Heidi Splete

WASHINGTON — With elderly patients taking more medications than ever before, convenient bisphosphonate regimen options may help reduce the overall medication burden and improve compliance with the osteoporosis therapy, suggest findings from a recent study of prescription trends.

In an investigation of prescription data for 250,286 postmenopausal women, about 65% of those prescribed daily or weekly bisphosphonates were also prescribed one to three concomitant medications, Deborah T. Gold, Ph.D., reported in a poster presented at an international symposium sponsored by the National Osteoporosis Foundation.

What's more, 12% of the study population received four concomitant medications, 7% received five, and 17% received six or more. On average, the women were taking more than three concomitant medications, a burden shown to increase the risk of noncompliance in elderly patients (Arthritis Rheum. 2004;15[Suppl.]:S513).

Compliance is a significant problem with bisphosphonate therapy, in part because the strict fasting and administration requirements of the osteoporosis drugs can conflict with those of other medications.

Dr. Gold of Duke University, Durham, North Carolina, and colleagues analyzed information from a longitudinal patient database to determine the degree of concomitant medication use among women prescribed bisphosphonates.

Overall, the mean number of concomitant medications among women who received daily bisphosphonates increased from 3.1 in November 1999 to 4.2 in June 2004.

The number of prescribed concomitant medications increased with patient age, from 2.7 to 3.2 among women aged 50–64 years, compared with 3.2 to 4.0 among women aged 75 years and older.

The most common medications prescribed in conjunction with bisphosphonates were levothyroxine, atorvastatin, atenolol, furosemide, amlodipine, potassium chloride, hydrochlorothiazide, lisinopril, celecoxib, and simvastatin.

WASHINGTON — With elderly patients taking more medications than ever before, convenient bisphosphonate regimen options may help reduce the overall medication burden and improve compliance with the osteoporosis therapy, suggest findings from a recent study of prescription trends.

In an investigation of prescription data for 250,286 postmenopausal women, about 65% of those prescribed daily or weekly bisphosphonates were also prescribed one to three concomitant medications, Deborah T. Gold, Ph.D., reported in a poster presented at an international symposium sponsored by the National Osteoporosis Foundation.

What's more, 12% of the study population received four concomitant medications, 7% received five, and 17% received six or more. On average, the women were taking more than three concomitant medications, a burden shown to increase the risk of noncompliance in elderly patients (Arthritis Rheum. 2004;15[Suppl.]:S513).

Compliance is a significant problem with bisphosphonate therapy, in part because the strict fasting and administration requirements of the osteoporosis drugs can conflict with those of other medications.

Dr. Gold of Duke University, Durham, North Carolina, and colleagues analyzed information from a longitudinal patient database to determine the degree of concomitant medication use among women prescribed bisphosphonates.

Overall, the mean number of concomitant medications among women who received daily bisphosphonates increased from 3.1 in November 1999 to 4.2 in June 2004.

The number of prescribed concomitant medications increased with patient age, from 2.7 to 3.2 among women aged 50–64 years, compared with 3.2 to 4.0 among women aged 75 years and older.

The most common medications prescribed in conjunction with bisphosphonates were levothyroxine, atorvastatin, atenolol, furosemide, amlodipine, potassium chloride, hydrochlorothiazide, lisinopril, celecoxib, and simvastatin.

WASHINGTON — With elderly patients taking more medications than ever before, convenient bisphosphonate regimen options may help reduce the overall medication burden and improve compliance with the osteoporosis therapy, suggest findings from a recent study of prescription trends.

In an investigation of prescription data for 250,286 postmenopausal women, about 65% of those prescribed daily or weekly bisphosphonates were also prescribed one to three concomitant medications, Deborah T. Gold, Ph.D., reported in a poster presented at an international symposium sponsored by the National Osteoporosis Foundation.

What's more, 12% of the study population received four concomitant medications, 7% received five, and 17% received six or more. On average, the women were taking more than three concomitant medications, a burden shown to increase the risk of noncompliance in elderly patients (Arthritis Rheum. 2004;15[Suppl.]:S513).

Compliance is a significant problem with bisphosphonate therapy, in part because the strict fasting and administration requirements of the osteoporosis drugs can conflict with those of other medications.

Dr. Gold of Duke University, Durham, North Carolina, and colleagues analyzed information from a longitudinal patient database to determine the degree of concomitant medication use among women prescribed bisphosphonates.

Overall, the mean number of concomitant medications among women who received daily bisphosphonates increased from 3.1 in November 1999 to 4.2 in June 2004.

The number of prescribed concomitant medications increased with patient age, from 2.7 to 3.2 among women aged 50–64 years, compared with 3.2 to 4.0 among women aged 75 years and older.

The most common medications prescribed in conjunction with bisphosphonates were levothyroxine, atorvastatin, atenolol, furosemide, amlodipine, potassium chloride, hydrochlorothiazide, lisinopril, celecoxib, and simvastatin.

WASHINGTON — Body temperature below 36° C at hospital admission was independently associated with a lower survival rate in a study of 56,659 patients with advanced heart failure.

Disordered thermoregulation is common in patients with advanced heart failure, and body temperature measurements may improve risk assessment in these patients, Brahmajee K. Nallamothu, M.D., wrote in a poster presented at the Clinical Research 2005 meeting sponsored by the American Federation for Medical Research.

Dr. Nallamothu, a cardiologist at the University of Michigan, Ann Arbor, and his associates reviewed data on patients aged 65 years and older who were participating in the National Heart Care Project.

The mean body temperature upon hospital admission was 36.5° C, and most of the patients' admission temperatures were between 36° C and 38° C. However, 10,754 (18.5%) of the patients had body temperatures below 36° C and 1,145 (1.9%) had body temperatures above 38° C.

After multivariate analysis, patients with body temperatures below 36° C had significantly higher mortality, both in hospital (adjusted risk ratio, 1.28) and at 1 year after their hospitalizations (adjusted risk ratio, 1.14). Body temperatures above 38° C were not significantly associated with in-hospital mortality, but they were significantly associated with lower mortality after 1 year (adjusted risk ratio, 0.80).

WASHINGTON — Body temperature below 36° C at hospital admission was independently associated with a lower survival rate in a study of 56,659 patients with advanced heart failure.

Disordered thermoregulation is common in patients with advanced heart failure, and body temperature measurements may improve risk assessment in these patients, Brahmajee K. Nallamothu, M.D., wrote in a poster presented at the Clinical Research 2005 meeting sponsored by the American Federation for Medical Research.

Dr. Nallamothu, a cardiologist at the University of Michigan, Ann Arbor, and his associates reviewed data on patients aged 65 years and older who were participating in the National Heart Care Project.

The mean body temperature upon hospital admission was 36.5° C, and most of the patients' admission temperatures were between 36° C and 38° C. However, 10,754 (18.5%) of the patients had body temperatures below 36° C and 1,145 (1.9%) had body temperatures above 38° C.

After multivariate analysis, patients with body temperatures below 36° C had significantly higher mortality, both in hospital (adjusted risk ratio, 1.28) and at 1 year after their hospitalizations (adjusted risk ratio, 1.14). Body temperatures above 38° C were not significantly associated with in-hospital mortality, but they were significantly associated with lower mortality after 1 year (adjusted risk ratio, 0.80).

WASHINGTON — Body temperature below 36° C at hospital admission was independently associated with a lower survival rate in a study of 56,659 patients with advanced heart failure.

Disordered thermoregulation is common in patients with advanced heart failure, and body temperature measurements may improve risk assessment in these patients, Brahmajee K. Nallamothu, M.D., wrote in a poster presented at the Clinical Research 2005 meeting sponsored by the American Federation for Medical Research.

Dr. Nallamothu, a cardiologist at the University of Michigan, Ann Arbor, and his associates reviewed data on patients aged 65 years and older who were participating in the National Heart Care Project.

The mean body temperature upon hospital admission was 36.5° C, and most of the patients' admission temperatures were between 36° C and 38° C. However, 10,754 (18.5%) of the patients had body temperatures below 36° C and 1,145 (1.9%) had body temperatures above 38° C.

After multivariate analysis, patients with body temperatures below 36° C had significantly higher mortality, both in hospital (adjusted risk ratio, 1.28) and at 1 year after their hospitalizations (adjusted risk ratio, 1.14). Body temperatures above 38° C were not significantly associated with in-hospital mortality, but they were significantly associated with lower mortality after 1 year (adjusted risk ratio, 0.80).

Pneumococcal Serogroups Emerge

In a retrospective review of Streptococcus pneumoniae cases from 1996 to 2003, the incidence decreased 27% after the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7 or Prevnar) in 2001, reported Carrie L. Byington, M.D., of the University of Utah, Salt Lake City, and her colleagues. In a study of children younger than 18 years treated at Intermountain Health Care, Salt Lake City, the overall percentage of cases from serogroups in PCV7 decreased after the introduction of the vaccine, but the number of invasive infections due to serotypes not included in PCV7 increased (Clin. Infect. Dis. 2005;41:21–9). The investigators identified 1,535 episodes of invasive pneumococcal disease, and the 86 children infected with non-PCV7 isolates had hospital stays twice as long as the 146 children infected with PCV7 isolates. Although the incidence of bacteremia and pneumonia decreased from the pre- to postvaccine periods (6.9 vs. 4.6 cases/100,000 children and 31 vs. 16 cases per 100,000 children, respectively), the incidence of parapneumonic empyema increased (10.3 vs. 14.3 cases/100,000 children). At approximately 5 years after PCV7's introduction, “the effect of colonization of nonvaccine S. pneumoniae serotypes depends entirely on whether new serotypes cause disease,” Sarah S. Long, M.D., of Drexel University, Philadelphia, wrote in an accompanying editorial (Clin. Infect. Dis. 2005;41:30–4).

Procalcitonin Predicts Reflux

A high concentration of procalcitonin was a significant independent predictor of vesicoureteral reflux (VUR) in a study of 136 infants aged 1 month to 4 years, said Sandrine Leroy, M.D., of Saint-Vincent-de-Paul Hospital, Paris, and colleagues (Pediatrics

http://pediatrics.aappublications.org/cgi/content/abstract/115/6/e706

Strep Lingers in Nose

An early clinical recurrence of acute otitis media (AOM) was significantly more likely if Streptococcus pneumoniae remained in the nose at the end of antibiotic treatment, said Shai Libson, M.D., and associates at Ben-Gurion University of the Negev, Beer-Sheva, Israel. Nasopharangeal aspirate samples were obtained after successful antibiotic treatment for AOM (J. Infect. Dis. 2005;191:1869–75). The study included 494 children aged 3–36 months who presented to an emergency room with AOM from Jan. 1, 1996, to Dec. 31, 2002. Overall, 208 (42%) of the cultures were positive for S. pneumoniae, and 86 (41%) of these patients also had yielded positive S. pneumoniae nasal cultures prior to their antibiotic treatment. In addition, 66 of the 208 (32%) patients with positive cultures after treatment developed another episode of AOM within 3 weeks, compared with 64 of 286 (22%) patients who had negative cultures after treatment. There were no significant differences between patients who did and did not have clinical AOM recurrence. The persistence of S. pneumoniae in the nose despite its eradication from the middle ear fluid suggests the need for further research into the impact of antibiotics on nasopharyngeal carriage, Keith P. Klugman, M.D., and Kerry J. Walsh, M.D., of Emory University, Atlanta, wrote in an accompanying editorial (J. Infect. Dis. 2005;191:1790–2).

Streptococcal Role in AOM

AOM caused by Streptococcus pyogenes was associated with older age and higher rates of tympanic perforation and mastoiditis, compared with AOM caused by other pathogens, said Nili Segal, M.D., and associates at Ben-Gurion University of the Negev, Beer-Sheva, Israel (Clin. Infect. Dis. 2005;41:35–41). In the study of 11,311 episodes, overall, those caused by S. pyogenes, also known as group A β-hemolytic Streptococcus (GAS), were significantly less often associated with fever or upper respiratory tract infection, compared with non-GAS episodes (60% vs. 77% and 35% vs. 55%, respectively). GAS episodes also were significantly less likely to be bilateral, or to be associated with antibiotic treatment during the month prior to the infection. The increased risk of mastoiditis supports data from previous studies, Stanford T. Shulman, M.D., and Robert R. Tanz, M.D., of Northwestern University, Chicago, wrote in an accompanying editorial (Clin. Infect. Dis. 2005;41:42–4). Episodes of GAS otitis media may be preceded by pharyngeal colonization, given the patients' older age, acute symptoms, and lack of respiratory tract complaints, and this colonization may contribute to the increased frequency of mastoiditis in these patients, they noted.

Pneumococcal Serogroups Emerge

In a retrospective review of Streptococcus pneumoniae cases from 1996 to 2003, the incidence decreased 27% after the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7 or Prevnar) in 2001, reported Carrie L. Byington, M.D., of the University of Utah, Salt Lake City, and her colleagues. In a study of children younger than 18 years treated at Intermountain Health Care, Salt Lake City, the overall percentage of cases from serogroups in PCV7 decreased after the introduction of the vaccine, but the number of invasive infections due to serotypes not included in PCV7 increased (Clin. Infect. Dis. 2005;41:21–9). The investigators identified 1,535 episodes of invasive pneumococcal disease, and the 86 children infected with non-PCV7 isolates had hospital stays twice as long as the 146 children infected with PCV7 isolates. Although the incidence of bacteremia and pneumonia decreased from the pre- to postvaccine periods (6.9 vs. 4.6 cases/100,000 children and 31 vs. 16 cases per 100,000 children, respectively), the incidence of parapneumonic empyema increased (10.3 vs. 14.3 cases/100,000 children). At approximately 5 years after PCV7's introduction, “the effect of colonization of nonvaccine S. pneumoniae serotypes depends entirely on whether new serotypes cause disease,” Sarah S. Long, M.D., of Drexel University, Philadelphia, wrote in an accompanying editorial (Clin. Infect. Dis. 2005;41:30–4).

Procalcitonin Predicts Reflux

A high concentration of procalcitonin was a significant independent predictor of vesicoureteral reflux (VUR) in a study of 136 infants aged 1 month to 4 years, said Sandrine Leroy, M.D., of Saint-Vincent-de-Paul Hospital, Paris, and colleagues (Pediatrics

http://pediatrics.aappublications.org/cgi/content/abstract/115/6/e706

Strep Lingers in Nose

An early clinical recurrence of acute otitis media (AOM) was significantly more likely if Streptococcus pneumoniae remained in the nose at the end of antibiotic treatment, said Shai Libson, M.D., and associates at Ben-Gurion University of the Negev, Beer-Sheva, Israel. Nasopharangeal aspirate samples were obtained after successful antibiotic treatment for AOM (J. Infect. Dis. 2005;191:1869–75). The study included 494 children aged 3–36 months who presented to an emergency room with AOM from Jan. 1, 1996, to Dec. 31, 2002. Overall, 208 (42%) of the cultures were positive for S. pneumoniae, and 86 (41%) of these patients also had yielded positive S. pneumoniae nasal cultures prior to their antibiotic treatment. In addition, 66 of the 208 (32%) patients with positive cultures after treatment developed another episode of AOM within 3 weeks, compared with 64 of 286 (22%) patients who had negative cultures after treatment. There were no significant differences between patients who did and did not have clinical AOM recurrence. The persistence of S. pneumoniae in the nose despite its eradication from the middle ear fluid suggests the need for further research into the impact of antibiotics on nasopharyngeal carriage, Keith P. Klugman, M.D., and Kerry J. Walsh, M.D., of Emory University, Atlanta, wrote in an accompanying editorial (J. Infect. Dis. 2005;191:1790–2).

Streptococcal Role in AOM

AOM caused by Streptococcus pyogenes was associated with older age and higher rates of tympanic perforation and mastoiditis, compared with AOM caused by other pathogens, said Nili Segal, M.D., and associates at Ben-Gurion University of the Negev, Beer-Sheva, Israel (Clin. Infect. Dis. 2005;41:35–41). In the study of 11,311 episodes, overall, those caused by S. pyogenes, also known as group A β-hemolytic Streptococcus (GAS), were significantly less often associated with fever or upper respiratory tract infection, compared with non-GAS episodes (60% vs. 77% and 35% vs. 55%, respectively). GAS episodes also were significantly less likely to be bilateral, or to be associated with antibiotic treatment during the month prior to the infection. The increased risk of mastoiditis supports data from previous studies, Stanford T. Shulman, M.D., and Robert R. Tanz, M.D., of Northwestern University, Chicago, wrote in an accompanying editorial (Clin. Infect. Dis. 2005;41:42–4). Episodes of GAS otitis media may be preceded by pharyngeal colonization, given the patients' older age, acute symptoms, and lack of respiratory tract complaints, and this colonization may contribute to the increased frequency of mastoiditis in these patients, they noted.

Pneumococcal Serogroups Emerge

In a retrospective review of Streptococcus pneumoniae cases from 1996 to 2003, the incidence decreased 27% after the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7 or Prevnar) in 2001, reported Carrie L. Byington, M.D., of the University of Utah, Salt Lake City, and her colleagues. In a study of children younger than 18 years treated at Intermountain Health Care, Salt Lake City, the overall percentage of cases from serogroups in PCV7 decreased after the introduction of the vaccine, but the number of invasive infections due to serotypes not included in PCV7 increased (Clin. Infect. Dis. 2005;41:21–9). The investigators identified 1,535 episodes of invasive pneumococcal disease, and the 86 children infected with non-PCV7 isolates had hospital stays twice as long as the 146 children infected with PCV7 isolates. Although the incidence of bacteremia and pneumonia decreased from the pre- to postvaccine periods (6.9 vs. 4.6 cases/100,000 children and 31 vs. 16 cases per 100,000 children, respectively), the incidence of parapneumonic empyema increased (10.3 vs. 14.3 cases/100,000 children). At approximately 5 years after PCV7's introduction, “the effect of colonization of nonvaccine S. pneumoniae serotypes depends entirely on whether new serotypes cause disease,” Sarah S. Long, M.D., of Drexel University, Philadelphia, wrote in an accompanying editorial (Clin. Infect. Dis. 2005;41:30–4).

Procalcitonin Predicts Reflux

A high concentration of procalcitonin was a significant independent predictor of vesicoureteral reflux (VUR) in a study of 136 infants aged 1 month to 4 years, said Sandrine Leroy, M.D., of Saint-Vincent-de-Paul Hospital, Paris, and colleagues (Pediatrics

http://pediatrics.aappublications.org/cgi/content/abstract/115/6/e706

Strep Lingers in Nose

An early clinical recurrence of acute otitis media (AOM) was significantly more likely if Streptococcus pneumoniae remained in the nose at the end of antibiotic treatment, said Shai Libson, M.D., and associates at Ben-Gurion University of the Negev, Beer-Sheva, Israel. Nasopharangeal aspirate samples were obtained after successful antibiotic treatment for AOM (J. Infect. Dis. 2005;191:1869–75). The study included 494 children aged 3–36 months who presented to an emergency room with AOM from Jan. 1, 1996, to Dec. 31, 2002. Overall, 208 (42%) of the cultures were positive for S. pneumoniae, and 86 (41%) of these patients also had yielded positive S. pneumoniae nasal cultures prior to their antibiotic treatment. In addition, 66 of the 208 (32%) patients with positive cultures after treatment developed another episode of AOM within 3 weeks, compared with 64 of 286 (22%) patients who had negative cultures after treatment. There were no significant differences between patients who did and did not have clinical AOM recurrence. The persistence of S. pneumoniae in the nose despite its eradication from the middle ear fluid suggests the need for further research into the impact of antibiotics on nasopharyngeal carriage, Keith P. Klugman, M.D., and Kerry J. Walsh, M.D., of Emory University, Atlanta, wrote in an accompanying editorial (J. Infect. Dis. 2005;191:1790–2).

Streptococcal Role in AOM

AOM caused by Streptococcus pyogenes was associated with older age and higher rates of tympanic perforation and mastoiditis, compared with AOM caused by other pathogens, said Nili Segal, M.D., and associates at Ben-Gurion University of the Negev, Beer-Sheva, Israel (Clin. Infect. Dis. 2005;41:35–41). In the study of 11,311 episodes, overall, those caused by S. pyogenes, also known as group A β-hemolytic Streptococcus (GAS), were significantly less often associated with fever or upper respiratory tract infection, compared with non-GAS episodes (60% vs. 77% and 35% vs. 55%, respectively). GAS episodes also were significantly less likely to be bilateral, or to be associated with antibiotic treatment during the month prior to the infection. The increased risk of mastoiditis supports data from previous studies, Stanford T. Shulman, M.D., and Robert R. Tanz, M.D., of Northwestern University, Chicago, wrote in an accompanying editorial (Clin. Infect. Dis. 2005;41:42–4). Episodes of GAS otitis media may be preceded by pharyngeal colonization, given the patients' older age, acute symptoms, and lack of respiratory tract complaints, and this colonization may contribute to the increased frequency of mastoiditis in these patients, they noted.

WASHINGTON — Vitamin D levels are inadequate in up to half of postmenopausal women who receive treatment for osteoporosis, Ethel Siris, M.D., reported at an international symposium sponsored by the National Osteoporosis Foundation.

Vitamin D inadequacy was significantly more common among women who took less than 400 IU of vitamin D supplementation daily, compared with women who took at least 400 IU of vitamin D daily (63% vs. 45%).

Previous study findings suggest that serum 25-hydroxyvitamin D concentrations of at least 30 ng/mL are needed to stabilize serum parathyroid hormone levels, Dr. Siris, director of the metabolic bone diseases program at Columbia University, New York, and her colleagues, wrote in a poster presentation.

In a cross-sectional, observational study conducted between November 2003 and March 2004, the investigators collected blood samples from 1,536 postmenopausal women, mean age 71 years, at 61 sites throughout North America. They used several cut points of serum 25-hydroxyvitamin D to define inadequacy—less than 9 ng/mL, less than 20 ng/mL, less than 25 ng/mL, and less than 30 ng/mL.

Parathyroid hormone values stabilized among patients with serum 25-hydroxyvitamin D concentrations of at least 29.8 ng/mL, which suggests that concentrations of approximately 30 ng/mL are important for healthy parathyroid levels.

Additional factors significantly related to vitamin D inadequacy in a multivariate analysis included age older than 80 years, BMI greater than 30, lack of exercise, and lack of physician counseling about the importance of vitamin D. More than half (59%) of the women reported that they had not discussed vitamin D with a doctor.

Dr. Siris is a paid consultant for Eli Lilly & Co., Merck & Co., Sanofi Aventis, Procter and Gamble Pharmaceuticals, and Novartis.

WASHINGTON — Vitamin D levels are inadequate in up to half of postmenopausal women who receive treatment for osteoporosis, Ethel Siris, M.D., reported at an international symposium sponsored by the National Osteoporosis Foundation.

Vitamin D inadequacy was significantly more common among women who took less than 400 IU of vitamin D supplementation daily, compared with women who took at least 400 IU of vitamin D daily (63% vs. 45%).

Previous study findings suggest that serum 25-hydroxyvitamin D concentrations of at least 30 ng/mL are needed to stabilize serum parathyroid hormone levels, Dr. Siris, director of the metabolic bone diseases program at Columbia University, New York, and her colleagues, wrote in a poster presentation.

In a cross-sectional, observational study conducted between November 2003 and March 2004, the investigators collected blood samples from 1,536 postmenopausal women, mean age 71 years, at 61 sites throughout North America. They used several cut points of serum 25-hydroxyvitamin D to define inadequacy—less than 9 ng/mL, less than 20 ng/mL, less than 25 ng/mL, and less than 30 ng/mL.

Parathyroid hormone values stabilized among patients with serum 25-hydroxyvitamin D concentrations of at least 29.8 ng/mL, which suggests that concentrations of approximately 30 ng/mL are important for healthy parathyroid levels.

Additional factors significantly related to vitamin D inadequacy in a multivariate analysis included age older than 80 years, BMI greater than 30, lack of exercise, and lack of physician counseling about the importance of vitamin D. More than half (59%) of the women reported that they had not discussed vitamin D with a doctor.

Dr. Siris is a paid consultant for Eli Lilly & Co., Merck & Co., Sanofi Aventis, Procter and Gamble Pharmaceuticals, and Novartis.

WASHINGTON — Vitamin D levels are inadequate in up to half of postmenopausal women who receive treatment for osteoporosis, Ethel Siris, M.D., reported at an international symposium sponsored by the National Osteoporosis Foundation.

Vitamin D inadequacy was significantly more common among women who took less than 400 IU of vitamin D supplementation daily, compared with women who took at least 400 IU of vitamin D daily (63% vs. 45%).

Previous study findings suggest that serum 25-hydroxyvitamin D concentrations of at least 30 ng/mL are needed to stabilize serum parathyroid hormone levels, Dr. Siris, director of the metabolic bone diseases program at Columbia University, New York, and her colleagues, wrote in a poster presentation.

In a cross-sectional, observational study conducted between November 2003 and March 2004, the investigators collected blood samples from 1,536 postmenopausal women, mean age 71 years, at 61 sites throughout North America. They used several cut points of serum 25-hydroxyvitamin D to define inadequacy—less than 9 ng/mL, less than 20 ng/mL, less than 25 ng/mL, and less than 30 ng/mL.

Parathyroid hormone values stabilized among patients with serum 25-hydroxyvitamin D concentrations of at least 29.8 ng/mL, which suggests that concentrations of approximately 30 ng/mL are important for healthy parathyroid levels.

Additional factors significantly related to vitamin D inadequacy in a multivariate analysis included age older than 80 years, BMI greater than 30, lack of exercise, and lack of physician counseling about the importance of vitamin D. More than half (59%) of the women reported that they had not discussed vitamin D with a doctor.

Dr. Siris is a paid consultant for Eli Lilly & Co., Merck & Co., Sanofi Aventis, Procter and Gamble Pharmaceuticals, and Novartis.

TORONTO — A complete blood count showed an increased number of activated endothelial cells, said Dr. Hakeem Sam of McGill University, Montreal.

The leg ulcer was associated with sickle cell disease. The interaction between the activated endothelial and sickle cells led to increased expression of endothelial cell adhesion molecules, which promoted thrombotic vaso-occlusion, causing the ulcer.

Leg ulcers are not uncommon complications of sickle cell disease, especially in Jamaica and Nigeria. Data from a study in the British Journal of Haematology showed that 75% of 183 sickle cell patients in Jamaica had significantly more venous incompetence, compared with 39% of controls (Br. J. Haematol. 2002; 119:567–71).

Reported treatments for leg ulcers in sickle cell disease patients include wet dressings, hydroxyurea, transfusions, recombinant erythropoietin, zinc sulfate supplements, and surgical grafts and flaps.

In this case, the wound base was cleaned via autolytic and enzymatic debridement to avoid trauma to the wound bed. The wound was treated with a nonadherent dressing, and the patient received medication for local and systemic pain. Foam, Hydrofiber, and calcium alginate were used to manage wound exudate, according to Dr. Sam.

A 29-year-old black man whose history included gallstones and a recurrent left leg ulcer presented with acute chest pain, fever, dyspnea, and a new and painful ulcer on his left leg. He was not a smoker and didn't drink alcohol. What's your diagnosis? Courtesy Dr. Hakeem Sam

TORONTO — A complete blood count showed an increased number of activated endothelial cells, said Dr. Hakeem Sam of McGill University, Montreal.

The leg ulcer was associated with sickle cell disease. The interaction between the activated endothelial and sickle cells led to increased expression of endothelial cell adhesion molecules, which promoted thrombotic vaso-occlusion, causing the ulcer.

Leg ulcers are not uncommon complications of sickle cell disease, especially in Jamaica and Nigeria. Data from a study in the British Journal of Haematology showed that 75% of 183 sickle cell patients in Jamaica had significantly more venous incompetence, compared with 39% of controls (Br. J. Haematol. 2002; 119:567–71).

Reported treatments for leg ulcers in sickle cell disease patients include wet dressings, hydroxyurea, transfusions, recombinant erythropoietin, zinc sulfate supplements, and surgical grafts and flaps.

In this case, the wound base was cleaned via autolytic and enzymatic debridement to avoid trauma to the wound bed. The wound was treated with a nonadherent dressing, and the patient received medication for local and systemic pain. Foam, Hydrofiber, and calcium alginate were used to manage wound exudate, according to Dr. Sam.

A 29-year-old black man whose history included gallstones and a recurrent left leg ulcer presented with acute chest pain, fever, dyspnea, and a new and painful ulcer on his left leg. He was not a smoker and didn't drink alcohol. What's your diagnosis? Courtesy Dr. Hakeem Sam

TORONTO — A complete blood count showed an increased number of activated endothelial cells, said Dr. Hakeem Sam of McGill University, Montreal.

The leg ulcer was associated with sickle cell disease. The interaction between the activated endothelial and sickle cells led to increased expression of endothelial cell adhesion molecules, which promoted thrombotic vaso-occlusion, causing the ulcer.

Leg ulcers are not uncommon complications of sickle cell disease, especially in Jamaica and Nigeria. Data from a study in the British Journal of Haematology showed that 75% of 183 sickle cell patients in Jamaica had significantly more venous incompetence, compared with 39% of controls (Br. J. Haematol. 2002; 119:567–71).

Reported treatments for leg ulcers in sickle cell disease patients include wet dressings, hydroxyurea, transfusions, recombinant erythropoietin, zinc sulfate supplements, and surgical grafts and flaps.

In this case, the wound base was cleaned via autolytic and enzymatic debridement to avoid trauma to the wound bed. The wound was treated with a nonadherent dressing, and the patient received medication for local and systemic pain. Foam, Hydrofiber, and calcium alginate were used to manage wound exudate, according to Dr. Sam.

A 29-year-old black man whose history included gallstones and a recurrent left leg ulcer presented with acute chest pain, fever, dyspnea, and a new and painful ulcer on his left leg. He was not a smoker and didn't drink alcohol. What's your diagnosis? Courtesy Dr. Hakeem Sam

WASHINGTON — Most adults say that they always or nearly always use at least one method of preventing overexposure to the sun, according to a convenience sample of 1,269 adults aged 18–39 years living in Maryland in 2004.

The most common strategies reported were avoiding the sun between 10 a.m. and 4 p.m. (35%); using sunscreen with at least SPF 15 regularly (30%); using protective clothing, such as long-sleeved shirts or pants (16%); and wearing a hat (12%), wrote Eileen Steinberger, M.D., in a poster presented at the annual meeting of the American College of Preventive Medicine.

Men and respondents with higher levels of education were more likely to wear hats, while women, white responders, and responders of an ethnicity other than white or black were more likely to use sunscreen, wrote Dr. Steinberger of the University of Maryland.

Overall, people aged 25 years and older were more likely to use at least one sun protection method. White responders accounted for almost all users of artificial tanning, with 8% of males and 23% of females reporting use of an artificial tanning device within the previous year.

WASHINGTON — Most adults say that they always or nearly always use at least one method of preventing overexposure to the sun, according to a convenience sample of 1,269 adults aged 18–39 years living in Maryland in 2004.

The most common strategies reported were avoiding the sun between 10 a.m. and 4 p.m. (35%); using sunscreen with at least SPF 15 regularly (30%); using protective clothing, such as long-sleeved shirts or pants (16%); and wearing a hat (12%), wrote Eileen Steinberger, M.D., in a poster presented at the annual meeting of the American College of Preventive Medicine.

Men and respondents with higher levels of education were more likely to wear hats, while women, white responders, and responders of an ethnicity other than white or black were more likely to use sunscreen, wrote Dr. Steinberger of the University of Maryland.

Overall, people aged 25 years and older were more likely to use at least one sun protection method. White responders accounted for almost all users of artificial tanning, with 8% of males and 23% of females reporting use of an artificial tanning device within the previous year.

WASHINGTON — Most adults say that they always or nearly always use at least one method of preventing overexposure to the sun, according to a convenience sample of 1,269 adults aged 18–39 years living in Maryland in 2004.

The most common strategies reported were avoiding the sun between 10 a.m. and 4 p.m. (35%); using sunscreen with at least SPF 15 regularly (30%); using protective clothing, such as long-sleeved shirts or pants (16%); and wearing a hat (12%), wrote Eileen Steinberger, M.D., in a poster presented at the annual meeting of the American College of Preventive Medicine.

Men and respondents with higher levels of education were more likely to wear hats, while women, white responders, and responders of an ethnicity other than white or black were more likely to use sunscreen, wrote Dr. Steinberger of the University of Maryland.

Overall, people aged 25 years and older were more likely to use at least one sun protection method. White responders accounted for almost all users of artificial tanning, with 8% of males and 23% of females reporting use of an artificial tanning device within the previous year.

WASHINGTON — Cases of multidrug resistance in immigrant populations in the United States and links to the AIDS epidemic in Africa are attracting the attention of researchers.

“There is an erroneous assumption that tuberculosis has been eradicated,” Catherine D. DeAngelis, M.D., editor of the Journal of the American Medical Association, said at a press briefing on tuberculosis sponsored by JAMA.

“In fact it is a big problem, and should be taken seriously,” she said.

Of note, 407 cases of multidrug-resistant tuberculosis (MDR-TB) with specific resistance to at least isoniazid and rifampin occurred in a study of 28,712 tuberculosis cases in California from 1994 to 2003, according to Reuben M. Granich, M.D., of the Centers for Disease Control and Prevention in Atlanta, and his colleagues.

Patients with MDR-TB were seven times more likely to have reported prior tuberculosis treatment, compared with those with non-MDR disease, Dr. Granich said at the press conference.

In addition, 83% of the MDR-TB patients were born outside the United States, which highlights the need for both international control and improved screening, said Dr. Granich.

Prior treatment for tuberculosis was the strongest risk factor for MDR-TB in his study.

“There are two ways to develop MDR-TB,” Dr. Granich said.

One is through noncompliance with the treatment regimen, and the other is via airborne transmission from one patient to another, he said.

Once infected, the average lifetime risk for developing tuberculosis is 10%, and the risk is highest during the first 2 years after infection.

Most healthy people who are exposed to tuberculosis won't go on to develop the disease, and a person's state of health can modify the risk, Dr. Granich noted. For example, the risk of HIV/AIDS patients for developing tuberculosis increases significantly over that of a healthy person exposed to tuberculosis to an approximately 10% annual risk.

Of the 407 MDR-TB cases in Dr. Granich's study, 71 (17%) were resistant only to isoniazid and rifampin, and 86 (21%) were resistant to all four first-line drugs—isoniazid, rifampin, ethambutol, and pyrazinamide.

Most cases of tuberculosis are curable if patients are compliant and take the right medication for 6–9 months.

The “right medication” depends on the seropositivity of the patient's sputum sample, Dr. Granich said. However, cases of MDR-TB are highly complex, and require 18–24 months of therapy under the supervision of a specialist in order to achieve recovery, he noted.

The World Health Organization has stated goals of detecting 70% of new TB cases and successfully treating 85% of them, said Christopher Dye, D.Phil., at the press briefing.

The most significant barriers to achieving the goals set by WHO exist in Africa, where the HIV epidemic has led to an increased vulnerability to tuberculosis, and in Eastern Europe, where tuberculosis rates doubled during the 1990s, and multidrug resistance is high due to low compliance.

Dr. Dye and his colleagues reported that, with the exception of Africa and Eastern Europe, WHO can achieve its goals with increased application of the Directly Observed Treatment Scheme (DOTS).

This public health strategy that includes gaining political commitment, detecting cases based on sputum smear microscopy, utilizing standard short-course therapy with supportive patient management, ensuring regular drug supplies, and standardizing systems for recording cases and reporting outcomes (JAMA 2005;293:2767–75).

“There is a major education job to be done in terms of keeping tuberculosis on the agenda,” he said.

Another study in the same issue of JAMA found that isoniazid reduced the odds of developing a primary case of tuberculosis in a highly vulnerable population—1,655 male gold miners in Orkney, South Africa, who had previously tested positive for HIV.

After adjustment for age, calendar date, and silicosis grade in 1,041 individuals, there was a 46% reduction in tuberculosis incidence with isoniazid.

Only nine patients discontinued the drug because of adverse events (JAMA 2005;293:2719–25).

WASHINGTON — Cases of multidrug resistance in immigrant populations in the United States and links to the AIDS epidemic in Africa are attracting the attention of researchers.

“There is an erroneous assumption that tuberculosis has been eradicated,” Catherine D. DeAngelis, M.D., editor of the Journal of the American Medical Association, said at a press briefing on tuberculosis sponsored by JAMA.

“In fact it is a big problem, and should be taken seriously,” she said.

Of note, 407 cases of multidrug-resistant tuberculosis (MDR-TB) with specific resistance to at least isoniazid and rifampin occurred in a study of 28,712 tuberculosis cases in California from 1994 to 2003, according to Reuben M. Granich, M.D., of the Centers for Disease Control and Prevention in Atlanta, and his colleagues.

Patients with MDR-TB were seven times more likely to have reported prior tuberculosis treatment, compared with those with non-MDR disease, Dr. Granich said at the press conference.

In addition, 83% of the MDR-TB patients were born outside the United States, which highlights the need for both international control and improved screening, said Dr. Granich.

Prior treatment for tuberculosis was the strongest risk factor for MDR-TB in his study.

“There are two ways to develop MDR-TB,” Dr. Granich said.

One is through noncompliance with the treatment regimen, and the other is via airborne transmission from one patient to another, he said.

Once infected, the average lifetime risk for developing tuberculosis is 10%, and the risk is highest during the first 2 years after infection.

Most healthy people who are exposed to tuberculosis won't go on to develop the disease, and a person's state of health can modify the risk, Dr. Granich noted. For example, the risk of HIV/AIDS patients for developing tuberculosis increases significantly over that of a healthy person exposed to tuberculosis to an approximately 10% annual risk.

Of the 407 MDR-TB cases in Dr. Granich's study, 71 (17%) were resistant only to isoniazid and rifampin, and 86 (21%) were resistant to all four first-line drugs—isoniazid, rifampin, ethambutol, and pyrazinamide.

Most cases of tuberculosis are curable if patients are compliant and take the right medication for 6–9 months.

The “right medication” depends on the seropositivity of the patient's sputum sample, Dr. Granich said. However, cases of MDR-TB are highly complex, and require 18–24 months of therapy under the supervision of a specialist in order to achieve recovery, he noted.

The World Health Organization has stated goals of detecting 70% of new TB cases and successfully treating 85% of them, said Christopher Dye, D.Phil., at the press briefing.

The most significant barriers to achieving the goals set by WHO exist in Africa, where the HIV epidemic has led to an increased vulnerability to tuberculosis, and in Eastern Europe, where tuberculosis rates doubled during the 1990s, and multidrug resistance is high due to low compliance.

Dr. Dye and his colleagues reported that, with the exception of Africa and Eastern Europe, WHO can achieve its goals with increased application of the Directly Observed Treatment Scheme (DOTS).

This public health strategy that includes gaining political commitment, detecting cases based on sputum smear microscopy, utilizing standard short-course therapy with supportive patient management, ensuring regular drug supplies, and standardizing systems for recording cases and reporting outcomes (JAMA 2005;293:2767–75).

“There is a major education job to be done in terms of keeping tuberculosis on the agenda,” he said.

Another study in the same issue of JAMA found that isoniazid reduced the odds of developing a primary case of tuberculosis in a highly vulnerable population—1,655 male gold miners in Orkney, South Africa, who had previously tested positive for HIV.

After adjustment for age, calendar date, and silicosis grade in 1,041 individuals, there was a 46% reduction in tuberculosis incidence with isoniazid.

Only nine patients discontinued the drug because of adverse events (JAMA 2005;293:2719–25).

WASHINGTON — Cases of multidrug resistance in immigrant populations in the United States and links to the AIDS epidemic in Africa are attracting the attention of researchers.

“There is an erroneous assumption that tuberculosis has been eradicated,” Catherine D. DeAngelis, M.D., editor of the Journal of the American Medical Association, said at a press briefing on tuberculosis sponsored by JAMA.

“In fact it is a big problem, and should be taken seriously,” she said.

Of note, 407 cases of multidrug-resistant tuberculosis (MDR-TB) with specific resistance to at least isoniazid and rifampin occurred in a study of 28,712 tuberculosis cases in California from 1994 to 2003, according to Reuben M. Granich, M.D., of the Centers for Disease Control and Prevention in Atlanta, and his colleagues.

Patients with MDR-TB were seven times more likely to have reported prior tuberculosis treatment, compared with those with non-MDR disease, Dr. Granich said at the press conference.

In addition, 83% of the MDR-TB patients were born outside the United States, which highlights the need for both international control and improved screening, said Dr. Granich.

Prior treatment for tuberculosis was the strongest risk factor for MDR-TB in his study.

“There are two ways to develop MDR-TB,” Dr. Granich said.

One is through noncompliance with the treatment regimen, and the other is via airborne transmission from one patient to another, he said.

Once infected, the average lifetime risk for developing tuberculosis is 10%, and the risk is highest during the first 2 years after infection.

Most healthy people who are exposed to tuberculosis won't go on to develop the disease, and a person's state of health can modify the risk, Dr. Granich noted. For example, the risk of HIV/AIDS patients for developing tuberculosis increases significantly over that of a healthy person exposed to tuberculosis to an approximately 10% annual risk.

Of the 407 MDR-TB cases in Dr. Granich's study, 71 (17%) were resistant only to isoniazid and rifampin, and 86 (21%) were resistant to all four first-line drugs—isoniazid, rifampin, ethambutol, and pyrazinamide.

Most cases of tuberculosis are curable if patients are compliant and take the right medication for 6–9 months.

The “right medication” depends on the seropositivity of the patient's sputum sample, Dr. Granich said. However, cases of MDR-TB are highly complex, and require 18–24 months of therapy under the supervision of a specialist in order to achieve recovery, he noted.

The World Health Organization has stated goals of detecting 70% of new TB cases and successfully treating 85% of them, said Christopher Dye, D.Phil., at the press briefing.

The most significant barriers to achieving the goals set by WHO exist in Africa, where the HIV epidemic has led to an increased vulnerability to tuberculosis, and in Eastern Europe, where tuberculosis rates doubled during the 1990s, and multidrug resistance is high due to low compliance.

Dr. Dye and his colleagues reported that, with the exception of Africa and Eastern Europe, WHO can achieve its goals with increased application of the Directly Observed Treatment Scheme (DOTS).

This public health strategy that includes gaining political commitment, detecting cases based on sputum smear microscopy, utilizing standard short-course therapy with supportive patient management, ensuring regular drug supplies, and standardizing systems for recording cases and reporting outcomes (JAMA 2005;293:2767–75).

“There is a major education job to be done in terms of keeping tuberculosis on the agenda,” he said.

Another study in the same issue of JAMA found that isoniazid reduced the odds of developing a primary case of tuberculosis in a highly vulnerable population—1,655 male gold miners in Orkney, South Africa, who had previously tested positive for HIV.

After adjustment for age, calendar date, and silicosis grade in 1,041 individuals, there was a 46% reduction in tuberculosis incidence with isoniazid.

Only nine patients discontinued the drug because of adverse events (JAMA 2005;293:2719–25).

Reception of a living liver graft is more acceptable in German and American culture than it is in Japanese society, according to data from a study of 330 undergraduate medical students from Germany, Japan, and the United States.

Liver transplantation from a living donor is becoming more common, but ethical questions remain as to donor morbidity and mortality after the operation, said Marc H. Dahlke, M.D., of the University of Regensburg (Germany) and his colleagues.

They compared attitudes toward living liver donation among people from three different nations with comparable socioeconomic structures but diversity in traditional values, religious beliefs, and politics. A total of 165 German students, 99 Japanese students, and 66 American students completed the 28-item questionnaire.

Most of the German and American students said they would accept a living liver donation under any circumstances, while most of Japanese students were undecided. Most of the students from all three nations, however, would accept a living liver graft in a life-and-death situation (Psychosomatics 2005;46:58–64).

The willingness to accept a living liver donation decreased across all groups if there was a significant risk to the donor and if it was suggested that the results from a living donation would be worse than a cadaveric donation. In addition, American and German students were more willing than Japanese students to receive a cadaveric liver instead of a living liver.

The study was supported by a grant from Roche Germany and by Fujisawa Germany.

Reception of a living liver graft is more acceptable in German and American culture than it is in Japanese society, according to data from a study of 330 undergraduate medical students from Germany, Japan, and the United States.

Liver transplantation from a living donor is becoming more common, but ethical questions remain as to donor morbidity and mortality after the operation, said Marc H. Dahlke, M.D., of the University of Regensburg (Germany) and his colleagues.

They compared attitudes toward living liver donation among people from three different nations with comparable socioeconomic structures but diversity in traditional values, religious beliefs, and politics. A total of 165 German students, 99 Japanese students, and 66 American students completed the 28-item questionnaire.

Most of the German and American students said they would accept a living liver donation under any circumstances, while most of Japanese students were undecided. Most of the students from all three nations, however, would accept a living liver graft in a life-and-death situation (Psychosomatics 2005;46:58–64).

The willingness to accept a living liver donation decreased across all groups if there was a significant risk to the donor and if it was suggested that the results from a living donation would be worse than a cadaveric donation. In addition, American and German students were more willing than Japanese students to receive a cadaveric liver instead of a living liver.

The study was supported by a grant from Roche Germany and by Fujisawa Germany.

Reception of a living liver graft is more acceptable in German and American culture than it is in Japanese society, according to data from a study of 330 undergraduate medical students from Germany, Japan, and the United States.

Liver transplantation from a living donor is becoming more common, but ethical questions remain as to donor morbidity and mortality after the operation, said Marc H. Dahlke, M.D., of the University of Regensburg (Germany) and his colleagues.

They compared attitudes toward living liver donation among people from three different nations with comparable socioeconomic structures but diversity in traditional values, religious beliefs, and politics. A total of 165 German students, 99 Japanese students, and 66 American students completed the 28-item questionnaire.

Most of the German and American students said they would accept a living liver donation under any circumstances, while most of Japanese students were undecided. Most of the students from all three nations, however, would accept a living liver graft in a life-and-death situation (Psychosomatics 2005;46:58–64).

The willingness to accept a living liver donation decreased across all groups if there was a significant risk to the donor and if it was suggested that the results from a living donation would be worse than a cadaveric donation. In addition, American and German students were more willing than Japanese students to receive a cadaveric liver instead of a living liver.

The study was supported by a grant from Roche Germany and by Fujisawa Germany.

Teen Girls React to Parental Rejection

Aggressive behavior in adolescents may be fueled in part by the depression associated with perceived parental rejection, said William W. Hale III, Ph.D., of Utrecht (the Netherlands) University and his colleagues.

In a study of 1,329 students aged 10–19 years, the investigators assessed aggressive and withdrawn behaviors with a 23-item questionnaire (J. Adolesc. Health 2005;36:466–74). Overall, significant associations appeared between perceived parental rejection and both aggression and depression.

When the population was divided into subgroups, the association between perceived parental rejection and depression was statistically significant for younger girls (aged 10–14 years) and older girls (aged 15–19 years) but not for boys, and the association was statistically significant for the older girls, compared with all other subgroups. Rejection did not appear to have a significant impact on depression or aggression in the subgroups of older or younger boys. The differences might reflect girls' stronger orientation towards interpersonal relationships, the investigators noted.

Adderall XR Effective Over Long Term

A once-daily dose of mixed amphetamine salts (Adderall XR) maintained improvement of ADHD symptoms in children aged 6–12 years during a 24-month period, said James J. McGough, M.D., of the University of California, Los Angeles, and his colleagues.

In a multicenter, open-label extension of two placebo-controlled studies that included 568 children, those who had been off treatment between studies as well as those who had received continuous treatment maintained their statistically significant improvements from baseline (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:530–8). The study consisted of 28 clinic visits–weekly for the first 4 weeks, followed by monthly visits–and the investigators measured effectiveness using the 10-item Conners Global Index Scale. The mean dosage ranged from 20–22 mg/day. The medication was well tolerated, with mild adverse effects.

Substance Use and School Sports

In a cross-sectional study of 891 8th grade students in northeastern Florida, there was no consistent protective effect between any specific sport and substance use, said Michele J. Moore, Ph.D., of the University of North Florida, Jacksonville.

Seven specific sports and activities–school-sponsored football, swimming, and wrestling and out-of-school dancing/cheerleading/gymnastics, skateboarding, surfing, and tennis–were associated with increased odds of alcohol or drug use in one or both genders (J. Adolesc. Health 2005;36:486–93).

On the other hand, participation in four other activities–school-sponsored dance/cheerleading/gymnastics and out-of-school basketball, rollerblading, and swimming–was associated with decreased odds of alcohol or drug use in one or both genders. The results may help explain previous contradictory findings about sports and substance use, the investigators noted.

Perceived Weight Prompts Suicide

Adolescents who perceived themselves to be very underweight (5th percentile or less), slightly underweight (6th–15th percentile), slightly overweight (85th–94th percentile), or very overweight (95th percentile or greater) were significantly more likely to experience suicidal ideation than those who thought their weight was appropriate, said Danice K. Eaton, Ph.D., of the Centers for Disease Control and Prevention, Atlanta, and her colleagues.

In an analysis of data on 13,601 students in grades 9–12 from the national 2001 Youth Risk Behavior Survey, the adjusted odds ratios for suicidal ideation were 2.29, 1.36, 1.33, and 2.50 for students who perceived themselves to be very underweight, slightly underweight, slightly overweight, and very overweight, respectively (Arch. Pediatr. Adolesc. Med. 2005;159:513–9).

Methylphenidate Patch Shows Promise

A methylphenidate transdermal system used for 3 months yielded improvement in ADHD symptoms similar to those achieved with standard methylphenidate, said William E. Pelham, Ph.D., of the State University of New York at Buffalo, and his colleagues.

In a multicenter, double-blind, randomized, dose-ranging study sponsored in part by Noven Pharmaceuticals Inc., 33 boys and 3 girls aged 6–13 years wore a patch with one of three doses–6.25 cm

Teen Girls React to Parental Rejection

Aggressive behavior in adolescents may be fueled in part by the depression associated with perceived parental rejection, said William W. Hale III, Ph.D., of Utrecht (the Netherlands) University and his colleagues.

In a study of 1,329 students aged 10–19 years, the investigators assessed aggressive and withdrawn behaviors with a 23-item questionnaire (J. Adolesc. Health 2005;36:466–74). Overall, significant associations appeared between perceived parental rejection and both aggression and depression.

When the population was divided into subgroups, the association between perceived parental rejection and depression was statistically significant for younger girls (aged 10–14 years) and older girls (aged 15–19 years) but not for boys, and the association was statistically significant for the older girls, compared with all other subgroups. Rejection did not appear to have a significant impact on depression or aggression in the subgroups of older or younger boys. The differences might reflect girls' stronger orientation towards interpersonal relationships, the investigators noted.

Adderall XR Effective Over Long Term

A once-daily dose of mixed amphetamine salts (Adderall XR) maintained improvement of ADHD symptoms in children aged 6–12 years during a 24-month period, said James J. McGough, M.D., of the University of California, Los Angeles, and his colleagues.

In a multicenter, open-label extension of two placebo-controlled studies that included 568 children, those who had been off treatment between studies as well as those who had received continuous treatment maintained their statistically significant improvements from baseline (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:530–8). The study consisted of 28 clinic visits–weekly for the first 4 weeks, followed by monthly visits–and the investigators measured effectiveness using the 10-item Conners Global Index Scale. The mean dosage ranged from 20–22 mg/day. The medication was well tolerated, with mild adverse effects.

Substance Use and School Sports

In a cross-sectional study of 891 8th grade students in northeastern Florida, there was no consistent protective effect between any specific sport and substance use, said Michele J. Moore, Ph.D., of the University of North Florida, Jacksonville.

Seven specific sports and activities–school-sponsored football, swimming, and wrestling and out-of-school dancing/cheerleading/gymnastics, skateboarding, surfing, and tennis–were associated with increased odds of alcohol or drug use in one or both genders (J. Adolesc. Health 2005;36:486–93).

On the other hand, participation in four other activities–school-sponsored dance/cheerleading/gymnastics and out-of-school basketball, rollerblading, and swimming–was associated with decreased odds of alcohol or drug use in one or both genders. The results may help explain previous contradictory findings about sports and substance use, the investigators noted.

Perceived Weight Prompts Suicide

Adolescents who perceived themselves to be very underweight (5th percentile or less), slightly underweight (6th–15th percentile), slightly overweight (85th–94th percentile), or very overweight (95th percentile or greater) were significantly more likely to experience suicidal ideation than those who thought their weight was appropriate, said Danice K. Eaton, Ph.D., of the Centers for Disease Control and Prevention, Atlanta, and her colleagues.

In an analysis of data on 13,601 students in grades 9–12 from the national 2001 Youth Risk Behavior Survey, the adjusted odds ratios for suicidal ideation were 2.29, 1.36, 1.33, and 2.50 for students who perceived themselves to be very underweight, slightly underweight, slightly overweight, and very overweight, respectively (Arch. Pediatr. Adolesc. Med. 2005;159:513–9).

Methylphenidate Patch Shows Promise

A methylphenidate transdermal system used for 3 months yielded improvement in ADHD symptoms similar to those achieved with standard methylphenidate, said William E. Pelham, Ph.D., of the State University of New York at Buffalo, and his colleagues.

In a multicenter, double-blind, randomized, dose-ranging study sponsored in part by Noven Pharmaceuticals Inc., 33 boys and 3 girls aged 6–13 years wore a patch with one of three doses–6.25 cm

Teen Girls React to Parental Rejection

Aggressive behavior in adolescents may be fueled in part by the depression associated with perceived parental rejection, said William W. Hale III, Ph.D., of Utrecht (the Netherlands) University and his colleagues.

In a study of 1,329 students aged 10–19 years, the investigators assessed aggressive and withdrawn behaviors with a 23-item questionnaire (J. Adolesc. Health 2005;36:466–74). Overall, significant associations appeared between perceived parental rejection and both aggression and depression.

When the population was divided into subgroups, the association between perceived parental rejection and depression was statistically significant for younger girls (aged 10–14 years) and older girls (aged 15–19 years) but not for boys, and the association was statistically significant for the older girls, compared with all other subgroups. Rejection did not appear to have a significant impact on depression or aggression in the subgroups of older or younger boys. The differences might reflect girls' stronger orientation towards interpersonal relationships, the investigators noted.

Adderall XR Effective Over Long Term

A once-daily dose of mixed amphetamine salts (Adderall XR) maintained improvement of ADHD symptoms in children aged 6–12 years during a 24-month period, said James J. McGough, M.D., of the University of California, Los Angeles, and his colleagues.

In a multicenter, open-label extension of two placebo-controlled studies that included 568 children, those who had been off treatment between studies as well as those who had received continuous treatment maintained their statistically significant improvements from baseline (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:530–8). The study consisted of 28 clinic visits–weekly for the first 4 weeks, followed by monthly visits–and the investigators measured effectiveness using the 10-item Conners Global Index Scale. The mean dosage ranged from 20–22 mg/day. The medication was well tolerated, with mild adverse effects.

Substance Use and School Sports

In a cross-sectional study of 891 8th grade students in northeastern Florida, there was no consistent protective effect between any specific sport and substance use, said Michele J. Moore, Ph.D., of the University of North Florida, Jacksonville.

Seven specific sports and activities–school-sponsored football, swimming, and wrestling and out-of-school dancing/cheerleading/gymnastics, skateboarding, surfing, and tennis–were associated with increased odds of alcohol or drug use in one or both genders (J. Adolesc. Health 2005;36:486–93).

On the other hand, participation in four other activities–school-sponsored dance/cheerleading/gymnastics and out-of-school basketball, rollerblading, and swimming–was associated with decreased odds of alcohol or drug use in one or both genders. The results may help explain previous contradictory findings about sports and substance use, the investigators noted.

Perceived Weight Prompts Suicide

Adolescents who perceived themselves to be very underweight (5th percentile or less), slightly underweight (6th–15th percentile), slightly overweight (85th–94th percentile), or very overweight (95th percentile or greater) were significantly more likely to experience suicidal ideation than those who thought their weight was appropriate, said Danice K. Eaton, Ph.D., of the Centers for Disease Control and Prevention, Atlanta, and her colleagues.

In an analysis of data on 13,601 students in grades 9–12 from the national 2001 Youth Risk Behavior Survey, the adjusted odds ratios for suicidal ideation were 2.29, 1.36, 1.33, and 2.50 for students who perceived themselves to be very underweight, slightly underweight, slightly overweight, and very overweight, respectively (Arch. Pediatr. Adolesc. Med. 2005;159:513–9).

Methylphenidate Patch Shows Promise

A methylphenidate transdermal system used for 3 months yielded improvement in ADHD symptoms similar to those achieved with standard methylphenidate, said William E. Pelham, Ph.D., of the State University of New York at Buffalo, and his colleagues.

In a multicenter, double-blind, randomized, dose-ranging study sponsored in part by Noven Pharmaceuticals Inc., 33 boys and 3 girls aged 6–13 years wore a patch with one of three doses–6.25 cm

HOUSTON – “When I am asked whether I think [attention-deficit hyperactivity disorder] is overdiagnosed, I say that kids are underfoot now more than they used to be,” Saundra Gilfillan, D.O., said at the annual meeting of the American Society for Adolescent Psychiatry.

“Did we miss ADHD before? No, the hyperactive kids wore themselves out,” said Dr. Gilfillan, a child and adolescent psychiatrist at the University of Texas Southwestern Medical Center at Dallas, which cosponsored the meeting.

Comorbidities are common with ADHD: As many as 80% of children and adolescents with ADHD meet criteria for a related category disorder, particularly conduct disorder, oppositional defiant disorder, and bipolar disorder. When evaluating a child or adolescent for ADHD, it is important to consider other conditions as well.

When Dr. Gilfillan assesses children and adolescents for ADHD, with or without comorbidities, she starts by asking parents about the child's behavior as an infant.

Hyperactive children were often very active in utero and active as infants; they didn't sleep well and were distracted when eating, she said. In addition, children with ADHD often skipped the crawling stage or spent very little time crawling. Dr. Gilfillan also asks whether the child or adolescent is invited to birthday parties.

“It's a very big developmental thing on the social side,” and parents who recognize a “hyper,” aggressive child may not want the child in their house, she noted. She also asks about emergency department visits and car accidents.

“I like to look at report cards, to see what teachers wrote about behavior,” she said. Another question is who babysits. “If the grandmother won't babysit the child, then that's a problem.”

People do not truly outgrow ADHD; the symptoms simply evolve. Motor hyperactivity in childhood evolves into internal feelings of restlessness in adolescence and adulthood. They often have problems in classes where they have to sit or take notes, she said.

Children with ADHD who do not have comorbid conditions generally exhibit less severe symptoms. Their carelessness and inattention may lead to destructiveness and misbehavior, but it appears to be unintentional. Children with ADHD who also have conduct disorder, oppositional defiant disorder, and bipolar disorder are more likely to have social problems, to require hospitalization, and to develop other problems such as depression and anxiety. Here are more specific observations on the comorbidities:

▸ Conduct disorder. “I call these the thugs and 'thugettes,'” Dr. Gilfillan said. These children or teens have no respect for societal norms–they genuinely do not care about the rights of others. The majority of child-onset cases of conduct disorder are in males, but by adolescence the numbers are approximately equal. Children with conduct disorder don't always make it to the psychiatrist because they go into the legal system first.

▸ Oppositional defiant disorder. By contrast, children with oppositional defiant disorders tend to be argumentative, but usually only within their immediate network of family and friends. Some kids negotiate that way; some derive satisfaction from engaging their parents in an argument.

▸ Bipolar disorder. More than 50% of adolescents with bipolar disorder have at least one coexisting psychiatric disorder. “In many areas, to get a child some time in a psychiatric hospital, you must have a diagnosis of bipolar disorder,” Dr. Gilfillan noted. As a result, many clinicians lead with the bipolar diagnosis because they know the child needs to spend some time in an inpatient facility, she said. Features of bipolar disorder in children and adults are similar to characteristics of ADHD. The prolonged outbursts, which she described as “affective storms,” are bipolar rather than hyperactive.

Early symptoms of childhood-onset bipolar disorder include oversensitivity to sensory stimulation and night terrors as an infant, and high levels of anxiety and difficulty controlling anger as a school-aged child. Reports from family members might suggest that the child has a difficult temperament.

Treatment options for children and adolescents with ADHD and other conditions include Strattera (atomoxetine), Adderall (amphetamine mixed salts), and Concerta (methylphenidate), as well as Ritalin (methylphenidate HCl) and Dexedrine (dextroamphetamine sulfate).

Underdosing is one of the most common reasons for discontinuing medication, Dr. Gilfillan said. Parents often are not used to titration for their children's medications, since it is not used for ear infections or urinary tract infections. Families become impatient and say that the medication is not working; they may want to switch drugs instead of increasing the dose. “Medication can do some things, but other things must be done at the same time,” she said. Nonmedication therapies for ADHD and comorbid problems include hobbies, sports that channel excess energy, and strategies for better academic performance, said Dr. Gilfillan, a consultant and member of the speakers' bureau for Pfizer, Ortho-McNeil, and Abbott, and a member of the speakers' bureau for AstraZeneca.

HOUSTON – “When I am asked whether I think [attention-deficit hyperactivity disorder] is overdiagnosed, I say that kids are underfoot now more than they used to be,” Saundra Gilfillan, D.O., said at the annual meeting of the American Society for Adolescent Psychiatry.

“Did we miss ADHD before? No, the hyperactive kids wore themselves out,” said Dr. Gilfillan, a child and adolescent psychiatrist at the University of Texas Southwestern Medical Center at Dallas, which cosponsored the meeting.

Comorbidities are common with ADHD: As many as 80% of children and adolescents with ADHD meet criteria for a related category disorder, particularly conduct disorder, oppositional defiant disorder, and bipolar disorder. When evaluating a child or adolescent for ADHD, it is important to consider other conditions as well.

When Dr. Gilfillan assesses children and adolescents for ADHD, with or without comorbidities, she starts by asking parents about the child's behavior as an infant.

Hyperactive children were often very active in utero and active as infants; they didn't sleep well and were distracted when eating, she said. In addition, children with ADHD often skipped the crawling stage or spent very little time crawling. Dr. Gilfillan also asks whether the child or adolescent is invited to birthday parties.

“It's a very big developmental thing on the social side,” and parents who recognize a “hyper,” aggressive child may not want the child in their house, she noted. She also asks about emergency department visits and car accidents.

“I like to look at report cards, to see what teachers wrote about behavior,” she said. Another question is who babysits. “If the grandmother won't babysit the child, then that's a problem.”

People do not truly outgrow ADHD; the symptoms simply evolve. Motor hyperactivity in childhood evolves into internal feelings of restlessness in adolescence and adulthood. They often have problems in classes where they have to sit or take notes, she said.

Children with ADHD who do not have comorbid conditions generally exhibit less severe symptoms. Their carelessness and inattention may lead to destructiveness and misbehavior, but it appears to be unintentional. Children with ADHD who also have conduct disorder, oppositional defiant disorder, and bipolar disorder are more likely to have social problems, to require hospitalization, and to develop other problems such as depression and anxiety. Here are more specific observations on the comorbidities:

▸ Conduct disorder. “I call these the thugs and 'thugettes,'” Dr. Gilfillan said. These children or teens have no respect for societal norms–they genuinely do not care about the rights of others. The majority of child-onset cases of conduct disorder are in males, but by adolescence the numbers are approximately equal. Children with conduct disorder don't always make it to the psychiatrist because they go into the legal system first.

▸ Oppositional defiant disorder. By contrast, children with oppositional defiant disorders tend to be argumentative, but usually only within their immediate network of family and friends. Some kids negotiate that way; some derive satisfaction from engaging their parents in an argument.

▸ Bipolar disorder. More than 50% of adolescents with bipolar disorder have at least one coexisting psychiatric disorder. “In many areas, to get a child some time in a psychiatric hospital, you must have a diagnosis of bipolar disorder,” Dr. Gilfillan noted. As a result, many clinicians lead with the bipolar diagnosis because they know the child needs to spend some time in an inpatient facility, she said. Features of bipolar disorder in children and adults are similar to characteristics of ADHD. The prolonged outbursts, which she described as “affective storms,” are bipolar rather than hyperactive.

Early symptoms of childhood-onset bipolar disorder include oversensitivity to sensory stimulation and night terrors as an infant, and high levels of anxiety and difficulty controlling anger as a school-aged child. Reports from family members might suggest that the child has a difficult temperament.

Treatment options for children and adolescents with ADHD and other conditions include Strattera (atomoxetine), Adderall (amphetamine mixed salts), and Concerta (methylphenidate), as well as Ritalin (methylphenidate HCl) and Dexedrine (dextroamphetamine sulfate).

Underdosing is one of the most common reasons for discontinuing medication, Dr. Gilfillan said. Parents often are not used to titration for their children's medications, since it is not used for ear infections or urinary tract infections. Families become impatient and say that the medication is not working; they may want to switch drugs instead of increasing the dose. “Medication can do some things, but other things must be done at the same time,” she said. Nonmedication therapies for ADHD and comorbid problems include hobbies, sports that channel excess energy, and strategies for better academic performance, said Dr. Gilfillan, a consultant and member of the speakers' bureau for Pfizer, Ortho-McNeil, and Abbott, and a member of the speakers' bureau for AstraZeneca.

HOUSTON – “When I am asked whether I think [attention-deficit hyperactivity disorder] is overdiagnosed, I say that kids are underfoot now more than they used to be,” Saundra Gilfillan, D.O., said at the annual meeting of the American Society for Adolescent Psychiatry.

“Did we miss ADHD before? No, the hyperactive kids wore themselves out,” said Dr. Gilfillan, a child and adolescent psychiatrist at the University of Texas Southwestern Medical Center at Dallas, which cosponsored the meeting.

Comorbidities are common with ADHD: As many as 80% of children and adolescents with ADHD meet criteria for a related category disorder, particularly conduct disorder, oppositional defiant disorder, and bipolar disorder. When evaluating a child or adolescent for ADHD, it is important to consider other conditions as well.

When Dr. Gilfillan assesses children and adolescents for ADHD, with or without comorbidities, she starts by asking parents about the child's behavior as an infant.

Hyperactive children were often very active in utero and active as infants; they didn't sleep well and were distracted when eating, she said. In addition, children with ADHD often skipped the crawling stage or spent very little time crawling. Dr. Gilfillan also asks whether the child or adolescent is invited to birthday parties.

“It's a very big developmental thing on the social side,” and parents who recognize a “hyper,” aggressive child may not want the child in their house, she noted. She also asks about emergency department visits and car accidents.

“I like to look at report cards, to see what teachers wrote about behavior,” she said. Another question is who babysits. “If the grandmother won't babysit the child, then that's a problem.”

People do not truly outgrow ADHD; the symptoms simply evolve. Motor hyperactivity in childhood evolves into internal feelings of restlessness in adolescence and adulthood. They often have problems in classes where they have to sit or take notes, she said.

Children with ADHD who do not have comorbid conditions generally exhibit less severe symptoms. Their carelessness and inattention may lead to destructiveness and misbehavior, but it appears to be unintentional. Children with ADHD who also have conduct disorder, oppositional defiant disorder, and bipolar disorder are more likely to have social problems, to require hospitalization, and to develop other problems such as depression and anxiety. Here are more specific observations on the comorbidities:

▸ Conduct disorder. “I call these the thugs and 'thugettes,'” Dr. Gilfillan said. These children or teens have no respect for societal norms–they genuinely do not care about the rights of others. The majority of child-onset cases of conduct disorder are in males, but by adolescence the numbers are approximately equal. Children with conduct disorder don't always make it to the psychiatrist because they go into the legal system first.

▸ Oppositional defiant disorder. By contrast, children with oppositional defiant disorders tend to be argumentative, but usually only within their immediate network of family and friends. Some kids negotiate that way; some derive satisfaction from engaging their parents in an argument.

▸ Bipolar disorder. More than 50% of adolescents with bipolar disorder have at least one coexisting psychiatric disorder. “In many areas, to get a child some time in a psychiatric hospital, you must have a diagnosis of bipolar disorder,” Dr. Gilfillan noted. As a result, many clinicians lead with the bipolar diagnosis because they know the child needs to spend some time in an inpatient facility, she said. Features of bipolar disorder in children and adults are similar to characteristics of ADHD. The prolonged outbursts, which she described as “affective storms,” are bipolar rather than hyperactive.

Early symptoms of childhood-onset bipolar disorder include oversensitivity to sensory stimulation and night terrors as an infant, and high levels of anxiety and difficulty controlling anger as a school-aged child. Reports from family members might suggest that the child has a difficult temperament.

Treatment options for children and adolescents with ADHD and other conditions include Strattera (atomoxetine), Adderall (amphetamine mixed salts), and Concerta (methylphenidate), as well as Ritalin (methylphenidate HCl) and Dexedrine (dextroamphetamine sulfate).

Underdosing is one of the most common reasons for discontinuing medication, Dr. Gilfillan said. Parents often are not used to titration for their children's medications, since it is not used for ear infections or urinary tract infections. Families become impatient and say that the medication is not working; they may want to switch drugs instead of increasing the dose. “Medication can do some things, but other things must be done at the same time,” she said. Nonmedication therapies for ADHD and comorbid problems include hobbies, sports that channel excess energy, and strategies for better academic performance, said Dr. Gilfillan, a consultant and member of the speakers' bureau for Pfizer, Ortho-McNeil, and Abbott, and a member of the speakers' bureau for AstraZeneca.