Heidi Splete

WASHINGTON — The first 1,000 uses of the OraQuick Advance Rapid HIV-1 Antibody Test in New Jersey identified nearly double the number of HIV-positive patients, compared with the traditional blood tests, Evan Cadoff, M.D., wrote in a poster presented at the annual meeting of the American College of Preventive Medicine.

However, the data represent rates of seropositivity, not necessarily rates of new HIV infections, wrote Dr. Cadoff of the University of Medicine and Dentistry of New Jersey.

The test requires an oral fluid sample, and delivers results in 20-40 minutes.

Rapid testing in New Jersey began in November 2003 at publicly funded counseling and testing sites throughout the state. After the first 1,000 results, the seropositive rate increased to 4.72%, or double the 2.36% seropositive rate recorded with traditional testing during the previous year.

Overall, 63% of the people who tested positive had not previously been diagnosed with HIV. However, whether the numbers represent improved detection rates in previously targeted at-risk populations or new groups of patients who previously went untested remains uncertain, according to the poster.

The rapid availability of test results reduces the time between a patient's initial diagnosis and referral, bolstering HIV prevention and treatment efforts, Dr. Cadoff said.

WASHINGTON — The first 1,000 uses of the OraQuick Advance Rapid HIV-1 Antibody Test in New Jersey identified nearly double the number of HIV-positive patients, compared with the traditional blood tests, Evan Cadoff, M.D., wrote in a poster presented at the annual meeting of the American College of Preventive Medicine.

However, the data represent rates of seropositivity, not necessarily rates of new HIV infections, wrote Dr. Cadoff of the University of Medicine and Dentistry of New Jersey.

The test requires an oral fluid sample, and delivers results in 20-40 minutes.

Rapid testing in New Jersey began in November 2003 at publicly funded counseling and testing sites throughout the state. After the first 1,000 results, the seropositive rate increased to 4.72%, or double the 2.36% seropositive rate recorded with traditional testing during the previous year.

Overall, 63% of the people who tested positive had not previously been diagnosed with HIV. However, whether the numbers represent improved detection rates in previously targeted at-risk populations or new groups of patients who previously went untested remains uncertain, according to the poster.

The rapid availability of test results reduces the time between a patient's initial diagnosis and referral, bolstering HIV prevention and treatment efforts, Dr. Cadoff said.

WASHINGTON — The first 1,000 uses of the OraQuick Advance Rapid HIV-1 Antibody Test in New Jersey identified nearly double the number of HIV-positive patients, compared with the traditional blood tests, Evan Cadoff, M.D., wrote in a poster presented at the annual meeting of the American College of Preventive Medicine.

However, the data represent rates of seropositivity, not necessarily rates of new HIV infections, wrote Dr. Cadoff of the University of Medicine and Dentistry of New Jersey.

The test requires an oral fluid sample, and delivers results in 20-40 minutes.

Rapid testing in New Jersey began in November 2003 at publicly funded counseling and testing sites throughout the state. After the first 1,000 results, the seropositive rate increased to 4.72%, or double the 2.36% seropositive rate recorded with traditional testing during the previous year.

Overall, 63% of the people who tested positive had not previously been diagnosed with HIV. However, whether the numbers represent improved detection rates in previously targeted at-risk populations or new groups of patients who previously went untested remains uncertain, according to the poster.

The rapid availability of test results reduces the time between a patient's initial diagnosis and referral, bolstering HIV prevention and treatment efforts, Dr. Cadoff said.

ARLINGTON, VA. — Can a surgeon who brings a gun to the operating room be trusted not to use it? That's an extreme example of the kinds of questions that psychiatrists must address when doctors are referred to them for evaluations.

“Disruptive physicians” are doctors whose behavior undermines their personal and professional effectiveness, Ronald Schouten, M.D., said at the annual conference of the Academy of Organizational and Occupational Psychiatry.

“We are talking about people who engage in problematic behavior that interferes with their relationships at work or at home and has a potential impact on patient care, productivity, and administrative functions,” said Dr. Schouten, director of the law and psychiatry service at Massachusetts General Hospital, Boston.

Dr. Schouten presented data from his experience with 82 cases of physicians who had been referred for disruptive behavior. The doctors studied were evaluated for Axis I disorders, but the primary problems proved to be disruptive or noncompliant behavior. The sample excluded disability cases.

Overall, 69 doctors were referred by Physicians' Health Services at their hospitals, 7 by their practices or facilities, 3 by attorneys, 2 by residency programs, and 1 by the medical board.

Surprisingly, 15 were internists and family practice physicians, compared with only 3 general surgeons. “We expected to see more surgical specialists,” since surgery is stereotypically considered to be a particularly stressful field, he said. The average age was 48 years, and most of the doctors (82%) were men. Six of the internal medicine physicians were cardiologists, making cardiology the most common subspecialty in the sample.

Anesthesia was the most common specialty, comprising 13 cases, followed by ob.gyn., with 12 cases. Four of the cases involved emergency medicine physicians, three involved neurologists, and two involved psychiatrists.

Displays of anger proved to be the most common reason for referrals. In 36 cases, doctors were referred because they had lashed out physically or verbally, or because they had spooked their colleagues with behaviors such as wearing a gun in the operating room.

An additional 19 cases involved performance and compliance issues, and 11 cases involved sexual misconduct by the doctors. Other problems included sexual harassment, suspicion of substance abuse, communication problems with staff or peers, theft, and antisocial behavior.

Dr. Schouten noted that in California, the state medical board investigates about 10,000 complaints about disruptive physicians per year. Typically, nearly 80% of these are closed after an initial inquiry, but 20% are investigated further.

In this review, which looked at 584 physicians who had been disciplined by a state medical board over a 30-month period, 75 or 12.8% were psychiatrists—although psychiatrists make up only 7.2% of the percentage of physicians in California, he said.

Diagnosing disruptive doctors involves a caveat, Dr. Schouten said. When physician referral programs send doctors for a psychiatric evaluation, they often are unable to keep physicians in a behavior improvement program without a diagnosis of an Axis I or II disorder.

“There is a bias in favor of finding something to write on the form,” Dr. Schouten said. As a result of that bias, the most common diagnosis in his sample was “personality disorder not otherwise specified,” for 37 doctors, followed by 15 cases of major depression. There were also 10 cases of substance abuse, 9 diagnoses involving personality traits, 7 cases of adjustment disorder, and 6 cases each of bipolar disorder and sleep disorder.

Other non-Axis I and II diagnoses included two cases of anxiety disorder, two cases of attention-deficit hyperactivity disorder, and one case of obsessive-compulsive disorder.

Complete medical screening is an important part of a fitness for work evaluation. Hypertension, found in six cases, was the most common medical problem in the group, followed by hypothyroidism in five cases, and sleep apnea in four. In addition, there were two cases of diabetes, two of obesity, and one case each of Lyme disease, colon cancer, and irritable bowel syndrome.

Among the postevaluation recommendations for these physicians were initiation or continuation of psychiatric treatment, including psychotherapy with a focus on gaining insight into the reasons for the bad behavior; anger management; cognitive-behavioral therapy; and random urine screens in cases of substance abuse. Dr. Schouten strongly recommended that physicians receive follow-up treatment from someone of the same cultural background if possible who is not a colleague, even if that means traveling out of town. Bringing in a business consultant may help a stressed solo practitioner.

The data on outcomes for doctors who have psychiatric referrals are soft, he admitted, but about 80% of physicians whom he has evaluated returned to work. About 9% went out on disability.

Motivating anyone—even physicians—to sustain behavioral change is difficult, Dr. Schouten said. The process of seeing a psychiatrist causes a short-term change in behavior, but over time, people tend to revert to their baseline habits. Many physicians who are referred for a psychiatric consultation resent any suggestion that they be held accountable for their actions. But the term “anger management” meets with less resistance than does “psychotherapy” because it lacks the stigma associated with a mental health problem, he noted.

“Physicians are amazingly lacking in insight into their own behavior,” Dr. Schouten said. “One of the things treatment programs struggle with is how to teach insight to these very bright, well-trained people.”

ARLINGTON, VA. — Can a surgeon who brings a gun to the operating room be trusted not to use it? That's an extreme example of the kinds of questions that psychiatrists must address when doctors are referred to them for evaluations.

“Disruptive physicians” are doctors whose behavior undermines their personal and professional effectiveness, Ronald Schouten, M.D., said at the annual conference of the Academy of Organizational and Occupational Psychiatry.

“We are talking about people who engage in problematic behavior that interferes with their relationships at work or at home and has a potential impact on patient care, productivity, and administrative functions,” said Dr. Schouten, director of the law and psychiatry service at Massachusetts General Hospital, Boston.

Dr. Schouten presented data from his experience with 82 cases of physicians who had been referred for disruptive behavior. The doctors studied were evaluated for Axis I disorders, but the primary problems proved to be disruptive or noncompliant behavior. The sample excluded disability cases.

Overall, 69 doctors were referred by Physicians' Health Services at their hospitals, 7 by their practices or facilities, 3 by attorneys, 2 by residency programs, and 1 by the medical board.

Surprisingly, 15 were internists and family practice physicians, compared with only 3 general surgeons. “We expected to see more surgical specialists,” since surgery is stereotypically considered to be a particularly stressful field, he said. The average age was 48 years, and most of the doctors (82%) were men. Six of the internal medicine physicians were cardiologists, making cardiology the most common subspecialty in the sample.

Anesthesia was the most common specialty, comprising 13 cases, followed by ob.gyn., with 12 cases. Four of the cases involved emergency medicine physicians, three involved neurologists, and two involved psychiatrists.

Displays of anger proved to be the most common reason for referrals. In 36 cases, doctors were referred because they had lashed out physically or verbally, or because they had spooked their colleagues with behaviors such as wearing a gun in the operating room.

An additional 19 cases involved performance and compliance issues, and 11 cases involved sexual misconduct by the doctors. Other problems included sexual harassment, suspicion of substance abuse, communication problems with staff or peers, theft, and antisocial behavior.

Dr. Schouten noted that in California, the state medical board investigates about 10,000 complaints about disruptive physicians per year. Typically, nearly 80% of these are closed after an initial inquiry, but 20% are investigated further.

In this review, which looked at 584 physicians who had been disciplined by a state medical board over a 30-month period, 75 or 12.8% were psychiatrists—although psychiatrists make up only 7.2% of the percentage of physicians in California, he said.

Diagnosing disruptive doctors involves a caveat, Dr. Schouten said. When physician referral programs send doctors for a psychiatric evaluation, they often are unable to keep physicians in a behavior improvement program without a diagnosis of an Axis I or II disorder.

“There is a bias in favor of finding something to write on the form,” Dr. Schouten said. As a result of that bias, the most common diagnosis in his sample was “personality disorder not otherwise specified,” for 37 doctors, followed by 15 cases of major depression. There were also 10 cases of substance abuse, 9 diagnoses involving personality traits, 7 cases of adjustment disorder, and 6 cases each of bipolar disorder and sleep disorder.

Other non-Axis I and II diagnoses included two cases of anxiety disorder, two cases of attention-deficit hyperactivity disorder, and one case of obsessive-compulsive disorder.

Complete medical screening is an important part of a fitness for work evaluation. Hypertension, found in six cases, was the most common medical problem in the group, followed by hypothyroidism in five cases, and sleep apnea in four. In addition, there were two cases of diabetes, two of obesity, and one case each of Lyme disease, colon cancer, and irritable bowel syndrome.

Among the postevaluation recommendations for these physicians were initiation or continuation of psychiatric treatment, including psychotherapy with a focus on gaining insight into the reasons for the bad behavior; anger management; cognitive-behavioral therapy; and random urine screens in cases of substance abuse. Dr. Schouten strongly recommended that physicians receive follow-up treatment from someone of the same cultural background if possible who is not a colleague, even if that means traveling out of town. Bringing in a business consultant may help a stressed solo practitioner.

The data on outcomes for doctors who have psychiatric referrals are soft, he admitted, but about 80% of physicians whom he has evaluated returned to work. About 9% went out on disability.

Motivating anyone—even physicians—to sustain behavioral change is difficult, Dr. Schouten said. The process of seeing a psychiatrist causes a short-term change in behavior, but over time, people tend to revert to their baseline habits. Many physicians who are referred for a psychiatric consultation resent any suggestion that they be held accountable for their actions. But the term “anger management” meets with less resistance than does “psychotherapy” because it lacks the stigma associated with a mental health problem, he noted.

“Physicians are amazingly lacking in insight into their own behavior,” Dr. Schouten said. “One of the things treatment programs struggle with is how to teach insight to these very bright, well-trained people.”

ARLINGTON, VA. — Can a surgeon who brings a gun to the operating room be trusted not to use it? That's an extreme example of the kinds of questions that psychiatrists must address when doctors are referred to them for evaluations.

“Disruptive physicians” are doctors whose behavior undermines their personal and professional effectiveness, Ronald Schouten, M.D., said at the annual conference of the Academy of Organizational and Occupational Psychiatry.

“We are talking about people who engage in problematic behavior that interferes with their relationships at work or at home and has a potential impact on patient care, productivity, and administrative functions,” said Dr. Schouten, director of the law and psychiatry service at Massachusetts General Hospital, Boston.

Dr. Schouten presented data from his experience with 82 cases of physicians who had been referred for disruptive behavior. The doctors studied were evaluated for Axis I disorders, but the primary problems proved to be disruptive or noncompliant behavior. The sample excluded disability cases.

Overall, 69 doctors were referred by Physicians' Health Services at their hospitals, 7 by their practices or facilities, 3 by attorneys, 2 by residency programs, and 1 by the medical board.

Surprisingly, 15 were internists and family practice physicians, compared with only 3 general surgeons. “We expected to see more surgical specialists,” since surgery is stereotypically considered to be a particularly stressful field, he said. The average age was 48 years, and most of the doctors (82%) were men. Six of the internal medicine physicians were cardiologists, making cardiology the most common subspecialty in the sample.

Anesthesia was the most common specialty, comprising 13 cases, followed by ob.gyn., with 12 cases. Four of the cases involved emergency medicine physicians, three involved neurologists, and two involved psychiatrists.

Displays of anger proved to be the most common reason for referrals. In 36 cases, doctors were referred because they had lashed out physically or verbally, or because they had spooked their colleagues with behaviors such as wearing a gun in the operating room.

An additional 19 cases involved performance and compliance issues, and 11 cases involved sexual misconduct by the doctors. Other problems included sexual harassment, suspicion of substance abuse, communication problems with staff or peers, theft, and antisocial behavior.

Dr. Schouten noted that in California, the state medical board investigates about 10,000 complaints about disruptive physicians per year. Typically, nearly 80% of these are closed after an initial inquiry, but 20% are investigated further.

In this review, which looked at 584 physicians who had been disciplined by a state medical board over a 30-month period, 75 or 12.8% were psychiatrists—although psychiatrists make up only 7.2% of the percentage of physicians in California, he said.

Diagnosing disruptive doctors involves a caveat, Dr. Schouten said. When physician referral programs send doctors for a psychiatric evaluation, they often are unable to keep physicians in a behavior improvement program without a diagnosis of an Axis I or II disorder.

“There is a bias in favor of finding something to write on the form,” Dr. Schouten said. As a result of that bias, the most common diagnosis in his sample was “personality disorder not otherwise specified,” for 37 doctors, followed by 15 cases of major depression. There were also 10 cases of substance abuse, 9 diagnoses involving personality traits, 7 cases of adjustment disorder, and 6 cases each of bipolar disorder and sleep disorder.

Other non-Axis I and II diagnoses included two cases of anxiety disorder, two cases of attention-deficit hyperactivity disorder, and one case of obsessive-compulsive disorder.

Complete medical screening is an important part of a fitness for work evaluation. Hypertension, found in six cases, was the most common medical problem in the group, followed by hypothyroidism in five cases, and sleep apnea in four. In addition, there were two cases of diabetes, two of obesity, and one case each of Lyme disease, colon cancer, and irritable bowel syndrome.

Among the postevaluation recommendations for these physicians were initiation or continuation of psychiatric treatment, including psychotherapy with a focus on gaining insight into the reasons for the bad behavior; anger management; cognitive-behavioral therapy; and random urine screens in cases of substance abuse. Dr. Schouten strongly recommended that physicians receive follow-up treatment from someone of the same cultural background if possible who is not a colleague, even if that means traveling out of town. Bringing in a business consultant may help a stressed solo practitioner.

The data on outcomes for doctors who have psychiatric referrals are soft, he admitted, but about 80% of physicians whom he has evaluated returned to work. About 9% went out on disability.

Motivating anyone—even physicians—to sustain behavioral change is difficult, Dr. Schouten said. The process of seeing a psychiatrist causes a short-term change in behavior, but over time, people tend to revert to their baseline habits. Many physicians who are referred for a psychiatric consultation resent any suggestion that they be held accountable for their actions. But the term “anger management” meets with less resistance than does “psychotherapy” because it lacks the stigma associated with a mental health problem, he noted.

“Physicians are amazingly lacking in insight into their own behavior,” Dr. Schouten said. “One of the things treatment programs struggle with is how to teach insight to these very bright, well-trained people.”

WASHINGTON — Women's perceptions that they gain weight when taking hormonal contraceptives are not realities, according to a randomized study.

Data from a poster presented at the annual meeting of the Association of Reproductive Health Professionals refuted the long-held association between use of hormonal contraception and weight gain, showing that women's perceived weight changes didn't match their actual weight changes while using contraceptives.

Concerns about weight gain may lead women to discontinue hormonal contraception, according to Lauren Osborne, a graduate student, and colleagues at Columbia University, New York. No significant weight changes occurred from baseline among women who used hormonal contraception in the form of either a pill or the vaginal ring in their randomized study of 201 subjects.

Overall, 167 of the 201 women completed three menstrual cycles using either oral contraception in the form of Ortho TriCyclen Lo (ethinyl estradiol and norgestimate) or a vaginal contraceptive ring (ethinyl estradiol and etonogestrel). The study was supported by a grant from Organon Pharmaceuticals Inc., maker of the NuvaRing vaginal contraceptive ring.

On average, the women who participated in the study gained 2.8 pounds, regardless of baseline weight or BMI and type of contraceptive used. The 34 women who reported a “bad change” in weight at the study's end had gained an average of 4.4 pounds, while the 112 women who reported “no change” had gained 2.2 pounds, and the 14 women who reported a “good change” had gained 3.3 pounds.

The mean weight of all the women studied was 146 pounds, and included women with BMIs in the healthy (less than 25), overweight (from 25 to 30), and obese (greater than 30) range.

WASHINGTON — Women's perceptions that they gain weight when taking hormonal contraceptives are not realities, according to a randomized study.

Data from a poster presented at the annual meeting of the Association of Reproductive Health Professionals refuted the long-held association between use of hormonal contraception and weight gain, showing that women's perceived weight changes didn't match their actual weight changes while using contraceptives.

Concerns about weight gain may lead women to discontinue hormonal contraception, according to Lauren Osborne, a graduate student, and colleagues at Columbia University, New York. No significant weight changes occurred from baseline among women who used hormonal contraception in the form of either a pill or the vaginal ring in their randomized study of 201 subjects.

Overall, 167 of the 201 women completed three menstrual cycles using either oral contraception in the form of Ortho TriCyclen Lo (ethinyl estradiol and norgestimate) or a vaginal contraceptive ring (ethinyl estradiol and etonogestrel). The study was supported by a grant from Organon Pharmaceuticals Inc., maker of the NuvaRing vaginal contraceptive ring.

On average, the women who participated in the study gained 2.8 pounds, regardless of baseline weight or BMI and type of contraceptive used. The 34 women who reported a “bad change” in weight at the study's end had gained an average of 4.4 pounds, while the 112 women who reported “no change” had gained 2.2 pounds, and the 14 women who reported a “good change” had gained 3.3 pounds.

The mean weight of all the women studied was 146 pounds, and included women with BMIs in the healthy (less than 25), overweight (from 25 to 30), and obese (greater than 30) range.

WASHINGTON — Women's perceptions that they gain weight when taking hormonal contraceptives are not realities, according to a randomized study.

Data from a poster presented at the annual meeting of the Association of Reproductive Health Professionals refuted the long-held association between use of hormonal contraception and weight gain, showing that women's perceived weight changes didn't match their actual weight changes while using contraceptives.

Concerns about weight gain may lead women to discontinue hormonal contraception, according to Lauren Osborne, a graduate student, and colleagues at Columbia University, New York. No significant weight changes occurred from baseline among women who used hormonal contraception in the form of either a pill or the vaginal ring in their randomized study of 201 subjects.

Overall, 167 of the 201 women completed three menstrual cycles using either oral contraception in the form of Ortho TriCyclen Lo (ethinyl estradiol and norgestimate) or a vaginal contraceptive ring (ethinyl estradiol and etonogestrel). The study was supported by a grant from Organon Pharmaceuticals Inc., maker of the NuvaRing vaginal contraceptive ring.

On average, the women who participated in the study gained 2.8 pounds, regardless of baseline weight or BMI and type of contraceptive used. The 34 women who reported a “bad change” in weight at the study's end had gained an average of 4.4 pounds, while the 112 women who reported “no change” had gained 2.2 pounds, and the 14 women who reported a “good change” had gained 3.3 pounds.

The mean weight of all the women studied was 146 pounds, and included women with BMIs in the healthy (less than 25), overweight (from 25 to 30), and obese (greater than 30) range.

WASHINGTON — Brooke Gurland, M.D., realized that, despite her training as a colorectal surgeon, she didn't have a complete perspective on pelvic floor dysfunction.

Fellows in colorectal surgery “weren't even trained to know the anatomy of the other organs, much less how to work with other pelvic specialists in the hospital system,” said Dr. Gurland, a colorectal surgeon at Maimonides Hospital in New York.

A multidisciplinary approach to women's pelvic floor disorders is important, because multiple pelvic floor defects often exist in the absence of patient complaints, she said at the annual meeting of the Gerontological Society of America.

Older women tend to underreport pelvic floor problems, especially those associated with fecal incontinence or defecation problems, because they don't feel comfortable raising the subject with their doctors, or because they find ways to compensate, such as using an enema or finger to complete their defecation.

Research in pelvic floor symptomatology is limited, and many physicians don't know that different treatment options exist for pelvic floor dysfunction, said Dr. Gurland, who is spearheading a pelvic floor task force at Maimonides. The main objectives are to establish a center to evaluate the pelvic floor compartments as a functional unit, to educate health professionals and the community about pelvic floor disorders, to create a database, and to coordinate studies of multicompartment pelvic floor disorders to improve knowledge in this area.

To help finance these efforts, Dr. Gurland received a career development grant totaling $200,000 over 2 years from the American Geriatrics Society to establish the Maimonides Center for Pelvic Floor Dysfunction and Reconstructive Surgery.

The first step was to identify a pelvic floor task force that includes physicians, nurse practitioners, continence specialists, physician assistants, and pain specialists from fields such as urology, gynecology, colorectal surgery, and geriatrics.

Education plans have included a nurses' public health symposium and a fellowship program in which an ob.gyn. would work with Dr. Gurland and a colleague in urogynecology. The staff conducted community outreach by placing ads in local newspapers to encourage women with pelvic floor complaints to visit the center.

“We are getting patients who would not have approached their primary doctors, but are seeking us out specifically,” Dr. Gurland noted.

The designated support staff has made all the difference in establishing the center and creating a multidisciplinary treatment protocol, she said. “I have two physician assistants and two medical assistants who coordinate care between subspecialists. They coordinate surgeries and are trained to do pelvic floor rehabilitation and biofeedback, and provide emotional support to the patients.”

In addition, Dr. Gurland combines office hours with a urogynecologist, which minimizes patient visits and eases the travel burden for elderly patients.

“Once we make a decision on how to care for a patient, I can sit down with the urogynecologist and create a plan,” Dr. Gurland commented. “We can also see the postops together and see how people are responding to treatment.”

Dr. Gurland and her colleagues list the symptoms of fecal dysfunction on their database for tracking patients and conducting research. They use the Wexner fecal incontinence score, which ranges from 0 to 20 (no incontinence to complete fecal incontinence) and included incontinence to flatus, liquid, and solid stool. The frequency of accidents and its effect on lifestyle also are included. In addition, the Rome criteria are used to define obstructive defecation, such as a feeling of anal blockage 25% of the time and the need for an enema or other help to fully evacuate.

Dr. Gurland reported results from the first 70 patients treated at the center. The women enrolled in the database had symptoms of urinary dysfunction and prolapse and either fecal incontinence or difficult evacuation.

The average age was 66 years, with an average parity of 3. Seventeen had undergone hysterectomies.

Although urinary incontinence was the most common symptom, 38 patients had fecal incontinence, 28 had obstructive defecation, and 22 reported rectal pressure.

Of those with fecal incontinence, 89% had urinary incontinence, 61% had pelvic pressure or a bulge, and 3% had pelvic pain.

An overwhelming majority, 82%, of those with obstructed defecation had rectal pressure, 43% had pelvic pressure or bulge, and 25% had pelvic pain. And of those with rectal pressure, 73% had urinary incontinence, 68% had pelvic pressure, and 18% had pelvic pain.

Rectocele was the most common physical finding in the entire group (60% of patients), followed by cystocele, enterocele, rectal prolapse, and anal sphincter defects diagnosed by endorectal ultrasound.

As for the outcomes, 35% had surgery, 25% are undergoing biofeedback treatment, and approximately 28% are considering surgical or nonsurgical treatment. An additional 10% decided they were satisfied with their quality of life and declined treatment.

WASHINGTON — Brooke Gurland, M.D., realized that, despite her training as a colorectal surgeon, she didn't have a complete perspective on pelvic floor dysfunction.

Fellows in colorectal surgery “weren't even trained to know the anatomy of the other organs, much less how to work with other pelvic specialists in the hospital system,” said Dr. Gurland, a colorectal surgeon at Maimonides Hospital in New York.

A multidisciplinary approach to women's pelvic floor disorders is important, because multiple pelvic floor defects often exist in the absence of patient complaints, she said at the annual meeting of the Gerontological Society of America.

Older women tend to underreport pelvic floor problems, especially those associated with fecal incontinence or defecation problems, because they don't feel comfortable raising the subject with their doctors, or because they find ways to compensate, such as using an enema or finger to complete their defecation.

Research in pelvic floor symptomatology is limited, and many physicians don't know that different treatment options exist for pelvic floor dysfunction, said Dr. Gurland, who is spearheading a pelvic floor task force at Maimonides. The main objectives are to establish a center to evaluate the pelvic floor compartments as a functional unit, to educate health professionals and the community about pelvic floor disorders, to create a database, and to coordinate studies of multicompartment pelvic floor disorders to improve knowledge in this area.

To help finance these efforts, Dr. Gurland received a career development grant totaling $200,000 over 2 years from the American Geriatrics Society to establish the Maimonides Center for Pelvic Floor Dysfunction and Reconstructive Surgery.

The first step was to identify a pelvic floor task force that includes physicians, nurse practitioners, continence specialists, physician assistants, and pain specialists from fields such as urology, gynecology, colorectal surgery, and geriatrics.

Education plans have included a nurses' public health symposium and a fellowship program in which an ob.gyn. would work with Dr. Gurland and a colleague in urogynecology. The staff conducted community outreach by placing ads in local newspapers to encourage women with pelvic floor complaints to visit the center.

“We are getting patients who would not have approached their primary doctors, but are seeking us out specifically,” Dr. Gurland noted.

The designated support staff has made all the difference in establishing the center and creating a multidisciplinary treatment protocol, she said. “I have two physician assistants and two medical assistants who coordinate care between subspecialists. They coordinate surgeries and are trained to do pelvic floor rehabilitation and biofeedback, and provide emotional support to the patients.”

In addition, Dr. Gurland combines office hours with a urogynecologist, which minimizes patient visits and eases the travel burden for elderly patients.

“Once we make a decision on how to care for a patient, I can sit down with the urogynecologist and create a plan,” Dr. Gurland commented. “We can also see the postops together and see how people are responding to treatment.”

Dr. Gurland and her colleagues list the symptoms of fecal dysfunction on their database for tracking patients and conducting research. They use the Wexner fecal incontinence score, which ranges from 0 to 20 (no incontinence to complete fecal incontinence) and included incontinence to flatus, liquid, and solid stool. The frequency of accidents and its effect on lifestyle also are included. In addition, the Rome criteria are used to define obstructive defecation, such as a feeling of anal blockage 25% of the time and the need for an enema or other help to fully evacuate.

Dr. Gurland reported results from the first 70 patients treated at the center. The women enrolled in the database had symptoms of urinary dysfunction and prolapse and either fecal incontinence or difficult evacuation.

The average age was 66 years, with an average parity of 3. Seventeen had undergone hysterectomies.

Although urinary incontinence was the most common symptom, 38 patients had fecal incontinence, 28 had obstructive defecation, and 22 reported rectal pressure.

Of those with fecal incontinence, 89% had urinary incontinence, 61% had pelvic pressure or a bulge, and 3% had pelvic pain.

An overwhelming majority, 82%, of those with obstructed defecation had rectal pressure, 43% had pelvic pressure or bulge, and 25% had pelvic pain. And of those with rectal pressure, 73% had urinary incontinence, 68% had pelvic pressure, and 18% had pelvic pain.

Rectocele was the most common physical finding in the entire group (60% of patients), followed by cystocele, enterocele, rectal prolapse, and anal sphincter defects diagnosed by endorectal ultrasound.

As for the outcomes, 35% had surgery, 25% are undergoing biofeedback treatment, and approximately 28% are considering surgical or nonsurgical treatment. An additional 10% decided they were satisfied with their quality of life and declined treatment.

WASHINGTON — Brooke Gurland, M.D., realized that, despite her training as a colorectal surgeon, she didn't have a complete perspective on pelvic floor dysfunction.

Fellows in colorectal surgery “weren't even trained to know the anatomy of the other organs, much less how to work with other pelvic specialists in the hospital system,” said Dr. Gurland, a colorectal surgeon at Maimonides Hospital in New York.

A multidisciplinary approach to women's pelvic floor disorders is important, because multiple pelvic floor defects often exist in the absence of patient complaints, she said at the annual meeting of the Gerontological Society of America.

Older women tend to underreport pelvic floor problems, especially those associated with fecal incontinence or defecation problems, because they don't feel comfortable raising the subject with their doctors, or because they find ways to compensate, such as using an enema or finger to complete their defecation.

Research in pelvic floor symptomatology is limited, and many physicians don't know that different treatment options exist for pelvic floor dysfunction, said Dr. Gurland, who is spearheading a pelvic floor task force at Maimonides. The main objectives are to establish a center to evaluate the pelvic floor compartments as a functional unit, to educate health professionals and the community about pelvic floor disorders, to create a database, and to coordinate studies of multicompartment pelvic floor disorders to improve knowledge in this area.

To help finance these efforts, Dr. Gurland received a career development grant totaling $200,000 over 2 years from the American Geriatrics Society to establish the Maimonides Center for Pelvic Floor Dysfunction and Reconstructive Surgery.

The first step was to identify a pelvic floor task force that includes physicians, nurse practitioners, continence specialists, physician assistants, and pain specialists from fields such as urology, gynecology, colorectal surgery, and geriatrics.

Education plans have included a nurses' public health symposium and a fellowship program in which an ob.gyn. would work with Dr. Gurland and a colleague in urogynecology. The staff conducted community outreach by placing ads in local newspapers to encourage women with pelvic floor complaints to visit the center.

“We are getting patients who would not have approached their primary doctors, but are seeking us out specifically,” Dr. Gurland noted.

The designated support staff has made all the difference in establishing the center and creating a multidisciplinary treatment protocol, she said. “I have two physician assistants and two medical assistants who coordinate care between subspecialists. They coordinate surgeries and are trained to do pelvic floor rehabilitation and biofeedback, and provide emotional support to the patients.”

In addition, Dr. Gurland combines office hours with a urogynecologist, which minimizes patient visits and eases the travel burden for elderly patients.

“Once we make a decision on how to care for a patient, I can sit down with the urogynecologist and create a plan,” Dr. Gurland commented. “We can also see the postops together and see how people are responding to treatment.”

Dr. Gurland and her colleagues list the symptoms of fecal dysfunction on their database for tracking patients and conducting research. They use the Wexner fecal incontinence score, which ranges from 0 to 20 (no incontinence to complete fecal incontinence) and included incontinence to flatus, liquid, and solid stool. The frequency of accidents and its effect on lifestyle also are included. In addition, the Rome criteria are used to define obstructive defecation, such as a feeling of anal blockage 25% of the time and the need for an enema or other help to fully evacuate.

Dr. Gurland reported results from the first 70 patients treated at the center. The women enrolled in the database had symptoms of urinary dysfunction and prolapse and either fecal incontinence or difficult evacuation.

The average age was 66 years, with an average parity of 3. Seventeen had undergone hysterectomies.

Although urinary incontinence was the most common symptom, 38 patients had fecal incontinence, 28 had obstructive defecation, and 22 reported rectal pressure.

Of those with fecal incontinence, 89% had urinary incontinence, 61% had pelvic pressure or a bulge, and 3% had pelvic pain.

An overwhelming majority, 82%, of those with obstructed defecation had rectal pressure, 43% had pelvic pressure or bulge, and 25% had pelvic pain. And of those with rectal pressure, 73% had urinary incontinence, 68% had pelvic pressure, and 18% had pelvic pain.

Rectocele was the most common physical finding in the entire group (60% of patients), followed by cystocele, enterocele, rectal prolapse, and anal sphincter defects diagnosed by endorectal ultrasound.

As for the outcomes, 35% had surgery, 25% are undergoing biofeedback treatment, and approximately 28% are considering surgical or nonsurgical treatment. An additional 10% decided they were satisfied with their quality of life and declined treatment.

FORT LAUDERDALE, FLA. — The chronic dry mouth that characterizes Sjögren's syndrome can accelerate dental decay in approximately 70% of patients with the disease, Steven J. Kusnick, D.D.S., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Patients who attempt to manage their dry mouth symptoms with gum or mints should be advised to use products that contain the natural sweetener xylitol instead of looking for ones that are merely sugar free because the latter won't prevent tooth decay, said Dr. Kusnick, a general dentist in private practice in Sunrise, Fla., and a specialist in cosmetic and reconstructive dentistry.

Over-the-counter products that contain xylitol include Smints, a brand of mints that stimulate saliva and have xylitol as the first ingredient, Koolerz gum in any flavor, and Starbucks gum in peppermint and cinnamon flavors.

Other tips include reminding patients to drink water throughout the day, use lip balm regularly, and avoid smoking and drinking alcohol. While some patients may realize they need to avoid acidic juices, such as orange and grape, many carbonated drinks, including diet sodas, also contain acid and should be avoided.

Two prescription salivary substitute medications—pilocarpine (Salagen) and cevimeline (Evoxac)—can be an effective adjunct to lifestyle modifications, but many patients are deterred by their side effects, which include flushing, sweating, and headaches.

Salivary substitutes can interact poorly with other medications, so physicians should inquire about all medications before prescribing them. And since Sjögren's patients are predisposed to several specific conditions—including liver disease and glaucoma—comorbitities should be thoroughly investigated since many are contraindications for the use of salivary substitutes.

“The earlier we catch a problem, such as a cavity, the easier it is to treat,” so regular checkups are key.

Dr. Kusnick also recommends that his Sjögren's patients use a standard, nonwhitening toothpaste, rather than any of the whitening formulas. “Whitening toothpastes have an ingredient that makes teeth more sensitive. They can also irritate the soft tissues of the mouth. And they don't whiten your teeth that much,” he explained.

Other rules for basic oral health in general apply to Sjögren's patients as well—floss, and avoid snacks between meals. If patients snack, remind them to rinse their mouths with water afterward.

Fluoride varnish can be helpful to prevent decay in high-risk patients, Dr. Kusnick noted. In patients with gumline decay, power toothbrushes can be helpful in getting the fluoride into the gum area. “If people get a lot of cavities, we give them fluoride trays to use at home,” he added.

When cavities occur, Dr. Kusnick recommends crowns rather than standard fillings. Many Sjögren's patients complain that their fillings fall out, and crowns cover the whole tooth, which makes them more secure. He advises Sjögren's patients to avoid dentures.

For more information about managing dry mouth and a list of additional products with xylitol, visit the Oral Health Education Foundation Web site at www.ohef.org

FORT LAUDERDALE, FLA. — The chronic dry mouth that characterizes Sjögren's syndrome can accelerate dental decay in approximately 70% of patients with the disease, Steven J. Kusnick, D.D.S., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Patients who attempt to manage their dry mouth symptoms with gum or mints should be advised to use products that contain the natural sweetener xylitol instead of looking for ones that are merely sugar free because the latter won't prevent tooth decay, said Dr. Kusnick, a general dentist in private practice in Sunrise, Fla., and a specialist in cosmetic and reconstructive dentistry.

Over-the-counter products that contain xylitol include Smints, a brand of mints that stimulate saliva and have xylitol as the first ingredient, Koolerz gum in any flavor, and Starbucks gum in peppermint and cinnamon flavors.

Other tips include reminding patients to drink water throughout the day, use lip balm regularly, and avoid smoking and drinking alcohol. While some patients may realize they need to avoid acidic juices, such as orange and grape, many carbonated drinks, including diet sodas, also contain acid and should be avoided.

Two prescription salivary substitute medications—pilocarpine (Salagen) and cevimeline (Evoxac)—can be an effective adjunct to lifestyle modifications, but many patients are deterred by their side effects, which include flushing, sweating, and headaches.

Salivary substitutes can interact poorly with other medications, so physicians should inquire about all medications before prescribing them. And since Sjögren's patients are predisposed to several specific conditions—including liver disease and glaucoma—comorbitities should be thoroughly investigated since many are contraindications for the use of salivary substitutes.

“The earlier we catch a problem, such as a cavity, the easier it is to treat,” so regular checkups are key.

Dr. Kusnick also recommends that his Sjögren's patients use a standard, nonwhitening toothpaste, rather than any of the whitening formulas. “Whitening toothpastes have an ingredient that makes teeth more sensitive. They can also irritate the soft tissues of the mouth. And they don't whiten your teeth that much,” he explained.

Other rules for basic oral health in general apply to Sjögren's patients as well—floss, and avoid snacks between meals. If patients snack, remind them to rinse their mouths with water afterward.

Fluoride varnish can be helpful to prevent decay in high-risk patients, Dr. Kusnick noted. In patients with gumline decay, power toothbrushes can be helpful in getting the fluoride into the gum area. “If people get a lot of cavities, we give them fluoride trays to use at home,” he added.

When cavities occur, Dr. Kusnick recommends crowns rather than standard fillings. Many Sjögren's patients complain that their fillings fall out, and crowns cover the whole tooth, which makes them more secure. He advises Sjögren's patients to avoid dentures.

For more information about managing dry mouth and a list of additional products with xylitol, visit the Oral Health Education Foundation Web site at www.ohef.org

FORT LAUDERDALE, FLA. — The chronic dry mouth that characterizes Sjögren's syndrome can accelerate dental decay in approximately 70% of patients with the disease, Steven J. Kusnick, D.D.S., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Patients who attempt to manage their dry mouth symptoms with gum or mints should be advised to use products that contain the natural sweetener xylitol instead of looking for ones that are merely sugar free because the latter won't prevent tooth decay, said Dr. Kusnick, a general dentist in private practice in Sunrise, Fla., and a specialist in cosmetic and reconstructive dentistry.

Over-the-counter products that contain xylitol include Smints, a brand of mints that stimulate saliva and have xylitol as the first ingredient, Koolerz gum in any flavor, and Starbucks gum in peppermint and cinnamon flavors.

Other tips include reminding patients to drink water throughout the day, use lip balm regularly, and avoid smoking and drinking alcohol. While some patients may realize they need to avoid acidic juices, such as orange and grape, many carbonated drinks, including diet sodas, also contain acid and should be avoided.

Two prescription salivary substitute medications—pilocarpine (Salagen) and cevimeline (Evoxac)—can be an effective adjunct to lifestyle modifications, but many patients are deterred by their side effects, which include flushing, sweating, and headaches.

Salivary substitutes can interact poorly with other medications, so physicians should inquire about all medications before prescribing them. And since Sjögren's patients are predisposed to several specific conditions—including liver disease and glaucoma—comorbitities should be thoroughly investigated since many are contraindications for the use of salivary substitutes.

“The earlier we catch a problem, such as a cavity, the easier it is to treat,” so regular checkups are key.

Dr. Kusnick also recommends that his Sjögren's patients use a standard, nonwhitening toothpaste, rather than any of the whitening formulas. “Whitening toothpastes have an ingredient that makes teeth more sensitive. They can also irritate the soft tissues of the mouth. And they don't whiten your teeth that much,” he explained.

Other rules for basic oral health in general apply to Sjögren's patients as well—floss, and avoid snacks between meals. If patients snack, remind them to rinse their mouths with water afterward.

Fluoride varnish can be helpful to prevent decay in high-risk patients, Dr. Kusnick noted. In patients with gumline decay, power toothbrushes can be helpful in getting the fluoride into the gum area. “If people get a lot of cavities, we give them fluoride trays to use at home,” he added.

When cavities occur, Dr. Kusnick recommends crowns rather than standard fillings. Many Sjögren's patients complain that their fillings fall out, and crowns cover the whole tooth, which makes them more secure. He advises Sjögren's patients to avoid dentures.

For more information about managing dry mouth and a list of additional products with xylitol, visit the Oral Health Education Foundation Web site at www.ohef.org

FORT LAUDERDALE, FLA. — Sjögren's syndrome is the second most common autoimmune disorder that affects the musculoskeletal system, and yet the average time to diagnosis is 6 years, said Yvonne Sherrer, M.D., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Until more reliable biomarkers for the syndrome are identified, expediting the diagnosis may require physicians to have a higher level of suspicion for some of the less common manifestations of Sjögren's, said Dr. Sherrer, medical director and director of clinical research at the Centre for Rheumatology, Immunology, and Arthritis in Fort Lauderdale.

Although the cause of the Sjögren's is still unknown, researchers suspect that a combination of genetic, environmental, and hormonal factors contribute to predisposition for the disease. Indeed, for every male with the syndrome, an estimated nine women are affected, underscoring the relevance of hormonal influences.

Inflammation of the exocrine glands, the common denominator of Sjögren's syndrome, most obviously affects the eyes, mouth, and vagina, Dr. Sherrer said.

Typically, Sjögren's occurs in the context of a previously diagnosed autoimmune disorder, such as lupus, rheumatoid arthritis, or scleroderma.

The atypical patients with primary Sjögren's “are our most challenging patients, because they don't have an accompanying autoimmune disease,” Dr. Sherrer said. These patients generally present with neuropathy, accelerated dental caries, salivary gland swelling, joint pain without overt arthritis or myositis, and corneal melt. The current international criteria for diagnosing Sjögren's require that patients demonstrate some objective evidence of autoimmunity, in addition to other symptoms. (See box.)

However, the following less typical symptoms may also warrant suspecting Sjögren's syndrome:

▸ Ocular. In addition to extreme dry eyes, patients may suffer from conjunctivitis, keratitis, blepharitis, ulcerations, and perforations.

▸ Ears, Nose, and Throat. Tracheal dryness causes a chronic dry cough in some patients. Nosebleeds, otitis, and sinusitis can be recurring problems.

▸ Oral. Severe dry mouth can cause swallowing problems, which may lead to malnourishment and excessive weight loss. Patients may also have accelerated caries, loss of dentition, and malfunctioning dentures.

▸ Dermatologic/Vascular. Skin rashes are common, and skin eruptions and purpura may occur. Raynaud's phenomenon is a typical vascular manifestation. Vasculitis is always a concern in Sjögren's patients, but symptoms vary depending on the location of the inflammation in the body.

▸ Gastrointestinal. Patients may suffer from esophageal dysmotility. In severe cases, they are at increased risk for pancreatitis, hepatitis, or atrophic gastritis.

▸ Hematologic. Anemia, blood dyscrasias, and cryoglobulinemias are rare but may occur. In addition, Sjögren's patients are at increased risk for lymphoma.

▸ Pulmonary. Lung involvement and coronary involvement are rare but can develop due to dryness of bronchial tubes. Other potential manifestations include bronchitis, bronchitis obliterans-organized pneumonia, and interstitial fibrosis.

▸ Neurologic. Neuropathies tend to be less symmetrical in Sjögren's patients, compared with other conditions. Central nervous system disorders might manifest as changes in cognitive function or as seizures.

▸ Renal. Renal involvement is rare, but when it occurs, it is usually interstitial tube involvement and is more likely to be chronic, compared with highly progressive kidney involvement associated with lupus.

▸ Musculoskeletal. More often than not, patients with Sjögren's have arthralgia, rather than arthritis, but secondary Sjögren's patients may have concurrent arthritis or myositis.

▸ Other. Fibromyalgia occurs in 20%-30% of Sjögren's patients. Sleep disorders, often due to dryness-related discomfort, are common and may contribute to the fibromyalgia. Depression is a common comorbidity, as it is in patients with other autoimmune disease.

Recommended Diagnostic Criteria

The diagnosis of primary Sjögren's syndrome requires that patients meet at least four of the following six criteria:

The patient must have at least one of three ocular symptoms:

▸ Dry eyes for less than 3 months.

▸ Need to use artificial tears more than three times daily.

▸ Sensation of a foreign body in the eye.

The patient must have at least of three oral symptoms:

▸ Persistent dry mouth for more than 3 months.

▸ Swollen salivary glands.

▸ Need to add extra liquid to the mouth in order to swallow.

The patient must have at least one of two ocular signs:

▸ Unanesthetized Schirmer's test result of 5 mm/5 minutes or less in both eyes.

▸ Positive vital dye staining.

The patient must have at least one of three signs of poor salivary gland function:

▸ Abnormal salivary scintigraphy.

▸ Abnormal parotid sialography.

▸ Unstimulated salivary flow rate of 0.1 mL/minute or less.

Positive lip biopsy.

Positive anti-SSA or anti-SSB tests.

Source: “The New Sjögren's Syndrome Handbook” (New York: Oxford University Press, 2005)

FORT LAUDERDALE, FLA. — Sjögren's syndrome is the second most common autoimmune disorder that affects the musculoskeletal system, and yet the average time to diagnosis is 6 years, said Yvonne Sherrer, M.D., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Until more reliable biomarkers for the syndrome are identified, expediting the diagnosis may require physicians to have a higher level of suspicion for some of the less common manifestations of Sjögren's, said Dr. Sherrer, medical director and director of clinical research at the Centre for Rheumatology, Immunology, and Arthritis in Fort Lauderdale.

Although the cause of the Sjögren's is still unknown, researchers suspect that a combination of genetic, environmental, and hormonal factors contribute to predisposition for the disease. Indeed, for every male with the syndrome, an estimated nine women are affected, underscoring the relevance of hormonal influences.

Inflammation of the exocrine glands, the common denominator of Sjögren's syndrome, most obviously affects the eyes, mouth, and vagina, Dr. Sherrer said.

Typically, Sjögren's occurs in the context of a previously diagnosed autoimmune disorder, such as lupus, rheumatoid arthritis, or scleroderma.

The atypical patients with primary Sjögren's “are our most challenging patients, because they don't have an accompanying autoimmune disease,” Dr. Sherrer said. These patients generally present with neuropathy, accelerated dental caries, salivary gland swelling, joint pain without overt arthritis or myositis, and corneal melt. The current international criteria for diagnosing Sjögren's require that patients demonstrate some objective evidence of autoimmunity, in addition to other symptoms. (See box.)

However, the following less typical symptoms may also warrant suspecting Sjögren's syndrome:

▸ Ocular. In addition to extreme dry eyes, patients may suffer from conjunctivitis, keratitis, blepharitis, ulcerations, and perforations.

▸ Ears, Nose, and Throat. Tracheal dryness causes a chronic dry cough in some patients. Nosebleeds, otitis, and sinusitis can be recurring problems.

▸ Oral. Severe dry mouth can cause swallowing problems, which may lead to malnourishment and excessive weight loss. Patients may also have accelerated caries, loss of dentition, and malfunctioning dentures.

▸ Dermatologic/Vascular. Skin rashes are common, and skin eruptions and purpura may occur. Raynaud's phenomenon is a typical vascular manifestation. Vasculitis is always a concern in Sjögren's patients, but symptoms vary depending on the location of the inflammation in the body.

▸ Gastrointestinal. Patients may suffer from esophageal dysmotility. In severe cases, they are at increased risk for pancreatitis, hepatitis, or atrophic gastritis.

▸ Hematologic. Anemia, blood dyscrasias, and cryoglobulinemias are rare but may occur. In addition, Sjögren's patients are at increased risk for lymphoma.

▸ Pulmonary. Lung involvement and coronary involvement are rare but can develop due to dryness of bronchial tubes. Other potential manifestations include bronchitis, bronchitis obliterans-organized pneumonia, and interstitial fibrosis.

▸ Neurologic. Neuropathies tend to be less symmetrical in Sjögren's patients, compared with other conditions. Central nervous system disorders might manifest as changes in cognitive function or as seizures.

▸ Renal. Renal involvement is rare, but when it occurs, it is usually interstitial tube involvement and is more likely to be chronic, compared with highly progressive kidney involvement associated with lupus.

▸ Musculoskeletal. More often than not, patients with Sjögren's have arthralgia, rather than arthritis, but secondary Sjögren's patients may have concurrent arthritis or myositis.

▸ Other. Fibromyalgia occurs in 20%-30% of Sjögren's patients. Sleep disorders, often due to dryness-related discomfort, are common and may contribute to the fibromyalgia. Depression is a common comorbidity, as it is in patients with other autoimmune disease.

Recommended Diagnostic Criteria

The diagnosis of primary Sjögren's syndrome requires that patients meet at least four of the following six criteria:

The patient must have at least one of three ocular symptoms:

▸ Dry eyes for less than 3 months.

▸ Need to use artificial tears more than three times daily.

▸ Sensation of a foreign body in the eye.

The patient must have at least of three oral symptoms:

▸ Persistent dry mouth for more than 3 months.

▸ Swollen salivary glands.

▸ Need to add extra liquid to the mouth in order to swallow.

The patient must have at least one of two ocular signs:

▸ Unanesthetized Schirmer's test result of 5 mm/5 minutes or less in both eyes.

▸ Positive vital dye staining.

The patient must have at least one of three signs of poor salivary gland function:

▸ Abnormal salivary scintigraphy.

▸ Abnormal parotid sialography.

▸ Unstimulated salivary flow rate of 0.1 mL/minute or less.

Positive lip biopsy.

Positive anti-SSA or anti-SSB tests.

Source: “The New Sjögren's Syndrome Handbook” (New York: Oxford University Press, 2005)

FORT LAUDERDALE, FLA. — Sjögren's syndrome is the second most common autoimmune disorder that affects the musculoskeletal system, and yet the average time to diagnosis is 6 years, said Yvonne Sherrer, M.D., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Until more reliable biomarkers for the syndrome are identified, expediting the diagnosis may require physicians to have a higher level of suspicion for some of the less common manifestations of Sjögren's, said Dr. Sherrer, medical director and director of clinical research at the Centre for Rheumatology, Immunology, and Arthritis in Fort Lauderdale.

Although the cause of the Sjögren's is still unknown, researchers suspect that a combination of genetic, environmental, and hormonal factors contribute to predisposition for the disease. Indeed, for every male with the syndrome, an estimated nine women are affected, underscoring the relevance of hormonal influences.

Inflammation of the exocrine glands, the common denominator of Sjögren's syndrome, most obviously affects the eyes, mouth, and vagina, Dr. Sherrer said.

Typically, Sjögren's occurs in the context of a previously diagnosed autoimmune disorder, such as lupus, rheumatoid arthritis, or scleroderma.

The atypical patients with primary Sjögren's “are our most challenging patients, because they don't have an accompanying autoimmune disease,” Dr. Sherrer said. These patients generally present with neuropathy, accelerated dental caries, salivary gland swelling, joint pain without overt arthritis or myositis, and corneal melt. The current international criteria for diagnosing Sjögren's require that patients demonstrate some objective evidence of autoimmunity, in addition to other symptoms. (See box.)

However, the following less typical symptoms may also warrant suspecting Sjögren's syndrome:

▸ Ocular. In addition to extreme dry eyes, patients may suffer from conjunctivitis, keratitis, blepharitis, ulcerations, and perforations.

▸ Ears, Nose, and Throat. Tracheal dryness causes a chronic dry cough in some patients. Nosebleeds, otitis, and sinusitis can be recurring problems.

▸ Oral. Severe dry mouth can cause swallowing problems, which may lead to malnourishment and excessive weight loss. Patients may also have accelerated caries, loss of dentition, and malfunctioning dentures.

▸ Dermatologic/Vascular. Skin rashes are common, and skin eruptions and purpura may occur. Raynaud's phenomenon is a typical vascular manifestation. Vasculitis is always a concern in Sjögren's patients, but symptoms vary depending on the location of the inflammation in the body.

▸ Gastrointestinal. Patients may suffer from esophageal dysmotility. In severe cases, they are at increased risk for pancreatitis, hepatitis, or atrophic gastritis.

▸ Hematologic. Anemia, blood dyscrasias, and cryoglobulinemias are rare but may occur. In addition, Sjögren's patients are at increased risk for lymphoma.

▸ Pulmonary. Lung involvement and coronary involvement are rare but can develop due to dryness of bronchial tubes. Other potential manifestations include bronchitis, bronchitis obliterans-organized pneumonia, and interstitial fibrosis.

▸ Neurologic. Neuropathies tend to be less symmetrical in Sjögren's patients, compared with other conditions. Central nervous system disorders might manifest as changes in cognitive function or as seizures.

▸ Renal. Renal involvement is rare, but when it occurs, it is usually interstitial tube involvement and is more likely to be chronic, compared with highly progressive kidney involvement associated with lupus.

▸ Musculoskeletal. More often than not, patients with Sjögren's have arthralgia, rather than arthritis, but secondary Sjögren's patients may have concurrent arthritis or myositis.

▸ Other. Fibromyalgia occurs in 20%-30% of Sjögren's patients. Sleep disorders, often due to dryness-related discomfort, are common and may contribute to the fibromyalgia. Depression is a common comorbidity, as it is in patients with other autoimmune disease.

Recommended Diagnostic Criteria

The diagnosis of primary Sjögren's syndrome requires that patients meet at least four of the following six criteria:

The patient must have at least one of three ocular symptoms:

▸ Dry eyes for less than 3 months.

▸ Need to use artificial tears more than three times daily.

▸ Sensation of a foreign body in the eye.

The patient must have at least of three oral symptoms:

▸ Persistent dry mouth for more than 3 months.

▸ Swollen salivary glands.

▸ Need to add extra liquid to the mouth in order to swallow.

The patient must have at least one of two ocular signs:

▸ Unanesthetized Schirmer's test result of 5 mm/5 minutes or less in both eyes.

▸ Positive vital dye staining.

The patient must have at least one of three signs of poor salivary gland function:

▸ Abnormal salivary scintigraphy.

▸ Abnormal parotid sialography.

▸ Unstimulated salivary flow rate of 0.1 mL/minute or less.

Positive lip biopsy.

Positive anti-SSA or anti-SSB tests.

Source: “The New Sjögren's Syndrome Handbook” (New York: Oxford University Press, 2005)

A new study puts a twist in the theory that statins could conveniently serve dual purposes in patients with inflammatory diseases that affect both the joints and heart.

Findings from the investigation, involving 5,678 women aged 65 and older, suggest that the use of statins appeared to modestly increase a woman's risk of developing new relatively severe radiographic hip osteoarthritis.

However, statin use did not appear to affect the progression of disease in patients who already had osteoarthritis, reported Mary S. Beattie, M.D., and her associates at the University of California, San Francisco (J. Rheumatol. 2005;32:106-10).

The rationale for the study was based on the fact that while statins are increasingly recognized for their broad anti-inflammatory effects, they have also been shown to increase the production of nitric oxide, which could have a deleterious effect on the cartilage matrix, the investigators said.

The researchers monitored the women, all of whom were white and aged 65 and older, for radiographic evidence of new-onset disease as well as for the progression of established radiographic hip osteoarthritis (RHOA) over an 8-year period. All the women had already been participants in a multicenter study of osteoporotic fractures.

Overall, 7% (397) of the women were statin users, and these women demonstrated nearly twice the risk of developing severe disease, defined radiographically as a summary grade of 3 or greater on the modified Croft scale.

At baseline, 4,933 women had no RHOA in either hip; 566 women had developed new, radiographic evidence of disease in 630 hips by the fifth follow-up visit. Of the 745 women who had RHOA in 936 hips at baseline, the disease worsened in 484 hips among 420 women.

Evidence of new-onset radiographic disease was deemed present if any of five criteria were met: a summary grade of 2 or greater; a minimum joint space (MJS) of 1.5 mm or less; joint space narrowing superolaterally of 2 or greater and superomedially of 3 or greater; or definite osteophytes in any location.

Radiographic progression was deemed present if the MJS decreased by 0.5 mm or more; summary grade increased by 1 or greater; or the osteophyte score increased by 2 or more.

Only 26 (6.5%) of the statin users showed signs of progressive disease. There was a moderate, but not statistically significant, trend toward a decreased risk of OA progression among statin users.

Women who showed signs of progressive RHOA were less likely to be taking vitamin D, compared with women whose disease did not progress (42.6% vs. 51.5%); however, the odds ratio was not statistically significant. There were no significant differences between those with and without RHOA in terms of age, BMI, and walking for exercise.

The study findings are limited by the fact that the investigation included only white women and a small number of statin users.

Evidence suggests that the use of statins can slightly improve symptoms among rheumatoid arthritis patients, Christopher J. Penney, M.D., of the University of Calgary (Alta.), noted in an accompanying editorial.

“The quite modest effect of statins in the management of human rheumatic disease may be related to the dose or to the differences between mouse, man, and test tube,” he said, adding that more prospective trials of statins are needed to determine whether the effects are clinically significant (J. Rheumatol. 2005;32:17-9).

“Obesity is the common denominator for the presence of high cholesterol and hip osteoarthritis in women, and this may explain the results of this trial,” Roy D. Altman, M.D., an osteoarthritis specialist in Agua Dulce, Calif., said in an interview.

The researchers alluded to the relationship between obesity and hip osteoarthritis in women by adjusting for height and weight, but they did not specifically adjust for BMI, noted Dr. Altman, a member of the RHEUMATOLOGY NEWS editorial advisory board.

A new study puts a twist in the theory that statins could conveniently serve dual purposes in patients with inflammatory diseases that affect both the joints and heart.

Findings from the investigation, involving 5,678 women aged 65 and older, suggest that the use of statins appeared to modestly increase a woman's risk of developing new relatively severe radiographic hip osteoarthritis.

However, statin use did not appear to affect the progression of disease in patients who already had osteoarthritis, reported Mary S. Beattie, M.D., and her associates at the University of California, San Francisco (J. Rheumatol. 2005;32:106-10).

The rationale for the study was based on the fact that while statins are increasingly recognized for their broad anti-inflammatory effects, they have also been shown to increase the production of nitric oxide, which could have a deleterious effect on the cartilage matrix, the investigators said.

The researchers monitored the women, all of whom were white and aged 65 and older, for radiographic evidence of new-onset disease as well as for the progression of established radiographic hip osteoarthritis (RHOA) over an 8-year period. All the women had already been participants in a multicenter study of osteoporotic fractures.

Overall, 7% (397) of the women were statin users, and these women demonstrated nearly twice the risk of developing severe disease, defined radiographically as a summary grade of 3 or greater on the modified Croft scale.

At baseline, 4,933 women had no RHOA in either hip; 566 women had developed new, radiographic evidence of disease in 630 hips by the fifth follow-up visit. Of the 745 women who had RHOA in 936 hips at baseline, the disease worsened in 484 hips among 420 women.

Evidence of new-onset radiographic disease was deemed present if any of five criteria were met: a summary grade of 2 or greater; a minimum joint space (MJS) of 1.5 mm or less; joint space narrowing superolaterally of 2 or greater and superomedially of 3 or greater; or definite osteophytes in any location.

Radiographic progression was deemed present if the MJS decreased by 0.5 mm or more; summary grade increased by 1 or greater; or the osteophyte score increased by 2 or more.

Only 26 (6.5%) of the statin users showed signs of progressive disease. There was a moderate, but not statistically significant, trend toward a decreased risk of OA progression among statin users.

Women who showed signs of progressive RHOA were less likely to be taking vitamin D, compared with women whose disease did not progress (42.6% vs. 51.5%); however, the odds ratio was not statistically significant. There were no significant differences between those with and without RHOA in terms of age, BMI, and walking for exercise.

The study findings are limited by the fact that the investigation included only white women and a small number of statin users.

Evidence suggests that the use of statins can slightly improve symptoms among rheumatoid arthritis patients, Christopher J. Penney, M.D., of the University of Calgary (Alta.), noted in an accompanying editorial.

“The quite modest effect of statins in the management of human rheumatic disease may be related to the dose or to the differences between mouse, man, and test tube,” he said, adding that more prospective trials of statins are needed to determine whether the effects are clinically significant (J. Rheumatol. 2005;32:17-9).

“Obesity is the common denominator for the presence of high cholesterol and hip osteoarthritis in women, and this may explain the results of this trial,” Roy D. Altman, M.D., an osteoarthritis specialist in Agua Dulce, Calif., said in an interview.

The researchers alluded to the relationship between obesity and hip osteoarthritis in women by adjusting for height and weight, but they did not specifically adjust for BMI, noted Dr. Altman, a member of the RHEUMATOLOGY NEWS editorial advisory board.

A new study puts a twist in the theory that statins could conveniently serve dual purposes in patients with inflammatory diseases that affect both the joints and heart.

Findings from the investigation, involving 5,678 women aged 65 and older, suggest that the use of statins appeared to modestly increase a woman's risk of developing new relatively severe radiographic hip osteoarthritis.

However, statin use did not appear to affect the progression of disease in patients who already had osteoarthritis, reported Mary S. Beattie, M.D., and her associates at the University of California, San Francisco (J. Rheumatol. 2005;32:106-10).

The rationale for the study was based on the fact that while statins are increasingly recognized for their broad anti-inflammatory effects, they have also been shown to increase the production of nitric oxide, which could have a deleterious effect on the cartilage matrix, the investigators said.

The researchers monitored the women, all of whom were white and aged 65 and older, for radiographic evidence of new-onset disease as well as for the progression of established radiographic hip osteoarthritis (RHOA) over an 8-year period. All the women had already been participants in a multicenter study of osteoporotic fractures.

Overall, 7% (397) of the women were statin users, and these women demonstrated nearly twice the risk of developing severe disease, defined radiographically as a summary grade of 3 or greater on the modified Croft scale.

At baseline, 4,933 women had no RHOA in either hip; 566 women had developed new, radiographic evidence of disease in 630 hips by the fifth follow-up visit. Of the 745 women who had RHOA in 936 hips at baseline, the disease worsened in 484 hips among 420 women.

Evidence of new-onset radiographic disease was deemed present if any of five criteria were met: a summary grade of 2 or greater; a minimum joint space (MJS) of 1.5 mm or less; joint space narrowing superolaterally of 2 or greater and superomedially of 3 or greater; or definite osteophytes in any location.

Radiographic progression was deemed present if the MJS decreased by 0.5 mm or more; summary grade increased by 1 or greater; or the osteophyte score increased by 2 or more.

Only 26 (6.5%) of the statin users showed signs of progressive disease. There was a moderate, but not statistically significant, trend toward a decreased risk of OA progression among statin users.

Women who showed signs of progressive RHOA were less likely to be taking vitamin D, compared with women whose disease did not progress (42.6% vs. 51.5%); however, the odds ratio was not statistically significant. There were no significant differences between those with and without RHOA in terms of age, BMI, and walking for exercise.

The study findings are limited by the fact that the investigation included only white women and a small number of statin users.

Evidence suggests that the use of statins can slightly improve symptoms among rheumatoid arthritis patients, Christopher J. Penney, M.D., of the University of Calgary (Alta.), noted in an accompanying editorial.

“The quite modest effect of statins in the management of human rheumatic disease may be related to the dose or to the differences between mouse, man, and test tube,” he said, adding that more prospective trials of statins are needed to determine whether the effects are clinically significant (J. Rheumatol. 2005;32:17-9).

“Obesity is the common denominator for the presence of high cholesterol and hip osteoarthritis in women, and this may explain the results of this trial,” Roy D. Altman, M.D., an osteoarthritis specialist in Agua Dulce, Calif., said in an interview.

The researchers alluded to the relationship between obesity and hip osteoarthritis in women by adjusting for height and weight, but they did not specifically adjust for BMI, noted Dr. Altman, a member of the RHEUMATOLOGY NEWS editorial advisory board.

HAART Stabilizes CD4+ Counts

The CD4+ T-cell counts of 31 children aged 2.4 months-16.4 years with HIV-1 remained stable throughout 4 years of highly active antiretroviral therapy (HAART), reported Pieter L.A. Fraaij, M.D., of Erasmus Medical Center-Sophia Children's Hospital, in Rotterdam, the Netherlands, and his colleagues. At baseline, 28 children started HAART that included indinavir and 3 started HAART that included nelfinavir (Clin. Infect. Dis. 2005;40:604-8). In the intent-to-treat analysis, 65% had HIV-1 levels less than 500 copies/mL and 61% had less than 50 copies/mL after 4 years of treatment. Overall, 28 children changed therapies 38 times during the study period, for reasons including 20 cases of treatment failure, 7 cases of drug toxicity, 7 cases of simplification of the drug regimen, 3 cases of refusal or intolerance of medication, and failure to reach appropriate results in 1 case. HAART was changed at least once in 13 children (41%) due to viral failure. Clinical adverse events occurred in 24 children (77%), but they were mostly mild gastrointestinal problems. Seven children changed medications due to toxicity associated with indinavir. Six were lost to follow-up, and one child died of serious invasive opportunistic infections 1 year into the therapy.

Varicella Vaccination Cuts Mortality

Mortality due to varicella fell from an average of 0.32 deaths per million between 1990 and 1994 to an average of 0.07 deaths per million between 1999 and 2001among children aged 1-4 years due to the adoption of universal childhood varicella vaccination in the United States, with the lowest rates for all groups in 2001, said Huong Q. Nguyen and colleagues at the Centers for Disease Control and Prevention (N. Engl. J. Med. 2005;352:450-8). In addition, deaths due to varicella fell significantly among children aged 10-19 years (67%) and among infants (66%) between the two periods. The decline in mortality was 100% among children aged 1-4 years and aged 5-9 years for children at high risk due to preexisting conditions; however, children with preexisting conditions might have received aggressive treatment when they developed varicella. Overall, mortality was similar across racial and ethnic groups, and similar among children born in the United States compared with foreign-born children.

E. coli Linked to Diarrhea

Diarrheagenic Escherichia coli was isolated significantly more often in children with acute gastroenteritis in an emergency department compared with inpatients and controls, said Mitchell B. Cohen, M.D., of Cincinnati Children's Hospital Medical Center, and his associates. In a study of 684 children who presented to an emergency department, 643 inpatient children, and 555 controls, the investigators used DNA probes to evaluate stool samples. A majority in each group was aged 5 years or younger (J. Pediatr. 2005;146:54-61). Diarrheagenic E. coli was present in 167 (24%) of 684 ED patients, compared with 78 (14%) of 555 control patients. However, there was no significant difference in prevalence of E. coli between the inpatients (13%) and controls (14%). There also was no significant difference in prevalence of E. coli between the inpatients and controls in the subset aged 5 years and younger (13.5% vs. 15.4%). In addition, the researchers found a significantly high isolation rate of enteroaggregative E. coli in ED patients less than 1 year old, compared with controls (10% vs. 1.4%). “Diarrheagenic E. coli may be an important, unrecognized cause of diarrhea in children in the [United States], perhaps accounting for 10% of all acute gastroenteritis,” the investigators said. Rotavirus was the most common single etiologic agent, found in 20.3% of inpatients and 20.2% of ED patients, compared with 1.1% of controls.

Urinalysis Predicts Kidney Diseases

Children with a combination of microhematuria and proteinuria were at significantly increased risk for kidney disease or decreased kidney function in a retrospective chart review of 239 children, reported Jayanthi Chandar, M.D., and colleagues at the University of Miami (Clin. Pediatr. 2005;44:43-8). Overall, 109 children had isolated microhematuria, 79 had isolated proteinuria, and 51 had a combination of the two conditions. The 11 children who initially presented with a combination of both conditions had odds ratios of 8.5 for developing kidney disease and 9.8 for decreased kidney function. An additional 17 children presented with proteinuria and later developed microhematuria, and 23 presented with microhematuria and later developed proteinuria, and these children also were at increased risk for kidney problems. A total of 163 children (68%) underwent renal ultrasounds, 16% of which showed genitourinary disease or abnormalities in kidney size or echogenicity. Although urinalysis remains controversial as a screening tool, children with persistent urine abnormalities should be evaluated in order to diagnose kidney disease as soon as possible.

HAART Stabilizes CD4+ Counts

The CD4+ T-cell counts of 31 children aged 2.4 months-16.4 years with HIV-1 remained stable throughout 4 years of highly active antiretroviral therapy (HAART), reported Pieter L.A. Fraaij, M.D., of Erasmus Medical Center-Sophia Children's Hospital, in Rotterdam, the Netherlands, and his colleagues. At baseline, 28 children started HAART that included indinavir and 3 started HAART that included nelfinavir (Clin. Infect. Dis. 2005;40:604-8). In the intent-to-treat analysis, 65% had HIV-1 levels less than 500 copies/mL and 61% had less than 50 copies/mL after 4 years of treatment. Overall, 28 children changed therapies 38 times during the study period, for reasons including 20 cases of treatment failure, 7 cases of drug toxicity, 7 cases of simplification of the drug regimen, 3 cases of refusal or intolerance of medication, and failure to reach appropriate results in 1 case. HAART was changed at least once in 13 children (41%) due to viral failure. Clinical adverse events occurred in 24 children (77%), but they were mostly mild gastrointestinal problems. Seven children changed medications due to toxicity associated with indinavir. Six were lost to follow-up, and one child died of serious invasive opportunistic infections 1 year into the therapy.

Varicella Vaccination Cuts Mortality

Mortality due to varicella fell from an average of 0.32 deaths per million between 1990 and 1994 to an average of 0.07 deaths per million between 1999 and 2001among children aged 1-4 years due to the adoption of universal childhood varicella vaccination in the United States, with the lowest rates for all groups in 2001, said Huong Q. Nguyen and colleagues at the Centers for Disease Control and Prevention (N. Engl. J. Med. 2005;352:450-8). In addition, deaths due to varicella fell significantly among children aged 10-19 years (67%) and among infants (66%) between the two periods. The decline in mortality was 100% among children aged 1-4 years and aged 5-9 years for children at high risk due to preexisting conditions; however, children with preexisting conditions might have received aggressive treatment when they developed varicella. Overall, mortality was similar across racial and ethnic groups, and similar among children born in the United States compared with foreign-born children.

E. coli Linked to Diarrhea

Diarrheagenic Escherichia coli was isolated significantly more often in children with acute gastroenteritis in an emergency department compared with inpatients and controls, said Mitchell B. Cohen, M.D., of Cincinnati Children's Hospital Medical Center, and his associates. In a study of 684 children who presented to an emergency department, 643 inpatient children, and 555 controls, the investigators used DNA probes to evaluate stool samples. A majority in each group was aged 5 years or younger (J. Pediatr. 2005;146:54-61). Diarrheagenic E. coli was present in 167 (24%) of 684 ED patients, compared with 78 (14%) of 555 control patients. However, there was no significant difference in prevalence of E. coli between the inpatients (13%) and controls (14%). There also was no significant difference in prevalence of E. coli between the inpatients and controls in the subset aged 5 years and younger (13.5% vs. 15.4%). In addition, the researchers found a significantly high isolation rate of enteroaggregative E. coli in ED patients less than 1 year old, compared with controls (10% vs. 1.4%). “Diarrheagenic E. coli may be an important, unrecognized cause of diarrhea in children in the [United States], perhaps accounting for 10% of all acute gastroenteritis,” the investigators said. Rotavirus was the most common single etiologic agent, found in 20.3% of inpatients and 20.2% of ED patients, compared with 1.1% of controls.

Urinalysis Predicts Kidney Diseases

Children with a combination of microhematuria and proteinuria were at significantly increased risk for kidney disease or decreased kidney function in a retrospective chart review of 239 children, reported Jayanthi Chandar, M.D., and colleagues at the University of Miami (Clin. Pediatr. 2005;44:43-8). Overall, 109 children had isolated microhematuria, 79 had isolated proteinuria, and 51 had a combination of the two conditions. The 11 children who initially presented with a combination of both conditions had odds ratios of 8.5 for developing kidney disease and 9.8 for decreased kidney function. An additional 17 children presented with proteinuria and later developed microhematuria, and 23 presented with microhematuria and later developed proteinuria, and these children also were at increased risk for kidney problems. A total of 163 children (68%) underwent renal ultrasounds, 16% of which showed genitourinary disease or abnormalities in kidney size or echogenicity. Although urinalysis remains controversial as a screening tool, children with persistent urine abnormalities should be evaluated in order to diagnose kidney disease as soon as possible.

HAART Stabilizes CD4+ Counts

The CD4+ T-cell counts of 31 children aged 2.4 months-16.4 years with HIV-1 remained stable throughout 4 years of highly active antiretroviral therapy (HAART), reported Pieter L.A. Fraaij, M.D., of Erasmus Medical Center-Sophia Children's Hospital, in Rotterdam, the Netherlands, and his colleagues. At baseline, 28 children started HAART that included indinavir and 3 started HAART that included nelfinavir (Clin. Infect. Dis. 2005;40:604-8). In the intent-to-treat analysis, 65% had HIV-1 levels less than 500 copies/mL and 61% had less than 50 copies/mL after 4 years of treatment. Overall, 28 children changed therapies 38 times during the study period, for reasons including 20 cases of treatment failure, 7 cases of drug toxicity, 7 cases of simplification of the drug regimen, 3 cases of refusal or intolerance of medication, and failure to reach appropriate results in 1 case. HAART was changed at least once in 13 children (41%) due to viral failure. Clinical adverse events occurred in 24 children (77%), but they were mostly mild gastrointestinal problems. Seven children changed medications due to toxicity associated with indinavir. Six were lost to follow-up, and one child died of serious invasive opportunistic infections 1 year into the therapy.

Varicella Vaccination Cuts Mortality

Mortality due to varicella fell from an average of 0.32 deaths per million between 1990 and 1994 to an average of 0.07 deaths per million between 1999 and 2001among children aged 1-4 years due to the adoption of universal childhood varicella vaccination in the United States, with the lowest rates for all groups in 2001, said Huong Q. Nguyen and colleagues at the Centers for Disease Control and Prevention (N. Engl. J. Med. 2005;352:450-8). In addition, deaths due to varicella fell significantly among children aged 10-19 years (67%) and among infants (66%) between the two periods. The decline in mortality was 100% among children aged 1-4 years and aged 5-9 years for children at high risk due to preexisting conditions; however, children with preexisting conditions might have received aggressive treatment when they developed varicella. Overall, mortality was similar across racial and ethnic groups, and similar among children born in the United States compared with foreign-born children.

E. coli Linked to Diarrhea

Diarrheagenic Escherichia coli was isolated significantly more often in children with acute gastroenteritis in an emergency department compared with inpatients and controls, said Mitchell B. Cohen, M.D., of Cincinnati Children's Hospital Medical Center, and his associates. In a study of 684 children who presented to an emergency department, 643 inpatient children, and 555 controls, the investigators used DNA probes to evaluate stool samples. A majority in each group was aged 5 years or younger (J. Pediatr. 2005;146:54-61). Diarrheagenic E. coli was present in 167 (24%) of 684 ED patients, compared with 78 (14%) of 555 control patients. However, there was no significant difference in prevalence of E. coli between the inpatients (13%) and controls (14%). There also was no significant difference in prevalence of E. coli between the inpatients and controls in the subset aged 5 years and younger (13.5% vs. 15.4%). In addition, the researchers found a significantly high isolation rate of enteroaggregative E. coli in ED patients less than 1 year old, compared with controls (10% vs. 1.4%). “Diarrheagenic E. coli may be an important, unrecognized cause of diarrhea in children in the [United States], perhaps accounting for 10% of all acute gastroenteritis,” the investigators said. Rotavirus was the most common single etiologic agent, found in 20.3% of inpatients and 20.2% of ED patients, compared with 1.1% of controls.

Urinalysis Predicts Kidney Diseases

Children with a combination of microhematuria and proteinuria were at significantly increased risk for kidney disease or decreased kidney function in a retrospective chart review of 239 children, reported Jayanthi Chandar, M.D., and colleagues at the University of Miami (Clin. Pediatr. 2005;44:43-8). Overall, 109 children had isolated microhematuria, 79 had isolated proteinuria, and 51 had a combination of the two conditions. The 11 children who initially presented with a combination of both conditions had odds ratios of 8.5 for developing kidney disease and 9.8 for decreased kidney function. An additional 17 children presented with proteinuria and later developed microhematuria, and 23 presented with microhematuria and later developed proteinuria, and these children also were at increased risk for kidney problems. A total of 163 children (68%) underwent renal ultrasounds, 16% of which showed genitourinary disease or abnormalities in kidney size or echogenicity. Although urinalysis remains controversial as a screening tool, children with persistent urine abnormalities should be evaluated in order to diagnose kidney disease as soon as possible.

WASHINGTON — Brooke Gurland, M.D., realized that, despite her training as a colorectal surgeon, she didn't have a complete perspective on pelvic floor dysfunction.

Fellows in colorectal surgery “weren't even trained to know the anatomy of the other organs, much less how to work with other pelvic specialists in the hospital system,” said Dr. Gurland, a colorectal surgeon at Maimonides Hospital in New York. A multidisciplinary approach to women's pelvic floor disorders is important, because multiple pelvic floor defects often exist in the absence of patient complaints, she said at the annual meeting of the Gerontological Society of America.

Older women tend to underreport pelvic floor problems, especially those associated with fecal incontinence or defecation problems, because they don't feel comfortable raising the subject with their doctors, or because they find ways to compensate, such as using an enema or finger to complete their defecation. “However, these problems have tremendous psychosocial implications for older women,” Dr. Gurland said. And failure to identify pelvic floor pathology can lead to treatment failure and frustration for both doctors and patients.

Research in pelvic floor symptomatology is limited, and many physicians don't know that different treatment options exist for pelvic floor dysfunction, said Dr. Gurland, who is spearheading a pelvic floor task force at Maimonides. The main objectives are to establish a center to evaluate the pelvic floor compartments as a functional unit, to educate health professionals and the community about pelvic floor disorders, to create a database, and to coordinate studies of multicompartment pelvic floor disorders to improve knowledge in this area.

To help finance these efforts, Dr. Gurland received a career development grant totaling $200,000 over 2 years from the American Geriatrics Society to establish the Maimonides Center for Pelvic Floor Dysfunction and Reconstructive Surgery.

The first step was to identify a pelvic floor task force that includes physicians, nurse practitioners, continence specialists, physician assistants, and pain specialists from fields such as urology, gynecology, colorectal surgery, and geriatrics.

Plans so far have included a nurses' public health symposium and a fellowship program in which an ob.gyn. would work with Dr. Gurland and a colleague in urogynecology. The staff conducted community outreach by placing ads in local newspapers to encourage women with pelvic floor complaints to visit the center.

“We are getting patients who would not have approached their primary doctors, but are seeking us out specifically,” Dr. Gurland noted.

The designated support staff has made all the difference in establishing the center and creating a multidisciplinary treatment protocol, she said. “I have two physician assistants and two medical assistants who coordinate care between subspecialists. They coordinate surgeries and are trained to do pelvic floor rehabilitation and biofeedback, and provide emotional support to the patients.”

In addition, Dr. Gurland combines office hours with a urogynecologist, which minimizes patient visits and eases the travel burden for elderly patients. “Once we make a decision on how to care for a patient, I can sit down with the urogynecologist and create a plan,” Dr. Gurland said. “We can also see the postops together and see how people are responding to treatment.”

Dr. Gurland and her colleagues list the symptoms of fecal dysfunction on their database for tracking patients and conducting research. They use the Wexner fecal incontinence score, which ranges from 0 to 20 (no incontinence to complete fecal incontinence) and includes incontinence to flatus, liquid, and solid stool. The frequency of accidents and its effect on lifestyle also are included. In addition, the Rome criteria are used to define obstructive defecation, such as a feeling of anal blockage 25% of the time and the need for an enema or other help to fully evacuate.

Dr. Gurland reported results from the first 70 patients treated at the center. The women enrolled in the database had symptoms of urinary dysfunction and prolapse and either fecal incontinence or difficult evacuation. The average age was 66 years, with an average parity of 3. Seventeen had undergone hysterectomies.

Although urinary incontinence was the most common symptom, 38 patients had fecal incontinence, 28 had obstructive defecation, and 22 reported rectal pressure. Of those with fecal incontinence, 89% had urinary incontinence, 61% had pelvic pressure or a bulge, and 3% had pelvic pain.

An overwhelming majority, 82%, of those with obstructed defecation had rectal pressure, 43% had pelvic pressure or bulge, and 25% had pelvic pain. And of those with rectal pressure, 73% had urinary incontinence, 68% had pelvic pressure, and 18% had pelvic pain.

Rectocele was the most common physical finding in the entire group (60% of patients), followed by cystocele, enterocele, rectal prolapse, and anal sphincter defects diagnosed by endorectal ultrasound.

As for the outcomes, 35% had surgery, 25% are undergoing biofeedback treatment, and approximately 28% are considering surgical or nonsurgical treatment. An additional 10% decided they were satisfied with their quality of life and declined treatment.

“There's no rush. This is a quality of life issue, and it has to be scheduled at the patient's convenience,” Dr. Gurland said, adding that a combined approach to pelvic floor dysfunction improves patient care.

WASHINGTON — Brooke Gurland, M.D., realized that, despite her training as a colorectal surgeon, she didn't have a complete perspective on pelvic floor dysfunction.

Fellows in colorectal surgery “weren't even trained to know the anatomy of the other organs, much less how to work with other pelvic specialists in the hospital system,” said Dr. Gurland, a colorectal surgeon at Maimonides Hospital in New York. A multidisciplinary approach to women's pelvic floor disorders is important, because multiple pelvic floor defects often exist in the absence of patient complaints, she said at the annual meeting of the Gerontological Society of America.

Older women tend to underreport pelvic floor problems, especially those associated with fecal incontinence or defecation problems, because they don't feel comfortable raising the subject with their doctors, or because they find ways to compensate, such as using an enema or finger to complete their defecation. “However, these problems have tremendous psychosocial implications for older women,” Dr. Gurland said. And failure to identify pelvic floor pathology can lead to treatment failure and frustration for both doctors and patients.

Research in pelvic floor symptomatology is limited, and many physicians don't know that different treatment options exist for pelvic floor dysfunction, said Dr. Gurland, who is spearheading a pelvic floor task force at Maimonides. The main objectives are to establish a center to evaluate the pelvic floor compartments as a functional unit, to educate health professionals and the community about pelvic floor disorders, to create a database, and to coordinate studies of multicompartment pelvic floor disorders to improve knowledge in this area.

To help finance these efforts, Dr. Gurland received a career development grant totaling $200,000 over 2 years from the American Geriatrics Society to establish the Maimonides Center for Pelvic Floor Dysfunction and Reconstructive Surgery.

The first step was to identify a pelvic floor task force that includes physicians, nurse practitioners, continence specialists, physician assistants, and pain specialists from fields such as urology, gynecology, colorectal surgery, and geriatrics.

Plans so far have included a nurses' public health symposium and a fellowship program in which an ob.gyn. would work with Dr. Gurland and a colleague in urogynecology. The staff conducted community outreach by placing ads in local newspapers to encourage women with pelvic floor complaints to visit the center.

“We are getting patients who would not have approached their primary doctors, but are seeking us out specifically,” Dr. Gurland noted.

The designated support staff has made all the difference in establishing the center and creating a multidisciplinary treatment protocol, she said. “I have two physician assistants and two medical assistants who coordinate care between subspecialists. They coordinate surgeries and are trained to do pelvic floor rehabilitation and biofeedback, and provide emotional support to the patients.”

In addition, Dr. Gurland combines office hours with a urogynecologist, which minimizes patient visits and eases the travel burden for elderly patients. “Once we make a decision on how to care for a patient, I can sit down with the urogynecologist and create a plan,” Dr. Gurland said. “We can also see the postops together and see how people are responding to treatment.”

Dr. Gurland and her colleagues list the symptoms of fecal dysfunction on their database for tracking patients and conducting research. They use the Wexner fecal incontinence score, which ranges from 0 to 20 (no incontinence to complete fecal incontinence) and includes incontinence to flatus, liquid, and solid stool. The frequency of accidents and its effect on lifestyle also are included. In addition, the Rome criteria are used to define obstructive defecation, such as a feeling of anal blockage 25% of the time and the need for an enema or other help to fully evacuate.

Dr. Gurland reported results from the first 70 patients treated at the center. The women enrolled in the database had symptoms of urinary dysfunction and prolapse and either fecal incontinence or difficult evacuation. The average age was 66 years, with an average parity of 3. Seventeen had undergone hysterectomies.

Although urinary incontinence was the most common symptom, 38 patients had fecal incontinence, 28 had obstructive defecation, and 22 reported rectal pressure. Of those with fecal incontinence, 89% had urinary incontinence, 61% had pelvic pressure or a bulge, and 3% had pelvic pain.

An overwhelming majority, 82%, of those with obstructed defecation had rectal pressure, 43% had pelvic pressure or bulge, and 25% had pelvic pain. And of those with rectal pressure, 73% had urinary incontinence, 68% had pelvic pressure, and 18% had pelvic pain.

Rectocele was the most common physical finding in the entire group (60% of patients), followed by cystocele, enterocele, rectal prolapse, and anal sphincter defects diagnosed by endorectal ultrasound.

As for the outcomes, 35% had surgery, 25% are undergoing biofeedback treatment, and approximately 28% are considering surgical or nonsurgical treatment. An additional 10% decided they were satisfied with their quality of life and declined treatment.

“There's no rush. This is a quality of life issue, and it has to be scheduled at the patient's convenience,” Dr. Gurland said, adding that a combined approach to pelvic floor dysfunction improves patient care.

WASHINGTON — Brooke Gurland, M.D., realized that, despite her training as a colorectal surgeon, she didn't have a complete perspective on pelvic floor dysfunction.

Fellows in colorectal surgery “weren't even trained to know the anatomy of the other organs, much less how to work with other pelvic specialists in the hospital system,” said Dr. Gurland, a colorectal surgeon at Maimonides Hospital in New York. A multidisciplinary approach to women's pelvic floor disorders is important, because multiple pelvic floor defects often exist in the absence of patient complaints, she said at the annual meeting of the Gerontological Society of America.

Older women tend to underreport pelvic floor problems, especially those associated with fecal incontinence or defecation problems, because they don't feel comfortable raising the subject with their doctors, or because they find ways to compensate, such as using an enema or finger to complete their defecation. “However, these problems have tremendous psychosocial implications for older women,” Dr. Gurland said. And failure to identify pelvic floor pathology can lead to treatment failure and frustration for both doctors and patients.

Research in pelvic floor symptomatology is limited, and many physicians don't know that different treatment options exist for pelvic floor dysfunction, said Dr. Gurland, who is spearheading a pelvic floor task force at Maimonides. The main objectives are to establish a center to evaluate the pelvic floor compartments as a functional unit, to educate health professionals and the community about pelvic floor disorders, to create a database, and to coordinate studies of multicompartment pelvic floor disorders to improve knowledge in this area.

To help finance these efforts, Dr. Gurland received a career development grant totaling $200,000 over 2 years from the American Geriatrics Society to establish the Maimonides Center for Pelvic Floor Dysfunction and Reconstructive Surgery.

The first step was to identify a pelvic floor task force that includes physicians, nurse practitioners, continence specialists, physician assistants, and pain specialists from fields such as urology, gynecology, colorectal surgery, and geriatrics.

Plans so far have included a nurses' public health symposium and a fellowship program in which an ob.gyn. would work with Dr. Gurland and a colleague in urogynecology. The staff conducted community outreach by placing ads in local newspapers to encourage women with pelvic floor complaints to visit the center.

“We are getting patients who would not have approached their primary doctors, but are seeking us out specifically,” Dr. Gurland noted.

The designated support staff has made all the difference in establishing the center and creating a multidisciplinary treatment protocol, she said. “I have two physician assistants and two medical assistants who coordinate care between subspecialists. They coordinate surgeries and are trained to do pelvic floor rehabilitation and biofeedback, and provide emotional support to the patients.”

In addition, Dr. Gurland combines office hours with a urogynecologist, which minimizes patient visits and eases the travel burden for elderly patients. “Once we make a decision on how to care for a patient, I can sit down with the urogynecologist and create a plan,” Dr. Gurland said. “We can also see the postops together and see how people are responding to treatment.”

Dr. Gurland and her colleagues list the symptoms of fecal dysfunction on their database for tracking patients and conducting research. They use the Wexner fecal incontinence score, which ranges from 0 to 20 (no incontinence to complete fecal incontinence) and includes incontinence to flatus, liquid, and solid stool. The frequency of accidents and its effect on lifestyle also are included. In addition, the Rome criteria are used to define obstructive defecation, such as a feeling of anal blockage 25% of the time and the need for an enema or other help to fully evacuate.

Dr. Gurland reported results from the first 70 patients treated at the center. The women enrolled in the database had symptoms of urinary dysfunction and prolapse and either fecal incontinence or difficult evacuation. The average age was 66 years, with an average parity of 3. Seventeen had undergone hysterectomies.

Although urinary incontinence was the most common symptom, 38 patients had fecal incontinence, 28 had obstructive defecation, and 22 reported rectal pressure. Of those with fecal incontinence, 89% had urinary incontinence, 61% had pelvic pressure or a bulge, and 3% had pelvic pain.

An overwhelming majority, 82%, of those with obstructed defecation had rectal pressure, 43% had pelvic pressure or bulge, and 25% had pelvic pain. And of those with rectal pressure, 73% had urinary incontinence, 68% had pelvic pressure, and 18% had pelvic pain.

Rectocele was the most common physical finding in the entire group (60% of patients), followed by cystocele, enterocele, rectal prolapse, and anal sphincter defects diagnosed by endorectal ultrasound.

As for the outcomes, 35% had surgery, 25% are undergoing biofeedback treatment, and approximately 28% are considering surgical or nonsurgical treatment. An additional 10% decided they were satisfied with their quality of life and declined treatment.

“There's no rush. This is a quality of life issue, and it has to be scheduled at the patient's convenience,” Dr. Gurland said, adding that a combined approach to pelvic floor dysfunction improves patient care.

FORT LAUDERDALE, FLA. — The chronic dry mouth that characterizes Sjögren's syndrome can accelerate dental decay in approximately 70% of patients with the disease, Steven J. Kusnick, D.D.S., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Patients who attempt to manage their dry mouth symptoms with gum or mints should be advised to use products that contain the natural sweetener xylitol instead of looking for ones that are merely sugar free because the latter won't prevent tooth decay, said Dr. Kusnick, a general dentist in private practice in Sunrise, Fla., and a specialist in cosmetic and reconstructive dentistry.

Over-the-counter products that contain xylitol include Smints, a brand of mints that stimulate saliva and have xylitol as the first ingredient, Koolerz gum in any flavor, and Starbucks gum.

Other tips include reminding patients to drink water throughout the day, use lip balm regularly, and avoid smoking and drinking alcohol. While some patients may realize they need to avoid acidic juices, such as orange and grape, many carbonated drinks, including diet sodas, also contain acid and should be avoided.

Two prescription salivary substitute medications—pilocarpine (Salagen) and cevimeline (Evoxac)—can be an effective adjunct to lifestyle modifications, but many patients are deterred by their side effects, which include flushing, sweating, and headaches.

Salivary substitutes can interact poorly with other medications, so physicians should inquire about all medications before prescribing them.

“The earlier we catch a problem, such as a cavity, the easier it is to treat,” so regular checkups are key. Dr. Kusnick also recommends that his Sjögren's patients use a standard, nonwhitening toothpaste. Whitening toothpastes have an ingredient that makes teeth more sensitive, irritates the soft tissues of the mouth, and they don't whiten your teeth that much.

Other rules for basic oral health apply and if patients snack, remind them to rinse their mouths with water afterwards to reduce dryness.

Fluoride varnish can be helpful to prevent decay in high-risk patients, Dr. Kusnick noted. In patients with gumline decay, power toothbrushes can be helpful in getting the fluoride into the gum area.

FORT LAUDERDALE, FLA. — The chronic dry mouth that characterizes Sjögren's syndrome can accelerate dental decay in approximately 70% of patients with the disease, Steven J. Kusnick, D.D.S., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Patients who attempt to manage their dry mouth symptoms with gum or mints should be advised to use products that contain the natural sweetener xylitol instead of looking for ones that are merely sugar free because the latter won't prevent tooth decay, said Dr. Kusnick, a general dentist in private practice in Sunrise, Fla., and a specialist in cosmetic and reconstructive dentistry.

Over-the-counter products that contain xylitol include Smints, a brand of mints that stimulate saliva and have xylitol as the first ingredient, Koolerz gum in any flavor, and Starbucks gum.

Other tips include reminding patients to drink water throughout the day, use lip balm regularly, and avoid smoking and drinking alcohol. While some patients may realize they need to avoid acidic juices, such as orange and grape, many carbonated drinks, including diet sodas, also contain acid and should be avoided.

Two prescription salivary substitute medications—pilocarpine (Salagen) and cevimeline (Evoxac)—can be an effective adjunct to lifestyle modifications, but many patients are deterred by their side effects, which include flushing, sweating, and headaches.

Salivary substitutes can interact poorly with other medications, so physicians should inquire about all medications before prescribing them.

“The earlier we catch a problem, such as a cavity, the easier it is to treat,” so regular checkups are key. Dr. Kusnick also recommends that his Sjögren's patients use a standard, nonwhitening toothpaste. Whitening toothpastes have an ingredient that makes teeth more sensitive, irritates the soft tissues of the mouth, and they don't whiten your teeth that much.

Other rules for basic oral health apply and if patients snack, remind them to rinse their mouths with water afterwards to reduce dryness.

Fluoride varnish can be helpful to prevent decay in high-risk patients, Dr. Kusnick noted. In patients with gumline decay, power toothbrushes can be helpful in getting the fluoride into the gum area.

FORT LAUDERDALE, FLA. — The chronic dry mouth that characterizes Sjögren's syndrome can accelerate dental decay in approximately 70% of patients with the disease, Steven J. Kusnick, D.D.S., said at a meeting sponsored by the Sjögren's Syndrome Foundation.

Patients who attempt to manage their dry mouth symptoms with gum or mints should be advised to use products that contain the natural sweetener xylitol instead of looking for ones that are merely sugar free because the latter won't prevent tooth decay, said Dr. Kusnick, a general dentist in private practice in Sunrise, Fla., and a specialist in cosmetic and reconstructive dentistry.

Over-the-counter products that contain xylitol include Smints, a brand of mints that stimulate saliva and have xylitol as the first ingredient, Koolerz gum in any flavor, and Starbucks gum.

Other tips include reminding patients to drink water throughout the day, use lip balm regularly, and avoid smoking and drinking alcohol. While some patients may realize they need to avoid acidic juices, such as orange and grape, many carbonated drinks, including diet sodas, also contain acid and should be avoided.

Two prescription salivary substitute medications—pilocarpine (Salagen) and cevimeline (Evoxac)—can be an effective adjunct to lifestyle modifications, but many patients are deterred by their side effects, which include flushing, sweating, and headaches.

Salivary substitutes can interact poorly with other medications, so physicians should inquire about all medications before prescribing them.

“The earlier we catch a problem, such as a cavity, the easier it is to treat,” so regular checkups are key. Dr. Kusnick also recommends that his Sjögren's patients use a standard, nonwhitening toothpaste. Whitening toothpastes have an ingredient that makes teeth more sensitive, irritates the soft tissues of the mouth, and they don't whiten your teeth that much.

Other rules for basic oral health apply and if patients snack, remind them to rinse their mouths with water afterwards to reduce dryness.

Fluoride varnish can be helpful to prevent decay in high-risk patients, Dr. Kusnick noted. In patients with gumline decay, power toothbrushes can be helpful in getting the fluoride into the gum area.