling disease,” said Dr. Marshall, who is chief of the pediatric infectious diseases division at the University of Louisville (Ky.). For example, the childhood immunization schedule saves more quality-adjusted life years than any other public health intervention. In addition, for every dollar spent, vaccine programs saved $5 in direct medical costs and an additional $11 in societal costs, based on estimates for the 2001 birth cohort (Arch. Pediatr. Adolesc. Med. 2005;159:1136-44).

Vaccine Refusal Can Cause Harm

“Being afraid of vaccines is not a benign thing. It does result directly in public harm,” warned Dr. Marshall. For example, a 1974 case series of children allegedly injured by the pertussis vaccine resulted in a precipitous drop in vaccinations in the United Kingdom. “What do you think happened after that? There were outbreaks of pertussis and about 600 infants who coughed themselves to death unnecessarily.”

Many states allow personal belief exemptions from vaccines. “If you live in a state that allows for personal belief exemptions, then you are at higher risk to get pertussis—even if you're immunized,” said Dr. Marshall. Interestingly, it's possible to correlate the risk with how easy it is to get the exemption (JAMA 2006;296:1757-63).

In recent years, parents have been concerned about purported links between the measles-mumps-rubella (MMR) vaccine and autism, but the evidence is overwhelmingly against such a link. Although autism rates have been steadily rising in the United States, the United Kingdom, and Canada, MMR vaccination rates have held steady over the same period, findings that call into question an autism-vaccine link. In addition, retrospective epidemiologic studies, such as the Danish Cohort study (N. Engl. J. Med. 2002;347;1477-82), have found no increased risk of autism with vaccine exposure. The rise in autism cases may be explained in part by both better detection and a broadened definition of autism spectrum disorders.

Back in 1994, measles had been eliminated in the United Kingdom. However, because of concerns about a possible autism link to the MMR vaccine, some parents chose not to have their children vaccinated. The result is that measles are now endemic again in the United Kingdom. “We now have had a resurgence of measles in the United States. This is directly related to people who have intentionally not been vaccinated,” said Dr. Marshall.

Fear of Adverse Events Is Pervasive

Dangerous infectious diseases have been effectively controlled through vaccination programs, and as a result, these diseases are no longer in the public mind. There has been a shift from fear of diseases to fear of adverse events from vaccines, said Dr. Marshall.

“Fear of vaccines is not new … but what people didn't have back then, that we have now, is the Internet.” A Google search using the word “vaccine” turns up hundreds of hits, many of which are for organizations dedicated to convincing parents that vaccines are dangerous.

Celebrities like actress Jenny McCarthy—herself the mother of an autistic son, though she claims to have cured him—and actor/comedian Jim Carrey keep fears of vaccine safety in parents' minds. They also promote misinformation about vaccines, claiming for instance that mercury (thimerosal) is still a vaccine component and that antifungal medicines can cure autism.

Nothing Is 100% Safe

“Vaccines are not 100% safe. Nothing is,” said Dr. Marshall. However, the risk of death due to vaccines is very small. In fact, no deaths due to vaccine adverse events occurred last year. You're more likely to die in an elevator accident or be struck by lightening.

“We need to be able to convince the public that the safety net that we have in this country is robust and it works.” The process starts with the well-regulated development of candidate vaccines and continues through clinical trials and Food and Drug Administration licensure. In addition, “we have committees of experts that review the data and decide who should get the vaccine and who shouldn't.” After that, vaccines are subject to adverse event scrutiny through the Vaccine Adverse Events Reporting System, the Vaccine Safety DataLink, and other organizations.

Heuristic Thinking Can Occur

Many people concerned about vaccines focus only on those with an exposure to vaccines who had a certain outcome (Guillain-Barré syndrome or febrile seizures, for example). They ignore the larger picture—those with an exposure who did not have a certain outcome, those with no exposure who did have a certain outcome, or those with no exposure and no outcome.

In addition, some parents demonstrate heuristic thinking when it comes to vaccines. In heuristic thinking, a known risk (the flu) is more acceptable than an unknown risk (an allergic reaction); a bad outcome is more tolerable if it occurs because of inaction than action; the probability that something will occur correlates with the ease with which we remember it or with the similarity of circumstances; rare risks are overestimated and common risks are underestimated. “Part of our challenge is to undo that kind of thinking,” said Dr. Marshall.

Many parents who are against childhood vaccinations think they can rely on herd immunity to protect their child. That is unfair to other parents and not necessarily a safeguard, he said. Unvaccinated children tend to live in clusters and spawn outbreaks, as in the case of a measles outbreak in March 2009 in California.

Vaccinology Isn't Understood

“People are confused about antigens. They see us, over the years, giving more and more vaccines, but what they don't understand is that the number of antigens that we're actually giving is much less,” Dr. Marshall said.

It's true that most pediatricians are not experts on vaccinology. “I don't think that all of us read all of the primary literature, but we do elect and appoint very smart people to our committees, who do look at every single piece of data and come up with recommendations,” he said. It is also true that natural immunity is better. “Natural chicken pox gives you more robust and longer-lasting immunity than the vaccine … but the cost of natural immunity is getting the disease. The cost of the vaccine is the very rare side effect.”

He reported that he has been a speaker and consultant for several pharmaceutical companies that make vaccines. Dr. Marshall has also received research grants from several pharmaceutical companies that make vaccines.

WASHINGTON — Refuting inaccurate information about vaccines and providing additional education are key to addressing parental concerns about childhood immunizations, according to Dr. Gary S. Marshall.

Many parents have concerns about the safety and necessity of childhood immunizations or simply refuse to vaccinate their child. It comes down to what the parents believe. “We have to fight the belief with the science,” he said at the annual meeting of the American Academy of Pediatrics.

Dr. Marshall recommended beginning the discussion before the baby is born, if possible. He also recommended having materials and resources that parents can take home. Be persistent and keep repeating your message. “Ultimately, though, you will have to make the decision about how long you're going to fight the fight.”

“It is legal and ethical to discontinue with that family. Whether it does any good is the question,” he pointed out. The American Medical Association Code of Ethics (E-8.115 and E-10.05) notes that while physicians are obligated to support continuity of care, it is ethically permissible for physicians to decline a potential patient when “the treatment request is known to be scientifically invalid.” Likewise, the AAP's All Star Pediatrics' Vaccine Policy Statement provides language for asking parents who refuse to vaccinate their children to find another physician for their child (www.aap.org/securemoc/immunizations/allstarpediatrics.doc

During his talk, Dr. Marshall offered several vaccine truths to keep in mind when dealing with concerned parents.

Vaccines Save Lives

“We've made tremendous progress in controlling disease,” said Dr. Marshall, who is chief of the pediatric infectious diseases division at the University of Louisville (Ky.). For example, the childhood immunization schedule saves more quality-adjusted life years than any other public health intervention. In addition, for every dollar spent, vaccine programs saved $5 in direct medical costs and an additional $11 in societal costs, based on estimates for the 2001 birth cohort (Arch. Pediatr. Adolesc. Med. 2005;159:1136-44).

Vaccine Refusal Can Cause Harm

“Being afraid of vaccines is not a benign thing. It does result directly in public harm,” warned Dr. Marshall. For example, a 1974 case series of children allegedly injured by the pertussis vaccine resulted in a precipitous drop in vaccinations in the United Kingdom. “What do you think happened after that? There were outbreaks of pertussis and about 600 infants who coughed themselves to death unnecessarily.”

Many states allow personal belief exemptions from vaccines. “If you live in a state that allows for personal belief exemptions, then you are at higher risk to get pertussis—even if you're immunized,” said Dr. Marshall. Interestingly, it's possible to correlate the risk with how easy it is to get the exemption (JAMA 2006;296:1757-63).

In recent years, parents have been concerned about purported links between the measles-mumps-rubella (MMR) vaccine and autism, but the evidence is overwhelmingly against such a link. Although autism rates have been steadily rising in the United States, the United Kingdom, and Canada, MMR vaccination rates have held steady over the same period, findings that call into question an autism-vaccine link. In addition, retrospective epidemiologic studies, such as the Danish Cohort study (N. Engl. J. Med. 2002;347;1477-82), have found no increased risk of autism with vaccine exposure. The rise in autism cases may be explained in part by both better detection and a broadened definition of autism spectrum disorders.

Back in 1994, measles had been eliminated in the United Kingdom. However, because of concerns about a possible autism link to the MMR vaccine, some parents chose not to have their children vaccinated. The result is that measles are now endemic again in the United Kingdom. “We now have had a resurgence of measles in the United States. This is directly related to people who have intentionally not been vaccinated,” said Dr. Marshall.

Fear of Adverse Events Is Pervasive

Dangerous infectious diseases have been effectively controlled through vaccination programs, and as a result, these diseases are no longer in the public mind. There has been a shift from fear of diseases to fear of adverse events from vaccines, said Dr. Marshall.

“Fear of vaccines is not new … but what people didn't have back then, that we have now, is the Internet.” A Google search using the word “vaccine” turns up hundreds of hits, many of which are for organizations dedicated to convincing parents that vaccines are dangerous.

Celebrities like actress Jenny McCarthy—herself the mother of an autistic son, though she claims to have cured him—and actor/comedian Jim Carrey keep fears of vaccine safety in parents' minds. They also promote misinformation about vaccines, claiming for instance that mercury (thimerosal) is still a vaccine component and that antifungal medicines can cure autism.

Nothing Is 100% Safe

“Vaccines are not 100% safe. Nothing is,” said Dr. Marshall. However, the risk of death due to vaccines is very small. In fact, no deaths due to vaccine adverse events occurred last year. You're more likely to die in an elevator accident or be struck by lightening.

“We need to be able to convince the public that the safety net that we have in this country is robust and it works.” The process starts with the well-regulated development of candidate vaccines and continues through clinical trials and Food and Drug Administration licensure. In addition, “we have committees of experts that review the data and decide who should get the vaccine and who shouldn't.” After that, vaccines are subject to adverse event scrutiny through the Vaccine Adverse Events Reporting System, the Vaccine Safety DataLink, and other organizations.

Heuristic Thinking Can Occur

Many people concerned about vaccines focus only on those with an exposure to vaccines who had a certain outcome (Guillain-Barré syndrome or febrile seizures, for example). They ignore the larger picture—those with an exposure who did not have a certain outcome, those with no exposure who did have a certain outcome, or those with no exposure and no outcome.

In addition, some parents demonstrate heuristic thinking when it comes to vaccines. In heuristic thinking, a known risk (the flu) is more acceptable than an unknown risk (an allergic reaction); a bad outcome is more tolerable if it occurs because of inaction than action; the probability that something will occur correlates with the ease with which we remember it or with the similarity of circumstances; rare risks are overestimated and common risks are underestimated. “Part of our challenge is to undo that kind of thinking,” said Dr. Marshall.

Many parents who are against childhood vaccinations think they can rely on herd immunity to protect their child. That is unfair to other parents and not necessarily a safeguard, he said. Unvaccinated children tend to live in clusters and spawn outbreaks, as in the case of a measles outbreak in March 2009 in California.

Vaccinology Isn't Understood

“People are confused about antigens. They see us, over the years, giving more and more vaccines, but what they don't understand is that the number of antigens that we're actually giving is much less,” Dr. Marshall said.

It's true that most pediatricians are not experts on vaccinology. “I don't think that all of us read all of the primary literature, but we do elect and appoint very smart people to our committees, who do look at every single piece of data and come up with recommendations,” he said. It is also true that natural immunity is better. “Natural chicken pox gives you more robust and longer-lasting immunity than the vaccine … but the cost of natural immunity is getting the disease. The cost of the vaccine is the very rare side effect.”

He reported that he has been a speaker and consultant for several pharmaceutical companies that make vaccines. Dr. Marshall has also received research grants from several pharmaceutical companies that make vaccines.

WASHINGTON — Refuting inaccurate information about vaccines and providing additional education are key to addressing parental concerns about childhood immunizations, according to Dr. Gary S. Marshall.

Many parents have concerns about the safety and necessity of childhood immunizations or simply refuse to vaccinate their child. It comes down to what the parents believe. “We have to fight the belief with the science,” he said at the annual meeting of the American Academy of Pediatrics.

Dr. Marshall recommended beginning the discussion before the baby is born, if possible. He also recommended having materials and resources that parents can take home. Be persistent and keep repeating your message. “Ultimately, though, you will have to make the decision about how long you're going to fight the fight.”

“It is legal and ethical to discontinue with that family. Whether it does any good is the question,” he pointed out. The American Medical Association Code of Ethics (E-8.115 and E-10.05) notes that while physicians are obligated to support continuity of care, it is ethically permissible for physicians to decline a potential patient when “the treatment request is known to be scientifically invalid.” Likewise, the AAP's All Star Pediatrics' Vaccine Policy Statement provides language for asking parents who refuse to vaccinate their children to find another physician for their child (www.aap.org/securemoc/immunizations/allstarpediatrics.doc

During his talk, Dr. Marshall offered several vaccine truths to keep in mind when dealing with concerned parents.

Vaccines Save Lives

“We've made tremendous progress in controlling disease,” said Dr. Marshall, who is chief of the pediatric infectious diseases division at the University of Louisville (Ky.). For example, the childhood immunization schedule saves more quality-adjusted life years than any other public health intervention. In addition, for every dollar spent, vaccine programs saved $5 in direct medical costs and an additional $11 in societal costs, based on estimates for the 2001 birth cohort (Arch. Pediatr. Adolesc. Med. 2005;159:1136-44).

Vaccine Refusal Can Cause Harm

“Being afraid of vaccines is not a benign thing. It does result directly in public harm,” warned Dr. Marshall. For example, a 1974 case series of children allegedly injured by the pertussis vaccine resulted in a precipitous drop in vaccinations in the United Kingdom. “What do you think happened after that? There were outbreaks of pertussis and about 600 infants who coughed themselves to death unnecessarily.”

Many states allow personal belief exemptions from vaccines. “If you live in a state that allows for personal belief exemptions, then you are at higher risk to get pertussis—even if you're immunized,” said Dr. Marshall. Interestingly, it's possible to correlate the risk with how easy it is to get the exemption (JAMA 2006;296:1757-63).

In recent years, parents have been concerned about purported links between the measles-mumps-rubella (MMR) vaccine and autism, but the evidence is overwhelmingly against such a link. Although autism rates have been steadily rising in the United States, the United Kingdom, and Canada, MMR vaccination rates have held steady over the same period, findings that call into question an autism-vaccine link. In addition, retrospective epidemiologic studies, such as the Danish Cohort study (N. Engl. J. Med. 2002;347;1477-82), have found no increased risk of autism with vaccine exposure. The rise in autism cases may be explained in part by both better detection and a broadened definition of autism spectrum disorders.

Back in 1994, measles had been eliminated in the United Kingdom. However, because of concerns about a possible autism link to the MMR vaccine, some parents chose not to have their children vaccinated. The result is that measles are now endemic again in the United Kingdom. “We now have had a resurgence of measles in the United States. This is directly related to people who have intentionally not been vaccinated,” said Dr. Marshall.

Fear of Adverse Events Is Pervasive

Dangerous infectious diseases have been effectively controlled through vaccination programs, and as a result, these diseases are no longer in the public mind. There has been a shift from fear of diseases to fear of adverse events from vaccines, said Dr. Marshall.

“Fear of vaccines is not new … but what people didn't have back then, that we have now, is the Internet.” A Google search using the word “vaccine” turns up hundreds of hits, many of which are for organizations dedicated to convincing parents that vaccines are dangerous.

Celebrities like actress Jenny McCarthy—herself the mother of an autistic son, though she claims to have cured him—and actor/comedian Jim Carrey keep fears of vaccine safety in parents' minds. They also promote misinformation about vaccines, claiming for instance that mercury (thimerosal) is still a vaccine component and that antifungal medicines can cure autism.

Nothing Is 100% Safe

“Vaccines are not 100% safe. Nothing is,” said Dr. Marshall. However, the risk of death due to vaccines is very small. In fact, no deaths due to vaccine adverse events occurred last year. You're more likely to die in an elevator accident or be struck by lightening.

“We need to be able to convince the public that the safety net that we have in this country is robust and it works.” The process starts with the well-regulated development of candidate vaccines and continues through clinical trials and Food and Drug Administration licensure. In addition, “we have committees of experts that review the data and decide who should get the vaccine and who shouldn't.” After that, vaccines are subject to adverse event scrutiny through the Vaccine Adverse Events Reporting System, the Vaccine Safety DataLink, and other organizations.

Heuristic Thinking Can Occur

Many people concerned about vaccines focus only on those with an exposure to vaccines who had a certain outcome (Guillain-Barré syndrome or febrile seizures, for example). They ignore the larger picture—those with an exposure who did not have a certain outcome, those with no exposure who did have a certain outcome, or those with no exposure and no outcome.

In addition, some parents demonstrate heuristic thinking when it comes to vaccines. In heuristic thinking, a known risk (the flu) is more acceptable than an unknown risk (an allergic reaction); a bad outcome is more tolerable if it occurs because of inaction than action; the probability that something will occur correlates with the ease with which we remember it or with the similarity of circumstances; rare risks are overestimated and common risks are underestimated. “Part of our challenge is to undo that kind of thinking,” said Dr. Marshall.

Many parents who are against childhood vaccinations think they can rely on herd immunity to protect their child. That is unfair to other parents and not necessarily a safeguard, he said. Unvaccinated children tend to live in clusters and spawn outbreaks, as in the case of a measles outbreak in March 2009 in California.

Vaccinology Isn't Understood

“People are confused about antigens. They see us, over the years, giving more and more vaccines, but what they don't understand is that the number of antigens that we're actually giving is much less,” Dr. Marshall said.

It's true that most pediatricians are not experts on vaccinology. “I don't think that all of us read all of the primary literature, but we do elect and appoint very smart people to our committees, who do look at every single piece of data and come up with recommendations,” he said. It is also true that natural immunity is better. “Natural chicken pox gives you more robust and longer-lasting immunity than the vaccine … but the cost of natural immunity is getting the disease. The cost of the vaccine is the very rare side effect.”

He reported that he has been a speaker and consultant for several pharmaceutical companies that make vaccines. Dr. Marshall has also received research grants from several pharmaceutical companies that make vaccines.

Multiple-session early psychological interventions are no better at reducing posttraumatic stress disorder symptoms than no intervention at all and might even increase symptoms in some individuals, a review of 11 randomized, controlled studies showed.

“There was no evidence that a multiple session intervention aimed at everyone following a traumatic event was effective. There was a trend that just failed to reach significance for no intervention to result in less self-reported PTSD symptoms at 3- to 6-month follow-up than a multiple session intervention,” wrote Neil P. Roberts, D.Clin.Psy., of the Traumatic Stress Service at Cardiff and Vale National Health Services (Wales), and his coauthors.

The results were published online in the Cochrane Database of Systemic Reviews (doi:10.1002/14651858.CD006869.pub2).

The researchers conducted searches of computerized databases (MEDLINE, Clin Psych, PsychLIT, EMBASE, and others) using key words such as trauma, PTSD, and early intervention.

The researchers also performed hand searches of the Journal of Traumatic Stress, the Journal of Consulting and Clinical Psychology, and reference lists. They also contacted key individuals in the field.

Any randomized, controlled trial was eligible for the review. The researchers focused on multiple-session early psychologic interventions intended to prevent symptoms of traumatic stress that were initiated within 3 months of the event.

Potential intervention categories included cognitive-behavioral therapy (CBT), trauma-focused CBT, trauma-focused group CBT, non–trauma-focused group CBT, stress management/relaxation, eye movement desensitization and reprocessing, other psychological interventions, education, provision of information, stepped care, and interventions aimed at enhancing positive coping skills and improving overall well-being.

The researchers limited studies to those that compared a psychological intervention versus a waiting list/usual care control or psychological intervention versus another psychological intervention.

The primary outcome was the rate of PTSD among those subjected to trauma, as measured by a standard classification system.

Commonly used PTSD measures include the Impact of Event Scale and the Post-traumatic Diagnostic Scale.

The final review included 11 studies, involving 914 participants. Nine studies (775 participants)—two conducted in the United States, two in Australia, two in Sweden, and one each in Canada, France, and the Netherlands—provided data for the final analysis.

Traumatic events experienced by the participants included traffic accidents, armed robbery/violence, traumatic childbirth, physical trauma, diagnosis of childhood cancer, and a range of other civilian traumatic experiences.

The studies evaluated individual counseling, interpersonal counseling, adapted debriefing, CBT, counseling/collaborative care, and integrated CBT/family therapy.

The average number of sessions attended by those who completed therapy was six.

The study findings “suggest that at this time there is little evidence to support the use of psychological intervention for routine use following traumatic events and that some multiple-session interventions … may have an adverse effect on some individuals,” the researchers wrote.

Multiple-session early psychological interventions are no better at reducing posttraumatic stress disorder symptoms than no intervention at all and might even increase symptoms in some individuals, a review of 11 randomized, controlled studies showed.

“There was no evidence that a multiple session intervention aimed at everyone following a traumatic event was effective. There was a trend that just failed to reach significance for no intervention to result in less self-reported PTSD symptoms at 3- to 6-month follow-up than a multiple session intervention,” wrote Neil P. Roberts, D.Clin.Psy., of the Traumatic Stress Service at Cardiff and Vale National Health Services (Wales), and his coauthors.

The results were published online in the Cochrane Database of Systemic Reviews (doi:10.1002/14651858.CD006869.pub2).

The researchers conducted searches of computerized databases (MEDLINE, Clin Psych, PsychLIT, EMBASE, and others) using key words such as trauma, PTSD, and early intervention.

The researchers also performed hand searches of the Journal of Traumatic Stress, the Journal of Consulting and Clinical Psychology, and reference lists. They also contacted key individuals in the field.

Any randomized, controlled trial was eligible for the review. The researchers focused on multiple-session early psychologic interventions intended to prevent symptoms of traumatic stress that were initiated within 3 months of the event.

Potential intervention categories included cognitive-behavioral therapy (CBT), trauma-focused CBT, trauma-focused group CBT, non–trauma-focused group CBT, stress management/relaxation, eye movement desensitization and reprocessing, other psychological interventions, education, provision of information, stepped care, and interventions aimed at enhancing positive coping skills and improving overall well-being.

The researchers limited studies to those that compared a psychological intervention versus a waiting list/usual care control or psychological intervention versus another psychological intervention.

The primary outcome was the rate of PTSD among those subjected to trauma, as measured by a standard classification system.

Commonly used PTSD measures include the Impact of Event Scale and the Post-traumatic Diagnostic Scale.

The final review included 11 studies, involving 914 participants. Nine studies (775 participants)—two conducted in the United States, two in Australia, two in Sweden, and one each in Canada, France, and the Netherlands—provided data for the final analysis.

Traumatic events experienced by the participants included traffic accidents, armed robbery/violence, traumatic childbirth, physical trauma, diagnosis of childhood cancer, and a range of other civilian traumatic experiences.

The studies evaluated individual counseling, interpersonal counseling, adapted debriefing, CBT, counseling/collaborative care, and integrated CBT/family therapy.

The average number of sessions attended by those who completed therapy was six.

The study findings “suggest that at this time there is little evidence to support the use of psychological intervention for routine use following traumatic events and that some multiple-session interventions … may have an adverse effect on some individuals,” the researchers wrote.

Multiple-session early psychological interventions are no better at reducing posttraumatic stress disorder symptoms than no intervention at all and might even increase symptoms in some individuals, a review of 11 randomized, controlled studies showed.

“There was no evidence that a multiple session intervention aimed at everyone following a traumatic event was effective. There was a trend that just failed to reach significance for no intervention to result in less self-reported PTSD symptoms at 3- to 6-month follow-up than a multiple session intervention,” wrote Neil P. Roberts, D.Clin.Psy., of the Traumatic Stress Service at Cardiff and Vale National Health Services (Wales), and his coauthors.

The results were published online in the Cochrane Database of Systemic Reviews (doi:10.1002/14651858.CD006869.pub2).

The researchers conducted searches of computerized databases (MEDLINE, Clin Psych, PsychLIT, EMBASE, and others) using key words such as trauma, PTSD, and early intervention.

The researchers also performed hand searches of the Journal of Traumatic Stress, the Journal of Consulting and Clinical Psychology, and reference lists. They also contacted key individuals in the field.

Any randomized, controlled trial was eligible for the review. The researchers focused on multiple-session early psychologic interventions intended to prevent symptoms of traumatic stress that were initiated within 3 months of the event.

Potential intervention categories included cognitive-behavioral therapy (CBT), trauma-focused CBT, trauma-focused group CBT, non–trauma-focused group CBT, stress management/relaxation, eye movement desensitization and reprocessing, other psychological interventions, education, provision of information, stepped care, and interventions aimed at enhancing positive coping skills and improving overall well-being.

The researchers limited studies to those that compared a psychological intervention versus a waiting list/usual care control or psychological intervention versus another psychological intervention.

The primary outcome was the rate of PTSD among those subjected to trauma, as measured by a standard classification system.

Commonly used PTSD measures include the Impact of Event Scale and the Post-traumatic Diagnostic Scale.

The final review included 11 studies, involving 914 participants. Nine studies (775 participants)—two conducted in the United States, two in Australia, two in Sweden, and one each in Canada, France, and the Netherlands—provided data for the final analysis.

Traumatic events experienced by the participants included traffic accidents, armed robbery/violence, traumatic childbirth, physical trauma, diagnosis of childhood cancer, and a range of other civilian traumatic experiences.

The studies evaluated individual counseling, interpersonal counseling, adapted debriefing, CBT, counseling/collaborative care, and integrated CBT/family therapy.

The average number of sessions attended by those who completed therapy was six.

The study findings “suggest that at this time there is little evidence to support the use of psychological intervention for routine use following traumatic events and that some multiple-session interventions … may have an adverse effect on some individuals,” the researchers wrote.

DENVER — Extended physiotherapy significantly reduced the rate of falls among patients with a prior hip fracture, and high-dose vitamin D significantly reduced the rate of hospital readmissions in a study of 173 patients.

A program of extended physiotherapy reduced the fall rate by 25%, compared with standard postfracture physiotherapy; high-dose vitamin D therapy reduced the hospital readmission rate by 39%, compared with a lower dose, the researchers found.

“The extended physiotherapy program, together with 2,000 IU vitamin D, has complementary benefits on post–hip fracture care,” Dr. Heike Bischoff-Ferrari said at the annual meeting of the American Society for Bone and Mineral Research.

The researchers enrolled 173 patients after their first acute hip fracture. Of these, most (79%) were women. Their mean age was 84 years, and 77% were living in the community. Half (51%) of the patients had severe vitamin D deficiency with serum 25-hydroxyvitamin D levels below 30 nmol/L; almost all (98%) had serum 25-hydroxyvitamin D levels below 75 nmol/L.

Patients were randomized to receive extended physiotherapy or standard physiotherapy. Extended physiotherapy consisted of supervised therapy for 1 hour per day during acute care, plus an unsupervised home program of exercises to perform regularly for 1 year. The standard therapy consisted of supervised therapy for 30 minutes per day during acute care. Physiotherapy included activities such as getting up from a chair, one-leg stands, climbing up and down stairs, and a rubber band exercise program for upper arm strength.

Patients were also randomized to receive vitamin D supplementation at 2,000 IU or 800 IU vitamin D3 per day. All patients received calcium.

Clinical assessment, which included laboratory tests and functional evaluations, took place at baseline and at 6 and 12 months' follow-up. Falls and readmissions were assessed by monthly calls to patients, patient calls to a hotline, and patient diaries.

The primary end point was the rate of falls over 12 months. The secondary end point was the rate of hospital readmission over 12 months.

In all, 86 participants were included in the high-dose vitamin D group and 87 were included in the lower-dose vitamin D group; 87 participants were included in the extensive physiotherapy group, and 86 were included in the regular physiotherapy group. The groups did not differ by age, gender, BMI, cognitive function, baseline 25-hydroxyvitamin D levels, and Charleston Comorbidity Index scores.

The researchers documented 212 falls in 92 participants. Of these, 41% fell once, 26% fell twice, 19% fell three times, and 14% fell more than three times. The rate of falls per patient-year was 1.43. There were 22 new nonvertebral fractures, nine of which were in the contralateral hip.

There were 74 readmissions among 54 participants. Of these, 72% had one readmission, 20% had two, and 8% had three. The rate of readmission was 50%.

Extended physiotherapy reduced the rate of falls by 25%, compared with regular physiotherapy, a significant reduction. Similar improvements were seen in function. However, extended physiotherapy did not reduce the rate of hospital readmissions.

There was no difference in the fall rate for the two vitamin D groups, but high-dose vitamin D did reduce the rate of hospital readmission by 39%, which was significant. There was also a significant 60% reduction in fall-related injuries. “This was mainly driven by a nonsignificant reduction in repeat nonvertebral fractures by 52%,” said Dr. Bischoff-Ferrari of the Centre on Aging and Mobility at the University Hospital Zurich.

The rate of readmissions due to infections decreased a significant 90%. Fall-related injuries went down 47% (which was nonsignificant) among those in the extended physiotherapy group, a decrease primarily driven by a nonsignificant 56% reduction in repeat nonvertebral fractures, said Dr. Bischoff-Ferrari, who is also a visiting scientist in the Bone Metabolism Laboratory at Tufts University, Boston.

In the first year after a hip fracture, an estimated 5%-10% of patients fracture the other hip and 30% are readmitted to acute care. Half of these patients are left with permanent functional impairment, a quarter require long-term care, and 10%-25% die, she said.

Dr. Bischoff-Ferrari reported having no conflicts of interest.

DENVER — Extended physiotherapy significantly reduced the rate of falls among patients with a prior hip fracture, and high-dose vitamin D significantly reduced the rate of hospital readmissions in a study of 173 patients.

A program of extended physiotherapy reduced the fall rate by 25%, compared with standard postfracture physiotherapy; high-dose vitamin D therapy reduced the hospital readmission rate by 39%, compared with a lower dose, the researchers found.

“The extended physiotherapy program, together with 2,000 IU vitamin D, has complementary benefits on post–hip fracture care,” Dr. Heike Bischoff-Ferrari said at the annual meeting of the American Society for Bone and Mineral Research.

The researchers enrolled 173 patients after their first acute hip fracture. Of these, most (79%) were women. Their mean age was 84 years, and 77% were living in the community. Half (51%) of the patients had severe vitamin D deficiency with serum 25-hydroxyvitamin D levels below 30 nmol/L; almost all (98%) had serum 25-hydroxyvitamin D levels below 75 nmol/L.

Patients were randomized to receive extended physiotherapy or standard physiotherapy. Extended physiotherapy consisted of supervised therapy for 1 hour per day during acute care, plus an unsupervised home program of exercises to perform regularly for 1 year. The standard therapy consisted of supervised therapy for 30 minutes per day during acute care. Physiotherapy included activities such as getting up from a chair, one-leg stands, climbing up and down stairs, and a rubber band exercise program for upper arm strength.

Patients were also randomized to receive vitamin D supplementation at 2,000 IU or 800 IU vitamin D3 per day. All patients received calcium.

Clinical assessment, which included laboratory tests and functional evaluations, took place at baseline and at 6 and 12 months' follow-up. Falls and readmissions were assessed by monthly calls to patients, patient calls to a hotline, and patient diaries.

The primary end point was the rate of falls over 12 months. The secondary end point was the rate of hospital readmission over 12 months.

In all, 86 participants were included in the high-dose vitamin D group and 87 were included in the lower-dose vitamin D group; 87 participants were included in the extensive physiotherapy group, and 86 were included in the regular physiotherapy group. The groups did not differ by age, gender, BMI, cognitive function, baseline 25-hydroxyvitamin D levels, and Charleston Comorbidity Index scores.

The researchers documented 212 falls in 92 participants. Of these, 41% fell once, 26% fell twice, 19% fell three times, and 14% fell more than three times. The rate of falls per patient-year was 1.43. There were 22 new nonvertebral fractures, nine of which were in the contralateral hip.

There were 74 readmissions among 54 participants. Of these, 72% had one readmission, 20% had two, and 8% had three. The rate of readmission was 50%.

Extended physiotherapy reduced the rate of falls by 25%, compared with regular physiotherapy, a significant reduction. Similar improvements were seen in function. However, extended physiotherapy did not reduce the rate of hospital readmissions.

There was no difference in the fall rate for the two vitamin D groups, but high-dose vitamin D did reduce the rate of hospital readmission by 39%, which was significant. There was also a significant 60% reduction in fall-related injuries. “This was mainly driven by a nonsignificant reduction in repeat nonvertebral fractures by 52%,” said Dr. Bischoff-Ferrari of the Centre on Aging and Mobility at the University Hospital Zurich.

The rate of readmissions due to infections decreased a significant 90%. Fall-related injuries went down 47% (which was nonsignificant) among those in the extended physiotherapy group, a decrease primarily driven by a nonsignificant 56% reduction in repeat nonvertebral fractures, said Dr. Bischoff-Ferrari, who is also a visiting scientist in the Bone Metabolism Laboratory at Tufts University, Boston.

In the first year after a hip fracture, an estimated 5%-10% of patients fracture the other hip and 30% are readmitted to acute care. Half of these patients are left with permanent functional impairment, a quarter require long-term care, and 10%-25% die, she said.

Dr. Bischoff-Ferrari reported having no conflicts of interest.

DENVER — Extended physiotherapy significantly reduced the rate of falls among patients with a prior hip fracture, and high-dose vitamin D significantly reduced the rate of hospital readmissions in a study of 173 patients.

A program of extended physiotherapy reduced the fall rate by 25%, compared with standard postfracture physiotherapy; high-dose vitamin D therapy reduced the hospital readmission rate by 39%, compared with a lower dose, the researchers found.

“The extended physiotherapy program, together with 2,000 IU vitamin D, has complementary benefits on post–hip fracture care,” Dr. Heike Bischoff-Ferrari said at the annual meeting of the American Society for Bone and Mineral Research.

The researchers enrolled 173 patients after their first acute hip fracture. Of these, most (79%) were women. Their mean age was 84 years, and 77% were living in the community. Half (51%) of the patients had severe vitamin D deficiency with serum 25-hydroxyvitamin D levels below 30 nmol/L; almost all (98%) had serum 25-hydroxyvitamin D levels below 75 nmol/L.

Patients were randomized to receive extended physiotherapy or standard physiotherapy. Extended physiotherapy consisted of supervised therapy for 1 hour per day during acute care, plus an unsupervised home program of exercises to perform regularly for 1 year. The standard therapy consisted of supervised therapy for 30 minutes per day during acute care. Physiotherapy included activities such as getting up from a chair, one-leg stands, climbing up and down stairs, and a rubber band exercise program for upper arm strength.

Patients were also randomized to receive vitamin D supplementation at 2,000 IU or 800 IU vitamin D3 per day. All patients received calcium.

Clinical assessment, which included laboratory tests and functional evaluations, took place at baseline and at 6 and 12 months' follow-up. Falls and readmissions were assessed by monthly calls to patients, patient calls to a hotline, and patient diaries.

The primary end point was the rate of falls over 12 months. The secondary end point was the rate of hospital readmission over 12 months.

In all, 86 participants were included in the high-dose vitamin D group and 87 were included in the lower-dose vitamin D group; 87 participants were included in the extensive physiotherapy group, and 86 were included in the regular physiotherapy group. The groups did not differ by age, gender, BMI, cognitive function, baseline 25-hydroxyvitamin D levels, and Charleston Comorbidity Index scores.

The researchers documented 212 falls in 92 participants. Of these, 41% fell once, 26% fell twice, 19% fell three times, and 14% fell more than three times. The rate of falls per patient-year was 1.43. There were 22 new nonvertebral fractures, nine of which were in the contralateral hip.

There were 74 readmissions among 54 participants. Of these, 72% had one readmission, 20% had two, and 8% had three. The rate of readmission was 50%.

Extended physiotherapy reduced the rate of falls by 25%, compared with regular physiotherapy, a significant reduction. Similar improvements were seen in function. However, extended physiotherapy did not reduce the rate of hospital readmissions.

There was no difference in the fall rate for the two vitamin D groups, but high-dose vitamin D did reduce the rate of hospital readmission by 39%, which was significant. There was also a significant 60% reduction in fall-related injuries. “This was mainly driven by a nonsignificant reduction in repeat nonvertebral fractures by 52%,” said Dr. Bischoff-Ferrari of the Centre on Aging and Mobility at the University Hospital Zurich.

The rate of readmissions due to infections decreased a significant 90%. Fall-related injuries went down 47% (which was nonsignificant) among those in the extended physiotherapy group, a decrease primarily driven by a nonsignificant 56% reduction in repeat nonvertebral fractures, said Dr. Bischoff-Ferrari, who is also a visiting scientist in the Bone Metabolism Laboratory at Tufts University, Boston.

In the first year after a hip fracture, an estimated 5%-10% of patients fracture the other hip and 30% are readmitted to acute care. Half of these patients are left with permanent functional impairment, a quarter require long-term care, and 10%-25% die, she said.

Dr. Bischoff-Ferrari reported having no conflicts of interest.

DENVER — The FRAX 10-year fracture risk tool was fairly accurate in predicting the observed number of hip fractures that occurred among more than 5,000 participants of the Framingham Heart Study, according to data presented as a poster at the annual meeting of the American Society for Bone and Mineral Research.

The 10-year observed incidence of hip fracture for women was 117 cases, which did not differ significantly from the FRAX predicted number of 113. For men, the observed incidence was 29 cases, not significantly different from the FRAX prediction of 38, reported Elizabeth J. Samelson, Ph.D., of the Institute for Aging Research in Boston, and her coinvestigators.

FRAX, developed by the World Health Organization, is an online tool to calculate the 10-year probability of hip fracture and major osteoporotic fracture in women and men aged 40–90 years, on the basis of bone mineral density (BMD), gender, age, smoking status, glucocorticoid use, height and weight, diagnosis of rheumatoid arthritis or secondary osteoporosis, history of fracture, and parental history of fracture.

This study included 5,204 Framingham cohort members (2,917 women and 2,287 men) who had a baseline examination between 1987 and 2001 and were followed for hip fracture over 10 years. All were white.

At baseline, patients were assessed for age, body mass index, current smoking status, alcohol consumption, glucocorticoid use, diagnosis of rheumatoid arthritis, prior fragility fracture, parental history of fracture, and T score. Original cohort members (1,456) for whom no parental hip fracture history was available were classified as having no such history. Femoral neck BMD was available for 4,224 participants.

The researchers used FRAX version 3.0 to calculate the 10-year probability of hip fracture and compared the expected number with that observed in the cohort.

Among women aged 40–75 years, the incidence was 52 cases, compared with 57 expected by FRAX; among men aged 40–75 years, the incidence was 12 cases, compared with 23 expected by FRAX.

The observed probability of hip fracture in the oldest adults (aged 76–90 years) exceeded the number predicted by FRAX, while the opposite was true for those aged 40–75. Among women aged 76–90 years, the incidence was 65 cases, compared with 55 expected by FRAX; among men aged 76–90 years, the incidence was 17 cases, compared with 14 expected by FRAX.

The study was supported by the National Institutes of Health. The researchers said they had no relevant financial relationships.

A video about the use of the FRAX tool is at www.youtube.com/clinicalendonews

DENVER — The FRAX 10-year fracture risk tool was fairly accurate in predicting the observed number of hip fractures that occurred among more than 5,000 participants of the Framingham Heart Study, according to data presented as a poster at the annual meeting of the American Society for Bone and Mineral Research.

The 10-year observed incidence of hip fracture for women was 117 cases, which did not differ significantly from the FRAX predicted number of 113. For men, the observed incidence was 29 cases, not significantly different from the FRAX prediction of 38, reported Elizabeth J. Samelson, Ph.D., of the Institute for Aging Research in Boston, and her coinvestigators.

FRAX, developed by the World Health Organization, is an online tool to calculate the 10-year probability of hip fracture and major osteoporotic fracture in women and men aged 40–90 years, on the basis of bone mineral density (BMD), gender, age, smoking status, glucocorticoid use, height and weight, diagnosis of rheumatoid arthritis or secondary osteoporosis, history of fracture, and parental history of fracture.

This study included 5,204 Framingham cohort members (2,917 women and 2,287 men) who had a baseline examination between 1987 and 2001 and were followed for hip fracture over 10 years. All were white.

At baseline, patients were assessed for age, body mass index, current smoking status, alcohol consumption, glucocorticoid use, diagnosis of rheumatoid arthritis, prior fragility fracture, parental history of fracture, and T score. Original cohort members (1,456) for whom no parental hip fracture history was available were classified as having no such history. Femoral neck BMD was available for 4,224 participants.

The researchers used FRAX version 3.0 to calculate the 10-year probability of hip fracture and compared the expected number with that observed in the cohort.

Among women aged 40–75 years, the incidence was 52 cases, compared with 57 expected by FRAX; among men aged 40–75 years, the incidence was 12 cases, compared with 23 expected by FRAX.

The observed probability of hip fracture in the oldest adults (aged 76–90 years) exceeded the number predicted by FRAX, while the opposite was true for those aged 40–75. Among women aged 76–90 years, the incidence was 65 cases, compared with 55 expected by FRAX; among men aged 76–90 years, the incidence was 17 cases, compared with 14 expected by FRAX.

The study was supported by the National Institutes of Health. The researchers said they had no relevant financial relationships.

A video about the use of the FRAX tool is at www.youtube.com/clinicalendonews

DENVER — The FRAX 10-year fracture risk tool was fairly accurate in predicting the observed number of hip fractures that occurred among more than 5,000 participants of the Framingham Heart Study, according to data presented as a poster at the annual meeting of the American Society for Bone and Mineral Research.

The 10-year observed incidence of hip fracture for women was 117 cases, which did not differ significantly from the FRAX predicted number of 113. For men, the observed incidence was 29 cases, not significantly different from the FRAX prediction of 38, reported Elizabeth J. Samelson, Ph.D., of the Institute for Aging Research in Boston, and her coinvestigators.

FRAX, developed by the World Health Organization, is an online tool to calculate the 10-year probability of hip fracture and major osteoporotic fracture in women and men aged 40–90 years, on the basis of bone mineral density (BMD), gender, age, smoking status, glucocorticoid use, height and weight, diagnosis of rheumatoid arthritis or secondary osteoporosis, history of fracture, and parental history of fracture.

This study included 5,204 Framingham cohort members (2,917 women and 2,287 men) who had a baseline examination between 1987 and 2001 and were followed for hip fracture over 10 years. All were white.

At baseline, patients were assessed for age, body mass index, current smoking status, alcohol consumption, glucocorticoid use, diagnosis of rheumatoid arthritis, prior fragility fracture, parental history of fracture, and T score. Original cohort members (1,456) for whom no parental hip fracture history was available were classified as having no such history. Femoral neck BMD was available for 4,224 participants.

The researchers used FRAX version 3.0 to calculate the 10-year probability of hip fracture and compared the expected number with that observed in the cohort.

Among women aged 40–75 years, the incidence was 52 cases, compared with 57 expected by FRAX; among men aged 40–75 years, the incidence was 12 cases, compared with 23 expected by FRAX.

The observed probability of hip fracture in the oldest adults (aged 76–90 years) exceeded the number predicted by FRAX, while the opposite was true for those aged 40–75. Among women aged 76–90 years, the incidence was 65 cases, compared with 55 expected by FRAX; among men aged 76–90 years, the incidence was 17 cases, compared with 14 expected by FRAX.

The study was supported by the National Institutes of Health. The researchers said they had no relevant financial relationships.

A video about the use of the FRAX tool is at www.youtube.com/clinicalendonews

DENVER — Patients with rheumatic diseases who were on long-term glucocorticoid therapy were almost twice as likely to have low bone mass as were those with who were not on glucocorticoids, results of a study of more than 200,000 patients have shown.

The findings were presented as a poster at the annual meeting of the American Society for Bone and Mineral Research by Dr. Viviana A. Reidel and her coinvestigators.

The researchers used UnitedHealth Group Inc.'s proprietary normative health information database of medical claims—both private and Medicare/Medicaid. In 2007, the database included information on 23.6 million people.

Dr. Reidel and her colleagues identified those who had had at least two visits resulting in an ICD-9-CM code for a rheumatic disease and an ICD-9-CM code for either osteoporosis or osteopenia occurring after the first prescription of a glucocorticoid.

Long-term glucocorticoid use was defined as one or more monthly prescriptions for at least 6 months. High-dose glucocorticoids were defined as a prednisone dosage of at least 7.5 mg/day, or the equivalent; low-dose use was a prednisone dosage of less than 7.5 mg/day, or the equivalent. The nonglucocorticoid group included patients with rheumatic diseases who were prescribed any other therapy or no therapy.

In all, 201,121 patients with rheumatic diseases were identified. The most common disease was rheumatoid arthritis (57%), followed by systemic lupus erythematosus, spondyloarthropathies, polymyalgia rheumatica, vasculitis, and enteropathic arthritis. Among those with long-term glucocorticoid use, 44% of women and 11% of men had low bone mineral density. Among those non–long-term users, 31% of women and 4% of men had low BMD.

Patients with rheumatic diseases who were on long-term glucocorticoids had a relative risk of 1.7 of having low bone mass, compared with those who were not on glucocorticoids. “However, our analysis suggests that the effect of long-term higher-dose glucocorticoid treatment on increasing risk of glucocorticoid-induced low bone mass compared to long-term lower-dose glucocorticoid treatment is weak,” wrote Dr. Reidel, medical director at i3 Research, a clinical research company. There was a slight but significantly increased risk of low bone mass in patients who were treated long term with high-dose glucocorticoids, compared with those treated long term with low doses.

The researchers also found that only 0.2% of patients with long-term glucocorticoid use had at least one dual-energy x-ray absorptiometry scan, compared with 8% of those with no known glucocorticoid exposure.

There are plans to look at any associations between long-term glucocorticoid use and BMD by rheumatic disease, Dr. Reidel said in an interview.

A whole-body dual-energy x-ray absorptiometry scan can provide information on total and regional BMD (left) and body composition (fat, muscle mass).

Source ©Elsevier

DENVER — Patients with rheumatic diseases who were on long-term glucocorticoid therapy were almost twice as likely to have low bone mass as were those with who were not on glucocorticoids, results of a study of more than 200,000 patients have shown.

The findings were presented as a poster at the annual meeting of the American Society for Bone and Mineral Research by Dr. Viviana A. Reidel and her coinvestigators.

The researchers used UnitedHealth Group Inc.'s proprietary normative health information database of medical claims—both private and Medicare/Medicaid. In 2007, the database included information on 23.6 million people.

Dr. Reidel and her colleagues identified those who had had at least two visits resulting in an ICD-9-CM code for a rheumatic disease and an ICD-9-CM code for either osteoporosis or osteopenia occurring after the first prescription of a glucocorticoid.

Long-term glucocorticoid use was defined as one or more monthly prescriptions for at least 6 months. High-dose glucocorticoids were defined as a prednisone dosage of at least 7.5 mg/day, or the equivalent; low-dose use was a prednisone dosage of less than 7.5 mg/day, or the equivalent. The nonglucocorticoid group included patients with rheumatic diseases who were prescribed any other therapy or no therapy.

In all, 201,121 patients with rheumatic diseases were identified. The most common disease was rheumatoid arthritis (57%), followed by systemic lupus erythematosus, spondyloarthropathies, polymyalgia rheumatica, vasculitis, and enteropathic arthritis. Among those with long-term glucocorticoid use, 44% of women and 11% of men had low bone mineral density. Among those non–long-term users, 31% of women and 4% of men had low BMD.

Patients with rheumatic diseases who were on long-term glucocorticoids had a relative risk of 1.7 of having low bone mass, compared with those who were not on glucocorticoids. “However, our analysis suggests that the effect of long-term higher-dose glucocorticoid treatment on increasing risk of glucocorticoid-induced low bone mass compared to long-term lower-dose glucocorticoid treatment is weak,” wrote Dr. Reidel, medical director at i3 Research, a clinical research company. There was a slight but significantly increased risk of low bone mass in patients who were treated long term with high-dose glucocorticoids, compared with those treated long term with low doses.

The researchers also found that only 0.2% of patients with long-term glucocorticoid use had at least one dual-energy x-ray absorptiometry scan, compared with 8% of those with no known glucocorticoid exposure.

There are plans to look at any associations between long-term glucocorticoid use and BMD by rheumatic disease, Dr. Reidel said in an interview.

A whole-body dual-energy x-ray absorptiometry scan can provide information on total and regional BMD (left) and body composition (fat, muscle mass).

Source ©Elsevier

DENVER — Patients with rheumatic diseases who were on long-term glucocorticoid therapy were almost twice as likely to have low bone mass as were those with who were not on glucocorticoids, results of a study of more than 200,000 patients have shown.

The findings were presented as a poster at the annual meeting of the American Society for Bone and Mineral Research by Dr. Viviana A. Reidel and her coinvestigators.

The researchers used UnitedHealth Group Inc.'s proprietary normative health information database of medical claims—both private and Medicare/Medicaid. In 2007, the database included information on 23.6 million people.

Dr. Reidel and her colleagues identified those who had had at least two visits resulting in an ICD-9-CM code for a rheumatic disease and an ICD-9-CM code for either osteoporosis or osteopenia occurring after the first prescription of a glucocorticoid.

Long-term glucocorticoid use was defined as one or more monthly prescriptions for at least 6 months. High-dose glucocorticoids were defined as a prednisone dosage of at least 7.5 mg/day, or the equivalent; low-dose use was a prednisone dosage of less than 7.5 mg/day, or the equivalent. The nonglucocorticoid group included patients with rheumatic diseases who were prescribed any other therapy or no therapy.

In all, 201,121 patients with rheumatic diseases were identified. The most common disease was rheumatoid arthritis (57%), followed by systemic lupus erythematosus, spondyloarthropathies, polymyalgia rheumatica, vasculitis, and enteropathic arthritis. Among those with long-term glucocorticoid use, 44% of women and 11% of men had low bone mineral density. Among those non–long-term users, 31% of women and 4% of men had low BMD.

Patients with rheumatic diseases who were on long-term glucocorticoids had a relative risk of 1.7 of having low bone mass, compared with those who were not on glucocorticoids. “However, our analysis suggests that the effect of long-term higher-dose glucocorticoid treatment on increasing risk of glucocorticoid-induced low bone mass compared to long-term lower-dose glucocorticoid treatment is weak,” wrote Dr. Reidel, medical director at i3 Research, a clinical research company. There was a slight but significantly increased risk of low bone mass in patients who were treated long term with high-dose glucocorticoids, compared with those treated long term with low doses.

The researchers also found that only 0.2% of patients with long-term glucocorticoid use had at least one dual-energy x-ray absorptiometry scan, compared with 8% of those with no known glucocorticoid exposure.

There are plans to look at any associations between long-term glucocorticoid use and BMD by rheumatic disease, Dr. Reidel said in an interview.

A whole-body dual-energy x-ray absorptiometry scan can provide information on total and regional BMD (left) and body composition (fat, muscle mass).

Source ©Elsevier

Medical imaging exposes a significant portion of patients to various doses of ionizing radiation, and in some cases, to substantial doses, potentially increasing the associated risk of cancer, according to findings of a retrospective cohort study.

The results are based on an analysis of 952,420 nonelderly adults who were enrolled in United Healthcare's database between Jan. 1, 2005 and Dec. 31, 2007, and living in Arizona, Dallas, Orlando, South Florida, and Wisconsin.

Roughly 70% of the study population underwent at least one imaging exam during the 3-year study period, “resulting in mean effective doses that almost doubled what would be expected from natural sources alone,” wrote Dr. Reza Fazel of Emory University, Atlanta, and her coinvestigators.

While most patients received less than 3 millisievert (mSv) per year—which was considered low exposure—there was a sizable minority of patients who received moderate, high, or very high radiation doses, they wrote.

CPT codes for imaging procedures involving radiation were used to identify claims from hospitals, outpatient facilities, and physicians' offices. They excluded procedures in which radiation was specifically delivered for therapeutic purposes, such as high-dose radiation for cancer. Procedures were categorized by technique: plain radiography, CT, fluoroscopy (including angiography), and nuclear imaging. They also categorized the procedures by area of focus: chest (including cardiac imaging), abdomen, pelvis, arm or leg, head and neck (including brain), multiple areas (including whole-body scanning), and unspecified.

To account for the possibility of procedure overlap—for example, coronary stent placement and catheterization of the left heart performed at the same time—subjects were limited to one procedure per day that involved the same type of technique and the same anatomical area, selecting the highest dose.

Estimates of typical effective doses from published literature were used to approximate radiation exposure for each imaging procedure. The effective dose is an inexact measure of the overall detrimental biologic effect from radiation exposure.

Patients were stratified by gender and age: 18–34, 35–39, 40–44, 45–49, 50–54, 55–59, and 60–64; 52% were women. The researchers calculated effective doses for the population overall and for each age-based and sex-based group and categorized them by dose: low (no more than 3 mSv/yr, the background level of radiation from natural sources in the United States); moderate (3–20 mSv/yr, the upper annual limit for occupational exposure for at-risk workers, averaged over 5 years); high (20–50 mSv/yr, the upper annual limit for occupational exposure for at-risk workers in any given year); and very high (greater than 50 mSv/yr).

A total of 3,442,111 imaging procedures associated with 655,613 patients were identified in the 3-year period. The average number of procedures per person per year was 1.2 and median number was 0.7/person per year. The mean effective dose was 2.4 mSv/person per year with a median effective dose of 0.1 mSv/year.

The proportion of patients undergoing at least one procedure during the study period increased with age—from 50% in those aged 18–34 years to 86% in those aged 60–64 years. A total of 79% of women underwent at least one procedure during the study period, compared with 60% for men (N. Engl. J. Med. 2009;361:849–57).

Moderate doses occurred at an annual rate of 199 per 1,000 patients. High and very high doses occurred at annual rates of 19 and 2 per 1,000 patients, respectively. “Each of these rates rose with advancing age,” noted Dr. Fazel.

“Generalization of our findings to the United States suggests that these procedures lead to cumulative effective doses that exceed 20 mSv per year in approximately 4 million Americans,” the researchers wrote.

Myocardial perfusion imaging accounted for almost a quarter of the total effective dose (22%). CT of the abdomen, pelvis, and chest accounted for 38% of the total effective dose.

“CT and nuclear imaging accounted for 21% of the total number of procedures and 71.4% of the total effective dose,” the researchers reported. By anatomical site, chest procedures accounted for 45% of the total effective dose. Lastly, the bulk of the total effective dose—82%—was delivered in outpatient settings, primarily physicians' offices.

The findings are concerning, particularly for patients who undergo several imaging tests in a short time, Dr. Michael S. Lauer wrote in an accompanying editorial (N. Engl. J. Med. 2009;361;841–3).

“Though the danger may be small, it is cumulative and hence of particular relevance to the small but substantial minority of patients, who … undergo clusters of tests.”

Despite the cumulative risk associated with radiation exposure, it's generally not something that is discussed with patients undergoing an imaging procedure, noted Dr. Lauer, who is director of the prevention and population sciences division of the National Heart, Lung and Blood Institute in Bethesda, Md. “The issue of radiation exposure is unlikely to come up because each procedure is considered in isolation [and] the risks posed by each procedure are low and seemingly unmeasurable….

“We have to think and talk explicitly about the elements of danger in exposing our patients to radiation,” wrote Dr. Lauer. Physicians will need to take a careful history to assess the cumulative dose of radiation that a specific patient has already received. This specific risk should be conveyed to the patient.

The study authors acknowledged the long-term risk, but noted that restricting patient dose—as is done for nuclear workers—is not feasible. “The exposure of patients cannot be restricted, largely because of the inherent difficulty in balancing the immediate clinical need for these procedures, which is frequently substantial, against stochastic risks of cancer that would not be evident for years, if at all.”

Dr. Fazel reported that she has no relevant conflicts of interest, though several of her coauthors reported significant relationships with pharmaceutical and medical imaging companies. Dr. Lauer reported that he has no relevant conflicts of interest.

Almost 80% of women had at least one imaging procedure in a 3-year period.

Source COURTESY NIH

NIH to Track Imaging Device Radiation

The National Institutes of Health will require new CT and PET equipment purchased by the agency's clinical center to routinely record the patient's radiation dose in their hospital-based electronic medical record.

“The [NIH] Clinical Center's approach is an important first step in making it possible to more easily document and track information about a patient's exposure to radiation,” Dr. John I. Gallin, director of the center, said in a statement.

The risks associated with exposure to low doses of radiation from medical imaging tests are unknown. However, the effects of radiation exposure are cumulative over a lifetime. The ability to track a person's radiation exposure will help researchers evaluate the health risks of these procedures.

The center plans to work with its vendors to develop software tools to extract the type of examination, the date, and the radiation dose for uploading to an electronic health record.

Both the American College of Radiology and the Radiological Society of North America recommend that patients keep a record of their x-ray history, according to the NIH statement.

Medical imaging exposes a significant portion of patients to various doses of ionizing radiation, and in some cases, to substantial doses, potentially increasing the associated risk of cancer, according to findings of a retrospective cohort study.

The results are based on an analysis of 952,420 nonelderly adults who were enrolled in United Healthcare's database between Jan. 1, 2005 and Dec. 31, 2007, and living in Arizona, Dallas, Orlando, South Florida, and Wisconsin.

Roughly 70% of the study population underwent at least one imaging exam during the 3-year study period, “resulting in mean effective doses that almost doubled what would be expected from natural sources alone,” wrote Dr. Reza Fazel of Emory University, Atlanta, and her coinvestigators.

While most patients received less than 3 millisievert (mSv) per year—which was considered low exposure—there was a sizable minority of patients who received moderate, high, or very high radiation doses, they wrote.

CPT codes for imaging procedures involving radiation were used to identify claims from hospitals, outpatient facilities, and physicians' offices. They excluded procedures in which radiation was specifically delivered for therapeutic purposes, such as high-dose radiation for cancer. Procedures were categorized by technique: plain radiography, CT, fluoroscopy (including angiography), and nuclear imaging. They also categorized the procedures by area of focus: chest (including cardiac imaging), abdomen, pelvis, arm or leg, head and neck (including brain), multiple areas (including whole-body scanning), and unspecified.

To account for the possibility of procedure overlap—for example, coronary stent placement and catheterization of the left heart performed at the same time—subjects were limited to one procedure per day that involved the same type of technique and the same anatomical area, selecting the highest dose.

Estimates of typical effective doses from published literature were used to approximate radiation exposure for each imaging procedure. The effective dose is an inexact measure of the overall detrimental biologic effect from radiation exposure.

Patients were stratified by gender and age: 18–34, 35–39, 40–44, 45–49, 50–54, 55–59, and 60–64; 52% were women. The researchers calculated effective doses for the population overall and for each age-based and sex-based group and categorized them by dose: low (no more than 3 mSv/yr, the background level of radiation from natural sources in the United States); moderate (3–20 mSv/yr, the upper annual limit for occupational exposure for at-risk workers, averaged over 5 years); high (20–50 mSv/yr, the upper annual limit for occupational exposure for at-risk workers in any given year); and very high (greater than 50 mSv/yr).

A total of 3,442,111 imaging procedures associated with 655,613 patients were identified in the 3-year period. The average number of procedures per person per year was 1.2 and median number was 0.7/person per year. The mean effective dose was 2.4 mSv/person per year with a median effective dose of 0.1 mSv/year.

The proportion of patients undergoing at least one procedure during the study period increased with age—from 50% in those aged 18–34 years to 86% in those aged 60–64 years. A total of 79% of women underwent at least one procedure during the study period, compared with 60% for men (N. Engl. J. Med. 2009;361:849–57).

Moderate doses occurred at an annual rate of 199 per 1,000 patients. High and very high doses occurred at annual rates of 19 and 2 per 1,000 patients, respectively. “Each of these rates rose with advancing age,” noted Dr. Fazel.

“Generalization of our findings to the United States suggests that these procedures lead to cumulative effective doses that exceed 20 mSv per year in approximately 4 million Americans,” the researchers wrote.

Myocardial perfusion imaging accounted for almost a quarter of the total effective dose (22%). CT of the abdomen, pelvis, and chest accounted for 38% of the total effective dose.

“CT and nuclear imaging accounted for 21% of the total number of procedures and 71.4% of the total effective dose,” the researchers reported. By anatomical site, chest procedures accounted for 45% of the total effective dose. Lastly, the bulk of the total effective dose—82%—was delivered in outpatient settings, primarily physicians' offices.

The findings are concerning, particularly for patients who undergo several imaging tests in a short time, Dr. Michael S. Lauer wrote in an accompanying editorial (N. Engl. J. Med. 2009;361;841–3).

“Though the danger may be small, it is cumulative and hence of particular relevance to the small but substantial minority of patients, who … undergo clusters of tests.”

Despite the cumulative risk associated with radiation exposure, it's generally not something that is discussed with patients undergoing an imaging procedure, noted Dr. Lauer, who is director of the prevention and population sciences division of the National Heart, Lung and Blood Institute in Bethesda, Md. “The issue of radiation exposure is unlikely to come up because each procedure is considered in isolation [and] the risks posed by each procedure are low and seemingly unmeasurable….

“We have to think and talk explicitly about the elements of danger in exposing our patients to radiation,” wrote Dr. Lauer. Physicians will need to take a careful history to assess the cumulative dose of radiation that a specific patient has already received. This specific risk should be conveyed to the patient.

The study authors acknowledged the long-term risk, but noted that restricting patient dose—as is done for nuclear workers—is not feasible. “The exposure of patients cannot be restricted, largely because of the inherent difficulty in balancing the immediate clinical need for these procedures, which is frequently substantial, against stochastic risks of cancer that would not be evident for years, if at all.”

Dr. Fazel reported that she has no relevant conflicts of interest, though several of her coauthors reported significant relationships with pharmaceutical and medical imaging companies. Dr. Lauer reported that he has no relevant conflicts of interest.

Almost 80% of women had at least one imaging procedure in a 3-year period.

Source COURTESY NIH

NIH to Track Imaging Device Radiation

The National Institutes of Health will require new CT and PET equipment purchased by the agency's clinical center to routinely record the patient's radiation dose in their hospital-based electronic medical record.

“The [NIH] Clinical Center's approach is an important first step in making it possible to more easily document and track information about a patient's exposure to radiation,” Dr. John I. Gallin, director of the center, said in a statement.

The risks associated with exposure to low doses of radiation from medical imaging tests are unknown. However, the effects of radiation exposure are cumulative over a lifetime. The ability to track a person's radiation exposure will help researchers evaluate the health risks of these procedures.

The center plans to work with its vendors to develop software tools to extract the type of examination, the date, and the radiation dose for uploading to an electronic health record.

Both the American College of Radiology and the Radiological Society of North America recommend that patients keep a record of their x-ray history, according to the NIH statement.

Medical imaging exposes a significant portion of patients to various doses of ionizing radiation, and in some cases, to substantial doses, potentially increasing the associated risk of cancer, according to findings of a retrospective cohort study.

The results are based on an analysis of 952,420 nonelderly adults who were enrolled in United Healthcare's database between Jan. 1, 2005 and Dec. 31, 2007, and living in Arizona, Dallas, Orlando, South Florida, and Wisconsin.

Roughly 70% of the study population underwent at least one imaging exam during the 3-year study period, “resulting in mean effective doses that almost doubled what would be expected from natural sources alone,” wrote Dr. Reza Fazel of Emory University, Atlanta, and her coinvestigators.

While most patients received less than 3 millisievert (mSv) per year—which was considered low exposure—there was a sizable minority of patients who received moderate, high, or very high radiation doses, they wrote.

CPT codes for imaging procedures involving radiation were used to identify claims from hospitals, outpatient facilities, and physicians' offices. They excluded procedures in which radiation was specifically delivered for therapeutic purposes, such as high-dose radiation for cancer. Procedures were categorized by technique: plain radiography, CT, fluoroscopy (including angiography), and nuclear imaging. They also categorized the procedures by area of focus: chest (including cardiac imaging), abdomen, pelvis, arm or leg, head and neck (including brain), multiple areas (including whole-body scanning), and unspecified.

To account for the possibility of procedure overlap—for example, coronary stent placement and catheterization of the left heart performed at the same time—subjects were limited to one procedure per day that involved the same type of technique and the same anatomical area, selecting the highest dose.

Estimates of typical effective doses from published literature were used to approximate radiation exposure for each imaging procedure. The effective dose is an inexact measure of the overall detrimental biologic effect from radiation exposure.

Patients were stratified by gender and age: 18–34, 35–39, 40–44, 45–49, 50–54, 55–59, and 60–64; 52% were women. The researchers calculated effective doses for the population overall and for each age-based and sex-based group and categorized them by dose: low (no more than 3 mSv/yr, the background level of radiation from natural sources in the United States); moderate (3–20 mSv/yr, the upper annual limit for occupational exposure for at-risk workers, averaged over 5 years); high (20–50 mSv/yr, the upper annual limit for occupational exposure for at-risk workers in any given year); and very high (greater than 50 mSv/yr).

A total of 3,442,111 imaging procedures associated with 655,613 patients were identified in the 3-year period. The average number of procedures per person per year was 1.2 and median number was 0.7/person per year. The mean effective dose was 2.4 mSv/person per year with a median effective dose of 0.1 mSv/year.

The proportion of patients undergoing at least one procedure during the study period increased with age—from 50% in those aged 18–34 years to 86% in those aged 60–64 years. A total of 79% of women underwent at least one procedure during the study period, compared with 60% for men (N. Engl. J. Med. 2009;361:849–57).

Moderate doses occurred at an annual rate of 199 per 1,000 patients. High and very high doses occurred at annual rates of 19 and 2 per 1,000 patients, respectively. “Each of these rates rose with advancing age,” noted Dr. Fazel.

“Generalization of our findings to the United States suggests that these procedures lead to cumulative effective doses that exceed 20 mSv per year in approximately 4 million Americans,” the researchers wrote.

Myocardial perfusion imaging accounted for almost a quarter of the total effective dose (22%). CT of the abdomen, pelvis, and chest accounted for 38% of the total effective dose.

“CT and nuclear imaging accounted for 21% of the total number of procedures and 71.4% of the total effective dose,” the researchers reported. By anatomical site, chest procedures accounted for 45% of the total effective dose. Lastly, the bulk of the total effective dose—82%—was delivered in outpatient settings, primarily physicians' offices.

The findings are concerning, particularly for patients who undergo several imaging tests in a short time, Dr. Michael S. Lauer wrote in an accompanying editorial (N. Engl. J. Med. 2009;361;841–3).

“Though the danger may be small, it is cumulative and hence of particular relevance to the small but substantial minority of patients, who … undergo clusters of tests.”

Despite the cumulative risk associated with radiation exposure, it's generally not something that is discussed with patients undergoing an imaging procedure, noted Dr. Lauer, who is director of the prevention and population sciences division of the National Heart, Lung and Blood Institute in Bethesda, Md. “The issue of radiation exposure is unlikely to come up because each procedure is considered in isolation [and] the risks posed by each procedure are low and seemingly unmeasurable….

“We have to think and talk explicitly about the elements of danger in exposing our patients to radiation,” wrote Dr. Lauer. Physicians will need to take a careful history to assess the cumulative dose of radiation that a specific patient has already received. This specific risk should be conveyed to the patient.

The study authors acknowledged the long-term risk, but noted that restricting patient dose—as is done for nuclear workers—is not feasible. “The exposure of patients cannot be restricted, largely because of the inherent difficulty in balancing the immediate clinical need for these procedures, which is frequently substantial, against stochastic risks of cancer that would not be evident for years, if at all.”

Dr. Fazel reported that she has no relevant conflicts of interest, though several of her coauthors reported significant relationships with pharmaceutical and medical imaging companies. Dr. Lauer reported that he has no relevant conflicts of interest.

Almost 80% of women had at least one imaging procedure in a 3-year period.

Source COURTESY NIH

NIH to Track Imaging Device Radiation

The National Institutes of Health will require new CT and PET equipment purchased by the agency's clinical center to routinely record the patient's radiation dose in their hospital-based electronic medical record.

“The [NIH] Clinical Center's approach is an important first step in making it possible to more easily document and track information about a patient's exposure to radiation,” Dr. John I. Gallin, director of the center, said in a statement.

The risks associated with exposure to low doses of radiation from medical imaging tests are unknown. However, the effects of radiation exposure are cumulative over a lifetime. The ability to track a person's radiation exposure will help researchers evaluate the health risks of these procedures.

The center plans to work with its vendors to develop software tools to extract the type of examination, the date, and the radiation dose for uploading to an electronic health record.

Both the American College of Radiology and the Radiological Society of North America recommend that patients keep a record of their x-ray history, according to the NIH statement.

Most patients in Australia and New Zealand who developed acute respiratory distress syndrome due to 2009 influenza A(H1N1) and were treated with extracorporeal membrane oxygenation survived, with a mortality rate of 21%. The results were drawn from data compiled during the winter season in these countries.

“Despite the disease severity and the intensity of treatment, the mortality rate was low,” Dr. Andrew R. Davies of Monash University, Melbourne, and his colleagues reported.

“Our findings have implications for health care planning and the clinical management of patients with 2009 influenza A(H1N1) during the 2009-2010 northern hemisphere winter. Our results indicate that the incidence of ARDS [acute respiratory distress syndrome] sufficient to warrant consideration of ECMO … exceeds 2.6 per million inhabitants.”

With a similar incidence of ECMO use, the United States and the European Union could provide ECMO to approximately 800 and 1,300 patients, respectively, during their 2009-2010 winter season, the researchers wrote (JAMA 2009;302:doi:10.1001/JAMA.2009.1535).

The study by the Australia and New Zealand Extracorporeal Membrane Oxygenation Influenza Investigators included all adult and pediatric patients who were treated with extracorporeal membrane oxygenation (ECMO) between June 1 and Aug. 31, 2009, in 15 ICUs in the two countries. Neonates and patients treated with ECMO for primary cardiac failure following heart and/or lung transplantation were excluded. All outcomes were censored at midnight Sept. 7, 2009.

A total of 252 patients were admitted with influenza to the participating ICUs. Of these, 201 received mechanical ventilation. A total of 68 received ECMO; 61 had confirmed H1N1 infection. The 68 ECMO patients had a mean age of 34 years; half were male. The most common comorbidities were obesity (body mass index greater than 30 kg/m

Among the 14 patients who died, intracranial hemorrhage (6 patients), other hemorrhage (4), and intractable respiratory failure (4) were the most common causes of death. Notably, 7 of the 10 pregnant/postpartum patients survived. All three of the children treated with ECMO were alive, though one was still in the ICU.

During ECMO, hemorrhagic complications occurred in 54% of patients and infective complications in 62%.

The researchers estimated the incidence of ECMO use for the combination of confirmed and suspected 2009 influenza A(H1N1) during the winter season to be 2.6 cases per million people. When only confirmed cases were considered, the incidence fell slightly to 2.0 cases per million. By comparison, 0.15 cases per million were treated with ECMO for ARDS in the preceding winter season.

The investigators also obtained data on 133 patients with confirmed H1N1 infection in the same ICUs who were treated with mechanical ventilation but not ECMO. Patients treated with ECMO had longer median durations of mechanical ventilation (18 days vs. 8 days), longer median ICU stays (22 vs. 12), and greater ICU mortality (14 vs. 12), compared with those who did not receive ECMO.

Dr. Davies treats patients in the ICU of Alfred Hospital in Melbourne. The authors reported that they have no relevant financial relationships.

Most patients in Australia and New Zealand who developed acute respiratory distress syndrome due to 2009 influenza A(H1N1) and were treated with extracorporeal membrane oxygenation survived, with a mortality rate of 21%. The results were drawn from data compiled during the winter season in these countries.

“Despite the disease severity and the intensity of treatment, the mortality rate was low,” Dr. Andrew R. Davies of Monash University, Melbourne, and his colleagues reported.

“Our findings have implications for health care planning and the clinical management of patients with 2009 influenza A(H1N1) during the 2009-2010 northern hemisphere winter. Our results indicate that the incidence of ARDS [acute respiratory distress syndrome] sufficient to warrant consideration of ECMO … exceeds 2.6 per million inhabitants.”

With a similar incidence of ECMO use, the United States and the European Union could provide ECMO to approximately 800 and 1,300 patients, respectively, during their 2009-2010 winter season, the researchers wrote (JAMA 2009;302:doi:10.1001/JAMA.2009.1535).

The study by the Australia and New Zealand Extracorporeal Membrane Oxygenation Influenza Investigators included all adult and pediatric patients who were treated with extracorporeal membrane oxygenation (ECMO) between June 1 and Aug. 31, 2009, in 15 ICUs in the two countries. Neonates and patients treated with ECMO for primary cardiac failure following heart and/or lung transplantation were excluded. All outcomes were censored at midnight Sept. 7, 2009.

A total of 252 patients were admitted with influenza to the participating ICUs. Of these, 201 received mechanical ventilation. A total of 68 received ECMO; 61 had confirmed H1N1 infection. The 68 ECMO patients had a mean age of 34 years; half were male. The most common comorbidities were obesity (body mass index greater than 30 kg/m

Among the 14 patients who died, intracranial hemorrhage (6 patients), other hemorrhage (4), and intractable respiratory failure (4) were the most common causes of death. Notably, 7 of the 10 pregnant/postpartum patients survived. All three of the children treated with ECMO were alive, though one was still in the ICU.

During ECMO, hemorrhagic complications occurred in 54% of patients and infective complications in 62%.

The researchers estimated the incidence of ECMO use for the combination of confirmed and suspected 2009 influenza A(H1N1) during the winter season to be 2.6 cases per million people. When only confirmed cases were considered, the incidence fell slightly to 2.0 cases per million. By comparison, 0.15 cases per million were treated with ECMO for ARDS in the preceding winter season.

The investigators also obtained data on 133 patients with confirmed H1N1 infection in the same ICUs who were treated with mechanical ventilation but not ECMO. Patients treated with ECMO had longer median durations of mechanical ventilation (18 days vs. 8 days), longer median ICU stays (22 vs. 12), and greater ICU mortality (14 vs. 12), compared with those who did not receive ECMO.

Dr. Davies treats patients in the ICU of Alfred Hospital in Melbourne. The authors reported that they have no relevant financial relationships.

Most patients in Australia and New Zealand who developed acute respiratory distress syndrome due to 2009 influenza A(H1N1) and were treated with extracorporeal membrane oxygenation survived, with a mortality rate of 21%. The results were drawn from data compiled during the winter season in these countries.

“Despite the disease severity and the intensity of treatment, the mortality rate was low,” Dr. Andrew R. Davies of Monash University, Melbourne, and his colleagues reported.

“Our findings have implications for health care planning and the clinical management of patients with 2009 influenza A(H1N1) during the 2009-2010 northern hemisphere winter. Our results indicate that the incidence of ARDS [acute respiratory distress syndrome] sufficient to warrant consideration of ECMO … exceeds 2.6 per million inhabitants.”

With a similar incidence of ECMO use, the United States and the European Union could provide ECMO to approximately 800 and 1,300 patients, respectively, during their 2009-2010 winter season, the researchers wrote (JAMA 2009;302:doi:10.1001/JAMA.2009.1535).

The study by the Australia and New Zealand Extracorporeal Membrane Oxygenation Influenza Investigators included all adult and pediatric patients who were treated with extracorporeal membrane oxygenation (ECMO) between June 1 and Aug. 31, 2009, in 15 ICUs in the two countries. Neonates and patients treated with ECMO for primary cardiac failure following heart and/or lung transplantation were excluded. All outcomes were censored at midnight Sept. 7, 2009.

A total of 252 patients were admitted with influenza to the participating ICUs. Of these, 201 received mechanical ventilation. A total of 68 received ECMO; 61 had confirmed H1N1 infection. The 68 ECMO patients had a mean age of 34 years; half were male. The most common comorbidities were obesity (body mass index greater than 30 kg/m

Among the 14 patients who died, intracranial hemorrhage (6 patients), other hemorrhage (4), and intractable respiratory failure (4) were the most common causes of death. Notably, 7 of the 10 pregnant/postpartum patients survived. All three of the children treated with ECMO were alive, though one was still in the ICU.

During ECMO, hemorrhagic complications occurred in 54% of patients and infective complications in 62%.

The researchers estimated the incidence of ECMO use for the combination of confirmed and suspected 2009 influenza A(H1N1) during the winter season to be 2.6 cases per million people. When only confirmed cases were considered, the incidence fell slightly to 2.0 cases per million. By comparison, 0.15 cases per million were treated with ECMO for ARDS in the preceding winter season.

The investigators also obtained data on 133 patients with confirmed H1N1 infection in the same ICUs who were treated with mechanical ventilation but not ECMO. Patients treated with ECMO had longer median durations of mechanical ventilation (18 days vs. 8 days), longer median ICU stays (22 vs. 12), and greater ICU mortality (14 vs. 12), compared with those who did not receive ECMO.

Dr. Davies treats patients in the ICU of Alfred Hospital in Melbourne. The authors reported that they have no relevant financial relationships.

DENVER — Menopausal status appears to modify the relationship between inflammation and bone mineral density, on the basis of findings from the Framingham Osteoporosis Study.

Postmenopausal women on estrogen replacement therapy (ERT) with higher levels of C-reactive protein—a measure of systemic inflammation—had greater bone mineral density (BMD) at the femoral neck than did those in the same group with lower CRP levels, Dr. Robert R. McLean and his coinvestigators reported in a poster presented at the annual meeting of the American Society for Bone and Mineral Research. In premenopausal women, increased CRP levels were associated with a decrease in BMD at the trochanter.

The Framingham Heart Study Offspring Cohort enrolled 5,124 children and spouses of the original Framingham cohort. From 1996 to 2001, BMD was measured in 3,035 offspring in the Framingham Osteoporosis Study, with fasting blood samples collected from 2,095 of them during 1998-2001. C-reactive protein levels were measured after BMD in 72% of participants, with a median time between assessments of 1.4 years.

BMD was measured at the right femoral neck and trochanter, and at the lumbar spine. Other variables obtained at the time of BMD measurement included age, height, weight, physical activity, smoking status, and use of NSAIDs. In women, menopause status, current ERT use, and years since menopause were also recorded. Separate analyses were performed for the 1,291 men, 229 premenopausal women, 497 postmenopausal women using ERT, and 888 postmenopausal women not using ERT. Analyses were adjusted for age, height, weight, physical activity, and smoking status.

Median CRP levels were higher for postmenopausal women (3.9 mg/L for those on ERT and 2.3 mg/L for those not on ERT) than for men (1.9 mg/L) or for premenopausal women (1.4 mg/L). In all, 74% of men, 62% of premenopausal women, 86% of postmenopausal women on ERT, and 77% of postmenopausal women not on ERT had CRP levels of at least 1 mg/L.

CRP level was not associated with BMD in men or in postmenopausal women using ERT. However, in those women, there was a significant association between years since menopause and BMD at all three sites. The researchers repeated the analysis for women fewer than 10 years past menopause and those at least 10 years past menopause. “The association of CRP with femoral neck BMD tended to be negative for those less than 10 years past menopause and positive for those at least 10 years past menopause, while there was no significant association at the trochanter or lumbar spine,” they wrote.

For postmenopausal women not using ERT, those with CRP levels of at least 1 mg/L had 2.5% greater BMD at the femoral neck, compared with the lower CRP level group, a significant difference. However, there were no significant associations at the trochanter or lumbar spine. “Contrary to our hypothesis, greater inflammation may be associated with higher BMD among postmenopausal women not using ERT,” wrote Dr. McLean of the Institute for Aging Research, a research affiliate of Harvard Medical School, Boston.

Dr. McLean reported that he has no relevant financial relationships.

DENVER — Menopausal status appears to modify the relationship between inflammation and bone mineral density, on the basis of findings from the Framingham Osteoporosis Study.

Postmenopausal women on estrogen replacement therapy (ERT) with higher levels of C-reactive protein—a measure of systemic inflammation—had greater bone mineral density (BMD) at the femoral neck than did those in the same group with lower CRP levels, Dr. Robert R. McLean and his coinvestigators reported in a poster presented at the annual meeting of the American Society for Bone and Mineral Research. In premenopausal women, increased CRP levels were associated with a decrease in BMD at the trochanter.

The Framingham Heart Study Offspring Cohort enrolled 5,124 children and spouses of the original Framingham cohort. From 1996 to 2001, BMD was measured in 3,035 offspring in the Framingham Osteoporosis Study, with fasting blood samples collected from 2,095 of them during 1998-2001. C-reactive protein levels were measured after BMD in 72% of participants, with a median time between assessments of 1.4 years.

BMD was measured at the right femoral neck and trochanter, and at the lumbar spine. Other variables obtained at the time of BMD measurement included age, height, weight, physical activity, smoking status, and use of NSAIDs. In women, menopause status, current ERT use, and years since menopause were also recorded. Separate analyses were performed for the 1,291 men, 229 premenopausal women, 497 postmenopausal women using ERT, and 888 postmenopausal women not using ERT. Analyses were adjusted for age, height, weight, physical activity, and smoking status.

Median CRP levels were higher for postmenopausal women (3.9 mg/L for those on ERT and 2.3 mg/L for those not on ERT) than for men (1.9 mg/L) or for premenopausal women (1.4 mg/L). In all, 74% of men, 62% of premenopausal women, 86% of postmenopausal women on ERT, and 77% of postmenopausal women not on ERT had CRP levels of at least 1 mg/L.

CRP level was not associated with BMD in men or in postmenopausal women using ERT. However, in those women, there was a significant association between years since menopause and BMD at all three sites. The researchers repeated the analysis for women fewer than 10 years past menopause and those at least 10 years past menopause. “The association of CRP with femoral neck BMD tended to be negative for those less than 10 years past menopause and positive for those at least 10 years past menopause, while there was no significant association at the trochanter or lumbar spine,” they wrote.

For postmenopausal women not using ERT, those with CRP levels of at least 1 mg/L had 2.5% greater BMD at the femoral neck, compared with the lower CRP level group, a significant difference. However, there were no significant associations at the trochanter or lumbar spine. “Contrary to our hypothesis, greater inflammation may be associated with higher BMD among postmenopausal women not using ERT,” wrote Dr. McLean of the Institute for Aging Research, a research affiliate of Harvard Medical School, Boston.

Dr. McLean reported that he has no relevant financial relationships.

DENVER — Menopausal status appears to modify the relationship between inflammation and bone mineral density, on the basis of findings from the Framingham Osteoporosis Study.

Postmenopausal women on estrogen replacement therapy (ERT) with higher levels of C-reactive protein—a measure of systemic inflammation—had greater bone mineral density (BMD) at the femoral neck than did those in the same group with lower CRP levels, Dr. Robert R. McLean and his coinvestigators reported in a poster presented at the annual meeting of the American Society for Bone and Mineral Research. In premenopausal women, increased CRP levels were associated with a decrease in BMD at the trochanter.

The Framingham Heart Study Offspring Cohort enrolled 5,124 children and spouses of the original Framingham cohort. From 1996 to 2001, BMD was measured in 3,035 offspring in the Framingham Osteoporosis Study, with fasting blood samples collected from 2,095 of them during 1998-2001. C-reactive protein levels were measured after BMD in 72% of participants, with a median time between assessments of 1.4 years.

BMD was measured at the right femoral neck and trochanter, and at the lumbar spine. Other variables obtained at the time of BMD measurement included age, height, weight, physical activity, smoking status, and use of NSAIDs. In women, menopause status, current ERT use, and years since menopause were also recorded. Separate analyses were performed for the 1,291 men, 229 premenopausal women, 497 postmenopausal women using ERT, and 888 postmenopausal women not using ERT. Analyses were adjusted for age, height, weight, physical activity, and smoking status.

Median CRP levels were higher for postmenopausal women (3.9 mg/L for those on ERT and 2.3 mg/L for those not on ERT) than for men (1.9 mg/L) or for premenopausal women (1.4 mg/L). In all, 74% of men, 62% of premenopausal women, 86% of postmenopausal women on ERT, and 77% of postmenopausal women not on ERT had CRP levels of at least 1 mg/L.

CRP level was not associated with BMD in men or in postmenopausal women using ERT. However, in those women, there was a significant association between years since menopause and BMD at all three sites. The researchers repeated the analysis for women fewer than 10 years past menopause and those at least 10 years past menopause. “The association of CRP with femoral neck BMD tended to be negative for those less than 10 years past menopause and positive for those at least 10 years past menopause, while there was no significant association at the trochanter or lumbar spine,” they wrote.

For postmenopausal women not using ERT, those with CRP levels of at least 1 mg/L had 2.5% greater BMD at the femoral neck, compared with the lower CRP level group, a significant difference. However, there were no significant associations at the trochanter or lumbar spine. “Contrary to our hypothesis, greater inflammation may be associated with higher BMD among postmenopausal women not using ERT,” wrote Dr. McLean of the Institute for Aging Research, a research affiliate of Harvard Medical School, Boston.

Dr. McLean reported that he has no relevant financial relationships.

DENVER — The FRAX 10-year fracture risk tool was fairly accurate in predicting the observed number of hip fractures that occurred among more than 5,000 participants of the Framingham Heart Study, according to data presented as a poster at the annual meeting of the American Society for Bone and Mineral Research.

The 10-year observed incidence of hip fracture for women was 117 cases, which did not differ significantly from the FRAX predicted number of 113. For men, the observed incidence was 29 cases, also not significantly different from the FRAX predicted number of 38, reported Elizabeth J. Samelson, Ph.D., a researcher at the Institute for Aging Research in Boston, and her coinvestigators.

FRAX is an online tool to calculate the 10-year probability of hip fracture and major osteoporotic fracture in women and men aged 40-90 years, on the basis of bone mineral density (BMD), gender, age, smoking status, glucocorticoid use, height and weight, diagnosis of rheumatoid arthritis or secondary osteoporosis, history of fracture, and parental history of fracture. FRAX was developed by the World Health Organization and was derived and validated using several population-based cohorts.

This study included 5,204 Framingham cohort members (2,917 women and 2,287 men) who had a baseline examination between 1987 and 2001 and were followed for hip fracture over 10 years. All were white.

At baseline, patients were assessed for age, body mass index, current smoking status, alcohol consumption, glucocorticoid use, diagnosis of rheumatoid arthritis, prior fragility fracture, parental history of fracture, and T score. History of parental hip fracture was not available for members of the original cohort (1,456); these participants were classified as having no parental history of hip fracture. Femoral neck BMD was available for 4,224 participants.

The researchers used FRAX version 3.0 to calculate the 10-year probability of hip fracture and compared the expected number with the number observed in the cohort. A hip fracture was defined as a proximal femur fracture and was confirmed by review of medical records (including radiographic and surgical reports).

Among women aged 40-75 years, the incidence was 52 cases, compared with 57 expected by FRAX; among men aged 40-75 years, the incidence was 12 cases, compared with 23 expected by FRAX.

Notably, the observed probability of hip fracture in the oldest adults (aged 76-90 years) exceeded the number predicted by FRAX, while the opposite was true for those aged 40-75. However, these differences were not significant, the authors noted. Among women aged 76-90 years, the incidence was 65 cases, compared with 55 expected by FRAX; among men aged 76-90 years, the incidence was 17 cases, compared with 14 expected by FRAX.

The latest version of FRAX can be accessed at www.shef.ac.uk/FRAX

The study was supported by the National Institutes of Health. The researchers reported that they have no relevant financial relationships.

See a related video at www.youtube.com/user/FamilyPracticeNews#p/u/5/rwnX0qauB74

DENVER — The FRAX 10-year fracture risk tool was fairly accurate in predicting the observed number of hip fractures that occurred among more than 5,000 participants of the Framingham Heart Study, according to data presented as a poster at the annual meeting of the American Society for Bone and Mineral Research.

The 10-year observed incidence of hip fracture for women was 117 cases, which did not differ significantly from the FRAX predicted number of 113. For men, the observed incidence was 29 cases, also not significantly different from the FRAX predicted number of 38, reported Elizabeth J. Samelson, Ph.D., a researcher at the Institute for Aging Research in Boston, and her coinvestigators.

FRAX is an online tool to calculate the 10-year probability of hip fracture and major osteoporotic fracture in women and men aged 40-90 years, on the basis of bone mineral density (BMD), gender, age, smoking status, glucocorticoid use, height and weight, diagnosis of rheumatoid arthritis or secondary osteoporosis, history of fracture, and parental history of fracture. FRAX was developed by the World Health Organization and was derived and validated using several population-based cohorts.

This study included 5,204 Framingham cohort members (2,917 women and 2,287 men) who had a baseline examination between 1987 and 2001 and were followed for hip fracture over 10 years. All were white.

At baseline, patients were assessed for age, body mass index, current smoking status, alcohol consumption, glucocorticoid use, diagnosis of rheumatoid arthritis, prior fragility fracture, parental history of fracture, and T score. History of parental hip fracture was not available for members of the original cohort (1,456); these participants were classified as having no parental history of hip fracture. Femoral neck BMD was available for 4,224 participants.

The researchers used FRAX version 3.0 to calculate the 10-year probability of hip fracture and compared the expected number with the number observed in the cohort. A hip fracture was defined as a proximal femur fracture and was confirmed by review of medical records (including radiographic and surgical reports).

Among women aged 40-75 years, the incidence was 52 cases, compared with 57 expected by FRAX; among men aged 40-75 years, the incidence was 12 cases, compared with 23 expected by FRAX.

Notably, the observed probability of hip fracture in the oldest adults (aged 76-90 years) exceeded the number predicted by FRAX, while the opposite was true for those aged 40-75. However, these differences were not significant, the authors noted. Among women aged 76-90 years, the incidence was 65 cases, compared with 55 expected by FRAX; among men aged 76-90 years, the incidence was 17 cases, compared with 14 expected by FRAX.

The latest version of FRAX can be accessed at www.shef.ac.uk/FRAX

The study was supported by the National Institutes of Health. The researchers reported that they have no relevant financial relationships.

See a related video at www.youtube.com/user/FamilyPracticeNews#p/u/5/rwnX0qauB74

DENVER — The FRAX 10-year fracture risk tool was fairly accurate in predicting the observed number of hip fractures that occurred among more than 5,000 participants of the Framingham Heart Study, according to data presented as a poster at the annual meeting of the American Society for Bone and Mineral Research.

The 10-year observed incidence of hip fracture for women was 117 cases, which did not differ significantly from the FRAX predicted number of 113. For men, the observed incidence was 29 cases, also not significantly different from the FRAX predicted number of 38, reported Elizabeth J. Samelson, Ph.D., a researcher at the Institute for Aging Research in Boston, and her coinvestigators.

FRAX is an online tool to calculate the 10-year probability of hip fracture and major osteoporotic fracture in women and men aged 40-90 years, on the basis of bone mineral density (BMD), gender, age, smoking status, glucocorticoid use, height and weight, diagnosis of rheumatoid arthritis or secondary osteoporosis, history of fracture, and parental history of fracture. FRAX was developed by the World Health Organization and was derived and validated using several population-based cohorts.

This study included 5,204 Framingham cohort members (2,917 women and 2,287 men) who had a baseline examination between 1987 and 2001 and were followed for hip fracture over 10 years. All were white.

At baseline, patients were assessed for age, body mass index, current smoking status, alcohol consumption, glucocorticoid use, diagnosis of rheumatoid arthritis, prior fragility fracture, parental history of fracture, and T score. History of parental hip fracture was not available for members of the original cohort (1,456); these participants were classified as having no parental history of hip fracture. Femoral neck BMD was available for 4,224 participants.

The researchers used FRAX version 3.0 to calculate the 10-year probability of hip fracture and compared the expected number with the number observed in the cohort. A hip fracture was defined as a proximal femur fracture and was confirmed by review of medical records (including radiographic and surgical reports).

Among women aged 40-75 years, the incidence was 52 cases, compared with 57 expected by FRAX; among men aged 40-75 years, the incidence was 12 cases, compared with 23 expected by FRAX.

Notably, the observed probability of hip fracture in the oldest adults (aged 76-90 years) exceeded the number predicted by FRAX, while the opposite was true for those aged 40-75. However, these differences were not significant, the authors noted. Among women aged 76-90 years, the incidence was 65 cases, compared with 55 expected by FRAX; among men aged 76-90 years, the incidence was 17 cases, compared with 14 expected by FRAX.

The latest version of FRAX can be accessed at www.shef.ac.uk/FRAX

The study was supported by the National Institutes of Health. The researchers reported that they have no relevant financial relationships.

See a related video at www.youtube.com/user/FamilyPracticeNews#p/u/5/rwnX0qauB74