Damian McNamara

MIAMI — Weight and type of sport played by Division I varsity female athletes were significant predictors of bone mineral density measurements, according to a study presented at the annual meeting of the American Medical Society for Sports Medicine.

Dr. Willa Fornetti performed a cross-sectional analysis of 103 female athletes in gymnastics, softball, running, track, field hockey, rowing, swimming/diving, and volleyball at Michigan State University.

“BMI was markedly similar among groups—not what we anticipated. The runners were slightly lower than others, though,” said Dr. Fornetti, of Michigan State University, East Lansing.

As might be expected, gymnasts had the lowest mean height, and volleyball players had the highest. Runners and gymnasts had the lowest weights and fat-free mass, as well as the highest percentage of menstrual dysfunction.

Dr. Fornetti used dual-energy x-ray absorptiometry to measure total body, lumbar spine, pelvic, and average right/left leg BMD. She compared BMD measurements between athletes involved in sports by using analyses of covariance. She also determined significant predictors of BMD for each site through a stepwise regression analysis.

The 6 athletes with amenorrhea and 18 with oligomenorrhea had statistically significant lower bone mineral density than did other participants, Dr. Fornetti said.

The World Health Organization defines osteopenia as a bone density between 1 and 2.5 standard deviations below the bone density of a normal young adult.

“The good news is that none of our athletes met WHO criteria for osteopenia, regardless of menstrual function,” Dr. Fornetti said.

Runners, swimmers, and divers had significantly lower BMD than the other athletes. Runners also had the lowest mean lumbar spine BMD. Pelvic BMD was lower for runners, swimmers, and divers, Dr. Fornetti said. “Runners had significantly lower BMD at every site, except average leg score, versus athletes in field hockey, softball, and volleyball.”

Limitations of the study include its lack of data on nutrition and eating disorders, and history of training or injury. A large number of participants, multiple-site BMD measurements, and an ability to compare different types of sports are among its strengths, Dr. Fornetti said.

Because lower body weight was associated with lower BMD, “it can be used to screen runners, swimmers and divers,” Dr. Fornetti said. She added that clinicians should consider weight and type of sport played by a female varsity athlete when evaluating bone health.

MIAMI — Weight and type of sport played by Division I varsity female athletes were significant predictors of bone mineral density measurements, according to a study presented at the annual meeting of the American Medical Society for Sports Medicine.

Dr. Willa Fornetti performed a cross-sectional analysis of 103 female athletes in gymnastics, softball, running, track, field hockey, rowing, swimming/diving, and volleyball at Michigan State University.

“BMI was markedly similar among groups—not what we anticipated. The runners were slightly lower than others, though,” said Dr. Fornetti, of Michigan State University, East Lansing.

As might be expected, gymnasts had the lowest mean height, and volleyball players had the highest. Runners and gymnasts had the lowest weights and fat-free mass, as well as the highest percentage of menstrual dysfunction.

Dr. Fornetti used dual-energy x-ray absorptiometry to measure total body, lumbar spine, pelvic, and average right/left leg BMD. She compared BMD measurements between athletes involved in sports by using analyses of covariance. She also determined significant predictors of BMD for each site through a stepwise regression analysis.

The 6 athletes with amenorrhea and 18 with oligomenorrhea had statistically significant lower bone mineral density than did other participants, Dr. Fornetti said.

The World Health Organization defines osteopenia as a bone density between 1 and 2.5 standard deviations below the bone density of a normal young adult.

“The good news is that none of our athletes met WHO criteria for osteopenia, regardless of menstrual function,” Dr. Fornetti said.

Runners, swimmers, and divers had significantly lower BMD than the other athletes. Runners also had the lowest mean lumbar spine BMD. Pelvic BMD was lower for runners, swimmers, and divers, Dr. Fornetti said. “Runners had significantly lower BMD at every site, except average leg score, versus athletes in field hockey, softball, and volleyball.”

Limitations of the study include its lack of data on nutrition and eating disorders, and history of training or injury. A large number of participants, multiple-site BMD measurements, and an ability to compare different types of sports are among its strengths, Dr. Fornetti said.

Because lower body weight was associated with lower BMD, “it can be used to screen runners, swimmers and divers,” Dr. Fornetti said. She added that clinicians should consider weight and type of sport played by a female varsity athlete when evaluating bone health.

MIAMI — Weight and type of sport played by Division I varsity female athletes were significant predictors of bone mineral density measurements, according to a study presented at the annual meeting of the American Medical Society for Sports Medicine.

Dr. Willa Fornetti performed a cross-sectional analysis of 103 female athletes in gymnastics, softball, running, track, field hockey, rowing, swimming/diving, and volleyball at Michigan State University.

“BMI was markedly similar among groups—not what we anticipated. The runners were slightly lower than others, though,” said Dr. Fornetti, of Michigan State University, East Lansing.

As might be expected, gymnasts had the lowest mean height, and volleyball players had the highest. Runners and gymnasts had the lowest weights and fat-free mass, as well as the highest percentage of menstrual dysfunction.

Dr. Fornetti used dual-energy x-ray absorptiometry to measure total body, lumbar spine, pelvic, and average right/left leg BMD. She compared BMD measurements between athletes involved in sports by using analyses of covariance. She also determined significant predictors of BMD for each site through a stepwise regression analysis.

The 6 athletes with amenorrhea and 18 with oligomenorrhea had statistically significant lower bone mineral density than did other participants, Dr. Fornetti said.

The World Health Organization defines osteopenia as a bone density between 1 and 2.5 standard deviations below the bone density of a normal young adult.

“The good news is that none of our athletes met WHO criteria for osteopenia, regardless of menstrual function,” Dr. Fornetti said.

Runners, swimmers, and divers had significantly lower BMD than the other athletes. Runners also had the lowest mean lumbar spine BMD. Pelvic BMD was lower for runners, swimmers, and divers, Dr. Fornetti said. “Runners had significantly lower BMD at every site, except average leg score, versus athletes in field hockey, softball, and volleyball.”

Limitations of the study include its lack of data on nutrition and eating disorders, and history of training or injury. A large number of participants, multiple-site BMD measurements, and an ability to compare different types of sports are among its strengths, Dr. Fornetti said.

Because lower body weight was associated with lower BMD, “it can be used to screen runners, swimmers and divers,” Dr. Fornetti said. She added that clinicians should consider weight and type of sport played by a female varsity athlete when evaluating bone health.

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 who 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, for example. “Resistance patterns vary in Chicago in children from patterns seen in adults. So, unfortunately, 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 TMP/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. Initial therapy with oral clindamycin is “no one's idea of fun,” he said, because of the bad taste of the medication. 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,” Dr. Alexander said. “If you see staph [S. aureus] 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), he added. “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 ask Dr. Alexander about use of 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.

Include herpes infection in the differential diagnosis for a patient with recurrent infections on the nails or in the nose, Dr. Alexander said. In addition, “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.

“Take staph [S. aureus] infections seriously, even seemingly minor ones,” he said.

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 who 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, for example. “Resistance patterns vary in Chicago in children from patterns seen in adults. So, unfortunately, 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 TMP/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. Initial therapy with oral clindamycin is “no one's idea of fun,” he said, because of the bad taste of the medication. 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,” Dr. Alexander said. “If you see staph [S. aureus] 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), he added. “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 ask Dr. Alexander about use of 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.

Include herpes infection in the differential diagnosis for a patient with recurrent infections on the nails or in the nose, Dr. Alexander said. In addition, “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.

“Take staph [S. aureus] infections seriously, even seemingly minor ones,” he said.

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 who 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, for example. “Resistance patterns vary in Chicago in children from patterns seen in adults. So, unfortunately, 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 TMP/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. Initial therapy with oral clindamycin is “no one's idea of fun,” he said, because of the bad taste of the medication. 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,” Dr. Alexander said. “If you see staph [S. aureus] 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), he added. “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 ask Dr. Alexander about use of 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.

Include herpes infection in the differential diagnosis for a patient with recurrent infections on the nails or in the nose, Dr. Alexander said. In addition, “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.

“Take staph [S. aureus] infections seriously, even seemingly minor ones,” he said.

MIAMI – Athletic patients with significant musculoskeletal pain should be screened for comorbid depression and panic disorder, according to study findings presented at the annual meeting of the American Medical Society for Sports Medicine.

In a study of 148 consecutively-treated athletic patients who presented to a sports medicine clinic with musculoskeletal complaints, the overall prevalence of a major depressive disorder was 6%; 7% had another form of depression.

Dr. William W. Dexter and his associates at the Maine Medical Center sports medicine program in Portland surveyed participants using the Primary Care Evaluation of Mental Disorders (PRIME-MD) patient questionnaire.

Although these overall prevalence rates are similar to those in a general primary care practice, the prevalence of mood disorders was even higher among those patients who presented with pain severity scores of 6 or higher on a scale of 0–10, Dr. Dexter noted in an interview.

Overall, the prevalence of panic disorder was 17%.

Although the association between mood disorders and musculoskeletal pain has been documented in the literature, there are no data on the prevalence of mental health disorders in a primary care sports medicine population. “In our clinic, we felt we were seeing a lot of musculoskeletal complaints in patients who had an undiagnosed or underdiagnosed mood disorder,” Dr. Dexter said.

If patients' comorbid depression and/or panic disorder are not addressed, significant improvements in musculoskeletal pain are unlikely, he added.

“Many of the subjects in the study did not have a prior diagnosis of mood disorder,” Dr. Dexter said. They were identified through screening with the PRIME-MD tool

MIAMI – Athletic patients with significant musculoskeletal pain should be screened for comorbid depression and panic disorder, according to study findings presented at the annual meeting of the American Medical Society for Sports Medicine.

In a study of 148 consecutively-treated athletic patients who presented to a sports medicine clinic with musculoskeletal complaints, the overall prevalence of a major depressive disorder was 6%; 7% had another form of depression.

Dr. William W. Dexter and his associates at the Maine Medical Center sports medicine program in Portland surveyed participants using the Primary Care Evaluation of Mental Disorders (PRIME-MD) patient questionnaire.

Although these overall prevalence rates are similar to those in a general primary care practice, the prevalence of mood disorders was even higher among those patients who presented with pain severity scores of 6 or higher on a scale of 0–10, Dr. Dexter noted in an interview.

Overall, the prevalence of panic disorder was 17%.

Although the association between mood disorders and musculoskeletal pain has been documented in the literature, there are no data on the prevalence of mental health disorders in a primary care sports medicine population. “In our clinic, we felt we were seeing a lot of musculoskeletal complaints in patients who had an undiagnosed or underdiagnosed mood disorder,” Dr. Dexter said.

If patients' comorbid depression and/or panic disorder are not addressed, significant improvements in musculoskeletal pain are unlikely, he added.

“Many of the subjects in the study did not have a prior diagnosis of mood disorder,” Dr. Dexter said. They were identified through screening with the PRIME-MD tool

MIAMI – Athletic patients with significant musculoskeletal pain should be screened for comorbid depression and panic disorder, according to study findings presented at the annual meeting of the American Medical Society for Sports Medicine.

In a study of 148 consecutively-treated athletic patients who presented to a sports medicine clinic with musculoskeletal complaints, the overall prevalence of a major depressive disorder was 6%; 7% had another form of depression.

Dr. William W. Dexter and his associates at the Maine Medical Center sports medicine program in Portland surveyed participants using the Primary Care Evaluation of Mental Disorders (PRIME-MD) patient questionnaire.

Although these overall prevalence rates are similar to those in a general primary care practice, the prevalence of mood disorders was even higher among those patients who presented with pain severity scores of 6 or higher on a scale of 0–10, Dr. Dexter noted in an interview.

Overall, the prevalence of panic disorder was 17%.

Although the association between mood disorders and musculoskeletal pain has been documented in the literature, there are no data on the prevalence of mental health disorders in a primary care sports medicine population. “In our clinic, we felt we were seeing a lot of musculoskeletal complaints in patients who had an undiagnosed or underdiagnosed mood disorder,” Dr. Dexter said.

If patients' comorbid depression and/or panic disorder are not addressed, significant improvements in musculoskeletal pain are unlikely, he added.

“Many of the subjects in the study did not have a prior diagnosis of mood disorder,” Dr. Dexter said. They were identified through screening with the PRIME-MD tool

BOCA RATON, FLA. – Severity of autism core symptoms and monitoring of improvements with treatment can be measured with a brief 10-item scale developed by researchers at Ohio State University, Columbus, according to a study presented at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

“We don't have a good brief scale to assess core symptoms of autism,” Eric M. Butter, Ph.D., of the pediatrics department at Ohio State, said in an interview at his poster presentation. Although effective treatments for autism have been few, some pharmaceutical agents appear promising, which increases the need for a quick assessment of treatment response, he added. The scale measures response to pharmaceutical and social interventions.

Dr. Butter and his associate James A. Mulick, Ph.D., a professor of pediatrics and psychology at the university, developed the Ohio Autism Clinical Impressions Scale (OACIS) as a symptom-specific version of the Clinical Global Impressions scale. They tested the OACIS's reliability with physicians and psychologists, and compared results with teacher ratings.

In addition to one item that rates global severity of autism, the scale measures impressions about the following nine core symptoms: social interaction, aberrant behaviors, repetitive behaviors, verbal communication, nonverbal communication, hyperactivity, anxiety, sensory sensitivity, and restricted, narrow interests. The rater scores each item on a scale of 1 to 7, with a higher number reflecting greater severity.

A total of 31 children being assessed for an initial diagnosis of pervasive developmental disorder made up the clinical sample assessed by physicians or psychologists. An additional 37 children were assessed by teachers at a specialized school for children with autism spectrum disorders. The children's mean age was 8 years; 62% were diagnosed with autism and 38% with pervasive developmental disorder.

The researchers found a 0.71 interrater reliability in the clinic sample and 0.52 in the school-based group. “Doctors and psychologists agreed better than the teachers did,” Dr. Butter said at the meeting, cosponsored by the American Society for Clinical Psychopharmacology. A reason for the disparity, he speculated, is that “the teachers had broader experience with the children, whereas pediatricians and psychologists were seeing them at the same time.”

Initial findings suggest internal reliability and test-retest reliability were strong. Specifically, internal reliability was 0.92 for the clinical raters and 0.94 for the teachers. Raters repeated the test with a subgroup of the children 1 week later; the test-retest reliability was 0.91 for the clinicians and 0.96 for the teachers.

To test the validity of OACIS, the researchers also tested all participants with the Gilliam Autism Rating Scale (GARS), the Aberrant Behavior Checklist (ABC) irritability subscale, and the Pervasive Developmental Disorders Behavior Inventory (PDDBI). They found that the OACIS total score had a 0.75 correlation with the GARS, 0.57 with the ABC-I, and 0.63 with the PDDBI.

Some of these correlations were surprising, Dr. Butter said. “I'm concerned about the high validity with the GARS–one of our goals is to replace this. I have to figure out why they correlated so well.” He was happy with the lower correlation with the ABC-I. “I wanted it to be divergent because only some kids with autism have irritability.”

The low correlation with the PDDBI was expected, because it is a comparison of a 180-item scale with a 10-item measure, Dr. Butter said.

Data collection is ongoing about how well the OACIS assesses response to pharmacologic or social interventions for autism, Dr. Butter said. Preliminary findings suggest the “improvement index did well, too.” The index had a 0.78 correlation with a language “learning rate” variable devised by the researchers.

“With Risperdal, it will be interesting to see if the scale picks up changes from this medication, as well as other medications in development for core symptoms,” Dr. Butter said.

BOCA RATON, FLA. – Severity of autism core symptoms and monitoring of improvements with treatment can be measured with a brief 10-item scale developed by researchers at Ohio State University, Columbus, according to a study presented at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

“We don't have a good brief scale to assess core symptoms of autism,” Eric M. Butter, Ph.D., of the pediatrics department at Ohio State, said in an interview at his poster presentation. Although effective treatments for autism have been few, some pharmaceutical agents appear promising, which increases the need for a quick assessment of treatment response, he added. The scale measures response to pharmaceutical and social interventions.

Dr. Butter and his associate James A. Mulick, Ph.D., a professor of pediatrics and psychology at the university, developed the Ohio Autism Clinical Impressions Scale (OACIS) as a symptom-specific version of the Clinical Global Impressions scale. They tested the OACIS's reliability with physicians and psychologists, and compared results with teacher ratings.

In addition to one item that rates global severity of autism, the scale measures impressions about the following nine core symptoms: social interaction, aberrant behaviors, repetitive behaviors, verbal communication, nonverbal communication, hyperactivity, anxiety, sensory sensitivity, and restricted, narrow interests. The rater scores each item on a scale of 1 to 7, with a higher number reflecting greater severity.

A total of 31 children being assessed for an initial diagnosis of pervasive developmental disorder made up the clinical sample assessed by physicians or psychologists. An additional 37 children were assessed by teachers at a specialized school for children with autism spectrum disorders. The children's mean age was 8 years; 62% were diagnosed with autism and 38% with pervasive developmental disorder.

The researchers found a 0.71 interrater reliability in the clinic sample and 0.52 in the school-based group. “Doctors and psychologists agreed better than the teachers did,” Dr. Butter said at the meeting, cosponsored by the American Society for Clinical Psychopharmacology. A reason for the disparity, he speculated, is that “the teachers had broader experience with the children, whereas pediatricians and psychologists were seeing them at the same time.”

Initial findings suggest internal reliability and test-retest reliability were strong. Specifically, internal reliability was 0.92 for the clinical raters and 0.94 for the teachers. Raters repeated the test with a subgroup of the children 1 week later; the test-retest reliability was 0.91 for the clinicians and 0.96 for the teachers.

To test the validity of OACIS, the researchers also tested all participants with the Gilliam Autism Rating Scale (GARS), the Aberrant Behavior Checklist (ABC) irritability subscale, and the Pervasive Developmental Disorders Behavior Inventory (PDDBI). They found that the OACIS total score had a 0.75 correlation with the GARS, 0.57 with the ABC-I, and 0.63 with the PDDBI.

Some of these correlations were surprising, Dr. Butter said. “I'm concerned about the high validity with the GARS–one of our goals is to replace this. I have to figure out why they correlated so well.” He was happy with the lower correlation with the ABC-I. “I wanted it to be divergent because only some kids with autism have irritability.”

The low correlation with the PDDBI was expected, because it is a comparison of a 180-item scale with a 10-item measure, Dr. Butter said.

Data collection is ongoing about how well the OACIS assesses response to pharmacologic or social interventions for autism, Dr. Butter said. Preliminary findings suggest the “improvement index did well, too.” The index had a 0.78 correlation with a language “learning rate” variable devised by the researchers.

“With Risperdal, it will be interesting to see if the scale picks up changes from this medication, as well as other medications in development for core symptoms,” Dr. Butter said.

BOCA RATON, FLA. – Severity of autism core symptoms and monitoring of improvements with treatment can be measured with a brief 10-item scale developed by researchers at Ohio State University, Columbus, according to a study presented at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

“We don't have a good brief scale to assess core symptoms of autism,” Eric M. Butter, Ph.D., of the pediatrics department at Ohio State, said in an interview at his poster presentation. Although effective treatments for autism have been few, some pharmaceutical agents appear promising, which increases the need for a quick assessment of treatment response, he added. The scale measures response to pharmaceutical and social interventions.

Dr. Butter and his associate James A. Mulick, Ph.D., a professor of pediatrics and psychology at the university, developed the Ohio Autism Clinical Impressions Scale (OACIS) as a symptom-specific version of the Clinical Global Impressions scale. They tested the OACIS's reliability with physicians and psychologists, and compared results with teacher ratings.

In addition to one item that rates global severity of autism, the scale measures impressions about the following nine core symptoms: social interaction, aberrant behaviors, repetitive behaviors, verbal communication, nonverbal communication, hyperactivity, anxiety, sensory sensitivity, and restricted, narrow interests. The rater scores each item on a scale of 1 to 7, with a higher number reflecting greater severity.

A total of 31 children being assessed for an initial diagnosis of pervasive developmental disorder made up the clinical sample assessed by physicians or psychologists. An additional 37 children were assessed by teachers at a specialized school for children with autism spectrum disorders. The children's mean age was 8 years; 62% were diagnosed with autism and 38% with pervasive developmental disorder.

The researchers found a 0.71 interrater reliability in the clinic sample and 0.52 in the school-based group. “Doctors and psychologists agreed better than the teachers did,” Dr. Butter said at the meeting, cosponsored by the American Society for Clinical Psychopharmacology. A reason for the disparity, he speculated, is that “the teachers had broader experience with the children, whereas pediatricians and psychologists were seeing them at the same time.”

Initial findings suggest internal reliability and test-retest reliability were strong. Specifically, internal reliability was 0.92 for the clinical raters and 0.94 for the teachers. Raters repeated the test with a subgroup of the children 1 week later; the test-retest reliability was 0.91 for the clinicians and 0.96 for the teachers.

To test the validity of OACIS, the researchers also tested all participants with the Gilliam Autism Rating Scale (GARS), the Aberrant Behavior Checklist (ABC) irritability subscale, and the Pervasive Developmental Disorders Behavior Inventory (PDDBI). They found that the OACIS total score had a 0.75 correlation with the GARS, 0.57 with the ABC-I, and 0.63 with the PDDBI.

Some of these correlations were surprising, Dr. Butter said. “I'm concerned about the high validity with the GARS–one of our goals is to replace this. I have to figure out why they correlated so well.” He was happy with the lower correlation with the ABC-I. “I wanted it to be divergent because only some kids with autism have irritability.”

The low correlation with the PDDBI was expected, because it is a comparison of a 180-item scale with a 10-item measure, Dr. Butter said.

Data collection is ongoing about how well the OACIS assesses response to pharmacologic or social interventions for autism, Dr. Butter said. Preliminary findings suggest the “improvement index did well, too.” The index had a 0.78 correlation with a language “learning rate” variable devised by the researchers.

“With Risperdal, it will be interesting to see if the scale picks up changes from this medication, as well as other medications in development for core symptoms,” Dr. Butter said.

AMELIA ISLAND, FLA. — Recent approval of the first vaccine to prevent human papillomavirus infection underlines the need for physicians to improve immunization of adolescents, Dr. Kenneth Alexander said at a meeting on pediatrics for the primary care physician sponsored by Nemours.

The good news is there are strategies that can optimize routine vaccination of teenagers for human papillomavirus (HPV), meningitis, and pertussis. Vaccine promotion, reminder calls, and mass mailings are among some “tried and true” tactics that office-based physicians can employ. Another idea is to enlist emergency physicians to immunize all adolescent patients. School-based vaccinations are another option, although somewhat controversial with human papillomavirus, said Dr. Alexander, a pediatric infectious disease specialist at the University of Chicago.

The American Academy of Pediatrics is advocating a routine 11- to 12-year-old visit to foster immunization for meningitis, pertussis, and the first of three injections against HPV. Getting adolescents to return for the second and third HPV vaccinations will be a challenge, plus “no one is more needle-phobic than an 11-year-old,” Dr. Alexander said.

“In terms of importance, HPV is probably the most important vaccine to hit us since the measles vaccines,” he said. “We are very good at immunizing infants, and I give adult doctors about a C+ for adults. Immunizing teenagers is not something we are particularly good at.”

Endorse the HPV vaccine in your office from the front door to the exit, Dr. Alexander suggested. “This is something your whole office should be promoting. Remind your staff to ask the kid who comes in for another reason. Contraindications to immunization are very limited.”

Contacting the parents of every teenager in your practice is another effective approach. However, going through the charts is time consuming and can be very expensive, Dr. Alexander said.

Send a mass mailing to inform parents that a new vaccine is available and how insurance companies are providing reimbursement. Also, schedule all three visits for the HPV vaccine regimen up front, Dr. Alexander said, and follow up with telephone reminders. “This could also be done with e-mail—a smart way to go.”

Cook County Hospital in Chicago uses its emergency department to immunize adults, Dr. Alexander said. This tactic could be extrapolated to pediatric patients. “If a kid shows up with a sprained ankle in the ER, can we treat it as an opportunity to immunize them? Darn tootin'. Should we look at school-based vaccinations? It will be controversial with HPV vaccine, as you can imagine,” he said.

Some fear that a vaccine against HPV will increase sexual activity among teenagers. The vaccine does not obviate the need for a safe sex talk with a teenager, he said. In addition, “it is important to talk about abstinence—I have two teenage daughters. You have to trust and verify, and then immunize them anyway.”

Parents want to hear the vaccine is effective, safe, and recommended by their child's health care provider, Dr. Alexander said. “But they don't want to hear about their child being sexually active. You can say the vaccine is for preventing infection in women who are or ever will become sexually active.”

Future endeavors related to HPV prevention include longer-term follow-up studies of vaccines, approval of the second HPV vaccine expected later this year, studies in males, and forthcoming recommendations from the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Obstetricians and Gynecologists.

Physicians will need to provide education about HPV because “parents will line up when you say meningitis, but they don't know what HPV is,” Dr. Alexander said.

The AAP advocates a routine 11- to 12-year-old visit to foster the new shots. ©FOTOSEARCH

AMELIA ISLAND, FLA. — Recent approval of the first vaccine to prevent human papillomavirus infection underlines the need for physicians to improve immunization of adolescents, Dr. Kenneth Alexander said at a meeting on pediatrics for the primary care physician sponsored by Nemours.

The good news is there are strategies that can optimize routine vaccination of teenagers for human papillomavirus (HPV), meningitis, and pertussis. Vaccine promotion, reminder calls, and mass mailings are among some “tried and true” tactics that office-based physicians can employ. Another idea is to enlist emergency physicians to immunize all adolescent patients. School-based vaccinations are another option, although somewhat controversial with human papillomavirus, said Dr. Alexander, a pediatric infectious disease specialist at the University of Chicago.

The American Academy of Pediatrics is advocating a routine 11- to 12-year-old visit to foster immunization for meningitis, pertussis, and the first of three injections against HPV. Getting adolescents to return for the second and third HPV vaccinations will be a challenge, plus “no one is more needle-phobic than an 11-year-old,” Dr. Alexander said.

“In terms of importance, HPV is probably the most important vaccine to hit us since the measles vaccines,” he said. “We are very good at immunizing infants, and I give adult doctors about a C+ for adults. Immunizing teenagers is not something we are particularly good at.”

Endorse the HPV vaccine in your office from the front door to the exit, Dr. Alexander suggested. “This is something your whole office should be promoting. Remind your staff to ask the kid who comes in for another reason. Contraindications to immunization are very limited.”

Contacting the parents of every teenager in your practice is another effective approach. However, going through the charts is time consuming and can be very expensive, Dr. Alexander said.

Send a mass mailing to inform parents that a new vaccine is available and how insurance companies are providing reimbursement. Also, schedule all three visits for the HPV vaccine regimen up front, Dr. Alexander said, and follow up with telephone reminders. “This could also be done with e-mail—a smart way to go.”

Cook County Hospital in Chicago uses its emergency department to immunize adults, Dr. Alexander said. This tactic could be extrapolated to pediatric patients. “If a kid shows up with a sprained ankle in the ER, can we treat it as an opportunity to immunize them? Darn tootin'. Should we look at school-based vaccinations? It will be controversial with HPV vaccine, as you can imagine,” he said.

Some fear that a vaccine against HPV will increase sexual activity among teenagers. The vaccine does not obviate the need for a safe sex talk with a teenager, he said. In addition, “it is important to talk about abstinence—I have two teenage daughters. You have to trust and verify, and then immunize them anyway.”

Parents want to hear the vaccine is effective, safe, and recommended by their child's health care provider, Dr. Alexander said. “But they don't want to hear about their child being sexually active. You can say the vaccine is for preventing infection in women who are or ever will become sexually active.”

Future endeavors related to HPV prevention include longer-term follow-up studies of vaccines, approval of the second HPV vaccine expected later this year, studies in males, and forthcoming recommendations from the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Obstetricians and Gynecologists.

Physicians will need to provide education about HPV because “parents will line up when you say meningitis, but they don't know what HPV is,” Dr. Alexander said.

The AAP advocates a routine 11- to 12-year-old visit to foster the new shots. ©FOTOSEARCH

AMELIA ISLAND, FLA. — Recent approval of the first vaccine to prevent human papillomavirus infection underlines the need for physicians to improve immunization of adolescents, Dr. Kenneth Alexander said at a meeting on pediatrics for the primary care physician sponsored by Nemours.

The good news is there are strategies that can optimize routine vaccination of teenagers for human papillomavirus (HPV), meningitis, and pertussis. Vaccine promotion, reminder calls, and mass mailings are among some “tried and true” tactics that office-based physicians can employ. Another idea is to enlist emergency physicians to immunize all adolescent patients. School-based vaccinations are another option, although somewhat controversial with human papillomavirus, said Dr. Alexander, a pediatric infectious disease specialist at the University of Chicago.

The American Academy of Pediatrics is advocating a routine 11- to 12-year-old visit to foster immunization for meningitis, pertussis, and the first of three injections against HPV. Getting adolescents to return for the second and third HPV vaccinations will be a challenge, plus “no one is more needle-phobic than an 11-year-old,” Dr. Alexander said.

“In terms of importance, HPV is probably the most important vaccine to hit us since the measles vaccines,” he said. “We are very good at immunizing infants, and I give adult doctors about a C+ for adults. Immunizing teenagers is not something we are particularly good at.”

Endorse the HPV vaccine in your office from the front door to the exit, Dr. Alexander suggested. “This is something your whole office should be promoting. Remind your staff to ask the kid who comes in for another reason. Contraindications to immunization are very limited.”

Contacting the parents of every teenager in your practice is another effective approach. However, going through the charts is time consuming and can be very expensive, Dr. Alexander said.

Send a mass mailing to inform parents that a new vaccine is available and how insurance companies are providing reimbursement. Also, schedule all three visits for the HPV vaccine regimen up front, Dr. Alexander said, and follow up with telephone reminders. “This could also be done with e-mail—a smart way to go.”

Cook County Hospital in Chicago uses its emergency department to immunize adults, Dr. Alexander said. This tactic could be extrapolated to pediatric patients. “If a kid shows up with a sprained ankle in the ER, can we treat it as an opportunity to immunize them? Darn tootin'. Should we look at school-based vaccinations? It will be controversial with HPV vaccine, as you can imagine,” he said.

Some fear that a vaccine against HPV will increase sexual activity among teenagers. The vaccine does not obviate the need for a safe sex talk with a teenager, he said. In addition, “it is important to talk about abstinence—I have two teenage daughters. You have to trust and verify, and then immunize them anyway.”

Parents want to hear the vaccine is effective, safe, and recommended by their child's health care provider, Dr. Alexander said. “But they don't want to hear about their child being sexually active. You can say the vaccine is for preventing infection in women who are or ever will become sexually active.”

Future endeavors related to HPV prevention include longer-term follow-up studies of vaccines, approval of the second HPV vaccine expected later this year, studies in males, and forthcoming recommendations from the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Obstetricians and Gynecologists.

Physicians will need to provide education about HPV because “parents will line up when you say meningitis, but they don't know what HPV is,” Dr. Alexander said.

The AAP advocates a routine 11- to 12-year-old visit to foster the new shots. ©FOTOSEARCH

JACKSONVILLE, FLA. — Universal immunization of preteenage girls with human papillomavirus vaccine would be ideal given the peak prevalence rates among adolescents in the United States, according to a presentation at an STD prevention conference sponsored by the Centers for Disease Control and Prevention.

“For the vaccine to have an optimal effect, it should be given before initiation of sexual behavior,” said Cristen Suhr, project coordinator of the HPV sentinel surveillance project sponsored by the CDC. [Since this meeting the CDC Advisory Committee on Immunization Practices recommended that the human papillomavirus vaccine should be given to all girls at age 11–12, and to all females aged 13–26 who have not been previously vaccinated. The vaccine can be given to girls as young as 9 years of age, at the provider's discretion (PEDIATRIC NEWS, July 2006, p. 1).]

A high overall prevalence of high-risk human papillomavirus (HR-HPV) infection, 22%—regardless of race—is among findings of the surveillance project. HR-HPV is defined as HPV strains 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68.

The prevalence of HR-HPV in 14- to 19-year-olds is 33%. The project is the first multisite surveillance to measure HR-HPV prevalence among U.S. women.

Researchers assessed 8,426 females aged 14–65 years. Participants had a routine Pap smear between January 2003 and December 2005 in one of six cities: Baltimore, Boston, Denver, Los Angeles, New Orleans, or Seattle. Medical records were later abstracted for results.

Although nearly 60% of participants fell into the two youngest age groups (14- to 19-year-olds and 20- to 29-year-olds), “a strength of the ongoing HPV Sentinel Surveillance is inclusion of older age groups,” said Ms. Suhr. “Older women were more likely to be enrolled through a primary care clinic, whereas younger women were more likely to be enrolled through a family planning or STD clinic.”

“There was a steady decline in prevalence as age increased, from more than 30% in 14- to 19-year-olds down to under 10% in 50- to 65-year-olds,” Ms. Suhr said. This higher prevalence among younger females supports other studies that suggest HPV infection is acquired shortly after initiation of sexual activity. Ms. Suhr is affiliated with the CDC Division of STD Prevention and with Business Computer Applications Inc. in Atlanta.

HPV is the most common sexually transmitted infection, with a prevalence estimated at 20 million cases in the United States. Approximately 5.5 million incident infections occur each year. The HPV family is large, with more than 100 viral types, including more than 40 that cause genital infections. Most new infections are asymptomatic and clear naturally, but those that persist can cause cervical lesions.

The quadrivalent vaccine (Gardasil, Merck & Co.) targets high-risk oncogenic virus types 16 and 18, implicated in 70% of cervical cancers, as well as low-risk, nononcogenic types 6 and 11, which cause 90% of genital warts. Licensure of an investigational HPV bivalent vaccine (Cervarix, GlaxoSmithKline) is expected as early as the end of 2006.

“In the U.S., it appears we will be able to reduce abnormal Pap smears with the vaccines,” Dr. Diane M. Harper said. “We know the vaccines are safe [and] immunogenic and can prevent HPV infections—incident and persistent—and prevent genital warts.” Dr. Harper is director of the Gynecologic Cancer Prevention Research Group at the Norris Cotton Cancer Center in Lebanon, N.H.

“Surveys indicate a high level of acceptability of this vaccine among adolescents, young adults, parents, and providers. But there are also concerns about increases in risky behavior with this vaccine,” Dr. Judith N. Wasserheit, professor of allergy and infectious diseases, University of Washington, Seattle, said in another presentation at the meeting. The median age of first coitus in the United States is 16–17 years, she reported. One-third of adolescents initiate coitus by ninth grade, and 10% of ninth graders report a history of more than four partners.

Another area of controversy is school immunization requirements. These requirements are critical to ensuring coverage for young people, especially for higher-risk youth who may have limited access to health care, Dr. Wasserheit said. “Some argue that HPV is not transmitted in schools, so why should it be required? But this is an access point. We may not get to school requirement in the first round with this vaccine, but it's important.”

Potential limitations of the study include its clinic-based population and use of noncentralized laboratories for testing of cervical fluid samples.

ELSEVIER GLOBAL MEDICAL NEWS

JACKSONVILLE, FLA. — Universal immunization of preteenage girls with human papillomavirus vaccine would be ideal given the peak prevalence rates among adolescents in the United States, according to a presentation at an STD prevention conference sponsored by the Centers for Disease Control and Prevention.

“For the vaccine to have an optimal effect, it should be given before initiation of sexual behavior,” said Cristen Suhr, project coordinator of the HPV sentinel surveillance project sponsored by the CDC. [Since this meeting the CDC Advisory Committee on Immunization Practices recommended that the human papillomavirus vaccine should be given to all girls at age 11–12, and to all females aged 13–26 who have not been previously vaccinated. The vaccine can be given to girls as young as 9 years of age, at the provider's discretion (PEDIATRIC NEWS, July 2006, p. 1).]

A high overall prevalence of high-risk human papillomavirus (HR-HPV) infection, 22%—regardless of race—is among findings of the surveillance project. HR-HPV is defined as HPV strains 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68.

The prevalence of HR-HPV in 14- to 19-year-olds is 33%. The project is the first multisite surveillance to measure HR-HPV prevalence among U.S. women.

Researchers assessed 8,426 females aged 14–65 years. Participants had a routine Pap smear between January 2003 and December 2005 in one of six cities: Baltimore, Boston, Denver, Los Angeles, New Orleans, or Seattle. Medical records were later abstracted for results.

Although nearly 60% of participants fell into the two youngest age groups (14- to 19-year-olds and 20- to 29-year-olds), “a strength of the ongoing HPV Sentinel Surveillance is inclusion of older age groups,” said Ms. Suhr. “Older women were more likely to be enrolled through a primary care clinic, whereas younger women were more likely to be enrolled through a family planning or STD clinic.”

“There was a steady decline in prevalence as age increased, from more than 30% in 14- to 19-year-olds down to under 10% in 50- to 65-year-olds,” Ms. Suhr said. This higher prevalence among younger females supports other studies that suggest HPV infection is acquired shortly after initiation of sexual activity. Ms. Suhr is affiliated with the CDC Division of STD Prevention and with Business Computer Applications Inc. in Atlanta.

HPV is the most common sexually transmitted infection, with a prevalence estimated at 20 million cases in the United States. Approximately 5.5 million incident infections occur each year. The HPV family is large, with more than 100 viral types, including more than 40 that cause genital infections. Most new infections are asymptomatic and clear naturally, but those that persist can cause cervical lesions.

The quadrivalent vaccine (Gardasil, Merck & Co.) targets high-risk oncogenic virus types 16 and 18, implicated in 70% of cervical cancers, as well as low-risk, nononcogenic types 6 and 11, which cause 90% of genital warts. Licensure of an investigational HPV bivalent vaccine (Cervarix, GlaxoSmithKline) is expected as early as the end of 2006.

“In the U.S., it appears we will be able to reduce abnormal Pap smears with the vaccines,” Dr. Diane M. Harper said. “We know the vaccines are safe [and] immunogenic and can prevent HPV infections—incident and persistent—and prevent genital warts.” Dr. Harper is director of the Gynecologic Cancer Prevention Research Group at the Norris Cotton Cancer Center in Lebanon, N.H.

“Surveys indicate a high level of acceptability of this vaccine among adolescents, young adults, parents, and providers. But there are also concerns about increases in risky behavior with this vaccine,” Dr. Judith N. Wasserheit, professor of allergy and infectious diseases, University of Washington, Seattle, said in another presentation at the meeting. The median age of first coitus in the United States is 16–17 years, she reported. One-third of adolescents initiate coitus by ninth grade, and 10% of ninth graders report a history of more than four partners.

Another area of controversy is school immunization requirements. These requirements are critical to ensuring coverage for young people, especially for higher-risk youth who may have limited access to health care, Dr. Wasserheit said. “Some argue that HPV is not transmitted in schools, so why should it be required? But this is an access point. We may not get to school requirement in the first round with this vaccine, but it's important.”

Potential limitations of the study include its clinic-based population and use of noncentralized laboratories for testing of cervical fluid samples.

ELSEVIER GLOBAL MEDICAL NEWS

JACKSONVILLE, FLA. — Universal immunization of preteenage girls with human papillomavirus vaccine would be ideal given the peak prevalence rates among adolescents in the United States, according to a presentation at an STD prevention conference sponsored by the Centers for Disease Control and Prevention.

“For the vaccine to have an optimal effect, it should be given before initiation of sexual behavior,” said Cristen Suhr, project coordinator of the HPV sentinel surveillance project sponsored by the CDC. [Since this meeting the CDC Advisory Committee on Immunization Practices recommended that the human papillomavirus vaccine should be given to all girls at age 11–12, and to all females aged 13–26 who have not been previously vaccinated. The vaccine can be given to girls as young as 9 years of age, at the provider's discretion (PEDIATRIC NEWS, July 2006, p. 1).]

A high overall prevalence of high-risk human papillomavirus (HR-HPV) infection, 22%—regardless of race—is among findings of the surveillance project. HR-HPV is defined as HPV strains 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68.

The prevalence of HR-HPV in 14- to 19-year-olds is 33%. The project is the first multisite surveillance to measure HR-HPV prevalence among U.S. women.

Researchers assessed 8,426 females aged 14–65 years. Participants had a routine Pap smear between January 2003 and December 2005 in one of six cities: Baltimore, Boston, Denver, Los Angeles, New Orleans, or Seattle. Medical records were later abstracted for results.

Although nearly 60% of participants fell into the two youngest age groups (14- to 19-year-olds and 20- to 29-year-olds), “a strength of the ongoing HPV Sentinel Surveillance is inclusion of older age groups,” said Ms. Suhr. “Older women were more likely to be enrolled through a primary care clinic, whereas younger women were more likely to be enrolled through a family planning or STD clinic.”

“There was a steady decline in prevalence as age increased, from more than 30% in 14- to 19-year-olds down to under 10% in 50- to 65-year-olds,” Ms. Suhr said. This higher prevalence among younger females supports other studies that suggest HPV infection is acquired shortly after initiation of sexual activity. Ms. Suhr is affiliated with the CDC Division of STD Prevention and with Business Computer Applications Inc. in Atlanta.

HPV is the most common sexually transmitted infection, with a prevalence estimated at 20 million cases in the United States. Approximately 5.5 million incident infections occur each year. The HPV family is large, with more than 100 viral types, including more than 40 that cause genital infections. Most new infections are asymptomatic and clear naturally, but those that persist can cause cervical lesions.

The quadrivalent vaccine (Gardasil, Merck & Co.) targets high-risk oncogenic virus types 16 and 18, implicated in 70% of cervical cancers, as well as low-risk, nononcogenic types 6 and 11, which cause 90% of genital warts. Licensure of an investigational HPV bivalent vaccine (Cervarix, GlaxoSmithKline) is expected as early as the end of 2006.

“In the U.S., it appears we will be able to reduce abnormal Pap smears with the vaccines,” Dr. Diane M. Harper said. “We know the vaccines are safe [and] immunogenic and can prevent HPV infections—incident and persistent—and prevent genital warts.” Dr. Harper is director of the Gynecologic Cancer Prevention Research Group at the Norris Cotton Cancer Center in Lebanon, N.H.

“Surveys indicate a high level of acceptability of this vaccine among adolescents, young adults, parents, and providers. But there are also concerns about increases in risky behavior with this vaccine,” Dr. Judith N. Wasserheit, professor of allergy and infectious diseases, University of Washington, Seattle, said in another presentation at the meeting. The median age of first coitus in the United States is 16–17 years, she reported. One-third of adolescents initiate coitus by ninth grade, and 10% of ninth graders report a history of more than four partners.

Another area of controversy is school immunization requirements. These requirements are critical to ensuring coverage for young people, especially for higher-risk youth who may have limited access to health care, Dr. Wasserheit said. “Some argue that HPV is not transmitted in schools, so why should it be required? But this is an access point. We may not get to school requirement in the first round with this vaccine, but it's important.”

Potential limitations of the study include its clinic-based population and use of noncentralized laboratories for testing of cervical fluid samples.

ELSEVIER GLOBAL MEDICAL NEWS

AMELIA ISLAND, FLA. — Recent approval of the first vaccine to prevent human papillomavirus infection underlines the need for physicians to improve immunization of adolescents, Dr. Kenneth Alexander said at a meeting on pediatrics for the primary care physician that was sponsored by Nemours.

The good news is there are strategies that can optimize routine vaccination of teenagers for human papillomavirus (HPV), meningitis, and pertussis. Vaccine promotion, reminder calls, and mass mailings are among some “tried and true” tactics that office-based physicians can employ. Another idea is to enlist emergency physicians to immunize all adolescent patients. School-based vaccinations are another option, although somewhat controversial with human papillomavirus, said Dr. Alexander, a pediatric infectious disease specialist at the University of Chicago.

The American Academy of Pediatrics (AAP) is advocating a routine 11- to 12-year-old visit to foster immunization for meningitis, pertussis, and the first of three injections against HPV. Getting adolescents to return for the second and third HPV vaccinations will be a challenge, plus “no one is more needle-phobic than an 11-year-old,” Dr. Alexander said.

“In terms of importance, HPV is probably the most important vaccine to hit us since the measles vaccines,” he said. “We are very good at immunizing infants, and I give adult doctors about a C+ for adults. Immunizing teenagers is not something we are particularly good at.”

Endorse the HPV vaccine in your office from the front door to the exit, Dr. Alexander suggested. “This is something your whole office should be promoting. Remind your staff to ask the kid who comes in for another reason. Contraindications to immunization are very limited.”

Contacting the parents of every teenager in your practice is another effective approach. However, going through the charts is time consuming and can be very expensive, Dr. Alexander said.

Send a mass mailing to inform parents that a new vaccine is available and how insurance companies are providing reimbursement. Also, schedule all three visits for the HPV vaccine regimen up front, Dr. Alexander said, and follow up with telephone reminders. “This could also be done with e-mail—a smart way to go.”

Cook County Hospital in Chicago uses its emergency department to immunize adults, Dr. Alexander said. This tactic could be extrapolated to pediatric patients. “If a kid shows up with a sprained ankle in the ER, can we treat it as an opportunity to immunize them? Darn tootin'.”

“Should we look at school-based vaccinations? It will be controversial with HPV vaccine, as you can imagine,” he said.

Some fear that a vaccine against HPV will increase sexual activity among teenagers. The vaccine does not obviate the need for a safe sex talk with a teenager, he said. In addition, “it is important to talk about abstinence—I have two teenage daughters. You have to trust and verify, and then immunize them anyway.”

Parents want to hear that the vaccine is effective, safe, and recommended by their child's health care provider, Dr. Alexander said. “But they don't want to hear about their child being sexually active. You can say that the vaccine is for preventing infection in women who are or ever will become sexually active.”

Future endeavors related to HPV prevention include longer-term follow-up studies of vaccines, approval of the second HPV vaccine expected later this year, studies in males, and forthcoming recommendations from the American Academy of Pediatrics, AAP, and American College of Obstetricians and Gynecologists.

Physicians will need to provide education about HPV because “parents will line up when you say meningitis, but they don't know what HPV is,” Dr. Alexander said.

AMELIA ISLAND, FLA. — Recent approval of the first vaccine to prevent human papillomavirus infection underlines the need for physicians to improve immunization of adolescents, Dr. Kenneth Alexander said at a meeting on pediatrics for the primary care physician that was sponsored by Nemours.

The good news is there are strategies that can optimize routine vaccination of teenagers for human papillomavirus (HPV), meningitis, and pertussis. Vaccine promotion, reminder calls, and mass mailings are among some “tried and true” tactics that office-based physicians can employ. Another idea is to enlist emergency physicians to immunize all adolescent patients. School-based vaccinations are another option, although somewhat controversial with human papillomavirus, said Dr. Alexander, a pediatric infectious disease specialist at the University of Chicago.

The American Academy of Pediatrics (AAP) is advocating a routine 11- to 12-year-old visit to foster immunization for meningitis, pertussis, and the first of three injections against HPV. Getting adolescents to return for the second and third HPV vaccinations will be a challenge, plus “no one is more needle-phobic than an 11-year-old,” Dr. Alexander said.

“In terms of importance, HPV is probably the most important vaccine to hit us since the measles vaccines,” he said. “We are very good at immunizing infants, and I give adult doctors about a C+ for adults. Immunizing teenagers is not something we are particularly good at.”

Endorse the HPV vaccine in your office from the front door to the exit, Dr. Alexander suggested. “This is something your whole office should be promoting. Remind your staff to ask the kid who comes in for another reason. Contraindications to immunization are very limited.”

Contacting the parents of every teenager in your practice is another effective approach. However, going through the charts is time consuming and can be very expensive, Dr. Alexander said.

Send a mass mailing to inform parents that a new vaccine is available and how insurance companies are providing reimbursement. Also, schedule all three visits for the HPV vaccine regimen up front, Dr. Alexander said, and follow up with telephone reminders. “This could also be done with e-mail—a smart way to go.”

Cook County Hospital in Chicago uses its emergency department to immunize adults, Dr. Alexander said. This tactic could be extrapolated to pediatric patients. “If a kid shows up with a sprained ankle in the ER, can we treat it as an opportunity to immunize them? Darn tootin'.”

“Should we look at school-based vaccinations? It will be controversial with HPV vaccine, as you can imagine,” he said.

Some fear that a vaccine against HPV will increase sexual activity among teenagers. The vaccine does not obviate the need for a safe sex talk with a teenager, he said. In addition, “it is important to talk about abstinence—I have two teenage daughters. You have to trust and verify, and then immunize them anyway.”

Parents want to hear that the vaccine is effective, safe, and recommended by their child's health care provider, Dr. Alexander said. “But they don't want to hear about their child being sexually active. You can say that the vaccine is for preventing infection in women who are or ever will become sexually active.”

Future endeavors related to HPV prevention include longer-term follow-up studies of vaccines, approval of the second HPV vaccine expected later this year, studies in males, and forthcoming recommendations from the American Academy of Pediatrics, AAP, and American College of Obstetricians and Gynecologists.

Physicians will need to provide education about HPV because “parents will line up when you say meningitis, but they don't know what HPV is,” Dr. Alexander said.

AMELIA ISLAND, FLA. — Recent approval of the first vaccine to prevent human papillomavirus infection underlines the need for physicians to improve immunization of adolescents, Dr. Kenneth Alexander said at a meeting on pediatrics for the primary care physician that was sponsored by Nemours.

The good news is there are strategies that can optimize routine vaccination of teenagers for human papillomavirus (HPV), meningitis, and pertussis. Vaccine promotion, reminder calls, and mass mailings are among some “tried and true” tactics that office-based physicians can employ. Another idea is to enlist emergency physicians to immunize all adolescent patients. School-based vaccinations are another option, although somewhat controversial with human papillomavirus, said Dr. Alexander, a pediatric infectious disease specialist at the University of Chicago.

The American Academy of Pediatrics (AAP) is advocating a routine 11- to 12-year-old visit to foster immunization for meningitis, pertussis, and the first of three injections against HPV. Getting adolescents to return for the second and third HPV vaccinations will be a challenge, plus “no one is more needle-phobic than an 11-year-old,” Dr. Alexander said.

“In terms of importance, HPV is probably the most important vaccine to hit us since the measles vaccines,” he said. “We are very good at immunizing infants, and I give adult doctors about a C+ for adults. Immunizing teenagers is not something we are particularly good at.”

Endorse the HPV vaccine in your office from the front door to the exit, Dr. Alexander suggested. “This is something your whole office should be promoting. Remind your staff to ask the kid who comes in for another reason. Contraindications to immunization are very limited.”

Contacting the parents of every teenager in your practice is another effective approach. However, going through the charts is time consuming and can be very expensive, Dr. Alexander said.

Send a mass mailing to inform parents that a new vaccine is available and how insurance companies are providing reimbursement. Also, schedule all three visits for the HPV vaccine regimen up front, Dr. Alexander said, and follow up with telephone reminders. “This could also be done with e-mail—a smart way to go.”

Cook County Hospital in Chicago uses its emergency department to immunize adults, Dr. Alexander said. This tactic could be extrapolated to pediatric patients. “If a kid shows up with a sprained ankle in the ER, can we treat it as an opportunity to immunize them? Darn tootin'.”

“Should we look at school-based vaccinations? It will be controversial with HPV vaccine, as you can imagine,” he said.

Some fear that a vaccine against HPV will increase sexual activity among teenagers. The vaccine does not obviate the need for a safe sex talk with a teenager, he said. In addition, “it is important to talk about abstinence—I have two teenage daughters. You have to trust and verify, and then immunize them anyway.”

Parents want to hear that the vaccine is effective, safe, and recommended by their child's health care provider, Dr. Alexander said. “But they don't want to hear about their child being sexually active. You can say that the vaccine is for preventing infection in women who are or ever will become sexually active.”

Future endeavors related to HPV prevention include longer-term follow-up studies of vaccines, approval of the second HPV vaccine expected later this year, studies in males, and forthcoming recommendations from the American Academy of Pediatrics, AAP, and American College of Obstetricians and Gynecologists.

Physicians will need to provide education about HPV because “parents will line up when you say meningitis, but they don't know what HPV is,” Dr. Alexander 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, said Dr. Shailesh Jain, a National Institute of Mental Health fellow at the Mood Disorders Research Program and Clinic at the University of Texas Southwestern Medical Center, Dallas.

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.

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 of the participants were outpatients with nonpsychotic major depressive disorder. The participants were culled from a randomized trial of fluoxetine 10 mg/day for one 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.”

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 that 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, said Dr. Shailesh Jain, a National Institute of Mental Health fellow at the Mood Disorders Research Program and Clinic at the University of Texas Southwestern Medical Center, Dallas.

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.

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 of the participants were outpatients with nonpsychotic major depressive disorder. The participants were culled from a randomized trial of fluoxetine 10 mg/day for one 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.”

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 that 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, said Dr. Shailesh Jain, a National Institute of Mental Health fellow at the Mood Disorders Research Program and Clinic at the University of Texas Southwestern Medical Center, Dallas.

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.

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 of the participants were outpatients with nonpsychotic major depressive disorder. The participants were culled from a randomized trial of fluoxetine 10 mg/day for one 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.”

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 that 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. — Telepsychiatry is a valid and reliable way to extend depression treatment to rural settings, according to a study from researchers at the University of California, Davis.

“Telepsychiatry has been hot and cold, hot and cold, and right now it's hot,” Dr. Donald M. Hilty said at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Attention-deficit hyperactivity disorder, depression, developmental disorders, eating disorders, posttraumatic stress, and schizophrenia are among the disorders being treated via telemedicine.

“The bottom line is that telepsychiatry is reliable and valid. There is no question that telepsychiatry can be used for these diagnoses,” said Dr. Hilty of the university.

Early surveys of physicians and patients regarding telepsychiatry yielded less than satisfactory results, perhaps partly because of technical limitations, Dr. Hilty said. “A lot of studies were done at 128 [kilobytes per second], which might give you a negative view. With 384 and 512 kb connections, we'll find it is even more satisfying.” Signal delays at the slower connection speed sometimes stilted interaction between the patient and physician, leading to conversation “collisions,” turn taking, and numerous pauses.

The UC Davis telepsychiatry program has provided 2,500 consultations to primary care physicians and their patients since 1996. A broadband connection now provides “quite powerful resolution” for videoconferencing to a patient at one of 40–60 sites in California, Dr. Hilty said. Secure e-mail interaction is another feature.

Psychiatrists control cameras on both ends during a video conference, thus allowing a closer look at facial expressions or nonverbal clues. “You can zoom the camera on the patient end. Generally, they are not aware of changes to their camera unless you go side to side,” Dr. Hilty said.

“Most people doing telepsychiatry are not trying to replace in-person care,” he said. The goal is to provide physician-patient interaction in locations where in-person care is not available or quality is an issue. “It would be nice to see patients in person at least once, but it is not always possible in rural areas with cost and transportation issues.”

Critics of telepsychiatry suggest that a long-distance connection is dangerous if a patient is in crisis. Some situations require patient supervision by the primary care physician, Dr. Hilty said. Patients in imminent danger from suicide ideation or intoxication are examples, as are those with an inability to use equipment because of sensory deficits and those with significant anxiety about meeting people or using technology. “We have their primary care physician come in for a few minutes, and that usually works out.”

A study by Dr. Hilty and his colleagues (in press) assessed 104 depressed adults over 12 months using the Structured Clinical Interview for the DSM-IV (SCID-IV). Participants in this randomized, controlled trial received primary care in rural settings. At 3 months and 6 months, those managed via telepsychiatry experienced a 60% reduction in depression symptoms, compared with 40% of controls.

MediCal provides some reimbursement for telemedicine to qualified California residents, Dr. Hilty said in response to a question from a person attending the meeting, which was cosponsored by the American Society for Clinical Psychopharmacology. “A model a lot of the academic programs use now is contracts with rural organizations. An organization can buy 20% of my time, salary, etc., and use the service or lose it.” The telemedicine program at UC Davis receives money from a variety of sources, including state funds, federal funds, and the National Institutes of Health.

Reduced time to travel for a consultation, reduced waiting time, and less time away from work are among advantages cited by patients. One benefit for psychiatrists is that sessions are recorded electronically, thus obviating the need for written chart documentation, Dr. Hilty said. Telepsychiatry consultations also can reduce nursing home admissions, use of emergency services, and misdiagnosis by primary care providers (J. Geriatr. Psychiatry Neurol. 2001;14:66–71).

Another study demonstrated equal outcomes for telemedicine vs. in-person care for adults with depression (Am. J. Psychiatry 2004;161:1471–6).

BOCA RATON, FLA. — Telepsychiatry is a valid and reliable way to extend depression treatment to rural settings, according to a study from researchers at the University of California, Davis.

“Telepsychiatry has been hot and cold, hot and cold, and right now it's hot,” Dr. Donald M. Hilty said at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Attention-deficit hyperactivity disorder, depression, developmental disorders, eating disorders, posttraumatic stress, and schizophrenia are among the disorders being treated via telemedicine.

“The bottom line is that telepsychiatry is reliable and valid. There is no question that telepsychiatry can be used for these diagnoses,” said Dr. Hilty of the university.

Early surveys of physicians and patients regarding telepsychiatry yielded less than satisfactory results, perhaps partly because of technical limitations, Dr. Hilty said. “A lot of studies were done at 128 [kilobytes per second], which might give you a negative view. With 384 and 512 kb connections, we'll find it is even more satisfying.” Signal delays at the slower connection speed sometimes stilted interaction between the patient and physician, leading to conversation “collisions,” turn taking, and numerous pauses.

The UC Davis telepsychiatry program has provided 2,500 consultations to primary care physicians and their patients since 1996. A broadband connection now provides “quite powerful resolution” for videoconferencing to a patient at one of 40–60 sites in California, Dr. Hilty said. Secure e-mail interaction is another feature.

Psychiatrists control cameras on both ends during a video conference, thus allowing a closer look at facial expressions or nonverbal clues. “You can zoom the camera on the patient end. Generally, they are not aware of changes to their camera unless you go side to side,” Dr. Hilty said.

“Most people doing telepsychiatry are not trying to replace in-person care,” he said. The goal is to provide physician-patient interaction in locations where in-person care is not available or quality is an issue. “It would be nice to see patients in person at least once, but it is not always possible in rural areas with cost and transportation issues.”

Critics of telepsychiatry suggest that a long-distance connection is dangerous if a patient is in crisis. Some situations require patient supervision by the primary care physician, Dr. Hilty said. Patients in imminent danger from suicide ideation or intoxication are examples, as are those with an inability to use equipment because of sensory deficits and those with significant anxiety about meeting people or using technology. “We have their primary care physician come in for a few minutes, and that usually works out.”

A study by Dr. Hilty and his colleagues (in press) assessed 104 depressed adults over 12 months using the Structured Clinical Interview for the DSM-IV (SCID-IV). Participants in this randomized, controlled trial received primary care in rural settings. At 3 months and 6 months, those managed via telepsychiatry experienced a 60% reduction in depression symptoms, compared with 40% of controls.

MediCal provides some reimbursement for telemedicine to qualified California residents, Dr. Hilty said in response to a question from a person attending the meeting, which was cosponsored by the American Society for Clinical Psychopharmacology. “A model a lot of the academic programs use now is contracts with rural organizations. An organization can buy 20% of my time, salary, etc., and use the service or lose it.” The telemedicine program at UC Davis receives money from a variety of sources, including state funds, federal funds, and the National Institutes of Health.

Reduced time to travel for a consultation, reduced waiting time, and less time away from work are among advantages cited by patients. One benefit for psychiatrists is that sessions are recorded electronically, thus obviating the need for written chart documentation, Dr. Hilty said. Telepsychiatry consultations also can reduce nursing home admissions, use of emergency services, and misdiagnosis by primary care providers (J. Geriatr. Psychiatry Neurol. 2001;14:66–71).

Another study demonstrated equal outcomes for telemedicine vs. in-person care for adults with depression (Am. J. Psychiatry 2004;161:1471–6).

BOCA RATON, FLA. — Telepsychiatry is a valid and reliable way to extend depression treatment to rural settings, according to a study from researchers at the University of California, Davis.

“Telepsychiatry has been hot and cold, hot and cold, and right now it's hot,” Dr. Donald M. Hilty said at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Attention-deficit hyperactivity disorder, depression, developmental disorders, eating disorders, posttraumatic stress, and schizophrenia are among the disorders being treated via telemedicine.

“The bottom line is that telepsychiatry is reliable and valid. There is no question that telepsychiatry can be used for these diagnoses,” said Dr. Hilty of the university.

Early surveys of physicians and patients regarding telepsychiatry yielded less than satisfactory results, perhaps partly because of technical limitations, Dr. Hilty said. “A lot of studies were done at 128 [kilobytes per second], which might give you a negative view. With 384 and 512 kb connections, we'll find it is even more satisfying.” Signal delays at the slower connection speed sometimes stilted interaction between the patient and physician, leading to conversation “collisions,” turn taking, and numerous pauses.

The UC Davis telepsychiatry program has provided 2,500 consultations to primary care physicians and their patients since 1996. A broadband connection now provides “quite powerful resolution” for videoconferencing to a patient at one of 40–60 sites in California, Dr. Hilty said. Secure e-mail interaction is another feature.

Psychiatrists control cameras on both ends during a video conference, thus allowing a closer look at facial expressions or nonverbal clues. “You can zoom the camera on the patient end. Generally, they are not aware of changes to their camera unless you go side to side,” Dr. Hilty said.

“Most people doing telepsychiatry are not trying to replace in-person care,” he said. The goal is to provide physician-patient interaction in locations where in-person care is not available or quality is an issue. “It would be nice to see patients in person at least once, but it is not always possible in rural areas with cost and transportation issues.”

Critics of telepsychiatry suggest that a long-distance connection is dangerous if a patient is in crisis. Some situations require patient supervision by the primary care physician, Dr. Hilty said. Patients in imminent danger from suicide ideation or intoxication are examples, as are those with an inability to use equipment because of sensory deficits and those with significant anxiety about meeting people or using technology. “We have their primary care physician come in for a few minutes, and that usually works out.”

A study by Dr. Hilty and his colleagues (in press) assessed 104 depressed adults over 12 months using the Structured Clinical Interview for the DSM-IV (SCID-IV). Participants in this randomized, controlled trial received primary care in rural settings. At 3 months and 6 months, those managed via telepsychiatry experienced a 60% reduction in depression symptoms, compared with 40% of controls.

MediCal provides some reimbursement for telemedicine to qualified California residents, Dr. Hilty said in response to a question from a person attending the meeting, which was cosponsored by the American Society for Clinical Psychopharmacology. “A model a lot of the academic programs use now is contracts with rural organizations. An organization can buy 20% of my time, salary, etc., and use the service or lose it.” The telemedicine program at UC Davis receives money from a variety of sources, including state funds, federal funds, and the National Institutes of Health.

Reduced time to travel for a consultation, reduced waiting time, and less time away from work are among advantages cited by patients. One benefit for psychiatrists is that sessions are recorded electronically, thus obviating the need for written chart documentation, Dr. Hilty said. Telepsychiatry consultations also can reduce nursing home admissions, use of emergency services, and misdiagnosis by primary care providers (J. Geriatr. Psychiatry Neurol. 2001;14:66–71).

Another study demonstrated equal outcomes for telemedicine vs. in-person care for adults with depression (Am. J. Psychiatry 2004;161:1471–6).

SAN JUAN, P.R. – Low heart rate variability is significantly associated with an increased risk of death in depressed versus nondepressed patients after an acute myocardial infarction, Robert M. Carney, Ph.D., said at the annual meeting of the American College of Psychiatrists.

Depression is common among patients with a recent, acute myocardial infarction (MI)–incidence of major depression ranges from 15% to 23% in the literature. Other researchers found that low 24-hour heart rate variability is a strong predictor of cardiac mortality in patients with a recent MI (Ann. Noninvasive Electrocardiol. 2005;10:88–101). Heart rate variability was as robust a predictor as ventricular dysfunction or the size of the infarction in this review article.

The aim of the current study was to determine whether 24-hour heart rate variability is lower in depressed patients, and if so, whether this finding explains why depression reduces cardiovascular mortality after an MI, said Dr. Carney, professor of psychiatry and director of the behavioral medicine center at Washington University, St. Louis.

He and his associates assessed 305 depressed patients (135 with major depression and 170 with minor depression) with 24-hour ambulatory ECG readings 1–3 weeks post MI. Another group of 366 nondepressed, post-MI patients was included for comparison.

The investigators measured frequency domain heart rate variability using very-low-frequency (VLF) power spectral analysis. “VLF reflects parasympathetic modulation and is one of the best predictors of post-MI mortality,” Dr. Carney said.

Dr. Carney and his associates found a difference in log of VLF power (LnVLF) measurements: 6.32 in the depressed group, compared with 6.59 in the nondepressed patients.

“This was statistically significant, but is it clinically significant?” Dr. Carney asked.

In the study, 16% of depressed patients and 7% of nondepressed controls had a VLF below 180 squared milliseconds. The estimated probability of survival over 30 months of follow-up was statistically lower among depressed patients.

“So low heart rate variability is a significant and important factor post MI,” Dr. Carney said.

After adjustment for other risk factors, including left ventricular ejection fraction, smoking, older age, and diabetes, the low heart rate variability hazard ratio “goes from 3.1 to 2.8–a tiny difference,” he said.

“About 27% of the mortality risk in these patients can be accounted for by low heart rate variability,” Dr. Carney said. “So there are other things that are important here–including platelet function and inflammation.”

The literature is conflicting about whether treatment of depression provides a beneficial increase in heart rate variability. For example, 10 studies with tricyclic antidepressants yielded mixed results, Dr. Carney said, “and the six SSRI studies are more confusing.” Three SSRI studies reported increased heart rate variability, and three reported no change. Studies with other antidepressants offer no clear answer, either. No change in heart rate variability was seen in a nefazodone study, while lower heart rate variability was observed in a bupropion study and a venlafaxine trial.

Dr. Carney assessed the effect of psychotherapy among depressed congestive heart disease (CHD) patients. After 12 sessions of cognitive-behavioral therapy, mean heart rate decreased 5 beats/min and root mean squared successive difference increased. There were no changes in other heart rate variability indices.

“Heart rate variability may be improved through medication, exercise, and cardiac risk factor modification,” Dr. Carney emphasized.

“Regardless, depression in cardiac patients should be treated to improve quality of life, because we know we can do that,” he said.

SAN JUAN, P.R. – Low heart rate variability is significantly associated with an increased risk of death in depressed versus nondepressed patients after an acute myocardial infarction, Robert M. Carney, Ph.D., said at the annual meeting of the American College of Psychiatrists.

Depression is common among patients with a recent, acute myocardial infarction (MI)–incidence of major depression ranges from 15% to 23% in the literature. Other researchers found that low 24-hour heart rate variability is a strong predictor of cardiac mortality in patients with a recent MI (Ann. Noninvasive Electrocardiol. 2005;10:88–101). Heart rate variability was as robust a predictor as ventricular dysfunction or the size of the infarction in this review article.

The aim of the current study was to determine whether 24-hour heart rate variability is lower in depressed patients, and if so, whether this finding explains why depression reduces cardiovascular mortality after an MI, said Dr. Carney, professor of psychiatry and director of the behavioral medicine center at Washington University, St. Louis.

He and his associates assessed 305 depressed patients (135 with major depression and 170 with minor depression) with 24-hour ambulatory ECG readings 1–3 weeks post MI. Another group of 366 nondepressed, post-MI patients was included for comparison.

The investigators measured frequency domain heart rate variability using very-low-frequency (VLF) power spectral analysis. “VLF reflects parasympathetic modulation and is one of the best predictors of post-MI mortality,” Dr. Carney said.

Dr. Carney and his associates found a difference in log of VLF power (LnVLF) measurements: 6.32 in the depressed group, compared with 6.59 in the nondepressed patients.

“This was statistically significant, but is it clinically significant?” Dr. Carney asked.

In the study, 16% of depressed patients and 7% of nondepressed controls had a VLF below 180 squared milliseconds. The estimated probability of survival over 30 months of follow-up was statistically lower among depressed patients.

“So low heart rate variability is a significant and important factor post MI,” Dr. Carney said.

After adjustment for other risk factors, including left ventricular ejection fraction, smoking, older age, and diabetes, the low heart rate variability hazard ratio “goes from 3.1 to 2.8–a tiny difference,” he said.

“About 27% of the mortality risk in these patients can be accounted for by low heart rate variability,” Dr. Carney said. “So there are other things that are important here–including platelet function and inflammation.”

The literature is conflicting about whether treatment of depression provides a beneficial increase in heart rate variability. For example, 10 studies with tricyclic antidepressants yielded mixed results, Dr. Carney said, “and the six SSRI studies are more confusing.” Three SSRI studies reported increased heart rate variability, and three reported no change. Studies with other antidepressants offer no clear answer, either. No change in heart rate variability was seen in a nefazodone study, while lower heart rate variability was observed in a bupropion study and a venlafaxine trial.

Dr. Carney assessed the effect of psychotherapy among depressed congestive heart disease (CHD) patients. After 12 sessions of cognitive-behavioral therapy, mean heart rate decreased 5 beats/min and root mean squared successive difference increased. There were no changes in other heart rate variability indices.

“Heart rate variability may be improved through medication, exercise, and cardiac risk factor modification,” Dr. Carney emphasized.

“Regardless, depression in cardiac patients should be treated to improve quality of life, because we know we can do that,” he said.

SAN JUAN, P.R. – Low heart rate variability is significantly associated with an increased risk of death in depressed versus nondepressed patients after an acute myocardial infarction, Robert M. Carney, Ph.D., said at the annual meeting of the American College of Psychiatrists.

Depression is common among patients with a recent, acute myocardial infarction (MI)–incidence of major depression ranges from 15% to 23% in the literature. Other researchers found that low 24-hour heart rate variability is a strong predictor of cardiac mortality in patients with a recent MI (Ann. Noninvasive Electrocardiol. 2005;10:88–101). Heart rate variability was as robust a predictor as ventricular dysfunction or the size of the infarction in this review article.

The aim of the current study was to determine whether 24-hour heart rate variability is lower in depressed patients, and if so, whether this finding explains why depression reduces cardiovascular mortality after an MI, said Dr. Carney, professor of psychiatry and director of the behavioral medicine center at Washington University, St. Louis.

He and his associates assessed 305 depressed patients (135 with major depression and 170 with minor depression) with 24-hour ambulatory ECG readings 1–3 weeks post MI. Another group of 366 nondepressed, post-MI patients was included for comparison.

The investigators measured frequency domain heart rate variability using very-low-frequency (VLF) power spectral analysis. “VLF reflects parasympathetic modulation and is one of the best predictors of post-MI mortality,” Dr. Carney said.

Dr. Carney and his associates found a difference in log of VLF power (LnVLF) measurements: 6.32 in the depressed group, compared with 6.59 in the nondepressed patients.

“This was statistically significant, but is it clinically significant?” Dr. Carney asked.

In the study, 16% of depressed patients and 7% of nondepressed controls had a VLF below 180 squared milliseconds. The estimated probability of survival over 30 months of follow-up was statistically lower among depressed patients.

“So low heart rate variability is a significant and important factor post MI,” Dr. Carney said.

After adjustment for other risk factors, including left ventricular ejection fraction, smoking, older age, and diabetes, the low heart rate variability hazard ratio “goes from 3.1 to 2.8–a tiny difference,” he said.

“About 27% of the mortality risk in these patients can be accounted for by low heart rate variability,” Dr. Carney said. “So there are other things that are important here–including platelet function and inflammation.”

The literature is conflicting about whether treatment of depression provides a beneficial increase in heart rate variability. For example, 10 studies with tricyclic antidepressants yielded mixed results, Dr. Carney said, “and the six SSRI studies are more confusing.” Three SSRI studies reported increased heart rate variability, and three reported no change. Studies with other antidepressants offer no clear answer, either. No change in heart rate variability was seen in a nefazodone study, while lower heart rate variability was observed in a bupropion study and a venlafaxine trial.

Dr. Carney assessed the effect of psychotherapy among depressed congestive heart disease (CHD) patients. After 12 sessions of cognitive-behavioral therapy, mean heart rate decreased 5 beats/min and root mean squared successive difference increased. There were no changes in other heart rate variability indices.

“Heart rate variability may be improved through medication, exercise, and cardiac risk factor modification,” Dr. Carney emphasized.

“Regardless, depression in cardiac patients should be treated to improve quality of life, because we know we can do that,” he said.