Damian McNamara

MIAMI BEACH — Be vigilant for acne vulgaris on the trunk because almost half of acne patients might have it on their shoulders, chest, or back, according to a presentation at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Assessment of acne patients for truncal involvement is important because “not all patients will tell you about it,” said James Q. Del Rosso, D.O., of the department of dermatology, University of Nevada, Las Vegas.

A recent treatment option for acne of the trunk is clindamycin phosphate 1% (Evoclin Foam, Connetics Corp).

In October 2004, the Food and Drug Administration approved the once-daily acne vulgaris topical treatment for patients aged 12 years and older.

Dr. Del Rosso disclosed that he is a consultant, advisory board member, and member of the speakers' bureau for Connetics Corp.

To determine a ballpark figure of the frequency of involvement of acne on the trunk, Dr. Del Rosso examined 100 consecutive patients with acne who were at least 16 years of age (range of 16–30 years). “I found 94% had facial acne vulgaris, which is to be expected,” he said.

In 44% of patients, there was truncal acne. Men were more likely to have this type of acne (61%), compared with women (41%).

Patient age often correlates with the location and type of acne vulgaris. In preteens, for example, acne tends to be centrofacial with predominantly comedonal lesions.

In teenagers, acne is located on the face or trunk and typically presents as a mixture of comedonal and inflammatory acne.

Adult females, on the other hand, can present with acne on perioral, chin, lower cheek, jawline, neck, and trunk areas. Inflammatory lesions are most common in this population.

The differential diagnosis of acne vulgaris on the trunk is aided by looking for lesions at different stages, Dr. Del Rosso said. In contrast, monomorphic lesions usually indicate other conditions such as hot tub folliculitis or “corticosteroid acne.”

MIAMI BEACH — Be vigilant for acne vulgaris on the trunk because almost half of acne patients might have it on their shoulders, chest, or back, according to a presentation at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Assessment of acne patients for truncal involvement is important because “not all patients will tell you about it,” said James Q. Del Rosso, D.O., of the department of dermatology, University of Nevada, Las Vegas.

A recent treatment option for acne of the trunk is clindamycin phosphate 1% (Evoclin Foam, Connetics Corp).

In October 2004, the Food and Drug Administration approved the once-daily acne vulgaris topical treatment for patients aged 12 years and older.

Dr. Del Rosso disclosed that he is a consultant, advisory board member, and member of the speakers' bureau for Connetics Corp.

To determine a ballpark figure of the frequency of involvement of acne on the trunk, Dr. Del Rosso examined 100 consecutive patients with acne who were at least 16 years of age (range of 16–30 years). “I found 94% had facial acne vulgaris, which is to be expected,” he said.

In 44% of patients, there was truncal acne. Men were more likely to have this type of acne (61%), compared with women (41%).

Patient age often correlates with the location and type of acne vulgaris. In preteens, for example, acne tends to be centrofacial with predominantly comedonal lesions.

In teenagers, acne is located on the face or trunk and typically presents as a mixture of comedonal and inflammatory acne.

Adult females, on the other hand, can present with acne on perioral, chin, lower cheek, jawline, neck, and trunk areas. Inflammatory lesions are most common in this population.

The differential diagnosis of acne vulgaris on the trunk is aided by looking for lesions at different stages, Dr. Del Rosso said. In contrast, monomorphic lesions usually indicate other conditions such as hot tub folliculitis or “corticosteroid acne.”

MIAMI BEACH — Be vigilant for acne vulgaris on the trunk because almost half of acne patients might have it on their shoulders, chest, or back, according to a presentation at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Assessment of acne patients for truncal involvement is important because “not all patients will tell you about it,” said James Q. Del Rosso, D.O., of the department of dermatology, University of Nevada, Las Vegas.

A recent treatment option for acne of the trunk is clindamycin phosphate 1% (Evoclin Foam, Connetics Corp).

In October 2004, the Food and Drug Administration approved the once-daily acne vulgaris topical treatment for patients aged 12 years and older.

Dr. Del Rosso disclosed that he is a consultant, advisory board member, and member of the speakers' bureau for Connetics Corp.

To determine a ballpark figure of the frequency of involvement of acne on the trunk, Dr. Del Rosso examined 100 consecutive patients with acne who were at least 16 years of age (range of 16–30 years). “I found 94% had facial acne vulgaris, which is to be expected,” he said.

In 44% of patients, there was truncal acne. Men were more likely to have this type of acne (61%), compared with women (41%).

Patient age often correlates with the location and type of acne vulgaris. In preteens, for example, acne tends to be centrofacial with predominantly comedonal lesions.

In teenagers, acne is located on the face or trunk and typically presents as a mixture of comedonal and inflammatory acne.

Adult females, on the other hand, can present with acne on perioral, chin, lower cheek, jawline, neck, and trunk areas. Inflammatory lesions are most common in this population.

The differential diagnosis of acne vulgaris on the trunk is aided by looking for lesions at different stages, Dr. Del Rosso said. In contrast, monomorphic lesions usually indicate other conditions such as hot tub folliculitis or “corticosteroid acne.”

NEW ORLEANS — Despite a higher risk of diabetes in some ethnic/racial groups, physicians are not discriminating and neglect to inform most patients about their risk, according to a study presented at the annual conference of the Society of Teachers of Family Medicine.

An estimated 6.6% of adults in the United States have type 2 diabetes. The prevalence is greater in African Americans—an estimated 10%—and slightly greater among Hispanics at 10.4%. An estimated 11% of overweight Americans aged between 45 and 74 years have undiagnosed diabetes, and another 23% have prediabetes (Diabetes Care 2003;26:645–9).

“Incidence rates continue climbing. The rate of diabetes among Latino males is increasingly more than other gender or racial groups. With growing representation of Latinos, this issue is only going to become more and more important,” said John G. Ryan, Dr.PH.

Efforts by physicians to prevent or delay diagnosis of diabetes among all patients are equally poor, regardless of subgroup, said Dr. Ryan of the department of family medicine and community health at the University of Miami. “The bad news is we are not informing patients about their risk. The good news, if you want to call it that, is we are not providing disproportionately poor care.”

Dr. Ryan and senior research associate, Fulton Velez conducted a cross-sectional study of 2,411 consecutive patients who presented to 16 primary care practices in the South Florida Primary Care Practice-Based Research Network. The aim was to identify the prevalence of undetected diabetes among high-risk patients. Participant mean age was 49 years and 67% were female. The mean body mass index was 28.5. More than half, 62%, were low-income, publicly insured patients.

The researchers used the American Diabetes Association Risk Assessment Questionnaire to determine risk of type 2 diabetes. This interactive seven-question test was used to calculate a diabetes risk score (DRS). The investigators also used the one-page Behavioral Risk Factor Surveillance System to ascertain if the participants' physicians had told them they had diabetes or were at risk.

A minority (22%) had been told they had diabetes. The researchers focused on the remaining 78% and studied these 1,880 participants further. Of the remaining patients, 892 (47%) had a DRS of 10 or more and were considered high risk.

“We then looked at this high-risk group to see if they were informed or not informed they were at high risk,” Dr. Ryan said. “The majority of this group had not been informed: 84%, or 746 participants.”

There was a difference in risk according to race and ethnicity, which was “sort of intuitive,” Dr. Ryan said. However, when patients were divided according to informed versus not informed status, there were no differences by race or ethnicity.

“So even though there is a difference in the risk categories, there is no difference in whether folks have been informed or not informed when we look at race and ethnicity,” Dr. Ryan said.

Possible limitations of the study include recall bias, validity of the American Diabetes Association screening tool when used to screen publicly insured patients, and variation in individual physician practices.

NEW ORLEANS — Despite a higher risk of diabetes in some ethnic/racial groups, physicians are not discriminating and neglect to inform most patients about their risk, according to a study presented at the annual conference of the Society of Teachers of Family Medicine.

An estimated 6.6% of adults in the United States have type 2 diabetes. The prevalence is greater in African Americans—an estimated 10%—and slightly greater among Hispanics at 10.4%. An estimated 11% of overweight Americans aged between 45 and 74 years have undiagnosed diabetes, and another 23% have prediabetes (Diabetes Care 2003;26:645–9).

“Incidence rates continue climbing. The rate of diabetes among Latino males is increasingly more than other gender or racial groups. With growing representation of Latinos, this issue is only going to become more and more important,” said John G. Ryan, Dr.PH.

Efforts by physicians to prevent or delay diagnosis of diabetes among all patients are equally poor, regardless of subgroup, said Dr. Ryan of the department of family medicine and community health at the University of Miami. “The bad news is we are not informing patients about their risk. The good news, if you want to call it that, is we are not providing disproportionately poor care.”

Dr. Ryan and senior research associate, Fulton Velez conducted a cross-sectional study of 2,411 consecutive patients who presented to 16 primary care practices in the South Florida Primary Care Practice-Based Research Network. The aim was to identify the prevalence of undetected diabetes among high-risk patients. Participant mean age was 49 years and 67% were female. The mean body mass index was 28.5. More than half, 62%, were low-income, publicly insured patients.

The researchers used the American Diabetes Association Risk Assessment Questionnaire to determine risk of type 2 diabetes. This interactive seven-question test was used to calculate a diabetes risk score (DRS). The investigators also used the one-page Behavioral Risk Factor Surveillance System to ascertain if the participants' physicians had told them they had diabetes or were at risk.

A minority (22%) had been told they had diabetes. The researchers focused on the remaining 78% and studied these 1,880 participants further. Of the remaining patients, 892 (47%) had a DRS of 10 or more and were considered high risk.

“We then looked at this high-risk group to see if they were informed or not informed they were at high risk,” Dr. Ryan said. “The majority of this group had not been informed: 84%, or 746 participants.”

There was a difference in risk according to race and ethnicity, which was “sort of intuitive,” Dr. Ryan said. However, when patients were divided according to informed versus not informed status, there were no differences by race or ethnicity.

“So even though there is a difference in the risk categories, there is no difference in whether folks have been informed or not informed when we look at race and ethnicity,” Dr. Ryan said.

Possible limitations of the study include recall bias, validity of the American Diabetes Association screening tool when used to screen publicly insured patients, and variation in individual physician practices.

NEW ORLEANS — Despite a higher risk of diabetes in some ethnic/racial groups, physicians are not discriminating and neglect to inform most patients about their risk, according to a study presented at the annual conference of the Society of Teachers of Family Medicine.

An estimated 6.6% of adults in the United States have type 2 diabetes. The prevalence is greater in African Americans—an estimated 10%—and slightly greater among Hispanics at 10.4%. An estimated 11% of overweight Americans aged between 45 and 74 years have undiagnosed diabetes, and another 23% have prediabetes (Diabetes Care 2003;26:645–9).

“Incidence rates continue climbing. The rate of diabetes among Latino males is increasingly more than other gender or racial groups. With growing representation of Latinos, this issue is only going to become more and more important,” said John G. Ryan, Dr.PH.

Efforts by physicians to prevent or delay diagnosis of diabetes among all patients are equally poor, regardless of subgroup, said Dr. Ryan of the department of family medicine and community health at the University of Miami. “The bad news is we are not informing patients about their risk. The good news, if you want to call it that, is we are not providing disproportionately poor care.”

Dr. Ryan and senior research associate, Fulton Velez conducted a cross-sectional study of 2,411 consecutive patients who presented to 16 primary care practices in the South Florida Primary Care Practice-Based Research Network. The aim was to identify the prevalence of undetected diabetes among high-risk patients. Participant mean age was 49 years and 67% were female. The mean body mass index was 28.5. More than half, 62%, were low-income, publicly insured patients.

The researchers used the American Diabetes Association Risk Assessment Questionnaire to determine risk of type 2 diabetes. This interactive seven-question test was used to calculate a diabetes risk score (DRS). The investigators also used the one-page Behavioral Risk Factor Surveillance System to ascertain if the participants' physicians had told them they had diabetes or were at risk.

A minority (22%) had been told they had diabetes. The researchers focused on the remaining 78% and studied these 1,880 participants further. Of the remaining patients, 892 (47%) had a DRS of 10 or more and were considered high risk.

“We then looked at this high-risk group to see if they were informed or not informed they were at high risk,” Dr. Ryan said. “The majority of this group had not been informed: 84%, or 746 participants.”

There was a difference in risk according to race and ethnicity, which was “sort of intuitive,” Dr. Ryan said. However, when patients were divided according to informed versus not informed status, there were no differences by race or ethnicity.

“So even though there is a difference in the risk categories, there is no difference in whether folks have been informed or not informed when we look at race and ethnicity,” Dr. Ryan said.

Possible limitations of the study include recall bias, validity of the American Diabetes Association screening tool when used to screen publicly insured patients, and variation in individual physician practices.

MIAMI BEACH – The antiparkinsonism drug ropinirole is now indicated for the treatment of adults with moderate to severe restless legs syndrome.

The Food and Drug Administration approved the new indication based on three randomized, double-blind, controlled trials that showed significant improvements in patient and physician symptom ratings, compared with placebo.

One of these studies showed that ropinirole (Requip, from GlaxoSmithKline) was well tolerated and effective at improving symptoms in as little as 1 week. Richard Bogan, M.D., presented results of this phase III study at the annual meeting of the American Academy of Neurology.

Restless legs syndrome is a sensorimotor neurologic disorder affecting 5%–10% of the U.S. population. The condition causes considerable sleep disturbance and impairs quality of life for some patients. Although the pathogenesis is unknown, dopamine agonists such as ropinirole may be effective as first-line treatment for moderate to severe cases, according to Dr. Bogan of the University of South Carolina.

To test safety and efficacy, Dr. Bogan and his colleagues randomized 187 patients to ropinirole and 193 others to placebo in a 12-week, double-blind, multicenter trial. All participants had mild to moderate impairment; entry requirements included an International Restless Legs Syndrome (IRLS) study group criteria score of 15 or more, at least 15 nights of symptoms in the last month, and 4 nights of symptoms in the last 7 nights.

“Patients do have changes in quality of life, and ropinirole can improve their lives,” said Dr. Bogan, president and medical director of SleepMed Inc.

The primary measure of efficacy was change in IRLS score between baseline and the last clinical observation before the end of the 12-week trial. Secondary outcomes included the change in IRLS score from baseline to week 1 and the proportion of patients in each group with a score of “much improved” or “very much improved” at weeks 1 and 12 on the Clinical Global Impression-Improvement scale. In addition, researchers assessed sleep quantity and quality with the Medical Outcomes Study sleep scale.

All participants were adults, with a mean age of 52 years (range 18–79 years). Women accounted for 58% of the ropinirole group and 63% of the placebo group. A total of 164 ropinirole recipients and 167 placebo recipients completed the study.

The treatment group received once-daily ropinirole 0.25 mg at baseline, 1–3 hours before bedtime. Dosages were titrated up to 4.0 mg/day to optimize efficacy without side effects. Dr. Bogan has received research grants from GlaxoSmithKline, the sponsor of this study.

There were “highly statistically significant” improvements in patient subjective assessments on the IRLS scale, Dr. Bogan said. Ropinirole reduced IRLS scores a mean of 3.7 points, compared with 2.0 points for placebo, at the patient's last clinical observation, which occurred either at 12 weeks or, in some cases, earlier.

Changes on the global impression scale “were highly statistically significant as well, although clearly, there is a placebo effect.” The proportion of patients with a Clinical Global Impression score of “much” or “very much improved” was significantly higher for ropinirole than placebo at week 12 (2.1 adjusted odds ratio).

“I am frustrated by my inability to tease out the placebo effect, by the scales we use, and the variability of their symptoms,” Dr. Bogan said in response to a question from the audience.

Ropinirole was associated with symptom relief as early as the first week of treatment. IRLS scores dropped by 4.1 points in the drug group versus 2.7 points in the placebo group at the end of the first week. In addition, a significantly higher proportion of ropinirole participants had Clinical Global Impression improvements at week one (2.4 adjusted odds ratio).

The treatment also provided qualitative improvements in sleep. Measures of sleep adequacy and quantity showed patients on active therapy experienced “dramatic improvements, especially in quantity of sleep,” Dr. Bogan said.

Ropinirole was generally well tolerated. The most common adverse events associated with ropinirole were nausea, headache, and somnolence. Nausea, for example, occurred in 42% of the treatment group, versus 8% of the placebo group.

MIAMI BEACH – The antiparkinsonism drug ropinirole is now indicated for the treatment of adults with moderate to severe restless legs syndrome.

The Food and Drug Administration approved the new indication based on three randomized, double-blind, controlled trials that showed significant improvements in patient and physician symptom ratings, compared with placebo.

One of these studies showed that ropinirole (Requip, from GlaxoSmithKline) was well tolerated and effective at improving symptoms in as little as 1 week. Richard Bogan, M.D., presented results of this phase III study at the annual meeting of the American Academy of Neurology.

Restless legs syndrome is a sensorimotor neurologic disorder affecting 5%–10% of the U.S. population. The condition causes considerable sleep disturbance and impairs quality of life for some patients. Although the pathogenesis is unknown, dopamine agonists such as ropinirole may be effective as first-line treatment for moderate to severe cases, according to Dr. Bogan of the University of South Carolina.

To test safety and efficacy, Dr. Bogan and his colleagues randomized 187 patients to ropinirole and 193 others to placebo in a 12-week, double-blind, multicenter trial. All participants had mild to moderate impairment; entry requirements included an International Restless Legs Syndrome (IRLS) study group criteria score of 15 or more, at least 15 nights of symptoms in the last month, and 4 nights of symptoms in the last 7 nights.

“Patients do have changes in quality of life, and ropinirole can improve their lives,” said Dr. Bogan, president and medical director of SleepMed Inc.

The primary measure of efficacy was change in IRLS score between baseline and the last clinical observation before the end of the 12-week trial. Secondary outcomes included the change in IRLS score from baseline to week 1 and the proportion of patients in each group with a score of “much improved” or “very much improved” at weeks 1 and 12 on the Clinical Global Impression-Improvement scale. In addition, researchers assessed sleep quantity and quality with the Medical Outcomes Study sleep scale.

All participants were adults, with a mean age of 52 years (range 18–79 years). Women accounted for 58% of the ropinirole group and 63% of the placebo group. A total of 164 ropinirole recipients and 167 placebo recipients completed the study.

The treatment group received once-daily ropinirole 0.25 mg at baseline, 1–3 hours before bedtime. Dosages were titrated up to 4.0 mg/day to optimize efficacy without side effects. Dr. Bogan has received research grants from GlaxoSmithKline, the sponsor of this study.

There were “highly statistically significant” improvements in patient subjective assessments on the IRLS scale, Dr. Bogan said. Ropinirole reduced IRLS scores a mean of 3.7 points, compared with 2.0 points for placebo, at the patient's last clinical observation, which occurred either at 12 weeks or, in some cases, earlier.

Changes on the global impression scale “were highly statistically significant as well, although clearly, there is a placebo effect.” The proportion of patients with a Clinical Global Impression score of “much” or “very much improved” was significantly higher for ropinirole than placebo at week 12 (2.1 adjusted odds ratio).

“I am frustrated by my inability to tease out the placebo effect, by the scales we use, and the variability of their symptoms,” Dr. Bogan said in response to a question from the audience.

Ropinirole was associated with symptom relief as early as the first week of treatment. IRLS scores dropped by 4.1 points in the drug group versus 2.7 points in the placebo group at the end of the first week. In addition, a significantly higher proportion of ropinirole participants had Clinical Global Impression improvements at week one (2.4 adjusted odds ratio).

The treatment also provided qualitative improvements in sleep. Measures of sleep adequacy and quantity showed patients on active therapy experienced “dramatic improvements, especially in quantity of sleep,” Dr. Bogan said.

Ropinirole was generally well tolerated. The most common adverse events associated with ropinirole were nausea, headache, and somnolence. Nausea, for example, occurred in 42% of the treatment group, versus 8% of the placebo group.

MIAMI BEACH – The antiparkinsonism drug ropinirole is now indicated for the treatment of adults with moderate to severe restless legs syndrome.

The Food and Drug Administration approved the new indication based on three randomized, double-blind, controlled trials that showed significant improvements in patient and physician symptom ratings, compared with placebo.

One of these studies showed that ropinirole (Requip, from GlaxoSmithKline) was well tolerated and effective at improving symptoms in as little as 1 week. Richard Bogan, M.D., presented results of this phase III study at the annual meeting of the American Academy of Neurology.

Restless legs syndrome is a sensorimotor neurologic disorder affecting 5%–10% of the U.S. population. The condition causes considerable sleep disturbance and impairs quality of life for some patients. Although the pathogenesis is unknown, dopamine agonists such as ropinirole may be effective as first-line treatment for moderate to severe cases, according to Dr. Bogan of the University of South Carolina.

To test safety and efficacy, Dr. Bogan and his colleagues randomized 187 patients to ropinirole and 193 others to placebo in a 12-week, double-blind, multicenter trial. All participants had mild to moderate impairment; entry requirements included an International Restless Legs Syndrome (IRLS) study group criteria score of 15 or more, at least 15 nights of symptoms in the last month, and 4 nights of symptoms in the last 7 nights.

“Patients do have changes in quality of life, and ropinirole can improve their lives,” said Dr. Bogan, president and medical director of SleepMed Inc.

The primary measure of efficacy was change in IRLS score between baseline and the last clinical observation before the end of the 12-week trial. Secondary outcomes included the change in IRLS score from baseline to week 1 and the proportion of patients in each group with a score of “much improved” or “very much improved” at weeks 1 and 12 on the Clinical Global Impression-Improvement scale. In addition, researchers assessed sleep quantity and quality with the Medical Outcomes Study sleep scale.

All participants were adults, with a mean age of 52 years (range 18–79 years). Women accounted for 58% of the ropinirole group and 63% of the placebo group. A total of 164 ropinirole recipients and 167 placebo recipients completed the study.

The treatment group received once-daily ropinirole 0.25 mg at baseline, 1–3 hours before bedtime. Dosages were titrated up to 4.0 mg/day to optimize efficacy without side effects. Dr. Bogan has received research grants from GlaxoSmithKline, the sponsor of this study.

There were “highly statistically significant” improvements in patient subjective assessments on the IRLS scale, Dr. Bogan said. Ropinirole reduced IRLS scores a mean of 3.7 points, compared with 2.0 points for placebo, at the patient's last clinical observation, which occurred either at 12 weeks or, in some cases, earlier.

Changes on the global impression scale “were highly statistically significant as well, although clearly, there is a placebo effect.” The proportion of patients with a Clinical Global Impression score of “much” or “very much improved” was significantly higher for ropinirole than placebo at week 12 (2.1 adjusted odds ratio).

“I am frustrated by my inability to tease out the placebo effect, by the scales we use, and the variability of their symptoms,” Dr. Bogan said in response to a question from the audience.

Ropinirole was associated with symptom relief as early as the first week of treatment. IRLS scores dropped by 4.1 points in the drug group versus 2.7 points in the placebo group at the end of the first week. In addition, a significantly higher proportion of ropinirole participants had Clinical Global Impression improvements at week one (2.4 adjusted odds ratio).

The treatment also provided qualitative improvements in sleep. Measures of sleep adequacy and quantity showed patients on active therapy experienced “dramatic improvements, especially in quantity of sleep,” Dr. Bogan said.

Ropinirole was generally well tolerated. The most common adverse events associated with ropinirole were nausea, headache, and somnolence. Nausea, for example, occurred in 42% of the treatment group, versus 8% of the placebo group.

BAL HARBOUR, FLA. – All people with multiple sclerosis should be screened for anxiety, according to a study presented at the annual meeting of the American Neuropsychiatric Association.

Researchers randomly selected 100 people with multiple sclerosis and screened them for anxiety using DSM-IV criteria. “We found the rates of anxiety were high. They would not have been diagnosed without neuropsychiatry screening for anxiety and depression,” Juan Carlos Urizar, M.D., told this newspaper.

“Data are very preliminary, but this is a good start to see how one can intervene clinically and not forget anxiety and depression in multiple sclerosis. This has implications for quality of life,” said Dr. Urizar of the department of psychiatry at Brigham and Women's Hospital, Boston, who was the second author of the study.

Early in multiple sclerosis, patients can also experience decreased memory and concentration. Some anxiety also may be related to demyelinization and brain function. “Although we know this is true for depression as many studies have correlated depression to white matter changes and undermining of cortical fibers by subcortical lesions,” lead author Zeina Chemali, M.D., said in a follow-up interview. “Not much is published in regard to anxiety.”

The researchers did not assess patient anxiety according to lesions visible on magnetic resonance imaging (MRI) or disease burden, but they plan to do so in the future. Dr. Chemali is the director of neuropsychiatry at the Brigham Behavioral Neurology Group at Brigham and Women's Hospital.

Researchers grouped the 70 women and 30 men according to the types of multiple sclerosis episodes. Participants included 49% with relapse-remitting disease, 32% with secondary progressive multiple sclerosis, 16% who experienced their first multiple sclerosis attack, and 3% with primary progressive disease.

Results indicate that anxiety is not related to severity or chronicity of multiple sclerosis, suggesting that screening is appropriate for all patients with the disease.

Researchers assessed prevalence of affective disorders, anxiety disorders, and comorbidity between the two. “An interesting finding is the higher level of anxiety than depression,” Dr. Urizar said.

A total of 37% of participants had an anxiety disorder, 20% had depression, and 20% had comorbid anxiety and depression. In addition, 21% presented with cognitive decline. Manic-depressive disorder was included with depression in the study, Dr. Chemali said.

The neuropsychological battery of tests included:

▸ The Boston Naming Test for language.

▸ The Drilled Word Span Test or the Buschke Selective Reminding Test for memory.

▸ The Trail Making Test (Parts A and B), a digit span test, and letter cancellation tested for attention.

▸ Beck Depression Inventory for mood assessment.

▸ Beck Anxiety Inventory for anxiety.

Participants also were asked to copy a cube and place the numbers and hands in a clock, and were given the Rey-Osterrieth Complex Figure Test.

The prevalence of anxiety was higher among women than men. “The gender difference … reflects the fact that MS is more common in women than in men,” Dr. Chemali said. The disparity could also reflect the reportedly higher prevalence of anxiety in women compared with men in the general population–a highly debated subject, because women present at or use more medical/psychiatric services than do men, which may result in prevalence being recorded as higher among women.

The study findings demonstrate that patients with multiple sclerosis can suffer debilitating anxiety with or without an affective disorder. However, the authors wrote in their poster, “Further study is needed to confirm these findings.”

BAL HARBOUR, FLA. – All people with multiple sclerosis should be screened for anxiety, according to a study presented at the annual meeting of the American Neuropsychiatric Association.

Researchers randomly selected 100 people with multiple sclerosis and screened them for anxiety using DSM-IV criteria. “We found the rates of anxiety were high. They would not have been diagnosed without neuropsychiatry screening for anxiety and depression,” Juan Carlos Urizar, M.D., told this newspaper.

“Data are very preliminary, but this is a good start to see how one can intervene clinically and not forget anxiety and depression in multiple sclerosis. This has implications for quality of life,” said Dr. Urizar of the department of psychiatry at Brigham and Women's Hospital, Boston, who was the second author of the study.

Early in multiple sclerosis, patients can also experience decreased memory and concentration. Some anxiety also may be related to demyelinization and brain function. “Although we know this is true for depression as many studies have correlated depression to white matter changes and undermining of cortical fibers by subcortical lesions,” lead author Zeina Chemali, M.D., said in a follow-up interview. “Not much is published in regard to anxiety.”

The researchers did not assess patient anxiety according to lesions visible on magnetic resonance imaging (MRI) or disease burden, but they plan to do so in the future. Dr. Chemali is the director of neuropsychiatry at the Brigham Behavioral Neurology Group at Brigham and Women's Hospital.

Researchers grouped the 70 women and 30 men according to the types of multiple sclerosis episodes. Participants included 49% with relapse-remitting disease, 32% with secondary progressive multiple sclerosis, 16% who experienced their first multiple sclerosis attack, and 3% with primary progressive disease.

Results indicate that anxiety is not related to severity or chronicity of multiple sclerosis, suggesting that screening is appropriate for all patients with the disease.

Researchers assessed prevalence of affective disorders, anxiety disorders, and comorbidity between the two. “An interesting finding is the higher level of anxiety than depression,” Dr. Urizar said.

A total of 37% of participants had an anxiety disorder, 20% had depression, and 20% had comorbid anxiety and depression. In addition, 21% presented with cognitive decline. Manic-depressive disorder was included with depression in the study, Dr. Chemali said.

The neuropsychological battery of tests included:

▸ The Boston Naming Test for language.

▸ The Drilled Word Span Test or the Buschke Selective Reminding Test for memory.

▸ The Trail Making Test (Parts A and B), a digit span test, and letter cancellation tested for attention.

▸ Beck Depression Inventory for mood assessment.

▸ Beck Anxiety Inventory for anxiety.

Participants also were asked to copy a cube and place the numbers and hands in a clock, and were given the Rey-Osterrieth Complex Figure Test.

The prevalence of anxiety was higher among women than men. “The gender difference … reflects the fact that MS is more common in women than in men,” Dr. Chemali said. The disparity could also reflect the reportedly higher prevalence of anxiety in women compared with men in the general population–a highly debated subject, because women present at or use more medical/psychiatric services than do men, which may result in prevalence being recorded as higher among women.

The study findings demonstrate that patients with multiple sclerosis can suffer debilitating anxiety with or without an affective disorder. However, the authors wrote in their poster, “Further study is needed to confirm these findings.”

BAL HARBOUR, FLA. – All people with multiple sclerosis should be screened for anxiety, according to a study presented at the annual meeting of the American Neuropsychiatric Association.

Researchers randomly selected 100 people with multiple sclerosis and screened them for anxiety using DSM-IV criteria. “We found the rates of anxiety were high. They would not have been diagnosed without neuropsychiatry screening for anxiety and depression,” Juan Carlos Urizar, M.D., told this newspaper.

“Data are very preliminary, but this is a good start to see how one can intervene clinically and not forget anxiety and depression in multiple sclerosis. This has implications for quality of life,” said Dr. Urizar of the department of psychiatry at Brigham and Women's Hospital, Boston, who was the second author of the study.

Early in multiple sclerosis, patients can also experience decreased memory and concentration. Some anxiety also may be related to demyelinization and brain function. “Although we know this is true for depression as many studies have correlated depression to white matter changes and undermining of cortical fibers by subcortical lesions,” lead author Zeina Chemali, M.D., said in a follow-up interview. “Not much is published in regard to anxiety.”

The researchers did not assess patient anxiety according to lesions visible on magnetic resonance imaging (MRI) or disease burden, but they plan to do so in the future. Dr. Chemali is the director of neuropsychiatry at the Brigham Behavioral Neurology Group at Brigham and Women's Hospital.

Researchers grouped the 70 women and 30 men according to the types of multiple sclerosis episodes. Participants included 49% with relapse-remitting disease, 32% with secondary progressive multiple sclerosis, 16% who experienced their first multiple sclerosis attack, and 3% with primary progressive disease.

Results indicate that anxiety is not related to severity or chronicity of multiple sclerosis, suggesting that screening is appropriate for all patients with the disease.

Researchers assessed prevalence of affective disorders, anxiety disorders, and comorbidity between the two. “An interesting finding is the higher level of anxiety than depression,” Dr. Urizar said.

A total of 37% of participants had an anxiety disorder, 20% had depression, and 20% had comorbid anxiety and depression. In addition, 21% presented with cognitive decline. Manic-depressive disorder was included with depression in the study, Dr. Chemali said.

The neuropsychological battery of tests included:

▸ The Boston Naming Test for language.

▸ The Drilled Word Span Test or the Buschke Selective Reminding Test for memory.

▸ The Trail Making Test (Parts A and B), a digit span test, and letter cancellation tested for attention.

▸ Beck Depression Inventory for mood assessment.

▸ Beck Anxiety Inventory for anxiety.

Participants also were asked to copy a cube and place the numbers and hands in a clock, and were given the Rey-Osterrieth Complex Figure Test.

The prevalence of anxiety was higher among women than men. “The gender difference … reflects the fact that MS is more common in women than in men,” Dr. Chemali said. The disparity could also reflect the reportedly higher prevalence of anxiety in women compared with men in the general population–a highly debated subject, because women present at or use more medical/psychiatric services than do men, which may result in prevalence being recorded as higher among women.

The study findings demonstrate that patients with multiple sclerosis can suffer debilitating anxiety with or without an affective disorder. However, the authors wrote in their poster, “Further study is needed to confirm these findings.”

SAN JUAN, P.R. – Contingency management increased abstinence for alcohol abusers in an intensive outpatient program, Nancy Petry, Ph.D., said at the annual meeting of the American Academy of Addiction Psychiatry.

The researchers randomized 42 alcohol-dependent veteran patients to either standard care or contingency management for 8 weeks. The standard-treatment group attended intensive outpatient day treatment for 5 hours a day, 5 days per week with blood alcohol content monitoring for 4 weeks, followed by one to three weekly group aftercare sessions up to week 8.

The contingency management group received the same standard care and monitoring but had a chance to win a prize from a fish bowl with each negative alcohol use test. Half the cards in the bowl had a prize, and participants had 1 in 2 odds of winning a $1 prize, a 1 in 16 chance of winning a $20 prize, and 1 in 500 odds for a $100 prize.

“Contingency management can significantly increase adherence to cocaine programs, but can be expensive,” commented Dr. Petry, who is professor of psychiatry at the University of Connecticut in Farmington.

There were reports of heavy drinking for 18% of the contingency group during the study, compared with 58% of the standard treatment group.

Reducing the primary drug of abuse, alcohol, had a positive effect on other substance use. At baseline, about 20% in each group tested positive on a urinalysis for illicit drug use.

Most had completed an inpatient detoxification prior to entry to the study. At 8 weeks, 10% of contingency management participants tested positive, so there was a suppressive effect.

For those in standard treatment, the rate of illicit drug use rose to 43%, Dr. Petry reported at the meeting.

“Costs still remain a concern in terms of instituting this in community practice, although prizes cost less than vouchers” used in some of the other contingency management approaches, Dr. Petry explained.

An attendee at the meeting asked about self-reported alcohol use.

“It's most problematic with contingency management, because there is a tangible reward for abstinence,” Dr. Petry said. “So we never rely on self-report with contingency management. We use objective confirmation.”

Controlled clinical trials support the general efficacy of contingency management and other types of behavioral therapy, such as community reinforcement, “but they are very intensive programs, and tend to be applied to more severe cases,” Dr. Petry said.

Community reinforcement is based on the view that people drink because they are gaining some kind of reinforcement from alcohol use.

The approach enhances reinforcement from other sources. The person's significant other oversees and reinforces medication adherence and helps to change the drinker's environment.

SAN JUAN, P.R. – Contingency management increased abstinence for alcohol abusers in an intensive outpatient program, Nancy Petry, Ph.D., said at the annual meeting of the American Academy of Addiction Psychiatry.

The researchers randomized 42 alcohol-dependent veteran patients to either standard care or contingency management for 8 weeks. The standard-treatment group attended intensive outpatient day treatment for 5 hours a day, 5 days per week with blood alcohol content monitoring for 4 weeks, followed by one to three weekly group aftercare sessions up to week 8.

The contingency management group received the same standard care and monitoring but had a chance to win a prize from a fish bowl with each negative alcohol use test. Half the cards in the bowl had a prize, and participants had 1 in 2 odds of winning a $1 prize, a 1 in 16 chance of winning a $20 prize, and 1 in 500 odds for a $100 prize.

“Contingency management can significantly increase adherence to cocaine programs, but can be expensive,” commented Dr. Petry, who is professor of psychiatry at the University of Connecticut in Farmington.

There were reports of heavy drinking for 18% of the contingency group during the study, compared with 58% of the standard treatment group.

Reducing the primary drug of abuse, alcohol, had a positive effect on other substance use. At baseline, about 20% in each group tested positive on a urinalysis for illicit drug use.

Most had completed an inpatient detoxification prior to entry to the study. At 8 weeks, 10% of contingency management participants tested positive, so there was a suppressive effect.

For those in standard treatment, the rate of illicit drug use rose to 43%, Dr. Petry reported at the meeting.

“Costs still remain a concern in terms of instituting this in community practice, although prizes cost less than vouchers” used in some of the other contingency management approaches, Dr. Petry explained.

An attendee at the meeting asked about self-reported alcohol use.

“It's most problematic with contingency management, because there is a tangible reward for abstinence,” Dr. Petry said. “So we never rely on self-report with contingency management. We use objective confirmation.”

Controlled clinical trials support the general efficacy of contingency management and other types of behavioral therapy, such as community reinforcement, “but they are very intensive programs, and tend to be applied to more severe cases,” Dr. Petry said.

Community reinforcement is based on the view that people drink because they are gaining some kind of reinforcement from alcohol use.

The approach enhances reinforcement from other sources. The person's significant other oversees and reinforces medication adherence and helps to change the drinker's environment.

SAN JUAN, P.R. – Contingency management increased abstinence for alcohol abusers in an intensive outpatient program, Nancy Petry, Ph.D., said at the annual meeting of the American Academy of Addiction Psychiatry.

The researchers randomized 42 alcohol-dependent veteran patients to either standard care or contingency management for 8 weeks. The standard-treatment group attended intensive outpatient day treatment for 5 hours a day, 5 days per week with blood alcohol content monitoring for 4 weeks, followed by one to three weekly group aftercare sessions up to week 8.

The contingency management group received the same standard care and monitoring but had a chance to win a prize from a fish bowl with each negative alcohol use test. Half the cards in the bowl had a prize, and participants had 1 in 2 odds of winning a $1 prize, a 1 in 16 chance of winning a $20 prize, and 1 in 500 odds for a $100 prize.

“Contingency management can significantly increase adherence to cocaine programs, but can be expensive,” commented Dr. Petry, who is professor of psychiatry at the University of Connecticut in Farmington.

There were reports of heavy drinking for 18% of the contingency group during the study, compared with 58% of the standard treatment group.

Reducing the primary drug of abuse, alcohol, had a positive effect on other substance use. At baseline, about 20% in each group tested positive on a urinalysis for illicit drug use.

Most had completed an inpatient detoxification prior to entry to the study. At 8 weeks, 10% of contingency management participants tested positive, so there was a suppressive effect.

For those in standard treatment, the rate of illicit drug use rose to 43%, Dr. Petry reported at the meeting.

“Costs still remain a concern in terms of instituting this in community practice, although prizes cost less than vouchers” used in some of the other contingency management approaches, Dr. Petry explained.

An attendee at the meeting asked about self-reported alcohol use.

“It's most problematic with contingency management, because there is a tangible reward for abstinence,” Dr. Petry said. “So we never rely on self-report with contingency management. We use objective confirmation.”

Controlled clinical trials support the general efficacy of contingency management and other types of behavioral therapy, such as community reinforcement, “but they are very intensive programs, and tend to be applied to more severe cases,” Dr. Petry said.

Community reinforcement is based on the view that people drink because they are gaining some kind of reinforcement from alcohol use.

The approach enhances reinforcement from other sources. The person's significant other oversees and reinforces medication adherence and helps to change the drinker's environment.

BOCA RATON, FLA. – The newly approved drug ramelteon significantly reduced sleep latency and increased total sleep time in a phase III study of elderly patients with chronic insomnia. In addition, researchers reported no evidence of next-day residual cognitive, psychomotor, or memory effects.

“There was really no problem with next-day psychomotor impairment that you can see with gamma-aminobutyric acid (GABA)-ergic agents. This study was done in an elderly population, so that is particularly important,” David Seiden, M.D., said in an interview at a poster presented at a meeting of the New Clinical Drug Evaluation Unit, sponsored by the National Institute of Mental Health. Use of sedative-hypnotic agents has been associated with increased risk of hip fractures from falls (J. Am. Geriatr. Soc. 1999;47:30–9).

Most agents approved by the Food and Drug Administration to treat insomnia work through the GABA-ergic system, including zolpidem (Ambien) or zaleplon (Sonata). But Dr. Seiden said ramelteon uses a novel approach and has a different mechanism of action through the melatonin system.

As a melatonin agonist, ramelteon has the ability to induce sleep and modulate circadian rhythm by binding to the same receptors, M1 and M2, targeted by endogenous melatonin, said Dr. Seiden, medical director of the Broward Research Group and Sleep-Wake Disorders Center of South Florida in Pembroke Pines.

Dr. Seiden and his associates studied 100 elderly patients with chronic insomnia in a crossover design. The mean age was 71 years, and 37 participants were men. Each participant took either ramelteon 4 mg/night, ramelteon 8 mg/night, or placebo for 5 weeks, followed by a 5- to 12-day washout period before switching. The drug was administered 30 minutes before the patient's usual bedtime.

The researchers used overnight polysomnography to assess efficacy. Patients also completed a postsleep questionnaire, Digital Symbol Substitution Test, and immediate and delayed memory recall tests.

“The major finding here is, there is an improvement in sleep latency,” he said.

Participants taking 4-mg/night ramelteon fell asleep faster than those taking a placebo (29 minutes versus 38 minutes), according to polysomnography. Similar improvements occurred with the higher dose of ramelteon (31 minutes). These differences were statistically significant.

Patients' subjective assessments of sleep latency were significantly different between those taking the 4-mg/night dose of ramelteon and those taking placebo (48 min vs. 58 min). However, patients taking the 8-mg/night dose reported it took them 51 minutes to fall asleep, which was not statistically different from results seen with placebo.

“Another positive finding was improvement in total sleep time. It could be an effect of them falling asleep quicker,” Dr. Seiden said. During the placebo phase, participants slept a mean of 350 total minutes, according to polysomnography. Total sleep time increased to 359 minutes at the 4-mg dose of ramelteon and 362 minutes at the 8-mg dose.

There were no consistent differences in wake time after sleep onset or number of nighttime awakenings between the two treatment groups.

“This drug has a really well tolerated side effect profile,” said Dr. Seiden, who has no financial affiliation with the company.

The most commonly reported adverse events were headache and nausea. Overall incidence of adverse events was similar between placebo (9%), ramelteon 4 mg (14%), and ramelteon 8 mg (7%) groups.

Dr. Seiden noted that the developer of ramelteon, Takeda Pharmaceuticals North America Inc., is currently looking at additional applications for the drug, including jet lag and shift work disorders.

BOCA RATON, FLA. – The newly approved drug ramelteon significantly reduced sleep latency and increased total sleep time in a phase III study of elderly patients with chronic insomnia. In addition, researchers reported no evidence of next-day residual cognitive, psychomotor, or memory effects.

“There was really no problem with next-day psychomotor impairment that you can see with gamma-aminobutyric acid (GABA)-ergic agents. This study was done in an elderly population, so that is particularly important,” David Seiden, M.D., said in an interview at a poster presented at a meeting of the New Clinical Drug Evaluation Unit, sponsored by the National Institute of Mental Health. Use of sedative-hypnotic agents has been associated with increased risk of hip fractures from falls (J. Am. Geriatr. Soc. 1999;47:30–9).

Most agents approved by the Food and Drug Administration to treat insomnia work through the GABA-ergic system, including zolpidem (Ambien) or zaleplon (Sonata). But Dr. Seiden said ramelteon uses a novel approach and has a different mechanism of action through the melatonin system.

As a melatonin agonist, ramelteon has the ability to induce sleep and modulate circadian rhythm by binding to the same receptors, M1 and M2, targeted by endogenous melatonin, said Dr. Seiden, medical director of the Broward Research Group and Sleep-Wake Disorders Center of South Florida in Pembroke Pines.

Dr. Seiden and his associates studied 100 elderly patients with chronic insomnia in a crossover design. The mean age was 71 years, and 37 participants were men. Each participant took either ramelteon 4 mg/night, ramelteon 8 mg/night, or placebo for 5 weeks, followed by a 5- to 12-day washout period before switching. The drug was administered 30 minutes before the patient's usual bedtime.

The researchers used overnight polysomnography to assess efficacy. Patients also completed a postsleep questionnaire, Digital Symbol Substitution Test, and immediate and delayed memory recall tests.

“The major finding here is, there is an improvement in sleep latency,” he said.

Participants taking 4-mg/night ramelteon fell asleep faster than those taking a placebo (29 minutes versus 38 minutes), according to polysomnography. Similar improvements occurred with the higher dose of ramelteon (31 minutes). These differences were statistically significant.

Patients' subjective assessments of sleep latency were significantly different between those taking the 4-mg/night dose of ramelteon and those taking placebo (48 min vs. 58 min). However, patients taking the 8-mg/night dose reported it took them 51 minutes to fall asleep, which was not statistically different from results seen with placebo.

“Another positive finding was improvement in total sleep time. It could be an effect of them falling asleep quicker,” Dr. Seiden said. During the placebo phase, participants slept a mean of 350 total minutes, according to polysomnography. Total sleep time increased to 359 minutes at the 4-mg dose of ramelteon and 362 minutes at the 8-mg dose.

There were no consistent differences in wake time after sleep onset or number of nighttime awakenings between the two treatment groups.

“This drug has a really well tolerated side effect profile,” said Dr. Seiden, who has no financial affiliation with the company.

The most commonly reported adverse events were headache and nausea. Overall incidence of adverse events was similar between placebo (9%), ramelteon 4 mg (14%), and ramelteon 8 mg (7%) groups.

Dr. Seiden noted that the developer of ramelteon, Takeda Pharmaceuticals North America Inc., is currently looking at additional applications for the drug, including jet lag and shift work disorders.

BOCA RATON, FLA. – The newly approved drug ramelteon significantly reduced sleep latency and increased total sleep time in a phase III study of elderly patients with chronic insomnia. In addition, researchers reported no evidence of next-day residual cognitive, psychomotor, or memory effects.

“There was really no problem with next-day psychomotor impairment that you can see with gamma-aminobutyric acid (GABA)-ergic agents. This study was done in an elderly population, so that is particularly important,” David Seiden, M.D., said in an interview at a poster presented at a meeting of the New Clinical Drug Evaluation Unit, sponsored by the National Institute of Mental Health. Use of sedative-hypnotic agents has been associated with increased risk of hip fractures from falls (J. Am. Geriatr. Soc. 1999;47:30–9).

Most agents approved by the Food and Drug Administration to treat insomnia work through the GABA-ergic system, including zolpidem (Ambien) or zaleplon (Sonata). But Dr. Seiden said ramelteon uses a novel approach and has a different mechanism of action through the melatonin system.

As a melatonin agonist, ramelteon has the ability to induce sleep and modulate circadian rhythm by binding to the same receptors, M1 and M2, targeted by endogenous melatonin, said Dr. Seiden, medical director of the Broward Research Group and Sleep-Wake Disorders Center of South Florida in Pembroke Pines.

Dr. Seiden and his associates studied 100 elderly patients with chronic insomnia in a crossover design. The mean age was 71 years, and 37 participants were men. Each participant took either ramelteon 4 mg/night, ramelteon 8 mg/night, or placebo for 5 weeks, followed by a 5- to 12-day washout period before switching. The drug was administered 30 minutes before the patient's usual bedtime.

The researchers used overnight polysomnography to assess efficacy. Patients also completed a postsleep questionnaire, Digital Symbol Substitution Test, and immediate and delayed memory recall tests.

“The major finding here is, there is an improvement in sleep latency,” he said.

Participants taking 4-mg/night ramelteon fell asleep faster than those taking a placebo (29 minutes versus 38 minutes), according to polysomnography. Similar improvements occurred with the higher dose of ramelteon (31 minutes). These differences were statistically significant.

Patients' subjective assessments of sleep latency were significantly different between those taking the 4-mg/night dose of ramelteon and those taking placebo (48 min vs. 58 min). However, patients taking the 8-mg/night dose reported it took them 51 minutes to fall asleep, which was not statistically different from results seen with placebo.

“Another positive finding was improvement in total sleep time. It could be an effect of them falling asleep quicker,” Dr. Seiden said. During the placebo phase, participants slept a mean of 350 total minutes, according to polysomnography. Total sleep time increased to 359 minutes at the 4-mg dose of ramelteon and 362 minutes at the 8-mg dose.

There were no consistent differences in wake time after sleep onset or number of nighttime awakenings between the two treatment groups.

“This drug has a really well tolerated side effect profile,” said Dr. Seiden, who has no financial affiliation with the company.

The most commonly reported adverse events were headache and nausea. Overall incidence of adverse events was similar between placebo (9%), ramelteon 4 mg (14%), and ramelteon 8 mg (7%) groups.

Dr. Seiden noted that the developer of ramelteon, Takeda Pharmaceuticals North America Inc., is currently looking at additional applications for the drug, including jet lag and shift work disorders.

SAN JUAN, P.R. — Better understanding of interactions between opioids and antiretroviral agents can improve clinical care and patient outcomes, said Elinore McCance-Katz, M.D.

“It may be that methadone is not the best opiate therapy for everyone with HIV who is opioid dependent,” Dr. McCance-Katz said at the annual meeting of the American Academy of Addiction Psychiatry. “These drug interactions are so potent, it is important to know if there are optimal combinations of opiate therapies and HIV medications.”

Through the cytochrome P-450 system, many antiretroviral agents interact with opioids, including methadone (see box), levomethadyl acetate (LAAM), and buprenorphine. HIV drugs that induce metabolism of methadone can cause symptoms of opiate withdrawal between doses; HIV drugs that inhibit such metabolism can cause opiate toxicity.

Such interactions can lead to nonadherence to antiretroviral regimens, viral resistance, and illicit drug use “in an attempt to self-medicate some of these noxious drug interactions that often go unrecognized,” said Dr. McCance-Katz, chair of the division of addiction psychiatry, Virginia Commonwealth University, Richmond.

Drug toxicities that are additive can be a significant risk to patients. Because of the clinically significant interactions, the Food and Drug Administration now requires methadone interaction data before approval of a new antiretroviral agent.

Researchers are assessing alternatives to methadone for HIV patients. Buprenorphine, for example, may not have the same liabilities as methadone in combination with antiretroviral therapy, she said. “I'm still looking at the data, but we don't see the toxicities with buprenorphine and LAAM that we see with methadone.”

Methadone-maintained patients who use efavirenz as part of highly active antiretroviral therapy require a 50% increase in methadone concentration, from 80 mg/dL at baseline to 120 mg/dL, according to research by Dr. McCance-Katz. With buprenorphine, the mean 17.2-mg/dL dosage did not change when efavirenz was added. “We did not have to increase the opiate dose for anyone, and we did not have to restabilize people as a result.”

Not all of methadone's effects on HIV drugs are via cytochrome P-450 metabolism. For example, didanosine and stavudine concentrations drop to subtherapeutic levels when these drugs are taken with methadone. Methadone decreases gastrointestinal motility, and didanosine and stavudine are particularly sensitive to stomach acid.

Dr. McCance-Katz highlighted some specific interactions between methadone and agents that combat HIV:

▸ Delavirdine mesylate inhibits cytochrome P-450, leading to a significant increase in methadone concentrations—the half-life is extended by almost 50%. “We would worry about accumulation,” she said. “With LAAM, we see even more dramatic effects and LAAM metabolites, which have implications for cardiac toxicity.”

▸ Nevirapine is similar to delavirdine, causing a decrease of about 50% in methadone area-under-the-curve concentrations. Withdrawal symptoms can occur if methadone dosages are not increased.

▸ Nelfinavir mesylate shows a “dramatic drop” in 7-day plasma levels when given with methadone. “Interestingly, we did not see withdrawal in these patients. We think that is because nelfinavir is a very good competitor for protein binding—so there was more free methadone available to protect them from opiate withdrawal,” she said.

▸ Kaletra, a combination of lopinavir and ritonavir, causes methadone levels to become subtherapeutic. Dr. McCance-Katz observed withdrawal symptoms in these patients. “But we did not know if it was an effect of lopinavir, ritonavir, or both.” When ritonavir was studied alone, the nonsignificant increase in methadone level implicated lopinavir as the component interacting with methadone.

Antiretroviral Agents Reported to Interact With Methadone

Abacavir

Combivir

Delavirdine

Didanosine

Efavirenz

Lopinavir

Nelfinavir

Nevirapine

Ritonavir

Saquinavir

Stavudine

Zidovudine

SOURCE: Dr. McCance-Katz

SAN JUAN, P.R. — Better understanding of interactions between opioids and antiretroviral agents can improve clinical care and patient outcomes, said Elinore McCance-Katz, M.D.

“It may be that methadone is not the best opiate therapy for everyone with HIV who is opioid dependent,” Dr. McCance-Katz said at the annual meeting of the American Academy of Addiction Psychiatry. “These drug interactions are so potent, it is important to know if there are optimal combinations of opiate therapies and HIV medications.”

Through the cytochrome P-450 system, many antiretroviral agents interact with opioids, including methadone (see box), levomethadyl acetate (LAAM), and buprenorphine. HIV drugs that induce metabolism of methadone can cause symptoms of opiate withdrawal between doses; HIV drugs that inhibit such metabolism can cause opiate toxicity.

Such interactions can lead to nonadherence to antiretroviral regimens, viral resistance, and illicit drug use “in an attempt to self-medicate some of these noxious drug interactions that often go unrecognized,” said Dr. McCance-Katz, chair of the division of addiction psychiatry, Virginia Commonwealth University, Richmond.

Drug toxicities that are additive can be a significant risk to patients. Because of the clinically significant interactions, the Food and Drug Administration now requires methadone interaction data before approval of a new antiretroviral agent.

Researchers are assessing alternatives to methadone for HIV patients. Buprenorphine, for example, may not have the same liabilities as methadone in combination with antiretroviral therapy, she said. “I'm still looking at the data, but we don't see the toxicities with buprenorphine and LAAM that we see with methadone.”

Methadone-maintained patients who use efavirenz as part of highly active antiretroviral therapy require a 50% increase in methadone concentration, from 80 mg/dL at baseline to 120 mg/dL, according to research by Dr. McCance-Katz. With buprenorphine, the mean 17.2-mg/dL dosage did not change when efavirenz was added. “We did not have to increase the opiate dose for anyone, and we did not have to restabilize people as a result.”

Not all of methadone's effects on HIV drugs are via cytochrome P-450 metabolism. For example, didanosine and stavudine concentrations drop to subtherapeutic levels when these drugs are taken with methadone. Methadone decreases gastrointestinal motility, and didanosine and stavudine are particularly sensitive to stomach acid.

Dr. McCance-Katz highlighted some specific interactions between methadone and agents that combat HIV:

▸ Delavirdine mesylate inhibits cytochrome P-450, leading to a significant increase in methadone concentrations—the half-life is extended by almost 50%. “We would worry about accumulation,” she said. “With LAAM, we see even more dramatic effects and LAAM metabolites, which have implications for cardiac toxicity.”

▸ Nevirapine is similar to delavirdine, causing a decrease of about 50% in methadone area-under-the-curve concentrations. Withdrawal symptoms can occur if methadone dosages are not increased.

▸ Nelfinavir mesylate shows a “dramatic drop” in 7-day plasma levels when given with methadone. “Interestingly, we did not see withdrawal in these patients. We think that is because nelfinavir is a very good competitor for protein binding—so there was more free methadone available to protect them from opiate withdrawal,” she said.

▸ Kaletra, a combination of lopinavir and ritonavir, causes methadone levels to become subtherapeutic. Dr. McCance-Katz observed withdrawal symptoms in these patients. “But we did not know if it was an effect of lopinavir, ritonavir, or both.” When ritonavir was studied alone, the nonsignificant increase in methadone level implicated lopinavir as the component interacting with methadone.

Antiretroviral Agents Reported to Interact With Methadone

Abacavir

Combivir

Delavirdine

Didanosine

Efavirenz

Lopinavir

Nelfinavir

Nevirapine

Ritonavir

Saquinavir

Stavudine

Zidovudine

SOURCE: Dr. McCance-Katz

SAN JUAN, P.R. — Better understanding of interactions between opioids and antiretroviral agents can improve clinical care and patient outcomes, said Elinore McCance-Katz, M.D.

“It may be that methadone is not the best opiate therapy for everyone with HIV who is opioid dependent,” Dr. McCance-Katz said at the annual meeting of the American Academy of Addiction Psychiatry. “These drug interactions are so potent, it is important to know if there are optimal combinations of opiate therapies and HIV medications.”

Through the cytochrome P-450 system, many antiretroviral agents interact with opioids, including methadone (see box), levomethadyl acetate (LAAM), and buprenorphine. HIV drugs that induce metabolism of methadone can cause symptoms of opiate withdrawal between doses; HIV drugs that inhibit such metabolism can cause opiate toxicity.

Such interactions can lead to nonadherence to antiretroviral regimens, viral resistance, and illicit drug use “in an attempt to self-medicate some of these noxious drug interactions that often go unrecognized,” said Dr. McCance-Katz, chair of the division of addiction psychiatry, Virginia Commonwealth University, Richmond.

Drug toxicities that are additive can be a significant risk to patients. Because of the clinically significant interactions, the Food and Drug Administration now requires methadone interaction data before approval of a new antiretroviral agent.

Researchers are assessing alternatives to methadone for HIV patients. Buprenorphine, for example, may not have the same liabilities as methadone in combination with antiretroviral therapy, she said. “I'm still looking at the data, but we don't see the toxicities with buprenorphine and LAAM that we see with methadone.”

Methadone-maintained patients who use efavirenz as part of highly active antiretroviral therapy require a 50% increase in methadone concentration, from 80 mg/dL at baseline to 120 mg/dL, according to research by Dr. McCance-Katz. With buprenorphine, the mean 17.2-mg/dL dosage did not change when efavirenz was added. “We did not have to increase the opiate dose for anyone, and we did not have to restabilize people as a result.”

Not all of methadone's effects on HIV drugs are via cytochrome P-450 metabolism. For example, didanosine and stavudine concentrations drop to subtherapeutic levels when these drugs are taken with methadone. Methadone decreases gastrointestinal motility, and didanosine and stavudine are particularly sensitive to stomach acid.

Dr. McCance-Katz highlighted some specific interactions between methadone and agents that combat HIV:

▸ Delavirdine mesylate inhibits cytochrome P-450, leading to a significant increase in methadone concentrations—the half-life is extended by almost 50%. “We would worry about accumulation,” she said. “With LAAM, we see even more dramatic effects and LAAM metabolites, which have implications for cardiac toxicity.”

▸ Nevirapine is similar to delavirdine, causing a decrease of about 50% in methadone area-under-the-curve concentrations. Withdrawal symptoms can occur if methadone dosages are not increased.

▸ Nelfinavir mesylate shows a “dramatic drop” in 7-day plasma levels when given with methadone. “Interestingly, we did not see withdrawal in these patients. We think that is because nelfinavir is a very good competitor for protein binding—so there was more free methadone available to protect them from opiate withdrawal,” she said.

▸ Kaletra, a combination of lopinavir and ritonavir, causes methadone levels to become subtherapeutic. Dr. McCance-Katz observed withdrawal symptoms in these patients. “But we did not know if it was an effect of lopinavir, ritonavir, or both.” When ritonavir was studied alone, the nonsignificant increase in methadone level implicated lopinavir as the component interacting with methadone.

Antiretroviral Agents Reported to Interact With Methadone

Abacavir

Combivir

Delavirdine

Didanosine

Efavirenz

Lopinavir

Nelfinavir

Nevirapine

Ritonavir

Saquinavir

Stavudine

Zidovudine

SOURCE: Dr. McCance-Katz

NEW ORLEANS — Neonatal and maternal mortality in California did not significantly change after the American College of Obstetricians and Gynecologists recommended vaginal births after cesarean delivery be performed only in settings with “immediately available” emergency care, according to a study.

Very low-birth-weight infants were the only group to experience significantly higher mortality associated with vaginal births after cesarean (VBACs). When the American College of Obstetricians and Gynecologists (ACOG) was contacted for comment, a representative criticized the study design and its implications.

In 1996, ACOG encouraged VBACs, John Zweifler, M.D., said at the annual conference of the Society of Teachers of Family Medicine. In 1998, the college changed its recommendations on VBACs and stated they should be attempted only where emergency care is “readily available.” The following year, ACOG further restricted the recommendations to settings where emergency care is “immediately available.” The college retained the wording of these recommendations in its latest update, Practice Bulletin No. 54 (Obstet. Gynecol. 2004;104:203–12).

“But for those of us in rural settings, this could impair our ability to do VBACs,” Dr. Zweifler said. “We were concerned that a change in ACOG guidelines would have deleterious effect on our [residency] program.”

Dr. Zweifler and research fellow Susan Hughes compared neonatal and maternal deaths from 1996 to 2002. They reviewed maternal demographics, birth data, and outcomes, noting previous C-sections and whether hospitals were in rural or urban areas. California Birth Statistical Master Files consider mortality to be associated with birth if it occurs within 72 hours of delivery, said Dr. Zweifler, director of the University of California, San Francisco's Fresno Family Medicine Residency Program.

There were more than 3.5 million single births in California in the seven years, including 2.7 million vaginal births, 456,000 primary cesarean sections, and 386,000 deliveries to women with a history of C-section. Of the women with a history of cesarean delivery, 311,000 had a repeat cesarean, and 74,000 had an attempted VBAC. There were 61,000 successful VBACs and 13,000 failed ones.

VBAC rates decreased from 1996 to 2002, reflecting national trends, Ms. Hughes said. The biggest decrease was in rural VBACs.

“There were very few maternal deaths—about 35. So statistically, there were no differences in maternal mortality between time periods or attempted VBAC, versus repeat cesareans,” Ms. Hughes said.

There was a statistically significant increase in mortality for infants weighing less than 1,500 grams. “Attempted VBACs in both time periods had higher death rates than repeat cesareans,” Ms. Hughes said.

However, there were no significant differences in mortality for infants born weighing more than 1,500 grams, including those greater than 4,000 grams.

Reliability of birth certificate data was a possible limitation of the study, Ms. Hughes said. In addition, there was no information on morbidities, such as uterine rupture or newborn encephalopathy.

“The more restrictive ACOG guidelines have not improved VBAC-related neonatal or maternal mortality,” Dr. Zweifler said.

“ACOG's recommendation is purely based on the fact there is no more catastrophic event that befalls women than uterine rupture,” said Gary Hankins, M.D., chair of the ACOG Committee on Obstetric Practice. “Studies clearly show that if you are not really available to respond to this emergency in a very quick fashion—generally less than 30 minutes—you can expect, in a significant number of cases, either the death of the baby or permanent neurologic injury of the baby from birth asphyxia.”

“That being the case, we opt to promote standards of safety, and patient safety if our first order is why these recommendations are made,” said Dr. Hankins, professor of obstetrics and gynecology at the University of Texas, Galveston.

The data used for the study—derived from Birth Statistical Master Files—are insufficient to address all the safety issues concerning VBAC deliveries, Dr. Hankins said. “I would challenge either of these people to see if they have ever stood on the front line and dealt with a woman who has had a uterine rupture.”

NEW ORLEANS — Neonatal and maternal mortality in California did not significantly change after the American College of Obstetricians and Gynecologists recommended vaginal births after cesarean delivery be performed only in settings with “immediately available” emergency care, according to a study.

Very low-birth-weight infants were the only group to experience significantly higher mortality associated with vaginal births after cesarean (VBACs). When the American College of Obstetricians and Gynecologists (ACOG) was contacted for comment, a representative criticized the study design and its implications.

In 1996, ACOG encouraged VBACs, John Zweifler, M.D., said at the annual conference of the Society of Teachers of Family Medicine. In 1998, the college changed its recommendations on VBACs and stated they should be attempted only where emergency care is “readily available.” The following year, ACOG further restricted the recommendations to settings where emergency care is “immediately available.” The college retained the wording of these recommendations in its latest update, Practice Bulletin No. 54 (Obstet. Gynecol. 2004;104:203–12).

“But for those of us in rural settings, this could impair our ability to do VBACs,” Dr. Zweifler said. “We were concerned that a change in ACOG guidelines would have deleterious effect on our [residency] program.”

Dr. Zweifler and research fellow Susan Hughes compared neonatal and maternal deaths from 1996 to 2002. They reviewed maternal demographics, birth data, and outcomes, noting previous C-sections and whether hospitals were in rural or urban areas. California Birth Statistical Master Files consider mortality to be associated with birth if it occurs within 72 hours of delivery, said Dr. Zweifler, director of the University of California, San Francisco's Fresno Family Medicine Residency Program.

There were more than 3.5 million single births in California in the seven years, including 2.7 million vaginal births, 456,000 primary cesarean sections, and 386,000 deliveries to women with a history of C-section. Of the women with a history of cesarean delivery, 311,000 had a repeat cesarean, and 74,000 had an attempted VBAC. There were 61,000 successful VBACs and 13,000 failed ones.

VBAC rates decreased from 1996 to 2002, reflecting national trends, Ms. Hughes said. The biggest decrease was in rural VBACs.

“There were very few maternal deaths—about 35. So statistically, there were no differences in maternal mortality between time periods or attempted VBAC, versus repeat cesareans,” Ms. Hughes said.

There was a statistically significant increase in mortality for infants weighing less than 1,500 grams. “Attempted VBACs in both time periods had higher death rates than repeat cesareans,” Ms. Hughes said.

However, there were no significant differences in mortality for infants born weighing more than 1,500 grams, including those greater than 4,000 grams.

Reliability of birth certificate data was a possible limitation of the study, Ms. Hughes said. In addition, there was no information on morbidities, such as uterine rupture or newborn encephalopathy.

“The more restrictive ACOG guidelines have not improved VBAC-related neonatal or maternal mortality,” Dr. Zweifler said.

“ACOG's recommendation is purely based on the fact there is no more catastrophic event that befalls women than uterine rupture,” said Gary Hankins, M.D., chair of the ACOG Committee on Obstetric Practice. “Studies clearly show that if you are not really available to respond to this emergency in a very quick fashion—generally less than 30 minutes—you can expect, in a significant number of cases, either the death of the baby or permanent neurologic injury of the baby from birth asphyxia.”

“That being the case, we opt to promote standards of safety, and patient safety if our first order is why these recommendations are made,” said Dr. Hankins, professor of obstetrics and gynecology at the University of Texas, Galveston.

The data used for the study—derived from Birth Statistical Master Files—are insufficient to address all the safety issues concerning VBAC deliveries, Dr. Hankins said. “I would challenge either of these people to see if they have ever stood on the front line and dealt with a woman who has had a uterine rupture.”

NEW ORLEANS — Neonatal and maternal mortality in California did not significantly change after the American College of Obstetricians and Gynecologists recommended vaginal births after cesarean delivery be performed only in settings with “immediately available” emergency care, according to a study.

Very low-birth-weight infants were the only group to experience significantly higher mortality associated with vaginal births after cesarean (VBACs). When the American College of Obstetricians and Gynecologists (ACOG) was contacted for comment, a representative criticized the study design and its implications.

In 1996, ACOG encouraged VBACs, John Zweifler, M.D., said at the annual conference of the Society of Teachers of Family Medicine. In 1998, the college changed its recommendations on VBACs and stated they should be attempted only where emergency care is “readily available.” The following year, ACOG further restricted the recommendations to settings where emergency care is “immediately available.” The college retained the wording of these recommendations in its latest update, Practice Bulletin No. 54 (Obstet. Gynecol. 2004;104:203–12).

“But for those of us in rural settings, this could impair our ability to do VBACs,” Dr. Zweifler said. “We were concerned that a change in ACOG guidelines would have deleterious effect on our [residency] program.”

Dr. Zweifler and research fellow Susan Hughes compared neonatal and maternal deaths from 1996 to 2002. They reviewed maternal demographics, birth data, and outcomes, noting previous C-sections and whether hospitals were in rural or urban areas. California Birth Statistical Master Files consider mortality to be associated with birth if it occurs within 72 hours of delivery, said Dr. Zweifler, director of the University of California, San Francisco's Fresno Family Medicine Residency Program.

There were more than 3.5 million single births in California in the seven years, including 2.7 million vaginal births, 456,000 primary cesarean sections, and 386,000 deliveries to women with a history of C-section. Of the women with a history of cesarean delivery, 311,000 had a repeat cesarean, and 74,000 had an attempted VBAC. There were 61,000 successful VBACs and 13,000 failed ones.

VBAC rates decreased from 1996 to 2002, reflecting national trends, Ms. Hughes said. The biggest decrease was in rural VBACs.

“There were very few maternal deaths—about 35. So statistically, there were no differences in maternal mortality between time periods or attempted VBAC, versus repeat cesareans,” Ms. Hughes said.

There was a statistically significant increase in mortality for infants weighing less than 1,500 grams. “Attempted VBACs in both time periods had higher death rates than repeat cesareans,” Ms. Hughes said.

However, there were no significant differences in mortality for infants born weighing more than 1,500 grams, including those greater than 4,000 grams.

Reliability of birth certificate data was a possible limitation of the study, Ms. Hughes said. In addition, there was no information on morbidities, such as uterine rupture or newborn encephalopathy.

“The more restrictive ACOG guidelines have not improved VBAC-related neonatal or maternal mortality,” Dr. Zweifler said.

“ACOG's recommendation is purely based on the fact there is no more catastrophic event that befalls women than uterine rupture,” said Gary Hankins, M.D., chair of the ACOG Committee on Obstetric Practice. “Studies clearly show that if you are not really available to respond to this emergency in a very quick fashion—generally less than 30 minutes—you can expect, in a significant number of cases, either the death of the baby or permanent neurologic injury of the baby from birth asphyxia.”

“That being the case, we opt to promote standards of safety, and patient safety if our first order is why these recommendations are made,” said Dr. Hankins, professor of obstetrics and gynecology at the University of Texas, Galveston.

The data used for the study—derived from Birth Statistical Master Files—are insufficient to address all the safety issues concerning VBAC deliveries, Dr. Hankins said. “I would challenge either of these people to see if they have ever stood on the front line and dealt with a woman who has had a uterine rupture.”

BAL HARBOUR, FLA. — Impaired graphesthesia, a prevalent finding among patients with mild cognitive impairment, may be an early sign when considered with memory loss that a patient has preclinical Alzheimer's disease, according to a study.

Mild cognitive impairment (MCI) is generally accepted as a precursor to Alzheimer's disease. Some neurologists screen MCI patients with a graphesthesia test, Edward Zamrini, M.D., said in an interview.

Graphesthesia is the sense by which people identify figures or numbers drawn on their hands with a dull-pointed object.

In an assessment for graphesthesia, people hold one hand out in front of them as if reading from it with the hand's long axis perpendicular to the midline axis of the body. While the patient's eyes are closed, the neurologist traces a number “1” on the patient's palm, asking the patient to identify the number out loud. Then the physician traces a second number on the patient's palm before repeating the process on the other hand.

Patients have two chances to identify the number correctly. If they fail to do so, they may be diagnosed with impaired graphesthesia.

Dr. Zamrini and his colleagues assessed more than 200 consecutive new patients at the Memory Disorders Clinic at the University of Alabama, Birmingham. Researchers identified patients by medical records between May 2001 and November 2002. Investigators took a detailed history, noted medications, and performed a thorough neurologic and cognitive assessment.

Examinations included light touch, pinprick, joint and position sense, vibration sense, and a Mini-Mental State Examination (MMSE). Patients were 58% female and 83% white, and their mean age was 68 years. Results were presented during a poster session at the annual meeting of the American Neuropsychiatric Association.

A total of 41 of the participants had MCI, 74 had Alzheimer's disease, and 96 were not diagnosed with either condition and were considered the control group. The control group included patients with vascular dementia, frontal lobe dementia, and other non-Alzheimer's dementias.

The prevalence of impaired graphesthesia was 54% in the MCI group, 79% in the Alzheimer's group, and 33% in controls, said Dr. Zamrini, a neurologist at the University of Alabama.

After incorporating such an exam into his practice, “I observed a disproportionately high number of my patients with MCI that have impaired graphesthesia,” he said. “It's just one more piece of evidence in support of the diagnosis of preclinical Alzheimer's disease, but you have to have the memory loss, too,” Dr. Zamrini said. If additional studies support impaired graphesthesia as a predictive variable, it would be the first physical sign of preclinical Alzheimer's disease.

Although Alzheimer's disease affects memory areas first, the parietal lobes are a “close second,” Dr. Zamrini said. The parietal areas are important to interpretation of senses, including graphesthesia.

Mean MMSE scores were 28 for the MCI group, 21 for the Alzheimer's disease group, and 26 for controls. The researchers grouped patients according to whether their MMSE score was 24 or greater or less than 24 to determine the effect of cognitive impairment on graphesthesia performance. There were significant differences in prevalence of impaired graphesthesia for participants scoring 24 or greater: 51% of the MCI group, 74% of the Alzheimer's group, and 24% of the control group.

The differential diagnosis for impaired graphesthesia should include stroke and severe sensory loss, Dr. Zamrini said.

The patient, eyes closed, tries to name the number being traced on the palm. Vivian E. Lee

BAL HARBOUR, FLA. — Impaired graphesthesia, a prevalent finding among patients with mild cognitive impairment, may be an early sign when considered with memory loss that a patient has preclinical Alzheimer's disease, according to a study.

Mild cognitive impairment (MCI) is generally accepted as a precursor to Alzheimer's disease. Some neurologists screen MCI patients with a graphesthesia test, Edward Zamrini, M.D., said in an interview.

Graphesthesia is the sense by which people identify figures or numbers drawn on their hands with a dull-pointed object.

In an assessment for graphesthesia, people hold one hand out in front of them as if reading from it with the hand's long axis perpendicular to the midline axis of the body. While the patient's eyes are closed, the neurologist traces a number “1” on the patient's palm, asking the patient to identify the number out loud. Then the physician traces a second number on the patient's palm before repeating the process on the other hand.

Patients have two chances to identify the number correctly. If they fail to do so, they may be diagnosed with impaired graphesthesia.

Dr. Zamrini and his colleagues assessed more than 200 consecutive new patients at the Memory Disorders Clinic at the University of Alabama, Birmingham. Researchers identified patients by medical records between May 2001 and November 2002. Investigators took a detailed history, noted medications, and performed a thorough neurologic and cognitive assessment.

Examinations included light touch, pinprick, joint and position sense, vibration sense, and a Mini-Mental State Examination (MMSE). Patients were 58% female and 83% white, and their mean age was 68 years. Results were presented during a poster session at the annual meeting of the American Neuropsychiatric Association.

A total of 41 of the participants had MCI, 74 had Alzheimer's disease, and 96 were not diagnosed with either condition and were considered the control group. The control group included patients with vascular dementia, frontal lobe dementia, and other non-Alzheimer's dementias.

The prevalence of impaired graphesthesia was 54% in the MCI group, 79% in the Alzheimer's group, and 33% in controls, said Dr. Zamrini, a neurologist at the University of Alabama.

After incorporating such an exam into his practice, “I observed a disproportionately high number of my patients with MCI that have impaired graphesthesia,” he said. “It's just one more piece of evidence in support of the diagnosis of preclinical Alzheimer's disease, but you have to have the memory loss, too,” Dr. Zamrini said. If additional studies support impaired graphesthesia as a predictive variable, it would be the first physical sign of preclinical Alzheimer's disease.

Although Alzheimer's disease affects memory areas first, the parietal lobes are a “close second,” Dr. Zamrini said. The parietal areas are important to interpretation of senses, including graphesthesia.

Mean MMSE scores were 28 for the MCI group, 21 for the Alzheimer's disease group, and 26 for controls. The researchers grouped patients according to whether their MMSE score was 24 or greater or less than 24 to determine the effect of cognitive impairment on graphesthesia performance. There were significant differences in prevalence of impaired graphesthesia for participants scoring 24 or greater: 51% of the MCI group, 74% of the Alzheimer's group, and 24% of the control group.

The differential diagnosis for impaired graphesthesia should include stroke and severe sensory loss, Dr. Zamrini said.

The patient, eyes closed, tries to name the number being traced on the palm. Vivian E. Lee

BAL HARBOUR, FLA. — Impaired graphesthesia, a prevalent finding among patients with mild cognitive impairment, may be an early sign when considered with memory loss that a patient has preclinical Alzheimer's disease, according to a study.

Mild cognitive impairment (MCI) is generally accepted as a precursor to Alzheimer's disease. Some neurologists screen MCI patients with a graphesthesia test, Edward Zamrini, M.D., said in an interview.

Graphesthesia is the sense by which people identify figures or numbers drawn on their hands with a dull-pointed object.

In an assessment for graphesthesia, people hold one hand out in front of them as if reading from it with the hand's long axis perpendicular to the midline axis of the body. While the patient's eyes are closed, the neurologist traces a number “1” on the patient's palm, asking the patient to identify the number out loud. Then the physician traces a second number on the patient's palm before repeating the process on the other hand.

Patients have two chances to identify the number correctly. If they fail to do so, they may be diagnosed with impaired graphesthesia.

Dr. Zamrini and his colleagues assessed more than 200 consecutive new patients at the Memory Disorders Clinic at the University of Alabama, Birmingham. Researchers identified patients by medical records between May 2001 and November 2002. Investigators took a detailed history, noted medications, and performed a thorough neurologic and cognitive assessment.

Examinations included light touch, pinprick, joint and position sense, vibration sense, and a Mini-Mental State Examination (MMSE). Patients were 58% female and 83% white, and their mean age was 68 years. Results were presented during a poster session at the annual meeting of the American Neuropsychiatric Association.

A total of 41 of the participants had MCI, 74 had Alzheimer's disease, and 96 were not diagnosed with either condition and were considered the control group. The control group included patients with vascular dementia, frontal lobe dementia, and other non-Alzheimer's dementias.

The prevalence of impaired graphesthesia was 54% in the MCI group, 79% in the Alzheimer's group, and 33% in controls, said Dr. Zamrini, a neurologist at the University of Alabama.

After incorporating such an exam into his practice, “I observed a disproportionately high number of my patients with MCI that have impaired graphesthesia,” he said. “It's just one more piece of evidence in support of the diagnosis of preclinical Alzheimer's disease, but you have to have the memory loss, too,” Dr. Zamrini said. If additional studies support impaired graphesthesia as a predictive variable, it would be the first physical sign of preclinical Alzheimer's disease.

Although Alzheimer's disease affects memory areas first, the parietal lobes are a “close second,” Dr. Zamrini said. The parietal areas are important to interpretation of senses, including graphesthesia.

Mean MMSE scores were 28 for the MCI group, 21 for the Alzheimer's disease group, and 26 for controls. The researchers grouped patients according to whether their MMSE score was 24 or greater or less than 24 to determine the effect of cognitive impairment on graphesthesia performance. There were significant differences in prevalence of impaired graphesthesia for participants scoring 24 or greater: 51% of the MCI group, 74% of the Alzheimer's group, and 24% of the control group.

The differential diagnosis for impaired graphesthesia should include stroke and severe sensory loss, Dr. Zamrini said.

The patient, eyes closed, tries to name the number being traced on the palm. Vivian E. Lee

BAL HARBOUR, FLA. — Impaired graphesthesia, a prevalent finding among patients with mild cognitive impairment, may be an early sign when considered with memory loss that a patient has preclinical Alzheimer's disease, according to a study.

Mild cognitive impairment (MCI) is generally accepted as a precursor to Alzheimer's disease. Some physicians screen MCI patients with a graphesthesia test, Edward Zamrini, M.D., said in an interview.

Graphesthesia is the sense by which people identify figures or numbers drawn on their hands with a dull-pointed object.

In an assessment for graphesthesia, people hold one hand out in front of them as if reading from it with the hand's long axis perpendicular to the midline axis of the body. While the patient's eyes are closed, the physician traces a number “1” on the patient's palm, asking the patient to identify the number out loud. Then the physician traces a second number on the patient's palm before repeating the process on the other hand. Patients who fail twice may be diagnosed with impaired graphesthesia.

Dr. Zamrini and his colleagues assessed more than 200 consecutive new patients at the Memory Disorders Clinic at the University of Alabama, Birmingham. Researchers identified patients by medical records between May 2001 and November 2002. Investigators took a detailed history, noted medications, and performed a thorough neurologic and cognitive assessment.

Examinations included light touch, pinprick, joint and position sense, vibration sense, and a Mini-Mental State Examination (MMSE).

Patients were 58% female and 83% white, and their mean age was 68 years. Results were presented during a poster session at the annual meeting of the American Neuropsychiatric Association.

A total of 41 participants had MCI, 74 had Alzheimer's disease, and 96 were not diagnosed with either condition and were considered the control group. The control group included patients with vascular dementia, frontal lobe dementia, and other non-Alzheimer's dementias.

The prevalence of impaired graphesthesia was 54% in the MCI group, 79% in the Alzheimer's group, and 33% in controls. The finding of higher impairment in the MCI patients, “even compared with other dementia patients, suggests that what I am catching is an early form of Alzheimer's disease, not only a memory loss,” said Dr. Zamrini, a neurologist at the University of Alabama.

After incorporating such an exam into his practice, “I observed a disproportionately high number of my patients with MCI that have impaired graphesthesia,” he said.

“It's just one more piece of evidence in support of the diagnosis of preclinical Alzheimer's disease, but you have to have the memory loss, too,” Dr. Zamrini said. If additional studies support impaired graphesthesia as a predictive variable, it would be the first physical sign of preclinical Alzheimer's disease.

Although Alzheimer's disease affects memory areas first, the parietal lobes are a “close second,” Dr. Zamrini said. The parietal areas are important to interpretation of senses, including graphesthesia.

Mean MMSE scores were 28 for the MCI group, 21 for the Alzheimer's disease group, and 26 for controls. The researchers grouped patients according to whether their MMSE score was 24 or greater or less than 24 to determine the effect of cognitive impairment on graphesthesia performance. There were significant differences in prevalence of impaired graphesthesia for participants scoring 24 or greater: 51% of the MCI group, 74% of the Alzheimer's group, and 24% of the control group.

It is easier for specialists to diagnose Alzheimer's disease than mild cognitive impairment, Dr. Zamrini said, because there are many reasons for memory loss. “Graphesthesia testing may help us in the future with that distinction,” he added.

“Further research is needed to corroborate this finding and to determine the potential contribution of impaired graphesthesia towards progression to Alzheimer's disease,” the authors wrote. Dr. Zamrini said, “It would be interesting to see as we follow a cohort of normal elderly if graphesthesia deficits develop independent of memory.”

In the graphesthesia test, the patient, with closed eyes, tries to name the number being traced on the palm. Vivian E. Lee

BAL HARBOUR, FLA. — Impaired graphesthesia, a prevalent finding among patients with mild cognitive impairment, may be an early sign when considered with memory loss that a patient has preclinical Alzheimer's disease, according to a study.

Mild cognitive impairment (MCI) is generally accepted as a precursor to Alzheimer's disease. Some physicians screen MCI patients with a graphesthesia test, Edward Zamrini, M.D., said in an interview.

Graphesthesia is the sense by which people identify figures or numbers drawn on their hands with a dull-pointed object.

In an assessment for graphesthesia, people hold one hand out in front of them as if reading from it with the hand's long axis perpendicular to the midline axis of the body. While the patient's eyes are closed, the physician traces a number “1” on the patient's palm, asking the patient to identify the number out loud. Then the physician traces a second number on the patient's palm before repeating the process on the other hand. Patients who fail twice may be diagnosed with impaired graphesthesia.

Dr. Zamrini and his colleagues assessed more than 200 consecutive new patients at the Memory Disorders Clinic at the University of Alabama, Birmingham. Researchers identified patients by medical records between May 2001 and November 2002. Investigators took a detailed history, noted medications, and performed a thorough neurologic and cognitive assessment.

Examinations included light touch, pinprick, joint and position sense, vibration sense, and a Mini-Mental State Examination (MMSE).

Patients were 58% female and 83% white, and their mean age was 68 years. Results were presented during a poster session at the annual meeting of the American Neuropsychiatric Association.

A total of 41 participants had MCI, 74 had Alzheimer's disease, and 96 were not diagnosed with either condition and were considered the control group. The control group included patients with vascular dementia, frontal lobe dementia, and other non-Alzheimer's dementias.

The prevalence of impaired graphesthesia was 54% in the MCI group, 79% in the Alzheimer's group, and 33% in controls. The finding of higher impairment in the MCI patients, “even compared with other dementia patients, suggests that what I am catching is an early form of Alzheimer's disease, not only a memory loss,” said Dr. Zamrini, a neurologist at the University of Alabama.

After incorporating such an exam into his practice, “I observed a disproportionately high number of my patients with MCI that have impaired graphesthesia,” he said.

“It's just one more piece of evidence in support of the diagnosis of preclinical Alzheimer's disease, but you have to have the memory loss, too,” Dr. Zamrini said. If additional studies support impaired graphesthesia as a predictive variable, it would be the first physical sign of preclinical Alzheimer's disease.

Although Alzheimer's disease affects memory areas first, the parietal lobes are a “close second,” Dr. Zamrini said. The parietal areas are important to interpretation of senses, including graphesthesia.

Mean MMSE scores were 28 for the MCI group, 21 for the Alzheimer's disease group, and 26 for controls. The researchers grouped patients according to whether their MMSE score was 24 or greater or less than 24 to determine the effect of cognitive impairment on graphesthesia performance. There were significant differences in prevalence of impaired graphesthesia for participants scoring 24 or greater: 51% of the MCI group, 74% of the Alzheimer's group, and 24% of the control group.

It is easier for specialists to diagnose Alzheimer's disease than mild cognitive impairment, Dr. Zamrini said, because there are many reasons for memory loss. “Graphesthesia testing may help us in the future with that distinction,” he added.

“Further research is needed to corroborate this finding and to determine the potential contribution of impaired graphesthesia towards progression to Alzheimer's disease,” the authors wrote. Dr. Zamrini said, “It would be interesting to see as we follow a cohort of normal elderly if graphesthesia deficits develop independent of memory.”

In the graphesthesia test, the patient, with closed eyes, tries to name the number being traced on the palm. Vivian E. Lee

BAL HARBOUR, FLA. — Impaired graphesthesia, a prevalent finding among patients with mild cognitive impairment, may be an early sign when considered with memory loss that a patient has preclinical Alzheimer's disease, according to a study.

Mild cognitive impairment (MCI) is generally accepted as a precursor to Alzheimer's disease. Some physicians screen MCI patients with a graphesthesia test, Edward Zamrini, M.D., said in an interview.

Graphesthesia is the sense by which people identify figures or numbers drawn on their hands with a dull-pointed object.

In an assessment for graphesthesia, people hold one hand out in front of them as if reading from it with the hand's long axis perpendicular to the midline axis of the body. While the patient's eyes are closed, the physician traces a number “1” on the patient's palm, asking the patient to identify the number out loud. Then the physician traces a second number on the patient's palm before repeating the process on the other hand. Patients who fail twice may be diagnosed with impaired graphesthesia.

Dr. Zamrini and his colleagues assessed more than 200 consecutive new patients at the Memory Disorders Clinic at the University of Alabama, Birmingham. Researchers identified patients by medical records between May 2001 and November 2002. Investigators took a detailed history, noted medications, and performed a thorough neurologic and cognitive assessment.

Examinations included light touch, pinprick, joint and position sense, vibration sense, and a Mini-Mental State Examination (MMSE).

Patients were 58% female and 83% white, and their mean age was 68 years. Results were presented during a poster session at the annual meeting of the American Neuropsychiatric Association.

A total of 41 participants had MCI, 74 had Alzheimer's disease, and 96 were not diagnosed with either condition and were considered the control group. The control group included patients with vascular dementia, frontal lobe dementia, and other non-Alzheimer's dementias.

The prevalence of impaired graphesthesia was 54% in the MCI group, 79% in the Alzheimer's group, and 33% in controls. The finding of higher impairment in the MCI patients, “even compared with other dementia patients, suggests that what I am catching is an early form of Alzheimer's disease, not only a memory loss,” said Dr. Zamrini, a neurologist at the University of Alabama.

After incorporating such an exam into his practice, “I observed a disproportionately high number of my patients with MCI that have impaired graphesthesia,” he said.

“It's just one more piece of evidence in support of the diagnosis of preclinical Alzheimer's disease, but you have to have the memory loss, too,” Dr. Zamrini said. If additional studies support impaired graphesthesia as a predictive variable, it would be the first physical sign of preclinical Alzheimer's disease.

Although Alzheimer's disease affects memory areas first, the parietal lobes are a “close second,” Dr. Zamrini said. The parietal areas are important to interpretation of senses, including graphesthesia.

Mean MMSE scores were 28 for the MCI group, 21 for the Alzheimer's disease group, and 26 for controls. The researchers grouped patients according to whether their MMSE score was 24 or greater or less than 24 to determine the effect of cognitive impairment on graphesthesia performance. There were significant differences in prevalence of impaired graphesthesia for participants scoring 24 or greater: 51% of the MCI group, 74% of the Alzheimer's group, and 24% of the control group.

It is easier for specialists to diagnose Alzheimer's disease than mild cognitive impairment, Dr. Zamrini said, because there are many reasons for memory loss. “Graphesthesia testing may help us in the future with that distinction,” he added.

“Further research is needed to corroborate this finding and to determine the potential contribution of impaired graphesthesia towards progression to Alzheimer's disease,” the authors wrote. Dr. Zamrini said, “It would be interesting to see as we follow a cohort of normal elderly if graphesthesia deficits develop independent of memory.”

In the graphesthesia test, the patient, with closed eyes, tries to name the number being traced on the palm. Vivian E. Lee