Damian McNamara

MIAMI BEACH — Investigators at the Centers for Disease Control and Prevention are still perplexed as to why a monkeypox outbreak in the United States was less virulent than a simultaneous outbreak in Africa. But genetic differences in the pox strains may provide an answer.

“Early in our outbreak, we noted that monkeypox in the United States appeared to be milder than what we expected,” Anna M. Likos, M.D., a researcher in the Epidemic Intelligence Service at the CDC, said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

The first human monkeypox infection reported in the United States stemmed from a shipment of infected rodents that arrived from Ghana in June 2003 (FAMILY PRACTICE NEWS, July 1, 2003, p. 6). A pet distributor in Illinois acquired the rodents and other small mammals and then sent them on to a number of distributors in Iowa and Texas. By August 2003, there were 37 confirmed human infections.

Dr. Likos and her colleagues compared 266 African cases (260 from the Democratic Republic of the Congo and 6 from West Africa) that had direct evidence of monkeypox infection with the cases in the United States. Infected Americans had significantly fewer lesions, lower rates of hospitalization, and no deaths. Higher complication rates in the Congo could have been attributed to differences in hygiene or socioeconomic status, but the investigators decided to look further.

“It is interesting to note that the only country with deaths was the Democratic Republic of the Congo. No deaths were reported in the United States,” Dr. Likos said.

Researchers sequenced the genomes of the different strains. They found that the U.S. and West African strains were essentially the same, which makes sense because the rodents were imported from Ghana. A strain with different protein and amino acid sequences caused the outbreak in the Congo. These genomic differences may explain the differences in disease manifestations, Dr. Likos explained, “although more work needs to be done.”

CDC investigators visited the Illinois animal distributor facility and found it to be clean. The animals were kept in close proximity, but “the mode of transmission among the animals is unknown,” said Christina Hutson, guest researcher at the CDC's Poxvirus Program.

“Introduction of monkeypox to North America may pose a very strong potential threat to the health of native rodent species and perhaps to humans,” Ms. Hutson said.

Of particular concern is transmission of monkeypox to North American prairie dogs, which are proving to be an especially suitable reservoir. “High levels of virus in some of these animals may explain why they could transmit the virus to humans … prairie dogs are exceptional vectors to humans and other animals,” she explained.

The investigative work is ongoing. CDC researchers plan to do a complete diagnostic evaluation of existing specimens and to continue the genomic comparisons to obtain additional clues, in case monkeypox reemerges in the United States.

“These were all observational infections—so we have a lot of questions remaining,” Ms. Hutson said.

MIAMI BEACH — Investigators at the Centers for Disease Control and Prevention are still perplexed as to why a monkeypox outbreak in the United States was less virulent than a simultaneous outbreak in Africa. But genetic differences in the pox strains may provide an answer.

“Early in our outbreak, we noted that monkeypox in the United States appeared to be milder than what we expected,” Anna M. Likos, M.D., a researcher in the Epidemic Intelligence Service at the CDC, said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

The first human monkeypox infection reported in the United States stemmed from a shipment of infected rodents that arrived from Ghana in June 2003 (FAMILY PRACTICE NEWS, July 1, 2003, p. 6). A pet distributor in Illinois acquired the rodents and other small mammals and then sent them on to a number of distributors in Iowa and Texas. By August 2003, there were 37 confirmed human infections.

Dr. Likos and her colleagues compared 266 African cases (260 from the Democratic Republic of the Congo and 6 from West Africa) that had direct evidence of monkeypox infection with the cases in the United States. Infected Americans had significantly fewer lesions, lower rates of hospitalization, and no deaths. Higher complication rates in the Congo could have been attributed to differences in hygiene or socioeconomic status, but the investigators decided to look further.

“It is interesting to note that the only country with deaths was the Democratic Republic of the Congo. No deaths were reported in the United States,” Dr. Likos said.

Researchers sequenced the genomes of the different strains. They found that the U.S. and West African strains were essentially the same, which makes sense because the rodents were imported from Ghana. A strain with different protein and amino acid sequences caused the outbreak in the Congo. These genomic differences may explain the differences in disease manifestations, Dr. Likos explained, “although more work needs to be done.”

CDC investigators visited the Illinois animal distributor facility and found it to be clean. The animals were kept in close proximity, but “the mode of transmission among the animals is unknown,” said Christina Hutson, guest researcher at the CDC's Poxvirus Program.

“Introduction of monkeypox to North America may pose a very strong potential threat to the health of native rodent species and perhaps to humans,” Ms. Hutson said.

Of particular concern is transmission of monkeypox to North American prairie dogs, which are proving to be an especially suitable reservoir. “High levels of virus in some of these animals may explain why they could transmit the virus to humans … prairie dogs are exceptional vectors to humans and other animals,” she explained.

The investigative work is ongoing. CDC researchers plan to do a complete diagnostic evaluation of existing specimens and to continue the genomic comparisons to obtain additional clues, in case monkeypox reemerges in the United States.

“These were all observational infections—so we have a lot of questions remaining,” Ms. Hutson said.

MIAMI BEACH — Investigators at the Centers for Disease Control and Prevention are still perplexed as to why a monkeypox outbreak in the United States was less virulent than a simultaneous outbreak in Africa. But genetic differences in the pox strains may provide an answer.

“Early in our outbreak, we noted that monkeypox in the United States appeared to be milder than what we expected,” Anna M. Likos, M.D., a researcher in the Epidemic Intelligence Service at the CDC, said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

The first human monkeypox infection reported in the United States stemmed from a shipment of infected rodents that arrived from Ghana in June 2003 (FAMILY PRACTICE NEWS, July 1, 2003, p. 6). A pet distributor in Illinois acquired the rodents and other small mammals and then sent them on to a number of distributors in Iowa and Texas. By August 2003, there were 37 confirmed human infections.

Dr. Likos and her colleagues compared 266 African cases (260 from the Democratic Republic of the Congo and 6 from West Africa) that had direct evidence of monkeypox infection with the cases in the United States. Infected Americans had significantly fewer lesions, lower rates of hospitalization, and no deaths. Higher complication rates in the Congo could have been attributed to differences in hygiene or socioeconomic status, but the investigators decided to look further.

“It is interesting to note that the only country with deaths was the Democratic Republic of the Congo. No deaths were reported in the United States,” Dr. Likos said.

Researchers sequenced the genomes of the different strains. They found that the U.S. and West African strains were essentially the same, which makes sense because the rodents were imported from Ghana. A strain with different protein and amino acid sequences caused the outbreak in the Congo. These genomic differences may explain the differences in disease manifestations, Dr. Likos explained, “although more work needs to be done.”

CDC investigators visited the Illinois animal distributor facility and found it to be clean. The animals were kept in close proximity, but “the mode of transmission among the animals is unknown,” said Christina Hutson, guest researcher at the CDC's Poxvirus Program.

“Introduction of monkeypox to North America may pose a very strong potential threat to the health of native rodent species and perhaps to humans,” Ms. Hutson said.

Of particular concern is transmission of monkeypox to North American prairie dogs, which are proving to be an especially suitable reservoir. “High levels of virus in some of these animals may explain why they could transmit the virus to humans … prairie dogs are exceptional vectors to humans and other animals,” she explained.

The investigative work is ongoing. CDC researchers plan to do a complete diagnostic evaluation of existing specimens and to continue the genomic comparisons to obtain additional clues, in case monkeypox reemerges in the United States.

“These were all observational infections—so we have a lot of questions remaining,” Ms. Hutson said.

MIAMI BEACH — Some American soldiers are returning from Iraq with a dormant pathogen in tow: cutaneous leishmaniasis.

Symptoms of the infection can take 4–6 months after a bite from an infected sand fly to appear, and unknowingly infected military personnel are returning to their communities before the lesions develop. This puts local doctors in the position of having to treat this tropical infection.

There is a seasonal variance to this protozoan parasitic infection that corresponds with the activity of sand flies in the Middle East. During the 2003–2004 season, localized cutaneous leishmaniasis was frequently diagnosed in U.S. military personnel, with most infections caused by Leishmania major, according to a presentation at the annual meeting of the American Society of Tropical Medicine and Hygiene. More than 500 have been reported cases since January 2003 among U.S. soldiers stationed in Iraq, according to U.S. Army medical research data.

Experience with 300 soldiers treated at Walter Reed Army Medical Center in Washington demonstrates that there are multiple presentations for localized cutaneous leishmaniasis. Of the infected patients, 98% were male, 96% were in the U.S. Army, and 91% were enlisted personnel. Almost three-quarters (73%) were white; 16% were African American, 6% were Hispanic, and 5% were from other ethnic groups. “Patients with lighter skin were overrepresented in our cohort,” said Naomi E. Aronson, M.D., professor of medicine and director of the infectious diseases division, Uniformed Services University of the Health Sciences, Bethesda, Md.

Cutaneous leishmaniasis manifests after the multiplication of leishmania in phagocytes in the skin. The mean number of cutaneous lesions was 3, and the range was 1–47. The mean time between appearance of a lesion and treatment was 13 weeks.

Papules often appear first, followed by ulcerative lesions. Lesions commonly appear in pairs. Nodules are uncommon. A rare presentation is a large psoriasiform-type plaque containing several small lesions. “I've seen about 10 cases of this form,” Dr. Aronson said.

Facial lesions, including those on the lips or pinna of the ear, tend to be more inflammatory, she added. Leishmaniasis lesions do not typically feature purulent drainage; if the lesion is tender with pus, it is likely a bacterial superinfection, she explained. Both the lesions and the resultant bacterial infection may require concurrent treatment courses.

Sand flies are attracted to bright colors, so soldiers are sometimes bitten on exposed tattoos. Dr. Aronson said, “A common complaint in our clinic is 'the sand fly messed up my tattoo.'”

The cutaneous form of the disease is ultimately self-healing, although disfiguring scars can remain. The visceral and mucosal forms of leishmaniasis are often more serious and sometimes fatal.

Educate patients that not all treatments are 100% effective, Dr. Aronson suggested. “It is important to give patients realistic expectations that leishmaniasis may not be gone, but it should improve.”

There is no Food and Drug Administration-approved treatment for leishmaniasis. Topical treatments include heat therapy and cryotherapy. Some lesions will respond to treatment with ThermoMed (Thermosurgery Technologies, Inc.) but others only partially respond, Dr. Aronson reported. A clinical trial investigating the technology is underway at Walter Reed Army Medical Center. Cryotherapy with liquid nitrogen is another treatment strategy.

Standard therapy for all forms of the disease is pentavalent antimony of sodium stibogluconate (Pentostam, GlaxoSmithKline) or meglumine antimonate (Glucantime, Aventis). The usual parenteral regimen of sodium stibogluconate, for example, is 20 mg/kg per day for 20 days.

Pentavalent antimonials are available only through an Investigational New Drug (IND) protocol from the Centers for Disease Control and Prevention. Investigational agents require a lot of paperwork—and institutional review board approval—before they are available for use, Kenneth R. Dardick, M.D., said during a separate presentation at the meeting.

It is possible that physicians working in a community hospital will see only one or two cases of this rare disease. Physicians unfamiliar with use of pentavalent antimonials should consult military and/or CDC infectious disease experts, suggested Dr. Dardick, a family physician at Mansfield Family Practice, Windham Hospital, Storrs, Conn.

The IND requirements “can be novel for a community hospital,” he said. “But cutaneous leishmaniasis can be successfully diagnosed and treated in a community hospital with appropriate index of suspicion.

Sand flies are attracted to bright colors, and soldiers may be bitten on tattoos. Courtesy Dr. Naomi E. Aronson

MIAMI BEACH — Some American soldiers are returning from Iraq with a dormant pathogen in tow: cutaneous leishmaniasis.

Symptoms of the infection can take 4–6 months after a bite from an infected sand fly to appear, and unknowingly infected military personnel are returning to their communities before the lesions develop. This puts local doctors in the position of having to treat this tropical infection.

There is a seasonal variance to this protozoan parasitic infection that corresponds with the activity of sand flies in the Middle East. During the 2003–2004 season, localized cutaneous leishmaniasis was frequently diagnosed in U.S. military personnel, with most infections caused by Leishmania major, according to a presentation at the annual meeting of the American Society of Tropical Medicine and Hygiene. More than 500 have been reported cases since January 2003 among U.S. soldiers stationed in Iraq, according to U.S. Army medical research data.

Experience with 300 soldiers treated at Walter Reed Army Medical Center in Washington demonstrates that there are multiple presentations for localized cutaneous leishmaniasis. Of the infected patients, 98% were male, 96% were in the U.S. Army, and 91% were enlisted personnel. Almost three-quarters (73%) were white; 16% were African American, 6% were Hispanic, and 5% were from other ethnic groups. “Patients with lighter skin were overrepresented in our cohort,” said Naomi E. Aronson, M.D., professor of medicine and director of the infectious diseases division, Uniformed Services University of the Health Sciences, Bethesda, Md.

Cutaneous leishmaniasis manifests after the multiplication of leishmania in phagocytes in the skin. The mean number of cutaneous lesions was 3, and the range was 1–47. The mean time between appearance of a lesion and treatment was 13 weeks.

Papules often appear first, followed by ulcerative lesions. Lesions commonly appear in pairs. Nodules are uncommon. A rare presentation is a large psoriasiform-type plaque containing several small lesions. “I've seen about 10 cases of this form,” Dr. Aronson said.

Facial lesions, including those on the lips or pinna of the ear, tend to be more inflammatory, she added. Leishmaniasis lesions do not typically feature purulent drainage; if the lesion is tender with pus, it is likely a bacterial superinfection, she explained. Both the lesions and the resultant bacterial infection may require concurrent treatment courses.

Sand flies are attracted to bright colors, so soldiers are sometimes bitten on exposed tattoos. Dr. Aronson said, “A common complaint in our clinic is 'the sand fly messed up my tattoo.'”

The cutaneous form of the disease is ultimately self-healing, although disfiguring scars can remain. The visceral and mucosal forms of leishmaniasis are often more serious and sometimes fatal.

Educate patients that not all treatments are 100% effective, Dr. Aronson suggested. “It is important to give patients realistic expectations that leishmaniasis may not be gone, but it should improve.”

There is no Food and Drug Administration-approved treatment for leishmaniasis. Topical treatments include heat therapy and cryotherapy. Some lesions will respond to treatment with ThermoMed (Thermosurgery Technologies, Inc.) but others only partially respond, Dr. Aronson reported. A clinical trial investigating the technology is underway at Walter Reed Army Medical Center. Cryotherapy with liquid nitrogen is another treatment strategy.

Standard therapy for all forms of the disease is pentavalent antimony of sodium stibogluconate (Pentostam, GlaxoSmithKline) or meglumine antimonate (Glucantime, Aventis). The usual parenteral regimen of sodium stibogluconate, for example, is 20 mg/kg per day for 20 days.

Pentavalent antimonials are available only through an Investigational New Drug (IND) protocol from the Centers for Disease Control and Prevention. Investigational agents require a lot of paperwork—and institutional review board approval—before they are available for use, Kenneth R. Dardick, M.D., said during a separate presentation at the meeting.

It is possible that physicians working in a community hospital will see only one or two cases of this rare disease. Physicians unfamiliar with use of pentavalent antimonials should consult military and/or CDC infectious disease experts, suggested Dr. Dardick, a family physician at Mansfield Family Practice, Windham Hospital, Storrs, Conn.

The IND requirements “can be novel for a community hospital,” he said. “But cutaneous leishmaniasis can be successfully diagnosed and treated in a community hospital with appropriate index of suspicion.

Sand flies are attracted to bright colors, and soldiers may be bitten on tattoos. Courtesy Dr. Naomi E. Aronson

MIAMI BEACH — Some American soldiers are returning from Iraq with a dormant pathogen in tow: cutaneous leishmaniasis.

Symptoms of the infection can take 4–6 months after a bite from an infected sand fly to appear, and unknowingly infected military personnel are returning to their communities before the lesions develop. This puts local doctors in the position of having to treat this tropical infection.

There is a seasonal variance to this protozoan parasitic infection that corresponds with the activity of sand flies in the Middle East. During the 2003–2004 season, localized cutaneous leishmaniasis was frequently diagnosed in U.S. military personnel, with most infections caused by Leishmania major, according to a presentation at the annual meeting of the American Society of Tropical Medicine and Hygiene. More than 500 have been reported cases since January 2003 among U.S. soldiers stationed in Iraq, according to U.S. Army medical research data.

Experience with 300 soldiers treated at Walter Reed Army Medical Center in Washington demonstrates that there are multiple presentations for localized cutaneous leishmaniasis. Of the infected patients, 98% were male, 96% were in the U.S. Army, and 91% were enlisted personnel. Almost three-quarters (73%) were white; 16% were African American, 6% were Hispanic, and 5% were from other ethnic groups. “Patients with lighter skin were overrepresented in our cohort,” said Naomi E. Aronson, M.D., professor of medicine and director of the infectious diseases division, Uniformed Services University of the Health Sciences, Bethesda, Md.

Cutaneous leishmaniasis manifests after the multiplication of leishmania in phagocytes in the skin. The mean number of cutaneous lesions was 3, and the range was 1–47. The mean time between appearance of a lesion and treatment was 13 weeks.

Papules often appear first, followed by ulcerative lesions. Lesions commonly appear in pairs. Nodules are uncommon. A rare presentation is a large psoriasiform-type plaque containing several small lesions. “I've seen about 10 cases of this form,” Dr. Aronson said.

Facial lesions, including those on the lips or pinna of the ear, tend to be more inflammatory, she added. Leishmaniasis lesions do not typically feature purulent drainage; if the lesion is tender with pus, it is likely a bacterial superinfection, she explained. Both the lesions and the resultant bacterial infection may require concurrent treatment courses.

Sand flies are attracted to bright colors, so soldiers are sometimes bitten on exposed tattoos. Dr. Aronson said, “A common complaint in our clinic is 'the sand fly messed up my tattoo.'”

The cutaneous form of the disease is ultimately self-healing, although disfiguring scars can remain. The visceral and mucosal forms of leishmaniasis are often more serious and sometimes fatal.

Educate patients that not all treatments are 100% effective, Dr. Aronson suggested. “It is important to give patients realistic expectations that leishmaniasis may not be gone, but it should improve.”

There is no Food and Drug Administration-approved treatment for leishmaniasis. Topical treatments include heat therapy and cryotherapy. Some lesions will respond to treatment with ThermoMed (Thermosurgery Technologies, Inc.) but others only partially respond, Dr. Aronson reported. A clinical trial investigating the technology is underway at Walter Reed Army Medical Center. Cryotherapy with liquid nitrogen is another treatment strategy.

Standard therapy for all forms of the disease is pentavalent antimony of sodium stibogluconate (Pentostam, GlaxoSmithKline) or meglumine antimonate (Glucantime, Aventis). The usual parenteral regimen of sodium stibogluconate, for example, is 20 mg/kg per day for 20 days.

Pentavalent antimonials are available only through an Investigational New Drug (IND) protocol from the Centers for Disease Control and Prevention. Investigational agents require a lot of paperwork—and institutional review board approval—before they are available for use, Kenneth R. Dardick, M.D., said during a separate presentation at the meeting.

It is possible that physicians working in a community hospital will see only one or two cases of this rare disease. Physicians unfamiliar with use of pentavalent antimonials should consult military and/or CDC infectious disease experts, suggested Dr. Dardick, a family physician at Mansfield Family Practice, Windham Hospital, Storrs, Conn.

The IND requirements “can be novel for a community hospital,” he said. “But cutaneous leishmaniasis can be successfully diagnosed and treated in a community hospital with appropriate index of suspicion.

Sand flies are attracted to bright colors, and soldiers may be bitten on tattoos. Courtesy Dr. Naomi E. Aronson

ORLANDO, FLA. — Nearly 20% of children and adolescents have a neuropsychiatric diagnosis at the time they are diagnosed with type 2 diabetes, according to a retrospective study presented at the annual scientific sessions of the American Diabetes Association.

“Adolescents with neuropsychiatric disease and other risk factors may have a higher risk for glucose intolerance or type 2 diabetes, and may benefit from screening,” Lorraine E. Levitt Katz, M.D., said. “The risk of type 2 diabetes may be greatest for obese children on atypical antipsychotics.”

The relationship between neuropsychiatric illness and type 2 diabetes is not completely clear and is likely multifactorial. Weight gain, caused by neuropsychiatric illness or antipsychotic medication, may play a role; obesity is a risk factor for type 2 diabetes in children and adolescents. Neuropsychiatric illness may promote a sedentary lifestyle, another factor associated with weight gain. Some medications may cause hyperglycemia through insulin resistance or effects on beta cells. Other risk factors for pediatric type 2 diabetes include family history, ethnicity, and female gender, said Dr. Levitt Katz, a pediatric endocrinologist at the Children's Hospital of Philadelphia.

“At [Children's Hospital of Philadelphia], we've seen an increase in new type 2 diabetes cases. The number has increased steadily each year, up to 55 in 2002,” said Dr. Levitt Katz, also of the University of Pennsylvania.

She and her colleagues reviewed the charts of 237 children and adolescents newly diagnosed with type 2 diabetes, to determine the prevalence of neuropsychiatric illness. They identified 46 such patients (19%). Diagnoses included depression, behavioral disorders (including attention-deficit hyperactivity disorder), mental retardation, autism, and developmental delay.

“A large number of pediatric patients with type 2 diabetes have neuropsychiatric disease,” Dr. Levitt Katz said. Pediatric endocrinologists diagnosed most of the diabetes in the study population, but primary care physicians diagnosed some patients. The study findings may not even reflect the true prevalence. “We would argue our data are an underestimation of neuropsychiatric illness among children with diabetes.”

Depression was the leading diagnosis (13 patients). A meeting attendee asked if preexisting depression interferes with a patient's motivation regarding diabetes. “It's an enormous challenge that will require creative thinking to address,” Dr. Levitt Katz said. Although the study focused on neuropsychiatric illness at the time of diagnosis, she added that there is also depression after diagnosis and a large number of undiagnosed disorders.

Investigators next looked at patient demographics for any factors that might be more strongly associated with neuropsychiatric illness. For example, they compared body mass index (BMI) Z scores between diabetics with a neuropsychiatric condition and those without. “We did not find statistically significant differences in BMI, unlike we expected,” she said.

Neither gender nor age at diabetes diagnosis was associated with a higher prevalence of neuropsychiatric illness. There was a trend toward a difference by ethnicity. The patient population included children who were African American (67%), Caucasian (24%), Asian Pacific (6%), and other (3%). “We found the African American population in the affected group was overrepresented at 79%, but it was not significantly different,” said Dr. Levitt Katz.

The large number of comorbid conditions was a limitation of the study. In addition, the frequency of neuropsychiatric disease was not studied in a comparable pediatric population without diabetes.

The researchers looked for an association between the use of antipsychotic medication and diabetes. They found that 37.5% of children taking antipsychotics were on one agent and 27.5% were on two agents, but there was no correlation. Dr. Levitt Katz said, “We were somewhat surprised by these results; we initially thought type 2 diabetes was associated with psychiatric medications.”

Twenty patients were taking mood stabilizers and eight were taking selective serotonin reuptake inhibitors. There were 17 patients on atypical antipsychotics, most commonly risperidone and olanzapine.

The atypical agents were prescribed for a wide range of diagnoses, including behavioral problems, bipolar disorder, schizophrenia, depression, and seizure disorder secondary to head trauma. Dr. Levitt Katz said, “This suggests there may be a lot of off-label use of these antipsychotics in children.”

One year ago, there was a consensus conference on antipsychotics, obesity, and diabetes. The recommendations that emerged from the meeting include performing a risk-benefit assessment before starting medications, tracking BMI and waist circumference, doing a baseline screening for diabetes, and monitoring patients regularly.

ORLANDO, FLA. — Nearly 20% of children and adolescents have a neuropsychiatric diagnosis at the time they are diagnosed with type 2 diabetes, according to a retrospective study presented at the annual scientific sessions of the American Diabetes Association.

“Adolescents with neuropsychiatric disease and other risk factors may have a higher risk for glucose intolerance or type 2 diabetes, and may benefit from screening,” Lorraine E. Levitt Katz, M.D., said. “The risk of type 2 diabetes may be greatest for obese children on atypical antipsychotics.”

The relationship between neuropsychiatric illness and type 2 diabetes is not completely clear and is likely multifactorial. Weight gain, caused by neuropsychiatric illness or antipsychotic medication, may play a role; obesity is a risk factor for type 2 diabetes in children and adolescents. Neuropsychiatric illness may promote a sedentary lifestyle, another factor associated with weight gain. Some medications may cause hyperglycemia through insulin resistance or effects on beta cells. Other risk factors for pediatric type 2 diabetes include family history, ethnicity, and female gender, said Dr. Levitt Katz, a pediatric endocrinologist at the Children's Hospital of Philadelphia.

“At [Children's Hospital of Philadelphia], we've seen an increase in new type 2 diabetes cases. The number has increased steadily each year, up to 55 in 2002,” said Dr. Levitt Katz, also of the University of Pennsylvania.

She and her colleagues reviewed the charts of 237 children and adolescents newly diagnosed with type 2 diabetes, to determine the prevalence of neuropsychiatric illness. They identified 46 such patients (19%). Diagnoses included depression, behavioral disorders (including attention-deficit hyperactivity disorder), mental retardation, autism, and developmental delay.

“A large number of pediatric patients with type 2 diabetes have neuropsychiatric disease,” Dr. Levitt Katz said. Pediatric endocrinologists diagnosed most of the diabetes in the study population, but primary care physicians diagnosed some patients. The study findings may not even reflect the true prevalence. “We would argue our data are an underestimation of neuropsychiatric illness among children with diabetes.”

Depression was the leading diagnosis (13 patients). A meeting attendee asked if preexisting depression interferes with a patient's motivation regarding diabetes. “It's an enormous challenge that will require creative thinking to address,” Dr. Levitt Katz said. Although the study focused on neuropsychiatric illness at the time of diagnosis, she added that there is also depression after diagnosis and a large number of undiagnosed disorders.

Investigators next looked at patient demographics for any factors that might be more strongly associated with neuropsychiatric illness. For example, they compared body mass index (BMI) Z scores between diabetics with a neuropsychiatric condition and those without. “We did not find statistically significant differences in BMI, unlike we expected,” she said.

Neither gender nor age at diabetes diagnosis was associated with a higher prevalence of neuropsychiatric illness. There was a trend toward a difference by ethnicity. The patient population included children who were African American (67%), Caucasian (24%), Asian Pacific (6%), and other (3%). “We found the African American population in the affected group was overrepresented at 79%, but it was not significantly different,” said Dr. Levitt Katz.

The large number of comorbid conditions was a limitation of the study. In addition, the frequency of neuropsychiatric disease was not studied in a comparable pediatric population without diabetes.

The researchers looked for an association between the use of antipsychotic medication and diabetes. They found that 37.5% of children taking antipsychotics were on one agent and 27.5% were on two agents, but there was no correlation. Dr. Levitt Katz said, “We were somewhat surprised by these results; we initially thought type 2 diabetes was associated with psychiatric medications.”

Twenty patients were taking mood stabilizers and eight were taking selective serotonin reuptake inhibitors. There were 17 patients on atypical antipsychotics, most commonly risperidone and olanzapine.

The atypical agents were prescribed for a wide range of diagnoses, including behavioral problems, bipolar disorder, schizophrenia, depression, and seizure disorder secondary to head trauma. Dr. Levitt Katz said, “This suggests there may be a lot of off-label use of these antipsychotics in children.”

One year ago, there was a consensus conference on antipsychotics, obesity, and diabetes. The recommendations that emerged from the meeting include performing a risk-benefit assessment before starting medications, tracking BMI and waist circumference, doing a baseline screening for diabetes, and monitoring patients regularly.

ORLANDO, FLA. — Nearly 20% of children and adolescents have a neuropsychiatric diagnosis at the time they are diagnosed with type 2 diabetes, according to a retrospective study presented at the annual scientific sessions of the American Diabetes Association.

“Adolescents with neuropsychiatric disease and other risk factors may have a higher risk for glucose intolerance or type 2 diabetes, and may benefit from screening,” Lorraine E. Levitt Katz, M.D., said. “The risk of type 2 diabetes may be greatest for obese children on atypical antipsychotics.”

The relationship between neuropsychiatric illness and type 2 diabetes is not completely clear and is likely multifactorial. Weight gain, caused by neuropsychiatric illness or antipsychotic medication, may play a role; obesity is a risk factor for type 2 diabetes in children and adolescents. Neuropsychiatric illness may promote a sedentary lifestyle, another factor associated with weight gain. Some medications may cause hyperglycemia through insulin resistance or effects on beta cells. Other risk factors for pediatric type 2 diabetes include family history, ethnicity, and female gender, said Dr. Levitt Katz, a pediatric endocrinologist at the Children's Hospital of Philadelphia.

“At [Children's Hospital of Philadelphia], we've seen an increase in new type 2 diabetes cases. The number has increased steadily each year, up to 55 in 2002,” said Dr. Levitt Katz, also of the University of Pennsylvania.

She and her colleagues reviewed the charts of 237 children and adolescents newly diagnosed with type 2 diabetes, to determine the prevalence of neuropsychiatric illness. They identified 46 such patients (19%). Diagnoses included depression, behavioral disorders (including attention-deficit hyperactivity disorder), mental retardation, autism, and developmental delay.

“A large number of pediatric patients with type 2 diabetes have neuropsychiatric disease,” Dr. Levitt Katz said. Pediatric endocrinologists diagnosed most of the diabetes in the study population, but primary care physicians diagnosed some patients. The study findings may not even reflect the true prevalence. “We would argue our data are an underestimation of neuropsychiatric illness among children with diabetes.”

Depression was the leading diagnosis (13 patients). A meeting attendee asked if preexisting depression interferes with a patient's motivation regarding diabetes. “It's an enormous challenge that will require creative thinking to address,” Dr. Levitt Katz said. Although the study focused on neuropsychiatric illness at the time of diagnosis, she added that there is also depression after diagnosis and a large number of undiagnosed disorders.

Investigators next looked at patient demographics for any factors that might be more strongly associated with neuropsychiatric illness. For example, they compared body mass index (BMI) Z scores between diabetics with a neuropsychiatric condition and those without. “We did not find statistically significant differences in BMI, unlike we expected,” she said.

Neither gender nor age at diabetes diagnosis was associated with a higher prevalence of neuropsychiatric illness. There was a trend toward a difference by ethnicity. The patient population included children who were African American (67%), Caucasian (24%), Asian Pacific (6%), and other (3%). “We found the African American population in the affected group was overrepresented at 79%, but it was not significantly different,” said Dr. Levitt Katz.

The large number of comorbid conditions was a limitation of the study. In addition, the frequency of neuropsychiatric disease was not studied in a comparable pediatric population without diabetes.

The researchers looked for an association between the use of antipsychotic medication and diabetes. They found that 37.5% of children taking antipsychotics were on one agent and 27.5% were on two agents, but there was no correlation. Dr. Levitt Katz said, “We were somewhat surprised by these results; we initially thought type 2 diabetes was associated with psychiatric medications.”

Twenty patients were taking mood stabilizers and eight were taking selective serotonin reuptake inhibitors. There were 17 patients on atypical antipsychotics, most commonly risperidone and olanzapine.

The atypical agents were prescribed for a wide range of diagnoses, including behavioral problems, bipolar disorder, schizophrenia, depression, and seizure disorder secondary to head trauma. Dr. Levitt Katz said, “This suggests there may be a lot of off-label use of these antipsychotics in children.”

One year ago, there was a consensus conference on antipsychotics, obesity, and diabetes. The recommendations that emerged from the meeting include performing a risk-benefit assessment before starting medications, tracking BMI and waist circumference, doing a baseline screening for diabetes, and monitoring patients regularly.

FORT MYERS, FLA.–Physicians who overinterpret the Health Information Portability and Accountability Act of 1996 and do not disclose any information, even in instances where it would be in the best interest of patient care, have “HIPAARANOIA,” according to a presentation at the annual meeting of the Academy of Psychosomatic Medicine.

The Health Insurance Portability and Accountability Act (HIPAA) limits disclosure of sensitive information, including HIV status, genetic information, alcohol and substance use, psycho-therapy notes, domestic violence, and sexual assault. Outside of those exceptions, information related to treatment, payment, and health care operations can be disclosed without patient consent, provided that patients are informed of the policy.

“The P in HIPAA is not for privacy. Anyone who tells you it is does not know what HIPAA is about,” said Rebecca W. Brendel, M.D. “HIPAA is really a disclosure policy.” Dr. Brendel is a fellow in forensic psychiatry at Massachusetts General Hospital, Boston.

“Even though the HIPAA 'P' may not stand for privacy, there is an indirect effect in making patients more aware of the privacy of their medical records,” commented Teresa A. Rummans, M.D.

Psychiatrists have always been cognizant of the private nature of patient information, and that's the case now more than ever. “We have to be careful about what we write in a medical record. We need to be very straightforward with patients about their diagnoses, not only Axis I, but Axis II as well,” said Dr. Rummans, professor of psychiatry, Mayo Clinic, Rochester, Minn.

Some physicians may not know that HIPAA permits disclosure of patient information with physician referrals and consultations. Dr. Brendel cited the following example: A consultant or liaison psychiatrist is consulted regarding a patient who is not stable following an overdose on “psych meds” in a suicide attempt. The patient is still intubated and sedated for aspiration pneumonia. The psychiatrist on site calls the patient's psychiatrist at an out-of-state hospital, but the physician refuses to share patient information, citing HIPAA.

“We now know that HIPAA would authorize disclosure without specific consent for treatment, payment, and health care operations,” Dr. Brendel said. “It's probably not too helpful to tell the other psychiatrist [he or she is] flat out wrong.” She suggested explaining your understanding of the HIPAA law or recommending the other psychiatrist contact a HIPAA manager at their institution.

“The old-fashioned way is to have the patient give verbal consent over the phone to the outside psychiatrist,” Dr. Brendel said.

A person attending the meeting asked whether the HIPAA disclosure provisions for psychiatrists working at an institution also apply to private practice. “If that person electronically bills they will be under HIPAA and can release information. No one is going to chase you down and put you in jail for acting in the best interest of the patient.”

One thing to keep in mind is that HIPAA is not absolute in all cases, Dr. Brendel said. For example, states may pass laws that are more protective, so HIPAA is a “floor” and not a “ceiling” statute. She added that individual providers might make their own policies more protective than HIPAA.

Another meeting attendee asked for advice regarding a case manager at a community mental health center who refuses to release information.

“We're talking about the emergency exception,” Dr. Brendel said.

In such cases, she advised e-mailing articles about HIPAA rules to outside case managers.

“The best antidote for misconstruction of HIPAA is education. The more accurate information is disseminated, the fewer problems we will have.”

FORT MYERS, FLA.–Physicians who overinterpret the Health Information Portability and Accountability Act of 1996 and do not disclose any information, even in instances where it would be in the best interest of patient care, have “HIPAARANOIA,” according to a presentation at the annual meeting of the Academy of Psychosomatic Medicine.

The Health Insurance Portability and Accountability Act (HIPAA) limits disclosure of sensitive information, including HIV status, genetic information, alcohol and substance use, psycho-therapy notes, domestic violence, and sexual assault. Outside of those exceptions, information related to treatment, payment, and health care operations can be disclosed without patient consent, provided that patients are informed of the policy.

“The P in HIPAA is not for privacy. Anyone who tells you it is does not know what HIPAA is about,” said Rebecca W. Brendel, M.D. “HIPAA is really a disclosure policy.” Dr. Brendel is a fellow in forensic psychiatry at Massachusetts General Hospital, Boston.

“Even though the HIPAA 'P' may not stand for privacy, there is an indirect effect in making patients more aware of the privacy of their medical records,” commented Teresa A. Rummans, M.D.

Psychiatrists have always been cognizant of the private nature of patient information, and that's the case now more than ever. “We have to be careful about what we write in a medical record. We need to be very straightforward with patients about their diagnoses, not only Axis I, but Axis II as well,” said Dr. Rummans, professor of psychiatry, Mayo Clinic, Rochester, Minn.

Some physicians may not know that HIPAA permits disclosure of patient information with physician referrals and consultations. Dr. Brendel cited the following example: A consultant or liaison psychiatrist is consulted regarding a patient who is not stable following an overdose on “psych meds” in a suicide attempt. The patient is still intubated and sedated for aspiration pneumonia. The psychiatrist on site calls the patient's psychiatrist at an out-of-state hospital, but the physician refuses to share patient information, citing HIPAA.

“We now know that HIPAA would authorize disclosure without specific consent for treatment, payment, and health care operations,” Dr. Brendel said. “It's probably not too helpful to tell the other psychiatrist [he or she is] flat out wrong.” She suggested explaining your understanding of the HIPAA law or recommending the other psychiatrist contact a HIPAA manager at their institution.

“The old-fashioned way is to have the patient give verbal consent over the phone to the outside psychiatrist,” Dr. Brendel said.

A person attending the meeting asked whether the HIPAA disclosure provisions for psychiatrists working at an institution also apply to private practice. “If that person electronically bills they will be under HIPAA and can release information. No one is going to chase you down and put you in jail for acting in the best interest of the patient.”

One thing to keep in mind is that HIPAA is not absolute in all cases, Dr. Brendel said. For example, states may pass laws that are more protective, so HIPAA is a “floor” and not a “ceiling” statute. She added that individual providers might make their own policies more protective than HIPAA.

Another meeting attendee asked for advice regarding a case manager at a community mental health center who refuses to release information.

“We're talking about the emergency exception,” Dr. Brendel said.

In such cases, she advised e-mailing articles about HIPAA rules to outside case managers.

“The best antidote for misconstruction of HIPAA is education. The more accurate information is disseminated, the fewer problems we will have.”

FORT MYERS, FLA.–Physicians who overinterpret the Health Information Portability and Accountability Act of 1996 and do not disclose any information, even in instances where it would be in the best interest of patient care, have “HIPAARANOIA,” according to a presentation at the annual meeting of the Academy of Psychosomatic Medicine.

The Health Insurance Portability and Accountability Act (HIPAA) limits disclosure of sensitive information, including HIV status, genetic information, alcohol and substance use, psycho-therapy notes, domestic violence, and sexual assault. Outside of those exceptions, information related to treatment, payment, and health care operations can be disclosed without patient consent, provided that patients are informed of the policy.

“The P in HIPAA is not for privacy. Anyone who tells you it is does not know what HIPAA is about,” said Rebecca W. Brendel, M.D. “HIPAA is really a disclosure policy.” Dr. Brendel is a fellow in forensic psychiatry at Massachusetts General Hospital, Boston.

“Even though the HIPAA 'P' may not stand for privacy, there is an indirect effect in making patients more aware of the privacy of their medical records,” commented Teresa A. Rummans, M.D.

Psychiatrists have always been cognizant of the private nature of patient information, and that's the case now more than ever. “We have to be careful about what we write in a medical record. We need to be very straightforward with patients about their diagnoses, not only Axis I, but Axis II as well,” said Dr. Rummans, professor of psychiatry, Mayo Clinic, Rochester, Minn.

Some physicians may not know that HIPAA permits disclosure of patient information with physician referrals and consultations. Dr. Brendel cited the following example: A consultant or liaison psychiatrist is consulted regarding a patient who is not stable following an overdose on “psych meds” in a suicide attempt. The patient is still intubated and sedated for aspiration pneumonia. The psychiatrist on site calls the patient's psychiatrist at an out-of-state hospital, but the physician refuses to share patient information, citing HIPAA.

“We now know that HIPAA would authorize disclosure without specific consent for treatment, payment, and health care operations,” Dr. Brendel said. “It's probably not too helpful to tell the other psychiatrist [he or she is] flat out wrong.” She suggested explaining your understanding of the HIPAA law or recommending the other psychiatrist contact a HIPAA manager at their institution.

“The old-fashioned way is to have the patient give verbal consent over the phone to the outside psychiatrist,” Dr. Brendel said.

A person attending the meeting asked whether the HIPAA disclosure provisions for psychiatrists working at an institution also apply to private practice. “If that person electronically bills they will be under HIPAA and can release information. No one is going to chase you down and put you in jail for acting in the best interest of the patient.”

One thing to keep in mind is that HIPAA is not absolute in all cases, Dr. Brendel said. For example, states may pass laws that are more protective, so HIPAA is a “floor” and not a “ceiling” statute. She added that individual providers might make their own policies more protective than HIPAA.

Another meeting attendee asked for advice regarding a case manager at a community mental health center who refuses to release information.

“We're talking about the emergency exception,” Dr. Brendel said.

In such cases, she advised e-mailing articles about HIPAA rules to outside case managers.

“The best antidote for misconstruction of HIPAA is education. The more accurate information is disseminated, the fewer problems we will have.”

MARCO ISLAND, FLA.–Posttraumatic stress disorder is not uncommon after moderate to severe traumatic brain injury, Jesse R. Fann, M.D., said at the annual meeting of the Academy of Psychosomatic Medicine.

Many people experience anxiety after moderate-to-severe traumatic brain injury. Because both brain injury and dissociation from posttraumatic stress disorder (PTSD) can impair declarative memory, the true occurrence of PTSD remains controversial, noted Dr. Fann, director of the psychiatry and psychology consultation service at the Seattle Cancer Care Alliance.

In a 6-month prospective follow-up study, Dr. Fann and his colleagues assessed 124 patients admitted to Harborview Medical Center in Seattle following traumatic brain injury to determine the incidence of PTSD, the risk factors, and how PTSD symptoms manifest in this population.

Researchers performed monthly assessments with the PTSD Checklist-Civilian Version, the Patient Health Questionnaire, and the Self Reported Health Status (SF-1) instruments. The first month had the highest incidence of PTSD, about 13%. “A lot of the PTSD may not be prolonged, lasting 1–3 months,” Dr. Fann said.

Patients with lower levels of education and those injured in an assault were significantly more likely to meet criteria for the disorder. Participants who met PTSD criteria most commonly reported feeling sad when recalling aspects of the event and feeling cut off from others, jumpy, hypervigilant, and irritable. Sleep disturbances were also common, he said.

The investigators looked at PTSD symptom clusters and found arousal symptoms in 23% of assessments over the 6 months. They also found intrusive symptoms in 20% and avoidance and numbing in 8%.

“There is a significant overlap of other comorbid psychiatric disorders, such as anxiety and depression, that can present a diagnostic challenge,” Dr. Fann said. “There is also overlap of PTSD and traumatic brain injury symptoms.”

The researchers also assessed patients for major depressive disorder, panic disorder, and other anxiety disorders. PTSD was significantly associated with current major depression, any other anxiety disorder, a blood alcohol level greater than 0.08, and a psychiatric history, according to a univariate analysis. A logistic regression analysis showed that people with a history of PTSD reported significantly increased functional impairment compared with those without PTSD.

The study was funded by the National Institutes of Health's National Center for Medical Rehabilitation Research.

MARCO ISLAND, FLA.–Posttraumatic stress disorder is not uncommon after moderate to severe traumatic brain injury, Jesse R. Fann, M.D., said at the annual meeting of the Academy of Psychosomatic Medicine.

Many people experience anxiety after moderate-to-severe traumatic brain injury. Because both brain injury and dissociation from posttraumatic stress disorder (PTSD) can impair declarative memory, the true occurrence of PTSD remains controversial, noted Dr. Fann, director of the psychiatry and psychology consultation service at the Seattle Cancer Care Alliance.

In a 6-month prospective follow-up study, Dr. Fann and his colleagues assessed 124 patients admitted to Harborview Medical Center in Seattle following traumatic brain injury to determine the incidence of PTSD, the risk factors, and how PTSD symptoms manifest in this population.

Researchers performed monthly assessments with the PTSD Checklist-Civilian Version, the Patient Health Questionnaire, and the Self Reported Health Status (SF-1) instruments. The first month had the highest incidence of PTSD, about 13%. “A lot of the PTSD may not be prolonged, lasting 1–3 months,” Dr. Fann said.

Patients with lower levels of education and those injured in an assault were significantly more likely to meet criteria for the disorder. Participants who met PTSD criteria most commonly reported feeling sad when recalling aspects of the event and feeling cut off from others, jumpy, hypervigilant, and irritable. Sleep disturbances were also common, he said.

The investigators looked at PTSD symptom clusters and found arousal symptoms in 23% of assessments over the 6 months. They also found intrusive symptoms in 20% and avoidance and numbing in 8%.

“There is a significant overlap of other comorbid psychiatric disorders, such as anxiety and depression, that can present a diagnostic challenge,” Dr. Fann said. “There is also overlap of PTSD and traumatic brain injury symptoms.”

The researchers also assessed patients for major depressive disorder, panic disorder, and other anxiety disorders. PTSD was significantly associated with current major depression, any other anxiety disorder, a blood alcohol level greater than 0.08, and a psychiatric history, according to a univariate analysis. A logistic regression analysis showed that people with a history of PTSD reported significantly increased functional impairment compared with those without PTSD.

The study was funded by the National Institutes of Health's National Center for Medical Rehabilitation Research.

MARCO ISLAND, FLA.–Posttraumatic stress disorder is not uncommon after moderate to severe traumatic brain injury, Jesse R. Fann, M.D., said at the annual meeting of the Academy of Psychosomatic Medicine.

Many people experience anxiety after moderate-to-severe traumatic brain injury. Because both brain injury and dissociation from posttraumatic stress disorder (PTSD) can impair declarative memory, the true occurrence of PTSD remains controversial, noted Dr. Fann, director of the psychiatry and psychology consultation service at the Seattle Cancer Care Alliance.

In a 6-month prospective follow-up study, Dr. Fann and his colleagues assessed 124 patients admitted to Harborview Medical Center in Seattle following traumatic brain injury to determine the incidence of PTSD, the risk factors, and how PTSD symptoms manifest in this population.

Researchers performed monthly assessments with the PTSD Checklist-Civilian Version, the Patient Health Questionnaire, and the Self Reported Health Status (SF-1) instruments. The first month had the highest incidence of PTSD, about 13%. “A lot of the PTSD may not be prolonged, lasting 1–3 months,” Dr. Fann said.

Patients with lower levels of education and those injured in an assault were significantly more likely to meet criteria for the disorder. Participants who met PTSD criteria most commonly reported feeling sad when recalling aspects of the event and feeling cut off from others, jumpy, hypervigilant, and irritable. Sleep disturbances were also common, he said.

The investigators looked at PTSD symptom clusters and found arousal symptoms in 23% of assessments over the 6 months. They also found intrusive symptoms in 20% and avoidance and numbing in 8%.

“There is a significant overlap of other comorbid psychiatric disorders, such as anxiety and depression, that can present a diagnostic challenge,” Dr. Fann said. “There is also overlap of PTSD and traumatic brain injury symptoms.”

The researchers also assessed patients for major depressive disorder, panic disorder, and other anxiety disorders. PTSD was significantly associated with current major depression, any other anxiety disorder, a blood alcohol level greater than 0.08, and a psychiatric history, according to a univariate analysis. A logistic regression analysis showed that people with a history of PTSD reported significantly increased functional impairment compared with those without PTSD.

The study was funded by the National Institutes of Health's National Center for Medical Rehabilitation Research.

MARCO ISLAND, FLA.–Semistructured group therapy improves mood state in HIV-positive men, which improves cortisol levels and immune function and thereby reduces viral load, Karl Goodkin, M.D., said at the annual meeting of the Academy of Psychosomatic Medicine.

Bereavement outside of HIV has long been known to be associated with immunosuppression. Bereavement is also associated with increased mortality risk for surviving partners. The risk increases 40% for the first 6 months and 10-fold in the first year, the same time frame as observed decrements in the immune system, said Dr. Goodkin, professor of psychiatry and behavioral sciences, neurology, and psychology at the University of Miami.

In a randomized controlled trial, Dr. Goodkin and his colleagues compared the intervention with usual care in HIV-positive and HIV-negative gay men who had experienced a loss in the previous 6 months. Although effects of grief were similar, the two-tier group intervention decreased overall psychological stress–which improved mood and immune measures, including CD4 counts and viral loads–and reduced physician health visits, compared with the usual-care control group.

Participants attended a 90-minute session once weekly for 10 weeks. The groups consisted of 6–10 attendees and two professional coleaders. Enrollment was ongoing throughout the study. The first tier of the intervention fostered grief resolution; the second tier fostered stressor management, including identification of stressor impact and maladaptive behaviors. In addition to specific grief-related topics for each session, including past experiences of personal loss, reactions to surviving and implications for one's spirituality and mortality, non-bereavement-related stressor management was planned as a major focus of this unique group intervention, he said.

The usual-care group received any medical and psychosocial care that they had begun prior to initial assessment (if used consistently for 1 month or longer). Furthermore, they received four telephone calls during the 10-week intervention period to assess their clinical status. The total time for these calls was limited to 90 minutes over the 10-week period. Study staff avoided any therapeutic interactions during these calls and maintained a log documenting call content.

In the study, 166 participants (97 HIV-positive and 69 HIV-negative) completed the intervention or community usual-care group conditions. Participants were primarily in their late 30s, employed, and college educated. More than one-third were members of an ethnic minority.

The Stressor-Support-Coping model appears to have utility “with or without bereavement. We found an increase in positive life events in HIV-positive men after the intervention. Social support increased in the intervention group and declined in controls,” Dr. Goodkin noted.

Evidence from the study suggests that increased serum cortisol from stress is associated with decreases in lymphocyte proliferation in response to the artificial stimulant phytohemagglutinin in HIV-positive men and women. This is a functional measure of immunity that tends to decrease before CD4 count, he said.

The intervention decreased overall psychological distress in HIV-negative men, compared with controls, according to scores on the Distress-Grief Composite Measure. However, the decreases in grief, specifically, were less prominent than those for distress or the composite of the two measures for both the HIV-positive and -negative men.

In terms of immune effects, HIV-positive people had a true increase in their lymphocyte proliferation response up to 2 years, and the intervention provided HIV-positive participants with a buffer against decreases in CD4 levels seen in controls. The decrement among HIV-positive participants was smaller, compared with HIV-negative groups, where there was a larger spread, Dr. Goodkin explained.

All participants were asked to self-report physician health care visits in the 6 months prior to assessment. Among HIV-positive participants, there was an increase in the control group that was not as great in the intervention group. Researchers found that the same pattern held true among HIV-negative individuals. There was increased health care utilization among control participants and a decrease among the intervention group, he said.

Researchers were not able to analyze whether all health care visits were HIV or symptom related, an important caveat of the study. Another potential limitation was the difference in atmosphere between HIV-positive and HIV-negative group sessions. “HIV-positive groups talked more about concerns around their own mortality, but nonetheless it is important to note the consistency in findings across multiple domains, especially the physical domains,” Dr. Goodkin said.

“That suggests that if you improve mood state, you will improve cortisol, and you will improve immune function, which relates to improvements in viral load,” he said.

MARCO ISLAND, FLA.–Semistructured group therapy improves mood state in HIV-positive men, which improves cortisol levels and immune function and thereby reduces viral load, Karl Goodkin, M.D., said at the annual meeting of the Academy of Psychosomatic Medicine.

Bereavement outside of HIV has long been known to be associated with immunosuppression. Bereavement is also associated with increased mortality risk for surviving partners. The risk increases 40% for the first 6 months and 10-fold in the first year, the same time frame as observed decrements in the immune system, said Dr. Goodkin, professor of psychiatry and behavioral sciences, neurology, and psychology at the University of Miami.

In a randomized controlled trial, Dr. Goodkin and his colleagues compared the intervention with usual care in HIV-positive and HIV-negative gay men who had experienced a loss in the previous 6 months. Although effects of grief were similar, the two-tier group intervention decreased overall psychological stress–which improved mood and immune measures, including CD4 counts and viral loads–and reduced physician health visits, compared with the usual-care control group.

Participants attended a 90-minute session once weekly for 10 weeks. The groups consisted of 6–10 attendees and two professional coleaders. Enrollment was ongoing throughout the study. The first tier of the intervention fostered grief resolution; the second tier fostered stressor management, including identification of stressor impact and maladaptive behaviors. In addition to specific grief-related topics for each session, including past experiences of personal loss, reactions to surviving and implications for one's spirituality and mortality, non-bereavement-related stressor management was planned as a major focus of this unique group intervention, he said.

The usual-care group received any medical and psychosocial care that they had begun prior to initial assessment (if used consistently for 1 month or longer). Furthermore, they received four telephone calls during the 10-week intervention period to assess their clinical status. The total time for these calls was limited to 90 minutes over the 10-week period. Study staff avoided any therapeutic interactions during these calls and maintained a log documenting call content.

In the study, 166 participants (97 HIV-positive and 69 HIV-negative) completed the intervention or community usual-care group conditions. Participants were primarily in their late 30s, employed, and college educated. More than one-third were members of an ethnic minority.

The Stressor-Support-Coping model appears to have utility “with or without bereavement. We found an increase in positive life events in HIV-positive men after the intervention. Social support increased in the intervention group and declined in controls,” Dr. Goodkin noted.

Evidence from the study suggests that increased serum cortisol from stress is associated with decreases in lymphocyte proliferation in response to the artificial stimulant phytohemagglutinin in HIV-positive men and women. This is a functional measure of immunity that tends to decrease before CD4 count, he said.

The intervention decreased overall psychological distress in HIV-negative men, compared with controls, according to scores on the Distress-Grief Composite Measure. However, the decreases in grief, specifically, were less prominent than those for distress or the composite of the two measures for both the HIV-positive and -negative men.

In terms of immune effects, HIV-positive people had a true increase in their lymphocyte proliferation response up to 2 years, and the intervention provided HIV-positive participants with a buffer against decreases in CD4 levels seen in controls. The decrement among HIV-positive participants was smaller, compared with HIV-negative groups, where there was a larger spread, Dr. Goodkin explained.

All participants were asked to self-report physician health care visits in the 6 months prior to assessment. Among HIV-positive participants, there was an increase in the control group that was not as great in the intervention group. Researchers found that the same pattern held true among HIV-negative individuals. There was increased health care utilization among control participants and a decrease among the intervention group, he said.

Researchers were not able to analyze whether all health care visits were HIV or symptom related, an important caveat of the study. Another potential limitation was the difference in atmosphere between HIV-positive and HIV-negative group sessions. “HIV-positive groups talked more about concerns around their own mortality, but nonetheless it is important to note the consistency in findings across multiple domains, especially the physical domains,” Dr. Goodkin said.

“That suggests that if you improve mood state, you will improve cortisol, and you will improve immune function, which relates to improvements in viral load,” he said.

MARCO ISLAND, FLA.–Semistructured group therapy improves mood state in HIV-positive men, which improves cortisol levels and immune function and thereby reduces viral load, Karl Goodkin, M.D., said at the annual meeting of the Academy of Psychosomatic Medicine.

Bereavement outside of HIV has long been known to be associated with immunosuppression. Bereavement is also associated with increased mortality risk for surviving partners. The risk increases 40% for the first 6 months and 10-fold in the first year, the same time frame as observed decrements in the immune system, said Dr. Goodkin, professor of psychiatry and behavioral sciences, neurology, and psychology at the University of Miami.

In a randomized controlled trial, Dr. Goodkin and his colleagues compared the intervention with usual care in HIV-positive and HIV-negative gay men who had experienced a loss in the previous 6 months. Although effects of grief were similar, the two-tier group intervention decreased overall psychological stress–which improved mood and immune measures, including CD4 counts and viral loads–and reduced physician health visits, compared with the usual-care control group.

Participants attended a 90-minute session once weekly for 10 weeks. The groups consisted of 6–10 attendees and two professional coleaders. Enrollment was ongoing throughout the study. The first tier of the intervention fostered grief resolution; the second tier fostered stressor management, including identification of stressor impact and maladaptive behaviors. In addition to specific grief-related topics for each session, including past experiences of personal loss, reactions to surviving and implications for one's spirituality and mortality, non-bereavement-related stressor management was planned as a major focus of this unique group intervention, he said.

The usual-care group received any medical and psychosocial care that they had begun prior to initial assessment (if used consistently for 1 month or longer). Furthermore, they received four telephone calls during the 10-week intervention period to assess their clinical status. The total time for these calls was limited to 90 minutes over the 10-week period. Study staff avoided any therapeutic interactions during these calls and maintained a log documenting call content.

In the study, 166 participants (97 HIV-positive and 69 HIV-negative) completed the intervention or community usual-care group conditions. Participants were primarily in their late 30s, employed, and college educated. More than one-third were members of an ethnic minority.

The Stressor-Support-Coping model appears to have utility “with or without bereavement. We found an increase in positive life events in HIV-positive men after the intervention. Social support increased in the intervention group and declined in controls,” Dr. Goodkin noted.

Evidence from the study suggests that increased serum cortisol from stress is associated with decreases in lymphocyte proliferation in response to the artificial stimulant phytohemagglutinin in HIV-positive men and women. This is a functional measure of immunity that tends to decrease before CD4 count, he said.

The intervention decreased overall psychological distress in HIV-negative men, compared with controls, according to scores on the Distress-Grief Composite Measure. However, the decreases in grief, specifically, were less prominent than those for distress or the composite of the two measures for both the HIV-positive and -negative men.

In terms of immune effects, HIV-positive people had a true increase in their lymphocyte proliferation response up to 2 years, and the intervention provided HIV-positive participants with a buffer against decreases in CD4 levels seen in controls. The decrement among HIV-positive participants was smaller, compared with HIV-negative groups, where there was a larger spread, Dr. Goodkin explained.

All participants were asked to self-report physician health care visits in the 6 months prior to assessment. Among HIV-positive participants, there was an increase in the control group that was not as great in the intervention group. Researchers found that the same pattern held true among HIV-negative individuals. There was increased health care utilization among control participants and a decrease among the intervention group, he said.

Researchers were not able to analyze whether all health care visits were HIV or symptom related, an important caveat of the study. Another potential limitation was the difference in atmosphere between HIV-positive and HIV-negative group sessions. “HIV-positive groups talked more about concerns around their own mortality, but nonetheless it is important to note the consistency in findings across multiple domains, especially the physical domains,” Dr. Goodkin said.

“That suggests that if you improve mood state, you will improve cortisol, and you will improve immune function, which relates to improvements in viral load,” he said.

MIAMI BEACH–Public health officials are stepping up efforts to combat cysticercosis, a parasitic infection with dire neurologic consequences that is on the rise in the United States, according to James H. Maguire, M.D., chief of the parasitic diseases branch of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta.

Each year in the United States, there are an estimated 1,000 new cases of cysticercosis, a leading cause of adult-onset epilepsy in endemic areas such as Central America and Africa, Dr. Maguire said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Cysticercosis is acquired after accidental ingestion of the eggs of the pork tapewormTaenia solium. Infected people shed the eggs in their feces and infection can spread through contaminated food, water, or surfaces.

Once the eggs hatch in the stomach, they penetrate the intestine and travel through the bloodstream. The eggs produce characteristic cysts anywhere in the body; cysts in the brain cause neurocysticercosis and produce seizures and other neurologic sequelae, Dr. Maguire said.

“The real message is if someone comes in with seizures and they have a single lesion on CT or MRI, it could be cysticercosis,” Dr. Maguire said. Physicians need a high index of suspicion; an accurate diagnosis could spare a patient neurosurgery.

If a central nervous system cyst blocks the flow of cerebrospinal fluid, hydrocephaly can ensue. Surgery or shunt placement is indicated in some of these patients, but in most cases the cysts resolve on their own. Other neurologic sequelae include a permanent, stroke-like syndrome. Even the scar left behind by a former cyst can become the focus for future seizures, Dr. Maguire warned.

Patients are generally treated with antiparasitic drugs in combination with anti-inflammatory agents.

Infection typically comes from eating contaminated pork, fruits, and vegetables, but T. solium is also spread through contact with infected people or fecal matter. Federal standards for the U.S. pork industry protect most Americans, Dr. Maguire said.

Larval stage infection with T. solium leads to symptomatic cysticercosis, but people with an adult tapeworm can be unknowing sources of infection. Four cases of neurocysticercosis in New York City among Orthodox Jews–who do not eat pork–were initially puzzling to investigators (N. Engl. J. Med. 1992;327:692–5).

Only one had traveled to an endemic area. However, six domestic employees were tested; one was found to have had an active infection with Taenia species and another had a positive serologic test. “If a person is infected by someone with an adult tapeworm, contact tracing becomes very important,” Dr. Maguire said.

Cysticercosis is becoming increasingly recognized in U.S.-born residents, although it is still primarily a disease of immigrants from countries such as Mexico, Central America, sub-Saharan Africa, India, and East Asia, Dr. Maguire said.

Increasingly, cysticercosis is reported in New Mexico, New York, and California, states with large numbers of immigrants. However, “we saw 6–12 cases per year in Boston when I worked there–not a hotbed of immigration,” he added.

MIAMI BEACH–Public health officials are stepping up efforts to combat cysticercosis, a parasitic infection with dire neurologic consequences that is on the rise in the United States, according to James H. Maguire, M.D., chief of the parasitic diseases branch of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta.

Each year in the United States, there are an estimated 1,000 new cases of cysticercosis, a leading cause of adult-onset epilepsy in endemic areas such as Central America and Africa, Dr. Maguire said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Cysticercosis is acquired after accidental ingestion of the eggs of the pork tapewormTaenia solium. Infected people shed the eggs in their feces and infection can spread through contaminated food, water, or surfaces.

Once the eggs hatch in the stomach, they penetrate the intestine and travel through the bloodstream. The eggs produce characteristic cysts anywhere in the body; cysts in the brain cause neurocysticercosis and produce seizures and other neurologic sequelae, Dr. Maguire said.

“The real message is if someone comes in with seizures and they have a single lesion on CT or MRI, it could be cysticercosis,” Dr. Maguire said. Physicians need a high index of suspicion; an accurate diagnosis could spare a patient neurosurgery.

If a central nervous system cyst blocks the flow of cerebrospinal fluid, hydrocephaly can ensue. Surgery or shunt placement is indicated in some of these patients, but in most cases the cysts resolve on their own. Other neurologic sequelae include a permanent, stroke-like syndrome. Even the scar left behind by a former cyst can become the focus for future seizures, Dr. Maguire warned.

Patients are generally treated with antiparasitic drugs in combination with anti-inflammatory agents.

Infection typically comes from eating contaminated pork, fruits, and vegetables, but T. solium is also spread through contact with infected people or fecal matter. Federal standards for the U.S. pork industry protect most Americans, Dr. Maguire said.

Larval stage infection with T. solium leads to symptomatic cysticercosis, but people with an adult tapeworm can be unknowing sources of infection. Four cases of neurocysticercosis in New York City among Orthodox Jews–who do not eat pork–were initially puzzling to investigators (N. Engl. J. Med. 1992;327:692–5).

Only one had traveled to an endemic area. However, six domestic employees were tested; one was found to have had an active infection with Taenia species and another had a positive serologic test. “If a person is infected by someone with an adult tapeworm, contact tracing becomes very important,” Dr. Maguire said.

Cysticercosis is becoming increasingly recognized in U.S.-born residents, although it is still primarily a disease of immigrants from countries such as Mexico, Central America, sub-Saharan Africa, India, and East Asia, Dr. Maguire said.

Increasingly, cysticercosis is reported in New Mexico, New York, and California, states with large numbers of immigrants. However, “we saw 6–12 cases per year in Boston when I worked there–not a hotbed of immigration,” he added.

MIAMI BEACH–Public health officials are stepping up efforts to combat cysticercosis, a parasitic infection with dire neurologic consequences that is on the rise in the United States, according to James H. Maguire, M.D., chief of the parasitic diseases branch of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta.

Each year in the United States, there are an estimated 1,000 new cases of cysticercosis, a leading cause of adult-onset epilepsy in endemic areas such as Central America and Africa, Dr. Maguire said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Cysticercosis is acquired after accidental ingestion of the eggs of the pork tapewormTaenia solium. Infected people shed the eggs in their feces and infection can spread through contaminated food, water, or surfaces.

Once the eggs hatch in the stomach, they penetrate the intestine and travel through the bloodstream. The eggs produce characteristic cysts anywhere in the body; cysts in the brain cause neurocysticercosis and produce seizures and other neurologic sequelae, Dr. Maguire said.

“The real message is if someone comes in with seizures and they have a single lesion on CT or MRI, it could be cysticercosis,” Dr. Maguire said. Physicians need a high index of suspicion; an accurate diagnosis could spare a patient neurosurgery.

If a central nervous system cyst blocks the flow of cerebrospinal fluid, hydrocephaly can ensue. Surgery or shunt placement is indicated in some of these patients, but in most cases the cysts resolve on their own. Other neurologic sequelae include a permanent, stroke-like syndrome. Even the scar left behind by a former cyst can become the focus for future seizures, Dr. Maguire warned.

Patients are generally treated with antiparasitic drugs in combination with anti-inflammatory agents.

Infection typically comes from eating contaminated pork, fruits, and vegetables, but T. solium is also spread through contact with infected people or fecal matter. Federal standards for the U.S. pork industry protect most Americans, Dr. Maguire said.

Larval stage infection with T. solium leads to symptomatic cysticercosis, but people with an adult tapeworm can be unknowing sources of infection. Four cases of neurocysticercosis in New York City among Orthodox Jews–who do not eat pork–were initially puzzling to investigators (N. Engl. J. Med. 1992;327:692–5).

Only one had traveled to an endemic area. However, six domestic employees were tested; one was found to have had an active infection with Taenia species and another had a positive serologic test. “If a person is infected by someone with an adult tapeworm, contact tracing becomes very important,” Dr. Maguire said.

Cysticercosis is becoming increasingly recognized in U.S.-born residents, although it is still primarily a disease of immigrants from countries such as Mexico, Central America, sub-Saharan Africa, India, and East Asia, Dr. Maguire said.

Increasingly, cysticercosis is reported in New Mexico, New York, and California, states with large numbers of immigrants. However, “we saw 6–12 cases per year in Boston when I worked there–not a hotbed of immigration,” he added.

FORT MYERS, FLA. – Home visits and follow-up telephone calls improved elderly depression in a program that used existing community services for seniors in Seattle, according to a presentation at the annual meeting of the Academy of Psychosomatic Medicine.

Rates of depression are higher in older adults who are socially isolated, have high medication comorbidity, or are homebound. About one-fifth to one-sixth of elderly individuals in the United States have clinically significant depression. They are more likely to have minor depression or dysthymia, compared with their younger counterparts.

A 12-month, randomized, controlled trial showed the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) effectively improved depression among older adults at higher risk, specifically those who are physically impaired, socially isolated, and/or of lower socioeconomic status.

“It is home based, so in a way it is a systematized, stylized way to do house calls, but a postmodern version done by social workers, not doctors,” Paul Ciechanowski, M.D., explained. “It's amazing how much extra information you get by observing and visiting patients in their own homes,” said Dr. Ciechanowski of the University of Washington, Seattle. The university runs PEARLS in collaboration with Senior Services Seattle/King County, Aging and Disability Services, and Public Health Seattle King County. The study was funded by the Centers for Disease Control and Prevention.

There were 138 participants, 99 referred from agencies and 39 who were self-referred. About half were diagnosed with dysthymia, the other half with minor depression. The mean age was 73 years, 79% were female, and the majority had a mean annual income of less than $10,000. At baseline, 35% were taking antidepressants. People were excluded if they had major depression or another psychiatric disorder, substance abuse, or a cognitive disorder.

After randomization, there were 66 patients in a routine care group and 72 in an intervention group. Routine care included referral and communication between the patient's primary care physician, the community agency social worker, and University of Washington researchers.

The intervention included a mean of 6.6 1-hour problem-solving treatment (PST) sessions in the home over 19 weeks. PST is effective, nonpsychiatric, and consistent with other modern self-management strategies in medical disease, Dr. Ciechanowski said.

“We define and break down problems, establish realistic goals, and take small, incremental steps. They begin to feel empowered.”

The intervention also included one or more of the following: problem-solving counseling sessions, social activation, physical activity, and/or prescription of antidepressants.

FORT MYERS, FLA. – Home visits and follow-up telephone calls improved elderly depression in a program that used existing community services for seniors in Seattle, according to a presentation at the annual meeting of the Academy of Psychosomatic Medicine.

Rates of depression are higher in older adults who are socially isolated, have high medication comorbidity, or are homebound. About one-fifth to one-sixth of elderly individuals in the United States have clinically significant depression. They are more likely to have minor depression or dysthymia, compared with their younger counterparts.

A 12-month, randomized, controlled trial showed the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) effectively improved depression among older adults at higher risk, specifically those who are physically impaired, socially isolated, and/or of lower socioeconomic status.

“It is home based, so in a way it is a systematized, stylized way to do house calls, but a postmodern version done by social workers, not doctors,” Paul Ciechanowski, M.D., explained. “It's amazing how much extra information you get by observing and visiting patients in their own homes,” said Dr. Ciechanowski of the University of Washington, Seattle. The university runs PEARLS in collaboration with Senior Services Seattle/King County, Aging and Disability Services, and Public Health Seattle King County. The study was funded by the Centers for Disease Control and Prevention.

There were 138 participants, 99 referred from agencies and 39 who were self-referred. About half were diagnosed with dysthymia, the other half with minor depression. The mean age was 73 years, 79% were female, and the majority had a mean annual income of less than $10,000. At baseline, 35% were taking antidepressants. People were excluded if they had major depression or another psychiatric disorder, substance abuse, or a cognitive disorder.

After randomization, there were 66 patients in a routine care group and 72 in an intervention group. Routine care included referral and communication between the patient's primary care physician, the community agency social worker, and University of Washington researchers.

The intervention included a mean of 6.6 1-hour problem-solving treatment (PST) sessions in the home over 19 weeks. PST is effective, nonpsychiatric, and consistent with other modern self-management strategies in medical disease, Dr. Ciechanowski said.

“We define and break down problems, establish realistic goals, and take small, incremental steps. They begin to feel empowered.”

The intervention also included one or more of the following: problem-solving counseling sessions, social activation, physical activity, and/or prescription of antidepressants.

FORT MYERS, FLA. – Home visits and follow-up telephone calls improved elderly depression in a program that used existing community services for seniors in Seattle, according to a presentation at the annual meeting of the Academy of Psychosomatic Medicine.

Rates of depression are higher in older adults who are socially isolated, have high medication comorbidity, or are homebound. About one-fifth to one-sixth of elderly individuals in the United States have clinically significant depression. They are more likely to have minor depression or dysthymia, compared with their younger counterparts.

A 12-month, randomized, controlled trial showed the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) effectively improved depression among older adults at higher risk, specifically those who are physically impaired, socially isolated, and/or of lower socioeconomic status.

“It is home based, so in a way it is a systematized, stylized way to do house calls, but a postmodern version done by social workers, not doctors,” Paul Ciechanowski, M.D., explained. “It's amazing how much extra information you get by observing and visiting patients in their own homes,” said Dr. Ciechanowski of the University of Washington, Seattle. The university runs PEARLS in collaboration with Senior Services Seattle/King County, Aging and Disability Services, and Public Health Seattle King County. The study was funded by the Centers for Disease Control and Prevention.

There were 138 participants, 99 referred from agencies and 39 who were self-referred. About half were diagnosed with dysthymia, the other half with minor depression. The mean age was 73 years, 79% were female, and the majority had a mean annual income of less than $10,000. At baseline, 35% were taking antidepressants. People were excluded if they had major depression or another psychiatric disorder, substance abuse, or a cognitive disorder.

After randomization, there were 66 patients in a routine care group and 72 in an intervention group. Routine care included referral and communication between the patient's primary care physician, the community agency social worker, and University of Washington researchers.

The intervention included a mean of 6.6 1-hour problem-solving treatment (PST) sessions in the home over 19 weeks. PST is effective, nonpsychiatric, and consistent with other modern self-management strategies in medical disease, Dr. Ciechanowski said.

“We define and break down problems, establish realistic goals, and take small, incremental steps. They begin to feel empowered.”

The intervention also included one or more of the following: problem-solving counseling sessions, social activation, physical activity, and/or prescription of antidepressants.

MIAMI BEACH — Some American soldiers are returning from Iraq with a dormant pathogen in tow: cutaneous leishmaniasis. Symptoms of the infection can take 4–6 months to appear after a bite from an infected sand fly, and some unknowingly infected military personnel return to their communities before the lesions develop. This puts community dermatologists in the position of having to treat this tropical infection.

There is a seasonal variance to this protozoan parasitic infection that corresponds with the activity of sand flies in the Middle East. During the 2003–2004 season, localized cutaneous leishmaniasis was frequently diagnosed in U.S. military personnel, with most infections caused by Leishmania major, according to a presentation at the annual meeting of the American Society of Tropical Medicine and Hygiene.

There have been more than 500 reported cases since January 2003 among soldiers from Operation Enduring Freedom and Operation Iraqi Freedom, according to U.S. Army medical research data.

Experience with 300 soldiers treated at Walter Reed Army Medical Center in Washington demonstrates that there are multiple presentations for localized cutaneous leishmaniasis. Of the infected patients, 98% were male, 96% were in the U.S. Army, and 91% were enlisted personnel. Almost three-quarters (73%) were white; 16% were African American, 6% were Hispanic, and 5% were from other ethnic groups.

“Patients with lighter skin were overrepresented in our cohort,” said Naomi E. Aronson, M.D., professor of medicine and director of the infectious diseases division, Uniformed Services University of the Health Sciences, Bethesda, Md.

Cutaneous leishmaniasis manifests after the multiplication of the organism in phagocytes in the skin. The mean number of skin lesions per patient was 3, and the range was 1–47. The mean time between appearance of a lesion and initiation of treatment was 13 weeks.

Papules often appear first, followed by ulcerative lesions. Lesions commonly appear in pairs. Nodules are uncommon in leishmaniasis. A rare presentation is a large psoriasiform-type plaque containing several small lesions. “I've seen about 10 cases of this form,” Dr. Aronson said. Facial lesions, including those on the lips or pinna of the ear, tend to be more inflammatory, Dr. Aronson commented.

Leishmaniasis lesions do not typically feature purulent drainage; if the lesion is tender with pus, it is likely a bacterial superinfection, Dr. Aronson explained. Both the lesions and the resultant bacterial infection may require concurrent treatment courses.

Sand flies are attracted to bright colors, so soldiers are sometimes bitten on exposed tattoos, she said. “A common complaint in our clinic is 'the sand fly messed up my tattoo.'” The cutaneous form of the disease is ultimately self-healing, although disfiguring scars can remain. The visceral and mucosal forms of leishmaniasis are often more serious and sometimes fatal. Educate patients that not all treatments are 100% effective, Dr. Aronson suggested. “It is important to give patients realistic expectations that leishmaniasis may not be gone, but it should improve.”

There are no leishmaniasis treatments that have been approved by the Food and Drug Administration. Topical treatments include heat therapy and cryotherapy. Some lesions will respond to treatment with ThermoMed (Thermosurgery Technologies, Inc.) but others only partially respond, Dr. Aronson reported. A clinical trial investigating the technology is underway at Walter Reed Army Medical Center. Cryotherapy with liquid nitrogen is another treatment strategy.

Standard therapy for all forms of the disease is pentavalent antimony of sodium stibogluconate (Pentostam, GlaxoSmithKline) or meglumine antimonate (Glucantime, Aventis). The usual parenteral regimen of sodium stibogluconate, for example, is 20 mg/kg per day for 20 days.

Pentavalent antimonials are available only through an Investigational New Drug (IND) protocol from the Centers for Disease Control and Prevention. Investigational agents require a lot of paperwork—and institutional review board approval—before they are available for use, Kenneth R. Dardick, M.D., said during a separate presentation at the meeting. Pharmacists need to be educated about storage requirements and nurses instructed to handle the agents as they would a chemotherapy drug. Informed consent is required from patients.

It is possible that physicians working in a community hospital will see only one or two cases of this rare disease. Physicians unfamiliar with use of pentavalent antimonials should consult military and/or CDC infectious disease experts, suggested Dr. Dardick, a family physician at Mansfield Family Practice, Windham Hospital, Storrs, Conn.

The IND requirements “can be novel for a community hospital,” Dr. Dardick added. “But cutaneous leishmaniasis can be successfully diagnosed and treated in a community hospital with appropriate index of suspicion.”

Soldiers may get bitten on exposed tattoos, Dr. Naomi E. Aronson said. Courtesy Dr. Naomi E. Aronson

MIAMI BEACH — Some American soldiers are returning from Iraq with a dormant pathogen in tow: cutaneous leishmaniasis. Symptoms of the infection can take 4–6 months to appear after a bite from an infected sand fly, and some unknowingly infected military personnel return to their communities before the lesions develop. This puts community dermatologists in the position of having to treat this tropical infection.

There is a seasonal variance to this protozoan parasitic infection that corresponds with the activity of sand flies in the Middle East. During the 2003–2004 season, localized cutaneous leishmaniasis was frequently diagnosed in U.S. military personnel, with most infections caused by Leishmania major, according to a presentation at the annual meeting of the American Society of Tropical Medicine and Hygiene.

There have been more than 500 reported cases since January 2003 among soldiers from Operation Enduring Freedom and Operation Iraqi Freedom, according to U.S. Army medical research data.

Experience with 300 soldiers treated at Walter Reed Army Medical Center in Washington demonstrates that there are multiple presentations for localized cutaneous leishmaniasis. Of the infected patients, 98% were male, 96% were in the U.S. Army, and 91% were enlisted personnel. Almost three-quarters (73%) were white; 16% were African American, 6% were Hispanic, and 5% were from other ethnic groups.

“Patients with lighter skin were overrepresented in our cohort,” said Naomi E. Aronson, M.D., professor of medicine and director of the infectious diseases division, Uniformed Services University of the Health Sciences, Bethesda, Md.

Cutaneous leishmaniasis manifests after the multiplication of the organism in phagocytes in the skin. The mean number of skin lesions per patient was 3, and the range was 1–47. The mean time between appearance of a lesion and initiation of treatment was 13 weeks.

Papules often appear first, followed by ulcerative lesions. Lesions commonly appear in pairs. Nodules are uncommon in leishmaniasis. A rare presentation is a large psoriasiform-type plaque containing several small lesions. “I've seen about 10 cases of this form,” Dr. Aronson said. Facial lesions, including those on the lips or pinna of the ear, tend to be more inflammatory, Dr. Aronson commented.

Leishmaniasis lesions do not typically feature purulent drainage; if the lesion is tender with pus, it is likely a bacterial superinfection, Dr. Aronson explained. Both the lesions and the resultant bacterial infection may require concurrent treatment courses.

Sand flies are attracted to bright colors, so soldiers are sometimes bitten on exposed tattoos, she said. “A common complaint in our clinic is 'the sand fly messed up my tattoo.'” The cutaneous form of the disease is ultimately self-healing, although disfiguring scars can remain. The visceral and mucosal forms of leishmaniasis are often more serious and sometimes fatal. Educate patients that not all treatments are 100% effective, Dr. Aronson suggested. “It is important to give patients realistic expectations that leishmaniasis may not be gone, but it should improve.”

There are no leishmaniasis treatments that have been approved by the Food and Drug Administration. Topical treatments include heat therapy and cryotherapy. Some lesions will respond to treatment with ThermoMed (Thermosurgery Technologies, Inc.) but others only partially respond, Dr. Aronson reported. A clinical trial investigating the technology is underway at Walter Reed Army Medical Center. Cryotherapy with liquid nitrogen is another treatment strategy.

Standard therapy for all forms of the disease is pentavalent antimony of sodium stibogluconate (Pentostam, GlaxoSmithKline) or meglumine antimonate (Glucantime, Aventis). The usual parenteral regimen of sodium stibogluconate, for example, is 20 mg/kg per day for 20 days.

Pentavalent antimonials are available only through an Investigational New Drug (IND) protocol from the Centers for Disease Control and Prevention. Investigational agents require a lot of paperwork—and institutional review board approval—before they are available for use, Kenneth R. Dardick, M.D., said during a separate presentation at the meeting. Pharmacists need to be educated about storage requirements and nurses instructed to handle the agents as they would a chemotherapy drug. Informed consent is required from patients.

It is possible that physicians working in a community hospital will see only one or two cases of this rare disease. Physicians unfamiliar with use of pentavalent antimonials should consult military and/or CDC infectious disease experts, suggested Dr. Dardick, a family physician at Mansfield Family Practice, Windham Hospital, Storrs, Conn.

The IND requirements “can be novel for a community hospital,” Dr. Dardick added. “But cutaneous leishmaniasis can be successfully diagnosed and treated in a community hospital with appropriate index of suspicion.”

Soldiers may get bitten on exposed tattoos, Dr. Naomi E. Aronson said. Courtesy Dr. Naomi E. Aronson

MIAMI BEACH — Some American soldiers are returning from Iraq with a dormant pathogen in tow: cutaneous leishmaniasis. Symptoms of the infection can take 4–6 months to appear after a bite from an infected sand fly, and some unknowingly infected military personnel return to their communities before the lesions develop. This puts community dermatologists in the position of having to treat this tropical infection.

There is a seasonal variance to this protozoan parasitic infection that corresponds with the activity of sand flies in the Middle East. During the 2003–2004 season, localized cutaneous leishmaniasis was frequently diagnosed in U.S. military personnel, with most infections caused by Leishmania major, according to a presentation at the annual meeting of the American Society of Tropical Medicine and Hygiene.

There have been more than 500 reported cases since January 2003 among soldiers from Operation Enduring Freedom and Operation Iraqi Freedom, according to U.S. Army medical research data.

Experience with 300 soldiers treated at Walter Reed Army Medical Center in Washington demonstrates that there are multiple presentations for localized cutaneous leishmaniasis. Of the infected patients, 98% were male, 96% were in the U.S. Army, and 91% were enlisted personnel. Almost three-quarters (73%) were white; 16% were African American, 6% were Hispanic, and 5% were from other ethnic groups.

“Patients with lighter skin were overrepresented in our cohort,” said Naomi E. Aronson, M.D., professor of medicine and director of the infectious diseases division, Uniformed Services University of the Health Sciences, Bethesda, Md.

Cutaneous leishmaniasis manifests after the multiplication of the organism in phagocytes in the skin. The mean number of skin lesions per patient was 3, and the range was 1–47. The mean time between appearance of a lesion and initiation of treatment was 13 weeks.

Papules often appear first, followed by ulcerative lesions. Lesions commonly appear in pairs. Nodules are uncommon in leishmaniasis. A rare presentation is a large psoriasiform-type plaque containing several small lesions. “I've seen about 10 cases of this form,” Dr. Aronson said. Facial lesions, including those on the lips or pinna of the ear, tend to be more inflammatory, Dr. Aronson commented.

Leishmaniasis lesions do not typically feature purulent drainage; if the lesion is tender with pus, it is likely a bacterial superinfection, Dr. Aronson explained. Both the lesions and the resultant bacterial infection may require concurrent treatment courses.

Sand flies are attracted to bright colors, so soldiers are sometimes bitten on exposed tattoos, she said. “A common complaint in our clinic is 'the sand fly messed up my tattoo.'” The cutaneous form of the disease is ultimately self-healing, although disfiguring scars can remain. The visceral and mucosal forms of leishmaniasis are often more serious and sometimes fatal. Educate patients that not all treatments are 100% effective, Dr. Aronson suggested. “It is important to give patients realistic expectations that leishmaniasis may not be gone, but it should improve.”

There are no leishmaniasis treatments that have been approved by the Food and Drug Administration. Topical treatments include heat therapy and cryotherapy. Some lesions will respond to treatment with ThermoMed (Thermosurgery Technologies, Inc.) but others only partially respond, Dr. Aronson reported. A clinical trial investigating the technology is underway at Walter Reed Army Medical Center. Cryotherapy with liquid nitrogen is another treatment strategy.

Standard therapy for all forms of the disease is pentavalent antimony of sodium stibogluconate (Pentostam, GlaxoSmithKline) or meglumine antimonate (Glucantime, Aventis). The usual parenteral regimen of sodium stibogluconate, for example, is 20 mg/kg per day for 20 days.

Pentavalent antimonials are available only through an Investigational New Drug (IND) protocol from the Centers for Disease Control and Prevention. Investigational agents require a lot of paperwork—and institutional review board approval—before they are available for use, Kenneth R. Dardick, M.D., said during a separate presentation at the meeting. Pharmacists need to be educated about storage requirements and nurses instructed to handle the agents as they would a chemotherapy drug. Informed consent is required from patients.

It is possible that physicians working in a community hospital will see only one or two cases of this rare disease. Physicians unfamiliar with use of pentavalent antimonials should consult military and/or CDC infectious disease experts, suggested Dr. Dardick, a family physician at Mansfield Family Practice, Windham Hospital, Storrs, Conn.

The IND requirements “can be novel for a community hospital,” Dr. Dardick added. “But cutaneous leishmaniasis can be successfully diagnosed and treated in a community hospital with appropriate index of suspicion.”

Soldiers may get bitten on exposed tattoos, Dr. Naomi E. Aronson said. Courtesy Dr. Naomi E. Aronson

MIAMI BEACH — The next edition of “Health Information for International Travel,” also known as the Centers for Disease Control and Prevention's “Yellow Book,” will be more clinically oriented and will include new chapters on specific diseases, such as SARS, according to a sneak preview at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Clinical presentation and treatment information will be added to the new and traditional chapters.

Previously, the book addressed only prevention, risk, descriptions, and occurrence of travel-related diseases, according to Christie Reed, M.D., of the CDC's Division of Global Migration and Quarantine.

“Increase in travel was exponential in the 1990s. And the places people were going were different—there was a marked increase in travel to developing parts of the world,” Dr. Reed said.

The volume of people migrating around the world also increased significantly, Dr. Reed said, adding, “Yesterday's migrant can become today's traveler.”

Many immigrants to the United States return to their countries of origin to visit family and friends, for example, and present unique challenges in travel-related health.

One of the main goals of the CDC's Travelers' Health division is to share information, primarily through the Yellow Book and the Internet (www.cdc.gov/travel

“The Web has been a boon to us in terms of getting information out there quickly. The Yellow Book is out of date every 2 years, but the Web site allows us to be accurate and up to date with rapidly changing information,” Dr. Reed said.

The 2005-2006 edition will include more information from experts outside the CDC and a new bibliography on evidence-based medicine for travelers. New chapters are expected to include:

▸ Norovirus.

▸ Severe acute respiratory syndrome.

▸ Pneumococcus.

▸ Legionella.

▸ Jet lag.

▸ Fish poisoning.

▸ Sunburn.

▸ Health-seeking travelers. “This includes people traveling for surgery, dental care, etc. The standards for health care may not be the same in other places as they are in the U.S.,” Dr. Reed said.

In addition, there will be expanded sections on preconception, pregnancy, and breastfeeding issues for travelers and more information on travel for immunocompromised people, not just for those with HIV infection, as in past editions.

There will be new maps to highlight regions of increased risks associated with Japanese encephalitis and yellow fever.

The 2005-2006 edition is expected to be available in May 2005, to coincide with the 9th Conference of the International Society of Travel Medicine in Lisbon, Portugal.

Although the next edition of the Yellow Book is nearly complete, online information is updated continuously.

Dr. Reed encouraged physicians to submit any travel health-related information or concerns using the “contact us” option on the Web site.

MIAMI BEACH — The next edition of “Health Information for International Travel,” also known as the Centers for Disease Control and Prevention's “Yellow Book,” will be more clinically oriented and will include new chapters on specific diseases, such as SARS, according to a sneak preview at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Clinical presentation and treatment information will be added to the new and traditional chapters.

Previously, the book addressed only prevention, risk, descriptions, and occurrence of travel-related diseases, according to Christie Reed, M.D., of the CDC's Division of Global Migration and Quarantine.

“Increase in travel was exponential in the 1990s. And the places people were going were different—there was a marked increase in travel to developing parts of the world,” Dr. Reed said.

The volume of people migrating around the world also increased significantly, Dr. Reed said, adding, “Yesterday's migrant can become today's traveler.”

Many immigrants to the United States return to their countries of origin to visit family and friends, for example, and present unique challenges in travel-related health.

One of the main goals of the CDC's Travelers' Health division is to share information, primarily through the Yellow Book and the Internet (www.cdc.gov/travel

“The Web has been a boon to us in terms of getting information out there quickly. The Yellow Book is out of date every 2 years, but the Web site allows us to be accurate and up to date with rapidly changing information,” Dr. Reed said.

The 2005-2006 edition will include more information from experts outside the CDC and a new bibliography on evidence-based medicine for travelers. New chapters are expected to include:

▸ Norovirus.

▸ Severe acute respiratory syndrome.

▸ Pneumococcus.

▸ Legionella.

▸ Jet lag.

▸ Fish poisoning.

▸ Sunburn.

▸ Health-seeking travelers. “This includes people traveling for surgery, dental care, etc. The standards for health care may not be the same in other places as they are in the U.S.,” Dr. Reed said.

In addition, there will be expanded sections on preconception, pregnancy, and breastfeeding issues for travelers and more information on travel for immunocompromised people, not just for those with HIV infection, as in past editions.

There will be new maps to highlight regions of increased risks associated with Japanese encephalitis and yellow fever.

The 2005-2006 edition is expected to be available in May 2005, to coincide with the 9th Conference of the International Society of Travel Medicine in Lisbon, Portugal.

Although the next edition of the Yellow Book is nearly complete, online information is updated continuously.

Dr. Reed encouraged physicians to submit any travel health-related information or concerns using the “contact us” option on the Web site.

MIAMI BEACH — The next edition of “Health Information for International Travel,” also known as the Centers for Disease Control and Prevention's “Yellow Book,” will be more clinically oriented and will include new chapters on specific diseases, such as SARS, according to a sneak preview at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Clinical presentation and treatment information will be added to the new and traditional chapters.

Previously, the book addressed only prevention, risk, descriptions, and occurrence of travel-related diseases, according to Christie Reed, M.D., of the CDC's Division of Global Migration and Quarantine.

“Increase in travel was exponential in the 1990s. And the places people were going were different—there was a marked increase in travel to developing parts of the world,” Dr. Reed said.

The volume of people migrating around the world also increased significantly, Dr. Reed said, adding, “Yesterday's migrant can become today's traveler.”

Many immigrants to the United States return to their countries of origin to visit family and friends, for example, and present unique challenges in travel-related health.

One of the main goals of the CDC's Travelers' Health division is to share information, primarily through the Yellow Book and the Internet (www.cdc.gov/travel

“The Web has been a boon to us in terms of getting information out there quickly. The Yellow Book is out of date every 2 years, but the Web site allows us to be accurate and up to date with rapidly changing information,” Dr. Reed said.

The 2005-2006 edition will include more information from experts outside the CDC and a new bibliography on evidence-based medicine for travelers. New chapters are expected to include:

▸ Norovirus.

▸ Severe acute respiratory syndrome.

▸ Pneumococcus.

▸ Legionella.

▸ Jet lag.

▸ Fish poisoning.

▸ Sunburn.

▸ Health-seeking travelers. “This includes people traveling for surgery, dental care, etc. The standards for health care may not be the same in other places as they are in the U.S.,” Dr. Reed said.

In addition, there will be expanded sections on preconception, pregnancy, and breastfeeding issues for travelers and more information on travel for immunocompromised people, not just for those with HIV infection, as in past editions.

There will be new maps to highlight regions of increased risks associated with Japanese encephalitis and yellow fever.

The 2005-2006 edition is expected to be available in May 2005, to coincide with the 9th Conference of the International Society of Travel Medicine in Lisbon, Portugal.

Although the next edition of the Yellow Book is nearly complete, online information is updated continuously.

Dr. Reed encouraged physicians to submit any travel health-related information or concerns using the “contact us” option on the Web site.