Damian McNamara

SAN ANTONIO — Older women are at increased risk for a number of skin conditions including alopecia, xerosis, and foot ulcers, compared with younger women, according to a presentation at a meeting of Skin Disease Education Foundation.

“The most commonly seen dermatologic disorders in older women are not cosmetic, they are medical. They are medical because they are secondary to decreased barrier function, decreased estrogen, and increased photodamage,” Dr. Wendy E. Roberts said.

“We are all familiar with the look of aging skin. When we look at a dull, gray-white color, it is due to heaps of corneocytes on the skin. The skin cycle increases in length with aging and the skin loses its ability to exfoliate,” said Dr. Roberts, who is in private practice in Rancho Mirage, Calif.

Seborrheic keratosis, hyperkeratosis, nail diseases, and varicose or spider veins are other common dermatologic complaints in this population, as are solar lentigines, she said, adding that they can be treated with cryotherapy or lasers.

Stasis dermatitis, also known as gravity dermatitis, is a sign of skin barrier dysfunction in older women and indicates impaired circulation of the lower extremities. Dr. Roberts suggested prescribing emollients as a treatment. Another common presentation is stellate or hypopigmented scars from torsional stress in photodamaged skin with a weak dermal-epidermal junction.

Nutrition can be a “major problem” in the elderly, particularly those in their 8th–10th decades, Dr. Roberts said. Many of these women simply eat less and/or their medications cause appetite loss.

Medications also cause diffuse alopecia in older women. Review their medication intake, Dr. Roberts suggested, because there are so many mediations with alopecia as a side effect. Examples include cytostatic agents, anticoagulants, hormones, and anticonvulsants.

The primary cause of alopecia is female pattern baldness. After ruling out hyperandrogenism, consider treatment with minoxidil, Dr. Roberts said. Although the 2% solution is FDA approved for women, she recommended off-label use of the 5% solution 2–3 times per week.

Minoxidil 5% is contraindicated in women of childbearing potential. Although she cited a warning for increased risk of facial hypertrichosis with either the 2% or 5% solution, Dr. Roberts said, “I love it, especially when women are just starting to thin.” Topical retinoids solutions and hair transplants are other options.

“Purpura is a major complaint in my practice,” Dr. Roberts said. In this population, purpura stem from decreased interdigitations of the dermal papilla and decreased arteriole elastic tissue content, which leads to increased fragility. There is no effective treatment, Dr. Roberts said, although topical vitamin K cream can speed recovery. She stresses prevention with sun protection, vitamin C supplementation—“which is all around good for blood vessels”—and exercise.

Women with xerosis, on the other hand, often have no chief complaint, Dr. Roberts said. “Women often accept xerosis and pruritus as 'part of getting old.'” Decreased sebaceous activity, eccrine activity, and altered desquamation contribute to xerosis in aging skin. Decreased sebaceous activity with aging increases the risk for dry skin, so review bathing habits, she suggested.

Discuss use of moisturizers for xerosis, Dr. Roberts said. “I take the time to find out what is in the stores so I know what to recommend.” Also talk with patients about ultraviolet protection, which might contribute to a higher prevalence of rosacea in this age group. “Many older women think by age 70 they have already done all the damage in terms of avoiding UV exposure.”

Decreased sebaceous and eccrine activity contributes to xerosis. Courtesy Dr. Wendy E. Roberts

SAN ANTONIO — Older women are at increased risk for a number of skin conditions including alopecia, xerosis, and foot ulcers, compared with younger women, according to a presentation at a meeting of Skin Disease Education Foundation.

“The most commonly seen dermatologic disorders in older women are not cosmetic, they are medical. They are medical because they are secondary to decreased barrier function, decreased estrogen, and increased photodamage,” Dr. Wendy E. Roberts said.

“We are all familiar with the look of aging skin. When we look at a dull, gray-white color, it is due to heaps of corneocytes on the skin. The skin cycle increases in length with aging and the skin loses its ability to exfoliate,” said Dr. Roberts, who is in private practice in Rancho Mirage, Calif.

Seborrheic keratosis, hyperkeratosis, nail diseases, and varicose or spider veins are other common dermatologic complaints in this population, as are solar lentigines, she said, adding that they can be treated with cryotherapy or lasers.

Stasis dermatitis, also known as gravity dermatitis, is a sign of skin barrier dysfunction in older women and indicates impaired circulation of the lower extremities. Dr. Roberts suggested prescribing emollients as a treatment. Another common presentation is stellate or hypopigmented scars from torsional stress in photodamaged skin with a weak dermal-epidermal junction.

Nutrition can be a “major problem” in the elderly, particularly those in their 8th–10th decades, Dr. Roberts said. Many of these women simply eat less and/or their medications cause appetite loss.

Medications also cause diffuse alopecia in older women. Review their medication intake, Dr. Roberts suggested, because there are so many mediations with alopecia as a side effect. Examples include cytostatic agents, anticoagulants, hormones, and anticonvulsants.

The primary cause of alopecia is female pattern baldness. After ruling out hyperandrogenism, consider treatment with minoxidil, Dr. Roberts said. Although the 2% solution is FDA approved for women, she recommended off-label use of the 5% solution 2–3 times per week.

Minoxidil 5% is contraindicated in women of childbearing potential. Although she cited a warning for increased risk of facial hypertrichosis with either the 2% or 5% solution, Dr. Roberts said, “I love it, especially when women are just starting to thin.” Topical retinoids solutions and hair transplants are other options.

“Purpura is a major complaint in my practice,” Dr. Roberts said. In this population, purpura stem from decreased interdigitations of the dermal papilla and decreased arteriole elastic tissue content, which leads to increased fragility. There is no effective treatment, Dr. Roberts said, although topical vitamin K cream can speed recovery. She stresses prevention with sun protection, vitamin C supplementation—“which is all around good for blood vessels”—and exercise.

Women with xerosis, on the other hand, often have no chief complaint, Dr. Roberts said. “Women often accept xerosis and pruritus as 'part of getting old.'” Decreased sebaceous activity, eccrine activity, and altered desquamation contribute to xerosis in aging skin. Decreased sebaceous activity with aging increases the risk for dry skin, so review bathing habits, she suggested.

Discuss use of moisturizers for xerosis, Dr. Roberts said. “I take the time to find out what is in the stores so I know what to recommend.” Also talk with patients about ultraviolet protection, which might contribute to a higher prevalence of rosacea in this age group. “Many older women think by age 70 they have already done all the damage in terms of avoiding UV exposure.”

Decreased sebaceous and eccrine activity contributes to xerosis. Courtesy Dr. Wendy E. Roberts

SAN ANTONIO — Older women are at increased risk for a number of skin conditions including alopecia, xerosis, and foot ulcers, compared with younger women, according to a presentation at a meeting of Skin Disease Education Foundation.

“The most commonly seen dermatologic disorders in older women are not cosmetic, they are medical. They are medical because they are secondary to decreased barrier function, decreased estrogen, and increased photodamage,” Dr. Wendy E. Roberts said.

“We are all familiar with the look of aging skin. When we look at a dull, gray-white color, it is due to heaps of corneocytes on the skin. The skin cycle increases in length with aging and the skin loses its ability to exfoliate,” said Dr. Roberts, who is in private practice in Rancho Mirage, Calif.

Seborrheic keratosis, hyperkeratosis, nail diseases, and varicose or spider veins are other common dermatologic complaints in this population, as are solar lentigines, she said, adding that they can be treated with cryotherapy or lasers.

Stasis dermatitis, also known as gravity dermatitis, is a sign of skin barrier dysfunction in older women and indicates impaired circulation of the lower extremities. Dr. Roberts suggested prescribing emollients as a treatment. Another common presentation is stellate or hypopigmented scars from torsional stress in photodamaged skin with a weak dermal-epidermal junction.

Nutrition can be a “major problem” in the elderly, particularly those in their 8th–10th decades, Dr. Roberts said. Many of these women simply eat less and/or their medications cause appetite loss.

Medications also cause diffuse alopecia in older women. Review their medication intake, Dr. Roberts suggested, because there are so many mediations with alopecia as a side effect. Examples include cytostatic agents, anticoagulants, hormones, and anticonvulsants.

The primary cause of alopecia is female pattern baldness. After ruling out hyperandrogenism, consider treatment with minoxidil, Dr. Roberts said. Although the 2% solution is FDA approved for women, she recommended off-label use of the 5% solution 2–3 times per week.

Minoxidil 5% is contraindicated in women of childbearing potential. Although she cited a warning for increased risk of facial hypertrichosis with either the 2% or 5% solution, Dr. Roberts said, “I love it, especially when women are just starting to thin.” Topical retinoids solutions and hair transplants are other options.

“Purpura is a major complaint in my practice,” Dr. Roberts said. In this population, purpura stem from decreased interdigitations of the dermal papilla and decreased arteriole elastic tissue content, which leads to increased fragility. There is no effective treatment, Dr. Roberts said, although topical vitamin K cream can speed recovery. She stresses prevention with sun protection, vitamin C supplementation—“which is all around good for blood vessels”—and exercise.

Women with xerosis, on the other hand, often have no chief complaint, Dr. Roberts said. “Women often accept xerosis and pruritus as 'part of getting old.'” Decreased sebaceous activity, eccrine activity, and altered desquamation contribute to xerosis in aging skin. Decreased sebaceous activity with aging increases the risk for dry skin, so review bathing habits, she suggested.

Discuss use of moisturizers for xerosis, Dr. Roberts said. “I take the time to find out what is in the stores so I know what to recommend.” Also talk with patients about ultraviolet protection, which might contribute to a higher prevalence of rosacea in this age group. “Many older women think by age 70 they have already done all the damage in terms of avoiding UV exposure.”

Decreased sebaceous and eccrine activity contributes to xerosis. Courtesy Dr. Wendy E. Roberts

SAN ANTONIO — Address the underlying androgen excess when a woman presents for correction of cutaneous effects of hyperandrogenism, Dr. Ellen E. Wilson said at a meeting of Skin Disease Education Foundation.

Polycystic ovary syndrome (PCOS) is the most common etiology of hyperandrogenism. “Dermatologic manifestations include hirsutism, acne, acanthosis nigricans, and androgenetic alopecia—in that order,” said Dr. Wilson, a reproductive endocrinologist at the University of Texas Southwestern Medical Center in Dallas.

PCOS affects an estimated 6%-10% of women in their reproductive years. The excess male hormone production or action can cause infertility. About 25% of women of reproductive age have polycystic ovaries but not the syndrome.

Patients must meet two out of three criteria for diagnosis: polycystic ovaries on ultrasound (more than 12 cysts per ovary); oligoanovulation; or clinical or biochemical evidence of hyperandrogenism. A testosterone level of 50–80 ng/dL is the upper range of normal for women, she said. Hirsutism is defined as male pattern hair growth in a female. Rapid onset of hair growth, deepening of the voice, and temporary balding can produce emotional anguish in patients from a presumptive loss of femininity.

Although hirsutism is the leading dermatology-related symptom of hyperandrogenism, physicians may not see it “because patients are self-treating for this—plucking, shaving, etc.,” Dr. Wilson added. “So make sure to ask about this.”

Cancer can also cause virilization, so androgen levels should be measured in the tests to rule out a tumor. “If someone has a testosterone level over 200 ng/dL we are going to look for a tumor, especially ovarian,” she noted.

Irregular cycles from menarche or shortly thereafter that do not normalize suggest PCOS. If a patient's cycle is irregular for more than a year, do an endometrial biopsy because she is at risk for hyperplasia or uterine cancer, Dr. Wilson said at the meeting. SDEF and this news organization are wholly owned subsidiaries of Elsevier.

An endocrinologist can address the long-term consequences of PCOS, which include endometrial cancer, diabetes mellitus, and cardiovascular disease. Dr. Wilson said that “there is a big overlap with metabolic syndrome. We don't know what the cause of PCOS is. We know there is a platform of insulin resistance.”

Endocrinologists are starting to prescribe metformin in PCOS patients because of these long-term risks. Metformin is the most popular and well-studied insulin sensitizer in PCOS patients, she said, but start slow to minimize side effects. “There is a big controversy in the pediatric realm [about] whether or not to put adolescents on metformin.”

A contraceptive pill, patch, or ring regimen can regularize periods and treat the effects of hyperandrogenism. Low-dose oral contraceptives lower free testosterone levels, with the progestins desogestrel, gestodene, and norgestimate being associated with greater reductions. “The bottom line is probably any low-dose formulation producing an overall similar clinical response.”

Treatment with hormonal suppression will be necessary for at least 6 months before there is an observable difference. “It takes time,” Dr. Wilson said. “For hirsutism, often I recommend they go to a dermatologist for hair removal, and I tell them there should be no new growth.”

Patients with PCOS may remain on oral contraceptives through their 30s and 40s, often until they are menopausal.

If oral contraceptives are not enough, “we will supplement with spironolactone,” Dr. Wilson said. “Spironolactone is a potential teratogen, so we feel more comfortable if they are already on an oral contraceptive.” Spironolactone is effective in doses of 100–200 mg/day.

Vaniqa (eflornithine) is approved for hirsutism as a twice-a-day local treatment. “It is expensive and works in one-third to two-thirds of women,” she said.

SAN ANTONIO — Address the underlying androgen excess when a woman presents for correction of cutaneous effects of hyperandrogenism, Dr. Ellen E. Wilson said at a meeting of Skin Disease Education Foundation.

Polycystic ovary syndrome (PCOS) is the most common etiology of hyperandrogenism. “Dermatologic manifestations include hirsutism, acne, acanthosis nigricans, and androgenetic alopecia—in that order,” said Dr. Wilson, a reproductive endocrinologist at the University of Texas Southwestern Medical Center in Dallas.

PCOS affects an estimated 6%-10% of women in their reproductive years. The excess male hormone production or action can cause infertility. About 25% of women of reproductive age have polycystic ovaries but not the syndrome.

Patients must meet two out of three criteria for diagnosis: polycystic ovaries on ultrasound (more than 12 cysts per ovary); oligoanovulation; or clinical or biochemical evidence of hyperandrogenism. A testosterone level of 50–80 ng/dL is the upper range of normal for women, she said. Hirsutism is defined as male pattern hair growth in a female. Rapid onset of hair growth, deepening of the voice, and temporary balding can produce emotional anguish in patients from a presumptive loss of femininity.

Although hirsutism is the leading dermatology-related symptom of hyperandrogenism, physicians may not see it “because patients are self-treating for this—plucking, shaving, etc.,” Dr. Wilson added. “So make sure to ask about this.”

Cancer can also cause virilization, so androgen levels should be measured in the tests to rule out a tumor. “If someone has a testosterone level over 200 ng/dL we are going to look for a tumor, especially ovarian,” she noted.

Irregular cycles from menarche or shortly thereafter that do not normalize suggest PCOS. If a patient's cycle is irregular for more than a year, do an endometrial biopsy because she is at risk for hyperplasia or uterine cancer, Dr. Wilson said at the meeting. SDEF and this news organization are wholly owned subsidiaries of Elsevier.

An endocrinologist can address the long-term consequences of PCOS, which include endometrial cancer, diabetes mellitus, and cardiovascular disease. Dr. Wilson said that “there is a big overlap with metabolic syndrome. We don't know what the cause of PCOS is. We know there is a platform of insulin resistance.”

Endocrinologists are starting to prescribe metformin in PCOS patients because of these long-term risks. Metformin is the most popular and well-studied insulin sensitizer in PCOS patients, she said, but start slow to minimize side effects. “There is a big controversy in the pediatric realm [about] whether or not to put adolescents on metformin.”

A contraceptive pill, patch, or ring regimen can regularize periods and treat the effects of hyperandrogenism. Low-dose oral contraceptives lower free testosterone levels, with the progestins desogestrel, gestodene, and norgestimate being associated with greater reductions. “The bottom line is probably any low-dose formulation producing an overall similar clinical response.”

Treatment with hormonal suppression will be necessary for at least 6 months before there is an observable difference. “It takes time,” Dr. Wilson said. “For hirsutism, often I recommend they go to a dermatologist for hair removal, and I tell them there should be no new growth.”

Patients with PCOS may remain on oral contraceptives through their 30s and 40s, often until they are menopausal.

If oral contraceptives are not enough, “we will supplement with spironolactone,” Dr. Wilson said. “Spironolactone is a potential teratogen, so we feel more comfortable if they are already on an oral contraceptive.” Spironolactone is effective in doses of 100–200 mg/day.

Vaniqa (eflornithine) is approved for hirsutism as a twice-a-day local treatment. “It is expensive and works in one-third to two-thirds of women,” she said.

SAN ANTONIO — Address the underlying androgen excess when a woman presents for correction of cutaneous effects of hyperandrogenism, Dr. Ellen E. Wilson said at a meeting of Skin Disease Education Foundation.

Polycystic ovary syndrome (PCOS) is the most common etiology of hyperandrogenism. “Dermatologic manifestations include hirsutism, acne, acanthosis nigricans, and androgenetic alopecia—in that order,” said Dr. Wilson, a reproductive endocrinologist at the University of Texas Southwestern Medical Center in Dallas.

PCOS affects an estimated 6%-10% of women in their reproductive years. The excess male hormone production or action can cause infertility. About 25% of women of reproductive age have polycystic ovaries but not the syndrome.

Patients must meet two out of three criteria for diagnosis: polycystic ovaries on ultrasound (more than 12 cysts per ovary); oligoanovulation; or clinical or biochemical evidence of hyperandrogenism. A testosterone level of 50–80 ng/dL is the upper range of normal for women, she said. Hirsutism is defined as male pattern hair growth in a female. Rapid onset of hair growth, deepening of the voice, and temporary balding can produce emotional anguish in patients from a presumptive loss of femininity.

Although hirsutism is the leading dermatology-related symptom of hyperandrogenism, physicians may not see it “because patients are self-treating for this—plucking, shaving, etc.,” Dr. Wilson added. “So make sure to ask about this.”

Cancer can also cause virilization, so androgen levels should be measured in the tests to rule out a tumor. “If someone has a testosterone level over 200 ng/dL we are going to look for a tumor, especially ovarian,” she noted.

Irregular cycles from menarche or shortly thereafter that do not normalize suggest PCOS. If a patient's cycle is irregular for more than a year, do an endometrial biopsy because she is at risk for hyperplasia or uterine cancer, Dr. Wilson said at the meeting. SDEF and this news organization are wholly owned subsidiaries of Elsevier.

An endocrinologist can address the long-term consequences of PCOS, which include endometrial cancer, diabetes mellitus, and cardiovascular disease. Dr. Wilson said that “there is a big overlap with metabolic syndrome. We don't know what the cause of PCOS is. We know there is a platform of insulin resistance.”

Endocrinologists are starting to prescribe metformin in PCOS patients because of these long-term risks. Metformin is the most popular and well-studied insulin sensitizer in PCOS patients, she said, but start slow to minimize side effects. “There is a big controversy in the pediatric realm [about] whether or not to put adolescents on metformin.”

A contraceptive pill, patch, or ring regimen can regularize periods and treat the effects of hyperandrogenism. Low-dose oral contraceptives lower free testosterone levels, with the progestins desogestrel, gestodene, and norgestimate being associated with greater reductions. “The bottom line is probably any low-dose formulation producing an overall similar clinical response.”

Treatment with hormonal suppression will be necessary for at least 6 months before there is an observable difference. “It takes time,” Dr. Wilson said. “For hirsutism, often I recommend they go to a dermatologist for hair removal, and I tell them there should be no new growth.”

Patients with PCOS may remain on oral contraceptives through their 30s and 40s, often until they are menopausal.

If oral contraceptives are not enough, “we will supplement with spironolactone,” Dr. Wilson said. “Spironolactone is a potential teratogen, so we feel more comfortable if they are already on an oral contraceptive.” Spironolactone is effective in doses of 100–200 mg/day.

Vaniqa (eflornithine) is approved for hirsutism as a twice-a-day local treatment. “It is expensive and works in one-third to two-thirds of women,” she said.

BOCA RATON, FLA. – Major depression in children and adolescents can be assessed quickly using a 10-item scale designed for adults. Results correlate well with a standard 45-minute pediatric measure, according to a study presented at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Major depression in pediatric patients is typically measured with the Child Depression Rating Scale-Revised (CDRS-R). This measure is not only time consuming but it requires clinician training to administer, according to Dr. Shailesh Jain, who is a National Institute of Mental Health fellow at the Mood Disorders Research Program and Clinic at the University of Texas Southwestern Medical Center, Dallas.

Right now, typically, practitioners interview the child or adolescent first, then talk with the parent(s), and use clinical judgment to combine the components.

“It takes a long time. For busy clinicians in child psychiatry, it's difficult to spend 45 minutes,” Dr. Jain said.

In addition, certain items on the scale rely on clinician judgment, and subjective assessments vary with clinician experience, according to Dr. Jain.

Dr. Jain and his associates compared the CDRS-R to the Montgomery-Asberg Depression Rating Scale (MADRS) in 96 children (aged 8–11 years old) and 123 adolescents (12–18 years).

All participants were outpatients with nonpsychotic major depressive disorder.

Participants were culled from a randomized trial of fluoxetine 10 mg/day for 1 week followed by a titration to 20 mg/day continued for 8 weeks vs. placebo.

The researchers rated depressive symptoms using both measures.

“The MADRS has advantages–it has 10 items,” Dr. Jain said in an interview at his poster presentation.

“But the MADRS has been used primarily in adults, and little is known about its psychometric properties in evaluation of pediatric patients,” Dr. Jain said.

Total score correlation between CDRS-R and MADRS was 0.85 at study completion for both children and adolescents, which shows that both scales agree to a considerable extent for assessment of depression, Dr. Jain said.

“When measuring the effect of antidepressants (fluoxetine), CDRS-R was statistically more sensitive in detecting changes in symptoms in response to medication in both children and adolescents,” Dr. Jain said.

Effect size for CDRS-R was 0.78 in children and 0.61 in adolescents, compared with the MADRS 0.38 in children and 0.15 adolescents.

These differences are statistically significant, but the clinical difference is less important because it can take three times longer to complete the CDRS-R, Dr. Jain said.

In addition, adolescents often do not like the CDRS-R requirement that clinicians ask parents about their functioning at each visit.

“This is not to suggest that clinicians completely circumvent parents, but the MADRS provides a reasonable alternative for assessment of depression severity and response to treatment,” Dr. Jain said.

“We now know how the scales correlate and, most importantly, the conversion factors between the scales.”

Busy practitioners can quickly assess symptoms of major depression in adolescents with the MADRS.

Dr. Jain said the scale is also useful for children, who are typically poor historians and very influenced by environmental conditions.

The meeting was cosponsored by the American Society for Clinical Psychopharmacology.

BOCA RATON, FLA. – Major depression in children and adolescents can be assessed quickly using a 10-item scale designed for adults. Results correlate well with a standard 45-minute pediatric measure, according to a study presented at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Major depression in pediatric patients is typically measured with the Child Depression Rating Scale-Revised (CDRS-R). This measure is not only time consuming but it requires clinician training to administer, according to Dr. Shailesh Jain, who is a National Institute of Mental Health fellow at the Mood Disorders Research Program and Clinic at the University of Texas Southwestern Medical Center, Dallas.

Right now, typically, practitioners interview the child or adolescent first, then talk with the parent(s), and use clinical judgment to combine the components.

“It takes a long time. For busy clinicians in child psychiatry, it's difficult to spend 45 minutes,” Dr. Jain said.

In addition, certain items on the scale rely on clinician judgment, and subjective assessments vary with clinician experience, according to Dr. Jain.

Dr. Jain and his associates compared the CDRS-R to the Montgomery-Asberg Depression Rating Scale (MADRS) in 96 children (aged 8–11 years old) and 123 adolescents (12–18 years).

All participants were outpatients with nonpsychotic major depressive disorder.

Participants were culled from a randomized trial of fluoxetine 10 mg/day for 1 week followed by a titration to 20 mg/day continued for 8 weeks vs. placebo.

The researchers rated depressive symptoms using both measures.

“The MADRS has advantages–it has 10 items,” Dr. Jain said in an interview at his poster presentation.

“But the MADRS has been used primarily in adults, and little is known about its psychometric properties in evaluation of pediatric patients,” Dr. Jain said.

Total score correlation between CDRS-R and MADRS was 0.85 at study completion for both children and adolescents, which shows that both scales agree to a considerable extent for assessment of depression, Dr. Jain said.

“When measuring the effect of antidepressants (fluoxetine), CDRS-R was statistically more sensitive in detecting changes in symptoms in response to medication in both children and adolescents,” Dr. Jain said.

Effect size for CDRS-R was 0.78 in children and 0.61 in adolescents, compared with the MADRS 0.38 in children and 0.15 adolescents.

These differences are statistically significant, but the clinical difference is less important because it can take three times longer to complete the CDRS-R, Dr. Jain said.

In addition, adolescents often do not like the CDRS-R requirement that clinicians ask parents about their functioning at each visit.

“This is not to suggest that clinicians completely circumvent parents, but the MADRS provides a reasonable alternative for assessment of depression severity and response to treatment,” Dr. Jain said.

“We now know how the scales correlate and, most importantly, the conversion factors between the scales.”

Busy practitioners can quickly assess symptoms of major depression in adolescents with the MADRS.

Dr. Jain said the scale is also useful for children, who are typically poor historians and very influenced by environmental conditions.

The meeting was cosponsored by the American Society for Clinical Psychopharmacology.

BOCA RATON, FLA. – Major depression in children and adolescents can be assessed quickly using a 10-item scale designed for adults. Results correlate well with a standard 45-minute pediatric measure, according to a study presented at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Major depression in pediatric patients is typically measured with the Child Depression Rating Scale-Revised (CDRS-R). This measure is not only time consuming but it requires clinician training to administer, according to Dr. Shailesh Jain, who is a National Institute of Mental Health fellow at the Mood Disorders Research Program and Clinic at the University of Texas Southwestern Medical Center, Dallas.

Right now, typically, practitioners interview the child or adolescent first, then talk with the parent(s), and use clinical judgment to combine the components.

“It takes a long time. For busy clinicians in child psychiatry, it's difficult to spend 45 minutes,” Dr. Jain said.

In addition, certain items on the scale rely on clinician judgment, and subjective assessments vary with clinician experience, according to Dr. Jain.

Dr. Jain and his associates compared the CDRS-R to the Montgomery-Asberg Depression Rating Scale (MADRS) in 96 children (aged 8–11 years old) and 123 adolescents (12–18 years).

All participants were outpatients with nonpsychotic major depressive disorder.

Participants were culled from a randomized trial of fluoxetine 10 mg/day for 1 week followed by a titration to 20 mg/day continued for 8 weeks vs. placebo.

The researchers rated depressive symptoms using both measures.

“The MADRS has advantages–it has 10 items,” Dr. Jain said in an interview at his poster presentation.

“But the MADRS has been used primarily in adults, and little is known about its psychometric properties in evaluation of pediatric patients,” Dr. Jain said.

Total score correlation between CDRS-R and MADRS was 0.85 at study completion for both children and adolescents, which shows that both scales agree to a considerable extent for assessment of depression, Dr. Jain said.

“When measuring the effect of antidepressants (fluoxetine), CDRS-R was statistically more sensitive in detecting changes in symptoms in response to medication in both children and adolescents,” Dr. Jain said.

Effect size for CDRS-R was 0.78 in children and 0.61 in adolescents, compared with the MADRS 0.38 in children and 0.15 adolescents.

These differences are statistically significant, but the clinical difference is less important because it can take three times longer to complete the CDRS-R, Dr. Jain said.

In addition, adolescents often do not like the CDRS-R requirement that clinicians ask parents about their functioning at each visit.

“This is not to suggest that clinicians completely circumvent parents, but the MADRS provides a reasonable alternative for assessment of depression severity and response to treatment,” Dr. Jain said.

“We now know how the scales correlate and, most importantly, the conversion factors between the scales.”

Busy practitioners can quickly assess symptoms of major depression in adolescents with the MADRS.

Dr. Jain said the scale is also useful for children, who are typically poor historians and very influenced by environmental conditions.

The meeting was cosponsored by the American Society for Clinical Psychopharmacology.

FORT LAUDERDALE, FLA. — Parents reported a nearly 50% overall improvement in their children with severe cerebral palsy following hyperbaric oxygen therapy, according to a study reported at a symposium on hyperbaric therapy.

To assess parental perception of hyperbaric oxygen therapy (HBOT), researchers at Nova Southeastern University in Fort Lauderdale, Fla., surveyed parents or caregivers of 73 children with cerebral palsy (CP). They rated levels of improvements for cognitive, motor, sensory, and overall function on a 0–10 scale via telephone. The ages of children ranged from 1 year to 26 years, and 51% were male.

“Preliminary analysis of the data thus far suggests hyperbaric oxygen can be an effective treatment for CP,” Brandon Korman said at the symposium, sponsored by the Ocean Hyperbaric Neurologic Center in Fort Lauderdale.

“Parents reported quite a bit of improvement,” said Mr. Korman, a graduate student at Nova Southeastern University. Parents found a 49.6% overall improvement in their children's conditions after HBOT.

Of the three domains on the survey, parents reported the greatest improvements in cognitive vs. motor or sensory areas. “This was a particularly interesting finding because mainstream medicine does not offer much for cognitive improvement in cerebral palsy,” Mr. Korman said.

He conducted the telephone survey with graduate student Maritza Figueroa.

“When interpreting these data, keep in mind this is based on parent perception rather than a control group,” Mr. Korman said. “There is no control group to rule out spontaneous improvement. Children at the program also received other therapies concurrently.”

There was no indication of an age-related recovery effect. “This was somewhat surprising,” Mr. Korman said.

“It could be that HBOT is increasing the period of plasticity that otherwise drops off after infancy.” Another finding that warrants further investigation, he said, was a lack of a significant dose-response relationship between the number of treatments and overall improvement.

A total of 73% of parents survey reported overall satisfaction with HBOT.

FORT LAUDERDALE, FLA. — Parents reported a nearly 50% overall improvement in their children with severe cerebral palsy following hyperbaric oxygen therapy, according to a study reported at a symposium on hyperbaric therapy.

To assess parental perception of hyperbaric oxygen therapy (HBOT), researchers at Nova Southeastern University in Fort Lauderdale, Fla., surveyed parents or caregivers of 73 children with cerebral palsy (CP). They rated levels of improvements for cognitive, motor, sensory, and overall function on a 0–10 scale via telephone. The ages of children ranged from 1 year to 26 years, and 51% were male.

“Preliminary analysis of the data thus far suggests hyperbaric oxygen can be an effective treatment for CP,” Brandon Korman said at the symposium, sponsored by the Ocean Hyperbaric Neurologic Center in Fort Lauderdale.

“Parents reported quite a bit of improvement,” said Mr. Korman, a graduate student at Nova Southeastern University. Parents found a 49.6% overall improvement in their children's conditions after HBOT.

Of the three domains on the survey, parents reported the greatest improvements in cognitive vs. motor or sensory areas. “This was a particularly interesting finding because mainstream medicine does not offer much for cognitive improvement in cerebral palsy,” Mr. Korman said.

He conducted the telephone survey with graduate student Maritza Figueroa.

“When interpreting these data, keep in mind this is based on parent perception rather than a control group,” Mr. Korman said. “There is no control group to rule out spontaneous improvement. Children at the program also received other therapies concurrently.”

There was no indication of an age-related recovery effect. “This was somewhat surprising,” Mr. Korman said.

“It could be that HBOT is increasing the period of plasticity that otherwise drops off after infancy.” Another finding that warrants further investigation, he said, was a lack of a significant dose-response relationship between the number of treatments and overall improvement.

A total of 73% of parents survey reported overall satisfaction with HBOT.

FORT LAUDERDALE, FLA. — Parents reported a nearly 50% overall improvement in their children with severe cerebral palsy following hyperbaric oxygen therapy, according to a study reported at a symposium on hyperbaric therapy.

To assess parental perception of hyperbaric oxygen therapy (HBOT), researchers at Nova Southeastern University in Fort Lauderdale, Fla., surveyed parents or caregivers of 73 children with cerebral palsy (CP). They rated levels of improvements for cognitive, motor, sensory, and overall function on a 0–10 scale via telephone. The ages of children ranged from 1 year to 26 years, and 51% were male.

“Preliminary analysis of the data thus far suggests hyperbaric oxygen can be an effective treatment for CP,” Brandon Korman said at the symposium, sponsored by the Ocean Hyperbaric Neurologic Center in Fort Lauderdale.

“Parents reported quite a bit of improvement,” said Mr. Korman, a graduate student at Nova Southeastern University. Parents found a 49.6% overall improvement in their children's conditions after HBOT.

Of the three domains on the survey, parents reported the greatest improvements in cognitive vs. motor or sensory areas. “This was a particularly interesting finding because mainstream medicine does not offer much for cognitive improvement in cerebral palsy,” Mr. Korman said.

He conducted the telephone survey with graduate student Maritza Figueroa.

“When interpreting these data, keep in mind this is based on parent perception rather than a control group,” Mr. Korman said. “There is no control group to rule out spontaneous improvement. Children at the program also received other therapies concurrently.”

There was no indication of an age-related recovery effect. “This was somewhat surprising,” Mr. Korman said.

“It could be that HBOT is increasing the period of plasticity that otherwise drops off after infancy.” Another finding that warrants further investigation, he said, was a lack of a significant dose-response relationship between the number of treatments and overall improvement.

A total of 73% of parents survey reported overall satisfaction with HBOT.

AMELIA ISLAND, FLA. — Clinical acuity aids the differential diagnosis of acute arthritis in pediatrics, according to a presentation at a meeting on pediatrics for the primary care physician, sponsored by Nemours.

Dr. Carlos D. Rosé, chief of rheumatology, Alfred I. DuPont Hospital for Children, Wilmington, Del., offered tips for diagnosis of the following forms of pediatric arthritis:

▸ Nonarticular disease. Beware of reports of joint pain that are truly limb or marrow pain, Dr. Rosé said. “The patient will tell you [the] knee, elbow, etc. hurts, but you will determine by physical exam that it is not in the joint.” Patients often describe limb pain as joint pain.

“Three to five times a year in my pediatric rheumatology practice I diagnose leukemia,” Dr. Rosé said. Pain that is nocturnal, occurs when the patients move their arms or walk, and/or cannot be localized are among symptoms of marrow involvement. Because NSAIDs work for leukemic pain, patients might be taking ibuprofen around the clock, Dr. Rosé said. “If they stop and feel pain again at 4-6 hours, this is a red flag for bony pain.”

Discomfort on limb compression, a “very abnormal” erythrocyte sedimentation rate (ESR), and absence of thrombocytosis are other signs of bony involvement, Dr. Rosé said.

▸ Transient synovitis. Transient synovitis can be severe and can signal the early phase of Legg-Calvé-Perthes disease, an idiopathic avascular necrosis of the femoral head. An ESR less than 40 mm/hr is diagnostic. Synovitis typically lasts 1-3 weeks and can be related to Legg-Calvé-Perthes disease or parvovirus.

Recurrent transient synovitis in some pediatric patients could be the onset of psoriasis or spondyloarthropathy, according to a multicenter study of 39 children with 102 episodes of transient synovitis (J. Rheumatol. 2006;33:810-11).

▸ Intermittent monoarthritis. Pediatric patients with intermittent arthritis often have a joint that gets swollen, the inflammation resolves in a few weeks, and then the joint gets swollen again. “Be patient with these patients. Just wait until the effusion goes away—most of the time it happens,” Dr. Rosé said.

A big, bland effusion without a contracture is a presentation that is very suggestive of Lyme arthritis, he added.

▸ Acute monoarthritis. There are multiple etiologies for acute monoarthritis. Septic arthritis, while important, is overdiagnosed, Dr. Rosé said. Septic arthritis is usually monoarticular; exceptions are cases caused by gonococcus or tuberculosis and nontuberculosis mycobacterium.

Nonpyogenic infection, foreign bodies, pigmented villonodular synovitis, coagulopathy, and vascular abnormalities are other causes of monoarthritis. Trauma also can cause acute monoarthritis, especially among children who fall on their knees. The pain should not last more than 48 hours, Dr. Rosé said.

“Be careful—I had some children present for monoarthritis, and on physical examination I found other areas of inflammation, such as the toes or knees. Look for a second joint to get away from the idea that it is monoarticular,” Dr. Rosé said.

▸ Migratory arthritis. This condition is an orderly involvement of primarily intermediate joints, approximately one per day, characterized by periarticular swelling. It is a sequential form of “polyarticular monoarthritis,” Dr. Rosé said. Migratory arthritis often is very painful but responsive to NSAIDs. Etiology is overwhelmingly postinfectious, he added.

▸ Acute polyarticular arthritis. “This is very important to recognize. Here every joint is painful in 1 day, it is not sequential,” Dr. Rosé said. Parvovirus infection is the most common cause. Approximately one-third present with an intense red rash in a symmetrical pattern on both hands and feet. Small epidemics often occur in springtime, he added. Common viral diseases such as Epstein-Barr virus, cytomegalovirus, hepatitis, and infections caused by Clostridium difficile can produce arthritis, Dr. Rosé said.

▸ Rheumatic fever. Diagnostic tips include a fever of 101.3° F daily and an ESR of greater than 50 mm/hr. The patient will look ill and a cardiac examination will demonstrate tachycardia, gallop, and murmurs. Order echocardiography within the first week for all cases of suspected rheumatic fever, Dr. Rosé suggested.

AMELIA ISLAND, FLA. — Clinical acuity aids the differential diagnosis of acute arthritis in pediatrics, according to a presentation at a meeting on pediatrics for the primary care physician, sponsored by Nemours.

Dr. Carlos D. Rosé, chief of rheumatology, Alfred I. DuPont Hospital for Children, Wilmington, Del., offered tips for diagnosis of the following forms of pediatric arthritis:

▸ Nonarticular disease. Beware of reports of joint pain that are truly limb or marrow pain, Dr. Rosé said. “The patient will tell you [the] knee, elbow, etc. hurts, but you will determine by physical exam that it is not in the joint.” Patients often describe limb pain as joint pain.

“Three to five times a year in my pediatric rheumatology practice I diagnose leukemia,” Dr. Rosé said. Pain that is nocturnal, occurs when the patients move their arms or walk, and/or cannot be localized are among symptoms of marrow involvement. Because NSAIDs work for leukemic pain, patients might be taking ibuprofen around the clock, Dr. Rosé said. “If they stop and feel pain again at 4-6 hours, this is a red flag for bony pain.”

Discomfort on limb compression, a “very abnormal” erythrocyte sedimentation rate (ESR), and absence of thrombocytosis are other signs of bony involvement, Dr. Rosé said.

▸ Transient synovitis. Transient synovitis can be severe and can signal the early phase of Legg-Calvé-Perthes disease, an idiopathic avascular necrosis of the femoral head. An ESR less than 40 mm/hr is diagnostic. Synovitis typically lasts 1-3 weeks and can be related to Legg-Calvé-Perthes disease or parvovirus.

Recurrent transient synovitis in some pediatric patients could be the onset of psoriasis or spondyloarthropathy, according to a multicenter study of 39 children with 102 episodes of transient synovitis (J. Rheumatol. 2006;33:810-11).

▸ Intermittent monoarthritis. Pediatric patients with intermittent arthritis often have a joint that gets swollen, the inflammation resolves in a few weeks, and then the joint gets swollen again. “Be patient with these patients. Just wait until the effusion goes away—most of the time it happens,” Dr. Rosé said.

A big, bland effusion without a contracture is a presentation that is very suggestive of Lyme arthritis, he added.

▸ Acute monoarthritis. There are multiple etiologies for acute monoarthritis. Septic arthritis, while important, is overdiagnosed, Dr. Rosé said. Septic arthritis is usually monoarticular; exceptions are cases caused by gonococcus or tuberculosis and nontuberculosis mycobacterium.

Nonpyogenic infection, foreign bodies, pigmented villonodular synovitis, coagulopathy, and vascular abnormalities are other causes of monoarthritis. Trauma also can cause acute monoarthritis, especially among children who fall on their knees. The pain should not last more than 48 hours, Dr. Rosé said.

“Be careful—I had some children present for monoarthritis, and on physical examination I found other areas of inflammation, such as the toes or knees. Look for a second joint to get away from the idea that it is monoarticular,” Dr. Rosé said.

▸ Migratory arthritis. This condition is an orderly involvement of primarily intermediate joints, approximately one per day, characterized by periarticular swelling. It is a sequential form of “polyarticular monoarthritis,” Dr. Rosé said. Migratory arthritis often is very painful but responsive to NSAIDs. Etiology is overwhelmingly postinfectious, he added.

▸ Acute polyarticular arthritis. “This is very important to recognize. Here every joint is painful in 1 day, it is not sequential,” Dr. Rosé said. Parvovirus infection is the most common cause. Approximately one-third present with an intense red rash in a symmetrical pattern on both hands and feet. Small epidemics often occur in springtime, he added. Common viral diseases such as Epstein-Barr virus, cytomegalovirus, hepatitis, and infections caused by Clostridium difficile can produce arthritis, Dr. Rosé said.

▸ Rheumatic fever. Diagnostic tips include a fever of 101.3° F daily and an ESR of greater than 50 mm/hr. The patient will look ill and a cardiac examination will demonstrate tachycardia, gallop, and murmurs. Order echocardiography within the first week for all cases of suspected rheumatic fever, Dr. Rosé suggested.

AMELIA ISLAND, FLA. — Clinical acuity aids the differential diagnosis of acute arthritis in pediatrics, according to a presentation at a meeting on pediatrics for the primary care physician, sponsored by Nemours.

Dr. Carlos D. Rosé, chief of rheumatology, Alfred I. DuPont Hospital for Children, Wilmington, Del., offered tips for diagnosis of the following forms of pediatric arthritis:

▸ Nonarticular disease. Beware of reports of joint pain that are truly limb or marrow pain, Dr. Rosé said. “The patient will tell you [the] knee, elbow, etc. hurts, but you will determine by physical exam that it is not in the joint.” Patients often describe limb pain as joint pain.

“Three to five times a year in my pediatric rheumatology practice I diagnose leukemia,” Dr. Rosé said. Pain that is nocturnal, occurs when the patients move their arms or walk, and/or cannot be localized are among symptoms of marrow involvement. Because NSAIDs work for leukemic pain, patients might be taking ibuprofen around the clock, Dr. Rosé said. “If they stop and feel pain again at 4-6 hours, this is a red flag for bony pain.”

Discomfort on limb compression, a “very abnormal” erythrocyte sedimentation rate (ESR), and absence of thrombocytosis are other signs of bony involvement, Dr. Rosé said.

▸ Transient synovitis. Transient synovitis can be severe and can signal the early phase of Legg-Calvé-Perthes disease, an idiopathic avascular necrosis of the femoral head. An ESR less than 40 mm/hr is diagnostic. Synovitis typically lasts 1-3 weeks and can be related to Legg-Calvé-Perthes disease or parvovirus.

Recurrent transient synovitis in some pediatric patients could be the onset of psoriasis or spondyloarthropathy, according to a multicenter study of 39 children with 102 episodes of transient synovitis (J. Rheumatol. 2006;33:810-11).

▸ Intermittent monoarthritis. Pediatric patients with intermittent arthritis often have a joint that gets swollen, the inflammation resolves in a few weeks, and then the joint gets swollen again. “Be patient with these patients. Just wait until the effusion goes away—most of the time it happens,” Dr. Rosé said.

A big, bland effusion without a contracture is a presentation that is very suggestive of Lyme arthritis, he added.

▸ Acute monoarthritis. There are multiple etiologies for acute monoarthritis. Septic arthritis, while important, is overdiagnosed, Dr. Rosé said. Septic arthritis is usually monoarticular; exceptions are cases caused by gonococcus or tuberculosis and nontuberculosis mycobacterium.

Nonpyogenic infection, foreign bodies, pigmented villonodular synovitis, coagulopathy, and vascular abnormalities are other causes of monoarthritis. Trauma also can cause acute monoarthritis, especially among children who fall on their knees. The pain should not last more than 48 hours, Dr. Rosé said.

“Be careful—I had some children present for monoarthritis, and on physical examination I found other areas of inflammation, such as the toes or knees. Look for a second joint to get away from the idea that it is monoarticular,” Dr. Rosé said.

▸ Migratory arthritis. This condition is an orderly involvement of primarily intermediate joints, approximately one per day, characterized by periarticular swelling. It is a sequential form of “polyarticular monoarthritis,” Dr. Rosé said. Migratory arthritis often is very painful but responsive to NSAIDs. Etiology is overwhelmingly postinfectious, he added.

▸ Acute polyarticular arthritis. “This is very important to recognize. Here every joint is painful in 1 day, it is not sequential,” Dr. Rosé said. Parvovirus infection is the most common cause. Approximately one-third present with an intense red rash in a symmetrical pattern on both hands and feet. Small epidemics often occur in springtime, he added. Common viral diseases such as Epstein-Barr virus, cytomegalovirus, hepatitis, and infections caused by Clostridium difficile can produce arthritis, Dr. Rosé said.

▸ Rheumatic fever. Diagnostic tips include a fever of 101.3° F daily and an ESR of greater than 50 mm/hr. The patient will look ill and a cardiac examination will demonstrate tachycardia, gallop, and murmurs. Order echocardiography within the first week for all cases of suspected rheumatic fever, Dr. Rosé suggested.

BOCA RATON, FLA. — The black box warning of potential increased suicidality among pediatric patients treated with antidepressants spurred an overall 10% decrease in prescriptions in the ensuing year, according to a study of a large managed care database.

There were 68,121 prescriptions for patients 17 years old and younger in the United Healthcare database in the year before the October 2004 bilack box warning, compared with 61,561 afterward. This 10% decrease was statistically significant (P < .001), Christine Thomason, Ph.D., said in an interview at a poster session at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

“We expected it to go down, but I want to make it clear that access to effective treatment is so important,” said Dr. Thomason, director of the pediatric CNS division of i3 Research.

Dr. Thomason and her associates assessed the data by individual agent(s) prescribed, antidepressant drug class, new prescriptions only, and patient age.

“Fluoxetine use increased. It is the only approved medication for major depressive disorder in children,” Dr. Thomason said. Postwarning prescriptions increased 9% for fluoxetine, while prescriptions decreased 19% for sertraline (Zoloft) and 29% for venlafaxine (Effexor).

When researchers specifically looked at only selective and nonselective serotonin reuptake inhibitors, the overall decrease was 12%. Regarding new prescriptions, the number fell 20% in the year after the black box warning, Dr. Thomason said. “It is likely that patients taking antidepressants are maintained on that treatment, but physicians are prescribing antidepressants at a lower rate for new patients,” the authors wrote.

The highest decreases for any antidepressant prescription were among younger patients. For example, prescriptions decreased 18% (from 466 before the warning to 383 afterward) among those 0–4 years old. Prescriptions dropped 15% among patients 5–9 years old; 11% among 10- to 14-year-olds; and 7% among 15- to 17-year-olds. About half of the pediatric patients in the study fell in the 15- to 17-year-old group.

Sex was almost evenly split between prewarning and postwarning groups. Psychiatric diagnoses (all counts at all encounters) were likewise similar between groups. For example, depressive disorder accounted for 30% of the prewarning encounters vs. 29% post warning; attention-deficit hyperactivity disorder accounted for 24% in each group; and anxiety/general anxiety disorder accounted for 10% of prewarning and 11% of postwarning encounters.

All data in the study were deidentified to protect patient privacy. Data were limited to outpatient retail, mail order, and specialty pharmacy claims.

The researchers plan to expand the study to cover more than 1 year before and after the black box warning. In addition, plans include a comparison of prescribing habits of general practitioners vs. child psychiatrists.

“We also want to see if there is any seasonal variation in prescriptions—such as increased use during the holidays or lower use during the summertime,” Dr. Thomason said at the meeting, which was cosponsored by the American Society for Clinical Psychopharmacology.

BOCA RATON, FLA. — The black box warning of potential increased suicidality among pediatric patients treated with antidepressants spurred an overall 10% decrease in prescriptions in the ensuing year, according to a study of a large managed care database.

There were 68,121 prescriptions for patients 17 years old and younger in the United Healthcare database in the year before the October 2004 bilack box warning, compared with 61,561 afterward. This 10% decrease was statistically significant (P < .001), Christine Thomason, Ph.D., said in an interview at a poster session at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

“We expected it to go down, but I want to make it clear that access to effective treatment is so important,” said Dr. Thomason, director of the pediatric CNS division of i3 Research.

Dr. Thomason and her associates assessed the data by individual agent(s) prescribed, antidepressant drug class, new prescriptions only, and patient age.

“Fluoxetine use increased. It is the only approved medication for major depressive disorder in children,” Dr. Thomason said. Postwarning prescriptions increased 9% for fluoxetine, while prescriptions decreased 19% for sertraline (Zoloft) and 29% for venlafaxine (Effexor).

When researchers specifically looked at only selective and nonselective serotonin reuptake inhibitors, the overall decrease was 12%. Regarding new prescriptions, the number fell 20% in the year after the black box warning, Dr. Thomason said. “It is likely that patients taking antidepressants are maintained on that treatment, but physicians are prescribing antidepressants at a lower rate for new patients,” the authors wrote.

The highest decreases for any antidepressant prescription were among younger patients. For example, prescriptions decreased 18% (from 466 before the warning to 383 afterward) among those 0–4 years old. Prescriptions dropped 15% among patients 5–9 years old; 11% among 10- to 14-year-olds; and 7% among 15- to 17-year-olds. About half of the pediatric patients in the study fell in the 15- to 17-year-old group.

Sex was almost evenly split between prewarning and postwarning groups. Psychiatric diagnoses (all counts at all encounters) were likewise similar between groups. For example, depressive disorder accounted for 30% of the prewarning encounters vs. 29% post warning; attention-deficit hyperactivity disorder accounted for 24% in each group; and anxiety/general anxiety disorder accounted for 10% of prewarning and 11% of postwarning encounters.

All data in the study were deidentified to protect patient privacy. Data were limited to outpatient retail, mail order, and specialty pharmacy claims.

The researchers plan to expand the study to cover more than 1 year before and after the black box warning. In addition, plans include a comparison of prescribing habits of general practitioners vs. child psychiatrists.

“We also want to see if there is any seasonal variation in prescriptions—such as increased use during the holidays or lower use during the summertime,” Dr. Thomason said at the meeting, which was cosponsored by the American Society for Clinical Psychopharmacology.

BOCA RATON, FLA. — The black box warning of potential increased suicidality among pediatric patients treated with antidepressants spurred an overall 10% decrease in prescriptions in the ensuing year, according to a study of a large managed care database.

There were 68,121 prescriptions for patients 17 years old and younger in the United Healthcare database in the year before the October 2004 bilack box warning, compared with 61,561 afterward. This 10% decrease was statistically significant (P < .001), Christine Thomason, Ph.D., said in an interview at a poster session at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

“We expected it to go down, but I want to make it clear that access to effective treatment is so important,” said Dr. Thomason, director of the pediatric CNS division of i3 Research.

Dr. Thomason and her associates assessed the data by individual agent(s) prescribed, antidepressant drug class, new prescriptions only, and patient age.

“Fluoxetine use increased. It is the only approved medication for major depressive disorder in children,” Dr. Thomason said. Postwarning prescriptions increased 9% for fluoxetine, while prescriptions decreased 19% for sertraline (Zoloft) and 29% for venlafaxine (Effexor).

When researchers specifically looked at only selective and nonselective serotonin reuptake inhibitors, the overall decrease was 12%. Regarding new prescriptions, the number fell 20% in the year after the black box warning, Dr. Thomason said. “It is likely that patients taking antidepressants are maintained on that treatment, but physicians are prescribing antidepressants at a lower rate for new patients,” the authors wrote.

The highest decreases for any antidepressant prescription were among younger patients. For example, prescriptions decreased 18% (from 466 before the warning to 383 afterward) among those 0–4 years old. Prescriptions dropped 15% among patients 5–9 years old; 11% among 10- to 14-year-olds; and 7% among 15- to 17-year-olds. About half of the pediatric patients in the study fell in the 15- to 17-year-old group.

Sex was almost evenly split between prewarning and postwarning groups. Psychiatric diagnoses (all counts at all encounters) were likewise similar between groups. For example, depressive disorder accounted for 30% of the prewarning encounters vs. 29% post warning; attention-deficit hyperactivity disorder accounted for 24% in each group; and anxiety/general anxiety disorder accounted for 10% of prewarning and 11% of postwarning encounters.

All data in the study were deidentified to protect patient privacy. Data were limited to outpatient retail, mail order, and specialty pharmacy claims.

The researchers plan to expand the study to cover more than 1 year before and after the black box warning. In addition, plans include a comparison of prescribing habits of general practitioners vs. child psychiatrists.

“We also want to see if there is any seasonal variation in prescriptions—such as increased use during the holidays or lower use during the summertime,” Dr. Thomason said at the meeting, which was cosponsored by the American Society for Clinical Psychopharmacology.

AMELIA ISLAND, FLA. — Vigilance, aggressive drainage, and the appropriate antibiotic are components of a strategy to counter community-acquired methicillin-resistant Staphylococcus aureus infections in an office practice setting, according to a presentation at a meeting on pediatrics for the primary care physician, sponsored by Nemours.

“There is something about staph that seems to wax and wane across the decades. I will contend that you and I are coming off a period of relatively mild staph and [entering] a period of bad staph,” Dr. Kenneth Alexander said. Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is increasingly common, appears to be permanent, and is polyclonal, he said.

CA-MRSA is distinct from hospital-acquired infection. “Kids are coming in with CA-MRSA and have no contact with the health care system whatsoever. So you don't need to look for that history,” said Dr. Alexander, a pediatric infectious diseases expert at the University of Chicago.

Management of children with suspected CA-MRSA begins with drainage and culture of any abscess, he said. “Be aggressive about drainage. Now more than ever, culturing staph infections is critically important to good patient care.”

Know your local S. aureus epidemiology and keep track of your own resistance data, Dr. Alexander said. In Chicago, about 85% of community-acquired S. aureus infections are methicillin resistant, compared with about 50% in northern Florida. “Resistance patterns in Chicago vary [between] children and adults. So a hospital antibiogram is not as helpful to us about kids.”

Trimethoprim and sulfamethoxazole (TMP/SMX), clindamycin, and minocycline are treatment options for minor CA-MRSA infections. “You can use something wimpy like TPM/SMX with a small drained abscess [less than 2 cm] or small areas of cellulitis or impetigo, with good follow-up,” Dr. Alexander said.

If those criteria cannot be met; or the patient has lesions on the face, head, neck, hands, or feet; the patient looks sick or febrile; the lesion looks deeper than the skin; or the infection is progressing, “then we have to pull out the big stick, clindamycin,” Dr. Alexander said. “TMP/SMX and clindamycin are your go-to antibiotics.” The good news, he said, is “CA-MRSA is more susceptible to these treatments than hospital-acquired infections” are.

For serious outpatient infections, Dr. Alexander suggested oral clindamycin or a combination of TMP/SMX and rifampin, although rifampin is expensive. If the culture subsequently indicates a susceptible form of infection, the child can be switched to Keflex (cephalexin).

“Fear staph [S. aureus] infections, especially in babies,” he said. “If you see staph in a baby, walk over to the wall and pull the fire alarm. This is a code-blue infection.”

For the most serious infections, admit the child to the hospital and treat with either intravenous clindamycin or intravenous vancomycin. Vancomycin is indicated if the S. aureus is erythromycin-resistant and resistance to clindamycin is inducible (indicated with a positive D-test). “At the University of Chicago, we use IV clindamycin.”

Linezolid (Zyvox) and daptomycin (Cubicin) are two newer antibiotics for MRSA, “although I am not suggesting you use them,” Dr. Alexander said. Linezolid shows reliable oral activity against MRSA. “The downside is this stuff is priced to compete with hospitalization. And it's three doses of a liquid that tastes terrible.” Daptomycin is restricted for life-threatening infections in hospitalized patients.

Some physicians asked Dr. Alexander about using amoxicillin-clavulanate (Augmentin). “If you have a kid with MRSA, and you treat with Augmentin, what you have is a kid with MRSA and diarrhea, nothing more,” he said.

One should include herpes infection in the differential diagnosis for a patient with recurrent infections on the nails or in the nose, he said. And, “if you see something that looks like a spider bite, and you are not in an endemic area, think CA-MRSA.”

Another common question is the prevention strategy for a family passing S. aureus infections back and forth, Dr. Alexander said. “Treat staph in family a little bit the way you would with lice.” Proper hygiene is important. Prescribe antibacterial soaps; use of clean, dry towels and bedding; and frequent hand washing. Also, assess skin care products to make sure they are not the vector.

AMELIA ISLAND, FLA. — Vigilance, aggressive drainage, and the appropriate antibiotic are components of a strategy to counter community-acquired methicillin-resistant Staphylococcus aureus infections in an office practice setting, according to a presentation at a meeting on pediatrics for the primary care physician, sponsored by Nemours.

“There is something about staph that seems to wax and wane across the decades. I will contend that you and I are coming off a period of relatively mild staph and [entering] a period of bad staph,” Dr. Kenneth Alexander said. Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is increasingly common, appears to be permanent, and is polyclonal, he said.

CA-MRSA is distinct from hospital-acquired infection. “Kids are coming in with CA-MRSA and have no contact with the health care system whatsoever. So you don't need to look for that history,” said Dr. Alexander, a pediatric infectious diseases expert at the University of Chicago.

Management of children with suspected CA-MRSA begins with drainage and culture of any abscess, he said. “Be aggressive about drainage. Now more than ever, culturing staph infections is critically important to good patient care.”

Know your local S. aureus epidemiology and keep track of your own resistance data, Dr. Alexander said. In Chicago, about 85% of community-acquired S. aureus infections are methicillin resistant, compared with about 50% in northern Florida. “Resistance patterns in Chicago vary [between] children and adults. So a hospital antibiogram is not as helpful to us about kids.”

Trimethoprim and sulfamethoxazole (TMP/SMX), clindamycin, and minocycline are treatment options for minor CA-MRSA infections. “You can use something wimpy like TPM/SMX with a small drained abscess [less than 2 cm] or small areas of cellulitis or impetigo, with good follow-up,” Dr. Alexander said.

If those criteria cannot be met; or the patient has lesions on the face, head, neck, hands, or feet; the patient looks sick or febrile; the lesion looks deeper than the skin; or the infection is progressing, “then we have to pull out the big stick, clindamycin,” Dr. Alexander said. “TMP/SMX and clindamycin are your go-to antibiotics.” The good news, he said, is “CA-MRSA is more susceptible to these treatments than hospital-acquired infections” are.

For serious outpatient infections, Dr. Alexander suggested oral clindamycin or a combination of TMP/SMX and rifampin, although rifampin is expensive. If the culture subsequently indicates a susceptible form of infection, the child can be switched to Keflex (cephalexin).

“Fear staph [S. aureus] infections, especially in babies,” he said. “If you see staph in a baby, walk over to the wall and pull the fire alarm. This is a code-blue infection.”

For the most serious infections, admit the child to the hospital and treat with either intravenous clindamycin or intravenous vancomycin. Vancomycin is indicated if the S. aureus is erythromycin-resistant and resistance to clindamycin is inducible (indicated with a positive D-test). “At the University of Chicago, we use IV clindamycin.”

Linezolid (Zyvox) and daptomycin (Cubicin) are two newer antibiotics for MRSA, “although I am not suggesting you use them,” Dr. Alexander said. Linezolid shows reliable oral activity against MRSA. “The downside is this stuff is priced to compete with hospitalization. And it's three doses of a liquid that tastes terrible.” Daptomycin is restricted for life-threatening infections in hospitalized patients.

Some physicians asked Dr. Alexander about using amoxicillin-clavulanate (Augmentin). “If you have a kid with MRSA, and you treat with Augmentin, what you have is a kid with MRSA and diarrhea, nothing more,” he said.

One should include herpes infection in the differential diagnosis for a patient with recurrent infections on the nails or in the nose, he said. And, “if you see something that looks like a spider bite, and you are not in an endemic area, think CA-MRSA.”

Another common question is the prevention strategy for a family passing S. aureus infections back and forth, Dr. Alexander said. “Treat staph in family a little bit the way you would with lice.” Proper hygiene is important. Prescribe antibacterial soaps; use of clean, dry towels and bedding; and frequent hand washing. Also, assess skin care products to make sure they are not the vector.

AMELIA ISLAND, FLA. — Vigilance, aggressive drainage, and the appropriate antibiotic are components of a strategy to counter community-acquired methicillin-resistant Staphylococcus aureus infections in an office practice setting, according to a presentation at a meeting on pediatrics for the primary care physician, sponsored by Nemours.

“There is something about staph that seems to wax and wane across the decades. I will contend that you and I are coming off a period of relatively mild staph and [entering] a period of bad staph,” Dr. Kenneth Alexander said. Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is increasingly common, appears to be permanent, and is polyclonal, he said.

CA-MRSA is distinct from hospital-acquired infection. “Kids are coming in with CA-MRSA and have no contact with the health care system whatsoever. So you don't need to look for that history,” said Dr. Alexander, a pediatric infectious diseases expert at the University of Chicago.

Management of children with suspected CA-MRSA begins with drainage and culture of any abscess, he said. “Be aggressive about drainage. Now more than ever, culturing staph infections is critically important to good patient care.”

Know your local S. aureus epidemiology and keep track of your own resistance data, Dr. Alexander said. In Chicago, about 85% of community-acquired S. aureus infections are methicillin resistant, compared with about 50% in northern Florida. “Resistance patterns in Chicago vary [between] children and adults. So a hospital antibiogram is not as helpful to us about kids.”

Trimethoprim and sulfamethoxazole (TMP/SMX), clindamycin, and minocycline are treatment options for minor CA-MRSA infections. “You can use something wimpy like TPM/SMX with a small drained abscess [less than 2 cm] or small areas of cellulitis or impetigo, with good follow-up,” Dr. Alexander said.

If those criteria cannot be met; or the patient has lesions on the face, head, neck, hands, or feet; the patient looks sick or febrile; the lesion looks deeper than the skin; or the infection is progressing, “then we have to pull out the big stick, clindamycin,” Dr. Alexander said. “TMP/SMX and clindamycin are your go-to antibiotics.” The good news, he said, is “CA-MRSA is more susceptible to these treatments than hospital-acquired infections” are.

For serious outpatient infections, Dr. Alexander suggested oral clindamycin or a combination of TMP/SMX and rifampin, although rifampin is expensive. If the culture subsequently indicates a susceptible form of infection, the child can be switched to Keflex (cephalexin).

“Fear staph [S. aureus] infections, especially in babies,” he said. “If you see staph in a baby, walk over to the wall and pull the fire alarm. This is a code-blue infection.”

For the most serious infections, admit the child to the hospital and treat with either intravenous clindamycin or intravenous vancomycin. Vancomycin is indicated if the S. aureus is erythromycin-resistant and resistance to clindamycin is inducible (indicated with a positive D-test). “At the University of Chicago, we use IV clindamycin.”

Linezolid (Zyvox) and daptomycin (Cubicin) are two newer antibiotics for MRSA, “although I am not suggesting you use them,” Dr. Alexander said. Linezolid shows reliable oral activity against MRSA. “The downside is this stuff is priced to compete with hospitalization. And it's three doses of a liquid that tastes terrible.” Daptomycin is restricted for life-threatening infections in hospitalized patients.

Some physicians asked Dr. Alexander about using amoxicillin-clavulanate (Augmentin). “If you have a kid with MRSA, and you treat with Augmentin, what you have is a kid with MRSA and diarrhea, nothing more,” he said.

One should include herpes infection in the differential diagnosis for a patient with recurrent infections on the nails or in the nose, he said. And, “if you see something that looks like a spider bite, and you are not in an endemic area, think CA-MRSA.”

Another common question is the prevention strategy for a family passing S. aureus infections back and forth, Dr. Alexander said. “Treat staph in family a little bit the way you would with lice.” Proper hygiene is important. Prescribe antibacterial soaps; use of clean, dry towels and bedding; and frequent hand washing. Also, assess skin care products to make sure they are not the vector.

MIAMI – Overprotection may be the mechanism through which parental anxiety and mood disorders lead to such disorders in their children, according to a poster presentation at the annual conference of the Anxiety Disorders Association of America.

A maternal anxiety disorder significantly predicted anxiety disorders in children in one report (J. Abnorm. Child Psychol. 2001;29:1–10). This study found that parental overprotection did not mediate the child's anxiety, although other research suggests it does. For example, parental control was specifically associated with symptoms of general anxiety disorder in children in a study showing that the more the children perceived parental behavior as anxious and controlling, the higher their reported anxiety levels were (Pers. Individ. Dif. 1998;25:1199–206).

To further elucidate the possible mediating effect of parental overprotection, Jacquelyn Doxie and associates assessed 63 children and adolescents from 7 to 16 years old. Children had to have three diagnoses–for example, phobia, social anxiety, and a mood disorder–to participate in the study. The current analysis is part of a larger study of how parental behavior might affect specific phobias in children.

The primary caregiver for each child completed the Anxiety Disorders Interview Schedule (ADIS)-Client Interview, the ADIS-Parent, and the Parental Bonding Instrument. Researchers administered the ADIS-Child to the participants to determine the number of childhood anxiety diagnoses. The investigators used two-step hierarchical regression analyses to determine if overprotection was indeed a mechanism to explain the relationship between parental and childhood anxiety.

“We found that if the parent has anxiety, then the child is more likely to,” said Ms. Doxie, who is a research assistant for the child and adolescent phobia project at Virginia Polytechnic Institute and State University, Blacksburg.

Parent mood and anxiety disorder diagnoses significantly predicted the number of child diagnoses in the first step of the analysis. In the second step, researchers added overprotection to the regression analysis and found the relationship between parental psychopathology and child anxiety disorder was no longer significant. However, Ms. Doxie said overprotection was significant, “affirming the mediational role of overprotection in predicting childhood diagnoses.”

In a separate presentation at the Anxiety Disorders Association meeting, Aureen Pinto Wagner, Ph.D., said parents might unwittingly fuel anxiety in their children. “Studies have shown that parents of anxious children are often overprotective.”

However, she added, “Not all parents of anxious children are overprotective.” The anxious child might elicit the parental behavior.

In addition, parents may deal differently with their nonanxious children. “Ask parents about how they interact with their other children,” suggested Dr. Pinto Wagner, professor of neurology at the University of Rochester (New York).

The take-home message for clinicians from the current study, Ms. Doxie said, is this: “If you do see a parent who is overprotective, you might have to treat the whole family.”

MIAMI – Overprotection may be the mechanism through which parental anxiety and mood disorders lead to such disorders in their children, according to a poster presentation at the annual conference of the Anxiety Disorders Association of America.

A maternal anxiety disorder significantly predicted anxiety disorders in children in one report (J. Abnorm. Child Psychol. 2001;29:1–10). This study found that parental overprotection did not mediate the child's anxiety, although other research suggests it does. For example, parental control was specifically associated with symptoms of general anxiety disorder in children in a study showing that the more the children perceived parental behavior as anxious and controlling, the higher their reported anxiety levels were (Pers. Individ. Dif. 1998;25:1199–206).

To further elucidate the possible mediating effect of parental overprotection, Jacquelyn Doxie and associates assessed 63 children and adolescents from 7 to 16 years old. Children had to have three diagnoses–for example, phobia, social anxiety, and a mood disorder–to participate in the study. The current analysis is part of a larger study of how parental behavior might affect specific phobias in children.

The primary caregiver for each child completed the Anxiety Disorders Interview Schedule (ADIS)-Client Interview, the ADIS-Parent, and the Parental Bonding Instrument. Researchers administered the ADIS-Child to the participants to determine the number of childhood anxiety diagnoses. The investigators used two-step hierarchical regression analyses to determine if overprotection was indeed a mechanism to explain the relationship between parental and childhood anxiety.

“We found that if the parent has anxiety, then the child is more likely to,” said Ms. Doxie, who is a research assistant for the child and adolescent phobia project at Virginia Polytechnic Institute and State University, Blacksburg.

Parent mood and anxiety disorder diagnoses significantly predicted the number of child diagnoses in the first step of the analysis. In the second step, researchers added overprotection to the regression analysis and found the relationship between parental psychopathology and child anxiety disorder was no longer significant. However, Ms. Doxie said overprotection was significant, “affirming the mediational role of overprotection in predicting childhood diagnoses.”

In a separate presentation at the Anxiety Disorders Association meeting, Aureen Pinto Wagner, Ph.D., said parents might unwittingly fuel anxiety in their children. “Studies have shown that parents of anxious children are often overprotective.”

However, she added, “Not all parents of anxious children are overprotective.” The anxious child might elicit the parental behavior.

In addition, parents may deal differently with their nonanxious children. “Ask parents about how they interact with their other children,” suggested Dr. Pinto Wagner, professor of neurology at the University of Rochester (New York).

The take-home message for clinicians from the current study, Ms. Doxie said, is this: “If you do see a parent who is overprotective, you might have to treat the whole family.”

MIAMI – Overprotection may be the mechanism through which parental anxiety and mood disorders lead to such disorders in their children, according to a poster presentation at the annual conference of the Anxiety Disorders Association of America.

A maternal anxiety disorder significantly predicted anxiety disorders in children in one report (J. Abnorm. Child Psychol. 2001;29:1–10). This study found that parental overprotection did not mediate the child's anxiety, although other research suggests it does. For example, parental control was specifically associated with symptoms of general anxiety disorder in children in a study showing that the more the children perceived parental behavior as anxious and controlling, the higher their reported anxiety levels were (Pers. Individ. Dif. 1998;25:1199–206).

To further elucidate the possible mediating effect of parental overprotection, Jacquelyn Doxie and associates assessed 63 children and adolescents from 7 to 16 years old. Children had to have three diagnoses–for example, phobia, social anxiety, and a mood disorder–to participate in the study. The current analysis is part of a larger study of how parental behavior might affect specific phobias in children.

The primary caregiver for each child completed the Anxiety Disorders Interview Schedule (ADIS)-Client Interview, the ADIS-Parent, and the Parental Bonding Instrument. Researchers administered the ADIS-Child to the participants to determine the number of childhood anxiety diagnoses. The investigators used two-step hierarchical regression analyses to determine if overprotection was indeed a mechanism to explain the relationship between parental and childhood anxiety.

“We found that if the parent has anxiety, then the child is more likely to,” said Ms. Doxie, who is a research assistant for the child and adolescent phobia project at Virginia Polytechnic Institute and State University, Blacksburg.

Parent mood and anxiety disorder diagnoses significantly predicted the number of child diagnoses in the first step of the analysis. In the second step, researchers added overprotection to the regression analysis and found the relationship between parental psychopathology and child anxiety disorder was no longer significant. However, Ms. Doxie said overprotection was significant, “affirming the mediational role of overprotection in predicting childhood diagnoses.”

In a separate presentation at the Anxiety Disorders Association meeting, Aureen Pinto Wagner, Ph.D., said parents might unwittingly fuel anxiety in their children. “Studies have shown that parents of anxious children are often overprotective.”

However, she added, “Not all parents of anxious children are overprotective.” The anxious child might elicit the parental behavior.

In addition, parents may deal differently with their nonanxious children. “Ask parents about how they interact with their other children,” suggested Dr. Pinto Wagner, professor of neurology at the University of Rochester (New York).

The take-home message for clinicians from the current study, Ms. Doxie said, is this: “If you do see a parent who is overprotective, you might have to treat the whole family.”

JACKSONVILLE, FLA. — Prevalence of bacterial vaginosis varies significantly by race/ethnicity in the United States, according to a large, nationally representative study from researchers at the Centers for Disease Control and Prevention.

As in previous studies, douching behavior was also significantly associated with bacterial vaginosis (BV). Lower education level, poverty, smoking, higher body mass index, and a history of pregnancy were associated with BV, but not significantly, Dr. Emilia Koumans said at a conference on STD prevention sponsored by the CDC.

BV is the most common cause of vaginal complaints among reproductive-age women. The condition increases the risk of acquiring HIV and sexually transmitted diseases. In pregnant women, BV infection increases the risk of miscarriage, chorioamnionitis, preterm labor, and preterm delivery.

Most of the 1,999 participants in the study were asymptomatic. There are few data to support treatment of asymptomatic women to reduce associated risks, Dr. Koumans said in response to an attendee question.

“There are studies underway to assess if chronic treatment of BV reduces risk of STD acquisition. It is difficult … to convince asymptomatic women of the need to continue using medication,” said Dr. Koumans, a medical officer in the division of STD prevention at the CDC.

Using 2001–2002 data from the National Health and Nutrition Examination Survey (NHANES), Dr. Koumans and her associates assessed self-collected vaginal swabs from 14- to 49-year-old females. The researchers determined pH, performed gram stains, and scored slides according to quantity of lactobacilli.

Overall prevalence of BV was 27%, and there were statistically significant differences according to race/ethnicity. “Non-Hispanic black women were disproportionately affected by BV,” Dr. Koumans said. Prevalence was 22% among whites, 29% among Mexican Americans, and 50% among blacks. “With further research, we hope to understand the cause or causes of BV and reasons for racial disparities,” she said.

BV prevalence did not vary by current pregnancy status, but women who had ever been pregnant and those who gave birth to a preterm baby showed a trend toward more BV, Dr. Koumans said.

Number of lifetime sex partners, age at first sex, and ever had sex with another woman were factors associated with increased prevalence of BV in univariate analyses. In a multivariate analysis, douching, income level, and ever having been pregnant were significant factors.

Another meeting attendee asked if BV is considered a sexually transmitted disease. “We would need more evidence,” Dr. Koumans said.

JACKSONVILLE, FLA. — Prevalence of bacterial vaginosis varies significantly by race/ethnicity in the United States, according to a large, nationally representative study from researchers at the Centers for Disease Control and Prevention.

As in previous studies, douching behavior was also significantly associated with bacterial vaginosis (BV). Lower education level, poverty, smoking, higher body mass index, and a history of pregnancy were associated with BV, but not significantly, Dr. Emilia Koumans said at a conference on STD prevention sponsored by the CDC.

BV is the most common cause of vaginal complaints among reproductive-age women. The condition increases the risk of acquiring HIV and sexually transmitted diseases. In pregnant women, BV infection increases the risk of miscarriage, chorioamnionitis, preterm labor, and preterm delivery.

Most of the 1,999 participants in the study were asymptomatic. There are few data to support treatment of asymptomatic women to reduce associated risks, Dr. Koumans said in response to an attendee question.

“There are studies underway to assess if chronic treatment of BV reduces risk of STD acquisition. It is difficult … to convince asymptomatic women of the need to continue using medication,” said Dr. Koumans, a medical officer in the division of STD prevention at the CDC.

Using 2001–2002 data from the National Health and Nutrition Examination Survey (NHANES), Dr. Koumans and her associates assessed self-collected vaginal swabs from 14- to 49-year-old females. The researchers determined pH, performed gram stains, and scored slides according to quantity of lactobacilli.

Overall prevalence of BV was 27%, and there were statistically significant differences according to race/ethnicity. “Non-Hispanic black women were disproportionately affected by BV,” Dr. Koumans said. Prevalence was 22% among whites, 29% among Mexican Americans, and 50% among blacks. “With further research, we hope to understand the cause or causes of BV and reasons for racial disparities,” she said.

BV prevalence did not vary by current pregnancy status, but women who had ever been pregnant and those who gave birth to a preterm baby showed a trend toward more BV, Dr. Koumans said.

Number of lifetime sex partners, age at first sex, and ever had sex with another woman were factors associated with increased prevalence of BV in univariate analyses. In a multivariate analysis, douching, income level, and ever having been pregnant were significant factors.

Another meeting attendee asked if BV is considered a sexually transmitted disease. “We would need more evidence,” Dr. Koumans said.

JACKSONVILLE, FLA. — Prevalence of bacterial vaginosis varies significantly by race/ethnicity in the United States, according to a large, nationally representative study from researchers at the Centers for Disease Control and Prevention.

As in previous studies, douching behavior was also significantly associated with bacterial vaginosis (BV). Lower education level, poverty, smoking, higher body mass index, and a history of pregnancy were associated with BV, but not significantly, Dr. Emilia Koumans said at a conference on STD prevention sponsored by the CDC.

BV is the most common cause of vaginal complaints among reproductive-age women. The condition increases the risk of acquiring HIV and sexually transmitted diseases. In pregnant women, BV infection increases the risk of miscarriage, chorioamnionitis, preterm labor, and preterm delivery.

Most of the 1,999 participants in the study were asymptomatic. There are few data to support treatment of asymptomatic women to reduce associated risks, Dr. Koumans said in response to an attendee question.

“There are studies underway to assess if chronic treatment of BV reduces risk of STD acquisition. It is difficult … to convince asymptomatic women of the need to continue using medication,” said Dr. Koumans, a medical officer in the division of STD prevention at the CDC.

Using 2001–2002 data from the National Health and Nutrition Examination Survey (NHANES), Dr. Koumans and her associates assessed self-collected vaginal swabs from 14- to 49-year-old females. The researchers determined pH, performed gram stains, and scored slides according to quantity of lactobacilli.

Overall prevalence of BV was 27%, and there were statistically significant differences according to race/ethnicity. “Non-Hispanic black women were disproportionately affected by BV,” Dr. Koumans said. Prevalence was 22% among whites, 29% among Mexican Americans, and 50% among blacks. “With further research, we hope to understand the cause or causes of BV and reasons for racial disparities,” she said.

BV prevalence did not vary by current pregnancy status, but women who had ever been pregnant and those who gave birth to a preterm baby showed a trend toward more BV, Dr. Koumans said.

Number of lifetime sex partners, age at first sex, and ever had sex with another woman were factors associated with increased prevalence of BV in univariate analyses. In a multivariate analysis, douching, income level, and ever having been pregnant were significant factors.

Another meeting attendee asked if BV is considered a sexually transmitted disease. “We would need more evidence,” Dr. Koumans said.

MIAMI — Arrhythmogenic right ventricular cardiomyopathy is a diagnostically challenging condition that is often overlooked as the cause of sudden cardiac death in athletes.

Family history, skin manifestations, and histology aid diagnosis, but some cases are missed even on autopsy, according to a presentation at the annual meeting of the American Medical Society for Sports Medicine.

The prevalence of arrhythmogenic right ventricular cardiomyopathy (ARVC) in the general population is an estimated 1:1,000 to 1:5,000, though it is often confused with the more common hypertrophic cardiomyopathy (prevalence of 1:500) as a cause of sudden cardiac death in young athletes. As such, high clinical suspicion is warranted, Dr. William J. McKenna said. “We do miss ARVC clinically and post mortem—you miss what you don't look for. That is why ARVC has only been diagnosed in the last 25 years.”

ARVC is an autosomal, dominant condition with fibrofatty replacement of myocytes in the right and left ventricles. These deposits cause structural, functional, and electrophysiologic changes. Arrhythmias and sudden death are typical presenting symptoms. There is age-related penetrance, which suggests the need for serial evaluations because an adolescent could have a normal examination one year and not the next.

“The vast majority do not know they have the condition. There are a lot of people who carry these genes and have some disease manifestation,” said Dr. McKenna, clinical director at the Heart Hospital at University College, London.

No single clinical test is diagnostic. Even after multiple examinations—including electrocardiography, signal-averaged electrocardiography, echocardiography, exercise testing, and Holter monitoring—“we are left telling the patients we don't know,” Dr. McKenna said. “The criteria for early disease are not specific.”

Phase I, or the early phase, is typically silent, can feature sporadic ventricular ectopic beats, subtle ECG changes, morphologic abnormalities, and sudden death.

“The real problem is in people who are asymptomatic and picked up during family evaluation or routine screening,” he said. Even after risk assessment with exercise testing or Holter monitoring, many remain asymptomatic. “The challenge is to predict the 'hot phase.' Currently, this is not feasible.”

Ventricular arrhythmias and recurrent syncope are signs of a “hot phase” and may be associated with active inflammation. “This phase should be treated as a medical emergency,” Dr. McKenna said.

Sustained ventricular tachycardia and diffuse right ventricular/left ventricular abnormalities are features of phase II disease. Phases III and IV characterize patients with advanced ARVC. There is increased dilatation and decreased contractility of the right and left ventricles. Left ventricular involvement can progress to heart failure.

Histology can confirm clinical suspicion. Look for myocytes in various stages of cell death, Dr. McKenna said. “If you are biopsying or just looking, you might see fat in the heart tissue, but it's not diagnostic—it comes with normal aging.”

Recent advances in imaging may help, he said. MRI has a role in the measurement of accurate right and left ventricular volumes, he noted, and he suggested that a four-chamber view be used to detect wall-motion abnormalities.

Researchers have identified seven genetic loci to date. ARVC is a disease of the desmosome, so skin manifestations—including palmar keratosis—are a clue that it may be present.

Molecular diagnosis has “a major potential role for mutation analysis,” Dr. McKenna said. Such diagnosis would help researchers define the specific genetic defects, identify sporadic cases, confirm diagnosis in borderline cases or neonates, and rule out some patients for future testing and evaluation.

MIAMI — Arrhythmogenic right ventricular cardiomyopathy is a diagnostically challenging condition that is often overlooked as the cause of sudden cardiac death in athletes.

Family history, skin manifestations, and histology aid diagnosis, but some cases are missed even on autopsy, according to a presentation at the annual meeting of the American Medical Society for Sports Medicine.

The prevalence of arrhythmogenic right ventricular cardiomyopathy (ARVC) in the general population is an estimated 1:1,000 to 1:5,000, though it is often confused with the more common hypertrophic cardiomyopathy (prevalence of 1:500) as a cause of sudden cardiac death in young athletes. As such, high clinical suspicion is warranted, Dr. William J. McKenna said. “We do miss ARVC clinically and post mortem—you miss what you don't look for. That is why ARVC has only been diagnosed in the last 25 years.”

ARVC is an autosomal, dominant condition with fibrofatty replacement of myocytes in the right and left ventricles. These deposits cause structural, functional, and electrophysiologic changes. Arrhythmias and sudden death are typical presenting symptoms. There is age-related penetrance, which suggests the need for serial evaluations because an adolescent could have a normal examination one year and not the next.

“The vast majority do not know they have the condition. There are a lot of people who carry these genes and have some disease manifestation,” said Dr. McKenna, clinical director at the Heart Hospital at University College, London.

No single clinical test is diagnostic. Even after multiple examinations—including electrocardiography, signal-averaged electrocardiography, echocardiography, exercise testing, and Holter monitoring—“we are left telling the patients we don't know,” Dr. McKenna said. “The criteria for early disease are not specific.”

Phase I, or the early phase, is typically silent, can feature sporadic ventricular ectopic beats, subtle ECG changes, morphologic abnormalities, and sudden death.

“The real problem is in people who are asymptomatic and picked up during family evaluation or routine screening,” he said. Even after risk assessment with exercise testing or Holter monitoring, many remain asymptomatic. “The challenge is to predict the 'hot phase.' Currently, this is not feasible.”

Ventricular arrhythmias and recurrent syncope are signs of a “hot phase” and may be associated with active inflammation. “This phase should be treated as a medical emergency,” Dr. McKenna said.

Sustained ventricular tachycardia and diffuse right ventricular/left ventricular abnormalities are features of phase II disease. Phases III and IV characterize patients with advanced ARVC. There is increased dilatation and decreased contractility of the right and left ventricles. Left ventricular involvement can progress to heart failure.

Histology can confirm clinical suspicion. Look for myocytes in various stages of cell death, Dr. McKenna said. “If you are biopsying or just looking, you might see fat in the heart tissue, but it's not diagnostic—it comes with normal aging.”

Recent advances in imaging may help, he said. MRI has a role in the measurement of accurate right and left ventricular volumes, he noted, and he suggested that a four-chamber view be used to detect wall-motion abnormalities.

Researchers have identified seven genetic loci to date. ARVC is a disease of the desmosome, so skin manifestations—including palmar keratosis—are a clue that it may be present.

Molecular diagnosis has “a major potential role for mutation analysis,” Dr. McKenna said. Such diagnosis would help researchers define the specific genetic defects, identify sporadic cases, confirm diagnosis in borderline cases or neonates, and rule out some patients for future testing and evaluation.

MIAMI — Arrhythmogenic right ventricular cardiomyopathy is a diagnostically challenging condition that is often overlooked as the cause of sudden cardiac death in athletes.

Family history, skin manifestations, and histology aid diagnosis, but some cases are missed even on autopsy, according to a presentation at the annual meeting of the American Medical Society for Sports Medicine.

The prevalence of arrhythmogenic right ventricular cardiomyopathy (ARVC) in the general population is an estimated 1:1,000 to 1:5,000, though it is often confused with the more common hypertrophic cardiomyopathy (prevalence of 1:500) as a cause of sudden cardiac death in young athletes. As such, high clinical suspicion is warranted, Dr. William J. McKenna said. “We do miss ARVC clinically and post mortem—you miss what you don't look for. That is why ARVC has only been diagnosed in the last 25 years.”

ARVC is an autosomal, dominant condition with fibrofatty replacement of myocytes in the right and left ventricles. These deposits cause structural, functional, and electrophysiologic changes. Arrhythmias and sudden death are typical presenting symptoms. There is age-related penetrance, which suggests the need for serial evaluations because an adolescent could have a normal examination one year and not the next.

“The vast majority do not know they have the condition. There are a lot of people who carry these genes and have some disease manifestation,” said Dr. McKenna, clinical director at the Heart Hospital at University College, London.

No single clinical test is diagnostic. Even after multiple examinations—including electrocardiography, signal-averaged electrocardiography, echocardiography, exercise testing, and Holter monitoring—“we are left telling the patients we don't know,” Dr. McKenna said. “The criteria for early disease are not specific.”

Phase I, or the early phase, is typically silent, can feature sporadic ventricular ectopic beats, subtle ECG changes, morphologic abnormalities, and sudden death.

“The real problem is in people who are asymptomatic and picked up during family evaluation or routine screening,” he said. Even after risk assessment with exercise testing or Holter monitoring, many remain asymptomatic. “The challenge is to predict the 'hot phase.' Currently, this is not feasible.”

Ventricular arrhythmias and recurrent syncope are signs of a “hot phase” and may be associated with active inflammation. “This phase should be treated as a medical emergency,” Dr. McKenna said.

Sustained ventricular tachycardia and diffuse right ventricular/left ventricular abnormalities are features of phase II disease. Phases III and IV characterize patients with advanced ARVC. There is increased dilatation and decreased contractility of the right and left ventricles. Left ventricular involvement can progress to heart failure.

Histology can confirm clinical suspicion. Look for myocytes in various stages of cell death, Dr. McKenna said. “If you are biopsying or just looking, you might see fat in the heart tissue, but it's not diagnostic—it comes with normal aging.”

Recent advances in imaging may help, he said. MRI has a role in the measurement of accurate right and left ventricular volumes, he noted, and he suggested that a four-chamber view be used to detect wall-motion abnormalities.

Researchers have identified seven genetic loci to date. ARVC is a disease of the desmosome, so skin manifestations—including palmar keratosis—are a clue that it may be present.

Molecular diagnosis has “a major potential role for mutation analysis,” Dr. McKenna said. Such diagnosis would help researchers define the specific genetic defects, identify sporadic cases, confirm diagnosis in borderline cases or neonates, and rule out some patients for future testing and evaluation.